Search Results (50)

Traumatic injuries are a major cause of disability in adults, with long-term consequences that extend beyond acute survival. Understanding the longitudinal trajectory of quality of life (QoL) following trauma is essential for optimising recovery pathways. This study aimed to evaluate changes in QoL over a six-month period after injury and to characterise the most affected health domains. Methods: A longitudinal observational study was conducted including 136 adult trauma patients. QoL was assessed using the EQ-5D-5L at three time points: retrospectively for the pre-trauma state, and prospectively at one and six months post-injury. Statistical analysis included Paired T-Tests and Cohen’s d to evaluate the significance and magnitude of changes across five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Results: The sample was predominantly male (57.4%), and falls were the most common mechanism of injury (57.4%). One month after trauma, a significant decline was observed across all EQ-5D dimensions (p < 0.001), with large effect sizes particularly in usual activities (d = 0.89) and self-care (d = 0.86). At six months, significant improvement was noted in all domains compared to the one-month assessment (p < 0.001). However, only mobility returned to pre-trauma levels (p = 0.137), while persistent impairments remained in pain/discomfort and anxiety/depression. The EQ-VAS score declined from a pre-trauma mean of 82.74 to 69.00 at one month and partially recovered to 77.29 at six months. Notably, only 15.4% of patients received specialized rehabilitation services. Conclusions: Trauma results in a profound immediate reduction in QoL. Although physical mobility tends to recover by six months, functional autonomy and psychological well-being remain compromised. The findings highlight the need for multidisciplinary post-discharge interventions, focusing on pain management and psychological support to bridge the gap in long-term recovery. Full article

Background/Objectives: Children with acute lymphoblastic leukemia (ALL) often experience treatment-related side effects. Physical therapy (PT) surveillance programs are helpful in identifying impairments; however, they do not typically incorporate assessments for peripheral neuropathy, motor proficiency, and foot drop. Our aim is to explore the feasibility of conducting additional functional tests to an existing surveillance program to improve the identification of impairments and characterize the prevalence of treatment-related deficits in children with ALL. Methods: A prospective, longitudinal descriptive study, embedded into a quality improvement initiative, was conducted. The surveillance program included standard assessments for ankle range of motion, activity level, balance, functional capacity, pain, gait, and kneeling to standing. Additional tests included motor and sensory function, foot posture, motor performance, quality of life, feasibility (recruitment and completion rates), service provision, and self-reported symptoms. Data were collected over 3 months. Results: Twenty children completed the study and 19 completed all assessments. Nineteen children presented deficits in at least two physical function tests. The most prevalent deficit identified from standard PT tests included decreased ankle range of motion (n = 19; 95%), and the most common deficit seen in the additional tests was impaired motor and sensory function (n = 14/19; 74%). Pain was the most common self-reported symptom in the checklist and the second worst subscale score in the pain dimension of the quality of life questionnaire (p < 0.001). Conclusions: Several treatment-related deficits were identified in children with ALL. Further research is warranted to explore the use of a standardized symptom checklist for the timely identification of functional limitations and impairments. Full article

Background: Acute coronary syndrome (ACS) is a “can’t miss” diagnosis. The gold-standard workup for this requires serial troponin biomarker evaluation over a period of hours. Traditionally, many of these patients required telemetry while being evaluated in this fashion; however, the high-quality literature suggests that low-risk patients do not require ongoing continuous cardiac monitoring. Locally, it was found that over 70% of patients presenting with low-risk chest pain to our high-volume urgent care were transferred to the main hospital for an ACS rule-out work-up via emergency medical services (EMS). We felt this intersection of patient care and medical services could be streamlined to reduce critical resource utilization. Objective: The aim of this study is to reduce the usage of EMS utilization for transport of low-risk chest-pain patients from the urgent care to the main hospital by 25% over a 3-month period. Methods: This study was conducted as an uncontrolled before–after interrupted time series design. A comprehensive data drilldown was performed through a chart review and structured clinical-practice evaluation. This led to a multi-factorial quality improvement initiative centered around the creation of an evidence-based safe-for-self-transport tool and physician education. The primary outcome measure was the proportion of patients transported via EMS with the main balancing measures being the proportion of self-transported patients admitted to the hospital and the time to troponin blood-draw in self-transported patients. Results: The education and the newly developed transport tool resulted in a sustained shift below the previous baseline system mean control limit, indicating a significant reduction in EMS usage for patient transport. The overall reduction in usage was 30%. No change in balancing (safety) measures was identified post-implementation. Conclusions: EMS remains a finite resource within many Canadian health regions. The results of this study show that by focusing on a cardinal emergency-department presentation like chest pain, adapting evidence-based practice through quality-improvement methodologies can result in a significant sustained reduction in EMS utilization. Full article

