The Evolving Role of Monomethyl Fumarate Treatment as Pharmacotherapy for Relapsing-Remitting Multiple Sclerosis

Multiple sclerosis is the most common autoimmune disease affecting the central nervous system (CNS) worldwide. Multiple sclerosis involves inflammatory demyelination of nerve fibers in the CNS, often presenting with recurrent episodes of focal sensory or motor deficits associated with the region of the CNS affected. The prevalence of this disease has increased rapidly over the last decade. Despite the approval of many new pharmaceutical therapies in the past 20 years, there remains a growing need for alternative therapies to manage the course of this disease. Treatments are separated into two main categories: management of acute flare versus long-term prevention of flares via disease-modifying therapy. Primary drug therapies for acute flare include corticosteroids to limit inflammation and symptomatic management, depending on symptoms. Several different drugs have been recently approved for use in modifying the course of the disease, including a group of medications known as fumarates (e.g., dimethyl fumarate, diroximel fumarate, monomethyl fumarate) that have been shown to be efficacious and relatively safe. In the present investigation, we review available evidence focused on monomethyl fumarate, also known as Bafiertam®, along with bioequivalent fumarates for the long-term treatment of relapsing-remitting multiple sclerosis.

Acute Care Surgery: Navigating Recent Developments, Protocols, and Challenges in the Comprehensive Management of Surgical Emergencies

Acute care surgery (ACS) is a crucial medical field that specifically deals with the rapid treatment of surgical emergencies. This investigation encompasses the most recent progress, procedures, and obstacles in ACS, utilizing various sources such as scholarly articles, clinical trials, and expert statements. The development of ACS as a specialized field is a significant area of concentration, particularly emphasizing its contribution to improving patient care. An examination is conducted on the efficacy of contemporary triage systems and prompt response mechanisms, specifically in diminishing the incidence of illness and death rates associated with illnesses such as trauma, acute appendicitis, and obstructed viscera. The emphasis is placed on the surgical protocols and principles that form the basis of ACS. Examining regional and international approaches provides insight into the distinctions and commonalities in surgical techniques. An assessment is conducted to determine the effects of the transition to minimally invasive procedures on patient outcomes, recuperation periods, and healthcare expenses. The assessment also examines the logistical obstacles that ACS encounters, such as resource allocation and managing diverse teams. The examination focuses on the delicate equilibrium between prompt decision-making and care grounded in evidence. It also evaluates the possible contribution of technical breakthroughs such as telemedicine and AI to improving patient care and overcoming current obstacles. The topic of training and education for surgeons in ACS is of utmost importance and requires careful consideration. The evaluation evaluates the sufficiency of existing educational frameworks and the necessity of specific training to equip surgeons for the requirements of ACS. This analysis explores the current discourse surrounding the standardization of ACS training, considering its potential ramifications for the future of surgical procedures. Exploring ethical and legal problems in ACS also includes situations when prompt decision-making may clash with patient autonomy and informed consent. The significance of proficient communication with patients and their families during emergency surgical scenarios is underscored, emphasizing the necessity for ethical awareness and interpersonal aptitude. The investigation of ACS demonstrates its dynamic character, signifying notable advancements while recognizing enduring obstacles. Continual research, interdisciplinary collaboration, and policy adjustments are necessary to improve ACS procedures. This thorough investigation offers valuable insights for professionals and researchers, facilitating future progress in managing surgical crises.

Treating Pulmonary Arterial Hypertension With Sotatercept: A Meta-Analysis

Pulmonary arterial hypertension (PAH) results from proliferative remodeling and narrowing of the pulmonary vasculature. Sotatercept is a first-in-class fusion protein that has recently garnered attention for showing improvements in patients with PAH. This meta-analysis of randomized controlled trials (RCTs) assesses the overall efficacy of Sotatercept in treating PAH. PubMed, Google Scholar, and Clinicaltrials.gov were searched using relevant keywords and MeSH terms. Studies were included if RCTs compared Sotatercept with placebo in patients with PAH. Our comprehensive literature search yielded 3,127 results, of which two RCTs with 429 patients were included in this meta-analysis. The patients were on background therapy for PAH. Results of the meta-analysis show that when compared with placebo, Sotatercept improved the six-minute walk distance (mean difference [MD] 34.99; 95% confidence interval [CI] 19.02-50.95; P < 0.0001), the World Health Organization (WHO) functional class (odds ratio [OR] 2.50; 95% CI 1.50-4.15; P = 0.0004), and pulmonary vascular resistance (PVR, MD -253.90; 95% CI -356.05 to -151.75; P < 0.00001). However, reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP, MD -1563.14; 95% CI -3271.93 to 145.65; P = 0.07) was not statistically significant in the Sotatercept group versus placebo. In conclusion, Sotatercept improves the six-minute walk distance, WHO functional class, and PVR in patients with PAH receiving background therapy. However, the effect on NT-proBNP levels was not statistically significant. More research is needed to assess the clinical relevance of these findings.

Hyperkalemia: Pharmacotherapies and Clinical Considerations

Hyperkalemia has been defined as a condition where a serum potassium level is >5.5 mmol/l. It is associated with fatal dysrhythmias and muscular dysfunction. Certain medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others, can lead to hyperkalemia. Many of the signs of hyperkalemia are nonspecific. A history and physical examination can be beneficial in the diagnosis of the condition. In this regard, certain characteristic electrocardiogram findings are associated with hyperkalemia along with laboratory potassium levels. In acute and potentially lethal conditions, hyperkalemia treatments include glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, hyperventilation, and dialysis. There are several drugs, both old and new, that can additionally aid in the reduction of serum potassium levels. The present investigation evaluated some of these different drugs, including sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer. These drugs each have increased selectivity for potassium and work primarily in the gastrointestinal (GI) tract. Each of these medications has unique benefits and contraindications. Clinicians must be aware of these medications when managing patients with hyperkalemia.

