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Association Between Neutrophil-to-Lymphocyte Ratio and Sepsis Severity in ICU Patients.Background Sepsis is a potentially fatal condition that necessitates prompt identification and assessment of its severity for effective management. However, evaluating sepsis severity using the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores can be complex and costly. This study aimed to assess the association between neutrophil-to-lymphocyte ratio (NLR) and sepsis severity, as well as the role of NLR as a predictive indicator of sepsis severity in ICU patients. Methods This cross-sectional study was conducted among 180 ICU-admitted patients at Benazir Bhutto Hospital (BBH) in Rawalpindi, Pakistan, from January 2022 to January 2023. Participants were enrolled using defined inclusion and exclusion criteria along with consecutive sampling. Following ethical approval and informed consent, data were collected using a self-structured form. The study population was divided into three groups based on sepsis severity, which was assessed via the SOFA score. Data analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, NY, USA) through chi-squared tests, one-way ANOVA, Pearson's correlation, and a simple linear regression model, with a significance threshold set at p < 0.05. Results In the study population of 180 patients, the frequencies of sepsis, severe sepsis, and septic shock were 69 (38.34%), 86 (47.78%), and 25 (13.88%), respectively. Significant variations were observed among the three study groups in the means of the PaO2/FiO2 ratio, mean arterial pressure, Glasgow Coma Scale score, total bilirubin level, serum creatinine level, platelet count, SOFA score, neutrophil count, lymphocyte count, and NLR (p < 0.05). Pearson's correlation analysis indicated a strong positive correlation between the NLR and SOFA score, with a correlation coefficient (r) of 0.80 and significance at p < 0.001. Furthermore, linear regression analysis identified NLR as a significant predictor of sepsis severity, with a beta coefficient (β) of 3.55 and a 95% CI of 1.92-5.60 (p < 0.001). Conclusions In the current study, a positive and significant correlation was found between the NLR and the severity of sepsis. Higher NLR values were associated with increased SOFA scores, indicating a greater severity of sepsis. This study supports the use of NLR as a complementary and cost-effective tool for the early detection of high-risk patients with sepsis, facilitating timely interventions and improving outcomes, particularly in under-resourced healthcare settings.
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Metoclopramide for analgesia in renal colic: a narrative systematic review.Metoclopramide, a prokinetic antiemetic with activity at multiple receptor types, may be a useful treatment for renal colic pain. This review investigated whether metoclopramide is an effective analgesic in the management of adults with renal colic.Eligible studies were randomised, quasi-randomised or case-control trials of metoclopramide for the management renal colic pain. Electronic database searches were performed in November 2022. Screening was performed by two authors independently; disagreement was resolved by discussion or by adjudication by a third author. The Cochrane Collaboration Risk of Bias Tool v2.0 was used to assess bias.Two studies were included, enrolling 279 patients. Heterogeneity of primary outcome measurement and comparators rendered meta-analysis inappropriate; a narrative review is presented. Both studies showed some evidence of analgesic effect. The largest study had a low risk of bias in all assessed domains, whilst the smaller study was at a high risk of bias.There is limited evidence that metoclopramide may be an effective analgesic in the management of renal colic, with the highest quality study demonstrating analgesic properties similar to an intravenous non-steroidal anti-inflammatory medication.Protocol registration Prospero (CRD42022346618).
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Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multicentre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2).INTRODUCTION: Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to suboptimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared with current standard (delayed) rehabilitation. METHODS AND ANALYSIS: The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multicentre, open-label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation and quintet recruitment intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. On completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least 4 weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index total score at 12-week postrandomisation. The trial timeline is 56 months in total, from September 2022. TRIAL REGISTRATION NUMBER: ISRCTN11499185.