Background: Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for clavicle fracture pain management carry significant adverse effect and allergic reaction risks. This study assessed ultrasound-guided nerve block (USNB) efficacy for acute clavicle fracture pain in emergency department (ED) patients, providing an alternative to NSAIDs and opioids with fewer adverse effects. Methods: This retrospective, single-center observational study was conducted in accordance with Methods of Medical Record Review Studies in Emergency Medicine Research guidelines. Adult patients (≥20 years) who presented to the ED with traumatic clavicle fractures between 1 January 2015 and 30 November 2023 were included. Of the 343 eligible patients, 12 received ultrasound-guided nerve blocks (USNB) and 331 received standard care. To improve exchangeability, 1:10 matching with replacement was performed according to patients’ characteristics, such as age, sex, initial pain score, and comorbidities. The primary outcome was pain relief, assessed via the pain intensity difference (PID) on the Numerical Rating Scale within 360 min post-intervention. Meaningful pain relief was defined as a PID ≥ 4. Secondary outcomes included rescue opioid use, ED length of stay, hospital length of stay, and USNB-associated complications, such as vascular puncture, nerve injury, or local anesthetic systemic toxicity. Data were analyzed using time-course, time-to-event (time to meaningful pain relief), and linear regression analyses. Results: A total of 12 patients in the USNB group and 85 matched patients in the standard care group were analyzed after baseline characteristics matching with replacement. Compared to standard care, USNB was associated with significantly greater pain relief (p < 0.001). In the time-to-event analysis, USNB led to a 3.41-fold faster achievement of meaningful pain relief compared with that achieved with standard care (HR = 3.41; 95% CI, 1.47–7.90; p = 0.004). No significant differences were observed between groups in rescue opioid use, ED length of stay, or hospital length of stay. No USNB-associated complication developed in the USNB group. Conclusions: In patients with traumatic clavicle fractures, USNB provides more rapid and sustained pain relief than standard analgesic care in the ED, without increasing the ED length of stay. Large prospective studies are needed to confirm these findings. Full article

Background: Inequities in pain management are well documented in chronic pain and outpatient settings, yet little is known about disparities in inpatient Acute Pain Service (APS) care. This study evaluated demographic, clinical, and social factors associated with APS utilization and outcomes in an urban safety-net hospital, with a subgroup analysis of trauma patients who presented with at least three rib fractures. Methods: We performed a retrospective cohort study of two patient populations from our institution: (1) all patients receiving APS consultation from 1 January 2020 to 1 November 2022 (n = 1445) and (2) all patients with traumatic rib fractures during this time, stratified by APS consult status (n = 650). Demographics, insurance, comorbidities, opioid prescribing, and discharge outcomes were analyzed using descriptive statistics, multivariable logistic regression, and log-linear models. As APS consultation criteria were not standardized during the study period, referral patterns reflected routine clinical practice rather than predefined eligibility criteria. Results: Across the full APS cohort, patients were disproportionately represented from vulnerable groups: 30.5% were Black, 81.0% had public insurance, and 32.9% had a substance use disorder (SUD). Methadone use was a strong predictor of non-home discharge, including discharges to a medical facility, hospice, or against medical advice (AMA). In the rib fracture cohort, patients receiving APS consults had significantly higher injury severity scores (Injury Severity Score 17.1 vs. 13.0, p < 0.001). Black patients were less likely to receive APS consult (17.3% vs. 28.8%, p = 0.024). However, this association appeared to be attributable to the younger age and male predominance within this subgroup, as both factors were identified as significant predictors of APS consultation. Conclusions: APS utilization at a high-volume safety-net hospital highlights the intersection of medical vulnerability and structural inequities, with greater involvement among patients who were members of racial and ethnic minorities, publicly insured, or diagnosed with SUD. In trauma populations, younger Black men were over-represented, reinforcing the heightened injury risks Black men may face and the downstream effects on patient care. Taken together, these results highlight how APS involvement acts not only as a marker of increased injury severity but also as an intervention to improve care for vulnerable patient populations. As APS teams regularly serve these populations, they are well-positioned to bridge broader gaps through the integration of addiction and social support services, individualized pain management, and seamless coordination of care across specialties. These findings underscore the need for standardized consultation criteria and integration of social and addiction medicine resources into APS care models. Full article

