Jean-Marc Chauny

Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies

Objective. To assess the evidence regarding the efficacy and safety of intravenous fat emulsion (IFE) in the management of poisoned patients. Methods. We performed a systematic review of the literature with no time or language restriction. The electronic databases were searched from their inception until June 1, 2009 (Medline, EMBASE, ISI web of science, Biological abstract, LILACS, ChemIndex, Toxnet, and Proquest). We also examined the references of identified articles and the gray literature. The target interventions eligible for inclusion were administration of any IFE before, during, or after poisoning in human or animals. All types of studies were reviewed. Eligibility for inclusion and study quality scores, based on criteria by Jadad and the STROBE statement, were evaluated by independent investigators. The primary outcome was mortality. Secondary outcomes included neurologic, hemodynamic, and electrocardiographic variables, as well as adverse effects. Results. Of the 938 publications identified by the search strategies, 74 met the inclusion criteria. We identified 23 animal trials, 50 human, and 1 animal case reports. Overall, the quality of evidence was weak and significant heterogeneity prevented data pooling. Available data suggest some benefits of IFE in bupivacaine, verapamil, chlorpromazine, and some tricyclic antidepressants and beta-blockers toxicity. No trial assessed the safety of IFE in the treatment of acute poisoning. Conclusion. The evidence for the efficacy of IFE in reducing mortality and improving hemodynamic, electrocardiographic, and neurological parameters in the poisoned patients is solely based on animal studies and human case reports. The safety of IFE has not been established.

Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury.

BACKGROUND Sleep complaints (e.g., frequent awakenings, nightmares), headaches and mood alterations (e.g., feeling depressed, irritable) can appear following a mild traumatic brain injury (MTBI). The objective of this retrospective study was to assess the relationships between the above symptoms. Our hypothesis was that sleep complaints might be among the risk factors for the development of headaches and mood alterations. METHODS The consecutive charts of 443 patients (68.2% males vs. 31.8% female; mean age of 46.9 years) diagnosed with MTBI were reviewed for past medical history and above symptoms using the Rivermead post-concussion symptom assessment questionnaire and self-report. Data were retrieved in 2 time courses: 10 days and 6 weeks. RESULTS For the 2 time courses, the prevalence of subjective sleep complaints were 13.3% and 33.5%; headaches 46.8% and 39.3%; feeling depressed 9.5% and 20.4%; and feeling irritable 5.6% and 20.2%, respectively. Reports of sleep complaints at 6 weeks were 2.9 times (p=0.004) more likely if such a symptom was reported at 10 days. Moreover, the presence of sleep complaints at 10 days is associated with concomitant headaches, depressive symptoms, and feeling irritable by 2.3, 9.9, and 12.2 times (p=0.0001 and 0.014); and by 2.9, 6.3, and 4.8 times (p=0.0001) at 6 weeks, respectively. CONCLUSIONS Our results suggest that patients afflicted with sleep complaints are more likely to suffer from concomitant headaches, depressive symptoms, and irritability.

Postoperative sleep disruptions: A potential catalyst of acute pain?

Despite the substantial advances in the understanding of pain mechanisms and management, postoperative pain relief remains an important health care issue. Surgical patients also frequently report postoperative sleep complaints. Major sleep alterations in the postoperative period include sleep fragmentation, reduced total sleep time, and loss of time spent in slow wave and rapid eye movement sleep. Clinical and experimental studies show that sleep disturbances may exacerbate pain, whereas pain and opioid treatments disturb sleep. Surgical stress appears to be a major contributor to both sleep disruptions and altered pain perception. However, pain and the use of opioid analgesics could worsen sleep alterations, whereas sleep disruptions may contribute to intensify pain. Nevertheless, little is known about the relationship between postoperative sleep and pain. Although the sleep-pain interaction has been addressed from both ends, this review focuses on the impact of sleep disruptions on pain perception. A better understanding of the effect of postoperative sleep disruptions on pain perception would help in selecting patients at risk for more severe pain and may facilitate the development of more effective and safer pain management programs.

Estimation of pain intensity in emergency medicine: a validation study.

