The effects of naloxone on human breast cancer progression: in vitro and in vivo studies on MDA.MB231 cells

BACKGROUND

Naloxone is viewed as a specific competitive opioid antagonist acting at the level of opioid receptors (μ, δ, and κ) with blended agonist-adversary or agonist action. The role of naloxone in tumor cell growth has been poorly studied in human cancer cell lines.

MATERIALS AND METHODS

In the present study, we report findings from in vitro and in vivo experiments performed to evaluate the effects of naloxone on human breast cancer cell growth and progression. In vitro assays were conducted on estrogen receptor-negative human breast carcinoma cells, MDA.MB231, treated with naloxone at different concentrations (10-100 μM). In vivo experiments were performed on a mouse model of human triple-negative breast cancer generated by using MDA.MB231 injected subcutaneously in mice. Naloxone was daily intraperitoneally injected in mice at 0.357 mg/kg for 2 weeks and at 0.714 mg/kg for the next 2 weeks. Microvessels formation was detected by fluorescein isothiocyanate-dextran (100 μL) injected into the tail vein of mice and confirmed by immunohistochemistry with CD31 on mice tumor sections.

RESULTS

In vitro tests showed that the cell proliferation of MDA.MB231 was inhibited by naloxone in a dose-dependent manner, whereas the cell death was increased. In vivo studies demonstrated that tumors of mice treated with naloxone were significantly smaller than those observed in the control groups, as long as naloxone was administered. Finally, naloxone was not able to impair the microvessel formation in tumors of treated mice.

CONCLUSION

Our data showed, for the first time, that naloxone reduced breast cancer progression without affecting angiogenesis.

A Delphi Consensus Approach for the Management of Chronic Pain during and after the COVID-19 Era

Due to a lack of published evidence on the topic, a modified Delphi approach was used to develop recommendations useful for chronic pain management during and after the COVID-19 pandemic. Focusing on the available literature and personal clinical expertise, an Italian board of nine professionals from different disciplines identified four main topics: prevention of chronic pain, treatment of chronic pain, consequences of inadequate treatment, and perspectives. They elaborated a semi-structured questionnaire. A multidisciplinary panel of experts in the field of pain management was requested to comment on the statements. Based on the answers provided, a structured questionnaire was prepared (Round 1). It included 21 statements divided into three categories (organizational issues; diagnosis and therapies; telemedicine and future perspectives). A five-point Likert scale was adopted. The threshold for consensus was set at a minimum of 70% of the number of respondents (level of agreement ≥ 4, Agree or Strongly Agree). A final questionnaire with rephrasing of the statements that did not reach the consensus threshold was elaborated (Round 2). A total of 29 clinicians were included in the panel. Twenty clinicians (69%) responded in both the first and second round. After two rounds, consensus (≥70%) was achieved in 20 out of 21 statements. The lack of consensus was recorded for the statement regarding the management of post-COVID pain (55%; Median 4; IQR 2.3). Another statement on telemedicine reached the threshold in the first round (70%), but the value was not confirmed in Round 2 (65%; Median 4; IQR 2). Most of the proposed items reached consensus, suggesting the need to make organizational changes, the structuring of careful diagnostic and therapeutic pathways, and the application of new technologies in pain medicine. Long-COVID-19 care is an issue that needs further research. Remote assistance for chronic pain must be regulated.

Role of Nigella sativa and Its Constituent Thymoquinone on Chemotherapy-Induced Nephrotoxicity: Evidences from Experimental Animal Studies

BACKGROUND

Most chemotherapeutic drugs are known to cause nephrotoxicity. Therefore, new strategies have been considered to prevent chemotherapy-induced nephrotoxicity. It is of note that Nigella sativa (NS), or its isolated compound Thymoquinone (TQ), has a potential role in combating chemotherapy-induced nephrotoxicity.

AIM

To analyze and report the outcome of experimental animal studies on the protective effects of NS/TQ on chemotherapy-associated kidney complications.

DESIGN

Standard systematic review and narrative synthesis.

DATA SOURCES

MEDLINE, EMBASE databases were searched for relevant articles published up to March 2017. Additionally, a manual search was performed. Criteria for a study's inclusion were: conducted in animals, systematic reviews and meta-analysis, containing data on nephroprotective effects of NS/TQ compared to a placebo or other substance. All strains and genders were included.

