Effect of age on acute pain perception of a standardized stimulus in the emergency department

The effect of training and workstation adjustability on teleworker discomfort during the COVID-19 pandemic

Technological advancements have increased occupational flexibility for employees and employers alike. However, while effective telework requires planning, the COVID-19 pandemic required many employees to quickly shift to working from home without ensuring that the requirements for telework were in place. This study evaluated the transition to telework on university faculty and staff and investigated the effect of one's telework setup and ergonomics training on work-related discomfort in the at-home environment. Fifty-one percent of respondents reported increases in their existing discomfort while 24% reported new discomfort since working from home. These results suggest a need for ergonomic interventions including ergonomic training and individual ergonomic assessments for those who work from home.

Postoperative Pain and Age: A Retrospective Cohort Association Study

BACKGROUND

As the population ages, the number of elderly people undergoing surgery increases. Literature on the incidence and intensity of postoperative pain in the elderly is conflicting. This study examines associations between age and pain-related patient reported outcomes and perioperative pain management in a dataset of surgical patients undergoing four common surgeries: spinal surgery, hip or knee replacement, or laparoscopic cholecystectomy. Based on the authors' clinical experience, they hypothesize that pain scores are lower in older patients.

METHODS

In this retrospective cohort, study data were collected between 2010 and 2018 as part of the international PAIN OUT program. Patients filled out the International Pain Outcomes Questionnaire on postoperative day 1.

RESULTS

A total of 11,510 patients from 26 countries, 59% female, with a mean age of 62 yr, underwent one of the aforementioned types of surgery. Large variation was detected within each age group for worst pain, yet for each surgical procedure, mean scores decreased significantly with age (mean Numeric Rating Scale range, 6.3 to 7.3; β = -0.2 per decade; P ≤ 0.001), representing a decrease of 1.3 Numeric Rating Scale points across a lifespan. The interference of pain with activities in bed, sleep, breathing deeply or coughing, nausea, drowsiness, anxiety, helplessness, opioid administration on the ward, and wish for more pain treatment also decreases with age for two or more of the procedures. Across the procedures, patients reported being in severe pain on postoperative day one 26 to 38% of the time, and pain interfered moderately to severely with movement.

CONCLUSIONS

The authors' findings indicate that postoperative pain decreases with increasing age. The change is, however, small and of questionable clinical significance. Additionally, there are still too many patients, at any age, undergoing common surgeries who suffer from moderate to severe pain, which interferes with function, supporting the need for tailoring care to the individual patient.

EDITOR’S PERSPECTIVE

The Minimum Clinically Significant Difference in Acute Nontraumatic Thoracoabdominal Pain in Adult Emergency Department Patients in Turkey

Objectives

To determine the minimum clinically significant difference (MCSD) in visual analog scale (VAS) pain scores for acute non-traumatic thoracoabdominal pain (TAP) in the emergency department (ED) and to determine its association with sociodemographic features, location and duration of pain.

Methods

An observational survey of adult ED patients with TAP lasting less than 48 hours was conducted over a six-week period. Demographic information and the duration and location of pain were recorded. Patients indicated their pain level on a 100-mm VAS at baseline and at 20, 40, and 60 minutes thereafter. Subjects were also asked to rate their pain as ‘much less’, ‘a little less’, ‘about the same’, ‘a little more’, or ‘much more’ at the 20-, 40-, and 60-minute time points. MCSD was calculated as the difference between the subsequent and preceding VAS scores if a patient reported pain as ‘a little less’ or ‘a little more’.

Results

Data was available for 306 of the 374 patients with TAP who presented during the study period. For pain comparisons (n=428) categorised as ‘a little less’ or ‘a little more’, the MCSD was 24.2 mm (95% CI 22.6-25.7 mm). The MCSD value was not significantly different among the factors of gender, age, level of education, duration, or location of pain.

Conclusions

The MCSD of ED patients with nontraumatic thoracoabominal pain in Turkey is 24.2 mm. The MCSD is not affected by gender, age, level of education, location, or duration of pain.

Comparison of the Effects of Hegu Point Ice Massage and 2% Lidocaine Gel on Arteriovenous Fistula Puncture-Related Pain in Hemodialysis Patients: A Randomized Controlled Trial

Introduction: There is a paucity of information on the effects of Hegu point ice massage and 2% lidocaine gel on fistula puncture-related pain in hemodialysis patients. The aim of the present research was compare the two methods in terms of their effectiveness.

