Global research highlights - March 2020

Every quarter, the African Journal of Emergency Medicine, in partnership with several other regional emergency medicine journals, publishes abstracts from each respective journal. Abstracts are not necessarily linked to open access papers, but where green access is available it is linked to.  Click 'Read More' to read further.

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments
Borobia AM, et al. Ann Emerg Med. 2020 Mar;75(3):315-328
Study objective:
The objective of the InMEDIATE study was to evaluate the change in intensity of traumatic pain over the first 20 min in adult patients treated with methoxyflurane versus standard analgesic treatment in Spain. This the first randomized, active-controlled, multicenter trial of methoxyflurane in the emergency setting in Europe.
Methods:
This was a randomized, controlled study that enrolled adult patients with acute moderate to severe (score ≥4 on the 11-point Numeric Rating Scale) trauma-associated pain in 14 Spanish emergency departments. Patients were randomized 1:1 to methoxyflurane (up to 2×3 mL) or standard analgesic treatment. Coprimary endpoints were the change from baseline in Numeric Rating Scale pain intensity score during the first 20 minutes of treatment and time to first pain relief.
Results:
Three hundred five patients were randomized (methoxyflurane 156; standard analgesic treatment 149). Most patients in the standard analgesic treatment group (70%) received intravenous first-step analgesics and 9.4% of patients were treated with opioids. Mean decrease from baseline in Numeric Rating Scale pain intensity score was greater for methoxyflurane than standard analgesic treatment at all points, with a significant treatment difference overall up to 20 minutes (repeated-measures model 2.47 versus 1.39; treatment difference 1.00; 95% confidence interval 0.84 to 1.32). Median time to first pain relief was significantly shorter for methoxyflurane than standard analgesic treatment (3 versus 10 minutes). Methoxyflurane achieved better patient and clinician ratings for pain control and comfort of treatment than standard analgesic treatment and exceeded patient and clinician expectations of treatment in, respectively, 77% and 72% of cases compared with 38% and 19% for standard analgesic treatment.
Conclusion:
These results support consideration of methoxyflurane as a nonnarcotic, easy-to-administer, rapid-acting, first-line alternative to currently available analgesic treatments for trauma pain.
​Reproduced with permission

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Feasibility and efficacy of a hospital-based violence intervention program on reducing repeat violent injury in youth: a randomized control trial
​Snider CE, et al. CJEM. 2019 Oct 24:1-8
Objectives:
To determine feasibility and efficacy of an Emergency Department Violence Intervention Program (EDVIP) to reduce violence related injuries in youth.
Methods:
One hundred and thirty youth aged 14-24 presenting to an emergency with violence related injury were randomized in parallel to receive EDVIP for 1 year (n = 65) or a waitlist control (n = 65). The primary outcome was to determine feasibility. Secondary outcomes are incidence, number/severity of repeat violence related injury, justice and education systems interactions, substance misuse and mental health presentations, and ED length of stay (LOS).
Results:
This study established feasibility in recruitment, outcomes collection and safety. Fidelity and adherence measures required optimization during the study. Efficacy analysis of EDVIP vs. the control group demonstrates an absolute decrease of 10.4% in repeat violence related injury (13.7% vs. 24.1%) (p = 0.15), reduction in new interactions in the justice system (OR = 0.36 (0.07-1.77)), improved engagement in education (11.8% EDVIP vs. 7.6% control, p = 0.42) and no change in repeat visits for substance or mental health. LOS decreased by 59.5 min (p = 0.21).
Conclusions:
This program is feasible for ED implementation and for completion of a future RCT to measure effectiveness.
Reproduced with permission

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Physical frailty and its impact on long-term outcomes in older patients with acute heart failure after discharge from an emergency department 
Llopis García G, et al. Emergencias. 2019;31:413-6
Objective: To study the frequency of physical frailty and explore whether its presence in older patients with acute heart failure (AHF) is associated with adverse outcomes in the year after discharge from a emergency department (ED). 
Methods: Prospective observational cohort study in patients with AHF aged 75 years or older who were discharged from our ED. Physical frailty was defined by a score of 7 or less on the Short Physical Performance Battery. The outcome was the development of a composite event (ED revisit for AHF, hospital readmission for AHF, or all-cause mortality) within 365 days of discharge from the ED. 
Results: Eighty-six patients with a mean (SD) age of 84 (6) years were included; 59.3% were women. Frailty was identified in 49 patients (57%). The composite outcome was observed in 46.5% within 365 days. Physical fragility was an independent predictor of the outcome (adjusted odds ratio, 3.6; 95% CI, 1.0–12.9; P=.047). 
Conclusions: Frailty in older patients with AHF may predict a poor outcome during the year following discharge from an emergency department. 
​Reproduced with permission

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What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?
Jafar AJN, et al. Emerg Med J. 2020 Feb;37(2):58-64
Background: In 2017, the WHO produced its first minimum data set (MDS) for emergency medical team (EMT) daily reporting during the sudden-onset disasters (SODs), following expert consensus. The MDS was deliberately designed to be simple in order to improve the rate of data capture; however, it is new and untested. This study assesses the inter-rater agreement between practitioners when performing the injury aspect of coding within the WHO EMT MDS.
Methods: 25 clinical case vignettes were developed, reflecting potential injuries encountered in an SOD. These were presented online from April to July 2018 to practitioners who have experience of/training in managing patients in SODs The practitioners were from UK-Med’s members, Australian Medical Assistance Team’s Northern Territory members and New Zealand Medical Assistance Team members. Practitioners were asked to code injuries according to WHO EMT MDS case classifications. Randolph’s kappa statistic for free-marginal multirater data was calculated for the whole dataset as well as subgroups to ascertain inter-rater agreement.
Results: 86 practitioners responded (20.6% response rate), giving >2000 individual case responses. Overall agreement was moderate at 67.9% with a kappa of 0.59 (95% CI 0.49 to 0.69). Despite subgroups of paramedics (kappa 0.63, 95% CI 0.53 to 0.72), doctors (kappa 0.61, 95% CI 0.52 to 0.69) and those with disaster experience (kappa 0.62, 95% CI 0.52 to 0.71) suggesting slightly higher agreement, their CIs (and those of other subgroups) suggest overall similar and moderate levels of practitioner agreement in classifying injuries according to the MDS categories.
Conclusions: An inter-rater agreement of 0.59 is moderate, at best, however, it gives ministries of health some sense of how tightly they may interpret injury data derived from daily reports using WHO EMT MDS. Furthermore, this kappa is similar to established but more complex (thus more contextually impractical) injury scores. Similar studies, with weighting for injury likelihood using sample data from SODs would further refine the level of expected inter-rater agreement.
Reproduced with permission

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