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Showing posts from August, 2012

Does this adult patient have septic arthritis?

Landmark Series
Margaretten ME, Kohlwes J, Moore D, Bent S. JAMA. 2007Apr.4;297(13):1478–88.
Article Link
This systematic overview from the excellent JAMA series reviewed the relatively weak evidence regarding assessment of patients with suspected septic arthritis. JC attendees found the odds ratios for clinical findings to be useful (high risk - age 80, recent joint surgery, joint prosthesis, joint pain; insensitive – fever) and the findings for synovial fluid to be informative (helpful - WBC, PMNs; not helpful – glucose, protein, LDH, gram stain). A low synovial WBC count cannot r/o septic arthritis if PMNs > 90%.

Randomized, Controlled Trial of Acetaminophen, Ibuprofen, and Codeine for Acute Pain Relief in Children With Musculoskeletal Trauma.

Landmark Series
Clark E, Plint AC, Correll R, Gaboury I, Passi B. A
Pediatrics. 20

Article Link

This high quality RCT by local investigators rigorously compared acetaminophen, ibuprofen and codeine analgesics among children in the ED with MSK trauma and found ibuprofen to be statistically and clinically significantly superior on a self-reported validated visual acuity pain scale. JC attendees felt this trial supports a change in current practice.

UPDATED Journal Club - March 2013
Methodology Score: 4.5/5     Usefulness Score: 4.5/5
This three-armed RCT in pediatric patients presenting with MSK pain at the Children’s Hospital of Eastern Ontario found that ibuprofen provided superior analgesia (∆VAS -24mm and 52% of patients achieving adequate analgesia at 60 min) than acetaminophen (∆VAS –12mm, 36%) and codeine (∆VAS –11mm, 40%). The group agreed that this study employed a robust methodology and supported the routine use of NSAIDS in musculoskeletal pain over codeine or a…

How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?

Landmark Series
Straus SE, Thorpe KE, Holroyd-Leduc J. JAMA. 2006Oct.25;296(16):2012–22.
PubMed Link

This systematic literature review and meta-analysis in the Rational Clinical Examination series found a non-significant trend towards less post-LP headache with the use of atraumatic needle a
nd mobilization post-LP. Reinsertion of the stylet significantly reduced post-LP headache and CSF wbc>500 and lactate>3.5mmol/L accurately diagnosed bacterial meningitis. JC attendees felt atraumatic needles should be universally adopted and that CSF lactate should be explored as a test to become available in our ED.

Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: A Randomized Clinical Trial

Landmark Series
Andrew K Chang, Polly E Bijur, Robert H Meyer, Mark K Kenny, Clemencia Solorzano, and E John Gallagher PubMed Link
This U.S. randomized trial in ED adults with severe pain found similar effectiveness for intravenous hydromorphone [0.015 mg/kg] and iv morphine [0.1 mg/kg]. This was a well-done study and many JC attendees professed their enthusiasm for hydromorphone as an alternative to morphine for severe pain.