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Quality improvement project to enhance adherence to RCEM standards for patients with paracetamol overdose.BACKGROUND: Delayed or inconsistent administration of N-acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety. METHOD: This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021-May 2022) and compared with outcomes during a 52-week intervention period (September 2023-August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels. RESULTS: A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases. CONCLUSION: This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.
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Assessing Morbidity and Malignancy Risk in Patients Presenting with Pulmonary Embolism in an Ambulatory Care Setting.Objectives: Venous thromboembolism (VTE), especially pulmonary embolism (PE), can be treated in an outpatient setting after appropriate risk assessment. However, front-door physicians may be resistant to follow this practice. The possibility of cancer-associated VTE complicates the outpatient management of PE. This study aimed to assess the morbidity and mortality in patients with PE who were managed in an emergency/acute medicine-led outpatient clinic as per risk stratification as well as detecting diagnoses of new cancer sites (NCSs) in these patients. Methods: This retrospective study included all patients with confirmed PE managed in an acute medicine outpatient setting at Queens Hospital, Burton-on-Trent, United Kingdom, from 2019 to 2022. Biochemical findings, radiological findings, mortality and morbidity rates, treatment administered, simplified Pulmonary Embolism Severity Index (sPESI) scores, complications and NCS diagnosis were obtained. Results: A total of 82 patients were included in this study; their mean age was 63.3 +/- 16.7 years and 56.1% (n = 46) were male. The two commonest presenting complaints were new shortness of breath (25.6%, n = 21) and pleuritic chest pain (19.5%, n = 16). Unprovoked PE was observed in 52.4% (n = 43) of patients. Increased sPESI scores were related to increased mortality rates; sPESI scores of 0 and 3 were associated with 0% and 50% mortality rates within 90 days, respectively. NCS was reported in 13.4% (n = 11). Statistical analyses using logistic regression and classification tree methods revealed that NCS can be predicted with 70.6% sensitivity and 97% specificity using 2 variables (history of cancer and age >73 years). Conclusion: The sPESI can help in the risk stratification of patients with PE showing poor outcomes; patients at a high risk of NCS development can be identified using the classification tree method.
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Gut Microbiota Modulation in Type 2 Diabetes and Cardiometabolic Risk: A Systematic Review.Cardiometabolic complications related to type 2 diabetes mellitus (T2DM) are often due to changes in the gut microbiota. The review analyzed studies looking at the effects of probiotics, prebiotics, high-fiber diets, and fecal microbiota transplantation (FMT) on glucose levels and heart and metabolic health in individuals either having T2DM or being at risk. The review followed the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. The literature was searched using text terms and controlled vocabulary, employing Boolean operators "AND," "OR," and various combinations across PubMed, Embase, and the Cochrane Library. Open-access, full-text English papers from 2005 to 2025, including those authored by people, were searched. The quality was assessed using the Risk of Bias 2.0 (RoB 2.0) tool, and the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Fifteen randomized controlled trials (RCTs) were analyzed for methodological quality, with three categorized as having a high risk of bias (RoB). The GRADE tool categorized two high RoB RCTs as "low quality." However, two RCTs had low RoB and were classified as "high quality." Ten RCTs had uncertain RoB, lowering the evidence by one point to "moderate quality." A comprehensive review of RCTs was conducted to assess outcomes related to glycemic parameters (e.g., glycated hemoglobin (HbA1c), fasting glucose), lipid profiles, inflammatory markers, anthropometric measures, and gut microbiota composition. Interventions included probiotic and prebiotic supplementation, high-fiber or Mediterranean-style diets, and FMT. Probiotic yogurt containing Lactobacillus acidophilus and Bifidobacterium lactis significantly improved lipid profiles by reducing low-density lipoprotein cholesterol (LDL-C) and total cholesterol. High-fiber diets consistently lowered fasting blood glucose, HbA1c, triglycerides, and LDL-C while elevating high-density lipoprotein cholesterol (HDL-C) and beneficial short-chain fatty acid (SCFA)-producing bacteria. Anti-inflammatory effects were observed across interventions, notably with probiotics and polyphenol-rich Mediterranean diets, which reduced tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and other inflammatory cytokines. The Green-Mediterranean diet significantly improved weight, insulin resistance, and Framingham risk scores. Novel mechanisms involving SCFAs and bile acid metabolism were also identified as key modulators of host metabolic response. Microbiota-based interventions offer promising avenues for glycemic control and cardiometabolic risk reduction in patients with T2DM.
