Reliability,validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0–5 years

Pain measurement is a prerequisite for individualized pain management and research into pain interventions. There is a need for reliable and valid pain measures for young children with burns. The aim of this study was to investigate whether the pain observation scale for young children (POCIS), the COMFORT behaviour scale (COMFORT-B) and the nurse observational visual analogue scale (VAS obs) are reliable, valid and clinically useful instruments to measure pain in children with burns aged 0–5 years. Participating trained nurses (N = 102) rated pain of 154 children during hospitalization. Two trained nurses simultaneously assessed pain at fixed intervals by using the previous mentioned measures. Cronbach’s alpha for POCIS was .87 for background and .89 for procedural pain. Intraclass Correlation Coefficients (ICCs) were .75 for background and .81 for procedural pain. COMFORT-B observations yielded Cronbach’s alpha of .77 for background and .86 for procedural pain and ICCs of .83 for background and .82 for procedural pain. The VAS obs resulted in ICCs of .55 for background and .60 for procedural pain. Correlation coefficient between POCIS and COMFORT-B was .79 (p < .01), Standardized response mean was 1.04 for both POCIS and COMFORT-B. Background pain measured with POCIS and COMFORT-B was lower than procedural pain (p < .001). Nurses found POCIS easier and quicker to use, but COMFORT-B was found to indicate pain more accurately. Both POCIS and COMFORT-B are reliable, valid and practical scales for pain measurement in young children with burns and can be used in practice and research. The VAS obs was found to be unreliable.     

Reliability and validity of the Brazilian-Portuguese version of the Burns Specific Pain Anxiety Scale (BSPAS)

Background

Pain and anxiety are a common problem in all recovery phases after a burn. The Burns Specific Pain Anxiety Scale (BSPAS) was proposed to assess anxiety in burn patients related to painful procedures.

Objectives

To assess internal consistency, discriminative construct validity, dimensionality and convergent construct validity of the Brazilian-Portuguese version of the Burns Specific Pain Anxiety Scale.

Design

In this cross-sectional study, the original version of the BSPAS, adapted into Brazilian Portuguese, was tested for internal consistency (Cronbach's Alpha), discriminative validity (related to total body surface area burned and sex), dimensionality (through factor analysis), and convergent construct validity (applying the Visual Analogue Scale for pain and State-Anxiety—STAI) in a group of 91 adult burn patients.

Results

The adapted version of the BSPAS displayed a moderate and positive correlation with pain assessments: immediately before baths and dressings (r = 0.32; p < 0.001), immediately after baths and dressings (r = 0.31; p < 0.001) and during the relaxation period (r = 0.31; p < 0.001) and with anxiety assessments (r = 0.34; p < 0.001). No statistically significant differences were observed when comparing the mean of the adapted version of the BSPAS scores with sex (p = 0.194) and total body surface area burned (p = 0.162) (discriminative validity). The principal components analysis applied to our sample seems to confirm anxiety as one single domain of the Brazilian-Portuguese version of the BSPAS. Cronbach's Alpha showed high internal consistency of the adapted version of the scale (0.90).

Conclusion

The Brazilian-Portuguese version of the BSPAS 9-items has shown statically acceptable levels of reliability and validity for pain-related anxiety evaluation in burn patients. This scale can be used to assess nursing interventions aimed at decreasing pain and anxiety related to the performance of painful procedures.     

Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial

Chronic osteoarthritis (OA) pain of the knee is often not effectively managed with current non-pharmacological or pharmacological treatments. Radiofrequency (RF) neurotomy is a therapeutic alternative for chronic pain. We investigated whether RF neurotomy applied to articular nerve branches (genicular nerves) was effective in relieving chronic OA knee joint pain. The study involved 38 elderly patients with (a) severe knee OA pain lasting more than 3 months, (b) positive response to a diagnostic genicular nerve block and (c) no response to conservative treatments. Patients were randomly assigned to receive percutaneous RF genicular neurotomy under fluoroscopic guidance (RF group; n = 19) or the same procedure without effective neurotomy (control group; n = 19). Visual analogue scale (VAS), Oxford knee scores, and global perceived effect on a 7-point scale were measured at baseline and at 1, 4, and 12 weeks post-procedure. VAS scores showed that the RF group had less knee joint pain at 4 (p < 0.001) and 12 (p < 0.001) weeks compared with the control group. Oxford knee scores showed similar findings (p < 0.001). In the RF group, 10/17 (59%), 11/17 (65%) and 10/17 (59%) achieved at least 50% knee pain relief at 1, 4, and 12 weeks, respectively. No patient reported a post-procedure adverse event during the follow-up period. RF neurotomy of genicular nerves leads to significant pain reduction and functional improvement in a subset of elderly chronic knee OA pain, and thus may be an effective treatment in such cases. Further trials with larger sample size and longer follow-up are warranted.     

