Role of mesotherapy in musculoskeletal pain: opinions from the italian society of mesotherapy.

Mesotherapy is the injection of active substances into the surface layer of the skin. This method allows a slower spread, higher levels, and longer lasting effects of drugs in the tissues underlying the site of injection (skin, muscle, and joint) compared with those following intramuscular injection. This technique is useful when a local pharmacological effect is required and relatively high doses of drug in the systemic circulation are not. Mesotherapy should only be undertaken following a complete clinical workup and subsequent diagnosis. Encouraging results have been reported in randomized, controlled clinical trials and in observational studies involving patients with various forms of musculoskeletal pain. Recommendations by experts from the Italian Society of Mesotherapy for appropriate use of mesotherapy in musculoskeletal pain and an algorithm for treating localized painful conditions are provided.

Clinical and psychosocial correlates of acute pain in herpes zoster.

BACKGROUND: Acute and persistent pain are the most significant clinical manifestations of herpes zoster (HZ), but the characteristics of acute pain in HZ patients have been inadequately investigated. OBJECTIVES: To correlate the severity of acute pain with clinical, demographic and psychosocial characteristics of HZ patients. STUDY DESIGN: Five hundred thirty-three patients with acute HZ were recruited by 119 dermatologists who collected medical and demographic data at diagnosis, provided counselling and therapy where appropriate and asked the patients to complete the Short Italian Questionnaire designed for comprehensive evaluation of HZ patients. RESULTS: In a univariate analysis, greater acute pain severity was significantly associated with female gender, number of dermatomes affected, presence of prodromal pain, abnormal sensations (dysesthesia), education level, anxiety and depression. Quality of life, even if greatly reduced, did not correlate with the intensity of pain. In a multivariate model, the intensity of pain was independently associated with the extent of rash (p=0.042), presence of prodromal pain (p=0.005), dysesthesia, education level (p=0.040), and depression (p<0.001), but not with gender, anxiety or quality of life. CONCLUSIONS: This study suggests that in patients with acute HZ the severity of the disease and depression at presentation are the main correlates of pain intensity.

Italian Oncological Pain Survey (IOPS): a multicentre Italian study of breakthrough pain performed in different settings.

OBJECTIVE: A survey of breakthrough pain (BTP) was performed in five palliative care units (PCU), seven oncology departments (ONC), and nine pain clinics (OPC). METHODS: A standard algorithm was used to confirm the diagnosis of BTP of patients refereed to different settings. RESULTS: 1,412 evaluable cancer patients were enrolled. 53.9% were males and the mean age was 63.7±13.1 years. The mean intensity of background pain was 2.8±0.73. Patients reported 2.4±1.1 BTP episodes/day with a mean intensity of 7.37±1.28. 80.6% patients reported that the BTP had a significant negative impact in everyday life. The majority of patients reported a fast onset of BTP, which was predictable in 50.7% of cases, while BTP with a gradual onset (>10 min) was less predictable (29%) (P=0.001). PCU patients were older, had lower Karnofsky levels, a lower number of BTP episodes/day, a slow onset of BTP onset, and a less predictable BTP. Cancer diagnosis was performed a mean of 23.5 months (SD±32.8) before the assessment. The mean duration of background pain was 3.5 months (SD±3.5), and the mean duration of any analgesic treatment was 2.5 months (SD±3). BTP started a mean of 2.2 months (SD±1.9) before the assessment. Characteristics of BTP were influenced by the course of disease, as well as the duration of background pain and initiation of BTP. Most patients took rapid onset opioids and were satisfied with the treatment. BTP diagnosis was prevalently made by ONC and OPC physicians, and rarely by GPs. CONCLUSION: This survey performed by an Italian observatory expert review group, has confirmed that the BTP represents a clinically relevant condition with a negative impact on the patient's quality of life. BTP was detected in all settings involved. A number of factors are associated with the BTP. Also factors regarding the course of disease and setting of care have been assessed. This information may help in stratifying patients or predicting the risk of development of BTP with specific characteristics.