Threat activation or deactivation in the brain–body is associated with learned nocebo or placebo somatic effects induced by fake invasive medical–surgical procedures. Some functional somatic disorders (FSDs) originate as acute nocebo somatic effects and can become 30–50% of chronic somatic presentations to primary care physicians. Patients with FSD overutilize medical–surgical services, despite the lack of identified pathophysiology, and are at risk for morbidity from unintentional iatrogenic injury. The Conditioned Response Model (CRM) of learning postulates three innate mechanisms, modulated by trait hypnotizability, which drive placebo and nocebo somatic effects and FSD. The High Risk Model of Threat Perception (HRMTP) postulates 10 psychosocial risk factors that modulate threat perception, driving placebo and nocebo somatic effectsandbiologically embedded FSD. Psychosocial factors and the trait of high and low hypnotizability modulate threat and are postulated to reduce heart rate variability(HRV), inducing autonomic nervous system(ANS)dysregulation. Reduced HRV was found in a large (N = 6,891) sample of patients with FSD. A total of 50% of patients with FSD with chronic pain (n = 224) without identified pathophysiology had a Paradoxical Increase in hand Temperature (PTI) during experimental threat induction. The HRMTP predicts that PTI associated with ANS dysregulation is associated with the risk factor Adverse Childhood Experiences (ACEs). This ACE prediction was independently confirmed. Learning predicts that threat activation by unconscious neutral stimuli (CS) can amplify nocebo and FSD and can negate placebo effects in clinician–patient relationships. Identifying psychosocial risk factors that modulate threat perception enables the diagnosis of FSD by inclusion and not simply by excluding pathophysiology. Full article

Objectives: We wished to demonstrate the utility of a novel quantitative assessment tool for the efficacy of regional anesthesia in children. Methods: The authors examined the records of all patients evaluated by the acute pain service during a 6-month period at a large quaternary-care pediatric hospital. The morphine equivalency rate (MER) in mcg/kg/hour was employed to compare the opioid use in children undergoing similar procedures with and without regional anesthesia (RA). Results: A total of 744 patients were included in this study, 333 of whom received RA. The RA group demonstrated a statistical and clinical benefit from having regional anesthesia, as demonstrated by the MER, compared to the non-RA group. Discussion: Objective measurements of RA in adults are overshadowed by subjective evidence of surgical tolerance in awake or lightly sedated patients. However, in pediatrics, objective measures are still needed to highlight the importance and utility of RA. Such objective tools could impact the adoption of RA by our surgical colleagues and have a long-term impact on opioid use and even abuse. We implemented the MER to quantify the benefit of RA. Given the adverse effects of opioids on gut motility, the incidence of nausea and vomiting, hypersensitivity reactions, and ubiquitous potential for abuse, the MER objectively demonstrates RA’s impact on pediatric surgical patients and why its utilization as an assessment tool could ultimately change practice. Full article