Cefiderocol (Fetroja) as a Treatment for Hospital-Acquired Pneumonia

With increasing resistance to conventional antibiotic treatments, especially among gram-negative bacilli, the search for new antibiotics has become critical on a global scale. Among infections with multidrug-resistant bacteria is hospital-acquired pneumonia (HAP), which is nosocomial pneumonia in patients who have been hospitalized for more than 48 hours. HAP carries a high mortality rate and continues to be a challenge with regard to adequate treatment. The typical multidrug-resistant gram negatives found in HAP include Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Many new antibiotics have been studied and tested against these pathogens as possible solutions, and the search continues. Cefiderocol, a novel siderophore cephalosporin, is effective against these pathogens. Cefiderocol is an iron-chelating agent that makes use of iron pumps on the membrane of bacteria via a catechol moiety on the C3 side chain of the molecule. This allows for easy access into the cytoplasm, where it can inhibit peptidoglycan synthesis by binding to penicillin-binding proteins. Cefiderocol displays linear pharmacokinetics and is mainly excreted through the kidneys. It is well tolerated in healthy individuals but may need adjustments of dosage in patients with impaired renal function. Studies have shown that both healthy subjects and those with impaired renal function experienced some adverse effects, including nausea, diarrhea, abdominal pain, and increased creatinine kinase; however, these adverse effects were limited and experienced in placebo groups. It has demonstrated efficacy in treating infections caused by many multidrug-resistant gram-negative pathogens and has demonstrated high stability against many classes of b-lactamases. There have been multiple phase 3 trials, such as the CREDIBLE-CR trial and the APEKS-NP trial, that demonstrated efficacy in treated nosocomial pneumonia caused by multidrug-resistant gram negatives, such as carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, compared to the best available treatment. While clinical data remain limited, a few studies are showing clinical efficacy and few adverse effects. Cefiderocol demonstrated effectivity in treating multidrug-resistant gram-negative pneumonia in patients with multiple comorbidities, such as chronic kidney disease, chronic-obstructive pulmonary disease, and diabetes mellitus. Cefiderocol shows promise as a novel antimicrobial agent in treating multidrug-resistant gram-negative in HAP.

Non-steroidal Anti-inflammatory Drug (NSAID)-, Potassium Supplement-, Bisphosphonate-, and Doxycycline-Mediated Peptic Ulcer Effects: A Narrative Review

Peptic ulcers are a common condition that arises from an imbalance between acid production and gastroduodenal protective factors. Various drugs, including non-steroidal anti-inflammatory drugs (NSAIDs), potassium supplements, bisphosphonates, and doxycycline, can increase the development of peptic ulcers. NSAIDs are one of the most common medications prescribed for pain relief, and they also inhibit the formation of cyclooxygenase-1 (COX-1). COX-1 helps in the production of mucus that lines the stomach, so by inhibiting COX-1, NSAIDs reduce the mucus produced by the stomach and increase the likelihood of gastric ulcer formation. Additionally, NSAIDs are acidic, and increasing the amount of any acid in the stomach can result in promoting ulcer development. Potassium supplements are used to reduce the effects of hypertension, decrease the development of kidney stones, and treat hypokalemia. The various types of transporters and channels used to move potassium across cell membranes increase hydrogen being pumped, increasing gastric acid production and ulcer formation. Bisphosphonates are used to treat a variety of skeletal disorders that require inhibition of osteoclast activity. Nitric oxide (NO) has been shown to have a therapeutic effect on gastric ulcers, and some bisphosphonates have been shown to decrease the production of nitric oxide, resulting in increased damage to the gastric mucosa. Finally, doxycycline is a broad-spectrum tetracycline antibiotic that is typically used to treat anthrax poisoning, skin lesions, and sexually transmitted diseases. A harmful adverse effect of doxycycline is the formation of peptic and gastric ulcers related to the drug being highly acidic once it has dissolved.

The Challenges of Pain Assessment in Geriatric Patients With Dementia: A Review

Pain in dementia patients is common, poorly measured, and undertreated. It is important to discuss the challenges in the pain assessment and management to find a possible solution for adequate pain management. The aim of this article is to discuss the challenges in the assessment of pain in geriatric patients with dementia. An extensive online database search was conducted via multiple websites using the following keywords: "dementia," "pain assessments," "pain assessment with dementia," "causes of pain with dementia," "pain assessments using recent technology," "geriatric," and "old age" to identify the relevant articles. Our inclusion criteria were articles that focused on pain in geriatric patients diagnosed with dementia, in English, published between January 2018 and January 2023, and available as free full text and those which were clinical trials, observational studies, review articles, systemic reviews, meta-analysis, or case series. The exclusion criteria were articles that did not have pain in geriatric patients diagnosed with dementia as their primary focus, involving geriatric or non-geriatric patients with major psychological distress, not in the English language, not published between January 2018 and January 2023, and not available as free full-text and those which were case reports and editorial articles. After manually excluding the articles that did not meet our inclusion criteria, we ended up with 38 articles. In conclusion, any instruments have been made for the pain assessment in patients with dementia. The two most common tools used to assess pain in this vulnerable population are the Pain Assessment in Advanced Dementia (PAINAD) and Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) scales. The utilization of new technology may offer promising solutions for the pain assessment in patients with dementia.

What's New in Neuropathy?

Neuropathic pain presents diagnostic and treatment challenges. Despite recent advances in our understanding of the diagnosis and treatment of neuropathy, much remains to be elucidated. Familiar with neuropathy is the paradox that aberrant nerve signaling causes both sensory loss and pain. Voltage-gated sodium channels play an important role in neuronal electrogenesis and communication among neurons, and their dysregulation leads to hyperexcitability and pain. While numerous validated diagnostic assessment tools are available for neuropathy, patients often experience a diagnostic delay about the cause of their neuropathy. New research is defining more specific types of neuropathy beyond peripheral and central forms. The prevalence of pain varies by type of neuropathy, with chronic idiopathic axonal polyneuropathy associated with the highest proportion of patients experiencing pain. In the majority of types, it exceeds 50%. Gluten neuropathy, a form of peripheral neuropathy, is a new diagnostic consideration. It may require electrochemical conductance testing of hands and feet to test for sudomotor dysfunction. Among those with serologically confirmed gluten sensitivity or celiac disease, gluten neuropathy is a common neurological manifestation and may be addressed at least partially by a gluten-free diet. In Greece, a new neuropathic pain registry was created in 2014 in order to help gather data from real-world neuropathic pain patients. While still in its earliest phase, this registry has already produced demographic and treatment data that suggest suboptimal prescribing and less than recommended use of interventional procedures. Awareness campaigns are underway to encourage more Greek pain clinics to participate in this important registry.

