Severe Acute Pain Research Articles

Diagnosing Peripartum Cardiomyopathy in a Resource-Limited Setting, a Clinical Perspective: Case Report

Peripartum cardiomyopathy is a rare case of heart failure with reduced ejection fraction and is considered a diagnosis of exclusion. The symptoms of heart failure in patients with peripartum cardiomyopathy can mimic the physiologic conditions of normal pregnancy. In an acute decompensated state, PPCM can present with acute severe upper abdominal or epigastric pain. We are presenting a 24-year-old female with no personal or family history of heart disease and no identifiable risk factor for PPCM. Based on her initial presentation in the emergency department, a diagnosis of acute severe pancreatitis was sought, and she was referred to the Intensive Care Unit. After further evaluation of the serological tests and imaging, she was eventually diagnosed as a case of PPCM. We emphasize the rare nature of the disease with a diverse presentation which poses a diagnostic challenge, especially in a resource-limited setting where advanced diagnostic tools may be restricted and socioeconomic condition poses a barrier to further patient evaluation. This case exemplifies the infrequent occurrence and atypical manifestation, presenting a learning opportunity for future clinicians.

An atypical presentation of axial spondyloarthritis with severe acute low back pain: A case report

Axial spondyloarthritis (axSpA) represents a chronic inflammatory condition primarily impacting axial joints, characterized by sacroiliitis and spondylitis. In axSpA patients, low back pain (LBP) typically assumes a chronic and inflammatory nature, where diagnostic delays can precipitate disability. However, atypical axSpA presentations pose challenges for early diagnosis and management. In the current study, we detail the case of a 39-year-old male presenting with acute, severe LBP and bilateral sacroiliitis. Initial treatment with non-steroidal anti-inflammatory drugs (NSAIDs), the standard first-line therapy, was discontinued due to severe gastrointestinal bleeding. Following a bone biopsy that excluded alternative etiologies, axSpA was confirmed based on diagnostic criteria. Elevated inflammatory markers, contraindications to NSAIDs, and magnetic resonance imaging findings prompted the initiation of anti-tumor necrosis factor (TNF) therapy. Remarkably, a marked improvement was observed in less than six weeks post anti-TNF therapy commencement. This case underscores the significance of recognizing atypical axSpA presentations and underscores the potential for swift and robust responses to anti-TNF agents. Optimal patient outcomes hinge upon effective disease pattern recognition and treatment selection.

Sickle cell disease iPSC-derived sensory neurons exhibit increased excitability and sensitization to patient plasma

AbstractIndividuals living with sickle cell disease (SCD) experience severe recurrent acute and chronic pain. Challenges to gaining mechanistic insight into pathogenic SCD pain processes include differential gene expression and function of sensory neurons between humans and mice with SCD, and extremely limited availability of neuronal tissues from patients with SCD. Here, we used induced pluripotent stem cells (iPSCs), derived from patients with SCD, differentiated into sensory neurons (SCD iSNs) to begin to overcome these challenges. We characterize key gene expression and function of SCD iSNs to establish a model to investigate intrinsic and extrinsic factors that may contribute to SCD pain. Despite similarities in receptor gene expression, SCD iSNs show pronounced excitability using patch clamp electrophysiology. Furthermore, we find that plasma taken from patients with SCD during acute pain associated with a vaso-occlusive event increases the calcium responses to the nociceptive stimulus capsaicin in SCD iSNs compared with those treated with paired plasma from patients with SCD at steady state baseline or healthy control plasma samples. We identified high levels of the polyamine spermine in baseline and acute pain states of plasma from patients with SCD, which sensitizes SCD iSNs to subthreshold concentrations of capsaicin. Together, these data identify potential intrinsic mechanisms within SCD iSNs that may extend beyond a blood-based pathology.

