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Pain management in the United States reflects attitudes to those in pain. Increased numbers of disabled veterans in the 1940s to 1960s led to an increased focus on pain and its treatment. The view of the person in pain has moved back and forth between a physiological construct to an individual with pain where perception may be related to social, emotional, and cultural factors. Conceptually, pain has both a medical basis and a political context, moving between, for example, objective evidence of disability due to pain and subjective concerns of malingering. In the 20th century, pain management became predominately pharmacologic. Perceptions of undertreatment led to increased use of opioids, at first for those with cancer-related pain and then later for noncancer pain without the multidimensional care that was intended. The increased use was related to exaggerated claims in the medical literature and by the pharmaceutical industry, of a lack of addiction in the setting of noncancer pain for these medications—a claim that was subsequently found to be false and deliberatively deceptive; an epidemic of opioid prescribing began in the 1990s. An alarming rise in deaths due to opioids has led to several efforts to decrease use, both in patients with noncancer conditions and in those with cancer and survivors of cancer.

Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 (\"upper good recovery\" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 (\"lower moderate disability\") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Ordinal endpoints offer more detailed outcome assessment than mortality, though some disabilities may be considered worse than death by patients. To evaluate how different Glasgow Outcome Scale - Extended (GOS-E) hierarchical structures affect effect estimation in the PATCH-Trauma trial. This post-hoc analysis of the PATCH-Trauma trial compared pre-hospital tranexamic acid (TXA) to placebo in severely injured patients at risk of acute traumatic coagulopathy. The study included patients with complete 6-month outcomes. Using generalized pairwise comparisons, researchers analyzed the 8-point GOS-E, ICU length-of-stay, and thromboembolic complications. Results were reported using win ratio (WR) statistics, with values above one favoring TXA. The analysis explored GOS-E with mortality rankings adjusted based on different outcomes being considered worse than death. The study included 1107 patients (546 placebo, 561 TXA). Original GOS-E results showed a neutral WR (1.03; 95 % CI 0.90–1.19). When death was considered preferable to progressively less impaired functionality (from vegetative state to upper moderate disability), the WR decreased to 0.86 (95 % CI 0.75–1.00). The assessment of TXA therapy's efficacy and safety may vary depending on scenarios where certain functional outcomes are considered worse than death. This analytical approach could inform functional outcome assessment in future acute care trials. [Display omitted] •PATCH-Trauma reanalysis showed different outcomes when death was preferred over severe disability•TXA win ratios declined when death was preferred over functional outcomes, suggesting potential harm•Patient preferences about death vs disability may impact how clinical trial using hierarchical endpoints should be interpreted

Patients who remain unconscious after resuscitation from cardiac arrest outside the hospital have a poor prognosis. In this trial, 77 patients were assigned to treatment with moderate induced hypothermia or normothermia. Survival to hospital discharge with good neurologic recovery was more frequent in the hypothermia group than in the normothermia group. Treatment with moderate hypothermia appears to improve outcomes. Cardiac arrest outside the hospital is a major cause of unexpected death in developed countries, with survival rates ranging from less than 5 percent to 35 percent. 1 – 3 In patients who are initially resuscitated, anoxic neurologic injury is an important cause of morbidity and mortality. 4 Currently, the treatment of patients with coma after resuscitation from out-of-hospital cardiac arrest is largely supportive. Because cerebral ischemia may persist for some hours after resuscitation, 5 the use of induced hypothermia to decrease cerebral oxygen demand has been proposed as a treatment option. 6 Although this suggestion has been supported by studies in animal models, 7 – . . .

AbstractObjectives: To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital.Design: A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team.Setting: 300 bed tertiary referral teaching hospital.Participants: All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847).Interventions: Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria.Main outcome measures: Incidence and outcome of unexpected cardiac arrest.Results: The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73).Conclusions: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.What is already known on this topicIn most studies mortality from unexpected cardiac arrest in hospital exceeds 50%Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrestWhat this paper addsEarly intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in hospital

