Boaz Gedaliahu Samolsky Dekel

Categories of congruence between inpatient self-reported pain and nurses evaluation

Objective: To enhance the awareness that biased pain estimation may undermine its treatment, we sought to determine the congruence categories (CCs) between inpatient self‐reported pain (PSRP) and nurse pain‐evaluation (NEP) and to look for associations between CCs and inpatient and situational moderators.

Oral oxycodone/naloxone for pain control in cirrhosis: Observational study in patients with symptomatic metastatic hepatocellular carcinoma

Pain management in cirrhosis is a clinical challenge. Most analgesics are metabolized in the liver and cirrhosis may deeply alter their concentration, favouring the appearance of side effects. We aimed to assess the efficacy and safety of oral prolonged‐release association of oxycodone/naloxone tablets (OXN) in the treatment of moderate/severe cancer pain in cirrhotic patients with metastatic hepatocellular carcinoma (HCC).

Dialyzability of Oxycodone and Its Metabolites in Chronic Noncancer Pain Patients with End-Stage Renal Disease

Opioids are the preferred analgesic drugs to treat severe chronic pain conditions among dialysis patients; however, knowledge about their dialyzability features is limited. Oxycodone is increasingly used for the treatment of chronic pain conditions as oral controlled release (CR) tablets; however, evidence about this drug and its metabolites’ dialyzability is lacking.

Psychometric properties and validation of the Italian version of the Mainz pain staging system as a tool for pain-patients referral selection

RATIONALE, AIMS AND OBJECTIVES Indications are lacking on which patient to refer to pain facilities. Pain-chronicity stage and outcome prognosis may be used for such aims. The Mainz pain-staging system (MPSS) classifies pain patients in three chronicity stages that respectively require more extensive management. We explored the psychometric and validation properties of its Italian version towards its application as screening/referral tool. METHODS I-MPSS was administered to n=120 mixed non-cancer-pain outpatients. Psychometric analyses and formal validation included: content validity, by assessing the hypothesis of an existing relationship between the I-MPSS classes and criteria derived from an operational case definition of chronic pain; construct validity, by principle component analysis (PCA); the autonomous construct of the I-MPSS was assessed by the strength of the Spearman correlation between its classes and the brief pain inventory (BPI) items; and reliability, by applying Cronbachs alpha statistics. Associations between psychosocial moderators and the I-MPSS were assessed applying χ(2) analyses. RESULTS Quantitative and qualitative analyses showed significant differences between I-MPSS classes for health care and drug utilization; BPI item scores significantly differed between the classes; Spearman correlation between I-MPSS classes and BPI items was mostly moderate or mild. PCA and scree test identified four components accounting for 63.7% of the variance. Cronbachs alpha was 0.842. CONCLUSIONS The I-MPSS showed satisfactory psychometric and validation properties. With adequate feasibility, it enabled the screening of mixed non-cancer-pain outpatients in three chronicity/prognostic stages. Results are sufficient to warrant its use for a subsequent impact study as a prognostic model and screening tool for referring pain patients.

Determination of oxycodone and its major metabolites in haematic and urinary matrices: Comparison of traditional and miniaturised sampling approaches

&NA; Oxycodone is a widely prescribed, full agonist opioid analgesic. As such, it is used clinically to treat different kinds of painful conditions, with a relatively high potential for doping practices in athletes. In this paper, different classic and innovative miniaturised matrices from blood and urine have been studied and compared, to evaluate their relative merits and drawbacks within therapeutic drug monitoring (TDM) and to implement new protocols for anti‐doping analysis. Plasma, dried blood spots (DBS) and dried plasma spots (DPS) have been studied for TDM purposes, while urine, dried urine spots (DUS) and volumetric absorptive microsamples (VAMS) from urine for anti‐doping. These sampling techniques were coupled to an original bioanalytical method based on liquid chromatography‐tandem mass spectrometry (LC–MS/MS) for the evaluation and monitoring of the levels of oxycodone and its major metabolites (noroxycodone and oxymorphone) in patients under pain management and in athletes. The method was validated according to international guidelines, with good results in terms of precision, extraction yield and accuracy for all considered micromatrices. Thus, the proposed sampling, pre‐treatment and analysis are attractive strategies for oxycodone determination in human blood and urine, with advanced options for application to derived micromatrices. Microsampling procedures have significant advantages over classic biological matrices like simplified sampling, storage and processing, but also in terms of precision (<9.0% for DBS, <7.7% for DPS, <7.1% for DUS, <5.3% for VAMS) and accuracy (>73% for DBS, >78% for DPS, >74% for DUS, >78% for VAMS). As regards extraction yield, traditional and miniaturised sampling approaches are comparable (>67% for DBS, >74% for DPS, >75% for DUS, >75% for VAMS). All dried matrices have very low volumes, leading to a significant advantage in terms of analysis feasibility. On the other hand, this also leads to a corresponding decrease in the overall sensitivity.

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

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 (ΔS=1.31), duration (ΔS=5.25), and predictability (ΔS=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.

