Pain management in adult patients with sickle cell disease in the emergency department: how does current practice compare with existing standards of care?

PURPOSE: Sickle cell disease (SCD) is an inherited blood disorder with a natural course punctuated by acute complications including painful vaso-occlusive episodes. The objectives were: (1) to determine what proportion of patients with SCD receive opioids within 30 min of triage as recommended by the current clinical recommendations and quality standard; and (2) to identify facilitators to timely opioid administration for patients with SCD. METHODS: This was a retrospective observational study. The primary outcome was the proportion of visits in which patients received opioid analgesia within 30 min of triage. Secondary outcomes were time in minutes from triage to any analgesic administration and time from triage to first opioid administration. Patient demographics and ED encounter characteristics were included as potential associated variables. RESULTS: There were 236 patient visits (by 103 patients) that met inclusion criteria. Patients received opioid analgesia within 30 min of triage in only 5.2% of visits. The median time from triage to opioid analgesia was 80 (IQR = 49.0, 125.5) minutes. Using an order set and receiving opioid analgesia prior to physician assessment were both associated with shorter times to opioid analgesia. CONCLUSION: Existing recommendations are that opioid analgesia be provided within 30 min of triage for patients with SCD and VOEs. Our data show this target is rarely met, even in a department in which SCD VOEs are a common presenting concern. The association of earlier opioid analgesia with order set use and administration prior to physician assessment highlights potential avenues for improving time to analgesia.

RéSUMé: OBJECTIF: La drépanocytose (ou l'anémie falciforme) est une maladie héréditaire du sang dont l'évolution naturelle est ponctuée de complications aiguës, notamment des épisodes vaso-occlusifs douloureux. Les objectifs étaient : (1) de déterminer quelle proportion de patients atteints de drépanocytose reçoivent des opioïdes dans les 30 minutes suivant le triage, comme le recommandent les recommandations cliniques et la norme de qualité actuelles ; et (2) d'identifier les facteurs facilitant l'administration rapide d'opioïdes aux patients atteints de drépanocytose. MéTHODES: Il s'agissait d'une étude observationnelle rétrospective. Le critère de jugement principal était la proportion de visites au cours desquelles les patients ont reçu une analgésie opioïde dans les 30 minutes suivant le triage. Les critères de jugement secondaires étaient le temps en minutes écoulé entre le triage et l'administration de tout analgésique et le temps écoulé entre le triage et la première administration d'opioïdes. Les caractéristiques démographiques des patients et les caractéristiques des rencontres aux urgences ont été incluses comme variables potentiellement associées. RéSULTATS: Il y a eu 236 visites de patients (par 103 patients) qui répondaient aux critères d'inclusion. Les patients ont reçu une analgésie opioïde dans les 30 minutes suivant le triage dans seulement 5,2 % des visites. Le temps médian écoulé entre le triage et l'analgésie opioïde était de 80 (IQR = 49,0, 125,5) minutes. L'utilisation d'un ensemble de commandes et la réception d'une analgésie opioïde avant l'évaluation du médecin étaient toutes deux associées à des temps plus courts d'analgésie opioïde. CONCLUSIONS: Les recommandations existantes sont que l'analgésie opioïde soit fournie dans les 30 minutes suivant le triage pour les patients atteints de drépanocytose et d'EVO. Nos données montrent que cet objectif est rarement atteint, même dans un service où les EVO de la drépanocytose sont une préoccupation courante. L'association d'une analgésie opioïde plus précoce avec l'utilisation d'un ensemble de commandes et l'administration avant l'évaluation du médecin met en évidence des pistes potentielles pour améliorer le temps d'analgésie.

Anti-seizure medication treatment trials prior to pre-surgical evaluation.

Purpose: Our study evaluates patterns of anti-seizure medication (ASM) usage prior to pre-surgical evaluation in drug resistant epilepsy (DRE). Methods: We conducted a retrospective study of patients with DRE presenting for pre-surgical evaluation from 1/1/2017 to 12/31/2018. We abstracted demographic data, ASM usage, MRI and EEG findings, and distance from home to our center. Results: In total, 54 patients (23 female) were included. The mean number of ASM trials at the time of pre-surgical evaluation was 5.62 (±3.3; range 1-15). A mean of 0.4 ASMs (±1.1; range 0-6) were initiated at our center prior to pre-surgical evaluation. MRI localization to regions other than the hippocampal or temporal region (p = 0.002) was associated with higher numbers of ASM trials. A trend for a larger number of ASM trials was seen for increased distance of patient primary residence from our center, right-sided ictal EEG laterality, and posterior quadrant or non-localized ictal EEG patterns. Conclusions: Only 17% of patients were referred for pre-surgical evaluation after a trial of 1-2 ASMs. On average, patients tried 5.6 different ASMs with most of those trials predating referral to our center. Temporal lobe lesions were associated with fewer ASM trials prior to referral. Female sex was associated with an average of two more ASM trials than males. Our data do not allow us to determine how access to care, patient choice, and physician opinions impact the variability of ASM trials prior to referral for surgical evaluation. Our data indicate that delays to pre-surgical evaluation continue to occur.