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Real world impact of Christmas BMJ research.Rapid Response: The real world impact of Christmas BMJ research Dear Editor Regular readers of the Christmas BMJ issue may have seen our 2022 article, "Taking the biscuit: defining excessive quantities of free refreshments in a healthcare library", investigating staff attitudes towards free refreshments and what constitutes “excessive consumption.” (1) This work identified that most people, when faced with the potential for unlimited free hot drinks and biscuits, would take no more than 3 free hot drinks and 2 packets of biscuits over the course of a working day. Free refreshments are usually intended to be a “work perk” to improve morale, and “back-of-a-biscuit-wrapper” calculations suggested that the cost to provide all NHS staff members with unlimited refreshments daily would be 0.084% of the total NHS budget. As such, the article concluded that any such initiative should be without restriction of “excessive consumption”, with staff allowed to exercise their own judgement about equitable intake. Christmas BMJ articles are frequently widely disseminated, generate significant positive publicity, and have excellent Altmetric scores; however, despite notable exceptions (2), we are unaware of many instances of them generating widespread changes to service delivery or clinical practice. We were therefore delighted to see that Derby and Burton Hospitals Charity had decided, independently of the authors of the original manuscript, to support an initiative providing free hot drinks for all staff members of University Hospitals of Derby and Burton NHS Foundation Trust. They credited the Christmas BMJ article with providing support for the proposal and its modelling. The recent implementation of this initiative unfortunately renders an impact assessment impossible. Whilst it is disappointing that other rigorous, snack-based research has not yet seen effective translation into clinical practice (3), it is pleasing to see that even light-hearted research can have a real-world impact. This programme will support staff well-being and morale, which in turn enables them to provide our patients with better care. Dare we say that this initiative may even spread Christmas cheer throughout the year?
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Intrinsic MotivationThe prevailing wisdom in neurological rehabilitation, and particularly for stroke, is that physical therapies are the key to improvements in function. Despite accepting the importance of 'the motivated patient', the lack of simple, proven ways to improve intrinsic motivation has hindered efforts to combine physical therapies with motivation. Now there is available a simple, free, well-validated approach to encourage intrinsic motivation ('Take Charge'). The benefits for people who had a stroke are well-established but this could be applied to people with a range of neurological and other disorders. We provide the evidential support for this approach and suggest ways of incorporating it into daily practice.
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Delivering manual cardiopulmonary resuscitation (CPR) in a diving bell: an analysis of head-to-chest and knee-to-chest compression techniques.INTRODUCTION: Chest compression often cannot be administered using conventional techniques in a diving bell. Multiple alternative techniques are taught, including head-to-chest and both prone and seated knee-to-chest compressions, but there are no supporting efficacy data. This study evaluated the efficacy, safety and sustainability of these techniques. METHODS: Chest compressions were delivered by a team of expert cardiopulmonary resuscitation (CPR) providers. The primary outcome was proportion of chest compressions delivered to target depth compared to conventional CPR. Techniques found to be safe and potentially effective by the study team were further trialled by 20 emergency department staff members. RESULTS: Expert providers delivered a median of 98% (interquartile range [IQR] 1.5%) of chest compressions to the target depth using conventional CPR. Only 32% (IQR 60.8%) of head-to-chest compressions were delivered to depth; evaluation of the technique was abandoned due to adverse effects. No study team member could register sustained compression outputs using prone knee-to-chest compressions. Seated knee-to-chest were delivered to depth 12% (IQR 49%) of the time; some compression providers delivered > 90% of compressions to depth. CONCLUSIONS: Head-to-chest compressions have limited efficacy and cause harm to providers; they should not be taught or used. Prone knee-to-chest compressions are ineffective. Seated knee-to-chest compressions have poor overall efficacy but some providers deliver them well. Further research is required to establish whether this technique is feasible, effective and sustainable in a diving bell setting, and whether it can be taught and improved with practise.
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An evaluation of the NUI Compact Chest Compression Device (NCCD), a mechanical CPR device suitable for use in the saturation diving environment.INTRODUCTION: Provision of manual chest compressions in a diving bell using a conventional technique is often impossible, and alternative techniques are poorly evidenced in terms of efficacy and sustainability. The first mechanical cardiopulmonary resuscitation (CPR) device suitable for use in this environment, the NUI Compact Chest Compression Device (NCCD), has recently been designed and manufactured. This study assessed both the efficacy of the device in delivering chest compressions to both prone and seated manikins, and the ability of novice users to apply and operate it. METHODS: Compression efficacy was assessed using a Resusi Anne QCPR intelligent manikin, and the primary outcome was the proportion of compressions delivered to target depth (50-60 mm). The gold standard was that achieved by expert CPR providers delivering manual CPR; the LUCAS 3 mCPR device was a further comparator. RESULTS: The NCCD delivered 100% of compressions to target depth compared to 98% for the gold standard (interquartile range 1.5%) and 98% for the LUCAS 3 when applied to both supine and seated manikins. The NCCD sometimes became dislodged and had to be reapplied when used with a seated manikin. CONCLUSIONS: The NCCD can deliver chest compressions at target rate and depth to both supine and seated manikins with efficacy equivalent to manual CPR and the LUCAS 3. It can become dislodged when applied to a seated manikin; its design has now been altered to prevent this. New users can be trained in use of the NCCD quickly, but practise is required to ensure effective use.
