Prednisone for emergency department low back pain: a randomized controlled trial.

BACKGROUND: Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE: To determine if a short course of oral corticosteroids benefits LBP ED patients. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS: 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS: The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION: We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.

Monthly variations in the diagnosis of carbon monoxide exposures in the emergency department.

INTRODUCTION: Carbon monoxide (CO) poisoning is the leading cause of toxicological deaths worldwide. Symptoms may be subtle, contributing to its frequent delay in diagnosis. If a seasonal variation occurs, a heightened awareness during peak time may lead to improved recognition and diagnosis. STUDY OBJECTIVES: To determine whether monthly variations in CO poisoning occur in emergency departments. DESIGN: A multicenter retrospective emergency department (ED) cohort. STUDY SETTING: 23 New Jersey and New York emergency departments. SUBJECTS: Consecutive patients with the ICD-9 primary diagnosis of"toxic effects CO" from January 1, 2000 to October 31, 2006. STATISTICS: We tested for significant differences using chi-square and Student's t-test with alpha set at 0.5. RESULTS: There were 1,006 patients who were diagnosed in the ED with CO toxicity (0.024% of all ED patients). Mean age was 30 years (SD +/- 20), 54% were female, and Caucasians compromised 54% of participants. Thirty-nine percent of documented patients arrived via ambulance and 90% were subsequently discharged. Incidence of CO visits peaked in December (0.036%) and were least likely in May (0.011%). Mean monthly CO visits were statistically increased during October (p = < 0.0001), November (p = 0.008), December (< 0.0001), January (p = 0.01), and March (p = 0.04). Statistically fewer case of CO exposure were diagnosed in May (p = 0.0003), June (p = 0.005), August (p = < 0.0001), and September (p = 0.002).

Behavioral risk factor and preventive health care practice survey of immigrants in the emergency department.

OBJECTIVE: To compare the demographic profiles, behavioral risk factors, and preventive health care practices of adult immigrant and non-immigrant patients while considering the effects of various socioeconomic variables. METHODS: This was a prospective survey administered at a large urban emergency department in New York City. Study subjects were adult immigrant patients presenting in an eight-week period in 1998. One non-immigrant control patient was recruited concurrently with every two immigrant patients. Differences between immigrants and non-immigrants were evaluated using the chi-square test. Multivariate logistic regression models were used to adjust for confounding variables. RESULTS: Eight hundred sixty-nine immigrant patients from 80 countries and 354 non-immigrant patients completed surveys. Immigrants were more likely not to have reached high school (28.9% vs 8.5%; p < 0.001), to have annual family incomes less than $20,000 (73.8% vs 64.5%; p < 0.01), and to have no health coverage (51.7% vs 30.8%; p < 0.001). Immigrant women were more likely never to have had a Papanicolaou test (16.1% vs 1.4%; OR 11.24, 95% CI = 2.70 to 46.8) and never to have performed a self-breast examination (20.8% vs 7.5%; OR 2.03, 95% CI = 1.29 to 3.20). Immigrants were more likely not to use condoms (63.4% vs 42.8%; OR 1.61, 95% CI = 1.20 to 2.15) and never to have visited a dentist (21.2% vs 7.8; OR 2.54, 95% CI = 1.60 to 4.04). Immigrants were more likely never to have received a purified protein derivative (PPD) skin test (30.3% vs 9.1%; OR 3.85, 95% CI = 2.56 to 5.80) and never to have received a tetanus immunization (48.1% vs 13.5%; OR 3.09, 95% CI = 2.17 to 4.42). These differences were independent of age, gender, marital status, employment, education, income, and health insurance status. When analyzing the immigrant group alone, region of origin, length of time in the United States, and English ability were significant independent predictors of higher-risk behavioral profiles and poor preventive health care practices. CONCLUSIONS: Differences exist between the socioeconomic profiles, behavioral risk profiles, and preventive health care practices of immigrant and non-immigrant patients presenting to a large inner-city municipal emergency department. Different populations within a heterogeneous group of immigrants have distinct health risks and public health needs.

Complications of ultrarapid opioid detoxification with subcutaneous naltrexone pellets.

UNLABELLED: Rapid and ultrarapid opioid detoxification (ROD and UROD) centers promise quick, painless, same-day detoxification treatment for patients with opioid addiction. The goal of ROD and UROD is to provide a rapid transition from opioid dependency to oral naltrexone therapy. The patient is given general anesthesia and high-dose opioid antagonists. This induces a severe withdrawal but spares the patient the experience. In theory, the process is complete within four to five hours. The patient awakens without opioid dependency and is started on oral naltrexone. Any subsequent, persistent withdrawal symptoms are treated symptomatically. A novel, unapproved approach is to compound a pellet of naltrexone and implant it in the subcutaneous tissue. In theory, this should result in continuous therapeutic levels for this drug, and avoid issues with noncompliance. CASE SERIES: This article reports six cases of complications from the same detoxification center that performed UROD with naltrexone pellet implantation, including pulmonary edema, prolonged withdrawal, drug toxicity, withdrawal from cross-addiction to alcohol and benzodiazepines, variceal rupture, aspiration pneumonia, and death. CONCLUSIONS: The risks of this procedure are great and further studies should assess its safety and the novel use of naltrexone.

Antiepileptic drugs: the old and the new.