Methods: This study is a randomized controlled trial. Seventy hemodialysis patients were divided into two groups. The fistula puncture-related pain in the two groups was measured in the first session of hemodialysis without any intervention. During a hemodialysis session, 2% lidocaine gel was applied on the patient’s arteriovenous fistula site in one group. Also, for the other group, an ice cube was used to massage on the Hegu point in the hand without fistula in the other hemodialysis session. The pain score was recorded, using the Visual Analogue Scale. The data were analyzed using SPSS ver.13.

Results: No significant differences were observed in the mean pain scores of the two groups in the preintervention phase. The comparison of the pain score before and after interventions of the lidocaine gel and ice massage groups was found to bear significant differences. Moreover, the comparison of the mean changes of the pain score before and after the intervention of the Hegu point ice massage groups revealed a further reduction for Hegu point than of lidocaine gel groups.

Conclusion: Lidocaine gel and Hegu point ice massage affect the intensity of fistula puncture related pain in hemodialysis patients. Given the higher effectiveness of Hegu point ice massage, this method is recommended to be used for fast and safe pain reduction in hemodialysis patients.

Pain Assessment and Control in the Injured Elderly

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

Pain Management in Elderly Patients

In elderly patients, persistent pain negatively impacts quality of life. An interdisciplinary approach to pain management and emphasis on quality improvement will help to achieve better therapeutic outcomes. Managing pain in the geriatric population is challenging because of age-related changes in pain perception, cognition, pharmacokinetics, and drug effects. Improvement and maintenance of physical and emotional function is the goal. Pharmacotherapy should be initiated conservatively and titrated to effective doses with minimal adverse effects. Milder pain should be treated with non-opioid analgesics with a progression toward opioids and/or adjuvant medications as the pain intensifies. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvant medications represent most of the analgesic agents used in pain management. Knowing the underlying mechanism of pain will help guide pharmacologic therapy. The patient should be monitored initially, with every dose change, and periodically to assess efficacy and severity of adverse effects.

Effect of Age on Response to Experimental Pain in Normal Indian Males

BACKGROUND AND OBJECTIVES

Response to experimental pain depends on the nature of the pain stimulus, as well as on gender, racial, cultural and socioeconomic factors. This study investigates the effect of age on pain sensitivity and cardiovascular reactivity produced by experimental pain. We have also compared the values of body mass index (BMI) and resting blood pressure of volunteers with the normal values.

MATERIALS AND METHODS

The study was conducted on 83 Indian males of different age groups. The volunteers were divided into 4 groups: Children, Young Adults, Middle-Aged Adults and Old Adults; and their basal parameters (BMI, resting pulse and blood pressure) were recorded. Selected volunteers were subjected to cold pressor task (CPT). Pain sensitivity (PS) (pain threshold, tolerance and pain rating on a visual analog scale) and cardiovascular reactivity (CVR) (increase in pulse and blood pressure) were recorded.

RESULTS

Many volunteers had abnormal values of BMI and resting blood pressure and had to be excluded from the study. PS and CVR between different groups were compared by one-way ANOVA. Significant differences in PS were observed, with highest pain sensitivity in Children and lowest in Old Adults. No significant differences were observed in the CVR.

CONCLUSION

The high numbers of volunteers with abnormal basal parameters (BMI and resting blood pressure) show an urgent need to educate the general public about the dangers and risk factors of obesity and hypertension. Less exposure of children to painful encounters may be responsible for their high pain sensitivity while higher values of resting blood pressure and decreased sensitivity of the sensory systems with advancing age may be responsible for the hypoalgesia observed in old adults.

Impact of Age on Pain Perception for Typical Painful Diagnoses in the Emergency Department

BACKGROUND

Age-related differences in pain perception have been demonstrated in experimental settings but have been investigated scarcely and without valid scale in the clinical framework.

OBJECTIVES

To examine the effect of age on pain perception for recognized painful diagnoses encountered in the emergency department (ED).

