A sequential, multiple-assignment, randomized trial of analgesic strategies for acute musculoskeletal Pain.

BACKGROUND: Most methodologically rigorous, ED-based, comparative effectiveness analgesic studies completed in the last two decades failed to find a clinically important difference between the comparators. We believe that many of these comparative effectiveness studies were biased towards the null hypothesis because some ED patients with intense pain will respond to relatively mild interventions. We hypothesized that including a run-in period would alter the results of an acute pain RCT. METHODS: We conducted a sequential, multiple-assignment, randomized study. Adults with acute moderate/severe musculoskeletal pain were randomized (3:1 ratio) to run-in period or no run-in. We administered 650 mg acetaminophen to run-in participants. Those run-in patients who reported insufficient relief one-hour later were randomized (1:1 ratio) to ibuprofen 800mg PO or ketorolac 20mg PO as were all participants randomized to no run-in. The primary outcome was achieving a clinically important improvement, defined as improvement ≥1.3 on a 0-10 scale. We built a logistic regression model including run-in/no run-in, ketorolac/ibuprofen, age and sex. RESULTS: Of 307 participants who received acetaminophen, 100 (32.6%) reported inadequate relief and were randomized to an NSAID. Of the 100 patients randomized to no run-in, 84/100 (84%) achieved the primary outcome versus 246/287 (86%) run-in participants (95% CI for difference = 2%:-7,10%). Among run-in participants who received an NSAID, 82/99(83%) achieved the primary outcome versus 84/100(84%) no run-in participants (p = 0.82). Among all ibuprofen participants, 44/49(90%) randomized to run-in and 42/50(84%) randomized to no run-in achieved the primary outcome. Among all ketorolac participants, 38/50(76%) randomized to run-in and 42/50 (84%) randomized to no run-in achieved the primary outcome. We observed the following results in a multivariable analysis: OR for ketorolac versus ibuprofen:0.60 (95% CI: 0.28, 1.28); OR for run-in versus no run-in:0.91(95% CI: 0.43, 1.93). CONCLUSIONS: Among patients with acute musculoskeletal pain, using an acetaminophen first strategy did not alter pain outcomes.

The effectiveness of parenteral agents for pain reduction in patients with migraine presenting to emergency settings: A systematic review and network analysis.

OBJECTIVES: To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine. BACKGROUND: Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear. METHODS: Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096). RESULTS: A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics. CONCLUSIONS: Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.

Topical Diclofenac Versus Oral Ibuprofen Versus Diclofenac + Ibuprofen for Emergency Department Patients With Acute Low Back Pain: A Randomized Study.

STUDY OBJECTIVE: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for a variety of musculoskeletal injuries. It is not known whether topical NSAIDs should be used for patients presenting with acute nonradicular musculoskeletal low back pain. METHODS: We conducted a randomized, placebo-controlled double-blind study in which patients 18 to 69 years of age visiting the emergency department (ED) with acute, nontraumatic, nonradicular, musculoskeletal low back pain were randomized at the time of discharge to treatment with 400 mg oral ibuprofen + placebo topical gel, 1% diclofenac topical gel + oral placebo, or 400 mg ibuprofen + 1% diclofenac topical gel. We measured outcomes using the Roland Morris Disability Questionnaire (RMDQ), a 24-item yes/no instrument about the effect of back pain on a respondent's daily activities. The primary outcome was change in RMDQ score between ED discharge and 2 days later. Medication-related adverse events were elicited by asking whether the study medications caused any new symptoms. RESULTS: In total, 3,281 patients were screened for participation, and 198 were randomized. Overall, 36% of the population were women, the mean age was 40 years (standard deviation, 13), and the median RMDQ score at baseline was 18 (25th to 75th percentile: 13 to 22), indicating substantial low back-related functional impairment. In total, 183 (92%) participants provided primary outcome data. Two days after the ED visit, the ibuprofen + placebo group had improved by 10.1 (95% confidence interval [CI] 7.5 to 12.7), the diclofenac gel + placebo group by 6.4 (95% CI 4.0 to 8.8), and the ibuprofen + diclofenac gel by 8.7 (95% CI 6.3 to 11.1). The between-group differences were as follows: ibuprofen versus diclofenac, 3.7 (95% CI 0.2 to 7.2); ibuprofen versus both medications 1.4 (95% CI -2.1 to 4.9); and diclofenac versus both medications, 2.3 (95% CI -5.7 to 1.0). Medication-related adverse events were reported by 3/60 (5%) ibuprofen patients, 1/63 (2%) diclofenac patients, and 4/64 (6%) patients who received both. CONCLUSION: Among patients with nontraumatic, nonradicular acute musculoskeletal low back pain discharged from an ED, topical diclofenac was probably less efficacious than oral ibuprofen. It demonstrated no additive benefit when coadministered with oral ibuprofen.

Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine.

BACKGROUND AND OBJECTIVES: Dexamethasone decreases the frequency of migraine recurrence after emergency department (ED) discharge. However, the optimal dose of dexamethasone is unknown. We hypothesized that dexamethasone 16 mg IV would allow greater rates of sustained headache relief than 4 mg when coadministered with metoclopramide 10 mg IV. METHODS: This was a randomized double-blind study. Adults who presented with a headache meeting International Classification of Headache Disorders, 3rd edition, migraine criteria were eligible if they rated the headache as moderate or severe in intensity. Pain intensity was assessed for up to 2 hours in the ED and through telephone 48 hours and 7 days later. The primary outcome was sustained headache relief. Secondary outcomes included headache relief within 2 hours and the number of headache days during the subsequent week. Relying on a priori criteria, the data safety monitoring committee recommended halting the study early for futility. RESULTS: A total of 1,823 patients were screened, and 209 patients were randomized. The mean age was 38 years (SD 11). One hundred seventy-nine of 209 (86%) identified as women. One hundred fifty-one of 209 (72%) of the population reported severe intensity; the rest reported moderate. Thirty-five of 102 (34%) participants in the metoclopramide +4 mg arm achieved sustained headache relief as did 42/102 (41%) participants in the metoclopramide +16 mg arm (absolute difference 7%, 95% CI -6% to 20%). Headache relief within 2 hours occurred in 77/104 (74%) low-dose and 82/105 (78%) high-dose participants (absolute difference 4%, 95% CI -8% to 16%). During the week after ED discharge, low-dose participants reported a median of 2 headache days (25th, 75th percentile 1, 5); in the high-dose arm, this was also 2 (25th, 75th percentile 0, 4) (mean difference 0.4, 95% CI -0.3 to 1.2). DISCUSSION: When added to 10 mg IV metoclopramide, doses of dexamethasone greater than 4 mg are unlikely to benefit patients in the ED with migraine. TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov on October 2, 2019 (NCT04112823). The first patient was enrolled on December 22, 2019. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that 16 mg of IV dexamethasone is unlikely to provide greater rates of sustained headache relief than 4 mg of IV dexamethasone among patients in the ED with migraine treated concurrently with IV metoclopramide.

Use of clinical phenotypes to characterize emergency department patients administered intravenous opioids for acute pain.

