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.

Characteristics of patients with Coronavirus Disease 2019 (COVID-19) and seasonal influenza at time of hospital admission: a single center comparative study.

BACKGROUND: In the future, co-circulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza viruses A/B is likely. From a clinical point of view, differentiation of the two disease entities is crucial for patient management. We therefore aim to detect clinical differences between Coronavirus Disease 2019 (COVID-19) and seasonal influenza patients at time of hospital admission. METHODS: In this single-center observational study, we included all consecutive patients hospitalized for COVID-19 or influenza between November 2019 and May 2020. Data were extracted from a nationwide surveillance program and from electronic health records. COVID-19 and influenza patients were compared in terms of baseline characteristics, clinical presentation and outcome. We used recursive partitioning to generate a classification tree to discriminate COVID-19 from influenza patients. RESULTS: We included 96 COVID-19 and 96 influenza patients. Median age was 68 vs. 70 years (p = 0.90), 72% vs. 56% (p = 0.024) were males, and median Charlson Comorbidity Index (CCI) was 1 vs. 2 (p = 0.027) in COVID-19 and influenza patients, respectively. Time from symptom onset to hospital admission was longer for COVID-19 (median 7 days, IQR 3-10) than for influenza patients (median 3 days, IQR 2-5, p < 0.001). Other variables favoring a diagnosis of COVID-19 in the classification tree were higher systolic blood pressure, lack of productive sputum, and lack of headache. The tree classified 86/192 patients (45%) into two subsets with ≥80% of patients having influenza or COVID-19, respectively. In-hospital mortality was higher for COVID-19 patients (16% vs. 5%, p = 0.018). CONCLUSION: Discriminating COVID-19 from influenza patients based on clinical presentation is challenging. Time from symptom onset to hospital admission is considerably longer in COVID-19 than in influenza patients and showed the strongest discriminatory power in our classification tree. Although they had fewer comorbidities, in-hospital mortality was higher for COVID-19 patients.

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.

Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study.

This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8-64.0) and Injury Severity Score of 9 (IQR = 4-17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83-0.94), Glasgow Coma Score (GCS) 3-8 (OR 1.10, 95% CI 1.02-1.19), falls >2 m (OR 4.17, 95% CI 3.98-4.37), sports injuries (OR 2.79, 95% CI 2.41-3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83-2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78-0.90), male gender (female OR 0.78, 95% CI 0.72-0.85), GCS <15 (OR 1.36-1.93), associated chest injury (OR 1.10, 95% CI 1.01-1.20), sports injuries (OR 3.98, 95% CI 3.04-5.21), falls >2 m (OR 3.60, 95% CI 3.21-4.04), RTCs (OR 2.20, 95% CI 1.96-2.46) and shooting (OR 1.91, 95% CI 1.21-3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.

Bioactive proteins and peptides in foods.

Increasing amounts of data demonstrate a bioactive role of proteins and peptides above and beyond their nutritional impact. The focus of the investigations has mainly been on vitamin- and mineral-binding proteins, on antimicrobial, immunosuppressing/-modulatory proteins, and on proteins with enzyme inhibitory activity as well as on hormones and growth factors from different food proteins; most research has been performed on milk proteins. Because of their molecular size, intact absorption of proteins in the human gastrointestinal tract is limited. Therefore, most of the proteins with biological functions show physiological activity in the gastrointestinal tract by enhancing nutrient absorption, inhibiting enzymes, and modulating the immune system to defend against pathogens. Peptides are released during fermentation or digestion from food proteins by proteolytic enzymes; such peptides have been found mainly in milk. Some of these released peptides exert biological activities such as opiate-like, antihypertensive, mineral-binding, antioxidative, antimicrobial, immuno-, and cytomodulating activity. Intact absorption of these smaller peptides is more likely than that of the larger proteins. Consequently, other organs than the gastrointestinal tract are possible targets for their biological functions. Bioactive proteins as well as bioactive peptides are part of a balanced diet. It is possible to accumulate bioactive peptides in food, for example by using specific microorganisms in fermented dairy products. Although bioactive peptides have been the subject of several studies in vitro and in vivo, their health potential is still under investigation. Up to now, the Commission of European Communities has not (yet) authorized any health claims for bioactive proteins and peptides from food.

