A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic

Superior efficacy of intramuscular diclofenac compared to intravenous tramadol for acute renal colic in northern Thai patients: A randomised double-blind, sham-controlled trial

OBJECTIVE

The present study aimed to compare time to effective pain relief between diclofenac 75 mg intramuscular (IM) and tramadol 50 mg intravenous (IV) for ED patients with acute renal colic.

METHODS

A randomised, double-blinded, sham-controlled, superiority trial was conducted. Patients diagnosed with acute renal colic (hydronephrosis and/or stone visualisation on point-of-care ultrasound) in the ED were randomly assigned to receive an IM injection of 75 mg of diclofenac or IV tramadol 50 mg. Pain relief was defined as a numerical rating scale reduction of two or more points (standard 0-10 scale) and a reduction of at least one level of pain transition question ('much better', 'little better', 'unchanged', 'little worse', 'much worse'). The primary outcome was the multivariable-adjusted subdistribution-hazard ratio (SHRs) within 120 min in the ED, estimated using the cumulative incidence function (CIF). The secondary outcome compared the average time to pain relief using the restricted mean survival time (RMST).

RESULTS

A total of 68 patients were randomised, with 34 patients allocated to each group. At the 120 min, pain relief was reported in diclofenac and tramadol, 32 (94%) and 22 (65%) patients respectively. SHR was 2.86 (95% CI: 1.80-4.55; P value <0.001). For diclofenac and tramadol, the RMSTs were 37.09 min (95% CI: 30.00, 44.15) and 78.74 min (95% CI: 66.49, 90.99) respectively, with the difference of 41.67 min (95% CI: 55.71, 27.62).

CONCLUSION

Diclofenac 75 mg IM provides faster effective pain relief compared with tramadol 50 mg IV.

Development and validation of a predictive model for acute kidney injury in patients with ureterolithiasis

OBJECTIVES

This study aims to identify risk factors for acute kidney injury (AKI) in patients with ureterolithiasis and to develop a predictive model for early AKI detection in this population.

METHODS

A retrospective analysis was conducted on data from 1,016 patients with ureterolithiasis who presented to our outpatient emergency department between January 2021 and December 2022. Using multifactorial logistic regression, we identified independent risk factors for AKI and constructed a nomogram to predict AKI risk. The predictive model's efficacy was assessed through the area under the ROC curve, calibration curves, Hosmer-Lemeshow (HL) test, and decision curve analysis (DCA).

RESULTS

AKI was diagnosed in 18.7% of the patients. Independent risk factors identified included age, fever, diabetes, hyperuricemia, bilateral calculi, functional solitary kidney, self-medication, and prehospital delay. The nomogram demonstrated excellent discriminatory capabilities, with AUCs of 0.818 (95% CI, 0.775-0.861) for the modeling set and 0.782 (95% CI, 0.708-0.856) for the validation set. Both calibration curve and HL test results confirmed strong concordance between the model's predictions and actual observations. DCA highlighted the model's significant clinical utility.

CONCLUSIONS

The predictive model developed in this study provides clinicians with a valuable tool for early identification and management of patients at high risk for AKI, thereby potentially enhancing patient outcomes.

Effect of Early-Intervention Acupuncture on Pain Relief Among Emergency Department Patients with Suspected Acute Renal Colic Due to Urinary Calculi: Study Protocol for a Randomized Clinical Trial

Introduction

Analgesia is often delayed for suspected acute renal colic due to urinary calculi (ARCUC) even in emergency department. Acupuncture has a rapid onset and is effective for analgesia, however, evidence about early-acupuncture for suspected ARCUC is limited. This trial aims to evaluate the efficacy of early-intervention acupuncture compared with sham acupuncture on pain relief among emergency department suspected ARCUC patients.

Methods and Analysis

A total of 84 eligible patients who are suspected diagnosed with ARCUC will be randomly allocated to the acupuncture group or the sham acupuncture group. Each patient will receive 1 session of acupuncture or sham acupuncture before diagnostic imaging. The primary outcome will be the response rate at 10 min after needle manipulation, defined as the proportion of patients whose Numeric Rating Scale (NRS) score decrease by at least 50% from baseline. Secondary outcomes will include pain intensity assessed by NRS, further analgesia requirement, revisit rate, surgical intervention rate, satisfaction evaluation, and adverse events. The final diagnosis rate determined by radiography will be recorded and reported. All patients who receive randomization will be included in the intention-to-treat analysis.

Conclusion

This study's findings are anticipated to evaluate the analgesic effect of early-intervention acupuncture for acute renal colic in emergency department, which could be useful for moving the timing of analgesia forward and aligning pain management for acute renal colic more with the guidelines.

Trial Registration Number

ChiCTR2100049069 (https://www.chictr.org.cn/showproj.html?proj=125338).

Enhancing analgesia in acute renal colic pain: a randomized controlled trial of gabapentin adjunct to ketorolac-based regimen

Background

Renal colic is characterized by severe pain that is highly disabling. Gabapentin, an antiepileptic medication, is often recommended as a first-line therapy for neuropathic pain. However, its effectiveness in managing somatic pain, which is defined as the result of activity by pain receptors in the deep tissues, such as renal colic pain, is not as well-established.

Method

A phase 3 randomized clinical trial was conducted to evaluate the adjuvant analgesic effects of gabapentin on acute renal colic pain. Eligible patients participated in the study via random allocation to the control or gabapentin groups using the block randomization method. All patients received a shared regimen of ketorolac and rescue morphine as the conventional analgesic treatment for renal colic pain. Gabapentin was added as an adjuvant analgesic for the gabapentin group.

Result

A total of 63 individuals with an average age of 41.35 ± 13.08, were enrolled and completed the study. At the time of admission, there were no significant differences between the baseline characteristics of two groups, with exception of weight. The gabapentin group showed a significantly higher percentage of patients with pain severity of less than 5 after 60 and 90 min, as well as a significantly lower percentage of morphine rescue requirement and total morphine intake (mg) and mg/kg.

Conclusion

In cases of acute renal colic, gabapentin significantly decreases both the amount of morphine required and the degree of pain, indicating that it may be a useful adjutant to standard analgesic regimens. Treatment regimens that include gabapentin may help individuals manage their pain and become less reliant on opioids.

Clinical Trial Registration

https://irct.behdasht.gov.ir/trial/56066, identifier: IRCT20200322046833N2.

A novel opioid/pramipexole combination treatment for the management of acute pain: a pilot study

Purpose

Despite their dangerous side effects, opioid drugs remain a standard of care for moderate to severe pain with few alternatives. Strategies to maintain the analgesic effects of opioids while minimizing the associated risks are needed. Pre-clinical studies have shown using a dopamine 3 receptor (D3R) agonist as an adjuvant to morphine provides superior analgesia against painful stimuli compared to morphine alone. Our objective was to test if adjunct treatment with a D3R agonist can lead to a reduction in opioid use while maintaining effective analgesia.

Patients and methods

This study was set up as a double-blinded, placebo-controlled randomized trial. Enrollment included acute renal colic patients presenting to the emergency department, from which patients were randomized to either the "control" or "study arm". The control group received standard treatment of care (morphine, 0.1 mg/kg; i.v.) and an oral placebo pill. The experimental group received half-dosed morphine and oral pramipexole pill (0.25 mg). Pain measurements including a numerical pain scale and visual analog scale were collected from enrollees at baseline and every subsequent 15 min.

