Sameer A. Pathan

Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial

BACKGROUND The excruciating pain of patients with renal colic on presentation to the emergency department requires effective analgesia to be administered in the shortest possible time. Trials comparing intramuscular non-steroidal anti-inflammatory drugs with intravenous opioids or paracetamol have been inconclusive because of the challenges associated with concealment of randomisation, small sample size, differences in outcome measures, and inadequate masking of participants and assessors. We did this trial to develop definitive evidence regarding the choice of initial analgesia and route of administration in participants presenting with renal colic to the emergency department. METHODS In this three-treatment group, double-blind, randomised controlled trial, adult participants (aged 18-65 years) presenting to the emergency department of an academic, tertiary care hospital in Qatar, with moderate to severe renal colic (Numerical pain Rating Scale ≥ 4) were recruited. With the use of computer-generated block randomisation (block sizes of six and nine), participants were assigned (1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0.1 mg/kg intravenous), or paracetamol (1 g/100 mL intravenous). Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants achieving at least a 50% reduction in initial pain score at 30 min after analgesia, assessed by intention-to-treat analysis and per-protocol analysis, which included patients where a calculus in the urinary tract was detected with imaging. This trial is registered with ClinicalTrials.gov, number NCT02187614. FINDINGS Between Aug 5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644 were included in the intention-to-treat analysis (547 in the diclofenac group, 548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi were detected in 1316 patients, who were analysed as the per-protocol population (438 in the diclofenac group, 435 in the paracetemol group, and 443 in the morphine group). The primary outcome was achieved in 371 (68%) patients in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in the morphine group in the intention-to-treat population. Compared to morphine, diclofenac was significantly more effective in achieving the primary outcome (odds ratio [OR] 1·35, 95% CI 1·05-1·73, p=0·0187), whereas no difference was detected in the effectiveness of morphine compared with intravenous paracetamol (1·26, 0·99-1·62, p=0·0629). In the per-protocol population, diclofenac (OR 1·49, 95% CI 1·13-1·97, p=0·0046) and paracetamol (1·40, 1·06-1·85, p=0·0166) were more effective than morphine in achieving the primary outcome. Acute adverse events in the morphine group occurred in 19 (3%) participants. Significantly lower numbers of adverse events were recorded in the diclofenac group (7 [1%] participants, OR 0·31, 95% CI 0·12-0·78, p=0·0088) and paracetamol group (7 [1%] participants, 0·36, 0·15-0·87, p=0·0175) than in the morphine group. During the 2 week follow-up, no additional adverse events were noted in any group. INTERPRETATION Intramuscular non-steroidal anti-inflammatory drugs offer the most effective sustained analgesia for renal colic in the emergency department and seem to have fewer side-effects. FUNDING Hamad Medical Corporation Medical Research Center, Doha, Qatar.

Computed Tomography Abnormalities and Epidemiology of Adult Patients Presenting With First Seizure to the Emergency Department in Qatar

OBJECTIVES There is little information available from the Middle Eastern region on adult patients presenting with first seizure. The objectives of this study were to describe epidemiological characteristics of patients presenting to the emergency department (ED) in Doha, Qatar, with first seizure and to determine the incidence of computed tomographic (CT) scan abnormalities. METHODS A retrospective cohort study was conducted on all adult patients with first seizure presenting to Hamad General Hospital ED over a 1-year period (June 2012 through May 2013). Electronic patient records were reviewed for demographics, neuroimaging, electroencephalography, laboratory test results, and medications administered. RESULTS There were 439 patients who satisfied inclusion criteria. Patients were aged a mean of 35.3 years (95% confidence interval [CI] = 33.92 to 36.69 years) with a male-to-female ratio of five to one. CT abnormalities were detected in 154 patients (35.3%; 95% CI = 30.81% to 39.82%). Out of reported abnormal scans, 14.7% patients had significant abnormalities such as neurocysticercosis (9.2%); brain metastasis and neoplasm (3.4%); and subarachnoid and subdural hemorrhage, cavernous sinus thrombosis, acute stroke, and brain edema (2.0%). None of the patients had any electrolyte abnormalities, and three patients had hypoglycemia. Patients with initial abnormal CT brain results were more likely to have recurrent seizures (OR = 1.65; 95% CI = 1.11 to 2.45) within 6 months. CONCLUSIONS Adults who presented with first seizure to the ED in Qatar had a young male predominance, and a high proportion of brain CT scans were reported as abnormal. It is recommended that all such patients in this population should undergo prompt CT scanning in the ED, but the utility of routine electrolyte tests requires further investigation.