During the past decade several new antiepileptic drugs (AEDs) have become available, including new formulations of some of the older medications. Understanding the pharmacokinetics of the new AEDs is important because they are primarily used for adjunctive therapy and interactions with other medications can result in significant toxicities. The new-generation AEDs do not cause serious morbidity in overdose, and treatment is primarily supportive. Specific medications should be chosen based on the patient's history and presentation.

Cocaine-associated seizures and incidence of status epilepticus.

OBJECTIVES: Acute complications from cocaine abuse are commonly treated in the emergency department (ED); one of the most consequential is status epilepticus. The incidence of this complication is not clearly defined in the prior literature on cocaine-associated sequelae. We evaluated the incidence of status epilepticus in patients with seizures secondary to suspected cocaine use. METHODS: We performed a retrospective multi-center study of patients with seizures resulting from cocaine use. We identified study subjects at 15 hospitals by record review and conducted a computer-assisted records search to identify patients with seizures for each institution over a four-year period. We selected subjects from this group on the basis of cocaine use and determined the occurrence of status epilepticus among them. Data were collected on each subject using a standardized data collection form. RESULTS: We evaluated 43 patients in the ED for cocaine-associated seizures. Their age range was 17 to 54, with a mean age was 31 years; 53% were male. Of 43 patients, 42 experienced a single tonic-clonic seizure and one developed status epilepticus. All patients had either a history of cocaine use or positive urine drug screen for cocaine. CONCLUSION: Despite reported cases of status epilepticus with cocaine-induced seizures, the incidence of this complication was unclear based on prior literature. This study shows that most cocaine-associated seizures are self-limited.

Survival after an intentional ingestion of crushed abrus seeds.

Abrus precatorius seeds contain one of the most potent toxins known to man. However, because of the seed's outer hard coat the vast majority of ingestions cause only mild symptoms and typically results in complete recovery. If the seeds are crushed and then ingested, more serious toxicity, including death, can occur.We present a case of a man who survived an intentional ingestion of crushed Abrus seeds after he was treated with aggressive gastric decontamination and supportive care.

Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis.

OBJECTIVE: We assessed the primary causes of rhabdomyolysis, the factors associated with the development of acute renal failure (ARF), and the need for hemodialysis (HD) among a series of patients presenting to an urban emergency department with rhabdomyolysis. METHODS: A chart review between January 1992 and December 1995 was conducted of patients aged 18 years or older with a diagnosis of rhabdomyolysis and an initial serum creatine phosphokinase greater than 1000 U/L. Patients were excluded if they had evidence of myocardial ischemia, cerebrovascular insufficiency, or the development of rhabdomyolysis after hospitalization. Demographic information, presumed causative factors, past medical history, medication usage, and laboratory data were collected. RESULTS: Ninety-seven patients (93 men, 4 women) were enrolled, with a mean age of 35.7 years. The most common causes of rhabdomyolysis were cocaine (30), exercise (29), and immobilization (18). Seventeen of 97 (17.5%) patients developed ARF; 8 patients (8.25%) needed HD. Several clinical and laboratory factors were statistically associated with development of ARF and need for HD. The only variable that was predictive of both ARF and need for HD in separate multivariate regression models was the initial creatinine (Cr). Initial blood urea nitrogen also was predictive of the need for HD. No patient developed ARF with an initial Cr less than 1.7 mg/dL. CONCLUSION: Acute renal failure and need for HD are common complications of rhabdomyolysis. Except for initial serum Cr and blood urea nitrogen, clinical and laboratory factors were not reliable predictors for the development of ARF or need for HD.

Ecgonine methyl ester protects against cocaine lethality in mice.

BACKGROUND: Plasma cholinesterase (PChE) metabolizes cocaine to ecgonine methyl ester (EME). Limited data demonstrate that EME is a mild vasodilator. Exogenous PChE protects against cocaine-induced seizures and lethality. It is unclear whether this protective effect results from enhanced degradation of cocaine, the loss of active metabolites (benzoylecgonine, norcocaine), or the production of a beneficial metabolite (EME). This study was designed to further investigate the pharmacologic effects of EME. METHODS: All experiments used female ICR Swiss albino mice weighing 20-30 grams. Mice were acclimated to 12 h alternating light-dark cycles and given food and water ad libitum. Using a randomized, blinded protocol, 80 mice were then pretreated with either IP EME (50 mg/kg) in a 0.9% sodium chloride solution or an equal volume of 0.9% sodium chloride solution as control. Five minutes later, all animals received 126 mg/kg of cocaine IP and were observed for seizures and death. Fatality was compared using a Fisher's exact test, and the time to seizures and death were compared using a Mann-Whitney U statistic. RESULTS: Pretreatment with EME increased survival following cocaine (9/40 vs. 2/40, for EME vs. control, respectively, p<0.05). The median times to seizure and death for both groups were 2.0 vs. 1.5 min (p>0.05), and 4.5 vs. 4.6 min (p>0.05) (EME vs. control for seizures and death, respectively). CONCLUSION: In this animal model, EME is protective against cocaine lethality. This effect is consistent with the previously described vasodilatory effects of EME. Further studies are indicated to determine whether the increase in EME produced by exogenous PChE administration contributes to the benefits that occur when PChE is given to cocaine-poisoned animals.