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      Intranasal Desmopressin Compared with Intravenous Ketorolac for Pain Management of Patients with Renal Colic Referring to the Emergency Department: A Randomized Clinical Trial

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          Abstract

          Background

          This double-blind randomized clinical trial aimed at comparing the effect of intranasal desmopressin with that of intravenous ketorolac in pain management of patients with renal colic referring to the emergency department.

          Methods

          The patients were randomly divided to two groups. One group received intravenous ketorolac 30 mg and intranasal normal saline, while, the other one received intranasal desmopressin 40 μg and 1 mL of intravenous distilled water. The patients’ pain was evaluated using the visual analog scale at the time of admission, 10, 30, and 60 minutes after drug administration.

          Results

          Overall, 40 patients with mean age of 32.53 ± 6.91 participated in this study. Gender ratio (P = 0.288), mean age (P = 0.165), and mean pain score on arrival (P = 0.694) had no significant difference. The mean pain scores, 10, 30, and 60 minutes after drug administration in the ketorolac group was significantly lower than the desmopressin group, and decreased more rapidly (P < 0.001).

          Conclusions

          It is likely for desmopressin to be less efficacious than ketorolac, and desmopressin leads to a significant alleviation of pain in patients with renal colic.

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          Most cited references 16

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          Clinically important change in the visual analog scale after adequate pain control.

          To define the minimum clinically important difference (MCID) for the visual analog scale (VAS) of pain severity by measuring the change in VAS associated with adequate pain control. The authors conducted a prospective, observational study. Adult emergency department (ED) patients with acute pain (<72 hours) were eligible. Patients rated their pain severity on a 100-mm VAS on presentation and at discharge. Patients were asked if they would accept any analgesic, then if they would accept a parenteral analgesic before treatment. At discharge, they were asked whether they had received adequate pain control. The authors enrolled 143 patients (mean age, 36 years; 54% female). The mean decrease in VAS was -30.0 mm (95% confidence interval [CI] = -36.4 to -23.6) for the 116 of 143 (81%) patients with adequate pain control at discharge vs. -5.7 (95% CI = -11.2 to -0.3) for the 27 with inadequate pain control (p < 0.001). At discharge, the mean VAS was 31.3 mm for those with adequate pain control vs. 55.1 for those without. Mean VAS for the 114 of 143 patients who would accept any analgesics initially was 64.7 vs. 47.1 for the 29 reporting no analgesic need. Initially, 77 patients would accept parenteral analgesics (mean VAS = 72.5 mm). A mean reduction in VAS of 30.0 mm represents a clinically important difference in pain severity that corresponds to patients' perception of adequate pain control. Defining MCID based on adequate analgesic control rather than minimal detectable change may be more appropriate for future analgesic trials, when effective treatments for acute pain exist.
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            Emergency department visits, use of imaging and drugs for urolithiasis have increased in the United States

            The occurrence of urolithiasis in the United States has increased, however, information on long-term trends, including recurrence rates, is lacking. Here we describe national trends in rates of emergency department visits, use of imaging, and drug treatment primarily using the National Hospital Ambulatory Medical Care Surveys to describe trends and the National Health and Nutrition Examination Survey to determine the frequency of lifetime passage of kidney stones. Emergency department visit rates for urolithiasis increased from 178 to 340 visits per 100,000 individuals from 1992 to 2009. Increases in visit rates were greater in women, Caucasians and in those 25–44 years of age. The use of computed tomography in urolithiasis patients more than tripled, from 21% to 71%. Medical expulsive therapy was used in 14% of patients with a urolithiasis diagnosis in 2007–2009. Among National Health and Nutrition Examination Survey participants who reported a history of kidney stones, 22.4% had passed three or more stones. Hence, emergency department urolithiasis visit rates have increased significantly, as has the use of computed tomography in the United States. Further research is necessary to determine whether recurrent stone formers receive unnecessary radiation exposure during diagnostic evaluation in the emergency department, and allow development of corresponding evidence-based guidelines.
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              Interventional Pain Management According to Evidence-Based Medicine

