Episodes Of Pain Research Articles

An Alternative Approach to Median Arcuate Ligament Syndrome

Abstract Median arcuate ligament syndrome (MALS) is a rare anatomical anomaly where the median arcuate ligament is too inferior in origin and causes compression of the celiac artery and plexus. Due to the nerve compression, patients with MALS commonly experience other pathologies such as postural orthostatic tachycardia syndrome (POTS), and gastroparesis. These patients often experience dizziness, lightheadedness, syncope, abdominal pain, vomiting, and nausea. This case report follows a 23-year-old female with MALS, POTS, and gastroparesis who was wheelchair bound due to her intense syncopal and pain episodes. After 4 treatments of osteopathic manipulative treatment (OMT) involving visceral techniques to increase bowel movements, as well as treatment of the origin and insertion of the median arcuate ligament, this patient had a substantial decrease in symptoms which allowed for a drastic increase in mobility and quality of life.

CSP2023: 535 - Patients’ and physiotherapists’ perspectives of treatment outcomes and experiences in primary care episodes of low back pain

CSP2023: 535 - Patients’ and physiotherapists’ perspectives of treatment outcomes and experiences in primary care episodes of low back pain

MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE THROUGH AYURVEDA: A CASE STUDY

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal ailment. Its symptoms include heartburn and regurgitation, epigastric pain, dysphagia, belching, nausea, bloating, etc.General line of treatment includes antacids, histamine-receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs). If medication treatment fails, patients may require surgical intervention, such as anti-reflux surgery, with varying outcomes for long-term care. This condition can be co-related with Amlapitta described in Ayurveda text. In present case study a 48-year-old patient having chief complaints as acid eructation, burning sensation in the chest (retrosternal burning), episodes of pain in the chest and nauseawere clinically diagnosed as case of amlapitta(corelated with GERD). The patient was treated with specific regimen - Tab Pittashamak, Tab Gulkacid, Tab Vruddhihar and mahatiktaghrita in prescribed dose. Therapeutic evaluation of treatment was done based on improvement in sign & symptoms. Patient was cured completely with no reoccurrence of symptomseven after 3 months. A chronic case of GERD was successfully treated with ayurvedic medicine along with diet and lifestyle modification.

Secondary Adrenal Insufficiency : A Case Report

Introduction: Insufficient pituitary hormone output is referred to as hypopituitarism. Individuals experiencing lethargy, dizziness, orthostatic hypotension, hypoglycemia, nausea, vomiting, or generalized abdominal pain may be diagnosed with acute adrenocorticotropic hormone (ACTH) insufficiency. This report detailed a unique instance of hypopituitarism in a patient who complained of nausea, vomiting, hypotension, hypoglycemia, and overall abdominal pain and soreness. Case presentation: A 65-year-old male presented to the outpatient department with complaints of a cough of 1-day duration on August 9/03/21 associated with 4 to 5 episodes of vomiting and pain in the abdomen, in addition to that whole body darkening, fatigue, and appetite loss of 6 months. weight loss intermittent sweating, and eyebrow and axillary hair loss. SOB with mild activity and also bilateral breast pain but no mass. Discussion: The diagnosis of hypothyroidism and inexplicable fatigue made us believe that there was an adrenal deficiency, which might be treated with cortisol around eight o’clock. Even though the patient with a high stress level the cortisol was immeasurable; so the diagnosis, of adrenal insufficiency, could be made. Other tests including ACTH and Imaging are usually needed to discover the subtype of insufficiency. The follow-up after 1 month showed no signs or symptoms left and a much better condition. Conclusion: When treating individuals who have fatigue that cannot be attributed to anything else, especially when weight loss and muscle weakness are present, adrenal insufficiency should be taken into consideration. A secondary adrenal insufficiency may exist even in the absence of skin pigmentation, which frequently triggers anxieties and ideas about Addison’s disease. If it is not identified promptly, it may potentially result in an adrenal crisis in situations with high-stress levels. Our patient presented with vague and largely mild symptoms related to early secondary adrenal insufficiency. These included nausea and vomiting, as well as fatigue. Laboratory studies indicated new hyponatremia and urine studies showed inappropriately normal urine sodium and osmolality. His morning serum cortisol was low, with borderline low ACTH, consistent with a secondary cause.