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EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION.AIMS: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
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Taking the biscuit: defining excessive quantities of free refreshments in a healthcare libraryEvidence suggests that complementary hot drinks and biscuits benefit an overworked and highly stressed healthcare workforce. But when signage in healthcare libraries asks patrons not to consume “excessive” quantities of free hot drinks and biscuits, how much is too much? Tabner and colleagues explore this resource allocation conundrum
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Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC).BACKGROUND: Renal colic is the pain experienced by a patient when a renal calculus (kidney stone) causes partial or complete obstruction of part of the renal outflow tract. The standard analgesic regimes for renal colic are often ineffective; in some studies, less than half of patients achieve complete pain relief, and a large proportion of patients require rescue analgesia within 4 h. Current analgesic regimes are also associated with significant side effects including nausea, vomiting, drowsiness and respiratory depression. It has been hypothesised that beta adrenoreceptor agonists, such as salbutamol, may reduce the pain of renal colic. They have been shown to impact a number of factors that target the physiological causes of pain in renal colic (ureteric spasm and increased peristalsis, increased pressure at the renal pelvis and prostaglandin release with inflammation). There is biological plausibility and a body of evidence sufficient to suggest that this novel treatment for the pain of renal colic should be taken to a phase II clinical trial. The aim of this trial is to test whether salbutamol is an efficacious analgesic adjunct when added to the standard analgesic regime for patients presenting to the ED with subsequently confirmed renal colic. METHODS: A phase II, randomised, placebo-controlled trial will be performed in an acute NHS Trust in the East Midlands. Patients presenting to the emergency department with pain requiring IV analgesia and working diagnosis of renal colic will be randomised to receive standard analgesia ± a single intravenous injection of Salbutamol. Secondary study objectives will explore the feasibility of conducting a larger, phase III trial. DISCUSSION: The trial will provide important information about the efficacy of salbutamol as an analgesic adjunct in renal colic. It will also guide the development of a definitive phase III trial to test the cost and clinical effectiveness of salbutamol as an analgesic adjunct in renal colic. Salbutamol benefits from widespread use across the health service for multiple indications, extensive staff familiarity and a good side effect profile; therefore, its potential use for pain relief may have significant benefits for patient care. TRIAL REGISTRATION: ISRCTN Registry ISRCTN14552440 . Registered on 22 July 2019.
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Trends in emergency department litigation within the NHS: a retrospective database analysis.The objectives of this study are to examine trends in litigation related to emergency department care within the NHS. The study is based on retrospective database analysis. NHS Resolution databases of litigation activity pertaining to Type I emergency departments within the NHS are used. The main outcome measures were number of claims, number of successful claims, costs associated with litigation and costs per claim, all in comparison to patterns of ED attendance numbers and inflation. The results showed that the annual cost of litigation relating to emergency department care within the NHS has increased from £25.5 million in 2005/6 to £161.9 million in 2017/18. Mean cost per claim has increased from £58,252 in 2005/6 to £168,966 in 2017/18. The number of claims received has increased significantly; the proportion of these which were successful has remained constant. Therefore, it was concluded that the costs of litigation are increasing disproportionately to inflation and attendance numbers. Multiple potential causes are discussed, with significant implications for clinical practice.
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Azithromycin versus standard care in patients with mild-to-moderate COVID-19 (ATOMIC2): an open-label, randomised trial.BACKGROUND: The antibacterial, anti-inflammatory, and antiviral properties of azithromycin suggest therapeutic potential against COVID-19. Randomised data in mild-to-moderate disease are not available. We assessed whether azithromycin is effective in reducing hospital admission in patients with mild-to-moderate COVID-19. METHODS: This prospective, open-label, randomised superiority trial was done at 19 hospitals in the UK. We enrolled adults aged at least 18 years presenting to hospitals with clinically diagnosed, highly probable or confirmed COVID-19 infection, with fewer than 14 days of symptoms, who were considered suitable for initial ambulatory management. Patients were randomly assigned (1:1) to azithromycin (500 mg once daily orally for 14 days) plus standard care or to standard care alone. The primary outcome was death or hospital admission from any cause over the 28 days from randomisation. The primary and safety outcomes were assessed according to the intention-to-treat principle. This trial is registered at ClinicalTrials.gov (NCT04381962) and recruitment is closed. FINDINGS: 298 participants were enrolled from June 3, 2020, to Jan 29, 2021. Three participants withdrew consent and requested removal of all data, and three further participants withdrew consent after randomisation, thus, the primary outcome was assessed in 292 participants (145 in the azithromycin group and 147 in the standard care group). The mean age of the participants was 45·9 years (SD 14·9). 15 (10%) participants in the azithromycin group and 17 (12%) in the standard care group were admitted to hospital or died during the study (adjusted OR 0·91 [95% CI 0·43-1·92], p=0·80). No serious adverse events were reported. INTERPRETATION: In patients with mild-to-moderate COVID-19 managed without hospital admission, adding azithromycin to standard care treatment did not reduce the risk of subsequent hospital admission or death. Our findings do not support the use of azithromycin in patients with mild-to-moderate COVID-19. FUNDING: National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Pfizer.