METHODS

A post-hoc analysis of real-time archived data was performed in a tertiary urban and a secondary regional ED. We included all consecutive adult patients (≥18 years) with the following diagnosis at discharge: renal colic, pancreatitis, appendicitis, headache/migraine, dislocation and extremities fractures, and a pain evaluation of ≥1 (0-10, verbal numerical scale) at triage. The primary outcome was to compare for each of these diagnoses the level of pain intensity between four age groups (18-44; 45-64; 65-74; 75+ years).

RESULTS

A total of 15,670 patients (48% women) were triaged with a mean pain intensity of 7.7 (SD=2.0). Women exhibited greater pain scores than men for pancreatitis, headache/migraine, and extremity fracture. Renal colic, pancreatitis, appendicitis, and headache/migraine showed a linear decrease in pain scores with age whereas dislocation and extremity fractures did not present age differences. Mean differences in pain intensity scores between young adults (18-44 years) and patients aged ≥75 years were 0.79 (95% confidence interval [95% CI] 0.5-1.1) for renal colic, 1.1 (95% CI 0.7-1.4) for pancreatitis, 0.70 (95% CI 0.2-1.2) for appendicitis, and 0.86 (95% CI 0.6-1.1) for headache/migraine.

CONCLUSION

Older patients perceive similar pain for dislocation and extremity fractures and less for visceral and headache/migraine pain; however, these age differences may not be clinically important.

Association between Multiple IV attempts and Perceived Pain levels in the Emergency Department

Purpose

Intravenous (IV) access is the most commonly performed procedure in the emergency department (ED). Patients with difficult venous access require multiple needlesticks (MNS) for successful IV cannulation and may experience increased pain with many attempts.

Objective

To determine the association between number of IV attempts and overall pain experienced by the patient from IV placement.

Methods

Cross-sectional observational study on consecutive patients undergoing IV placement with a 20-gauge IV in the upper extremity in an urban academic hospital. Exclusion criteria included refusal to participate or fully complete all survey questions. The total number of IV attempts and patient pain scores marked on a standardized visual analog scale was recorded. Mean pain scores of two groups, single needlestick (SNS) and MNS, were compared using Student's t-test.

Results

A total of 760 patients were approached, of whom 31 were excluded, leaving 729 patients in the analysis; 556 with SNS (76%) and 173 with MNS (24%). The mean pain score (95% CI) was 51 mm (46–55 mm) for the MNS group and 25 mm (23–28 mm) for the SNS group, p<0.001. Compared to patients who underwent one IV attempt, patients with two and three attempts had an average 19 mm and 33 mm increase in pain scores, respectively, with the highest average pain associated with five attempts. A total of 58% of MNS patients rated IV placement as the most painful experience while in the ED.

Conclusions

Patients experience increased pain in association with multiple IV attempts.

The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients

OBJECTIVE

This study sought to determine the effects of lavender aromatherapy on pain following needle insertion into a fistula in patients undergoing hemodialysis.

METHOD

This is a randomized controlled clinical trial in which 92 patients undergoing hemodialysis with arteriovenous fistulas were randomly divided into two groups. The experimental-group patients inhaled lavender essence with a concentration of 10% for 5 min during 3 hemodialysis sessions, while the control-group patients received aromatherapy free of lavender essence.

RESULTS

The mean VAS pain intensity score in the experimental and control groups before the intervention was 3.78 ± 0.24 and 4.16 ± 0.32, respectively (p = 0.35). The mean VAS pain intensity score in the experimental and control groups after three aromatherapy sessions was 2.36 ± 0.25 and 3.43 ± 0.31, respectively (p = 0.009).

CONCLUSION

Lavender aromatherapy may be an effective technique to reduce pain following needle insertion into a fistula in hemodialysis patients.

The diagnostic value of the numeric pain rating scale in older postoperative patients

AIMS AND OBJECTIVES

To measure the diagnostic value of the Numeric Rating Scale by comparing it to a Verbal Rating Scale in older patients.

BACKGROUND

Pain management in older patients is an important challenge because of their greater susceptibility to adverse effects of analgesics. Nurses play an important role in applying guidelines for postoperative pain treatment. However, effective pain management is dependent upon valid and reliable pain assessment.

DESIGN

Cross-sectional study.