RESULTS

The database search yielded 71 studies, of which 12 (cisplatin-induced nephrotoxicity 8; methotrexate-induced nephrotoxicity 1; doxorubicin-induced nephrotoxicity 2; ifosfamide-induced nephrotoxicity 1) were included in this review.

CONCLUSIONS

Experimental animal studies showed the protective effect of NS, or TQ, on chemotherapy-induced nephrotoxicity. These effects are caused by decreasing lipid peroxidation and increasing activity of antioxidant enzymes in renal tissue of chemotherapy-treated animals.

Artificial Intelligence for Automatic Pain Assessment: Research Methods and Perspectives

Although proper pain evaluation is mandatory for establishing the appropriate therapy, self-reported pain level assessment has several limitations. Data-driven artificial intelligence (AI) methods can be employed for research on automatic pain assessment (APA). The goal is the development of objective, standardized, and generalizable instruments useful for pain assessment in different clinical contexts. The purpose of this article is to discuss the state of the art of research and perspectives on APA applications in both research and clinical scenarios. Principles of AI functioning will be addressed. For narrative purposes, AI-based methods are grouped into behavioral-based approaches and neurophysiology-based pain detection methods. Since pain is generally accompanied by spontaneous facial behaviors, several approaches for APA are based on image classification and feature extraction. Language features through natural language strategies, body postures, and respiratory-derived elements are other investigated behavioral-based approaches. Neurophysiology-based pain detection is obtained through electroencephalography, electromyography, electrodermal activity, and other biosignals. Recent approaches involve multimode strategies by combining behaviors with neurophysiological findings. Concerning methods, early studies were conducted by machine learning algorithms such as support vector machine, decision tree, and random forest classifiers. More recently, artificial neural networks such as convolutional and recurrent neural network algorithms are implemented, even in combination. Collaboration programs involving clinicians and computer scientists must be aimed at structuring and processing robust datasets that can be used in various settings, from acute to different chronic pain conditions. Finally, it is crucial to apply the concepts of explainability and ethics when examining AI applications for pain research and management.

Satisfaction with Telemedicine for Cancer Pain Management: A Model of Care and Cross-Sectional Patient Satisfaction Study

Background: Since cancer pain requires complex modalities of care, the proper strategy for addressing its telemedicine-based management should be better defined. This study aimed to trace a pathway for a progressive implementation of the telemedicine process for the treatment of pain in the setting of cancer patients. Methods: The features of the model were investigated to dissect the dropout from the telemedicine pathway. A cross-sectional patient satisfaction study was conducted. The degree of satisfaction was evaluated through a developed 22-item questionnaire (Likert scale 0−7). Results: A total of 375 video consultations for 164 patients (mean age 62.9 years) were performed through remote consultations for cancer pain management between March 2021 and February 2022. After the exclusion of 72 patients, 92 (56.1%) were included in the analysis. The dropout ratio was 8.7%. The number of visits and pharmacological therapies for neuropathic pain correlated with the risk for readmission (p < 0.05). Overall, the satisfaction was very high (mean > 5.5 for all items). Conclusion: Feedback from patients reflected high satisfaction rates with the care provided. A methodological approach based on the degree of satisfaction combined with the analysis of the pathways can help to implement the quality of a service provided through telemedicine. While not without limitations, our hybrid protocol can be useful for addressing cancer pain through a patient-centered approach.

Potential application of the Kampo medicine goshajinkigan for prevention of chemotherapy-induced peripheral neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most common and severe adverse effects related to cancer treatment. Unfortunately, although several agents and protocols have been proposed, no prophylactic strategies have yet to be proven useful. Therefore, new alternative therapies have been considered for CIPN prevention. Herbal medicine in Japan, called Kampo medicine, is derived from traditional Chinese medicine. Goshajinkigan (GJG) is a Kampo medicine, that is comprised of ten herbs. The aim of this work is to analyse the results of pre-clinical and clinical studies on the potential applications of GJG in CIPN prevention.