OBJECTIVE: Individual experience with opioids is highly variable. Some patients with acute pain do not experience pain relief with opioids, and many report no euphoria or dysphoric reactions. In this study, we describe the clinical phenotypes of patients who receive intravenous opioids. METHODS: This was an emergency department-based study in which we enrolled patients who received an intravenous opioid. We collected 0 to 10 pain scores prior to opioid administration and 15 minutes after. We also used 0 to 10 instruments to determine how high and how much euphoria the patient felt after receipt of the opioid. Using a cutoff point of ≥50% improvement in pain and the median score on the high and euphoria scales, we assigned each participant to one of the following clinical phenotypes: pain relief with feeling high or euphoria, pain relief without feeling high or euphoria, inadequate relief with feeling high or euphoria, and inadequate relief without feeling high or euphoria. RESULTS: A total of 713 patients were enrolled, 409 (57%) of whom reported not feeling high, and 465 (65%) reported no feeling of euphoria. Median percent improvement in pain was 37.5% (interquartile range, 12.5%-60.0%). One hundred seventy-eight participants (25%) were classified as experiencing pain relief with euphoria or feeling high, 190 (27%) experienced inadequate relief with euphoria or feeling high, 101 (14%) experienced pain relief without euphoria or feeling high, and 244 (34%) reported inadequate relief without euphoria or feeling high. CONCLUSION: Among patients who receive intravenous opioids in the emergency department, the experiences of pain relief and euphoria are highly variable. For many, pain relief is independent of feeling high.

Improving physician well-being and reducing burnout using a peer-to-peer recognition program.

Background: Drivers of physician burnout include an intricate interplay between health care organizational structures, societal influences, and individual-level factors. In the traditional workforce, peer-to-peer recognition programs (PRPs) have reduced burnout by building a sense of community and effectively creating a "wellness culture." We implemented a PRP in an emergency medicine (EM) residency and determined its impact on subjective symptoms of burnout and wellness. Methods: This was a prospective, pre- and postintervention study conducted in a single residency over a 6-month period. All 84 EM residents of the program were sent a voluntary anonymized survey that included a validated instrument on wellness and burnout. A PRP was initiated. After 6 months, a second survey was distributed. The outcome of the study was to examine whether the addition of a PRP reduced burnout and improved wellness. Results: There were 84 respondents to the pre-PRP survey and 72 to the post-PRP survey. Respondents reported an improvement after the inception of the use of the PRP in two factors that contribute to a physician's wellness: feeling recognized for accomplishments at work, which improved from 45% (38/84) affirmative to 63% (45/72; 95% confidence interval [CI] 2.3%-32.4%, p = 0.025) and a comfortable and supportive work environment, which improved from 68% (57/84) to 85% (61/72; 95% CI 3.5%-29.3%, p = 0.014). There was no significant effect in the Stanford Professional Fulfillment Index (PFI) as a result of this intervention over the 6 months. Conclusions: A PRP initiative resulted in improvements in several factors that drive physician wellness but overall burnout measured by the Stanford PFI did not show any improvement over the 6-month period. A future longitudinal study examining the continuous assessment of PRP on the EM residents throughout the entire course of 4 years of residency training would be beneficial to determine if it could change burnout from year to year.

Barriers and Best Practices for the Use of Patient-Reported Outcome Measures in Emergency Medicine.

Patient-reported outcome measures are commonly used in clinical trials and have been incorporated into routine clinical care in select specialties but have not been widely implemented in emergency medicine research and clinical care. We describe measurement-related barriers to patient-reported outcome measure use in the emergency department; administrative and practical considerations; implications of developing novel emergency medicine-specific patient-reported outcome measures; and key considerations for the use of patient-reported outcome measures in emergency medicine research and clinical care. Despite the unique barriers of the ED environment, potential solutions include the use of ED-validated patient-reported outcome measures when available; adapting existing short-form, multidimensional patient-reported outcome measures previously validated in diverse populations, ideally using computer-adapted testing; and collecting responses during anticipated wait times. With this work, we aim to inform barriers and best practices to the use of patient-reported outcome measures in emergency medicine research and clinical care to support future, more widespread implementation of patient-reported outcome measures within emergency care. The successful adoption of patient-reported outcome measures for diverse ED patient populations within the unique constraints of the acute care environment may help researchers, clinicians, and policymakers improve the quality and patient-centeredness of acute care.

Factors Associated with Anticoagulation Initiation for New Atrial Fibrillation in an Urban Emergency Department.

