Chest pain in a heart transplant recipient: A case report

BACKGROUNDHeart transplantation is recommended for the treatment of patients with refractory heart failure. Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart. However, data from case reports on tacrolimus-induced achalasia after heart transplantation are limited. We aimed to present a case of tacrolimus-induced achalasia that developed after heart transplantation, which was successfully relieved by laparoscopic Heller myotomy.CASE SUMMARYA 67-year-old man with a history of Type 2 diabetes mellitus, hyperlipidemia, and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago. At the 10-year follow-up after the heart transplantation, the patient presented with persistent cough, dysphagia, heartburn, and retrosternal chest pain lasting for 2 wk. Upper endoscopy revealed no specific findings. Two years later, the patient experienced the same symptoms, including chest pain lasting for 4 wk. Esophagogram and manometry confirmed the presence of achalasia. Previous reports showed that discontinuing calcineurin inhibitor (CNI) treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia. Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia, the patient underwent laparoscopic Heller myotomy. Dysphagia was relieved without complications. Eight months later, he had no signs of recurrence of the achalasia.CONCLUSIONIn transplant patients with chest pain and gastrointestinal symptoms, CNI-induced achalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.     

Approach to the ED patient with "low-risk" chest pain

Patients who present to the ED with chest pain (or its equivalent) but have no electrocardiographic changes or elevation in cardiac biomarkers after an appropriate interval can be considered low risk for acute coronary syndrome. Combined with a low demographic risk for coronary artery disease (eg, using Framingham criteria), such patients can be said to be "low risk" for a subsequent coronary event. Whether there is a role for further risk stratification with provocative testing and/or coronary imaging before discharge remains open to debate.     

Facial expression and pain assessment in the pediatric patient: the primal face of pain.

PURPOSE: This paper aims to explore the role of facial expression in pediatric pain assessment. A comparison of tools employing facial expression methodology is presented. The concept of the primal face of pain (PFP) is introduced. CONCLUSION: The PFP offers an explanation to the utility and deficiency of facial pain scales and facial expression in pain assessment. PRACTICE IMPLICATIONS. The complexities of pain measurement should preclude the clinical application of untested instruments. For reported tools, a careful evaluation of the psychometric properties and the clinical context must precede application. The concept of the PFP warns against the application of facial pain scales as proxy measures in their intended population. Reliance on facial expression to assess pain in the school-age child is imprecise.     

掌上超声诊断仪对胸闷、胸痛急诊患者的针对性检查

目的评价掌上超声诊断仪对急诊胸痛、胸闷患者进行超声心动图检查、快捷诊断和初筛的临床价值。 方法选择2014年1至10月中国医学科学院阜外医院收治的271例急诊患者。应用美国GE Vscan型掌上超声诊断仪进行床旁超声心动图检查,主要评估心腔内径、左心室收缩功能、节段性室壁运动异常,心包以及升主动脉等。所有患者均在应用美国GE Vscan型掌上超声诊断仪检查之后,再应用美国GE Vivid i型超声心动图检查仪进行检查。采用χ²检验比较Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查结果差异;采用独立样本t检验比较Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪、高年资医师与低年资医师检查用时差异。 结果掌上超声诊断仪能对全部271例患者进行清晰成像。经Vscan型掌上超声诊断仪扫查确诊,存在节段性室壁运动异常者91例,左心室收缩功能减低者37例,心包积液3例,升主动脉夹层14例;其余患者超声心动图检查结果未提示存在室壁运动异常或收缩功能异常。Vscan型掌上超声诊断仪在评价节段性室壁运动异常及左心室收缩功能异常各漏诊1例,但Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查结果差异无统计学意义（χ²=0.03,P>0.05）。每个患者的检查时间为1~5 min,Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查用时差异也无统计学意义（t=-1.478,P>0.05）。应用Vscan型掌上超声诊断仪检查时,高年资医师比低年资医师检查用时短,且差异有统计学意义[（2.6±1.4）min vs （3.5±1.8）min,t=-2.41,P<0.05]。 结论对于以胸闷、胸痛等为主诉就诊的急诊患者,其临床诊断不明确且体格检查等结果为阴性时,掌上超声诊断仪能够有针对性的快速、准确评价心脏解剖结构、功能以及血流动力学状态,从而指导有效治疗,避免漏诊,具有重要的临床应用价值。     

Severe hypokalemia in thyrotoxic periodic paralysis

Thyrotoxic hypokalemic periodic paralysis is an uncommon but sometimes fatal disease in which early recognition and therapy may prevent untoward complications. The case of a 26-year-old Chinese man who presented to the emergency department with rapidly progressive profound weakness and severe hypokalemia (serum potassium, 1.2 mEq/L) is presented. The patient required endotracheal intubation, ventilatory assistance, and intravenous potassium administration. Emergency medical evaluation and management of this entity are discussed.     

