Opportunities and barriers for telemedicine in pain management: insights from a SIAARTI survey among Italian pain physicians.

BACKGROUND: The integration of telemedicine in pain management represents a significant advancement in healthcare delivery, offering opportunities to enhance patient access to specialized care, improve satisfaction, and streamline chronic pain management. Despite its growing adoption, there remains a lack of comprehensive data on its utilization in pain therapy, necessitating a deeper understanding of physicians' perspectives, experiences, and challenges. METHODS: A survey was conducted in Italy between January 2024 and May 2024. Specialist center members of the SIAARTI were sent an online questionnaire testing the state of the art of telemedicine for pain medicine. RESULTS: One-hundred thirty-one centers across Italy reveal varied adoption rates, with 40% routinely using telemedicine. Regional disparities exist, with Northern Italy showing higher adoption rates. Barriers include the absence of protocols, resource constraints, and bureaucratic obstacles. Despite challenges, telemedicine has shown positive impacts on service delivery, with increased service volume reported. Technological capabilities, including image sharing and teleconsultation with specialists, indicate promising interdisciplinary potential. CONCLUSIONS: The integration of advanced telemedicine software utilizing artificial intelligence holds promise for enhancing telemonitoring and alert systems, potentially leading to more proactive and personalized pain management strategies.

Advancing the integration of biosignal-based automated pain assessment methods into a comprehensive model for addressing cancer pain.

BACKGROUND: Tailoring effective strategies for cancer pain management requires a careful analysis of multiple factors that influence pain phenomena and, ultimately, guide the therapy. While there is a wealth of research on automatic pain assessment (APA), its integration with clinical data remains inadequately explored. This study aimed to address the potential correlations between subjective and APA-derived objectives variables in a cohort of cancer patients. METHODS: A multidimensional statistical approach was employed. Demographic, clinical, and pain-related variables were examined. Objective measures included electrodermal activity (EDA) and electrocardiogram (ECG) signals. Sensitivity analysis, multiple factorial analysis (MFA), hierarchical clustering on principal components (HCPC), and multivariable regression were used for data analysis. RESULTS: The study analyzed data from 64 cancer patients. MFA revealed correlations between pain intensity, type, Eastern Cooperative Oncology Group Performance status (ECOG), opioids, and metastases. Clustering identified three distinct patient groups based on pain characteristics, treatments, and ECOG. Multivariable regression analysis showed associations between pain intensity, ECOG, type of breakthrough cancer pain, and opioid dosages. The analyses failed to find a correlation between subjective and objective pain variables. CONCLUSIONS: The reported pain perception is unrelated to the objective variables of APA. An in-depth investigation of APA is required to understand the variables to be studied, the operational modalities, and above all, strategies for appropriate integration with data obtained from self-reporting. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov, number (NCT04726228), registered 27 January 2021, https://classic. CLINICALTRIALS: gov/ct2/show/NCT04726228?term=nct04726228&draw=2&rank=1.

Advanced statistical approaches for predicting pain after pediatric thoracotomy: a cross-sectional study using zero-inflated and Poisson models.

BACKGROUND: Thoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population. METHODS: A retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity. RESULTS: Gender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week. CONCLUSIONS: The study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

Maladaptive personality traits are associated with burnout risk in Italian anesthesiologists and intensivists: a secondary analysis from a cross-sectional study.

BACKGROUND: Burnout is a maladaptive response to chronic stress, particularly prevalent among clinicians. Anesthesiologists are at risk of burnout, but the role of maladaptive traits in their vulnerability to burnout remains understudied. METHODS: A secondary analysis was performed on data from the Italian Association of Hospital Anesthesiologists, Pain Medicine Specialists, Critical Care, and Emergency (AAROI-EMAC) physicians. The survey included demographic data, burnout assessment using the Maslach Burnout Inventory (MBI) and subscales (emotional exhaustion, MBI-EE; depersonalization, MBI-DP; personal accomplishment, MBI-PA), and evaluation of personality disorders (PDs) based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) criteria using the assessment of DSM-IV PDs (ADP-IV). We investigated the aggregated scores of maladaptive personality traits as predictor variables of burnout. Subsequently, the components of personality traits were individually assessed. RESULTS: Out of 310 respondents, 300 (96.77%) provided complete information. The maladaptive personality traits global score was associated with the MBI-EE and MBI-DP components. There was a significant negative correlation with the MBI-PA component. Significant positive correlations were found between the MBI-EE subscale and the paranoid (r = 0.42), borderline (r = 0.39), and dependent (r = 0.39) maladaptive personality traits. MBI-DP was significantly associated with the passive-aggressive (r = 0.35), borderline (r = 0.33), and avoidant (r = 0.32) traits. Moreover, MBI-PA was negatively associated with dependent (r = - 0.26) and avoidant (r = - 0.25) maladaptive personality features. CONCLUSIONS: There is a significant association between different maladaptive personality traits and the risk of experiencing burnout among anesthesiologists. This underscores the importance of understanding and addressing personality traits in healthcare professionals to promote their well-being and prevent this serious emotional, mental, and physical exhaustion state.

