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Ma XX, Xiao ZH, Chen W, Zhao SY. The relationship between gastrointestinal symptoms in FGID patients and D-type personality and emotion regulation strategies. iScience 2024; 27:109867. [PMID: 38784000 PMCID: PMC11112364 DOI: 10.1016/j.isci.2024.109867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
This study examines the relationship between gastrointestinal symptoms in patients with functional gastrointestinal disorders (FGIDs) and type D personality traits, as well as emotion regulation strategies. Analyzing a diverse group of FGID patients, we uncover significant effects of gender and age on gastrointestinal symptoms. Negative Affectivity emerges as a key predictor, positively associated with symptom severity, whereas Social Inhibition correlates negatively with Abdominal Pain. Additionally, our findings suggest that the expressive suppression strategy predicts heightened gastrointestinal symptoms, whereas cognitive reappraisal predicts lower levels of certain symptoms. These findings provide valuable insights for precise diagnosis and tailored treatments of FGIDs. Further research is warranted to explore underlying mechanisms and inform evidence-based interventions.
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Affiliation(s)
- Xin-Xin Ma
- School of Psychology, Guizhou Normal University, Guiyang, Guizhou 550025, China
| | - Zheng-Hua Xiao
- The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou 550003, China
| | - Wei Chen
- School of Psychology, Guizhou Normal University, Guiyang, Guizhou 550025, China
| | - Shou-Ying Zhao
- School of Psychology, Guizhou Normal University, Guiyang, Guizhou 550025, China
- Kaili University, Kaili, Guizhou 556011, China
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2
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Forestell B, Sabbineni M, Sharif S, Chao J, Eltorki M. Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain. Ann Emerg Med 2023; 82:615-623. [PMID: 37178102 DOI: 10.1016/j.annemergmed.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVES Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. METHODS The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. RESULTS This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). CONCLUSION In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Monica Sabbineni
- Department of Medicine, Michael G DeGroote Medical School, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Sharif
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Chao
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver and Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Broder JS, Oliveira J E Silva L, Bellolio F, Freiermuth CE, Griffey RT, Hooker E, Jang TB, Meltzer AC, Mills AM, Pepper JD, Prakken SD, Repplinger MD, Upadhye S, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:526-560. [PMID: 35543712 DOI: 10.1111/acem.14495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023]
Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
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Affiliation(s)
- Joshua S Broder
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Richard T Griffey
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edmond Hooker
- Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA
| | - Timothy B Jang
- Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA
| | - Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| | | | | | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
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Friedman AB, Chen AT, Wu R, Coe NB, Halpern SD, Hwang U, Kelz RR, Cappola AR. Evaluation and disposition of older adults presenting to the emergency department with abdominal pain. J Am Geriatr Soc 2022; 70:501-511. [PMID: 34628638 PMCID: PMC10078825 DOI: 10.1111/jgs.17503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/30/2021] [Accepted: 09/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain. METHODS We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits. RESULTS Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG). CONCLUSIONS Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.
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Affiliation(s)
- Ari B. Friedman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angela T. Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Wu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norma B. Coe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ula Hwang
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Rachel R. Kelz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne R. Cappola
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial. J Trauma Acute Care Surg 2020; 87:1181-1188. [PMID: 31425468 DOI: 10.1097/ta.0000000000002479] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population. METHODS A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 μg·kg·min or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events. RESULTS Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted. CONCLUSION Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients. LEVEL OF EVIDENCE Therapeutic, level I.
