Peter Währborg

Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction

OBJECTIVES To describe the localization of pain in consecutive patients admitted to the coronary care unit for possible acute myocardial infarction (AMI) and to relate it to the development of AMI, age, and gender. DESIGN Prospective evaluation. SETTING Sahlgrenska Hospital, covering half the area of the city of Göteborg, with half a million inhabitants. SUBJECTS Nine hundred three consecutive patients admitted to the coronary care unit for possible AMI between 24 and 87 years old with a mean age of 64 years. OUTCOME MEASURES Localizations of pain according to a self-constructed figure. Patient were approached between 1 and 14 days after onset of symptoms and asked to describe the localization of pain according to the figure, including nine positions on the chest, left and right arm, neck, and back. RESULTS AMI developed in 50% of patients during the first 3 days in hospital. Patients in whom AMI developed localized their pain to an extent similar to those without AMI in seven of nine chest areas. However, patients with AMI reported pain in the upper right square of the chest more frequently (p < 0.001) and in the middle left square of the chest less frequently (p < 0.01) than did patients without AMI. Pain in both the right (p < 0.001) and left arms (p < 0.01) was more frequently reported by patients who had AMI. Among patients with AMI, women reported pain in the neck (p < 0.05) and in the back (p < 0.01) more frequently than did men. Compared with elderly patients, younger patients reported pain more frequently in the left arm (p < 0.01), right arm (p < 0.01), and neck (p < 0.05). CONCLUSIONS Among consecutive patients with possible AMI admitted to the coronary care unit, patients who had confirmed AMI reported pain in both arms more frequently than did patients without AMI. However, both groups described their chest surface distribution of pain similarly in the majority of positions, thereby indicating that the localization of chest pain is of limited use in predicting which patients will eventually have AMI.

COX-2-Specific Inhibitors – the Emergence of a New Class of Analgesic and Anti-inflammatory Drugs

Abstract: The prostaglandin series of bioactive compounds is formed by the interaction of two distinct but related enzymes, cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2). COX-1 is a constitutive form which is present mainly in the gastric mucosa, kidney and platelets. COX-2 is mainly an inducible form, although also to some extent present constitutively in the CNS, the juxtaglomerular apparatus of the kidney and in the placenta during late gestation. Both isoforms contribute to the inflammatory process, but COX-2 is of considerable therapeutic interest as it is induced, resulting in an enhanced formation of prostaglandins, during acute as well as chronic inflammation. Conventional NSAIDs inhibit both isoforms to a similar extent and in an approximately equal dose and concentration range. The two recently developed and clinically available selective COX-2 inhibitors, celecoxib and rofecoxib, are about 100–1000 times more selective on the COX-2 than on the COX-1 isoform. In Europe rofecoxib is today indicated for the symptoms and signs of osteoarthritis, whereas celecoxib is indicated for both osteoarthritis and rheumatoid arthritis. The major clinical interest of these drugs has been related to the lower incidence of gastrointestinal bleeding which, with the conventional COX-1/COX-2 agents has been a source of hospitalisation, disablement and death, especially in the elderly. Clinical trials have convincingly demonstrated that celecoxib and rofecoxib in clinical use induce very few gastrointestinal complications compared to conventional and non-selective NSAIDs. However, the well known contraindications for NSAIDs, such as late pregnancy, aspirin-induced asthma, congestive heart failure and renal dysfunction, will so far apply also to the COX-2 inhibitors. Compared to the traditional and non-selective NSAIDs, COX-2 inhibitors may provide an insight into additional therapeutic areas, such as gastrointestinal cancer and dementia, where the potential relevance to COX-2 mechanisms are currently being explored and clinical trials being performed. With the rapid clinical acceptance of celecoxib and rofecoxib, knowledge about their clinical usefulness in various inflammatory disease states and pain disorders is increasing. For the many patients suffering from such conditions, the selective COX-2 inhibitors are likely to become a significant addition to the therapeutic arsenal of analgesic and anti-inflammatory drugs.

A new instrument for measuring self‐efficacy in patients with an anterior cruciate ligament injury

It has been suggested that self‐efficacy belief is of major importance for rehabilitation outcome after sports‐related injuries. No instruments are, however, available to evaluate perceived self‐efficacy for prognostic and outcome expectations in patients with an anterior cruciate ligament (ACL) injury. Perceived self‐efficacy is defined as a judgment of ones potential ability to carry out a task, rather than a measure of whether or not one actually can or does perform the task. The purpose of this study was to develop a reliable and valid instrument for measuring perceived self‐efficacy in patients with an ACL injury.

