Determinants of inappropriate acute pain management in old people unable to communicate verbally in the emergency department

Objectives: Poor pain management is relevant among individuals unable to communicate verbally (UCV). Analgesia may be due to three determinants: patients' status, physician's characteristics and pain etiology. Our aim is to investigate the association between prescription of ED pain treatment and these determinants. Materials and Methods: An observational prospective study including UCV patients was conducted. Severity of pain was evaluated by ALGOPLUS Scale and a score P â¥Â 2 out of 5 on the pain scale was retained as the threshold for the presence of acute pain in elderly UCV patients. Results: Our data showed that only 31,9% of UCV patients received a pharmacological treatment. The presence of the caregiver would influence the rate of therapy administration [OR 6,19 (95% CI 2,6â14,75)]. The presence of leg pain [OR 0,32 (95% CI 0,12â0,86)] and head pain [OR 0,29 (95% CI 0,10â0,84)] were less likely associated to receive analgesia. Pain related to trauma [OR 4.82 (95% CI 1.17 to 19.78)] and youngest physicians [OR 1.08 (95% CI 1.001 to 1.18)] were variables associated with the administration of drugs opiates. Discussion: Older UCV patients presenting to the ED with pain are at high risk of inadequate analgesia. Providers should always suspect presence of pain and an increasing need for behavioural pain evaluation is necessary for a complete assessment. Conclusions: Presence of a caregiver influences a more appropriate pain management in these patients. Staff training on pain management could result in better assessment, treatment, and interaction with caregivers. Keywords: Emergency department, Pain, Oligoanalgesi

Reduced thiamine availability and hyperglycemia impair thiamine transport in renal glomerular cells through modulation of thiamine transporter 2

Thiamine helps transketolase in removing toxic metabolites, counteracting high glucose-induced damage in microvascular cells, and progression of diabetic retinopathy/nephropathy in diabetic animals. Diabetic subjects show reduced thiamine levels. Hyperglycemia and reduced thiamine availability concur in impairing thiamine transport inside the blood-retinal barrier, with thiamine transporter-2 (THTR2) primarily involved. Here, we examined the behavior of thiamine transporter-1 (THTR1), THTR2, and their transcription factor Sp1 in response to high glucose and altered thiamine availability in renal cells involved in diabetic nephropathy. Human proximal tubule epithelial cells, podocytes, glomerular endothelial, and mesangial cells were exposed to high glucose and/or thiamine deficiency/oversupplementation. Localization and modulation of THTR1, THTR2, and Sp1; intracellular thiamine; transketolase activity; and permeability to thiamine were examined. Reduced thiamine availability and hyperglycemia impaired thiamine transport and THTR2/Sp1 expression. Intracellular thiamine, transketolase activity, and permeability were strongly dependent on thiamine concentrations and, partly, excess glucose. Glomerular endothelial cells were the most affected by the microenvironmental conditions. Our results confirmed the primary role of THTR2 in altered thiamine transport in cells involved in diabetic microvascular complications. Lack of thiamine concurs with hyperglycemia in impairing thiamine transport. Thiamine supplementation could represent a therapeutic option to prevent or slow the progression of these complications

Effect of the Monocyte Chemoattractant Protein-1/CC Chemokine Receptor 2 System on Nephrin Expression in Streptozotocin-Treated Mice and Human Cultured Podocytes

OBJECTIVE-Monocyte chemoattractant protein-1 (MCP-1), a chemokine binding to the CC chemokine receptor 2 (CCR2) and promoting monocyte infiltration, has been implicated in the pathogenesis of diabetic nephropathy. To assess the potential relevance of the MCP-1/CCR2 system in the pathogenesis of diabetic proteinuria, we studied in vitro if MCP-1 binding to the CCR2 receptor modulates nephrin expression in cultured podocytes. Moreover, we investigated in vivo if glomerular CCR2 expression is altered in kidney biopsies from patients with diabetic nephropathy and whether lack of MCP-1 affects proteinuria and expression of nephrin in experimental diabetes. RESEARCH DESIGN AND METHODS-Expression of nephrin was assessed in human podocytes exposed to rh-MCP-1 by immunofluorescence and real-time PCR. Glomerular CCR2 expression was studied in 10 kidney sections from patients with overt nephropathy and eight control subjects by immunohistochemistry. Both wild-type and MCP-1 knockout mice were made diabetic with streptozotocin. Ten weeks after the onset of diabetes, albuminuria and expression of nephrin, synaptopodin, and zonula occludens-1 were examined by immunofluorescence and immunoblotting. RESULTS-In human podocytes, MCP-1 binding to the CCR2 receptor induced a significant reduction in nephrin both mRNA and protein expression via a Rho-dependent mechanism. The MCP-1 receptor, CCR2, was overexpressed in the glomerular podocytes of patients with overt nephropathy. In experimental diabetes, MCP-1 was overexpressed within the glomeruli and the absence of MCP-1 reduced both albuminuria and downregulation of nephrin and synaptopodin. CONCLUSIONS-These findings suggest that the MCP-1/CCR2 system may be relevant in the pathogenesis of proteinuria in diabetes

Disturbo dell’equilibrio nel paziente con BPCO riacutizzata: efficacia del training cardiorespiratorio