Objective and continuous measurement of peripheral motor indicators of pain in hospitalized infants: A feasibility study

Measurement of pain in pre-verbal infants is complex. Until now, pain behavior has mainly been assessed intermittently using observational tools. Therefore, we determined the feasibility of long-term, objective and continuous measurement of peripheral motor parameters through body-fixed sensors to discriminate between pain and no pain in hospitalized pre-verbal infants. Two pain modes were studied: for procedural pain 10 measurements were performed before, during and after routine heel lances in 9 infants (age range infants: 5–175 days), and for post-operative pain 14 infants (age range 45–400 days) were measured for prolonged periods (mean 7 h) using the validated COMFORT-behavior scale as reference method. Several peripheral motor parameters were studied: three body part activity parameters derived from acceleration sensors attached to one arm and both legs, and two muscle activity parameters derived from electromyographic (EMG) sensors attached to wrist flexor and extensor muscles. Results showed that the accelerometry-based parameters legs activity and overall extremity activity (i.e. mean of arm and legs) were significantly higher during heel lance than before or after lance (p ? 0.001), whereas arm activity accelerometry data and wrist muscle activity EMG data showed no significant change. For the post-operative pain measurements, relationships were found between accelerometry-based overall extremity activity and COMFORT-behavior (r = 0.76, p < 0.001), and between EMG-based wrist flexor activity and COMFORT-behavior (r = 0.55, p < 0.001, for a subgroup of 7 infants). We conclude that long-term, objective and continuous measurement of peripheral motor parameters is feasible, has high potential, and is promising to assess pain in pre-verbal hospitalized infants.     

The psychometric properties of an Arabic numeric pain rating scale for measuring osteoarthritis knee pain

Purpose: The aims of this study were to translate the numeric rating scale (NRS) into Arabic and to evaluate the test–retest reliability and convergent validity of an Arabic Numeric Pain Rating Scale (ANPRS) for measuring pain in osteoarthritis (OA) of the knee.

Methods: The English version of the NRS was translated into Arabic as per the translation process guidelines for patient-rated outcome scales. One hundred twenty-one consecutive patients with OA of the knee who had experienced pain for more than 6 months were asked to report their pain levels on the ANPRS, visual analogue scale (VAS), and verbal rating scale (VRS). A second assessment was performed 48 h after the first to assess test–retest reliability. The test–retest reliability was calculated using the intraclass correlation coefficient (ICC_2,1). The convergent validity was assessed using Spearman rank correlation coefficient. In addition, the minimum detectable change (MDC) and standard error of measurement (SEM) were also assessed.

Results: The repeatability of ANPRS was good to excellent (ICC 0.89). The SEM and MDC were 0.71 and 1.96, respectively. Significant correlations were found with the VAS and VRS scores (p?<0.01).

Conclusions: The Arabic numeric pain rating scale is a valid and reliable scale for measuring pain levels in OA of the knee.

• Implications for Rehabilitation

• The Arabic Numeric Pain Rating Scale (ANPRS) is a reliable and valid instrument for measuring pain in osteoarthritis (OA) of the knee, with psychometric properties in agreement with other widely used scales.

• The ANPRS is well correlated with the VAS and NRS scores in patients with OA of the knee.

• The ANPRS appears to measure pain intensity similar to the VAS, NRS, and VRS and may provide additional advantages to Arab populations, as Arabic numbers are easily understood by this population.

     

Pain Scores among Emergency Department (ED) Patients: Comparison by ED Diagnosis

Background

Treatment for pain and pain-related conditions has been identified as the most common reason for Emergency Department (ED) visits.