Results

A total of 19 patients completed the study, 10 in the experimental arm and 9 in the control arm. During the study period, effective analgesia (50% decrease from baseline) was achieved in 80% of patients in the experimental arm vs. 33.3% in the control arm.

Conclusion

Our pilot clinical trial demonstrated that D3R recruitment can serve as an effective adjuvant to low-dose morphine for control of renal colic pain and potentially other acute pain conditions.

Clinical Trial Registration

ClinicalTrials.gov, identifier, (NCT04160520).

Transcutaneous electrical nerve stimulation (TENS) for pain control in women with primary dysmenorrhoea

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological treatment that works by delivering electrical currents via electrodes attached to the skin at the site of pain. It can be an alternative to pharmacological treatments. The mechanism of action of TENS for pain relief is related to the inhibition of the transmission of painful stimuli, release of endogenous opioids, and reduced muscle ischaemia of the uterus. Although it has been used for primary dysmenorrhoea ((PD); period pain or menstrual cramps), evidence of the efficacy and safety of high-frequency TENS, low-frequency TENS, or other treatments for PD is limited.

OBJECTIVES

To evaluate the effectiveness and safety of transcutaneous electrical nerve stimulation (TENS) in comparison with placebo, no treatment, and other treatments for primary dysmenorrhoea (PD).

SEARCH METHODS

We searched the Gynaecology and Fertility Group's Specialized Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, and the Korean and Chinese language databases up to 9 April 2024. We also searched for ongoing trials in trials registries and the reference lists of relevant studies for additional trials. Language restrictions were not applied.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that included women (aged 12 to 49 years) with PD. Included trials compared low-frequency TENS or high-frequency TENS with other TENS, placebo, or other treatment.

DATA COLLECTION AND ANALYSIS

Four review authors screened the trials, extracted the data according to the protocol, assessed the risk of bias using RoB 2, and assessed the certainty of evidence for all review comparisons and primary outcomes (i.e. pain relief and adverse effects) using the GRADE approach.

MAIN RESULTS

This review replaces the current review, published in 2009. We included 20 RCTs involving 585 randomized women with high-frequency TENS, low-frequency TENS, placebo or no treatment, or other treatment. We included five comparisons: high-frequency TENS versus placebo or no treatment, low-frequency TENS versus placebo or no treatment, high-frequency TENS versus low-frequency TENS, high-frequency TENS versus other treatments, and low-frequency TENS versus other treatments. High-frequency TENS versus placebo or no treatment High-frequency TENS may reduce pain compared with placebo or no treatment (mean difference (MD) -1.39, 95% confidence interval (CI) -2.51 to -0.28; 10 RCTs, 345 women; low-certainty evidence; I2 = 88%). Two out of three RCTs reported no adverse effects and hence we were unable to estimate the effect of high-frequency TENS on adverse effects. Low-frequency TENS versus placebo or no treatment Low-frequency TENS may reduce pain compared with placebo or no treatment (MD -2.04, 95% CI -2.95 to -1.14; 3 RCTs, 645 women; low-certainty evidence; I2 = 0%). No trials reported adverse effects for this comparison. High-frequency TENS versus low-frequency TENS It is uncertain whether high-frequency TENS had an effect on pain relief compared with low-frequency TENS (MD 0.89, 95% CI -0.19 to 1.96; 3 RCTs, 54 women; low-certainty evidence; I2 = 0%). One trial contributed data on adverse effects but no adverse events occurred. High-frequency TENS versus other treatments It is uncertain whether high-frequency TENS had an effect on pain relief compared to acupressure (MD -0.66, 95% CI -1.72 to 0.40; 1 RCT, 18 women; very low-certainty evidence), acetaminophen (paracetamol) (MD -0.98, 95% CI -3.30 to 1.34; 1 RCT, 20 women; very low-certainty evidence), and interferential current therapy (MD -0.03, 95% CI -1.04 to 0.98; 2 RCTs, 62 women; low-certainty evidence; I2 = 0%). The occurrence of adverse effects may not differ significantly between high-frequency TENS and NSAIDs (OR 12.06, 95% CI 0.26 to 570.62; 2 RCTs, 88 women; low-certainty evidence; I2 = 78%). Low-frequency TENS versus other treatments It is uncertain whether low-frequency TENS had an effect on pain relief compared with acetaminophen (MD -1.48, 95% CI -3.61 to 0.65; 1 RCT, 20 women; very low-certainty evidence). No trials reported adverse effects for this comparison.

AUTHORS' CONCLUSIONS

High-frequency TENS and low-frequency TENS may reduce pain compared with placebo or no treatment. We downgraded the certainty of the evidence because of the risk of bias. Future RCTs should focus more on secondary outcomes of this review (e.g. requirement for additional analgesics, limitation of daily activities, or health-related quality of life) and should be designed to ensure a low risk of bias.

Visceral Adiposity and Its Impact on Nephrolithiasis: A Narrative Review

Kidney stones represent a serious medical problem, resulting from several factors such as diet, genetics, and certain medical conditions. Visceral adipose tissue has been shown in recent research to play a significant role in kidney stone formation, making it a more precise indicator than traditional obesity indicators such as body mass index. The main aim of this review is to summarize studies on visceral obesity as a predictive marker for nephrolithiasis and to highlight new mechanistic pathways such as adipokine-mediated inflammation and its impact on kidney stone formation. This review emphasizes the importance of considering visceral fat in the prevention and management of kidney stones, suggesting that targeted strategies to reduce visceral fat could decrease the incidence of kidney stones and their management costs. Further prospective studies are needed to validate these findings and propose preventive strategies based on visceral adiposity assessments.

Renal screening sonography-A comparative study in a Portuguese basic emergency service

INTRODUCTION

Renal Point-of-Care Ultrasound (POCUS) is a screening modality that aids in clinical decision-making for patients with suspected renal colic. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with the imaging findings at the Referral Hospital (RH).

METHODS

Thirty-one patients suspected of having renal pathology underwent initial sonography screening with POCUS at the BES and were subsequently referred to the RH for additional imaging examinations. The results of both examinations were compared to verify whether the findings from the BES were confirmed by the radiologist in the RH and to ensure that the patient referrals from BES to RH were appropriate.

RESULTS

In our sample, the majority of patients (80%) exhibited varying degrees of pyelocaliceal distension, with nearly half (48%) patients presenting obstructions. A strong association between the sonographic findings in the BES and the RH was found in the variables 'Dilatation of pyelocaliceal system' (V = 0.895; P = 0.00), 'Simple cystic formation' (V = 0.878; P = 0.000), respectively. There was a statistically significant correlation between BES and RH findings, indicating a strong association between these two variables, respectively (k = 0.890; P = 0.000) and (k = 0.870; P = 0.000). There was also a strong statistically significant correlation in the ultrasonographic findings between BES and RH performers (k = 0.890; P = 0.000 and k = 0.870; P = 0.000). In this research, an achieved sensitivity of 96% and a specificity of 85% were demonstrated in the identification of pyelocaliceal dilatation.

CONCLUSION

Renal POCUS screening successfully detected abnormalities in the urinary system of patients suspected of having renal colic. The sonographic findings at the BES had a good correlation with the complementary imaging results obtained at the RH in Portugal. These results suggest that Radiographers/Sonographers can have an important role in the preliminary assessment of urgent renal pathology in remote areas, contributing to a correct referral and early treatment.

