Multidimensional versus unidimensional pain scales for the assessment of analgesic requirement in the emergency department: a systematic review.

Pain is a multidimensional experience, potentially rendering unidimensional pain scales inappropriate for assessment. Prior research highlighted their inadequacy as reliable indicators of analgesic requirement. This systematic review aimed to compare multidimensional with unidimensional pain scales in assessing analgesic requirements in the emergency department (ED). Embase, Medline, CINAHL, and PubMed Central were searched to identify ED studies utilizing both unidimensional and multidimensional pain scales. Primary outcome was desire for analgesia. Secondary outcomes were amount of administered analgesia and patient satisfaction. Two independent reviewers screened, assessed quality, and extracted data of eligible studies. We assessed risk of bias with the ROBINS-I tool and provide a descriptive summary. Out of 845 publications, none met primary outcome criteria. Three studies analyzed secondary outcomes. One study compared the multidimensional Defense and Veterans Pain Rating Scale (DVPRS) to the unidimensional Numerical Rating Scale (NRS) for opioid administration. DVPRS identified more patients with moderate instead of severe pain compared to the NRS. Therefore, the DVPRS might lead to a potential reduction in opioid administration for individuals who do not require it. Two studies assessing patient satisfaction favored the short forms (SF) of the Brief Pain Inventory (BPI) and McGill Pain Questionnaire (MPQ) over the Visual Analogue Scale (VAS) and the NRS. Limited heterogenous literature suggests that in the ED, a multidimensional pain scale (DVPRS), may better discriminate moderate and severe pain compared to a unidimensional pain scale (NRS). This potentially impacts analgesia, particularly when analgesic interventions rely on pain scores. Patients might prefer multidimensional pain scales (BPI-SF, MPQ-SF) over NRS or VAS for assessing their pain experience.

Accuracy of Point-of-care Ultrasound in Diagnosing Acute Appendicitis During Pregnancy.

INTRODUCTION: Acute appendicitis is the most common non-obstetrical surgical emergency in pregnancy. Ultrasound is the imaging tool of choice, but its use is complicated due to anatomical changes during pregnancy and depends on the clinician's expertise. In this study, our aim was to investigate the diagnostic accuracy of point-of-care ultrasound (POCUS) in suspected appendicitis in pregnant women. METHODS: We conducted a retrospective analysis of all pregnant women undergoing POCUS for suspected appendicitis between June 2010-June 2020 in a tertiary emergency department. The primary outcome was to establish sensitivity, specificity, and likelihood ratios of POCUS in diagnosing acute appendicitis, overall and for each trimester. We used histology of the appendix as the reference standard in case of surgery. If appendectomy was not performed, the clinical course until childbirth was used to rule out appendicitis. If the patients underwent magnetic resonance imaging (MRI), we compared readings to POCUS. RESULTS: A total of 61 women were included in the study, of whom 34 (55.7%) underwent appendectomy and in 30 (49.2%) an acute appendicitis was histopathologically confirmed. Sensitivity of POCUS was 66.7% (confidence interval [CI] 95% 47.1-82.7), specificity 96.8% (CI 95% 83.3-99.9), and positive likelihood ratio 20.7. Performance of POCUS was comparable in all trimesters, with highest sensitivity in the first trimester (72.7%). The MRI reading showed a sensitivity of 84.6% and a specificity of 100%. In the four negative appendectomies a MRI was not performed. CONCLUSION: Point-of-care ultrasound showed a high specificity and positive likelihood ratio in diagnosing acute appendicitis in pregnant women in all trimesters with suspected appendicitis. In negative (or inconclusive) cases further imaging as MRI could be helpful to avoid negative appendectomy.

Reply to Böning et al. Comment on "Ceruti et al. Temporal Changes in the Oxyhemoglobin Dissociation Curve of Critically Ill COVID-19 Patients. J. Clin. Med. 2022, 11, 788".

We would like to thank Böning et al. for all the important issues raised in the present commentary [...].

