Medical Specialties

Epiploic appendagitis.

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A 46-year-old man presented with left lower quadrant pain, tenderness, and rebound tenderness on examination. He was afebrile and did not have leucocytosis. The abdominal CT showed a hypodense pericolonic oval mass of 2·5 cm with adjacent fat stranding: a classic picture of epiploic appendagitis

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Epiploic appendages are roughly 50—100 pedunculated adipose structures protruding from the serosal surface of the colon from the caecum to the rectosigmoid junction. Torsion of the pedicle or central venous thrombosis could cause epiploic appendagitis, which can simulate diverticulitis, appendicitis, and cholecystitis. Fever, chills, and leucocytosis are usually absent. In addition to the CT indicating this diagnosis, a non-compressible hyperechoic mass connected to the adjacent colon at the point of maximum tenderness on ultrasonography is indicative of epiploic appendages. Epiploic appendagitis needs only conservative management and pain control; however, failure to recognise this diagnosis could lead to unnecessary intervention.

Source: Lancet

Anxiolytics in patients suffering a suspected acute coronary syndrome: Multi-centre randomised controlled trial in Emergency Medical Service..

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Abstract

BACKGROUND:

The prehospital treatment of pain and discomfort among patients who suffer from acute coronary syndrome (ACS) needs a treatment strategy which combines relief of pain with relief of anxiety.

AIM:

The aim of the present study was to evaluate the impact on pain and anxiety of the combination of an anxiolytic and an analgesic as compared with an analgesic alone in the prehospital setting of suspected ACS.

METHODS:

A multi-centre randomised controlled trial compared the combination of Midazolam (Mi)+Morphine (Mo) and Mo alone. All measures took part: Prior to randomisation, 15min thereafter and on admission to a hospital. Inclusion criteria were: 1) pain raising suspicion of ACS and 2) pain score ≥4.

PRIMARY ENDPOINT:

Pain score after 15min.

RESULTS:

In all, 890 patients were randomised to Mi+Mo and 873 to Mo alone. Pain was reduced from a median of 6 to 4 and finally to 3 in both groups. The mean dose of Mo was 5.3mg in Mi+Mo and 6.0mg in Mo alone (p<0.0001). Anxiety was reported in 66% in Mi+Mo and in 64% in Mo alone at randomisation (NS); 15min thereafter in 31% and 39% (p=0.002) and finally in 12% and 26% respectively (p<0.0001). On admission to a hospital nausea or vomiting was reported in 9% in Mi+Mo and in 13% in Mo alone (p=0.003). Drowsiness differed; 15% and 14% were drowsy in Mi+Mo versus 2% and 3% in Mo alone respectively (p<0.001).

CONCLUSION:

Despite the fact that the combination of anxiolytics and analgesics as compared with analgesics alone reduced anxiety and the requirement of Morphine in the prehospital setting of acute coronary syndrome, this strategy did not reduce patients’ estimation of pain (primary endpoint). More effective pain relief among these patients is warranted.

Source: Pubmed

 

Patients’ attitudes about the use of placebo treatments: telephone survey.

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Abstract

Objective To examine the attitudes of US patients about the use of placebo treatments in medical care.

Design One time telephone surveys.

Setting Northern California.

Participants 853 members of Kaiser Permanente Northern California, aged 18-75, who had been seen by a primary care provider for a chronic health problem at least once in the prior six months.

Results The response rate was 53.4% (853/1598) of all members who were eligible to participate, and 73.2% (853/1165) of all who could be reached by telephone. Most respondents (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to doctors’ level of certainty about the benefits and safety of the treatment, the purpose of the treatment, and the transparency with which the treatment was described to patients. Only 21.9% of respondents judged that it was never acceptable for doctors to recommend placebo treatments. Respondents valued honesty by physicians regarding the use of placebos and believed that non-transparent use could undermine the relationship between patients and physicians.

Conclusions Most patients in this survey seemed favorable to the idea of placebo treatments and valued honesty and transparency in this context, suggesting that physicians should consider engaging with patients to discuss their values and attitudes about the appropriateness of using treatments aimed at promoting placebo responses in the context of clinical decision making.