Opioid Misuse: A Review of the Main Issues, Challenges, and Strategies

In the United States, from 1999 to 2019, opioid overdose, either regularly prescribed or illegally acquired, was the cause of death for nearly 500,000 people. In addition to this pronounced mortality burden that has increased gradually over time, opioid overdose has significant morbidity with severe risks and side effects. As a result, opioid misuse is a cause for concern and is considered an epidemic. This article examines the trends and consequences of the opioid epidemic presented in recent international literature, reflecting on the causes of this phenomenon and the possible strategies to address it. The detailed analysis of 33 international articles highlights numerous impacts in the social, public health, economic, and political spheres. The prescription opioid epidemic is an almost exclusively North American problem. This phenomenon should be carefully evaluated from a healthcare systems perspective, for consequential risks and harms of aggressive opioid prescription practices for pain management. Appropriate policies are required to manage opioid use and prevent abuse efficiently. Examples of proper policies vary, such as the use of validated questionnaires for the early identification of patients at risk of addiction, the effective use of regional and national prescription monitoring programs, and the proper dissemination and translation of knowledge to highlight the risks of prescription opioid abuse.

Mechanisms underlying brain monitoring during anesthesia: limitations, possible improvements, and perspectives

Currently, anesthesiologists use clinical parameters to directly measure the depth of anesthesia (DoA). This clinical standard of monitoring is often combined with brain monitoring for better assessment of the hypnotic component of anesthesia. Brain monitoring devices provide indices allowing for an immediate assessment of the impact of anesthetics on consciousness. However, questions remain regarding the mechanisms underpinning these indices of hypnosis. By briefly describing current knowledge of the brain's electrical activity during general anesthesia, as well as the operating principles of DoA monitors, the aim of this work is to simplify our understanding of the mathematical processes that allow for translation of complex patterns of brain electrical activity into dimensionless indices. This is a challenging task because mathematical concepts appear remote from clinical practice. Moreover, most DoA algorithms are proprietary algorithms and the difficulty of exploring the inner workings of mathematical models represents an obstacle to accurate simplification. The limitations of current DoA monitors - and the possibility for improvement - as well as perspectives on brain monitoring derived from recent research on corticocortical connectivity and communication are also discussed.

Envisioning gamification in anesthesia, pain management, and critical care: basic principles, integration of artificial intelligence, and simulation strategies

Unlike traditional video games developed solely for entertainment purposes, game-based learning employs intentionally crafted approaches that seamlessly merge entertainment and educational content, resulting in captivating and effective learning encounters. These pedagogical methods include serious video games and gamification. Serious games are video games utilized as tools for acquiring crucial (serious) knowledge and skills. On the other hand, gamification requires integrating gaming elements (game mechanics) such as points, leaderboards, missions, levels, rewards, and more, into a context that may not be associated with video gaming activities. They can be dynamically (game dynamics) combined developing various strategic approaches. Operatively, gamification adopts simulation elements and leverages the interactive nature of gaming to teach players specific skills, convey knowledge, or address real-world issues. External incentives stimulate internal motivation. Therefore, these techniques place the learners in the central role, allowing them to actively construct knowledge through firsthand experiences.Anesthesia, pain medicine, and critical care demand a delicate interplay of technical competence and non-technical proficiencies. Gamification techniques can offer advantages to both domains. Game-based modalities provide a dynamic, interactive, and highly effective opportunity to learn, practice, and improve both technical and non-technical skills, enriching the overall proficiency of anesthesia professionals. These properties are crucial in a discipline where personal skills, human factors, and the influence of stressors significantly impact daily work activities. Furthermore, gamification can also be embraced for patient education to enhance comfort and compliance, particularly within pediatric settings (game-based distraction), and in pain medicine through stress management techniques. On these bases, the creation of effective gamification tools for anesthesiologists can present a formidable opportunity for users and developers.This narrative review comprehensively examines the intricate aspects of gamification and its potentially transformative influence on the fields of anesthesiology. It delves into theoretical frameworks, potential advantages in education and training, integration with artificial intelligence systems and immersive techniques, and also addresses the challenges that could arise within these contexts.

