Analgesic and psychoactive drugs in the chronic pain patient

In contrast to the management of pain in patients with malignant disease, where manipulation of analgesic and psychoactive drugs may be necessary and effective, the elimination of drug use is a primary goal in programs for patients with chronic pain of benign rig in.; Drug use is often a significant component of pain behavior and, therefore, it is important to alter the use of drugs in freeing the patient of the chronic pain syndrome. Elimination of the unwanted side effects and medical complications of drug use may contribute significantly to the patient's physical and psychological well-being. Also, because many of these drugs are associated with physiological or psychological dependency, it also becomes important to identify and treat drug abuse and chemical dependency, which is a primary problem in a subgroup of chronic pain patients. This discussion will focus on the relationship of drug use to chronic pain behavior and methods of medication withdrawal. In addition, the problems of chemical dependency and its identification and management will be discussed.J Orthop Sports Phys Ther 1984;5(6):315-317.     

The UK pre-hospital management of burn patients: current practice and the need for a standard approach

INTRODUCTION: In any system of burn care, first-aid, packaging and transportation of the burn injured patient from outside of hospital is a most important contribution to the successful management and outcome. This study aimed to assess the current initial care of burn patients given by the statutory ambulance services and then compare this to a survey of opinions among the plastic surgery and burns consultants in the United Kingdom (UK). METHODS: In 1999, each of the UK ambulance services was contacted via a postal questionnaire. A similar survey was sent to all of the plastic surgery consultants within the UK (taken from the specialist register) therefore, canvassing the plastic surgeons who deal less commonly with burn patients as well as the burns units. RESULTS: A total of 58% of ambulance services said that they had no treatment policy for burns patients; 97% sent patients to their nearest A&E department; 84% of services employed cooling; 12 different types of dressing were used for burn patients; 74% of services used nalbuphine hydrochloride and 97% used entonox; 74% services gave oxygen to all burn patients; 90% cannulated patients, with or without fluid administration.Plastic surgical opinion indicated that the most important aspects of basic first-aid should include: stopping the burning process; cooling (15 min (median)); airway, breathing and circulation assessment; clothing removal and dressings (clingfilm). Oxygen need not be given to all patients, but they should be kept warm and administered entonox and/or intravenous morphine. Most surgeons felt that patients should be taken to the nearest A&E and the majority of surgeons caring for this large group of patients did not have good and regular liaison with their local ambulance service. CONCLUSIONS: There seems to be a wide variation in the basic approach to the first-aid and pre-hospital care of burns patients. A significant improvement in management for this large and important group of patients is achievable, if a standard approach across all ambulance services could be achieved.     

Principles,protocols and patients: the practical management of a limit in ICU

The definition and management of a limit is a common but sometimes extremely complex problem in the Intensive Care Unit (ICU). Guidelines and consensus documents have been published in order to help clinicians. Yet, many controversial issues are brought into question. Legal rules are sometimes vague and derive more from the interpretation of various and unrelated principles (which vary from country to country) than from a clear ad hoc law. In this sense, the practical management of a limit in ICU is usually run by a dual normativity: an external one, which derives from the cultural, moral and legal values of the society, and an internal one, which depends on the particular clinical and human situation, namely the values of everybody involved in (the patient, his/her relatives, the health staff) and the relationships among these people. The considerable freedom left for the decision by an open communication is a great and favourable potential which must be used in the interest of the patient's and of his/her family.     

An observational study into the management of arteriomegaly: a call for a revised classification system

INTRODUCTION

Arteriomegaly is the diffuse ectasia of arteries with or without aneurysmal disease. Patients with arteriomegaly have a higher incidence of morbidity including limb loss compared to patients with other arteriopathies. The aim of this observational study was to review the management of these patients in our institution.

METHODS

Radiologists and surgeons prospectively reviewed aortofemoral angiography. Patients with arteriomegaly were identified. Data relating to demographics, mode of presentation, risk factors, type of arteriomegaly, management and progression of disease were analysed.

RESULTS

Arteriomegaly was identified in 1.3% of patients (n=69) undergoing lower limb angiography in the study period. Of these, the majority (n=67) were men. The mean age was 74 years (range: 60–89 years) and 76% were smokers. Co-morbidities included coronary artery disease (55%), diabetes mellitus (20%), hypertension (45%) and cerebrovascular events (6%). Fortynine patients presented with critical limb ischaemia and eighteen patients were seen electively in the outpatients department with symptoms of intermittent claudication. Data were incomplete for two male patients and were therefore not included. At presentation, 22 patients were classified as Hoi lier type I, 5 were type II and 9 were type III. Thirty-one patients had arteriomegalic vessels but no aneurysmal disease.After a median follow-up duration of 76 months (range: 6–146 months), 34 patients progressed to type I, 2 to type II and 18 to type III. Thirteen remained without aneurysmal disease. Twenty-nine patients required angioplasty and twenty-eight required bypass surgery during this time. In total, 102 procedures were required for complicated disease. The limb salvage rate was 92%. Although 8 patients in our series died, the remaining 59 are under regular follow up.

