Prevalence and characteristics of breakthrough cancer pain in an outpatient clinic in a Catalan teaching hospital: incorporation of the Edmonton Classification System for Cancer pain into the diagnostic algorithm.

BACKGROUND: Breakthrough cancer pain (BTcP) is defined according to its principal characteristics: high intensity, short time interval between onset and peak intensity, short duration, potential recurrence over 24 h and non-responsiveness to standard analgesic regimes. The Edmonton Classification System for Cancer Pain (ECS-CP) is a classification tool that evaluates different dimensions of pain. The aim of this study was to measure prevalence and the main characteristics of BTcP in a sample of advanced cancer patients and to explore the complexity observed when ECS-CP is incorporated into BTcP diagnostics algorithm. METHODS: Descriptive prevalence study (Retrospective chart review). Davies' algorithm was used to identify BTcP and ECS-CP was used to recognize appropriate dimensions of pain. The study was conducted in a sample of advanced cancer patients attending hospital outpatient clinic in Lleida, Spain. 277 patients were included from 01/01/2014 to 31/12/2015. No direct contact was made with participants. The following information was extracted from the palliative care outpatient clinic database: age, gender, civil status, cognitive impairment status, functional performance status and variables related to tumour. Only BTcP cases were included. RESULTS: Prevalence of BTcP was 39.34% (63.9% men). Mean of age was 68.2 years. Main diagnosis was lung cancer (n = 154; 31.6%). Metastases were diagnosed in 83% of the sample. 138 patients (49.8%) were diagnosed with 1 type of BTcP and 139 (50.2%) were diagnosed with more than one type of BTcP. In total, 488 different types of BTcP were recorded (mean 1.75 ± 0, 9), 244 of these types (50%) presented a component of neuropathic pain. Addictive behaviour, measured through CAGE test, was present in 29.2% (N = 81) of the patients and psychological distress was present in 40.8% (n = 113). CONCLUSIONS: Prevalence of BTcP (39.34%) is similar to the one reflected in the existing literature. Study results indicate that the routine use of ECS-CP in a clinical setting allows us to detect more than one type of BTcP as well as additional complexity associated with pain (neuropathic, addictive behavior and psychological distress).

[Incidence and predictive factors of iron deficiency anemia after acute non-variceal upper gastrointestinal bleeding without portal hypertension]. / Incidencia y factores predictivos de anemia ferropénica tras una hemorragia digestiva alta no asociada a hipertensión portal.

INTRODUCTION: There are few studies on iron deficiency anemia (IDA) after non-variceal acute upper gastrointestinal bleeding (UGIB) in patients without portal hypertension. OBJECTIVES: To define the incidence of IDA after UGIB, to characterize the predictive factors for IDA and to design algorithms that could help physicians identify those patients who could benefit from iron therapy. MATERIAL AND METHOD: We registered 391 patients with UGIB between April 2007 and May 2009. Patients with portal hypertension and those with clinical or/and biological conditions that could affect the ferrokinetic pattern were excluded. Blood analyses were performed, including ferric parameters upon admission, on the 5th day, and on the 30th day after the hemorrhage episode. We used a multiple logistic regression model and a classification and regression tree model. RESULTS: A total of 124 patients were included, of which 76 (61.3%) developed IDA 30 days after UGIB. The predictive variables were age >75 years (P=.037; OR 3.9; 95% CI: 1.3-11.6), initial urea level >80mg/dL (P=.027; OR 2.9; 95% CI: 1.1-7.6), initial ferritin level ≤65ng/dL (P=.002; OR 7.6; 95% CI: 2.9-18.5), initial hemoglobin level ≤100g/L (P=.003; OR 3.2; 95% CI: 1.3-8.0), hemoglobin level on the 5th day ≤100g/L (P<.001; OR 14.9; 95% CI: 3.6-61.1) and the value of the transferrin saturation index on the 5th day <10% (p<0.001; OR 7.2; 95% CI: 2.6-20.3). CONCLUSIONS: Most patients with UGIB developed IDA 30 days after the episode. Identification of the predictive factors for IDA may help to establish guidelines for the administration of iron therapy.

Time to sputum conversion in patients with pulmonary tuberculosis: A score to estimate the infectious period.