[Renal colic]

INTRODUCTION

Renal colic accounts for 5-10% of all emergency department visits, making it a common condition in acute medicine. The typical clinical presentation is an early indication of urolithiasis.

DIAGNOSIS

Diagnostic measures include laboratory tests, ultrasound, and low-dose noncontrast computed tomography (CT) scans. Kidney, ureter, bladder (KUB) plain film radiography has been widely replaced by low-dose noncontrast CT with similar radiation dosage. In special patient groups such as children or pregnant women, ionizing radiation should be avoided if possible.

TREATMENT

General measures involve pain management (non-steroidal anti-inflammatory agents, opioids) and empirical antibiotic treatment for suspected bacterial infection. Depending on the location/size of the stone, pharmacological stone expulsion therapy may be considered. In cases of obstructive pyelonephritis or acute renal insufficiency, early urinary drainage (JJ stent/nephrostomy) is recommended. Definitive stone removal may be performed primarily in some cases (rather small and rather distal ureterolithiasis). It is common to schedule stone removal as a secondary intervention.

Prevention, diagnosis, and treatment of urolithiasis in geriatric patients - differences, similarities and caveats in comparison to the general population

PURPOSE OF REVIEW

Purpose of the review is to address management and prevention of urolithiasis in elderly patients examining the dynamic interplay between general measures, dietary adjustments, lifestyle modifications, and targeted pharmacological and/ or surgical interventions. The goal is to provide understanding of the evolving strategies required for effective urolithiasis prevention in the geriatric population.

RECENT FINDINGS

Age-specific diagnostic considerations are necessary because urolithiasis in the elderly population is characterized by bigger stones, greater peri-operative risks, and heightened symptom severity. When comorbidities are present, conservative treatments - especially analgesia - provide difficulties. Surgical procedures prove to be safe and effective, with complication rates and practical application comparable to younger cohorts. Prevention approaches that include lifestyle changes and the investigation of novel pharmaceutical options such as sodium-dependent glucose co-transporter 2 (SGLT-2)-inhibitors are promising in the management of urolithiasis in the elderly population.

SUMMARY

Our review offers a thorough investigation of urolithiasis in the elderly population, elucidating distinct clinical manifestations, complex diagnostic issues, and treatment implications. The safety and effectiveness of ureteroscopy in older patients, as well as the possible prophylactic function of SGLT-2-I, offer crucial insights for clinicians. Subsequent studies are necessary to enhance age-specific therapies, addressing the distinct obstacles presented by urolithiasis in the elderly population within this rapidly growing demographic.

Trends in Opioid and Nonsteroidal Anti-Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments from 2015 to 2021

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location

BACKGROUND

The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates.

PURPOSE

To identify predictors of revisits among patients with ureteral calculi in the ED.

DESIGN, SETTING, AND PARTICIPANTS

Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit.

RESULTS

Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021).

CONCLUSIONS

Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Acupuncture for response and complete pain relief time of acute renal colic: Secondary analysis of a randomized controlled trial

Background

The integration of acupuncture with intramuscular injection of diclofenac sodium can expedite the onset of analgesia in treating acute renal colic caused by urolithiasis. However, it remains unclear whether acupuncture can accelerate pain relief constantly until complete remission. This study aimed to explore the extent to which acupuncture can expedite the onset time of response or complete pain relief in treating acute renal colic, and the predictive value of patient characteristics for treatment efficacy.

Methods

This secondary analysis utilized data from a prior randomized controlled trial. Eighty patients with acute renal colic were randomly assigned 1:1 to the acupuncture group or the sham acupuncture group. After intramuscular injection of diclofenac sodium, acupuncture or sham acupuncture was delivered to patients. The outcomes included time to response (at least a 50 % reduction in pain) and complete pain relief. Between-group comparison under the 2 events was estimated by Kaplan-Meier methodology. Subgroup analysis was performed utilizing the Cox proportional hazards model.

Results

The median response time and complete pain relief time in the acupuncture group were lower than those in the sham acupuncture group (5 vs 30 min, Log Rank P < 0.001; 20 min vs not observed, Log Rank P < 0.001, respectively). Hazard Ratios (HRs) for response across all subgroups favored the acupuncture group. All HRs for complete pain relief favored acupuncture, expect large stone and moderate pain at baseline. No interaction was found in either event.

Conclusion

Acupuncture can accelerate the response time and complete pain relief time for patients with acute renal colic, with the efficacy universally.

Trial registration

This study has been registered at Chinese Clinical Trial Registry: ChiCTR1900025202.

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department

BACKGROUND

The optimal pain relief method for acute renal colic in the emergency department remains controversial.

OBJECTIVE

We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

METHODS

This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

RESULTS

VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

CONCLUSIONS

ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Nonopioid Pain Management Pathways for Stone Disease

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Clinical patterns and implications of prescription opioid use in a pediatric population for the management of urolithiasis in the emergency room

Extrapolations from the adult population have suggested that opioids should be avoided in the management of pediatric urolithiasis, but the literature is sparse with regards to actual practice patterns and the downstream implications. We sought to investigate the rate of oral opioid administration for children presenting to the emergency room (ER) with urolithiasis and to identify associations between opioid administration and return visits and persistent opioid use. The TriNetX Research and Diamond Networks were used for retrospective exploratory and validation analyses, respectively. Patients <18 years presenting to the emergency room with urolithiasis were stratified by the receipt of oral opioids. Propensity score matching was performed in a 1:1 fashion. Incident cases of opioid administration and risk ratios (RRs) for a return ER visit within 14 days and the presence of an opioid prescription at 6 to 12 months were calculated. Of the 4672 patients in the exploratory cohort, 11.9% were prescribed oral opioids. Matching yielded a total of 1084 patients. Opioids at the index visit were associated with an increased risk of return visits (RR 1.51, 95% CI 1.04-2.20, P = 0.03) and persistent opioid use (RR 4.00, 95% CI 2.20-7.26, P < 0.001). The validation cohort included 6524 patients, of whom 5.7% were prescribed oral opioids. Matching yielded a total of 722 patients and demonstrated that opioids were associated with an increased risk of return visits (RR 1.50, 95% CI 1.04-2.16, P = 0.03) but not persistent opioid use (RR 1.70, 95% CI 0.79-3.67, P = 0.17). We find that the opioid administration rate for pediatric urolithiasis appears reassuringly low and that opioids are associated with a greater risk of return visits and persistent use.

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis

BACKGROUND

Renal colic is a disease in which a calculus obstructs the urinary tract, resulting in severe pain do ureteric peristaltic movements. Other symptoms, such as hematuria, nausea, and vomiting, may accompany the pain. This network meta-analysis aimed to compare the efficacy and safety of different analgesic agents for the treatment of acute renal colic.

METHODS

Medline, Embase, and CENTRAL databases were searched. Randomized controlled trials (RCTs) that compared different analgesic agents, either alone or in combination were included. For the management of acute renal colic, analgesic agents were selected based on the current standard medical practice. The medications included intravenous acetaminophen, ketamine, ketorolac, and morphine. This study sought to evaluate the pain score on the visual analog scale (VAS) at 15, 30, and 60 min; adverse events; and the utilization of rescue therapy. The efficacy of different analgesic agents was explored through a frequentist network meta-analysis using the Netmeta statistical package in R software. All treatments were ranked using the Netrank function, yielding P-scores.

