Long-term Cannabis-based oil therapy and pain medications prescribing patterns: an Italian observational study.

OBJECTIVE: Chronic pain is one of the most common medical conditions in developed countries. The 2020 Italian National Report on Medicines shows how, in the last years, there was a light but constant increase in the prescription of pain medications. The purpose of our study was to assess the effects of long-term cannabis-based oil consumption on the distribution of patients with analgesics prescriptions for chronic pain in a Pain Medicine Unit in Northern Italy. PATIENTS AND METHODS: This is a retrospective, observational study in which patients treated with long-term medical cannabis-based oils, followed between June 2016 and July 2019, were enrolled. The effects of cannabis-based oil consumption on the distribution of patients with pain medications, before and after its long-term use, were evaluated with a Related Samples McNemar Test. Subgroups analyses were performed based on sex, age, comorbidity, duration of cannabis treatment, and condition driving cannabis prescription. RESULTS: A significant difference in opioid non-users after a long-term cannabis-based oil therapy was identified (from 32.1% to 55.4%, p = 0.0023), while no significant differences were found in the distribution of anticonvulsant, antidepressant, and benzodiazepine users. A high benzodiazepine use prevalence was revealed, while subgroup analyses showed increased antidepressant use in people over 65 years old (from 93.7% to 56.2%; p = 0.0313). CONCLUSIONS: Pain medication patterns of prescribing show how necessary it is to improve prescription practices among chronic pain patients. Opioid-sparing medications represent a crucial aspect of the pain treatment process, along with deprescribing protocols. Clinicians and clinical pharmacologists must cooperate to meet the need of a guide that can represent the most possible appropriate therapy for these patients.

Chronic, acute and acute-on-chronic pain prevalence in a tertiary care hospital setting.

OBJECTIVE: The aim of the study was to develop appropriate pain therapy and prevention plans; pain needs to be understood in terms of prevalence and associated predictor factors in hospital and primary care. The purpose of our research was to assess the prevalence of chronic, acute, and acute-on-chronic pain, and ascertain the effects of several factors on the likelihood of pain in an Italian Tertiary Care Hospital. PATIENTS AND METHODS: This is a prevalence study in which the primary outcome was the prevalence rate of chronic pain inpatients. Fisher's exact tests and binomial logistic regression were performed for the prevalence measures, and to ascertain the effects of Hospital Unit, sex, age, surgery and preexisting chronic pain on the likelihood of pain during the hospitalization, respectively. RESULTS: Chronic pain was reported in one-fifth of inpatients [21.7% (95% CI: 0.1764, 0.2625)], with a high prevalence of pain-related interference on sleep and emotional status. Nearly 70% of chronic pain patients accused acute-on-chronic pain [15.3% (95% CI: 0.1178, 0.1934)]. High pain prevalence rates were assessed at the time of the interview (37.3%; 95% CI: 0.3234, 0.4239) and in the last 24 hours of hospitalization (53.3%; 95% CI: 0.4814, 0.5850). A 2.7 and 2.6 higher odds to suffer from pain during the hospitalization were associated with surgery, and preexisting chronic, respectively. CONCLUSIONS: This study raises awareness of the necessity to refine pain assessment and management in hospital and outpatient services. The promotion and enhancement of hospital-territory integration are essential for improving pain prescribing practices and increasing patient safety.

Prescribing cascades and medications most frequently involved in pain therapy: a review.

OBJECTIVE: The aging of the population and chronic pain represents topical issues in developed countries. These often translate into polypharmacy, inappropriate medications, and adverse drug events, with the risk of misinterpreting these latter with new medical conditions, generating what is referred to prescribing cascade. Prescribing cascades may lead to the prescription of new drugs, which could cause new potential side effects and unnecessary costs for individuals and healthcare systems. Therefore, the purpose of our review was to collect a good deal of prescribing cascades examples involving pain therapy medicines, to help clinicians minimize drug-related clinical outcomes. MATERIALS AND METHODS: We search in MEDLINE database through PubMed, including 31 studies and 80 different examples of prescribing cascades. RESULTS: The medications most commonly resulting in the initial drug therapy prescribed were represented by psychoanaleptics (27/80, 33.7%). Among adverse drug events, the most common one, misinterpreted as a new medical condition, was represented by tremor and extrapyramidal symptoms (20/80, 25%). As regards the new drug therapies prescribed for adverse drug events, the therapeutic subgroups most commonly resulting in the new drug therapy prescribed were represented by psycholeptics (12/80, 15%), and by anti-Parkinson drugs (12/80, 15%). CONCLUSIONS: This study provides a list of several examples of prescribing cascades in pain medicine and is essential to raise awareness of the potential dangers they could involve in all patient populations. Collaboration between clinicians and clinical pharmacologists may lead to more appropriate polypharmacy schemes.

Italian SARS-CoV-2 patients in intensive care: towards an identikit for subjects at risk?

