Pain Consciousness Research Articles

Ruptured Abdominal Aortic Aneurysm: A 7‐Year Retrospective Observational Study in an Emergency Department of Hong Kong

ObjectivesTo review the clinical presentations and outcomes of patients with ruptured abdominal aortic aneurysm (AAA) in a regional hospital and its evaluation in the accident and emergency department (AED).MethodsThis is a retrospective observational study of patients admitted through the AED with the discharge or post‐mortem diagnosis of ruptured AAA from 1st January 2002 to 31st December 2008 in a regional pubic hospital of Hong Kong. Their demographic and clinical data were recorded and analysed. The sensitivity of the AED in detecting ruptured AAA or symptomatic AAA was evaluated.ResultsTwenty‐six patients were found to have ruptured AAA and included in the study. All were Chinese. Seventeen patients had repair surgery done by open surgical method. Eighteen (69%) patients were diagnosed to have ruptured AAA or found to have symptomatic AAA in the AED. Three (12%) ruptured AAAs were diagnosed at post‐mortem. The most common presenting symptoms were abdominal pain (73%) and loss of consciousness (46%). Only five (19%) patients had the classical triad of abdominal pain, haemorrhagic shock and a pulsatile abdominal mass. Ultrasound of aorta was performed in 74% of cases in the group with ruptured AAA or symptomatic AAA diagnosed in the AED but none in the delayed diagnosis group (p=0.001). The former group were 3.7 times more likely to proceed to repair surgery (p=0.188) and had surgical repair operation 40.8 hours earlier than the latter group (p=0.006). Systolic blood pressure less than 90 mmHg at any time point before operation was found to correlate significantly with mortality (p=0.029).ConclusionA high index of suspicion and prompt recognition of ruptured AAA is of paramount importance. Emergency physicians should familiarise themselves with the clinical presentation and management of patients with ruptured AAA. Emergency ultrasound performed in the AED helps in the early detection of AAA.

Anaphylaxis during skin testing with food allergens in children

Skin testing is the diagnostic cornerstone for allergies and is considered extremely safe. It is usually performed with the prick and the prick-to-prick method. The aim of this study is to report the first two pediatric cases of systemic allergic reactions during skin prick tests (SPT) with commercial food allergens. Both patients had a history of fish allergy. A 5-year-old girl, with a history of atopic dermatitis and asthma, reported an episode of urticaria and angioedema due to ingestion of fish, which had occurred 2 years before consultation. Ten minutes after having completed SPT to fish extracts, which had resulted positive, she suffered from generalized pruritus, nausea, stomach pain, and loss of consciousness. A 9-year-old boy, with a history of asthma and two episodes of acute urticaria and angioedema upon eating fish during infancy, reported a recent episode of oropharyngeal pruritus after tasting salmon. He was evaluated for fish allergy with SPT but developed conjunctivitis and acute urticaria during the first 10 min of the test. Anaphylaxis appears to be a rare side effect of skin testing in pediatric patients. Children with a history of asthma and atopic dermatitis are more likely to react.

Arrhythmogenesis and diagnosis of cardiac sarcoidosis. An immunohistochemical study in a sudden cardiac death

We present an uncommon case of sudden cardiac death in a 34-year-old white woman. She was found lifeless at home by her parents. Three months before death she was recovered at the Emergency Room for chest pain, palpitation and loss of consciousness. Subsequent cardiological evaluation with ECG showed sinusal rhythm, QRS deviation to the left, QS aspect, asymmetric and rounded T waves and slight length of QT. During hospitalization she presented some episodes of supraventricular paroxysmal tachycardia and non-sustained ventricular tachycardia. No echocardiography alterations were found. An anti-arrhythmic treatment was prescribed. Autopsy revealed some fibrotic scarring in the myocardium of left ventricle. The histological examination of the heart revealed diffuse and extensive fibrosis with non-caseating sarcoid granulomas. The lungs, kidneys and lymph node also showed the same non-caseating granulomas. The diagnosis of sarcoidosis with massive and extensive cardiac involvement was established as cause of death.

Insomniac Country

1. Waking into pastel deserts the soul roams over cracked blisters on these wastes of moon Though it also lingers with the breath of burros on brief grasslands islanded in stone Among tiny towns wedged between slagheaps of granite like outpourings of ancient punishment To those who wake again on these vast plains in shanties cowered by shale chimneys Where two hundred million years of sediment sleep soundly through the pain of consciousness. 2. The cataract of a dream shattered into stasis: a planet of scorpions in distances of heat so furious I had to piss on my shirt and wear it as a turban so as to not incinerate my brain. Was it madness demanded I uncover signs among those craters and broke a crack, oracular, in the desert floor opening a new ravine within the heart of this one? Switchbacks swept back into a valley of pinon and misshapen stones rose like Golgothas in the setting sun, for once again it was evening and again the source of the dream was gone.