Splenic Infarction Diagnosed by Contrast-enhanced Ultrasound in Infectious Mononucleosis - An Appropriate Diagnostic Option: A Case Report with Review of the Literature.

Infectious mononucleosis is caused by Epstein.Barr virus (EBV) infection. Although typically self.limiting, complications such as splenic infarction and splenic rupture are described. A 17.year.old man presented in the emergency department due to a 3 days history of fever with chills, soreness, fatigue, and loose stool. Ultrasound examination showed a homoechogenic splenomegaly. Viral enteritis was diagnosed and the patient was dismissed. Six days later, he reassessed due to increasing left upper quadrant abdominal pain. Ultrasound showed inhomogeneous splenomegaly with irregular hypoechogenic subcapsular lesions. Contrast.enhanced ultrasound (CEUS) characterized the lesions as not perfused tissue until the late venous phase, compatible with spleen infarctions. Serologic studies were positive for EBV. In the literature, splenic infarction is considered under.recognized. Contrast.enhanced computed tomography (CECT) and magnetic resonance imaging are associated with costs and radiation (CECT). B.mode ultrasound examination is usually used as the first imaging modality, although showing a poor sensitivity in the question of splenic lesions/infarctions. CEUS has shown instead very good sensitivity and does not harm. Therefore, we recommend CEUS examination as the first imaging modality if suspicion of spleen infarction arises, especially when B.mode ultrasound is normal.

Acute Appendicitis with the Presence of Peristalsis Seen in Ultrasound.

A 27-year-old male patient presented in the emergency department (ED) with right acute abdominal pain, tenderness of the abdominal wall, and abdominal guarding. With suspicion of acute appendicitis, we performed bedside sonography. A blind-ending tubular structure, originating from the base of cecum with the presence of an intraluminal calcified "stone," with the presence of clear peristalsis was seen. Whether this structure represented the appendix or the small bowel, it was not distinguishable sonographically. A consequent surgical consultation indicated a computer tomography scan, and the finding showed acute appendicitis with appendicolith. An inflamed appendix of 15 cm in length was seen laparoscopically and consequently an appendectomy was performed. The histology confirmed a putrid, ulcero-phlegmonous, and hemorrhagic appendicitis with appendicolith. Postoperatively, the patient made a good recovery without complications. The absence of peristalsis is a well-known criterion for diagnosing acute appendicitis. However, we have shown here, that this should be taken into account with caution, as in rare cases such as this appendicitis can be present with peristalsis.

Ability of pain scoring scales to differentiate between patients desiring analgesia and those who do not in the emergency department.

BACKGROUND AND IMPORTANCE: Pain is one of the most reasons for a visit to an emergency department (ED). Pain scores as the verbal rating scale (VRS) or numerical rating scale (NRS) are used to determine pain management. While it is crucial to measure pain levels, it is equally important to identify patients who desire pain medication, so that adequate provision of analgesia can occur. OBJECTIVE: To establish the association between pain scores on the NRS and VRS, and the desire for, and provision of, pain medication. DESIGN, SETTINGS AND PARTICIPANTS: Retrospective monocentric observational cohort study of ED patients presenting with painful conditions. OUTCOMES MEASURE AND ANALYSIS: The primary outcome was to establish for each pain score (NRS and/or VRS), those patients who desired, and were ultimately provided with, pain medication, and those who did not. Secondary outcomes included establishing the prediction of pain scores to determine desire of pain medication, and the correlation between NRS and VRS when both were reported. MAIN RESULTS: 130,279 patients were included for analysis. For each patient who desired pain medication, pain medication was provided. Proportion of patients desiring pain medication were 4.1-17.8% in the pain score range 0.5-3.5, 31.9-63.4% in the range 4-6.5, and 65-84.6% in the range 7-10. The prediction probability of pain scores to determine desire for pain medication was represented with an AUROC of 0.829 (95% CI 0.826-0.831). The optimal threshold predicting the desire for pain medication would be a pain score of 4.25, with sensitivity 0.86, and specificity 0.68. For the 7835 patients with both NRS and VRS scores available, the Spearman-Rho coefficient assessing correlation was 0.946 (p < 0.001). CONCLUSIONS: Despite guidelines currently recommending pain medication in patients with a NRS score > 4, we found a discrepancy between pain scores and desire for pain medication. Results of this large retrospective cohort support that the desire for pain medication in the ED might not be derived from a pain score alone.