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Neuman MD, Elkassabany NM, Ochroch J, Newcomb C, Brensinger C, Mehta S, Gaskins LJ, Lane-Fall MB. Nerve Block Use after Hip Fracture Versus Elective Hip or Knee Arthroplasty: Retrospective Analysis. J Am Geriatr Soc 2020; 68:835-840. [PMID: 32124973 DOI: 10.1111/jgs.16362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt. DESIGN Retrospective cohort study of claims data from one large national private US insurer. SETTING US acute care hospitals. PARTICIPANTS A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016. MEASUREMENTS Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims. RESULTS Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9-3.1) received a nerve block for pain control, and the percentage receiving a block increased from .4% in 2004-2006 (95% CI = .3%-.6%) to 4.6% in 2013-2016 (95% CI = 4.4%-4.8%; P < .001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] = .88; 95% CI = .80-.98; P = .02) and among patients aged 75 to 84 vs 64 years or younger (OR = .86; 95% CI = .74-1.00; P = .02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement. CONCLUSION Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835-840, 2020.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Medicine, Division of Geriatric Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jason Ochroch
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Craig Newcomb
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Colleen Brensinger
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samir Mehta
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lakisha J Gaskins
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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7
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Montesino-Goicolea S, Sinha P, Huo Z, Rani A, Foster TC, Cruz-Almeida Y. Enrichment of genomic pathways based on differential DNA methylation profiles associated with chronic musculoskeletal pain in older adults: An exploratory study. Mol Pain 2020; 16:1744806920966902. [PMID: 33073674 PMCID: PMC7711149 DOI: 10.1177/1744806920966902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/19/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023] Open
Abstract
Our study aimed to identify differentially methylated CpGs/regions and their enriched genomic pathways associated with underlying chronic musculoskeletal pain in older individuals. We recruited cognitively healthy older adults with (n = 20) and without (n = 9) self-reported musculoskeletal pain and collected DNA from peripheral blood that was analyzed using MethylationEPIC arrays. We identified 31,739 hypermethylated CpG and 10,811 hypomethylated CpG probes (ps ≤ 0.05). All CpG probes were clustered into 5966 regions, among which 600 regions were differentially methylated at p ≤ 0.05 level, including 294 hypermethylated regions and 306 hypomethylated regions (differentially methylated regions). Ingenuity pathway enrichment analysis revealed that the pain-related differentially methylated regions were enriched across multiple pathways. The top 10 canonical pathways were linked to cellular signaling processes related to immune responses (i.e. antigen presentation, programed cell death 1 receptor/PD-1 ligand 1, interleukin-4, OX40 signaling, T cell exhaustion, and apoptosis) and gamma-aminobutyric acid receptor signaling. Further, Weighted Gene Correlation Network Analysis revealed a comethylation network module in the pain group that was not preserved in the control group, where the hub gene was the cyclic adenosine monophosphate-dependent transcription factor ATF-2. Our preliminary findings provide new epigenetic insights into the role of aberrant immune signaling in musculoskeletal pain in older adults while further supporting involvement of dysfunctional GABAergic signaling mechanisms in chronic pain. Our findings need to be urgently replicated in larger cohorts as they may serve as a basis for developing and targeting future interventions.
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Affiliation(s)
- Soamy Montesino-Goicolea
- Pain Research & Intervention Center of Excellence,
University of Florida, Gainesville, FL, USA
- Department of Community Dentistry & Behavioral Science,
College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Puja Sinha
- Department of Neuroscience, College of Medicine, University of
Florida, Gainesville, FL, USA
| | - Zhiguang Huo
- Department of Biostatistics, College of Public Health &
Health Professions and College of Medicine, University of Florida, Gainesville,
FL, USA
| | - Asha Rani
- Department of Neuroscience, College of Medicine, University of
Florida, Gainesville, FL, USA
| | - Thomas C Foster
- Department of Neuroscience, College of Medicine, University of
Florida, Gainesville, FL, USA
- Genetics and Genomics Program, University of Florida,
Gainesville, FL, USA
- Institute on Aging, University of Florida, Gainesville, FL,
USA
| | - Yenisel Cruz-Almeida
- Pain Research & Intervention Center of Excellence,
University of Florida, Gainesville, FL, USA
- Department of Community Dentistry & Behavioral Science,
College of Dentistry, University of Florida, Gainesville, FL, USA
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de Vries M, Gravel J, Horn D, McLeod S, Varner C. Comparative efficacy of opioids for older adults presenting to the emergency department with acute pain: Systematic review. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e538-e543. [PMID: 31831503 PMCID: PMC6907377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To systematically review the literature for studies comparing the efficacy of opioid analgesics for older adults (≥ 65 years) presenting to the emergency department (ED) with acute pain. DATA SOURCES The Cochrane Library, MEDLINE, EMBASE, Web of Science, and CINAHL were searched up to August or September 2017. Reference lists were searched for potential articles and ClinicalTrials.gov was searched for unpublished trials. STUDY SELECTION Randomized controlled trials (RCTs) were sought that compared the efficacy of 2 or more opioid analgesics for acute pain in older patients (≥ 65 years) in the ED. Two reviewers independently screened abstracts, assessed study quality, and extracted data. SYNTHESIS After screening titles and abstracts of 1315 citations, the full texts of 63 studies were reviewed and 1 RCT met the inclusion criteria. This study randomized older adult patients presenting to an urban academic ED with acute, severe pain to receive a single dose of either 0.0075 mg/kg intravenous hydromorphone or 0.05 mg/kg intravenous morphine. This study found no clinical or statistical difference between the 2 treatments. CONCLUSION The lack of published research in this area demonstrates a considerable gap in knowledge of the comparative efficacy of opioid analgesics in the growing older adult patient population. Physicians are often uncertain in their choice of analgesia, potentially contributing to the undertreatment of pain. It is clear that well designed RCTs are urgently needed.