METHODS

In total, 2674 older patients scored their postoperative pain on an 11-point numeric rating scale (NRS) and an adjective scale (VRS) including no pain, little pain, painful but bearable, considerable pain and terrible pain. The diagnostic value of different NRS cut-off values for administering analgesics is determined by an ROC curve.

RESULTS

Sensitivity of NRS > 3 for 'unbearable' pain in older patients was 72% with a specificity of 97·2%. With a cut-off point NRS > 4, sensitivity increased to 83%, while specificity was 96·7%. With a cut-off point NRS > 5, sensitivity was 94%, while specificity was 85%. A high proportion (75%) of older old patients (≥ 75 years) with 'painful but bearable' considers NRS 4, 5 and 6 to this VRS category.

CONCLUSION

Using an NRS cut-off point > 3 or > 4, a large group of older patients with 'bearable' pain would incorrectly classified as 'unbearable'. When we make the assumption that bearable pain means no wish for additional analgesics, this misclassification might result in overtreatment with analgesics, while 3% would be undertreated. With NRS cut-off point > 5, 6% have a risk of overtreatment and 15% of undertreatment.

RELEVANCE TO CLINICAL PRACTICE

Nurses should not rely solely on the NRS score in determining pain treatment; they need to communicate with older patients about their pain, the need for analgesics and eventual misconceptions about analgesics.

Time of admission, gender and age: challenging factors in emergency renal colic - a preliminary study

BACKGROUND

Nephrolithiasis is a relatively common problem and a frequent Emergency Department (ED) diagnosis in patients who present with acute flank/abdominal pain. The pain management in these patients is often challenging.

OBJECTIVES

To investigate the most effective dose of morphine with the least side effects in emergency renal colic patients.

MATERIALS AND METHODS

150 renal colic patients who experienced a pain level of 4 or greater, based on visual analog scale (VAS) at admission time were included. Pain was scored on a 100 mm VAS (0 = no pain, 100 = the worst pain imagined). When patients arrived at ED, a physician would examine the patients and assessed initial pain score, then filled a questionnaire according to the patient information. Patients were assigned to receive 2.5 mg morphine sulfate intravenously. We monitored patients' visual analog scale (VAS), and adverse events at different time points (every 15 minutes) for 90 minutes. Additional doses of intravenous morphine (2.5 mg) were administered if the patient still had pain. (Max dose: 10 mg). The cumulative dose of morphine, defined as the total amount of morphine prescribed to each patient during the 90 minutes of the study, was recorded. Patients were not permitted to use any nonsteroidal anti-inflammatory drugs as coadjuvant analgesics during the study period. Subjects with inadequate pain relief at 90 minutes received rescue morphine and were excluded from the study. The primary end point in this study was pain relief at 90 minutes, defined as either VAS<40 or decrease of 50% or more as compared to the initial VAS. The secondary objective was to detect the occurrence of adverse effects at any time points in ED.

RESULTS

The studied patients consisted of 104 men and 46 women with the mean age of 43 ±14 years (range, 18 to 75 years). There was no statistically significant difference between the mean age and gender differences in pain response. Rescue analgesia at 30 minutes were given in 54.5% receiving morphine. The average time to painless was 35 minutes. But there were no statistically significant differences between the mean age and gender differences in pain response (P > 0.05). Older patients responded sooner to morphine than the young. Most of the patients had a pain score of 90 -100 (77.3 %) at the beginning that was reduced to 29.4% during the 30 minutes follow up. During the first hour, we found that 94.7% of the patients had no pain or significant pain reduction and only 2.1% of the patients still had pain.

CONCLUSIONS

We conclude that there were no significant differences among the gender, time of admission and side - effects in renal colic patients in response to morphine.

Considering the patient's perspective in the injury severity score

BACKGROUND

The injury severity score (ISS) assesses anatomical threat to life, but does not correlate with severity perceived by the patient. The purpose of this study was to assess how and why patients assign perceived injury severity.

METHODS

One hundred twenty consecutive patients were asked "Would you say your injury is mild, moderate, severe or very severe?" and "Why do you rate your injury that way?" Explanations were categorized and compared by age, perceived injury severity, and injury mechanism. Categories were pain, injury assessment, injury description, and others. The age groups used were <55 and ≥ 55 y old. The data were analyzed with Wilcoxon rank sum, Spearman's correlation coefficient, and Mantel-Haenszel tests.