Intravenous acetaminophen does not reduce morphine use for pain relief in emergency department patients: A multicenter, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Pain is one of the main reasons to present to emergency departments (EDs). Opioids are indispensable for acute pain management but are associated with side effects, misuse, and dependence. The aim of this study was to test whether a single dose of intravenous (IV) acetaminophen (paracetamol) can reduce the use of morphine for pain relief and/or morphine-related adverse events (AEs). METHODS: ED patients >18 years with acute pain (i.e., Numeric Rating Scale [NRS] > 4) were screened for eligibility. Patients with analgesia in the past 6 h, chronic pain, or clinical instability were excluded. Patients were randomized in a 1:1 ratio to receive either morphine 0.1 mg/kg and 1 g acetaminophen IV or morphine 0.1 mg/kg and placebo IV. The intervention was double-blinded. Additional morphine 0.05 mg/kg IV was administered every 15 minutes until pain relief (defined as NRS < 4) and whether the pain recurred. The primary outcome was the mean morphine dose for pain relief. Secondary outcomes were the total amount of morphine given, time to achieve pain relief, and AEs. RESULTS: A total of 220 patients were randomized and 202 evaluated for the primary outcome. The mean morphine dose for pain relief was similar in both groups (acetaminophen 0.15 mg ± 0.07 mg/kg, placebo 0.16 ± 0.07 mg/kg). There were no differences in the total amount of morphine given (acetaminophen 0.19 ± 0.09 mg/kg, placebo 0.19 ± 0.1 mg/kg), the time to achieve pain relief (acetaminophen 30 min [95% CI 17-31 min], placebo 30 min [95% CI 30-35 min]), and the frequency of AEs (overall 27.4%). Time to pain recurrence did not differ significantly between the groups (hazard ratio 1.23 [0.76-1.98], p = 0.40). CONCLUSIONS: In ED patients, acetaminophen had no additional effect on pain control or morphine-sparing effect at the time of first morphine administration. Titrated morphine with the algorithm used was highly effective, with 80% of all patients reporting pain relief within 60 min of starting therapy.

Temporal Changes in the Oxyhemoglobin Dissociation Curve of Critically Ill COVID-19 Patients.

Critical COVID-19 is a life-threatening disease characterized by severe hypoxemia with complex pathophysiological mechanisms that are not yet completely understood. A pathological shift in the oxyhemoglobin curve (ODC) was previously described through the analysis of p50, intended as the oxygen tension at which hemoglobin is saturated by oxygen at 50%. The aim of this study was to analyze Hb-O2 affinity features over time in a cohort of critically ill COVID-19 patients, through the analysis of ODC p50 behavior. A retrospective analysis was performed; through multiple arterial blood gas (ABG) analyses, each p50 was calculated and normalized according to PaCO2, pH and temperature; patients' p50 evolution over time was reported, comparing the first 3 days (early p50s) with the last 3 days (late p50s) of ICU stay. A total of 3514 ABG analyses of 32 consecutive patients were analyzed. The majority of patients presented a left shift over time (p = 0.03). A difference between early p50s and late p50s was found (20.63 ± 2.1 vs. 18.68 ± 3.3 mmHg, p = 0.03); median p50 of deceased patients showed more right shifts than those of alive patients (24.1 vs. 18.45 mmHg, p = 0.01). One-way ANOVA revealed a p50 variance greater in the early p50s (σ2 = 8.6) than in the late p50s (σ2 = 3.84), associated with a reduction over time (p < 0.001). Comparing the Hb-O2 affinity in critically ill COVID-19 patients between ICU admission and ICU discharge, a temporal shift in the ODC was observed.