Is Fibromyalgia a Fashionable Diagnosis or a Medical Mystery?

Despite its prevalence, there is no clear-cut diagnostic path or treatment paradigm for fibromyalgia; this can lead to a multiplicity of symptoms and comorbid conditions that complicate care. "Overlapping symptoms" describe conditions that can occur concomitantly with fibromyalgia and include migraine, irritable bowel syndrome, obesity, and pelvic pain syndromes. A variety of pharmacologic and nonpharmacologic treatments are available for fibromyalgia, but treatment is best personalized for an individual and recognizes potential comorbidities. Opioids are not the recommended front-line treatment, cannabinoids hold promise but with limitations and nonpharmacologic options, such as aerobic or resistance exercise and cognitive behavior therapy, can play a very important but often underestimated role. Amitriptyline appears to be safe and effective in treating six of the main fibromyalgia domains: pain, disturbed sleep, fatigue, affective symptoms, functional limitations, and impaired cognition ("fibro fog"). Very low-dose naltrexone (2.5-4.5 mg) may offer analgesic and anti-inflammatory benefits to fibromyalgia patients, but further studies are needed. Fibromyalgia can be a devastating and debilitating condition for patients, and clinicians are challenged with its diagnosis and treatment as well. Further research as well as compassionate approaches to offering personalized care to those with fibromyalgia are required.

Looking Back, Moving Forward in Pain Medicine

Pain is an ancient medical complaint and a clinical riddle that has never been entirely solved. Looking back into history was the springboard to a look into the future of pain medicine. This article was based on a series of presentations given in a recent congress (May 2023) and represents the research, views, and opinions of the authors. Opium has been used for millennia to treat pain, but when it gained broad use in the United States in the 1980s and 1990s, it was so vastly overprescribed and mis-prescribed that it led to a public health crisis. This, in turn, led to the reaction where opioids at times were under-prescribed, leaving out many patients who may have benefited from opioids while leaving many legacy pain patients to manage withdrawal on their own and with few analgesic options. Cannabinoids (CB) were likewise widely used for various conditions, including pain, but were outlawed in the 20th century, only to be brought back as a potential analgesic agent. Interventional pain medicine is a developing discipline and has reinforced the concept of the interdisciplinary pain clinic. It plays an increasingly important part in modern medicine overall, especially with the support of ultrasound, for both diagnosis and therapy. Today, the views about pain have changed. Anyone has accepted that pain is not purely a physical phenomenon but a biopsychosocial phenomenon that occurs within a cultural context. Pain management remains a small but vitally important medical subspecialty that is critical from a functional enablement and population health perspective, which is helping to navigate new therapeutic targets, new drugs and routes of administration, greater understanding of pain psychology, and new technologies. Pain control today means early intervention, functional enablement through pain alleviation, educating patients about pain management, and minimizing the transition from acute to chronic pain.

Current Approaches to Four Challenging Pain Syndromes

During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.

Iatrogenic Side Effects of Pain Therapies

Pain regimens, particularly for chronic cancer and noncancer pain, must balance the important analgesic benefits against potential risks. Many effective and frequently used pain control regimens are associated with iatrogenic adverse events. Interventional procedures can be associated with nerve injuries, vascular injuries, trauma to the spinal cord, and epidural abscesses. Although rare, these adverse events are potentially catastrophic. Pharmacologic remedies for pain must also consider potential side effects that can occur even at therapeutic doses of over-the-counter remedies such as paracetamol (acetaminophen) or nonsteroidal anti-inflammatory drugs. Opioids are effective pain relievers but are associated with many side effects, some of which can be treatment limiting. A prevalent and distressing side effect of opioid therapy is constipation. Opioid-induced constipation is caused by binding to opioid receptors in the gastrointestinal system, making conventional laxatives ineffective. Peripherally acting mu-opioid receptor antagonists are a new drug class that offers the benefits of preserving opioid analgesia without side effects in the gastrointestinal system. An important safety concern, particularly among geriatric patients is the increasingly prevalent condition of polypharmacy. Many senior patients take five or more medications, including some that may be contraindicated in geriatric patients, duplicative of other drugs, have potential pharmacokinetic drug-drug interactions, or may not be the optimal choice for the patient's age and condition. Careful assessment of medications in the elderly, including possibly deprescribing with tapering of certain drugs, may be warranted but should be done systematically and under clinical supervision.

Digital Pathology: Transforming Diagnosis in the Digital Age

In the context of rapid technological advancements, the narrative review titled "Digital Pathology: Transforming Diagnosis in the Digital Age" explores the significant impact of digital pathology in reshaping diagnostic approaches. This review delves into the various effects of the field, including remote consultations and artificial intelligence (AI)-assisted analysis, revealing the ongoing transformation taking place. The investigation explores the process of digitizing traditional glass slides, which aims to improve accessibility and facilitate sharing. Additionally, it addresses the complexities associated with data security and standardization challenges. Incorporating AI enhances pathologists' diagnostic capabilities and accelerates analytical procedures. Furthermore, the review highlights the growing importance of collaborative networks facilitating global knowledge sharing. It also emphasizes the significant impact of this technology on medical education and patient care. This narrative review aims to provide an overview of digital pathology's transformative and innovative potential, highlighting its disruptive nature in reshaping diagnostic practices.

Advances in the Management of Acute Postsurgical Pain: A Review

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Cognitive-Behavioral Play Therapy and COVID-19 Pandemic Trauma in Preschool Children

Traumatic life events, such as the ongoing COVID-19 pandemic, can be a challenging health emergency, among others. The pandemic can also affect young preschoolers. They can experience negative emotions and behavioral and social difficulties. It can be hard for children to understand on their own what is going on, as well as for their families. This narrative review summarizes the role of psychotherapeutic approaches in working with trauma and aims to manage trauma, such as COVID-19, in preschool children. It focuses on the possibilities of applying cognitive-behavioral play therapy (CBPT) in preschool children who suffer from trauma during the COVID-19 pandemic period. The therapeutic approaches are tailored to specific development in preschoolers. Furthermore, the article provides insights into the relationship between negative emotions, thinking, and behavior, and COVID-19 as a threat, by describing a cognitive model in preschool-aged children. Finally, the article offers possible ways of applying play-based cognitive-behavioral therapy programs in preschool children who are victims of trauma.

