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Al-Mahrouqi T, Al Busaidi SA, Al Alawi AM. Cyclic Vomiting Syndrome: A Case Report and Mini Literature Review. Cureus 2020; 12:e11695. [PMID: 33391928 PMCID: PMC7769787 DOI: 10.7759/cureus.11695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 27-year-old man presented to the emergency department with nausea, vomiting, and abdominal pain. He had been having similar episodes for the last seven years, and all of the previous workups had been unremarkable. After excluding all organic causes of his presentation, the patient was diagnosed with cyclic vomiting syndrome (CVS) and managed accordingly. He has shown remarkable improvement and no further attack has been reported for almost five months since the diagnosis was made. This case report highlights the diagnostic challenge represented by CVS. Also, it summarizes the main aspects of management to achieve and maintain the remission of the condition.
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Clarke H, Weinrib A, Kotteeswaran Y, Katz J, Yu A, Tanguay R. Remote buprenorphine-naloxone initiation as an essential service for people with chronic pain and opioid dependence during the COVID-19 pandemic: Case reports, clinical pathways, and implications for the future. Can J Pain 2020; 4:224-235. [PMID: 33987501 PMCID: PMC7951165 DOI: 10.1080/24740527.2020.1795634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 12/19/2022]
Abstract
Many health care professions have reacted swiftly to the COVID-19 pandemic. In-person care has been ramped down and telemedicine/telehealth has been thrust to the forefront of clinical care. For people living with chronic pain and often concomitantly dealing with opioid-related issues, this is a time of great stress. With population-wide movements to shelter in place, people living with pain are more isolated, more stressed, and more vulnerable to mental health concerns like depression and anxiety that can increase pain-related suffering. This article presents two case reports of patients struggling with chronic pain and opioid dependence in which a telemedicine-based buprenorphine-naloxone conversion was chosen as a treatment option by two Canadian programs: The Transitional Pain Service at the Toronto General Hospital in Toronto, Ontario, and The Opioid Deprescribing Program in Calgary, Alberta. Both cases presented highlight the use of telemedicine during the COVID-19 pandemic and suggest that there will be substantial need for these services well beyond the apex of the crisis. A buprenorphine-naloxone home induction protocol is presented and we provide insight into important lessons learned regarding the appropriate selection of patients with chronic pain struggling with opioid use disorder for buprenorphine-naloxone conversion. The provision of health care during the COVID-19 pandemic has rapidly forced practitioners to evolve novel health care practices, and these changes will have long-term implications.
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Affiliation(s)
- Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto Centre for the Study of Pain, Toronto, Ontario, Canada
| | - Aliza Weinrib
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Yuvaraj Kotteeswaran
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto Centre for the Study of Pain, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Alvis Yu
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
- Opioid Deprescribing Program, Alberta Health Services, Calgary, Alberta, Canada
| | - Robert Tanguay
- Opioid Deprescribing Program, Alberta Health Services, Calgary, Alberta, Canada
- Department of Psychiatry and Surgery, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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A Nonopioid, Nonbenzodiazepine Treatment Approach for Intractable Nausea and Vomiting in the Emergency Department. J Clin Gastroenterol 2020; 54:327-332. [PMID: 31567626 DOI: 10.1097/mcg.0000000000001258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOAL We sought to assess the feasibility and efficacy of a treatment protocol for nausea and vomiting using the combination of chlorpromazine, a dopamine antagonist antiemetic, and ketamine, a nonopioid analgesic. BACKGROUND Increasing numbers of patients with cannabis use disorder are presenting to emergency departments with a poorly understood syndrome characterized by intractable nausea and vomiting. METHODS This is a prospective, observational study involving a convenience sample of patients with unexplained nausea and vomiting. Subjects were given ketamine 15 mg slow intravenous push and chlorpromazine 12.5 mg intravenous over 15 minutes. Outcomes were number of episodes of emesis after study drug administration; change in nausea severity; change in pain severity; adverse events; and patient satisfaction. RESULTS We enrolled 28 subjects on 30 emergency department visits. Twenty-three subjects (82%) reported at least weekly cannabis use with 19 reporting daily use. Initial symptoms were severe, with median pain and nausea scores both 10. After receiving study medication, the mean decrease in pain score over 120 minutes was 4.1 (95% confidence interval: 3.2, 5.0) and the mean decrease in nausea score was 4.9 (95% confidence interval: 4.0, 5.8). There were no adverse events. All 28 subjects who were asked reported they would want to receive these medications again. CONCLUSION In this single-center study, the majority of patients presenting with intractable nausea and vomiting reported heavy cannabis use, and symptoms were severe. The combination of chlorpromazine plus ketamine resulted in rapid, definitive cessation of symptoms in most of these patients without the need for opioids or benzodiazepines.
