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.

Airway management in anesthesia for thoracic surgery: a "real life" observational study

Background

One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs.

Methods

A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway.

Results

Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted.

Conclusions

DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.

Epidemiology of Chronic Pain in the Latium Region, Italy: A Cross-Sectional Study on the Clinical Characteristics of Patients Attending Pain Clinics

In Italy, chronic pain affects more than a quarter of the population, whereas the average European prevalence is 21%. This high prevalence might be due to the high percentage of Italian people who do not receive treatment, even after the passing of law 38/2010 (the right to access pain management in Italy), which created a regional network for the diagnosis and treatment of noncancer chronic pain. Italian epidemiologic studies on chronic pain are scanty, and this observational, multicenter, cross-sectional study is the first to investigate the clinical characteristics of patients who attended the pain management clinics in the Latium Region, Italy, for the management of their noncancer chronic pain. A total of 1,606 patients (mean age 56.8 years, standard deviation ± 11.4), 67% women, were analyzed. Severe pain was present in 54% of the sample. Women experienced pain and had it in two or more sites more often than men (57% vs. 50%, p = .02; and 55.2% vs. 45.9%, p < .001, respectively). Chronic pain was musculoskeletal (45%), mixed (34%), and neuropathic (21%). In more than 60% of the cases, chronic pain was continuous, and in 20% it had lasted for more than 48 months; long-lasting pain was often neuropathic. Low back (33.4%) and lower limbs (28.2%) were the main locations. Severe intensity of pain was statistically significantly associated with female gender (odds ratio [OR] 1.39; 95% confidence interval [CI] 1.06-1.84); with International Classification of Diseases, Ninth Revision, codes for chronic pain syndrome (OR 2.14; 95% CI 1.55-2.95); and with continuous pain (OR 2.02; 95% CI 1.54-2.66). Neuropathic pain and mixed pain were significantly associated with number of sites, and a trend seemed to be present (OR 2.11 and 3.02 for 2 and 3 + sites; 95% CI 1.59-2.79 and 2.00-4.55, respectively).

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.

Mechanical ventilation in patients with end-stage idiopathic pulmonary fibrosis

BACKGROUND

Acute respiratory failure (ARF) occurring during idiopathic pulmonary fibrosis (IPF) is associated with a poor prognosis. In this subset of individuals, mechanical ventilation (MV) may be required.

OBJECTIVES

We analysed the characteristics of a group of IPF patients undergoing MV for ARF in order to give some indications on the supposed prognosis.

METHODS

Hospital records of 34 consecutive patients with IPF, who underwent MV for ARF, were retrospectively examined. Demographic data, time from diagnosis, gas exchange, Acute Physiology and Chronic Health Evaluation (APACHE) II score, ARF causes and MV failure were recorded.

RESULTS

Fifteen subjects (group A) underwent invasive MV and 19 patients (group B) non-invasive ventilation (NIV). The 2 groups were different for disease severity (APACHE II score 24.2 +/- 6 vs. 19.5 +/- 5.9; p = 0.01). Both ventilatory strategies temporarily increased PaO2/FiO2 as compared with spontaneous breathing (group A: 148.5 +/- 52 vs. 99 +/- 39, p = 0.0004; group B: 134 +/- 36 vs. 89 +/- 26, p = 0.0004). NIV reduced the respiratory rate (26 +/- 7 vs. 36 +/- 9 with spontaneous breathing; p = 0.002). Duration of MV correlated with the time of evolution of IPF (r = 0.45; p = 0.018). The in-hospital mortality rate was 85% (100% for invasive MV, 74% for NIV). Four of the 5 survivors died within 6 months from hospital discharge (range 2-6 months).

CONCLUSIONS

MV does not appear to have a significant impact on the survival of patients with end-stage IPF. NIV may be useful for compassionate use, providing relief from dyspnoea and avoiding aggressive approaches.

Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6-year experience

BACKGROUND

Timing and surgical approach in the treatment of primary spontaneous pneumothorax (PSP) are not well defined. The objective of this study is to propose a treatment protocol by videothoracoscopy (VATS) in PSP.

METHODS

From July 1992 to May 1998, 432 patients underwent VATS treatment of PSP. Indications were: recurrent ipsilateral pneumothorax: 322 cases; persistent air leak following a first episode: 93 patients; recurrence following VATS: 16 cases; recurrence following thoracotomy: 1 patient. Vanderschueren's classification was used for staging. Surgical indications were: stages I and II, subtotal pleurectomy or talc poudrage; stages III and IV, stapling or ligation of the bullae and subtotal pleurectomy or talc poudrage. Differences in recurrence rates were calculated to compare the specific procedures.

RESULTS

No postoperative deaths occurred. Complication rate was 4.16%. Conversion rate was 2.3%. Mean follow-up was 38 months (2 to 72 months). Overall recurrence rate was 4.4%. Specific recurrence rates following stapling and talc poudrage were, respectively, 1.27% and 1.79%. Talc poudrage and stapling of the bullae are respectively superior to subtotal pleurectomy (p < 0.0001) and ligation (p < 0.0001).

CONCLUSIONS

Stapling of the bullae and talc poudrage by VATS represent the treatment of choice of PSP.