OBJECTIVE: To investigate patient characteristics and factors that increase the risk of being admitted to intensive care and that influence survival in cases of SARS-CoV-2 pneumonia. PATIENTS AND METHODS: One-hundred and ninety-one SARS-CoV-2 patients were admitted to the "Fondazione Poliambulanza di Brescia" Hospital (Brescia, Lombardy, Italy) in the period 1st March 2020 to 11th April 2020. Data on demographics, clinical presentation at admission, co-morbidities, pharmacological treatment, admission to intensive care and death was recorded. Logistic regression and survival analysis were carried out to investigate the risk of being admitted to intensive care and the risk of death. RESULTS: The mean age of the study cohort was 64.6±9.9 years (range 20-88). Median BMI was 28.5±5 kg/m2. Fever (81%) and dyspnea (65%) were the most common symptoms on admission. Most of patients (63%) had at least one co-existing disease. The 157 (82%) patients admitted to intensive care were more likely to be of intermediate age (60-69 years; OR 3.23, 95% CI 1.32-8.38), overweight (OR 2.66, 95% CI 1.02-7.07) or obese (OR 5.63, 95% CI 1.73-21.09) and with lymphocytopenia (OR 2.75, 95% CI 1.17-6.89) than the 34 patients admitted to the ordinary ward. During intensive care, 50% of patients died and their death was associated with older age (HR 2.06, 95% CI 1.07-3.97), obesity (HR 2.23, 95% CI 1.15-4.35) and male gender (HR 1.9, 95% CI 1.02-3.57). CONCLUSIONS: We found that admission to intensive care and poor survival were associated with advanced age and higher body mass index, albeit with differences in statistical significance. Pre-existing diseases and symptoms on admission were not associated with different clinical outcomes. Interestingly, male gender was more prevalent among SARS-CoV-2 patients and was related negatively to survival, but it was not associated with more frequent admission to intensive care.

Features and organization of Pain Centers in the Lazio Region, Italy, in 2011.

BACKGROUND: Evidence on pain management highlights the importance of a multidisciplinary approach in order to achieve optimal therapeutic results. Such programs can be guaranteed by the Centers for Pain Management (CPMs), in which multidisciplinary teams are able to provide advanced and specialized activities for the assessment, diagnosis and treatment of chronic benign pain. To date, information related to healthcare supply and the organizational structure of these centers in Italy is incomplete. The aim of this paper was to provide an overview of the healthcare network of the CPMs in the Lazio region. METHODS: A descriptive survey was conducted in all the 37 CPMs existing in the Lazio region in 2011 of which 28 participated. RESULTS: CPMs were located either in Universities or in public or private hospital facilities. They included a clinic, a Day Hospital service, Day surgery and day-beds. CPMs were managed by anaesthesiologists who, in most instances, did not work in a multidisciplinary team. The number of other health professionals available, such as nurses, psychologists and physiotherapists, was limited. CPMs mainly provided drug therapy, Complementary Alternative Medicine (CAM) and complex interventional treatments. The median waiting time was 30 days. The clinics were not homogeneously distributed in the region with a higher concentration in Rome (56%), followed by other provinces of the Lazio region (26%) and the province of Rome (18%). Clearly, Rome was the city which offered the greatest range of healthcare services and the highest number of consultations with patients, which significantly differed from those of the other areas (χ²=19.6 p<0.01). CONCLUSIONS: In 2011, the availability of CPMs was not equally distributed throughout the territory, and there was an over-utilization of the facilities in Rome and an under-utilization in the provincial areas. Moreover, this study showed a lack of a multi-professional approach to chronic pain management.

Children's understanding of psychogenic bodily reactions.

One hundred twenty-eight children in preschool through fifth grade (range = 4,3-11,4) and 76 adults serving as a comparison group participated in two studies that examined how children reason about psychogenic bodily reactions, that is, ailments or nonconscious physiological responses with origins in the mind (e.g., stress-induced headache). Psychogenic bodily reactions provide an opportunity to study how children integrate knowledge between the domains of bodily response and psychology. In Study 1, participants were asked whether various familiar psychogenic bodily reactions were possible (e.g., can someone get a tummyache from worrying?). In Study 2, participants were presented with a novel domain (hypothetical "aliens" from outer space) and were asked whether various unfamiliar bodily conditions (e.g., toes swelling) could arise from various physical or psychological causes. As predicted, adults typically reported that psychogenic bodily reactions were possible, and that unfamiliar bodily conditions could result from either psychological or physical causes. In contrast, young children typically denied that psychogenic bodily reactions could occur and predicted that unfamiliar bodily conditions resulted from physical causes only. The results support a developmental path: younger children view psychogenic bodily responses as wholly physical, but with age, view them as both physical and psychological phenomena.

Infant affect and affect regulation during the still-face paradigm with mothers and fathers: the role of infant characteristics and parental sensitivity.

This laboratory study examined mothers' and fathers' sensitivity during face-to-face interactions with their infants as well as infants' affective and regulatory responses during mother-infant versus father-infant still face (SF). The degree to which infant gender and temperament as well as parental sensitivity predicted SF responses was also examined. Participants included 94 healthy, primarily White, middle-class 4-month-olds and their parents. Results indicated that mothers and fathers were equally sensitive toward their infants. Infants' affect and regulatory behaviors were also significantly stable across mother- and father-infant SF situations, although several differences in mean levels of regulation emerged. Finally, the extent to which exogenous and endogenous variables predicted infant SF responses differed as a function of which affect or regulatory variable was being examined and with which parent the infant was experiencing SF.