Bridging Old and New in Pain Medicine: An Historical Review

Pain is both one of the oldest complaints known to medicine and a field for some of medicine's latest breakthroughs and innovations. Pharmacologic treatment of pain is one of the oldest remedies, and opioids have been used since ancient times as an effective pain reliever but with certain specific risks for abuse. Greater knowledge of opioids led to a more thorough understanding of the complexities of pain, which may have any number of mechanisms. A greater understanding of nerve fibers and pain signaling led to the development of more drugs and the more targeted delivery of analgesics using the hollow needle. The hollow needle changed pain treatment and led to percutaneous injections and what would later become interventional pain medicine with regional anesthesia and nerve blocks. Today, imaging can be combined with interventional techniques for more precise localization of nerves for diagnosis and treatment. The role of artificial intelligence in interventional pain medicine, especially in imaging for interventional procedures, remains unknown but will likely become extremely beneficial.

Answering Big Questions in Pain Medicine

The future of pain medicine is marked by many questions. What can other nations around the world learn from the opioid crisis that is still affecting the United States? The American opioid experience was mischaracterized and wrongly described, and its causes were misdiagnosed from the outset, leading to its mismanagement and the abandonment of many chronic pain patients to their suffering. There are a few new drugs in the analgesic armamentarium. What new targets do we have in pain medicine? There are many breakthroughs, discoveries, and potential new targets that could add to our analgesic prescribing choices. These include sigma receptors, d-amino acid oxidase, endoplasmic reticulum stress receptors, histone deacetylase, and others. Neuromodulation had been used with varying degrees of success for years, but with a simplistic approach based on the gate theory of pain. Despite our familiarity with neuromodulation and spinal cord stimulators, neuromodulation research indicates that the activation of glial cells may activate the immune system and enhance analgesia. Neuromodulation studies have concentrated on how electricity affects neuronal activity rather than how electrical activity could reduce pain. There are still more frontiers in our battle against pain and some promising avenues for treatments. This narrative review will try to summarize what can be done from the perspective of recent technological and pharmacological developments.

Individualizing Medicinal Therapy Post Heart Stent Implantation: Tailoring for Patient Factors

The field of cardiovascular medicine is undergoing a transformative shift towards personalized medicinal therapy, particularly in the context of post stent implantation. This narrative review explores the significance, challenges, and future directions of individualized treatment strategies for patients with coronary stents. The review highlights the pivotal role of personalized approaches in optimizing treatment efficacy and minimizing adverse events. Real-world clinical studies and trials underscore the importance of tailoring antiplatelet therapy based on platelet function testing, genetic testing, and risk scoring. These studies reveal that personalized medicinal treatment improves clinical outcomes by balancing preventing thrombotic events and mitigating bleeding risks. Challenges, including cost, test availability, patient adherence, and ethical considerations, are discussed in depth, shedding light on the complexities of implementing personalized approaches. Technological advancements, including omics data integration, artificial intelligence, and big data analytics, shape the future of personalized medicinal therapy. These tools enable precise pharmacogenomic selection of medications and the development of integrated risk-scoring systems. Patient engagement and education are also central, with empowered patients and remote monitoring contributing to collaborative decision-making. In conclusion, the narrative review underscores that personalized medicinal therapy post stent implantation holds immense promise for revolutionizing cardiovascular care. By embracing a comprehensive approach that considers genetics, clinical factors, and patient preferences, healthcare providers can optimize treatment outcomes and improve patient quality of life. The evolving landscape of personalized medicine offers a glimpse into a future where tailored treatment strategies become the cornerstone of precision cardiovascular care.

Guillain-Barré Syndrome Induced by Vaccination Against COVID-19: A Systematic Review and Meta-Analysis

Guillain-Barré syndrome (GBS) is a rare but serious immune-mediated neurological condition characterized by damage to the peripheral nervous system. Two-thirds of cases of GBS are diagnosed following infection; however, vaccination has also been linked to GBS pathogenesis. The aim of this systematic review and meta-analysis was to establish the prevalence of GBS following vaccination against the SARS-CoV-2 virus, which causes COVID-19, describe the clinical and neurophysiological characteristics, and identify potential determinants. A systematic review of the literature regarding post-vaccination GBS was conducted using the PubMed database. Seventy papers were included. The pooled prevalence of GBS after vaccination against COVID-19 per has been established to be 8.1 (95% CI 30-220) per 1,000,000 vaccinations. Vaccination with vector vaccines - but not mRNA - has been associated with an increased risk of GBS. More than 80% of the patients developed GBS within 21 days following the first dose of the vaccination. The interval between the vaccination and GBS was shorter in patients who were vaccinated with mRNA versus vector vaccines (9.7±6.7 days versus 14.2±6.6 days). Epidemiological findings regarding post-vaccination GBS revealed a higher prevalence in males and people between the ages of 40 and 60 years, with a mean age of 56.8±16.1 years. The most common type was the acute inflammatory demyelinating polyneuropathy type. Most cases responded well to treatment. In conclusion, vaccination against COVID-19 with vector vaccines seems to increase the risk of GBS. GBS occurring following vaccination does differ in characteristics from GBS during the pre-COVID-19 era.

Chronic Non-cancer Pain Management in a Tertiary Pain Clinic Network: a Retrospective Study

INTRODUCTION

Chronic pain is a distressing condition that should be treated in specialized pain clinics. Pain clinics offer a holistic, evidence-based approach, including pharmacological, complementary, and invasive treatments. This study aimed to provide preliminary information regarding chronic pain treatments and identify reasons for accessing an important hub-spoke pain clinic network.

METHODS

A retrospective multicenter cross-sectional study was carried out. A total of 1606 patients' records were included. Patients were selected from the 26 pain clinics of a single region in Italy. Univariate and multivariate logistic regression models were used.

RESULTS

Multivariate models showed that the use of opioids were considered effective for severe or moderate pain [odds ratio (OR) 0.41; 95% 0.33-0.51], while the use of invasive treatments (OR 2.45; 95% 1.95-3.06) and the use of complementary therapy (OR 1.87; 95% 1.38-2.51) were associated with severe or moderate pain. Overall, age, sex, nonsteroidal anti-inflammatory drugs (NSAID) use, a combination of NSAIDs, complementary therapies, and a combination of opioids and invasive treatments did not seem to be significantly associated with the nature of pain. Multivariate models confirmed that clinical parameters such as the nature of pain, multi-diagnosis, more than one site of pain, treatments, and general practitioner, but not the severity of pain and use of invasive treatments, had an impact on the choice of a pain clinic.