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Affiliation(s)
- Maaike de Vries
- Doctoral student at the Institute of Health Policy, Management and Evaluation at the University of Toronto in Ontario.
| | - Jonathan Gravel
- Emergency medicine resident in the Department of Medicine and the Department of Family Medicine at McMaster University in Hamilton, Ont
| | - Daphne Horn
- Lead, Library Services, at Scarborough Health Network in Ontario
| | - Shelley McLeod
- Research Director at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health Systems and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
| | - Catherine Varner
- Emergency physician at Mount Sinai Hospital, Clinician Investigator at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health Systems, and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
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9
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Weng Y, Tian L, Tedesco D, Desai K, Asch SM, Carroll I, Curtin C, McDonald KM, Hernandez-Boussard T. Trajectory analysis for postoperative pain using electronic health records: A nonparametric method with robust linear regression and K-medians cluster analysis. Health Informatics J 2019; 26:1404-1418. [PMID: 31621460 DOI: 10.1177/1460458219881339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative pain scores are widely monitored and collected in the electronic health record, yet current methods fail to fully leverage the data with fast implementation. A robust linear regression was fitted to describe the association between the log-scaled pain score and time from discharge after total knee replacement. The estimated trajectories were used for a subsequent K-medians cluster analysis to categorize the longitudinal pain score patterns into distinct clusters. For each cluster, a mixture regression model estimated the association between pain score and time to discharge adjusting for confounding. The fitted regression model generated the pain trajectory pattern for given cluster. Finally, regression analyses examined the association between pain trajectories and patient outcomes. A total of 3442 surgeries were identified with a median of 22 pain scores at an academic hospital during 2009-2016. Four pain trajectory patterns were identified and one was associated with higher rates of outcomes. In conclusion, we described a novel approach with fast implementation to model patients' pain experience using electronic health records. In the era of big data science, clinical research should be learning from all available data regarding a patient's episode of care instead of focusing on the "average" patient outcomes.
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Harmon J, Summons P, Higgins I. Experiences of the older hospitalised person on nursing pain care: An ethnographic insight. J Clin Nurs 2019; 28:4447-4459. [DOI: 10.1111/jocn.15029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/04/2019] [Accepted: 08/03/2019] [Indexed: 01/30/2023]
Affiliation(s)
- Joanne Harmon
- Division of Health School of Nursing and Midwifery University of South Australia Adelaide SA Australia
| | - Peter Summons
- Faculty of Science and Information Technology School of Design Communication and IT University of Newcastle Callaghan NSW Australia
| | - Isabel Higgins
- Faculty of Health and Medicine School of Nursing and Midwifery University of Newcastle Callaghan NSW Australia
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11
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Zerillo J, Agarwal P, Poeran J, Zubizarreta N, Poultsides G, Schwartz M, Memtsoudis S, Mazumdar M, DeMaria S. Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns. Anesth Analg 2019; 127:855-863. [PMID: 29933267 DOI: 10.1213/ane.0000000000003579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.