RESULTS

Twelve RCTs were deemed eligible. As per the P-scores, acetaminophen was the most effective in reducing pain score at 15 min (P-score = 0.74). Ketorolac was the most effective in reducing the pain score at 30 and 60 min (P-score = 0.84) (P-score = 0.99), whereas morphine was the least effective (P-score = 0.07). Moreover, morphine was correlated with the highest odds of adverse events after treatment (P-score = 0.89). Morphine was the most frequently required rescue therapy in cases of suboptimal pain relief (P-score = 0.96).

CONCLUSION

This network meta-analysis demonstrated that ketorolac and acetaminophen were the most effective analgesic agents according to the pain score. Morphine showed the highest adverse event profile and the highest rate at which rescue therapy was required for the management of acute renal colic.

Obstructive nephropathy and molecular pathophysiology of renal interstitial fibrosis

The kidneys play a key role in maintaining total body homeostasis. The complexity of this task is reflected in the unique architecture of the organ. Ureteral obstruction greatly affects renal physiology by altering hemodynamics, changing glomerular filtration and renal metabolism, and inducing architectural malformations of the kidney parenchyma, most importantly renal fibrosis. Persisting pathological changes lead to chronic kidney disease, which currently affects ∼10% of the global population and is one of the major causes of death worldwide. Studies on the consequences of ureteral obstruction date back to the 1800s. Even today, experimental unilateral ureteral obstruction (UUO) remains the standard model for tubulointerstitial fibrosis. However, the model has certain limitations when it comes to studying tubular injury and repair, as well as a limited potential for human translation. Nevertheless, ureteral obstruction has provided the scientific community with a wealth of knowledge on renal (patho)physiology. With the introduction of advanced omics techniques, the classical UUO model has remained relevant to this day and has been instrumental in understanding renal fibrosis at the molecular, genomic, and cellular levels. This review details key concepts and recent advances in the understanding of obstructive nephropathy, highlighting the pathophysiological hallmarks responsible for the functional and architectural changes induced by ureteral obstruction, with a special emphasis on renal fibrosis.

Efficacy and Safety of Ketamine Versus Opiates in the Treatment of Patients with Renal Colic: A Systematic Review and Meta-analysis

INTRODUCTION

Renal colic is one of the most common urological emergencies, and is usually caused by ureteral colic spasms. Pain management in renal colic remains the central focus of emergency treatment. The purpose of this meta-analysis is to identify the efficacy and safety of ketamine versus opioids in the treatment of patients with renal colic.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and Web of Science databases for published randomized controlled trials (RCTs) that referred to the use of ketamine and opioids for patients with renal colic. The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI) was used to analyze the data. The results were pooled using a fixed-effects model or random-effects model. The primary outcome measure was patient-reported pain scores 5, 15, 30, and 60 min after drug administration. The secondary outcome measure was side effects.

RESULTS

The data analysis revealed that ketamine was similar to opioids in pain intensity at the time of 5 min post-dose (MD = - 0.40, 95% CI - 1.82 to 1.01, P = 0.57), 15 min post-dose (MD = - 0.15, 95% CI - 0.82 to 0.52, P = 0.67), 30 min post-dose (MD = 0.38, 95% CI - 0.25 to 1.01, P = 0.24). Also, the pain score of ketamine was better than that of opioids at 60 min after administration (MD = - 0.12, 95% CI - 0.22 to - 0.02, P = 0.02). As for safety, the ketamine group was linked to a significant decrease in the incidence of hypotensive (OR = 0.08, 95% CI 0.01-0.65, P = 0.02). The two groups did not statistically differ in the incidence of nausea, vomiting, and dizziness.

CONCLUSIONS

Compared with opioids, ketamine showed a longer duration of analgesia in renal colic, with satisfactory safety.

TRIAL REGISTRATION

The PROSPERO registration number is CRD42022355246.

Comparison of intravenous paracetamol (acetaminophen) to intravenously or intramuscularly administered non-steroidal anti-inflammatory drugs (NSAIDs) or opioids for patients presenting with moderate to severe acute pain conditions to the ED: systematic review and meta-analysis

OBJECTIVE

Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opiates/opioids, administered parenterally via intravenous or intramuscular route, are widely used to provide analgesia for patients with moderate to severe pain. This systematic review and meta-analysis evaluated the level of analgesia provided by intravenous paracetamol (IVP) alone compared with NSAIDs (intravenous or intramuscular), or opioids (intravenous) alone in adults attending the ED with acute pain.

METHODS

Two authors independently searched PubMed (MEDLINE), Web of Science, Embase (OVID), Cochrane Library, SCOPUS and Google Scholar (3 March 2021-20 May 2022) for randomised trials without any language or date restriction. Clinical trials were evaluated using the Risk of Bias V.2 tool. The primary outcome was mean difference (MD) for pain reduction at 30 min (T30) post analgesia delivery. The secondary outcomes were MD in pain reduction at 60, 90 and 120 min; the need for rescue analgesia; and the occurrence of adverse events (AEs).

RESULTS

Twenty-seven trials (5427 patients) were included in the systematic review and 25 trials (5006 patients) in the meta-analysis. There was no significant difference in pain reduction at T30 between the IVP group and opioids (MD -0.13, 95% CI -1.49 to 1.22) or IVP and NSAIDs (MD -0.27, 95% CI -1.0 to 1.54. There was also no difference at 60 min, IVP group versus opioid group (MD -0.09, 95% CI -2.69 to 2.52) or IVP versus NSAIDs (MD 0.51, 95% CI 0.11 to 0.91). The quality of the evidence using Grading of Recommendations, Assessments, Development and Evaluations methodology was low for MD in pain scores.The need for rescue analgesia at T30 was significantly higher in the IVP group compared with the NSAID group (risk ratio (RR): 1.50, 95% CI 1.23 to 1.83), with no difference found between the IVP group and the opioid group (RR: 1.07, 95% CI 0.67 to 1.70). AEs were 50% lower in the IVP group compared with the opioid group (RR: 0.50, 95% CI 0.40 to 0.62), whereas no difference was observed in the IVP group compared with the NSAID group (RR: 1.30, 95% CI 0.78 to 2.15).

CONCLUSION

In patients presenting to the ED with a diverse range of pain conditions, IVP provides similar levels of pain relief compared with opiates/opioids or NSAIDs at T30 post administration. Patients treated with NSAIDs had lower risk of rescue analgesia, and opioids cause more AEs, suggesting NSAIDs as the first-choice analgesia and IVP as a suitable alternative.