Diagnostic prognostic tool for breakthrough pain

Abstract: The shift from manufacturing and resource-based jobs to the service industry has transformed the nature of work injuries and disability. Neck pain is a major problem among computer users which causes considerable personal suffering due to pain, disability, and impaired quality of life, inducing great socioeconomic burden on both patients and society. Computer related health problems if ignored can prove debilitating. There is a need to understand the dynamics of these problems and prevent it from assuming epidemic proportion. The present study was done with an aim to find an appropriate physical intervention for management of neck pain among computer users. A total of 60 computer users with a history neck pain, who satisfied the inclusion criteria, were randomly assigned to three intervention groups; Group A (Conventional physiotherapy), Group B (Muscle Energy Technique and conventional physiotherapy) and Group C (Microwave diathermy, Muscle Energy Technique and Conventional physiotherapy). All the interventions were given thrice a week for a period of 4 weeks. Clinical tests including VAS scale and Neck disability index (NDI) were used to assess the post intervention outcomes. Results of the within group analysis (paired t test) indicated significant improvement in all the three intervention groups for both the outcomes; VAS (t= 6.2, 14.12, 19.9 respectively for the Group A, B and C).), NDI (t=10.8, 10.7, 14.9 respectively in Group A, B and C) at p≤ 0.05. Findings of the inter group comparison (one way ANOVA) suggested a statistically significant difference among the three interventions groups with f= 29.46, 36.51 at p≤ 0.05 for VAS and NDI respectively. Further comparisons were done using Tukey’s Kramer post hoc test. The results indicated that intervention C (Microwave diathermy plus Muscle energy technique and conventional) was the most effective intervention amongst the three interventions for decreasing the neck disability (NDI). However in reference to pain (VAS), intervention B and C proved to be equally and significantly more effective than the intervention A (conventional physiotherapy). Thus it is concluded that Microwave diathermy and MET when added to the conventional physiotherapy programs may enhance the effectiveness of the protocol in reference to neck pain and disability.T Neuralgia is a unique condition in which patient suffers severe distressing paroxysms of lancinating pain along the distribution of one or multiple divisions of the trigeminal pain occurring spontaneously or triggered by trivial daily routine activities like brushing, chewing, shaving etc. It can be of a classic [idiopathic] variety or secondary resulting from an organic pathology in the central nervous system. Pharmacotherapy is the mainstay of treatment in majority of patients as the first line of management with reasonably good results. There is however a small percentage who will not be adequately controlled with medications, where invasive options need to be considered. In the minimally invasive options for patients who are not fit or willing for surgery Radiofrequency Ablation of trigeminal ganglion emerges as the safest and the most efficacious option. This is due to the evidence in the literature which reveals 97-100% success rate with ability for selective lesioning of one or more divisions with some acceptable side-effect profile again with lower incidence as compared to other techniques. At our centre we have performed 600 such procedures over the past 14 years. In this video I have demonstrated the practical technique followed at our centre which yields excellent result.C pain is an unmet clinical need which severely deteriorates the quality of life of individuals and imposes heavy financial burden on the health care system. Its treatment is rather challenging due to the unclear underlying mechanism. Growing evidence indicates that peripheral (nociceptor) and central sensitization caused by inflammatory mediators plays an essential role in the genesis of chronic pain. Pain mediator prostaglandin E2 (PGE2) abundantly produced in inflamed tissues is known to sensitize dorsal root ganglion (DRG) neurons and potentiates sensitizing effects of other pain mediators such as capsaicin and its receptor, transient receptor potential vanilloid-1 (TRPV1). We hypothesized that facilitating the long-term synthesis, axonal and cell surface trafficking of PGE2/EP4 receptor and capsaicin/TRPV1 channel in DRG neuronsis involved in nociceptor sensitization and transition from acute to chronic pain. In cultured DRG neurons, PGE2 and EP4 agonist increased cell surface trafficking of EP4 receptor and TRPV1 channel, events mediated through PKA and PKC signaling transduction pathways and coupled with enhanced nociceptive activities of EP4 and TRPV1. In a model of transition from acute to chronic pain, pre-exposure to PGE2 prolonged mechanical allodynia evoked by subsequent PGE2 or capsaicin challenge. This event was blocked by pre-injection of EP4 antagonist. Intraplanar (i.pl.) injection of PGE2 increased the levels of EP4 and TRPV1 in DRG neurons, sciatic nerves and plantarskin, which was suppressed by co-injection of EP4 antagonist. In inflammatory pain models, i.pl.co-injection of COX2 inhibitor or EP4 antagonists with carrageenan or complete Freud’s adjuvant blocked or shortened mechanical allodynia evoked by subsequent PGE2 challenge. Inflammation-increased EP4 and TRPV1 in DRG neurons were reversed by COX2 inhibitor or EP4 antagonists. These data suggest facilitating synthesis, axonal trafficking and cell surface trafficking of EP4 and TRPV1 through PGE2/EP4 signaling contributes to nociceptor sensitization and potentiation as well as transition from acute to chronic pain.