Pain Management

Paula Hernandez has completed her MD from the University of Puerto Rico Medical Sciences Campus. She is the currently in her first year of internal medicine residency at the University of South Florida Morsani School of Medicine in Tampa. She has published 4 papers in reputed journals and is currently engaged in diverse scholarly activities. She is interested in pursuing a cardiology fellowship and continuing research on imaging cardiology.

Hyponatremia is the most common electrolyte imbalance managed by hospitalists. Although a rare entity, a relationship between hyponatremia and cardiac tamponade has been reported in a few published reports that highlight the normalization of sodium levels following pericardial drainage. This is the case of a 57-year-old lady with rapidly progressive stage IV pulmonary adenocarcinoma who presented two months following diagnosis with findings of significant hyponatremia. Upon admission, she was afebrile, hypotensive and tachycardic. Her laboratory studies revealed a sodium level of 119 mEq/L, as well as hypokalemia and hypochloremia. Although her presentation was consistent with Syndrome of Inappropriate Antidiuretic Hormone, her hyponatremia did not improve despite adequate management with fluid restriction and salt tabs. During hospitalization, she was also found to have a large pericardial effusion with echocardiographic evidence consistent with tamponade physiology that required an emergent pericardial window. Her sodium levels normalized immediately following pericardial drainage, suggesting a correlation between her hyponatremia and cardiac tamponade. A handful of published reports present a similar scenario in which pericardial drainage resulted in immediate resolution of the hyponatremia, particularly in patients with underlying malignancies. It is suggested that a decreased cardiac output stimulates antidiuretic hormone release and suppresses atrial natriuretic factor release,causing volume retention, increased heart rate and increased peripheral resistance. Following pericardiocentesis, there is marked diuresis and a normalization in sodium concentration. Cardiac tamponade should be included in the differential of hyponatremia in patients with active malignancy, since prompt management with pericardial drainage can result in marked improvement of yponatremia.

Janet M Colón Castellano completed her Bachelor’s degree in Natural Sciences with a minor on Biotechnology from the University of Puerto Rico in Ponce. Following her growing research interests in human immunodeficiency virus (HIV), she worked as a Laboratory Technician at one of the few HIV research centers of Puerto Rico. Afterwards, she decided to pursue a Doctorate in Medicine from the Ponce Health Sciences University which she completed on 2016. She is currently completing her Internal Medicine residency at the Veteran’s Affairs Caribbean Healthcare System located in San Juan, Puerto Rico.

A case of a 68-year-old man with past medical history of dengue hemorrhagic fever who was admitted to the medical intensive care unit (MICU) with the diagnosis of septic shock. His symptoms started the prior week with sudden onset of fever, polyarthralgia and skin rash over the abdomen extending to the back, buttocks and xtremities. The patient visited a community primary care physician who recommended acetaminophen for symptom relief. After 2 days of no improvement and development of abdominal pain, nausea, non-bloody vomiting and dark-colored stools, the patient visited the emergency department. Physical examination was remarkable for hypotension, tachycardia, tachypnea and oxygen desaturation, and a non-blanching maculopapular rash over the abdomen, back, buttocks, and extremities. No evidence of acute neurological deficits or cardiopulmonary involvement. Laboratory workup showed hemoconcentration,thrombocytopenia, hepatic transaminitis, and acute renal injury, findings suggestive of circulatory compromise due to systemic capillary leak syndrome. Patient developed ardiorespiratory arrest requiring advanced cardiac support measures and mechanical ventilation for which he was admitted to MICU. While on MICU, he was initiated on broad spectrum antibiotics, aggressive fluid resuscitation, and vasopressors. He persisted with profound shock and died 7 hours after admission to MICU. Final laboratory reports were remarkable for RNA-PCR positive for chikungunya virus and negative for dengue virus. Chikungunya infection is usually a self-limited disease and only required supportive therapy. This case highlights an unusual presentation of chikungunya fever with systemic capillary leak syndrome, a well-known complication of dengue hemorrhagic fever.