PROSPERO REGISTRATION NUMBER

CRD42021240099.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Diminutive Ureteral Stone Causing Caylyceal Rupture: Case Report and a Review of the Treatment Options

Rupture of the renal collecting system is a rare event, usually occurring at the ureterovesical junction (UVJ). The most common cause is nephrolithiasis, usually directly correlated with the size of the stone. Other causes include bladder outlet obstruction, ureteropelvic junction obstruction, and extrinsic ureteral compression by a malignant pathology. The mechanism is increased pressure within the collecting system, and symptoms vary from vague mild abdominal pain to severe excruciating pain. We present a case of a 19-year-old female with obstructive uropathy and renal calyceal rupture caused by a 3 mm stone at the UVJ. Due to the small size of the stone and her hemodynamic stability, she was treated conservatively with tamsulosin and IV ceftriaxone. The following day she passed sediment in the urine and noted pain improvement. Calyceal rupture with small stones is exceedingly rare, may be missed on a CT without contrast, and should be suspected when perinephric edema or fluid is seen. This is the smallest recorded stone causing calyceal rupture to the best of our knowledge. CT with contrast is indicated for diagnosis when calyceal rupture is suspected and is suggested by extravasation of contrast. Early diagnosis and intervention, in collaboration with urologists, can help to avoid long-term complications such as acute kidney injury, urosepsis, and urinoma. Conservative management may still be considered after a calyceal rupture in patients with small, potentially passable stones. However, if there is associated obstructive uropathy, infection, or significant rupture, then stenting may be indicated. This case highlights the diagnosis of calyceal rupture in the setting of tiny stones and the efficacy of conservative therapy versus early stenting in the management of stable patients.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis

PURPOSE

Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis.

METHODS

The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods.

RESULTS

Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis.

CONCLUSIONS

The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Acupressure versus parecoxib sodium in acute renal colic: A prospective cohort study

Background

Here provides a complementary treatment, acupressure at the Qiu acupoint, a novel acupoint, which potentially alleviates renal colic.

Materials and methods

90 patients were included in this study. Acupressure-group patients (n = 46) were administered acupressure at the Qiu acupoint following a preset protocol. Parecoxib sodium-group patients (n = 44) were administered parecoxib sodium (40 mg) (via the direct intravenous route). The visual analog scale (VAS) was used to evaluate pain intensity at baseline and at 1, 5, 10, 20, 30, and 120 min after initiating the intervention. Linear mixed effects model was performed to detect the rate of decrease of VAS per time and their covariant effect on the efficacy of acupressure.

Results

No significant statistical differences in baseline data and VAS scores were observed. The acupressure group obtained lower VAS scores at the 1st, 5th, 10th, and 20th minute than the parecoxib sodium group after initiating the intervention (mean: 4.33 vs. 7.61, mean difference (MD): 3.29, 95% CI: 0.23, 2.84; mean: 2.65 vs. 7.61, MD: 4.96, 95% CI: 4.44, 5.49; mean: 1.63 vs. 6.59, MD: 4.96, 95% CI: 4.48, 5.44; mean: 1.26 vs. 3.64 MD: 2.38, 95% CI: 1.87, 2.88; P < 0.05). The markedly effective rate was similar between the two groups. The linear mixed effects model demonstrated that acupressure at the Qiu point was significantly faster than parecoxib sodium in decreasing VAS scores with an estimate of -2.05 (95% CI: -2.51, -1.59, p = 0.000), especially within 10 minutes with an estimate of 0.18 (95% CI: 0.12, 0.25, p = 0.000).

Conclusion

Acupressure at the Qiu acupoint is significantly faster than parecoxib sodium in decreasing VAS scores within 10 minutes.

Clinical trial registration

http://www.chictr.org.cn/, identifier 2100047168.

Clinical efficacy of acupuncture for pain relief from renal colic: A meta-analysis and trial sequence analysis

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for relieving renal colic and reducing the risk of analgesic-related complications.

Methods

Randomized controlled trials (RCTs) comparing the efficacy of acupuncture (acupuncture group) with conventional interventions (control group) were screened from MEDLINE, EMBASE, Cochrane library databases, China Knowledge Network (CNKI), and Airiti Library till July 15, 2022. The primary outcome was the rate of effective pain relief (response rate), while secondary outcomes included the time of onset of pain relief, visual analog scale (VAS) at 30-60 min and risk of side effects.

Results

Thirteen eligible studies involving 1,212 participants published between 1992 and 2021 were analyzed. Compared with the control group, patients receiving acupuncture had a higher overall response rate [risk ratio (RR) = 1.12, 95% CI: 1.05-1.19, p = 0.0002, I ² = 41%, 1,136 patients] (primary outcome) and a faster pain relief [MD = -10.74 min, 95% CI: -12.65 to -8.82, p < 0.00001, I ² = 87%, 839 patients]. Patients receiving acupuncture had a lower pain score [MD = -0.65, 95% CI: -1.09 to -0.21, p = 0.21, I ² = 55%, 327 patients] and risk of side effects (RR = 0.11, 95% CI: 0.04-0.26, p < 0.00001, I ² = 0, 314 patients) compared to those receiving conventional interventions. Results from trial sequence analysis revealed sufficient evidence supporting the beneficial effects of acupuncture on response rate, time to pain relief, and pain score at 30-60 min.

Conclusion

Compared with conventional analgesic-based interventions, acupuncture can more efficiently relieve renal colic with fewer adverse effects. The limited number and quality of included studies warrant more clinical RCTs to support our findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022346714.

UPLC Technique in Pharmacy—An Important Tool of the Modern Analyst

In recent years, ultra-efficient liquid chromatography (UPLC) has gained particular popularity due to the possibility of faster separation of small molecules. This technique, used to separate the ingredients present in multi-component mixtures, has found application in many fields, such as chemistry, pharmacy, food, and biochemistry. It is an important tool in both research and production. UPLC created new possibilities for analytical separation without reducing the quality of the obtained results. This technique is therefore a milestone in liquid chromatography. Thanks to the increased resolution, new analytical procedures, in many cases, based on existing methods, are being developed, eliminating the need for re-analysis. Researchers are trying to modify and transfer the analytical conditions from the commonly used HPLC method to UPLC. This topic may be of strategic importance in the analysis of medicinal substances. The information contained in this manuscript indicates the importance of the UPLC technique in drug analysis. The information gathered highlights the importance of selecting the appropriate drug control tools. We focused on drugs commonly used in medicine that belong to various pharmacological groups. Rational prescribing based on clinical pharmacology is essential if the right drug is to be administered to the right patient at the right time. The presented data is to assist the analyst in the field of broadly understood quality control, which is very important, especially for human health and treatment. This manuscript shows that the UPLC technique is now an increasingly used tool for assessing the quality of drugs and determining the identity and content of active substances. It also allows the monitoring of active substances and finished products during their processing and storage.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Intranasal Ketorolac for Acute Pain in Adult Emergency Department Patients

Pain is a common complaint in the emergency department. An alternative to opioids is desirable. Oral medications are not feasible with gastrointestinal disorders or NPO. Intravenous medications require skill and time. Intravenous/intramuscular medications are painful with potential needlestick injury. Intranasal medications have rapid onset, easy administration, do not need skilled providers, and no risk of needlestick injury. A total of 28 adults with acute pain (numeric rating scale ≥ 4) received intranasal ketorolac. Numeric rating scale decreased in all: 32% complete pain relief, median (interquartile range) decrease -5 (-6.8 to -4) (p < .001). Pain relief onset was median [interquartile range] 5 (2.3, 15.0) min. Vital signs remained normal. There were no nasal mucosal changes, no complications. Minor side effects, mostly nasal burning, in 43%, resolved within 5 min. Patients and nurses were satisfied with intranasal ketorolac, and would use it again. Intranasal ketorolac had a rapid onset, was effective, safe, well tolerated with minor side effects that resolved quickly.

