Which factors can aid clinicians to identify a risk of pain during the following month in patients with bone metastases? A longitudinal analyses.

PURPOSE: Explore clinical factors associated with higher pain intensity and future pain in patients with bone metastases to identify patients who can benefit from closer follow-up or pain-modifying interventions. METHODS: This is a secondary analysis of 606 patients with bone metastases included in a multicenter longitudinal study. The dependent variables were "average pain" and "worst pain" in the last 24 h (0-10 NRS). Twenty independent variables with potential association to pain intensity were selected based on previous literature. Cross-sectional analyses were performed with multiple linear regression to explore factors associated with pain intensity at baseline. Longitudinal data were analyzed with a generalized equation models to explore current factors associated with pain intensity at the next visit in 1 month. RESULTS: Current pain intensity (p < 0.001), sleep disturbances (p 0.01 and 0.006), drowsiness (p 0.003 and 0.033) and male gender (p 0.045 and 0.001) were associated with higher average and worst pain intensity in 1 month. In addition, breakthrough pain was related to higher worst pain intensity (p 0.003) in 1 month. The same variables were also associated with higher average pain intensity at baseline. CONCLUSION: Higher current pain intensity, sleep disturbances, drowsiness, male gender, and breakthrough pain are factors associated with higher pain intensity in patients with bone metastases at the next follow-up in 1 month. These factors should be assessed in clinical practice and may aid clinicians in identifying patients that can benefit from closer follow-up or interventions to prevent lack of future pain control. TRIAL REGISTRATION IN CLINICALTRIALS.GOV : NCT01362816.

Population-based analysis of the impact of trauma on longer-term functional outcomes.

BACKGROUND: Functional outcome measures are important as most patients survive trauma. The aim of this study was to describe the long-term impact of trauma within a healthcare region from a social perspective. METHODS: People active in work or education and admitted to hospitals in Central Norway in the interval 1 June 2007 to 31 May 2010 after sustaining trauma were included in the study. Clinical data were linked to Norwegian national registers of cause of death, sickness and disability benefits, employment and education. Primary outcome measures were receipt of medical benefits and time to return to preinjury work level. Secondary outcome measures were mortality within 30 days or during follow-up. RESULTS: Some 1191 patients were included in the study, of whom 193 (16·2 per cent) were severely injured (Injury Severity Score greater than 15). Five years after injury, the prevalence of medical benefits was 15·6 per cent among workers with minor injuries, 22·3 per cent in those with moderate injuries and 40·5 per cent among workers with severe injuries. The median time after injury until return to work was 1, 4 and 11 months for patients with minor, moderate and severe injuries respectively. Twelve patients died within 30 days and an additional 17 (1·4 per cent) during follow-up. CONCLUSION: Patients experiencing minor or major trauma received high levels of medical benefits; however, most recovered within the first year and resumed preinjury work activity. Patients with severe trauma were more likely to receive medical benefits and have a delayed return to work. Registration number: NCT02602405 (http://www.clinicaltrials.gov).

Trauma care in a combined rural and urban region: an observational study.

BACKGROUND: The available information on trauma care in mixed rural-urban areas with scattered populations is limited. The aim of this study is to describe epidemiology, resource use, transfers and outcomes for trauma care within such an area, prior to implementation of a formal trauma system. METHODS: A multicentre observational study including potential severely injured patients from June 2007 to May 2010. All patients received by trauma teams at seven acute care hospitals (ACH) and one major trauma centre (MTC) were included. Major trauma was defined as Injury Severity Score (ISS) > 15. RESULTS: A total of 2323 patients were included. ACH received 1330 patients and delivered definite care to 85% of these. Only 329 (14%) patients were major trauma of which 134 (41%) were initially received at an ACH. Nine per cent of patients were transferred between hospitals. After inter-hospital transfers, 79% of all major trauma patients received definite care at the MTC. Helicopter emergency services admitted 52% of major trauma and performed 68% of inter-hospital transfers from ACH to MTC. Forty-eight patients (2%) died within 30 days. CONCLUSION: In a region with a dispersed network of hospitals, geographical challenges, and low rate of major trauma cases, efforts should be made to identify patients with major trauma for treatment at a MTC as early as possible. This can be done by implementing triage and transfer guidelines, maintaining competence at ACHs for initial stabilization, and sustaining an organization for effective inter-facility transfers.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival.