Neck pain among students of the faculty of medicine and pharmacy of Marrakech

Our objective was to investigate neck pain occurrence among students at the Faculty of Medicine and Pharmacy of Marrakech (FMPM), pinpoint its associated factors, and propose effective prevention strategies. Additionally, we aimed to evaluate its medical and psychological impact on physical activity and study quality. To achieve our goals, we conducted over three-month period a cross-sectional study among FMPM students from 2nd to 7th year, using a self-questionnaire with both descriptive and analytical purposes, from June 2022 to September 2022.We considered students with neck pain as those who had undergone an episode of neck pain within the previous year. Our research consisted of 206 students, with a gender ratio of 3.4 and an average age of 23 years. The results indicated that the vast majority of students (81.1%) had experienced neck pain within the past year, but for most, the pain lasted less than a week. During the survey, neck pain was reported by 18.4% of students. Our analysis discovered that there was a significant correlation between the occurrence of neck pain within the past year and age, family history of degenerative disc diseases, prior neck pain, amount of sleep, and computer use for studying. Through our research, we have confirmed that neck pain is a significant health issue for FMPM students. In order to address this problem and decrease its occurrence and impact, we have suggested preventative measures. To achieve this, we have put up posters in the faculty hall and shared a link online within student groups, which provides information on exercises and proper posture.

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities. In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale. Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture. ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Secondary Prevention of Multifocal Atherosclerosis Combined with Chronic Obstructive Pulmonary Disease

The problem of secondary prevention of multifocal atherosclerosis (MAS) combined with chronic obstructive pulmonary disease (COPD), is a leading cause of death in the world. Therefore, the search for drugs capable of affecting the destructive mechanisms underlying both MAS and COPD is an extremely urgent problem today. Objective — to reduce the risks of destabilization of atherosclerotic plaques by reducing the levels of metallomatrix metalloproteases (MMP)-2 and MMP-9 in patients on MAS combined with COPD. Materials and methods. The study included 62 men (68.1 ± 4.2) years old with MAS. All patients with MAS had clinical and functional signs of injury in coronary, cerebral and femoral vascular territories, 30 of these patients (group MAS-2) additionally had clinical and functional signs of COPD (GOLD-2). The control group (CG) consisted of 18 practically healthy men, aged (65.4 ± 3.7) years. Examination of the patients included echocardiography, dopplerography of the vessels of the neck and arteries of the lower extremities, determination of walking distance and ankle-brachial index, Holter ECG monitoring, spirography and determination of MMP-2 and MMP-9 levels in blood. Patients of both groups were prescribed cilostazol (50 mg twice a day) and GABA aminalon (250 mg twice a day) on the background of basic treatment. The course of treatment lasted 16 weeks. Results and discussion. During the initial examination of patients, MAS-2 group showed significantly (p < 0.001) lower volumetric blood flow in the studied arteries, and significantly (p < 0.01) higher levels of MMP-2 and MMP-9, as compared to CG, as well as with patients of the MAS-1 group. After 16 weeks of treatment, with the addition of cilostazol and aminalon, the level of MMP in the blood significantly (p < 0.05) decreased in both groups, in particular, in the MAS-2 group, in patients with the combined pathology of MAS and COPD, a significant decrease was found MMP-2 by 23.6 % (p < 0.01), and MMP-9 by 12.1 % (p < 0.05). Volumetric blood flow indicators increased significantly (p < 0.05) in all studied vascular territories, which led to improvement in clinical manifestations of the disease — a decrease in the number of painful and painless episodes of myocardial ischemia, and an increase in walking distance. Conclusions. The use of a complex therapy of statins, cilostazol and GABA in patients with MAS combined with COPD allows to reduce significantly the levels of MMP-2 and MMP-9, which ensures the stability of atheromatous plaques and significantly improves blood supply in vascular territories with atherosclerotic lesions.

