BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previousstudy reported that emergency providers did not adequately manage patients with severe paindespite objective findings for surgical...BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previousstudy reported that emergency providers did not adequately manage patients with severe paindespite objective findings for surgical pathologies. Our study aims to investigate clinical andlaboratory factors, in addition to providers’ interventions, that might have been associated witholigoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.METHODS: We conducted a retrospective study of adult patients who were transferred directlyfrom referring EDs to the emergency general surgery (EGS) service at a quaternary academic centerbetween January 2014 and December 2016. Patients who were intubated, did not have adequaterecords, or had mild pain were excluded. The primary outcome was refractory pain, which wasdefi ned as pain reduction <2 units on the 0–10 pain scale between triage and ED departure.RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory painhad signifi cantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and lessfrequent pain medication administration (median [interquartile range], 3 [3–5] vs. 4 [3–7], P=0.001), whencompared to patients with no refractory pain. Multivariable logistic regression showed that the number of painmedication administration (odds ratio [OR] 0.80, 95% confi dence interval [95% CI] 0.68–0.98) and ED serumlactate levels (OR 3.80, 95% CI 2.10–6.80) were signifi cantly associated with the likelihood of refractory pain.CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levelswere associated with a higher likelihood of refractory pain.展开更多
Objective The aim of the study was to investigate the efficacy and adverse effects of olanzapine in the treatment of moderate to severe refractory neuropathic pain.Methods Forty patients with digestive system cancer w...Objective The aim of the study was to investigate the efficacy and adverse effects of olanzapine in the treatment of moderate to severe refractory neuropathic pain.Methods Forty patients with digestive system cancer were enrolled,who had moderate to severe refractory neuropathic pain;the patients were treated with olanzapine for 2 weeks at a daily dosage of 5 mg to 10 mg per night according to patients’response and tolerability,combined with conventional analgesic therapy.Pain intensity was evaluated by using a Numeral Rating Scale(NRS)at baseline,3 days,and 2 weeks after therapy.The Pittsburg Sleep Quality Index(PSQI)was evaluated at baseline and 2 weeks after therapy.Data on adverse events were recorded.The dosage of conventional analgesics was adjusted over time based on the severity of pain.Results The mean pain score decreased by 2.575±1.318(P<0.000)at 3 days and by 3.400±1.614(P<0.000)at 2 weeks;30%of the patients experienced significant pain relief at 3 days and 50%at 2 weeks.The PSQI decreased by 4.725±2.828(P<0.000)at 2 weeks.The adverse events induced by olanzapine included sleepiness,weight gain,dizziness,fatigue,dry mouth,and constipation;all the side effects were mild.Conclusion When combined with conventional analgesic therapy,olanzapine was effective in relieving pain and sleep disturbance,and was well-tolerated among patients with refractory neuropathic pain.展开更多
<strong>Background</strong>: Inpatient subanaesthetic ketamine infusion for 5 days may improve pain and reduce oral opioid usage in patients with chronic pain. <strong>Objective</strong>: This ...<strong>Background</strong>: Inpatient subanaesthetic ketamine infusion for 5 days may improve pain and reduce oral opioid usage in patients with chronic pain. <strong>Objective</strong>: This study aims to investigate pain and psychological outcomes of ketamine parenteral infusion (0.1 - 0.35 mg/kg/h or maximum 24 mg/hour) for 5 days in patients with chronic refractory pain. The secondary objective is to explore any prognostic pain and psychological factors associated with the successful response to the ketamine treatment. <strong>Methodology</strong>: A prospective longitudinal study of a small cohort (N = 35) of patients with heterogenous chronic refractory pain conditions was conducted from one week to two months follow-up. <strong>Results</strong>: Pain Severity was significantly improved from mean 6.5 to 5.1 (t = 3.77, p < 0.001, d = 0.6) at 1-week and 5.9 (t = 2.14, p = 0.042, d = 0.4) at 2-month;Pain Interference from mean 7.0 to 5.1 (t = 4.99, p < 0.001, d = 0.9) at 1-week and 6.1 (t = 2.16, p = 0.041, d = 0.4) at 2-month;Pain Self-Efficacy Questionnaire (PSEQ) from mean 17 to 24 (t = <span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>3.37, p = 0.002, d = <span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>0.6) at 1-week and 23 (t =<span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>2.60, p = 0.016, d =<span style="white-space:nowrap;">−</span><span style="white-space:nowrap;"></span>0.5) at 2-month;Pain Catastrophizing (PCS) from 28 to 23 (t = 3.4, p = 0.002;d = 0.6) at 1-week and 21 (t = 2.45, p = 0.022, d = 0.5) at 2-month;Depression from mean 21 to 16 (t = 2.16, p = 0.038, d = 0.4) at 1-week and 16 (t = 3.53, p = 0.002, d = 0.7) at 2-month;and oral Morphine Equivalent Daily Dose (oMEDD) reduced from mean 191 mg/day on admission to 122 mg/day at 1-week (t = 2.38, p = 0.023;d = 0.4) and 93 mg/day at 2-month (t = 2.59, p = 0.016;d = 0.5). There was no significant difference between responders and non-responders on baseline psychological measures (t<sub>33</sub> < 1.19, p > 0.244) and pain classifications ( <img src="Edit_c68fc9e4-a875-4b79-b0cf-af146ed090fe.png" alt="" /> = 0.610, p = 0.894). <strong>Conclusion</strong>: Ketamine subanaesthetic dose infusion for 5 days was found to be effective in managing chronic refractory pain with significant opioid reduction and small improvements in all chronic pain outcomes, except anxiety, at 1-week and 2-month follow-up and with minimal severe adverse effects.展开更多
Background: Due to the aging population and increased survival of the patients with coronary artery disease, there is an increasing number of patients with debilitating angina refractory to optimal medical treatment w...Background: Due to the aging population and increased survival of the patients with coronary artery disease, there is an increasing number of patients with debilitating angina refractory to optimal medical treatment who are not candidates for revascularization. In case of low ischemic load, the treatment of stable refractory angina is aimed at symptom reduction. There are several new treatment methods targeting myocardial ischemia available, including coronary sinus flow reducer (CFR) implantation. Case Report: We report a case of a patient suffering from CCS class IV angina despite optimal medical therapy, with further revascualrization options exhausted, who was successfully treated with coronary sinus flow reducer (CFR). Besides technical skill to reach ostium of coronary sinus, the most important technical tip is precise positioning of the CFR. The reduction of angina symptoms started after epithelisation of CFR frame, usually 6 - 7 weeks after implantation. At 6-month follow-up, the patient reported a marked reduction of angina symptoms, with CCS grade improving by three classes (from IV to I). At 10-month follow-up, the sustainment of CCS grade I angina symptoms was reported by the patient. Conclusions: We conclude that CFR can be safely and successfully implanted in patients suffering from refractory angina. Considerable improvements in CCS grade may be experienced in certain cases.展开更多
BACKGROUND Heart transplantation is recommended for the treatment of patients with refractory heart failure.Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart.However...BACKGROUND Heart transplantation is recommended for the treatment of patients with refractory heart failure.Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart.However,data from case reports on tacrolimus-induced achalasia after heart transplantation are limited.We aimed to present a case of tacrolimus-induced achalasia that developed after heart tran-splantation,which was successfully relieved by laparoscopic Heller myotomy.CASE SUMMARY A 67-year-old man with a history of Type 2 diabetes mellitus,hyperlipidemia,and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago.At the 10-year follow-up after the heart transplantation,the patient presented with persistent cough,dysphagia,heartburn,and retrosternal chest pain lasting for 2 wk.Upper endoscopy revealed no specific findings.Two years later,the patient experienced the same symptoms,including chest pain lasting for 4 wk.Esophagogram and manometry confirmed the presence of achalasia.Previous reports showed that discontinuing calcineurin inhibitor(CNI)treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia.Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia,the patient underwent laparoscopic Heller myotomy.Dysphagia was relieved without complications.Eight months later,he had no signs of recurrence of the achalasia.CONCLUSION In transplant patients with chest pain and gastrointestinal symptoms, CNIinducedachalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.展开更多
Pancreatic cancer-related pain(PCRP)gains widespread attention for its high prevalence,extreme complexity,poor prognosis,and decreased survival rate.Current treatment of PCRP remains unsatisfactory since the underlyin...Pancreatic cancer-related pain(PCRP)gains widespread attention for its high prevalence,extreme complexity,poor prognosis,and decreased survival rate.Current treatment of PCRP remains unsatisfactory since the underlying mechanism is not clear.The occurrence of PCRP is mainly related to the neurotropic nature of pancreatic cancer,and perineural invasion,neural remodeling and plasticity play important roles.Upon the understanding of PCRP mechanism,the management of PCRP is a multidisciplinary and multifaceted strategy.Traditional pain medications,invasive or intervention treatment,psychological support,integrative therapy,and palliative care are all the potential aspects for the management of PCRP.展开更多
