• Take a Seat—Your Patients Will Thank You
  • Buddy Taping vs Plaster Casting in Boxer’s Fractures
  • Efficacy of Baclofen in Back Pain
  • Rapid Testing for Gonorrhea and Chlamydia
  • Five- vs 10-day Treatment for Strep Throat
  • A Better Screening Test for ACL Rupture

Yijung Russell, MD

Sitting During an Encounter Is an Easy Way to Increase Patient Satisfaction

Key Point: If a provider sits during an encounter, the patient feels that they care more, listen more, inform better, is polite, and spends more time.

Citation: Orloski CJ, Tabakin ER, Shofer FS, et al. Grab a seat! Nudging providers to sit improves the patient experience in the emergency department. J Patient Exp. 2019;6(2):110-116.

Relevance: The hurried nature of acute care does not create an ideal setting for good communication, and patient satisfaction frequently suffers for perceived lack of it. Additionally, there is a positive correlation between effective communication and compliance. There are both verbal and nonverbal aspects of communication—and both can be improved.

Study Summary: The authors completed a prospective trial in two academic EDs—one control and one intervention. In the intervention ED, exam rooms had folding chairs for providers and signs saying Grab a Seat. Of 2,827 patients who were given a 12-question survey before and after the chairs were placed, only 13% thought it was important for providers to sit during encounters. However, the results indicate that sitting at any time during the encounter led to a perception that the providers cared more, listened more, informed better, were more polite, and spent more time with them. In addition, placing a chair with the Grab a Seat sign in the room increased the chance of providers sitting by 30%.

Buddy Taping Is Noninferior to Plaster Casting for Uncomplicated Boxer’s Fractures

Key point: Buddy taping the ring and little finger in uncomplicated boxer’s fractures results in similar functional outcomes as plaster casting, fewer missed days of work, and shorter ED stays.

Citation: Pellatt R, Fomin I, Pienaar C, et al. Is buddy taping as effective as plaster immobilization for adults with an uncomplicated neck of fifth metacarpal fracture? A randomized controlled trial. Ann Emerg Med. 2019;74(1):88-97.

Relevance: Fractures of the fifth metacarpal bone (ie, boxer’s fractures) are among the more common hand injuries seen in urgent care. Boxer’s fractures which are minimally displaced, closed, and isolated injuries with <70% angulation are considered uncomplicated and managed nonsurgically with various methods of immobilization, including buddy taping and use of plaster casts and splints. As these methods offer different timelines for patients to return to work and hobbies, it is important to characterize and compare their efficacies.

Study Summary: Ninety-seven patients with uncomplicated boxer’s fractures were randomized to receive either buddy taping or plaster casting. Hand function at 12 weeks was measured via the quickDASH questionnaire, which presents 11 questions that assess pain, disability, and ability for everyday tasks. At 12 weeks, both groups had quickDASH scores of 0 (lowest degree of disability). There was also no difference in pain or satisfaction scores at 12 weeks, with both groups reporting a high level of satisfaction with their treatment. In addition, patients randomized to receive plaster casting missed a median of 2 days of work whereas patients in the buddy tape group missed none. Finally, the buddy taping group had a median length of ED stay that was 36 minutes shorter than that of the plaster casting group.

Adding Baclofen to Ibuprofen for Acute Lower Back Pain Does Not Improve Outcomes

Key point: Adding a muscle relaxant to ibuprofen led to no difference in disability or pain level at 1 week post ED visit for acute lower back pain.

Citation: Friedman BW, Irizarry E, Solorzano C, et al. A randomized, placebo-controlled trial of ibuprofen plus metaxalone, tizanidine, or baclofen for acute low back pain. Ann Emerg Med. 2019;74(4):512-520.

Relevance: Providers often prescribe “muscle relaxants” along with NSAIDs for patients who present with lower back pain in the acute care setting. This study sought to identify whether addition of a “muscle relaxant” made a meaningful difference when added to ibuprofen.

Study Summary: In this randomized, double-blind study, 320 patients presenting with functionally impairing back pain for <2 weeks were allocated to receive either ibuprofen and placebo or ibuprofen and a “muscle relaxant” (metaxalone, tizanidine, or baclofen). At 1 week postvisit, patients completed the Roland-Morris Disability Questionnaire, a validated scale often used in back pain research. In addition, patients were asked to score their pain level as none, mild, moderate, or severe. After 1 week of treatment, the average RMDQ score decreased from 19 to 10.8, with no significant difference detected among the four groups. There was also no clinically significant difference in reported pain levels or adverse events.