A methodologic survey on use of the GRADE approach in evidence syntheses published in high-impact factor urology and nephrology journals

Background

To identify and describe the use of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for rating the certainty of systematic reviews (SRs) evidence published in urology and nephrology journals.

Methods

SRs that were published in the top ten "urology and nephrology" journals with the highest impact factor according to the 2020 Journal Citation Reports (covering 2016–2020) were systematically searched and evaluated using the GRADE approach.

Results

A total of 445 SRs were researched. Sixty SRs of randomized control trials (RCTs) and/or non-randomized studies (NRSs) were evaluated using the GRADE approach. Forty-nine SRs (11%) rated the outcome-specific certainty of evidence (n = 29 in 2019–2020). We identified 811 certainty of evidence outcome ratings (n = 544 RCT ratings) as follows: very low (33.0%); low (32.1%); moderate (24.5%); and high (10.4%). Very low and high certainty of evidence ratings accounted for 55.0% and 0.4% of ratings in SRs of NRSs compared to 23.0% and 15.3% in SRs of RCTs. The certainty of evidence for RCTs and NRSs was downgraded most often for risk of bias and imprecision.

Conclusions

We recommend increased emphasis on acceptance of the GRADE approach, as well as optimal use of the GRADE approach, in the synthesis of urinary tract evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01701-x.

Effect of Adjunctive Acupuncture on Pain Relief Among Emergency Department Patients With Acute Renal Colic Due to Urolithiasis: A Randomized Clinical Trial

IMPORTANCE

Renal colic is described as one of the worst types of pain, and effective analgesia in the shortest possible time is of paramount importance.

OBJECTIVES

To examine whether acupuncture, as an adjunctive therapy to analgesics, could accelerate pain relief in patients with acute renal colic.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, sham-controlled, randomized clinical trial was conducted in an emergency department in China between March 2020 and September 2020. Participants with acute renal colic (visual analog scale [VAS] score ≥4) due to urolithiasis were recruited. Data were analyzed from October 2020 to January 2022.

INTERVENTIONS

After diagnosis and randomization, all patients received 50 mg/2 mL of diclofenac sodium intramuscular injection immediately followed by 30-minute acupuncture or sham acupuncture.

MAIN OUTCOMES AND MEASURES

The primary outcome was the response rate at 10 minutes after needle manipulation, which was defined as the proportion of participants whose VAS score decreased by at least 50% from baseline. Secondary outcomes included response rates at 0, 5, 15, 20, 30, 45, and 60 minutes, rescue analgesia, and adverse events.

RESULTS

A total of 115 participants were screened and 80 participants (66 men [82.5%]; mean [SD] age, 45.8 [13.8] years) were enrolled, consisting of 40 per group. The response rates at 10 minutes were 77.5% (31 of 40) and 10.0% (4 of 40) in the acupuncture and sham acupuncture groups, respectively. The between-group differences were 67.5% (95% CI, 51.5% to 83.4%; P < .001). The response rates of acupuncture were also significantly higher than sham acupuncture at 0, 5, 15, 20 and 30 minutes, whereas no significant difference was detected at 45 and 60 minutes. However, there was no difference between the 2 groups in rescue analgesia rate (difference 2.5%; 95% CI -8.8% to 13.2%; P > .99). No adverse events occurred during the trial.

CONCLUSIONS AND RELEVANCE

These findings suggest that acupuncture plus intramuscular injection of diclofenac is safe and provides fast and substantial pain relief for patients with renal colic compared with sham acupuncture in the emergency setting. However, no difference in rescue analgesia was found, possibly because of the ceiling effect caused by subsequent but robust analgesia of diclofenac. Acupuncture can be considered an optional adjunctive therapy in relieving acute renal colic.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900025202.

Efficacy and Safety of Acupuncture in Renal Colic Caused by Urinary Calculi in Adults: A Systematic Review and Meta-Analysis

Background

Acute renal colic caused by urinary calculi has a considerable impact on the quality of life. Pain relief is the primary goal in the management of patients with acute renal colic caused by urinary calculi. At present, there is no systematic evaluation of the efficacy and safety of manual acupuncture in the treatment of acute renal colic caused by urinary calculi in adults.

Objective

To evaluate the efficacy and safety of manual acupuncture in the treatment of acute renal colic caused by urinary calculi in adults.

Methods

Databases of PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Medical, VIP Database for Chinese Technical Periodicals (VIP), and China Biomedical Literature (SinoMed) were searched for literature and other randomized controlled registration platforms. We searched to identify the relevant randomized controlled trials from the establishment of the database to February 9, 2022. Only randomized controlled trials (RCTs) of manual acupuncture as the therapy for acute renal colic caused by urinary calculi in adults were included, whether or not the blind method is used. The patients were adults diagnosed with urinary calculi and renal colic. The control group was treated with commonly used analgesics and antispasmodics. The experimental group was treated with acupuncture as a monotherapy or as an adjuvant therapy (manual acupuncture combined with analgesics and antispasmodics). Two review authors independently assessed titles and abstracts for relevance and extracted data on study design, participants, interventions, and outcomes from potentially relevant articles. Cochrane risk bias assessment tool was used to evaluate the quality of the included study, and RevMan5.4 software was used for meta-analysis. Our primary outcomes were response rate and time duration before pain remission. Secondary outcomes were the time of complete pain relief, pain variation, need for rescue analgesia, and adverse events.

Results

Out of 1123 records identified, 15 were found to be of relevance to this study, and 1210 participants were included in the meta-analysis. The meta-analysis of the results shows that, in terms of response rate, compared with the control group, acupuncture as a monotherapy seems to have a slight advantage (RR = 1.10 (95% CI: 1.03, 1.18), I² = 28%, P=0.004), while acupuncture as an adjuvant therapy has no advantage (RR = 1.06 (95% CI: 0.95, 1.20), I² = 77%, P=0.30). In terms of duration before pain relief, acupuncture as a monotherapy had an advantage over the control group (MD = −10.28(95% CI: −14.40, −6.17), I² = 93%, P < 0.00001). Acupuncture as a monotherapy was similar to positive medication in terms of complete pain relief (MD = −7.13 (95% CI: −20.19, 5.94), I² = 95%, P=0.28). Pain variation: VAS scores at 10 min, acupuncture as a monotherapy (MD = −2.47 (95% CI: −3.40, −1.53), I² = 84%, P < 0.00001) or as an adjuvant therapy (MD = −3.38 (95% CI: −4.33, −2.43), I² = 60%, P < 0.00001) was better than the control group. VAS scores at 30 min, compared with the control group, there was no difference between acupuncture as a monotherapy (MD = −0.27 (95% CI: −1.43, 0.88), I² = 88%, P=0.64) and acupuncture as an adjuvant therapy (MD = −1.17 (95% CI: −3.15, 0.81), I² = 96%, P=0.25). VAS scores at 60 min, compared with the control group, there was no difference in the acupuncture as a monotherapy (MD = 0.58 (95% CI: −0.28, 1.45), I² = 77%, P=0.19), while acupuncture as an adjuvant therapy was better (MD = −1.22 (95% CI: −1.93, −0.51), I² = 72%, P=0.0007). VAS scores at 120 min, there was no difference in acupuncture as a monotherapy compared to the control group (MD = −0.24 (95% CI:−1.22, 0.75), I² = 0, P=0.64). One study reported on rescue analgesia. Fewer adverse events occurred in the experimental group compared to the control group.

