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.

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.

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.

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.

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 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 .

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 using 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 noncancer 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, noncancer, 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.

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

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.

Efficacy and Safety of Tranexamic Acid in Cancer Surgery. An Update of Clinical Findings and Ongoing Research.

In cancer patients undergoing surgery, tumor biology and anticancer treatments can increase the risk of perioperative bleeding and blood transfusions. Notably, blood transfusions can be potentially associated with an increased risk of life-threatening immune responses, acute lung injury, postoperative infections, and thromboembolism. Moreover, the link between perioperative transfusion and increased risk of cancer recurrence cannot be excluded. On the other hand, cancer patients have an increased risk of thromboembolism due to cancer itself and antineoplastic systemic treatments including chemotherapy and anti-angiogenic drugs. In this complex scenario, effective and safe strategies aimed at the prevention of blood transfusions are warranted. This narrative review addresses the efficacy, and the safety of the synthetic antifibrinolytic agent tranexamic acid (TXA) when used perioperatively in cancer surgery. Although in not oncologic surgery the use of TXA has been extensively studied, in the setting of cancer patients requiring surgery, the evidence is scarce. An overview of the ongoing clinical research is also provided.

VOSviewer-Based Bibliometric Network Analysis for Evaluating Research on Juvenile Primary Fibromyalgia Syndrome (JPFS).

BACKGROUND: Juvenile primary fibromyalgia syndrome (JPFS) is a chronic musculoskeletal pain syndrome that affects children and adolescents. METHODS: A VOSviewer-based bibliometric network analysis was performed by scanning the global literature on JPFS in the Web of Science (WOS) online database. The search string applied to identify the closest matching articles was "juvenile primary fibromyalgia syndrome (all field)". RESULTS: A total of 67 articles on JPFS were published from 1985 to March 2022, in the WOS. Regarding article types, 39 were research manuscripts, 16 reviews, 8 meeting abstracts, 2 letters, 1 book chapter, 1 correction, and 1 proceeding paper. The Quartile analysis demonstrated that 44% of papers were published in Q1, 37% in Q2, 8% in Q3, and 11% in Q4. CONCLUSIONS: Our analysis highlights that more efforts are warranted to increase the production of quality papers and enhance the connections between the various research groups. JFPS represents a research field still to be explored and which deserves greater investments to obtain quality scientific evidence.

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 5-8 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.

Strengths and Weaknesses of Cancer Pain Management in Italy: Findings from a Nationwide SIAARTI Survey.

OBJECTIVES: Despite guidelines, a large percentage of cancer patients continue to suffer from ineffectively treated pain. The authors undertook this survey to assess the strengths and weaknesses of cancer pain management in Italy. DESIGN: This was a prospectively administered survey. PARTICIPANTS: The participants were anesthesiologists of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). INTERVENTION: A 58-item questionnaire covered the demographics and features of cancer pain management in the Italian context. RESULTS: The authors received responses from 611 pain therapists of 279 centers. Only 22% of physicians are exclusively pain therapists. Seventy-five percent are specialists in anesthesiology, intensive care, and pain medicine. Most pain centers are hospital or university facilities (78%). The strengths of cancer pain management in Italy are the careful opioid prescriptions, the use of strategies for the treatment of neuropathic pain, patient/healthcare provider partnerships, and breakthrough cancer pain management. Weaknesses to be addressed include poor adherence to guidelines, inadequate attention toward the patient's quality of life, insufficient use of minimally invasive techniques, lack of teamwork approaches, inappropriate timing of pain specialist engagement, and poor telemedicine use. CONCLUSIONS: Despite several strengths, further efforts are needed to improve the care of patients suffering from cancer pain in Italy.

Bibliometric Network Analysis on Rapid-Onset Opioids for Breakthrough Cancer Pain Treatment.

