Gender, age and ethnicity influence on pain levels and analgesic use in the acute whiplash injury.

PURPOSE: Initial pain level in the acute whiplash injury is the most consistent predictor of transformation to a chronic pain syndrome. The risk factors for those early pain levels were, to our knowledge, scarcely evaluate to this date. We set to evaluate whether gender, age or ethnicity comprise a risk factor for those initial pain levels. Further, gender, age and ethnicity have been shown to be bias factors in pain management. We investigated if gender, age or ethnicity are bias factor in pain management in the face of a standardized pain treatment protocol in the acute whiplash injury. METHODS: We reviewed 2,538 patients with acute whiplash injury that were treated at our emergency department (ED). Gender, age and ethnicity were investigated as risk factors for elevated visual analog scale (VAS) scores. Those factors were also investigated as bias in pain medication administration in the face of a standardized analgesic protocol. RESULTS: Women had significantly higher VAS scores (p = 0.009). Age and ethnicity did not influence pain levels. There was no influence of gender or age on pain medication administration. The Jewish patients (the majority in Israel) were administered fewer pain medication (p < 0.0001). CONCLUSION: Women have higher initial pain levels in the acute whiplash injury. Age and ethnicity have less impact on those pain levels. A pain management protocol might reduce bias in pain management in the acute whiplash injury in the ED. The Jewish population tends to be less receptive to pain medication administration.

Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study.

BACKGROUND AND STUDY AIMS: Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department. PATIENTS AND METHODS: We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD). We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction. RESULTS: The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ±â€†19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P = 0.035). There was no significant difference in the identification of peptic/inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P = 0.10, OR 0.39 95 %CI 0.11 - 1.15). Capsule endoscopy reached the duodenum in 45 /46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion. CONCLUSIONS: In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD.

Do cervical spine X-rays for trauma have clinically significant incidental findings?

OBJECTIVES: About 800,000 cervical X-rays for trauma are taken every year in the USA. Those X-rays are reviewed by orthopedic specialists in the emergency room (ER) for traumatic findings. The quantity of incidental atraumatic findings in this very prevalent examination is unknown. We sought to determine the incidence of those findings. METHODS: We retrospectively reviewed 521 consecutive cervical X-rays of patients with a whiplash injury that visited our ER from February to July 2010. X-rays that were technically insufficient were excluded. This left 356 X-rays that met the inclusion criteria, which were analyzed for incidental findings. The examinations were reviewed by five staff radiologists for incidental findings. The findings were reviewed and classified. RESULTS: We identified incidental X-ray findings in 22 of the 356 patients (6.2 %) who underwent X-ray of the cervical spine during their visit to the ER. Stenosis with disk narrowing was the most common finding (2.8 %), followed by congenital anomaly of the cervical spine (2.2 %). Other findings were enlarged sella turcica (0.6 %), carotid atherosclerosis (0.3 %), and calcification of the stylomastoid ligament (0.3 %). Older age was found to be a risk factor for an incidental finding (p < 0.0001). CONCLUSION: Incidental findings in the cervical spine were associated with older age. Awareness of the prevalence of incidental findings is important in order to ensure that they are detected and managed appropriately.

Intestinal intussusception in elderly patients.

Intussusception is the most common cause of bowel obstruction in children, but it is a very rare cause of bowel obstruction in the elderly. Diagnosis is based on a high index of suspicion, complete anamnestic recall, physical examination, and imaging modalities. We find abdominal CT scans to be highly sensitive and accurate for making the diagnosis. Treatment of intussusception in adults is always surgical. Segmental bowel resection must be performed. The extent of resection should include any nonviable bowel as well as the leading point of the intussusception. We present a case of an 82-year-old patient with ileo-cecal intussusception, followed by a discussion of the diagnostic and therapeutic options.

Factitious hyperamylasuria by a nurse: a symptom of Munchausen syndrome.

A 30-year-old nurse presented with abdominal pain and tenderness. Her blood tests, including amylase, were normal. Urinary amylase was extremely high. The source of the increased urinary amylase was found to be the patient's saliva-she had spat into her urine sample. Subsequent investigation showed that she had Munchausen syndrome.

Factitious hyperamylasuria by a nurse: symptom of Munchausen's syndrome.

A 30-year-old nurse presented with abdominal pain and tenderness. Her blood tests, including amylase, were normal. Urinary amylase was extremely high. The source of the increased urinary amylase was found to be the patient's saliva - she had spit into her urine sample. Subsequent investigation showed that she had Munchausen's syndrome.

Tissue-specific distribution and subcellular distribution of phospholipase D in rat: evidence for distinct RhoA- and ADP-ribosylation factor (ARF)-regulated isoenzymes.

Phospholipase D (PLD) is regulated by many factors including the small G-proteins, RhoA and ADP-ribosylation factor (ARF). The present study examined the distribution of RhoA- and ARF-responsive PLD in membranes, microsomes and cytosol of rat tissues and in rat liver subcellular fractions. PLD was present in all tissue fractions examined and was stimulated by guanosine 5'-[gamma-thio]triphosphate (GTP[S]), with the highes: specific activities being in lung, kidney and spleen. When myristoylated recombinant ARF (mARF) was added with GTP[S], the PLD activity was stimulated further, but the addition of RhoA was without effect. However, in extracts from crude membranes both mARF and RhoA enhanced the stimulation by GTP[S], with high specific activities of PLD being observed in all tissues except muscle. The response to mARF was usually greater than to RhoA, and the responses were additive, except for liver, which showed synergism. When the PLD activity of subcellular fractions of liver was examined, GTP[S] caused increases in all fractions except microsomes and mitochondria, which exhibited low activity. All fractions except mitochondria showed responses to RhoA and mARF, with the response to RhoA being greater in plasma membranes and that to mARF being greater in Golgi and nuclei. Western blotting showed that RhoA was located mainly in the cytosol and plasma membranes, whereas ARF was principally in the cytosol. These findings demonstrate the widespread occurrence of significant activity of both Rho- and ARF-responsive forms of PLD in membranes from all tissues except muscle, and the presence of both forms in liver subcellular fractions except mitochondria. The large variations in the relative responses of PLD to Rho and ARF observed in different tissues and fractions support the existence of different isoforms of the enzyme.