Objective: To explore factors associated with anticoagulation (AC) initiation after atrial fibrillation (AF) diagnosis. Design: Retrospective cohort study. Setting: Urban medical center. Patients: Adults with emergency department (ED) diagnosis of new onset AF from 1/1/2017-1/1/2020 discharged home. Methods: We compared patients initiated on AC, our primary outcome, to those not initiated on AC. Stroke, major bleeding, and AC initiation within 1 year of visit were secondary outcomes. We hypothesized that minority race and non-English language preference are associated with failure to initiate AC. Results: Of 111 patients with AF, 88 met inclusion criteria. Mean age was 65 (SD 15); 47 (53%) were women. 49 (56%) patients were initiated on AC. Age (61 vs 68 years; P=.02), non-English language (28% vs 10%; P=.03), leaving ED against medical advice (AMA) (36% vs 14%; P=.04), and CHA2DS2-VASc score of 1 (41% vs 6%; P<=.001) were associated with no AC initiation. There were no associations between patient-reported race/ethnicity and AC. Cardiology consultation (83.67% vs 30.78%; P<.0001) and higher median CHA2DS2-VASc score (3[2-4]) vs. 2[1-4]; P=.047) were associated with AC. Of 73 patients with follow-up data at 1 year, 2 (8%) not initiated on AC had strokes, 2 (4%) initiated on AC had major bleeds, and 15 (62.5%) not initiated on AC in the ED subsequently were initiated on AC. Conclusion: More than half of ED patients with new AF eligible for AC were initiated on it. Work to improve AC utilization among patients with new AF who left AMA from ED and those who prefer to communicate in a non-English language may be warranted.

"Diffusion of innovations": a feasibility study on the pericapsular nerve group block in the emergency department for hip fractures.

OBJECTIVE: Hip fractures are associated with significant morbidity and mortality. Ultrasound-guided peripheral nerve blocks are a safe method to manage pain and decrease opioid usage. The pericapsular nerve group (PENG) block is a novel, potentially superior block because of its motor-sparing effects. Through training, simulation, and supervision, we aim to determine whether it is feasible to perform the PENG block in the emergency department. METHODS: Phase 1 consisted of emergency physicians attending a workshop to demonstrate ultrasound proficiency, anatomical understanding, and procedural competency using a low-fidelity model. Phase 2 consisted of a prospective, observational, feasibility study of 10 patients with hip fractures. Pain scores, side effects, and opioid usage data were collected. RESULTS: The median pain score at time 0 (time of block) was 9 (interquartile range [IQR], 6.5-9). The median pain score at 30 minutes was 4 (IQR, 2.0-6.8) and 3.5 (IQR, 1.0-4.8) at 4 hours. All 10 patients required narcotics prior to the initiation of the PENG block with a median dosage of 6.25 morphine milligram equivalents (MME; IQR, 4.25-7.38 MME). After the PENG block, only 30% of the patients required further narcotics with a median dosage of 0 MME (IQR, 0-0.6 MME) until operative fixation. CONCLUSION: In this feasibility study, PENG blocks were safely administered by trained emergency physicians under supervision. We demonstrated data suggesting a trend of pain relief and decreased opiate requirements, and further investigation is necessary to measure efficacy.

A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain.

STUDY OBJECTIVE: We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. METHODS: This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. RESULTS: The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was -8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was -4% to 14%) and included dizziness, drowsiness, headache, and nausea. CONCLUSION: Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.

Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis.

OBJECTIVE: To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. METHODS: This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. RESULTS: There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%-9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40-50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. CONCLUSION: The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.

Learning Outcomes of High-fidelity versus Table-Top Simulation in Undergraduate Emergency Medicine Education: Prospective, Randomized, Crossover-Controlled Study.