Open Issues and Practical Suggestions for Telemedicine in Chronic Pain

Telemedicine represents a major opportunity to facilitate continued assistance for patients with chronic pain and improve their access to care. Preliminary data show that an improvement can be expected of the monitoring, treatment adherence, assessment of treatment effect including the emotional distress associated with pain. Moreover, this approach seems to be convenient and cost-effective, and particularly suitable for personalized treatment. Nevertheless, several open issues must be highlighted such as identification of assessment tools, implementation of monitoring instruments, and ability to evaluate personal needs and expectations. Open questions exist, such as how to evaluate the need for medical intervention and interventional procedures, and how to define when a clinical examination is required for certain conditions. In this context, it is necessary to establish dynamic protocols that provide the right balance between face-to-face visits and telemedicine. Useful tips are provided to start an efficient experience. More data are needed to develop precise operating procedures. In the meantime, the first experiences from such settings can pave the way to initiate effective care pathways in chronic pain.

Liver fungal infections: an overview of the etiology and epidemiology in patients affected or not affected by oncohematologic malignancies

Fungal infections of the liver, most commonly caused by Candida spp., often occur in patients with hematologic malignancies treated with chemotherapy. Colonization of the gastrointestinal tract is thought to be the main origin of dissemination of Candida; mucositis and neutropenia facilitate the spread of Candida from the gastrointestinal tract to the liver. Hepatic involvement due to other fungi is a less common infectious complication in this setting. Fungal infections represent a less common cause of hepatic abscesses in non-oncohematologic population and the trend appears to be decreasing in recent years. Understanding of the etiology and epidemiology of fungal infections of the liver is indicated for an appropriate antimicrobial therapy and an overall optimal management of fungal liver infections.

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

BACKGROUND

Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes.

METHODS

An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile.

RESULTS

650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust.

DISCUSSION

The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study

BACKGROUND

Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated.

METHODS

This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy.

RESULTS

Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02).

CONCLUSIONS

In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events.

CLINICAL TRIAL REGISTRATION

NCT03616054.

Different Machine Learning Approaches for Implementing Telehealth-Based Cancer Pain Management Strategies

Background: The most effective strategy for managing cancer pain remotely should be better defined. There is a need to identify those patients who require increased attention and calibrated follow-up programs. Methods: Machine learning (ML) models were developed using the data prospectively obtained from a single-center program of telemedicine-based cancer pain management. These models included random forest (RF), gradient boosting machine (GBM), artificial neural network (ANN), and the LASSO−RIDGE algorithm. Thirteen demographic, social, clinical, and therapeutic variables were adopted to define the conditions that can affect the number of teleconsultations. After ML validation, the risk analysis for more than one remote consultation was assessed in target individuals. Results: The data from 158 patients were collected. In the training set, the accuracy was about 95% and 98% for ANN and RF, respectively. Nevertheless, the best accuracy on the test set was obtained with RF (70%). The ML-based simulations showed that young age (<55 years), lung cancer, and occurrence of breakthrough cancer pain help to predict the number of remote consultations. Elderly patients (>75 years) with bone metastases may require more telemedicine-based clinical evaluations. Conclusion: ML-based analyses may enable clinicians to identify the best model for predicting the need for more remote consultations. It could be useful for calibrating care interventions and resource allocation.

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.

Exploring Artificial Intelligence in Anesthesia: A Primer on Ethics, and Clinical Applications

The field of anesthesia has always been at the forefront of innovation and technology, and the integration of Artificial Intelligence (AI) represents the next frontier in anesthesia care. The use of AI and its subtypes, such as machine learning, has the potential to improve efficiency, reduce costs, and ameliorate patient outcomes. AI can assist with decision making, but its primary advantage lies in empowering anesthesiologists to adopt a proactive approach to address clinical issues. The potential uses of AI in anesthesia can be schematically grouped into clinical decision support and pharmacologic and mechanical robotic applications. Tele-anesthesia includes strategies of telemedicine, as well as device networking, for improving logistics in the operating room, and augmented reality approaches for training and assistance. Despite the growing scientific interest, further research and validation are needed to fully understand the benefits and limitations of these applications in clinical practice. Moreover, the ethical implications of AI in anesthesia must also be considered to ensure that patient safety and privacy are not compromised. This paper aims to provide a comprehensive overview of AI in anesthesia, including its current and potential applications, and the ethical considerations that must be considered to ensure the safe and effective use of the technology.

