Characteristics and Outcome of Cancer Patients Admitted to the ICU in England, Wales, and Northern Ireland and National Trends Between 1997 and 2013.

OBJECTIVE: To describe trends in outcomes of cancer patients with an unplanned admission to the ICU between 1997 and 2013 and to identify risk factors for mortality of those admitted between 2009 and 2013. DESIGN: Retrospective analysis. SETTING: Intensive Care National Audit & Research Centre Case Mix Programme Database including data of ICUs in England, Wales, and Northern Ireland. PATIENTS: Patients (99,590) with a solid tumor and 13,538 patients with a hematological malignancy with an unplanned ICU admission between 1997 and 2013; 39,734 solid tumor patients and 6,652 patients with a hematological malignancy who were admitted between 2009 and 2013 were analyzed in depth. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In solid tumor patients admitted between 2009 and 2013, hospital mortality was 26.4%. Independent risk factors for hospital mortality were metastatic disease (odds ratio, 1.99), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.63), Intensive Care National Audit & Research Centre Physiology score (odds ratio, 1.14), admission for gastrointestinal (odds ratio, 1.12), respiratory (odds ratio, 1.48) or neurological (odds ratio, 1.65) reasons, and previous ICU admission (odds ratio, 1.18). In patients with a hematological malignancy admitted between 2009 and 2013, hospital mortality was 53.6%. Independent risk factors for hospital mortality were age (odds ratio, 1.02), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.90), Intensive Care National Audit & Research Centre Physiology Score (odds ratio, 1.12), admission for hematological (odds ratio, 1.48) or respiratory (odds ratio, 1.56) reasons, bone marrow transplant (odds ratio, 1.53), previous ICU admission (odds ratio, 1.43), and mechanical ventilation within 24 hours of admission (odds ratio, 1.33). Trend analysis showed a significant decrease in ICU and hospital mortality and length of stay between 1997 and 2013 despite little change in severity of illness during this time. CONCLUSIONS: Between 1997 and 2013, the outcome of cancer patients with an unplanned admission to ICU improved significantly. Among those admitted between 2009 and 2013, independent risk factors for hospital mortality were age, severity of illness, previous cardiopulmonary resuscitation, previous ICU admission, metastatic disease, and admission for respiratory reasons.

Pain inhibition by blocking leukocytic and neuronal opioid peptidases in peripheral inflamed tissue.

Inflammatory pain can be controlled by endogenous opioid peptides. Here we blocked the degradation of opioids in peripheral injured tissue to locally augment this physiological system. In rats with hindpaw inflammation, inhibitors of aminopeptidase N (APN; bestatin) or neutral endopeptidase (NEP; thiorphan), and a dual inhibitor, NH(2)-CH-Ph-P(O)(OH)CH(2)-CH-CH(2)Ph(p-Ph)-CONH-CH-CH(3)-COOH (P8B), were applied to injured paws. Combined bestatin (1.25-5 mg)/thiorphan (0.2-0.8 mg) or P8B (0.0625-1 mg) alone elevated mechanical nociceptive thresholds to 307 and 227% of vehicle-treated controls, respectively. This analgesia was abolished by antibodies to methionine-enkephalin, leucine-enkephalin, and dynorphin A 1-17, by peripherally restricted and by selective µ-, δ-, and κ-opioid receptor antagonists. Flow cytometry and photospectrometry revealed expression and metabolic activity of APN and NEP on macrophages, granulocytes, and sciatic nerves from inflamed tissue. Radioimmunoassays showed that inhibition of leukocytic APN and NEP by bestatin (5-500 µM)/thiorphan (1-100 µM) combinations or by P8B (1-100 µM) prevented the degradation of enkephalins. Blockade of neuronal peptidases by bestatin (0.5-10 mM)/thiorphan (0.1-5 mM) or by P8B (0.1-10 mM) additionally hindered dynorphin A 1-17 catabolism. Thus, leukocytes and peripheral nerves are important sources of APN and NEP in inflamed tissue, and their blockade promotes peripheral opioid analgesia.

Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial.

BACKGROUND: Before clinical treatment and during transportation, the analgesic therapy offered to patients with painful knee trauma may be quite insufficient. We hypothesize that a femoral nerve blockade for analgesia can be administered in a preclinical setting at the injury site and provides better pain relief than intravenous metamizole, whose analgesic effect is comparable with that of opioids. METHODS: After an initial clinical investigation, 52 patients were randomized according to computer-generated codes; 26 patients received a femoral nerve blockade and 26 received metamizole. The treatment was started at the injury site and the level of pain on the 100-mm visual analog scale was assessed at the beginning and the end of treatment. RESULTS: Pain and anxiety scores were significantly reduced by half in the femoral nerve blockade group; peripheral vasoconstriction was noted in 26 patients at the injury site and dropped to six at the time of arrival at the hospital. Two of 26 patients in the blockade group did not benefit from the treatment. In the metamizole group, pain and anxiety did not decrease significantly; vasoconstriction persisted in all patients. CONCLUSION: Patients with painful knee trauma benefited from femoral nerve blockade administered before hospitalization. The treatment can be administered safely in the preclinical setting and provides effective analgesia.

A randomized controlled trial of femoral nerve blockade administered preclinically for pain relief in femoral trauma.