Introduction: Patients with pulmonary tuberculosis (PTB) disease and positive sputum cultures are the main source of infection. Culture conversion time is inconsistent and defining the length of respiratory isolation is challenging. The objective of this study is to develop a score to predict the length of isolation period. Methods: A retrospective study was carried out to evaluated risk factors associated with persistent positive sputum cultures after 4 weeks of treatment in 229 patients with PTB. A multivariable logistic regression model was used to determinate predictors for positive culture and a scoring system was created based on the coefficients of the final model. Results: Sputum culture was persistently positive in 40.6%. Fever at consultation (1.87, 95% CI:1.02-3.41), smoking (2.44, 95% CI:1.36-4.37), >2 affected lung lobes (1.95, 95% CI:1.08-3.54), and neutrophil-to-lymphocyte ratio > 3.5 (2.22, 95% CI:1.24-3.99), were significantly associated with delayed culture conversion. Therefore, we assembled a severity score that achieved an area under the curve of 0.71 (95% CI:0.64-0.78). Conclusions: In patients with smear positive PTB, a score with clinical, radiological and analytical parameters can be used as a supplemental tool to assist clinical decisions in isolation period.

The Effect of Enteral Immunonutrition in the Intensive Care Unit: Does It Impact on Outcomes?

Background: The present research aimed to evaluate the effect on outcomes of immunonutrition (IMN) enteral formulas during the intensive care unit (ICU) stay. Methods: A multicenter prospective observational study was performed. Patient characteristics, disease severity, nutritional status, type of nutritional therapy and outcomes, and laboratory parameters were collected in a database. Statistical differences were analyzed according to the administration of IMN or other types of enteral formulas. Results: In total, 406 patients were included in the analysis, of whom 15.02% (61) received IMN. Univariate analysis showed that patients treated with IMN formulas received higher mean caloric and protein intake, and better 28-day survival (85.2% vs. 73.3%; p = 0.014. Unadjusted Hazard Ratio (HR): 0.15; 95% CI (Confidence Interval): 0.06−0.36; p < 0.001). Once adjusted for confounding factors, multivariate analysis showed a lower need for vasopressor support (OR: 0.49; 95% CI: 0.26−0.91; p = 0.023) and continuous renal replacement therapies (OR: 0.13; 95% CI: 0.01−0.65; p = 0.049) in those patients who received IMN formulas, independently of the severity of the disease. IMN use was also associated with higher protein intake during the administration of nutritional therapy (OR: 6.23; 95% CI: 2.59−15.54; p < 0.001), regardless of the type of patient. No differences were found in the laboratory parameters, except for a trend toward lower triglyceride levels (HR: 0.97; 95% CI: 0.95−0.99; p = 0.045). Conclusion: The use of IMN formulas may be associated with better outcomes (i.e., lower need for vasopressors and continuous renal replacement), together with a trend toward higher protein enteral delivery during the ICU stay. These findings may ultimately be related to their modulating effect on the inflammatory response in the critically ill. NCT Registry: 03634943.

Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

BACKGROUND & AIMS: The importance of artificial nutritional therapy is underrecognized, typically being considered an adjunctive rather than a primary therapy. We aimed to evaluate the influence of nutritional therapy on mortality in critically ill patients. METHODS: This multicenter prospective observational study included adult patients needing artificial nutritional therapy for >48 h if they stayed in one of 38 participating intensive care units for ≥72 h between April and July 2018. Demographic data, comorbidities, diagnoses, nutritional status and therapy (type and details for ≤14 days), and outcomes were registered in a database. Confounders such as disease severity, patient type (e.g., medical, surgical or trauma), and type and duration of nutritional therapy were also included in a multivariate analysis, and hazard ratios (HRs) and 95% confidence intervals (95%CIs) were reported. RESULTS: We included 639 patients among whom 448 (70.1%) and 191 (29.9%) received enteral and parenteral nutrition, respectively. Mortality was 25.6%, with non-survivors having the following characteristics: older age; more comorbidities; higher Sequential Organ Failure Assessment (SOFA) scores (6.6 ± 3.3 vs 8.4 ± 3.7; P < 0.001); greater nutritional risk (Nutrition Risk in the Critically Ill [NUTRIC] score: 3.8 ± 2.1 vs 5.2 ± 1.7; P < 0.001); more vasopressor requirements (70.4% vs 83.5%; P=0.001); and more renal replacement therapy (12.2% vs 23.2%; P=0.001). Multivariate analysis showed that older age (HR: 1.023; 95% CI: 1.008-1.038; P=0.003), higher SOFA score (HR: 1.096; 95% CI: 1.036-1.160; P=0.001), higher NUTRIC score (HR: 1.136; 95% CI: 1.025-1.259; P=0.015), requiring parenteral nutrition after starting enteral nutrition (HR: 2.368; 95% CI: 1.168-4.798; P=0.017), and a higher mean Kcal/Kg/day intake (HR: 1.057; 95% CI: 1.015-1.101; P=0.008) were associated with mortality. By contrast, a higher mean protein intake protected against mortality (HR: 0.507; 95% CI: 0.263-0.977; P=0.042). CONCLUSIONS: Old age, higher organ failure scores, and greater nutritional risk appear to be associated with higher mortality. Patients who need parenteral nutrition after starting enteral nutrition may represent a high-risk subgroup for mortality due to illness severity and problems receiving appropriate nutritional therapy. Mean calorie and protein delivery also appeared to influence outcomes. TRIAL REGISTRATION: ClinicaTrials.gov NCT: 03634943.

