Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest #pain who can safely be removed from cardiac #monitoring

http://m.cmaj.ca/content/189/4/E139?ijkey=89cdc54f7aa0b4dd071990b90ae8e040971eb780&keytype2=tf_ipsecsha

We successfully validated the decision rule for safe removal of a large subset of patients with chest pain from cardiac monitoring after initial evaluation in the emergency department. Implementation of this simple yet highly sensitive rule will allow for improved use of health care resources.

#Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back #Pain

http://www.annemergmed.com/article/S0196-0644(16)31214-8/abstract

Among ED patients with acute, nontraumatic, nonradicular low back pain, naproxen+diazepam did not improve functional outcomes or pain compared with naproxen+placebo 1 week and 3 months after ED discharge.

#Prognosis of undiagnosed #chest #pain: linked electronic health record cohort study
http://www.bmj.com/content/357/bmj.j1194

Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. Efforts to better assess and reduce the cardiovascular risk of such patients are warranted.

Effect of Using the #HEART Score in Patients With Chest #Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial
http://annals.org/aim/article/2622872/effect-using-heart-score-patients-chest-pain-emergency-department-stepped

The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.

Conclusion:
Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.

#Pain Sensitization is Associated with Disease #Activity in #Rheumatoid Arthritis Patients: A Cross-Sectional Study
http://onlinelibrary.wiley.com/doi/10.1002/acr.23266/abstract

Pain sensitization may contribute to pain severity in rheumatoid arthritis (RA), impacting assessment of disease activity. We examined whether pain processing mechanisms were associated with disease activity among RA patients with active disease.

Conclusion. High pain sensitization is associated with elevations in disease activity measures. Longitudinal studies are underway to elucidate the cause-effect relationships between pain sensitization and inflammatory disease activity in RA.

The role of #touch in regulating inter-partner physiological coupling during empathy for #pain
https://www.nature.com/articles/s41598-017-03627-7

The human ability to synchronize with other individuals is critical for the development of social behavior. Recent research has shown that physiological inter-personal synchronization may underlie behavioral synchrony. The results indicate that the partner touch increased interpersonal respiration coupling under both pain and no-pain conditions and increased heart rate coupling under pain conditions. In addition, physiological coupling was diminished by pain in the absence of the partner’s touch.

Critically, we found that high partner’s empathy and high levels of analgesia enhanced coupling during the partner’s touch.

Collectively, the evidence indicates that social touch increases interpersonal physiological coupling during pain. Furthermore, the effects of touch on cardio-respiratory inter-partner coupling may contribute to the analgesic effects of touch via the autonomic nervous system.

Musculoskeletal #pain associated with recreational #yoga participation: A prospective cohort study with 1-year follow-up
http://www.sciencedirect.com/science/article/pii/S1360859217301225

Yoga is a popular complementary therapy for musculoskeletal pain. There are few studies however, that have examined the risks of recreational participation for causing musculoskeletal pain.

Results

The final sample included 354 participants from two suburban yoga studios. The incidence rate of pain caused by yoga was 10.7%. More than one-third of incident cases resulted in lost yoga participation time and/or symptoms lasting more than 3 months. None of the risk factors at baseline increased the risk for subsequent incident cases of pain caused by yoga.

Conclusions
Yoga can cause musculoskeletal pain. Participants may benefit from disclosure of practice to their healthcare professionals and by informing teachers of injuries they may have prior to participation. Yoga teachers should also discuss the risks for injury with their students.