Electrocardiographic alterations by pneumothorax: a case-control study with review of the literature.

BACKGROUND: Numerous ECG alterations due to pneumothorax have been reported. The objective of the study was to establish the presence of ECG changes associated with pneumothorax in the literature, and in a cohort of patients with proven pneumothorax compared with age- and sex-matched healthy controls. METHODS: A systematic review for ECG alterations associated with pneumothorax was performed. We then reviewed our hospital database for patients with pneumothorax and identified all patients with an ECG available at this time. The retrieved ECG alterations in the systematic review were identified in our pneumothorax patients and compared with a healthy sex- and age-matched control group. Accordingly, we calculated sensitivity and specificity for all alterations. RESULTS: Seventeen ECG alterations were found and defined from the systematic review. Our pneumothorax cohort consisted of 82 pneumothorax patients and 82 control patients. Specificity was mostly more than 90%, but sensitivities were low. Phasic R voltage (pneumothorax group 25.6% vs control group 1.2%), T-wave inversion (31.7% vs 2.4%), prolonged QTc (11.0% vs 2.4%), right axis deviation (14.6% vs 3.6%) and QRS voltage ratio in aVF/I >2 (41.5% vs 22.0%) were significantly more frequent in pneumothorax patients compared with controls. CONCLUSION: The sensitivity of published ECG signs in predicting pneumothorax in our cohort was low, which means that ECG findings are an unsuitable tool for pneumothorax screening. However, presence of these ECG signs might raise a suspicion of pneumothorax in patients presenting with dyspnoea, or unclear chest discomfort.

[Outpatient Management of Primary Spontaneous Pneumothorax]. / Ambulantes Management des primären Spontanpneumothorax.

Outpatient Management of Primary Spontaneous Pneumothorax Abstract. Pneumothorax (PT) is defined as a collapse of the lung due to the collection of air in the pleural space. In primary spontaneous pneumothorax (PSP) there is no underlying pulmonary pathology. Treatment, either conservative or invasive, depends on the size of the PT, the patient's clinical situation and the patient's setting/environment. According to the actual literature, the uncomplicated PSP can at best be treated conservatively and on an outpatient basis. Management with intervention (needle aspiration or chest drainage) is historically carried out on an inpatient basis, but outpatient management (without comorbidities and without symptoms) is also possible. In these cases, the patient compliance (motivation, cognition, support, housing situation …) has to be proven. For outpatient management with intervention, a small-caliber chest tube (<14 F) with a Heimlich valve should be used.

The "Spiked Helmet" Sign Associated with ST-Elevation Myocardial Infarction: A Case Report.

INTRODUCTION: The "spiked helmet" sign was first described in 2011 by Littmann and Monroe in a case series of eight patients. This sign is characterized by an ST-elevation atypically with the upward shift starting before the onset of the QRS complex. Nowadays the sign is associated with critical non-cardiac illness. CASE REPORT: An 84-year-old man with a history of three-vessel disease presented to the emergency department with intermittent pain in the upper abdomen. The electrocardiogram revealed the "spiked helmet" sign. After ruling out non-cardiac conditions the catherization lab was activated. The coronary angiography revealed an acute occlusion of the right coronary artery, which was balloon-dilated followed by angioplasty. The first 24 hours went uneventfully with resolution of the "spiked helmet" sign. On the second day, however, the patient died suddenly and unexpectedly. CONCLUSION: Despite the association with non-cardiac illness, the "spiked helmet" sign can be seen by an acute coronary artery occlusion as an ST-elevation myocardial infarction (STEMI). Reciprocal ST-depression in these cases should raise the suspicion of STEMI.

[Abdominal Pain Caused by Viral Infection Is Not Always Trivial]. / Bauchschmerzen bei viralem Infekt sind nicht immer trivial.

