A comparison of oral controlled-release morphine and oxycodone with transdermal formulations of buprenorphine and fentanyl in the treatment of severe pain in cancer patients

Aim of the study: To compare analgesia and adverse effects during oral morphine and oxycodone and transdermal fentanyl and buprenorphine administration in cancer patients with pain. Patients and methods: Cancer patients treated at home and in outpatient clinics with severe pain (numerical rating scale score 6–10) fail to respond to non-opioids and/or weak opioids. All patients were randomized to either morphine, oxycodone, fentanyl or buprenorphine and divided into subgroups with predominant neuropathic and nociceptive pain component. Doses of opioids were titrated to satisfactory analgesia and acceptable adverse effects intensity. Patients were assessed at baseline and followed for 28 days. In all patient groups, immediate-release oral morphine was the rescue analgesic and lactulose 10 mL twice daily was the prophylaxis of constipation; no antiemetics were used as prophylaxis. Results: A total of 62 patients participated and 53 patients completed the study. Good analgesia was obtained for all 4 opioids, for both nociceptive and neuropathic pain. The use of co-analgesics was greater in patients with neuropathic pain. Morphine treatment was associated with less negative impact of pain on ability to walk, work and activity (trend) according to Brief Pain Inventory-Short Form scores and less consumption of rescue morphine. The most common adverse effects included nausea and drowsiness, which increased at the beginning of the treatment and gradually decreased over the days to come. Appetite, well-being, anxiety, depression, and fatigue improved. There was no constipation (the Bowel Function Index scores were within normal range) during the treatment with all opioids. No changes were seen for constipation, vomiting and dyspnea. Conclusion: All opioids were effective and well-tolerated. Morphine was the most effective in the improvement in some of the Brief Pain Inventory-Short Form items regarding negative impact of pain on patients’ daily activities. Prophylaxis of constipation was effective; antiemetics may be considered for nausea prevention

Pierwotna nadczynność przytarczyc w ciąży — wyzwanie diagnostyczne i terapeutyczne

Hypercalcaemia during pregnancy is uncommon, and mostly associated with primary hyperparathyroidism (pHPT). If unrecognised, it poses a significant risk for the mother and the foetus. Maternal symptoms include: hyperemesis, muscle weakness, pancreatitis, nephrolithiasis, bone disease, mental status changes, and hypercalcaemic crisis. Untreated disease complicates foetal development and foetal death is a significant risk. Our case illustrates the difficulty in detecting pHPT during pregnancy, serious complications connected with severe hypercalcaemia, and difficulties in preparing the patient for surgical treatment. Our review of the medical literature did not identify any previous case of a pregnant woman with hypercalcaemic crisis (total calcium 17 mg/dL, parathyroid hormone 2302 pg/mL), acute pancreatitis caused by pHPT, and with hyperthyroidism, who had undergone a successful surgical treatment. (Endokrynol Pol 2015; 66 (3): 270–274)Hyperkalcemia w ciąży jest rzadko spotykanym zaburzeniem. Jej główną przyczyną jest pierwotna nadczynność przytarczyc (pHPT). Brak prawidłowo postawionego rozpoznania stanowi ryzyko zarówno dla matki, jaki płodu. Wśród objawów występujących u matki wymienia się wymioty, osłabienie siły mięśniowej, ostre zapalenie trzustki, kamicę nerkową, objawy kostne, zaburzenia psychiczne i przełom hiperkalcemiczny. Nieleczona hiperkalcemia może być przyczyną ograniczenia wzrostu, a także obumarcia płodu. Przedstawiony przypadek ukazuje trudności w rozpoznaniu pHPT w ciąży, poważne powikłania ciężkiej hiperkalcemii oraz trudności w przygotowaniu pacjentki do leczenia operacyjnego. W dotychczas opublikowanej literaturze według wiedzy autorów pracy nie przedstawiano przypadku ciężarnej z przełomem hiperkalcemicznym (całkowite stężenie wapnia 17 mg/dl, parathormon 2302 pg/ml), ostrym zapaleniem trzustki z towarzyszącą nadczynnością tarczycy, u której przeprowadzono skuteczne leczenie operacyjne. (Endokrynol Pol 2015; 66 (3): 270–274

Methadone in the treatment of bone pain in a patient with disseminated breast cancer

Treatment of pain is an important element of therapeutic management in cancer patients. The article presentsthe case of a patient diagnosed with breast cancer, which spread to the liver and lungs and presentingwith severe bone pain syndrome caused by lumbosacral metastases. Treatment of pain with non-opioidanalgesics, opioids, analgesic adjuvants and palliative radiotherapy proved ineffective. The addition ofsmall doses of methadone to the applied pharmacotherapy produced a satisfactory analgesic effect and asignificant functional improvement (an ability to move around without increased pain) as well as ensureda better quality of patient’s life

Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section — a controlled clinical study

Objectives: Quadratus Lumborum Block in contrast to Transversus Abdominis Plane Block contains a unique component which not only stops somatic pain but also inhibits visceral pain by spreading the local anesthetic to the paravertebral space. This study was designed to determine whether performing the Quadratus Lumborum Block type I in patients un­dergoing cesarean section would be associated with both decreased morphine consumption and decreased pain levels in the postoperative 48-hour period. Material and methods: Sixty patients undergoing caesarean section under spinal anesthesia were randomly and equally assigned to one or other of two groups: QLB I (who received Bilateral Quadratus Lumborum Block type I with the use of 24 mL 0.375% ropivacaine per side) or a Control group. In both groups, on-demand morphine analgesia was administered postoperatively within the first 48 hours. The following were measured: the morphine consumption; the time elapsed from the C-section until the first dose of morphine; and the levels of pain intensity among patients in rest (numeral pain rating scale). Results: There were no statistically significant demographic data differences between the QLB I and Control groups. The following significant differences were observed in the 48-hour postoperative period: morphine consumption was higher in the Control group (p = 0.000); the time elapsed from the C-section until the first dose of morphine was longer in QLB I group (p < 0.05); and the median of the pain numeric rating scale was higher in the Control group (p < 0.05). Conclusions: Quadratus Lumborum Block type I significantly reduces morphine consumption and pain levels up to 48 hours postoperatively

Clinical characteristics and predictors of in-hospital mortality of patients hospitalized with myocardial infarction before and during COVID-19 pandemic

Background:The COVID-19 pandemic has impacted many acute coronary syndrome (ACS) care aspects. The aim was to compare the patient profile, ACS characteristics, and the outcomes in patients referred to the invasive cardiology department before (March 2019 – February 2020) and during the COVID-19 pandemic (March 2020 – February 2021). METHODS: Clinical and demographic features, comorbidities, laboratory parameters at admission, and periprocedural data were recorded. The relationship of these parameters with in-hospital mortality was assessed. RESULTS: Before the COVID-19 pandemic, 664 patients were admitted due to ACS (mean age 67.16 ± 11.94 years, females 32.1%), and during the COVID-19 pandemic 545 ACS patients were recorded [mean age 66.02 ± 12.02 years (p = 0.463), females 31% (p = 0.706)]. A 17.8% decrease in the ACS rate was observed. During the pandemic, there were more STEMI patients (44.3% vs. 52.1%, p < 0.001) and fewer patients treated conservatively (24.9% vs. 8%, p < 0.001). Most lesions were located in the left anterior descending artery (53.4% vs. 54.7%), but post-percutaneous coronary intervention TIMI 3 was observed more frequently before the pandemic (83.9% vs. 75.1%, p < 0.001). Periprocedural complication rates did not differ between the groups. In-hospital outcomes did not differ between analyzed periods regarding all-cause death nor cardiac death rates, 5.3% vs. 4.6% (p = 0.598) and 4.5% vs. 3.7% (p = 0.473), respectively. CONCLUSIONS: Based on the analysis of 1209 patients, a decrease in ACS patients admitted during the pandemic was recorded, but in-hospital mortality remained similar

Assessment of the applicability of transthoracic lung ultrasound for diagnosing purulent lobar pneumonia – A case study

Introduction: Purulent lobar pneumonia is an inflammation of pulmonary tissue that may progress to parenchymal necrosis and abscess formation. The authors present a case of purulent lobar pneumonia diagnosed using transthoracic lung ultrasound (TLU). Abscess-type lesions had not been visualized in previous computed tomography (CT) scans. Aim: To analyze the potential of TLU as a diagnostic tool for purulent lobar pneumonia. Case study: A 55-year-old patient with a several-week history of cough, abdominal pain, and diarrhea was admitted to the intensive care unit due to rapidly progressing cardiopulmonary failure. CT revealed merging parenchymal/interstitial densities within the right lung. Broad-spectrum antibiotics were initiated. TLU revealed the presence of lesions characteristic of pneumonia with the development of abscesses and acute respiratory distress syndrome. Despite treatment initiation, the patient’s condition progressively worsened. On the 3rd day of hospitalization, the patient passed away. At autopsy, purulent lobar pneumonia was identified as the direct cause of death. Results and discussion: Despite broad and well-documented knowledge regarding its applicability, ultrasound has not been widely used as a diagnostic tool. Conclusions: TLU is a safe, repeatable, and inexpensive diagnostic tool. The use of ultrasound in diagnosing pneumonia is well documented, and based on specific diagnostic criteria. As a diagnostic tool for pneumonia, dynamic air bronchogram had a high specificity and positive predictive value. The high sensitivity and specificity of TLU, as pertains to detecting necrosis or abscesses in the course of pneumonia, is comparable with CT. TLU facilitated visualization of small-diameter abscesses.</jats:p