Massive Upper GI Bleed Secondary to Splenic Artery Pseudoaneurysm

Purpose: 22 year old male, history of abdominal trauma, presented with sudden onset of 3 episodes of hematemesis associated with abdominal pain and loss of consciousness. He denied previous episodes of GI bleeding. Two years prior, he had multiple stab wounds to the abdomen and subsequently underwent exploratory laparotomy and ostomy with reversal for perforated bowel. Reports heavy alcohol use on weekends and smokes 1 ppd × 6 years. Upon arrival to the emergency room, vital signs were stable: P73, BP 122/68 with no orthostasis. Abd exam: + BS, NT, ND, + midline and ostomy scars, no organomegaly. Rectal exam: brown stool, guaiac positive. NG lavage was not performed. Labs: WBC 11,900 mm3, Hg 12.5 g/dL, Hct 37.9%, Platelets 323/mm3, BUN/cr ratio19 with normal coagulation profile and liver tests. An EGD was performed. A large fresh clot was seen in the gastric body which could not be suctioned. In addition, fresh blood was seen in the second portion of the duodenum, but no source of bleeding was identified. During endoscopy, the patient had several more episodes of hematemesis and was taken to interventional radiology. A 5 F catheter was placed in the celiac axis and an angiogram was performed. A pseudoaneurysm off the mid splenic artery was identified as the source of bleeding and coils were deployed and packed into the pseudoaneurysm. Repeat angiogram showed no residual flow with good thrombosis. Subsequently, the patient was discharged with no further episodes of GI bleeding and Hct 35%. Few cases have reported GI bleeding in patients where pseudoaneurysms have been thought to spontaneously erode into the GI tract secondary to compression/stress/trauma. Since this patient had sustained prior abdominal trauma in the same anatomical location as the formation of the splenic artery pseudoaneurysm, spontaneous fistularization of the pseudoaneurysm and the gastric wall could have occurred thus explaining his presentation. A thorough review of the literature has reported pseuodocyst and pseudoaneurysm fistularization to arteries supplying the GI tract or to the pancreatic duct in patients with chronic pancreatitis resulting in upper GI bleeding. However, to date, there is no reported case of a pseudoaneurysm of the splenic artery caused as a result of prior abdominal and presenting as trauma hematemesis. Hence, as gastroenterologists, we must be aware of the increasing role of angiographical methods for diagnosing and controlling acute GI bleeding.

Metástasis cerebrales de coriocarcinoma tras una gestación a término

We report the case of a patient who presented to the emergency department with holocranial pain and loss of consciousness. She had given birth to her fourth child 3 months previously. After several days of investigations, we observed a high serum beta-human chorionic gonadotrophin level and hemorrhagic brain metastases. These data led to a diagnosis of metastases from choriocarcinoma.

Insect Stings

Insect Stings

49-Year-Old Woman With Back Pain and Loss of Consciousness

49-year-old woman had a lO-month history of low­ back pain that had developed insidiously. Two months after the back pain was initially noted, it precipi­ tously worsened, and an evaluation by her local physician included a roentgenogram of the lumbar spine that showed a compression fracture of the L-2 vertebral body. Among the tests done in assessment, a serum IgG 1C level was increased at 3,910 mg/dL. A subsequent bone marrow biopsy specimen showed IgG 1C multiple myeloma. She was treated with melphalan hydrochloride and prednisone for 4 months (total melphalan dose, 172 mg). Her serum IgG decreased to 1,420 mg/dL. Three months later, the serum IgG level increased to 1,600 mg/dL. One month thereafter, she came to the Division of Hematology/ Oncology at Mayo Clinic Jacksonville for a second opinion on further treatment. On physical examination, the patient's weight was 70.9 kg and height was 157 cm. Her vital signs and findings on general physical and neurologic examinations were nor­ mal. Laboratory investigations showed abnormal serum IgG and total protein, and review of a slide of the previ­ ously obtained bone marrow biopsy specimen confirmed the diagnosis. Three 5-week cycles of chemotherapy were planned, with each cycle consisting of vincristine (0.5 mg/ day continuous intravenous infusion) and doxorubicin (10 mg/m- per day intravenously) on days 1 through 4 and dexamethasone (40 mg/day orally) on days 1 through 4, 9 through 12, and 17 through 20 of each 5-week treatment cycle. She returned home to begin treatment. One month after the aforementioned therapy was begun, while taking dexamethasone only, the patient suddenly felt sharp diffuse pain in her head and neck. The pain began while she was lying down and was associated with an ascending whiteout of her visual field bilaterally. The abnormal visual phenomenon lasted seconds and resolved