Discussion

The opinions of US patients have been missing from debates over the use of placebo treatments in clinical practice and deliberate efforts by physicians to enhance patient care by promoting placebo responses. Our data show that patients are open to the idea of placebo treatments. Most (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to the doctor’s level of certainty about the benefits of the treatment, the purpose of the treatment (for example, to address a patient’s need to receive a treatment), and the transparency with which the treatment was described to patients. Fewer than a quarter stated that it was never acceptable for doctors to recommend placebo treatments. In addition, many respondents indicated a willingness to try placebo treatments in different scenarios. This is generally compatible with trends reported in previous patient surveys in other countries regarding willingness to try placebo treatments.16 17 18 20

Our findings also underscore the importance of honesty and trust in the prescription of placebo treatments. Respondents indicated that the use of placebo treatments could have a negative impact on the doctor-patient relationship if patients learnt that a doctor had recommended a placebo to placate patient’s expectations for treatment–especially if it did not work. Respondents said that doctors should be honest about an intervention being a placebo treatment when patients ask specific questions about the treatment, and they disagreed about whether it is acceptable for physicians to call a placebo treatment “real medicine.” Interestingly, some respondents thought that doctors should not disclose that a treatment is a placebo if it is working, suggesting some support for the non-transparent use of placebo treatments, a finding not reported in previous surveys.

Although clinical practice guidelines recommend against the use of placebo treatments to mollify patients,10 most participants in this survey judged their use to be acceptable to address patients’ need to feel like they received some treatment. Patients did, however, specify limits on how far physicians should go to placate patients, with over 90% judging it inappropriate for doctors to prescribe antibiotics for a cold, even when patients ask for it. Yet recent surveys suggest that a small proportion of physicians would indeed prescribe antibiotics to some patients in this situation, and that they had done so at least once within the past year.4 21 Taken together, these findings hint at a disconnect between clinical practice guidelines, patients’ opinions, and physicians’ practices that should be further explored.

Although our data indicate a general acceptance of placebo treatments by patients, responses to different questions about the effectiveness of such treatments varied. While most thought when asked directly that placebo treatments are only effective when patients do not know they are receiving them, the responses to the more nuanced scenarios indicated a general acceptance of transparently prescribed “open” placebo treatments—both a belief that they are effective (62%) and a willingness to take them (61-65%). This discrepancy prompts questions about how well patients understand the concept of placebo treatments in general and whether providing additional detail in the scenarios adds to their understanding such that their answers to the corresponding questions are more accurate.

The study sample was representative of the population of Northern California but may not be representative of US patients in general. Our sample was more highly educated (≥44% college graduates) than the general population, had health insurance coverage through Kaiser Permanente Northern California, and had seen a physician within the past six months for a chronic medical condition. Although we constructed our definition of placebo treatments based on feedback from focus groups and pretest interviews, respondents may none the less have variable or limited understandings of the concepts of the placebo effect and placebo treatments. This is perhaps not surprising, given the variable understandings of these concepts among the placebo research community.5In view of the widespread variability in definitions and conceptions of placebo in the literature, we endeavored to employ a pragmatic definition of the placebo effect in our questionnaire that would be useful in the context of a patient survey. While there may be some vagueness and ambiguity in the concept of placebo treatments, the pattern of survey responses and our experience in exploring placebo treatments with focus groups indicate that patients are able to understand the difference between treatments that work on the basis of their inherent pharmacologic properties and those that may produce benefit primarily by means of positive expectations. We observed some variability in answers to analogous questions that were asked in different ways (for example, directly versus in contextualized scenarios), and it is difficult to know which formulation of the questions is likely to reflect attitudes more accurately. Furthermore, the survey captures patients’ opinions about a series of plausible hypothetical scenarios rather than actual behaviors and experiences.

Researchers of one study have argued that models of shared decision making need to include conversations between physicians and patients about the role of the placebo effect in clinical care,22 and clinical practice guidelines leave the door open for the use of placebo treatments when presented to patients transparently.10 Researchers of another study further suggest that attitudinal data can help develop and foster the use of effective and non-deceptive placebo treatment techniques.20 That many patients in this survey seem favorable to the idea of placebo treatments suggests that physicians should consider engaging with patients to discuss their values and attitudes concerning the appropriateness of using placebos in the context of clinical decision making. Such conversations could allow physicians to determine which patients might be open to the use of placebo treatments and could help physicians tailor their description of placebo treatments according to patients’ preferences and level of understanding. Further research is needed to determine how physicians can optimally promote placebo responses in clinical practice and to guide the appropriate use of placebo treatments.