INTRODUCTION: Over the last several decades simulation, in both graduate and undergraduate emergency medicine education, has continued to develop as a leading and highly effective teaching modality. Limited research exists to evaluate the efficacy of low-fidelity (table-top) simulation, as compared to high-fidelity standards, as it relates to medical knowledge learning outcomes. We sought to assess the efficacy of a low-fidelity simulation modality in undergraduate emergency medicine education, based on quantitative medical knowledge learning outcomes. METHODS: A prospective, randomized, crossover-control study comparing objective medical knowledge learning outcomes between simulation modalities. Analysis was designed to evaluate for the statistical equivalence of learning outcomes between the two cohorts. This was done by comparing a calculated 95% confidence interval (CI) around the mean difference in post-test scores, between experimental and control modalities, to a pre-established equivalence margin. RESULTS: Primary outcomes evaluating student performance on post-test examinations demonstrated a total cohort CI (95% CI, -0.22 and 0.68). Additional course-subject subgroup analysis demonstrated non-inferior CIs with: Shortness of Breath (95% CI, -0.35 and 1.27); Chest Pain (95% CI, -0.53 and.94); Abdominal Pain (95% CI, -0.88 and 1.17); Cardiovascular Shock (95% CI, -0.04 and 1.29). Secondary outcome analysis was done to evaluate medical knowledge acquisition by comparing the difference in pre and post-test examination between the cohorts. CI of the full cohort ranged from (95% CI, -0.14 and 0.96). CONCLUSION: The student's performance on quantitative medical-knowledge assessment was equivalent between the high-fidelity control and low-fidelity experimental simulation groups. Analysis of knowledge acquisition between the two groups also demonstrated statistical equivalence.

A Randomized, Placebo-Controlled Study of Intranasal Fentanyl as an Analgesic Adjunct For Incision and Drainage of Abscess.

BACKGROUND: Incision and drainage (I&D) of abscesses is one of the most painful procedures performed in emergency departments (EDs). OBJECTIVE: We tested the following hypothesis: The addition of intranasal fentanyl to the standard practice of local infiltration with lidocaine would provide better pain control than lidocaine alone for adult ED patients undergoing I&D. METHODS: This was a randomized, double-blind study. Participants received 2 µg/kg of intranasal fentanyl or a comparable amount of intranasal water in addition to local lidocaine infiltration. The primary outcome, which we assessed immediately after the I&D was completed, was a summary 0-10 pain score for which we asked study subjects to provide a number depicting their entire experience with the procedure. RESULTS: During a 19-month enrollment period, we screened 176 patients for eligibility and enrolled 49; 25 received placebo and 24 received fentanyl. Baseline characteristics were comparable. Mean (standard deviation) summary pain scores were as follows: fentanyl 6.2 (3.3) and placebo 7.0 (3.2). The 95% confidence interval for a rounded between-group difference of 0.9 was -1.1 to 2.6. CONCLUSIONS: In this small study, the addition of intranasal fentanyl did not substantially impact the pain scores of ED patients undergoing I&D.

The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies.

BACKGROUND: Low back pain (LBP) causes 2.6 million visits to U.S. emergency departments (EDs) annually. These patients are often treated with skeletal muscle relaxants (SMRs). OBJECTIVES: The goal of this study was to determine whether efficacy of SMRs is associated with age, sex, or baseline LBP severity. METHODS: This was a planned analysis of data from 4 randomized studies of patients with acute nonradicular LBP. Patients were enrolled during an ED visit and followed-up 1 week later. The primary outcome was improvement in the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and the 1-week follow-up. We compared the change in RMDQ among 8 groups: placebo, baclofen, metaxalone, tizanidine, diazepam, orphenadrine, methocarbamol, and cyclobenzaprine. All patients also received a nonsteroidal anti-inflammatory drug. We performed analysis of variance to determine statistically significant differences between medications and linear regression to determine the association of age, sex, and baseline severity with the primary outcome. RESULTS: The mean improvement in RMDQ per group was placebo 10.5 (95% confidence interval [CI] 9.5-11.5), baclofen 10.6 (95% CI 8.6-12.7), metaxalone 10.3 (95% CI 8.1-12.4), tizanidine 11.5 (95% CI 9.5-13.4), diazepam 11.1 (95% CI 9-13.2), orphenadrine 9.5 (95% CI 7.4-11.5), methocarbamol 8.1 (95% CI 6.1-10.1), and cyclobenzaprine 10.1 (95% CI 8.3-12). The between-group differences were not statistically significantly different. Results were similar regardless of age, sex, and baseline severity. Higher baseline RMDQ was associated with greater clinical improvement (B coefficient 5.7, p < 0.01). Adverse medication effects were more common with cyclobenzaprine than with placebo (p < 0.01). CONCLUSIONS: Among patients in the ED with acute LBP treated with a nonsteroidal anti-inflammatory drug, SMRs do not improve outcomes more than placebo. Neither age, sex, nor baseline impairment impacts these results.