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain

ABSTRACT Objective The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined. Design Repeated measures (test-retest) design, methods study Methods The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years’ experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss’ kappa coefficient. Results Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.) Conclusion Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Predictive validity of the STarT Back screening tool among older adults with back pain.

The predictive validity of the STarT Back screening tool among older adults is uncertain. This study aimed to assess the predictive validity of the SBT among older adults in primary care. This prospective cohort study included 452 patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain. A poor outcome (persistent disabling back pain) was defined as a score of ≥7/24 on the Roland-Morris Disability Questionnaire (RMDQ) at 3, 6 or 12 months of follow-up. The ability of the SBT risk groups to identify persistent disabling back pain was assessed with multivariable logistic regression, area under receiver operating characteristics curve (AUC), and with the accuracy measures sensitivity, specificity, predictive values and likelihood ratios. The adjusted odds ratios (95% CI) for persistent disabling back pain were 2.40 (1.34-4.30) at 3 months, 3.42 (1.76-6.67) at 6 months and 2.81 (1.47-5.38) at 12 months for the medium-risk group (n = 118), and 8.90 (1.83-43.24), 2.66 (0.81-8.67) and 4.53 (1.24-16.46) for the high-risk group (n = 27), compared to the low-risk group (n = 282). There were no statistically significant differences in odds between the medium- and high-risk groups at any time point. AUC values (95% CI) were 0.65 (0.59-0.71), 0.67 (0.60-0.73) and 0.65 (0.58-0.71) at 3, 6 and 12 months. Accuracy measures were poor at all time points, with particularly poor sensitivity and negative likelihood ratio values. The predictive validity of the SBT risk groups in predicting persistent disabling back pain in older adults was poor. This study found that the STarT Back screening tool had poor predictive validity among older adults and that it may need recalibration or extension before widespread implementation among older adults. Having valid tools for this population may aid clinicians with allocating scarce healthcare resources, which is especially important considering the rapidly ageing population and its expected challenge to the healthcare systems.

HCM AT THE CROSSROAD

Abstract Introduction Treatment of oHCM frequently requires difficult choices, especially when it is superimposed on other urgent clinical conditions,such as AMI or mechanical complications. Clinical Case A 52–year–old man with known oHCM, who spontaneously quickly discontinued recommended therapy, presents to theED with a sudden episode of dyspnea and presyncope. A firstECG was essentially normal for pathology. After 1h, the patient experiences a sudden episode of chest pain with rapid hemodynamic deterioration and cardiogenic shock(CS). The ECG shows changes compatible with inferolateral MI. The TTE shows severe LVOTO, SAM, severe MR and a suspicious oval image attached to the anterior mitral leaflet. The patient underwent orotracheal intubation, coronary angiography and TEE. Coronary angiography shows a thrombotic occlusion of the proximal circumflex artery, treated with pPCI. TEE confirms a partial rupture of the papillary muscle head. Treatment:The patient‘s CS can be caused by 2different conditions that require treatments with opposing pathophysiological principles. SevereMR due to papillary muscle rupture, as mechanical complication of MI, requires afterload reduction, hemodynamic stabilization with IABP and emergency transfer to a cardiac surgery center. In contrast, the treatment of the underlying pathology(severe LVOTO and severe rMR due to SAM)requires pharmacological stabilization with depression of cardiac contractility and increase in afterload. In the context of cardiogenic shock a rapid choice was required. To help us make the right choice, an Esmolol test was performed. After iv administration of 2mg Esmolol, heart rate was reduced without reduction in BP. The patient was then treated with esmolol in continuous infusion and norepinephrine. In oHCM the ventriculo–arterial coupling is reduced, less than 1. This treatment favored better V–A coupling, ensuring an increase in afterload and a reduction in myocardial contractility. The patient‘s clinical condition rapidly improved, allowing extubation at48h and early mobilization at96h. Myectomy and mitral repair surgery was scheduled 1 month afterPCI. Conclusions Through the use of a short–lived drug such as Esmolol, it was possible to trace the prevailing mechanism of the patient‘s CS. Differently from other cases of CS, to rebalance the V–Acoupling, it was crucial to reduce myocardial contractility and increase afterload. A pathophysiological pharmacological approach ensured a good outcome.