BACKGROUND: Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS: Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS: The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION: Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Chronic postsurgical pain in patients 5 years after cardiac surgery: A prospective cohort study.

BACKGROUND: Chronic postsurgical pain (CPSP) is a common complication after many surgical procedures, including cardiac surgery. The prevalence of CPSP after cardiac surgery ranges from 9.5% to 56%. Most studies on CPSP after cardiac surgery are retrospective and long-term prospective studies are scarce. The aim of this study was to follow CPSP and health-related quality of life (HRQOL) prospectively in a cohort of patients, emphasizing the prevalence from 12 months to 5 years. METHODS: A total of 534 patients (23% ≥75 years, 67% men) were consecutively included before surgery. Study-specific questionnaires and the Brief Pain Inventory (BPI) were used to measure CPSP at baseline, 12 months and 5-year follow-up. Short-Form Health Survey (SF-36) was used to measure HRQOL. RESULTS: Among 458 patients who were alive after 5 years, 82% responded (n = 373). The majority, 89.8% (335/373), did not report CPSP, neither 12 months nor 5 years after surgery. Among the 38 patients who reported CPSP after 12 months, 24 (63%) patients did not report CPSP after 5 years. The overall prevalence of CPSP after 5 years was 3.8% (14/373). Patients reporting CPSP and resolved CPSP had lower scores on HRQOL and more pain preoperatively than patients who did not report CPSP. CONCLUSIONS: The prevalence of CPSP was lower in this study than previously reported. Among the patients reporting CPSP at 12 months, 63% did not report CPSP after 5 years. Hence, the observed decline in CPSP is in line with studies evaluating CPSP in noncardiac surgery. SIGNIFICANCE: The prevalence of chronic postsurgical pain (CPSP) at 5 years after surgery of 3.8% is lower than previously reported. The majority of patients reporting CPSP after 12 months did not report CPSP after 5 years.

The rare Arg181Cys mutation in the µ opioid receptor can abolish opioid responses.

BACKGROUND: Genetic variability contributes to variable clinical response to opioids. This study emerged from the observation of three Norwegian patients who showed no or extraordinary poor response to very high doses of opioids. We suspected a genetic defect and applied a 'most likely candidate gene' approach to investigate this possibility. METHODS: DNA sequencing was used to search for mutations in coding regions of the OPRM1 gene, encoding the µ opioid receptor (hMOR), in one patient. The remaining two patients, and two cohorts comprising 2158 European cancer pain patients and 600 Norwegian healthy volunteers, respectively, were genotyped using a custom-made TaqMan SNP allelic discrimination assay. RESULTS: DNA sequencing disclosed a homozygous, inactivating Arg181Cys mutation in hMOR in the patient who showed no effects from opioids. The two patients with poor effect from very high doses of opioids were both heterozygous for the mutation. Six heterozygous patients identified among the European cancer patients all used high doses of opioids and/or reported inferior effect on their pain. About one in every 100 Norwegians is heterozygous for the mutation. CONCLUSIONS: The Arg181Cys mutation occurs at clinically relevant frequencies and produces a signaling dead hMOR which may abolish or significantly reduce opioid effects in affected individuals. Anesthesiologists and practitioners in pain medicine should be aware of this mutation as a possible explanation for inefficiency of opioids and consider genotyping in relevant cases. Individuals homozygous for the mutation may need a highly personalized approach to pain therapy.

Renal function and symptoms/adverse effects in opioid-treated patients with cancer.

BACKGROUND: Renal impairment and the risk of toxicity caused by accumulation of opioids and/or active metabolites is an under-investigated issue. This study aimed at analysing if symptoms/adverse effects in opioid-treated patients with cancer were associated with renal function. METHODS: Cross-sectional multicentre study (European Pharmacogenetic Opioid Study, 2005-2008), in which 1147 adult patients treated exclusively with only one of the most frequently reported opioids (morphine/oxycodone/fentanyl) for at least 3 days were analysed. Fatigue, nausea/vomiting, pain, loss of appetite, constipation and cognitive dysfunction were assessed (EORTC QLQ-C30). Glomerular filtration rate (GFR) was estimated using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI Creatinine) equations. RESULTS: Mild to severe low GFR was observed among 40-54% of patients. CG equation showed that patients with mild and moderate/severe low GFR on morphine treatment had higher odds of having severe constipation (P < 0.01) than patients with normal GFR. In addition, patients with moderate/severe low GFR on morphine treatment were more likely to have loss of appetite (P = 0.04). No other significant associations were found. CONCLUSION: Only severe constipation and loss of appetite were associated with low GFR in patients treated with morphine. Oxycodone and fentanyl, in relation to the symptoms studied, seem to be safe as used and titrated in routine cancer pain care.