Dr. Brinkers has completed his MD at the university of Bonn. His postdoctoral studies are based on the habilitation thesis about the influence of CL on pain therapy. He is now senior house officer at the pain clinic of the university Magdeburg.

Background: Since 2001 it has been shown that successful pain therapy by consultations of the classical type cannot be provided in somatic medical disciplines. Aim: The aim of the study is to work in liaison mode and to elucidate specific qualitative and quantitative aspects. Methodology: For anesthesiologists, basic guidelines of pain therapy were provided in an SOP (Standard perating Procedures) available at each time. On the side of general and abdominal surgery, anesthesiologists were allowed to prescribe medication in parallel to the surgeons. Results: This approach achieved: 1. the pain therapists (anesthesiologists responsible for pain therapy)- took care for the surgical patients longer in average than before; accept responsibility for the consequences of their therapeutic recommendations. 2. patients did not receive unrealistic recommendations. 3. advices were implemented 1:1. 4. the working group consisting of surgeons and pain therapists (Dept. of Anesthesiology) can devolve xperiences obtained during the last years to the other surgeons. Conclusions: The algorithms may serve to achieve that i) as a 1st step, pain therapy is reliable and can be used in each individual case, ii) as 2nd step, surgeons are better qualified, in particular, on an individual base, to provide/prescribe appropriate pain therapy (with more than only prescribing metamizole and/or piritramide, iii) as 3rd step (in the near future), the general pain niveau on wards of general and abdominal surgery is reduced to a minimum, and iv) as 4th step, consultations by pain therapists should be reduced with no disadvantage for the efficacy of pain therapy.

Stamatis Karakonstantis, Kalliopi Milaki, Dafni Korela, Sofia Pitsigavdaki, Ifigeneia Kassotaki and Despoina Galani General Hospital of Heraklion “Venizeleio- Pananeio”, Greece Stamatis Karakonstantis is a resident of Internal Medicine. He graduated from the Medical Faculty of the University of Crete, in Heraklion and completed an MRes degree from the University of Birmingham. He is a new author and has so far published 8 manuscripts.

Background: G6PD deficiency is common in Mediterranean countries and is associated with favism, i.e., hemolytic anemia following consumption of fava beans. Given it is an x-linked recessive inherited disorder, it is uncommon in women. Case Report: A 74-year-old female presented due to jaundice that developed in the past 24 hours. Her oxygen saturation on pulse oximetry was 86%, while her arterial blood gases showed a saturation of 94.7%. Lab tests revealed a hemolytic anemia (hemoglobin 9.4 mg/dl, 2.5% reticulocytes, LDH 582U/l, total bilirubin 8.4mg/dl, conjugated bilirubin 1.25mg/dl, normal coagulation times, normal platelet count and negative direct coombs). She denied taking any new medications. She reported consumption of fava beans the day before, although she reported uneventful prior consumption 2 years ago. Family history taking revealed that she had a son diagnosed with G6PD deficiency. G6PD deficiency was confirmed with quantitative testing (enzyme activity 6.7U/g Hb, normal range 7-16). During the first day the hematocrit fell to 21.8%, with 25% reticulocytes. She was managed with intravenous hydration and blood transfusion. The hematocrit rapidly rose, pulse oximetry saturation normalized, and she was discharged with a diagnosis of favism.Discussion: Favism may occur in elderly women with heterozygous G6PD deficiency despite normal prior consumption of fava beans. This may happen due to skewed X-chromosome inactivation with aging, affecting the wild-type allele. The low oxygen saturation on pulse oximetry can be explained by favism associated methemoglobinemia, as previously described.Recent Publications 1. Nkhoma E T, Poole C, Vannappagari V, Hall S A and Beutler E (2009) The global prevalence of glucose-6- phosphate dehydrogenase deficiency: a systematic review and meta-analysis. Blood Cells, Molecules and Diseases 42:267-78. 2. Au W Y, Lam V, Pang A, et al. (2006) Glucose-6-phosphate dehydrogenase deficiency in female octogenarians, nanogenarians, and centenarians. J Gerontol A Biol Sci Med Sci. 61:1086-9. 3. Hassan K S, Al-Riyami A Z, Al-Huneini M, Al-Farsi K and Al-Khabori M (2014) Methemoglobinemia in an elderly patient with glucose-6-phosphate dehydrogenase deficiency: a case report. Oman Medical Journal 29:135- 7.4. Schuurman M, van Waardenburg D, Da Costa J,Niemarkt H and Leroy P (2009) Severe hemolysis and methemoglobinemia following fava beans ingestion in glucose-6-phosphatase ehydrogenase deficiency: case report and literature review. European Journal of Pediatrics 168:779-82.

