Oral Prednisolone in the Treatment of Acute Gout: A Pragmatic, Multicenter, Double-Blind, Randomized Trial.

BACKGROUND: Two recent double-blind, randomized, controlled trials (RCTs) showed that oral steroids and nonsteroidal anti-inflammatory drugs have similar analgesic effectiveness for management of gout, but the trials had small sample sizes and other methodological limitations. OBJECTIVE: To compare the effectiveness and safety of oral prednisolone versus oral indomethacin in patients presenting to emergency departments (EDs) with acute gout. DESIGN: Multicenter, double-blind, randomized equivalence trial. Patients were randomly assigned (1:1 ratio) to receive either indomethacin or prednisolone. (ISRCTN registry number: ISRCTN45724113). SETTING: Four EDs in Hong Kong. PARTICIPANTS: 416 patients aged 18 years or older. MEASUREMENTS: Analgesic effectiveness was defined as changes in pain (at rest or with activity) greater than 13 mm on a 100-mm visual analogue scale. Outcomes were measured during the first 2 hours in the ED and from days 1 to 14. RESULTS: 376 patients completed the study. Equivalent and clinically significant within-group reductions in mean pain score were observed with indomethacin and prednisolone in the ED (approximately 10 mm [rest] and 20 mm [activity]) and from days 1 to 14 (approximately 25 mm [rest] and 45 mm [activity]). No major adverse events occurred during the study. During the ED phase, patients in the indomethacin group had more minor adverse events than those in the prednisolone group (19% vs. 6%; P < 0.001). During days 1 to 14, 37% of patients in each group had minor adverse events. LIMITATION: Diagnosis of gout was usually based on clinical criteria rather than examination of joint fluid. CONCLUSION: Oral prednisolone and indomethacin had similar analgesic effectiveness among patients with acute gout. Prednisolone is a safe, effective first-line option for treatment of acute gout. PRIMARY FUNDING SOURCE: Health and Health Services Research Grant Committee of the Hong Kong Government.

Ambulatory care program for patients presenting with acute urinary retention secondary to benign prostatic hyperplasia.

OBJECTIVE: We analyze the clinical and economical outcomes of an ambulatory care program for the management of patients presenting to the emergency department with acute urinary retention (AUR). METHOD: A standardized ambulatory care program for managing male patients presenting with AUR was established in October 2007. Prospective data collected in 194 ambulatory patients from January to December 2008 were compared to a historical cohort of 168 patients who were managed by in-patient care from October 2006 to September 2007 for their clinical and economic outcomes. RESULTS: For the historical cohort, the mean length of hospital stay was 4.67±3.34 days and the trial without catheterization (TWOC) success rate was 66.1%. Two patients (1.2%) developed dizziness after using α(1)-blockers. For the patients in the ambulatory care program, the mean duration of catheterization was 4.72±2.26 days and the TWOC success rate was 69.1%. There were four unplanned admissions (2.1%) among the patients who were managed under the ambulatory care program; three of them had catheter-related complications (i.e., hematuria and urinary tract infection) and one developed dizziness after the use of alfuzosin. All of them were managed accordingly and no unfavorable sequelae were resulted. This new program reduced hospital admission rate of male patients presenting with AUR by 59.1%. It leads to significant cost reduction of USD 375,614.3 in our hospital in year 2008. CONCLUSION: The ambulatory care program reduced the hospital admission rate and reduced cost without jeopardizing the TWOC success rate and safety in the management of patients presenting with AUR.

Oral prednisolone is more cost-effective than oral indomethacin for treating patients with acute gout-like arthritis.