Abdominal Pain Caused by Viral Infection Is Not Always Trivial Abstract. We report on a 28-year-old previously healthy patient with initially elevated temperature and cough and developing most severe epigastric pain and peritonism in the right upper abdomen. A "bedside" sonography revealed a portal vein thrombosis, the CT additionally partial thromboses of the vena lienalis, vena mesenterica superior. During the examination, a SARS-CoV-2 infection (IgM, IgG) was confirmed. Currently (pandemic), extrapulmonary thromboembolism must also be considered. For this purpose, sonography is the appropriate "search method" - it can be used from "head to toe", immediately and at the "bedside".

Prevalence of microhematuria in renal colic and urolithiasis: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aims to investigate the prevalence of microhematuria in patients presenting with suspected acute renal colic and/or confirmed urolithiasis at the emergency department. METHODS: A comprehensive literature search was conducted to find relevant data on prevalence of microhematuria in patients with suspected acute renal colic and/or confirmed urolithiasis. Data from each study regarding study design, patient characteristics and prevalence of microhematuria were retrieved. A random effect-model was used for the pooled analyses. RESULTS: Forty-nine articles including 15'860 patients were selected through the literature search. The pooled microhematuria prevalence was 77% (95%CI: 73-80%) and 84% (95%CI: 80-87%) for suspected acute renal colic and confirmed urolithiasis, respectively. This proportion was much higher when the dipstick was used as diagnostic test (80 and 90% for acute renal colic and urolithiasis, respectively) compared to the microscopic urinalysis (74 and 78% for acute renal colic and urolithiasis, respectively). CONCLUSIONS: This meta-analysis revealed a high prevalence of microhematuria in patients with acute renal colic (77%), including those with confirmed urolithiasis (84%). Intending this prevalence as sensitivity, we reached moderate values, which make microhematuria alone a poor diagnostic test for acute renal colic or urolithiasis. Microhematuria could possibly still important to assess the risk in patients with renal colic.

Persistent postdischarge pain and chronic postoperative pain after breast cancer surgery under general anesthesia and single-shot paravertebral block: incidence, characteristics and impact on quality of life and healthcare costs.

Introduction: Breast surgery is associated with persistent postsurgical pain; usually related to poorly treated acute pain. Paravertebral block has been successfully employed in analgesic protocols for breast surgery; its impact on postdischarge pain (PDP) has not been investigated. The aim of this study was to assess characteristics of PDP after breast surgery, the development of chronic postoperative pain (CPP) and its impact on health care costs. Methods: We conducted a retrospective, observational study on a continuous cohort of adult female patients undergoing local breast cancer surgery under combined anesthesia. All patients were interviewed 6 months after hospital discharge. The survey was specifically conceived to assess incidence, features and duration of PDP. The overall cost of additional healthcare resources consumed with a specific relationship to persistent PDP was estimated. Results: A database of 244 patients was preliminarily analyzed. Of these, 188 were included in the following statistical analysis; 123 patients (65.2%) reported significant PDP, with a median intensity on NRS of 6 (IQR=2), more frequently described as burning and associated with paresthesia and/or hyperalgesia (87 patients, 46%). One hundred and six patients (56.5%) reported this pain as interfering with their normal daily activities, work and sleep. In 26.8% of cases (50 patients) symptoms lasted more than 1 month and in 28 patients (15.0%) pain became chronic. The majority of patients self-treated their pain with non-steroideal anti-inflammatory drugs, but in 50 patients (26.8%) this therapy was reported as ineffective. This additional consumption of healthcare resources led to a significant economical impact. Conclusion: PDP and CPP seem to be common complications after breast cancer surgery, even if a combined anesthesia technique with a thoracic paravertebral block is performed, leading to severe consequences on patients' quality of life and increasing consumption of healthcare resources after discharge. Trial number: NCT03618459 (www.clinicaltrials.gov).