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Affiliation(s)
| | - Parul Agarwal
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Myron Schwartz
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
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Anderson GL, Mattson AE, Brown CS, Cabrera D, Mara KC, Bellolio MF. Safety of parenteral ketorolac use for analgesia in geriatric emergency department patients. Am J Emerg Med 2019; 38:727-730. [PMID: 31201117 DOI: 10.1016/j.ajem.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/10/2019] [Accepted: 06/04/2019] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess the safety of a single dose of parenteral ketorolac for analgesia management in geriatric emergency department (ED) patients. METHODS This was a retrospective study of all administrations of parenteral ketorolac to adults ≥65 years of age and matched controls. The primary outcome was the occurrence of any of the following adverse events within 30 days of the ED visit: gastrointestinal bleeding, intracranial bleeding, acute decompensated heart failure, acute coronary syndrome, dialysis, transfusion, and death. The secondary outcome was the occurrence of an increase in serum creatinine of ≥1.5 times baseline within 7 and 30 days of the ED visit. RESULTS There were 480 patients included in the final analysis, of which 120 received ketorolac (3: 1 matching). The primary outcome occurred in 14 of 360 patients who did not receive ketorolac and 2 of 120 ketorolac patients (3.9% vs 1.7%, p = 0.38; OR 2.39, 95% CI 0.54-10.66). There was no occurrence of dialysis or death in either group. The secondary outcome occurred in 1 of 13 and 1 of 23 ketorolac patients with both a baseline serum creatinine and a measure within 7 and 30 days, respectively, but did not occur in patients who did not receive ketorolac (7 days: 7.7% vs 0.0%, p = 0.29; 30 days: 4.4% vs 0.0%, p = 0.22). CONCLUSION The use of single doses of parenteral ketorolac for analgesia management was not associated with an increased incidence of adverse cardiovascular, gastrointestinal, or renal adverse outcomes in a select group of older adults.
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Affiliation(s)
| | | | | | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Belland L, Rivera-Reyes L, Hwang U. Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2018; 15:450-455. [PMID: 29103414 DOI: 10.1016/s2095-4964(17)60341-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED. OBJECTIVE The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections. MAIN OUTCOME MEASURES The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later. RESULTS A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03). CONCLUSION These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.
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Affiliation(s)
- Laura Belland
- Center for Family Medicine, NewYork-Presbyterian/Columbia University Medical Center, New York, NY 10032, USA
| | - Laura Rivera-Reyes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, New York, NY 10029, USA
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Abstract
PURPOSE OF REVIEW The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances. RECENT FINDINGS Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University, TMP3 333, Cedar Street, New Haven, CT, 06520, USA.
| | - Alice M Kai
- Department of Internal Medicine, NYU Winthrop Hospital, 259 First Street, Mineola, NY, 11501, USA
| | - Vijay Kodumudi
- Medical Student, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-1905, USA
| | - Julie Sramcik
- Department of Anesthesiology, Yale University, TMP3 333, Cedar Street, New Haven, CT, 06520, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Ave, Suite 656, New Orleans, LA, 70112, USA
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16
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Kostev K, Von Vultée C, Usinger DM, Reese JP. Tramadol prescription patterns in patients followed by general practitioners and orthopedists in Germany in the year 2015. Postgrad Med 2017; 130:37-41. [PMID: 29157058 DOI: 10.1080/00325481.2018.1407205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The aim of this study was to analyze tramadol prescription patterns in acute pain patients followed by general practitioners and orthopedists in Germany. METHODS This study included patients ≥18 years diagnosed with acute pain who received at least one tramadol prescription each in one of 1,129 general or 179 orthopedic practices in Germany between January and December 2015 (index date). Patients were excluded if they had received a prescription for another analgesic in the year prior to the index date, had a follow-up of less than 15 months after the index date, or were prescribed tramadol for a period of more than three months. The main outcome of this retrospective study was the share of patients receiving tramadol in combination therapy. Combination therapy was defined as the prescription of tramadol in conjunction with at least one other analgesic during the same medical visit. RESULTS The present study included a total of 8,766 individuals. Overall, 1,492 (22.0%) of tramadol patients seen by general practitioners and 370 (18.7%) of those seen by orthopedists received tramadol in combination with other analgesics. Although this proportion was similar throughout the different subgroups in orthopedic practices, it was considerably higher in patients >80 years and in those with private health insurance coverage in general practices. CONCLUSIONS Approximately one of five tramadol patients was prescribed tramadol in combination therapy. Further research is needed to gain a better understanding of the demographic and clinical factors that have an effect on tramadol prescription patterns in Germany.
