Abuse in Women and Men with and without Functional Gastrointestinal Disorders

We aimed to investigate the history of abuse in childhood and adulthood and health-related quality of life (HRQL) in women and men with FGID in the general adult population. A cross-sectional study in a random population sample (n = 1,537, 20-87 years) living in Osthammar municipality, Sweden, in 1995 was performed. Persons with FGID (n = 141) and a group of abdominal symptom-free controls (SSF, n = 97) were selected by means of a validated questionnaire assessing gastrointestinal symptoms (the ASQ). Abuse, anxiety and depression (the HADS) and HRQL (the PGWB) were measured. Women with FGID had a higher risk of having a history of some kind of abuse, as compared with the SSF controls (45% vs.16%, OR = 2.0, 95% CI: 1.01-3.9; SSF = 1), in contrast to men (29% vs. 24% n.s.). Women with a history of abuse and FGID had reduced HRQL 91 (95% CI 85-97) as compared with women without abuse history 100 (95% CI 96-104, P = 0.01, "healthy" = 102-105 on PGWB). Childhood emotional abuse was a predictor for consulting with OR = 4.20 (95% CI: 1.12-15.7.7). Thus, previous abuse is common in women with FGID and must be considered by the physician for diagnosis and treatment of the disorder.     

Magnetocardiography Predicts Coronary Artery Disease in Patients with Acute Chest Pain

Background: The value of magnetocardiography (MCG) for the detection of cardiac electrical disturbances associated with myocardial ischemia was studied. Methods: Sensitivity and predictivity of admission MCG for the presence of coronary artery disease (CAD) were prospectively evaluated in 264 consecutive patients presenting with acute chest pain and without ST‐segment elevation. MCG findings were compared with 12‐lead ECG, echocardiography (ECHO), and troponin‐I in a head‐to‐head design. Coronary angiography was used for CAD diagnosis. Results: The visual assessment of magnetocardiograms by the experienced reader (R1) was superior to that by the unexperienced reader (R2) and superior to the automated computer analysis. Specificity and positive predictive value of MCG by R1 were comparable with those of ECG and troponin‐I (>90%), while ECHO specificity and ECHO positive predictive value were lower (76.2% and 87.9%, respectively). Sensitivity and negative predictive value of MCG were twice as high as those in the ECG, troponin‐I, and ECHO tests. Conclusion: For the prediction of CAD in patients presenting with acute chest pain and without ST‐segment elevation, an admission MCG test was superior to an admission ECG, ECHO, and troponin‐I. The results of the study, however, are applicable only to a highly selected population comprising patients in whom immediate coronary angiography can be performed based on their clinical course in the hospital.     

Past-Year Violence Typologies Among Patients with Cocaine-Related Chest Pain

This study examines a consecutive cohort of patients (n = 219) presenting to an urban Emergency Department (ED) for cocaine-related chest pain (June 2002 to February 2005). Patients were interviewed regarding violence, substance use, and psychosocial factors. Significant markers of violence were increases in: past-year medical service use, binge drinking, marijuana use, cocaine diagnosis, but not cocaine use days. Rates and correlates of violence differed by relationship type (intimate partner, nonpartner) and role context (victimization, perpetration). Understanding these correlates has public health implications, both for preventing future violence and its associated ED service utilization, and for future interventions in cocaine users presenting to the ED.     

Behavioral Intervention in Children with Functional Abdominal Pain Disorders: A Promising Option

Background The objectives of this study were to identify and classify patients with functional abdominal pain disorders (FAPD) into its various subtypes as per the Rome IV criteria and to evaluate the underlying psychological factors and the effect of behavioral intervention in children with FAPD.Methods A validated Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) based on Rome IV criteria was used to identify and classify children presenting with abdominal pain. The children diagnosed as having FAPD were referred for psychological screening to evaluate for underlying psychosocial problems. The scales namely Pediatric Anxiety Rating Scale (PARS), Depression self-rating scale (DSRS), and Visual Analog Scale (VAS) were administered to children to assess the response of the child to behavioral therapy. Results Of 100 children, 32, 26, 22, and 20% of children belonged to the subtypes of functional abdominal pain—not otherwise specified, abdominal migraine, irritable bowel syndrome, and functional dyspepsia, respectively. The most common associated psychosocial factors were academic burden, poor financial condition, exam-related stress, and bullying at school. The influence of behavioral therapy was statistically significant (P < .05). The mean (±standard deviation) PARS and DSRS scores were significantly reduced at 3 months of follow-up.Discussion The most common subtypes reported were functional abdominal pain—not otherwise specified and abdominal migraine. Psychological factors such as academic burden, poor financial condition, exam-related stress, and bullying at school need to be ruled out in children with this condition. Non-pharmacological intervention such as behavioral therapy can confer a remarkable improvement in the symptoms of children with FAPD.     