Cristian Funieru completed his PhD from “Carol Davila” University of Bucharest, Romania in 2010. He is Assistant Professor at Preventive Dentistry Department from “Carol Davila” Bucharest School of Dental Medicine and a specialist in oral surgery. He has published more than 28 papers in medical and dentistry journals (4 in PubMed).

The association between oral lichen planus (OLP) and Hashimoto’s thyroiditis (HT) has been reported for several times but many details remain unclear. One hypothesis considers that HT antibodies could be the trigger for the autoimmune mechanism responsible for OLP lesions. Our study has as main role to analyse if there is any relation between OLP and HT in a group of Romanian patients. 211 medical records of OLP patients who addressed to the Department of Oral Medicine from Bucharest “Carol Davila” School of Dental Medicine between 2015 and 2017 were analysed in this study. It has been selected 99 patients who meet the OLP diagnostic WHO criteria (1978) modified by Meij and van der Waal in 2003 and they were tested for anti-thyroid peroxidase antibodies (ATPO). 30% of them were diagnosed with HT, the level of ATPO antibodies being higher than normal. 62% of OLP lesions associated with HT were symptomatic, patients complaining of local pain, burning sensation of oral mucosa and slight discomfort. The most common clinical form of OLP found in this study among patients with HT was the associated form (keratotic and atrophic lesions), followed by keratotic, ulcerative and atrophic forms OLP. As conclusion, it would seem to exist a link between OLP and HT that makes oral lesions and their symptoms more evident and severe.

Luiza Lazarescu has graduated at Carol Davila University of Medicine, Bucharest, and Specialist in Internal Medicine from 2008 and Mayor in InternalMedicine from 2016.

Background: Crohn’s disease is an auto-immune condition where immunological inflammation may affect other organs apart from the intestines, such as the joints. These are disorders that develop secondarily to the inflammatory bowel disease (IBD), but appear independently of IBD exacerbations. One of these conditions is classified as seronegative spondylarthritis, sometimes called enteropathic arthritis.Case report: We report a case of a 30-year- old woman known with Crohn’s disease from the age of five, who was hospitalized for pain and swelling in the sacroiliac joints. She had been in treatment with adalimumab 40 mg twice daily, prior to hospital admission. The MRI investigation of sacroiliac joints revealed bilateral reduction in joint spaces, but no bone edema or other significant changes. Blood tests showed chronic anemia (Hb 11.4 g/dl and Ht 35.7%) with normal ESR and C-reactive protein and negative HLA- B27 phenotyping. The diagnosis of seronegative spondyloarthritis was made by excluding other joint pathology,based on the European group criteria for this condition.Results & Conclusion: Based on the clinical, immunological and imagistic findings, I believe that the patient has developed reactive spondylarthritis, most likely secondary to Crohn’s disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the medication of choice for spondyloarthritis; however we chose to avoid them while IBD is active and refer the patientfor physiotherapy. The patient has concomitantly continued her treatment with adalimumab. She has had a good result afterthe first sessions of physiotherapy, with reduced swelling and recovered mobility in her joints.

Kwang Bok Lee has completed his MD from Chonbuk National University Medical School and Hospital, South Korea. He has worked as a Professor at the same university. He has published more than 88 papers in reputed journals and has been serving as a Director in the Department of Orthopaedic Surgery at Chonbuk National University Hospital.