What is the best analgesic option for patients presenting with renal colic to the emergency department? Protocol for a systematic review and meta-analysis.

Introduction Patients with renal colic present to the emergency department in excruciating pain. There is variability in practice regarding the choice of initial analgesic to be used in renal colic. The aim of this article is to outline the protocol for review of the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), opioids and paracetamol use in renal colic pain management. Methods and analysis This is the protocol for a systematic review, comparing efficacy of NSAIDs, opioids and paracetamol in renal colic studied under randomised controlled trial (RCT) design. This protocol reporting is based on the PRISMA-P recommendations (PRISMA-P-checklist). We will conduct a comprehensive literature search for both peer-reviewed and grey literature published until 18 December 2016. Using a predefined search strategy, MEDLINE, Embase and Cochrane Central Register of Controlled Trials will be searched. Additional searches will include WHO International Clinical Trials Registry Platform, abstract list of relevant major conferences and the reference lists of relevant publications. Two authors will independently screen and identify the studies to be included. The RCT comparing NSAIDs versus opioids or paracetamol will be included in the review, if the age of participants in the study was >16 years and they presented with moderate to severe renal colic. Any disagreement between the screening authors will be resolved through discussion and reaching consensus; if not, a third reviewer will arbitrate. Quantitative data from homogeneous studies will be pooled in the meta-analysis using RevMan V.5.3 software. The findings of this review will be presented according to the guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Ethics and dissemination Formal ethics approval is not required, as primary data will not be collected. We plan to publish the result of this review in a peer-reviewed journal.

A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic

CONTEXT Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. However, the fear of NSAID adverse effects and the uncertainty about superior analgesic effect have maintained the practice of advocating intravenous opioids as the initial analgesia. OBJECTIVE The objective of this systematic review and meta-analysis was to compare the safety and efficacy of NSAIDs with opioids and paracetamol (acetaminophen) for the management of acute renal colic. EVIDENCE ACQUISITION Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and the reference list of retrieved articles were searched up to December 2016 without language restrictions. Two reviewers independently assessed eligible studies using the Cochrane Collaboration tool for assessing and reporting the risk of bias and abstracted data using predefined data fields. EVIDENCE SYNTHESIS From 468 potentially relevant studies, 36 randomized controlled trials (RCTs) including 4887 patients, published between 1982 and 2016, were included in this systematic review. The treatment effect observed indicated marginal benefit of NSAIDs over opioids in initial pain reduction at 30min (11 RCTs, n=1985, mean difference [MD] -5.58, 95% confidence interval [CI] -10.22 to -0.95; heterogeneity I2=81%). In the subgroup analyses by the route of administration, NSAIDs required fewer rescue treatments (seven RCTs, n=541, number needed to treat [NNT] 11, 95% CI 6-75) and had lower vomiting rates compared with opioids (five RCTs, n=531, NNT 5, 95% CI 4-8). Comparisons of NSAIDs with paracetamol showed no difference for both drugs at 30min (four RCTs, n=1325, MD -5.67, 95% CI -17.52 to 6.18, p=0.35; I2=89%). Patients treated with NSAIDs required fewer rescue treatments (two trials, n=1145, risk ratio 0.56, 95% CI 0.42-0.74, p<0.001; I2=0%). CONCLUSIONS NSAIDs were equivalent to opioids or paracetamol in the relief of acute renal colic pain at 30min. There was less vomiting and fewer requirements for rescue analgesia with NSAIDs compared with opioids. Patients treated with NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of a lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of ease of delivery, suggest that NSAIDs should be the preferred analgesic option for patients presenting to the emergency department with renal colic. PATIENT SUMMARY In kidney stone-related acute pain episodes in patients with adequate renal function, treatment with nonsteroidal anti-inflammatory drugs offers effective and most sustained pain relief, with fewer side effects, when compared with opioids or paracetamol.

