Pain management during invasive procedures at Italian NICUs: has anything changed in the last five years?

OBJECTIVE

To ascertain the extent to which neonatal analgesia for invasive procedures has changed in the last 5 years since the publication of Italian guidelines.

METHODS

We compared survey data for the years 2004 and 2010 on analgesia policy and practices for common invasive procedures at Italian Neonatal Intensive Care Units (NICUs); 75 NICUs answered questionnaires for both years and formed the object of this analysis.

RESULTS

By 2010 analgesia practices for procedural pain had improved significantly for almost all invasive procedures (p < 0.05), both non-pharmacological and pharmacological methods being adopted by the majority of NICUs (unlike the situation in 2004). The routine use of medication for major invasive procedures was still limited, however (35% of lumbar punctures, 40% of tracheal intubations, 46% during mechanical ventilation). Postoperative pain treatment was still inadequate, and 41% of facilities caring for patients after surgery did not treat pain routinely. Pain monitoring had definitely improved since 2004 (p < 0.05), but not enough: only 21% and 17% of NICUs routinely assess pain during mechanical ventilation and after surgery, respectively.

CONCLUSION

There have been improvements in neonatal analgesia practices in Italy since national guidelines were published, but pain is still undertreated and underscored, especially during major invasive procedures. It is mandatory to address the gap between the recommendations in the guidelines and clinical practice must be addressed through with effective quality improvement initiatives.

Assessing the need for computed tomography for lower-third-molar extraction: a survey among 322 dentists

PURPOSE

Orthopantomograms (OPT) are used to assess the anatomical relationship between the inferior alveolar nerves (IAN) and the roots of third molars and the related risk of postextraction iatrogenic neurological lesions. When the risk is high, computed tomography (CT) or conebeam CT may be warranted. We investigated how dentists judged the need for CT from OPT to ascertain whether they comply with criteria of justification, appropriateness and optimisation in prescribing examinations involving radiation.

MATERIALS AND METHODS

A total of 2,713 letters were sent to Italian dentists (Veneto region), inviting them to access an Internet Web site showing 20 OPTs and answer a questionnaire on the need for CT or periapical X-ray. The gold standards were CT images corresponding to the OPTs. The respondents' answers were rated for appropriateness and their tendency to over- or underprescribe CT.

RESULTS

The questionnaire was completed by 11.9% of the dentists contacted. The response rate was compatible with a Web survey. Their answers generally came close to the gold standard, achieving a mean appropriateness rating of 0.636 (range 0-1). An overlap between the mandibular canal and the third-molar root was the anatomical relationship most often noted. Recommendations for CT were proportional to the number of radiographic signs indicating a risk of inferior alveolar nerve injury. Periapical X-ray was considered useful by 54.9% of dentists not recommending CT. The main reason stated for not recommending CT was that it was unnecessary for the purposes of the extraction.

CONCLUSIONS

Our survey revealed a cautious approach among the professionals interviewed, who tended to overprescribe CT.

Influence of estroprogestinic therapy on the postoperative course following impacted third molar extraction

AIM

Female patients on estroprogestinic therapy undergoing extraction of the third lower molar have a higher incidence of postoperative complications (dry socket -DS- pain). The purpose of this study is to verify such data and analyse if there are risk factors for the appearance of other postoperative complications.

METHODS

One hundred eighteen non-smoking healthy patients were included who underwent extraction of the impacted third lower molar (38 on oral contraceptives, OC, 80 as control). After the extraction, patients were prescribed with a pharmacological therapy, consisting of a per os antibiotic and antiseptic rinse. Each patient was examined after 7 days following surgery to verify the state of tissues. In addition subjective postoperative pain (VAS - Visual Analogue Scale) and intake of analgesic drugs were recorded.

RESULTS

One case of DS (2.64%) occurred in the OC group, and 1 case of DS occurred in control-patients group (1.25%) (P=0.4436). The postoperative pain proved significantly higher in OC compared to control (first and fifth postoperation day). In OC a predisposition to dehiscence of the wound (86.84% P=0.0021) and emergence of laterocervical lymphadenitis (81.57% P=0.0010) was found, while no cases of postextractive abscesses and trismus of the masseter were found.

CONCLUSION

Although no correlation between DS and estroprogestinic therapy has been found, a more difficult healing of tissues has been observed as well as a significantly higher subjective pain index in the postoperative days considered in OC patients.

[Evolution of voluntary interruption of pregnancy in Italy from its legalization until today]

Induced abortion was legalized in Italy in 1978. After an initial increase in the incidence, from 187,631 in 1979 to 234,801 in 1983, induced abortion has steadily decreased to 140,398 in 1996. Analysis of the abortion rates has shown that the main decrease has been among married women aged 25-35, while there has been an increase among unmarried women. Women with lower levels of education tend to have higher rates and housewives have higher rates than women in paid work. Programmes for the prevention of induced abortion should be directed at directed at easily accessible groups: women who have just delivered a baby, couples who marry, teenagers in school and women who have already had an induced abortion. In any case, the need for rationalisation of the procedure to obtain an induced abortion is urgent.