Erector spinae plane block (ESPB) for intractable, non-surgical abdominal pain: a scoping review.

Abdominal pain is one of the most common presenting chief complaints in the emergency department (ED). Erector spinae plane block (ESPB) is an ultrasound-guided nerve block with proven effectiveness in treating visceral and somatic abdominal pain. Despite the increasing popularity of ESPB, its role in the management of non-surgical abdominal pain has not yet been characterized. Our scoping review aims to review the current literature on the safety and efficacy of ESPB in the management of patients experiencing intractable, non-surgical abdominal pain. We searched PubMed and Scopus to evaluate the existing literature on ESPB for non-surgical abdominal pain. Reviewers screened 30 titles and abstracts that met the predefined inclusion and exclusion criteria. Following initial screening, 24 articles underwent full-text review. Two reviewers also screened references included in each study. A total of 14 journal articles were reviewed, including 12 case-based studies, one systematic review, and one narrative review of ESPB in the treatment of non-surgical abdominal pain. All cases described the successful use of ESPB in treating abdominal pain refractory to oral or intravenous analgesic medications, and each case reported no complications. This scoping review provides support for ESPB in the management of intractable, non-surgical abdominal pain. ESPB demonstrates efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain. Theoretical risks such as pneumothorax, bleeding, and infection are possible, although the studies reviewed did not report such complications.

The impact of emergency medicine residents on clinical productivity.

CONTEXT: Faculty productivity is of interest for hospital and university administrators as pressure is placed on them by government and private payors. Further, the effect of trainees on clinical productivity is of personal interest to physicians because their performance evaluations and earning potential are often tied to their productivity. Several groups have utilized creative methodology to study the effect of learners on emergency department (ED) productivity, but they were faced with multiple confounding variables for which it was difficult to adjust. In this study, we utilize relative value unit (RVU)/h to study the effect of resident physicians and medical students on the productivity of academic emergency physicians (EPs) during the implementation of a new residency program. Each physician's productivity on shifts with distinct types of learners present is compared to their shifts worked without any learners during the same time frame. Each attending physician serves as their own control while the confounding variables introduced by comparing over multiple years are minimized. OBJECTIVES: The objective of this study is to measure the influence of emergency medicine (EM) residents on the clinical productivity of attending EPs. METHODS: We conducted an observational study of a single ED during implementation of a new residency program. The productivity of each EP was measured by RVU/h billed. Trainees' schedules and end-of-shift evaluations were utilized to determine what learners (if any) were working with the EP on each shift. RVU/h calculations were performed for each EP (overall, when working without learners, and when working with each of the four learner categories). The primary outcome (determined a priori) was the difference in RVU/h for the attending EPs when they worked without learners compared to when they worked a majority of their shift with at least one learner. The secondary outcome (also determined a priori) was determining the influence of the learners of each type on EP RVU/h for the subgrouped shifts in which a learner was present for the majority of the shift. RESULTS: There was no significant difference in mean EP RVU/h when attendings worked with a medical student or non-EM R1 in comparison to working without learners in the 1761 ED encounters analyzed (12.95 RVU/h vs. 12.52 RVU/h; p=0.125). Although there was variability among individual physicians, EP RVU/h increased significantly for the overall group when one or more EM R1s were present (15.19 RVU/h with one EM R1 present, 15.25 RVU/h with two, 24.75 RVU/h with three; p<0.001). Similarly, mean EP productivity increased significantly with the addition of an EM R2 (17.96 RVU/h vs. 16.84 RVU/h; p=0.001). CONCLUSIONS: The presence of EM residents was positively associated with the clinical productivity of EM faculty as measured by RVU/h. There was also a positive association between productivity and the number of EM residents present as well as their training level. Non-EM residents and medical students had no effect on EP productivity.

Long-term treatment retention of an emergency department initiated medication for opioid use disorder program.