Ultrasound-assisted Thoracic Intervertebral Foramen Block. A Cadaveric Study.

BACKGROUND: A thoracic paravertebral block can be a useful opioid-sparing technique for controlling postoperative pain after thoracic and visceral abdominal surgery. OBJECTIVES: Our aim was to assess dye spread into the ventral branch, connecting branch, sympathetic trunk, thoracic paravertebral space, and epidural space after performing a modified ultrasound-assisted thoracic paravertebral block via the intervertebral foramen. STUDY DESIGN: This was a nonrandomized cadaveric study. SETTING: The cadavers were kept at the Department of Anatomopathology of the San Salvatore Academic Hospital of L'Aquila (L'Aquila, Italy). METHODS: We performed a bilateral thoracic paravertebral block via the intervertebral foramen at the second, fifth, ninth, and twelfth thoracic vertebrae. A linear array ultrasound transducer was used. Then, cadaveric dissection was performed. A Tuohy needle was gently inserted in-plane with the ultrasound beam in a lateromedial direction to contact the spinous process. Subsequently, the needle tip was advanced 2 mm along the transverse process of the vertebra, and 5 mL of methylene blue 1% dye was injected at each level. Then, 2 continuous catheter sets were inserted. RESULTS: Forty intervertebral foramen blocks were performed in 5 cadavers. For 38 injection sites, we found dye on both sides of the thoracic paravertebral space and epidural space at each level of puncture. The retropleural organs were also stained. In 2 cases, methylene blue accumulated intramuscularly at the level of the twelfth thoracic vertebra. RESULTS: The spread of dye into the ventral rami, communicating rami, and sympathetic trunk in the thoracic paravertebral space and the epidural space was assessed. We also evaluated the position and the distance (mm) between the catheter tip and the thoracic intervertebral foramen content. Finally, puncturing of intervertebral blood vessels, nerve rootlet and root damage, lung and pleural injuries, and the extent of intramuscular dye accumulation were evaluated and recorded as iatrogenic complications related to the anesthetic procedure. Forty thoracic paravertebral blocks in 5 cadavers were performed. For 38 injection sites, we found dye on both sides of the thoracic paravertebral space and the epidural space at each level of puncture. The ventral rami, the communicating rami, and the sympathetic trunk were also stained. In 2 cases, methylene blue accumulated intramuscularly at the level of the twelfth thoracic vertebra. LIMITATIONS: The first limitation of this study is its small sample size. In addition, the study design did not consider or measure the width of the transverse processes. Another limitation is that the ultrasound beam could not identify the thoracic intervertebral foramen content or the needle tip behind the acoustic shadow of the transverse and vertebral articular processes. CONCLUSION: Paravertebral block via the thoracic intervertebral foramen achieved consistent dye spread into the thoracic paravertebral space and epidural space, capturing retropleural organs.

Pulsed radiofrequency on peripheral nerve as a rehabilitation aid.

The work described below explores the field of the effects of pulsed radiofrequency for pain relief purposes. While the effects of this technique on pain modulation (A-delta and C fibers) are relatively well-known, little has been written yet about the potential of pulsed radiofrequency interactions with other fibers. The proposed algorithm, specifically elaborated, investigates the effect of this technique on neuromuscular fatigue, through a surface electromyographic study of the femoral nerve of a patient with residual pain after knee arthroplasty surgery, before and after the treatment. This work yields a preliminary result that is encouraging for subsequent large-scale studies.

Corrigendum: Neuroimaging in PRUNE1 syndrome: a mini-review of the literature.