The practical considerations of managing negative pressure pulmonary edema for anesthesiologists – literature review

IntroductionNegative pressure pulmonary edema (NPPE) is an uncommon perioperative complication with a potentially fatal outcome. It is most predominant in young healthy men undergoing surgical procedures under general anesthesia. Due to its rare occurrence and uncharacteristic clinical presentation, it poses a potential diagnostic pitfall.AimThe purpose of this article is to present clinical characteristics and management of NPPE.Material and methodsThis paper is based on the available literature and the authors’ experience.Results and discussionClinical presentation of NPPE is uncharacteristic and includes i.e. agitation, tachypnea, tachycardia, cyanosis and pink frothy sputum. Postponed extubation after general anesthesia is believed to be optimal in order to prevent NPPE as it minimizes asynchrony of muscle function reversal and probability of laryngospasm. Differential diagnosis includes and is not limited to pulmonary edema, aspiration pneumonia, anaphylaxis, septic shock, pulmonary embolism or exacerbation of bronchial asthma. Management of NPPE is symptomatic and focuses on symptomatic treatment and maintaining an open airway passage. Endotracheal intubation with low tidal volume ventilation of 6 mL/kg of ideal body weight with a plateau pressure of less than 30 cm H&lt;sub&gt;2&lt;/sub&gt;O and high positive end-expiratory pressure (PEEP) may improve patients outcomes.ConclusionsIt is crucial for anesthesiologists to familiarize themselves with this phenomenon for early recognition and proper therapeutic decisions. It should be emphasized that under the highest risk of developing NPPE are young male patients and the most common cause is post-extubation laryngospasm.</jats:sec

The differences between two selected intensive care units located in central and northern Europe — preliminary observation

 BACKGROUND: The aim of this study was to evaluate possible differences in the functioning of two selected intensive care units in Poland and Finland. The activity of the units was analysed over a period of one year. METHODS: The following parameters were compared: demography of treated populations, site of admission, category of illness, severity of illness (APACHE-II scale), mean length of stay, demanded workload (TISS-28 scale), mortality (both ICU and hospital) and standardized mortality ratio (SMR). RESULTS: The results of this study indicated that most of the patients in the Polish ICU, regardless of age, diagnosis and APACHE II score, presented significantly longer lengths of stay (14.65 ± 13.6 vs 4.1 ± 4.7 days, P = 0.0001), higher mean TISS-28 score (38.9 ± 9.1 vs 31.2 ± 6.1, P = 0.0001) and higher ICU and hospital mortality (41.5% vs 10.2% and 44.7% vs 21.8%, respectively, P = 0.0001). The values of SMR were 0.9 and 0.85 for the Finnish and Polish ICUs, respectively. CONCLUSION: The collected data indicate huge differences in the utilisation of critical care resources. Treatment in Polish ICU is concentrated on much more severely ill patients which might be sometimes accompanied by futility of care. In order to verify and correctly interpret the presented phenomena, further studies are needed.  BACKGROUND: The aim of this study was to evaluate possible differences in the functioning of two selected intensive care units in Poland and Finland. The activity of the units was analysed over a period of one year. METHODS: The following parameters were compared: demography of treated populations, site of admission, category of illness, severity of illness (APACHE-II scale), mean length of stay, demanded workload (TISS-28 scale), mortality (both ICU and hospital) and standardized mortality ratio (SMR). RESULTS: The results of this study indicated that most of the patients in the Polish ICU, regardless of age, diagnosis and APACHE II score, presented significantly longer lengths of stay (14.65 ± 13.6 vs 4.1 ± 4.7 days, P = 0.0001), higher mean TISS-28 score (38.9 ± 9.1 vs 31.2 ± 6.1, P = 0.0001) and higher ICU and hospital mortality (41.5% vs 10.2% and 44.7% vs 21.8%, respectively, P = 0.0001). The values of SMR were 0.9 and 0.85 for the Finnish and Polish ICUs, respectively. CONCLUSION: The collected data indicate huge differences in the utilisation of critical care resources. Treatment in Polish ICU is concentrated on much more severely ill patients which might be sometimes accompanied by futility of care. In order to verify and correctly interpret the presented phenomena, further studies are needed.