BACKGROUND AND AIMS:Acute kidney injury (AKI) is a key contributor to multiorgan dysfunction and mortality in ruptured abdominal aortic aneurysm (rAAA). Intra-abdominal hypertension and abdominal compartment syndrome (ACS), complications potentially resulting in AKI, can be prevented or managed with open abdomen treatment (OAT). Using consensus-based definitions, this study characterizes AKI in rAAA patients managed with OAT and examines the impact of abdominal wall closure on renal function. METHODS:A single-center observational cohort study including all consecutive patients treated with OAT after open surgical repair for rAAA from September 2009 to January 2024. AKI was diagnosed and staged based on urine output (UO) and S-creatinine (SCr) as defined by the KDIGO classification, reassessed at closure of the abdomen and at discharge. RESULTS:Seventy-three patients (mean age 73 years, 85% male) received OAT, prophylactically in 63 (85%) and due to ACS in 11 (15%). AKI occurred in 71 patients (97%) at a median of 2 (IQR, 2-3) days of admittance; 22 patients (30%) had stage 3 AKI, including 13 (18%) needing renal replacement therapy. The multivariable logistic regression showed SCr at admittance (p = .034) and perioperative diuresis (p = .018) as predictors of stage 3 AKI. The UO criterion diagnosed more patients than SCr alone (p = .001). Abdominal closure did not aggravate kidney function. In AKI stage 3, 90-day survival was 46% versus 80% in AKI stage 1 and 2 (p = .008). Forty-seven out of 51 survivors (92%) had resolution of their AKI before discharge. CONCLUSIONS:Defined by KDIGO, AKI developed in 71/73 (97%) of rAAA patients with OAT after surgical repair. UO was the most sensitive parameter. AKI was diagnosed at median 2 days of admittance and was transient in majority of survivors. There was no aggravation of kidney function at delayed primary abdominal closure.

BACKGROUND:Acute kidney injury (AKI) is frequent and influences the prognosis of intensive care unit (ICU) patients. AKI may be categorised as contrast-associated AKI (CA-AKI). We investigated the development of CA-AKI, including temporal and dose-response relationships. METHODS:Adult patients admitted between 2010 and 2015 with a minimum ICU stay of 54 h were eligible for inclusion. AKI was scored on an hourly basis to enable temporal analyses. CA-AKI was defined as an increase in Kidney Disease: Improving Global Outcomes (KDIGO) AKI stage occurring within 48 h of contrast media administration. For the matched analysis, contrast-exposed patients were matched to unexposed patients on duration of stay and renal function. RESULTS:Of 1057 patients, 277 patients were exposed to contrast media. Sixteen percent (n = 43) developed CA-AKI (KDIGO AKI stage 1/2/3: 63%/23%/14%). AKI preceded contrast in 76.2% of cases (95% confidence interval [CI]: 66%-85%, p < 0.001). After contrast exposure, AKI reversal occurred in 65 cases. The proportion of CA-AKI was similar between dose quartiles (p = 0.746). The length of ICU stay (length of stay [LOS]) was longer in the exposed group (10.9 vs. 5.5 days, p < 0.001) regardless of CA-AKI status. In the matched analysis, exposed patients had longer remaining LOS (mean difference 1.47 days, 95% CI: 1.35-1.60) and higher ICU mortality (OR: 1.67, 95% CI: 1.1-2.6), but use of renal replacement therapy (RRT) was similar. CONCLUSIONS:CA-AKI was observed in one of six ICU patients exposed to contrast media and associated with higher mortality and ICU LOS. However, AKI most often precedes contrast. AKI reversal was more common than AKI following exposure. No clear evidence of a dose-response relationship was found. The findings question whether AKI in an ICU population is related to contrast media exposure, but the observational design precludes ruling out contrast media as a cause of AKI. EDITORIAL COMMENT:This ICU cohort analysis presents kidney injury findings where there is intravenous contrast exposure. Where some kidney injury was sometimes present before contrast exposure, this makes exploring the relation of contrast to injury and recovery more complex.

