Pain following extremity injury: management, predictions and outcomes

Chronic pain patients often relate their pain onset to acute injury such as surgery or trauma, drawing attention to the need to prevent the transition from acute to chronic pain. This transition is still a complex and poorly understood developmental process. A range of factors has been associated with the persistence of pain. The PROTACT-study was initiated as a one year prospective follow-up study with the primary aim to determine prognostic factors involved in the transition from acute to chronic pain after extremity injury. This will give the ability to target high-risk patients in the emergency setting and to intervene on one or more of these factors thereby preventing the development of chronic pain. Secondary objectives were to describe the current state of pain management following extremity injury and to determine the consequences of extremity injury and developing chronic pain post-injury in terms of quality of life. At 6 months post-injury, 43.9% of the patients still had some degree of pain and 10.1% developed chronic pain, defined as persisting pain with a pain score ≥4 on the site of injury. Chronic pain affects patient’s quality of life. Six prognostic factors for the development of chronic pain were found, of which only pain severity in the acute phase and pain catastrophizing are potentially modifiable and thus useful to prevent chronic pain. This arises the question whether and how these findings can contribute to a better clinical outcome. To reduce inadequate pain relief in the ED, the implementation of a nurse-initiated pain protocol was studied. This implementation appears to lead to an increase of analgesic provision, a shorter time to analgesics and a higher (clinically relevant) pain relief in patients with acute pain following extremity injury. Despite improvements in pain management, the results reflected by the amount of patients discharged with moderate to severe pain showed that there is still room for improvement in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Following extremity injury, nurses significantly under assessed patient’s pain

Epidemiological characteristics and societal burden of varicella zoster virus in the Netherlands

Background: Varicella and herpes zoster are both caused by varicella zoster virus (VZV) infection or reactivation and may lead to complications associated with a (severe) societal burden. Because the epidemiology of VZV-related diseases in the Netherlands remains largely unknown or incomplete, the main objective of this study was to study the primary care incidence, associated complications and health care resource use.Methods: We investigated the incidence of VZV complications in the Dutch general practitioner (GP) practices and pharmacies in a retrospective population-based cohort study (2004-2008) based on longitudinal GP data including free text fields, hospital referral and discharge letters from approximately 165,000 patients.Results: The average annual incidence of varicella GP-consultations was 51.5 per 10,000 (95% CI 44.4-58.7) overall; 465.5 per 10,000 for 0-1 year-olds; 610.8 per 10,000 for 1-4 year-olds; 153.5 per 10,000 for 5-9 year-olds; 8,3 per 10,000 for &gt;10 year olds. When only ICPC coded diagnoses were analyzed the incidence was 27% lower. The proportion of complications among varicella patients was 34.9%. Most frequently complications were upper respiratory tract infections. Almost half of the varicella patients received medication. The referral rate based on GP consultations was 1.7%. The average annual incidence of herpes zoster GP-consultations was 47.5 per 10,000 (95% CI 40.6-54.4). The incidence increased with age; 32.8 per 10,000 for 65 year olds. When estimating herpes zoster incidence only on ICPC coded information, the incidence was 28% lower. The complication rate of herpes zoster was 32.9%. Post herpetic neuralgia was seen most often. Of patients diagnosed with herpes zoster 67.8% received medication. The referral rate based on GP consultations was 3.5%.Conclusions: For varicella the highest incidence of GP-consultations was found in 1-4 year-olds, for herpes zoster in the &gt;65 years olds. The occurrence of complications was not age-dependent but varies per complication. When estimating incidence of VZV-related diseases in primary care, based on diagnostic codes only, one should be aware of a gross underestimation of the incidence. Our analysis may have important implications for the outcomes of upcoming cost-effectiveness analyses on VZV vaccination.</p

Hartpatiënt moet meer weten over alarmsymptomen

Inleiding: Patiënten met symptomen van een acuut coronair syndroom (ACS) hebben zo snel mogelijk de juiste behandeling nodig om schade aan het hart te voorkomen of te beperken. Hoewel er veel onderzoek is gedaan naar prehospitale vertraging en de oorzaken daarvan, is er weinig bekend over de motivatie van de patiënt voor het kiezen van een keteningang. Het doel van dit onderzoek is het vinden van factoren die invloed hebben op deze keuze. Methode: We deden een explorerend dwarsdoorsnedeonderzoek, waarbij we met een vragenlijst gegevens verzamelden van 67 ACS-patiënten. Resultaten: Patiënten kregen toegang tot de acute zorgketen via vier verschillende ingangen: de huisarts (43%), de huisartsenpost (28%), de meldkamer ambulancezorg (112) (21%) of de spoedeisende hulp (7%). De overtuiging van patiënten dat hun huisarts het beste weet wat ze nodig hebben maakte dat ze vaker contact zochten met hun eigen huisarts. Dit deden ook de patiënten die alleen waren toen de symptomen ontstonden. Patiënten met een fast onset van de klachten en acute pijn belden vaker 112, net als patiënten die hun klachten als ernstig inschatten. Conclusie: Niet de kennis over alarmsymptomen, maar vooral subjectieve factoren, zoals de interpretatie van de ernst van de klachten, de overtuigingen van de patiënt over wie de juiste zorgverlener is, en de manier (plotseling, pijn) waarop de klachten zich voordoen zijn bepalend voor de keuze van de keteningang bij patiënten met ACS-klachten. Voor het reduceren van prehospitale vertraging kunnen huisartsen een rol spelen door patiënten de juiste voorlichting te geven

Painful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients’ Pain by Nurses

Introduction Unrelieved acute musculoskeletal pain continues to be a reality of major clinical importance, despite advancements in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Yet inaccurate pain assessment is a consistent finding worldwide in various clinical settings, including the emergency department. In this study, pain assessments between nurses and patients with acute musculoskeletal pain after extremity injury will be compared to assess discrepancies. A second aim is to identify patients at high risk for underassessment by emergency nurses. Methods The prospective PROTACT study included 539 adult patients who were admitted to the emergency department with musculoskeletal pain. Data on pain assessment and characteristics of patients including demographics, pain, and injury, psychosocial, and clinical factors were collected using questionnaires and hospital registry. Results Nurses significantly underestimated patients’ pain with a mean difference of 2.4 and a 95% confidence interval of 2.2-2.6 on an 11-points numerical rating scale. Agreement between nurses’ documented and patients’ self-reported pain was only 27%, and 63% of the pain was underassessed. Pain was particularly underassessed in women, in persons with a lower educational level, in patients who used prehospital analgesics, in smokers, in patients with injury to the lower extremities, in anxious patients, and in patients with a lower urgency level. Discussion Underassessment of pain by emergency nurses is still a major problem and might result in undertreatment of pain if the emergency nurses rely on their assessment to provide further pain treatment. Strategies that focus on awareness among nurses of which patients are at high risk of underassessment of pain are needed

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury

Background Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. Methods The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. Results At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. Conclusions Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive–behavioural techniques involving reducing catastrophizing might be useful

A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain

While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre–post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients’ self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P &lt; 0.05), whereas time to opioids decreased from 37 to 15 min (P &lt; 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.</p