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Improving the percentage of HIV tests offered to patients admitted to an acute hospital trust with community-acquired pneumoniaYoung people and adults diagnosed with an HIV indicator condition should be offered an HIV test (NICE [National Institute of Clinical Excellence] guidance). Community-acquired pneumonia (CAP) is considered to be an HIV indicator condition as it has an undiagnosed HIV prevalence of 0.76%. We observed however, that the offer of HIV testing to patients with radiologically diagnosed CAP remained low even after a senior respiratory physician review. Our aim was to improve the percentage of patients being offered an HIV test with CAP requiring hospital admission across four acute medical wards at Royal Derby Hospital within 12 months. We identified several key steps in the process. These included the identification of CAP, the role of the medical clerking team and the respiratory infections nursing team that manage pneumonia admissions. After collecting baseline data and staff interviews, we conducted seven plan-do-study-act (PDSA) interventions. These included; iterative communication, educational interventions, system changes that involved a direct HIV test offering by our respiratory infection team and the addition of an HIV test to the electronic CAP bundle. Data collected from 177 patients were analysed over a period of one year. The main outcome measure of the project 'Did patients with a diagnosis of CAP on admission have a documented HIV test offered?' improved from 28% during the first cycle of data collection to 76.4% during the final cycle. Patients were more likely to be offered an HIV test if they had no comorbidity compared with those with a diagnosis of asthma or chronic obstructive pulmonary disease. Our most impactful PDSA interventions were the respiratory infection nurses directly offering an HIV test to patients and adding HIV to the electronic ordering CAP bundle. Our quality improvement programme has shown that educational, communication and system changes can help improve the uptake of HIV testing. Education on HIV testing is now part of our induction programme for new doctors and we are using a new CAP bundle to help streamline the request of HIV testing at the first clinician clerking. Our dedicated respiratory infection nursing team also ensures that patients with CAP have a documented offer of an HIV test.
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Toxicological analysis of George's marvellous medicine: literature reviewObjective: To analyse the therapeutic effects and toxicity of the eponymous concoction described in Roald Dahl's book George's Marvellous Medicine. Design: Literature review. Setting: Two literature loving households in England. Participants: George Kranky and grandma Kranky. Main outcome measures: Clinical and toxic effects of the individual ingredients checked against those listed in ToxBase, the National Poisons Information Service's poisons database. Results: The medicine contained 34 ingredients. The most common toxic effect identified on ToxBase was nausea and vomiting (16 ingredients, 47%). Potentially life threatening effects were associated with 13 (38%) ingredients, including depression of the central nervous system, kidney injury, convulsions, cardiac toxicity, and mucosal erosion. The effects described in the book were accurate initially but then diverted from the most likely clinical outcome (death). Conclusions: Although Dahl ought to be applauded for his initial accuracy about the toxicology of the ingredients in George's marvellous medicine, the overall effect would be fatal catastrophic physiological collapse. Scientific exploration and experimentation should be encouraged in children, although any medicinal ingredients need to be checked for potential toxicity before being administered-to grandmas or anyone else.
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Handheld electronic device use in patient care: the emergency department patient perspective-a cross-sectional survey.BACKGROUND: Staff use of smartphones and tablets in the healthcare setting is increasingly prevalent, but little is known about whether this use is acceptable to patients. Staff are concerned that the use of handheld electronic devices (HEDs) may be negatively misconstrued by patients. The HED can be a valuable tool, offering the emergency clinician access to a wealth of resources; it is therefore vital that patient views are addressed during their widespread adoption into clinical practice. METHODS: Patients, or those accompanying them, within the ED of the Royal Derby Hospital between April and June 2017 were asked to complete a survey consisting of 22 questions. Data collection took place to include all times of day and every day of the week. Every eligible individual within the department during a data collection period was approached. RESULTS: A total of 438 respondents successfully completed the survey with a response rate of 92%. Only 2% of those who observed staff using HEDs during their ED visit thought that they were being used for non-clinical purposes. 339 (78%) agreed that staff should be allowed to use HEDs in the workplace. Concerns expressed by respondents included devices being used for non-clinical purposes and data security. The main suggestion by respondents was that the purpose of the HEDs should be explained to patients to avoid misinterpretation. CONCLUSION: Our survey shows that the majority of survey respondents felt that clinical staff should be allowed to use HEDs in the workplace and that many of the concerns raised could be addressed with adequate patient information and clear governance.