Introduzione - Nella nostra esperienza clinica, confermata da diverse evidenze di letteratura il paziente con BPCO presenta spesso un deficit di equilibrio e del controllo posturale. Quest\u2019alterazione risulta correlata a un aumentato rischio di caduta e quindi all\u2019incremento delle comorbidit\ue0 associate e dei costi diretti e indiretti per questa patologia. Appare quindi di fondamentale importanza un\u2019accurata valutazione di questa funzione utilizzando strumenti il pi\uf9 possibile riproducibili e oggettivi. Attualmente quelli pi\uf9 comunemente utilizzati sono le scale di valutazione Berg Balance Scale (BBS) e la Balance Evaluation Systems Test (BESTest). Per quanto validate e attendibili, queste scale sono metodiche operatore-dipendente, pertanto oggetto di bassa riproducibilit\ue0 inter-operatore. Da questa osservazione deriva la necessit\ue0 di standardizzare questo tipo valutazione attraverso strumenti che garantiscano risultati riproducibili esenti da bias legati al singolo operatore. In quest\u2019ottica, il presente studio si propone d\u2019inserire nell\u2019iter di valutazione l\u2019esame di stabilit\ue0 posturale attraverso una pedana stabilometrica. Abbiamo inoltre voluto valutare se il training cardio-respiratorio, al quale sono sottoposti i pazienti affetti da BPCO nelle prime due settimane di trattamento, incidesse positivamente sul deficit di equilibrio, migliorando oltre la resistenza allo sforzo anche la stabilit\ue0 e quindi la sicurezza dei pazienti. Materiali e Metodi - Lo studio \ue8 stato eseguito presso l\u2019U. O. dell\u2019Ospedale San Carlo di Milano, tra febbraio e maggio 2019. Sono stati arruolati dieci pazienti, di et\ue0 compresa fra i 55 e gli 85 anni. I pazienti, durante la degenza, sono stati sottoposti unicamente al training cardio-respiratorio standard, oltre alla terapia medica adeguata a ciascun caso. Non sono stati eseguiti esercizi specifici per il miglioramento dell\u2019equilibrio. Sono stati rilevati i dati di emogasanalisi arteriosa, six minutes walking test, rilevazione della scala di GOLD e MRC, all\u2019inizio e alla fine del programma riabilitativo. Contestualmente \ue8 stata effettuata una valutazione in due tempi su pedana stabilometrica, oltre alla somministrazione della scala BBS. Le variabili considerate sono state: la frequenza di oscillazione del punto di proiezione del baricentro su pedana (misurata in Hz), l\u2019ampiezza totale di oscillazione (misurata in unit\ue0 pari alla minima variazione percettibile dallo strumento, pari a circa 0,5 mm) e l\u2019area dell\u2019ellissoide disegnato da tale proiezione (misurata in unit\ue0 quadratiche con intervallo di confidenza del 90%) Le valutazioni sono state eseguite al momento dell\u2019accesso presso l\u2019U.O. di Riabilitazione Intensiva Cardiopolmonare e al servizio di Fisioterapia e sono state ripetute a distanza di due settimane dalla prima valutazione. Come variabile di confronto \ue8 stata utilizzata la valutazione spirometrica per attestare il contestuale miglioramento della performance respiratoria, oltre all\u2019 emogasanalisi e alle scale di valutazione riportate. Risultati - Fino ad ora si \ue8 assistito a un miglioramento sia nei dati stabilometrici sopra riportati, sia in quelli rilevati attraverso la scala di valutazione BBS, parallelamente a un miglioramento della performance respiratoria misurati attraverso spirometria. Tutti i risultati sono provvisori e richiedono un parziale incremento di dimensioni del campione e una pi\uf9 accurata analisi statistica. Conclusioni I risultati preliminari sembrerebbero confermare l\u2019ipotesi secondo la quale la riacutizzazione della patologia BPCO, provochi nei pazienti, soprattutto se ipercapnici, un disturbo dell\u2019equilibrio, che migliora con la regolarizzazione degli scambi gassosi. Bibliografia - De Castro LA, Ribeiro LR, Mesquita R, et al. Static and functional balance in individuals With COPD: comparison with healthy controls and differences according to sex and disease severity. Respir Care 2016; 61: 1488\u20131496. Beuchamp MK, Balance assessment in people with COPD: An evidence-based guide. Chron Resp Dis 2018; 16: 1\u20138

Heat shock protein expression in diabetic nephropathy

Heat shock protein (HSP) HSP27, HSP60, HSP70, and HSP90 are induced by cellular stresses and play a key role in cytoprotection. Both hyperglycemia and glomerular hypertension are crucial determinants in the pathogenesis of diabetic nephropathy and impose cellular stresses on renal target cells. We studied both the expression and the phosphorylation state of HSP27, HSP60, HSP70, and HSP90 in vivo in rats made diabetic with streptozotocin and in vitro in mesangial cells and podocytes exposed to either high glucose or mechanical stretch. Diabetic and control animals were studied 4, 12, and 24 wk after the onset of diabetes. Immunohistochemical analysis revealed an overexpression of HSP25, HSP60, and HSP72 in the diabetic outer medulla, whereas no differences were seen in the glomeruli. Similarly, exposure neither to high glucose nor to stretch altered HSP expression in mesangial cells and podocytes. By contrast, the phosphorylated form of HSP27 was enhanced in the glomerular podocytes of diabetic animals, and in vitro exposure of podocytes to stretch induced HSP27 phosphorylation via a P38-dependent mechanism. In conclusion, diabetes and diabetes-related insults differentially modulate HSP27, HSP60, and HSP70 expression/phosphorylation in the glomeruli and in the medulla, and this may affect the ability of renal cells to mount an effective cytoprotective response. Copyrigh