BACKGROUND:Accurate estimation of prognosis and life expectancy is essential in patients with advanced cancer, as it guides clinical decision-making and helps avoid unnecessary interventions while facilitating timely integration of palliative and supportive care. Palliative radiotherapy plays a key role within multidisciplinary management, offering effective and well-tolerated symptom relief for complications such as pain, bleeding, and obstruction, with treatment strategies closely tailored to expected survival. Although recent advances in machine learning have improved prognostic accuracy by modeling complex variable interactions, their application in palliative care settings remains limited. PURPOSE:To aid clinical decision-making, we developed a decision tree multi-classifier to predict the mortality at 3, 24, and 52 weeks following palliative radiotherapy for bone metastases. METHODS:Data from 573 adults diagnosed with metastatic cancer were analyzed. The primary endpoint was the overall survival (OS) defined as the number of months from treatment to death event. Four clinically relevant classes were defined: Class 0 (OS: ≤ 3 weeks), Class 1 (OS: 3-24 weeks), Class 2 (OS: 24-52 weeks) and Class 3 (OS ≥ 52 weeks). Candidate covariate predictors consisted of 65 clinical, dosimetric and laboratory variables. Two supervised decision tree machine-learning models were trained and validated using the Python package. A SHapley Additive exPlanations (SHAP) explanaibility analysis was performed to infer the global and local feature importance. RESULTS:The SHAP analysis selected three laboratory variables, the interleukin8, haemoglobin and lymphocytes count as the first three ranked variables representing the major impact on OS in each of the four classes and accounting for more than 80% of contribution. In all classes, higher chance of OS was associated with low values of interleukin8 (IL8) and higher values of haemoglobin (HEM) and lymphocytes count (LYMPH). Pre-treatment values of IL8 > 36.7 relocated more than 50% of patients with survival < 3 weeks and only 1.5% of patient with survival > 52 weeks. On the other hand, pre-treatment values of IL8 < 19 relocated about 92% of patients with survival > 52 weeks. Patients are then additionally separated based on the lymphocytes count (LYMPH). LYMPH values higher than 7.5 will drive the probability of survival > 52 weeks still over 90% while it drops down to 2.1% for LYMPH < 7.5. CONCLUSION:An explainable machine learning approach based on decision trees is able to predict the survival at different timing after radiotherapy in patients with advanced cancer. This approach provides an intelligible explanation of individualized risk prediction, helping clinicians to identify the best strategy for patient stratification and treatment selection.

BACKGROUND:Intensive care physicians often provide end-of-life (EOL) care in the intensive care units (ICUs). However, knowledge about the physicians' role and confidence in EOL care after the decision to withdraw life-sustaining therapy is unknown. This study aimed to explore the confidence and the self-perceived role of specialized ICU physicians in performing EOL care. MATERIALS AND METHODS:Following criteria-based sampling, a questionnaire was sent to ICU physicians in Iceland, Sweden, Norway, Finland, and Denmark. Questions included: (1) Background information and existing guidelines, (2) Physicians' confidence in EOL care in ICUs, and (3) Self-perceived role in EOL care. The questionnaire collected both quantitative and qualitative data, which were subsequently analyzed separately. RESULTS:A total of 178 ICU physicians answered the questionnaire. Most physicians (66%) felt very confident performing EOL care. Responses to the open-ended qualitative questions emphasized that ICU physicians regarded EO care as a central professional responsibility, marked by personal presence, active support for patients and families, and attention to individual needs. They reported the value of transparent communication, thorough preparation for treatment withdrawal, and accommodation of personal, cultural, and religious preferences. Participants highlighted the importance of individualized transfer decisions while also emphasizing the need for adaptable EOL guidelines and enhanced training, particularly for residents. CONCLUSIONS:Our study showed that Scandinavian ICU physicians felt very confident in performing EOL care and recognized their unique role and responsibility in delivering ICU EOL care. EDITORIAL COMMENT:This study surveyed ICU physicians in Nordic countries concerning perceptions and confidence for end care in their ICU clinical practice. The responses indicated that the survey responders were quite confident in how they manage this group of cases in the ICU.

Background: Undernutrition and cachexia are common in advanced cancer and often linked to systemic inflammation. While inflammation is associated with poorer prognosis, accelerated weight loss, and reduced treatment tolerance, its direct impact on food intake remains insufficiently investigated. Aim: To examine the association between systemic inflammation and energy and protein intake over time in patients with advanced cancer. Methods: A total of 170 patients from the Palliative Radiotherapy and Inflammation Study were included. Nutritional status was assessed using PG-SGA SF. Dietary intake was recorded using repeated 24 h recalls. Systemic inflammation was defined as CRP > 10 mg/L. Mixed linear models were applied to evaluate the association between inflammation energy and protein intake over time. Results: Systemic inflammation (CRP >10 mg/L) was present in 87 (51%) patients and associated with significantly lower energy (-3.6 kcal/kg, p = 0.04) and lower protein intake (-0.25 g/kg, p = 0.003). Patients with inflammation were more often undernourished and had shorter survival. Conclusions: Systemic inflammation is likely associated with clinically relevant reductions in energy and protein intake in advanced cancer. CRP may help identify patients for whom standard nutritional support is insufficient.

