The Occipital Nerves Applied Strain Test to Support Occipital Neuralgia Diagnosis

Introduction: Occipital neuralgia (ON) is a disabling cephalalgia form with demanding diagnostic workflow. We report the description and reliability analyses of the occipital nerves applied strain (ONAS) test for occipital neuralgia (ON) early-stage diagnosis in cephalalgia patients. Methods: In a retrospective and observational study, we evaluated, among n = 163 consecutive cephalalgia patients, the sensitivity, specificity, and prior probability [positive (PPV) and negative (NPV) predictive values] of the ONAS test against two reference tests (occipital nerve anesthetic block and the painDETECT questionnaire). Multinomial logistic regression (MLR) and v2 analyses verified the ONAS test outcome’s dependence upon independent variables (gender, age, pain site, block test, and painDETECT outcomes). We assessed inter-rater agreement with Cohen’s kappa statistic. Results: ONAS test showed sensitivity and specificity of 81 and 18%, respectively, against the painDETECT and of 94 and 46%, respectively, against the block test. PPV was >70% against both tests, while NPV was 81% against the block test and 26% against the painDETECT. Interrater agreement Cohen’s kappa was excellent. Significant association (X2 analyses) and relationship (MLR) were found only between ONAS test and pain site but not with the other independent predictors. Conclusions: The ONAS test showed satisfactory reliability among cephalalgia patients; thus, it might be considered a valuable early stage tool for ON diagnosis in these patients.PLAIN LANGUAGE SUMMARY We report the description and reliability features of an occipital neuralgia diagnostic tool. The latter is based on the assertion that applying a strain on putatively compromised occipital nerves prompts abnormal nerve discharges and subjective pain reactions and thus may reveal occipital neuralgia. Among 163 cephalalgia patients, the test showed sensitivity and specificity of 81 and 18%, respectively, against the painDETECT questionnaire and 94 and 46%, respectively, against the occipital nerves’ block test. Interrater agreement was excellent, and significant associations and relationships were found only between the tool and congruent pain site but not with the other independent predictors. This tool may help clinicians’ early detection of occipital neuralgia in cephalalgia patients

Nationwide survey on the management of pediatric pharyngitis in Italian emergency units

Background: Acute pharyngitis is a frequent reason for primary care or emergency unit visits in children. Most available data on pharyngitis management come from primary care studies that demonstrate an underuse of microbiological tests, a tendency to over-prescribe antibiotics and a risk of antimicrobial resistance increase. However, a comprehensive understanding of acute pharyngitis management in emergency units is lacking. This study aimed to investigate the frequency of rapid antigen test use to diagnose acute pharyngitis, as well as other diagnostic approaches, the therapeutic attitude, and follow-up of children with this condition in the emergency units. Methods: A multicentric national study was conducted in Italian emergency departments between April and June 2022. Results: A total of 107 out of 131 invited units (response rate 82%), participated in the survey. The results showed that half of the units use a scoring system to diagnose pharyngitis, with the McIsaac score being the most commonly used. Most emergency units (56%) were not provided with a rapid antigen diagnostic test by their hospital, but the test was more frequently available in units visiting more than 10,000 children yearly (57% vs 33%, respectively, p = 0.02). Almost half (47%) of the units prescribe antibiotics in children with pharyngitis despite the lack of microbiologically confirmed cases of Group A β-hemolytic streptococcus. Finally, about 25% of units prescribe amoxicillin-clavulanic acid to treat Group A β-hemolytic streptococcus pharyngitis. Conclusions: The study sheds light on the approach to pharyngitis in emergency units, providing valuable information to improve the appropriate management of acute pharyngitis in this setting. The routinary provision of rapid antigen tests in the hospitals could enhance the diagnostic and therapeutic approach to pharyngitis

Opioid-induced constipation in mixed chronic pain patients: Prevalence and predictors analysis