RESULTS

The ISS was not significantly correlated with perceived injury severity scores (r(2) = 0.177, P = 0.0535, Spearman's correlation), and most patients reported a higher injury severity. Patients with penetrating injuries significantly overestimated their injury severity (P = 0.014, Wilcoxon rank sum). Patients with mild and moderate injuries gave more assessment explanations, whereas patients with severe or very severe injuries gave more description explanations (P = 0.0220, Mantel-Haenszel).

CONCLUSIONS

Patients based perceived severity on their injuries, but it did not correlate with ISS, likely because ISS considers injuries graded events, while the patient considers them all or none events. Assessment responses suggested relief, whereas description responses indicated more distress. It is important to ask patients about their injury severity to help them better cope with their experience, which will likely improve quality of life outcomes.

The perioperative management of pain from intracranial surgery

Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the "balanced" general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. This reluctance to use opioids following intracranial surgery is enabled by decades of training and anecdote emphasizing that pain is minimal following these procedures. However, recent data suggests otherwise, and raises the question of how to provide safe and effective analgesia for these patients. Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients.

Factors Influencing Neck Pain Intensity in Whiplash-associated Disorders in Sweden

OBJECTIVES

To investigate if sociodemographic and economic factors, preinjury health status, and collision factors are associated with initial neck pain intensity in whiplash-associated disorders (WAD) in Sweden. The factors of interest were demographic and socioeconomic factors, prior health, and collision factors.

METHODS

A cohort study of car occupants, insured by either of 2 Swedish traffic insurers, age 18 to 74 years, who filed an injury claim and reported WAD after a motor vehicle collision (n=1187) were approached with mailed questionnaires. These contained questions about prior health, details about the collision, and symptoms after the collision. Neck pain intensity was measured on a visual analog scale and categorized into mild pain (0 to 30 mm), moderate pain (31 to 54 mm), and severe pain (55 to 100 mm).

RESULTS

Low educational level [odds ratio (OR) 2.8; 95% confidence interval (CI) 1.8-4.5], being sole adult in the family (OR 1.6; 95%CI 1.1-2.2), prior neck pain (OR 2.9; 95%CI 1.4-6.2), prior headache (OR 2.2; 95%CI 0.7-6.9), prior poor general health (OR 2.6; 95%CI 1.4-4.8), and exposure to rollover collision (OR 1.9; 95%CI 1.0-3.8) were all associated with severe initial neck pain intensity. Most of these factors were also associated with moderate pain intensity.

DISCUSSION

This study confirms results from a previous study that sociodemographic and economic status, preinjury health status, and collision-related factors are associated with participants' rating of initial neck pain intensity in WAD. The findings are of importance for interpreting and understanding the underlying factors of pain rating.

Pain among the oldest old in community and institutional settings

The relationship between pain and increasing age was investigated using data from two different care settings collected on a province-wide basis in Ontario. Home care clients (HC) and complex continuing care patients (CCC) are assessed using the Resident Assessment Instrument-Home Care and Resident Assessment Instrument 2.0 instruments, respectively, as part of normal clinical practice. For this study, the sample was restricted to those aged 65 years and older and totaled 193,158 individuals. Centenarians (those 100 years of age or older) made up 0.41% (n=788) of the sample. Pain was assessed according to a previously validated pain scale embedded in both assessments that uses items on frequency and intensity. Based on 5-year age groups beginning at 65, the mean reported pain score was lower with each increment in age for men and women. Multiple logistic regression models were constructed and the odds ratios for pain in both HC and CCC groups decreased consistently in higher age groups after adjusting for disease diagnoses, cognition, functional status and health indicators. A model that included categories of analgesic medications coded based on the WHO pain ladder showed the relationship persisted after controlling for analgesia. In clinical settings, the oldest old appear to have lower levels of pain compared with the young old after adjusting for a variety of potential confounding variables.