CONCLUSIONS

This study illustrates the progressive nature of arteriomegaly. Results of the management of these patients in our institution are similar to those in the literature. We suggest an additional fourth category to Hollier’s classification that describes arteriomegalic disease without aneurysmal degeneration as this, too, deserves special management. Regular follow-up visits and early intervention for patients with arteriomegaly is advocated to reduce the high incidence of morbidity.     

Undetected injuries: a preventable cause of increased morbidity and mortality

A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) required management in the intensive care unit. Eight patients died (44%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma care centers does much to reduce unnecessary morbidity and mortality.     

Non-metastatic castrate-resistant prostate cancer: a call for improved guidance on clinical management

Background

Guidelines on the clinical management of non-metastatic castrate-resistant prostate cancer (nmCRPC) generally focus on the need to continue androgen deprivation therapy and enrol patients into clinical trials of investigational agents. This guidance reflects the lack of clinical trial data with established agents in the nmCRPC patient population and the need for trials of new agents.

Aim

To review the evidence base and consider ways of improving the management of nmCRPC.

Conclusion

Upon the development of castrate resistance, it is essential to rule out the presence of metastases or micrometastases by optimising the use of bone scans and possibly newer procedures and techniques. When nmCRPC is established, management decisions should be individualised according to risk, but risk stratification in this diverse population is poorly defined. Currently, prostate-specific antigen (PSA) levels and PSA doubling time remain the best method of assessing the risk of progression and response to treatment in nmCRPC. However, optimising imaging protocols can also help assess the changing metastatic burden in patients with CRPC. Clinical trials of novel agents in nmCRPC are limited and have problems with enrolment, and therefore, improved risk stratification and imaging may be crucial to the improved management. The statements presented in this paper, reflecting the views of the authors, provide a discussion of the most recent evidence in nmCRPC and provide some advice on how to ensure these patients receive the best management available. However, there is an urgent need for more data on the management of nmCRPC.

     

Adopting the pre-hospital index for interfacility helicopter transport: a proposal

BACKGROUND: Interfacility helicopter transport is expensive without proven outcome benefit in trauma patients. Our objectives were to determine the fastest method of rural to urban interfacility transport, and develop a triage tool to identify patients most in need of rapid transport. METHODS: Retrospective cohort study. Adults ISS > or = 12 transported from January 1996 to December 1998. Transport time variables were compared between geographical zones. A pre-transport index (PTI) identified two patient cohorts in which outcome was assessed. RESULTS: Air ambulance was faster than ground transport, with helicopter overall superior to fixed-wing (< 225 km range). Seventy-two percent of patients with PTI < 4 (n = 196) had no outcome indicating severe injury versus 29% of the PTI > or = 4 cohort (n=151). Mortality for PTI<4 was 1.4% versus 22% for PTI > or = 4. CONCLUSION: Interfacility helicopter transport of severely injured rural trauma patients was the overall fastest method within a 225 km range. PTI > 4 identifies patients most in need of this fast but expensive method of transport.     

The impact of clinical protocols in the management of severe sepsis: a prospective cohort study

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.     

Antiplatelet drugs: a review of their pharmacology and management in the perioperative period

In the normal course of the delivery of care, anesthesiologists encounter many patients who are receiving drugs that affect platelet function as a fundamental part of primary and secondary management of atherosclerotic thrombotic disease. There are several antiplatelet drugs available for use in clinical practice and several under investigation. Aspirin and clopidogrel (alone and in combination) have been the most studied and have the most favorable risk-benefit profiles of drugs currently available. Prasugrel was recently approved for patients with acute coronary syndrome undergoing percutaneous interventions. Other drugs such as dipyridamole and cilostazol have not been as extensively investigated. There are several newer investigational drugs such as cangrelor and ticagrelor, but whether they confer significant additional benefits remains to be established. Management of patients who are receiving antiplatelet drugs during the perioperative period requires an understanding of the underlying pathology and rationale for their administration, pharmacology and pharmacokinetics, and drug interactions. Furthermore, the risk and benefit assessment of discontinuing or continuing these drugs should be made bearing in mind the proposed surgery and its inherent risk for bleeding complications as well as decisions relating to appropriate use of general or some form of regional anesthesia. In general, the safest approach to prevent thrombosis seems to be continuation of these drugs throughout the perioperative period except where concerns about perioperative bleeding outweigh those associated with the development of thrombotic occlusion. Knowledge of the pharmacodynamics and pharmacokinetics of antiplatelet drugs may allow practitioners to anticipate difficulties associated with drug withdrawal and administration in the perioperative period including the potential for drug interactions.     

Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review

ObjectiveTo identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research.MethodsSeven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1 year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications).Results124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8–72; 60% male), with a mean follow-up of 34.9 months (range 12–264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4–6 weeks (39% of studies), with a further 4–6 weeks of partial weight bearing (51% of studies), resulting in 9–12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10 kg (28%), 10 kg–20 kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r = 0.465, p = 0.029) and Schatzker type IV–VI (r = 0.614, p < 0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3–6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0–26%) for abnormal varus/valgus and 1% (range 0–22%) for non-union or delayed union.ConclusionsPostoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9–12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.