Rapid Gonorrhea/Chlamydia Testing Reduces Errors in Treatment

Key point: Rapid GC and chlamydia testing in the ED significantly decreased under- and overtreatment of patients without increasing length of stay.

Reference: Gaydos CA, Ako M-C, Lewis M, et al. Use of a rapid diagnostic test for Chlamydia trachomatis and Neisseria gonorrhoeae for women in the emergency department can improve clinical management: report of a randomized clinical trial Ann Emerg Med. 2019;74(1):36-44.

Relevance: Sexually transmitted infection (STI) in women with C trachomatis and N gonorrhea is common and the incidence of both infections is increasing in the U.S.—with widespread consequences, including infertility. However, the results of current assays are not available for 2-4 days, making their utility in the acute care setting limited. 

Study Summary: In this randomized study, 254 women clinically deemed to need a pelvic exam and testing for GC/CT were allocated to receive standard-of-care nucleic acid amplification testing or the FDA-approved rapid point-of-care GC/CT test GeneXpert, in addition to the standard-of-care. In the latter group, there was 100% agreement in results between nucleic acid amplification and GeneXpert. The results show that 46% and 57% of patients infected with C trachomatis and N gonorrhea, respectively, were inappropriately not treated in the standard-of-care group. There was no undertreatment in the GeneExpert group. In addition, there was a significant increase in overtreatment (treatment in women who did not test positive for either organism) in the standard-of-care group when compared with the GeneXpert group.

Five days of Penicillin is Noninferior to 10 Days for Strep Throat

Key point: Five days of treatment with QID penicillin V was noninferior to 10 days of TID treatment in confirmed strep pharyngitis, and led to faster relief of symptoms and decreased adverse events.

Citation: Skoog Ståhlgren G, Tyrstrup M, Edlund C, et al. Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337.

Relevance: Sore throat is one of the most common presenting symptoms in acute care settings, with group A streptococcus (GAS) the most common pathogen implicated. Current guidelines recommend 10 days of treatment with antibiotics for GAS pharyngitis. In the setting of antibiotic resistance, it is important for us to act as stewards in using antimicrobials as effectively as possible. In addition, reducing treatment duration could increase patient adherence and decrease side effects (such as impacting the patients’ microbiota).

Study Summary: In this randomized, noninferiority multicenter study, 433 patients were allocated to be treated with either penicillin V 800 mg QID for 5 days or 1000 mg TID for 10 days. The primary outcome was clinical cure at 5─7 days after the end of antibiotic treatment at the test-of-cure visit. Clinical cure at evaluation was 89.6% in the 5-day treatment group and 93.3% in the 10-day treatment group, with the 95% confidence interval crossing the noninferiority line (-10.04 to 1.9). In addition, only four patients, all in the 10-day group, experienced complications. Finally, time to first day of relief from symptoms was significantly shorter in the 5-day group according to the patients’ treatment diaries.

The Lever Test Can Detect ACL Rupture with 100% Sensitivity

Key point: The lever test was 100% sensitive and 93.75% specific for rupture of the anterior cruciate ligament, whereas the anterior drawer/Lachman test was only 40% sensitive and 100% specific for ACL rupture.

Citation: McQuivey KS, Christopher ZK, Chung AS, et al. Implementing the lever sign in the emergency department: does it assist in acute anterior cruciate ligament rupture diagnosis? A pilot study. J Emerg Med. 2019;57(6):805-811.

Relevance: There are an estimated 200,000 cases of ACL tear in the U.S. annually. Untreated, ACL tears can lead to deterioration of the meniscus and, ultimately, to the necessity for total joint arthroplasty. A recent study estimated that only 26% of acute ACL tears are correctly diagnosed in the emergency setting. It is important to develop better methods to screen for ACL injury.

Study Summary: Forty-five patients were allocated to be screened for ACL tear using either the lever test or anterior drawer/Lachman test. In a subsequent follow-up, a sports medicine specialist completed evaluation of the patient, including MRI of the knee. Results show that the lever test is 100% sensitive, whereas the anterior drawer test is 40% sensitive for ACL injury. However, the lever test had 94% specificity while the anterior drawer/Lachman test had 100% specificity.

Abstracts in Urgent Care
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Yijung Russell, MD