Prolonged-release oxycodone/naloxone in nonmalignant pain: single-center study in patients with constipation.

INTRODUCTION: Opioid treatment for chronic malignant and nonmalignant pain of moderateto-severe intensity is associated with bowel dysfunction leading to constipation; this often requires opioid dose reduction or interruption. Combination opioid agonist/antagonist therapy can restore normal bowel function. A prolonged-released (PR) fixed-dose combination of oxycodone and naloxone has been developed and efficacy has been demonstrated in phase 3 clinical trials. METHODS: This 2-month, retrospective, singlecenter, observational study assessed the effectiveness and safety of PR oxycodone/naloxone in consecutive nononcological patients with constipation and chronic pain despite analgesic treatment; specific subgroup analyses were performed in opioid-experienced or opioid-naïve patients and in age subgroups. Efficacy was assessed by: intensity of pain; bowel function; effective oxycodone/naloxone dose; Patients' Global Impression of Change (PGIC) scale; rescue paracetamol; and laxative use. Safety evaluations were also performed. RESULTS: Of 1,051 patients starting on the oxycodone/naloxone combination (32.0% male; mean age 67 ± 13 years, 53.9% opioid naïve), 1,012 completed 2 months of treatment. Overall, PR oxycodone/naloxone was associated with a significant decrease in pain intensity (P < 0.001), a reduced need for rescue paracetamol (P < 0.001), and PGIC score of "very much improved" or "much improved" in 84.0% of patients. Constipation markedly decreased (P < 0.001) despite reduced laxative use (P < 0.001 vs. baseline). The most frequent treatment-emergent adverse events were somnolence (2.0%), dizziness (1.1%), and confusion (1.0%). Clinical differences in endpoints were seen between opioid-naïve and opioid-experienced patients, and among agestratified groups, but efficacy was similar to the overall population. CONCLUSIONS: Fixed combination PR oxycodone/naloxone was effective and well tolerated in moderate-to-severe chronic pain in patients with constipation, providing analgesia and relief from bowel dysfunction. Consistent efficacy across patient subgroups provides guidance for daily management of chronic pain when therapy options are limited due to bowel dysfunction, regardless of age or previous medication. Supplementary material belonging to this paper is available on SpringerLink.

Intra- and inter-beat modeling of cardiovascular dynamics and control: assessing haemodynamic stability and responsiveness.

In critical care patient management, extensive and invasive patient monitoring is routinely performed in order to quantify patient status in view of therapeutic interventions. Little quantitative integration is performed when collecting information from multiple monitors, and processing algorithms are often based on little physiological understanding. Mechanistic modeling can offer insight into the mechanisms underlying patient stability and sensitivity to alterations in physiological variables. Starting from existing models, we construct an integrated model which combines detailed neural cardiovascular regulation with realistic circulation modeling, using Monte-Carlo techniques for reparameterisation when merging the two models. The combined model is analyzed in terms of its dynamical stability and sensitivity to parameter perturbations under simulated conditions of fluid deficit, anaesthesia, and dilatative cardiomyopathy. The results exemplify how a structural model can serve as a quantitative guide in assessing how different underlying patient states can alter the haemodynamics impact of external therapeutic intervention.

Arterial blood pressure regulation following aorta clamping and declamping during surgery.

In this paper, we propose the use of black box models for the system identification of the cardiopulmonary baroreflex control of arterial resistance and of ventricular contractility and of arterial baroreflex control of heart rate (HR) from invasive, continuous measurements of arterial blood pressure (ABP) and central venous pressure (CVP), and non invasive, continuous recordings of ECG and respiration. Two crucial phases of the abdominal aortic aneurism (AAA) repair were investigated: the clamping and declamping of aorta. The objective of the present work is to evaluate and to test the ability to monitor baroreflex responses to clamping and declamping maneuvers preceding and following aneurism removal.

Estimation of baroreflex sensitivity during anesthesia induction with propofol.