What is already known on this topic

  • The use of placebo treatments by physicians in clinical practice has been documented in recent surveys
  • Attitudinal surveys in other countries suggest that patients are open to the use of placebo treatments in specific circumstances
  • This study provides data on US patients’ attitudes about the use of placebo treatments in clinical practice
  • These data suggest that many patients are favorable to the idea of placebo treatments

What this study adds

 

Source: BMJ

 

Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial..

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Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain.

METHODS: This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS
RESULTS: Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol.
CONCLUSIONS: This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting.

Source: Acad Emerg Med.

 

Autologous and Allogeneic Stem-Cell Transplantation for Transformed Follicular Lymphoma: A Report of the Canadian Blood and Marrow Transplant Group.

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Abstract

Purpose To determine whether autologous (auto) or allogeneic (allo) stem-cell transplantation (SCT) improves outcome in patients with transformed follicular lymphoma compared with rituximab-containing chemotherapy alone.

Patients and Methods This was a multicenter cohort study of patients with follicular lymphoma and subsequent biopsy-proven aggressive histology transformation. Patient, treatment, and outcome data were collected from each transplantation center and combined for analysis. A separate control group was composed of patients with transformation treated with rituximab-containing chemotherapy but not SCT. The primary end point was overall survival (OS) after transformation.

Results One hundred seventy-two patients were identified: 22 (13%) treated with alloSCT, 97 (56%) with autoSCT, and 53 (31%) with rituximab-containing chemotherapy. Five-year OS after transformation was 46% for patients treated with alloSCT, 65% with autoSCT, and 61% with rituximab-containing chemotherapy (P = .24). Five-year progression-free survival (PFS) after transformation was 46% for those treated with alloSCT, 55% with autoSCT, and 40% with rituximab-containing chemotherapy (P = .12). In multivariate analysis, patients treated with autoSCT had improved OS compared with those who received rituximab-containing chemotherapy (hazard ratio [HR], 0.13; 95% CI, 0.05 to 0.34; P < .001). On the other hand, there was no OS difference between those treated with alloSCT and rituximab-containing chemotherapy (HR, 0.44; 95% CI, 0.16 to 1.24; P = .12). OS and PFS after SCT were similar between those treated with autoSCT and alloSCT. Five-year transplantation-related mortality was 23% for those treated with alloSCT and 5% for autoSCT.

Conclusion Patients undergoing autoSCT had better outcomes than those treated with rituximab-containing chemotherapy alone. AlloSCT did not improve outcome compared with rituximab-containing chemotherapy and was associated with clinically significant toxicity.

Source: JCO

 

 

Comparing Scoring Systems to Predict Outcomes in Upper Gastrointestinal Bleeding.

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AIMS65 better predicted mortality and Glasgow-Blatchford better predicted the need for transfusion, but both scoring systems can be helpful in identifying high-risk patients with UGIB.

Investigators recently derived and validated AIMS65 — a new scoring system to predict outcomes for patients with acute upper gastrointestinal bleeding (UGIB) — using a large population of patients from 187 U.S. hospitals (JW Gastroenterol Dec 9 2011).

Now, the researchers have revalidated AIMS65 using data on 278 UGIB patients from a tertiary-care hospital who had a higher severity of disease than that observed in the original population. They also compared the performance of AIMS65 with that of the Glasgow-Blatchford system (GBS; JW Gastroenterol Jul 29 2011) in predicting the primary outcome of inpatient mortality and several secondary outcomes: the composite endpoint of mortality, rebleeding, and endoscopic, radiologic, or surgical intervention; transfusion requirement; intensive care unit admission; rebleeding; length of hospital stay; and the timing of endoscopy.

Overall inpatient mortality was 6.5%. The composite endpoint was seen in 35%. AIMS65 was superior to GBS for predicting mortality (area under the receiver operating curve, 0.93 vs. 0.68; P<0.001), but GBS was superior for predicting the need for transfusion (AUROC, 0.85 vs. 0.65; P<0.01). The two systems were similarly accurate for predicting and other secondary outcomes. GBS values of 10 and 12 maximized the accuracy for predicting mortality and rebleeding, respectively. AIMS65 values of ≥2 maximized the accuracy for predicting both outcomes.