Background/Objectives: Thoracic outlet syndrome (TOS) is a rare and difficult-to-diagnose condition in children, characterized by the compression of neurovascular structures in the thoracic outlet. Neurogenic TOS (nTOS) often presents with nonspecific symptoms such as paresthesia, weakness, and upper extremity discomfort. While anterior scalene muscle block (ASMB) has been used in adults as a diagnostic adjunct, its role in pediatric patients remains underreported. Methods: We present two adolescent female patients with suspected neurogenic thoracic outlet syndrome (nTOS) who were referred to the acute pain service for further evaluation. Both patients underwent ultrasound-guided ASMB. Results: Following the block, both patients experienced rapid and marked relief of symptoms. Subsequently, each underwent first rib resection with brachial plexus neurolysis. At follow-up, both patients reported a complete resolution of symptoms and a return to baseline function. Conclusions: These cases suggest that ASMB may serve as a functional diagnostic tool and short-term therapeutic test in pediatric nTOS patients. It also helps guide surgical decision-making for invasive treatment. However, as ASMB is not without risk, its role should be considered supportive rather than confirmatory. Further studies are needed to better define its utility and safety in the pediatric population. Full article

Background/Objectives: Ultrasonography is a diagnostic modality characterized by high sensitivity in detecting hepato-biliary pathology, particularly intrahepatic biliary duct dilation. This study compares the sonographic findings obtained by a radiographer/sonographer in a Basic Emergency Service (BES) using Point-of-Care Ultrasonography (POCUS) in Portugal with the sonographic findings from the same patients acquired by radiologists at a referral hospital (RH) for suspected intrahepatic biliary dilatation. Methods: Nineteen patients presenting with right upper quadrant (RUQ) pain and suspected abdominal pathology underwent sonographic screening using POCUS in the BES. Subsequently, the same patients were referred to the RH, where a radiologist performed a comprehensive ultrasound. Both examinations were compared to determine whether the findings obtained in the BES were confirmed by radiologists in the RH. Results: Cholestasis, cholangitis, lithiasis, pancreatitis, peri-ampullary lithiasis, and neoplasms were observed in association with intrahepatic biliary dilation in this study sample. All six variables showed a strong association between the BES and RH findings (Cramer’s V > 0.6; p < 0.006). A strong kappa measure of agreement between the radiographer and radiologist findings was obtained in “cholelithiasis/sludge/gallbladder acute sonographic changes” (k = 0.802; p = 0.000). A moderate kappa value was obtained for the variable “abdominal free fluid”, (k = 0.706; p = 0.001). Conclusions: In this study, all patients referred from the BES to the RH required hospitalization for treatment and additional imaging exams. Although pre-hospital screening ultrasound is not intended for definitive diagnoses, the early detection of intrahepatic biliary tract dilatation through screening sonography played a significant role in the clinical referral of patients, with a sensitivity of 94% and specificity of 75%. Full article

Italy’s immigrant population has risen in the last two decades. Integration into society, including access to healthcare, is critical for the well-being of this population. Objectives: We compared regular immigrants and Italians to determine whether the groups received different care. Methods: Inpatient and outpatient medical records were collected from January 2017 to December 2021. We abstracted the identification code, nationality, sex, age, ICD-9 codes, date of the first and additional visits, and surgical intervention. Pathologies were categorized with ICD-9 codes. Patients were grouped according to geographical origin: European Union (EU), Central and Eastern Europe, Asia, North Africa, Central and South Africa, North America, and Central and South America. Results: More patients from Asia and Africa presented to inpatient than outpatient clinics (p-value: 0.001). The median age was lower for patients from Asia and Eastern Europe than from the EU. More patients presented with acute spine pain (26.4% versus 19.6%, p-value: 0.001) as inpatients, while patients presented as outpatients more for degenerative spine issues (77.1% versus 69.0%, p-value: <0.001) but less for brain neoplasms (p-value: 0.009). Additional visit rates were higher for immigrants than for Italians (IRR 1.32 visits/year, 95% CI 0.99–1.77 visits/year, p-value: 0.06), especially for patients with spinal issues (spinal versus cranial: 1.27 visits/year, 95% CI 1.14–1.43 visits/year, p-value: <0.001) and younger patients (<65 years old: 1.52 visits/year, 95% CI 1.39–1.71 visits per year, p-value: <0.001). There was no difference in the incidence of new visits when stratified by sex. Conclusions: Access to emergency care and additional visits were more prevalent in the recent immigrant population, especially from Asia, reflecting unconsolidated health habits. Immigrants from Central and Eastern Europe or North Africa seemed fully integrated. A healthcare policy tailored to the needs of immigrants—taking into account their cultural and social backgrounds and ensuring effective communication—can be highly beneficial. Specifically, it is essential to reintegrate general practitioners and guide individuals toward the most appropriate services. Full article