The purpose of this study is to investigate the relationship between percutaneous procedures (nerve block and kyphoplasty) or open surgeries and spinal infections using the 5-year large unit national dataset. This study used disease codes (ICD-10: International Classification of Disease) and operation fee codes (national medical insurance) registered in the National Health Insurance Review & Assessment Service for the 5 years from January 1, 2007 to December 31, 2011. Using the above disease codes, the number of each percutaneous procedure, open surgery, and the number of lumbar infections were investigated by regional and national units, and the relationship between procedures or open surgeries and lumbar infection was compared statistically. Lumbar infection showed a gradually growing annual trend, with a 3-fold increase in 2011 compared to 2007. Percutaneous procedures (nerve blocks) increased by approximately 2.6 times over 4 years. Kyphoplasty tended to decrease each year. Open surgeries (posterior fusion, discectomy,and laminectomy) were at a similar level each year. Lumbar infection and percutaneous procedures were positively correlated, and a negative correlation was observed between kyphoplasty and open surgeries. The incidence of lumbar infection was higher in large cities than provinces and increased 2-3 times in 2011 compared to 2007 in all regions. There was no significant difference in the number of open surgeries for the 5 years studied,but the number of percutaneous procedures (nerve blocks) increased each year, showing an approximate 4-fold increase in 4 years. Lumbar infection showed a positive correlation with percutaneous procedures, and kyphoplasty and open surgeries were negatively correlated. Therefore, since selective nerve block procedure is also considered an important factor affecting the growing trend of lumbar infections, attention should be given to prevent spinal infections when performing selective nerve root block procedures by updating axenic conditions, environment and disinfectant materials.

Garda Widhi Nurraga is a final year Medical Student who has completed his Clerkship in Faculty of Medicine, Diponegoro University, Indonesia. In this project, he was supervised by Dr. Muchlis Sofro from Department of Internal Medicine, Faculty of Medicine, Diponegoro University/Dr Kariadi General Hospital.

Background: The administration of zidovudine (ZDV) has an important role in decreasing the number of mortality on HIV/AIDS patients, despite the side effect of anaemia. The incidence of anaemia can be influenced by several factors, e.g. age, sex, duration of treatment, CD4 count, and ALT level. Methods: This research is an analytic observational with cohortretrospective method used. The study was taken in VCT Clinic, Dr.Kariadi General Hospital Semarang. The data was collated among HIV/AIDS patients’ medical records from April 2014 to May 2015. 70 out of over 300 patients on zidovudine were eligible: 35 belonged to case group, the other 35 as control. The data was analyzed by Chi-square and Fischer test.Results: The average age of patients with and without anaemia in this study are 33.65 years old and 38.02 years old, respectively.However, age did not have any significant relation with the incidence of anaemia (p=0.075). A statistically significant relation was shown between sex and incidences of anaemia (p=0.027);indicated by 18 female HIV/AIDS patients (51.4%) suffered from anaemia. Duration of treatment (2.1 months average) was the most influential factor towards occurrences of anaemia (p=0.000). No significant relationship between low CD4 count (<200 cells/mm3) and ALT level to the occurrence of anaemia (p=0.055 and p=1.000 respectively).Conclusion: The incidence of anaemia on HIV/AIDS patients from Dr. Kariadi General Hospital Semarang is related to sex (gender) and duration of treatment as the influencing factors; age, CD4 count, and ALT level do not appear to have any significant relation with it in response to the administration of zidovudine.

Maria Satya Paramitha is a Medical Doctor who has completed her Undergraduate study in Faculty of Medicine, Universitas Indonesia. She has completed her Master’s degree by Research in Cancer from Newcastle University Medical School, United Kingdom. In this evidence-based case report, she was supervised by Dr. Tri Juli Edi Tarigan, SpPD-KEMD from Department of Internal Medicine, Metabolic Endocrine Division, Faculty of Medicine, Universitas Indonesia.

