Breakthrough Cancer Pain Clinical Features and Differential Opioids Response: A Machine Learning Approach in Patients With Cancer From the IOPS-MS Study

PURPOSE

A large proportion of patients with cancer suffer from breakthrough cancer pain (BTcP). Several unmet clinical needs concerning BTcP treatment, such as optimal opioid dosages, are being investigated. In this analysis the hypothesis, we explore with an unsupervised learning algorithm whether distinct subtypes of BTcP exist and whether they can provide new insights into clinical practice.

METHODS

Partitioning around a k-medoids algorithm on a large data set of patients with BTcP, previously collected by the Italian Oncologic Pain Survey group, was used to identify possible subgroups of BTcP. Resulting clusters were analyzed in terms of BTcP therapy satisfaction, clinical features, and use of basal pain and rapid-onset opioids. Opioid dosages were converted to a unique scale and the BTcP opioids-to-basal pain opioids ratio was calculated for each patient. We used polynomial logistic regression to catch nonlinear relationships between therapy satisfaction and opioid use.

RESULTS

Our algorithm identified 12 distinct BTcP clusters. Optimal BTcP opioids-to-basal pain opioids ratios differed across the clusters, ranging from 15% to 50%. The majority of clusters were linked to a peculiar association of certain drugs with therapy satisfaction or dissatisfaction. A free online tool was created for new patients’ cluster computation to validate these clusters in future studies and provide handy indications for personalized BTcP therapy.

CONCLUSION

This work proposes a classification for BTcP and identifies subgroups of patients with unique efficacy of different pain medications. This work supports the theory that the optimal dose of BTcP opioids depends on the dose of basal opioids and identifies novel values that are possibly useful for future trials. These results will allow us to target BTcP therapy on the basis of patient characteristics and to define a precision medicine strategy also for supportive care.

Etiopathogenesis of sacroiliitis: implications for assessment and management

The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of low back pain. This article aims to provide a concise overview of the anatomy, physiology, and molecular biology of sacroiliitis to aid clinicians in the assessment and management of sacroiliitis. For this narrative review, we evaluated articles in English published before August 2019 in PubMed. Then, we selected articles related to the painful manifestations of the sacroiliac joint. From the retrieved articles, we found that chronic sacroiliitis may be caused by various forms of spondyloarthritis, such as ankylosing spondyloarthritis. Sacroiliitis can also be associated with inflammatory bowel disease, Crohn’s disease, gout, tuberculosis, brucellosis, and osteoarthritis, indicating common underlying etiological factors. The pathophysiology of sacroiliitis is complex and may involve internal, environmental, immunological, and genetic factors. Finally, genetic factors may also play a central role in progression of the disease. Knowing the genetic pre-disposition for sacroiliitis can be useful for diagnosis and for formulating treatment regimens, and may lead to a substantial reduction in disease severity and duration and to improved patient performance.

Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS)

Introduction

An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here.

Methods

Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and characteristics of background pain and BTP and their treatments were recorded. Background pain and BTP intensity were measured. Patients were also questioned about BTP predictability, BTP onset (≤10 or >10 min), BTP duration, background and BTP medications and their doses, time to meaningful pain relief after BTP medication, and satisfaction with BTP medication. The occurrence of adverse reactions was also assessed, as well as mucosal toxicity.

Results

Background pain was well controlled with opioid treatment (numerical rating scale 3.0 ± 1.1). Patients reported 2.5 ± 1.6 BTP episodes/day with a mean intensity of 7.5 ± 1.4 and duration of 43 ± 40 min; 977 patients (65.1%) reported non-predictable BTP, and 1076 patients (71.7%) reported a rapid onset of BTP (≤10 min). Higher patient satisfaction was reported by patients treated with fast onset opioids.

Conclusions

These preliminary data underline that the standard algorithm used is a valid tool for a proper diagnosis of BTP in cancer patients. Moreover, rapid relief of pain is crucial for patients’ satisfaction. The final IOPS-MS data are necessary to understand relationships between BTP characteristics and other clinical variables in oncologic patients.

