Gianfranco Di Nino

Pain prevalence and predictors among inpatients in a major Italian teaching hospital. A baseline survey towards a pain free hospital.

Pain prevalence among inpatients is an important indicator of quality care; it may reach over 80% in various clinical settings. A cross‐sectional survey was conducted in a teaching hospital to depict benchmark data regarding pain prevalence and predictors among the entire inpatient population. Overall 892 patients, ≥6 years old and hospitalized for at least 24 h in 57 hospital wards were interviewed using an internationally applied questionnaire. Patients self‐reported their pain intensity at the time of the interview (T0) and worst pain perceived during the previous 24 h (T‐1), using a numerical rating scale (NRS) and indicated current pain duration. Specific pain predictor data (hospital stay, gender, age and marital status) were obtained from patient medical charts. Pain prevalence at T0 was 38% and 52% at T‐1. Pain was moderate to severe (NRS ≥ 4) in 25% of the patients at T0 and in 40% at T‐1. High pain prevalence was found (at T0 and T‐1, respectively) in Radiotherapy (63%;77%), Obstetrics (68%;54%), and Surgery (59%;45%) wards. Gender was a prominent determinant as pain was significantly associated with females. Pain prevalence was high among young adults or divorced/separated individuals and low among pediatric patients (20%). Protracted hospitalization and prolonged pain duration were associated with major pain severity. Results yield Quality Assurance interventions to ameliorate pain undertreatment. Predictor analysis suggests that attention should be paid to pain management in young adults, socially vulnerable patients and those with protracted hospitalization and pain.

Hypotension as an isolated factor may not be sufficient to provoke hearing impairment

OBJECTIVE We investigated the possible role of hypotension and related autonomic phenomena in the pathogenic mechanism of sudden sensorineural hearing loss. METHODS Forty-nine patients belonging to the ASA I-II classes of anaesthesiological risk and submitted to a non-otological surgical procedure were examined. Each operation was performed under general anaesthesia by controlled hypotension technique. Hearing function of the patients was evaluated before and after surgery by means of a pure tone audiometry recorded by the same clinician with the same instrument. RESULTS No cases of bilateral hearing worsening were recorded after surgery. CONCLUSIONS An induced and controlled steady hypotension under general anaesthesia did not affect the hearing function of any of the patients. It may be supposed, therefore, that an adverse effect on the cochlear oxygenation is more likely to be caused by the sympathetic changes induced by a consistent decrease of blood pressure rather than to hypotension itself.

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.

Pre-Operative, High-IL-6 Blood Level is a Risk Factor of Post-Operative Delirium Onset in Old Patients

Background: Post-operative delirium (POD) is a common complication in elderly patients undergoing surgery, but the underpinning causes are not clear. We hypothesized that inflammaging, the subclinical low and chronic grade inflammation characteristic of old people, can contribute to POD onset. Accordingly, we investigated the association of pre-operative and circulating cytokines in elderly patients (>65 years), admitted for elective and emergency surgery. Methods: This is a secondary analysis of a sub-cohort of patients belonging to a previous large case–control study, where 351 patients were clinically and cognitively thoroughly characterized, together with the assessment of POD (47 patients) by confusion assessment method and delirium rating scale. Seventy-four pre-operative plasma samples were selected from a larger bio-bank and they included 37 subjects with POD and 37 without POD. Inflammaging related cytokines, i.e., IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α, were assayed by ELISA in pre-operative blood samples; univariate and multivariable analyses have been applied to identify cytokines independently associated to POD. Associations of cytokine levels with functional status, cognitive decline, intra-hospital mortality, and comorbidity were also analyzed independently of POD onset. Results: High IL-6 and low-IL-2 levels were significantly associated with POD. After adjustment for potential confounders in multivariate analysis, high level of pre-operative IL-6 was confirmed to be significantly associated with risk of POD onset. High level of IL-6 was also associated with several baseline features (including poor functional status, cognitive impairment, emergency admission, and higher comorbidity burden) and intra-hospital mortality. Conclusion: Pre-operative, high-plasma level of IL-6 (≥9 pg/mL) was significantly associated with POD onset. We propose IL-6 as an additional risk factor of POD onset together with the previously identified factors. Discovery of all risk factors contributing to POD onset will permit to improve hospitalized patient management and the decrease of healthcare cost.