Acute suppurative salpingitis with concomitant intrauterine pregnancy

A 20-year-old woman presented to the emergency department with a history of lower abdominal pain and recent loss of consciousness. She was admitted with a primary diagnosis of abdominal pain; ectopic pregnancy was ruled out. The culture of the endocervix was positive for Neisseria gonorrhoeae. Surgical exploration of the pelvis was performed, and histological analysis of the specimen showed an acute suppurative salpingitis and an intrauterine pregnancy. The patient was placed on intravenous antibiotics. Postoperative course was unremarkable, and the patient was discharged on oral antibiotics. Although a rare entity acute suppurative salpingitis with concomitant intrauterine pregnancy are not mutually exclusive. Ectopic pregnancy should be the presumptive diagnosis when clinical presentation is consistent with pelvic inflammatory disease and pregnancy especially in the first trimester. Patients who are pregnant and exhibit clinical signs and symptoms that are consistent with salpingitis should be admitted for aggressive management of their highrisk pregnancy. Fetal wastage seems to be significant in spite of aggressive management. Endocervical culture for N gonorrhoeae should be obtained from all pregnant patients with follow-up treatment pending culture results. The following is a case presentation along with a review of the existing cases in the English literature and discussion of the possible pathogenesis and clinical outcome of this entity.

Occasional Review: Allergy to Coitus

Acute systemic hypersensitivity reactions to semen are rare but may be life-threatening. Chronic or recurrent local reactions are more common and may be misdiagnosed as infective or nonspecific vaginitis. The antigen(s) involved in these reactions reside in a glycoprotein fraction of seminal plasma. Allergic vulvovaginitis may also occur in sensitized women when they are exposed to exogenous allergens such as drugs, food and infective agents during sexual activity. Skin testing and other relevant investigations are indicated when these disorders are suspected. Condom usage will prevent symptoms of coital allergy. Desensitization has had variable success in acute systemic hypersensitivity. Precoital antihistamines may modify local reactions.

Non-invasive pain control in the terminally ill patient

Although terminal patients with chronic pain are best managed with oral analgesia, patients who cannot take oral medication of ten receive treatment liy parenteral routes. Seventy consecutive terminal patients admitted to our hospice inpatient facility were evaluatedfor pain control over a three day period. Level ofpain was evaluated on a scale of zero to three (0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain). Patients were also evaluated for level of consciousness on a scale of one to four (1=alert, 2=confused, 3=semi-comatose, 4=comatose). Patients were medicated with morphine sulfate, either orally or by suppository, on a regular, four-hour schedule. Level of pain and level ofconsciousness evaluations were performed at the time each dose of morphine sulfate was administered. Data were compared for the level of pain and level of consciousness for the three day study period using Chisquared analysis. The results showed a significant decrease in levelofpain over the study period (p<.005). During this time, no significant alteration in level of consciousness was noted. Thirtynine out of 65 patients were treated via the suppository route and a significant decrease in the level of pain was seen in this sub-group as well (p<.005). Median morphine sulfate dose in all patients on day three was 15 mg. every four hours, with no significant difference between oral and suppository sub-groups. Parenteral analgesia was not required by any patient to achieve adequate pain control. This study demonstrates that effective pain control in terminal patients can be achieved withoutparenteral administration of analgesia and without alteration in level of consciousness. In patients unable to receive oral analgesia, the use of suppository analgesia is an effective alternative, avoiding the increased discomfort associated with parenteral analgesia administration.