Atypical Antipsychotic Quetiapine in the Management of Severe Refractory Functional Gastrointestinal Disorders

Management of severe refractory functional gastrointestinal disorders (FGIDs) is difficult. Quetiapine, an atypical antipsychotic, may benefit patients by mitigating associated anxiety and sleep disturbances, augmenting the effect of antidepressants, and providing an independent analgesic effect. Outpatient records from a university-based FGID clinic were reviewed, and 21 patients with refractory symptoms who received quetiapine were identified and interviewed. Outcomes included global relief of symptoms, treatment efficacy questionnaire, and change in gastrointestinal (GI) and psychological symptoms. Eleven of 21 patients continued therapy at the time of interview. Six of 11 demonstrated global relief of symptoms, and 9 were satisfied with treatment. The remaining 10 of 21 discontinued therapy because of somnolence and lack of GI benefits. Quetiapine in low doses appeared beneficial in more than half of the adults with severe FGIDs who stayed on treatment. This response in otherwise refractory patients suggests quetiapine might augment the effectiveness of antidepressants in severe FGIDs.     

Critical Pathways for Patients with Acute Chest Pain at Low Risk

Critical pathways are predefined protocols that define the crucial steps in evaluating and treating a clinical problem to improve quality of patient care, reduce variability and enhance efficiency. Critical pathways have proliferated for a variety of diagnoses, including evaluation of patients with chest pain, a common and costly complaint. This review will outline the development, implementation, and assessment of critical pathways using as a paradigm our experience with a pathway for patients presenting to the Emergency Department with acute chest pain who are at low risk of myocardial ischemia. The goals of the pathway were to expedite evaluation of low-risk patients and reduce admission rates among these patients and in the cohort overall without compromising outcomes.The pathway was developed by a multidisciplinary team in an iterative process that considered published literature, as well as the experience and consensus of local opinion leaders. Patients at least 30 years old presenting to the Emergency Department of an urban teaching hospital who were pain-free without heart failure or ischemic changes on EKG, but who were not considered appropriate for discharge by the treating physician, were eligible for the critical pathway. The pathway involved one set of creatine kinase-MB enzymes drawn at least 4 hours after pain, a 6 hour observation period after the last episode of pain and exercise testing. Outcomes during evaluation and admission rates were assessed. Clinical outcomes at 7 days and 6 months after evaluation and patient satisfaction at 7 days were also measured.Of 1363 patient visits, 145 (10.6%) were triaged by the pathway: 131 (90.3%) were discharged, 14 (9.7%) were admitted. The overall admission rate decreased from 63% (2898/4595) to 60% (819/1363) [p < 0.05] in comparison to a cohort studied prior to pathway implementation. Pathway patients reported low rates of subsequent cardiac procedures. No deaths or myocardial infarctions were recorded. At 7 days, only 2 respondents (2%) reported going to an Emergency Department since their evaluation. Most respondents (83%) rated their care as very good or excellent.Critical pathways designed to enhance efficiency, reduce variability, and improve the quality of care are becoming increasingly common. Our pathway for evaluation of patients with chest pain at low risk of myocardial ischemia was feasible and safe and was associated with a decline in absolute admission rates. Because of the possibility of concomitant secular trends and the effects of a changing medical environment, further rigorous research on the efficacy of individual pathways is needed.     

Risk of Gastrointestinal Cancer in Patients with Unexplained Chest/Epigastric Pain and Normal Upper Endoscopy: A Danish 10-Year Follow-up Study

Unexplained chest/epigastric pain is a common symptom in the general population. However, it has not previously been studied whether such pain could be a marker of subsequent gastrointestinal cancer. We aimed to estimate the risk of gastrointestinal cancers in a Danish 10-year follow-up study among patients with chest/epigastric pain, normal upper endoscopy, and no prior discharge diagnosis of ischemic heart disease (N = 386), compared with population controls (N = 3860). The overall 10-year risk of gastrointestinal cancer (stomach, colorectal, liver, and pancreas) was 2.9% for patients with unexplained chest/epigastric pain vs. 1.5% for controls. The adjusted relative risks <1 year and ≥1 year after upper endoscopy were 8.4 (95% confidence interval [CI], 2.6–27.5) and 1.2 (95% CI, 0.5–2.9), respectively. We found that patients with unexplained chest/epigastric pain have an increased risk of gastrointestinal cancer within the first year after upper endoscopy. Consequently, unexplained chest/epigastric pain might be an early gastrointestinal cancer symptom.     

Hand-Held Echocardiogram Does Not Aid in Triaging Chest Pain Patients from the Emergency Department

Background: Accurate triage of emergency department (ED) patients presenting with chest pain is a primary goal of the ED physician. In addition to standard clinical history and examination, a hand-held echocardiogram (HHE) may aid the emergency physician in making correct decisions. We tested the hypothesis that an HHE performed and interpreted by a cardiology fellow could help risk-stratify patients presenting to the ED with chest pain. Methods: ED physicians evaluated 36 patients presenting with cardiovascular symptoms. Patients were then dispositioned to either an intensive care bed, a monitored bed, an unmonitored bed, or home. Following disposition, an HHE was performed and interpreted by a cardiology fellow to evaluate for cardiac function and pathology. The outcomes evaluated (1) a change in the level of care and (2) additional testing ordered as a result of the HHE. Results: The HHE showed wall motion abnormalities in 31% (11 out of 36) of the studies, but the level of care did not change after HHE for any patients who presented with chest pain to the ED. No additional laboratory or imaging tests were ordered for any patients based on the results of the HHE. Eighty-six percent (31 out of 36) of the studies were of adequate quality for interpretation, and 32 out of 36 (89%) interpretations correlated with an attending overread. Conclusion: Despite the high prevalence of abnormal wall motion in this population, hand-held echocardiography performed in this ED setting did not aid in the risk stratification process of chest pain patients.     