Funding

Molteni Farmaceutici, Italy.

What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

Headache, low back pain, other nociceptive and mixed pain conditions in neurorehabilitation. Evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Pain is a disabling symptom and is often the foremost symptom of conditions for which patients undergo neurorehabilitation. We systematically searched the PubMed and Embase electronic databases for current evidence on the frequency, evolution, predictors, assessment, and pharmacological and non-pharmacological treatment of pain in patients with headache, craniofacial pain, low back pain, failed back surgery syndrome, osteoarticular pain, myofascial pain syndrome, fibromyalgia, and chronic pelvic pain. Despite the heterogeneity of published data, consensus was reached on pain assessment and management of patients with these conditions and on the utility of a multidisciplinary approach to pain therapy that combines the benefits of pharmacological therapy, physiotherapy, neurorehabilitation, and psychotherapy. We of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) suggest a need to conduct randomized controlled trials on the efficacy of pain treatments and their risk-benefit profile for the conditions we have reviewed.

Protein Supplementation Does Not Further Increase Latissimus Dorsi Muscle Fiber Hypertrophy after Eight Weeks of Resistance Training in Novice Subjects, but Partially Counteracts the Fast-to-Slow Muscle Fiber Transition

The response to resistance training and protein supplementation in the latissimus dorsi muscle (LDM) has never been investigated. We investigated the effects of resistance training (RT) and protein supplementation on muscle mass, strength, and fiber characteristics of the LDM. Eighteen healthy young subjects were randomly assigned to a progressive eight-week RT program with a normal protein diet (NP) or high protein diet (HP) (NP 0.85 vs. HP 1.8 g of protein·kg⁻¹·day⁻¹). One repetition maximum tests, magnetic resonance imaging for cross-sectional muscle area (CSA), body composition, and single muscle fibers mechanical and phenotype characteristics were measured. RT induced a significant gain in strength (+17%, p < 0.0001), whole muscle CSA (p = 0.024), and single muscle fibers CSA (p < 0.05) of LDM in all subjects. Fiber isometric force increased in proportion to CSA (+22%, p < 0.005) and thus no change in specific tension occurred. A significant transition from 2X to 2A myosin expression was induced by training. The protein supplementation showed no significant effects on all measured outcomes except for a smaller reduction of 2X myosin expression. Our results suggest that in LDM protein supplementation does not further enhance RT-induced muscle fiber hypertrophy nor influence mechanic muscle fiber characteristics but partially counteracts the fast-to-slow fiber shift.

Quantitative and qualitative adaptations of muscle fibers to glucocorticoids

INTRODUCTION

The aim of this study was to understand the effects of short-term glucocorticoid administration in healthy subjects.

METHODS

Five healthy men received dexamethasone (8 mg/day) for 7 days. Vastus lateralis muscle biopsy and knee extension torque measurement were performed before and after administration. A large number of individual muscle fibers were dissected from the biopsy samples (pre-administration: n = 165, post-administration: n = 177).

RESULTS

Maximal knee extension torque increased after administration (∼ 13%), whereas both type 1 and type 2A fibers had decreased cross-sectional area (type 1: ∼ 11%, type 2A: ∼ 17%), myosin loss (type 1: ∼ 18%, type 2A: ∼ 32%), and loss of specific force (type 1: ∼ 24%, type 2A: ∼ 33%), which were preferential for fast fibers.

CONCLUSION

Short-term dexamethasone administration in healthy subjects elicits quantitative and qualitative adaptations of muscle fibers that precede (and may predict) the clinical appearance of myopathy in glucocorticoid-treated subjects.

Percutaneous arthrodesis of sacro-iliac joint: a pilot study

AIM

Between 15-30% of patients presenting with low back pain have some SI joint involvement. The diagnosis of SI joint involvement in low back pain is quite difficult and depends on a detailed combination of clinical manoeuvres and injection tests. In 5% of patients with SI joint pain, the joint is physically unstable (termed disruption) resulting in ineffective medical and conservative therapeutic options. In this study we present the results of the first 12 cases of SI joint disruption treated using a minimally invasive SI joint arthrodesis system in order to evaluate the safety and the efficacy of this system.