Cancer Cell Metabolism Reprogramming and Its Potential Implications on Therapy in Squamous Cell Carcinoma of the Head and Neck: A Review

Carcinogenesis is a multistep process that consists of the transformation of healthy cells into cancer cells. Such an alteration goes through various stages and is closely linked to random mutations of genes that have a key role in the neoplastic phenotype. During carcinogenesis, cancer cells acquire and exhibit several characteristics including sustaining proliferative signaling, evading growth suppressors, resisting cell death, enabling replicative immortality, inducing angiogenesis, activating invasion and metastasis, and expressing an immune phenotype, which allow them to evade recognition and destruction through cognate immune cells. In addition, cancer cells may acquire the ability to reprogram their metabolism in order to further promote growth, survival, and energy production. This phenomenon, termed metabolic reprogramming, is typical of all solid tumors, including squamous carcinomas of the head and neck (SCCHN). In this review, we analyze the genetic and biological mechanisms underlying metabolic reprogramming of SCCHN, focusing on potential therapeutic strategies that are able to counteract it.

Metastatic colorectal cancer and type 2 diabetes: prognostic and genetic interactions

The present study was undertaken to analyze prognostic and genetic interactions between type 2 diabetes and metastatic colorectal cancer. Patients' survival was depicted through the Kaplan-Meier product limit method. Prognostic factors were examined through the Cox proportional-hazards regression model, and associations between diabetes and clinical-pathologic variables were evaluated by the χ2 test. In total, 203 metastatic colorectal cancer patients were enrolled. Lymph nodes (P = 0.0004) and distant organs (> 2 distant sites, P = 0.0451) were more frequently involved in diabetic patients compared with those without diabetes. Diabetes had an independent statistically significant negative prognostic value for survival. Highly selected patients with cancer and/or diabetes as their only illness(es) were divided into three groups: (a) seven oligo-metastatic patients without diabetes, (b) 10 poly-metastatic patients without diabetes, and (c) 12 poly-metastatic diabetic patients. These groups of patients were genetically characterized through the Illumina NovaSeq 6000 (San Diego, CA, USA) platform and TruSigt™Oncology 500 kit, focusing on genes involved in diabetes and colorectal cancer. Gene variants associated with diabetes and cancer were more frequent in patients in group 3. We found that type 2 diabetes is a negative prognostic factor for survival in colorectal cancer. Diabetes-associated gene variants could concur with malignancy, providing a rational basis for innovative models of tumor progression and therapy.

Spontaneous peritonitis in critically ill cirrhotic patients: a diagnostic algorithm for clinicians and future perspectives

Spontaneous peritonitis (SP) is the most common infection among decompensated end-stage liver disease patients. SP is the infection of ascitic fluid (neutrophil ascitic count ≥250/mL) without an alternative focus of abdominal infection. According to the causative agent, clinicians can make the diagnosis of spontaneous bacterial peritonitis or spontaneous fungal peritonitis. The mortality rate is very high, ranging from one-fifth of the patients with spontaneous bacterial peritonitis to four-fifths of the patients with spontaneous fungal peritonitis. An immediate and accurate diagnosis can improve the outcome in end-stage liver disease patients. The aim of this work is to provide physicians with a practical diagnostic guidance for SP diagnosis according to current evidence, in order to improve the management of cirrhotic patients with infected ascitic fluid.

Multidimensional Statistical Technique for Interpreting the Spontaneous Breakthrough Cancer Pain Phenomenon. A Secondary Analysis from the IOPS-MS Study

Breakthrough cancer pain (BTcP) is a temporary exacerbation of pain that "breaks through" a phase of adequate pain control by an opioid-based therapy. The non-predictable BTcP (NP-BTcP) is a subtype of BTcP that occurs in the absence of any specific activity. Since NP-BTcP has an important clinical impact, this analysis is aimed at characterizing the NP-BTcP phenomenon through a multidimensional statistical technique. This is a secondary analysis based on the Italian Oncologic Pain multiSetting-Multicentric Survey (IOPS-MS). A correlation analysis was performed to characterize the NP-BTcP profile about its intensity, number of episodes per day, and type. The multiple correspondence analysis (MCA) determined the identification of four groups (phenotypes). A univariate analysis was performed to assess differences between the four phenotypes and selected covariates. The four phenotypes represent the hierarchical classification according to the status of NP-BTcP: from the best (phenotype 1) to the worst (phenotype 4). The univariate analysis found a significant association between the onset time >10 min in the phenotype 1 (37.3%)' vs. the onset > 10 min in phenotype 4 (25.8%) (p < 0.001). Phenotype 1 was characterized by the gastrointestinal type of cancer (26.4%) with respect to phenotype 4, where the most frequent cancer affected the lung (28.8%) (p < 0.001). Phenotype 4 was mainly managed with rapid-onset opioids, while in phenotype 1, many patients were treated with oral, subcutaneous, or intravenous morphine (56.4% and 44.4%, respectively; p = 0.008). The ability to characterize NP-BTcP can offer enormous benefits for the management of this serious aspect of cancer pain. Although requiring validation, this strategy can provide many indications for identifying the diagnostic and therapeutic gaps in NP-BTcP management.