DOUBLE ST–ELEVATION, DOUBLE OCCLUSION?

Abstract Case Presentation A 71–year–old woman was referred to our outpatient clinic for two episodes of chest pain during last two days. Her past medical history was remarkable for arterial hypertension, obesity, diabetes mellitus type 2 treated by oral hypoglycaemic agents complicated by diabetic maculopathy. Diagnostic Work–Up At the presentation, the patient was symptomathic for chest pain, hemodynamically stable. The ECG showed synus rhythm, left–axis deviation, Q wave and ST–elevation from V2 to V5 and in DIII and ST–elevation in DII and aVF (FIGURE 1). Transthoracic echocardiography revealed concentric hypertrophy, mildly reduced LV ejection fraction (EF 45%) with akinesia of intreventricular septum and apex, without severe valvulopathies and no pericardial effusion. Given the clinical data the patient was addressed to urgent coronary angiography that showed LAD occlusion at the end of his proximal tract and right coronary artery occlusion at the beggining of his second tract (FIGURE 2); furthermore omo and etero–coronaric collaterals for right coronary artery area were detected. By using a workhorse guidewire flow was restored in both coronary arteries and PTCA was performed with 3 DES on LAD and other 2 DES on right coronary artery (FIGURE 3). The patient was transferred to our coronaric intensive unit care after the procedure; no complications were noticed during the hospitalization. A week after the patient was discharged in good general health. Conclusion Multiple simultaneous coronary occlusions are reported in literature, yet the accurate incidence and physiopathology of this occurrence is still uncertain. Probably the symphathetic system activation caused by first coronary occlusion could promote an increased basal platelets activation and then the second coronary occlusion. Our case shows that during coronary angiography identifying a culprit lesion may be delicate and cardiologists should be prepared to manage multiple coronary occlusions.

IS IT REALLY A CASE OF TAKOTSUBO? SOMETIMES APPEARENCES CAN BE DECEPTIVE

Abstract We report the case of a 22–year–old female with a history of David procedure and mechanical valve replacement (ATS 22 mm) due to bicuspid aortic valve and severe AR with ascending aorta aneurysm in 2015. Regular annual clinical follow–up (EKG and ultrasound) was always normal. Since 2022 the patient suffered from episodes of dyspnea, chest pain and sadness diagnosed as Panic Disorder. Home–therapy: Warfarin, estroprogestinic pill. At the latest outpatient visit she was asymptomatic and in good overall condition, but her EKG showed novel alterations (T wave inversion in antero–lateral leads and QT prolongation). She was then sent to the ED. LAB: troponin levels were normal (6.8 ng/ml) with an elevated Nt–proBNP (425 ng/ml) and a low INR (1.53). Questioned about recent events she reported a road trauma which occurred two weeks prior. She was then admitted to Cardiology clinic. Ultrasound: apical akinesia with reduced wall thickness, EF 48%, E/E‘ 10, and normal right ventricular function. The aortic valve prosthesis was functional without pathological regurgitation, and other echocardiographic parameters were within normal limits. EKG and ultrasound abnormalities along with a recent history of trauma supported Takotsubo Syndrome diagnosis (InterTAK score = 79.8% – 67pt), even though troponin levels were normal. Throughout hospitalization there were no changes in the EKG or pathological increases in troponin, and the patient remained asymptomatic. The patient was treated with LMWH to achieve adequate INR levels and initiated on B–blocker, ACEi, and SGLT2i for HFmrEF. Cardiac MRI revealed apical segment akinesia with dilation and reduced wall thickness (EDV 97 ml/m²), EF 41%, transmural ischemic LGE in the apical region and a ventricular thrombus (16x4 mm). The patient underwent coronary angiography which showed normal epicardial coronary arteries. Upon careful history–taking, the patient admitted irregular intake of VKA in the previous months. Given this information, the MRI and angiographic findings the diagnosis of unrecognized prior acute coronary syndrome, likely due to coronary thromboembolism in a patient with PHV and suboptimal compliance with VKA, was established. The patient was discharged home upon achieving a persistently therapeutic INR, with instructions to discontinue contraceptive therapy. Conclusion: coronary thromboembolism is a rare complication of PHV with inadequate anticoagulation leading, in this case, to an unrecognized MI.