Objective

This study was undertaken to characterize the distribution of self-reported pain scores for common ED diagnoses.

Methods

In this retrospective exploratory chart review, eligible participants included all adult ED patients age 18 years and over, with a self-reported triage pain score of 1 or higher during January–June 2011. Data were collected from ED electronic medical records.

Results

Among 1229 patients, the mean age was 44 years; 56% of patients were female, and 59% were white. The mean triage pain score for all patients was 7.1 (interquartile range 6–9). The most common reported diagnoses included: minor injuries (10%), abdominal pain (8%), and respiratory infections (8%). The diagnoses with the highest mean pain scores were: sickle cell crisis (mean pain score 8.7), back/neck/shoulder pain (8.5), and headache/migraine (8.3). Higher pain scores were significantly correlated with younger age (p < 0.001) and number of ED visits (p < 0.001). Demographic factors including female gender, African American race, and Medicaid insurance reported significantly higher pain scores (p < 0.001). Patients with multiple ED visits in the recent 12 months reported significantly higher pain scores (p < 0.001).

Conclusion

ED patients report a wide variety of pain scores. Factors associated with higher pain scores included younger age, female gender, African American race, Medicaid insurance status, multiple ED visits in the past year, and ED diagnoses of sickle cell crisis, back/neck/shoulder pain, and headache.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

Effect of conditioned pain modulation on trigeminal somatosensory function evaluated by quantitative sensory testing

The aim of the study was to systematically investigate the effect of craniofacially evoked conditioned pain modulation on somatosensory function using a quantitative sensory testing (QST) protocol applied to the trigeminal area in healthy humans. Pressure pain evoked by a mechanical compressive device was applied as conditioning stimulus (CS) in the craniofacial region, with a pain intensity of 5 on a visual analogue scale (VAS: 0–10 cm) (painful session) or with VAS score of 0 (control session). A full QST battery of 13 parameters was performed as test stimuli on the dominant-side cheek. The individual QST data from 11 men and 12 women were transformed into z scores, and the QST data and z scores were tested using analyses of variance. Analyses of variance of pressure pain threshold (PPT) data (log-transformed values and z scores) indicated significant session (P ? .003) and time (P < .001) effects with a session–time interaction (P < .001), but no main effect of sex (P ? .053, effect size ? .166). The session–time interaction showed that the PPTs in the painful session were associated with significantly higher log-transformed PPT values and significantly lower z scores compared with the control session at the time point during CS (hypoalgesia) (P < .001). No other QST parameters were significantly modulated by the CS. Sex differences were not detected in this study; a larger sample size may be needed to further explore this possibility. However, the findings indicate that when extensive QST protocols are applied, PPT may be the most sensitive measure to detect endogenous pain inhibitory mechanisms.     

Post-resuscitation electrocardiograms,acute coronary findings and in-hospital prognosis of survivors of out-of-hospital cardiac arrest

Background

Identification of acute coronary lesions amenable to urgent intervention in survivors of out-of-hospital cardiac arrest is crucial. We aimed to compare the clinical and electrocardiographic characteristics to urgent coronary findings, and to analyze in-hospital prognosis of these patients.

Methods

From January 2005 to December 2012 we retrospectively identified consecutive patients resuscitated from out-of-hospital cardiac arrest, and analyzed the clinical characteristics, post-resuscitation electrocardiogram and coronary angiogram of those who underwent emergent angiography. Mortality and neurologic status at discharge were also assessed.

Results

Patients with ST-elevation more frequently had obstructive coronary artery disease (89% vs. 51%, p < 0.001) or acute coronary occlusions (83% vs. 8%, p < 0.001) than patients without ST-elevation. Independent predictors of an acute coronary occlusion were chest pain before arrest (OR 0.16, 95% CI 0.04–0.7, p = 0.01), a shockable initial rhythm (OR 0.16, 95% CI 0.03–0.9, p = 0.03), and ST-elevation on the post-resuscitation electrocardiogram (OR 0.02, 95% CI 0.004–0.13, p < 0.001). Survival with favorable neurologic recovery at discharge was 59%. Independent predictors of mortality or unfavorable neurological outcome at discharge were absence of basic life support (OR 0.2, 95% CI 0.06–0.9, p = 0.04), prolonged resuscitation time (OR 0.9, 95% CI 0.8–0.9, p = 0.01), and necessity of vasopressors (OR 14.8, 95% CI 3.3–65.4, p = 0.001).