Frequency of Persistent Opioid Use 6 Months After Exposure to IV Opioids in the Emergency Department: A Prospective Cohort Study

BackgroundAs rates of opioid use disorder in the general population have increased, some have questioned whether IV opioids should be used routinely for treatment of acute severe pain in the emergency department (ED). ObjectivesWe determined the incidence of persistent opioid use among opioid-naïve patients exposed to IV opioids in the ED. MethodsThis was a prospective observational cohort study conducted in two EDs in the Bronx, NY. Opioid-naïve adults with severe pain who received IV opioids in the ED were followed-up 6 months later by telephone interview and review of the state opioid prescription database. We defined persistent opioid use as filling 6 or more prescriptions for opioids in the 6 months following the ED visit or an average of one prescription per month. ResultsWe screened 1555 patients. Of these, 506 patients met entry criteria and provided analyzable data. Morphine was the IV opioid most frequently administered in the ED (478, 94%), followed by hydromorphone (20, 4%). Of the 506, 8 (2%) received both IV morphine and hydromorphone and 63 (12%) participants were prescribed an opioid for use after the ED visit. One patient/506 (0%) met our apriori criteria for persistent opioid use within 6 months. ConclusionAmong 506 opioid naïve ED patients administered IV opioids for acute severe pain, only one used opioids persistently during the subsequent 6 months.

Enhancing pain care with the American Pain Society Patient Outcome Questionnaire for use in the emergency department (APS-POQ-RED): validating a patient-reported outcome measure

BackgroundIn general, the quality of pain care in emergency departments (ED) is poor, despite up to 80% of all ED patients presenting with pain. This may be due to the...

REKOVER study protocol: a pRospective patient treatment rEgistry of tramadol and dexKetoprofen trometamol oral fixed-dose combination (SKUDEXA) in mOderate to seVere acutE pain in Real-world setting in Asia

IntroductionSatisfactory management of acute pain remains a major medical challenge despite the availability of multiple therapeutic options including the fixed-dose combination (FDC) drugs. Tramadol and dexketoprofen trometamol (TRAM/DKP) 75/25 mg...

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study.

Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery. Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay. A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference. The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

Dexketoprofen versus Tenoxicam in Acute Severe Pain Due to Primary Dysmenorrhea.

To evaluate the analgaesic efficacy of tenoxicam and dexketoprofen in patients admitted to the Emergency Medicine (EM) Clinic with severe acute pain due to primary dysmenorrhea (PD). Randomised-controlled trial. Place and Duration of the Study: Emergency Medicine Clinic, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkiye, from January to December 2022. Patients presenting with PD, were divided into two groups of 60 each, administered 50 mg dexketoprofen and 20 mg tenoxicam intravenously. Visual analogue scale (VAS) scores were recorded at the 15th, 30th, 60th, and 120th minutes. VAS scores and ΔVAS scores were compared with the effectiveness of drugs, the need for rescue drugs and its side-effects. Intravenous (IV) dexketoprofen was administered to 60 of the patients and IV tenoxicam was administered to another 60. At the time of admission, mean VAS scores of the patients were 8.8 ± 0.9 for the dexketoprofen group and 8.6 ± 0.8 for the tenoxicam group. The VAS scores of the dexketoprofen group were found to be statistically significantly lower after 30 minutes with lower need for rescue analgaesics. ΔVAS scores of the dexketoprofen group were statistically significantly higher from the 30th minute. According to the VAS scoring, IV dexketoprofen was a more effective drug than IV tenoxicam in patients who were admitted to the EM clinic with severe pain due to PD. Dexketoprofen, Primary dysmenorrhea, VAS score.

Treatment of sickle cell anemia using CRISPR and prime editing

Sickle cell disease is a hereditary blood disease caused by an invisible genetic mutation on the autosome, caused by a transversion mutation in which the 6th amino acid of the -peptide chain, glutamate, is replaced by valine, resulting in the formation of sickle hemoglobin, instead of normal hemoglobin. Due to genetic mutations leading to structural abnormalities in hemoglobin and morphological changes in red blood cells, red blood cells lose their deformability in hypoxic environments, leading to vascular blockage, causing severe pain and partial tissue ischemia in patients. Oxygen needs to be transported to various parts of the body through red blood cells, thereby affecting the transportation of oxygen in the body. In general, red blood cells are circular and elastic, making them easy to move in blood vessels. However, in sickle cells, these red blood cells are compressed and deformed, causing the transportation of oxygen in the blood to become stiff and viscous, potentially slowing or blocking blood flow. The most common complication of SCA is blockage of blood vessels, which leads to pain. Although this is a complex phenomenon, HbS aggregation is a fundamental pathological physiological phenomenon in SCA. HbS aggregation can lead to malignant changes in the shape and physical properties of red blood cells, leading to hemolytic anemia and preventing blood flow, especially in small blood vessels, which may damage some organs. Clinical manifestations include anemia, immunodeficiency, multiple organ damage, severe acute and chronic pain, and premature death. The quality of life of the patients was seriously affected.