BACKGROUND AND OBJECTIVES: Proper breakthrough cancer pain (BTcP) management is of pivotal importance. Although rapid-acting, oral and nasal transmucosal, fentanyl formulations (rapid-onset opioids, ROOs) are licensed for BTcP treatment, not all guidelines recommend their use. Presumably, some research gaps need to be bridged to produce solid evidence. We present a bibliometric network analysis on ROOs for BTcP treatment. METHODS: Documents were retrieved from the Web of Science (WOS) online database. The string was "rapid onset opioids" or "transmucosal fentanyl" and "breakthrough cancer pain". Year of publication, journal metrics (impact factor and quartile), title, document type, topic, and clinical setting (in-patients, outpatients, and palliative care) were extracted. The software tool VOSviewer (version 1.6.17) was used to analyze the semantic network analyzes, bibliographic coupling, journals analysis, and research networks. RESULTS: 502 articles were found in WOS. A declining trend in published articles from 2014 to 2021 was observed. Approximately 50% of documents regard top quartile (Q1) journals. Most articles focused on ROOs efficacy, but abuse and misuse issues are poorly addressed. With respect to article type, we calculated 132 clinical investigations. The semantic network analysis found interconnections between the terms "breakthrough cancer pain," "opioids," and "cancers." The top co-cited article was published in 2000 and addressed pain assessment. The largest number of partnerships regarded the United States, Italy, and England. CONCLUSION: In this research area, most articles are published in top-ranked journals. Nevertheless, paramount topics should be better addressed, and the implementation of research networks is needed.

Incidence of Acute and Chronic Post-Thoracotomy Pain in Pediatric Patients.

We studied acute and chronic pain in pediatric patients who underwent thoracotomy for benign disease with a follow-up of at least three months. A telephone interview investigated about the presence of pain and the analgesic therapy in progress. The results were compared with the anesthetic technique, postoperative pain and the adequacy of pain therapy, both during the first week after surgery and at the time of interview. Fifty-six families consented to the study. The mean age of the children at surgery was 2.9 ± 4.5 years, while at the time of the interview was 6.5 ± 4.4 years. We performed different anesthetic strategies: Group A: general anesthesia (36 pts); Group B: general anesthesia and thoracic epidural (10 pts); Group C: general anesthesia and intercostal nerve block (10 pts). During the immediate postoperative period, 21 patients (37.5%) had at least one painful episode. At the time of interview, 3 children (5.3%) had moderate chronic neuropathic (burning) pain on surgical scar. There was no statistically significant difference between the type of anesthesia and the incidence and severity of acute post-operative pain. Despite its limitations, this study confirms the low incidence of chronic post-thoracotomy pain syndrome in children.

Ibuprofen and postoperative bleeding in children undergoing tonsillectomy or adenotonsillectomy: a systematic review and meta-analysis of randomized clinical trials.

INTRODUCTION: Ibuprofen is a drug widely used in children who underwent elective tonsillectomy or adenotonsillectomy because compared to the other Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) it is considered a safe drug with a low risk of postoperative bleeding. AREAS COVERED: We conducted a systematic review with meta-analysis of randomized clinical trials (RCTs) comparing ibuprofen vs. placebo or not-NSAIDs drugs in children aged up to 17 years of age, who underwent elective tonsillectomy or adenotonsillectomy. We searched in MEDLINE, EMBASE and Cochrane from 1990 through 30 April 2019. We searched www.clinicaltrials.gov for relevant ongoing studies. Our primary outcome was postoperative bleeding requiring surgical intervention. Secondary outcomes were postoperative bleeding not requiring further surgical intervention, the need for blood transfusion, nausea, vomiting, prolonged hospital stay, postoperative pain, and adverse events related to ibuprofen administration. The database search yielded 1227 patients from 7 studies. EXPERT OPINION: Given the imprecision of our estimates, the quality of evidence very low/moderate and the few RCTs identified, the results of this analysis were consistent with either a benefit or a detrimental effect of the administration of ibuprofen and do not provide a definitive answer to the review question. Further studies are needed on this important topic.