Raising Awareness on the Clinical and Social Relevance of Adequate Chronic Pain Care

Appropriate pain care should be regarded as a right and effectively guaranteed to people with chronic pain (CP). Law 38, enacted in Italy in 2010, establishes the citizen's right not to suffer. Twelve years later, such right appears still disregarded in Italy and the current access to adequate pain care reveals significant shortcomings. In addition, a mismatch between CP-associated burden and the available healthcare resources in the framework of our national health system has been observed. This article gathers the perspectives of a Board of Italian anesthesiologists on the state of the art of CP management in Italy and aims at strengthening the scientific rationale and clinical relevance of pursuing the enforceability of the right not to suffer and at promoting widespread multidisciplinary care of patients with CP

Case report: PIK3CA somatic mutation leading to Klippel Trenaunay Syndrome and multiple tumors

We report a case of Klippel Trenaunay Syndrome that was monitored both clinically and molecularly over a period of 9 years. A somatic mosaic mutation of PIK3CA (p(E545G)) was identified using both cfDNA NGS liquid biopsy and tissue biopsy. At the age of 56, due to intervening clonal mutations in PIK3CA background, she developed a squamous cell carcinoma in the right affected leg which was treated surgically. Nine years later, lung bilateral adenocarcinoma arose on PIK3CA mutated tissues supported by different clonal mutations. One year later, the patient died from metastases led by a new FGFR3 clone unresponsive to standard-of-care, immunotherapy-based. Our results highlight the presence of a molecular hallmark underlying neoplastic transformation that occurs upon an angiodysplastic process and support the view that PIK3CA mutated tissues must be treated as precancerous lesions. Importantly, they remark the effectiveness of combining cfDNA NGS liquid and tissue biopsies to monitor disease evolution as well as to identify aggressive clones targetable by tailored therapy, which is more efficient than conventional protocols

Can pre-procedure neuroaxial ultrasound improve the identification of the potential epidural space when compared with anatomical landmarks? Aprospective randomized study

BACKGROUND: Regional epidural analgesia is considered the gold standard for pain treatment in labor. However, epidural catheter placement may be a challenging procedure because of the difficulty in the palpation of anatomical landmarks, particularly in pregnant women. Pre-procedural neuroaxial ultrasound may facilitate the procedure. METHODS: A prospective randomized controlled study was conducted in a labor ward. Two groups of women undergoing epidural analgesia were randomized: Group A (N.=28), which was subjected to the loss of resistance technique, and Group B (N.=30) which was subjected to an ultrasound (US)-assisted procedure. The real depth of epidural space was calculated in both groups by measuring the needle skin-to-tip distance, while the USdepth was measured only in Group B. RESULTS: The mean number of attempts in group A (3.43±3.8) was significantly higher than in Group B (1.70±0.87, P=0.019). Analysis of data from Group B revealed a strong positive correlation between the epidural real depth and US depth (r=0.88, P<0.0001). CONCLUSIONS: The US-assisted technique for epidural catheter placement for labor analgesia is safe, effective, easy to perform, and is a valuable aid to improve the identification of the epidural space compared with the palpation of anatomical landmarks and the loss of resistance technique. Pre-puncture ultrasound assessment shows the exact location of the intervertebral space, the optimal point of insertion and the tilt angle of the needle, the depth of the epidural space and any anatomical abnormalities of the spine, thereby increasing the success rate and reducing procedural complications of the blind approach

An Italian Expert Consensus on the Use of Opioids for the Management of Chronic Non-Oncological Pain in Clinical Practice: Focus on Buprenorphine

Purpose: The aim of the present work was to evaluate the knowledge and prescriptive habits of clinicians involved in the management of chronic non cancer pain (CNCP), with a special focus on the use of opioids. Methods: A Delphi method was used. A Board of specialists elaborated and discussed a series of statements, based on available literature and personal clinical expertise, about particularly controversial topics on pain pathophysiology and treatment. A Panel of experts in the field of pain management, selected by the Board, was invited to vote the proposed statements, indicating the level of agreement on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: partially agree; 4: agree; 5: strongly agree). The threshold for consensus was set at minimum 66.6% of the number of respondents with a level of agreement ≥4 (Agree or Strongly agree). Results: The Board included 5 pain therapists, 1 pharmacologist and 1 methodology expert and drew up a total of 36 statements (for a total of 40 requested answers)". A total of 100 clinicians were included in the Expert Panel. Respondents were 89 (89%). Consensus was achieved for 32 out of 40 answers. Most of the lack of consensus was recorded for statements regarding opioids use, and resulted from a low level of agreement (3 on the Likert scale), suggesting a neutral position deriving from a lack of knowledge rather than a strong contrary opinion. Conclusion: Most of the proposed items reached consensus, suggesting a generally homogeneous approach to CNCP management. However, the lack of consensus recorded for several items regarding opioid use confirms the need to fill important gaps in the knowledge of available agents. A clear explanation of the peculiar pharmacological properties of drugs associated with potential clinical advantages (such as buprenorphine) will help optimize pain treatment in both primary care and hospital settings and improving pain control in CNCP patients

