As a scientic journal with a national dimension, the TJEM is sensitive to the experiments carried out by clinicians wishing to enlighten their action and to contribute to the collective development of emergency specialty. One of the major goals of TJEM is to become a tool, serving all emergency doctors in Tunisia and beyond. e challenge is to convince our colleagues that they are capable of raising emergency medicine in their country to a level that commands respect. Yes, they can. Not having a past is not a handicap; it is rather an advantage. Joining this important project will help us in this exciting process.
In this issue of TJEM, Dr Beltaief et al provided the results of a study aiming to test the diagnostic value of baseline C-reactive protein and its early change combined to modied Alvarado score in a cohort of 500 patients with suspected acute appendicitis. e authors should be congratulated for completing such a dicult trial and presenting it in an elegant manner. ey found that these parameters are of modest value in this issue. erefore, this report by Beltaief et al provides additional evidence to suggest that laboratory markers have very limited diagnostic utility on their own but show promise when used in combination (1). CRP is an acute phase reactant.
Its diagnostic signicance is largely based on both its kinetic properties and its utility as a marker for complicated/advanced appendicitis. CRP levels show an increase between 8–12 hours after the onset of inammatory processes with a peak between 24 and 48 hours, which is later than that of white blood cells.
Consequently, CRP contributes little diagnostic utility early in the case of simple appendicitis. A CRP cut-o of >10 mg/L yielded a range of sensitivity between 65–85% and a specicity between 59–73%. In a study of 542 patients the AUC of admission CRP was only 0.60 compared to 0.77 on day 2 and 0.88 day 3. In cases of perforated appendicitis, the AUC was 0.90 on day 1, 0.92 on day 2 and 0.96 on day 3 (2). us, CRP serves as a strong predictor for appendicular perforation but is quite limited for appendicitis in general. Virtually every diagnostic test used in medicine is susceptible to inaccuracies, false-negative and false-positive results, or a lack of sensitivity or specicity. Nonetheless, imperfect tests can still be highly useful when applied by physicians in the proper diagnostic setting. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.
In this issue of TJEM, Haj Ali et al showed the rst results of Sahloul Emergency department regarding acute coronary syndrome registry (ReSCU registry). One of their main objectives is to compare their management of these patients with current guidelines in order to improve clinical practice. The authors studied 150 adults and their results were quite impressive as 130 patients had undergone primary percutaneous coronary intervention and all the others received intravenous thrombolysis. Of course, this is not the usual practice and it is not sure that this sample was not selected.
is issue of TJEM includes a study of Ghazali et al whose objective was to identify factors associated with the diagnosis of non-ST-segment elevation acute coronary syndrome in patients admitted to the ED with undierentiated chest pain and normal EKG. ey found that advanced age, history of diabetes or known coronaropathy and elevated troponin are the main markers of ACS. What should be highlighted is that all these factors are included in many available diagnostic models. It was perhaps more suitable that the authors tried to validate one of these models in their population. It should also be noted that the same study was performed in Monastir ED where a new score was proposed (3).
From its origins, point-of-care echocardiography in EDs have had 2 main challenges. e rst has been convincing doubtful colleagues that emergency physicians are capable of performing an examination with acceptable accuracy after focused training. The second obstacle has been providing data of improved outcome from incorporating echocardiography into ED clinical practice. Why should an emergency physician bother learning this diagnostic method when he can simply has cardiologist or someone else to do this? is is a good question that needs to be answered. One common challenge of any new procedure in emergency medicine is overcoming the inertia of comfort with the status quo. e American College of Emergency Medicine issued a position paper in 1990 that supported the use of point of care ultrasonography (POCUS); this was followed by a similar document written by the Society for Academic Emergency Medicine in 1991 (4). With this early support for the use of POCUS by EM physicians, EM residency programs in the United States and Canada started to introduce ultrasonography as a standard part of training. The American College of Graduate Medical Education (ACGME) has established POCUS as a required part of EM training.
All EM residencies accredited by the ACGME provide POCUS training that include a minimum 80 hours of dedicated clinical ultrasonography, 20 hours of didactic ultrasonography education, and accurate performance of 150 independently reviewed ultrasound studies. Accordingly, ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively inuences patient outcomes. In this issue of TJEM Ben Lassoued et al compared in their study the ndings of echocardiography performed in 204 adult ED patients by emergency physicians and cardiologists. ey found an excellent concordance. ese results are not new; they should add an additional support to the widespread use of echocardiography in the EDs. e authors should clarify whether there was one or more physicians involved in this study and also give us more precision about the training level of the physicians included in their study.
Last but not least is the question of pain treatment in EDs. Optimal pain management is imperative in ED. Indeed, the consequences of pain on the cardiovascular and the neurovegetative systems are susceptible to aggravate the already unstable patients. In addition, anxious, agitated or aggressive behaviors frequently observed in patients with acute pain can lead to diagnostic errors and treatment failure. It is clear that beyond all these considerations, a signicant obstacle to optimal pain management in ED patients would be related to the high medical and nursing workload in this setting. Some studies concluded that there is a linear correlation between emergency department overcrowding and the failure to receive adequate pain treatment (5). As a result, clinical practice guidelines have been developed with the goal of promoting eective pain treatment in ED. A simple action based on the early prescription of paracetamol could be associated with a signicant decrease in pain intensity and improve patients’ satisfaction. is was demonstrated in this issue of TJEM by the study of Mezgar et al conducted on 500 patients admitted to the ED.
Although we apologize their eort to improve pain treatment in the emergency care setting, we suggest to the authors to conduct a randomized controlled study using the same objective.