[This corrects the article DOI: 10.3389/fneur.2023.1301147.].

Bridging knowledge gaps: a bibliometric analysis of non-invasive ventilation in palliative care studies.

BACKGROUND: Despite being a useful strategy for providing respiratory support to patients with advanced or terminal illnesses, non-invasive ventilation (NIV) requires in-depth investigation in several key aspects. OBJECTIVES: This bibliometric analysis seeks to comprehensively examine the existing research on the subject. Its goal is to uncover valuable insights that can inform the prediction trajectory of studies, guide the implementation of corrective measures, and contribute to the improvement of research networks. METHODS: A comprehensive review of literature on NIV in the context of palliative care was conducted using the Web of Science core collection online database. The search utilized the key terms "non-invasive ventilation" and "palliative care" to identify the most relevant articles. All data were gathered on November 7, 2023. Relevant information from documents meeting the specified criteria was extracted, and Journal Citation Reports™ 2022 (Clarivate Analytics) served as the data source. The analysis employed literature analysis and knowledge visualization tools, specifically CiteScope (version 6.2.R4) and VOSviewer (version 1.6.20). RESULTS: A dataset with bibliometric findings from 192 items was analyzed. We found a consistent upward of the scientific output trend over time. Guidelines on amyotrophic lateral sclerosis management received the highest number of citations. Most documents were published in top-ranked journals. Less than one-third of the documents pertain to clinical studies, especially retrospective analyses (25%). Key topics such as "decision making", and "communication" were less addressed. CONCLUSIONS: Given the substantial clinical implications, further high-quality studies on this subject are recommended. Encouraging international collaborations is needed. Despite the growing volume of documents in the field, this bibliometric analysis indicates a decline in collaborative networks.

Evaluating Nutritional Risk Factors for Delirium in Intensive-Care-Unit Patients: Present Insights and Prospects for Future Research.

Malnutrition, hypercatabolism, and metabolic changes are well-established risk factors for delirium in critically ill patients. Although the exact mechanisms are not fully understood, there is mounting evidence suggesting that malnutrition can cause a variety of changes that contribute to delirium, such as electrolyte imbalances, immune dysfunction, and alterations in drug metabolism. Therefore, a comprehensive metabolic and malnutrition assessment, along with appropriate nutritional support, may help to prevent or ameliorate malnutrition, reduce hypercatabolism, and improve overall physiological function, ultimately lowering the risk of delirium. For this aim, bioelectrical impedance analysis can represent a valuable strategy. Further research into the underlying mechanisms and nutritional risk factors for delirium is crucial to developing more effective prevention strategies. Understanding these processes will allow clinicians to personalize treatment plans for individual patients, leading to improved outcomes and quality of life in the intensive-care-unit survivors.

Pediatric Pain Management: The Time for Action Is Now.

Pediatric anesthesia is a field of research and assistance in which more specialization needs are emerging [...].

Unplanned admissions after day-case surgery in an Italian third-level pediatric hospital: a retrospective study.

BACKGROUND: Increasing procedures in day-case surgery can mitigate the costs of health service, without reducing safety and quality standards. The Ospedale Pediatrico Bambino Gesù has adopted an educational program for healthcare personnel and patients' families to increase the number of day-case surgery procedures performed without reducing the level of safety. The unplanned admission rate after day-case surgery can be a quality benchmark for pediatric day-case surgery, and in literature, there are no Italian data. METHODS: We made a retrospective analysis of the hospital database and focused on children requiring unplanned admission to the central venue of the hospital for the night. The audit covered the period from September 2012 to April 2018. RESULTS: We performed general anesthesia for 8826 procedures (urology 33.60%, plastic surgery 30.87%, general surgery 17.44%, dermatology 11.66%, dentistry 3.16%, orthopedics 1.64%, digestive endoscopy 1.63%). Unplanned admission for anesthetic reasons resulted in two cases: one case of syncope and one case of vomit (0.023% rate). No one major complication. CONCLUSIONS: Good quality of patient selection, the safety of the structure, family education, and an efficient organizational model combined with an educational program for anesthesiologists can improve the safety of anesthesia for day-case surgery.

"Emerging Topics in Pain Medicine": Advancing Research and Patient-Centered Health Strategies.

Pain, in all its various forms and manifestations, impacts the lives of millions worldwide [...].