METHODS

Medical charts at a single center were reviewed for demographics, perioperative metrics, patient reported outcomes for pain, function and quality of life (NRS, ODI and RDQ respectively), as well as satisfaction with surgery (yes/no) and results of postoperative CT scan.

RESULTS

Mean age was 53 years (range 36-71) and all patients were female. Patient reported outcomes at follow up (range 8-18 months) improved clinically as well as statistically as evidenced by a mean improvement in pain on NRS of 4 points, back related function on ODI by 19.4 points, and in quality of life measured using RDQ of 13.6 points (all P=0.01). Local hematoma requiring drainage was apparent in 2 patients. Patient satisfaction was 100%. All 3 month CT scans showed initial fusion.

CONCLUSION

The results of this study confirm that MIS SI joint fusion using the iFuse Implant System is safe and effective method of treating patients with SI joint disruption.

Variability in muscle adaptation to electrical stimulation

The aims were to investigate the plasticity of the myosin heavy chain (MHC) phenotype following neuromuscular electrical stimulation (NMES) and to assess the correlation between MHC isoform distribution and muscle fibre conduction velocity (MFCV).14 men were subjected to 24 sessions of quadriceps NMES. Needle biopsies were taken from the dominant vastus lateralis and neuromuscular tests were performed on the dominant thigh before and after training. NMES significantly increased the quadriceps maximal force by 14.4±19.7% (P=0.02), vastus lateralis thickness by 10.7±8.6% (P=0.01), vastus lateralis MFCV by 11.1±3.5% (P<0.001), vastus medialis MFCV by 8.4±1.8% (P<0.001). The whole spectrum of possible MHC isoform adaptations to training was observed: fast-to-slow transition (4 subjects), bi-directional transformation from MHC-1 and MHC-2X isoforms toward MHC-2A isoform (7 subjects), shift toward MHC-2X (2 subjects), no MHC distribution change (1 subject). No significant correlation was observed between MHC-2 relative content and vastus lateralis MFCV (pre-training: R2=0.04, P=0.46; post-training: R2=0.02, P=0.67). NMES elicited distinct adaptations in the MHC composition and increased force, muscle thickness, and MFCV. The MHC isoform distribution did not correlate with MFCV, thus implying that the proportion of different fibre types cannot be estimated from this electrophysiological variable.

Knowledge and expectations of patients in palliative care: issues regarding communication with people affected by life-threatening diseases

OBJECTIVE

Different social norms influence the type and amount of information transmitted to palliative care patients. In Italy disclosure rate is low and medical decisions are often mediated by the family since communication of diagnosis and prognosis is viewed as harmful and brutal. Aims of our study were to assess palliative care patients' knowledge about their diagnosis and prognosis and expectations; and to evaluate possible differences between palliative care patients with and without cancer.

METHOD

232 palliative care in-patients participated to the study and were interviewed about their knowledge about his/her diagnosis and prognosis, and about cure and disease expectations, perceived family/social support.

RESULTS

Overall, 45.4% of the patients knew their diagnosis and 35.3% had partial knowledge of it; 39.2% knew their prognosis. When the prognosis was fatal, only few patients explicitly referred to it (22.0%). Expectations during admission to the palliative care unit were: return back home after symptom management (61.6%), increase personal autonomy (51.3%), and pain relief (45.2%). Family/social support was frequently perceived as good (84.0%). Patients with cancer less frequently knew their diagnosis (44.7% vs. 52.9%) and prognosis (37.7% vs. 64.7%) compared to patients with a non-cancer diagnosis.

CONCLUSIONS

About half of our patients were unaware of their diagnosis, although, in reality, about one-third of the patients had some knowledge, albeit partial, of their diagnostic and therapeutic course. What to tell or not to tell in palliative care is still controversial and stems from a tailored intervention involving the patient, his/her family and professionals and silence may be more effective than intrusive communication in helping a patient to approach death with tolerable knowledge and dignity.