CONCLUSION

Opioids are useful in managing moderate or severe chronic pain. Multimodal approaches are used for the management of chronic pain. Moreover, it is not clear how patients are addressed to access different pain clinics (spoke versus hub) networks. More widespread adoption is needed for an interdisciplinary approach to managing chronic pain and adopting guideline recommendations, and rigorous research is required to provide more substantial evidence and support clinical practice.

The stress response of intensive care unit medical doctors facing repeated severe emergencies

Objectives

This study assesses the psychopathological distress experienced by doctors working in an Intensive care unit (ICU) during the COVID-19 pandemic. These doctors were the same who faced the consequences of a previous natural disaster, a severe 6.3 magnitude earthquake. A second objective is to evaluate their current mental attitude, professional performances and coping strategies adopted in the pandemic in relation to the conditioning effect of that first emergency, the earthquake.

Methods

Thirty-seven ICU medical doctors were recruited and assessed using Rapid Stress Assessment (RSA) rating scale, Symptom Checklist-90 Revised (SCL-90-R), Zung Self-Rating Anxiety Scale, Beck Depression Inventory, Beck Hopelessness Scale, Millon Clinical Multiaxial Inventory III. Comparison between exposure to the earthquake and COVID pandemic has been made in terms of professional role and psychological burden.

Results

Comparison between 2009 earthquake catastrophe and COVID pandemic conditions evidenced relevant changes in professional role, team, environment, shifts, and work organization.

Conclusion

The doctors, who already experienced the 2009 earthquake reported a feeling of greater insecurity facing this latter catastrophe, the COVID pandemic, as well as perception of greater concern for their family and the global situation. However, having participated in the medical management of another emergency (the 2009 earthquake) appears to have contributed to limiting demoralization and psychological distress. The feeling of having greater decision-making possibilities and participation in the organization of work, strengthen coping skills in the face of the emergency.

Education in Urban Health: the experience of Public Health residents in an Italian high school

Background

Urban health has become an increasingly important aspect of Public Health curriculum for residents as people living in urban areas will substantially rise in the next 30 years so will their impact on health. Residents are both contributors and partners in creating sustainable solutions for their growing cities and can be involved in this aim as individual learners and also educators for younger students.

Objectives

A group of 15 Italian residents in Public Health were involved in creating and delivering 4 lessons on urban health to 319 students at Nomentano High School in Rome during spring 2022. After the 4th lesson, semi-structured interviews were conducted with the residents in order to assess perceptions, acceptance, barriers and facilitators of the experience. Data was gathered anonymously and analyzed using standard qualitative methods.

Results

All the residents answered the interview. Almost all reported the experience as highly impactful for training, team building, and increase in accountability. Most of residents also felt more confident on the topic of urban health and more involved in concrete actions for tackling pollution and climate change after delivering the lessons. Most perceived barriers mentioned were difficulties interacting with students, especially during the first two lessons, and their compliance. The opportunity to give lessons in the high school setting facilitated direct contact with students and better feedback was received.

Conclusions

Giving responsibility and leadership roles to Public Health residents and involving them in the education of younger students could improve their self-confidence and feelings of value and helpfulness, especially for urban health and climate change issues sensed by youth. Further experiences in other settings, specialties, and countries could be valuable to notice differences related to age groups and personal involvement.

Key messages

• The involvement of Public Health residents in education on urban health is highly impactful and well perceived for their personal growth.

• This kind of experience is applicable to other relevant topics in Public Health.

Increasing urban health awareness using an interactive approach: evidence from a school-based study

Issue

Urbanization is a cause of climate change, as cities are where these changes are most visible. Climate change also leads to significant inequalities and health issues in urban settings. In this context, urban health promotion is mandatory to increase adaptive capacity. Since the late 1980s the World Health Organization (WHO) has emphasized schools’ role in promoting health, as they can play a crucial role in increasing health awareness to future urban inhabitants.

Description

The objective of this pre/post-interventional study is to measure the awareness of urban health and green spaces among high school students and to rise it through an educational intervention. Four interactive sessions were delivered to 319 students from 13 to 18 years old in a high school in Rome, Italy during spring 2022. Data was gathered anonymously and analysed using descriptive and inferential statistics.

Results

A total of 192 (60%) students successfully completed the pre/post-intervention surveys. An increase in students’ knowledge of urban health and urban green areas was observed. Before the intervention 11.8% of participants were aware of urban health, whereas after the intervention 87.5% were aware. A rise across different areas appeared to be related to how many times the teachers repeated that concept during the intervention. For topics discussed in more than one session, the increase in correct answers averaged 13.9%. Two different trends emerged from the data analysis: one whose post-intervention test improved on most of questions and one whose post-intervention test remained unchanged.

Lessons

The results of the present study suggest that school-based interventions using interactive approaches on climate change and urban health are effective for increasing the knowledge level of scholars on these topics, and can be a useful way to promote health in an urban setting. This type of approach maintains high levels of concentration and interest in most students.

Key messages

• Urban health training activities in schools are needed to empower youth who live in urban settings.

• Interactive sessions keep student concentration high and improve their participation.

Training needs assessment of European healthcare workers on vaccinology and vaccine acceptance

Background

Healthcare workers (HCWs) are at the frontline of interaction with those that are taking decisions around vaccination. They need adequate training. The general aim of this systematic review is to assess HCWs’ training needs on vaccinology and vaccine acceptance. This work was performed for the European Centre for Disease Control (ECDC) under the specific contract No 1ECD.12108 ID.12922 implementing the framework contract number ECDC/2021/005.

Methods

The search was performed using MEDLINE, Scopus and Google Scholar databases in February 2022. The following inclusion criteria were used: date (from 01/01/2011 to 24/02/2022); language (English, Italian, Portuguese, Spanish, French and Romanian); geographic location of the study (Europe). Appraisal tool for Cross-Sectional Studies (AXIS checklist) was used to assess the methodological quality of the included papers.