A meta-analysis of experienced incivility and its correlates: Exploring the dual path model of experienced workplace incivility.

The present study proposes and examines a theoretical Dual Path Model of Experienced Workplace Incivility using meta-analytic relationships (k = 246; N = 145, 008) between experienced incivility and frequent correlates. The stress-induced mechanism was supported with perceived stress mediating the meta-analytical relationship between experienced incivility and occupational health (i.e., emotional exhaustion and somatic complaints). The commitment-induced mechanism was also supported with affective commitment to the organization mediating the relationship between experienced incivility and organizational correlates (i.e., job satisfaction and turnover intentions). However, these paths were not able to explain the strong relationship between experienced and enacted workplace incivility. Moderating analysis revealed that the experienced-enactment link is stronger between coworkers, in comparison to incivility experienced from supervisors; experienced incivility is more strongly related to organizational correlates, when incivility is enacted by supervisors in comparison to coworkers, and in human service samples when compared to samples comprised of mixed occupations. We discuss theoretical and practical implications as well as directions for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Larger neural responses produce BOLD signals that begin earlier in time.

Functional MRI analyses commonly rely on the assumption that the temporal dynamics of hemodynamic response functions (HRFs) are independent of the amplitude of the neural signals that give rise to them. The validity of this assumption is particularly important for techniques that use fMRI to resolve sub-second timing distinctions between responses, in order to make inferences about the ordering of neural processes. Whether or not the detailed shape of the HRF is independent of neural response amplitude remains an open question, however. We performed experiments in which we measured responses in primary visual cortex (V1) to large, contrast-reversing checkerboards at a range of contrast levels, which should produce varying amounts of neural activity. Ten subjects (ages 22-52) were studied in each of two experiments using 3 Tesla scanners. We used rapid, 250 ms, temporal sampling (repetition time, or TR) and both short and long inter-stimulus interval (ISI) stimulus presentations. We tested for a systematic relationship between the onset of the HRF and its amplitude across conditions, and found a strong negative correlation between the two measures when stimuli were separated in time (long- and medium-ISI experiments, but not the short-ISI experiment). Thus, stimuli that produce larger neural responses, as indexed by HRF amplitude, also produced HRFs with shorter onsets. The relationship between amplitude and latency was strongest in voxels with lowest mean-normalized variance (i.e., parenchymal voxels). The onset differences observed in the longer-ISI experiments are likely attributable to mechanisms of neurovascular coupling, since they are substantially larger than reported differences in the onset of action potentials in V1 as a function of response amplitude.

Object recognition in clutter: cortical responses depend on the type of learning.

Theoretical studies suggest that the visual system uses prior knowledge of visual objects to recognize them in visual clutter, and posit that the strategies for recognizing objects in clutter may differ depending on whether or not the object was learned in clutter to begin with. We tested this hypothesis using functional magnetic resonance imaging (fMRI) of human subjects. We trained subjects to recognize naturalistic, yet novel objects in strong or weak clutter. We then tested subjects' recognition performance for both sets of objects in strong clutter. We found many brain regions that were differentially responsive to objects during object recognition depending on whether they were learned in strong or weak clutter. In particular, the responses of the left fusiform gyrus (FG) reliably reflected, on a trial-to-trial basis, subjects' object recognition performance for objects learned in the presence of strong clutter. These results indicate that the visual system does not use a single, general-purpose mechanism to cope with clutter. Instead, there are two distinct spatial patterns of activation whose responses are attributable not to the visual context in which the objects were seen, but to the context in which the objects were learned.

Contrast Response Functions for Single Gabor Patches: ROI-Based Analysis Over-Represents Low-Contrast Patches for GE BOLD.

IMPORTANT FOR THE INTERPRETATION OF BOLD FMRI DATA IS A LINEAR RELATIONSHIP BETWEEN THE BOLD RESPONSE AND THE UNDERLYING NEURAL ACTIVITY: increased BOLD responses should reflect proportionate increases in the underlying neural activity. While previous studies have demonstrated a linear relationship between the peak amplitude of the BOLD response and neural activity in primary visual cortex (V1), these studies have used stimuli that excite large areas of cortex, and the linearity of the BOLD response has not been demonstrated when only a small patch of cortex is stimulated. The BOLD response to isolated Gabor patches of increasing contrast was measured with gradient echo (GE) BOLD and spin echo (SE) BOLD at 7 T. Our primary finding is notable spatial heterogeneity of the BOLD contrast response, particularly for the GE BOLD data, resulting in a more reliably linear relationship between BOLD data and estimated neural responses in the center of the cortical representations of the individual Gabor patches than near the edges. A control experiment with larger sinusoidal grating patches confirms that the observed sensitivity to voxel selection in the regions of interest-based analysis is unique to the small stimuli.