Innovazioni nel trattamento del dolore acuto post-operatorio

Despite the availability of guidelines, treatment of acute pain after surgery is still a challenge. Although patient-controlled analgesia (PCA) systems represent the gold standard for the systemic administration of opioids, the majority of patients in Italy are treated with continuous intravenous (IV) infusion delivered through elastomeric pumps. Limitations of the currently available IV PCA could be one reason for the poor adherence to the guidelines observed in clinical practice. Recently, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have approved two new non-invasive pre-programmed PCA systems. The fentanyl iontophoretic transdermal system and the sufentanil sublingual nano tablet system have several potential advantages compared to the currently used PCA devices. In particular, they do not require an intravenous line and eliminate the risk of medication delivery errors typically associated with misprogramming IV PCA pumps. Further studies however are needed to address the potential interindividual variability especially in opioid tolerant patients

Gender and Pain

• Chronic pain afflicts approximately 20% of the adult population worldwide. • Gender is one of the critical factors influencing the experience of pain. • Women report more severe levels of pain and chronic pain than men. • The response to pain therapy appears to be gender-related. • Sex hormones, endogenous opioid function, genetic factors, and psychosocial mechanisms contribute to gender differences in pain

Development and performance of a diagnostic/prognostic scoring system for breakthrough pain

none6noObjectives: Variable prevalence and treatment of breakthrough pain (BTP) in different clinical contexts are partially due to the lack of reliable/validated diagnostic tools with prognostic capability. We report the statistical basis and performance analysis of a novel BTP scoring system based on the naïve Bayes classifier (NBC) approach and an 11-item IQ-BTP validated questionnaire. This system aims at classifying potential BTP presence in three likelihood classes: "High," "Intermediate," and "Low." Methods: Out of a training set of n=120 mixed chronic pain patients, predictors associated with the BTP likelihood variables (Pearson’s Χ2 and/or Fisher’s exact test) were employed for the NBC planning. Adjusting the binary classification to a three-likelihood classes case enabled the building of a scoring algorithm and to retrieve the score of each predictor’s answer options and the Patient’s Global Score (PGS). The latter medians were used to establish the NBC thresholds, needed to evaluate the scoring system performance (leave-one-out cross-validation). Results: Medians of PGS in the "High," "Intermediate," and "Low” likelihood classes were 3.44, 1.53, and -2.84, respectively. Leading predictors for the model (based on score differences) were flair frequency (ΔS=1.31), duration (ΔS=5.25), and predictability (ΔS=1.17). Percentages of correct classification were 63.6% for the "High” and of 100.0% for either the "Intermediate” and "Low” likelihood classes; overall accuracy of the scoring system was 90.9%. Conclusion: The NBC-based BTP scoring system showed satisfactory performance in classifying potential BTP in three likelihood classes. The reliability, flexibility, and simplicity of this statistical approach may have significant relevance for BTP epidemiology and management. These results need further impact studies to generalize our findings.openSamolsky Dekel, Boaz Gedaliahu; Palma, Marco; Sorella, Maria Cristina; Gori, Alberto; Vasarri, Alessio; Melotti, Rita MariaSamolsky Dekel, Boaz Gedaliahu; Palma, Marco; Sorella, Maria Cristina; Gori, Alberto; Vasarri, Alessio; Melotti, Rita Mari

Iontophoretic transdermal fentanyl for the management of acute perioperative pain in hospitalized patients

Introduction: Intravenous (I.V.) morphine administered through a patient-controlled system currently represents the gold standard treatment for moderate to severe acute postoperative pain. To fix the limitations showed by the available I.V. patient-controlled analgesia (PCA) systems that may restrict its use in the clinical practice a needle-free, iontophoretic, fentanyl patient-controlled transdermal system has been developed and recently approved by the United States Food and Drug Administration (FDA) and by the European Medicines Agency (EMA).Areas covered: This review aims at describing the technology, pharmacology and clinical efficacy of fentanyl iontophoretic transdermal system (ITS) in the treatment of acute pain. A literature search was conducted in the PUBMED database using the term fentanyl iontophoretic transdermal system through September 2015 and results from the main clinical trials are discussed.Expert opinion: In 2015, the appropriate treatment of acute pain after surgery is still a challenge and it represents a primary goal in the care of the surgical patient. When regional analgesia techniques are not applicable and systemic analgesia is required, patient controlled systems represent the standard of care for opioid administration. The fentanyl ITS presents several potential advantages compared to the currently used PCA devices. In particular, it does not require intravenous lines and eliminates the potential for drug administration errors, observed with manually programmed standard PCA devices. Nevertheless, further studies are needed to address eventual inter-individual variability especially for opioid tolerant patients