Anger, depression and anxiety associated with endothelial function in childhood and adolescence

Objective Psychosocial adversity is a risk factor for cardiovascular disease (CVD) in adults. The authors assessed associations of reactive hyperaemia peripheral arterial tonometry (RH-PAT), a measure of endothelial function predictive of CVD, with self-assessed psychological health among school children. Methods A total of 248 healthy school children (mean (SD) age 14.0 (1.0); 136 girls and 112 boys) underwent RH-PAT testing. They completed the Beck Youth Inventories (BYI) of emotional and social impairment scales, which is used to screen for depression, anxiety, anger and disruptive behaviour. Results No sex differences were observed for the RH-PAT score. Statistically significant differences were observed for the BYI scores; girls had higher scores for depression, anger and anxiety. Among the girls, there were statistically significant associations between lower RH-PAT scores and higher scores for anger (B coefficient=−0.100, p=0.040), depression (−0.108, p=0.009) and anxiety (−0.138, p=0.039) after adjustment for age. Among the boys, disruptive behaviour was associated with higher RH-PAT scores (0.09, p=0.006). Conclusions The girls have higher levels of self-assessed anger; depression and anxiety compared with the boys, and these characteristics are associated with lower RH-PAT scores, indicating attenuated endothelial function. Among the boys, disruptive behaviour was associated with better endothelial function. Although psychological ill-health is associated with impaired endothelial function and CVD among adults, such processes may also be relevant to children. Psychosocial adversity in childhood might be a risk factor for subsequent CVD.

Fatality, morbidity and quality of life in patients with refractory angina pectoris

BACKGROUND Refractory angina pectoris has been defined as coronary artery disease and severe angina, not available for further conventional pharmacological treatment or for revascularization procedures. The aim of the study was to assess fatality, morbidity and quality of life in patients with refractory angina. METHODS Patients with refractory angina were prospectively identified at seven centres and were compared with an age and gender matched group of patients accepted for revascularization due to severe angina. RESULTS Over three years, 139 patients with refractory angina were identified. The refractory group had more pronounced cardiac disease in terms of more previous myocardial infarctions (p < 0.05), more previous revascularization procedures (p < 0.0001), more severely impaired left ventricular ejection fraction (p < 0.001) as well as higher prevalence of renal dysfunction (p < 0.001) and insulin treated diabetes (p < 0.01) compared to the controls. The refractory patients had a higher one year fatality rate than the control group (10% vs. 0.7%; p < 0.001). Compared to the controls, the refractory group had significantly more impaired quality of life according to the Short Form 36 and the Seattle Angina Questionnaire with regard to physical function, physical well-being and impact of angina symptoms, but there were no differences with regard to mental health and emotional function. CONCLUSIONS Patients with refractory angina pectoris have severe angina symptoms, a more pronounced cardiac disease, a higher fatality rate and a markedly impaired quality of life compared with patients who undergo revascularization procedures due to symptomatic coronary artery disease. Additional symptomatic treatment modalities are highly warranted for this patient group.

A new short self-rating questionnaire to assess stress in children

We constructed a test to assess stress in children and compared it with establishedmeasures of depression, anxiety, anger, disruptive behavior, and negative self-perception. A total of 181 children aged between 9 and 12 years were enrolled at various stages of the construction of a new short questionnaire; Stress in Children (SiC). Baseline data, completed questionnaires, salivary cortisol (SC) five times during (1 day), and 24-h urinary catecholamines were collected during an ordinary school week. The SiCwas validated using the Beck Youth Inventories of Emotional and Social Impairment (BYI). Associations with self-reported psychosomatic symptoms for urinary catecholamines and cortisol concentrations were assessed. Cronbach’s á used in this study for the entire SiC questionnaire is 0.86. Statistically significant associations were found between the SiC Global Mean Score (GMS) and all of the five BYI subscales. Spearman’s rho coefficient for the association of SiC GMS with the first SC sample is 0.30 (p = 0.01). When stratified by sex, the magnitude of the association between SC and SiC was higher in girls, while there was no significant association among boys. No significant associations with catecholamine levels were observed for self-rating scores from the SiC or BYI. This study demonstrated that the SiC questionnaire has satisfactory reliability and its ratings are associated with those generated by the BYI. The SiC GMS was associated with higher morning saliva cortisol in girls. Our results demonstrate that it is possible to screen for stress in schoolchildren using an easily administered self-rating instrument.