              Evidence-based medicine (EBM) endeavors to apply the best available evidence gained from scientific methods to clinical decision making (1). It aims to assess the strength of the evidence based on both the risks and benefits of treatments and diagnostic tests. The quality of the evidence can be evaluated from the source type (mostly from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials), as well as other factors which include statistical validity, efficacy, clinical relevance, currency, and peer-review acceptance (2). A systematic review is, however, the best method in order to identify, and critically evaluate all relevant research on the effectiveness of a particular treatment. Initially, EBM was called, “a critical appraisal,” as it described the application of basic rules of evidence. This evidence was first presented by a group of clinical epidemiologists at McMaster University in 1990, usage of this technique later expanded to all medical fields, and it has now found global acceptance. In our practice, it is generally accepted that interventional pain management techniques have gained a definite place in the management of chronic pain syndromes. Actually, the most important goal of pain medicine is to use a specific treatment; conservative and/or interventional, for the right patient at the right time. Therefore, treatment selection should be made according to the clinical diagnoses. In reality, patients receive treatments that vary both due to their geographical location, as well as the specialty of the treating physicians. According to the literature, the treatment of pain syndromes should involve a multidisciplinary approach and should ideally entail the evaluation and treatment of the patient by; physicians, physical therapists, and psychologists well-versed in the complex biopsychosocial and pathophysiological causes in the development and maintenance of pain syndromes. For the correct application of interventional pain management techniques, both a good theoretical knowledge, as well as practical experience is mandatory. In evaluating the literature and developing recommendations, the Cochrane Database and other recent systematic reviews are emphasized the most. Efficacy of a procedure or drug is considered to have been demonstrated if the results of a randomized clinical trial (RCT) are found to give statistically significant greater pain reduction, versus a placebo for the primary outcome measure, and the results are then assessed by the centers responsible for levels of EBM. All medications or procedures with efficacy supported by at least one systematic review or positive placebo-controlled or procedure or dose-response RCT, in which the reduction of chronic pain is a primary or co-primary endpoint, are considered for inclusion. Published data, unpublished data (if available), and the clinical experience of the authors are used to evaluate each of these modalities in terms of their degree of efficacy, safety, tolerability, drug interactions, ease of use, and impact on health-related quality of life. Nowadays, with such a plethora of pain knowledge findings, the efficacy of pain management techniques have been described in multiple randomized controlled trials, observational studies, retrospective studies, and case reports. So, usually there is lots of existing information and data to support any clinical practice. Finally, evidence-based practice guidelines are written by the organizations responsible, and these provide a good review of the literature in a context that makes it accessible and useful to both the clinician and researcher (3, 4). Having looked at this issue from different aspects, one comes to understand that in the new and modern world of pain practice, EBM, systematic reviews, and guidelines are a major part of interventional pain management. A well designed management strategy starts with an accurate evaluation process to identify the pain diagnosis. It is of the utmost importance that so-called red flags are checked first, as they may be indicative of an underlying primary pathology, which needs adequate attention and treatment prior to the application of symptomatic pain management techniques. With interventional pain management techniques, a non-algorithmic approach to patients can be problematic or overly expensive, so interventionist should always remain cautious. Consequently, evidence based practice guidelines are of greater practical value when they are specific for each different pain diagnosis. It is recommended that the interventionist takes note of the algorithmic pattern and follows the rules, meanwhile observing the patient for potential red flags. The series of articles published in the EBM section of pain practice and pain physician journals have covered the most important pain diagnoses and using these guidelines is strongly recommended to all pain physicians. These guidelines could help to solve the above mentioned impediments. These articles have been published between 2009 up to the present time. Different pain syndromes such as; trigeminal neuralgia, cervical and lumbar radicular pain, facetogenic pain, headaches, phantom pain, and post herpetic neuralgia, have been described in these articles and an algorithmic treatment approach has been planned for them. Essentially, this series of articles forms global guidelines for interventional pain management. Due to the continual development of more specific diagnostic tools and to the improved understanding of pathophysiology, and consequently the mechanism of action of the different pain treatment options, it is generally accepted that treatment selection for chronic pain syndromes will become based more on the mechanism. Careful attention to this evolution is warranted and, when necessary, updates to the guidelines should be made. More and more guidelines are being released according to the recent literature and if necessary these are corrected by the latest findings (5, 6). Based on the philosophy that guideline panels should make recommendations on whether to administer, or not administer, a particular intervention, the taskforce chose to classify recommendations into strong and weak levels. The relationship between the quality of evidence and strength of the recommendation are complex issues, which requires the careful consideration of numerous factors. For this purpose multiple meetings and panels have been facilitated by pain organizations to gather different opinions in order to design or revise a guideline (6, 7). The modern pain physician realizes that scientific and relevant evidence is essential in clinic care, policy-making, dispute resolution, and law. Thus, evidence-based pain practice provides strong, acceptable, trustworthy information by; systematically acquiring, analyzing and transferring research findings into clinical, management, and policy arenas (7-9). It is hoped that in the near future more attention will be payed to these aspects of pain practice by pain physicians and that further useful guidelines for each parts of this field are created, so a treatment can only be recommended when the effects of it, have been proven in well-designed trials and analyzed by centers with appropriate expertise.
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                Author and article information

                Journal
                Anesth Pain Med
                Anesth Pain Med
                10.5812/aapm.
                Kowsar
                Anesthesiology and Pain Medicine
                Kowsar
                2228-7523
                2228-7531
                25 February 2017
                April 2017
                : 7
                : 2
                Affiliations
                [1 ]Department of Emergency Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                [2 ]Department of Anesthesiology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                [3 ]Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran
                Author notes
                [* ]Corresponding author: Kambiz Nasiri Gigloo, Department of Emergency Medicine, Imam Hossein Hospital, Shahid Madani, Tehran, Iran. Tel: +98-9367023703, E-mail: kambiznasiry@ 123456gmail.com
                Article
                10.5812/aapm.43595
                5556593
                b27d42d0-621a-48da-8b61-48987780bbb4
                Copyright © 2017, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

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