Medical Evidence Influence on Inpatients and Nurses Pain Ratings Agreement

Biased pain evaluation due to automated heuristics driven by symptom uncertainty may undermine pain treatment; medical evidence moderators are thought to play a role in such circumstances. We explored, in this cross-sectional survey, the effect of such moderators (e.g., nurse awareness of patients' pain experience and treatment) on the agreement between n = 862 inpatients' self-reported pain and n = 115 nurses' pain ratings using a numerical rating scale. We assessed the mean of absolute difference, agreement (κ-statistics), and correlation (Spearman rank) of inpatients and nurses' pain ratings and analyzed congruence categories' (CCs: underestimation, congruence, and overestimation) proportions and dependence upon pain categories for each medical evidence moderator (χ2 analysis). Pain ratings agreement and correlation were limited; the CCs proportions were further modulated by the studied moderators. Medical evidence promoted in nurses overestimation of low and underestimation of high inpatients' self-reported pain. Knowledge of the negative influence of automated heuristics driven by symptoms uncertainty and medical-evidence moderators on pain evaluation may render pain assessment more accurate

Reliability of the Buttock Applied Strain test to uncover radicular pain in Low Back Pain patients

BACKGROUND: Low-back pain (LBP) pathophysiological conditions include nociceptive back pain, somatic referred pain, radicular pain (RP), and radiculopathy. Differential diagnosis is challenging; guidance may come from patients' thorough clinical history and physical examination, and particularly, for lumbar RP, from the evaluation of subjective responses of injured lumbar nerves to a strain applied at the buttock (Buttock Applied Strain, BUAS-test). METHODS: In a sample of n=395 consecutive LBP patients, sensitivity, specificity, and prior probability (positive and negative predictive values, PPV and NPV, respectively) of the BUAS-test were evaluated against two Reference tests: the Straight Leg Raising Test (SLRT) and the painDETECT (PD) questionnaire. Multinomial Logistic Regression (MLR) and \u3c72 analyses were used to evaluate the BUAS-test outcomes dependence upon independent variables (gender, age group, pain localization, SLRT, and PD outcomes). Cohen's Kappa statistic was used to assess inter-rater agreement. RESULTS: Against PD, the BUAS-test showed a sensitivity of 92%, specificity, and PPV of 100%, respectively, and NPV of 82%; against the SLRT, sensitivity and NPV of 82%, respectively, and specificity and PPV of 40%, respectively. Interrater agreement Cohen's Kappa was 0.911. Significant associations were found between BUAS-test outcomes and pain localization, SLRT, and PD outcomes, but not with gender or age group predictors. MLR showed significant congruent relationship between BUAS-test and the PD outcomes. CONCLUSION: Among LBP patients, the BUAS-test showed satisfactory sensitivity, specificity, Prior Probability, and interrater reliability, and thus, it may be considered a useful adjunctive tool to uncover RP in LBP patients. For results generalization, more research, in different clinical settings other than pain clinics, is needed

Reply to the Letter “Regarding Samolsky Dekel et al. Reliability of the Buttock Applied Strain Test to Diagnose Radicular Pain in Patients With Low Back Pain”

Thank you for the opportunity to respond to the authors of the letter "Regarding Samolsky Dekel et al. Reliability of the Buttock Applied Strain Test to Diagnose Radicular Pain in Patients with Low Back Pain." We appreciate the comments of the authors and congratulate their interest in our work; a fruitful exchange of opinion is always welcome