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Affiliation(s)
- Karel Kostev
- a Epidemiology , QuintilesIMS , Frankfurt am Main , Germany
| | | | | | - Jens-Peter Reese
- d Institute of Health Service Research and Clinical Epidemiolgy and Coordinating Center for Clinical Trials , Philipps-University , Marburg , Germany
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17
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Mistry B, Balhara KS, Hinson JS, Anton X, Othman IY, E'nouz MAL, Avila NA, Henry S, Levin S, De Ramirez SS. Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis. J Emerg Nurs 2017; 44:360-367. [PMID: 29167033 DOI: 10.1016/j.jen.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/23/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally. METHODS We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes. RESULTS Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment. DISCUSSION Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes.
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Affiliation(s)
- Binoy Mistry
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates.
| | - Kamna S Balhara
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | | | - Xavier Anton
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | | | | | | | - Sophia Henry
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | - Scott Levin
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
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Todd KH. A Review of Current and Emerging Approaches to Pain Management in the Emergency Department. Pain Ther 2017; 6:193-202. [PMID: 29127600 PMCID: PMC5693816 DOI: 10.1007/s40122-017-0090-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Pain is the most common symptom prompting an emergency department visit and emergency physicians are responsible for managing both acute pain and acute exacerbations of chronic pain resulting from a broad range of illnesses and injuries. The responsibility to treat must be balanced by the duty to limit harm resulting from analgesics. In recent years, opioid-related adverse effects, including overdose and deaths, have increased dramatically in the USA. In response to the US opioid crisis, emergency physicians have broadened their analgesic armamentarium to include a variety of non-opioid approaches. For some of these therapies, sparse evidence exists to support their efficacy for emergency department use. The purpose of this paper is to review historical trends and emerging approaches to emergency department analgesia, with a particular focus on the USA and Canada. METHODS We conducted a qualitative review of past and current descriptive studies of emergency department pain practice, as well as clinical trials of emerging pain treatment modalities. The review considers the increasing use of non-opioid and multimodal analgesic therapies, including migraine therapies, regional anesthesia, subdissociative-dose ketamine, nitrous oxide, intravenous lidocaine and gabapentinoids, as well as broad programmatic initiatives promoting the use of non-opioid analgesics and nonpharmacologic interventions. RESULTS While migraine therapies, regional anesthesia, nitrous oxide and subdissociative-dose ketamine are supported by a relatively robust evidence base, data supporting the emergency department use of intravenous lidocaine, gabapentinoids and various non-pharmacologic analgesic interventions remain sparse. CONCLUSION Additional research on the relative safety and efficacy of non-opioid approaches to emergency department analgesia is needed. Despite a limited research base, it is likely that non-opioid analgesic modalities will be employed with increasing frequency. A new generation of emergency physicians is seeking additional training in pain medicine and increasing dialogue between emergency medicine and pain medicine researchers, educators and clinicians could contribute to better management of emergency department pain.
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Eltumi HG, Tashani OA. Effect of Age, Sex and Gender on Pain Sensitivity: A Narrative Review. ACTA ACUST UNITED AC 2017. [DOI: 10.2174/1876386301710010044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction:
An increasing body of literature on sex and gender differences in pain sensitivity has been accumulated in recent years. There is also evidence from epidemiological research that painful conditions are more prevalent in older people. The aim of this narrative review is to critically appraise the relevant literature investigating the presence of age and sex differences in clinical and experimental pain conditions.
Methods:
A scoping search of the literature identifying relevant peer reviewed articles was conducted on May 2016. Information and evidence from the key articles were narratively described and data was quantitatively synthesised to identify gaps of knowledge in the research literature concerning age and sex differences in pain responses.
Results:
This critical appraisal of the literature suggests that the results of the experimental and clinical studies regarding age and sex differences in pain contain some contradictions as far as age differences in pain are concerned. While data from the clinical studies are more consistent and seem to point towards the fact that chronic pain prevalence increases in the elderly findings from the experimental studies on the other hand were inconsistent, with pain threshold increasing with age in some studies and decreasing with age in others.