Conclusions

Most patients with ST-elevation on the post-resuscitation electrocardiogram had an acute coronary occlusion, as opposed to patients without ST-elevation. Absence of basic life support, prolonged resuscitation time and use of vasopressors were independent predictors of worse in-hospital outcome.     

High-frequency,high-intensity transcutaneous electrical nerve stimulation as treatment of pain after surgical abortion

The aim of the study was to compare the pain-relieving effect and the time spent in the recovery ward after treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) conventional pharmacological treatment after surgical abortion. Two-hundred women who underwent surgical abortion and postoperatively reported a visual analogue scale (VAS) pain score ? 3 were included. The patients were randomised to TENS or conventional pharmacological treatment for their postoperative pain. The TENS treatment was given with a stimulus intensity between 20 and 60 mA during 1 min and repeated once if insufficient pain relief (VAS ? 3). In the conventional pharmacological treatment group, a maximum dose of 100 μg fentanyl was given IV. There was no difference between the groups with regard to pain relief according to the VAS pain score (TENS = VAS 1.3 vs. IV opioids = VAS 1.6; p = 0.09) upon discharge from the recovery ward. However, the patients in the TENS group spent shorter time (44 min) in the recovery ward than the conventional pharmacological treatment group (62 min; p < 0.0001). The number of patients who needed additional analgesics in the recovery ward was comparable in both groups, as was the reported VAS pain score upon leaving the hospital (TENS = 2.0 vs. conventional pharmacological treatment = 1.8, NS). These results suggest that the pain-relieving effect of TENS seems to be comparable to conventional pharmacological treatment with IV opioids. Hence, TENS may be a suitable alternative to conventional pain management with IV opioids after surgical abortion.     

Measurement of lower limb volume: Agreement between the vertically oriented perometer and a tape measure method

Objective

To investigate the agreement between lower limb volume measurements for the vertically oriented perometer and a tape measure method.

Design

Between-methods agreement and test–retest reliability study.

Setting

University setting.

Participants

Thirty university staff and students were recruited using convenience sampling with no participant drop-outs.

Interventions

All participants’ dominant lower limb volumes were measured using the vertically oriented perometer and a tape measure method.

Main outcome measures

The Bland–Altman difference plot was reported for determining the bias between the two methods and its 95% confidence interval. Test–retest reliability and the measurement error for the perometer method were determined using the ICC(2,1) model and within-subject standard deviation (s_w) respectively.

Results

There was a lack of agreement between the tape measure and perometer method. The Bland–Altman difference plot showed that the tape measure method overestimated limb volume by 157 ml compared to the perometer method. A 95% confidence interval of −834 ml to 519 ml was observed. The test–retest reliability of the perometer method was ICC(2,1) = 0.99. The measurement error of the perometer method was clinically acceptable (s_w = 121 ml).

Conclusions

There was a lack of agreement between the two methods investigated. Therefore the perometer and tape measure methods are not interchangeable. It is recommended that future validity and reliability studies for the vertically oriented perometer are conducted on clinical populations.     

Methodological problems in the measurement of pain: A comparison between the verbal rating scale and the visual analogue scale

The effect of analgesics on pathological pain in a double-blind, complete cross-over design was assessed by means of two rating scales, a verbal rating scale (VRS) and visual analogue scale (VAS). The VRS is widely used, but has several disadvantages as compared to the VAS. The results obtained by means of the VRS showed higher F-ratios (analysis of variance and Kruskall-Wallis H-test) than those obtained by means of the VAS. The VRS, which transfers a continous feeling into a digital system, seems to augment artificially the measurement of effects produced by analgesics, and the VAS seems to assess more closely what a patient actually experiences with respect to change in pain intensities. The correlation between the two scales was highly significant (r = 0.81, P < 0.001). The calculated regression line (y = ?29.6 + 0.55 · x) was not similar to the line of identity and showed much lower values for the VAS, supporting our intepretation. The distribution of the variances of the values obtained by means of both scales was not homogenous. This indicates that the homogeneity of the distribution of variances should always be checked and a Kruskall-Wallis H-test used, if they are inhomogenously distributed.     