Results

The scientific literature search retrieved 640 results on PubMed, 556 on Scopus and 15 on Google Scholar. In total, 1211 records were identified. After the duplicate removal and the title/abstract assessment, 132 publications were assessed for eligibility. Finally, after the full-text assessment, only 25 articles were included. As regards for the quality assessment, all studies were judged of moderate-good quality. The majority of studies stressed the need to deepen general knowledge of vaccine preventable diseases, vaccine efficacy, vaccination schedule and adverse effects of vaccines.

Conclusions

Considering their role in the community, especially as source of information and trust for vaccine acceptance, educational initiatives in vaccinology and vaccine hesitancy should be prioritized for HCWs, aimed at increasing their knowledge, awareness, and attitudes. An important heterogeneity of educational backgrounds, activities performed and training needs of the HCWs involved in vaccination at European level was one of the main critical issue to be addressed for future actions.

Key messages

Rimegepant for the treatment of migraine

Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.

Treatment and Management of Xiphoidalgia

Xiphodynia is a rare but debilitating condition that can be described as a form of pain on the xiphisternal joint or any related structures that are anchored to the xiphoid process. Although xiphodynia is a musculoskeletal pain in nature, the pain located in the anterior chest can commonly mislead physicians into pursuing other diagnoses such as cardiac diseases. This leads to a prolonged duration of pain before receiving treatment. In the attempt to alleviate pain resulting from this condition, physicians have previously utilized a range of treatment options, including conservative management, injections, or in severe cases, xiphoidectomy. In this review, we aim to give a brief overview of xiphodynia, including clinical diagnoses and current treatment modalities.

Key Summary Points

1. Xiphodynia can be described as pain radiating from an irritated xiphoid process that can travel to the chest, abdomen, throat, and arms2. Risk factors for developing secondary xiphoidalgia include GERD, gall-bladder disease, angina pectoris, and coronary-artery disease3. The treatment of xiphodynia can range from conservative management to injections or a xiphoidectomy4. Further research is required to develop a standardized treatment protocol and currently the choice of treatment depends on the patient's individual case and the degree of severity.

Pharmacological Management of Neuropathic Pain after Radiotherapy in Head and Neck Cancer Patients: A Systematic Review

Background: Neuropathic pain (NP) in head and neck cancer (HNC) patients represents a treatment challenge. Most studies investigating drugs against NP are conducted in patients suffering with diabetic neuropathy or postherpetic neuralgia, while data are limited in cancer pain management. Additionally, regarding cancer therapy-related NP, most of the studies do not focus on HNC patients. The aim of this review is to identify the studies on systematically administered medication for NP management that included HNC patients under radiotherapy. Methods: A systematic literature search was performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in PubMed, Cochrane Library, Web of Science and ClinicalTrials.gov on 30 October 2021. The medical subject heading (MeSH) terms were (“head and neck cancer” OR “tumor”) AND “neuropathic pain” AND “medication” AND “radiotherapy.” The Cochrane Collaboration tool was used for quality assessment. Results: The search identified 432 articles. Three more articles were identified after searching the reference lists of the retrieved articles. A total of 10 articles met the eligibility inclusion criteria and were included in this review; 6 on gabapentin, 1 on pregabalin, 1 on nortriptyline, 1 on methadone, and 1 on ketamine. Statistically significant results in pain reduction compared to placebo or standard pain medication were found in the studies on pregabalin (p = 0.003), methadone (p = 0.03), ketamine (p = 0.012), and in two out of six gabapentin studies (p < 0.004). Two of the studies (both concerning gabapentin) had no comparison arm. Conclusions: Treatments including pregabalin, methadone, ketamine, and gabapentin were found to provide pain relief against HNC NP. While there is a plethora of pharmacological treatments available for the management of NP, only a few studies have been conducted regarding the pharmacological management of therapy-related NP in HNC patients. More studies should be conducted regarding the pharmacological approaches in HNC therapy-related NP so that specific treatment algorithms can be developed.

Potential neurological manifestations of COVID-19: a narrative review

Neurological manifestations are increasingly reported in a subset of COVID-19 patients. Previous infections related to coronaviruses, namely Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS) also appeared to have neurological effects on some patients. The viruses associated with COVID-19 like that of SARS enters the body via the ACE-2 receptors in the central nervous system, which causes the body to balance an immune response against potential damage to nonrenewable cells. A few rare cases of neurological sequelae of SARS and MERS have been reported. A growing body of evidence is accumulating that COVID-19, particularly in severe cases, may have neurological consequences although respiratory symptoms nearly always develop prior to neurological ones. Patients with preexisting neurological conditions may be at elevated risk for COVID-19-associated neurological symptoms. Neurological reports in COVID-19 patients have described encephalopathy, Guillain-Barré syndrome, myopathy, neuromuscular disorders, encephalitis, cephalgia, delirium, critical illness polyneuropathy, and others. Treating neurological symptoms can pose clinical challenges as drugs that suppress immune response may be contraindicated in COVID-19 patients. It is possible that in some COVID-19 patients, neurological symptoms are being overlooked or misinterpreted. To date, neurological manifestations of COVID-19 have been described largely within the disease trajectory and the long-term effects of such manifestations remain unknown.

Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review

Introduction

Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment.

Methods

A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles.

Discussion

This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided.

Conclusions

Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.

Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review

Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.

Anthelmintic activity of Stevia multiaristata extract against Echinococcus granulosus sensu stricto

Cystic echinococcosis is a zoonotic disease caused by the larval stage of the parasite Echinococcus granulosus sensu lato. The available anti-parasitic treatment is mostly limited to a continuous administration of albendazole. However, due to its numerous side-effects and efficacy of around 50%, there is a need to find new drugs to improve the treatment for this disease. In the current study, the in vitro and in vivo efficacy of a Stevia multiaristata extract against E. granulosus sensu stricto (s.s.) was demonstrated. Stevia multiaristata extract (100 and 50 μg mL−1) caused a quick viability decrease on protoscoleces which was consistent with the observed tegumental alterations. Loss of turgidity was detected in 95 ± 3.4% of cysts incubated with S. multiaristata extract during 2 days (100 μg mL−1) and the collapse of the germinal layer was observed in 60 ± 9.3% of cysts treated with 100 μg mL−1 of the S. multiaristata extract during 4 days. The half maximal effective concentration value was 69.6 μg mL−1 and the selectivity index for E. granulosus s.s. cysts was 1.9. In this clinical efficacy study, the treatment of infected mice with the S. multiaristata extract (50 mg kg−1) caused a significant decrease in the weight of the cysts compared with the control group. These results coincided with the tissue damage observed in the cysts at the ultrastructural level. In conclusion, we observed high protoscolicidal and cysticidal effects, and significant reduction in the weight of the cysts in experimentally infected mice following treatment with the S. multiaristata extract.