CARDIOGENIC SHOCK IN A PATIENT WITH SEVERE AORTIC VALVE STENOSIS AND MULTIVESSEL CORONARY DISEASE: ADVANCED THERAPEUTIC STRATEGIES

Abstract We describe a case of a 58 years old man. He was referred to emergency room for episodes of vomiting and epigastric pain for about a week. Upon admission he was confused with systolic–diastolic blood pressure values ​​70/40 mmHg, heart rate 120 bpm, sinus rhythm. pO2 was 80 mmHg and SO2 in air 97%. Lactate values 10, blood sugar &amp;gt; 300 mg/dl. The electrocardiogram showed sinus tachycardia with the results of antero–septal necrosis and incomplete left bundle branch block. The fast echocardiogram showed a dilated left ventricle with severe depression of the ejection fraction (EF about 10–15%), severe low flow–low gradient aortic valve stenosis (AVA bidimensional was approximately 0.9 cm²), severe mitral valve insufficiency due to a dual mechanism. The dimension of Inferior vena cava was 1.5 cm, collapsible. There was thrombotic stratification in the apex of the left ventricle and VA coupling was 2. The patient was admitted to the ICU with stage C cardiogenic shock according to SCAI classification. We found a value of PVC 3 mmHg. After fluide challenge there was an increase in blood pressure values to 100/60 mmHg. Noradrenaline vasopressor was started and subsequently a low dose of adrenaline. Blood pressure values maintained around 90/60 mmHg and undergo a sudden drop after increasing the dosage of the vasopressor. Diuresis was approximately 50 ml/h, lactates clear completely after approximately 4 hours. After 6 hours, due to a new sudden reduction in blood pressure, the patient was referred for IABP and coronary angiography control. In the context of multivessel coronary artery disease and cardiogenic shock he was therefore a candidate for urgent cardiac surgery of aortic valve replacement, by–pass and mitral anulovalvuloplasty. This case gave us the opportunity to analyze how to proceed in such a critical conditions with the below conclusions: a) the choice of vasopressors and inotropes is limited in case of severe aortic valve stenosis b) the presence of left ventricular intracavitary thrombosis limits the choice of ventricular assistance system c) in case of cardiogenic shock and severe aortic valve stenosis the patient must be a candidate for valve replacement surgery as soon as possible.

