This paper reports on the experience gained using World Health Organization Guidelines for cancer pain relief over a 10-year period in an anaesthesiology-based pain service associated with a palliative care programme. The course of treatment of 2118 patients was assessed prospectively over a period of 140,478 treatment days. Non-opioid analgesics (WHO step I) were used on 11%, weak opioids (WHO step II) on 31% and strong opioids (WHO step III) on 49% of treatment days. Administration was via the enteral route on 82% and parenterally on 9% of treatment days. On the remaining days, either spinally applied opioids (2%) or other treatments (6%) were utilised. Fifty-six percent of the patients were treated with morphine. Morphine dose escalation was observed in about one-half of the patients being cared for until death, whereas the other half had stable or decreasing doses over the course of treatment. Co-analgesics were administered on 37% of days, most often antidepressants (15%), anticonvulsants (13%) and corticosteroids (13%). Adjuvants to treat symptoms other than pain were prescribed on 79% of days, most commonly laxatives (42%), histamine-2-receptor antagonists (39%) and antiemetics (35%). In addition, palliative antineoplastic treatment was performed in 42%, nerve blocks in 8%, physiotherapy in 5%, psychotherapy in 3% and TENS in 3% of patients. A highly significant pain reduction was achieved within the 1st week of treatment (P < 0.001). Over the whole treatment period, good pain relief was reported in 76%, satisfactory efficacy in 12% and inadequate efficacy in 12% of patients. In the final days of life, 84% rated their pain as moderate or less, while 10% were unable to give a rating. Analgesics remained constantly effective in all 3 steps of the WHO ladder. Other clinical symptoms were likewise significantly reduced at 1 week after initial assessment, with the exception of neuropsychiatric symptoms. During the course of treatment, the latter were the major symptoms on 23% of days, followed by nausea (23%), constipation (23%) and anorexia (20%). Our results emphasise once again the marked efficacy and low rate of complications associated with oral and parenteral analgesic therapy as the mainstay of pain treatment in the palliative care of patients with advanced cancer. Wide dissemination of WHO guidelines among doctors and healthcare workers is thus necessary to effect a clear improvement in the treatment of the many patients suffering from cancer pain in the clinical and home setting.
The efficacy of the World Health Organization's guidelines for cancer pain relief was examined in 401 dying patients. At the time of death, only 3% of the patients experienced severe or very severe pain; whereas 52% had no pain at all, 24% experienced only mild or moderate pain, and 20% were unable to rate their pain intensity. Analgesic drugs were the mainstay of therapy during the last 24 hr of life, being administered by mouth in 47% and parenterally in 44% of the patients. Only 9% of the patients required no systemic analgesics. Nonopioid analgesics alone were effective in 5% and a combination of nonopioids and "weak" opioids were effective in 16% of the patients. In the remaining 70% of the patients "strong" opioids alone or in combination with nonopioid analgesics were necessary to achieve adequate pain reduction. Additional adjuvant drugs to treat special types of pain or other symptoms were prescribed in 90% of the patients. Nonpharmacological measures, such as radiotherapy, nerve blocks or neurosurgery played only a very minor role at this stage of the disease. This study shows that cancer pain can be treated satisfactorily until death.
this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr).The National Football League (NFL) and the NFL Players Association (NFLPA) began the 2020 football season in July, implementing extensive mitigation and surveillance measures in facilities and during travel and gameplay. Mitigation protocols* were evaluated and modified based on data from routine reverse transcription-polymerase chain reaction (RT-PCR) tests for SARS-CoV-2, the virus that causes coronavirus 2019 (COVID-19); proximity tracking devices; and detailed interviews. Midseason, transmission was observed in persons who had cumulative interactions of <15 minutes' duration, leading to a revised definition of highrisk contacts that required consideration of mask use, setting and room ventilation in addition to proximity and duration of interaction. The NFL also developed an intensive protocol that imposed stricter infection prevention precautions when a case was identified at an NFL club. The intensive protocol effectively prevented the occurrence of high-risk interactions, with no high-risk contacts identified for 71% of traced cases at clubs under the intensive protocol. The incorporation of the nature and location of the interaction, including mask use, indoor versus outdoor setting, and ventilation, in addition to proximity and duration, likely improved identification of exposed persons at higher risk for SARS-CoV-2 infection. Quarantine of these persons, along with testing and intensive protocols, can reduce spread of infection.The NFL consists of 32 member clubs based in 24 states. The NFL-NFLPA implemented a standard COVID-19 mitigation protocol in July that included mandatory masking; physical distancing; frequent handwashing; facility disinfection; restricted facility access; and regular, frequent testing of players and staff members (1). Contact tracing was performed by trained staff members and supported by KINEXON wearable proximity devices (https://kinexon.com) that were required to be worn by players and personnel when in club environments (2). Device recordings captured consecutive and cumulative minutes/seconds of interactions among persons within 1.8 meters (6 feet) of one another. When testing identified a new COVID-19 case, trained staff members conducted interviews to identify contacts *
Purpose: To report a potentially serious complication resulting from a faulty guide wire during central venous catheterization. Clinical features:We report breakage of a guide wire with potential severe implications for a 47-yr-old critical care patient. The tip of the J-wire became lodged in the internal jugular vein, and required fluoroscopic guidance for removal, which occurred without complication. Conclusion:Breakage of a guide wire during central venous catheter insertion has been very rarely reported. However, inherent faults in design or in the manufacturing process of the guide wire could lead to this rare complication. A simple bedside test is proposed to detect breakage in the core section of the guide wire. 5% and 19%. 2,3 Catheterization of the superior vena cava is usually carried out using the method described by Seldinger. 4,5 Under certain circumstances, breakage of the guide wire can occur with ensuing risk of foreign body embolism. This complication is extremely rare, with only a few case reports in the literature. 6 Our case demonstrates that guide wire breakage is not necessarily due to handling mistakes, but may also be attributed to inherent design flaws or manufacturing errors. Consent for reporting of personal health information was obtained in accordance with our local institutional guidelines. Objectif Case reportA 47-yr-old male intensive care patient (ASA III, body mass index 21) suffered from an infected large tissue defect on the right lower leg sustained in an accident ten days previously. The past medical history included Crohn's disease which was inactive at that time. His ongoing management required central venous pressure monitoring.A standard single-lumen central venous catheter set was used (Certofix®Mono, 16G, B. Braun, Melsungen, Germany). The enclosed standard steel needle was used for puncture of the right internal jugular vein. Despite free aspiration of blood, the first attempt to insert the J-shaped end of the guide wire failed. A second attempt using the straight end of the guide wire was also unsuccessful. For both attempts, the guide wire could only be advanced a few millimetres beyond the tip of the needle, indicated by a black indicator on the wire. The needle and the guide wire were then removed together, and a second puncture GENERAL ANESTHESIA
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