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.

Pain management policies and reported practices in Swiss emergency departments: a national survey.

BACKGROUND: Acute pain is the most common complaint of patients presenting to emergency departments (EDs). Effective pain management is a core ED mission, but numerous studies have pointed to insufficient pain treatment or oligoanalgesia. According to a 1997 national survey in Swiss EDs, a validated pain scale was used in only 14%, an analgesia protocol in <5%, and 1.1% had a nurse-initiated pain protocol. Since then, numerous societal and health care factors have led to improved ED pain care. The aim of this study was to assess the state of ED pain management in Switzerland. METHODS: Hospital-based Swiss EDs open 24 hours a day and 7 days a week in 2013 were surveyed using a questionnaire. Data from 2013 were collected. Questions queried the pain management process by nurses and physicians in each ED. RESULTS: The response rate was 115 of 137 eligible EDs (84%). Pain intensity was assessed with a validated instrument in 71% of waiting rooms and in 99% of treatment areas. A nurse-initiated analgesia protocol was available in 56% of waiting rooms and in 70% of treatment areas. Physician pain protocols were available in 75%, and analgesia-sedation protocols in 51%. CONCLUSION: The pain management processes in Swiss EDs have improved over the last 17 years, and are now equivalent to other western countries. Our study did not, however, assess if these improvements resulted in better analgesia at the bedside, an important topic that will require further study.

Honey for nutrition and health: a review.

Due to the variation of botanical origin honey differs in appearance, sensory perception and composition. The main nutritional and health relevant components are carbohydrates, mainly fructose and glucose but also about 25 different oligosaccharides. Although honey is a high carbohydrate food, its glycemic index varies within a wide range from 32 to 85, depending on the botanical source. It contains small amounts of proteins, enzymes, amino acids, minerals, trace elements, vitamins, aroma compounds and polyphenols. The review covers the composition, the nutritional contribution of its components, its physiological and nutritional effects. It shows that honey has a variety of positive nutritional and health effects, if consumed at higher doses of 50 to 80 g per intake.

Effect of dietary alpine butter rich in conjugated linoleic acid on milk fat composition of lactating sows.

Multiparous sows (n 17) were included in a controlled cross-over-study in order to investigate the influence of a natural source of conjugated linoleic acid (CLA) (alpine butter) on the milk fatty acid composition of lactating sows (as an animal model for lactating women) and on the growth performance of their progeny. The usual fat source of a standard lactation diet was replaced by either CLA-rich alpine butter or margarine (control diet). Compared with the margarine diet, feeding the alpine butter-supplemented diet increased (P 0.05) affected. Growth performance of the progeny was similar for both dietary treatments. In summary, the findings show that adding alpine butter to the diet does not provoke a milk fat depression and does not alter the composition of total SFA, MUFA and PUFA in sow milk but increases its CLA concentration.

Lack of evidence for microplastic contamination in honey.

Honey samples from Switzerland were investigated with regard to their microplastic particle burden. Five representative honey samples of different origin were processed following a standardized protocol to separate plastic-based microparticles from particles of natural origin, such as pollen, propolis, wax, and bee-related debris. The procedure was optimized to minimize post-sampling microplastic cross-contamination in the laboratory. The isolated microplastic particles were characterized and grouped by means of light microscopy as well as chemically characterized by microscopically coupled Raman and Fourier transform infrared spectroscopy. Five particle classes with an abundance significantly above blank levels were identified: black particles (particle count between 1760/kg and 8680/kg), white transparent fibres (particle count between 132/kg and 728/kg), white transparent particles (particle count between 60/kg and 172/kg), coloured fibres (particle count between 32/kg and 108/kg), and coloured particles (particle count between 8/kg and 64/kg). The black particles, which represented the majority of particles, were identified as char or soot and most probably originated from the use of smokers, a widespread practice in beekeeping. The majority of fibres were identified as cellulose or polyethylene terephthalate and were most likely of textile origin. In addition to these particle and fibre groups lower numbers of fragments were detected that were related to glass, polysaccharides or chitin, and few bluish particles contained copper phthalocyanine pigment. We found no indications that the honey samples were significantly contaminated with microplastic particles.