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Mitigating the Psychological Impact of COVID-19 on Healthcare Workers: A Digital Learning Package.The coronavirus pandemic (COVID-19) will undoubtedly have psychological impacts for healthcare workers, which could be sustained; frontline workers will be particularly at risk. Actions are needed to mitigate the impacts of COVID-19 on mental health by protecting and promoting the psychological wellbeing of healthcare workers during and after the outbreak. We developed and evaluated a digital learning package using Agile methodology within the first three weeks of UK outbreak. This e-package includes evidence-based guidance, support and signposting relating to psychological wellbeing for all UK healthcare employees. A three-step rapid development process included public involvement activities (PPIs) (STEP 1), content and technical development with iterative peer review (STEP 2), and delivery and evaluation (STEP 3). The package outlines the actions that team leaders can take to provide psychologically safe spaces for staff, together with guidance on communication and reducing social stigma, peer and family support, signposting others through psychological first aid (PFA), self-care strategies (e.g., rest, work breaks, sleep, shift work, fatigue, healthy lifestyle behaviours), and managing emotions (e.g., moral injury, coping, guilt, grief, fear, anxiety, depression, preventing burnout and psychological trauma). The e-package includes advice from experts in mental wellbeing as well as those with direct pandemic experiences from the frontline, as well as signposting to public mental health guidance. Rapid delivery in STEP 3 was achieved via direct emails through professional networks and social media. Evaluation included assessment of fidelity and implementation qualities. Essential content was identified through PPIs (n = 97) and peer review (n = 10) in STEPS 1 and 2. The most important messages to convey were deemed to be normalisation of psychological responses during a crisis, and encouragement of self-care and help-seeking behaviour. Within 7 days of completion, the package had been accessed 17,633 times, and healthcare providers had confirmed immediate adoption within their health and wellbeing provisions. Evaluation (STEP 3, n = 55) indicated high user satisfaction with content, usability and utility. Assessment of implementation qualities indicated that the package was perceived to be usable, practical, low cost and low burden. Our digital support package on 'psychological wellbeing for healthcare workers' is free to use, has been positively evaluated and was highly accessed within one week of release. It is available here: Supplementary Materials. This package was deemed to be appropriate, meaningful and useful for the needs of UK healthcare workers. We recommend provision of this e-package to healthcare workers alongside wider strategies to support their psychological wellbeing during and after the COVID-19 pandemic.
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Increased Risk of Acute Pancreatitis with Codeine Use in Patients with a History of Cholecystectomy.BACKGROUND: Codeine has a spasmodic effect on sphincter of Oddi and is suspected to cause acute pancreatitis in patients with a history of cholecystectomy. AIMS: To assess the association between codeine use and acute pancreatitis in patients with a previous cholecystectomy. METHODS: We conducted a retrospective nested case-control study using the 2005-2015 MarketScan® Commercial Claims and Encounters Database. The cohort included patients aged 18-64; cohort entry began 365 days after cholecystectomy. Odds ratios (ORs) and 95% CIs for acute pancreatitis hospitalization were estimated comparing use of codeine with non-use of codeine. In a secondary analysis, use of codeine was compared with an active comparator: use of non-steroidal anti-inflammatory drugs (NSAIDs). RESULTS: Of the 664,083 patients included in the cohort, 1707 patients were hospitalized for acute pancreatitis (incidence 1.1 per 1000 person-years) and were matched to 17,063 controls. Compared with non-use of codeine, use of codeine was associated with an increased risk of acute pancreatitis (OR 2.67; 95% CI 1.63, 4.36), particularly elevated in the first 15 days of codeine use (OR 5.37; 95% CI 2.70, 10.68). Compared with use of NSAIDs, use of codeine was also associated with an increased risk of acute pancreatitis (OR 2.64; 95% CI 1.54, 4.52). CONCLUSION: Codeine is associated with an increased risk of acute pancreatitis in patients who have previously undergone cholecystectomy; greater clinician awareness of this association is needed.
