Recording of the webinar on Monday 6 December 2021.
Rural health news and research from the Rural Section, Dept. GP and Rural Health
Recording of the webinar on Monday 6 December 2021.
Medical RiSC is a course run by the University of Otago Rural Postgraduate Programme. Designed specifically for interprofessional rural hospital teams in New Zealand, it is an immersive three-day course that focuses on emergency medical care using highly realistic skills simulations and workshops.
We are inviting rural hospital doctors, nurses, paramedics and rural GPs to attend and extend their clinical knowledge and skills for medical emergency management.
Is looking to be a great course!
Sign up your team or attend as an individual!
Register @ bit.ly/RuralCME-StrokeUpdate
Recording from the latest Rural CME webinar in case you missed it or want to watch it again. Below are some additional resources including Dan’s Pneumonic device for delirium (I CLAP in time).
There are some really good printable self help guides here; https://web.ntw.nhs.uk/selfhelp/
I often recommend people have a look at https://www.headspace.com/ which is a smart phone app that teaches / guides people through relaxation exercises.
http://www.mhaids.health.nz/your-health/help-for-mild-to-moderate-mental-health-issues/ is a page with a lot of links to other support resources and there are a whole load of other information and support agencies out there.
I CLAP (in time)
I Inattention (most sensitive sign)
C Cognitive Impairment (Think of the domains on the MoCA)
L Level of Consciousness (usually decreased but can be increased arousal)
A Affective changes (usually depression)
P Perceptual disturbance (visual hallucinations)
These are the classic symptoms of delirium.
They occur ACUTELY and TEND TO FLUCTUATE (that’s the ‘time’ bit).
Conway JC, Friedman BW. Medical Expulsive Therapy (Alpha Blockers) for Urological Stone Disease. Academic Emergency Medicine. 2020 Feb 7. EZ Proxy link
A systematic review that updates the Cochrane review from 2014. Table summarising findings below: Alpha blockers appear safe and effective, especially if stone >5mm, for expelling stone and reducing need for hospital admissions.
Urinary tract stones are common and usually painful. Lifetime prevalence is approximately 10%.1 Direct health care costs are estimated to be over $10 billion dollars annually.2 First‐line treatment is typically analgesia with nonsteroidal anti‐inflammatory drugs until the stone passes. If the stone does not pass spontaneously, urologic intervention may be necessary.3 Spontaneous passage rates for small stones less than 5 mm is 68% and for stones between 5 and 10 mm is 47%.4 Certain medications such as alpha blockers are sometimes used to hasten passage of stones and decrease the need for urologic intervention or hospitalization. Alpha blockers act on ureteral alpha‐1 receptors and decrease the basal tone and peristalsis, thereby facilitating stone passage.5 However, conflicting results from randomized controlled trials (RCTs) have limited their use. The systematic review discussed here is an update of a 2014 Cochrane review.6 It includes several new, large, RCTs.
The purpose of this systematic review was to determine the effectiveness of alpha blockers for adult patients with symptomatic ureteral stones measuring less than 1 cm and confirmed by imaging. The systematic review included 67 trials with 10,509 patients. The included studies compared alpha blockers with placebo or medical therapy with non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. The primary outcomes were stone clearance (defined as stone free imaging, symptomatic relief, or stone collection by the last day of the trial) and major adverse events (defined as orthostatic hypotension, collapse, syncope, palpitations, or tachycardia). Secondary outcomes included hospitalization and the need for surgical intervention. Subgroup analysis compared stone clearance rates for stones 5 mm or smaller versus stones greater than 5 mm. Further analyses examined only high‐quality studies, excluding studies at high risk of bias.6
Overall, the use of alpha blockers was associated with increased stone passage (relative risk [RR] = 1.45, 95% confidence interval [CI] = 1.36 to 1.55, absolute risk difference [ARD] = 28%, number needed to treat [NNT] = 4, low‐quality evidence) without increasing the risk of major adverse events. Alpha blockers were also associated with a lower risk of hospitalization (RR = 0.51, 95% CI = 0.34 to 0.77, ARD = 14%, NNT = 7, moderate‐quality evidence) and no difference in the risk of surgical intervention (low‐quality evidence). The subgroup analysis based on the size of the stone revealed that alpha blockers did not impact passing of stones ≤ 5 mm but did improve passing of stones > 5 mm (RR = 1.45, 95% CI = 1.22 to 1.72, ARD = 30%, NNT = 3, moderate‐quality evidence).6 When the analysis was performed using high‐quality trials only, alpha blockers increased stone passing (RR = 1.09, 95% CI = 1.06 to 1.13; ARD = 7%, NNT = 15, high‐quality evidence, five studies, 4,133 participants) while having no effect on major adverse events, hospitalization, or surgical intervention.6
This review is limited in several ways. Most importantly, the quality of evidence for most outcomes was low due to several methodologic limitations of the included studies, inconsistency in study results, publication bias, a lack of prospectively stratified subgroups, and clinically important heterogeneity.