Neuromuscular electrical stimulation training induces atypical adaptations of the human skeletal muscle phenotype: a functional and proteomic analysis

The aim of the present study was to define the chronic effects of neuromuscular electrical stimulation (NMES) on the neuromuscular properties of human skeletal muscle. Eight young healthy male subjects were subjected to 25 sessions of isometric NMES of the quadriceps muscle over an 8-wk period. Needle biopsies were taken from the vastus lateralis muscle before and after training. The training status, myosin heavy chain (MHC) isoform distribution, and global protein pattern, as assessed by proteomic analysis, widely varied among subjects at baseline and prompted the identification of two subgroups: an "active" (ACT) group, which performed regular exercise and had a slower MHC profile, and a sedentary (SED) group, which did not perform any exercise and had a faster MHC profile. Maximum voluntary force and neural activation significantly increased after NMES in both groups (+∼30% and +∼10%, respectively). Both type 1 and 2 fibers showed significant muscle hypertrophy. After NMES, both groups showed a significant shift from MHC-2X toward MHC-2A and MHC-1, i.e., a fast-to-slow transition. Proteomic maps showing ∼500 spots were obtained before and after training in both groups. Differentially expressed proteins were identified and grouped into functional categories. The most relevant changes regarded 1) myofibrillar proteins, whose changes were consistent with a fast-to-slow phenotype shift and with a strengthening of the cytoskeleton; 2) energy production systems, whose changes indicated a glycolytic-to-oxidative shift in the metabolic profile; and 3) antioxidant defense systems, whose changes indicated an enhancement of intracellular defenses against reactive oxygen species. The adaptations in the protein pattern of the ACT and SED groups were different but were, in both groups, typical of both resistance (i.e., strength gains and hypertrophy) and endurance (i.e., a fast-to-slow shift in MHC and metabolic profile) training. These training-induced adaptations can be ascribed to the peculiar motor unit recruitment pattern associated with NMES.

Latissimus dorsi fine needle muscle biopsy: a novel and efficient approach to study proximal muscles of upper limbs

BACKGROUND

The muscle biopsy based on the Bergström needle has been widely used for more than 40 y for diagnosis and experimental studies on muscle. More recently, thinner needles and tru-cut needles have also been introduced. Such techniques have been largely tested on various muscles, including the quadriceps, with few studies on upper limb muscles like deltoid, and no studies on latissimus dorsi muscle (LDM). In this study, we implemented and validated a protocol to collect samples of LDM for experimental purposes, causing minimal discomfort to volunteers. Two main problems were considered: the anatomical localization of the biopsy site and the selection of an appropriate needle.

MATERIAL AND METHODS

A strict protocol of palpatory anatomy was adopted and validated with ultrasonography to localize the biopsy site in LDM in subjects with various degrees of muscle development. A 14 gauge tru-cut needle was selected as the smallest and still effective device for sampling. Biopsy sampling was performed in 18 subjects without any complications, or complains of pain or functional limitations.

RESULTS

Approximately 4 mg of tissue were recovered from each introduction of the inner notched cannula of the needle. With three consecutive samplings, an amount of tissue sufficient to prepare proteins for gel electrophoresis and Western blot and to dissect single fiber segment for functional experiments, was obtained.

CONCLUSIONS

Taken together, the results suggest that this biopsy technique opens to experimental studies muscles until now never considered accessible.

Resistance training of long duration modulates force and unloaded shortening velocity of single muscle fibres of young women

The aim of the present study was to clarify the impact of long term (1 year) resistance training (RT) on structure and function of single muscle fibres of vastus lateralis in young female subjects. Five young women (age: 25.4+/-6.2 year) performed exercise sessions at 60% of single subject own repetition maximum (1 RM) 1h twice a week. Maximum voluntary force was determined pre- and post-RT and was found to significantly increase post-RT ensuring a successful impact of RT on muscle performance in vivo. Needle muscle biopsy samples were obtained both pre- and post-RT and the following determinations were performed: myosin heavy chain isoform (MHC) distribution of the whole muscle samples by SDS-PAGE; cross sectional area (CSA), specific force (Po/CSA) and maximum shortening velocity (Vo) of a large population (n=358) of single skinned muscle fibres classified on the basis of MHC isoform composition by SDS-PAGE. The results suggest that the long duration of RT can determine a significant increase in specific force (Po/CSA) and unloaded shortening velocity (Vo) of single muscle fibres in female subjects, whereas no muscle fibre hypertrophy and no shift in MHC isoform content was observed.