和肽素在急性胸痛患者中的表达及意义

目的:探讨和肽素在急性胸痛患者中的表达及意义。方法:选取2010年12月—2012年6月就诊的急性胸痛患者491例,其中男性278例,女性213例;年龄(54±15)岁;采用酶联免疫吸附试验检测所有患者血清中和肽素。选取性别、年龄匹配的30例健康志愿者作为对照组,其中男性17例,女性13例;年龄(51±13)岁;检测其血清中和肽素水平。结果:491例急性胸痛的患者中,急性心肌梗死49例(9.98%),不稳定性心绞痛126例(25.66%),心源性疾病但非冠心病85例(17.31%),主动脉夹层10例(2.04%),肺栓塞8例(1.63%),气胸或纵隔气肿26例(5.30%),胸膜炎47例(9.57%),肺部肿瘤19例(3.87%),肋神经炎或肋软骨炎58例(11.81%),带状疱疹18例(3.67%),植物神经功能紊乱38例(7.74%),消化道疾病7例(1.42%);其中急性心肌梗死患者的和肽素水平(中位数:0.590 ng/mL,四分位距:0.340~0.990)明显高于其他组,差异均有统计学意义(P<0.001)。急性胸痛患者按照疾病大类分组,心血管疾病患者和肽素水平(中位数:0.198 ng/mL,四分位距:0.133~0.281)明显高于其他疾病患者,差异均有统计学意义(P<0.001)。结论:和肽素在急性心肌梗死患者血清中的水平明显高于其他原因胸痛患者;对于急性胸痛患者,和肽素具有明显的诊断和鉴别诊断意义,可提高急性心肌梗死的诊断率。     

心绞痛样胸痛误诊为冠心病分析

目的　探讨心绞痛样胸痛误诊为冠心病的原因。方法　分析了连续 16 2例因胸痛诊断为冠心病 ,接受冠状动脉造影患者的临床表现、医疗费用及误诊原因。结果　接受冠动脉造影前 ,16 2例中有 5 0例被误诊为冠心病。其中 X综合征 18例 ,β受体高敏征 12例 ,心神经症 8例 ,扩张型心肌病 2例 ,肥厚型心肌病 2例 ,肌桥 1例 ,肌桥并肥厚型心肌病 1例 ,心肌炎 1例 ,主动脉瓣关闭不全 1例 ,其他 4例。结论　胸痛误诊为冠心病的主要原因是未进行必要的检查 ,有经济能力的心绞痛样胸痛患者应该尽早接受冠状动脉造影。     

Facial pain as first manifestation of anti-Hu paraneoplastic syndrome

The diagnosis of anti-Hu-associated encephalomyelitis/sensory neuropathy may be particularly difficult when cranial nerve involvement represents the first clinical manifestation of the disease. We report a case of a patient who presented with facial pain as the first manifestation of an anti-Hu paraneoplastic syndrome, which needs a rapid detection and treatment of the underlying tumour. We suggest that paraneoplastic neuropathy should be considered during the management of trigeminal neuropathic pain, especially when brain imagery is normal.     