Conclusion:
There is a need for further research using the latest advanced quantitative sensory testing protocols to measure the function of small nerve fibres that are involved in nociception and pain sensitivity across the human life span.
Implications:
Findings from these studies should feed into and inform evidence emerging from other types of studies (e.g. brain imaging technique and psychometrics) suggesting that pain in the older humans may have unique characteristics that affect how old patients respond to intervention.
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Riordan JP, Dell WL, Patrie JT. Can Patient Variables Measured on Arrival to the Emergency Department Predict Disposition in Medium-acuity Patients? J Emerg Med 2017; 52:769-779. [DOI: 10.1016/j.jemermed.2016.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/25/2016] [Accepted: 11/03/2016] [Indexed: 11/24/2022]
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Abstract
: Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic.
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22
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Pickering G, Monacelli F, Pérez-Castejón Garrote JM, Guarda H, Batalha L, Gibson S, Savas S, Odetti P, Gandolfo F, Pastorino E, Carrilho Mugeiro MJ, Dias IP, Kilavuz A, Macian N, Pereira B. Reliability Study in Five Languages of the Translation of the Pain Observational Scale Algoplus. PAIN MEDICINE 2017; 19:252-261. [DOI: 10.1093/pm/pnw356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Siddiqui A, Belland L, Rivera-Reyes L, Handel D, Yadav K, Heard K, Eisenberg A, Khelemsky Y, Hwang U. A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures. PAIN MEDICINE 2017; 18:41-48. [PMID: 27245631 DOI: 10.1093/pm/pnw072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients. Design Secondary analysis of retrospective cohort study. Setting Five EDs (four academic, one community) in the United States. Participants Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]). Measurements Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type. Results A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55-163] vs. 76 [35-149] minutes, P = 0.057), but no other differences in process outcomes were found. Conclusion Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.
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Affiliation(s)
- Ammar Siddiqui
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Belland
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Rivera-Reyes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Daniel Handel
- Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda Eisenberg
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, New York, USA
| | - Yury Khelemsky
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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24
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Abstract
Pain in aging adults is a global health problem requiring a proactive and consistent assessment approach. Pain assessment is critical to detecting pain and developing a collaborative and adaptive pain management plan. Getting health providers to assess and measure pain even in older adults who are communicative and can self-report remains a challenge. Self-report is the best method for identifying pain. Using a validated pain assessment scale is key to evaluate pain intensity. This article discusses techniques to obtain self-report and describe appropriate self-report pain tools for a focused pain assessment and reassessment in adults in later life.
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Affiliation(s)
- Staja Q Booker
- The University of Iowa, College of Nursing, 50 Newton Road, Iowa City, IA 52242, USA
| | - Keela A Herr
- The University of Iowa, College of Nursing, 50 Newton Road, Iowa City, IA 52242, USA.
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Moustafa F, Macian N, Giron F, Schmidt J, Pereira B, Pickering G. Intervention Study with Algoplus®: A Pain Behavioral Scale for Older Patients in the Emergency Department. Pain Pract 2016; 17:655-662. [DOI: 10.1111/papr.12498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Nicolas Macian
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
| | - Fatiha Giron
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
| | | | - Bruno Pereira
- CHU Clermont-Ferrand; Biostatistics Unit; Clermont-Ferrand France
| | - Gisèle Pickering
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
- Inserm 1107 and 1405; Clermont-Ferrand France
- Pharmacology Department; Medical Faculty; Clermont University; Clermont-Ferrand France