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Shearer J, Luthra P, Ford AC. Cyclic vomiting syndrome: a case series and review of the literature. Frontline Gastroenterol 2018; 9:2-9. [PMID: 29484154 PMCID: PMC5824764 DOI: 10.1136/flgastro-2016-100705] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/18/2016] [Accepted: 05/10/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Cyclic vomiting syndrome (CVS) is under-recognised. Treatment is difficult as the pathophysiology is incompletely understood. We report our experience of treating patients with amitriptyline, and review the literature to summarise symptoms and associated features, epidemiology, potential pathophysiological mechanisms, differential diagnoses and treatment. DESIGN Consecutive adult patients with CVS were identified during a 5-year period from January 2010 until December 2015. Medical records were reviewed retrospectively, and age and sex of the patient, symptoms, associated features and response to treatment with amitriptyline were recorded. SETTING A luminal gastroenterology clinic at a teaching hospital. RESULTS Seventeen patients were identified (mean age 29.8 years, 13 (76.5%) female). Five had a history of cannabis use. Duration of symptoms prior to diagnosis ranged from 5 months to 15 years. Fourteen patients commenced amitriptyline, and in eight (57.1%) symptoms either ceased entirely or improved. Review of the literature suggested the prevalence of CVS was 0.5%. Symptoms are stereotypical, with acute episodes of nausea and vomiting, interspersed by periods when the patient is symptom-free. Proposed pathophysiologies include neuroendocrine dysfunction, mutations in mitochondrial DNA and re-intoxication effects from cannabis stored in fat tissues. Treatment during the acute phase is supportive, with rehydration, sedation and antiemetics. Prophylaxis to prevent future attacks with antihistamines, antimigraine drugs, antiepileptics and tricyclic antidepressants may be beneficial. Complete cessation of cannabis smoking should be advised. CONCLUSIONS Diagnosis of CVS is often delayed in adults. Once identified, patients respond well to amitriptyline.
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Affiliation(s)
- Jessica Shearer
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Pavit Luthra
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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Bhandari S, Venkatesan T. Clinical Characteristics, Comorbidities and Hospital Outcomes in Hospitalizations with Cyclic Vomiting Syndrome: A Nationwide Analysis. Dig Dis Sci 2017; 62:2035-2044. [PMID: 28050780 DOI: 10.1007/s10620-016-4432-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/21/2016] [Indexed: 12/09/2022]
Abstract
BACKGROUND Data on cyclic vomiting syndrome (CVS) are limited to studies from tertiary care centers. There is a paucity of information about CVS on a national scale. AIM To study the clinical characteristics, comorbidities, and hospital outcomes in patients hospitalized with CVS using a nationwide database. METHODS We identified all hospitalizations associated with a primary diagnosis of CVS in 2010 and 2011 using the Nationwide Inpatient Sample with an age category of 18-55 years. A 1:2 random sample of non-CVS hospitalizations with the same age category was obtained, and comparisons between groups were made. Multivariate logistic regression analysis was used to determine comorbidities independently associated with CVS. RESULTS Our study included 20,952 CVS and 44,262 non-CVS patients. CVS patients tended to be younger, male, and white compared to non-CVS patients. On multivariate analysis, CVS was significantly associated with comorbidities including dysautonomia, migraine, anxiety, marijuana use, irritable bowel syndrome, gastroparesis, gastroesophageal reflux disease, asthma, cigarette smoking, and hypertension. CVS patients underwent esophagogastroduodenoscopy, colonoscopy, and gastric emptying tests more frequently. They had more favorable hospital outcomes like more routine discharges (discharge to home/self-care), lower mortality, and shorter length of stay but tended to leave against medical advice more frequently. CVS patients incurred total hospital charges of about $400 million over the 2 years. CONCLUSIONS Our study showed that CVS is associated with several comorbidities and incurred substantial health care costs despite benign outcomes. Efforts to optimize therapy of CVS, manage comorbid conditions and reduce healthcare utilization are warranted.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA.
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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