文摘BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previousstudy reported that emergency providers did not adequately manage patients with severe paindespite objective findings for surgical pathologies. Our study aims to investigate clinical andlaboratory factors, in addition to providers’ interventions, that might have been associated witholigoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.METHODS: We conducted a retrospective study of adult patients who were transferred directlyfrom referring EDs to the emergency general surgery (EGS) service at a quaternary academic centerbetween January 2014 and December 2016. Patients who were intubated, did not have adequaterecords, or had mild pain were excluded. The primary outcome was refractory pain, which wasdefi ned as pain reduction <2 units on the 0–10 pain scale between triage and ED departure.RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory painhad signifi cantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and lessfrequent pain medication administration (median [interquartile range], 3 [3–5] vs. 4 [3–7], P=0.001), whencompared to patients with no refractory pain. Multivariable logistic regression showed that the number of painmedication administration (odds ratio [OR] 0.80, 95% confi dence interval [95% CI] 0.68–0.98) and ED serumlactate levels (OR 3.80, 95% CI 2.10–6.80) were signifi cantly associated with the likelihood of refractory pain.CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levelswere associated with a higher likelihood of refractory pain.
基金grants from double top independent innovation physician funded projects of Huazhong University of Science and Technology(No.3011540024,5001540074,5001540095)Wuhan young and middle-age medical backbone training project(No.2016whzqnyxggrcl).
文摘Objective The aim of the study was to investigate the efficacy and adverse effects of olanzapine in the treatment of moderate to severe refractory neuropathic pain.Methods Forty patients with digestive system cancer were enrolled,who had moderate to severe refractory neuropathic pain;the patients were treated with olanzapine for 2 weeks at a daily dosage of 5 mg to 10 mg per night according to patients’response and tolerability,combined with conventional analgesic therapy.Pain intensity was evaluated by using a Numeral Rating Scale(NRS)at baseline,3 days,and 2 weeks after therapy.The Pittsburg Sleep Quality Index(PSQI)was evaluated at baseline and 2 weeks after therapy.Data on adverse events were recorded.The dosage of conventional analgesics was adjusted over time based on the severity of pain.Results The mean pain score decreased by 2.575±1.318(P<0.000)at 3 days and by 3.400±1.614(P<0.000)at 2 weeks;30%of the patients experienced significant pain relief at 3 days and 50%at 2 weeks.The PSQI decreased by 4.725±2.828(P<0.000)at 2 weeks.The adverse events induced by olanzapine included sleepiness,weight gain,dizziness,fatigue,dry mouth,and constipation;all the side effects were mild.Conclusion When combined with conventional analgesic therapy,olanzapine was effective in relieving pain and sleep disturbance,and was well-tolerated among patients with refractory neuropathic pain.
文摘<strong>Background</strong>: Inpatient subanaesthetic ketamine infusion for 5 days may improve pain and reduce oral opioid usage in patients with chronic pain. <strong>Objective</strong>: This study aims to investigate pain and psychological outcomes of ketamine parenteral infusion (0.1 - 0.35 mg/kg/h or maximum 24 mg/hour) for 5 days in patients with chronic refractory pain. The secondary objective is to explore any prognostic pain and psychological factors associated with the successful response to the ketamine treatment. <strong>Methodology</strong>: A prospective longitudinal study of a small cohort (N = 35) of patients with heterogenous chronic refractory pain conditions was conducted from one week to two months follow-up. <strong>Results</strong>: Pain Severity was significantly improved from mean 6.5 to 5.1 (t = 3.77, p < 0.001, d = 0.6) at 1-week and 5.9 (t = 2.14, p = 0.042, d = 0.4) at 2-month;Pain Interference from mean 7.0 to 5.1 (t = 4.99, p < 0.001, d = 0.9) at 1-week and 6.1 (t = 2.16, p = 0.041, d = 0.4) at 2-month;Pain Self-Efficacy Questionnaire (PSEQ) from mean 17 to 24 (t = <span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>3.37, p = 0.002, d = <span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>0.6) at 1-week and 23 (t =<span style="white-space:nowrap;"><span style="white-space:nowrap;">−</span></span>2.60, p = 0.016, d =<span style="white-space:nowrap;">−</span><span style="white-space:nowrap;"></span>0.5) at 2-month;Pain Catastrophizing (PCS) from 28 to 23 (t = 3.4, p = 0.002;d = 0.6) at 1-week and 21 (t = 2.45, p = 0.022, d = 0.5) at 2-month;Depression from mean 21 to 16 (t = 2.16, p = 0.038, d = 0.4) at 1-week and 16 (t = 3.53, p = 0.002, d = 0.7) at 2-month;and oral Morphine Equivalent Daily Dose (oMEDD) reduced from mean 191 mg/day on admission to 122 mg/day at 1-week (t = 2.38, p = 0.023;d = 0.4) and 93 mg/day at 2-month (t = 2.59, p = 0.016;d = 0.5). There was no significant difference between responders and non-responders on baseline psychological measures (t<sub>33</sub> < 1.19, p > 0.244) and pain classifications ( <img src="Edit_c68fc9e4-a875-4b79-b0cf-af146ed090fe.png" alt="" /> = 0.610, p = 0.894). <strong>Conclusion</strong>: Ketamine subanaesthetic dose infusion for 5 days was found to be effective in managing chronic refractory pain with significant opioid reduction and small improvements in all chronic pain outcomes, except anxiety, at 1-week and 2-month follow-up and with minimal severe adverse effects.
文摘Background: Due to the aging population and increased survival of the patients with coronary artery disease, there is an increasing number of patients with debilitating angina refractory to optimal medical treatment who are not candidates for revascularization. In case of low ischemic load, the treatment of stable refractory angina is aimed at symptom reduction. There are several new treatment methods targeting myocardial ischemia available, including coronary sinus flow reducer (CFR) implantation. Case Report: We report a case of a patient suffering from CCS class IV angina despite optimal medical therapy, with further revascualrization options exhausted, who was successfully treated with coronary sinus flow reducer (CFR). Besides technical skill to reach ostium of coronary sinus, the most important technical tip is precise positioning of the CFR. The reduction of angina symptoms started after epithelisation of CFR frame, usually 6 - 7 weeks after implantation. At 6-month follow-up, the patient reported a marked reduction of angina symptoms, with CCS grade improving by three classes (from IV to I). At 10-month follow-up, the sustainment of CCS grade I angina symptoms was reported by the patient. Conclusions: We conclude that CFR can be safely and successfully implanted in patients suffering from refractory angina. Considerable improvements in CCS grade may be experienced in certain cases.
文摘BACKGROUND Heart transplantation is recommended for the treatment of patients with refractory heart failure.Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart.However,data from case reports on tacrolimus-induced achalasia after heart transplantation are limited.We aimed to present a case of tacrolimus-induced achalasia that developed after heart tran-splantation,which was successfully relieved by laparoscopic Heller myotomy.CASE SUMMARY A 67-year-old man with a history of Type 2 diabetes mellitus,hyperlipidemia,and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago.At the 10-year follow-up after the heart transplantation,the patient presented with persistent cough,dysphagia,heartburn,and retrosternal chest pain lasting for 2 wk.Upper endoscopy revealed no specific findings.Two years later,the patient experienced the same symptoms,including chest pain lasting for 4 wk.Esophagogram and manometry confirmed the presence of achalasia.Previous reports showed that discontinuing calcineurin inhibitor(CNI)treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia.Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia,the patient underwent laparoscopic Heller myotomy.Dysphagia was relieved without complications.Eight months later,he had no signs of recurrence of the achalasia.CONCLUSION In transplant patients with chest pain and gastrointestinal symptoms, CNIinducedachalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.
基金supported by the National High Level Hospital Clinical Research Funding(2022-PUMCH-B-007 and 2022-PUMCH-A-147).
文摘Pancreatic cancer-related pain(PCRP)gains widespread attention for its high prevalence,extreme complexity,poor prognosis,and decreased survival rate.Current treatment of PCRP remains unsatisfactory since the underlying mechanism is not clear.The occurrence of PCRP is mainly related to the neurotropic nature of pancreatic cancer,and perineural invasion,neural remodeling and plasticity play important roles.Upon the understanding of PCRP mechanism,the management of PCRP is a multidisciplinary and multifaceted strategy.Traditional pain medications,invasive or intervention treatment,psychological support,integrative therapy,and palliative care are all the potential aspects for the management of PCRP.
