Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis.

A short cut review was carried out to establish whether there is any evidence that for the use of corticosteroids in the treatment of costochondritis. No papers were found using the reported search. The clinical bottom line is that further research is needed in this area.

A retrospective analysis of cervical spine radiography in a specialist trauma unit for head injury.

OBJECTIVES: The performance of an adequate and complete series of cervical radiographs in the trauma patient is essential in order to ensure safe trauma management. Eastern Association for the Surgery of Trauma (EAST) has produced widely recognised guidelines with which trauma units should comply. The aim of the study is to ascertain the adequacy of cervical spine imaging of trauma patients in a specialist trauma unit (head injury) using EAST guidelines as gold standard. An additional assessment of institutional reporting accuracy is conducted. METHODS: Data were examined from 81 consecutive trauma patients requiring cervical spine radiography. EAST guidelines were applied retrospectively to this cohort in order to define guideline compliance. An additional cohort assessment was conducted addressing the accuracy and adequacy of the formal institutional reports associated with these radiographs. RESULTS: 99% of patients undergoing a full cervical trauma series had at least one inadequate initial image. Of these, 85% had at least one inadequate lateral or peg view (of which 26% did not have repeat radiographs performed). Over one-third of all trauma patients left the emergency department with inadequate cervical spine imaging (incomplete cervical spine series or inadequate films). From the institutional reporting perspective, only 27% of all inadequate initial and repeat lateral or peg views were subsequently explicitly reported as being inadequate. DISCUSSION: These findings call into question current practice. Clearly, multiple confounders exist in the context of process variability in a heterogeneous population such as that attending an emergency department. This study offer solutions to address this problem.

N-acylethanolamine regulation of TLR3-induced hyperthermia and neuroinflammatory gene expression: A role for PPARα.

Increasing evidence suggests that SARS-CoV-2, the virus responsible for the COVID-19 pandemic, is associated with increased risk of developing neurological or psychiatric conditions such as depression, anxiety or dementia. While the precise mechanism underlying this association is unknown, aberrant activation of toll-like receptor (TLR)3, a viral recognizing pattern recognition receptor, may play a key role. Synthetic cannabinoids and enhancing cannabinoid tone via inhibition of fatty acid amide hydrolase (FAAH) has been demonstrated to modulate TLR3-induced neuroimmune responses and associated sickness behaviour. However, the role of individual FAAH substrates, and the receptor mechanisms mediating these effects, are unknown. The present study examined the effects of intracerebral or systemic administration of the FAAH substrates N-oleoylethanolamide (OEA), N-palmitoylethanolamide (PEA) or the anandamide (AEA) analogue meth-AEA on hyperthermia and hypothalamic inflammatory gene expression following administration of the TLR3 agonist, and viral mimetic, poly I:C. The data demonstrate that meth-AEA does not alter TLR3-induced hyperthermia or hypothalamic inflammatory gene expression. In comparison, OEA and PEA attenuated the TLR3-induced hyperthermia, although only OEA attenuated the expression of hyperthermia-related genes (IL-1ß, iNOS, COX2 and m-PGES) in the hypothalamus. OEA, but not PEA, attenuated TLR3-induced increases in the expression of all IRF- and NFκB-related genes examined in the hypothalamus, but not in the spleen. Antagonism of PPARα prevented the OEA-induced attenuation of IRF- and NFκB-related genes in the hypothalamus following TLR3 activation but did not significantly alter temperature. PPARα agonism did not alter TLR3-induced hyperthermia or hypothalamic inflammatory gene expression. These data indicate that OEA may be the primary FAAH substrate that modulates TLR3-induced neuroinflammation and hyperthermia, effects partially mediated by PPARα.

An implementation strategy for a multicenter pediatric rapid response system in Ontario.

A rapid response system using a medical emergency team was implemented across four pediatric hospitals in Ontario, Canada, in a social marketing approach.

CT pulmonary angiogram compared with ventilation-perfusion scan for the diagnosis of pulmonary embolism in patients with cardiorespiratory disease.

A short cut review was carried out to establish whether VQ scanning has better utility than CT in investigating possible pulmonary embolus in patients with chronic respiratory disease. A total of 239 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. A clinical bottom line is stated.

Best evidence topic report. Abdominal radiography in "body packers".

A short cut review was carried out to establish whether an abdominal radiograph has clinical utility in the management of patients who claim to have swallowed drug filled packages. Twelve papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Best evidence topic report. Prophylactic antibiotics for subungual haematoma.

A short cut review was carried out to establish whether antibiotic prophylaxis is indicated after trephining of a subungual haematoma. Two papers were found using the reported search, of which neither presented any evidence to answer the clinical question. It is concluded that there is no evidence available to answer this question. Further research is needed.

Best evidence topic report. Nebulised magnesium in asthma.

A short cut review was carried out to establish whether the addition of nebulised magnesium sulphate to beta agonist therapy improves outcome in acute asthma. Altogether 69 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Undiagnosed intussusception in an adult 'small and large bowel'.

Two cases of adult intussusception (large bowel and small bowel) are presented highlighting the challenges posed by their often innocuous presentation in addition to significant morbidity resulting from delayed diagnosis.