The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review.

BACKGROUND: The present systematic review analysed the existing evidence of analgesic efficacy and side effects of opioids without and with adjuvant analgesics delivered by neuraxial route (epidural and subarachnoid) in adult patients with cancer. METHODS: Search strategy was elaborated with words related to cancer, pain, neuraxial route, analgesic and side effects. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. Studies were analysed according to methods, results, quality of evidence, and strength of recommendation. RESULTS: The number of abstracts retrieved was 2147, and 84 articles were selected for full reading. The final selection comprised nine articles regarding randomised controlled trials (RCTs) divided in four groups: neuraxial combinations of opioid and adjuvant analgesic compared with neuraxial administration of opioid alone (n = 4); single neuraxial drug in bolus compared with continuous administration (n = 2); single neuraxial drug compared with neuraxial placebo (n = 1); and neuraxial opioid combined with or without adjuvant analgesic compared with other comprehensive medical management than neuraxial analgesics (n = 2). The RCTs presented clinical and methodological diversity that precluded a meta-analysis. They also presented several limitations, which reduced study internal validity. However, they demonstrated better pain control for all interventions analysed. Side effects were described, but there were few significant differences in favour of the tested interventions. CONCLUSION: Heterogeneous characteristics and several methodological limitations of the studies resulted in evidence of low quality and a weak recommendation for neuraxial administration of opioids with or without adjuvant analgesics in adult patients with cancer.

Evidence of peripheral nerve blocks for cancer-related pain: a systematic review.

The European Association for Palliative Care has initiated a comprehensive program to achieve an over-all review of the evidence of multiple cancer pain management strategies in order to extend the current guideline for treatment of cancer pain. The present systematic review analyzed the existing evidence of analgesic efficacy for peripheral nerve blocks in adult patients with cancer. A search strategy was elaborated with words related to cancer, pain, peripheral nerve and block. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. The number of abstracts retrieved was 155. No controlled studies were identified. Sixteen papers presented a total of 79 cases. The blocks applied were paravertebral blocks (10 cases), blocks in the head region (2 cases), plexus blocks (13 cases), intercostal blocks (43 cases) and others (11 cases). In general, most cases reported good pain relief and no side effects. The use of peripheral blocks is based upon anecdotal evidence. However, this review only demonstrates the lack of studies, which does not equal a lack of effectiveness.

Concentrations of remifentanil, propofol, fentanyl, and midazolam during rewarming from therapeutic hypothermia.

BACKGROUND: The clearance of sedatives and analgesics may be reduced by therapeutic hypothermia. However, little is known about the concentrations of such drugs during rewarming. The aim of this study was to describe the serum concentrations of sedatives and analgesics during rewarming from therapeutic hypothermia. METHODS: Blood samples were collected for quantification of drug concentrations in 22 patients given analgesia/sedation with either remifentanil/propofol or fentanyl/midazolam during rewarming from therapeutic hypothermia (33-34°C) after cardiac arrest. Samples for were drawn before (-2 h) and during rewarming (0-8 h). Linear mixed effects models were used to describe serum concentrations and adjust for rates of infusion during rewarming from therapeutic hypothermia. RESULTS: Subjects with samples analyzed were remifentanil (n = 8), propofol (n = 14), fentanyl (n = 8), and midazolam (n = 8). Age, body mass index, and simplified acute physiology score II [mean (standard deviation)] were 64 (14.2) years, 27.3 (3.7) kg/m(2), and 69 (13.2), respectively. While the concentration of fentanyl was not significantly affected by temperature, concentrations of remifentanil, propofol, and midazolam decreased with core temperature by 16%, 12%, and 11% (mean values) from 33°C to 37°C after adjusting for rates of infusion, respectively. CONCLUSION: Concentrations of remifentanil, propofol, and midazolam decreased during rewarming from therapeutic hypothermia when adjusting for rates of infusion. No changes were demonstrated for fentanyl.

Intensive care and traumatic brain injury after the introduction of a treatment protocol: a prospective study.

