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Brief report
Cannabis hyperemesis syndrome: Incidence and treatment with topical capsaicin
Síndrome de hiperémesis por cannabis: incidencia y tratamiento con capsaicina tópica
Guillermo Burillo-Putzea,b,
Corresponding author
gburillo@telefonica.net

Corresponding author.
, David Trujillo-Burilloa, Jose Carlos García-Hernandeza, M. Angeles López-Hernándezb,c, Iván Hernández-Ramosb,c, Isabel Ramos-Suárezb,d, John R. Richardsd
a Departamento de Medicina Física y Farmacología, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
b Grupo de investigación Urgencias y toxicología clínica: patologías agudas y procesos asistenciales (GRUCATOX), Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
c Servicio de Urgencias, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
d Department of Emergency Medicine, University of California, Davis Medical Center, Davis, CA, United States
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cannabis hyperemesis syndrome &#40;CHS&#41; is characterised by abdominal pain and vomiting in people who have been using cannabis for years and in high daily amounts&#44; with symptoms typically relieved by very hot showers<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Described in 2004<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; many clinicians are still unaware of it&#44; and it was not included in the Rome IV classification until 2016 &#8211;section B3&#44; together with cyclic vomiting syndrome&#8211;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prevalence in Spain could be as high as 18&#37; among chronic users<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; while in the US it could be as high as 33&#37; in heavy users&#44; where it is estimated that 2&#46;4&#37; of hospital emergency department &#40;ED&#41; visits may be due to CHS<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Its incidence in EDs is unknown in Europe<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aetiology of CHS is not well known&#44; probably multifactorial&#44; so there is no standard treatment either<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; The most common antiemetics &#40;metoclopramide and ondansetron&#41; are not very effective&#46; The most commonly used antiemetic treatment in the medical literature is topical capsaicin&#44; although off-label<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study is to describe the incidence and clinical and care characteristics of patients treated for CHS in an ED&#44; and the outcomes associated with the use of topical capsaicin&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Retrospective study of patients with CHS seen in the ED of a university hospital during 2018 and 2019 &#40;reference population of 332&#44;000 citizens over 14 years of age and 135&#44;000 ED visits in that period and age group&#41;&#46; Cases from this centre belonging to the Network for the Study of Addictive Drugs in Hospital Emergencies in Spain -REDUrHE- &#40;centre&#8217;s research ethics committee approval code&#58; 2016&#47;071&#41; were used for this purpose<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of CHS was based on 3 criteria&#58; compatible clinical features &#40;abdominal pain and presence of nausea or vomiting&#44; with no other organ or functional cause&#41;&#44; cannabis use within 48 h and positive urine cannabis test &#40;COBAS-INTEGRA&#174; 400 plus&#44; Hoffmann-La Roche Ltd&#46;&#44; Basel&#44; Switzerland&#41;&#44; the latter criterion could be omitted at subsequent visits&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Epidemiological variables &#40;age&#44; sex&#44; number of joints&#47;day&#44; years of use&#44; other toxic substances&#44; relief with hot showers and psychiatric history&#41;&#44; treatment times&#44; treatment administered&#44; and therapeutic intervals were collected&#46; Previous visits compatible with CHS&#44; visits after &#8220;visit zero&#8221; &#40;up to 3 months after the end of screening&#41;&#44; previous hospital admissions due to vomiting&#44; and complementary tests performed were recorded in the CHS diagnosis visit&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once the syndrome and therapeutic options had been explained&#44; topical capsaicin &#40;0&#46;075&#37;&#41; was used once the rest of the treatments for vomiting and abdominal pain had been exhausted&#44; under medical criteria and with the patient&#39;s consent&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Qualitative data are expressed as absolute frequencies and percentages&#59; continuous variables as means and standard deviations&#46; Comparisons between groups were made using the chi-square and Student&#8217;s t-test &#40;or the Mann&#8211;Whitney U test if the distribution was not normal&#41; for categorical and continuous variables&#44; respectively&#46; P values &#60; 0&#46;05 were considered significant&#46; The SPSS&#174; 25&#46;0 statistical software for Windows&#174; &#40;IBM&#44; Armonk&#44; New York&#44; USA&#41; was used&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 67 visits for CHS were recorded&#44; of which 8 were discarded due to lack of basic information&#44; with the final sample being 59 visits&#44; corresponding to 29 patients&#44; with a frequency in the Emergency Department of 4&#46;4 cases&#47;10&#44;000 visits &#40;95&#37; CI 2&#46;8&#8211;4&#46;7&#41; and a population incidence of 8&#46;8 episodes&#47;100&#44;000 inhabitants-year &#40;95&#37; CI 5&#46;2&#8211;11&#46;1&#41;&#46; Their demographic&#44; consumption and clinical history characteristics are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There were no significant gender differences in these characteristics&#46; Fifteen patients &#40;52&#37;&#41; had previously visited the ED for symptoms compatible with CHS and 3 patients had been admitted for symptoms possibly related to CHS &#40;10&#46;3&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Thirteen