Treatment algorithm reduces oxygen use in the Emergency Department.

OBJECTIVES: Evaluation of an O2 treatment algorithm on the basis of current recommendations to reduce the number of patients unnecessarily treated with O2 in the Emergency Department of a tertiary hospital compared with the traditional application, and analysis of the use of O2. DESIGN: This was a single-centre cohort study with 4 weeks of observation before and after the introduction of an O2 treatment algorithm. The main outcome measures were the proportion of patients treated with O2, distribution of indications for O2 therapy and occurrence of hypoxia and hypercapnia as undesired effects. RESULTS: The 4-week period before the intervention included 2190 patients and the 4-week period after the intervention included 2122 patients. The indications for O2 therapy were very similar in the two periods. After the intervention, the proportion of patients with supplemental O2 therapy was reduced from 11% (246) to 9% (182) (P<0.003), a relative decrease of 18%. Undesired effects were similar in nature and frequency in the two observation periods. CONCLUSION: The introduction of an O2 treatment algorithm in the Emergency Department reduced the number of patients treated with O2, and the nature and frequency of undesired effects was similar before and after the intervention.

Maternal dietary Alpine butter intake affects human milk: fatty acids and conjugated linoleic acid isomers.

Consumption of CLA by lactating women affects the composition of their milk, but the pattern of the different CLA isomers is still unknown. We determined the effects of short maternal supplementation with CLA-rich Alpine butter on the occurrence of FA and CLA isomers in human milk. In an open randomized controlled study with a two-period cross-over design, milk FA and CLA isomer concentrations were measured on postpartum days > or = 20 in two parallel groups of lactating women before, during, and after consumption of defined quantities of Alpine butter or margarine with comparable fat content (10 d of butter followed by 10 d of margarine for one group, and vice versa in the other). In the 16 women who completed the study (8/group), Alpine butter supplementation increased the C16 and C18 FA, the sum of saturated FA, the 18:1 trans FA, and the trans FA with CLA. The CLA isomer 18:2 c9,t11 increased by 49.7%. Significant increases were also found for the isomers t9,t11, t7,c9, t11,c13, and t8,c10 18:2. The remaining nine of the total 14 detectable isomers showed no changes, and concentrations were <5 mg/100 g fat. A breastfeeding mother can therefore modulate the FA/CLA supply of her child by consuming Alpine butter. Further studies will show whether human milk containing this FA and CLA isomer pattern acts as a functional food for newborns.

[Controlled orthodontic extrusion with subsequent implantation]. / Die kontrollierte kieferorthopädische Extrusion mit anschliessender Implantation.

Controlled orthodontic extrusion constitutes a non-surgical technique to increase alveolar bone material. Prosthetic reconstruction alone frequently does not achieve sufficient long-term aesthetics. An adequate implantation bed is indispensable to meet aesthetic demands. Controlled orthodontic extrusion represents an alternative to pre-implantological augmentation of the vertically reduced alveolar process and its soft tissue.

CLA isomers in milk fat from cows fed diets with high levels of unsaturated fatty acids.