The Use of Tocilizumab in Patients with COVID-19: A Systematic Review, Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Studies

BACKGROUND

Among the several therapeutic options assessed for the treatment of coronavirus disease 2019 (COVID-19), tocilizumab (TCZ), an antagonist of the interleukine-6 receptor, has emerged as a promising therapeutic choice, especially for the severe form of the disease. Proper synthesis of the available randomized clinical trials (RCTs) is needed to inform clinical practice.

METHODS

A systematic review with a meta-analysis of RCTs investigating the efficacy of TCZ in COVID-19 patients was conducted. PubMed, EMBASE, and the Cochrane COVID-19 Study Register were searched up until 30 April 2021.

RESULTS

The database search yielded 2885 records; 11 studies were considered eligible for full-text review, and nine met the inclusion criteria. Overall, 3358 patients composed the TCZ arm, and 3131 the comparator group. The main outcome was all-cause mortality at 28-30 days. Subgroup analyses according to trials' and patients' features were performed. A trial sequential analysis (TSA) was also carried out to minimize type I and type II errors. According to the fixed-effect model approach, TCZ was associated with a better survival odds ratio (OR) (0.84; 95% confidence interval (CI): 0.75-0.94; I2: 24% (low heterogeneity)). The result was consistent in the subgroup of severe disease (OR: 0.83; 95% CI: 0.74-0.93; I2: 53% (moderate heterogeneity)). However, the TSA illustrated that the required information size was not met unless the study that was the major source of heterogeneity was omitted.

CONCLUSIONS

TCZ may represent an important weapon against severe COVID-19. Further studies are needed to consolidate this finding.

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 .

The Potential Roles of Epigallocatechin-3-Gallate in the Treatment of Ovarian Cancer: Current State of Knowledge

Ovarian cancer represents the principal leading cause of women dying in the world. The first standard of care involved surgical resection followed by chemotherapy with taxane and platinum, mainly connected with cytotoxic chemotherapies causing diverse severe side effects. Unfortunately, recurrence represents a significant problem, and finally, patients develop resistance to cytotoxic chemotherapy. Other alternative treatments had been developed so far to reduce side effects; however, the outcomes are yet not empowering. Current shreds of evidence showed that epigallocatechin-3-gallate (EGCG) possesses an anticancer effect on ovarian carcinoma, mainly through the inhibition of different genetic signaling pathways which are closely linked with tumorigenesis. This review recapitulates these findings and highlights the roles of EGCG for the chemoprevention and treatment of ovarian cancer.

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.

Chemotherapy-related cognitive impairment: mechanisms, clinical features and research perspectives

The term chemotherapy-related cognitive impairment (CRCI), or cognitive dysfunction, or chemo fog, or chemo brain, is referred to a decline in a variety of neuropsychological tasks after chemotherapy, or following other anticancer treatments such as radiation therapy or surgery, in patients with non-central nervous system cancers. Furthermore, several pieces of evidence suggest that clinical manifestations of cognitive impairment may occur in cancer patients, prior to chemotherapy or in those not treated with cancer therapies. In these circumstances, it should be more appropriate to use the term cancer-related cognitive dysfunction. Because there is no consensus about its definition and diagnostic criteria, no specific test for CRCI diagnose exists. Whatever the cause, this manifestation of central nervous system toxicity is of increasing concern as the survival rates for cancer have improved steadily and, in turn, cognitive dysfunction can negatively impact the patients and cancer survivors' quality of life. The aim of this work is to offer an overview of the topic and recommendations for future research.