- The Importance (or Not) of High BP Readings
- Learning While Driving—Does It Work?
- Considering Sucralfate in Pediatric Oral Ulcers
- Osteopathic Manipulation for Low Back Pain
- Safety of Oral Corticosteroid Bursts in Children
Nathan M Finnerty, MD FACEP and Brett C Ebeling, MD
Do High Blood Pressure Readings Matter?
Take-home Point: Elevated blood pressure readings in the emergency room were not associated with an increased risk of poor cardiovascular outcomes in 2 years.
Citation: McAlister F, Youngson E, Rowe BH. Elevated blood pressures are common in the emergency department but are they important? A retrospective cohort study of 30,278 adults. Ann Emerg Med. 2021;77(4):425-432.
Relevance: This study aims to determine the clinical significance of a high blood pressure reading in the acute care setting with regard to medium-term cardiovascular outcomes.
Methods: This was a retrospective cohort study in which the authors studied all adult ED visits in a large-volume facility in 2016, involving patients with 2 years of records before and after their visit. The authors used the electronic medical record to examine the patients’ health history over the subsequent 2 years for a primary outcome of a composite acute coronary syndrome (ACS), new-onset congestive heart failure (CHF), transient ischemic attack (TIA), or cerebral vascular accident (CVA).
Results: The study included 30,000 patients seen in the ED and revealed that >50% had blood pressures >160/100 at some point during their visit. Approximately 75% of patients had not previously been diagnosed with hypertension. Around 50% of patients were diagnosed with chronic hypertension and/or started on at least one antihypertensive medication in the subsequent 2 years. Among patients without a prior diagnosis of hypertension with an elevated BP reading in the ED, there was an increase in the composite outcome of cardiovascular or cerebrovascular disease (3.3% vs 2.5%) compared with normotensive patients. At 2 years, the difference was 5.9% vs 3.8%. However, when adjusted for other cardiovascular disease risk factors, the risk between the two BP groups was no different.
Editor’s comments: This study is limited by retrospective design and its non-UC setting; there are limited conclusions to be drawn for patients with elevated BP in the urgent care center. Despite these limitations, this study’s results are consistent with other recent studies suggesting that patients with asymptomatic elevated BP readings in acute care settings do not benefit from aggressive BP management in the short- or medium-term.
Does Listening to Podcasts while Driving Affect Retention?
Take-home point: Driving while listening to podcasts does not meaningfully affect knowledge acquisition or retention when compared with undistracted podcast listening.
Citation: Gottlieb M, Riddell J, Cooney, et al. Maximizing the morning commute: a randomized trial assessing the effect of driving on podcast knowledge acquisition and retention. Ann Emerg Med. 2021;78(3):416-424. Epub ahead of print April 27, 2021.
Objective: Approximately 90% of current residents training in emergency medicine listen to podcasts—75% of them while driving. These authors aimed to determine whether driving while listening to podcasts affected the listener’s retention of knowledge.
Methods: This was a multicenter randomized crossover trial among EM residents at four institutions who listened to podcasts both while driving and sitting quietly. Subjects crossed over and served as their own controls. Subjects took a 20-question test assessing knowledge retention immediately after listening to the podcast and again a month later.
Results: A total of 96 residents completed both tests. There was no difference between test results in either the immediate or delayed recall between driving and undistracted listening conditions.
Editor’s comments: This was a well-designed and unique study that offers reasonably strong evidence that listening to educational podcasts while driving does not meaningfully affect retention.
Sucralfate Fails to Show Benefit for Oral Ulcers
Take-home point: Sucralfate as an adjunct to oral analgesics was not superior to placebo in improving oral intake in children with acute oral ulcers.
Citation: Singh NV, Gabriele GA, Wilkinson MH. Sucralfate as an adjunct to analgesia to improve oral intake in children with infectious oral ulcers: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. 2021;78(3):331-339.
Relevance: Oral ulcers are common with many pediatric infectious conditions. This study soughtto determine if sucralfate added to standard acetaminophen/ibuprofen improves pain relief for children with oral ulcerative conditions.
Methods: This was a randomized, double-blind, placebo-controlled trial of sucralfate vs placebo in children between 6 months and 5 years of age with acute infectious oral ulcers and poor oral intake. Subjects received either acetaminophen or ibuprofen and were then randomized to receive either sucralfate at 20 mg/kg per dose or a placebo solution. The primary outcome was oral fluid intake within 60 minutes of medication administration. The secondary outcomes were repeat emergency department visits, ED length of stay, need for intravenous hydration, hospital admission, adverse events, and the emergency clinician’s determination of the adequacy of oral intake.