Pain perception among Emergency Department patients with headache: Responses to standardized painful stimuli

Perception of pain varies significantly across groups of patients. The primary objective of this study was to measure perceived pain among Emergency Department (ED) patients with headache in response to standardized painful stimuli, including blood pressure (BP) cuff inflation and intravenous catheterization (IVC). In this prospective, case-control series, ED patients undergoing IVC and with a headache were compared to those undergoing IVC but without a headache. Medical care of participants was not altered. Data were collected by trained research assistants, including demographic and historical characteristics, and perceived pain scores. Using a 10-point verbal numeric rating scale (0 = no pain ... 10 = worst imaginable pain), participants rated their perceived pain of BP measurement and IVC. Ninety-five percent confidence intervals (CI) constructed around means and proportions were used to assess group differences. One hundred participants had headache; 100 participants with no headache served as controls. There were no differences between groups with regard to gender, ethnicity, or insurance status. Intravenous catheterization was successful in all 200 participants, with a median intravenous catheter gauge of 20 (range 18-24). There were no differences between groups in difficulty of insertion of intravenous catheter or number of intravenous catheterization attempts. Participants with headache reported significantly higher pain scores from BP cuff inflation (mean score 2.9) compared to participants without headache (mean 1.4; mean difference between groups 1.5, 95% CI 0.7-2.3). Participants with headache reported slightly higher pain scores from IVC (mean 4.6) compared to participants without headache (mean 3.9; mean difference between groups 0.7, 95% CI -0.2-1.6), but this difference was not significant. Among participants with headache, there were no statistically significant differences between single headache, acute headache (<10/past 30 days), and chronic headache (>or=10/past 30 days) for reported pain scores of BP cuff inflation or IVC. ED participants with headache reported significantly higher pain scores secondary to BP cuff inflation when compared to control participants without headache.

Effects of aging on contact heat-evoked potentials: The physiological assessment of thermal perception

Age significantly influences the detection thresholds to noxious heat; such thresholds depend on responses in the cerebral cortex to thermal stimuli and the psychophysical perception of such responses. To understand the influence of age on cerebral responses, we used contact heat-evoked potentials (CHEPs) to investigate the physiology of cerebral responses to thermal stimuli in 70 healthy subjects (33 men and 37 women, 39.56 +/- 12.12 years of age). With heat stimulation of fixed intensity (51 degrees C) on the distal forearm and distal leg, CHEPs revealed consistent waveforms with an initial negative peak (N1 latency: 398.63 +/- 28.55 and 449.03 +/- 32.21 ms for upper and lower limbs) and a later positive peak (P1 latency: 541.63 +/- 37.92 and 595.41 +/- 39.24 ms for upper and lower limbs) with N1-P1 interpeak amplitude of 42.30 +/- 12.57 microV in the upper limb and 39.67 +/- 12.03 microV in the lower limb. On analyses with models of multiple linear regression, N1-P1 amplitudes were negatively correlated with age and N1 latencies were correlated with gender, with females having shorter latencies. The verbal rating scale (VRS) for pain perception was higher in females than males, and decreased with aging. In addition, VRS paralleled changes in N1-P1 amplitude and N1 latency; the higher the VRS, the shorter the N1 latency and the higher the N1-P1 amplitude. These results provide evidence that CHEPs are influenced significantly by aging, corresponding to aging-related changes in thermal pain perception.

The verbal numeric pain scale: effects of patient education on self-reports of pain

BACKGROUND

Emergency department (ED) patients are frequently asked to provide a self-report of the level of pain experienced using a verbal numeric rating scale.

OBJECTIVES

To determine the effects of patient education regarding the verbal numeric rating scale on self-reports of pain among ED patients.

METHODS

In this prospective, interventional study, 310 eligible ED patients with pain, aged 18 years and older, were randomized to view either a novel educational video (n = 155) or a novel print brochure (n = 155) as an educational intervention, both developed to deliver educational information about the verbal numeric pain scale and its use. Participants initially rated their pain on a scale from 0 to 10 and then were administered the educational intervention. Following the educational intervention, participants completed a survey that included demographic information, postinterventional pain score, prior pain experience, and subjective rating of the helpfulness of the educational intervention. Fifty-five consecutive participants were enrolled as controls and received no educational intervention but gave a self-reported triage pain score and a second pain score at an equivalent time interval. Clinical significance was defined as a decrease in pain of 2 or more points following the education.