Artificial Intelligence for Automatic Pain Assessment: Research Methods and Perspectives.

Although proper pain evaluation is mandatory for establishing the appropriate therapy, self-reported pain level assessment has several limitations. Data-driven artificial intelligence (AI) methods can be employed for research on automatic pain assessment (APA). The goal is the development of objective, standardized, and generalizable instruments useful for pain assessment in different clinical contexts. The purpose of this article is to discuss the state of the art of research and perspectives on APA applications in both research and clinical scenarios. Principles of AI functioning will be addressed. For narrative purposes, AI-based methods are grouped into behavioral-based approaches and neurophysiology-based pain detection methods. Since pain is generally accompanied by spontaneous facial behaviors, several approaches for APA are based on image classification and feature extraction. Language features through natural language strategies, body postures, and respiratory-derived elements are other investigated behavioral-based approaches. Neurophysiology-based pain detection is obtained through electroencephalography, electromyography, electrodermal activity, and other biosignals. Recent approaches involve multimode strategies by combining behaviors with neurophysiological findings. Concerning methods, early studies were conducted by machine learning algorithms such as support vector machine, decision tree, and random forest classifiers. More recently, artificial neural networks such as convolutional and recurrent neural network algorithms are implemented, even in combination. Collaboration programs involving clinicians and computer scientists must be aimed at structuring and processing robust datasets that can be used in various settings, from acute to different chronic pain conditions. Finally, it is crucial to apply the concepts of explainability and ethics when examining AI applications for pain research and management.

Investigating Functional Impairment in Chronic Low Back Pain: A Qualitative Study from the Patients and Specialists' Perspectives.

Prompt and appropriate treatment of chronic low back pain (cLBP) is of the utmost importance for preventing relevant disability, high burden of disease, and increasing costs for the healthcare system. Recently, the concept of functional impairment has been associated with any type of chronic pain, and mounting attention has been paid to extending the aims of treatment beyond mere pain remission, including restoration of working capacity, everyday functioning, mobility, and quality of life. Nevertheless, a shared definition of functionality is still lacking. Notably, different specialists involved in the treatment of cLBP such as general practitioners, orthopedists, pain therapists, and physiatrists, and patients themselves have different opinions on what "functional impairment" actually means. On these premises, a qualitative interview study was performed to investigate how the concept of "functionality" is interpreted by different specialists involved in the management of cLBP, and by patients. Overall, all different specialists agreed that functionality should be assessed in clinical practice. However, in spite of several instruments available for evaluating functionality, no homogeneity of behavior is observable.

Utilizing an artificial intelligence framework (conditional generative adversarial network) to enhance telemedicine strategies for cancer pain management.

BACKGROUND: The utilization of artificial intelligence (AI) in healthcare has significant potential to revolutionize the delivery of medical services, particularly in the field of telemedicine. In this article, we investigate the capabilities of a specific deep learning model, a generative adversarial network (GAN), and explore its potential for enhancing the telemedicine approach to cancer pain management. MATERIALS AND METHODS: We implemented a structured dataset comprising demographic and clinical variables from 226 patients and 489 telemedicine visits for cancer pain management. The deep learning model, specifically a conditional GAN, was employed to generate synthetic samples that closely resemble real individuals in terms of their characteristics. Subsequently, four machine learning (ML) algorithms were used to assess the variables associated with a higher number of remote visits. RESULTS: The generated dataset exhibits a distribution comparable to the reference dataset for all considered variables, including age, number of visits, tumor type, performance status, characteristics of metastasis, opioid dosage, and type of pain. Among the algorithms tested, random forest demonstrated the highest performance in predicting a higher number of remote visits, achieving an accuracy of 0.8 on the test data. The simulations based on ML indicated that individuals who are younger than 45 years old, and those experiencing breakthrough cancer pain, may require an increased number of telemedicine-based clinical evaluations. CONCLUSION: As the advancement of healthcare processes relies on scientific evidence, AI techniques such as GANs can play a vital role in bridging knowledge gaps and accelerating the integration of telemedicine into clinical practice. Nonetheless, it is crucial to carefully address the limitations of these approaches.

The Clinical Researcher Journey in the Artificial Intelligence Era: The PAC-MAN's Challenge.