&NA; This study was designed to estimate the validity of an 11‐point verbal numerical rating scale (VNRS) and a 100 Unit (U) plasticized visual analogue scale (VASp) using a 100 mm paper visual analogue scale (VAS) as a gold standard, to recommend the best method of reporting the intensity of acute pain in an emergency department (ED). A convenience sample of 1176 patients with acute pain were recruited in the ED of a teaching hospital. Patients >18 years and able to use the different scales were included. Scales were presented randomly. Results were converted to a 0–100 U scale and validity was quantified using the Bland–Altman method and the intra‐class correlation (ICC). The limits of acceptability were previously set for the limits of agreement at ±20 U, with a constant bias. The Bland–Altman method revealed a small bias of –4 U for the VNRS and +1 U for VASp. However, the bias of the VNRS varied with the intensity of pain from −10 to +1 U. The limits of agreement between the VNRS&VAS and the VASp&VAS were −25; +17 U and −17; +18 U, respectively. The ICC was excellent between the VNRS&VAS (0.88) and the VASp&VAS (0.92). In conclusion, the VASp has a small bias, acceptable limits of agreement and an excellent intra‐class correlation. It is probably a valid tool to estimate acute pain in the ED. However, the VNRS is less valid in that context because of its wide limits of agreement and variable bias (mainly in lower scores).

Pain and sleep in post-concussion/mild traumatic brain injury

Abstract Concussion after a force to the head is called mild traumatic brain injury (mTBI). Approximately 1 in 5 patients with mTBI will develop chronic pain (headache and widespread pain, possibly of central origin) and/or sleep problems (insomnia, disordered breathing, periodic limb movements). However, the predisposing mechanisms for chronic pain in patients with mTBI are unknown. Mild traumatic brain injury is a rare model to prospectively assess the risk factors and mechanisms for pain chronification from the injury onset in the absence of pretrauma comorbidity or medication. In the acute phase, headaches and sleep disturbances seem to predict the poorest long-term cognitive and mood outcomes. Although recent studies suggest that certain brain biomarkers and mood alterations (eg, anxiety, depression) contribute, the causality of chronic pain remains unclear. In mTBI patients with pain, poor sleep quality was correlated with fast beta and gamma electroencephalographic activity in frontal, central, and occipital electroencephalographic (EEG) derivations in all sleep stages. Sleep recuperative function seems to be disturbed by persistent wake EEG activity, corroborating patient complaints such as feeling awake when asleep. Pain and sleep management in mTBI is not yet evidence-based. Treatments include cognitive behavioral and light therapies, medications, and continuous positive airway pressure (CPAP) or oral appliances for disordered sleep breathing. Customized approaches are indicated for mTBI, pain, and sleep complaints. Further studies in pediatric, sport, and transportation populations are needed to prevent TBI chronification. Improvements are emerging in biomarker sensitivity and specificity and management strategies for TBI, pain, and sleep comorbidities.

Interventions provided in the acute phase for mild traumatic brain injury: a systematic review

BackgroundMost patients who sustain mild traumatic brain injury (mTBI) have persistent symptoms at 1 week and 1 month after injury. This systematic review investigated the effectiveness of interventions initiated in acute settings for patients who experience mTBI.MethodsWe performed a systematic review of all randomized clinical trials evaluating any intervention initiated in an acute setting for patients experiencing acute mTBI. All possible outcomes were included. The primary sources of identification were MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central register of Controlled Trials, from 1980 to August 2012. Hand searching of proceedings from five meetings related to mTBI was also performed. Study selection was conducted by two co-authors, and data abstraction was completed by a research assistant specialized in conducting systematic reviews. Study quality was evaluated using Cochrane’s Risk of Bias assessment tool.ResultsFrom a potential 15,156 studies, 1,268 abstracts were evaluated and 120 articles were read completely. Of these, 15 studies fulfilled the inclusion/exclusion criteria. One study evaluated a pharmacological intervention, two evaluated activity restriction, one evaluated head computed tomography scan versus admission, four evaluated information interventions, and seven evaluated different follow-up interventions. Use of different outcome measures limited the possibilities for analysis. However, a meta-analysis of three studies evaluating various follow-up strategies versus routine follow-up or no follow-up failed to show any effect on three outcomes at 6 to 12 months post-trauma. In addition, a meta-analysis of two studies found no effect of an information intervention on headache at 3 months post-injury.ConclusionsThere is a paucity of well-designed clinical studies for patients who sustain mTBI. The large variability in outcomes measured in studies limits comparison between them.