Evaluation of nutritional status and dietary intake in patients with advanced cancer on palliative care

AIM

Cancer cachexia and malnutrition are very common in patients receiving palliative care. They cause a deterioration in the quality of life.

METHODS

We studied 144 patients (52 females, 92 males) admitted to our Palliative Care Unit. Anthropometric measurements, food and nutritional intake, and plasma levels of few serum proteins were determined. Basal metabolic rate (BMR) was calculated.

RESULTS

A body mass index (BMI) below 18.5 kg/m2 was observed in 23% of females and in 13% of males (P = NS). Twenty females (44%) and 52 males (63%) showed a weight loss of more than 10% over the 6-month period (P = 0.073). Ten females (19%) and 58 males (63%) had an arm muscle area (AMA) below the 5th percentile (P < 0.001), while 20 females (38%) and 21 males (23%) had an arm fat area (AFA) below the 5th percentile (P = 0.071). The daily calorie intake was below the BMR in 22 females (42%) and in 53 males (58%) (P = NS). Plasma levels of prealbumin, transferrin, and albumin were found below the normal range in more than 70% in both sexes.

CONCLUSION

Protein energy malnutrition can be easily detected by anthropometric and laboratory indexes. The larger percentage of males with a reduction in lean body mass compared to females could signify an advantage for females since lean body mass is preserved for longer in them. Patients with advanced cancer receiving palliative care should thus be evaluated routinely to assess their nutritional status in order to plan an adequate nutritional program when appropriate.

Neuromuscular Adaptations to Electrostimulation Resistance Training

A combination of in vivo and in vitro analyses was performed to investigate muscular and neural adaptations of the weaker (nondominant) quadriceps femoris muscle of one healthy individual to short-term electrostimulation resistance training. The increase in maximal voluntary strength (+12%) was accompanied by neural (cross-education effect and increased muscle activation) and muscle adaptations (impairment of whole-muscle contractile properties). Significant changes in myosin heavy chain (MHC) isoforms relative content (+22% for MHC-2A and -28% for MHC-2X), single-fiber cross-sectional area (+27% for type 1 and +6% for type 2A muscle fibers), and specific tension of type 1 (+67%) but not type 2A fibers were also observed after training. Plastic changes in neural control confirm the possible involvement of both spinal and supraspinal structures to electrically evoked contractions. Changes at the single muscle fiber level induced by electrostimulation resistance training were significant and preferentially affected slow, type 1 fibers.

Skeletal muscle hypertrophy and structure and function of skeletal muscle fibres in male body builders

Needle biopsy samples were taken from vastus lateralis muscle (VL) of five male body builders (BB, age 27.4+/-0.93 years; mean+/-s.e.m.), who had being performing hypertrophic heavy resistance exercise (HHRE) for at least 2 years, and from five male active, but untrained control subjects (CTRL, age 29.9+/-2.01 years). The following determinations were performed: anatomical cross-sectional area and volume of the quadriceps and VL muscles in vivo by magnetic resonance imaging (MRI); myosin heavy chain isoform (MHC) distribution of the whole biopsy samples by SDS-PAGE; cross-sectional area (CSA), force (Po), specific force (Po/CSA) and maximum shortening velocity (Vo) of a large population (n=524) of single skinned muscle fibres classified on the basis of MHC isoform composition by SDS-PAGE; actin sliding velocity (Vf) on pure myosin isoforms by in vitro motility assays. In BB a preferential hypertrophy of fast and especially type 2X fibres was observed. The very large hypertrophy of VL in vivo could not be fully accounted for by single muscle fibre hypertrophy. CSA of VL in vivo was, in fact, 54% larger in BB than in CTRL, whereas mean fibre area was only 14% larger in BB than in CTRL. MHC isoform distribution was shifted towards 2X fibres in BB. Po/CSA was significantly lower in type 1 fibres from BB than in type 1 fibres from CTRL whereas both type 2A and type 2X fibres were significantly stronger in BB than in CTRL. Vo of type 1 fibres and Vf of myosin 1 were significantly lower in BB than in CTRL, whereas no difference was observed among fast fibres and myosin 2A. The findings indicate that skeletal muscle of BB was markedly adapted to HHRE through extreme hypertrophy, a shift towards the stronger and more powerful fibre types and an increase in specific force of muscle fibres. Such adaptations could not be fully accounted for by well known mechanisms of muscle plasticity, i.e. by the hypertrophy of single muscle fibre (quantitative mechanism) and by a regulation of contractile properties of muscle fibres based on MHC isoform content (qualitative mechanism). Two BB subjects took anabolic steroids and three BB subjects did not. The former BB differed from the latter BB mostly for the size of their muscles and muscle fibres.

[Validazione della versione italiana del Brief Pain Inventory nei pazienti con dolore cronico]

BACKGROUND

The purpose of this study has been the validation of an Italian version of the Brief Pain Inventory (BPI), Breve Questionario per la valutazione del Dolore (BQVD), in patients with chronic pain not-caused by neoplastic illness.

METHODS

The analysis has been proposed to 113 patients affected by different kinds of chronic pain of non-neoplastic origin while hospitalized, both as outpatients or as in-patients. The descriptive analysis of the specimen and of each item of the BPI has been carried out. Moreover, the psychometric characteristics of the analysis, intended as an instrument to describe intensity of pain and its interference in the various aspects of life have been investigated, evaluating with factorial analysis its validity both as a construct, and its internal coherence calculating the Cronbach's alpha of the whole instrument and of each identifier with factorial analysis.

RESULTS

From the factorial analysis emerged a frame with three factors that have been identified as Pain intensity, Pain interference in emotional sphere and Interference in working activities.

CONCLUSIONS

The Brief Pain Inventory can be considered a suitable useful instrument in the global evaluation of patients affected by chronic pain since its allows a contemporaneous analysis of three factors that characterize the phenomenon and contribute equally in defining the various facet of the pain universe. The Italian version of the BPI may be included in the essential evaluation instruments in the diagnosis and therapy of chronic pain.

[Validation of the Italian version of the "Neuropathic Pain Scale" and its clinical applications]

BACKGROUND

The Neuropathic Pain Scale is the first specific tool to measure and analyse pain due to a lesion in the nervous system; this kind of pain is usually difficult to describe for the patient because it is characterized by unusual qualities. Aim of this study is to evaluate a possible relation between pain descriptions and underlying pathogenetic mechanisms.

METHODS

The Italian version of the Neuropathic Pain Scale has been administered to 145 patients with neuropathic pain due to chronic radiculopathy, diabetic neuropathy, post-traumatic neuropathy, Complex Regional Pain Syndrome or postherpetic neuralgia. As it has been done in Galer's study, the predictive validity and the items' correlation have been evaluated; moreover, the structure validity of the scale has been studied.

RESULTS

Pain values were high in all pain syndromes with the prevalence of certain items in particular pathologies. The correlation of some items with "deep pain" and others with "superficial pain" was also observed.

CONCLUSIONS

The results have confirmed the statistical validity of the Italian version of the scale; they also pointed out the usefulness of the scale to distinguish between superficial pain, typical of neuropathic pain, and deep pain, typical of somatic pain.

Clinical toxicity of cryopreserved circulating progenitor cells infusion

BACKGROUND

We evaluated the infusion-related toxicity of cryopreserved autologous circulating progenitor cells transplanted in 22 patients receiving high dose chemotherapy and stem cells transplantation for malignancy.