Claw Hand in Parsonage Turner syndrome

An elderly patient with an extensive smoking history presented with acute severe right-hand pain and evolving weakness with patchy sensory deficit. He had minimal relief from multiple analgesics, gabapentin, and acupuncture. Motor deficits in his right-hand progressed. A nerve conduction study confirmed motor-predominant polyneuropathy and magnetic resonance imaging (MRI) of his C-spine and brachial plexus ruled out apical lung mass or other structural lesions. A positive GalNAc-GD1a ganglioside antibody (IgG) was noted. A diagnosis of immune mediated neuralgic amyotrophy or Parsonage-Turner Syndrome was made. Intravenous immune globulin (IVIG) was started with partial improvement in motor function, six months later. Although this patient did not have SARS-CoV-2 infection nor was he recently vaccinated, this case is of interest to hospital-based internists as the Covid pandemic has seen an increase in the in reported cases of neuralgic amyotrophy worldwide due to the virus itself as well as the associated COVID-19 vaccines.

Sphenopalatine Ganglion Block Using Intranasal Lignocaine Spray for Trigeminal Neuralgia: A Case Series

Abstract Various interventions have been tried for the management of trigeminal neuralgia which is a sharp, shooting recurrent neuropathic pain. The use of the sphenopalatine ganglion (SPG) block has been established as a fast, safe, and effective means of pain relief for these patients. Recently, 10% lignocaine spray has been described as a less invasive alternative for this block. We report seven patients of idiopathic trigeminal neuralgia with acute unilateral severe pain managed by SPG blocks using 10% intranasal lignocaine spray. Seven patients with unilateral trigeminal neuralgia were included in the study. Two puffs of 10% lignocaine were sprayed into the nostril of the affected side in a slightly medial and inferior direction. Before the procedure and 30 min later, Visual Analog Scale (VAS) scoring was done. The procedure was repeated in case of no pain relief after 1 h of nasal spray (VAS 4 or 5). All patients were observed for 2 h and oral medication was prescribed if required after assessment at 24 h. Four patients reported complete relief (VAS 0 or 1) and two of them reported pain (VAS 4 and 5) after 24 h. The procedure had to be repeated in two patients with no pain relief (VAS 4 and 5) after 1 h. There was no relief in one patient even after repeated administration (VAS 5). The findings suggest a role for intranasal lignocaine spray for SPG block in trigeminal neuralgia for alleviating acute exacerbations of pain and obtaining quick relief.

Haemodynamics, side effects and safety of the combination of continuous femoral nerve block and intravenous parecoxib for pain management after Total Knee Arthroplasty: A pilot study.

Total Knee Arthroplasty (TKA) is a well-established surgical procedure for the treatment of knee joint diseases. This operation leads to severe acute and chronic pain, and intravenous administration of parecoxib could provide significant pain relief. The aim of the study was to compare the hemodynamic data and safety profile of patients who received parecoxib compared to placebo following TKA. Ninety patients were followed during this study and were randomly assigned into two equal groups. Group P received parecoxib and Group C received the placebo. Exclusion criteria included age < 40 or > 80 years, ASA III or higher, obesity (>140 kg), allergy to local anaesthetics, opioid dependence, contraindications for subarachnoid anaesthesia, femoral block or the administration of parecoxib.The haemodynamic data collected were Systolic Arterial Pressure (SAP), Diastolic Arterial Pressure (DAP), Heart Rate (HR), Oxygen Saturation (Ox-Sat), blood transfusion requirements and side effects. Recordings were performed every hour for up to 10 hours and at 15min, 4, 8, 12, 24, 36 hours postoperatively. The postoperative SAP and DAP data presented similar findings among groups (p>0.05) within the aforementioned time intervals. The postoperative HR data for both groups displayed no statistically significant difference between the two cohorts (p>0.05). Regarding the occurrence of transfusion, there is no statistically significant difference between the parecoxib and placebo cohorts. The frequency of side effects was negligible and could not be correlated with either group. Therefore, parecoxib did not render any noticeable impact on the hemodynamic profile of the patients.