Introduction: Transfusion-dependent iron overload is a determinant of further complications in patients with conditions requiring regular blood transfusion; such as thalassemia-β major. Currently, liver biopsy is used as a gold standard for measuring liver iron concentration. Magnetic resonance imaging (MRI) has been proposed as a non-invasive diagnostic method for measuring liver iron concentration. Methods: Literature searching was conducted from Pubmed®, Embase®, and SCOPUS®. One systematic review and metaanalysis article was selected from twelve chosen studies. The article was critically appraised afterwards, using standard criteria for diagnostic research. Results: Twenty eligible studies (cohort and case-control) that utilized 1.5-T or higher scanner system as the index test, and liver biopsy as the reference standard were analyzed. In the analysis of T2 spin echo (SE) and T2* gradient recalled echo (GRE), the results obtained were positive predictive values (0.81 and 0.74),negative predictive values (0.83 and 0.88), likelihood ratio positive (8.85 and 4.86), and likelihood ratio negative (0.10 and 0.05) respectively. Meta-regression analysis was conducted to explore heterogeneity between studies.Discussion: In comparison to liver biopsy, MRI is proven to be poorly invasive with the amount of possible sampling errors similar to the gold standard. Although MRI is not considered cannot be used for depicting histological stages, it has been validated as a sensitive and non-invasive diagnostic technique to evaluate tissue iron content.Conclusion: MRI has been proven to be moderately sufficient for ruling in definite diagnosis of liver iron overload and highly sufficient for ruling out diagnosis of the same condition.

Hemda Weiss she is currently working in Hasharon Hospital, Israel.

Background: Recently lowering upper limit of normal (ULN)values of serum alanine aminotransferase (ALT) was suggested.Aim: To investigate the prevalence of significant liver disease among community dwelling elderly (>65 years) in central Israel, whose ALT level fell in the range between the former and the new range (‘delta range’). Patients & Methods: The database was searched for those who underwent ≥ 1 ALT measurement (IU/L) in 2002-2012. In a previous study a new range of ALT has been proposed: men: 15-42, women: 10-26. In this study the prevalence of significant liver disease in the delta range: men 42-45, women 26-34 was investigated. APRI, FIB-4 and AAR were applied for evaluating liver fibrosis. Prevalence of significant liver diseases was set by Chi-Square tests, mean fibrosis scores were compared using ANOVA followed by Bonferroni post-hoc test. The receiver operating characteristic model was used to test the ability of the scores to predict cirrhosis. Results: 2022 of 49634 (41% male, mean age of 83±6 years) were diagnosed with chronic liver disease (CLD) and 366 with cirrhosis. The two were more prevalent among men (15.3% vs. 4.9% and 4.2% vs. 0.9%, respectively) and women (7.8% vs. 3.3% and 1.5% vs. 0.4%, respectively) in the delta range compared to the new ALT range. Mean fibrosis scores of FIB4, APRI and AAR were significantly increased in the ‘delta range’ compared to the new ALT range. Conclusion: Lowering the current ULN of ALT l may help detecting significant liver diseases.

Avaharan Weiss is currently working in Beilinson Hospital – RMC, Israel.

Background: Serum alanine aminotransferase (ALT) levels below and above normal range has been found to serve as a marker of liver injury and to predict all-cause mortality. The need to adjust the normal range by age, gender, or other parameters remains unclear. The current normal range of serum ALT in Israel is 0-34 IU/L for women and 0-45 IU/L for men. Aim: We aimed to test the applicability of the current normalrange values of ALT in the elderly. Design: A retrospective design was used. The study population consisted of community-dwelling individuals aged ≥65 years who were tested for serum ALT in 2002 at a large health management organization and followed until end-December 2012. Methods: Data were collected on demographics, laboratory tests, co-morbidities, and mortality. Results: The population included 49,634 subjects (59% women, mean age 83.2±6.3 years). ALT levels in the range of 16-25 IU/L were associated with the lowest mortality (HR=1), and values of <16 IU/L and >25 IU/L (unadjusted) were associated with higher mortality risk, yielding a U-shaped pattern. Conclusions: Very low and very high levels of serum ALT within current normal range are associated with an increased risk of death in community-dwelling individuals ≥65 years old.