Noninvasive Cardiac Imaging in Chest Pain Syndromes

Journal of Thrombosis and Thrombolysis -     

Pain/Depression Dyad: A Key to a Better Understanding and Treatment of Functional Somatic Syndromes

Functional somatic syndromes include some of the most common and frustrating illnesses seen by primary care physicians and medical specialists. An extensive literature search of the 2 best characterized functional somatic syndromes, fibromyalgia and irritable bowel syndrome, reveals the overlap of these 2 disorders and their close relationship to depression. New pathophysiologic studies have shown that there are similar central nervous system changes in fibromyalgia, irritable bowel syndrome, and depression. These clinical and biologic similarities are consistent with the observations that the effective management of fibromyalgia and irritable bowel syndrome is comparable to that of depression.     

Decreased Cerebrospinal Fluid β-Endorphin and Increased Pain Sensitivity in Patients with Functional Abdominal Pain

Jørgensen LS, Bach FW, Christiansen P, Raundahl U, Østgaard S, Ekman R. Decreased cerebrospinal fluid β-endorphin and increased pain sensitivity in patients with functional abdominal pain. Scand J Gastroenterol 1993;28:763-766.

We investigated whether central pain mechanisms including the endogenous antinociceptive system are involved in functional abdominal pain–that is, abdominal pain without abnormal findings at routine examinations. β-Endorphin, met-enkephalin immunoreactivity, and dynorphin immunoreactivity were measured in cerebrospinal fluid (CSF) from nine patients with long-lasting functional abdominal pain and nine pain-free controls undergoing minor surgery while under spinal analgesia. Furthermore, pain sensitivity was evaluated with an ischaemic pain test comparing 21 functional abdominal pain patients with two control groups: 1) 24 patients with organic abdominal pain due to duodenal ulcer, gallstone, or urinary tract calculi, and 2) 13 healthy pain-free controls. The CSF β-endorphin concentration was significantly decreased in the functional abdominal pain group as compared with nine matched controls (P = 0.01). Met-enkephalin and dynorphin immunoreactivities were normal. This part of the investigation was suspended after nine patients had been tested, because of post-lumbar-puncture headache. With regard to pain sensitivity, no significant difference between the three groups was shown, but subdivision of the functional abdominal pain group showed that individuals with pain and no symptoms of irritable bowel syndrome (IBS) were significantly more sensitive to pain than functional abdominal pain patients with IBS and healthy controls (P = 0.04).     

Adequacy of an Exercise Test in Excluding Angina on Patients Presenting to the Emergency Department with Chest Pain

Background: The clinical utility and cost effectiveness of exercise testing (ET) following evaluation by a cardiologist to exclude angina in patients presenting to the emergency department (ED) with chest pain was evaluated. Methods: Patients presenting to the ED with no apparent cause were evaluated. Of 239 patients presenting to the ED with chest pain without a history of coronary artery disease, 23 underwent sestamibi scanning with 216 undergoing ET. Follow-up evaluation was performed by telephone. Results: Of 216 ETs, 168 (77.8%) were negative, 24 (11.1%) positive, 24 (11.1%) indeterminate (209 discharged home directly). During follow-up (mean 20 months: range 5–37) there were three noncardiac deaths (malignancies = two, pneumonia = one) with five patients diagnosed with angina among the 168 with negative tests. Forty-two patients indicated unscheduled return visits (ED = 15, physician's office = 23, admissions = 4). The present management strategy realized a saving of Canadian (Cdn). $86,585.60 when compared with sestamibi scanning as the primary test. Conclusions: ET following an evaluation by a cardiologist can be used for the initial screening of patients presenting with chest pain to the ED with a high negative predictive accuracy with regard to future coronary events. Nuclear perfusion imaging can be used in a minority of patients where an ET is not feasible. A.N.E. 1999;4(4):408–415     

急诊胸痛中心的现状与未来

急诊胸痛中心专为救治急性冠状动脉综合征患者而设立,是集接诊、分诊、检查、转运、监护、常规药物治疗和急诊冠状动脉介入治疗为一体的独立单元。是整合急诊医学、心脏病学、导管介入技术、医疗管理和社会医学等多学科资源,代表现代医学和社会文明最高水平的全新医疗服务模式,也被形象地称为“胸痛绿色通道”。借助完善、配套、便捷的设施、设备,规范训练、团结高效的医、技、护团队为急性冠状动脉综合征患者做出合理诊断和风险评估,迅速实施首诊救治、尽快转运或就地实施急诊冠状动脉介入治疗,通过缩短心肌恢复灌注前的总缺血时间,最大限度降低患者病死率和不良事件率。现复习文献,分析急诊胸痛中心的发展现状和未来走向。