Degrees of Testicular Atrophy Following Orchidopexy for Testicular Torsion.

Introduction Testicular torsion is an urological emergency. It is a time-sensitive condition in which twisting of the spermatic cord and testicular blood supply occurs, causing acute onset severe scrotal pain. The incidence of testicular torsion is highest amongst prepubertal males; however, it can occur at any age. Every hour that passes from the onset of symptoms has been shown to decrease the salvageability rate of the torted testis. Another significant factor that impacts testicular salvage is the degree of torsion. Prompt surgical exploration of the scrotum and orchidopexy, if the testis is salvageable, is the mainstay of treatment. A major sequela following orchidopexy for torsion is the decrease in testicular volume. The aim of this study is to assess testicular volume loss post orchidopexy in patients who presented with testicular torsion, as well as to identify the significance of the degree of rotation and duration of torsion in post-fixation volume loss. Methods This is a retrospective study in which all patients who underwent scrotal exploration for a primary diagnosis of testicular torsion between June 1, 2016, to January 15, 2023, were reviewed. The information obtained included the patients' demographics such as age, duration of symptoms, and laterality. Ultrasound images were reviewed for pre- and postoperative findings which included confirmation of testicular torsion as well as testicular volume measurements. Patients were excluded if they underwent an orchidectomy, had a diagnosis other than testicular torsion once scrotal exploration was done, or did not perform a follow-up scrotal ultrasound. Additionally, patients who underwent an orchidopexy for undescended testis earlier in life were also excluded. For statistical analysis purposes, degrees of testicular torsion and time to surgery were classified into mild, moderate, and severe. Results A total of 109 patient records were reviewed within the specific time frame. Of these, 47 patients were excluded as per the exclusion criteria mentioned previously, which gave us a sample size of 62 patients. Our findings showed that increasing severity of the degree of torsion as well as the time for surgery have statistically significant (p-value <0.05) effects on postoperative testicular volume loss. However, it was noted that time to surgery has a more pronounced effect on the mean volume loss than the degree of torsion. Moreover, the analysis also showed that, on average, with every additional hour from the onset of symptoms to surgery, the approximate volume loss is 0.15 ml. However, once time exceeds the 4.5-hour mark, the mean volume loss is 0.4 ml for each additional hour. Conclusion The current study indicates that earlier surgical intervention and correction of torsion are associated with enhanced preservation of postoperative testicular volume. Both the degree of torsion and time to surgery influence mean volume loss; however, time to surgery has a greater impact on the mean volume loss. These results highlight the importance of early diagnosis and intervention in cases of testicular torsion to minimize the risk of long-term testicular volume loss.

Chronic Pain and Time - A Theoretical Analysis.

When theoretically discussing pain, the distinction between acute and chronic pain is not always taken into consideration. By contrast, informed by the pain medicine distinction between acute and chronic pain, the present theoretical paper analyses the phenomena of chronicity and chronification in the pain setting. Philosopher Fredrik Svenaeus and his paper The phenomenology of chronic pain: embodiment and alienation (Continental Philosophy Review 2015;48:107-122) is used as a dialogue partner. Three aspects, relevant for clinicians, are discussed: (1) the distinction between emotion and mood, arguing that the process of chronification entails pain evolving from the former to the latter; (2) chronification as a process in which the pain patient becomes aware of his/her temporality, both the past and the future coming to the fore (as opposed to severe acute pain in which only the present counts, ie, getting rid of the pain now); (3) the acquisition of a pain-related narrative identity, interdisciplinary pain rehabilitation programs being described as helping patients regain a narrative identity that is not dominated by pain or by a fruitless chase after pain relief. Chronic pain reminds us of our temporality and of the narrative character of our lives.