Neuropathic Pain in Neurologic Disorders: A Narrative Review

Neuropathic pain is defined as a painful condition caused by neurological lesions or diseases. Sometimes, neurological disorders may also be associated with neuropathic pain, which can be challenging to manage. For example, multiple sclerosis (MS) may cause chronic centralized painful symptoms due to nerve damage. Other chronic neuropathic pain syndromes may occur in the form of post-stroke pain, spinal cord injury pain, and other central pain syndromes. Chronic neuropathic pain is associated with dysfunction, disability, depression, disturbed sleep, and reduced quality of life. Early diagnosis may help improve outcomes, and pain control can be an important factor in restoring function. There are more than 100 different types of peripheral neuropathy and those involving sensory neurons can provoke painful symptoms. Accurate diagnosis of peripheral neuropathy is essential for pain control. Further examples are represented by gluten neuropathy, which is an extraintestinal manifestation of gluten sensitivity and presents as a form of peripheral neuropathy; in these unusual cases, neuropathy may be managed with diet. Neuropathic pain has been linked to CoronaVirus Disease (COVID) infection both during acute infection and as a post-viral syndrome known as long COVID. In this last case, neuropathic pain relates to the host’s response to the virus. However, neuropathic pain may occur after any critical illness and has been observed as part of a syndrome following intensive care unit hospitalization.

Decompression Using Minimally Invasive Surgery for Lumbar Spinal Stenosis Associated with Degenerative Spondylolisthesis: A Review

Lumbar spinal stenosis (LSS), which often occurs concurrently with degenerative spondylolisthesis (DS), is a common disease in the elderly population, affecting the quality of life of aged people significantly. Notwithstanding the frequently good effect of conservative therapy on LSS, a minority of the patients ultimately require surgery. Surgery for LSS aims to decompress the narrowed spinal canals with preservation of spinal stability. Traditional open surgery, either pure decompression or decompression with fusion, was considered effective for the treatment of LSS with or without DS. However, the long-term clinical outcomes of traditional open surgery are still unclear. Moreover, the disadvantages of conventional open surgery are extensive, examples including tissue injuries or secondary instability, with limited outcomes and significant reoperation rates. With the development and improvement of surgical tools, various minimally invasive spine surgery (MISS) methods, including indirect decompression techniques of interspinous process devices (IPDs) and direct decompression techniques such as microscopic spine surgery or endoscopic spine surgery (ESS), have been updated with enhancement. IPDs, such as Superion devices, were reported to behave with comparable physical function, disability, and symptoms outcomes to laminectomy decompression. As an emerging technique of MISS, ESS has beneficial hallmarks including minimal tissue injuries, reduced complication rates, and shortened recovery periods, thus gaining popularity in recent years. ESS can be classified in terms of endoscopic hallmarks and approaches. Predictably, with the continuous development and gradual maturity, MISS is expected to replace traditional open surgery widely in the surgical treatment of LSS associated with DS in the future.

Complex Regional Pain Syndrome: A Comprehensive Review

Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.

A Comprehensive Update of the Treatment and Management of Bertolotti's Syndrome: A Best Practices Review

Bertolotti's Syndrome is defined as chronic back pain caused by transitional lumbosacral vertebra. The transitional vertebra may present with numerous clinical manifestations leading to a myriad of associated pain types. The most common is pain in the sacroiliac joint, groin, and hip region and may or may not be associated with radiculopathy. Diagnosis is made through a combination of clinical presentations and imaging studies and falls into one of four types. The incidence of transitional vertebra has a reported incidence between 4 and 36%; however, Bertolotti's Syndrome is only diagnosed when the cause of pain is attributed to this transitional anatomy. Therefore, the actual incidence is difficult to determine. Initial management with conservative treatment includes medical management and physical therapy. Injection therapy has been established as an effective second line. Epidural steroid injection at the level of the transitional articulation is effective, with either local anesthetics alone or in combination with steroids. Surgery carries higher risks and is reserved for patients failing previous lines of treatment. Options include surgical removal of the transitional segment, decompression of stenosed foramina, and spinal fusion. Recent evidence suggests that radiofrequency ablation (RFA) around the transitional segment may also provide relief. This manuscript is a comprehensive review of the literature related to Bertolotti's Syndrome. It describes the background, including epidemiology, pathophysiology, and etiology of the Syndrome, and presents the best evidence available regarding management options. Bertolotti's Syndrome is considered an uncommon cause of chronic back pain, though the actual incidence is unclear. Most evidence supporting these therapies is of lower-level evidence with small cohorts, and more extensive studies are required to provide strong evidence supporting best practices.

Diagnostic and therapeutic pathway for pain in a Continuing Care setting: a survey at an Italian Continuing Care Service

Background

Law no. 38 of 15 March 2010 ensures and governs the access to the palliative care and pain management network for patients who require it. The professional roles involved in the project have been identified by the law, with the specific experience and expertise in the field of palliative care and pain management, by allocating a meaningful role to general practitioners (GPs). For this reason, an important direct training plan has been drawn up that GPs can count on for dedicated refresher courses to increase and deepen their knowledge in this specific clinical field. If the role of the GPs in the pain management and palliative care network was well-defined by the law, we cannot say the same for the Continuing Care Physician (CCP), a role that only partially overlaps that of the GP. The study observed the response of a Continuing Care Service (CCS) to the demand for services from patients with pain-related problems. The role of the CCP is, therefore, outlined in the pain therapy care network by observing the services provided to patients experiencing pain that is understood as being a non-deferrable problem.

