The challenge of triaging chest pain patients: the bernese university hospital experience

Accurate diagnosis of the causes of chest pain and dyspnea remain challenging. In this preliminary observational study with a 5-year follow-up, we attempted to find a simplified approach to selecting patients with chest pain needing immediate care based on the initial evaluation in ED. During a 24-month period were randomly selected 301 patients and a conditional inference tree (CIT) was used as the basis of the prognostic rule. Common diagnoses were musculoskeletal chest pain (27%), ACS (19%) and panic attack (12%). Using variables of ACS symptoms we estimated the likelihood of ACS based on a CIT to be high at 91% (32), low at 4% (198) and intermediate at 20.5-40% in (71) patients. Coronary catheterization was performed within 24 hours in 91% of the patients with ACS. A culprit lesion was found in 79%. Follow-up (median 4.2 years) information was available for 70% of the patients. Of the 164 patients without ACS who were followed up, 5 were treated with revascularization for stable angina pectoris, 2 were treated with revascularization for myocardial infarction, and 25 died. Although a simple triage decision tree could theoretically help to efficient select patients needing immediate care we need also to be vigilant for those presenting with atypical symptoms.

[Pain disorders in traumatized individuals - neurophysiology and clinical presentation]

This overview portrays the salient physiological mechanisms being involved in the clinical manifestation of chronic pain in traumatized patients. A «hypermnesia-hyperarousal-model» is purported to support the neurophysiologic plausibility of the trauma-pain-relationship. We discuss seven characteristic clinical pain entities which alone or in combination can be found in patients with a previous psychological trauma.

[Assessment of musculoskeletal pain]

The rationale for a successful treatment of musculoskeletal pain is an adequate initial assessment. Standardized questionnaires, modern imaging modalities such as computed tomography, magnetic resonance imaging and musculoskeletal ultrasound or electrophysiology have enriched our armamentarium in the last decades. Pain inducing pathologies can often be identified and treated in a targeted way due to these procedures. But none of these techniques allows an adequate judgment of the acquired findings. Supplementary tests have to be indicated and interpreted in the context of the patient's entire history and the clinical findings. These two remain to be the cornerstones of the assessment of painful musculoskeletal disorders.

[Adhesions and abdominal pain]

Adhesions occur with a high incidence after intra-abdominal surgery but can also develop due to infections, radiation or for idiopathic reasons. The formation of adhesions is initiated by tissue damage and is the result of peritoneal tissue repair involving the activation of the inflammatory system and the coagulation cascade. Acute small bowel obstruction is one of the most common complications and should be diagnosed rapidly using clinical examination and radiological imaging. A complete obstruction is life threatening and in a high percentage of patients requires rapid surgical intervention by laparotomy or laparoscopy depending on the clinical situation and the patients history. Despite numerous investigations, there is no reliable, commonly used method to prevent intra-abdominal adhesions. Minimizing tissue damage and foreign body exposure, avoiding spillage of intestinal and biliary contents as well as a laparoscopic approach seem to have a beneficial effect on the formation of intra-abdominal adhesions.

[Chronic pain - new therapeutic strategies]

Patient suffering from chronic pain need treatment in a multimodal setting. Enriched environment might be a new therapeutical approach.

Postoperative pain management after ambulatory surgery. A survey of anaesthesiologists

Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting.

Structural and procedural properties important in promoting bio-enterprises as alternative livelihoods to pastoral and agro-pastoral livelihoods

Alternative livelihoods to pastoral and agro-pastoral livelihoods are increasingly gaining attention in rural development but few empirical evidence exist on how to go about supporting such initiatives. As pastoral and agro-pastoral production conditions change due to various factors including market conditions, climate variability and change, pastoralists and agro-pastoralists are increasingly faced with the challenge of finding alternative livelihoods. Bio-enterprises offer such alternatives or complementary activities for rural actors to adapt to changing socio-ecological conditions. This study examines the roles of bio-enterprise initiatives from a livelihood perspective and identifies the features important for such initiatives to reduce poverty and improve the adaptive capacities of pastoralists and agro-pastoralists. It draws on four different bio-enterprise initiatives on agro-pastoral and pastoral livelihoods and on improved natural resources management (NRM) in the drylands of Kenya. Data were collected through interviews, focus group discussions, informal discussions and the study of reports. Results shows among other factors that diversification into enterprises requires cooperation among the stakeholders with their varying experiences in development, NRM and business development. Other factors such as sustained financial support, capacity development to survive the market introduction phase, as well as quantity and quality of the product, are critical. Mentoring proved to be a driver of success in some initiatives.

Schmerzmanagement bei Kindern in der Schweiz

Hintergrund Schmerzen bei stationär aufgenommenen Kindern werden häufig unzureichend behandelt. Bisher gab es keine Informationen zum Schmerzmanagement von Kinderkrankenhäusern in der Schweiz. Ziel der vorliegenden Studie war, den aktuellen Stand der Schmerzerfassung, -interpretation und -behandlung zu bestimmen. Studiendesign Ein Fragebogen wurde an alle pädiatrischen Krankenhäuser in der Schweiz gesendet. Ergebnisse Insgesamt antworteten 27 von 45 Einheiten (Antwortrate: 60%). Die meisten Abteilungen verwenden Schmerzerfassungstools (96%) und führten diesbezügliche Leitlinien ein (78%). Die Behandlung von Schmerzen erfolgt ebenfalls meist nach hausinterner Leitlinie (78%). Prozedurale und postoperative Schmerzen werden stets (100%) analgetisch behandelt. Bei Frühgeborenen und Kindern auf Intensivpflegestationen werden bei invasiven Eingriffen häufig Analgetika (> 87%) verwendet. Auf Intensivstationen liegen in 44% diesbezügliche Leitlinien vor. Resümee Der Nutzen eines effektiven Schmerzmanagements bei Kindern ist eindeutig belegt. Viele Ansätze zur Verbesserung werden in der Schweiz gut umgesetzt. Vor allem im internationalen Vergleich verbesserte sich das Schmerzmanagement. Es gibt aber noch Optimierungsmöglichkeiten. Beispielsweise besitzen weniger als die Hälfte aller schweizerischen Intensivstationen eine Leitlinie für die Behandlung von Schmerzen bei invasiven Eingriffen.

Pain and swelling after periapical surgery related to the hemostatic agent used: anesthetic solution with vasoconstrictor or aluminum chloride

To assess pain and swelling in the first 7 days after periapical surgery and their relationship with the agent used for bleeding control.