The Optimal Threshold for Hemoglobin S Percent Level While Performing Regular Blood Transfusion Therapy to Prevent Severe Vaso-Occlusive Pain Events in Children with Sickle Cell Anemia: A Secondary Data Analysis of Participants in the SIT Trial

Introduction: Children with sickle cell disease (SCD) often experience frequent severe acute vaso-occlusive pain events, unresponsive to FDA-approved therapies (hydroxyurea, L-glutamine, crizanlizumab) to decrease the severe acute vaso-occlusive pain event incidence rate. The ASH guidelines for pain management recommend regular blood transfusion therapy after FDA-approved therapies have failed to decrease the high rate of severe acute vaso-occlusive pain events ( The Journal of Pediatrics, 139(6), 785-789). However, unlike regular blood transfusion therapy for primary and secondary stroke prevention, for which the goal hemoglobin S (Hb S) level is ≤ 30% , no optimal Hb S threshold has been established to attenuate the severe acute vaso-occlusive pain event incidence rate. We tested the hypothesis that among children receiving regular blood transfusion therapy with a goal to keep the mean hemoglobin S level &amp;lt; 30%, participants that achieved a mean Hb S level &amp;lt; 30% would have lower rates of severe acute vaso-occlusive pain events requiring hospitalization than children regularly transfused with mean Hb S level &amp;gt; 30%. Evidence to support our hypothesis would provide the first evidence-based guidelines for the optimal hemoglobin S threshold to decrease the acute vaso-occlusive pain event incidence rate in children with sickle cell anemia (HbSS). Methods: The SIT trial was a single-blind clinical trial( Blood Advances, 4(12), 2656-2701), where participants were children with sickle cell anemia randomly allocated to receive regular blood transfusion therapy (transfusion group) or standard care (observation group). Participants receiving regular blood transfusion therapy from the SIT Trial were included in the secondary analysis. Eligibility criteria include participants between 5 and 15 years of age, with no history of stroke, one or more silent cerebral infarcts on magnetic resonance imaging, and a neurologic examination showing no abnormalities. The transfusion therapy goal was to keep the maximum Hb S level &amp;lt; 30%. For the ancillary study, participants were included only in the transfusion arm of the trial. The primary endpoint of this ancillary study was the incidence rate of hospitalization for vaso-occlusive pain episodes among those receiving only regular blood transfusion therapy. We conducted a zero-inflated negative binomial regression analysis to determine the association between the incidence rate for severe acute vaso-occlusive pain events requiring hospitalization and independent covariates, including age at the time of random allocation, sex, and mean hemoglobin S level (&amp;lt; 30% and &amp;gt; 30%). Results: A total of 90 participants received regular blood transfusion therapy in the SIT trial. Among participants transfused, 53 and 37 individuals had a mean Hb S level of &amp;lt; 30% and &amp;gt; 30%, respectively. The median time on transfusions for the groups with Hb S levels of &amp;lt; 30% and &amp;gt; 30% was 2.9 years for both groups. Among the participants, 10.8% (4/37) who had a mean Hb S &amp;lt; 30% and 20.8% (11/53) of those with a mean Hb S &amp;gt; 30% experienced at least one hospitalization for a severe acute vaso-occlusive pain event. The mean hemoglobin S levels in the &amp;lt; 30% and &amp;gt; 30% groups were 25.4% and 37.5%, respectively. The mean hospital rates for severe acute vaso-occlusive pain events in the two groups &amp;lt; 30% and &amp;gt;30% were 9.4 (95% confidence interval 9.4 - 17.2 person-years) and 29.2 per 100 person-years (95% confidence interval, 21.0 - 39.5 person-years), respectively, P = 0.078. In the multivariable analysis, the incidence rate ratio for severe acute vaso-occlusive pain events showed that there was no statistical difference between those with a mean Hb S level in groups &amp;lt; 30% and &amp;gt; 30%, 0.65; P=0.43. Children with a higher baseline hemoglobin level were more likely to achieve a mean hemoglobin S level &amp;lt; 30%. Conclusion: In children with sickle cell anemia, receiving regular blood transfusion therapy with the goal of keeping the mean hemoglobin S level &amp;lt; 30%, achieving a mean hemoglobin S level &amp;gt; 30% was as effective as a mean hemoglobin S level &amp;lt; 30 % in decreasing the incidence rate of severe acute vaso-occlusive pain events requiring hospitalization. Further studies are warranted to identify reliable measures of the efficacy of regular blood transfusion therapy for the reduction of acute vaso-occlusive pain events.

