The Overuse of the Emergency Department at a Multidisciplinary Pain Clinic by Patients with Chronic Pain: A Cross-Sectional Study.

Introduction Pain represents up to 78% of emergency department (ED) appointments, and an average of 16% of patients that consume ED resources have chronic pain. ED overuse could be an indicator of poor pain management. We are not aware of any study that has ever been carried out to understand the incidence of patients followed up at a multidisciplinary pain clinic (MPC) who overuse the ED. We aim to characterize patients in our MPC who overuse the emergency department, comprehend our percentages, and develop effective methods to reduce these numbers in the near future. Materials and methods We reviewed the medical records of patients observed in our MPC in 2019, selected patients with more than six ED visits from 2019 to 2021, and registered their ED visit diagnosis and evolution. We followed up on these patients and characterized them according to demographic aspects, chronic pain diagnostics, comorbidities, chronic medication, number of chronic pain department appointments, and patients that underwent invasive pain treatment. Results In 2019, 1892 patients were evaluated at our MPC, and only 1% were classified as overusers of the ED. The average number of episodes per patient was 10 in 2019, seven in 2020, and four in 2021. 70% of episodes were due to pain, and 94% were discharged immediately. The majority were women, and 69% were under the age of 69. Seventy-three percent had psychiatric disorders, and 95% and 89% were medicated with opioid and antidepressant medication, respectively, prior to the ED evaluation. Chronic primary pain was the most common diagnosis (47%), followed by chronic secondary musculoskeletal pain (21%). In 2019, most of these patients had only one appointment at our MPC, and in 2021, 79% had no appointments at all. Conclusion Our findings emphasize the particularities of patients with chronic pain who are followed in an MPC and misuse the ED. We observe the predominance of middle-aged people, which raises concerns about the impact of chronic pain in the active population. Issues like the predominance of patients with a diagnosis of primary chronic pain, psychiatric disorders, and being polymedicated with antidepressants and opioids are also a concern. We also realized that a high percentage of patients who overuse EDs lost follow-up at MPC over the past three years, which may reinforce the idea that they were misguided in the treatment of their chronic pain. We recognized the need to improve teamwork with primary care in the follow-up of these patients as well as sensitize emergency service professionals to refer this patient rather than medicate acutely so that follow-up could be carried out in the appropriate places to reduce the percentage of ED overuse.

Anesthesia strategy for factor X deficiency coagulopathy: case report

Abstract Factor X deficiency ranks among the rarest coagulopathies and has a variable presentation spectrum. We intend to present a proposal for anesthesia protocol for individuals with the coagulopathy. The excision of an ovarian neoplasm was proposed for a 26-year-old, female, ASA II patient, with congenital Factor X deficiency. Physical examination and lab tests were normal, except for Prothrombin Time (PT) 22.1s (VR: 8-14s), International Normalized Ratio (INR) 1.99 (VR: 0.8-1.2) and Activated Partial Thromboplastin Time (aPTT) 41.4s (VR: 25-37s). We concluded that a history of bleeding should always be investigated, along with a pre-anesthetic coagulation study.

Patient blood management in a Cardiac Surgery Center, how to start?

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Anesthesia strategy for factor X deficiency coagulopathy: case report.

Factor X deficiency ranks among the rarest coagulopathies and has a variable presentation spectrum. We intend to present a proposal for anesthesia protocol for individuals with the coagulopathy. The excision of an ovarian neoplasm was proposed for a 26-year-old, female, ASA II patient, with congenital Factor X deficiency. Physical examination and lab tests were normal, except for Prothrombin Time (PT) 22.1s (VR: 8-14s), International Normalized Ratio (INR) 1.99 (VR: 0.8-1.2) and Activated Partial Thromboplastin Time (aPTT) 41.4s (VR: 25-37s). We concluded that a history of bleeding should always be investigated, along with a pre-anesthetic coagulation study.

Combined effect of interventions with pure or enriched mixtures of (poly)phenols and anti-diabetic medication in type 2 diabetes management: a meta-analysis of randomized controlled human trials.

PURPOSE: (Poly)phenols have been reported to confer protective effects against type 2 diabetes but the precise association remains elusive. This meta-analysis aimed to assess the effects of (poly)phenol intake on well-established biomarkers in people with type 2 diabetes or at risk of developing diabetes. METHODS: A systematic search was conducted using the following selection criteria: (1) human randomized controlled trials involving individuals with prediabetes and type 2 diabetes; (2) one or more of the following biomarkers: glucose, glycated haemoglobin (HbA1c), insulin, pro-insulin, homeostatic model assessment of insulin resistance (HOMA-IR), islet amyloid polypeptide (IAPP)/amylin, pro-IAPP/pro-amylin, glucagon, C-peptide; (3) chronic intervention with pure or enriched mixtures of (poly)phenols. From 488 references, 88 were assessed for eligibility; data were extracted from 27 studies and 20 were used for meta-analysis. The groups included in the meta-analysis were: (poly)phenol mixtures, isoflavones, flavanols, anthocyanins and resveratrol. RESULTS: Estimated intervention/control mean differences evidenced that, overall, the consumption of (poly)phenols contributed to reduced fasting glucose levels (- 3.32 mg/dL; 95% CI - 5.86, - 0.77; P = 0.011). Hb1Ac was only slightly reduced (- 0.24%; 95% CI - 0.43, - 0.044; P = 0.016) whereas the levels of insulin and HOMA-IR were not altered. Subgroup comparative analyses indicated a stronger effect on blood glucose in individuals with diabetes (- 5.86 mg/dL, 95% CI - 11.34, - 0.39; P = 0.036) and this effect was even stronger in individuals taking anti-diabetic medication (- 10.17 mg/dL, 95% CI - 16.59, - 3.75; P = 0.002). CONCLUSIONS: Our results support that the consumption of (poly)phenols may contribute to lower glucose levels in individuals with type 2 diabetes or at risk of diabetes and that these compounds may also act in combination with anti-diabetic drugs.