Implementing Point-of-Care Troponin Testing in the Emergency Department: Impact on Time to Result

IntroductionIn the emergency department, troponin assays are commonly used and essential in the evaluation of chest pain and diagnosis of acute coronary syndrome. This study was designed to assess the potential impact of implementing point-of-care troponin testing by comparing the time to point-of-care laboratory result and time to conventional laboratory result.MethodsThe study enrolled 60 ED patients deemed to need a troponin test in the evaluation of low-risk chest pain (HEART score <4 based on history, electrocardiogram, age, risk factors). Point-of-care troponin testing was performed with the same blood sample obtained for a conventional troponin assay. If the provider determined that the patient required 2 troponin tests, the second laboratory draw was used in the data collection. This was to correlate the time of laboratory result to time of disposition.ResultsOf the 60 subjects enrolled, 2 subjects were excluded because of user errors with the point-of-care testing equipment and 2 others for not meeting inclusion criteria on later review. The median times for the point-of-care troponin and conventional troponin assays were 11:00 minutes (interquartile range 10:00-15:30) and 40:00 minutes (interquartile range 31:30-52:30), respectively; P < 0.001. There were 3 extreme outliers from the conventional troponin assay that significantly skewed the distribution of the mean, making the median the more accurate assessment of the central tendency.DiscussionPoint-of-care troponin testing provided results in a median time 29 minutes quicker than the conventional troponin assay. This result is statistically significant and has the potential to greatly improve time to disposition in all patients with chest pain requiring a troponin assay.     

Consideration of Testicular Torsion in Young Males With Abdominal Pain Is Essential: A Case Review

Testicular torsion is a surgical emergency and requires prompt recognition and treatment. Health care personnel often forget this differential diagnosis in males who present with abdominal pain as their only complaint. There is a 4- to 6-hour window from the onset of symptoms to the surgical intervention to salvage the testes. It is imperative for health care personnel to consider testicular torsion in any male presenting with abdominal pain and to complete a genitourinary examination. The purpose of this case review is to highlight the importance of a genitourinary examination in recognizing testicular torsion.     

趋化因子CXCL13及其受体CXCR5在1型糖尿病DPNP中的作用机制

目的 探讨趋化因子CXCL13及其受体CXCR5在1型糖尿病引发的糖尿病性周围神经病理性疼痛（DPNP）中的作用机制。方法 将36只C57BL/6小鼠随机分为C57BL/6空白对照组和C57BL/6模型组（每组18只）。C57BL/6模型组采用腹腔注射链脲佐菌素（60 mg/kg）构建1型糖尿病模型。每周观测小鼠的体质量、血糖、机械痛和热痛阈值。于第15周检测2组脊髓中趋化因子、趋化因子受体和促炎因子水平的变化以及血清中炎症因子的变化。在上述试验基础上,再分别取12只C57BL/6小鼠和12只CXCR5^-/-小鼠按前述方法分别设立对照组和模型组（每组6只）,于第4周检测各组机械痛敏、第6周检测热痛敏。结果 C57BL/6模型组小鼠的脊髓中CXCL13和CXCR5等趋化因子及其受体的mRNA明显上调（P均<0.05）。C57BL/6模型组小鼠血糖升高、体质量减少,第4周的机械痛阈值降低、第6周的热痛阈值降低（P均<0.05）,但CXCR5^-/-模型组小鼠机械痛和热痛阈值无变化。与C57BL/6空白对照组比较,C57BL/6模型组小鼠的星形胶质细胞标志物胶质纤维酸性蛋白、小型胶质细胞标志物离子钙结合衔接分子1以及炎症因子标志物环氧化酶-2、IL-1β以及磷酸化的丝裂原活化蛋白激酶（ERK）和信号转导和转录激活因子3（STAT3）的水平升高（P均<0.05）;血清中炎症因子IL-6、TNF-α和IL-1β蛋白水平升高（P均<0.01）。结论 趋化因子CXCL13及其受体CXCR5的激活或可促使1型糖尿病DPNP的发生,相关机制可能是通过激活胶质细胞与磷酸化的ERK、STAT3和炎症因子表达实现的。     

Successful application of burst spinal cord stimulation for refractory upper limb pain: a case series

Spinal cord stimulation (SCS) has been used to treat sustained pain that is intractable despite various types of treatment. However, conventional tonic waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or postamputation pain. The pain signal mechanisms of burst waveforms are different to those of conventional tonic waveforms, but few reports have presented the therapeutic potential of burst waveforms for the abovementioned indications. This current case report describes two patients with refractory upper limb pain after SCI and upper limb amputation that were treated with burst waveform SCS. While the patients could not obtain sufficient therapeutic effect with conventional tonic waveforms, the burst waveforms provided better pain reduction with less discomfort. However, further studies are necessary to better clarify the mechanisms and efficacy of burst waveform SCS in patients with intractable pain.     