CLINICAL CHALLENGE: AORTITIS IN THE EMERGENCY DEPARTMENT

Abstract A 67 yo woman presented to the ED for a sustained episode of palpitations and acute chest pain. Past medical history: suspected psoriatic arthritis previously treated with steroids and hydroxychloroquine; previous suspicion of rheumatic polymyalgia and Horton arteritis, regressed with steroids; gastroesophageal reflux disease; mild hypercholesterolemia and a family history of premature coronary artery disease. In the ED the patient was hemodynamically stable. On physical examination: tachyarrhythmic heart sounds with no murmurs. The peripheral arterial pulses were preserved and symmetrical. The remaining physical examination was unremarkable. ECG: atrial fibrillation at 150 bpm. The D–dimer was increased, normal hs–troponin and normal haemoglobin. On echocardiography: normal biventricular structure and function; normal aortic root with dilatation of proximal ascending aorta (47 mm), without visible intimal flaps. The anterior wall of the proximal ascending aorta was thickened. A moderate circumferential pericardial effusion was present, without signs of hemodynamic impact. On suspicion of an acute aortic syndrome with possible intramural haematoma of an ascending aortic aneurism, an urgent CT scan was ordered. It showed a severe dilatation of ascending aorta (52 mm) involving of the proximal aortic arch. The anterior aortic wall was thickened (5 mm), without clear images of IMH, aortic dissection or penetrating ulcer. The pericardial effusion had a supra–fluid density without blood density. A repeated CT at 6 hours showed no changes. The case was suggestive of an inflammatory aetiology. The patient was admitted to the cardiac intensive care unit. A PET–CT scan showed signs of an inflammatory disease of the great vessels. A serological autoimmunity screening was negative. The patient was diagnosed with inflammatory aortitis (giant cell vs Takayasu arteritis) and started on high dose iv glucocorticoid therapy. Given the high risk of severe aortic complications, adjunctive therapy with tocilizumab was prescribed. The therapy was gradually tapered, with subsequent switch to oral steroids plus tocilizumab. At one and a half month of follow–up, a CT scan was repeated, documenting stable aortic diameters and the disappearance of the abnormal thickness and of the enhancement of the aortic wall. A follow–up PET–CT scan has been scheduled at 6 months time. An elective aortic intervention has been indicated after remission of the inflammatory phase.

ACUTE CORONARY SYNDROME IN A PATIENT WITH LEFT SUBCLAVIAN OCCLUSION AND ANTEROLATERAL CORONARY STEAL

Abstract This is a 57–year–old male patient suffering from multiple cardiovascular risk factors: obesity, arterial hypertension, dyslipidemia, type 2 diabetes mellitus, active smoker. Chronic obstructive pulmonary disease. Stage 2 chronic kidney disease. Peripheral vascular disease with previous bilateral thromboendarterectomy and percutaneous revascularization of the lower limbs. Stable angina for which three years ago he underwent Coronary Artery Bypass Graft: left internal mammary artery (LIMA) to left anterior descending artery combined with saphenous vein grafts to the main obtuse marginal branch. The patient presented with Acute Coronary Syndrome non ST–segment elevation myocardial infarction (N–STEMI), intermittent episodes of chest pain due to mild exertion in the previous days. Antero–lateral ST depression and inverted T waves, associated with a mild reduction in left ventricular systolic function due to hypokinesia of the antero–lateral walls and increased troponin values were present. Coronary angiography documented patency of the LIMA graft without evidence of any culprit lesions on the coronary branches. However, selective angiography documented a sub–occlusion of the proximal left subclavian artery (Figure 1). A computed tomography scan confirmed a hyperdense calcified plaque occluding 95% of the origin of the left subclavian artery. The patient then underwent angioplasty with stenting of the left subclavian artery (Figure 2). Subclavian coronary steal syndrome usually presents with exertional angina, but rarely can cause Acute Coronary Syndrome. During coronary angiography performed for Acute Coronary Syndrome and in the absence of detection of clear coronary culprit lesions, selective angiography of the subclavian artery may confirm the suspicion of coronary steal syndrome.

It's Not Cyclic Vomiting Syndrome Until Dietl's is Ruled Out: A Case for Point of Care Renal Ultrasound

BackgroundAbdominal pain and vomiting are frequent complaints for pediatric patients presenting to the Emergency Department (ED). When a diagnosis such as chronic abdominal pain, cyclic vomiting, or abdominal migraine has previously been made, it can lead to diagnostic momentum and confirmation bias on behalf of the treating physician. Dietl's crisis is a commonly missed diagnosis in the pediatric population that presents with intermittent episodes of pain and vomiting. It can be readily diagnosed at the bedside by the emergency physician (EP) through the employment of point of care ultrasound (POCUS). Case SeriesWe present two cases of pediatric patients with episodic abdominal pain and vomiting who were previously diagnosed with cyclic vomiting syndrome. In both cases, pediatric gastroenterology evaluations had occurred with negative diagnostic testing having been performed. Both patients also presented to their primary pediatrician and the ED multiple times with each encounter resulting in treatment of symptoms and discharge. Each patient eventually presented to the ED when an EP was present who performed a renal POCUS. In each patient, the POCUS revealed severe unilateral hydronephrosis. Subsequent workup confirmed the diagnosis of Dietl's crisis as the etiology of symptoms. Why Should an Emergency Physician Be Aware of This?In pediatric patients, EPs should be wary of the diagnosis of cyclic vomiting syndrome until ureteral obstruction has been ruled out. A bedside POCUS can rapidly establish this diagnosis and potentially preclude recurrent health care visits, unnecessary diagnostic testing, and permanent loss of renal function.