The findings of this meta‐analysis are consistent with other recently published meta‐analyses.7 However, some included RCTs, such as the SUSPEND trial, did not demonstrate a benefit for MET.8–10 The findings of individual RCTs may have been skewed toward no benefit because of limited sample size, a high percentage of smaller stones, and insufficient power to detect group differences between small and large stones. Additionally, a recent, large RCT, the STONE trial, was not included in this meta‐analysis. The STONE trial, which included 512 patients found no significant differences in outcomes.11 These findings are unsurprising as this trial has the same limitations as other individual RCTs. Because of the lack support for MET by several well‐designed RCTs, it is important to counsel patients on the potential limitations of the evidence that is being used to recommend MET.
In summary, using alpha blockers appears to be beneficial in increasing ureteral stone passage (especially if stones are >5 mm) and reducing hospitalization. They appear to be safe as they do not increase the risk of major adverse events when compared to placebo, non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. Because benefit is likely (particularly for stones larger than 5 mm) and there is no apparent harm, we have assigned a color recommendation of green (benefits > harm) to this treatment.
Parker CM and Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019;144(3):e20183772
Comment from Yan:
Parker et al concluded that there is no significant difference between dexamethasone 0.6mg/kg, 0.15 mg/kg and prednisolone at 1 mg/kg in the treatment of croup in this prospective, double-blind, noninferiority randomised controlled trial in an Australian tertiary ED paediatric population. Primary outcomes were an hourly croup score and 7 days re-attendance rate.
My biggest criticism of this otherwise well carried out trial was that only 1 in 7 croup cases were enrolled (deemed ‘convenience sample’). There was also no analysis to look at any potential differences between the enrolled and non enrolled group. The study in the end did not achieve the pre-determined target number of subjects for the non inferiority analysis, but the confidence intervals clearly overlap across the groups.
Also 30% of enrolled patients did not have phone follow up (meaning GP re-attendance not accounted for in this group). Note also that the single dose prednisolone 1mg/kg group is more likely to require further doses of steroids than the dexamethasone groups. I think this study still doesn’t answer the question about which steroid to give these kids conclusively.
In practice, this study seems not to contradict what is probably the most common practice in rural—for the bulk of croup patients, prescribe single dose oral dexamethasone if available or a course of prednisolone if not (Starship recommends 2 days at 1mg/kg.)
OBJECTIVES: The use of either prednisolone or low-dose dexamethasone in the treatment of childhood croup lacks a rigorous evidence base despite widespread use. In this study, we compare dexamethasone at 0.6 mg/kg with both low-dose dexamethasone at 0.15 mg/kg and prednisolone at 1 mg/kg.
METHODS: Prospective, double-blind, noninferiority randomized controlled trial based in 1 tertiary pediatric emergency department and 1 urban district emergency department in Perth, Western Australia. Inclusions were age >6 months, maximum weight 20 kg, contactable by telephone, and English-speaking caregivers. Exclusion criteria were known prednisolone or dexamethasone allergy, immunosuppressive disease or treatment, steroid therapy or enrollment in the study within the previous 14 days, and a high clinical suspicion of an alternative diagnosis. A total of 1252 participants were enrolled and randomly assigned to receive dexamethasone (0.6 mg/kg; n = 410), low-dose dexamethasone (0.15 mg/kg; n = 410), or prednisolone (1 mg/kg; n = 411). Primary outcome measures included Westley Croup Score 1-hour after treatment and unscheduled medical re-attendance during the 7 days after treatment.
RESULTS: Mean Westley Croup Score at baseline was 1.4 for dexamethasone, 1.5 for low-dose dexamethasone, and 1.5 for prednisolone. Adjusted difference in scores at 1 hour, compared with dexamethasone, was 0.03 (95% confidence interval −0.09 to 0.15) for low-dose dexamethasone and 0.05 (95% confidence interval −0.07 to 0.17) for prednisolone. Re-attendance rates were 17.8% for dexamethasone, 19.5% for low-dose dexamethasone, and 21.7% for prednisolone (not significant [P = .59 and .19]).
CONCLUSIONS: Noninferiority was demonstrated for both low-dose dexamethasone and prednisolone. The type of oral steroid seems to have no clinically significant impact on efficacy, both acutely and during the week after treatment.
Yan Wong is a rural doctor in Balclutha, Otago. He is also a convener for the GENA725 – Communication in Rural Hospital Medicine, which is running in semester 1 of this year. This course covers palliative care, Māori health, mental health, alcohol and drugs/addiction among other things, all with a rural context focus. The residential is based on a marae in the beautiful Hoikianga
Recording of the inaugural webinar hosted by Dr. Matilda Hamilton. Gerry Wilkins, a cardiologist at Dunedin Hospital gives an update on Atrial Fibrillation.
Webinar will be recorded and posted here for viewing when suits.