Pain Recollection after Chest Pain of Cardiac Origin

Memory for pain is an important research and clinical issue since patients ability to accurately recall pain plays a prominent role in medical practice. The purpose of this prospective study was to find out if patients, with an episode of chest pain due to suspected acute myocardial infarction could accurately retrieve the pain initially experienced at home and during the first day of hospitalization after 6 months. A total of 177 patients were included in this analysis. The patients rated their experience of pain on a numerical rating scale. The maximal pain at home was retrospectively assessed, thereafter pain assessments were made at several points of time after admission. After 6 months they were asked to recall the intensity of pain and once again rate it on the numerical rating scale. The results from the initial and 6-month registrations were compared. In general, patients rated their maximal intensity of chest pain as being higher at the 6-month recollection as compared with the assessments made during the initial hospitalization. In particular, in patients with a high level of emotional distress, there was a systematic overestimation of the pain intensity at recall.

Dispatcher-assisted telephone CPR: a qualitative study exploring how dispatchers perceive their experiences.

OBJECTIVES To investigate how emergency medical dispatchers (EMDs) perceive their experience of identifying suspected cardiac arrests (CA), and offer and provide instructions in cardiopulmonary resuscitation via telephone (t-CPR). DESIGN A qualitative method using the phenomenographic design where 10 EMDs were approached for semi-structured interviews. MAIN OUTCOME MEASURES Perception in identifying CA, perception in offering t-CPR and perception in providing t-CPR. RESULTS In this analysis, 12 categories and 31 subcategories emerged. The categories for perception in identifying CA were; to trust the witnesss account, to be open-minded and to be organised. The categories for perception in offering t-CPR were: to feel prepared to connect with the witness on a mental level by being organised, flexible and supportive, to obtain a basis for assessments and to be observant for diverse obstacles in a situation. Finally, the categories for perception in providing t-CPR were: to feel engaged, to be supportive of the witness, to feel secure by recognising response-feedback from the witness, to observe external conditions with regard to the locality and technical complications, to be composed and adjust to the needs of the situation, to feel competent or to feel despair. CONCLUSIONS By listening in an open-minded way, a vast amount of information can be collected. Using criteria-based dispatch (CBD) and their own resources, the possibilities and difficulties of the situation are analysed. The EMDs believe that they are being an empathic support, relieving the witness of the burden of responsibility, and connecting with them mentally to enable them to act at the scene. There are EMDs who feel competent and experienced in managing these cases, and other EMDs who feel insecure and despair. The choice between providing t-CPR and answering incoming calls is prioritised differently among EMDs. There is also a broad subjective assessment among EMDs of offering t-CPR, especially to persons over 70 years old whom they consider incapable of performing CPR. The competence of the EMDs in t-CPR is dependent on re-training and a feedback on patient outcome. Witnesses who are negative towards acting constitute a common problem. There are witnesses with physical impediments or psychologically not susceptible to suggestions. The EMD is also dependent on the knowledge and trustworthiness of the witness. Convincing answers from witnesses prompt a more secure feeling in the EMDs, just as lack of knowledge in the witness has a negative effect on the efforts.

24-h Systolic blood pressure and heart rate recordings in lean and obese adolescents

Objective  We assessed the hypothesis that differences in day and night‐time systolic blood pressure (SBP) and heart rate (HR) recordings were smaller in obese versus lean children and adolescents, and whether measurements obtained during a school week or during weekends or holidays influenced these nocturnal falls. We also wanted to determine whether the results were influenced by gender.

The cortisol awakening response and the metabolic syndrome in a population-based sample of middle-aged men and women

The objective was to explore the relationship between the cortisol awakening response (CAR) and the metabolic syndrome (MetS) as defined by the National Cholesterol Education Program criteria. The final study sample consisted of 91 women (14 with MetS) and 84 men (15 with MetS), aged 45 to 70 years, from a general population sample. The only exclusion criteria were no consent, pregnancy, or insufficient cortisol testing. On the day of measurement (weekday), salivary cortisol was sampled at awakening and 15 minutes after awakening. Relative CAR (CAR%) and the MetS were the main variables studied. Results showed that, in women with the MetS, cortisol at awakening was significantly lower (mean, 8.92 vs 12.33 nmol/L; P = .05) and the CAR was significantly higher (91.4% vs 36.5%, P < .001) than in women without the syndrome. Significant difference in the relative CAR was also present between men and women with MetS (38.5% and 91.4%, respectively; P = .02). No difference was seen in the awakening response comparing men with and without the MetS. In a regression model, the response to awakening was dependent on the MetS in women (F(1,89) = 13.19, P < .001); but the model was not significant in men. Furthermore, the awakening response was associated with more depressive symptoms in women (F(1,80) = 8.12, P = .01) and with weekday/weekend cortisol sampling in men (F(1,82) = 4.63, P = .03). The association between the relative CAR and the MetS remained significant but somewhat attenuated after adjusting for depressive symptoms (P = .01). Results indicate a sex difference in the CAR% in the presence of the MetS independent of depressive symptoms, a known correlate of the MetS.