Unexpected return visits to emergency department: A healthcare quality management challenge

ABSTRACT Objective: The aim of the study was to assess the unexpected return visits (URV) rate attributed to emergency physicians (EP) diagnostic or therapeutic errors. Methods: Retrospective review was conducted based on electronic medical records (EMR) database of an emergency department with an annual attendance of 460,000 patient visits. The EMR tracked any revisit within 48 h of discharge from ED. Two teams of three EP reviewed EMR for each identified URV independently. The cases were categorized as Category-1: URV clearly unrelated to EP quality of care; Category-2: URV attributable to EP quality of care; or Category-3: uncategorizable into either of the above. The results were presented as proportions with 95% CI for categorical outcomes and kappa (κ) testing was utilized as an indicator of the inter-group agreement. Results: Total URV was 1753 with a URV rate of 5.1% (95% CI, 4.8–5.3) of the monthly census (34,649). The n of category-2 URVs were 615 (1.7%, 95% CI 1.6–1.9%) during the study month. Out of total URVs, 575 were registered as left without being seen (LWBS) on the initial visit. None of the URV patients died within a month from index visit, and none of the LWBS were admitted to the ICU. The κ calculation for the two groups agreement was .94 (95% CI 0.93–0.96). Conclusion: We found URVs were frequently due to factors that were exceedingly unlikely due to physician care quality on the initial ED visit. Study also found that there was nearly perfect agreement between independent groups of physicians tasked to categorized URVs, supporting the use of single physician review to do the task in resource limited setting.

Inaccuracy in electronic medical record-reported wait times to initial emergency physician evaluation

ABSTRACT Objectives: There are sparse data addressing the accuracy of electronic medical records (EMRs) reported time-tophysician (tMD), a time frame between registration and initial evaluation by an emergency physician. We aimed to determine whether the EMR- reported tMDs were accurate. Methods: The study was conducted at an academic urban ED, six months after transition from paper-based charting to an EMR. The EMR-assigned tMD (tMDEMR) was defined by default as the time of tracking-board assignment of a physician to a patient. Research assistants also used stopwatches to assess actual tMD (tMDTimed). The primary study methodology was descriptive, to assess for presence and magnitude of difference between tMDTimed and tMDEMR. Results: For all 100 patients, the tMDEMR exceeded the tMDTimed; the range of differences was 2– 255 minutes and the median (IQR) was 21 minutes (10–45). The tMDEMR was longer than (i.e. overestimated) tMDTimed by at least 10 minutes in 2/3rds of cases. There was no association between the magnitude of tMDEMR overestimate of tMDTimed and ambulance arrival (p =.0219), pediatric status (p=.589), chief complaint category (p=.447), triage acuity (p=.318), or area of the ED (p=.328). Conclusions: At the study site, the EMR consistently overestimated human-timed tMD to a degree that could be judged clinically and operationally significant.

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

AIMS There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar. METHODS This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015. RESULTS There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25-0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30-6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0-1.04, p = 0.02). CONCLUSIONS North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.

