A survey of acute pain services in the UK

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400-839 [120-2800]) beds. Each acute pain specialist nurse was responsible for 299 (238-534 [70-1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0-2.5 [0.2-7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

The impact of emergency department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain

The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44-56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24-54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control - patient-controlled analgesia) -8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7-23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI -30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Cricoid pressure: which hand?

We studied 20 anaesthetic assistants applying simulated cricoid pressure with the left or right hand in random order. Simulated cricoid pressure was continued for up to 5 min with one hand and then, after resting, with the other hand. Applied pressure was measured at intervals and the subjects were blind to the results. Nineteen assistants were right-handed and all routinely applied cricoid pressure with their right hand. Mean (SD) force applied during simulated 'awake' cricoid pressure was 13.8 (5.7) N with either left or right hand, and during 'anaesthetised' cricoid pressure it was initially 25.1 (8.2) N and 24.7 (8.8) N with left or right hand, respectively. Mean force was maintained above 20 N and below 30 N throughout the study period with either hand. Force applied with the left hand was significantly lower than with the right hand but the difference was clinically insignificant (0.4 N). Inadequate or excessive force was more frequently associated with use of the left hand (p < 0.0001). Cricoid pressure was released before 5 min in three cases, two left-handed and one right-handed. Our results demonstrate that anaesthetic assistants apply a lower force than is classically taught and are able to maintain the force with either hand for a sustained period. Application with the left hand is justified where clinically indicated but may have a lower margin for error than when applied with the right hand.

Ankle fracture classification: a comparison of reliability of three X-ray views versus two

Our hypothesis was that malleolar ankle fractures could be classified with two radiographic views as reliably as with three views. Four different observers independently evaluated 99 sets of ankle radiographs. The examiners classified the ankle fractures by using both the Lauge-Hansen and Danis-Weber systems. The interobserver and intraobserver variations were analyzed by kappa statistics. With regard to intraexaminer reliability, the examiners demonstrated excellent accord in classifying the fractures in the Danis-Weber system with either three views or two views. The kappa values were comparable. In the Lauge-Hansen system, three examiners demonstrated excellent accord and one examiner demonstrated good accord in classifying the fractures. Similar kappa values were generated when examiners classified fractures with either three views or two views. With regard to interexaminer reliability, good to excellent accord was demonstrated overall among the four examiners when they used the Danis-Weber system with either three views or two views. The examiners were in good agreement when they used the Lauge-Hansen system. Similar kappa values were generated whether the examiners used three views or two views. Three radiographic views are usually ordered for evaluation of an acute ankle injury. Previous studies have shown that only two views are needed for diagnosis of a malleolar ankle fracture. This study demonstrates that malleolar ankle fractures can be classified with two views, lateral or mortise, with a reliability as good as that achieved with three views. The best agreement is achieved with lateral and mortise views.

Ultrasonographic-surgical correlation of ankle tendon tears

This study evaluates the accuracy of ultrasonography in detecting ankle tendon tears of the peroneal, posterior tibial, and flexor digitorum longus tendons based on operative findings and clinical follow-up. A prospective study was performed in 33 patients with clinically suspected tendon injury. Sixty-eight tendons were evaluated sonographically. The diagnosis of an intrasubstance tear was made when disruption of uniform tendon architecture by hypoechoic linear or globular clefts was observed. Criteria used to diagnose complete tendon rupture included discontinuity or gap within the tendon or complete nonvisualization of the tendon. Treatment decisions were based on a combination of clinical parameters and imaging studies. Twenty-six patients had the presence or absence of tear confirmed at surgery. Five patients had a final diagnosis based on clinical findings, and two were lost to follow-up. Of the 68 tendons evaluated sonographically, 54 were directly inspected at surgery; 20 were found to be torn and 34 were intact. Ultrasonography was able to identify all tears correctly with an accuracy of 93%, a sensitivity of 100%, and a specificity of 88%. The positive and negative predictive values were 83% and 100%, respectively. The combined accuracy, sensitivity, and specificity of ultrasonography in detecting tendon tears in all patients evaluated both surgically and by clinical follow-up were 94%, 100%, and 90%, respectively.

Blue-yellow vision deficits in patients with diabetes

Home blood glucose monitoring has been introduced as a means to achieve good control in patients with diabetes mellitus. Many patients use color-reagent strips and color comparisons to determine blood glucose levels. Intact color vision in the blue-yellow range is necessary for accurately interpreting these strips.Blue-yellow vision deficits occur as a consequence of eye disease and are not genetic or sex-linked. We evaluated blue-yellow vision acuity in 70 diabetic patients and in 19 age-matched control subjects. The patients with diabetes were subdivided according to their degree of retinopathy as follows: no disease (N = 14), nonproliferative diabetic retinopathy (N = 16), proliferative diabetic retinopathy (N = 14) and postlaser-treated (N = 26). None of the control group had deficits. Each group of diabetic patients had a statistically significant increase in color vision deficits compared with the controls. In the laser-treated group, deficits occurred in most patients, were more severe and were significantly increased over all other diabetic subgroups. These deficits may impair visual interpretation of home blood glucose monitoring strips.