Conclusion

In the course of manual acupuncture treatment of acute renal colic caused by urinary calculi in adults, available evidence suggests that manual acupuncture is as effective as positive treatment drugs, either as a monotherapy or as an adjunctive therapy, with the advantage of acupuncture being its rapid onset of action. However, the number of existing clinical studies is small, and the quality of evidence is generally low, so it is recommended to use it with caution. In order to further verify the above conclusions, more high-quality clinical RCTs need to be carried out. Trial Registration. The present review protocol was registered with the International Prospective Register of Systematic Reviews (CRD42019134900).

Renal and ureteric stones: a clinical review

This clinical review on renal and ureteric stones discusses how stones form, the incidence, risks, and complications associated with calculi. It reflects on the management and treatment options available, and highlights the important contribution by nurses and those working in advanced clinical practice roles in using their knowledge and rational clinical decision making to ensure timely recognition, prompt investigation, management and ongoing health promotion.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Sterile water injections for management of renal colic pain: a systematic review

BACKGROUND

Since the 1950s a small number of centres have used sterile water injections (SWI) to treat renal colic pain. We undertook this review to determine the efficacy of SWI to manage the pain of renal colic.

METHODS

We searched the electronic databases PubMed, Cochrane Central Register, CINAHL, and Scopus from database inception to 7 November 2021 for randomized controlled trials that met the inclusion criteria.

RESULTS

Six trials were included in the review (n = 894 patients). Two placebo controlled trials were included in the meta-analysis. Other trials compared SWI to Diclofenac, Morphine, or oral Paracetamol. The overall quality of the trial was low. Compared to a placebo SWI demonstrated a significant reduction in self-reported pain at 30 min (Mean difference [MD] = -4.68, 95% Confidence Interval [CI] = -5.21, -4.15. p < 0.001, I² = 0%) and at or beyond 60 min post-injection (MD = -5.34 95% CI = -5.85, -4.82, p ≤ 0.001, I² = 0%). Pain relief provided by SWI was significantly better than oral paracetamol and equivalent to Diclofenac and Morphine. No significant side-effects were attributed to SWI use in any trials.

DISCUSSION/CONCLUSION

SWI could be a suitable alternative for management of renal colic pain where alternatives such as non-steroidal anti-inflammatory and opioid drugs are either unavailable or contraindicated. However, further research is required to establish the role of SWI in renal colic pain management.

Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study

BACKGROUND

Community-based perspectives are needed to more broadly inform policy-makers, public health practitioners, prescribers, and pharmacists about community-led and broader efforts to reduce opioid overprescribing, and ultimately reduce prescription opioid use disorder, overdoses and fatalities. The aim of this study is to explore community-based perspectives on efforts to change opioid prescribing practices in their communities.

METHODS

Semi-structured interviews were conducted with 388 community stakeholders across four states (Kentucky, Massachusetts, New York, Ohio) from November 2019 to January 2020 about community approaches and goals of community-led responses to the opioid crisis. Data analysis combined deductive and inductive approaches to identify themes and sub-themes related to improving opioid prescribing practices.

RESULTS

Three major themes and different subthemes were characterized: (1) acknowledging progress (i.e., healthcare providers being part of the solution, provider education, and prescription drug monitoring programs); (2) emergent challenges (i.e., physician nonadherence with safer opioid prescribing guidelines, difficulty identifying appropriate use of opioids, and concerns about accelerating the progression from opioid misuse to drug abuse); and (3) opportunities for change (i.e., educating patients about safer use and proper disposal of opioids, expanding prescriber and pharmacist education, changing unrealistic expectations around eliminating pain, expanding and increasing insurance coverage for alternative treatment options).

CONCLUSIONS

Community stakeholders appeared to support specific opportunities to reduce prescription opioid misuse and improve safer prescribing. The opportunities included culture change around pain expectations, awareness of safe disposal, additional provider education, and increased coverage and acceptability of non-opioid treatments.

Pharmacokinetic Evaluation of a Novel Transdermal Ketoprofen Formulation in Healthy Dogs

Dogs undergo various surgical procedures such as castration, ovariohysterectomy, and other orthopedic procedures, which are known to cause inflammation and pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are very effective analgesics for alleviating postoperative pain in veterinary medicine. Ketoprofen is currently approved in Australia and the United States for treating different painful conditions in dogs. This study evaluated the pharmacokinetic parameters of ketoprofen after intravenous (IV) and transdermal (TD) administration in healthy dogs. A novel transdermal ketoprofen (TDK) formulation containing 20% ketoprofen, dissolved in a combination of 45:45% isopropanol and Transcutol, along with 10% eucalyptus oil, was developed and evaluated for in vitro dermal permeation using Franz diffusion cells. A crossover study was then conducted to determine the pharmacokinetic parameters of the formulation in six dogs following IV ketoprofen (1 mg/kg) and TDK (10 mg/kg) administration. A liquid chromatography–mass spectrometry (LC-M/MS) method was used to measure plasma concentrations of ketoprofen over time, and a non-compartmental analysis determined the pharmacokinetic parameters. The mean terminal elimination half-life (T_½ h), AUC_0-t (µg·h/mL), and mean residence time (MRT, h) between IV and TDK groups were 4.69 ± 1.33 and 25.77 ± 22.15 h, 15.75 ± 7.72 and 8.13 ± 4.28 µg·h/mL, and 4.86 ± 1.81 and 41.63 ± 32.33 h, respectively. The calculated bioavailability (F%) was ~7%, with a lag time of 30 min to achieve effective plasma concentrations after the application of TDK.

Efficacy of Intravenous Lidocaine for Pain Relief in the Emergency Department: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the efficacy of intravenous (IV) lidocaine with standard analgesics (NSAIDS, opioids) for pain control due to any cause in the emergency department.

METHODS

The electronic databases of PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were explored from 1st January 2000 to 30th March 2021 and randomized controlled trials (RCTs) comparing IV lidocaine with a control group of standard analgesics were included.

RESULTS

Twelve RCTs including 1,351 patients were included. The cause of pain included abdominal pain, renal or biliary colic, traumatic pain, radicular low back pain, critical limb ischemia, migraine, tension-type headache, and pain of unknown origin. On pooled analysis, we found no statistically significant difference in pain scores between IV lidocaine and control group at 15 min (MD: -0.24 95% CI: -1.08, 0.61 I 2 = 81% p = 0.59), 30 min (MD: -0.24 95% CI: -1.03, 0.55 I 2 = 86% p = 0.55), 45 min (MD: 0.31 95% CI: -0.66, 1.29 I 2 = 66% p = 0.53), and 60 min (MD: 0.59 95% CI: -0.26, 1.44 I 2 = 75% p = 0.18). There was no statistically significant difference in the need for rescue analgesics between the two groups (OR: 1.45 95% CI: 0.82, 2.56 I 2 = 41% p = 0.20), but on subgroup analysis, the need for rescue analgesics was significantly higher with IV lidocaine in studies on abdominal pain but not for musculoskeletal pain. On meta-analysis, there was no statistically significant difference in the incidence of side-effects between the two study groups (OR: 1.09 95% CI: 0.59, 2.02 I 2 = 48% p = 0.78).

CONCLUSION

IV lidocaine can be considered as an alternative analgesic for pain control in the ED. However, its efficacy may not be higher than standard analgesics. Further RCTs with a large sample size are needed to corroborate the current conclusions.