INTRODUCTION: Medication for Opioid Use Disorder (MOUD) has been shown to decrease mortality, reduce overdoses, and increase treatment retention for patients with opioid use disorder (OUD) and has become the state-of-the-art treatment strategy in the emergency department (ED). There is little evidence on long-term (6 and 12 month) treatment retention outcomes for patients enrolled in MOUD from the ED. METHODS: A prospective observational study used a convenience sample of patients seen at one community hospital ED over 12 months. Patients >18 years with OUD were eligible for MOUD enrollment. After medical screening, patients were evaluated by the addiction care coordinator (ACC) who evaluated and counselled the patient and if eligible, directly connected them with an addiction medicine appointment. Once enrolled, the patient received treatment with buprenorphine in the ED. A chart review was completed for all enrollments during the first year of the program. Treatment retention was determined by review of the prescription drug monitoring program and defined as patients receiving regular suboxone prescriptions at 6 and 12 months after index ED visit date. RESULTS: From June 2018 - May 2019 the ACCs evaluated patients during 691 visits, screening 571 unique patients. Of the 571 unique patients screened, 279 (48.9%) were enrolled into the MOUD program. 210 (75.3%) attended their first addiction medicine appointment, 151 (54.1%) were engaged in treatment at 1 month, 120 (43.0%) at 3 months, 105 (37.6%) at 6 months, and 97 (34.8%) at 12 months post index ED visit. Self-pay insurance status was associated with a significantly decrease in the odds of long-term treatment retention. CONCLUSION: Our ED-initiated MOUD program, in partnership with local addiction medicine services, produced high rates of long-term treatment retention.

The use of tDCS as a therapeutic option for tinnitus: a systematic review / O uso da tDCS como opção terapêutica para o zumbido: uma revisão sistemática

Abstract Introduction: Due to the subjectivity of the tinnitus diagnosis and its diverse etiologies, establishing an effective treatment is complex. In this context, transcranial direct current stimulation, a noninvasive option, is available for most patients and has shown good results in the treatment of other symptoms such as chronic pain. Objective: To evaluate the therapeutic response of tinnitus to transcranial direct current stimulation. Methods: A systematic review of the literature was performed using the following descriptors: tinnitus, transcranial direct current stimulation and randomized clinical trial. The research was carried out in the MEDLINE/PUBMED, Lilacs, and Scielo databases. The inclusion criteria were: patients over 18 years of age with no associated comorbidities, who had a diagnosis established by a specialist or through the application of previously validated scales and criteria applied by a non-specialist physician. Results: A total of 4165 studies were found, and a total of six were selected after the inclusion criteria were applied, obtaining a sample of 602 patients. Based on the defined criteria, there was a positive response to transcranial direct current stimulation in 14.86% of the participants. Conclusion: Based on literature studied, there is no therapeutic response of tinnitus to transcranial direct current stimulation.

Resumo Introdução: Devido à subjetividade do diagnóstico do zumbido e a suas diversas etiologias, o estabelecimento de um tratamento eficaz é complexo. Nesse contexto surge a transcranial direct current stimulation, uma opção não invasiva, acessível para grande parte dos pacientes, e que tem apresentado bons resultados no tratamento de outros sintomas como dor crônica. Objetivo: Avaliar a resposta terapêutica do zumbido ao transcranial direct current stimulation. Método: Foi realizada uma revisão sistemática da literatura, por meio dos seguintes descritores: zumbido, transcranial direct current stimulation e ensaio clínico randomizado. A pesquisa foi realizada nas bases de dados MEDLINE/PubMed, Lilacs, Scielo. Os critérios de inclusão foram: pacientes maiores de 18 anos sem outras comorbidades associadas, que tiveram diagnóstico estabelecido por um especialista ou por meio da aplicação de escalas e critérios previamente validados aplicados por médico não especialista. Resultados: Foram encontrados 4.165 estudos, sendo selecionado após a aplicação dos critérios de inclusão um total de seis, obtendo-se uma amostra de 602 pacientes. A partir dos critérios definidos, houve uma resposta positiva ao transcranial direct current stimulation em 14.86% dos participantes. Conclusão: Baseada na presente revisão, não há ainda uma resposta terapêutica do zumbido ao transcranial direct current stimulation.

The use of tDCS as a therapeutic option for tinnitus: a systematic review.

INTRODUCTION: Due to the subjectivity of the tinnitus diagnosis and its diverse etiologies, establishing an effective treatment is complex. In this context, transcranial direct current stimulation, a noninvasive option, is available for most patients and has shown good results in the treatment of other symptoms such as chronic pain. OBJECTIVE: To evaluate the therapeutic response of tinnitus to transcranial direct current stimulation. METHODS: A systematic review of the literature was performed using the following descriptors: tinnitus, transcranial direct current stimulation and randomized clinical trial. The research was carried out in the MEDLINE/PUBMED, Lilacs, and Scielo databases. The inclusion criteria were: patients over 18 years of age with no associated comorbidities, who had a diagnosis established by a specialist or through the application of previously validated scales and criteria applied by a non-specialist physician. RESULTS: A total of 4165 studies were found, and a total of six were selected after the inclusion criteria were applied, obtaining a sample of 602 patients. Based on the defined criteria, there was a positive response to transcranial direct current stimulation in 14.86% of the participants. CONCLUSION: Based on literature studied, there is no therapeutic response of tinnitus to transcranial direct current stimulation.