National Mortality Outcomes of Acute Chest Syndrome Hospitalization during the COVID-19 Pandemic

Introduction Sickle cell disease (SCD) is an hereditary hemoglobin disorder characterized by repeated episodes of severe acute pain, acute chest syndrome (ACS) and other complications. The average life expectancy of SCD patients remains 20 years less than the general population, and ACS is the leading cause of mortality. This retrospective study describes the effect of the COVID-19 pandemic on epidemiologic trends and outcomes of Acute Chest Syndrome. Methods The National Inpatient Sample (NIS) database from 2016 to 2020 was searched for hospitalizations with ACS as the principal diagnosis using Clinical Classifications Software Refined codes. The ACS admission rate for each calendar year was obtained as admission per 10,000 SCD adults hospitalized. The primary outcome was a comparison of inpatient mortality, and the secondary outcomes were the length of hospital stay (LOS) and total hospital charge (THC) between prepandemic (2019) and pandemic years (2020). Results In 2019 (prepandemic), there were 5,160 hospitalizations for ACS, accounting for 624 per 10,000 adult SCD hospitalizations. In 2020 (pandemic), there were 4,285 patients hospitalized for ACS, accounting for 540 per 10,000 adult SCD hospitalizations. The mean age of admission was similar for both years (31.5 vs 32 years, P=0.143), and there was no significant difference in age categories when both years were compared. The gender distribution was similar during both periods (females: 45.6 vs 46.7%, p=0.68). The racial distribution was predominantly blacks with no significant difference during both year (92 vs 92%, p=0.3). There was no significant difference in hospitalizations with regard to insurance status, hospital region, or hospital size between both years. There was a three-fold increase in overall proportion of ACS inpatient mortality in the pandemic year of 2020 compared to the prepandemic level (0.6% vs 1.9%, P=0.009). Proportion of mortality among women had a five-fold increase (0.4% vs 2.3%, P=0.02). There was a four-fold increase in mortality proportions among the Black population (0.5% vs 2%; p=0.007). Mortality outcomes were similar over both years when stratified for income quartiles and hospital regions. The LOS during the pandemic was similar to the prepandemic level (6.5. vs 7.4days, P=0.563). Also, there was no statistically significant difference in the total hospital charge ($61,515 vs $80,191, P=0.108). Conclusion This study depicts a statistically significant increase in inpatient mortality outcomes of Acute chest syndrome during the pandemic period. However, the length of hospital stay and total hospital charge were similar. Further studies need be conducted to evaluate the long-term effect of the COVID-19 pandemic on SCD.

Association of Health-Related Quality of Life and Work Productivity with Clinical Characteristics in Adults with Sickle Cell Disease