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Genes N, Kim MS, Thum FL, Rivera L, Beato R, Song C, Soriano J, Kannry J, Baumlin K, Hwang U. Usability Evaluation of a Clinical Decision Support System for Geriatric ED Pain Treatment. Appl Clin Inform 2016; 7:128-42. [PMID: 27081412 DOI: 10.4338/aci-2015-08-ra-0108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older adults are at risk for inadequate emergency department (ED) pain care. Unrelieved acute pain is associated with poor outcomes. Clinical decision support systems (CDSS) hold promise to improve patient care, but CDSS quality varies widely, particularly when usability evaluation is not employed. OBJECTIVE To conduct an iterative usability and redesign process of a novel geriatric abdominal pain care CDSS. We hypothesized this process would result in the creation of more usable and favorable pain care interventions. METHODS Thirteen emergency physicians familiar with the Electronic Health Record (EHR) in use at the study site were recruited. Over a 10-week period, 17 1-hour usability test sessions were conducted across 3 rounds of testing. Participants were given 3 patient scenarios and provided simulated clinical care using the EHR, while interacting with the CDSS interventions. Quantitative System Usability Scores (SUS), favorability scores and qualitative narrative feedback were collected for each session. Using a multi-step review process by an interdisciplinary team, positive and negative usability issues in effectiveness, efficiency, and satisfaction were considered, prioritized and incorporated in the iterative redesign process of the CDSS. Video analysis was used to determine the appropriateness of the CDS appearances during simulated clinical care. RESULTS Over the 3 rounds of usability evaluations and subsequent redesign processes, mean SUS progressively improved from 74.8 to 81.2 to 88.9; mean favorability scores improved from 3.23 to 4.29 (1 worst, 5 best). Video analysis revealed that, in the course of the iterative redesign processes, rates of physicians' acknowledgment of CDS interventions increased, however most rates of desired actions by physicians (such as more frequent pain score updates) decreased. CONCLUSION The iterative usability redesign process was instrumental in improving the usability of the CDSS; if implemented in practice, it could improve geriatric pain care. The usability evaluation process led to improved acknowledgement and favorability. Incorporating usability testing when designing CDSS interventions for studies may be effective to enhance clinician use.
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Affiliation(s)
- Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Min Soon Kim
- Department of Health Management & Informatics, University of Missouri School of Medicine, Columbia, MO; Informatics Institute, University of Missouri, Columbia, MO
| | - Frederick L Thum
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Laura Rivera
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Rosemary Beato
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Carolyn Song
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Jared Soriano
- Information Technology, Mount Sinai Health System , New York, NY
| | - Joseph Kannry
- Information Technology, Mount Sinai Health System, New York, NY; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin Baumlin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Ula Hwang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J Peters VAMC, Bronx, NY
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27
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Van Ryn M. Avoiding Unintended Bias: Strategies for Providing More Equitable Health Care. MINNESOTA MEDICINE 2016; 99:40-46. [PMID: 27089675 PMCID: PMC5476527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Research shows that unintentional bias on the part of physicians can influence the way they treat patients from certain racial and ethnic groups. Most physicians are unaware that they hold such biases, which can unknowingly contribute to inequalities in health care delivery. This article explains why a person's thoughts and behaviors may not align, and provides strategies for preventing implicit biases from interfering with patient care.
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Abstract
BACKGROUND Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders. OBJECTIVE A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes. RESEARCH DESIGN A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009. SUBJECTS A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included. MEASURES The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity. RESULTS On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357). DISCUSSION In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.
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Baumbauer KM, Young EE, Starkweather AR, Guite JW, Russell BS, Manworren RCB. Managing Chronic Pain in Special Populations with Emphasis on Pediatric, Geriatric, and Drug Abuser Populations. Med Clin North Am 2016; 100:183-97. [PMID: 26614727 PMCID: PMC4766002 DOI: 10.1016/j.mcna.2015.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the adult population chronic pain can lead to loss of productivity and earning potential, and decreased quality of life. There are distinct groups with increased vulnerability for the emergence of chronic pain. These groups may be defined by developmental status and/or life circumstances. Within the pediatric, geriatric, and drug abuser populations, chronic pain represents a significant health issue. This article focuses on known anatomic, physiologic, and genetic mechanisms underlying chronic pain in these populations, and highlights the need for a multimodal approach from multiple health care professionals for management of chronic pain in those with the most risk.