BACKGROUND: Traumatic brain injury (TBI) treatment protocols have been introduced in the intensive care unit (ICU) to avoid secondary brain injury. In this study, we aimed to evaluate the deviations from such a treatment protocol and the frequency of extracranial complications, and relate these findings to outcome. METHODS: During a 5-year period (2004-2009), 133 patients with severe TBI [Glasgow Coma Scale (GCS) score ≤ 8] were prospectively included. The following deviations from treatment goals were studied: intracranial pressure (ICP), blood pressure, haemoglobin, blood glucose, serum sodium, serum albumin, body temperature and extracranial complications during the ICU stay. Outcome was assessed using Glasgow Outcome Scale Extended score at 12 months. RESULTS: The frequencies of deviations from the treatment goals were: episodes of intracranial hypertension 69.5% (of monitored patients), hypotension 20.3%, anaemia 77.4%, hyperglycaemia 42.9%, hyponatremia 34.6%, hypoalbuminemia 30.8% and hyperthermia 54.9%. Pulmonary complications were common (pneumonia 72.2%, acute respiratory distress syndrome/acute lung injury 31.6%). Thrombocytopenia (4.5%), severe sepsis (3.0%), renal failure (0.8%) and liver failure (0.8%) were infrequent. Twenty-six (19.5%) patients died within the first 12 months due to the head injury. Age, GCS score, pupil dilation, Injury Severity Score (ISS), ICP > 25 mmHg, hyperglycaemia and pneumonia predicted a worse outcome. CONCLUSIONS: Deviations from the TBI treatment protocol were frequent. Pneumonia was the most frequent extracranial complication. Age, GCS score, pupil dilation, ISS, high ICP, hyperglycaemia and pneumonia predicted a worse outcome.

Nociceptive stimuli responses at different levels of general anaesthesia and genetic variability.

BACKGROUND: Changes in skin conductance (SC), clinical stress score (CSS), the bispectral index spectroscopy (BIS) index and the variation in the BIS index may be used to monitor responses to nociceptive stimuli. We wanted to examine these methods during noxious stimulation during general anaesthesia and if the responses were associated with variability in genes related to pain. METHODS: Sixty patients, given propofol to a BIS level of 40-50, were stimulated with standardised tetanic electrical stimuli during propofol infusion, plasma level of 3 µg/ml alone, or together with remifentanil target plasma level of 3 ng/ml or 10 ng/ml. The CSS, SC, BIS index and the variability of the BIS index were registered. The inter-individual variation in nociceptive responses was analysed for co-variation with genotypes of 89 single nucleotide polymorphisms from 23 candidate genes. RESULTS: During tetanic stimuli, CSS and SC increased significantly and were attenuated with increasing level of remifentanil, different from the BIS index and the variation in the BIS index. Polymorphisms in the P-glycoprotein (ABCB1), tachykinin 1 receptor (TACR1), dopamine receptor D3 (DRD3) and beta arrestin 2 (ARRB2) genes were associated with the co-variation in SC variables or CSS response or both during standardised nociceptive stimuli (P < 0.05). Because of no corrections for multiple testing, the genetic analyses are explorative, and associations must be tested in further studies. CONCLUSION: This exploratory study suggests genes that may be tested further with relation to nociceptive response during anaesthesia. SC and CSS may be useful tools for monitoring nociceptive response during general anaesthesia.

Genetic clustering of European cancer patients indicates that opioid-mediated pain relief is independent of ancestry.

The European Pharmacogenetic Opioid Study (EPOS) of a large series of European cancer patients treated with opioids was carried out to assess the influence of genetics on cancer pain relief. As response to opioid therapy was associated with the patients' country of origin, we tested whether population stratification might represent a confounding factor in the analysis of genetic control of response to opioid therapy. From the whole EPOS series representing 2294 patients' genotypes for 379 single-nucleotide polymorphisms (SNPs), we extracted 117 autosomal SNPs with minor allele frequency>0.28 to obtain highly informative genetic markers, and analyzed the SNPs in 1724 individuals showing <20% missing genotypes. Use of the AWclust program to detect clusters of genetically related individuals in the EPOS series showed that the 117-SNP panel distinguished four main European subgroups statistically associated with ethnicity, but not with country of origin or with the pain relief phenotype. Subethnic European groups of genetically related individuals exist that can be correctly identified using an ∼100-SNP panel. Such genetic clustering may control for admixture in association studies and may allow discrimination between genetic and environmental effects on phenotypes showing association with country of origin, as in the case of pain relief.

Is there a genetic cause for cancer cachexia? - a clinical validation study in 1797 patients.