Corrective surgery using a gridiron incision for abdominal pain caused by a folded ovary in the third trimester of pregnancy

IntroductionSonography and magnetic resonance imaging (MRI) may be helpful to obtain an accurate diagnosis of acute abdominal pain in pregnancy. Adnexal torsion presenting in the first or second trimester can be confirmed and treated through laparoscopic surgery; however laparoscopic surgery in the third trimester can be difficult owing to the large uterus, and a gridiron incision can be useful.Case Report/Case presentationAn 18-year-old gravida 1, para 0 (G1P0) woman at 30 + 4 weeks of gestation presented with sudden-onset cyclic pain in the right lower quadrant. Abdominal ultrasonography showed a normal appendix, and MRI showed a normal appendix and normal ovaries. The patient’s prominent tender point was marked and compared with the MR images, which confirmed the mark as the position of the right ovary. Laparotomy was performed through a gridiron incision, and a folded right ovary was identified. The ovary was unfolded, and TachoSil® and Surgicel® were used to maintain the unfolded position. The patient’s pain resolved, and her postoperative course was uneventful. She delivered a healthy, 2540-g male baby at 35 weeks’ gestation.Discussion/ConclusionsA gridiron incision was useful to treat a folded ovary in the third trimester and to evaluate the adnexa and minimize uterine manipulation.     

Activation profile of dorsal root ganglia Iba-1 (+) macrophages varies with the type of lesion in rats

The interactions between neurons, immune and immune-like glial cells can initiate the abnormal processes that underlie neuropathic pain. In the peripheral nervous system the resident macrophages may play an important role. In this study we investigated in experimental adult Sprague-Dawley rats how Iba-1 (ionized calcium binding adaptor molecule 1) (+) resident macrophages in the dorsal root ganglion (DRG) are activated after a spinal nerve ligation (SNL) or streptozotocin (STZ)-induced diabetes. The activation profile was defined by comparing the responses of resident macrophages against microglia in the spinal cord as they share a common origin. After SNL, the Iba-1 (+) macrophages in L5 DRG reached their activation peak 5 days later, clustered as satellite cells around large A-neurons, expressed the MHC-II marker, but did not show p-p38 and p-ERK1/2 activation and did not secrete IL-18. After STZ-induced diabetes, the Iba-1 (+) macrophages reached their activation peak 1 week later in L4 and L5 DRG, remained scattered between neurons, expressed the MHC-II marker only in L5 DRG, did not show p-p38 and p-ERK1/2 activation and did not secrete any of the investigated cytokines/chemokines. These responses suggest that depending on the type of lesion DRG Iba-1 (+) resident macrophages have different activation mechanisms, which are dissimilar to those in microglia.     

Spinal cord injury pain

Spinal cord injury pain encompasses musculoskeletal and neuropathic pain. Its management is often multidisciplinary and involves specific drugs such as antidepressants and antiepileptics, and nonpharmacological treatment including psychotherapy, physical therapy and neuromodulation techniques. Recent progress in the diagnosis, assessment, and understanding of its mechanisms offers the perspective of a more rational therapeutic management, which should result in better therapeutic outcome.     

Optimism and the Experience of Pain: A Systematic Review

Abstract

A growing body of literature provides evidence of the health-promoting effects of optimism, including its protective role in acute and chronic pain. Optimists are characterized by positive expectations concerning the future. These positive outcome expectancies lead to more and longer goal-directed efforts and the use of approach coping strategies. No systematic review on the effects of optimism on the experience of pain has so far been conducted. A search in the databases PubMed, Web of Science and PsycInfo, and the scanning of reference lists identified 69 eligible studies. These were categorized according to sample size, participants’ age and sex, design, optimism-pain relation as primary vs. secondary study objective, and level of study/publication quality. Overall percentages of positive, zero, and negative associations between optimism and pain as well as relative frequencies of these associations in the different categories were analyzed. About 70% of the studies showed a positive, i.e., beneficial association between optimism and at least one pain outcome. A larger percentage of beneficial associations was found in studies with experimental designs, in studies with the optimism-pain relation as primary objective, in high-quality studies/publications, and in studies including participants with a higher average age. The review suggests that optimism is associated with less acute and chronic pain, especially since a higher percentage of beneficial associations was found with high study/publication quality and with the primary focus on this relationship. For the moderating role of age, different explanations are proposed. Further research on causal relationships and on optimism-fostering clinical interventions is needed.