Eman H EL-Adawy has completed Her MD from Mansoura University. She is a Associate Professor of Internal Medicine and Endocrinology Department in Spescialized Medical Hospital,Faculty of Medicine, Mansoura City, Egypt. She published more than 10 papers in reputed journals.

Background: Genetic susceptibility has been proposed in development and progression of diabetic nephropathy (DN) which accounts for the majority of chronic renal failure on hemodialysis among Egyptians. IGF-1 gene polymorphism has been studied in DN in type 1 diabetes but not yet in type2. Aim: The aim of this study is to investigate the association of IGF-1 gene polymorphism with DN in Egyptians with T2DM. Methods: A case control study of 52 T2DM were divided into 26 without DN and 26 with DN, of average age 52.7±6.1. Twenty five age and sex matched healthy control were selected. We genotyped two tagging single nucleotide polymorphisms (SNPs) in IGF-1; rs6214 and rs10860860. Genotypic distribution was tested for Hardy–Weinberg equilibrium and was evaluated by using the χ2 tests. Participants were assessed clinically and laboratory for FBS, HBA1c, serum creatinine, urine albumin, uric acid and lipid profile. Results: The genotype frequency GG of IGF-1 gene SNP rs6214 was associated with the risk of DN (AA: OR=0.98, 95% CI: 0.25 –3.84, p = 0.97; AG: OR=0.21, 95% CI: 0.05 – 0.79, p = 0.002; GG: OR= 20.57, 95% CI: 2.25 – 74, p = 0.001). The AA variant genotype of rs10860860 also associated with the risk of DN (AA: OR=7.37,95% CI: 1.87 – 30.07, p = 0.001; AT: OR=0.20, 95% CI: 0.05 – 0.78,p = 0.007; TT: OR= 0.29, 95% CI: 0.01 – 3.59, p = 0.28) Conclusion: The variants of rs6214 and rs10860860 in IGF-1 gene entail the risk of DN in Egyptians with T2DM.

Eman G Youssef is a PhD student at Beni-Suef University. She is a Teaching Assistant at Department of Biotechnology, Faculty of Postgraduate Studies for Advanced Sciences, Beni-Suef University. She performed her PhD research at Harbour UCLA, CA as a non-degree program for one year funded by Fulbright. She is interested in discovering new vaccines and to study about the microbial pathogenesis and immune responses.

Klebsiella pneumonia is one of the most common bacteria causing pneumonia, especially in hospitals. The incidence of carbapenem-resistant klebsiella pneumoniae carbapenemases (KPC) strains are in increasing manner. Even the multi-drug resistance strains evolution increasing, the virulence of them are under question. In this study, we are aiming to study the relationship between KPC strains and virulence in pneumonia infection. Three KPC clinical isolates and one multi-drug resistant non-KPC strain were included in this study. KPC strains were confirmed to contain plasmid having bla KPC gene. When ICR mice infected with different KPC strains, mice were apparently healthy and didn’t show any mortality during 21 days of monitoring while Non-KPC strain showed ~90% mortality within two days of infection in all inocula used. Infecting neutropenic mice (induced by cyclophosphamide 200 mg/Kg and cortisone acetate 250 mg/Kg at day -2, +3, and +8 relative to infection) with KPC strains using higher inocula were carried out to confirm lower virulence of KPC strains, in which the mice start to die after day +3 relative to infection. Screening of all the strains for eight virulent capsular genes which associated mostly with pathogenesis and invasion was done. It showed that virulent Non-KPC strain has a highly virulent gene wcaG which encodes capsular fucose synthesis, and enhance the ability of the bacteria to evade phagocytosis by macrophages. While the KPC strains didn’t include any of these capsular virulent genes. Klebsiella isolates having KPC plasmid process low virulence than non-KPC strains in pneumoniainfection.