WELLENS SYNDROME: TIMELY RECOGNITION AND SUCCESSFUL REVASCULARIZATION

Abstract Wellens syndrome is a condition characterized by clinical and instrumental signs suggestive of a critical proximal left anterior descending (LAD) coronary artery stenosis and requires early revascularization. Diagnostic criteria include T–wave changes in ECG during asymptomatic periods in patients with a history of chest pain, absence of significant cardiac enzyme movement, no ST–segment elevation, preserved R–wave, and no pathological Q waves. Early recognition of this syndrome is crucial, due to its 10–15% prevalence, allowing proper management and myocardial function recovery, avoiding potentially catastrophic outcomes. A 64–year–old male, with hypertension, undiagnosed diabetes, and family history of CAD, presented to our ER with sudden, brief chest pain radiating to the left upper limb. Similar episodes had occurred in the past week. The patient denied previous cardiovascular events and home therapy. ECG conducted by the attending cardiologist, during free chest pain period, showed biphasic T–wave in V1–V3 (a). Admission ECG resembled the ambulatory one. Lab results: Hb 14.7 g/dl, Troponin I 0.059 ng/ml (cut–off 0.034). Echocardiogram indicated distal septum akinesia. Urgent coronary angiography was performed, detecting subocclusive stenosis in the proximal–mid LAD. Successful revascularization was achieved by PTCA and implantation of 1 DES. (b) Subsequently, the patient was admitted to the Cardiac Intensive Care Unit for multiparametric monitoring. The ECG showed deeply negative T waves from V1 to V6. (c) No complications during hospitalization. Discharge ECG showed repolarization anomalies improvement. Echocardiography revealed preserved systolic function, without global or segmental anomalies in wall motion. Wellens syndrome is a manifestation of acute coronary syndrome that precedes an anterior wall MI. This condition can be identified by its characteristic T–wave patterns on ECG. Patients with this syndrome have severe LAD occlusion and require early coronary intervention. In chest pain episodes, the ECG appears normal, and troponin levels often remain within the normal range, which can potentially provide false reassurance. Wellens syndrome is a cardiac emergency requiring immediate attention; it is crucial for the physician to promptly identify the typical ECG signs of Wellens Syndrome, facilitating early coronary revascularization to prevent adverse patient outcomes.

Episodic Hyponatremia in Acute Intermittent Porphyria: A Case Report

Background: Acute intermittent porphyria (AIP) is an uncommon, ubiquitously distributed autosomal dominant disorder with low penetrance characterized by decreased enzyme activity of hydroxymethylbilane synthase (HMBS) an enzyme of heme synthesis pathway. It is often an elusive diagnosis due to rarity and non-specific signs and symptoms. Case report: A 28 years old female from Nawalparasi (district in central Nepal) presented with history of recurrent episodes of abdominal pain and vomiting. Her current episode began two weeks before presentation to our center. Abdominal pain was diffuse, colicky in nature without exacerbating or relieving factor. There was no postural or diurnal variation. On examination, there was no tenderness and abdominal examination findings were unremarkable. Her biochemical investigations were unremarkable except for severe hyponatremia (S. Na of 100mmol/L) which was SIADH/SIADH like presentation (Table 1 and Table 2). Severe episodic hyponatremia, port-wine color of urine, gastrointestinal symptoms and previous hospital stay two years back with similar episode of hyponatremia and abdominal pain were valuable clues for suspicion of acute porphyria. On further evaluation, patient was found to have presence of porphyrogenic precursors in urine and diagnosis of acute intermittent porphyria was confirmed. After diagnosis, she was managed conservatively with carbohydrate loading with intravenous dextrose, opioids and pregabalin as analgesics. Her symptoms gradually improved, hyponatremia subsided and was discharged in normal condition. Conclusion: Acute intermittent porphyria has signs and symptoms common to several clinical, neurological, psychiatric and gastroenterological pathologies, which complicate diagnosis. In young patients with hyponatremia (with SIADH –like picture), AIP should be considered in differential diagnosis.