对急性冠脉综合征有独立预测价值的临床症状

目的；评价胸痛以及相关临床症状与急性冠脉综合征的关系，识别对急性冠脉综合征有独立预测价值的临床症状。方法；对398例临床拟诊为急性冠脉综合征的患者，记录胸痛等临床症状，并行选择性冠状动脉造影明确诊断。采用Logistic多元回归模型分析临床症状与急性冠脉综合征的关系。结果：398例中有298例（74．9％）确诊为急性冠脉综合征。急性冠脉综合征组和非冠心病组的年龄、性别和吸烟史差异有显著性（P〈0．001），呼吸困难、出汗、恶心或呕吐等临床症状两组差异亦有显著性（P〈0．05）。经Logistic多元回归模型分析，出汗、恶心或呕吐是对急性冠脉综合征有显著意义的临床症状（P〈0．05）。结论：出汗、恶心或呕吐等临床症状是急性冠脉综合征的独立预测症状。     

Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain

The evaluation of pleuritic pain in the emergency department (ED) presents a considerable challenge for the attending physician. Chest radiography (CXR) is a basic test, but its sensitivity is low, and often more sophisticated imaging techniques are needed. Our aim is to assess the diagnostic value of bedside B-mode lung ultrasound (LUS) in the visualization of radio-occult pulmonary lesions. Forty-nine patients complaining of pleuritic pain with negative CXR were prospectively studied by LUS. Detection of at least one of the following sonographic signs in the painful thoracic area was considered diagnostic: (i) the absence of pleural sliding; (ii) the focal alveolar-interstitial syndrome (AIS), defined by multiple artifacts B-line; (iii) the peripheral alveolar consolidation (PAC), defined by hypoechoic subpleural images; and (iv) the pleural disruption with thickening and irregularity of the line, with or without localized effusion. The final diagnoses were confirmed by spiral CT scanning (n = 12) and follow-up (n = 37). Final diagnoses were chest wall pain (n = 30), pleuropneumonia (n = 14), pulmonary embolism (n = 4), lung metastasis (n = 1). In 18 patients of the group with pulmonary conditions, LUS showed signs of pleurisy. They were PAC (n = 12), AIS (n = 17), pleural disruption (n = 17). If any sign is considered, the sensitivity of LUS in the diagnosis of radio-occult lesions was 94.7%, specificity was 96.7%, positive and negative predictive values were 94.7% and 96.7%, respectively, and accuracy was 95.9%. In patients with pleuritic pain of unknown cause, real-time LUS enables the diagnosis of radio-occult lung and pleural lesions.     

外来工作人员低钾血症64例临床分析

目的探讨外来工作人员低钾血症的发病因素、临床特点及治疗方法，提高诊治水平。方法回顾性分析2003年1月至2007年12月间收治的64例低钾血症患者的临床资料。结果50例（78．1％）在发病之前受到不当治疗。12例重度低钾血症患者及5例心律失常及其他所有病例经口服、静脉补钾等治疗后症状均获缓解。结论外来工作人员低钾症患者的主要发病因素可能与滥用地塞米松和某些抗生素有关，与摄入不足有关；另外在治疗重度低钾血症时除常规补钾的基础上，辅以安体舒通、精氨酸和门冬氨酸钾镁治疗是安全有效的。     

老年人低钾血症原因分析及治疗对策

目的 探讨引起低钾血症的不同病因及治疗措施.方法 回顾性分析98例老年人低钾血症患者的临床和生化资料.结果 引起低钾的病因主要为高血压(32.7%)、心力衰竭(26.5%)、糖尿病(12.2%)、甲状腺功能亢进症(10.2%)、消化系统疾病(10.2%)、重症感染(4.1%)、口腔痰患(2.0%),其他(2.0%).对策以治疗原发病和口服或静脉补钾为主.结论 老年低钾血症应重视其病因的治疗,并适量补钾.     

Comparison of three preverbal scales for postoperative pain assessment in a diverse pediatric sample

The purposes of this study were to compare the reliability and validity of three pain measurement scales for assessing pain in preverbal and nonverbal children and to determine which of the scales was mos tappropriate in a clinical setting to evaluate pain for infants and young children regardless of developmental stage or cognitive or physical disability. Pain scales tested were revised versions of the Riley Infant Pain Scale (RIPS), the Nursing Assessment of Pain Intensity (NAPI), and the Postoperative Pain Score (POPS). Purposive sampling of 391 postoperative infants and children was used for evaluation of pain in a midwestern children's hospital. Four assessments with each scale were done 1 hr apart by trained observers blinded to pain medications. Data analyses supported high inter-rater reliability, satisfactory discrimination between pain and no-pain observations, and suggested acceptability for all three scales with lower caregiver burden for RIPS and NAPI.