Round and about Górecki's Symphony No.3

Wagner's Tristan is often referred to as the beginning of modern music: justifiably, in that in it a thousand years of European consciousness, will, desire, aspiration, pain, renunciation and guilt implode and explode. Taking his theme from the twilight of Europe's Middle Ages when the modern world was born, Wagner created a mythic drama which anticipates the central myth-makers of our time – Freud, Jung, and Marx. In a concept appropriating Christian redemption to Greek-tragedy's pity and terror, the gods are ourselves; and what Hardy called the pain of consciousness, proving too great to be borne, seeks release in unconscious nirvana. Much of the then avant garde music of the early 20th century, notably the Second Viennese School, stems from that tortuously self-involved but verklärte night; and it is hardly surprising that so incestuous a notion should have been balanced by its polar opposite. In his Rite of Spring of 1913 Stravinsky, born in a White Russia that had bypassed the European Renaissance, effected a conscious cult of the barbarically unconscious: a fertility rite and sacrifical murder in tune with the elemental cycles of the year, but also with the impending ‘death of Europe’ in the World Wars. Bartók, living in a country where a folk culture was still active, had less need of Stravinsky's cosmopolitan self-consciousness, but could fuse primitive techniques with the European legacy of Beethoven. Janáček, in Moravia, could create operas that were allied to seasonal rites, while probing the depths of the modern, divided psyche.

Emergency medical care requirements for large public assemblies and a new strategy for managing cardiac arrest in this setting.

During the 1986 World's Exposition held in Vancouver, British Columbia, the types and frequencies of emergency medical problems were assessed. The average number of patients seeking care was 3.93 +/- 0.95 per 1,000 visitors (daily range, 1.94 to 6.8). Patient loads were linearly related to gate attendance, but the correlation was imperfect (P less than .001, r = .63). Only 4.4% of patients evaluated on site by nurses and paramedics were referred for additional testing and treatment: of these patients, 30% had suspected serious musculoskeletal injury, 16% had abdominal pain, and 25% had complaints of chest pain, dizziness, or loss of consciousness. Lay employees (security personnel) were trained to use automatic external defibrillators. There were six cardiac arrests (0.3 per million visitors). Two patients collapsed with ventricular fibrillation, were defibrillated by lay personnel, quickly regained consciousness, and survived. The other arrests were associated with asystole or electromechanical dissociation; no shocks were inappropriately given, and all four died. We conclude that four of every 1,000 persons at this assembly sought emergency medical care, that 95% of the problems seen were minor with few requiring physician skills, and that the automatic external defibrillator was suited for this setting and could be used by lay responders to provide early definitive treatment.

Absurdity and Creation in the Work of Sadeq Hedayat

Two impulses, the desire to create and the desire to withdraw into oblivion and death, lie at the heart of Sadeq Hedayat's character. He was painfully sensitive to human weaknesses, loneliness, and suffering in a world that seemed all the darker through his eyes because the values against which he measured it were so demanding. He expected more of and for humanity than could be attained. A part of him sought to reject a life doomed to such imperfection, to draw back from the searing pain of a consciousness without hope.Yet it is also through this pain of consciousness that the creative act arises. This second force, the impulse to objectify the vision of Absurdity by transforming it into art, provided for Hedayat a somewhat precarious counterbalance to the impulse of negation. For creation, however tentative, constitutes a challenge to the forces of darkness. In the very act of depicting a universe without meaning, the artist implicitly contributes meaning of his own.

Brainstorms: Philosophical Essays on Mind and Psychology.

A collection of 17 essays exploring the central issues of the philosophy of the mind, and human interaction with psychology and evolutionary biology. This book questions the relationship between psychology and morality as well as exploring the concept of human intentionality. It argues that intentional attributes such as desires, goals, beliefs and knowledge are purely mechanistic. The author also considers the meaning of mental imagery, sensations, pain and other puzzling aspects of consciousness. Central to the discussion of the book is the question of whether psychology can support a vision of humans as moral agents, free to choose what they do and responsible for their actions.

Vertigo attributable to dental and temporomandibular joint causes

1. An 8 year study of 105 patients with vertigo indicates that a surprisingly high percentage of vertigo associated ocular and vagal symptoms are caused by dental occlusal and temporomandibular joint abnormalities which irritate and injure the adjacent structures of the ears. 2. The symptoms of these patients included pain, blurring of vision, dizziness, staggering gait, light-headedness, nausea, vomiting, abdominal pain, blackouts, and loss of consciousness. These symptoms had resulted in previous inadequate diagnoses of Meniere's disease, brain tumor, brain degeneration, hypertension, athersclerosis, cholecystitis, abdominal epilepsy, and psychoneuroses. 3. Dental treatment that established a harmonious dental occlusion and nonpathogenic relationships of the temporomandibular joints, with the adjacent structures of the ear, resulted in complete relief of vertigo and associated symptoms in 89 per cent of the patients.