BACKGROUND: Cachexia has major impact on cancer patients' morbidity and mortality. Future development of cachexia treatment needs methods for early identification of patients at risk. The aim of the study was to validate nine single-nucleotide polymorphisms (SNPs) previously associated with cachexia, and to explore 182 other candidate SNPs with the potential to be involved in the pathophysiology. METHOD: A total of 1797 cancer patients, classified as either having severe cachexia, mild cachexia or no cachexia, were genotyped. RESULTS: After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and the cachexia groups. However, consistent with prior reports, two SNPs from the acylpeptide hydrolase (APEH) gene showed suggestive statistical significance (P=0.02; OR, 0.78). CONCLUSION: This study failed to detect any significant association between any of the SNPs analysed and cachexia; although two SNPs from the APEH gene had a trend towards significance. The APEH gene encodes the enzyme APEH, postulated to be important in the endpoint of the ubiquitin system and thus the breakdown of proteins into free amino acids. In cachexia, there is an extensive breakdown of muscle proteins and an increase in the production of acute phase proteins in the liver.

How to switch from morphine or oxycodone to methadone in cancer patients? a randomised clinical phase II trial.

AIM: Opioid switching is a treatment strategy in cancer patients with unacceptable pain and/or adverse effects (AEs). We investigated whether patients switched to methadone by the stop and go (SAG) strategy have lower pain intensity (PI) than the patients switched over three days (3DS), and whether the SAG strategy is as safe as the 3DS strategy. METHODS: In this prospective, open, parallel-group, multicentre study, 42 cancer patients on morphine or oxycodone were randomised to the SAG or 3DS switching-strategy to methadone. The methadone dose was calculated using a dose-dependent ratio. PI, AEs and serious adverse events (SAEs) were recorded daily for 14 days. Primary outcome was average PI day 3. Secondary outcomes were PI now and AEs day 3 and 14 and number of SAEs. RESULTS: Twenty one patients were randomised to each group, 16 (SAG) and 19 (3DS) patients received methadone. The mean preswitch morphine doses were 900 mg/day in SAG and 1330 mg/day in 3DS. No differences between groups were found in mean average PI day 3 (mean difference 0.5 (CI -1.2-2.2); SAG 4.1 (CI 2.3-5.9) and 3DS 3.6 (CI 2.9-4.3) or in PI now. The SAG group had more dropouts and three SAEs (two deaths and one severe sedation). No SAEs were observed in the 3DS group. CONCLUSION: The SAG patients reported a trend of more pain, had significantly more dropouts and three SAEs, which indicate that the SAG strategy should not replace the 3DS when switching from high doses of morphine or oxycodone to methadone.

Influence from genetic variability on opioid use for cancer pain: a European genetic association study of 2294 cancer pain patients.

Cancer pain patients need variable opioid doses. Preclinical and clinical studies suggest that opioid efficacy is related to genetic variability. However, the studies have small samples, findings are not replicated, and several candidate genes have not been studied. Therefore, a study of genetic variability with opioid doses in a large population using a confirmatory validation population was warranted. We recruited 2294 adult European patients using a World Health Organization (WHO) step III opioid and analyzed single nucleotide polymorphisms (SNPs) in genes with a putative influence on opioid mechanisms. The patients' mean age was 62.5 years, and the average pain intensity was 3.5. The patients' primary opioids were morphine (n=830), oxycodone (n=446), fentanyl (n=699), or other opioids (n=234). Pain intensity, time on opioids, age, gender, performance status, and bone or CNS metastases predicted opioid dose and were included as covariates. The patients were randomly divided into 1 development sample and 1 validation sample. None of 112 SNPs in the 25 candidate genes OPRM1, OPRD1, OPRK1, ARRB2, GNAZ, HINT1, Stat6, ABCB1, COMT, HRH1, ADRA2A, MC1R, TACR1, GCH1, DRD2, DRD3, HTR3A, HTR3B, HTR2A, HTR3C, HTR3D, HTR3E, HTR1, or CNR1 showed significant associations with opioid dose in both the development and the validation analyzes. These findings do not support the use of pharmacogenetic analyses for the assessed SNPs to guide opioid treatment. The study also demonstrates the importance of validating findings obtained in genetic association studies to avoid reporting spurious associations as valid findings. To elicit knowledge about new genes that influence pain and the need for opioids, strategies other than the candidate gene approach is needed.