Objectives: Assessment of opioid-induced constipation (OIC) prevalence and relationship with demographic, clinical, and drug predictors in our daily practice. Design: Observational and retrospective study. Setting: Chronic pain (CP) center of Bologna\u2019s Teaching Hospital, Italy. Subjects: Mixed consecutive CP opioid-user outpatients (n = 128). Main outcome measure(s): OIC was assessed with the Bowel Function Index (BFI) in three consecutive visits. Absolute difference and Student\u2019s t-test were used to compare BFI scores. Predictors (opioid compound and type, morphine-equivalent daily-dose [MEDD], and laxatives) were retrieved from the patients\u2019 charts. BFI and predictors relationships were checked by multinomial logistic regression (MLR); independent predictors of BFI scores were assessed with \u3c72 analysis. Results: Of the 384 evaluations, 85 percent were on strong opioids with a MEDD range of 11-50 mg per day in the majority (60 percent) and 64 percent showed moderate constipation; 42 percent did not use laxatives while 24 percent used macrogol with significant decrease in the BFI. MLR showed that oxycodone was associated with a risk for moderate constipation. Lactulose and glycerin suppositories were associated with severe constipation. Non-opioid users and cancer patients were associated with normal bowel function and severe constipation, respectively. Conclusions: OIC was found in almost all evaluations of weak or strong opioid-users (97 percent); moderate to severe OIC was found in 72 percent of the evaluations. Cancer patients were associated with severe constipation. Macrogol was superior to other laxatives. In our experience, macrogol relieved constipation in those on the combination of oxycodone and naloxone and in those on fentanyl patches. Lactulose and glycerol suppositories were associated with severe constipation

Scoring system for breakthrough-pain likelihood in cancer patients

Scoring system for breakthrough-pain likelihood in cancer patients Submission No: 2044 Submission Type: Poster Abstract Submission Aim of Investigation: Breakthrough pain (BTP) shows variable prevalence in different clinical contexts of cancer patients. BTP diagnostic tools with demonstrated reliability, validation and prognostic capability are lacking. We report the preliminary results of an ongoing impact study following the development of a diagnostic/prognostic tool, the IQ-BTP, for BTP recognition and its likelihood among cancer patients. Methods: A sample of 120 chronic pain patients was used as a learning set. An univariate analysis was conducted in order to select the variables associated with the variable of interest (likelihood level of BTP); these have been employed in the planning of a Naive Bayes classifier; a set of scores for each predictor was computed, by extending the approach usually used for binary classification to the case of three likelihood classes of BTP (High, Low, None). The developed BTP-likelihood scoring system, under the form of a questionnaire (IQ-BTP), recently validated, is now used in a multicenter impact study. The study was authorized by the hospital Ethics Committee, and conducted according to the Helsinki declaration and IASP's guidelines for pain research in animals and humans. Results: The scoring system analysis showed that two thirds of the patients may be correctly classified as potentially having (or not having) BTP; proportions of correct classification for BTP likelihood classes "High" and "No BTP" was greater than 80%: most of the patients satisfying the criteria for having BTP were correctly recognized. Conclusions: The IQ-BTP with its peculiar scoring system and with adequate feasibility may enable, in cancer patients, the detection of potential-BTP and its likelihood. The latter may have significant relevance to BTP epidemiology and management

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

Boaz Gedaliahu Samolsky Dekel,1–3 Marco Palma,4 Maria Cristina Sorella,1–3 Alberto Gori,3 Alessio Vasarri,3 Rita Maria Melotti1–3 1Department of Medicine and Surgery Sciences, University of Bologna, 2Department of Emergency-Urgency, Bologna’s University Teaching Hospital, Policlinic S. Orsola-Malpighi, 3University of Bologna, Post Graduate School of Anaesthesia and Intensive Care, 4Collegio Superiore, Istituto di Studi Superiori – ISS, University of Bologna, Bologna, Italy Objectives: 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 (∆S=1.31), duration (∆S=5.25), and predictability (∆S=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. Keywords: naïve Bayes classifier, breakthrough pain, multiclass scoring-syste