Artificial intelligence (AI) is a powerful tool that can assist researchers and clinicians in various settings. However, like any technology, it must be used with caution and awareness as there are numerous potential pitfalls. To provide a creative analogy, we have likened research to the PAC-MAN classic arcade video game. Just as the protagonist of the game is constantly seeking data, researchers are constantly seeking information that must be acquired and managed within the constraints of the research rules. In our analogy, the obstacles that researchers face are represented by "ghosts", which symbolize major ethical concerns, low-quality data, legal issues, and educational challenges. In short, clinical researchers need to meticulously collect and analyze data from various sources, often navigating through intricate and nuanced challenges to ensure that the data they obtain are both precise and pertinent to their research inquiry. Reflecting on this analogy can foster a deeper comprehension of the significance of employing AI and other powerful technologies with heightened awareness and attentiveness.

The impact of emergence delirium on hospital length of stay for children who underwent tonsillectomy/adenotonsillectomy: an observational retrospective study

Abstract Background Emergence Delirium (ED) is a combination of disturbance of perception and psychomotor agitation that is common in pediatric patients after general anesthesia, especially at preschool age. Since the effect of ED on the length of stay has been studied in adults but infrequently in children, the aim of this study was to investigate the relationship between ED and length of stay in this population. Methods A single center, retrospective, observational study was carried out in children who underwent tonsillectomy or adenotonsillectomy. The Pediatric Anesthesia Emergence Delirium (PAED) scale was used to assess ED. In addition to the time to hospital discharge (time frame 24 hours), drugs used, comorbidities, early postoperative complications, and pain were investigated if potentially associated with the complication. Results Four hundred sixteen children aged from 1.5 to 10 years (183 female, 233 male) were included. ED occurred in 25.5% of patients (n = 106). Patients were divided into the ED group and the No-ED group. The discharge time was similar in both groups. No significant differences were observed in the frequency of postoperative complications. The use of fentanyl or dexmedetomidine did not affect ED occurrence. The frequency of pain was greater in the ED group, both in the recovery room and in the ward (p= 0.01). Conclusions The occurrence of ED in children after tonsillectomy/adenotonsillectomy did not extend the length of stay.

Pain prevalence and pain management in children and adolescents in an italian third level pediatric hospital: a cross-sectional study.

BACKGROUND: In 2016, we performed a one-day investigation to analyze the prevalence of pain, pain intensity, and pain therapy in the Departments of Surgery and Onco-Hematology of the Ospedale Pediatrico Bambino Gesù. To improve the knowledge gap highlighted in the previous study, refresher courses and even personalized audits have been carried out during these years. The purpose of this study is to evaluate if, after 5 years, there have been improvements in the management of pain. METHODS: The study was conducted on 25 January 2020. Pain assessment, pain therapies, pain prevalence and intensity in the preceding 24 h and during the recovery period were recorded. Pain outcomes were compared with previous audit results. RESULTS: Out of the 63 children with at least one documented pain assessment (starting from 100 eligible), 35 (55.4%) experienced pain: 32 children (50.7%) experienced moderate /severe pain while 3 patients (4%) felt mild pain. In the preceding 24 h, 20 patients (31.7%) reported moderate/severe pain while 10 (16%) reported moderate or severe pain during the interview. The average value of the Pain Management Index (PMI) was - 1.3 ± 0.9 with a minimum of -3 and a maximum of 0. 28 patients (87%) undergoing analgesic therapy for moderate/severe pain had a PMI of less than 0 (undertreated pain), while 3 patients (13%) scored value of 0 or higher (adequate pain therapy), 4 patients (12.5%) received multimodal analgesia with opioids and 2 patients (6%) opioids alone. Time-based therapy was prescribed to 20 patients (62.5%), intermittent therapy was prescribed to 7 patients (22%) and 5 patients (15.5%) did not receive any therapy. The prevalence of pain was higher during hospitalization and 24 h before the interview, while at the time of the interview, the proportion was the same. In this audit, the daily prescription modality of the therapy had some improvements (time-based: 62.5% vs. 44%; intermittent: 22%vs 25%; no therapy: 15.5% vs. 31%). CONCLUSION: Pain management in hospitalized children constantly requires special daily attention from health professionals aimed at mitigating the components of intractable pain and resolving those of treatable pain. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov, number (NCT04209764), registered 24 December 2019, https://clinicaltrials.gov/ct2/show/NCT04209764?term=NCT04209764&draw=2&rank=1 .