Methods

A survey was conducted at the CCSs site in Aquila, AS-01 Abruzzo. For this reason, the attending physician records the data of patients who consult the CCSs for pain-related problems on an appropriate questionnaire. The survey period covered a total of 68 days (1 January - 8 March 2020). Results. One hundred sixty five sheets were completed; females were more represented than males (57.6% v 42.4%) and the 36-65 age group appears most greatly represented (47.9%). One of the most frequent reasons for consulting the service is "musculoskeletal pain" (58.2%), followed by abdominal pain (15.8%). In the majority of patients, pain lasted from days (53.9%), with an average of approximately 3 days (3.1± 2.9), or hours in 40% of cases, with an average of over 6 hours (6.54±3.1). 88.5% of patients defined the level of pain experienced as "severe" (NRS=7-10), and the intensity of the pain associated with its repetitiveness (80.3% vs 92.6%) as "severe", with a statistically significant difference in relation to nonrepetitiveness cases (p=0.02). 66.1% of patients said that they had taken analgesics independently, with nonsteroidal anti-inflammatory drugs (NSAIDs) the most frequently taken (53.5%). Patients who turned to the CCS received a pharmacological prescription in almost all cases. NSAIDs, specifically, were the most prescribed medicines (64.8%), followed by muscle relaxants (29.7%). Tramadol was the most represented among opioids, which was prescribed in 7.9% of cases. Just 6.1% of patients were entered into the regional pain management network.

Conclusions

The results of the survey show that a large number of patients turn to the CCS to resolve painful symptoms of various natures. The study offers some food for thought concerning the role of CCPs and the importance of providing for their inclusion in the pain therapy clinical and training pathways provided for by Law 38/2010. This would ensure its more effective implementation and, therefore, better care for patients experiencing painful pathologies.

Public opinion on vaccines: the role of the scientific community in Italy

Background

After rising for years, vaccination rates in Italy fell until 2015 because of unfounded safety concerns, abetted by some government and court actions. Public education and a 2017 law on mandatory vaccination have boosted rates since then. So far only a few papers have examined the correlation between beliefs and attitudes towards vaccines and the level of trust in the scientific community regarding vaccinations in the general population.

Methods

Data were extracted from the Italian section of the last two editions of the European Social Survey (ESS), the first carried out between September and November 2017, the latter between December 2018 and March 2019. A descriptive analysis was conducted using survey data. In the two editions respectively 2,626 and 2,745 persons were interviewed. The main outcomes assessed was comparing the two surveys, so as to highlight the key changes in public opinion on vaccines.

Results

In the 2017 edition, 19% of the respondents believed in the harmfulness of vaccines, out of them 29% did not even have trust in the scientific community while those confident in the safety of vaccines were 50%. In the 2019 survey, the proportion of those who believed vaccines to be harmful fell to 15%, the undecided rose to 15%, those opposed to the idea that vaccines are harmful became 63%, not responding people were 8%. Correspondingly, trust in the scientific community about vaccines has increased from 57% in the first survey to 70% in the last one.

Conclusions

The scientific community and research bodies in the last years, in support of the Ministry of Health, have made a huge effort in the public debate on vaccines. This might play a role in increasing the public confidence in the safety of vaccines and the adherence to vaccination campaigns, changing the climate with regard to vaccination in general.

Key messages

Italians changed their opinions on vaccines between two ESS surveys. The scientific community had a relevant role in the public debate on vaccines.

Italian health workers’ knowledge, attitudes and behaviours towards COVID-19 vaccination

Background

Vaccine hesitancy is the reluctance or refusal to be vaccinated. While it has been widely studied for various contagious diseases, there is still a lack of knowledge about this phenomenon for COVID-19, especially if health workers' hesitancy is considered.

Methods

An extensive review of the literature was conducted to identify the main determinants of vaccine hesitancy in health workers, as well as to find already validated surveys to evaluate the knowledge, attitudes and behaviors (KAB) of health workers towards vaccination, both in general and with specific regard to COVID-19. Building on the available information, a new survey was developed to assess the KAB of Italian health care workers towards COVID-19 vaccination after validation with a pilot study in a diverse sample of 30 Italian health workers.

Results

A new survey was validated to assess the KAB of health workers towards COVID-19 vaccination in Italian health workers. The survey requires about 6 minutes to complete and is composed of 30 questions, investigating different domains: socio-demographic and professional characteristics (6); health status (2); attitudes (11); behaviors (6); knowledge (4). The survey will be administered to a representative sample of at least 385 Italian health workers through the web platform SurveyMonkey in the period June-September 2021. Preliminary results will be available by the end of October 2021.

Conclusions

By analyzing KAB towards COVID-19 vaccination with a new tool, the magnitude and determinants of health worker's COVID-19 vaccine hesitancy will be evaluated to understand how to improve health workers' perception towards COVID-19 vaccination and, consequently, foster their positive influence on the general population.

Key messages

We explore the knowledge, attitudes and behaviors towards COVID-19 vaccination in all categories of health workers operating on the Italian territory to understand the reasons of vaccine hesitancy.

Understanding the determinants of COVID-19 vaccine hesitancy in Italian health workers is necessary given their influence on the perception of the general population in Italy.

What Your Death Certificate Says About You May Be Wrong: A Narrative Review on CDC's Efforts to Quantify Prescription Opioid Overdose Deaths

Mortality data in most countries are reported using the International Classification of Diseases (ICD), managed by the WHO. In this paper, we show how the ICD is ill-suited for classifying drug-involved deaths, many of which involve polysubstance abuse and/or illicitly manufactured fentanyl (IMF). Opioids identified in death certificates are categorized according to six ICD T-codes: opium (T40.0), heroin (T40.1), methadone (T40.3), other synthetic narcotics (T40.4), and other and unspecified narcotics (T40.6). Except for opium, heroin, and methadone, all other opioids except those that are unspecified are aggregated in two T-codes (T40.2 and T40.4), depending upon whether they are natural/semisynthetic or synthetic opioids other than methadone. The result is a system that obscures the actual cause of most drug overdose deaths and, instead, just tallies the number of times each drug is mentioned in an overdose situation. We examined the CDC's methodology for coding other controlled substances according to the ICD and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances. Moreover, we discovered that the CDC codes all methadone-related deaths as resulting from the prescribed form of the drug. These and other anomalies in the CDC's mortality reporting are discussed in this report. We conclude that the CDC was at fault for failing to correct the miscoding of IMF. Finally, we briefly discuss some of the public policy consequences of this error, the misguided focus by public health and safety officials on pharmaceutical opioids, their prescribers and users, and the pressing necessity for the CDC to reassess how it measures and reports drug-involved mortality.