Learning pains: system design, management, and lessons learned using electronic patient reported outcomes in the QUEST study of chronic post-amputation pain

BackgroundStudying pain clinically can be challenging. Typically, studies use paper diaries and measure pain from baseline and some pre-specified study endpoints. Both can lead to inaccuracies if studying on-demand device use. The QUEST study evaluating the safety and effectiveness of the investigational Altius device for treating chronic post-amputation pain (PAP) became, to our knowledge, the first longitudinal study to capture and validate repeated measurements using electronic patient-reported outcomes (ePRO).MethodsThe system was designed to capture pain episodes, device use, pain medication use and prosthetic use in “real-time.” Subjects received an electronic diary (eDiary) during screening and were required to demonstrate compliant reporting, and requisite pain levels to progress towards device implantation. Data were collected and merged with Altius session data and study visit data for 3 Month Primary Endpoint analysis. Compliance data across Device Treatment and End-of-Day Reports were also collected.ResultseDiary Eligibility pass rate during screening was 82% (410/497 subjects). Subjects generated 1,773,356 datapoints and 197,952 reports throughout QUEST. A total of 14,337 device uses were captured during Randomized Testing, with 77.0% and 82.7% compliant Device-use Reports and End-of-Day Reports captured, respectively. QUEST results are presented elsewhere (clinicaltrials.gov Identifier NCT 00221934).ConclusionsNeuros and partner vendors developed a unique system to capture accurate, “real-time” pain and treatment data from subjects with chronic PAP, despite health and technical-related challenges. This system provided a robust data set not yet seen in chronic pain literature and could provide a framework for better understanding chronic pain.Clinical Trial Information ClinicalTrials.gov ID NCT02221934, Registration Date: 2014–08-15.

Uso da Toxina Botulínica Tipo A em pacientes com Neuralgia Trigeminal

This article provides a systematic review of the efficacy of Botulinum Toxin Type A (TBA) in treating trigeminal neuralgia (TN), a painful disorder affecting the trigeminal nerve. TN is described in the literature as a facial pain of acute nature, often unilateral, characterized by episodes of intense and transient pain, comparable to electric shocks. The diagnosis is made through a detailed evaluation that includes anamnesis, characterization of symptoms, and imaging tests to exclude similar pathologies. Conventional therapy for TN involves the use of carbamazepine; however, in cases of pharmacological resistance or ineffectiveness of standard treatments, TBA emerges as a viable therapeutic alternative. The efficacy of TBA, as demonstrated in retrospective and prospective studies, is due to its ability to inhibit the release of neurotransmitters responsible for pain transmission and inflammatory processes. Various studies corroborate the efficacy of TBA, especially in patients over 50 years old, observing substantial improvement in symptoms with minimal adverse effects. The administration of TBA is carried out directly in the trigger zones, where it has proven to be well-tolerated, providing significant improvement in the quality of life of the affected patients. Despite promising results, the literature suggests the need for additional studies to optimize the dosage protocols and application of TBA, aiming to ensure its efficacy and safety in the long term. In conclusion, this article reiterates that TBA represents an effective and minimally invasive therapeutic alternative for the treatment of TN. However, it is essential to develop individualized therapeutic protocols and conduct more comprehensive studies to consolidate its use as the treatment of choice.