Short-term benefits and risks of intravenous iron: a systematic review and meta-analysis

BACKGROUND: Intravenous (IV) iron may correct anemia more efficiently than oral iron, but it has been associated with allergic and hemodynamic reactions, and it may increase the risks of infectious complications. The objective of this systematic review and meta‐analysis was to clarify these controversial issues.

Comparing Two Brief Psychological Interventions to Usual Care in Panic Disorder Patients Presenting to the Emergency Department with Chest Pain

BACKGROUND There has been considerable acknowledgement in treatment outcome research that, although the assessment of treatment integrity is essential in many respects, it requires great effort as well as resources and is therefore often neglected. AIMS In order to fill this gap, the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP) was developed, based on the Cognitive Therapy Scale, to measure therapist competence in delivering cognitive therapy for social phobia. The aim of the present study was to investigate interrater reliability, internal consistency and retest reliability of the scale. METHOD Raters evaluated therapist competence from 161 videotaped sessions (98 patients) selected from 234 cognitive treatments within a multi-centre study. RESULTS Interrater-reliability was found to be high for the overall score (ICC = .81) and moderate for individual items (ICC = .62-.92). Internal consistency and retest reliability were also found to be high (Cronbachs alpha = .89; (ICCretest = .86). CONCLUSIONS The results indicate that the CTCS-SP is highly reliable. As even individual items yield satisfactory reliability, the scale can be used in various fields of research, including the measurement of changes in skill acquisition and the impact of competence on outcome criteria.BACKGROUND Panic disorder (PD) is a common, often unrecognized condition among patients presenting with chest pain to the emergency departments (ED). Nevertheless, psychological treatment is rarely initiated. We are unaware of studies that evaluated the efficacy of brief cognitive-behavioural therapy (CBT) for this population. AIM Evaluate the efficacy of two brief CBT interventions in PD patients presenting to the ED with chest pain. METHOD Fifty-eight PD patients were assigned to either a 1-session CBT-based panic management intervention (PMI) (n = 24), a 7-session CBT intervention (n = 19), or a usual-care control condition (n = 15). A structured diagnostic interview and self-reported questionnaires were administered at pre-test, post-test, 3- and 6-month follow-ups. RESULTS Statistical analysis showed significant reduction in PD severity following both interventions compared to usual care control condition, but with neither showing superiority compared to the other. CONCLUSIONS CBT-based interventions as brief as a single session initiated within 2 weeks after an ED visit for chest pain appear to be effective for PD. Given the high prevalence of PD in emergency care settings, greater efforts should be made to implement these interventions in the ED and/or primary care setting.

Current views on acute to chronic pain transition in post-traumatic patients: risk factors and potential for pre-emptive treatments.

E year in the United States, 2.6 million hospital admissions and 36 million emergency department visits are accounted for by trauma patients. Proportionally similar ratios are reported in Canada. In many cases, acute pain from tissue damage subsides normally with wound healing. Yet, in many patients, maladaptive sensitization of the nervous system may trigger chronic pain syndromes that eventually persist for years after that healing has taken place. While the definition of chronic pain may vary, it is generally considered as an ongoing pain state experienced on most days and persisting for at least 3 months. Patients presenting with chronic pain experience persistent manifestations of allodynia, hyperalgesia, and spontaneous pain, making it a major cause of disability. Allodynia is characterized by a painful sensation triggered by normally nonpainful stimuli such as light brushes of the skin or the simple touch of clothes. Hyperalgesia is an exaggerated pain intensity perception for a painful stimuli. ‘‘Spontaneous’’ pain would occur in the absence of identified stimuli and is often considered a major clinical issue in the manifestation of a neuropathic pain state. Underlying inflammation or the physiologic consequences of the summation of allodynic and hyperalgesic stimuli during the course of time may contribute to the physiologic background of apparent ‘‘spontaneous’’ experiences. In Canada, the costs associated with chronic pain total more than those of cancer, heart disease, and human immunodeficiency virus combined, with direct health care costs reaching more than

Portrait of rural emergency departments in Quebec and utilisation of the Quebec Emergency Department Management Guide: a study protocol

6 billion per year. Overall, 60% of active people living with chronic pain will eventually lose their job, incur an income loss, or see their professional responsibilities decrease, depending on the level of disability incurred. The total cost to society amounts to