Wahid Bouida

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Paracetamol vs piroxicam to relieve pain in renal colic. Results of a randomized controlled trial.

PURPOSE We tested whether paracetamol could improve pain relief in patients visiting the emergency department with acute renal colic as compared to piroxicam, a nonsteroidal anti-inflammatory drug (NSAID). MATERIALS AND METHODS Patients with a diagnosis of acute renal colic were prospectively randomized to receive either intravenous paracetamol (1 g) or intramuscular piroxicam (20 mg). We monitored patients for visual analog scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 90 minutes. We recorded admission requirement and new visit for renal colic at 72 hours. The primary end point was pain relief at 90 minutes, defined as a decrease of 50% or more as compared to the initial VAS. The secondary objectives were comparison of the 2 groups for VAS at any time points and the occurrence of adverse events. RESULTS Of the 226 eligible patients, 100 entered the study. Fifty patients received paracetamol and 50 received NSAID. Pain relief at 90 minutes was obtained in 40 patients receiving paracetamol (80%) and 24 (48%) receiving NSAID (P = .002). Visual analog scale was lower in the paracetamol group since 45 minutes. Only 2 adverse events were observed. CONCLUSION A single therapy with intravenous paracetamol more efficiently relieved pain in acute renal colic than did intramuscular piroxicam.

Accuracy of Two Scores in the Diagnosis of Stroke Subtype in a Multicenter Cohort Study

STUDY OBJECTIVE The distinction between hemorrhagic and ischemic stroke has critical implications for management. For that purpose, clinical scores have been proposed to be used in areas with limited health care resources where brain computed tomographic (CT) scan is not readily available. We conducted this study to evaluate the predictive value of the Allen and Siriraj scores in the differential diagnosis of stroke subtypes. METHODS We prospectively collected data for 4 years on the clinical characteristics of patients with stroke in a multicenter study. For all patients, we calculated the Allen and the Siriraj scores and we assessed their accuracy in predicting stroke subtypes with receiver operating characteristics (ROC) curves. RESULTS We assessed 1,023 patients. Of these, 82.7% (n=846) had ischemic stroke. The area under the ROC curve was higher for Siriraj score compared with the Allen score (0.780 versus 0.702; P=.04). Using the original cutoff points, Siriraj score has a sensitivity for the diagnosis of hemorrhage of 60% and a specificity of 95%; the corresponding values for the Allen score are 55% and 70%, respectively. The negative predictive value was higher for Siriraj score compared to the Allen score (90% versus 80%). The diagnosis of stroke subtype was best predicted at Siriraj score less than -4. CONCLUSION Siriraj score is a valid and useful tool for predicting stroke subtype in a clinical setting in which financial constraints make systematic brain CT scan unfeasible.

Severe ranitidine-induced anaphylaxis: a case report and literature review

What is known and Objective:  Ranitidine is a generally well‐tolerated drug, and serious side effects are rare. However, ranitidine‐induced anaphylaxis has been reported on rare occasions. We report on such a case and review other cases reported in the literature.

Phloroglucinol as an adjuvant analgesic to treat renal colic

PURPOSE We tested whether the addition of phloroglucinol to piroxicam could improve pain relief in patients with acute renal colic visiting the emergency department. MATERIALS AND METHODS Patients with a diagnosis of acute renal colic were prospectively randomized to receive intravenous phloroglucinol (200 mg) or placebo combined with intramuscular piroxicam (20 mg). We monitored the visual analogic scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 1 hour. We recorded admission requirement and new visit at 72 hours for renal colic. The primary end point was to assess pain relief at 1 hour, defined as a decrease of 50% or more as compared with the initial VAS. The secondary objectives were to compare the 2 groups for VAS at any time points, the need for rescue therapy, and the occurrence of adverse events. RESULTS Of the 309 eligible patients, 253 entered the study. A total of 126 patients received phloroglucinol and 127 patients received placebo. Pain relief at 1 hour was obtained in 89 patients (71%) receiving phloroglucinol and 89 patients (70%) receiving placebo (P = .89). There were no differences in VAS between the 2 groups at any time points. Rescue therapy was required in 37 patients (29%) receiving phloroglucinol and 38 patients (30%) receiving placebo (P = .51). Number of adverse events was similar with phloroglucinol and placebo: 20 (16%) and 16 (13%), respectively (P = .44). CONCLUSIONS There was no evidence that the addition of phloroglucinol improved the efficiency of piroxicam to relieve pain in acute renal colic.

Acupuncture vs intravenous morphine in the management of acute pain in the ED

BACKGROUND Acupuncture is one of the oldest techniques to treat pain and is commonly used for a large number of indications. However, there is no sufficient evidence to support its application in acute medical settings. METHODS This was a prospective, randomized trial of acupuncture vs morphine to treat ED patients with acute onset moderate to severe pain. Primary outcome consists of the degree of pain relief with significant pain reduction defined as a pain score reduction ≥50% of its initial value. We also analyzed the pain reduction time and the occurrence of short-term adverse effects. We included in the protocol 300 patients with acute pain: 150 in each group. RESULTS Success rate was significantly different between the 2 groups (92% in the acupuncture group vs 78% in the morphine group P<.001). Resolution time was 16±8 minutes in the acupuncture group vs 28±14 minutes in the morphine group (P<.005). Overall, 89 patients (29.6%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group (P<.001). No major adverse effects were recorded during the study protocol. In patients with acute pain presenting to the ED, acupuncture was associated with more effective and faster analgesia with better tolerance. CONCLUSION This article provides an update on one of the oldest pain relief techniques (acupuncture) that could find a central place in the management of acute care settings. This should be considered especially in todays increasingly complicated and polymedicated patients to avoid adverse drug reactions.