Pursuing the Recovery of Severe Chronic Musculoskeletal Pain in Italy: Clinical and Organizational Perspectives from a SIAARTI Survey

Background: Increased attention to the functional impact of chronic pain (CP), as highlighted by the 11th revision of the International Classification of Diseases (ICD-11) and advocated by the International Classification of Functioning, Disability and Health (ICF), is an important step forward for optimizing its management. Evidence about perspectives of Italian physicians on the relevance of musculoskeletal (MSK) pain care to improve patients &amp; rsquo; functioning and Quality of Life is scant. The study aimed to investigate the physicians &amp; rsquo; perception of the value of functional recovery in severe MSK pain patients, their attitude towards its assessment and achievement in Italy. Methods: A survey was conducted in Italy between October 2020 and January 2021. Specialist centers members of the SIAARTI (n = 395) were sent an online questionnaire encompassing the Italian pain therapy network. Participants rated their agreement to questionnaire items according to a 5-point Likert-type scale. Results: A total of 305 centers (77%) completed the survey. Most physicians rated the recovery of functioning as very relevant in MSK pain treatment and, when they assessed it, devoted great attention to the ability to perform daily activities, pain, ability to ambulate and sleep quality. Multidimensional questionnaires were less employed in favor of physical examination and pain intensity scales. Pharmacological therapy, rehabilitation and lifestyle changes and/or physical exercise were all rated optimal strategies to pursue the recovery of patients &amp; rsquo; functioning. When considering pharmacological therapy, weak and strong opioids, either alone or combined with paracetamol, were the most frequently employed analgesics. Conclusion: Clinicians seem to recognize the recovery of functioning as equally important as pain intensity reduction, but there is a need of streamlining available tools to effectively assess both across different MSK pain patients

Pathophysiology of Nociception and Rare Genetic Disorders with Increased Pain Threshold or Pain Insensitivity

Pain and nociception are different phenomena. Nociception is the result of complex activity in sensory pathways. On the other hand, pain is the effect of interactions between nociceptive processes, and cognition, emotions, as well as the social context of the individual. Alterations in the nociceptive route can have different genesis and affect the entire sensorial process. Genetic problems in nociception, clinically characterized by reduced or absent pain sensitivity, compose an important chapter within pain medicine. This chapter encompasses a wide range of very rare diseases. Several genes have been identified. These genes encode the Nav channels 1.7 and 1.9 (SCN9A, and SCN11A genes, respectively), NGFβ and its receptor tyrosine receptor kinase A, as well as the transcription factor PRDM12, and autophagy controllers (TECPR2). Monogenic disorders provoke hereditary sensory and autonomic neuropathies. Their clinical pictures are extremely variable, and a precise classification has yet to be established. Additionally, pain insensitivity is described in diverse numerical and structural chromosomal abnormalities, such as Angelman syndrome, Prader Willy syndrome, Chromosome 15q duplication syndrome, and Chromosome 4 interstitial deletion. Studying these conditions could be a practical strategy to better understand the mechanisms of nociception and investigate potential therapeutic targets against pain

Neurostimulation for Chronic Low Back Pain during Pregnancy: Implications for Child and Mother Safety

Pain therapy for low back pain in pregnancy is a very topical issue. In fact, it is necessary to balance the patient’s needs to control pain with the need to manage a pregnancy without negative effects on the fetus. We report a case of a 37-year-old woman with low back pain treated with neurostimulation before pregnancy. She described severe chronic low back pain unresponsive to pharmacologic treatments. We first implanted a subcutaneous stimulator into the patient, and then a definitive stimulator resulting in excellent pain control. The improvement in her quality of life allowed the woman to become pregnant. We decided to stop neurostimulation with the patient during pregnancy. The patient completed her pregnancy without complications and the baby was born healthy. During the pregnancy, the woman took only paracetamol when needed. However, this painful symptomatology, completely anecdotal, is not attributable solely to the previous spine problem but probably also to the changes occurring during pregnancy. At the end of pregnancy, the neurostimulator was reactivated without any discomfort for the patient, who is now pain free. This case report provides a first line of evidence of a possible treatment of low back pain in women intending to become pregnant, with risk-free management for both the patient and the child