This paper presents the analysis of the autonomic nervous system (ANS) control and cardiac baroreflex sensitivity in patients undergoing general anesthesia for major surgery, with the goal of evaluating the effects of anesthesia bolus induction with propofol on autonomic control of heart rate (HR) and arterial blood pressure (ABP). The increase in baroreflex gain in the LF band observed through two different methods hints at the fact that the baroreflex may increase heart period (HP) following a transient ABP decrease, but its response displays a larger amplitude, to compensate for the blunting of the sympathetic action on heart rate and vascular resistance.

Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective, randomized, clinical trial compared pain intensity and analgesic drug consumption after anterior cruciate ligament (ACL) reconstruction with patellar tendon under femoral-sciatic nerve block anesthesia in patients who received either a continuous femoral nerve block (CFNB) or continuous local anesthetic wound and intra-articular infusions. METHODS: Fifty patients were randomized to CFNB (n = 25) or an ON-Q device (I-Flow Corp, Lake Forest, Calif) (n = 25). All patients received sciatic nerve block (25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). The first group received a CFNB (2 mg/mL of ropivacaine at 7 mL/hr), and the second group received a single-shot femoral nerve block (both using 25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). At the end of the intervention, an ON-Q device was positioned on the ON-Q patients to continuously infuse the patellar tendon wound and intra-articular cavity with ropivacaine 2 mg/mL at 2 mL/hr for each catheter. Data regarding demographic, hemodynamic, pain scores, adverse effects, and need for supplemental analgesia were registered in a 36-hr follow-up period. RESULTS: The CFNB group reported lower visual analog scale values than the ON-Q group: at rest at 12 hrs (2.4 [SD, 2.2] vs 5.4 [SD, 3.1]; P < 0.001) and on movement at 12 (3.1 [SD, 2.5] vs 6.3 [SD, 2.9]; P < 0.001) and 24 hrs (2.7 [SD, 1.9] vs 4.6 [SD, 2.6]; P = 0.01) after surgery. The number of morphine and ketorolac boluses was lower in the CNFB group (morphine: 3.2 [SD, 2.2] vs 6.2 [SD, 2.5]; P < 0.001; ketorolac: 1.1 [SD, 1.0] vs 2.4 [SD, 0.9]; P < 0.001). CONCLUSION: Continuous femoral nerve block provides better analgesia than the continuous patellar tendon wound and intra-articular infusions after anterior cruciate ligament reconstruction with patellar tendon.

Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules.

BACKGROUND: General anesthesia with single-lung ventilation is considered mandatory for thoracoscopic pulmonary resection. We assessed in a randomized study the feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. METHODS: Between March 2001 and February 2003, 60 patients were randomized into two 30-patients arms: a general anesthesia arm entailing double-lumen intubation and thoracic epidural anesthesia (control group); and an awake arm entailing sole thoracic epidural anesthesia at T4-T5 (awake group). Anesthesia time; operative time; global operating room time; patient satisfaction with the anesthesia and technical feasibility scored into 4 grades (from 1 = poor to 4 = excellent); visual analog pain score (VAS), nursing care (number of patient calls per day), 24 hours changes in arterial oxygenation (DeltaPaO2), and hospital stay were assessed. RESULTS: There was no mortality. There was no difference in technical feasibility between the groups although 2 patients in the awake group required conversion to thoracotomy due to severe adhesions. Other 2 patients in each group required conversion due to unexpected lung cancer requiring lobectomy. Comparisons of awake versus control group results showed that in the awake group, anesthesia satisfaction score was greater (4 vs 3, p = 0.04), whereas DeltaPaO2 (-3 mm Hg vs -6.5 mm Hg, p = 0.002); nursing care (2.5 calls per day vs 4 calls per day, p = 0.0001), and hospital stay (2 days vs 3 days, p = 0.02) were significantly reduced. CONCLUSIONS: In our study, awake thoracoscopic resection of solitary pulmonary nodules proved safely feasible. It resulted in better patient satisfaction, less nursing care and shorter in-hospital stay than procedures performed under general anesthesia.