Metastatic spinal cord compression (MSCC) is a common complication in cancer patients, occurring in 3–5% of diagnosed cases annually, and serves as the initial manifestation of malignancy in 20% of patients. Timely diagnosis and management are critical due to the risk of irreversible neurological damage and the significant impact on both quality and quantity of life. The National Institute for Health and Care Excellence (NICE) recommends that patients presenting with back pain accompanied by neurological signs and/or symptoms undergo whole-spine magnetic resonance imaging (MRI) within 24 h. This retrospective study at Medway Maritime Hospital in England aimed to assess adherence to these guidelines by reviewing the time from presentation to MRI for patients exhibiting symptoms and/or signs of MSCC. Data for 69 patients were collected over one year using electronic patient records and the acute oncology service database. Analysis revealed that MRI was conducted within 24 h in only 43 out of 69 cases (62%), and 16 out of 25 delayed cases (i.e., MRI done beyond the recommended 24 h window) experienced delays of more than 48 h. To improve guideline adherence, interventions such as informational flyers and regular MSCC training sessions, including trainee teaching and presentations during grand rounds, were implemented. A follow-up re-audit involving 113 patients over one year demonstrated improved adherence to the 24 h MRI guideline, with 81 out of 113 cases (71%) meeting the target. The second cycle also documented reasons for delays, identifying patient compliance and pain control as primary factors. Additionally, the timing of steroid administration following suspicion of MSCC was recorded. Future studies should re-assess adherence, focus on better documentation of delay causes, enhance pain management before MRI scans, and ensure prompt steroid administration. Full article

Background/Objectives: Patient-reported outcome measures (PROMs) assess the severity and impact of both pain and dyspnea in those with acute exacerbations of chronic obstructive pulmonary disease (COPD), but their frequency of use in clinical practice is unknown. This study aimed to determine the point prevalence of pain and dyspnea assessment in patients hospitalized with an acute exacerbation of COPD and the measurement tools applied for this purpose in clinical practice. Methods: Clinical notes and observation charts of patients admitted with acute exacerbations of COPD to a metropolitan hospital in 2019 and 2020 were retrospectively audited to identify the point prevalence of pain and dyspnea assessment, the PROMs applied, and their associated focal periods. Results: Pain and dyspnea were assessed using a PROM in 99% and 8% of cases of acute exacerbation of COPD, respectively. All PROMs used measured symptom intensity. Focal periods were rarely reported in the assessment of pain; in the dyspnea assessment, timeframes predominantly reflected the impact of exertion. Conclusions: At this single health service site, in people hospitalized with an acute exacerbation of COPD, pain was more frequently assessed using a PROM than dyspnea. Understanding factors influencing clinicians’ choice of assessment tools may inform future recommendations for the assessment of these symptoms in people hospitalized with exacerbations of COPD. Full article