Antioxidative properties of hydrogen sulfide may involve in its antiadhesive action on blood platelets

Background

Hydrogen sulfide (H₂S) is a signaling molecule in different systems, including the cardiovascular system. However, mechanisms involved in the relationship between the action of H₂S and hemostasis process are still unclear.

Objective and methods

The present work was designed to study the effects of hydrogen sulfide on adhesion of blood platelets in vitro. Platelet suspensions were preincubated (5–30 min) with NaHS as a hydrogen sulfide donor at the final concentrations of 0.00001–10 mM. Then, for platelet activation thrombin (0.1 U/mL) or TRAP, peptide with the sequence Ser-Phe-Leu-Leu-Arg-Asn (SFLLRN; 20 μM) was used. We also measured the effects of H₂S on superoxide anion radicals (O₂^−•) production in blood platelets.

Results

We observed that adhesion to collagen and to fibrinogen of resting platelets preincubated with NaHS was changed, and this process was statistically significant (for 0.00001–5 mM NaHS, p < 0.05; 10 mM, p < 0.01). The inhibitory effect of NaHS on adhesion of thrombin – or TRAP – stimulated platelets to collagen was found (for 0.00001 and 0.0001 mM NaHS, p < 0.05; 0.001–1 mM NaHS, p < 0.01; 5 and 10 mM NaHS, p < 0.001). Hydrogen sulfide reduced also the thrombin- or TRAP-induced platelet adhesion to fibrinogen (for 0.00001 and 0.0001 mM NaHS, p < 0.05; 0.001–1 mM NaHS, p < 0.01; 5 and 10 mM NaHS, p < 0.001). Moreover, H₂S caused a dose-dependent reduction of O₂^−• produced in platelets (p < 0.05).

Conclusion

The results obtained that the antioxidative activity of H₂S may involve in its antiadhesive properties on blood platelets.     

Surgical management of neuroma pain: a prospective follow-up study

Painful neuromas can cause severe loss of function and have great impact on the daily life of patients. Surgical management remains challenging; despite improving techniques, success rates are low. To accurately study the success of surgical neuroma treatment and factors predictive of outcome, a prospective follow-up study was performed. Between 2006 and 2009, pre- and post-operative questionnaires regarding pain (VAS, McGill), function (DASH), quality of life (SF-36), symptoms of psychopathology (SCL-90), epidemiologic determinants and other outcome factors were sent to patients surgically treated for upper extremity neuroma pain. Pain scores after diagnostic nerve blocks were documented at the outpatient clinic before surgery. Thirty-four patients were included, with an average follow up time of 22 months. The mean VAS score decreased from 6.8 to 4.9 after surgery (p < 0.01), 19 (56%) of patients were satisfied with surgical results. Upper extremity function improved significantly (p = 0.001). Neuroma patients had significantly lower quality of life compared to a normal population. Employment status, duration of pain and CRPS symptoms were found to be prognostic factors. VAS scores after diagnostic nerve block were predictive of post-operative VAS scores (p = 0.001). Furthermore, smoking was significantly related to worse outcome (relative risk: 2.10). The results could lead to improved patient selection and treatment strategies. If a diagnostic nerve block is ineffective in relieving pain, patients will most likely not benefit from surgical treatment. Patients should be encouraged to focus on activity and employment instead of their symptoms. Smoking should be discouraged in patients who will undergo surgical neuroma treatment.     

Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity

Despite wide usage of the Numerical Rating Scale (NRS) for self-report of pain intensity in clinical practice with children and adolescents, validation data are lacking. We present here three datasets from studies in which the NRS was used together with another self-report scale. Study A compared post-operative pain ratings on the NRS with scores on the Faces Pain Scale-Revised (FPS-R) in 69 children age 7–17 years who had undergone a variety of surgical procedures. Study B compared post-operative pain ratings on the NRS with scores on the Visual Analogue Scale (VAS) in 29 children age 9–17 years who had undergone pectus excavatum repair. Study C compared ratings of remembered immunization pain in 236 children who comprised an NRS group and a sex- and age-matched VAS group. Correlations of the NRS with the FPS-R and VAS were r = 0.87 and 0.89 in Studies A and B, respectively. In Study C, the distributions of scores on the NRS and VAS were very similar except that scores closest to the no pain anchor were more likely to be selected on the VAS than the NRS. The NRS can be considered functionally equivalent to the VAS and FPS-R except for very mild pain (<1/10). We conclude that use of the NRS is tentatively supported for clinical practice with children of 8 years and older, and we recommend further research on the lower age limit and on standardized age-appropriate anchors and instructions for this scale.     