Aim We describe improved reporting of paediatric out-of-hospital cardiac arrest (OHCA) by adding coronial findings to a cardiac arrest registry. Methods Non-traumatic OHCA occurring in paediatric patients aged less than 16 years were identified using the Victorian Ambulance Cardiac Arrest Registry and available coronial findings reviewed. Results Between the years 2001 and 2009, emergency medical services (EMS) attended 26 974 non-traumatic OHCA of which 390 (1.4%) occurred in children less than 16 years of age. We successfully linked 301 patients with the coronial registry; excluding patients discharged alive from hospital (n=22) and patients with terminal illness (n=16), this represents 86% of OHCA attended by the ambulance. Agreement between the paramedic cause of OHCA and the coronial cause of death was 66.5% (κ 0.16) for presumed cardiac, 74.4% (κ 0.43) for sudden infant death syndrome (SIDS), 81.1% (κ 0.17) for respiratory, 92.7% (κ 0.18) for neurological and 98.3% (κ 0.27) for drug overdose precipitants to OHCA. Undiagnosed congenital heart disease was a rare cause of OHCA (n=3, 1%). Intentional injury was found on autopsy in 13 cases; six cases were clinically thought to be SIDS and two cases presumed cardiac. Co-sleeping was found in 35 cases (39%) of SIDS. Conclusions This study highlights the limitations associated with ascribing the cause of OHCA on the basis of clinical details. Improved reporting is possible by linkage with coronial data. Such robust data inform EMS service providers but also the wider healthcare system where preventive, diagnostic and treatment strategies can be maximised.

Malignant pleural effusions (MPEs) are common complications that occur with advanced stages of cancer. In general, they indicate a poor prognosis and greatly affect quality of life (QOL). The treatment goal of MPEs is to provide relief of symptoms. The standard treatment for MPEs is talc pleurodesis; however, indwelling pleural catheters have become more frequently used. This article focuses on current management strategies for MPEs and assesses their influence on QOL.At a GlanceSymptoms of malignant pleural effusions (MPEs), which involve the accumulation of fluid in the pleural space, include dyspnea, shortness of breath, chest pain, and other issues that decrease functional status.Treatment for MPEs should be palliative, achieving immediate symptom relief and improved quality of life.The optimal treatment strategy for MPEs should have minimal side effects, require minimal or no hospitalization, and have low rates of recurrence.

Objective. To determine the viability of prehospital noninvasive ventilation (NIV) as a prelude to a definitive clinical trial. Methods. This was a retrospective observational study of patients (aged > 55 years, severe shortness of breath) transported to a tertiary emergency department (10/5/03-12/28/04). Data were extracted from paramedic andhospital medical records. The primary outcome measure was the number of patients who could potentially benefit from prehospital NIV. They were defined as \"conscious upon paramedic arrival andwho required ventilatory support (bag/valve/mask ventilation [BVM], NIV or endotracheal intubation) during transport or within 30 minutes of arrival at the emergency department (ED).\" The secondary outcome measures were the effectiveness of existing paramedic treatment regimens andparamedic management times. Results. Two hundred sixty-four patients were enrolled (mean age 75.5 ± 8.7 years, 59.1% male). Sixty-seven patients (25.4%, 95% CI: 20.3-31.2) met the primary outcome measure: 31 (11.7%, 95% CI: 8.2-16.4) received prehospital BVM, an additional 35 (13.3%, 95% CI: 9.5-18.1) received NIV in the ED andone (0.4%, 95% CI: 0.0-2.4) was intubated in the ED. Prehospital treatment resulted in significant (p < 0.001) improvements in systolic blood pressure (151.2 dropping to 144.2 mmHg), respiratory rate (29.4 dropping to 26.3 breaths/minute), andoxygen saturation (92.3% rising to 96.2%). Median paramedic management time was 33 minutes (IQR 29-40). Conclusion. Prehospital treatment significantly improved patient vital signs. However, a considerable proportion of patients still required ventilatory support either prehospital or early in their ED course. Further research is indicated to determine if these patients would benefit from prehospital NIV.

To the Editor: The results of two studies reported in the Journal (Feb. 21 issue) 1 , 2 suggest that therapeutic hypothermia has a beneficial effect on neurologic outcome in survivors of out-of-hospital cardiac arrest. The authors of the accompanying editorial 3 support the conclusions of these studies and firmly recommend the use of hypothermia for at least 12 hours after cardiac arrest. Before this complex intervention becomes accepted as standard therapy, a closer examination of these studies is warranted. The authors of both studies cite problems in study design and in the interpretation of their results, but neither they nor the authors . . .

The federal government told the Charlotte, N.C.-based bank that it should raise $33.9 billion in capital to boost its reserves in case the economy worsens further. As part of its \"stress tests\" of 19 banks, the government said Bank of America needed the most additional cash to withstand a potentially worsening economy. Bank of America said none of the preferred shares that were converted to common stock were shares held by the government as part of the Troubled Asset Relief Program launched last fall by the U.S. Treasury Department. That program provided loans to hundreds of banks amid the mushrooming credit crisis as part of an effort to alleviate stagnant markets. In return, the government received preferred shares. Bank of America received $45 billion as part of the program.