A Modified Approach for Ultrasound-Guided Thoracic Paravertebral Block via Thoracic Intervertebral Foramen in an Adolescent Patient: A Case Report

This case report describes a modified approach for a thoracic paravertebral block by performing a bilateral ultrasound-assisted injection of 12 mL of 0.5% levobupivacaine near the thoracic intervertebral foramen, combined with general anesthesia, in a patient who underwent emergent laparotomy for small intestinal volvulus. Two continuous catheter sets were used for a bilateral continuous block with levobupivacaine 0.25% at a rate of 5&ndash;8 mL/h. No complications during the execution of the block were recorded. No supplemental opioids were administered and the patient was hemodynamically stable, requiring no pharmacological cardiovascular support during surgery. At the end of the surgical procedure, the patient received a continuous flow of 0.2% levobupivacaine as postoperative analgesia, at a basal flow of 4 mL/h per each side, a bolus of 4 mL, and a lockout time of 60 min was used. The postoperative pain on the Numeric Rating Scale was 2 at rest and it was 4 in motion, without neurological or respiratory sequelae due to block in the first 72 h after surgery

Bilateral transversus abdominis plane (TAP) block reduces pain and the need for additional analgesics after elective cesarean section under opioid-free spinal anesthesia: findings from a randomized clinical trial

Background Cesarean section (CS) is the most frequently performed obstetric procedure globally, and postopera- tive pain remains a prominent concern. This study aimed to evaluate the effectiveness of the bilateral transversus abdominis plane (TAP) block in addressing this issue. Methods We performed a randomized trial in women with term pregnancies who underwent elective CS with spinal anesthesia. The women were randomized (1:1) to receive bilateral TAP or postoperative systemic analgesics (control group). The primary outcome was the effect on postoperative pain assessed using the numeric rating score (NRS) at 2, 6, 12, and 24 h in the postoperative period. Results At 2 and 6 h after the surgical procedure, there was a significant reduction in both resting (rNRS p = 0.004) and movement-related pain (dNRS p = 0.0001, p = 0.001 respectively). However, at 12 h, a reduction of dNRS was dem- onstrated (p = 0.0001), while no benefit was observed at rest. The percentage of women with NRS ≤ 4 was higher after the block at 2 h for both resting and movement-related pain (rNRS p = 0.010; dNRS p = 0.0001); at 6 and 12 h, it was only significant for dNRS (p = 0.002). Rescue doses of analgesics were significantly higher in the control group at 2, 6, and 12 h (p = 0.01, p = 0.0383, p = 0.0003 respectively). No complications with the procedure were recorded. Conclusion Bilateral TAP block has the potential to alleviate postoperative pain and reduce the need for additional analgesics after CS

Strategies to build and maintain competence in pain management: insights from a SIAARTI survey on educational needs among Italian anesthesiologists

Purpose: Fulfilling educational needs in pain management should be a lifelong process, even involving physicians board certified in pain medicine such as the anesthesiologists/pain therapists. The aim of the study was to investigate Italian anesthesiologists' self-perceived competency, confidence, and interest to attend educational programs in relation to their seniority in pain management. Methods: SIAARTI members were sent an online questionnaire addressing the following items: education, skills (both soft and hard skills), technical expertise and engaged to participate between December 2020 and January 2021. Participants rated their competence based on the following range (no knowledge, knowledge, competence) while their agreement to attend educational courses was assessed with a 5-point Likert-type scale. Results: Less than one in four participants declare to be dedicated to pain medicine activity with greater proportion among older (over 61 years) compared to younger ones (31-40 years). Regarding cancer and chronic non-cancer pain a positive gradient of self-perceived competence has been observed in relation to seniority. In contrast, no gradient of self-perceived competence was reported about musculoskeletal and low back pain. Participants self-perceived competent in both opioid use and prevention of opioid-related adverse event while feeling less competent when managing drugs with abuse potential. The lowest competence has been observed in pediatric pain along with the lowest interest to attend educational courses. Participants were much and very much interested to education regarding cancer, non-cancer, musculoskeletal and low back pain, invasive analgesic procedures but less regarding items for which they declared less competence, such as use of pain scales, pain management in children and use of drugs with abuse potential. Conclusion: This work provides first evidence of a summative assessment of competency and related educational needs' profile of anesthesiologists/pain therapists thus paving the way for developing a nationwide educational program to improve chronic pain care in Italy