Opiate titration in patients with moderate/severe cancer pain

Background and Goal of Study: The management of moderate/severe cancer pain with opiates implies an essential stage of initial titration.(1) Literature provides no univocal guidelines for such stage; the use of immediate release morphine sulphate, administered every 4 hours with the double dose at night (2) is awkward because of management, pharmacokinetic and patients' compliance limitations. Aim of this study was to verify the effectiveness and applicability of a titration approach based on the administration of a combination of sustained release (SR) opiate and an immediate release (IR) opiate as rescue dose. Materials and Methods: In this observational and retrospective study (hospital ethic committee notified) were included 98 consecutive inpatients with moderate/severe cancer pain (NRS>4), followed by the hospital pain management service in 2008-2009. Opiate titration in these patients consisted of the administration of oxycodone SR (OS-SR ≥ 5mg) twice a day and morphine IR (MS-IR, 30% daily dose of OS-SR) administered as 'rescue dose', maximum four times daily. Measures: socio-demographic characteristics, initial OS-SR dose, initial MS-IR dose, initial and post-treatment pain scores, (NRSs, under static and NRSd, dynamic- conditions), number of rescue doses administered in the 24h, variations of OS-SR dose and side effects. Results and Discussion: Titration approach was satisfactory in most patients: statistically significant and rapid decrease of pain were shown after 24h. In particular, pain intensity decreased from a median of NRSs=5 and NRSd=7 to NRSs=2 and NRSd=4, with scarce presence of side effects, along with high patient and caregiver satisfaction. In the following days OS-SR dose was hence stabilized. Conclusion(s): The proposed titration approach can be considered as a valid alternative to that suggested in the literature; it guarantees: efficient and rapid pain control, improvement of the patients' quality of life and involvement in the therapy process, less opiates side effects, major patient and care giver compliance with the prescribed therapy, and rational use of opiates. References: 1. Mercadante S. Opioid titration in cancer pain: a critical review. Eur.J.Pain 2007;11:823-30 2.Twycross R.G. Control of pain. J R Coll Physicians Lond 1984;18,1:32-3

VALIDAZIONE DI UN QUESTIONARIO PER LA DIAGNOSI DEL DOLORE EPISODICO INTENSO (BTP)

INTRODUZIONE Il Breakthrough pain (BTP) \ue8 un\u2019esacerbazione transitoria del dolore che si verifica dal 51% al 95% dei pazienti che presentano dolore cronico di base (background pain), moderato-severo, cancro correlato, ben controllato con oppiacei. I pazienti oncologici con BTP presentano in genere, dolore pi\uf9 intenso, una maggiore compromissione funzionale, una minore qualit\ue0 di vita e pi\uf9 importanti distress psicologici, rispetto a quelli senza BTP. (1) Inoltre il BTP, presente anche nei pazienti non oncologici, determina un maggiore impatto socio-economico in termini di ricoveri ospedalieri, visite in pronto soccorso e visite ambulatoriali. (2) Lo scopo dello studio \ue8 la validazione di un questionario diagnostico del BTP, attraverso il quale si potrebbe sia quantificare il fenomeno che perfezionare coerentemente l\u2019analgesia. METODI Il q-BTP, composto da 12 quesiti, \ue8 stato costruito ad hoc sul modello proposto da Portenoy. Sono stati arruolati nello studio pilota (2^ settimana del mese di Giugno 2010) pazienti con dolore cronico moderato-severo trattati con oppiacei. La somministrazione del q-BTP avveniva durante la prima visita in regime di consulenza intra-ospedaliera oppure presso l\u2019Ambulatorio di Terapia Antalgica. RISULTATI Tra le n=28 nuove visite effettuate nel periodo considerato, n=9 pazienti sono stati arruolati nello studio. L\u2019et\ue0 media del campione era 62,4 (\ub19,6) anni; n=6 era di sesso femminile e n=7 presentava patologia neoplastica. In base al q-BTP, n=7 pazienti presentavano dolore episodico intenso. L\u2019intensit\ue0 media del BTP era moderata-forte. DISCUSSIONE E NOTE CONCLUSIVE Il BTP \ue8 un fenomeno clinico complesso (3) che richiede un'accurata diagnosi. Il q-BTP si \ue8 rivelato di facile applicazione e di alta specificit\ue0. Somministrato sottoforma d\u2019intervista, aiuta il medico nella diagnosi di dolore episodico intenso e facilita l\u2019adeguamento della terapia antalgica nei pazienti neoplastici e non. Il questionario indaga sulla presenza di esacerbazioni transitorie di dolore, sulla loro frequenza, sede e durata. Il q-BTP ha permesso di evidenziare un\u2019elevata prevalenza del BTP nel campione studiato. In seguito a questo studio pilota \ue8 prevista l\u2019estensione dello studio su un campione maggiore. BIBLIOGRAFIA: 1. Portenoy RK, Paine D, Jacobsen P. Breakthrough pain: characteristics and impact in patient with cancer pain. Pain 1999;81:129-134 2. Portenoy RK, Hagen NA. Breakthrou pain:definition, prevalence and characteristics pain.1990;41:273-281 3. Caraceni A, Martini C, Zecca E, et al; Working Group ofan IASP Task Force on Cancer Pain. Breakthrough pain characteristics and syndromes in patients with cancer pain.An international survey. Palliat Med. 2004;18:177-183