Content development for EUROPEAN GUIDELINES on the use of opioids for cancer pain: a systematic review and Expert Consensus Study.

Workpackage 3.1 (WP 3.1), within the European Palliative Research Collaborative (EPCRC), was aimed at critically revising and updating the European Association for Palliative Care recommendations on cancer pain management. The aim of this paper is to report the results of the first phase in the revision process which consists of a literature review and an expert consensus about the contents to be considered relevant in the development of the new guidelines. A systematic literature search was carried out from 2001 to 2008 through various databases including Medline, Cinahl, Cochrane Database of Systematic Reviews, Embase and Google. Through this process, guideline quality was evaluated, content was compared with EAPC recommendations and a first set of key-points was developed. A modified two-round Delphi method was applied to choose the most relevant topics for future systematic literature reviews. Fourteen guidelines on cancer pain management, published or updated after 2000, were retrieved. A comparison of these guidelines with the EAPC recommendations led to the formulation of 37 key-points, which were submitted to a panel of experts through a Delphi method. Through the responses given by the experts (25 after the first round and 19 after the second) and after a revision by the WP 3.1 local and steering committees, a final list of 22 topics was generated to answer all identified key-points. Each of these topics will be the object of systematic literature reviews. The final version of the "Evidence-based guidelines for the use of opioid analgesics in the treatment of cancer pain: the EAPC recommendations" will be based on the results of the 22 systematic literature reviews.

Cognitive dysfunction and health-related quality of life after a cardiac arrest and therapeutic hypothermia.

BACKGROUND: Evidence-based treatment protocols including therapeutic hypothermia have increased hospital survival to over 50% in unconscious out-of-hospital cardiac arrest survivors. In this study we estimated the incidence of cognitive dysfunctions in a group of cardiac arrest survivors with a high functional outcome treated with therapeutic hypothermia. Secondarily, we assessed the cardiac arrest group's level of cognitive performance in each tested cognitive domain and investigated the relationship between cognitive function and age, time since cardiac arrest and health-related quality of life (HRQOL). METHODS: We included 26 patients 13-28 months after a cardiac arrest. All patients were scored using the Cerebral Performance Category scale (CPC) and Mini-Mental State Examination (MMSE). Twenty-five of the patients were tested for cognitive function using the Cambridge Neuropsychological Test Automated Battery (CANTAB). These patients were tested using four cognitive tests: Motor Screening Test, Delayed Matching to Sample, Stockings of Cambridge and Paired Associate Learning from CANTAB. All patients filled in the Short Form-36 for the assessment of HRQOL. RESULTS: Thirteen of 25 (52%) patients were classified as having a cognitive dysfunction. Compared with the reference population, there was no difference in the performance in motor function and delayed memory but there were significant differences in executive function and episodic memory. We found no associations between cognitive function and age, time since cardiac arrest or HRQOL. CONCLUSION: Half of the patients had a cognitive dysfunction with reduced performance on executive function and episodic memory, indicating frontal and temporal lobe affection, respectively. Reduced performance did not affect HRQOL.

Chronic pain after cardiac surgery: a prospective study.

BACKGROUND: Chronic pain is a complication of several surgical procedures. The prevalence of chronic pain reported after cardiac surgery varies from 18% to 61%. However, most studies are retrospective, do not use validated instruments for pain measurement or include only pain at the sternum site. The aim of the present study was to assess chronic pain and health-related quality of life (HRQOL) after cardiac surgery. METHODS: In a prospective, population-based study, we included 534 patients (413 males) and assessed chronic pain and HRQOL before, 6 months after, and 12 months after cardiac surgery. Pain was measured by the Brief Pain Inventory, while HRQOL was measured by the Short-Form 36 (SF-36). RESULTS: Five hundred and twenty-one patients were alive 12 months after surgery; 462 (89%) and 465 (89%) responded after 6 and 12 months, respectively. Chronic pain was reported by 11% of the patients at both measurements. Younger age was associated with chronic pain [odds ratio 0.7 (95% confidence interval: 0.5-0.9)] at 12 months. Patients with chronic pain reported lower scores on seven of eight SF-36 subscales. DISCUSSION: In conclusion, we observed a lower prevalence of chronic pain after cardiac surgery than in previous studies. Still, more than one out of 10 patients reported chronic pain after cardiac surgery. Chronic pain appears to affect HRQOL. Thus, given the large number of patients subjected to cardiac surgery, this study confirms that chronic pain after cardiac surgery is an important health care issue.