BACKGROUND: Analgesia at the location of the accident and on transport for femoral trauma is often delayed or insufficient. In this prospective, randomized, controlled study, we evaluated the preclinical use of femoral nerve blockade for reducing pain and anxiety compared with IV analgesia using metamizol. METHODS: Patients with painful femoral trauma, such as fracture or severe contusion, were randomized to receive at the site of the accident a femoral nerve blockade (n = 31) or IV analgesia with metamizol (n = 31). A visual analog scale (VAS) was used to assess pain and anxiety. Variables were assessed at baseline, during transport and upon arrival at the hospital. RESULTS: In patients receiving the femoral nerve blockade, pain values decreased by half from VAS 86 +/- 6 mm at the site of the accident to VAS 41 +/- 15 mm during transport. Anxiety decreased by half from VAS 84 +/- 11 mm to VAS 39 +/- 14 mm. Heart rate decreased by 20 +/- 5 bpm. In the metamizol group, pain, anxiety, and heart rate did not decrease (P < 0.001). Time of treatment was 7.4 +/- 3.5 min longer in the femoral nerve blockade group. CONCLUSION: Preclinically administered femoral nerve blockade effectively decreases pain, anxiety, and heart rate after femoral trauma. Regional blockade is an option for out-of-hospital analgesia administered by a trained physician.

Lymphocytes upregulate signal sequence-encoding proopiomelanocortin mRNA and beta-endorphin during painful inflammation in vivo.

Proopiomelanocortin (POMC)-derived beta-endorphin1-31 (END) released from immune cells inhibits inflammatory pain. We examined the expression of END and POMC mRNA encoding the signal sequence required for entry of the nascent polypeptide into the regulated secretory pathway in lymphocytes of rats with inflamed hindpaws. Within 12 h of inflammation, END increased in popliteal lymph nodes and at 96 h the intraplantar neutralization of END exacerbated pain. Lymphocytes expressed POMC, END, and full-length POMC mRNA. Semi-nested PCR revealed 8-fold increased exon 2-3 spanning POMC mRNA. Thus, painful inflammation enhances signal sequence-encoding lymphocytic POMC mRNA needed for regulated secretion of functionally active END.

Transcutaneous electrical nerve stimulation: an effective treatment for pain caused by renal colic in emergency care.

PURPOSE: Acute renal colic is one of the most anguishing forms of pain in humans. We hypothesized that TENS is an effective pain treatment in patients with acute renal colic. MATERIALS AND METHODS: A total of 100 patients with acute flank pain and suspected renal colic consented to participate in our study. Paramedic 1 recorded baseline parameters at the emergency site and at the end of transportation. Paramedic 2 performed TENS in patients randomly assigned to G1 with actual TENS or to G2 with sham TENS. Pain and anxiety were measured using paper based visual analog scales on a scale of 0 to 100 mm. RESULTS: Of 100 screened patients 73 had renal colic, including 39 in G1 and 34 in G2. There was no significant difference with regard to potentially influencing factors, such as patient age, sex, weight, height, blood pressure and heart rate, pain, nausea and anxiety between the groups before treatment. G1 showed a significant mean pain decrease +/- SD of more than 50% (85.7 +/- 10.5 to 33.3 +/- 16.0 mm, p <0.01). G2 showed no variation in mean pain scores (85.8 +/- 18.0 to 82.6 +/- 14.3 mm). G1 showed changes in the mean anxiety score (69.0 +/- 8.4 to 37.7 +/- 15.1 mm, p <0.01), nausea score (90.7 +/- 9.2 to 44.9 +/- 22.0 mm) and heart rate (92 +/- 10 to 64 +/- 8 bpm), while G2 showed nonsignificant changes. CONCLUSIONS: This trial shows that local TENS is a rapid and effective treatment for renal colic pain. We found TENS to be a good nondrug therapy under the difficult circumstances of out of hospital rescue.

Active warming during emergency transport relieves acute low back pain.

STUDY DESIGN: Prospective randomized blinded trial in a prehospital emergency system. OBJECTIVES: To evaluate the effects of external active warming on acute back pain during rescue transport to hospital. BACKGROUND DATA: Acute low back pain is one of the complaints that most often entails a visit to the physician or use of the emergency system. Superficial (e.g., hydrocolloid packs) and deep heating (e.g., ultrasound) can relieve acute low back pain in a clinical setting. Recent data showed significant benefit for patients in pain from minor trauma treated by active warming during emergency transport. Accordingly, we tested the hypothesis that active warming would reduce pain and anxiety in patients with acute low back pain being transported to a hospital. METHODS: A total of 100 patients were included in our study. We selected only those suffering from acute pain > 60 mm on a visual analog scale in the lower back. Patients were randomly assigned to two groups: active warming with a carbon-fiber electric heating blanket (Group 1) versus passive warming with a woolen blanket (Group 2) during transfer to hospital. RESULTS.: Pain scores on arrival at the hospital differed significantly between Group 1 and Group 2 (P < 0.01). In Group 1, pain reduction from 74.2 +/- 8.5 mm VAS to 41.9 +/- 18.9 mm VAS (P < 0.01) was noted between departure from the emergency site and arrival at the hospital. Pain scores remained practically unchanged in Group 2 (73.3 +/- 11.9 mm VAS and 74.1 +/- 12.0 mm VAS). CONCLUSIONS: Active warming reduces acute low back pain during rescue transport.