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| |  ACEP: New Studies Challenge Validity of Commonly Held Beliefs By Jeanne Lenzer SAN FRANCISCO, CA -- October 20, 2004 -- Commonly held beliefs in emergency medicine are being challenged by new studies and by critical analyses of older studies, said W Richard Bukata, MD, associate clinical professor of emergency medicine, University of Southern California Medical Center, Los Angeles, California, and Jerome R. Hoffman, MD, professor of medicine/emergency medicine, University of California, Los Angeles, California. Drs. Bukata and Hoffman presented their "Clinical Pearls in Emergency Medicine" here October 17th at the American College of Emergency Physicians Annual Meeting. Widely held beliefs that do not stand up to scientific scrutiny include some of the following, they said: Myth: The diagnosis of appendicitis can be difficult to make in children, and computed tomography (CT) scans can achieve good diagnostic accuracy. Evidence: Of 616 children evaluated between 1997 and 2001, 50% underwent imaging preoperatively; 30% had a CT scan, and 17% had ultrasonography. The rate of negative exploratory surgeries (12% in 1997 and 7% in 2001) and perforation (36% in 1997 and 33% in 2001) were not significantly different (J Pediatr Surg. May 2003;38(5):659-662). Conclusion: Preoperative CT scanning increased from 1% in 1997 to 58% in 2001, yet the utilization of CT scanning "has not been associated with a significant reduction in the rate of negative appendectomy or of perforation," concluded Dr Hoffman. Although some studies show that CT or other imaging techniques are superior to clinical impression in identifying appendicitis or other diagnoses, such studies should be read with care if they are not identifying actual outcome measures. Although the use of CT may have benefits in some children, the risks of radiation from radiation exposure may be of some concern in this population. Myth: Urinalysis should be performed in all women suspected of having a urinary tract infection (UTI). Evidence: Multiple studies of dipstick urinalysis in women with UTIs proven by urine culture show sensitivities of 75% to 92%. The prevalence of UTI in women with urinary symptoms is 50% and rises to 90% or more in women with a strong history, defined as absence of vaginal symptoms and discharge (Emerg Med J. Jul 2003;20(4):362-363). Conclusion: Urine dipstick analysis is insufficiently sensitive to rule out UTI in women and can lead many doctors to treat based on symptoms. "If a test doesn't change what you're going to do, there's no need to do the test," said Dr Bukata. Myth: Patients with abdominal pain should not be given analgesics before assessment by a surgeon because it interferes with surgical assessment and increases the risk of perforation. Evidence: Findings from several studies are consistent with a recent study of 279 patients aged 15 or older who underwent surgery, in which 41% of patients received parenteral analgesics including anti-inflammatory agents and narcotics prior to surgical consultation (Emerg Med J 2004;21(1):41-43). Time to surgery was 13.9 hours in patients receiving analgesics and 18.9 hours in patients not treated with analgesics. The perforation rate was 21.7% and 21.3%, respectively. Conclusion: The use of parenteral analgesics, including narcotics, did not delay surgery or result in any statistically significant change in the rates of perforation.
[Presentation title: Clinical Pearls From the Recent Medical Literature (Part 1). Abstract SU-63]
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