Ketamine Use and Opioid-Tolerant Cancer Patients

Pain occurs in up to 70% of cancer patients and it can be challenging to manage. The standard for analgesic therapy is the World Health Organization ladder; however, up to 25% of patients don’t reach a level of comfort using this approach. Ketamine has been recognized as an excellent adjuvant for cancer pain treatment, especially when other analgesics have failed. Some randomized clinical trials have confirmed ketamine’s efficacy in refractory cancer pain, but most had small sample sizes and low power. Some publications have confirmed the beneficial effect of oral, intranasal, subcutaneous, or intravenous ketamine in treatment of refractory chronic cancer pain, while others are less conclusive. While ketamine is rapidly gaining ground as an adjuvant in treating pain in patients with cancers refractory to conventional therapy and/or patients with opioid tolerance, care should be taken to identify patients with ketamine contraindications in order to offer the greatest benefit with the lowest risk of side effects.</p

ENFORCER, internet-based interventions for cardiac arrest survivors: A study protocol for a randomised, parallel-group, multicentre clinical trial

Background Out-of-hospital cardiac arrest (OHCA) is a major health concern in Europe, leading to significant morbidity and mortality. Survivors often suffer from cognitive deficits, anxiety, and depression, that affect significantly their quality of life. Current post-discharge care is inconsistent and frequently overlooks subtle but disabling symptoms. The ENFORCER trial aims to significantly enhance the health and quality of life of OHCA survivors by providing a comprehensive, accessible, and user-friendly internet-based lifestyle intervention. Methods ENFORCER is a multicentre, parallel group randomized controlled trial involving OHCA survivors aged 18–80 years with cognitive impairment or anxiety/depression measured through validated instruments. Participants will be randomized 1:1 to the intervention or the control group. The intervention group will receive a one-year program via a secure web application, offering cognitive, emotional, and physical rehabilitation support. The control group will receive standard care. The primary outcome is the difference in the proportion of patients without cognitive or emotional symptoms between the two groups after one year. Secondary outcomes include changes in the level of patients’ cognitive and emotional symptoms, quality of life, sleep quality, sexual interest and satisfaction, and caregivers’ burden, quality of life, sleep quality and emotional symptoms in the two groups. Discussion The trial addresses the need for consistent post-discharge care, and the timely detection and treatment of cognitive and emotional problems. The internet-based approach allows to potentially reach many patients, ensuring cost-effectiveness and high adherence rates. The study results could establish a standard for post-OHCA care, improving long-term recovery and quality of life for survivors. Trial registration. The trial is registered at clinicaltrials.gov (NCT06395558)

SARS‐CoV‐2 infection and venous thromboembolism after surgery: an international prospective cohort study

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (&gt;= 7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3-6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly