The evolution and practice of acute pain medicine

Acute Pain Services and pain-related patient-reported outcomes in Hungarian hospitals

BACKGROUND

Postoperative pain management is an important part of surgical care, where Acute Pain Service offers added value in terms of patient outcomes and costs. The technology, however, has hardly been adopted in Hungary, with only two hospitals operating Acute Pain Service and whose performance has not been evaluated yet. This research compared pain management outcomes of surgical, orthopedic, and traumatology patients in Hungarian hospitals with and without Acute Pain Service.

METHODS

We recruited 348 patients, 120 in the APS group and 228 in the control group, whose experience was surveyed with an adapted version of the American Pain Society Patient Outcome Questionnaire. The questionnaire covered pain intensity, pain interference with physical and emotional functions, side effects, patient satisfaction, information received, and participation in treatment decisions. The differences were analyzed by Fisher's exact test and Mann-Whitney U test.

RESULTS

The APS group showed better results with lower pain intensity scores regarding worst postoperative pain (χ2 = 18.919, p = 0.0043). They reported less pain interference with activities in bed (χ2 = 21.978, p = 0.0006) and out of bed (χ2 = 14.341, p = 0.0129). Furthermore, patients in the APS group experienced fewer pain-management-related side effects, like nausea (χ2 = 15.240, p = 0.0101), drowsiness (χ2 = 26.965, p = 0.0001), and dizziness (χ2 = 13.980, p = 0.0124). However, patient information (χ2 = 3.480, p = 0.0945) and patient satisfaction (χ2 = 5.781, p = 0.2127) did not differ significantly between the two groups.

CONCLUSIONS

Our findings confirm earlier international evidence on the benefits of Acute Pain Service in postoperative pain management and support the wider adoption of the technology in Hungarian hospitals. Nevertheless, close attention should be paid to patient information and involvement as better outcomes alone do not necessarily increase patient satisfaction.

A review on wound management strategies in enhanced recovery after craniotomy: An in-depth analysis of their influence on patient recovery and surgical outcomes

Craniotomy, an essential neurosurgical operation, poses distinct difficulties in the realm of post-operative care, specifically with regard to the management of wounds. Efficient wound management is critical in order to optimize the surgical outcomes, reduce complications and facilitate a speedier recovery. The purpose of this comprehensive review was to assess contemporary wound management approaches as they pertain to improved recovery following craniotomy. This was achieved by contrasting conventional methods with more recent and innovative techniques and analysing the effects of these approaches on patient recovery and surgical results. An exhaustive literature search was undertaken, comprising narrative reviews, clinical studies, peer-reviewed articles and expert opinions. The emphasis was on the evolution of wound management strategies and techniques utilized after cranial section, as well as their contributions to patient recovery. The analysis reveals that while conventional wound management methods, including suturing and antiseptics, continue to be essential, innovative strategies such as negative pressure wound therapy, skin adhesives and advanced pain management protocols are becoming increasingly recognized. It has been demonstrated that these novel approaches improve recovery by decreasing the incidence of infections, enhancing patient comfort and producing superior cosmetic results. Nevertheless, obstacles continue to endure, including patient-specific variables, technological and financial considerations and the enduring consequences of recovery. Thus the treatment of wounds during craniotomy recuperation necessitates an integrated strategy that incorporates conventional techniques alongside contemporary advancements. Progress in this domain necessitates the customization of approaches to suit the unique requirements of each patient, the resolution of identified obstacles and an emphasis on ongoing investigation and interdisciplinary cooperation. The ever-changing terrain of wound management approaches underscores the ever-changing character of neurosurgical treatment and the continuous endeavour to enhance patient results following cranial resection.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Practice patterns in the United States for ablation of osseous tumors using Medicare claims analysis

OBJECTIVES

To describe national practice trends in bone radiofrequency ablation (RFA) and cryoablation for osseous lesions by physician specialty and site-of-service from 2015 to 2018.

MATERIALS AND METHODS

This study used data from the US Centers for Medicare and Medicaid Services public use files for 2015-2018. Current Procedural Terminology (CPT) codes for bone RFA (20982) and cryoablation (20983) were analyzed. Based on the specialty code, the specialty was sorted into five categories: radiology (diagnostic and interventional), orthopedic surgery, neurosurgery, pain management (pain management, anesthesiology, physical medicine and rehabilitation, and interventional pain management), and all others. Annual volume of billed services was additionally evaluated by site of service and provider specialty.

RESULTS

Aggregate claims dramatically increased from 2015 to 2018. The enrollment adjusted overall growth averaged 45.2.% year-over-year, strongly driven by growth in RFA. Annual market share for radiology decreased slightly from 80.6% to 73.3% with neurosurgery making the largest gain, increasing from 4.7% to 11.3% from 2015 to 2018. Clinical site-of-service analysis demonstrated that outpatient is the main site-of-service for ablation (62.7% cumulatively from 2015 to 2018). Growth rates of outpatient and inpatient services are about the same over this time.

CONCLUSIONS

There has been significant growth in osseous ablation between 2015 and 2018, with the growth dominated by Radiologists, although the overall growth rate and the market share of radiology are declining as the growth is outstripped by neurosurgery and orthopedics. Further consideration of these trends will be important for interventional radiologists to assure their involvement and expertise in ablation procedures.

Effect of surgical damage to spinal nerve on dorsal root ganglion genes expression: Comprehensive analysis of differentially expressed genes

BACKGROUND

Neuropathic pain can cause significant physical and economic burden, and there are no effective long-term treatments. We conducted a bioinformatics analysis to identify mechanisms to determine strategies for more effective treatments of neuropathic pain.

METHOD

GSE24982 and GSE63442 microarray datasets were extracted from the Gene Expression Omnibus database to analyze transcriptome differences of neuropathic pain in the dorsal root ganglions (DRGs). We filtered the differentially expressed genes (DEGs) in the two datasets and conducted Gene Ontology (GO) functional analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis of the shared DEGs. The Protein-Protein Interaction network was used to determine the hub genes, which were verified in the GSE30691 dataset. miRDB and miRWalk Databases were used to predict potential miRNA of the selected DEGs. We made the spinal nerve ligation (SNL) rat model and qPCR was used to verify the differential expression of hub genes.

RESULTS

A total of 182 overlapped DEGs were found between GSE24982 and GSE63442 datasets. The GO and KEGG analysis showed that the selected DEGs were enriched in infection, transmembrane transport of ion channels, and synaptic transmission. We identified seven hub genes (Atf3, Aif1, Ctss, Gfap, Scg2, Jun, and Vgf). qPCR verified the expression differences of the hub genes in the DRGs after SNL model. Predicted miRNA targeting each selected hub genes were identified.

CONCLUSIONS

Seven hub genes related to the pathogenesis of neuropathic pain and potential targeting miRNA were identified, expanding understanding of the mechanism of neuropathic pain and facilitating treatment development.

Hepatic Arterial Infusion of Chemotherapy for Advanced Hepatobiliary Cancers: State of the Art

Simple Summary

Liver functional failure is one of the leading causes of cancer-related death. Systemic chemotherapy usually offers a modest benefit in terms of disease control rate, progression-free survival, and overall survival at the cost of a significant percentage of adverse events. Liver malignancies are mostly perfused by the hepatic artery while the normal liver parenchyma by the portal vein network. On these bases, the therapeutic strategy consisting of hepatic arterial infusion of chemotherapy takes place. This review aims to summarize the current knowledge on this approach from different points of view, such as techniques, drugs pharmacology and pharmacokinetics, and clinical outcomes for advanced hepatobiliary cancers. Most of the collected studies have several limitations: non-randomized retrospective design, a relatively small number of patients, the hepatic arterial administration of different chemotherapeutic agents, as well as its combination with a great heterogeneity of systemic agents. However, despite these limitations, the presented data show favorable results in terms of safety and efficacy for hepatic arterial infusion of chemotherapy, with respect or in alternative to the gold standard treatment, even when they are combined with systemic treatments. Therefore, this therapeutic strategy may be an alternative or an integrative treatment option for advanced hepatobiliary cancers. Further and larger prospective, randomized, multi-center studies, with well-defined inclusion criteria and treatment strategies, are required to confirm the presented data.

Abstract

Liver functional failure is one of the leading causes of cancer-related death. Primary liver tumors grow up mainly in the liver, and thus happens for liver metastases deriving from other organs having a lower burden of disease at the primary site. Systemic chemotherapy usually offers a modest benefit in terms of disease control rate, progression-free survival, and overall survival at the cost of a significant percentage of adverse events. Liver malignancies are mostly perfused by the hepatic artery while the normal liver parenchyma by the portal vein network. On these bases, the therapeutic strategy consisting of hepatic arterial infusion (HAI) of chemotherapy takes place. In literature, HAI chemotherapy was applied for the treatment of advanced hepatobiliary cancers with encouraging results. Different chemotherapeutic agents were used such as Oxaliplatin, Cisplatin, Gemcitabine, Floxuridine, 5-Fluorouracil, Epirubicin, individually or in combination. However, the efficacy of this treatment strategy remains controversial. Therefore, this review aims to summarize the current knowledge on this approach from different points of view, such as techniques, drugs pharmacology and pharmacokinetics, and clinical outcomes for advanced hepatobiliary cancers.

A survey of acute pain service in Canadian teaching hospitals

BACKGROUND

The first national survey to ascertain the prevalence, structure, and functioning of the APS in Canadian university affiliated hospitals was conducted in 1991. This is a follow-up survey to assess the current status of the APS in Canada.

METHODS

We requested completion of a 26-question survey from lead personnel of the APS teams or Anesthesia departments of Canadian teaching hospitals.

RESULTS

Among the 32 centers that were contacted, 21 (65.6%) responded. Of these respondents, 18 (85.7%) indicated that they have a structured APS (72.22% adults, 5.56% pediatrics, 22.22% mixed). Among the 18 centers with an APS, 16 of the services are led by an anesthesiologist. Eight centers (44.44%) have a regional anesthesia group, of which five (27.75%) have a regional anesthesia group that is distinct from the APS team. Nine centers (50%) offer ambulatory nerve catheter analgesia after discharge home. Fifteen centers (83.33%) use standardized order sets, and 13 centers (72.22%) use an electronic record for APS. More than 50% of the centers use intravenous lidocaine and ketamine as a part of their multimodal analgesia.

CONCLUSION

Most Canadian teaching hospitals do have a functioning APS. This survey has the potential to generate research questions about the availability of standardized and advanced acute pain management in Canada's teaching hospitals.

Management of Procedural Pain in Children

In recent years, there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context, this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.

Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative

Background

Effective pain management is a fundamental human right. However, global disparities in pain management practices exist across health settings. This study explored healthcare practitioners’ views on pain management in the acute care hospital setting.

Methods

The focus groups included clinical specialties most likely to encounter patients with ‘difficult to manage pain’, namely those in the Geriatrics and Palliative Care Unit (2 doctors and 3 nurses), Critical Care Unit (7 doctors), and the Pain Management Team (3 doctors and 2 nurses). The transcripts were analyzed using a qualitative thematic analysis.

Results

The data analysis revealed four themes. Theme 1, ‘Being too safe’ described the presence of apprehensive attitudes among patients and healthcare practitioners that limits the appropriate use of diverse and tailored pain medications in acute care hospital settings. Theme 2, ‘Working as a team’ described the need for collaborative approaches to achieve hospital-wide evidence-based pain management. Theme 3, ‘Adaptation for local and cultural preferences’ explored how pain was perceived through cultural lenses and suggested strategies to tailor pain management to local and cultural preferences. Finally, Theme 4, ‘Driving acute pain management forward’ listed clinician solutions for improving pain management in acute care hospital settings toward a pain-free hospital initiative.

Conclusion

Despite advances in pain medicine and pain teaching strategies, effective pain management is proportionate to both clinical and cultural preferences. Future studies should investigate the standardization of global pain management tools and guidelines to fit the local culture and context.

Sedation and analgesia in interventional radiology: Where do we stand, where are we heading and why does it matter?

The aims of this review were to describe the rationale and the techniques of sedation in interventional radiology, and to compile the safety and efficacy results available so far in the literature. A systematic MEDLINE/PubMed literature search was performed. Preliminary results from several studies demonstrated the feasibility, the efficacy and the safety of using sedative techniques in interventional radiology. Beyond pharmacological sedation and clinical hypnosis, digital sedation could reduce the anxiety and pain associated with interventional radiology procedures.

Using the principles of multimodal analgesia as a component of Fast-Track surgery in practice

Aim. To evaluate the effectiveness of reducing postoperative pain in the first days after surgery in accelerating postoperative recovery of patients and reducing the length of stay in hospital. Materials and methods. In the period from September 2011 to May 2019 we performed 569 scheduled surgeries using the Fast­track surgery principles, including MMA. Depending on the type of surgery, we defined VAS pain impulses indicators and the average stay in hospital. Results. Analyzing the impulses of pain after laparoscopic cholecystectomy in the first postoperative day (POD) VAS level was 2.87 ± 0.74, the second POD – 2.01 ± 0.50 (p < 0.001). The average hospital stay was 1.72 days. In laparoscopic hernioplasty, the results of the study of the level of pain according to VAS were as follows: the first POD – 3.44 ± 0.67, the second POD – 2.06 ± 0.51 (p < 0.001). The average hospital stay was 1.43 days after surgery. Analyzing laparoscopic bariatric interventions and interventions on the large intestine the first POD level according to VAS was 4.24 ± 0.75 and 4.39 ± 0.84 respectively; the second POD – 3.48 ± 0.57 and 3.48 ± 0.77, the third POD – 2.79 ± 0.67 and 2.84 ± 0.69. When comparing the first and second PODs after bariatric interventions, the level of pain impulsion decreased to 3.48 ± 0.57 (p < 0.001), and to the third POD – to 2.79 ± 0.67 (p < 0.001). A similar tendency was observed after laparoscopic interventions on the large intestine: the second POD – the level of pain impulsion decreased 3.48 ± 0.77 (p < 0.001), the third POD – 2.84 ± 0.69 (p < 0.001). The average hospital stay was 4.99 ± 0.45 and 4.10 ± 0.60, respectively. Conclusions. The effectiveness of reducing postoperative pain in the first days after surgery directly affects the rate of recovery of the patient and the length of stay in hospital.

Clinical efficacy of virtual reality for acute procedural pain management: A systematic review and meta-analysis

BACKGROUND

Acutely painful procedures are commonplace. Current approaches to pain most often involve pharmacotherapy, however, there is interest in virtual reality (VR) as a non-pharmacological alternative. A methodologically rigorous systematic review and meta-analysis is lacking.

METHODS

Following PRISMA guidelines, we searched the Cochrane Library, Ovid MEDLINE, Embase, CINAHL, ERIC, NIHR Centre for Review and Dissemination, Proquest, the System for Information on Grey Literature in Europe and the WHO International Clinical Trials Registry Platform from inception to 5 November 2017. Included studies were randomised with an experimental trial design, included a non-VR control group and examined the efficacy of VR with regards to an acutely painful clinical intervention. Bias was assessed along Cochrane guidelines, with performance bias not assessed due to the non-blindable nature of VR. We extracted summary data for maximal pain score and used standard mean difference DerSimonian-Laird random-effects meta-analysis (RevMan 5.3). This review was prospectively registered (PROSPERO CRD42017058204).

FINDINGS

Of the 12,450 studies identified, 20 studies were eligible for the systematic review. No trials reported in sufficient detail to judge their risk of bias, and 10 studies were at high risk of bias in at least one domain. 16 studies (9 randomised controlled trials, 7 crossover studies) examining 656 individuals were included in quantitative synthesis. Pain scales were heterogenous, but mostly employed 100-point scales. Across all trials, meta-analysis was suggestive of a -0.49 (95%CI -0.83 to -0.41, p = 0.006) standardised mean difference reduction in pain score with VR. However there was a high degree of statistical heterogeneity (χ2 p<0.001, I2 81%, 95%CI for I2 70-88%), driven by randomised studies, with substantial clinical heterogeneity.

CONCLUSION

These data suggest that VR may have a role in acutely painful procedures, however included studies were clinically and statistically heterogenous. Further research is required to validate findings, establish cost efficacy and optimal clinical settings for usage. Future trials should report in accordance with established guidelines.

Comprehensive Preoperative Assessment and Global Optimization

To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.

Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management

As newer pharmacologic and procedural interventions, technology, and data on outcomes in pain management are becoming available, effective acute pain management will require a dedicated Acute Pain Service (APS) to help determine the most optimal pain management plan for the patients. Goals for pain management must take into consideration the side effect profile of drugs and potential complications of procedural interventions. Multiple objective optimization is the combination of multiple different objectives for acute pain management. Simple use of opioids, for example, can reduce all pain to minimal levels, but at what cost to the patient, the medical system, and to public health as a whole? Many models for APS exist based on personnel's skills, knowledge and experience, but effective use of an APS will also require allocation of time, space, financial, and personnel resources with clear objectives and a feedback mechanism to guide changes to acute pain medicine practices to meet the constantly evolving medical field. Physician-based practices have the advantage of developing protocols for the management of low-variability, high-occurrence scenarios in addition to tailoring care to individual patients with high-variability, low-occurrence scenarios. Frequent feedback and data collection/assessment on patient outcomes is essential in evaluating the efficacy of the Acute Pain Service's intervention in improving patient outcomes in the acute and perioperative setting.

[Optimizing post-operative pain management in Latin America]

Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.

[Postoperative pain therapy in Germany. Status quo]

A great deal of progress has been made in the field of postoperative pain therapy in the last 20 years. Beginning from clinical trials on the effectiveness of individual procedures, such as epidural anesthesia and patient-controlled analgesia, a wide range of healthcare services research as well as basic research with human and animal experiments has been established. Whereas health services research in the 1980s and 1990s focused more on the implementation of acute pain services, outcome-oriented research approaches are nowadays the center of attention. Acute pain registries and pain certification projects initiated in Germany have to be mentioned particularly in this respect. Basic research papers from recent years increasingly address specific aspects of acute postoperative pain and have provided translational approaches that are applied around the world for studying neurobiological mechanisms of postoperative pain. At the same time, interdisciplinary cooperation in research projects has led to a better understanding of complex correlations regarding predictors and mechanisms (including psychosocial aspects) of acute and in recent times also chronic pain after surgery. In parallel, evidence-based medicine has found its way into acute pain medicine in Germany. In 2007, clinical acute pain therapy in Germany was enhanced by S3 level guidelines for the first time; however, the implementation is still incomplete. In future, questions concerning mechanism-based therapy of acute pain need to be equally in the center of attention of research, such as prevention of persisting pain after surgery and acute pain of different origins.

Ten Myths and Misconceptions Regarding Pain Management in the ICU

OBJECTIVES

The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU.

DATA SOURCES

Current peer-reviewed academic journals, as well as standards and guidelines from professional societies.

STUDY SELECTION

The most current evidence was selected for review based on the highest degree of supportive evidence.

DATA EXTRACTION

Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed.

DATA SYNTHESIS

After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU.

CONCLUSIONS

Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.

Acute Pain Management/Regional Anesthesia

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.

Automated Assessment of Children's Postoperative Pain Using Computer Vision

BACKGROUND

Current pain assessment methods in youth are suboptimal and vulnerable to bias and underrecognition of clinical pain. Facial expressions are a sensitive, specific biomarker of the presence and severity of pain, and computer vision (CV) and machine-learning (ML) techniques enable reliable, valid measurement of pain-related facial expressions from video. We developed and evaluated a CVML approach to measure pain-related facial expressions for automated pain assessment in youth.

METHODS

A CVML-based model for assessment of pediatric postoperative pain was developed from videos of 50 neurotypical youth 5 to 18 years old in both endogenous/ongoing and exogenous/transient pain conditions after laparoscopic appendectomy. Model accuracy was assessed for self-reported pain ratings in children and time since surgery, and compared with by-proxy parent and nurse estimates of observed pain in youth.

RESULTS

Model detection of pain versus no-pain demonstrated good-to-excellent accuracy (Area under the receiver operating characteristic curve 0.84-0.94) in both ongoing and transient pain conditions. Model detection of pain severity demonstrated moderate-to-strong correlations (r = 0.65-0.86 within; r = 0.47-0.61 across subjects) for both pain conditions. The model performed equivalently to nurses but not as well as parents in detecting pain versus no-pain conditions, but performed equivalently to parents in estimating pain severity. Nurses were more likely than the model to underestimate youth self-reported pain ratings. Demographic factors did not affect model performance.

CONCLUSIONS

CVML pain assessment models derived from automatic facial expression measurements demonstrated good-to-excellent accuracy in binary pain classifications, strong correlations with patient self-reported pain ratings, and parent-equivalent estimation of children's pain levels over typical pain trajectories in youth after appendectomy.

Acute pain service: past, present and future

SUMMARY 

Post surgical pain is a continuing major medical challenge despite all the advances in understanding acute pain and the development of new modalities of pain management. Since 1985 when the first acute pain service (APS) was started, many organizations initiated APS protocols and guidelines and it became mandatory to have an APS in all major acute care centers. This review focuses on the stages of development of APS and the challenges of postoperative pain management to provide optimal analgesia. Further clinical studies are required to determine best medication regimen for post-operative pain management.

Pain prevalence and management in an internal medicine setting in Italy

Background. Since data on pain evaluation and management in patients admitted to internal medicine wards (IMWs) are limited, we aimed to evaluate these aspects in a cohort of internistic patients. Methods. We considered all patients consecutively admitted from June to December 2011 to our unit. Age, gender, and length-of-hospital-stay (LOS) were recorded. Comorbidities were arbitrarily defined, and pain severity was evaluated by Numeric Rating Scale (NRS) on admission and discharge. Results. The final sample consisted of 526 patients (mean age 74 ± 14 years; 308 women). Significant pain (NRS ≥ 3) was detected in 63% of cases, and severe (NRS ≥ 7) in 7.6%. Pain was successfully treated, and NRS decreased from 4.65 ± 2.05 to 0.89 ± 1.3 (P < 0.001). Compared with subjects with NRS < 3, those with significant pain were older (75.5 ± 13.9 versus 72.9 ± 14.5 years, P = 0.038), and had a higher LOS (7.9 ± 6.1 versus 7.3 ± 6.8, P = 0.048). Significant pain was independently associated with age (OR 0.984, P = 0.018), cancer (OR 3.347, P < 0.001), musculoskeletal disease (OR 3.054, P < 0.0001), biliary disease (OR 3.100, P < 0.01), and bowel disease (OR 3.100, P < 0.003). Conclusion. In an internal medicine setting, multiple diseases represent significant cause of pain. Prompt pain evaluation and management should be performed as soon as possible, in order to avoid patients' suffering and reduce the need of hospital stay.

Acute pain medicine in anesthesiology

The American Academy of Pain Medicine and the American Society for Regional Anesthesia have recently focused on the evolving practice of acute pain medicine. There is increasing recognition that the scope and practice of acute pain therapies must extend beyond the subacute pain phase to include pre-pain and pre-intervention risk stratification, resident and fellow education in regional anesthesia and multimodal analgesia, as well as a deeper understanding of the pathophysiologic mechanisms that are integral to the variability observed among individual responses to nociception. Acute pain medicine is also being established as a vital component of successful systems-level acute pain management programs, inpatient cost containment, and patient satisfaction scores. In this review, we discuss the evolution and practice of acute pain medicine and we aim to facilitate further discussion on the evolution and advancement of this field as a subspecialty of anesthesiology.