Design and Validation of a Computer Application for Diagnosis of Shoulder Locomotor System Pathology.

OBJECTIVES: To design and validate a computer application for the diagnosis of shoulder locomotor system pathology. METHODS: The first phase involved the construction of the application using the Delphi method. In the second phase, the application was validated with a sample of 250 patients with shoulder pathology. Validity was measured for each diagnostic group using sensitivity, specificity, and positive and negative likelihood ratio (LR(+) and LR(-)). The correct classification ratio (CCR) for each patient and the factors related to worse classification were calculated using multivariate binary logistic regression (odds ratio, 95% confidence interval). RESULTS: The mean time to complete the application was 15 ± 7 minutes. The validity values were the following: LR(+) 7.8 and LR(-) 0.1 for cervical radiculopathy, LR(+) 4.1 and LR(-) 0.4 for glenohumeral arthrosis, LR(+) 15.5 and LR(-) 0.2 for glenohumeral instability, LR(+) 17.2 and LR(-) 0.2 for massive rotator cuff tear, LR(+) 6.2 and LR(-) 0.2 for capsular syndrome, LR(+) 4.0 and LR(-) 0.3 for subacromial impingement/rotator cuff tendinopathy, and LR(+) 2.5 and LR(-) 0.6 for acromioclavicular arthropathy. A total of 70% of the patients had a CCR greater than 85%. Factors that negatively affected accuracy were massive rotator cuff tear, acromioclavicular arthropathy, age over 55 years, and high pain intensity (p < 0.05). CONCLUSIONS: The developed application achieved an acceptable validity for most pathologies. Because the tool had a limited capacity to identify the full clinical picture in the same patient, improvements and new studies applied to other groups of patients are required.

[Recall and memory after intensive care unit stay. Development of posttraumatic stress disorder]. / Recuerdos y memoria del paciente crítico a largo plazo. Desarrollo de estrés postraumático.

BACKGROUND AND OBJECTIVE: The intensive care unit (ICU) confers a stress on patients and may affect the memory. The aim of the study was to examine the memory after critical care and the relationship with therapy and the development of posttraumatic stress disorder. PATIENTS AND METHOD: Prospectively study conducted between December 2001 and June 2003. Patients were excluded if language difficulties or had a neurologic or psychiatric disease. We collected data on gender and age, length of stay in the ICU, severity of acute illness, diagnoses and medical treatment with mechanical ventilation, propofol, midazolam and dopamine during the ICU stay. 12 months after ICU eligible patients were contacted to assess memory. The ICUM (Intensive Care Memory) tool and IES (Impact Event Scale) were used to assess memory and posttraumatic stress disorder. RESULTS: A total of 169 patients were included. The incidence of memory was 77.6%. 41 patients recalled delusional memories and these patients had higher IES after discharge. The logistic regression suggested a relationship with propofol, dopamine and length of stay. CONCLUSIONS: ICU treatment may be related more to recall of delusions. The delusional memory is associated with posttraumatic stress disorder symptoms after ICU.

Occult donor metastatic adenocarcinoma. Contribution of the forensic autopsy. A case report.

BACKGROUND: The transmission of malignancies from the organ donor to the recipients is an uncommon complication, but it can be fatal. Older donors may increase the risk of tumor transmission. A forensic autopsy will help identify diseases that might be transmitted to the recipient. CASE REPORT: Donor was a 75-year-old man with traumatic brain injury caused by an accidental fall, which led to brain death. He had no previous cancer history. The forensic autopsy conducted on the following day revealed a suspicious spot in the lung, on which a biopsy was done. Histological examination confirmed the presence of a metastatic adenocarcinoma in the lung 7 days after both kidneys had been transplanted. After notifying the transplant team, both recipients underwent an early transplant nephrectomy. 15 months later, no signs of malignancy have been detected in the recipients and so they have received a new transplant. CONCLUSIONS: Conducting a forensic autopsy on donors deceased as a result of a fatality offers an additional opportunity to detect previously undiagnosed malignancies. Any suspicious lesion found that could compromise transplant viability should be notified to the transplant team notwithstanding the pathologist's legal requirements. This case shows the need for an exhaustive donor evaluation, including, in selected cases, the performance of an autopsy.