Comment: Results of this study from a tertiary-care hospital with expertise in treating patients with upper gastrointestinal bleeding might not be generalizable to other settings. What seems clear from the evidence regarding UGIB scoring systems is that shock, advanced age, and comorbid conditions used in any scoring system can identify patients at high risk for adverse outcomes. However, the issue is not about which system is better; rather, it is about ensuring that some system is used to identify high-risk patients, who will benefit from urgent endoscopy, endoscopic therapy, and more aggressive care, and low-risk patients, who can be treated as outpatients.

Source: Journal Watch Gastroenterology

 

Symptom-Triggered Dosing Is Better Than Fixed Dosing for Treating Alcohol Withdrawal.

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Symptom-triggered dosing leads to lower total benzodiazepine dose and shorter hospital stay than fixed-tapered dosing.

In a retrospective chart review, researchers compared outcomes between 49 patients who received symptom-triggered benzodiazepine dosing and 50 who received standard fixed-tapered dosing for treatment of alcohol withdrawal in an emergency department (ED) clinical decision unit in Ireland during a 2-year period. Patients treated with the symptom-triggered dose regimen were assessed at 90-minute intervals using the Clinical Institute Withdrawal Assessment for Alcohol scoring tool and were given a dose of a benzodiazepine if the score indicated need. Patients treated with the standard regimen received tapered doses of benzodiazepine over 5 to 7 days. Benzodiazepine doses were reported in diazepam dosing equivalents, with 25 mg of chlordiazepoxide considered equivalent to 10 mg of diazepam.

The two groups were comparable in demographics, alcohol use, and reasons for coming to the ED. The symptom-triggered dosing group had a shorter median hospital stay (2 days vs. 3 days) and received a lower median cumulative benzodiazepine dose (equivalent to 80 mg vs. 170 mg of diazepam).

Comment: Many emergency physicians have already adopted the practice of treating alcohol withdrawal based on symptoms with the goal of the patient being calm but able to be aroused. This study suggests that this approach may not only reduce the amount of benzodiazepine needed, but it may also shorten hospital stay.

Source: Journal Watch Emergency Medicine

 

Topical pregabalin and diclofenac for the treatment of neuropathic orofacial pain in rats.

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Objective

The aim of this study was to evaluate the effect of topical treatment with pregabalin and diclofenac on neuropathic orofacial pain induced by infraorbital nerve injury in the rat.

Study Design

Sixty-four Sprague-Dawley rats underwent infraorbital nerve injury. Seven days after surgery, pain was verified and the rats randomly assigned to topical or systemic treatment with pregabalin or diclofenac, or to no treatment. Pain intensity and motor coordination were assessed at baseline, after surgery, and daily after treatment for 4 consecutive days. Medication plasma levels were assessed at the end of the study.

Results

Topical treatment with 10% pregabalin or 5% diclofenac reduced the pain significantly. A significant decrease in motor coordination was found in the systemic pregabalin. The medications’ plasma levels were significantly higher in the systemic treatment compared with the topical.

Conclusions

Topical treatment with pregabalin or diclofenac can reduce neuropathic orofacial pain induced by nerve injury.

Source: Science Direct.

 

What’s the Best Route for Subacromial Injections?

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In a randomized trial, lateral and anterior routes were better than posterior.

The subacromial bursa can be injected using anterior, lateral, or posterior approaches. To determine which approach is best, U.S. researchers performed a study in which each of 75 patients with rotator cuff syndrome was randomized to one of these three approaches. A single orthopedist (who traditionally had used the posterior approach) performed all injections, which contained corticosteroid, local anesthetic, and radiopaque contrast medium. After the injections, shoulders were x-rayed to determine whether the contrast was within the bursa.

The proportion of patients whose injections were intrabursal was significantly greater with the lateral and anterior approaches (92% and 84%, respectively) than with the posterior approach (56%). The lower accuracy of the posterior approach was especially striking in women. Pain relief at 1 hour was significantly greater in patients whose injections were intrabursal than in those whose injections were extrabursal.

Comment: A limitation of this study is that a single physician did the injections; nevertheless, the authors discuss anatomic reasons why the posterior route might be the least accurate. I’ve always done subacromial injections via the lateral approach; this study vindicates that practice.

Source: Journal Watch General Medicine