Results: One hundred children with mild dehydration (median age 1.5 years) were included. Oral intake 1 hour after drug administration was similar in both groups. According to the emergency physician’s report, the secondary outcomes were significant only for adequate oral intake (71% in the sucralfate group vs 88% in the placebo group).
Editor’s comments: This was a small, single-site study. Quantifying oral intake in small children is challenging; however, sucralfate seems to have no effect on a child’s willingness to eat and drink in the setting of infectious oral ulcerative conditions.
Osteopathic Manipulation for Low Back Pain
Take-home point: Osteopathic manipulative treatment had a small, non clinically significant effect on low back pain-specific activity limitations vs sham treatment.
Citation: Nguyen C, Boutron I, Zegarra-Parodi R, et al. Effect of osteopathic manipulative treatment vs sham treatment on activity limitations in patients with nonspecific subacute and chronic low back pain: a randomized clinical trial. JAMA Intern Med. 2021;181(5):620-630.
Relevance: Osteopathic manipulative treatment (OMT) is commonly utilized for mechanical low back pain. This study compares OMT with sham treatment for nonspecific low back pain (LBP).
Methods: This was a French prospective parallel group, single-blind, single-center, sham-controlled randomized clinical trial evaluating patients with subacute-chronic mechanical, low back pain. Patients were randomized to six sessions of standard OMT or sham OMT administered biweekly. The primary endpoint was the mean reduction in low back pain-specific activity limited at 3 months as measured by the self-administered Quebec Back Pain Disability Index. Secondary outcomes included mean reduction in LBP specific limitations, mean changes in pain and health-related quality of life, sick leave, and the number of low back pain episodes.
Results: Two hundred participants were randomly allocated to each group. The mean Quebec Back Pain Disability Index scores for the standard OMT group were 31.5 at baseline and 25.3 at 3 months. In the sham OMT group, index scores were 27.2 at baseline and 26.1 at 3 months. The mean reduction in low back pain-specific activity and limitations at 3 months was -4.7 and -1.3, respectively, which is not clinically significant. There were no significant differences in any secondary outcomes.
Editor’s comments: This study corroborates the findings of most prior studies on the topic. Its robust design supports that there is limited-to-no role for OMT for the management of low back pain.
Safety of Oral Corticosteroid Bursts in Children
Take-home point: Steroid bursts were associated with a significant increase in adverse events within 31-90 days of exposure.
Citation: Yao TC, Huan Y-W, Chang S-M, et al. Association of oral corticosteroid bursts with severe adverse events in children. JAMA Pediatr. 2021;175(7):723-729-330. [Correction published July 6, 2021, to fix errors in the Abstract, Key Points, and text.]
Relevance: Steroids are commonly prescribed in many pediatric conditions. This study aimsto determine the frequency of severe adverse events in children after receiving a burst of oral steroids.
Methods: This was a self-controlled, case series, cohort study of Taiwanese children who were prescribed oral steroids for <14 days. The National Health Insurance Database was also used to determine incidence of GI hemorrhage, sepsis, pneumonia, and glaucoma in patients receiving steroids vs those who did not.
Results: Out of 4.5 million children whose cases were reviewed, 23% received a steroid burst during the 7-month study period. The most common indications for steroid prescriptions were viral respiratory infections and allergic reactions. Patients receiving steroids had a higher risk of GI bleed (incidence rate ratio, (IRR) = 1.41), sepsis (IRR=2.0), and pneumonia (IRR=2.2).
Editor’s comments: This study was limited by retrospective design and a homogenous study population. Steroid prescriptions included were up to 14 days, which is longer than usual practice in the U.S. Despite the study limitations, the large number of prescriptions reviewed suggests it is worth avoiding overly liberal steroid prescribing in children.
Nathan M Finnerty, MD FACEP practices in the Department of Emergency Medicine at Intermountain Medical Center in Salt Lake City, UT; is Assistant Professor of Emergency Medicine, Adjunct in the Department of Emergency Medicine at Wexner Medical Center at The Ohio State University; and Contributing Medical Editor, Urgent Care Reviews and Perspectives,
Brett C Ebeling, MD practices in the Department of Emergency Medicine at Genesis Healthcare System in Zanesville, OH and is Contributing Medical Editor, Urgent Care Reviews and Perspectives, Hippo Education.