Oxycodone induced euphoria in ED patients with acute musculoskeletal pain. A secondary analysis of data from a randomized trial.

OBJECTIVES: Some opioid-naïve patients with acute musculoskeletal pain who are treated with opioids develop persistent opioid use. The impact of opioid-induced euphoria on this transition to persistent use has not been explored. We determined whether opioid-induced euphoria could be measured as a phenomenon distinct from relief of pain. METHODS: Patients with acute pain were randomized to receive oxycodone/acetaminophen (Oxy) or acetaminophen (APAP). We measured pain using a 0-10 verbal scale. To assess euphoria, participants provided a 0-10 response to each of these: 1) How good did the medication make you feel?; 2) How high did the medication make you feel?; 3) How blissful did the medication make you feel? We analyzed these data using successive multivariable linear regression models, in which each of these items was the dependent variable, and improvement in pain and medication were the independent variables, while controlling for age and sex. RESULTS: 75 were randomized to Oxy, 76 to APAP. Mean "how good" scores were 6.3 (SD 3.3) in the Oxy group and 4.8 (3.3) in the APAP group. Mean "how high" scores were 3.8 (3.7) in the Oxy group and 2.0 (3.0) in the APAP group. Mean "how blissful" scores were 4.9 (3.7) in the Oxy group and 3.1 (3.4) in the APAP group. After controlling for improvement in pain, age, and sex, the between-group difference in "how good" was 1.0 (95%CI: -0.1, 2.0), "how high" 1.5 (95% CI 0.4, 2.6), and "how blissful" 1.5 (95%CI: 0.4, 2.7). DISCUSSION: "How high" and "how blissful" but not "how good" were associated with opioid use after controlling for improvement in pain.

Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial.

BACKGROUND: Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS: We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS: Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS: Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.

Treating High-Risk TIA and Minor Stroke Patients With Dual Antiplatelet Therapy: A National Survey of Emergency Medicine Physicians.

BACKGROUND: Treatment with aspirin plus clopidogrel, dual antiplatelet therapy (DAPT), within 24 hours of high-risk transient ischemic attack (TIA) or minor stroke symptoms to eligible patients is recommended by national guidelines. Whether or not this treatment has been adopted by emergency medicine (EM) physicians is uncertain. METHODS: We conducted an online survey of EM physicians in the United States. The survey consisted of 13 multiple choice questions regarding physician characteristics, practice settings, and usual approach to TIA and minor stroke treatment. We report participant characteristics and use chi-squared tests to compare between groups. RESULTS: We included 162 participants in the final study analysis. 103 participants (64%) were in practice for >5 years and 96 (59%) were at nonacademic centers; all were EM board-certified or board-eligible. Only 9 (6%) participants reported that they would start DAPT for minor stroke and 8 (5%) reported that they would start DAPT after high-risk TIA. Aspirin alone was the selected treatment by 81 (50%) participants for minor stroke patients who presented within 24 hours of symptom onset and were not candidates for thrombolysis. For minor stroke, 69 (43%) participants indicated that they would defer medical management to consultants or another team. Similarly, 75 (46%) of participants chose aspirin alone to treat high-risk TIA; 74 (46%) reported they would defer medical management after TIA to consultants or another team. CONCLUSION: In a survey of EM physicians, we found that the reported rate of DAPT treatment for eligible patients with high-risk TIA and minor stroke was low.