CAEP/ACMU 2000 Scientific Abstracts: 15-17

CAEP Abstracts

CJEM 2001;2(3):173169-187

015 Does More Accurate Testing Result in Patient Benefit in the Investigation of Suspected Acute Urolithiasis?
Worster A. McMaster University, Hamilton, Ont.

OBJECTIVES: To determine if the replacement of intravenous pyelography (IVP) with helical CT scanning (CT) for the investigation of flank pain results in reduction of hospital admission and surgical rates or reduced length of stay (LOS) in the emergency department (ED) for patients. STUDY DESIGN: Retrospective, before and after, cohort study.
METHODS: A review of the ED admissions of all patients with a discharge diagnosis of acute urolithiasis/renal colic for a 5-month period prior to the implementation of CT in July 1999 as the primary investigation for acute urolithiasis and for a 5-month period after implementation.
RESULTS: A review of 230 patient charts revealed 121 patients who underwent either of the investigations prior to discharge. The surgical rates for the IVP (n = 60) and CT (n = 61) groups were 5 and 9 respectively (p < 0.27) and the admission rates were 12 and 13 respectively (p < 0.86). The median times for LOS in the ED for the CT group (n = 48) and IVP group (n = 47) were compared and revealed the IVP group had a minimally longer stay in the ED (4.77 hours) than the CT group (4.655 hours). Point estimate was 0.235 (95% CI ­1.000 hours to 1.490 hours; Mann­Whitney U test (Wilcoxon Rank Test) W = 2302.5; p < 0.716).
CONCLUSION: Despite being reported as more accurate for the investigation of suspected acute urolithiasis, noncontrast helical CT of the abdomen has not resulted in reduced admission or surgical rates for patients. The suggestion that CT can possibly reduce ED LOS for patients cannot be supported by these findings.
Key words: renal colic, diagnosis, radiography, computed tomography

016 Application of the NEXUS Low-Risk Criteria for Cervical Spine Radiography in Canadian Emergency Departments.
Stiell I, McKnight D, Wells G, Lesiuk H, Vandemheen K, Clement C, Worthington J, Schull M, Reardon M, Morrison L, MacPhail I, Greenberg G, Eisenhauer M, Dreyer J, Cass D, Brison R. Clinical Epidemiology Unit, University of Ottawa, Ottawa.

OBJECTIVES: To evaluate the accuracy, reliability, and potential impact of the NEXUS Low-Risk Criteria for cervical spine radiography, when applied in Canadian emergency departments.
METHODS: This prospective cohort study was conducted as a component of the Canadian C-Spine/CT Head (CCC) Study in 10 Canadian EDs and involved alert and stable adult trauma patients. Physicians completed a 20-item data form for each patient and performed interobserver assessments when feasible. The prospective assessments included the five individual NEXUS Criteria but not an explicit interpretation of the overall need for radiography according to the criteria. Patients underwent radiography, CT, and follow-up to determine clinically important cervical spine injury, the previously validated outcome measurement. Analyses included sensitivity and specificity with 95% CIs, kappa coefficient, and potential radiography rates.
RESULTS: Among 8,933 patients, the mean age was 36.8 (range 16­97), 51.6% were male, and 148 (1.7%) had an important C-spine injury (fracture 140, dislocation 23, ligamentous instability 9). Kappa values for the NEXUS Criteria were: a) posterior midline cervical spine tenderness 0.78 (95% CI 0.67­0.89), b) focal neurological deficit 0.93 (0.79­1.0), c) altered level of alertness N/A (exclusion criterion for study), d) intoxication 0.23 (­0.17­0.63), e) distracting painful injury 0.41 (0.16­0.66). The combined NEXUS Criteria identified important C-spine injury with a sensitivity of 91.2% (95% CI 85%­95%), a specificity of 37.8% (37%­39%), and a potential 8% increase in C-spine radiography rates to 62.6%. Of 13 patients with important injuries not identified, 1 was treated with internal fixation and 4 with a halo.
CONCLUSIONS: The NEXUS Low-Risk Criteria should be further explicitly and prospectively evaluated for accuracy, reliability, and potential impact prior to widespread clinical use.
Key words: cervical spine, radiography, clinical prediction rule, utilization

017 The Efficacy of Inhaled Corticosteroids in the Treatment of Acute Asthma: Treatment Following Emergency Department Discharge.
Edmonds ML, Camargo CA Jr, Brenner BE, Rowe BH. University of Alberta, Edmonton, Alta.

OBJECTIVES: Using oral corticosteroids at discharge for acute asthma is now standard practice; however, the benefit of treatment with inhaled corticosteroid (ICS) in the acute setting is unclear. The objective of this systematic review was to determine the effect of ICS on outcomes in the treatment of acute asthma following discharge (D/C) from the emergency department (ED).
METHODS: Randomized controlled trials (RCTs) were identified using the Cochrane Collaboration's Airways Review Group database (using MEDLINE, EMBASE and CINAHL standardized searches), hand searching, bibliographies, pharmaceutical company and author contact. Studies in which an ICS was compared to placebo or any CS after ED discharge (D/C) were considered. Relevance, inclusion and study quality were assessed independently by two reviewers.
RESULTS: 10 RCTs were selected for inclusion, from 352 articles identified in the computerized ARG register search. Three RCTs (n = 909 pts) compared ICS + CS vs. oral CS alone after ED D/C. Relapses were reduced, but not significantly, with the addition of ICS therapy (OR: 0.68; 95% CI: 0.46, 1.02). No differences were demonstrated between the two groups for relapses causing admission, quality of life, symptom scores, or side effects. Seven RCTs (n = 1204 pts) compared high-dose ICS therapy alone vs. oral CS alone after D/C. There were no significant differences between ICS and CS monotherapy for relapse rates (OR: 1.00; 95% CI: 0.66 to 1.52) or for secondary outcomes such as ß-agonist use, symptoms, and side effects. However, short follow-up and the inclusion of mild asthmatics in these latter RCTs complicates interpretation.
CONCLUSIONS: The literature on the use of ICS after discharged from the ED with acute asthma, either alone or in combination with CS, remains unclear. Further research is needed to clarify how ICS therapy should be employed following ED care.
Key words: asthma, corticosteroids