Postoperative Versus Preoperative Initiation of Deep-Vein Thrombosis Prophylaxis with a Low-Molecular-Weight Heparin (Nadroparin) in Elective Hip Replacement

The aim of this multicenter, randomized, dou ble-blind study performed in patients undergoing elective hip surgery was to compare the efficacy and safety of prophylaxis with low-molecular-weight heparin (LMWH) (Nadroparin, 7,500 anti-Xa IC units for the first 3 days and 10,000 from the fourth day on, s.c. o.i.d.) begun in one group shortly after surgery and in the other 12 h before operation, as is usually recommended. Preopera tive administration (drug or placebo) was the only differ ence between the two groups. Deep vein thrombosis (DVT) was detected by bilateral venography 10-15 days after surgery. The study investigated 179 patients (55 men), 40-80 years old, in seven Italian orthopedic cen ters. In 131 patients efficacy analysis was possible be cause of adequate bilateral venography. All 179 patients were evaluated for bleeding complications. The preva lence of thrombotic complications was similar in the two groups. Proximal DVT was found in 8.4% of patients (10.8% and 6.1% in the preop and postop groups, respec tively ; difference not statistically significant). Distal DVT was recorded in 30.5% of patients (30.8% and 30.3% in the pre- and postop groups, respectively). DVTs were more common in patients ≥65 years old (54.2% versus 28.4%, p < 0.05); no significant differences were detected in terms of other characteristics. No significant differ ences were recorded in the number or type of bleeding complications: major (nonfatal) bleeding episodes were reported in five patients (2.8%, two and three in the pre- and postop groups); minor bleeding was noted in 25 (13.9%, 14 and 11 in the pre- and postop groups). In con clusion, the present study suggests that a LMWH regi men started postoperatively is no less effective in pre venting DVT in elective hip replacement than the classi cal regimen started preoperatively. Surprisingly, postoperative commencement offered no significant ad vantage in terms of bleeding complications.

Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: A pilot assessment of the CoDem protocol

OBJECTIVES Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain. METHODS Observational and retrospective analysis of cancer in-patients treated for ≥7 days with the CoDem protocol. OUTCOME MEASURES Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction. EFFICACY ENDPOINTS In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs ≤ 3 and NRSd ≤4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2. RESULTS Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd ≤ 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent. CONCLUSIONS The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.

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.

Vacuum Assisted Closure Therapy in Severe Acute Pancreatitis: Case Report and Literature Review

Context Abdominal compartment syndrome (ACS) is one of the most worrisome complications of hemorrhagic necrotic pancreatitis (HNP) and its prevention or correct treatment is crucial for patient survival. Case report A 29-year-old male patient with clinical history of sarcoidosis and alcoholic consumption was admitted to our Surgical Unit in March 2012 with diagnosis of severe acute pancreatitis. Clinical evaluation and laboratory tests revealed concurrent sepsis and anemia (WBC 34.91 x10 3 /µL; PCR 34.76 mg/dL; LDH 714 U/L; Hb 10.1 g/L); a CT scan showed a wide pancreatic necrosis and multiple abdominal collections. These findings were suggestive of an infected pancreatic necrosis. A surgical abdominal toilette, necrosectomy and drainage of a large serous-hematic retroperitoneal collection were performed. In postoperative day 3, a gradual increase of intra-abdominal pressure (IAP: 22 mmHg) led up to an ACS, with respiratory distress, acute renal failure and paralytic ileus. Therefore, the patient underwent a second abdominal toilette, with laparostomy covered by a Bogota bag. This latter was replaced every 72 hours. In postoperative day 12, the onset of severe anemia brought to a third operation consisting in abdominal toilette, wide necrosectomy, hemostasis of proper hepatic artery and replacement of the Bogota bag. In postoperative day 22, the Bogota bag was replaced with a vacuum assisted closure (VAC) therapy. VAC therapy was then changed every 48-72 hours. Clinical conditions improved rapidly, in postoperative day 43 the laparostomy was closed with a biological mesh and a CT scan, performed in postoperative day 45, showed the complete resolution of abdominal inflammation and peripancreatic collections. Patient was discharged in postoperative day 68. Conclusion In literature, a standardized surgical strategy for ACS developed from HNP is missing. While the use of laparostomy is widely accepted, only few cases treated with VAC therapy are described. In our experience, laparostomy seemed a good “bridge” treatment, but the best results in terms of clinical response have been gained with the use of VAC therapy.