The effects of #Cannabis Among Adults With Chronic #Pain and an Overview of General Harms: A Systematic Review

http://annals.org/aim/article/2648595/effects-cannabis-among-adults-chronic-pain-overview-general-harms-systematic

Cannabis is increasingly available for the treatment of chronic pain, yet its efficacy remains uncertain From 27 chronic pain trials, there is low-strength evidence that cannabis alleviates neuropathic pain but insufficient evidence in other pain populations. According to 11 systematic reviews and 32 primary studies, harms in general population studies include increased risk for motor vehicle accidents, psychotic symptoms, and short-term cognitive impairment. Although adverse pulmonary effects were not seen in younger populations, evidence on most other long-term physical harms, in heavy or long-term cannabis users, or in older populations is insufficient

Limited evidence suggests that cannabis may alleviate neuropathic pain in some patients, but insufficient evidence exists for other types of chronic pain. Among general populations, limited evidence suggests that cannabis is associated with an increased risk for adverse mental health effects

Stable High-Sensitivity Cardiac #Troponin T Levels and Outcomes in Patients With Chest #Pain
http://www.onlinejacc.org/content/70/18/2226

.. Cox regression was used to estimate risks for all-cause, cardiovascular, and noncardiovascular mortality, MI, and heart failure at different levels of troponins A total of 19,460 patients with a mean age of 54 ± 17 years were included. During a mean follow-up of 3.3 ± 1.2 years, 1,349 (6.9%) patients died. Adjusted hazard ratios (with 95% confidence intervals) for all-cause mortality were 2.00 (1.66 to 2.42), 2.92 (2.38 to 3.59), 4.07 (3.28 to 5.05), 6.77 (5.22 to 8.78), and 9.68 (7.18 to 13.00) in patients with hs-cTnT levels of 5 to 9, 10 to 14, 15 to 29, 30 to 49, and ≥50 ng/l, respectively, compared with patients with hs-cTnT levels <5 ng/l. There was a strong and graded association between all detectable levels of hs-cTnT and risk for MI, heart failure, and cardiovascular and noncardiovascular mortality.

Conclusions

Among patients with chest pain and stable troponin levels, any detectable level of hs-cTnT is associated with an increased risk of death and cardiovascular outcomes and should merit further attention

Effect of a Single Dose of Oral #Opioid and #Nonopioid Analgesics on Acute Extremity #Pain in the Emergency Department
A Randomized Clinical Trial
https://jamanetwork.com/journals/jama/article-abstract/2661581

The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative Of 416 patients randomized, 411 were analyzed (mean SD age, 37 12 years; 199 48% women; 247 60% Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053). The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, −0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3. Adverse events were not assessed.

Conclusions and Relevance For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics. Further research to assess adverse events and other dosing may be warranted

Noninvasive Cardiac Testing vs Clinical Evaluation Alone in Acute #Chest #Pain
A Secondary Analysis of the ROMICAT-II Randomized Clinical Trial
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2663304

The incremental benefit of noninvasive testing in addition to clinical evaluation (history, physical examination, an electrocardiogram ECG, and biomarker assessment) vs clinical evaluation alone for patients who present to the emergency department (ED) with acute chest pain is unknown

Patients who underwent clinical evaluation alone experienced a shorter LOS (20.3 vs 27.9 hours; P < .001), lower rates of diagnostic testing (P < .001) and angiography (2% vs 11%; P < .001), lower median costs ($2261.50 vs $2584.30; P = .009), and less cumulative radiation exposure (0 vs 9.9 mSv; P < .001) during the 28-day study period. Lack of testing was associated with a lower rate of diagnosis of ACS (0% vs 9%; P < .001) and less coronary angiography and percutaneous coronary intervention (PCI) during the index visit (0% vs 10%; P < .001, and 0% vs 4%; P = .02, respectively). There was no difference in rates of PCI (2% vs 5%; P = .15), coronary artery bypass surgery (0% vs 1%; P = .61), return ED visits (5.8% vs 2.8%; P = .08), or MACE (2% vs 1%; P = .24) in the 28-day follow-up period.

Conclusions and Relevance In patients presenting to the ED with acute chest pain, negative biomarkers, and a nonischemic ECG result, noninvasive testing with CCTA or stress testing leads to longer LOS, more downstream testing, more radiation exposure, and greater cost without an improvement in clinical outcomes.