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More than roll, move and multiple-choice questions: Application of tabletop game mechanics in anatomy education.Anatomy is a challenging topic, and educators have used games as a tool to teach the content. The three-dimensional aspects of anatomy provide unique advantages and challenges for presentation in a tabletop game format. Games are built on mechanics, which include the actions players take, such as rolling dice to move a pawn. Integration of the game mechanics with learning goals can lead to better outcomes by allowing players to explore the content through gameplay. We hypothesize that educators making games for anatomy education will have adopted tabletop game mechanisms that facilitate this integration of the educational content with the gameplay. To explore this a body of games for anatomy education was generated from online sources of games and the literature. Online and literature content, including game rules or videos when available, were reviewed, and mechanisms were categorized by the framework in Building Blocks of Tabletop Game design. Thirty-two games with sufficient information for analysis were identified, and the relation of the game mechanics to the educational content is described. The most common mechanics connected to the learning goals were question and answers, communication limits and set collection. Strongly integrated examples included using tabletop mechanics to travel through neuroanatomy, collecting related sets of anatomic components and tracing pathways for the spread of oral infections. We have found designers of games for anatomy education have adopted variable tabletop game mechanics based on the content area being presented, ranging from games as a framework for quiz questions to more robustly integrated educational content.
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Effectiveness of Beta-Blockers in Reducing Mortality and Recurrence After Myocardial Infarction: A Systematic Review of Contemporary and Foundational Evidence.Beta-blockers have traditionally been a mainstay in the management of patients recovering from myocardial infarction (MI). However, their role in the era of modern cardiac interventions remains a topic of active discussion. This systematic review evaluated evidence from 1983 to 2014, drawn from PubMed, Embase, Scopus, and CENTRAL, on the effectiveness of beta-blockers in reducing mortality and recurrent cardiovascular events in adults following MI. After a comprehensive screening process, four eligible studies (two randomized controlled trials, one post hoc analysis, and one observational study) were included, encompassing a total of 19,078 participants with varied clinical settings and patient profiles. Across these studies, beta-blocker therapy was consistently associated with reductions in all-cause mortality, cardiovascular mortality, and recurrent MI, particularly among individuals with reduced left ventricular function. Some benefit was also observed in those with preserved function, though with less consistency. The magnitude of benefit included a 23-26% reduction in overall mortality and up to a 41% reduction in recurrent MI. Despite differences in study design, patient characteristics, and treatment protocols, the overall findings support the continued use of beta-blockers in post-infarction care. Limitations included heterogeneity in populations, beta-blocker regimens, and study eras, highlighting the need for individualized treatment approaches. Nonetheless, these results align with current guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology, reaffirming the relevance of beta-blockers in improving outcomes in this patient population.
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Can an ECG performed during emergency department triage and interpreted as normal by computer analysis safely wait for clinician review until the time of patient assessment? A pilot study.INTRODUCTION: Electrocardiograms (ECGs) are frequently performed during patient triage in Emergency Departments (EDs). Emergency Physicians (EPs) are interrupted during other tasks to review ECGs. Critics believe this practice could lead to distraction with consequent medical error and decision fatigue. ECGs can be interpreted by computer software at the time of capture; some evidence exists to suggest that an ECG performed during ED triage with an immediate computer interpretation (ICI) of 'normal' will seldom contain information necessitating a change to triage management. MATERIAL AND METHODS: All ED triage ECGs performed in the Royal Derby Hospital between 13th July 2017 and 12th July 2018 in patients without chest pain and with an ICI of 'normal' were identified through a database search. Forty were randomly selected and reviewed by two EPs (blinded to patient details, ICI and outcome) who were asked to identify those that required a change to triage management.RESULTS: The study processes were feasible. At least one of the two EP reviewers felt that a change to triage management was required in 48% of cases (e.g. "review patient", "obtain blood gas", "review old ECGs"); they agreed on the need for change of management in 13% of cases. An ICI of normal had a NPV of 53% (95% CI 37-67%) for the need for a change to triage management based upon ECG findings. Inter-observer agreement was poor (kappa = 0.17). CONCLUSIONS: Based on these results, ED triage ECGs should still be presented to EPs for immediate review regardless of the ICI. Inter-observer agreement between EPs was poor. Further research is required to link triage ECG interpretation, need for intervention and patient outcome.