patients returned to the Emergency Department for CHS &#40;44&#46;8&#37;&#41;&#44; with a mean number of re-visits of 1&#46;77 &#40;SD 0&#46;93&#41; &#40;one patient had 4 visits&#44; 6 had 3 visits&#44; 6 had 2 visits&#44; and 15 patients had one more visit&#41;&#46; Regarding the differences between the cases with a single visit and the repeaters&#44; the latter consumed more toxic substances &#40;p &#61; 0&#46;01&#41;&#44; specifically more tobacco &#40;p &#61; 0&#46;01&#41; and more cocaine &#40;p &#61; 0&#46;031&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The drugs used as initial treatment for CHS were the antiemetics ondansetron &#40;52&#46;5&#37;&#41; and metoclopramide &#40;40&#46;7&#37;&#41;&#44; omeprazole &#40;30&#46;5&#37;&#41;&#44; analgesics such as paracetamol &#40;22&#37;&#41; and metamizole &#40;5&#46;1 &#37;&#41;&#44; spasmolytics &#40;scopolamine butylbromide 10&#46;2&#37;&#41; and opiates &#8211;tramadol &#40;8&#46;5&#37;&#41;&#44; pethidine &#40;6&#46;8&#37;&#41; and fentanyl &#40;3&#46;4&#37;&#41;&#8211;&#46; Droperidol was used in 8&#46;5&#37;&#44; haloperidol in 6&#46;8&#37;&#44; and benzodiazepines in 10&#46;2&#37;&#46; Capsaicin was applied in 74&#46;6&#37; of the visits and was not necessary in the rest due to resolution of the clinical symptoms with the previous drugs&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to complementary tests &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; fewer abdominal X-rays&#44; ultrasounds and CT scans were requested in repeat patients&#44; although this difference was not significant&#46; Treatment began on average at 173 min&#44; with no differences between the first and successive visits&#44; although this data was only recorded in 83&#37; of the patients&#46; Time to capsaicin application was 254 min&#46; Capsaicin was used less in the repeat group &#40;p &#61; 0&#46;015&#41;&#46; The mean time to resolution of vomiting after capsaicin was 17&#46;87 min&#44; ranging from 13&#46;73 for visit zero to 27 for repeaters&#44; although without statistical significance&#46; Conversely&#44; when calculating the overall length of stay in the Emergency Department&#44; repeat patients spent an average of 114&#46;62 min less than the first episodes&#44; although without statistical significance&#46; One case of adverse reaction to capsaicin was recorded&#44; consisting of erythema and intense burning sensation in the area of application &#40;abdomen&#41;&#46; Finally&#44; no association was found between the time-course of care for patients with CHS over the 2 years of the study and the decrease in treatment times&#44; nor in the application of capsaicin&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This paper presents the first case series of CHS in an ED in Spain&#46; The incidence found will help to calculate the sample size for further prospective studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We agree with other series in age &#40;35 years&#41;&#44; visits prior to diagnosis &#40;2 visits&#41;&#44; years of use &#40;13 years&#41; and number of joints&#47;day &#40;4 joints&#47;day&#41;&#46; Also&#44; in the percentage of patients who report symptom relief with hot showers &#40;37&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;11</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The percentage of patients with a psychiatric history &#40;20&#37;&#41; is higher than in other series&#44; although Bruguera et al&#46;&#44; studying a Spanish cohort of psychiatric patients&#44; found a CHS prevalence of 18&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Our percentage of smokers &#40;44&#37;&#41; is similar to that described&#44; although cocaine use &#40;20&#46;7&#37;&#41; is much higher<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; In addition&#44; ED revisits for CHS in our study were related to these 2 toxic substances&#44; something not previously described&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The use of capsaicin was found to be effective and low risk&#44; with symptom control in 18 min&#44; and virtually no side effects<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; Despite the characteristically poor response to antiemetics in CHS&#44; up to 25&#37; did not require capsaicin in our series<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Following this study&#44; a clinical trial &#40;single-centre and with 30 patients&#41; comparing capsaicin with placebo has been published&#46; A significant reduction in nausea was observed at 60 min and a complete resolution of vomiting in 29&#37; of those treated with capsaicin&#44; compared to 0&#37; in the placebo group<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">This study has limitations&#58; given its retrospective nature&#44; it was not possible to obtain some data&#44; such as data on consumption &#40;not recorded during history taking&#41;&#44; the reason for the lower use of capsaicin in the repeat group&#44; and data on treatment times&#46; Furthermore&#44; it was not possible to standardise the dose of capsaicin&#44; nor the area and site of application&#46; Thirdly&#44; as it is a single-center study and in an ED with a clinical toxicology area&#44; it is possible that the data do not represent the reality of the rest of the Spanish or European EDs&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">CHS has a low incidence in EDs but has probably been under-diagnosed and should be considered in patients with abdominal pain and vomiting&#44; especially in cannabis users&#46; Capsaicin 0&#46;075&#37; topical cream is an efficient and safe treatment&#46; However&#44; more multicenter clinical trials are needed to support its use with a higher level of evidence&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">This work has been partially funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">National Plan on Addictive Drugs</span>&#44; 2016 Call&#44; within the project Network for the Study of Addictive Drugs in Hospital Emergencies in Spain&#44; ref&#46; 2016&#47;071&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2021-05-19"