The concentrations of CLA isomers were determined by Ag+ -HPLC in the milk fat of cows fed a control diet consisting of hay ad libitum and 15 kg of fodder beets or this diet supplemented with oilseeds containing either high levels of oleic acid (rapeseed), linoleic acid (sunflower seed), or alphalinolenic acid (linseed). Highly significant (P < or = 0.001) correlations were found between the daily intakes of oleic acid and the concentration of the CLA isomer trans-7,cis-9 in milk fat; of linoleic acid and the CLA isomers trans-10,trans-12, trans-9,trans-11, trans-8,trans-10, trans-7,trans-9, trans-10,cis-12, cis-9,trans-11, trans-8,cis-10, and trans-7,cis-9; and of alpha-linolenic acid and the CLA isomers trans-12,trans-14, trans-11 ,trans-13, cis,trans/trans,cis-12,14, trans-11 ,cis-13, and cis-11 ,trans-13. CLA concentrations were also determined in the milk fat of cows grazing in the lowlands (600-650 m), the mountains (900-1210 m), and the highlands (1275-2120 m). The concentrations of many isomers were highest in milk fat from the highlands, but only three CLA isomers (cis-9,trans-11, trans-11 ,cis-13, and trans-8,cis-10) showed a nearly linear increase with elevation. Therefore, these three CLA isomers, and particularly the CLA isomer trans- 11,cis-13, the second-most important CLA in milk fat from cows grazing at the three altitudes, could be useful indicators of milk products of Alpine origin.

Differences in CLA isomer distribution of cow's milk lipids.

The uniqueness of ruminant milk lipids is based on their high concentration of CLA. Maximal CLA concentrations in milk lipids require optimal conditions of ruminal fermentation and substrate availability, conditions like those present in pasture-fed cows. Our previous work showed that farm management (indoor feeding vs. pasture feeding) markedly influenced the CLA concentration. In this study, the objective was to evaluate the influence of the farm management system as dependent on different locations. Milk samples from different locations (Thuringia and the Alps, representing diverse altitudes) were collected during the summer months and analyzed for FA profile and CLA isomer distribution. The proportion of PUFA and total CLA in milk fat was significantly lower in milk from indoor cows compared with the pasture cows in the Alps. The trans-11 18:1 in milk fat of Alpine cows was elevated, in contrast to lower values for trans-10 18:1. Milk from cows grazing pasture in the Alps was higher in EPA and lower in arachidonic acid than milk from indoor-fed cows. The proportion of cis,trans/trans,cis isomers of CLA was 10 times higher from the indoor cows than from the Alpine cows. In addition to the major isomer cis-9,trans-11, this difference also occurred for the trans-11,cis-13 isomer, which represented more than a fourth of the total CLA present in milk fat. This is the first report showing a special isomer distribution in the milk fat of cows living under very natural conditions. We hypothesize that the CLA isomer trans-11,cis-13 is formed in large quantity as a result of grazing mountain pasture, which is rich in alpha-linolenic acid.

Infection of the central nervous system caused by varicella zoster virus reactivation: a retrospective case series study.

BACKGROUND: Recent data suggest that varicella zoster virus (VZV)-associated complications of the central nervous system (CNS) are more common and diverse than previously thought. The main purpose of this article is to describe the clinical characteristics and the outcome of patients suffering from meningitis and encephalitis caused by VZV reactivation. METHODS: A retrospective case study of adult patients (≥16 years old) diagnosed with a VZV reactivation in the CNS was performed. The cases were identified by a qualitative PCR DNA assay of the cerebrospinal fluid (CSF) at the Regional Hospital of Lugano between January 1, 2003 and July 31, 2010. RESULTS: Eleven out of 519 CSF samples (2.1%), submitted from patients with a clinical diagnosis of viral meningitis or encephalitis, were positive for VZV. A vesiculo-pustular skin eruption was observed in only five patients (45%). In six cases (55%), a systemic inflammatory syndrome was absent. The clinical outcome was favorable in eight patients (73%). Only one out of 11 patients (9%) died. The four patients with encephalitis had a less favorable prognosis: one patient recovered without residual neurological sequelae; two had a chronic neuropsychological handicap, speech difficulties, facial nerve palsy, and focal seizures; one patient died. We estimated an annual incidence rate of VZV infection of the CNS of 1.02/100,000 inhabitants for southern Switzerland. CONCLUSIONS: Screening of CSF for VZV by PCR is recommended for all patients with encephalitis and for those with viral meningitis of unclear origin in order to better target antiviral treatment.

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006.

BACKGROUND: Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland. METHODS: In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012. RESULTS: In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available. CONCLUSIONS: Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.