Canadian Journal of Emergency Medicine最新文献

Objectives

Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) as adjunct cellulitis treatment improves clinical response and cure.

Methods

Systematic review and meta-analysis including randomized controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) vs. placebo or no intervention. Medline (PubMed), Embase (via Elsevier), and Cochrane CENTRAL were searched from inception to August 1, 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure.

Results

Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95%CI 1.42–2.31, I² = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95%CI 0.62–2.26), although heterogeneity was high (I² = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (N = 3 trials) were infrequent.

Conclusions

For patients with cellulitis, the best available data suggest that oral nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies.

Registration

Open Science Framework: https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81.

Purpose

We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment—Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care.

Methods

Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital’s administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020. Primary outcome: mean quarterly length of stay. Secondary outcomes: delirium, intensive care unit (ICU) admission, other post-admission complications, mortality.

Results

N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI − 0.03 to 0.6), intercept change, 0.06 (− 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2–7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3–5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020).

Conclusions

This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.

Introduction

Indigenous health equity interventions situated within emergency care settings remain underexplored, despite their potential to influence patient care satisfaction and empowerment. This study aimed to systematically review and identify Indigenous equity interventions and their outcomes within acute care settings, which can potentially be utilized to improve equity within Canadian healthcare for Indigenous patients.

Methods

A database search was completed of Medline, PubMed, Embase, Google Scholar, Scopus and CINAHL from inception to April 2023. For inclusion in the review, articles were interventional and encompassed program descriptions, evaluations, or theoretical frameworks within acute care settings for Indigenous patients. We evaluated the methodological quality using both the Joanna Briggs Institute checklist and the Ways Tried and True framework.

Results

Our literature search generated 122 publications. 11 articles were selected for full-text review, with five included in the final analysis. Two focusing on Canadian First Nations populations and three on Aboriginal Australians. The main intervention strategies included cultural safety training, integration of Indigenous knowledge into care models, optimizing waiting-room environments, and emphasizing sustainable evaluation methodologies. The quality of the interventions was varied, with the most promising studies including Indigenous perspectives and partnerships with local Indigenous organizations.

Conclusions

Acute care settings, serving as the primary point of access to health care for many Indigenous populations, are well-positioned to implement health equity interventions such as cultural safety training, Indigenous knowledge integration, and optimization of waiting room environments, combined with sustainable evaluation methods. Participatory discussions with Indigenous communities are needed to advance this area of research and determine which interventions are relevant and appropriate for their local context.

Objectives

This study’s aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia.

Methods

Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits.

Results

There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18–65 age group.

Conclusions

This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.