OBJECTIVES: Acute gouty arthritis is often treated with NSAIDs, but recent studies have suggested that treatment with prednisolone has at least equivalent analgesic efficacy and fewer adverse effects. No formal economic analysis has been performed earlier. In this study, we aimed to compare the economic impact of oral indomethacin therapy and oral prednisolone therapy in the treatment of acute gout in patients presenting to an emergency department in Hong Kong. METHODS: Data from a previously published randomized controlled trial were used to compare the costs of the two treatment options. Direct, incremental costs incurred in the 2 weeks after the initial presentation were considered from the perspective of the healthcare provider. Costs were subdivided into those incurred in the emergency department phase; admission on day 1 to the emergency department's observation ward; admission subsequently to the general medical ward for adverse events and reattendance to the hospital outpatients' or emergency department. RESULTS: The prednisolone strategy resulted in cost savings in the emergency department of HK$5.67 (US$0.73; pound0.37) and in medical admissions of HK$1727.48 (US$221.47; pound111.45) per patient treated. Overall, the average saving with prednisolone was HK$1235 (US$158.33; pound79.68) per patient treated, which was equivalent to one admission bed/day saved for every two patients treated. Treatment for each of the six patients in the indomethacin group admitted for serious adverse effects cost the healthcare provider HK$13 244 (US$1697.95; pound854.45). CONCLUSION: Treatment of acute gouty arthritis with a 5-day course of prednisolone is significantly more cost-effective than treatment with indomethacin.

Sport-related ankle injuries attending an accident and emergency department.

INTRODUCTION: This study investigated the sport-related ankle injuries attending an accident and emergency (A&E) department during a 1-year period. METHODS: A total of 1715 sports injuries cases attending an A&E department from 1 January 2005 to 31 December 2005 were prospectively recorded. Details of each classified case were recorded in a computerised record system by the triage nurse. At the end of the study period, all sport-related ankle injury cases were analysed. RESULTS: A total of 240 sport-related ankle injury cases were reported. Most cases were sustained from basketball (32.9%), soccer (31.7%) and hiking (5.8%) sports. The majority of the cases was ligamentous sprains (81.3%) and fractures (10.4%). The mean age of all patients was 24.6 years (S.D. = 12.3). Four fifths (80.4%) were male patients. All cases were not life threatening. Most cases (99.2%) were referred to orthopedics specialty. Radiography was routinely employed in 99.2% of the cases. Ligamentous sprains were mostly sustained in basketball (37.4%) and soccer (28.7%), and were often treated with bandaging (60.0%) and analgesics (48.7%). Most cases were discharged with or without referral to physiotherapy and specialty clinic (95.4%). Fractures were mostly sustained in soccer (52.0%), basketball (20.0%) and hiking (16.0%), and were very often admitted to hospital wards (84.0%). The estimated A&E attendance rate for all sports injuries, ankle injuries, ligamentous sprains and fractures were 1.68, 0.24, 0.19 and 0.02/1000 person-year. CONCLUSIONS: The results of this study together with the previous study on ankle sprain epidemiology suggested the following sports ankle injury pattern in Hong Kong-major and serious ankle ligamentous sprains and fractures were sustained from basketball, soccer and hiking, leading to A&E attendance, while minor sprains were sustained in running and jogging and racquet sports. We suggested that the Sports medicine specialists in Hong Kong should emphasise the ankle injury prevention strategies in these sports.

Issues associated with dog bite injuries in children and adolescents assessed at the emergency department.

OBJECTIVES: The aim of this study was to determine the pattern of dog bites seen at the emergency department of a university hospital. The information will be used to plan prevention and enhance management strategies. METHODS: All patients (younger than 22 years) assessed at the emergency department between January 2003 and December 2004 with a discharge diagnosis of animal bites were identified through the computerized discharge network. RESULTS: One hundred forty-four incidents of animal bites (82 males and 62 females) occurred over the 2-year period. Eighty-nine percent was due to dog bites. Among the dog bite victims, the mean age was 11.82 years (SD, 6.39 years; range, 0.06-21.83 years). Family dogs were only involved in 15% of cases. The species of dogs were not recognized in three fifths, and attacks provoked in two fifths of victims. Most bites (90%) of bites involved only single anatomical sites. The extremities were commonly involved (right upper limb [23%], left upper limb [16%], right lower limb [35%], left lower limb [20%]). Torso (4%) and genitalia (0.8%) were uncommonly involved. Pain, erythema, bleeding, and bruising were common symptoms, but 60 patients were asymptomatic at presentation. Compared with older patients, children younger than 10 years had a much higher risk of facial injuries (25% vs. 2%, P = 0.0002; odds ratio, 21.8, 95% confidence interval, 2.9-455.9) and were more likely to be triaged as being urgent (P = 0.01). Most attacks were trivial and did not require hospitalization. Antirabies treatment was given in approximately half, analgesics in two fifths, and antibiotics in one fourth. CONCLUSIONS: In mammalian attacks, canines are most commonly involved. Most injuries are trivial, and the limbs are usually involved. However, younger children are at higher risk of facial injuries. Extent of pain and adverse psychological impacts are typically not documented in the emergency assessment.

Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial.

STUDY OBJECTIVE: We compare the analgesic efficacy and adverse effects of oral prednisolone/acetaminophen and oral indomethacin/acetaminophen combination therapy in the treatment of acute goutlike arthritis in patients presenting to an emergency department (ED). METHODS: This is a double-blind, randomized, controlled study in a university hospital emergency department (ED) in the New Territories of Hong Kong. Patients older than 17 years and presenting between February 1, 2003, and June 30, 2004, with a clinical diagnosis of goutlike arthritis were randomized to receive either oral prednisolone/acetaminophen or oral indomethacin/acetaminophen combination therapy. Primary outcome measures were pain scores, time to resolution of symptoms and signs, and adverse effects. Secondary outcome measures were the need for additional acetaminophen and relapse rate. RESULTS: There were 90 patients randomized: 46 patients to the indomethacin group and 44 patients to the prednisolone group. Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatment groups had a similar decrease in pain score in the ED. The mean rate of decrease in pain score with activity for indomethacin was -1.7+/-1.6 (SD) mm per day and for prednisolone was -2.9+/-2.0 (SD) mm per day (mean difference 1.2 mm/day; 95% confidence interval 0.4 to 2.0 mm/day; P=.0026). Although these differences were statistically significant, at no time was the difference in mean pain score greater than 13 mm. Therefore, it is unclear whether these differences are clinically significant. The mean total dose of acetaminophen consumed by the prednisolone group was significantly more than in the indomethacin group (mean 10.3 g, range 1 to 21 g versus mean 6.4 g, range 1 to 21 g). Twenty-nine patients in the indomethacin group and 12 patients in the prednisolone group experienced adverse effects (P<.05). The commonest adverse effects in the indomethacin group were nausea, indigestion, epigastric pain, dizziness, and gastrointestinal bleeding (N=5; 11%). None of the patients in the prednisolone group developed gastrointestinal bleeding. The relapse rate for both groups was similar. CONCLUSION: In the treatment of acute goutlike arthritis, oral prednisolone/acetaminophen combination is as effective as oral indomethacin/acetaminophen combination in relieving pain but is associated with fewer adverse effects.

Impact of SARS on an emergency department in Hong Kong.

OBJECTIVE: To report on the impact of a Severe Acute Respiratory Syndrome (SARS) outbreak on the attendances of a major teaching hospital ED. METHODS: Two periods were studied. The first was prior to the closure of the ED due to SARS and the second was after re-opening of the ED. Data on attendances, discharge against medical advice, triage categories, trauma and ambulance cases were retrieved from the computer and compared with the data in the same periods in 2002. RESULTS: In the first period, when compared with 2002 there was a significant decrease in the mean daily attendance (397 vs 524), trauma cases (68 vs 111), minor cases (category 4: 283 vs 361, and category 5: 20 vs 43). In the second period, there was a significant decrease in the mean daily attendance (265 vs 545), trauma cases (40 vs 111), minor cases (category 4:181 vs 376, and category 5: 12 vs 45), discharge against medical advice (4 vs 6 daily) and ambulance cases (70 vs 86 daily). Patients requiring immediate care however, remained similar. CONCLUSION: There was a significant drop in the overall ED attendance, trauma cases and minor cases after the outbreak of SARS. Possible causes include changes in community behaviour, resulting in a lower incidence of trauma and disease and fear of presenting to hospital and contracting SARS.