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Feasibility, reach, and acceptability of social prescribing in the emergency department.BACKGROUND: Social prescribing (SP) connects individuals with community resources to address practical, social and emotional needs affecting health. While predominantly located in primary care, SP models have been introduced in some Emergency Departments (EDs). This study evaluated the feasibility, reach and acceptability of an ED-based SP pilot in the United Kingdom. METHODS: Feasibility and reach were assessed through a retrospective review of anonymised patient trackers and clinical records. Acceptability was evaluated via a staff survey exploring knowledge, attitudes and referral practices. RESULTS: Over 14 months Social Prescribers supported 1,057 ED patients, with mental wellbeing being the most common referral reason. Patients were signposted or referred to over 200 different community organisations. The programme was valued by ED staff, who recognised its potential to improve patient health and wellbeing. Reported barriers included limited awareness of the out-of-hours referral pathway. DISCUSSION: This is the first published evaluation of an ED-based SP programme, building upon existing conceptual models and qualitative studies that have explored its potential. The findings demonstrate that the model is both feasible and acceptable to staff, while effectively reaching patients with a broad range of health and social needs. Further research is needed to explore long-term impacts on patient outcomes and broader system-wide benefits.
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Impact of 'the Q word' on hospital speciality activity levels: a narrative systematic review.BACKGROUND: Healthcare professionals commonly believe that saying the word 'quiet' can jinx a shift and lead to increased workload or particularly unwell patients. A previous small integrative review found no effect but had some methodological limitations. This narrative systematic review aimed to synthesise the evidence from studies on the impact of saying 'quiet' on clinical workload measures. METHODS: A comprehensive search was carried out across multiple electronic databases for any studies performed in a human healthcare setting investigating the impact of the use of 'the Q word' (or variations thereof) on workload. Outcomes of interest were objective measures of workload, such as patient volume, admissions or tasks. RESULTS: Eight randomised controlled trials (RCTs) were included. Settings included EDs, specialised hospital units and clinical support services. Outcome measures varied between studies, so meta-analysis was not possible. Seven RCTs found no significant differences in objective workload measures between intervention groups where 'q****" was uttered and control groups where it was not. One RCT in orthopaedics reported an increase in overnight admissions when 'q****" was said but had significant methodological limitations. Two RCTs noted potential impacts on subjective perceptions of workload among believers. Limitations of included studies include small sample sizes, lack of blinding and inadequate control for confounders. DISCUSSION: The available evidence does not support the assertion that saying the word 'quiet' affects clinical workload metrics. Healthcare professionals should be encouraged to prioritise communication based on evidence rather than myth, and there is insufficient evidence that saying 'quiet' while on shift will bring negative consequences for themselves or colleagues.
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Methaemoglobinaemia as an Alternative Diagnosis for Shortness of Breath: A Case Report.Methaemoglobinaemia is rarely considered as a differential diagnosis in patients presenting with shortness of breath and cyanosis. It can occur due to either congenital or acquired causes. The effect of medication is an important consideration as an acquired cause of methaemoglobinaemia, and if the diagnosis is missed, it may result in a fatal outcome. This scenario highlights the importance of awareness through thorough history-taking and careful review of investigations. Dapsone (4,4'-diaminodiphenyl sulfone) was identified as the main contributing factor in this case, and the symptoms resolved following its immediate discontinuation, with an improvement in oxygen saturation and a reduction in methaemoglobin levels.
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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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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.