Background and Objectives: Video-assisted thoracoscopic surgery (VATS) is associated with less postoperative pain than traditional open thoracotomy. However, trocar and chest tube placement may damage the intercostal nerves, causing significant discomfort. An ultrasound-guided serratus anterior plane block (SAPB) is a promising mode of pain management; this reduces the need for opioids and the associated side-effects. This study evaluated whether SAPB, compared to intravenous analgesia alone, reduces opioid consumption after thoracoscopic lung wedge resection. Materials and Methods: In total, 22 patients undergoing VATS lung wedge resections were randomized into two groups (SAPB and control): both received intravenous patient-controlled analgesia (PCA), and one group received additional SAPB. The primary outcome was the cumulative intravenous fentanyl consumption at 8 h postoperatively. The visual analog scale (VAS) pain scores and the incidence of postoperative complications were assessed over 48 h post surgery. Results: Fentanyl consumption by 8 h post surgery was significantly lower in the SAPB group than in the control group (183 ± 107 μg vs. 347 ± 202 μg, p = 0.035). Although the VAS scores decreased with time in both groups, the differences were not statistically significant. The SAPB group required fewer opioids by 48 h. No significant between-group differences were observed in postoperative complications, including nausea and vomiting. Conclusions: SAPB effectively reduced opioid consumption after VATS lung wedge resection. SABP may serve as a valuable component of multimodal pain management. Full article

Objectives: Chronic pain is a common symptom in Post-Acute COVID-19 Syndrome (PACS), affecting 11–60% of patients, but the link between COVID-19 and chronic pain remains unclear. This study assesses healthcare resource utilization (HRU) for pain management among French COVID-19 survivors, using the National French Claims Database (SNDS). We analyzed medical consultations, rehabilitation services, diagnostic procedures, and medication dispensing to identify PACS-related pain patterns and their impact on the healthcare system. Methods: The cohort included 68,822 patients hospitalized during the first COVID-19 wave (March–June 2020), with 13,939 ICU survivors. HRU was assessed for six months pre- and post-hospitalization in four areas: (1) medical consultations and rehabilitation; (2) pain-related medication dispensing; (3) neuropathic diagnostic procedures; (4) hospital admissions for chronic pain. A post–pre ratio (PP-Ratio) compared post-COVID to pre-COVID HRU. Results: Significant changes in HRU were observed, particularly for ICU survivors. Neurology consultations (PP-Ratio 1.41) and outpatient physical therapy (PP-Ratio 1.69) increased. Dispensing of strong opioids, antiepileptics, anxiolytics, and hypnotics rose, while NSAID use decreased. Hospitalizations for chronic pain also increased (PP-Ratio 1.52). Similar trends were seen among ICU survivors, with notable increases in opioid and antiepileptic use. No distinct PACS-related pain patterns emerged. Conclusions: Non-specific increases in HRU for pain management were found following COVID-19 hospitalization, likely due to disease severity and ICU care rather than PACS-related chronic pain. Further research is needed to explore long-term pain outcomes in this population. Full article

Background/Objectives: Prescription opioid use before adulthood is typically effective for acute pain control and is also associated with adverse short- and long-term consequences. Methods: This study examined pediatric opioid prescribing trends over time across different age groups (early childhood, school age, adolescence, young adult) and sociodemographic subgroups (sex, ethnicity, race, language, payer type) from 2005 to 2016. Results: Utilizing 42,020 first outpatient opioid prescriptions for youth aged 0–21 years from a large US children’s hospital, this research found notable trends and disparities. Prescription rates increased by 35% from 2005–2007 to 2008–2010, then decreased by 14% from 2008–2010 to 2011–2013, and decreased again by 22% from 2011–2013 to 2014–2016. Chi-squared tests indicated significant changes in prescription rates across all sociodemographic subgroups, though only age group, ethnicity, and payer type (i.e., the party responsible for payment for hospital services) had changes with non-negligible effect sizes (Cramer’s V). Specifically, age group showed small to medium effects (V = 0.16), while ethnicity and payer demonstrated small effects (V = 0.10 each). This study highlights variations in opioid prescribing trends, particularly among different age groups, ethnicities, and payer statuses up to 2016. Conclusions: These findings reveal differing trends in pediatric opioid prescribing during the peak of the opioid epidemic, highlighting the importance of considering age and sociodemographic variables for understanding prescribing patterns fully and raising potential concerns about inequities in pain management. Future studies should explore similar trends from 2016 onward. Full article