Transdermal Buprenorphine for Pain Management Following a Neck of Femur Fracture.

INTRODUCTION: Pain management in patients with hip fractures can be challenging. Poor pain control is associated with reduced mobility and increased morbidity. Inadequate analgesia in patients with dementia is a concern. After using several different alternatives, transdermal buprenorphine was chosen as a standardised approach for analgesia in patients with fragility fracture in our hospital. There is limited evidence on the use of buprenorphine in this population. Our aim was to investigate the safety and effectiveness of transdermal buprenorphine in patients with hip fractures. METHODS: A review of consecutive patients presenting with a hip fracture from June 2018 to December 2018 was conducted using medical records. Our primary outcome was the incidence of complications as a consequence of transdermal buprenorphine. Our secondary outcome was adequate analgesia measured by reviewing the requirement for analgesia during the first week following the patient's admission. Analgesia demands were considered adequate if patients required less than 20 mg of oral morphine in total during the first week following injury. RESULTS: In total, 148 patients presented with a hip fracture during the study period. 128 patients had documented evidence of buprenorphine patch application. Complete data was available for the primary outcome of complications in all cases. Data was available for the secondary outcome in 124 patients. Buprenorphine was discontinued in 24 patients (19%), most commonly due to due to concerns about contribution to hypoactive delirium (9%), and when strong analgesia was no longer required (4%). There were no severe complications. Adequate analgesia was achieved using this regime in 68% patients. 38 patients (32%) required more than 20 mg of oral morphine sulphate solution in the first week post-admission. CONCLUSION: This series suggests that transdermal buprenorphine is safe and effective in the management of pain following a neck of femur fragility fracture.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report.

Background Cognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions. Methods We used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four. Intervention A simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients. Results Post-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%. Conclusions Simple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Trends in Real-World Neovascular AMD Treatment Outcomes in the UK.

PURPOSE: To report trends in real-world outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD) in the United Kingdom (UK) over the last decade. DESIGN: Systematic review. METHODS: Medline, PubMed, and Embase databases were searched from 9 April 2010 to 8 April 2020 for publications that met the inclusion criteria: treatment-naïve eyes, UK-only data and ≥1 year of follow-up. ICHOM (International Consortium for Health Outcome Measures) outcomes and study quality were assessed. Visual acuity (VA) trends were assessed in studies with ≥100 eyes at baseline. RESULTS: Twenty-six studies (n=25,761 eyes) were included, meeting 14-17 out of 20 Institute of Health Economics Quality Appraisal of Case Series checklist domains. Only ranibizumab and aflibercept outcome data were available. The mean injection number in the first year of treatment was 5.9 in publications from 2010 to 2015 and 7.1 from 2015 to 2020. Average baseline VA and mean one-year, two-year and three-year VA gains gradually improved over the last decade. Longer-term studies reported that the visual gains achieved in the first year of treatment were rarely maintained, with under-treatment a likely contributing factor. CONCLUSION: UK real-world outcomes have improved over the last decade with improved service delivery and the adoption of more proactive treatment regimens but are still not always as impressive as registration clinical trial results. Access to longer-acting anti-VEGF therapies would reduce the treatment burden for patients, carers, and the healthcare system, potentially making replication of clinical trial results possible in the NHS.

How do medical students use and understand pain rating scales?

BACKGROUND AND AIMS: Pain is a multidimensional experience that is difficult to describe and to assess. To scale current pain, assessment refers to a maximum level of pain, but little is known about this process. Further, clinicians tend to underestimate patients' pain, with or without patients' own reports, and to underestimate to a greater extent with more clinical experience, possibly due to recalibration of a personal pain scale with increasing exposure to severe pain. We sought to determine how medical students rated pain in early years of clinical exposure, and in relation to experience of their own and others' worst pains. METHODS: An online survey sampled medical students' rating and description of their own worst pain and of that witnessed in another; also what would cause the maximum level of pain and what behaviours characterised it. Last, they indicated their preference among pain scales. RESULTS: Thirty-six medical students provided responses, the majority in their first six months of clinical exposure. Students' own worst pain was rated a mean of 6.7/10 (s.d. 1.6) on a numerical scale; causes were diverse but with many bone fractures. Mean worst pain observed in another was rated 8.6/10 (s.d. 1.4); causes included fractures, gallstones, and sickle cell crises. Another's worst pain was significantly higher (mean 9.4, s.d. 0.8 vs mean 8.0 s.d. 1.4) when rated after the student's own pain than before it (presentation order randomised). We found no effect of clinical exposure on estimation of worst pain in another person, nor was there a personal tendency to rate pain using more or less extreme values. Students expected pain of 10/10 to be presented with many verbal, facial and whole body behaviours, and signs of physiological stress. Collectively, behavioural descriptions were rich and varied, but with many incompatibilities: for instance, between 'writhing' and 'rigidity' expected in the person with extreme pain. Most students preferred the numerical rating scale over visual analogue and verbal scales. CONCLUSIONS: The study requires replication, particularly for clinical experience, where we found no significant difference in estimation of another's pain over the first three years of medical students' clinical exposure, but the comparison was underpowered. Despite no systematic individual difference in using pain ratings, there was a marked effect of rating another's worst pain higher when the rater had previously rated his/her own worst pain. This suggests anchoring estimate of another's pain in personal pain experience, and a possible way to mitigate clinicians' underestimation of patients' pain. Medical students' recognition of the importance of facial expression in indicating another's pain severity was encouraging, but most students anticipated only a narrow range of behaviours associated with extreme pain, thereby excluding other authentic behaviours. IMPLICATIONS: Many clinical guidelines mandate regular pain assessment for hospital inpatients, and encourage routine assessment in community and outpatient settings, in order to decide on and monitor treatment. Replication and elaboration of this study could extend our understanding of how clinicians interpret pain scales completed by patients, and how they estimate patients' pain.