VALIDAZIONE DELLA VERSIONE ITALIANA DEL MAINZ PAIN STAGING SYSTEM (MPSS) \u2013 primi risultati

INTRODUZIONE Il dolore cronico non-neoplastico (DC) \ue8 spesso multifattoriale, resistente alla terapia, ricorrente o parzialmente controllato nonostante lo sforzo terapeutico. In assenza di uno strumento in grado di stimare gli obiettivi terapeutici individuali \ue8 difficile programmare un piano terapeutico realistico. Il Mainz Pain Staging System (MPSS) \ue8 uno strumento, in lingua tedesca, che classifica il paziente con DC in 3 classi di gravit\ue0 prognostica (1). SCOPO La validazione del MPSS in lingua italiana e il confronto col BPI. METODI Previa notifica al comitato etico e dopo la traduzione dal tedesco, seguendo i consueti criteri scientifici, il MPSS-I \ue8 stato somministrato ad un campione pilota. Sono stati arruolati i pazienti con DC che da Marzo a Maggio 2010 accedevano per la prima volta all\u2019ambulatorio di Terapia Antalgica. Oltre ai dati socio-anagrafici sono stati raccolti i dati del BPI. E\u2019stato calcolato un indice che risulta dalla media degli item 7-13 del BPI per quantificare l\u2019interferenza del dolore sulla qualit\ue0 della vita (QDL). RISULTATI Sono stati analizzati i dati di 55 pazienti; il 64% erano di sesso femminile, l\u2019et\ue0 media del campione era 66,3 anni (\ub116,7). La distribuzione dei paziente nelle tre classi (I,II e III) del MPSS erano rispettivamente: n=21, 38,2%; n=29, 52,7% e n=5, 9,1%. \uc8 stata trovata una correlazione tra l\u2019indice dell\u2019interferenza del dolore con la QDL. La media dei valori degli item 7-13 del BPI nelle tre classi del MPSS era rispettivamente: 4,6; 5,3 e 6,1. DISCUSSIONE/CONCLUSIONE Il MPSS \ue8 un questionario multimodale somministrato sotto forma di intervista ed \ue8 composto da 10 item (2). Le tre classi di gravit\ue0 prognostica con esso determinabili sono: I, pazienti in cui la terapia pu\uf2 prevenire l\u2019evoluzione del dolore acuto in cronico; II, pazienti in cui \ue8 necessaria una terapia multimodale e III, pazienti in cui la remissione del dolore cronico non \ue8 assicurata. I dati analizzati mostrano un rapporto direttamente proporzionale tra le classi del MPSS-I e il peggioramento della QDL. Occorrer\ue0 confrontare in seguito i dati del BPI degli stessi pz. a 6 mesi dalla presa in carico dell\u2019Ambulatorio di Terapia Antalgica, per verificare l\u2019accuratezza prognostica del MPSS-I. Lo studio dovrebbe concludersi nel luglio 2010, a quel punto il MPSS-I potrebbe diventare uno strumento di routine nella terapia antalgica. BIBLIOGRAFIA 1. Frettl\uf6h J, Maier C, Gockel H, H\ufcppe M.Validation of the German Mainz Pain Staging System in different pain syndromes. Schmerz. 2003 Aug;17(4):240-51 2. M.Pfingsten, P.Sch\uf6ps, Th.Wille, L.Terp, J. Hildebrandt. Chronifizierungsausma f von Schmerzerkrankungen Quantifizierung und Graduierung. anhand des Mainzer Stadienmodells Schmerz 2000 \u202214:10\u20131