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Jones CL, Gallagher R, Quinn P, Lan NSR, Thomas DR, Wood C, Lau C, Chow WMS, Raju V, Rankin JM, Ihdayhid AR, Arendts G. A streamlined Emergency Department approach to moderate risk chest pain in patients with no pre-existing coronary artery disease: A pilot study. Emerg Med Australas 2024; 36:378-388. [PMID: 38100118 DOI: 10.1111/1742-6723.14360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE Moderate risk patients with chest pain and no previously diagnosed coronary artery disease (CAD) who present to ED require further risk stratification. We hypothesise that management of these patients by ED physicians can decrease length of stay (LOS), without increasing patient harm. METHODS A prospective pilot study with comparison to a pre-intervention control group was performed on patients presenting with chest pain to an ED in Perth, Australia between May and October 2021, following the introduction of a streamlined guideline consisting of ED led decision making and early follow up. Patients had no documented CAD and were at moderate risk of major adverse cardiac events (MACE). Electronic data was used for comparison. Primary outcomes were total LOS and LOS following troponin. RESULTS One hundred eighty-six patients were included. Median total LOS was reduced by 62 min, but this change was not statistically significant (482 [360-795] vs 420 [360-525] min, P = 0.06). However, a significant 60 min decrease in LOS was found following the final troponin (240 (120-571) vs 180 (135-270) min, P = 0.02). There was no difference in the rate of MACE (0% vs 2%, P = 0.50), with no myocardial infarction or death. CONCLUSIONS Our study suggests that patients with no pre-existing CAD can be safely managed by emergency physicians streamlining their ED management and decreasing LOS. This pathway could be used in other centres following confirmation of the results by a larger study.
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Affiliation(s)
- Christopher L Jones
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Robyn Gallagher
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Paddy Quinn
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - David-Raj Thomas
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher Wood
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher Lau
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Weng Man Sofia Chow
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vikram Raju
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Curtin University, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Glenn Arendts
- Medical School, The University of Western Australia Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
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Presto P, Sehar U, Kopel J, Reddy PH. Mechanisms of pain in aging and age-related conditions: Focus on caregivers. Ageing Res Rev 2024; 95:102249. [PMID: 38417712 DOI: 10.1016/j.arr.2024.102249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
Pain is a complex, subjective experience that can significantly impact quality of life, particularly in aging individuals, by adversely affecting physical and emotional well-being. Whereas acute pain usually serves a protective function, chronic pain is a persistent pathological condition that contributes to functional deficits, cognitive decline, and emotional disturbances in the elderly. Despite substantial progress that has been made in characterizing age-related changes in pain, complete mechanistic details of pain processing mechanisms in the aging patient remain unknown. Pain is particularly under-recognized and under-managed in the elderly, especially among patients with Alzheimer's disease (AD), Alzheimer's disease-related dementias (ADRD), and other age-related conditions. Furthermore, difficulties in assessing pain in patients with AD/ADRD and other age-related conditions may contribute to the familial caregiver burden. The purpose of this article is to discuss the mechanisms and risk factors for chronic pain development and persistence, with a particular focus on age-related changes. Our article also highlights the importance of caregivers working with aging chronic pain patients, and emphasizes the urgent need for increased legislative awareness and improved pain management in these populations to substantially alleviate caregiver burden.