Schoolchildren as life savers: At what age do they become strong enough?

Objective

It is not clear when schoolchildren become enough strong to perform good quality chest compressions (CC). Our purpose was to assess CC quality in schoolchildren.

Methods

721 children, 10–15 years old (YO) participated in 1 h hands-on training session. Subjects were tested during performing 2 min of continuous CC by means of Laerdal Resusci Anne^® with Skillreporter^®, without feedback.

Results

Mean compression depth (MCD) increased with age, from 30.7 mm in 10YO to 42.9 mm in 15YO (p < 0.05) and was related to height, weight, and BMI. Boys delivered significantly deeper CC than girls in the 10, 13, 14 and 15YO groups (p < 0.001). The percentage of children who achieved the MCD goal (50–60 mm), increased with age, from 0.0% at 10 years to 26.5% at 15 years (p < 0.001). Mean compression rate (MCR) ranged from 121 min^–1 in 15YO to 134 min^–1 in 12YO. The percentage of children who achieved a CC rate inside the goal (100–120 min^–1), ranged from 20.3% in 11YO to 31.0% in 15YO. Correct CC fraction was low and ranged from 2% in the 10YO to 22% in the 15YO (p < 0.05). Children older than 13YO obtained better results than younger ones for all analyzed variables (p < 0.001). Performance decreased with time: 12% of children achieved >50% of correct CC fraction in first minute, while only 5% did it in second minute (p < 0.001).

Conclusions

In schoolchildren, age, sex and anthropometry are significant CPR quality factors. Although quality increases with age, their global performance is poor. Thirteen years is the minimum age to be able to achieve a minimum CPR quality similar to the one adult possess. CPR performance in schoolchildren significantly deteriorates within 60 s.     

Prodromal symptoms and health care consumption prior to out-of-hospital cardiac arrest in patients without previously known ischaemic heart disease

Aims

To describe prodromal symptoms and health care consumption prior to an out-of-hospital cardiac arrest (OHCA) in patients without previously known ischaemic heart disease (IHD).

Background

The most common lethal event of cardiovascular disease is sudden cardiac death, and the majority occur outside hospital. Little is known about prodromal symptoms and health care consumption associated with OHCAs.

Design

Case-crossover study.

Methods

Medical records of 403 OHCA cases without previously known IHD, age 25–74 years in the MONICA myocardial registry in Norrbotten County 2000–2008, were reviewed. Presenting symptoms and emergency visits at public primary care facilities and internal medicine clinics in Norrbotten County were analyzed from the week prior to the OHCA and from the same week one year previously, which served as a control week. Unlike most studies we included unwitnessed arrests and those where no cardiopulmonary resuscitation (CPR) was attempted.

Results

Emergency visits were more common during the week prior to the OHCA than during the control week, both for visits to primary care (29 vs. 6, p < 0.001) and to internal medicine clinics (16 vs. 0, p < 0.001). Symptoms were more prevalent during the week prior to the OHCA (36.7 vs. 6.7%, p < 0.001). The most prevalent symptoms were chest pain (14.6 vs. 0%, p < 0.001), gastrointestinal symptoms (7.7 vs. 1.2%, p < 0.001) and dyspnoea/peripheral oedema (6.9 vs. 0.2%, p < 0.001).

Conclusions

Patients who suffer an OHCA seek health care and present prodromal symptoms significantly more often the week prior to the event than the same week one year earlier.     