Value of anatomic and physiologic scoring systems in outcome prediction of trauma patients.

Objective The goal of this study was to compare the prediction performance of two anatomic scales, the Injury Severity Scale (ISS) and the New Injury Severity Scale (NISS), with two physiologic scales, the Revised Trauma Scale (RTS) and the Simplified Acute Physiology Scale II (SAPS II), in trauma patients. Design Prospective study carried out over a 16-month period. Setting Emergency department of a teaching hospital. Patients Hospitalized victims of trauma up to 14 years of age. Interventions The primary endpoint was the survival status at hospital discharge; the secondary outcome was need for ICU admission. Model discrimination was evaluated by the area under the receiver-operating characteristic curve and model calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit statistic. Measurements and main results A total of 1136 patients, with an average age of 37.6 years, fulfilled the inclusion criteria. The mortality rate was 4.5%. The combined rate of hospital death and ICU admission was 17.3%. The ISS and the NISS showed excellent discriminative power for mortality prediction (AUC 0.94 and 0.93, respectively) and ICU admission decision (0.91 and 0.89, respectively), and a good calibration. The SAPS II and the RTS showed lower discriminative power. Combining ISS or NISS with SAPS II did not improve significantly the predictive performance of each scale alone. Conclusion Both ISS and NISS showed better predictive severity performance compared with RTS and SAPS II in trauma patients. The combination of anatomic scales with physiologic ones did not improve the prediction performance of each scale considered alone.

A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin

Background Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy. Objectives To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin. Methods In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve. Results ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%). Conclusions The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study.

Acute coronary syndrome among patients with chest pain: Prevalence, incidence and risk factors

BACKGROUND Urbanization and adoption of new diet and lifestyles had increased the cardiovascular risk factor (CVRF) rate and therefore, acute coronary syndrome (ACS) in developing countries such as Tunisia. We aimed at determining ACS prevalence among a sample of Tunisian patients with chest pain, at establishing the standardized incidence rate (SIR) of ACS, and at quantifying the relationship between ASC and CVRF in this population. METHODS We studied 3158 patients admitted to a chest pain unit for non-traumatic chest pain collected in Emergency Data from January 2012 to December 2014. For all patients, the data were collected using a standardized form. We performed univariate rather than multivariate logistic regression analyses to identify age and gender-related CVRF in ACS. Linear interpolation was used for curve estimation. RESULTS 707 (22.3%) chest pain patients were classified as ACS. The age-SIR per 10(-5)personyear (PY) was 85.7; it was 112.6 in men and 45.3 in women. Eighty one percent of patient with ACS cumulated 2 CVRF and more. The highest odds ratio were 2.00 (95% CI 1.64-2.44) for diabetes and 1.81 (95% CI 1.50-2.18) for active smoking. ACS in elderly patients was significantly associated with active smoking (OR: 2.36), diabetes (OR: 1.72) and personal ACS history (OR: 1.71). We found a significant and very high linear relation between the number of CVRF and ACS odds ratio (R(2)=0.958). CONCLUSION Our results showed that the incidence of ACS in a Tunisian population is not very different from what is observed in developed countries; with a close relation with CVRF especially diabetes and smoking.

Magnesium sulfate versus ipratropium bromide in chronic obstructive pulmonary disease exacerbation: a randomized trial.

Treatment with short-acting &bgr;2-agonists for exacerbations of chronic obstructive pulmonary disease (COPD) results in clinical improvement. It has not been established whether combining short-acting &bgr;2-agonists to other bronchodilators is more effective than &bgr;2-agonists alone. We conducted a study in patients presenting to the emergency department with exacerbation of COPD. They were randomized to receive nebulized ipratropium bromide (IB group; n = 62) or combined nebulized and intravenous bolus of magnesium sulfate (MgSO4 group; n = 62). All nebulized drugs were administered at 30-minute intervals for 2 hours. Primary outcome included hospital admission, endotracheal intubation, and hospital death rates. Secondary outcome measures were improvement in peak expiratory flow, dyspnea score, and arterial blood gas changes within the first 3 hours. There were no significant differences in primary outcome between MgSO4 and IB groups. Patients given IB average 32 L greater improvement in peak expiratory flow rate compared with magnesium sulfate (95% confidence interval, 19–43 L) at 180 minutes. Simultaneously, there was a significant reduction in PaCO2 compared with baseline values in IB group but not in MgSO4 group. There was a statistically nonsignificant trend toward a decrease in dyspnea score in both groups although adverse events were similar. Although the improvement in peak expiratory flow rate and arterial blood gas favored nebulized IB over magnesium sulfate, there was a nonsignificant difference between both drugs with regard to hospital admission, intubation, and hospital death rates in patients with COPD treated in the emergency department for acute exacerbation.