Pain Management

Khushali Jhaveri is doing her Internal medicine Residency from Georgetown University. She has done around 5 abstract/post¬er presentations in reputed international conferences

A previously healthy 26 year old female presented with initial symptom of isolated neck pain. She denied any headache, nausea, vomiting, blurry vision,numbness, tingling, muscle weakness or radiating pain. She denied any fever, fatigue, joint pain, recent trauma, travel, sick contacts or changes in weight or appetite. No risk factors for HIV were identified. Patient was afebrile with normal vital signs. On physical examination, isolated neck tenderness was noted without any redness or swelling. Range of motion was preserved. Nuchal rigidity, Kernig and Brudzinki’s sign were negative. Neuro exam revealed 5/5 motor strength in all extremities and intact sensation in all dermatomes. Normal reflexes were noted. Chest, cardiovascular, abdominal and extremities examination were unremarkable. Initial laboratory examination including CBC with differential, inflammatory markers, renal and liver function were within normal limits. X-ray was done and was unremarkable. A trial of muscle relaxants was given. On non-resolution of symptoms, An MRI of the cervical spine was offered which revealed a heterogenous intramedullary lesion raising suspicion for an intramedullary neoplastic lesion. Screening of entire CNS was otherwise unremarkable. To establish a specific diagnosis, patient underwent a posterior cervical laminectomy for tumor resection. Gross-total resection was not achieved due to drop in somatosensory potentials during intraoperative monitoring. Histopathological examination showed WHO grade 2 ependymoma. Patient had no significant motor neurological impairment after surgery. However, significant sensory and proprioceptive loss was observed due to posterior spinal approach. She remains progression free at 1 year with MRI with stable residual tumor.

Ryan Duffy has completed his Bachelors in Science from Appalachian State University. He is currently a fourth year medical student at Virginia Tech Carilion School of Medicine, a research intensive medical school in Roanoke, Virginia. After obtaining his MD in May, he will begin his residency training in Internal Medicine in June 2019.

Patients with sepsis often require large volumes of intravenous fluids during resuscitation. Historically, normal saline (NS) has been the default fluid for these patients. However, the composition of NS does not reflect physiologic concentrations of electrolytes and recent studies have associated NS administration with increased risk of hyperchloremic metabolic acidosis and kidney injury. In 2015, our institution’s Emergency Department (ED) began using normosol, a more balanced crystalloid as their default resuscitation fluid. We performed a retrospective before and after cohort study of all patients admitted through our facility’s ED with a diagnosis of sepsis, severe sepsis, or septic shock during two six month periods, when either NS or normosol was used as the default resuscitation fluid. Regression modeling controlling for baseline characteristics and 24h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol TM-R cohort were found to have a lower rate of hyperchloremia at 72 h post admission (28% vs., 13%, P<0.0001).

Leanne Price currently works for the Acute Hospital At Home (AHAH) department at Dorset County Hospital. C Wilson completed his Under Graduate Medical Degree from Bristol Univeristy in 2017. He currently works for the Acute Hospital At Home (AHAH) department at Dorset County Hospital.

The National Diabetes Foot Care Audit (NDFA) estimates that the cost of diabetic foot disease to the NHS in England is £1 billion per annum. Our service manages patients with diabetic foot ulcers in the community. This should result in financial gains and improved patient outcomes whilst in accordance with the national objective of managing patients in the community. Our Acute Hospital at Home (AHAH) service is run by a multidisciplinary team including medical consultants, junior doctors, microbiologists, nurses’ physiotherapists and healthcare assistants. A virtual ward round occurs daily in addition to a flexible ability to review patients either in hospital or at home. We have performed a retrospective analysis from a snapshot of 20 patients to provide initial data and are currently analyzing an increased cohort of patients in this study. The primary clinical outcomes include length of hospital admission, amputation rates, readmission, patient satisfaction and potential cost implications. The snapshot study showed patients managed through AHAH had shorter length of inpatient stays: 4 days compared to 15. This results in a saving of £1980 per patient per admission. We are confident that our larger study will continue to prove equivalence in rates of amputations, readmissions and death. To date our results demonstrate clear benefits of managing patients with diabetic foot ulcers in the community. Not only clear cost advantages but also significantly improved patient satisfaction. We believe that the AHAH service is a safe and hugely valuable clinical service which could be widely applied across healthcare.

Nikoletta Daoulari is a Internal Medicine Resident at General Hospital of RIO, University of Patras, Greece. Her research inter¬est is Internal Medicine. She also worked as Assistant in Emer¬gency Department at Hospital Brugmann Bruxelles.

Background: Deficiency of vitamin B12 (cobalamin) is a well-known cause of megaloblastic anemia. It is a reversible cause of bone marrow failure and demyelinating nervous system disorder, hence early detection and prompt treatment of vitamin B12 deficiency is essential. Documented symptomatic pancytopenia related to B12 deficiency is very rare representing less than 5% cases making the diagnosis in emergency department more challenging. Clinical case: A 52-year old woman with a history of Graves Basedow’s disease is sent by her generalist to the emergency department to be transfused for severe anemia found in blood test without any other information. Her complaints of extreme tiredness and dyspnea at the least effort aggravated this past week without signs of melena or hematemesis. She describes having lost 13 kilos in a 3-month period and loss of appetite. No chest pain but sometimes palpitations. She has been put on propylthiouracil stopped two months ago. No others medications, no drugs but consummation of alcohol 2-3 glasses per day the last 25 years. In physical examination she is pale and icteric but the rest is normal. She has no fever and her electrocardiography reveals sinus rhythm without evidence of myocardial ischemia. Laboratory testing reveals a profound pancytopenia with severe macrocytosis, no blasts, LDH 4860 UI/L and indirect bilirubin 1.6 mg/dL. The rest was normal and further workup for the cause of pancytopenia revealed non-measurable levels of B12 and folic acid. Direct Coombs was negative. Treatment with intramuscular injection of B12 and folic acid POS was started and control with abdominal scanning and gastroscopy were scheduled during hospitalization to investigate the cause of B12 deficiency. After one week of treatment laboratory testing control shows retreat of pancytopenia Conclusions: Vitamin B12 deficiency is a rare condition and the presentation with severe pancytopenia is challenging for the emergency physicians. Prompt treatment in emergency department without waiting the results of levels of B12 must be considered to avoid deterioration of neurological condition with serious consequences for the quality of patient’s life.

Marjan Zaletel has completed his PhD in University of Ljubljana and Postdoctoral studies from University Clinical Centre of Lju-bljana. He has worked as Professor of Neurology in Ljubljana Clinical Centre. He has published more than 50 papers in reput¬ed journals and has been serving as a Consultant Neurologist in the Pain Clinic of Ljubljana.

Background: First, we wanted to obtain as much as possible in depth information about the headache prevalence among the Slovenian adults based on a complex analysis of the available data. Methods: The study data were collected in the frame of the continuous monitoring of behavioral factors for non-communicable diseases in Slovenia according to the CINDI Health Monitor methodology. The analysis included data for 2012. In total, 9498 adults aged 25−74 years were included. In the multivariate model, a headache was observed in the last month prior the survey, while as the explanatory factors behavioral, demographic and socioeconomic factors were observed. Results: The prevalence of headache in the last month prior the survey was 38.1%. Analysis showed that with the observed outcome the following factors were most strongly associated: risky stress behavior (or yes:no = 2.04, p < 0.001), sleeping behavior (or 6-7 hr: ≥8 hr = 1.25, p<0.001; or <6 hr:≥8 hr =1.45, p<0.001), coffee drinking behavior (or upto 1 cup:0=1.30, p=0.003; or>1 cup:0=1.63, p<0.001), alcoholic beverages consumption habits (or yes: no =0.79, p<0.001), sex/gender (or females:males = 1.96, p < 0.001), age ( 25-29:70-74 = 5.67, p < 0.001, or 30-39:70-74=3.60, p<0.001, OR40-49:70-74 = 2.76, p < 0.001, OR50-59:70-74 = 1.76, p<0.001, OR60-69:70-74 =1.41, p=0.015), persons under 18 years of age in the household (or yes: no = 1.14, p = 0.039), Conclusion: The study showed where potential holdings of headache management at the population level, as well as at the level of individuals are at risk and suggests the need to develop appropriate policies for managing this major public health problem.

Ivan Jeremic has completed his Research Master’s Degree in Rheumatology from Belgrade School of Medicine and Clinical medicine PhD candidate at Novi Sad University.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe, potentially life-threatening idiosyncratic drug reaction, usually caused by anti-epileptics, antibiotics or non-steroidal anti-inflammatory drugs, after a latency period of three weeks to three months. Typical clinical features include mucocutaneous rash, fever, lymphadenopathy and internal organ involvement. We report a patient with systemic sclerosis, rheumatoid arthritis and osteoporosis, who developed possible DRESS syndrome to lamotrigine, used to treat epilepsy. Clinical features suggesting DRESS syndrome includes severe rash, fever, lymphocytopenia and thrombocytopenia. The condition was initially unsuccessfully treated as an acute allergic reaction to ibandronate with parenteral glucocorticosteroid and antihistamine. This report aims to increase the awareness of this rare entity in the rheumatology community.