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Affiliation(s)
- Kyle M Baumbauer
- School of Nursing, The Center for Advancing Management of Pain, University of Connecticut, Storrs, CT 06269-4026, USA; Department of Neuroscience, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030, USA; Institute for Systems Genomics, University of Connecticut Health Center, 400 Farmington Ave, CT 06030, USA
| | - Erin E Young
- School of Nursing, The Center for Advancing Management of Pain, University of Connecticut, Storrs, CT 06269-4026, USA; Institute for Systems Genomics, University of Connecticut Health Center, 400 Farmington Ave, CT 06030, USA; Department of Genetics and Genome Sciences, University of Connecticut Health Center, 400 Farmington Ave, Farmington, CT 06030, USA
| | - Angela R Starkweather
- School of Nursing, The Center for Advancing Management of Pain, University of Connecticut, Storrs, CT 06269-4026, USA
| | - Jessica W Guite
- Department of Pediatrics, University of Connecticut School of Medicine, 236 Farmington Ave, Farmington, CT 06030, USA; Children's Center for Community Research (C3R), 12 Charter Oak Place, Hartford, CT 06106, USA; Pediatric Psychology, Hartford Hospital/The Institute of Living, 100 Retreat, Suite 515, Hartford, CT 06106, USA; Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, 282 Washington St, Hartford, CT 06106, USA
| | - Beth S Russell
- Human Development & Family Studies, University of Connecticut, 368 Mansfield Rd, Storrs, CT 06269-1058, USA
| | - Renee C B Manworren
- School of Nursing, The Center for Advancing Management of Pain, University of Connecticut, Storrs, CT 06269-4026, USA; Department of Pediatrics, University of Connecticut School of Medicine, 236 Farmington Ave, Farmington, CT 06030, USA; Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, 282 Washington St, Hartford, CT 06106, USA.
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30
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Bulls HW, Goodin BR, McNew M, Gossett EW, Bradley LA. Minority Aging and Endogenous Pain Facilitatory Processes. PAIN MEDICINE 2015; 17:1037-48. [PMID: 26814250 DOI: 10.1093/pm/pnv014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/05/2015] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of the current study was to examine the relationships among age, ethnicity, and endogenous pain facilitation using temporal summation (TS) responses to mechanical and heat stimuli. DESIGN The present study assessed hyperalgesia and pain facilitation to thermal and mechanical stimuli at the knee and distal sites in 98 pain-free men and women. Participants were drawn from two ethnic groups [African-American (AA) and non-Hispanic white (NHW)] and two age groups (19-35 and 45-85). RESULTS Significant main effects of ethnicity were demonstrated for both mechanical and heat modalities (all P's ≤ 0.05), suggesting that AA participants, relative to NHW counterparts, demonstrated enhanced hyperalgesia. Age differences (older > younger) in hyperalgesia were found in mechanical pain ratings only. Results indicated that mechanical pain ratings significantly increased from first to maximal pain as a function of both age group and ethnicity (all P's ≤ 0.05), and a significant ethnicity by age interaction for TS of mechanical pain was found at the forearm (P < 0.05) and trended toward significance at the knee (P = 0.071). Post-hoc tests suggested that results were primarily driven by the older AA participants, who demonstrated the greatest mechanical TS. Additionally, evidence of differences in heat TS due to both ethnicity alone (all P's ≤ 0.05) and minority aging was also found. CONCLUSIONS This study provides evidence suggesting that older AAs demonstrate enhanced pain facilitatory processes, which is important because this group may be at increased risk for development of chronic pain. These results underscore the necessity of testing pain modulatory mechanisms when addressing questions related to pain perception and minority aging.
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Affiliation(s)
| | - Burel R Goodin
- *Department of Psychology Division of Pain Medicine, Department of Anesthesiology
| | | | | | - Laurence A Bradley
- *Department of Psychology Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
Adequate treatment of pain is of utmost importance in making uncomplicated the perioperative course for geriatric surgical patients. Effective analgesia reduces morbidity, improves patient and family satisfaction, and is a natural expectation of high-quality care. Pain treatment in older adults is more complicated than in younger counterparts, and great consideration must be given to age-related changes in physiology and pharmacokinetics. Pain treatment must be individualized based on each patient's profile. Side effects must be minimized and organ toxicity avoided. When complications occur they may be more severe, and treatment must be prompt. Alternative plans for analgesia must be readily enacted.
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Affiliation(s)
- Jason L McKeown
- Department of Anesthesiology and Perioperative Medicine, University of Alabama, Birmingham, 619 19th Street South JT862, Birmingham, AL 35249, USA.
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