[Evaluation of renal function during orthotopic liver transplantation]. / Valutazione della funzione renale in corso di trapianto ortotopico di fegato.

BACKGROUND: Orthotopic liver transplantation (OLI) is a recognised means of therapy for endstage liver failure (ESLF). Both the preoperative alterations of renal function, closely correlated with the ESLF, and the frequent and abrupt changes of circulating blood volumes occurring during the various phases of OLT are able to significantly alter renal function during the perioperative period. METHODS: In order to define the specific changes of renal function during the various phases of OLT, six postnecrotic cirrhotic patients undergoing their first OLT entered a prospective study protocol. All the patients had standard and anesthetic techniques including the venovenous bypass (VVBP) during the anhepatic phase. At standard intervals (baseline, during hepatic dissection, during the anhepatic phase, following reperfusion, at the end of surgery) together with complete hemodynamic and metabolic profiles, arterial blood and urine samples were obtained to determine electrolytes and creatinine concentrations, blood levels of atrial natriuretic factor, aldosterone and renin activity. Using standard formulas creatinine clearance (Ccreat) and Na absolute and fractional excretions (FeNa%) were calculated. RESULTS: Major changes in the hemodynamic profile occurred during the anhepatic phase in spite of the use of the VVBP (reduced cardiac index, reduced pulmonary wedge pressure, increased systemic vascular resistances). Concomitantly a significant decrease in Ccreat (-67%) and in urinary output, was present while aldosterone and renin activity increased. The changes in Ccreat persisted at the end of surgery in spite of the optimal hemodynamic profile. Aldosterone and renin activity returned to values close to baseline at the end of surgery. CONCLUSIONS: From these data it is possible to conclude that renal function markedly deteriorates during OLT and it has to be considered at increased risk in the immediate postoperative period. The use of VVBP does not seem to prevent the intraoperative renal impairment.

Lactate blood levels in the perioperative period of orthotopic liver transplantation.

To investigate whether early postoperative changes in blood lactate concentration indicate the functional recovery of the newly grafted liver, changes in oxygen supply, oxygen consumption, acid-base equilibrium, and blood lactate concentrations were prospectively studied in a group of 53 postnecrotic cirrhotic patients during the various phases of orthotopic liver transplantation (preanhepatic, anhepatic, neohepatic) and for the first 48 h following reperfusion. The patients were divided into two groups according to the quality of the early graft function, as indicated by alanine aminotransferase, bile flow, and prothrombin activity: group A (49 patients), good immediate graft function and group B (4 patients), immediate graft non-function. Lactate levels rose in the same manner during the preanhepatic and anhepatic stages and peaked after revascularization of the graft. Following reperfusion, however, distinctly different blood lactate profiles were recorded in the two groups of patients. A fall in lactate concentration was recorded in group A patients, whereas a continuous rise occurred in group B patients: the difference becoming significant by the end of surgery (P < or = 0.05). During the first 48 h following revascularization of the graft, opposite trends in lactate concentration, bile flow, alanine aminotransferase, and prothrombin activity were evident in the two groups of patients: 24 h after reperfusion, lactate levels were below 2 mmol/l in 47 of 49 patients from group A, while they plateaued above 4 mmol/l in all patients from group B. Group A patients had lower alanine aminotransferase levels (P < or = 0.001), higher prothrombin activity, (P < or = 0.01), and greater bile flow (P < or = 0.02). If validated in larger series, the blood lactate profile, probably more than the absolute level, appears to be a useful indicator of the early recovery of liver metabolic capacities in the immediate postoperative period of orthotopic liver transplantation.

External root resorption--fact or fancy.

A review of external resorption is presented with an emphasis on a wide range of etiological factors. This case report details the possible pitfalls in basing the diagnosis solely on radiographic interpretation.

[Preparation of patients in diagnostic contrast radiography of the urinary and bile tracts and the large intestine]. / Sull a preparazione del paziente nella radiodiagnostica contrastografica delle vie urinarie, biliari e del grosso intestino.

A preparation schedule including, for clysterisation, a substance based on palmitate, stearate and oleate of sodium of vegetable origin has been experimented in 130 patients of both sexes (70 awaiting contrastography of the urinary and bile ways, and 60 double contrastography of the colon). Excellent results were obtained in urography and colangiocholecystography when the schedule was limited to just one clyster with double dose of Radioced carried out on the same morning as the investigation. For an examination like double contrast clyster, which is more demanding from the viewpoint of correct intestinal cleansing, the number of clysters has to be increased to four. Three, at appropriate intervals, are carried out on the day preceding examination, and the last no more than two hours prior to the clyster. In all four, a double dose of Radioced dissolved in warm water (two litres for each of the first three and a litre and a half for the fourth) is used. Still on double contrast clyster, the preparation schedule requires a three-day diet (the first two involving low-waste foods and the third a liquid diet only) plus 30 g of Epsom salts (and no less than a litre of water) the day before double contrastography.