RESULTS

Following the educational interventions, there were statistically significant, although not clinically significant, decreases in mean pain scores within each intervention group (video: mean change, 1 point [95% confidence interval [CI] = 0.7 to 1.2]; printed brochure: mean change, 0.6 points [95% CI = 0.4 to 0.8]). For participants in the control group (no intervention), there was no significant change (mean change, 0.2 points [95% CI = -0.2 to 0.5]). A clinically significant decrease in pain was seen in 28% of the video group, 23% of the brochure group, and 5% of controls. Most patients had no change (71% of the video group, 73% of the brochure group, and 89% of controls). Participants rated the helpfulness of the video educational intervention as 7.1 (95% CI = 6.7 to 7.5) and the print educational intervention as 6.7 (95% CI = 6.2 to 7.1) on a scale from 0 (least effective) to 10 (most helpful).

CONCLUSIONS

Among ED participants with pain, both educational interventions (video and printed brochure) resulted in statistically and clinically significant decreased self-reported pain scores by 2 or more points in 26% of participants compared with 5% of controls. The educational interventions were rated as helpful by participants, with no appreciable difference between the two intervention groups.

Prescribing to older ED patients

The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.

Factors influencing neck pain intensity in whiplash-associated disorders

STUDY DESIGN

Cohort study of subjects with whiplash-associated disorders (WAD).

OBJECTIVE

To assess the association between preinjury factors and neck pain intensity within 30 days after a motor vehicle collision.

SUMMARY OF BACKGROUND DATA

Neck pain is the main symptom in WAD. There are studies of nonspecific musculoskeletal pain suggesting that pain intensity can be modified by psychologic, personal, or social factors, but, to our knowledge, no studies have investigated the association between such factors and neck pain intensity in WAD.

METHODS

The subjects (n = 5970) either filed a claim or were treated for neck pain within 30 days after a collision. Neck pain intensity was measured on the visual analog scale.

RESULTS

Fair or poor health before the collision was associated with severe neck pain in females (odds ratio 4.0, 95% confidence interval 1.8-8.9). Other associated factors in females included low education and prior neck pain. Low family income was associated with severe neck pain in males (odds ratio 2.3, 95% confidence interval 1.5-3.4), as was prior headache and being unaware of the head position at the time of collision.

CONCLUSION

The results suggest that neck pain intensity in WAD seems to be influenced by several factors other than characteristics related to the injury event itself.

Analysis of factors affecting pain in intravenous catheter placement: a survey of 925 patients

The aim of the study was to determine some factors affecting pain during intravenous (i.v.) catheter placement in an emergency department (ED). A cross-sectional, observational study was conducted at an academic ED. Nine hundred and twenty five adult patients who had a 20 gauge i.v. catheter placed were enrolled the study. Patients were excluded for the following conditions: more than one i.v. attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the i.v. site. The magnitude of pain of i.v. catheter placement was not related to age, sex, experience of the individual placing the i.v. catheter, site of i.v. catheter insertion and use of analgesic or antidepressive drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressive patients (p = 0.001). Depressive patients reported higher severity of pain during i.v. catheter placement than nondepressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Factors affecting pain in intravenous catheter placement: role of depression illness

The aim of the study was to examine factors affecting pain during intravenous (IV) catheter placement in an emergency department. A cross-sectional, observational study was conducted at an academic emergency department. Nine hundred and twenty-five adult patients who had a 20-gauge IV catheter placed were enrolled in the study. Patients were excluded for the following conditions: more than one IV attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the IV site. The magnitude of pain in IV catheter placement was not related to age, sex, experience of the individual placing the IV catheter, site of IV catheter insertion and use of analgesic or antidepressant drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressed patients (p = 0.001). Depressed patients reported higher severity of pain during IV catheter placement than non-depressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Patient expectations for pain relief in the ED

The objective of the study was to assess patient expectations for pain relief in the ED. A convenience sample of 522 patients with pain and 144 patients without pain were enrolled in a prospective observational study at a university ED. Patients reported a mean expectation for pain relief of 72 % (95% CI 70-74). Eighteen percent expected complete (100%) pain relief in the ED. Patient expectations for pain relief were poorly correlated (r = 0.150) with initial pain intensity. Patients without pain reported a mean expectation for pain relief of 74% (95% CI 71-77) if they had presented with pain. There were no differences in patient expectations for pain relief based on age or gender. Patients expect a large percentage of their pain to be relieved in the ED, and many expect complete analgesia. Patient expectations for pain relief do not vary based on age, gender or pain intensity.