MATERIALS AND METHODS

Progenitor cells were collected following mobilization with chemotherapy plus filgrastim and stored in liquid nitrogen in the presence of 10% dimethylsulfoxide (DMSO). Before infusion of the graft, patients were medicated with mannitol, hydrocortisone and clorphenamine. The amount of DMSO infused as well as the number of dead and damaged cells were evaluated as possible cause of toxicity.

RESULTS

Eleven patients (50%) experienced symptoms related to graft infusion, nausea and vomiting being the most common adverse events. Hypotension was documented in 3 patients (one of them developing transient bradycardia resolved with atropin administration) and one had hypertension with tachycardia. Other observed side effects were: chest tightness (2 pts), fever and chills (3 pts), associated with abdominal cramps (2 pts). 7 out of 8 (88%) patients infused with greater than 30 mL volume of DMSO experienced side-effects, the grade of toxicity being significantly less in those receiving lower amount (< 30 mL) of DMSO. Two out of 4 pts who received the highest number of dead cells (> 10 x 10(9)) developed toxicity.

CONCLUSIONS

In our experience the infusion of cryopreserved peripheral blood progenitors caused minor to moderate toxicity in most cases and, when present, side effects were observed only during infusion. The amount of DMSO present in the graft is related to the grade of toxicity.

[Occupational exposure to vibration: Raynaud's phenomenon and the vascular response to methacholine iontophoresis]

A homogeneous group of 34 subjects exposed to occupational vibratory stress were studied to determine their vasodilatory response to methacoline. The methacoline was administered by iontophoresis. Methacoline is an acetylcholine derivate with the same pharmacological properties of acetylcholine. The 34 study subjects were divided into 3 groups according to their plethysmographic response to a preliminary cold test: group 1, had a typical Raynaud's response; group 2 had normal response to cold, and group 3 had an "intermediate" response. The subjects in group 1 did not respond to methacoline with vasodilation, suggesting endothelial damage at the arterial and arteriolar level, those in group 2 responded with clear vasodilation, and those in group 3 had an intermediate plethysmographic response to methacoline--modest, slowed vasodilation. Based on the results obtained, the authors believe that the true pathogenetic mechanism is an alteration in the vasomotor stability. This change in circulatory homeostasis occur after a vasoconstrictive stimulus, due to vascular endothelium disfunction, in its turn damaged by vibratory microtrauma. This would be the basis for diminished autonomic vascular regulation, mediated by EDRF at the arterial and arteriolar level. It is also probable that the pathogenesis of Raynaud's syndrome in workers exposed to physical or chemical stress has a similar mechanism.

Electromotive administration of a new morphine formulation: morphine citrate

Two formulations of morphine citrate were synthesized: trimorphine citrate, 3(MH)+(C6H5O7)3- and morphine sodium citrate, 3(MH)+3Na+2(C6H5O7)3-. Four healthy individuals volunteered to undergo electromotive administration of the two formulations. Application of electric current (2 mA) to solutions of trimorphine citrate for 1 h resulted in iontophoretic transcutaneous administration of therapeutic quantities of morphine, without deleterious reduction in the pH of the drug solutions. Application of a 2-mA current to solutions of morphine sodium citrate for 2 h resulted in combined iontophoretic and electrophoretic delivery of morphine with increased administration rates and an improved buffering capacity of the drug solutions.

Electromotive administration of guanethidine for treatment of reflex sympathetic dystrophy: a pilot study in eight patients

Persistent neuropathic pain is associated with diagnostic and therapeutic challenges that may be very difficult to resolve. This report describes eight patients with incapacitating, posttraumatic neuropathic pain characteristic of reflex sympathetic dystrophy (RSD) who were treated by electromotive administration of guanethidine into affected areas of skin. Following 1-5 treatments, six patients experienced complete resolution of all superficial symptoms of hyperalgesia, pain, pallor, coolness, and sweating of the affected areas. One patient demonstrated partial relief of these symptoms, and one patient failed to respond. The results of this preliminary study suggest that electromotive administration of the the sympatholytic agent, guanethidine, may be useful in the treatment of some types of neuropathic pain. These findings justify the implementation of further controlled studies.