Introduction: Adults with sickle cell disease (SCD) suffer from periodic episodes of severe acute pain, chronic pain, fatigue, acute complications, end-organ damage and early mortality. We explored clinical characteristics associated with health-related quality of life (HRQoL) and work productivity and activity impairment (WPAI) in adults with SCD. Methods: Between January 2022 and June 2023, we recruited 87 adults aged ≥18 years with a diagnosis of SCD from four U.S. NASCC recognized SCD centers participating in the Globin Research Network for Data and Discovery ( GRNDaD) registry. We collected data on patient socio-demographics, fatigue, chronic pain, WPAI, and HRQoL measured by EQ-5D-5L and ASCQ-Me via patient survey. Medical history checklist (MHC) score sums 9 SCD complications and treatment history. Clinical charateristis on SCD subtype and baseline hemoglobin were obtained from the medical record. Clinical characteristics and self-reported MHC, chronic pain associated with HRQoL, and WPAI scores were assessed by Student T-tests or Pearson correlation. Results: Mean age was 38.0±13.4 (standard deviation) years, 58.6% of the sample was female, 64.3% had hemoglobin (Hb) SS disease, 73.6% reported chronic pain (experiencing pain on ≥3 days per week in the past 6 months). Mean EQ visual analogue scale (VAS) was 71.3 (lower than the U.S. 35-44 age mean of 81.8). Mean EQ index score was 0.73 (lower than the U.S. 35-44 age group population norm 0.85). Mean fatigue score was 52.1 (range 33.7-75.8) and was negatively correlated with HRQoL scores, indicating higher fatigue correlated with lower patient's self-rated health, including the EQ VAS (correlation coefficient r=-0.49, p&amp;lt;0.0001), EQ index score (r=-0.53, p&amp;lt;0.0001), and all domain of ASCQ-Me scores including pain (r=-0.52, p&amp;lt;0.0001), stiffness (r=-0.55, p&amp;lt;0.0001), sleep (r=-0.43, p&amp;lt;0.0001), emotion (r=-0.65, p&amp;lt;0.0001), and social functioning score (r=-0.64, p&amp;lt;0.0001). Fatigue score was correlated with pain episode frequency (r=0.29, p=&amp;lt;0.001, indicated more frequent pain episodes correlated with higher fatigue), and pain episode severity score (r=0.34, p=0.002). Fatigue score also correlated with overall activity impairment due to SCD (r=0.47, p&amp;lt;0.0001). MHC score was negatively correlated with EQ VAS (r=-0.32, p=0.003), EQ index score (r=-0.35, p=0.001), ASCQ-Me pain (r=-0.25, p=0.02), stiffness (r=-0.28, p=0.009), emotion (-0.23, p=0.03), social (r=-0.28, p=0.01), pain episode severity score (r=0.26, p=0.02) and fatigue score (r=0.35, p=0.0009). Hemoglobin was not correlated with HRQoL or fatigue scores. MHC score significantly correlated with overall activity impairment (r=0.22, p=0.04). As compared to patients who had MHC≤2, those with score&amp;gt;2 had significantly lower mean EQ-VAS, EQ index score, ASCQ-Me domain impacts in pain, stiffness, sleep, emotion, social funtioning, and pain episode severity, but higher fatigue score and greater absenteeism. Patients who reported chronic pain had significantly lower mean EQ VAS, EQ index score, ASCQ-Me domain impacts in pain, stiffness, sleep, emotion, social functioning, higher pain episode frequency, pain episode severity, and fatigue score, greater presenteeism score (impairment while working), overall work productivity loss and overall activity impairment than those without chronic pain. SCD subtype was not associated with HRQoL and fatigue scores. Conclusions: Hemoglobin and SCD subtype were not significantly associated with HRQoL and fatigue in this sample (possibly due to selection bias, where higher functioning patients were more likely to be selected for study participation). Fatigue in adults with SCD is moderately correlated with EQ-5D-5L scores, ASCQ-Me domains on pain, stiffness, sleep, emotion, and social functioning, as well as overall activity impairment, but weakly correlated with pain episode frequency and severity. MHC had weak correlation with EQ-5D-5L scores, ASCQ-Me domains on pain, stiffness, emotion, and social, and activity impairment. Individuals who had higher fatigue score, MHC score≥2, and reported chronic pain showed lower HRQoL and higher impairment of work productivity and activity. Future analyses will explore how multiplicity problems that SCD patients suffer impact HRQoL and work productivity and activity impairment in longitudinal data, which will identify the opportunity on intervention to improve patient care.