Ongoing visual analog score display improves Emergency Department pain care

The study purpose was to test two methods of pain assessment and display: ongoing (11 times over 2 h) visual analog scale (VAS) determination with data tabulation in the ED chart (Tabulation group), and similar VAS assessments with display of the information at the head of the ED bed (Graph group). A Control group had initial and 2-h VAS ascertainments charted (not graphed). Tertiary-care university-affiliated ED patients were randomized into the three groups and pain care outcomes assessed. Compared to Controls, those in the Graph group had the following findings (p < 0.05): 1) treating physicians more likely aware of initial and final VAS scores, 2) earlier analgesia, 3) likelier perception (by patients and physicians) that VAS was useful and likelier patient perception that pain care was adequate. Tabulation group results were intermediate to those of Control and Graph patients. The data support further investigation of VAS display as a means of improving ED pain assessment.

[Treatment of postoperative pain in elderly oncology patients with intravenous administration of a 50% glucose solution]

Postoperative pain is the most important factor od so called "tumor-promotive effect of surgery" i.e. of endocrine-metabolic changes having the consequence drop in immune, antiinfective and antitumor defense. Due to presence of organic involutive changes, old people (= 65 years), often have serious side effects during application of usual analgetics. Since hypertonic glucose (33%) given i.v. or per os, works analgesically in small children there is assumption that it can be used in treatment of postoperative pain in old oncology patients. We tested the hypothesis that postoperative pain in old oncology patients can be treated with i.v. application of 50% of glucose solution. 37 oncology patients over 65 years, 26 females and 11 males, operated for breast cancer and soft tissue cancer, were investigated. Average age of the patients was 72 +/- 4 years. 50% Glucose solution was given in two boluses of 20 ml each: the first bolus was given to all patients at the end of anesthesia, and the other bolus was given individually after appearance of post-operative pain. Pain intensity (in coefficients of the visual analogue scale VAK = 1-100) and its characteristics were tested by oral testing of operated patients; after weakening from anesthesia, after the first appearance of the pain and 15 minutes after giving of the second glucose bolus. None patient had pain weakening from anesthesia. All tested patients experienced pain during the first 70 minutes and it could be categorized as very strong pain (= 82 VAK). The pain was decreased with another glucose bolus by approximately (= 56% VAK) so it was classifies in category of bearable pains (= 36 VAK). In 9 patients (24.3%) the pain had neuropathic component (filing of "burning") which could not be eliminated by hypertonic glucose, but only with application of tramadol. Activation of the central cholinergic transmission is the most significant mechanism of analgesic glucose effect, but, probably there is another one: facilitation of entrance of formerly given analgesics in the brain cells. As energetic substrate, entering all organism cells, glucose could make easier intracell breakthrough of any other analgesic drug, of the peripheral or central action, and final antipain effect could be potential or additional one. It was concluded that 40 ml of 50% glucose solution given in two identical boluses, has good analgesic effect in treatment of postoperative pain in old oncology patient: the pain was not completely eliminated, but it was significantly decreased and became tolerable. Hypertonic glucose neither eliminates, nor decreases neuropathic component of the pain, so, when the pain appears the therapy should be supplemented with other drugs, which may completely eliminate all pain components.

Opioids prolong nuclear hepatobiliary imaging when given prior to scanning

Opioid-mediated contraction of the distal common bile duct (CBD) may delay tracer passage during nuclear hepatobiliary imaging (NHI), mimicking pathologic obstruction. We sought to determine if opioid administration before NHI delays CBD visualization and prolongs imaging. The records of 198 Emergency Department patients who underwent NHI were reviewed (after excluding those with evidence for pathologic CBD obstruction). Opioids were administered before NHI in 56 cases. Delayed CBD visualization occurred in 28.6% of subjects who had received opioids and in 12.0% of those who had not (p < 0.01). Delayed imaging was performed in 77.8% of those who had received opioids and in 53.5% of those who had not (p < 0.01). The relative risk of delayed CBD visualization was 1.46 [95%CI 0.65-3.28] for meperidine, 4.18 [95%CI 2.00-8.82] for morphine, and 2.38 [95%CI 1.29-4.39] for any opioid. We conclude that opioids given before NHI are associated with delayed CBD visualization and more imaging sessions.