    "fechaAceptado" => "2021-07-12"
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          "clase" => "keyword"
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            0 => "Cannabinoid hyperemesis syndrome"
            1 => "Cannabis"
            2 => "Capsaicin"
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          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "S&#237;ndrome de hiper&#233;mesis cannabinoide"
            1 => "Cannabis"
            2 => "Capsaicina"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There are few studies in Spain on cannabinoid hyperemesis syndrome &#40;CHS&#41;&#44; as well as on the use of topical capsaicin as a treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of patients over 14 years of age seen in a hospital emergency department during 2018 and 2019 with a diagnosis of CHS based on the following criteria&#58; compatible clinical picture&#44; cannabis use less than 48 h and positive urine cannabis test&#46; Epidemiological and clinical variables&#44; attendance times and treatment &#40;including use of topical capsaicin 0&#46;075&#37;&#41; were collected&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fifty-nine attendances were studied&#44; from 29 patients &#40;4&#46;4 cases&#47;10&#44;000 visits&#44; 95&#37; CI 2&#46;8&#8211;4&#46;7&#41;&#46; Fifty per cent returned for CHS&#44; differing only in more tobacco &#40;<span class="elsevierStyleItalic">P</span> &#61; 0&#46;01&#41; and cocaine &#40;<span class="elsevierStyleItalic">P</span> &#61; 0&#46;031&#41; use&#46; Capsaicin was used in 74&#46;6&#37; of visits&#46; The mean time to resolution of vomiting after application was 17&#46;87 min&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Although probably underdiagnosed&#44; CHS has a low incidence in the emergency department in Spain&#44; with high patient recurrence&#46; The use of capsaicin ointment is efficient and safe&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
            "titulo" => "Introduction"
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            "titulo" => "Methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Existen pocos estudios en Espa&#241;a acerca del s&#237;ndrome de hiper&#233;mesis cannabinoide &#40;SHC&#41;&#44; as&#237; como sobre el uso de capsaicina t&#243;pica para su tratamiento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de pacientes mayores de 14 a&#241;os atendidos en un servicio de urgencias hospitalario durante 2018 y 2019 con diagn&#243;stico de SHC con base en los siguientes criterios&#58; cuadro cl&#237;nico compatible&#44; consumo de cannabis menor de 48 h y test de cannabis en orina positivo&#46; Se recogieron variables epidemiol&#243;gicas&#44; cl&#237;nicas&#44; tiempos asistenciales y tratamiento &#40;incluyendo el uso de capsaicina t&#243;pica al 0&#44;075&#37;&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 59 asistencias de 29 pacientes &#40;4&#44;4 casos&#47;10&#46;000 visitas&#44; IC 95&#37; 2&#44;8&#8722;4&#44;7&#41;&#46; Un 50&#37; volvieron a urgencias por SHC&#44; diferenci&#225;ndose estos solo en m&#225;s consumo de tabaco &#40;p &#61; 0&#44;01&#41; y coca&#237;na &#40;p &#61; 0&#44;031&#41;&#46; En un 74&#44;6&#37; de las visitas se utiliz&#243; capsaicina&#46; El tiempo medio de resoluci&#243;n de los v&#243;mitos tras su aplicaci&#243;n fue de 17&#44;87 min&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Aunque probablemente est&#233; infradiagnosticado&#44; el SHC presenta una incidencia baja en las urgencias en Espa&#241;a&#44; y con alta reincidencia de los pacientes&#46; El uso de pomada de capsaicina es eficiente y seguro&#46;</p></span>"
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            "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall">Miguel Benito-Lozano&#44; Guillermo Burillo-Putze&#44; Jorge Dur&#225;n-Quintero&#44; Marcos Exp&#243;sito Rodr&#237;guez&#44; Bego&#241;a Garc&#237;a-Calder&#243;n&#44; Clara Giron&#233;s Bredy&#44; Aceysele Gonzalez-D&#237;az&#44; Iv&#225;n Hern&#225;ndez-Ramos&#44; Dima Ibrahim-Achi&#44; M&#46; Angeles L&#243;pez-Hern&#225;ndez&#44; Isabel Ramos-Su&#225;rez&#44; Guillermo Rodriguez Gonzalez&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Members of GRUCATOX who have collaborated in this study"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N &#61; 29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#61; 5 &#40;7&#46;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Years of use&#44; mean &#177; SD &#40;n &#61; 11&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Joints&#47;day&#44; average &#177; SD &#40;n &#61; 12&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Relief with hot showers&#44; n &#40;&#37;&#41; &#40;n &#61; 16&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Psychiatric history&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Previous visits&#44; mean &#177; SD &#40;n &#61; 15&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Consumption of other toxic substances&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  """
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                  \t\t\t\t">30 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Abdominal ultrasound&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdominal CT&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arrival T-first treatment &#40;min&#41;&#44; mean &#40;N&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;49&#41; 174 &#177; 169&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;26&#41; 166 &#177; 146&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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ISSN: 23870206
Original language: English
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