Assessing the Impact of the Covid-19 Pandemic on Outcomes of Patient Admitted with Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy which affects millions of people worldwide. It is caused by a substitution of the glutamic acid (Glu) amino acid with valine (Val) at the sixth position of the β-globin gene, resulting in a mutated hemoglobin tetramer, HbS, in the erythrocytes of affected individuals. This morphology results in sickle-shaped red blood cells and hemolysis when deoxygenated and leads to vaso-occlusion with associated ischemia. SCD is characterized by repeated severe acute pain episodes, acute chest syndrome, and can be complicated by stroke, nephropathy, avascular necrosis, and more. Many studies have shown disparities in outcomes in racial/ethnic minorities as well as in those with lower socioeconomic status. These factors have also been linked to increased risk of COVID-19 infection and infection related mortality. In this study, we aim to explore the baseline characteristics of patients with SCD, prevalence of hospitalizations, and compare inpatient outcomes during the COVID-19 pandemic with those prior to the pandemic. Methods: Nationwide Inpatient Sample (NIS) was queried to determine adult hospitalized patients with a primary diagnosis of SCD using ICD-10 codes. They were stratified into two cohort groups based on year of admission, comparing admissions during 2016-2019 with admission during the year 2020. Primary outcomes assessed were inpatient mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes included respiratory failure, need for mechanical ventilation, cerebrovascular accident (CVA), myocardial infarction (MI), acute kidney injury (AKI), pulmonary embolism (PE), and need for blood transfusions. Multivariate linear and logistic regression analysis was performed to adjust for confounding variables. Results: A total of 456, 750 patients were hospitalized with SCD. 377, 285 were admitted between 2016-2019 and 79, 465 were admitted during 2020. Age distribution and sex were similar between the two groups. Patients admitted in the year 2020 were older and had more comorbidities when compared to patients admitted during prior years. Distribution of race, insurance type, hospital type, hospital size, hospital locations, and household income was not significantly different between the two groups. In 2020 patients admitted with SCD had greater odds of developing acute respiratory failure and PE, though the overall prevalence of these secondary outcomes were very low (3.6% and 0.80% respectively). Despite these outcomes, there was no significant difference in inpatient mortality (0.31% vs. 0.23%) for SCD patients admitted during 2020 when compared to prior years. In addition, the length of hospital stay was not significantly different in these two groups as well (5.1 vs. 4.9 days). Finally, patients admitted in 2020 incurred significantly higher hospital costs than SCD during pre-pandemic years ($42, 307 vs. $36, 087). Conclusion: SCD is the most common hemoglobinopathy in the United States. The African American population is most commonly affected by this disease. In addition, it is well known that this racial minority suffers inequities in accessing and receiving health care, which is associated with worse overall outcomes. During the COVID-19 pandemic, reduced access to hospital services combined with fear of exposure to the virus, led to a significant drop in overall access to healthcare and treatment. In this study, we found that those with SCD admitted during the COVID-19 pandemic overall had more comorbidities and more commonly had respiratory failure and pulmonary embolism, yet there was no change in inpatient mortality and LOS for these patients. Although disparities existed during the pandemic, it is fortunate that SCD itself did not serve as an additional risk factor for inpatient mortality and hospitalization duration.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BackgroundPrehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.MethodsA two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.DiscussionThe PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.Trial registration: ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474

Case Report: Severe intermittent acute abdominal pain caused by extremely rare case of lienorenal accessory spleen torsion and detorsion: an accurate diagnostic and treatment strategy

Background: Accessory spleen (AS) is a rare condition that usually does not cause any symptoms. However recurrent torsion and detorsion of AS commonly happen in the case of AS with long pedicles. Thus diagnostic and treatment procedure is needed to prevent further complication in this case. Case presentation: An extreme case of an Austronesian 22-year-old college student who presented clinical symptoms of crampy abdominal pain in the left upper quadrant (LUQ) three days before being administered in a hospital. The pain was periodically worsened and relieved for the past year due to recurrent torsion and detorsion of the accessory spleen. Radiologic findings were accessory spleen located in the lienorenalis region with the size of 1.6 x 1.8 x 1.4 cm and the vascular accessory spleen extends from the splenic pedicle to the left splenorenal region. The intraoperative finding was a blackish-brown mass with spongy consistency with 0.5 cm of the pedicle. Conclusion: A combination of USG and CT scan with arterial and venous phase is preferred to diagnose the accessory spleen early. While the findings of the accessory spleen with long pedicle are highly suggested to be treated using modified anti-Trendelenburg 3-port laparoscopic excision of the accessory spleen (LEAS).