Acceptability and feasibility of the standardized direct observation assessment tool in the emergency department in Qatar

Workplace-based Assessments (WBAs) are important tools designed to assess the performance of residents in a clinical setting. The Standardized Direct Observation Tool (SDOT) is a WBA tool used by emergency medicine (EM) residency programs to assess the performance of residents. The SDOT, originally designed for use in the United States (US) residency programs, was implemented in other international programs as a part of their accreditation by the Accreditation Council for Graduate Medical Education-International (ACGME-I).1 Along with the many foundational requirements, the ACGME-I sets out the six core competencies of medical knowledge, patient care, professionalism, interpersonal communication skills, practice-based learning, and system-based practice. The SDOT is designed to assess these competencies. Studies on the SDOT have focused on its reliability, but have not assessed its feasibility and acceptability to practitioner and institutions.2,3 The busy clinical practice environment of an emergency department (ED) presents numerous challenges which could adversely impact the implementation of the SDOT. The resource implications of time spent in conducting and documenting, the potential cost of the physicians’ time and other administrative variables need consideration. The EM residency program (EMRP) in Qatar is based at one of the busiest EDs in the world, with an annual attendance of over four hundred thousand patients. The SDOT was introduced to the EMRP in 2013 as a part of ACGME-I accreditation. The EMRP had a rich mix of approximately 40 residents and 100 faculty physicians drawn from international training and cultural backgrounds for those who the concept of WBA was unfamiliar. In its early phase, the implementation of the SDOT was mitigated by several feasibility and acceptability issues. Therefore, we embarked on an evaluation of SDOT use in the ED with an intention to make subsequent improvements to its implementation within the program. The aim of the paper is to explain our experiences and the lessons learned of the acceptability and feasibility of the SDOT in Qatar.

Health system response and adaptation to the largest sandstorm in the Middle East

The State of Qatar experienced a sandstorm on the night of April 1, 2015, lasting approximately 12 hours, with winds of more than 100 km/h and average particulate matter of approximately 10 μm in diameter. The emergency department (ED) of the main tertiary hospital in Qatar managed 62% of the total emergency calls and those of higher triage order. The peak load of patients during the event manifested approximately 6 hours after the onset. The Major Emergency Command Centre of the hospital ensured the department was maximally organized in terms of disaster management, and established protocols were brought into action. Multiple timely meetings were convened in efforts to effectively execute plans that included rapid emergency medical services handover time, resourcing staff, maximizing bed space, preventing dust entry in the ED, bypassing certain administrative processes, canceling day-surgeries that did not affect inpatient morbidity, and procuring additional respiratory equipment. Patients arrived mainly with exacerbations of asthma and respiratory distress, ophthalmic emergencies, and vehicular trauma; surprisingly, the incidence of pedestrian injuries did not vary. (Disaster Med Public Health Preparedness. 2017;11:227-238).

Nontuberculous mycobacterial infection presenting as empyema and life threatening pneumothorax: A challenging situation in the emergency department

Nontuberculous mycobacterial infection in an immunocompetent young patient complicated with empyema and pneumothorax is rarely reported. A 36-year-old man presented to the emergency department with a history of worsening dyspnea and pleuritic chest pain. The patient had unstable vital signs on presentation, and was referred to the resuscitation area on a monitored bed. The patient had a chest x-ray (CXR) performed on a prior occasion at a primary health clinic, revealing pneumothorax and some fluid at the left costophrenic angle. On arrival at the hospital, bedside ultrasound was performed which confirmed the diagnosis of pneumothorax. His vital signs were pulse 153, BP 88/62, RR 50 breaths per minute and his oxygen saturation on air was 92%. Tension pneumothorax was diagnosed based on clinical presentation and given vital signs. It was managed immediately with needle decompression followed by chest tube insertion. The patient improved dramatically after needle decompression with stabilization of vital signs. A CXR was repeated post-needle decompression which showed an incompletely resolved pneumothorax with an increase in the size of the effusion. Iatrogenic haemothorax was a possible explanation for this increase in effusion size. Chest tube was successfully inserted in the fourth intercostal space just anterior to the midaxillary line under full aseptic precautions. The chest tube drained 1.4 liters of blood, which on analysis showed a low pH and elevated adenosine deaminase level. Two out of three sputum samples sent from the medical ward were positive for mycobacteria other than tuberculosis as confirmed on culture. The patients symptoms improved with percutaneous tube drainage of hemopneumothorax and antituberculous medications.