Effects of adding oral clonidine to standard treatments on pain intensity of patients with acute renal colic: A randomized clinical trial

Background:

The aim of this study was to compare the effect of adding oral clonidine to standard treatments on pain intensity in patients with acute renal colic.

Materials and Methods:

This is a randomized clinical trial that was performed in 2020 in Isfahan. The study population consisted of 200 patients with renal colic. Pain of the patients was assessed using Visual Analog Scale. Patients were then randomized into 4 groups of 50 patients. Group A received 0.1 mg/kg morphine and clonidine tablets (0.2 mg). Group B received morphine and placebo. Group C received 30 mg ketorolac and clonidine tablets. Group D received 30 mg ketorolac and placebo tablets. Pain of patients was assessed. 0.05 mg/kg morphine was administered and repeated every 40 min if the pain was not reduced.

Results:

Our data showed that there was a significant difference between pains of patient by the time of admission in groups (P = 0.04). However, no significant differences were observed between pains of patients in different measuring times (P > 0.05). Using general linear model, we showed that the decreases in pain scores of each group were significant (P < 0.05) but there were no significant differences in pains of patients in different measuring times (P > 0.05). Our data showed that Group A and Group C had lowest frequencies of morphine administrations while Groups B and D had the highest frequencies (P < 0.001).

Conclusion:

We showed that administration of clonidine in patients with renal colic resulted in better pain control and lower morphine injections.

Acupuncture versus Lornoxicam in the Treatment of Acute Renal Colic: A Randomized Controlled Trial

Objective

To compare the analgesic efficacy and safety of acupuncture and lornoxicam in acute renal colic (ARC).

Design, Setting, Participant

A randomized, double-blind, parallel-controlled, single-centered trial was conducted at Susong County People’s Hospital from October 2019 to November 2020. Eighty-four patients with ARC were randomly divided into lornoxicam group (Group L) and acupuncture group (Group A). Group A was treated with acupuncture at Sanyinjiao (SP6), Yinlingquan (SP9) and normal saline, and Group L was treated with sham acupuncture at SP6, SP9 and lornoxicam.

Main Outcome Measures

Visual analogue scale (VAS) scores and adverse reactions such as nausea and dizziness were recorded within 5, 10, 15, 20 and 40 minutes after treatment. The main outcome of this study was the short-term effective (STE) rate, the secondary outcome was the onset time, and the safety index was incidence of adverse reactions.

Results

A total of 80 patients completed this study, including 41 patients (21 males and 20 females) in Group L and 39 patients (21 males and 18 females) in Group A. Group A exhibited lower scores versus group L after treatment (P < 0.05). The overall STE of group L was 61.00% (25/41), significantly lower than group A [84.62% (33/39)] (P < 0.001). There was no difference in the incidence of adverse reactions between group A [2.6% (1/39)] and group L [7.3% (3/41)] (P = 0.616). The ordered logistic regression analysis showed patients receiving acupuncture therapy are more likely to be cured [OR = 2.887, 95% CI: (1.190, 7.000), P = 0.019].

Conclusion

Acupuncture at SP6, SP9 and intramuscular injection of lornoxicam can effectively and safely relieve ARC, but the former has faster and better analgesic effect. Moreover, the incidence of adverse reactions was similar between the two treatments. This acupuncture therapy is recommended as a complementary therapy for ARC.

[Renal colic: How to calm and optimize the stone expulsion? Which treatment for pregnant women and children?]

INTRODUCTION

The aims of this narrative review was to report on the contemporary data of renal colic (RC) in terms of epidemiology and pressure on emergency structures and also to describe the latest therapeutic developments about uncomplicated RC, depending on the pediatric, adult and pregnancy population.

MATERIAL AND METHODS

A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the contemporary epidemiology of renal colic. A narrative synthesis of the articles (French, English) available on the Pubmed database was produced in June 2021.

RESULTS

Renal colic represents 1.1% of the annual total of emergency room visits. The mean age at admission was 45 years and 62% of patients were men. NSAIDs and Paracetamol are the most effective analgesic treatments and should be given priority over opioids. Non-drug analgesic treatments by tactile stimulation probably have a place in the CN management, particularly in case of contraindications. Among the validated treatments, alphablockers allow better expulsion when the stone is located in the pelvic ureter and if its size is between 5 and 10mm in diameter. In pregnant women, the predominant problem is to confirm the diagnostic. If there is a strong suspicion, MRI or a low-dose CT scan is possible. Ureteroscopy is feasible in particular in the first part of pregnancy to avoid iterative ureteral catheter changes. The care for children is now based on that of adults.

CONCLUSION

The renal colic care pathway in 2021 can benefit from various optimizations in the field of expulsion and analgesic treatments. Good knowledge of the specific situations in pregnant women and children allowing to improve the quality of care.

Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway

OBJECTIVE

To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care.

MATERIALS AND METHODS

The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge.

RESULTS

441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs. 23%, p<0.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs. 62%, p<0.001), and were less likely to return to the ED within 30 days (13% vs. 2%, p=0.01). These measures demonstrated special cause variation following Pathway release.

CONCLUSIONS

Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.

Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients

BACKGROUND

Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain.

OBJECTIVES

Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis.

METHODS

We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge.

RESULTS

Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90.

CONCLUSIONS

Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.

Acupuncture as adjunctive therapy for acute renal colic caused by urinary calculi: study protocol for a randomized controlled trial

BACKGROUND

Acute renal colic caused by urinary calculi (ARCUC) has a considerable impact on the quality of life. Acupuncture might be a potential treatment option. However, the evidence is limited. We will conduct this trial to evaluate the efficacy and safety of acupuncture as adjunctive treatment to diclofenac for ARCUC.

METHODS/DESIGN

A total of 80 eligible patients who are diagnosed with urinary stone renal colic will be randomly allocated to the acupuncture group or the sham acupuncture group. Each patient will receive 1 session of acupuncture or sham acupuncture. The primary outcome will be the response rate of patients achieving a reduction of > 50% on visual analog score (VAS) from baseline to 10 min after treatment. Secondary outcomes will include the VAS, remedial analgesia, re-visit and admission rate, blinding assessment, credibility and expectancy, and adverse event. All patients who receive randomization will be included in the intent-to-treat analysis.

DISCUSSION

The finding of this trial will provide evidence on the efficacy and safety of acupuncture for the treatment of ARCUC. The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.gov ChiCTR 1900025202 . Registered on August 16, 2019.

Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar

BACKGROUND

Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar.

METHODS

An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed.

RESULTS

Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist.

CONCLUSION

The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.

The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews

OBJECTIVE

To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions.

STUDY DESIGN

Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo-controlled trials. Conduct of systematic reviews was assessed with AMSTAR-2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 - 30 April 2020.

DATA SYNTHESIS

We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0-10-point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, -0.3 points; 95% CI, -0.6 to -0.1 points) and after craniotomy (MD, -0.8 points; 95% CI, -1.4 to -0.2 points); there is moderate quality evidence for its efficacy in tension-type headache (pain-free at 2 hours: RR, 1.3; 95% CI, 1.1-1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5-3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, -0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9-7.4).

CONCLUSIONS

For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required.

PROSPERO REGISTRATION

CRD42015029282 (prospective).