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Affiliation(s)
- Peyton Presto
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ujala Sehar
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jonathan Kopel
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - P Hemachandra Reddy
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Nutritional Sciences Department, College of Human Sciences, Texas Tech University, Lubbock, TX 79409, USA; Department of Speech, Language and Hearing Sciences, School Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Public Health, School of Population and Public Health, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Neurology, Departments of School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Helms J, De Jong A, Einav S. Yentl syndrome and the ICU. Intensive Care Med 2021; 47:594-597. [PMID: 33950371 DOI: 10.1007/s00134-021-06420-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Julie Helms
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France. .,Laboratoire d'ImmunoRhumatologie Moléculaire, Faculté de Médecine, Institut National de la Santé et de la Recherche Médicale (INSERM)UMR_S 1109, Institut Thématique Interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NGFédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, CEDEX 5, Montpellier, France
| | - Sharon Einav
- University Faculty of Medicine, Intensive Care Unit of the Shaare Zedek Medical Medical Centre and 2Hebrew, Jerusalem, Israel
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Mnatzaganian G, Lee CMY, Robinson S, Sitas F, Chow CK, Woodward M, Huxley RR. Socioeconomic disparities in the management of coronary heart disease in 438 general practices in Australia. Eur J Prev Cardiol 2020; 28:400-407. [PMID: 33966082 DOI: 10.1177/2047487320912087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND This population-based cross-stional and panel study investigated disparities in the management of coronary heart disease (CHD) by level of socioeconomic status. METHODS CHD patients (aged ≥18 years), treated in 438 general practices in Australia, with ≥3 recent encounters with their general practitioners, with last encounter being during 2016-2018, were included. Secondary prevention prescriptions and number of treatment targets achieved were each modelled using a Poisson regression adjusting for demographics, socioeconomic indicators, remoteness of patient's residence, comorbidities, lifetime follow-up, number of patient-general practitioner encounters and cluster effect within the general practices. The latter model was constructed using the Generalised Estimating Equations approach. Sensitivity analysis was run by comorbidity. RESULTS Of 137,408 patients (47% women), approximately 48% were prescribed ≥3 secondary prevention medications. However, only 44% were screened for CHD-associated risk factors. Of the latter, 45% achieved ≥5 treatment targets. Compared with patients from the highest socioeconomic status fifth, those from the lowest socioeconomic status fifth were 8% more likely to be prescribed more medications for secondary prevention (incidence rate ratio (95% confidence interval): 1.08 (1.04-1.12)) but 4% less likely to achieve treatment targets (incidence rate ratio: 0.96 (0.95-0.98)). These disparities were also observed when stratified by comorbidities. CONCLUSION Despite being more likely to be prescribed medications for secondary prevention, those who are most socioeconomically disadvantaged are less likely to achieve treatment targets. It remains to be determined whether barriers such as low adherence to treatment, failure to fill prescriptions, low income, low level of education or other barriers may explain these findings.
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Affiliation(s)
| | - Crystal Man Ying Lee
- School of Psychology and Public Health, La Trobe University, Australia.,Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Australia
| | | | - Freddy Sitas
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia.,Menzies Centre for Health Policy, School of Public Health, University of Sydney, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia.,The George Institute for Global Health, University of New South Wales, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Australia.,The George Institute for Global Health, University of Oxford, UK
| | - Rachel R Huxley
- The George Institute for Global Health, University of New South Wales, Australia.,Faculty of Health, Deakin University, Australia
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Mnatzaganian G, Hiller JE, Braitberg G, Kingsley M, Putland M, Bish M, Tori K, Huxley R. Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments. Heart 2019; 106:111-118. [PMID: 31554655 DOI: 10.1136/heartjnl-2019-315667] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED). METHODS All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach. RESULTS Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively. CONCLUSIONS In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.
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Affiliation(s)
- George Mnatzaganian
- La Trobe Rural Health School, La Trobe University - Bendigo Campus, Bendigo, Victoria, Australia
| | - Janet E Hiller
- Swinburne University of Technology, Hawthorn, Victoria, Australia.,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - George Braitberg
- Centre for Integrated Critical Care Medicine, Department of Medicine and Radiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Kingsley
- La Trobe Rural Health School, La Trobe University - Bendigo Campus, Bendigo, Victoria, Australia
| | - Mark Putland
- Emergency Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Bish
- La Trobe Rural Health School, La Trobe University - Bendigo Campus, Bendigo, Victoria, Australia
| | - Kathleen Tori
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Rachel Huxley
- La Trobe University College of Science, Health and Engineering, Melbourne, Victoria, Australia .,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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