Prevention of medication overuse in patients with migraine

This multi-center study compared the therapeutic effect of a cognitive-behavioral minimal contact program (MCT) to the effect of a brochure (bibliotherapy) for the prevention of medication overuse headache (MOH) in migraine patients. Seven German headache centers recruited 182 migraine patients with high triptan or analgesic intake frequency. Patients were randomly allocated to either the MCT-group, receiving both an MCT program and an educational brochure or to the biblio-group receiving only the brochure. All participants continued usual medical treatment. Course of headaches, intake of analgesics or triptans after training, 3 months post-training as well as 1-2 years (mean 15.7 months) later and psychological variables were defined as outcome variables. A significant decline was observed in the number of headache days (11.0-8.8), migraine days (7.3-5.7) and medication intake days (7.4-6.1) from pre to post in the MCT-group (p < 0.001 each) and in the biblio-group (p < 0.001 each). The pre-to-post-improvements were maintained from pre- to short- and from pre- to long-term follow-up (p < 0.001 each) in both groups. Both groups improved significantly from pre to post in psychological variables, e.g. pain acceptance: p < 0.001; pain catastrophizing: p < 0.001; functional pain coping: p < 0.001; and pain related internal control beliefs: p < 0.01. Psychological improvements remained stable in both groups at short- and long-term follow-up. During the study, none of the patients developed an MOH. MCT- and bibliotherapy are useful in migraine patients to prevent medication overuse headache or the transition of episodic to chronic headache.     

Effect of lingual nerve block on burning mouth syndrome (stomatodynia): A randomized crossover trial

Burning mouth syndrome (stomatodynia) is associated with changes of a neuropathic nature the main location of which, peripheral or central, remains unknown. A randomised, double-blind crossover design was used to investigate the effects of lingual nerve block on spontaneous burning pain and a possible correlation with the effects of topical clonazepam, the patient’s response to a psychological questionnaire, and the taste and heat thresholds. The spontaneous burning was measured with a visual analogue scale (VAS) just before and 15 min after injection. The decreases in VAS score after lidocaine or saline injection were not significantly different (2.7 ± 3.9 and 2.0 ± 2.6, respectively; n = 20). However, two groups of patients could be identified: in a “peripheral group” (n = 10) the VAS decrease due to lingual nerve injection was 4.3 ± 3.1 cm after lidocaine and 0.9 ± 0.3 cm after saline (p = 0.02). In a “central group” (n = 7), there were an increase in pain intensity score (−0.8 ± 2.6 cm) after lidocaine and a decrease (1.5 ± 3.0 cm) after saline (p = 0.15). An increase in the hospital anxiety and depression (HAD) score and a decreased taste sensitivity and heat pain threshold of painful oral area were seen in patients compared with age-and-sex-matched controls (p < 0.05). Topical clonazepam treatment tended to be more effective (p = 0.07) and HAD score lower (p < 0.03) in the peripheral than in the central group. These results suggest that the neuropathic disorder associated with stomatodynia may be predominantly peripheral, central or mixed depending on the individual. Topical application of clonazepam and HAD may serve as indicators of which mechanism is dominating.     

Experimental pelvic pain facilitates pain provocation tests and causes regional hyperalgesia

The extra-articular sacroiliac joint (SIJ) structure is a potential source for low back and pelvic pain. This study hypothesised that experimental pain induced in a superficial pelvic ligament causes (1) hyperalgesia to pressure, (2) distinct pain referral, and (3) an increased frequency of positive pain provocation tests of the SIJ complex. Thirty healthy subjects (15 females) participated in this study designed as a randomised crossover trial. Pain was induced in the long posterior sacroiliac ligament by injection of hypertonic saline, with the contralateral ligament injected with isotonic saline as control. Pain intensity was assessed on an electronic visual analogue scale (VAS). Pressure pain thresholds (PPTs) and pain provocation tests were assessed on 3 occasions: at baseline, after injection, and when pain had subsided. PPT sites were located bilaterally at the injection site, lateral to spinous processes of S2 and L5, and at the gluteus medius and gastrocnemius muscles. Hypertonic saline caused significantly higher VAS scores and more extended pain referral than isotonic saline (P < 0.001). PPTs at the injection site and lateral to S2 were significantly reduced after hypertonic saline compared with baseline and isotonic saline (P < 0.002). Significantly more subjects had positive pain provocation tests after hypertonic (67% of subjects) compared with isotonic saline (20%; P < 0.001). These data demonstrate that the extra-articular SIJ structure accommodates nociceptors that are capable of inducing pain referral and regional hyperalgesia sensitive to manual pain provocation tests similar to what previously have been found in pelvic girdle pain patients.