BACKGROUND:The EuroQol EQ-5D-5L is recommended to assess health-related quality of life (HRQoL) in intensive care unit (ICU) survivors and included in many national ICU registries at the time of follow-up. While establishing baseline HRQoL in elderly ICU survivors is important for informing follow-up services, it is rarely performed in clinical practice. We aimed to compare pre-critical illness EQ-5D-5L scores with Norwegian general population norms in elderly adults. METHODS:We conducted a prospective multicenter observational study across five ICUs to assess pre-critical illness HRQoL in mechanically ventilated patients ≥ 65 years old using EQ-5D-5L. Data assessing HRQoL before critical illness were collected during the ICU stay, obtained primarily from proxies or via patient self-report where feasible. Response frequencies for the EQ-5D-5L dimensions, EQ-5D-5L index, and EQ VAS scores were compared with those for general population norms after random exact matching for age and sex. The five dimensions were dichotomized into the presence of health problems or not. RESULTS:Based on responses from 345 participants, the ICU population had a baseline mean EQ-5D-5L index of 0.78 (±0.24), an EQ VAS of 61 (±23), and 60 ICU patients reported no problems in any of the five domains. The norm population had a mean EQ-5D-5L index of 0.88 (±0.17), an EQ VAS of 79 (±20), and 107 had no problems in any of the five dimensions. Pearson chi-square or two-tailed t-tests showed significantly (p < 0.05) poorer scores for all EQ-5D-5L scores for the ICU population compared to the norm data. The greatest differences were found in the younger age group 65-72 years. Comorbidity was a strong independent predictor of baseline health status, whereas chronological age showed no significant association. CONCLUSION:Compared to the age- and sex-matched general population, the elderly ICU population had poorer HRQoL before critical illness occurred. To improve the interpretation of post-ICU assessments, baseline EQ-5D-5L should be assessed at ICU admission. The results highlight the need for studies in ICU patients that include HRQoL as part of a prospective study design. EDITORIAL COMMENT:This study presents pre-ICU quality of life scoring for older cases requiring mechanical ventilation. Compared to a matched non-ICU cohort, significant lower reported quality of life scoring was observed.

BACKGROUND:Opioids in step III of the WHO analgesic ladder are the standard of care for treating cancer pain. However, a significant minority of patients do not benefit from therapy. Genetics might play a role in predisposing patients to a good or poor response to opioids. Here, we investigated this issue by conducting a genome-wide association study (GWAS). METHODS:We genotyped 2057 European advanced cancer patients treated with morphine, buprenorphine, fentanyl and oxycodone. We carried out a whole-genome regression model (using REGENIE software) between genotypes and the opioid response phenotype, defined as a numerical score measuring patient pain intensity. RESULTS:The GWAS identified five non-coding variants on chromosome 20 with a p-value <5.0 × 10-8. For all of them, the minor allele was associated with lower pain intensity. These variants were intronic to the PCMTD2 gene and were 200 kbp downstream of OPRL1, the opioid related nociceptin receptor 1. Notably according to the eQTLGen database, these variants act as expression quantitative trait loci, modulating the expression mainly of PCMTD2 but also of OPRL1. Variants in the same chromosomal region were recently reported to be significantly associated with pain intensity in a GWAS conducted in subjects with different chronic pain conditions. CONCLUSIONS:Our results support the role of genetics in the opioid response in advanced cancer patients. Further functional analyses are needed to understand the biological mechanism underlying the observed association and lead to the development of individualized pain treatment plans, ultimately improving the quality of life for cancer patients. SIGNIFICANCE STATEMENT:This genome-wide association study on European advanced cancer patients treated with opioids identifies novel regulatory variants on chromosome 20 (near PCMTD2 and OPRL1 genes) associated with pain intensity. These findings enhance our understanding of the genetic basis of opioid response, suggesting new potential markers for opioid efficacy. The study is a significant advancement in pharmacogenomics, providing a robust dataset and new insights into the genetic factors influencing pain intensity, which could lead to personalized cancer pain management.

Differences in in-hospital pain and consumption of opioids after primary total hip arthroplasty (THA) and knee arthroplasty (TKA) have been rarely studied in a setting where the patient course is otherwise similar. The aim of this study was to compare early pain intensity and opioid usage between patients who have undergone THA and TKA to identify potential implications for outpatient surgery. This institutional register study included 4655 patients receiving THA and 2675 patients receiving TKA. Pain at rest and during mobilization were collected once preoperatively, and postoperatively at five time-points, twice on the Day of surgery, once each on day 1 and day 2 after surgery, and at discharge, on a numeric rating scale (NRS) 0–10. Rescue opioids in oral morphine-equivalent doses (MME) were consecutively registered. Postoperative mobilization was registered twice daily. Overall mean pain were 2.0 (Cl 2.0–2.0) after THA and 2.3 (Cl 2.3–2.4) after TKA at rest, and 3.3 (Cl 3.3–3.3) and 3.7 (Cl 3.7–3.8) during mobilization, respectively. Patients undergoing TKA had a transient increase in pain intensity the day after surgery, whereas patients undergoing THA had improved pain levels. Outpatient criteria for pain (NRS < 5 during mobilization) were feasible for 37

BACKGROUND:End-of-life care in the Intensive Care Unit (ICU) is complex, requiring a balance of ethical, cultural and medical considerations while ensuring comfort and dignity for critically ill patients and their families. AIM:We aimed to develop a set of core domains for end-of-life care at Scandinavian ICUs along with corresponding consensus statements from patients, families and multidisciplinary experts. METHODS:In a three-round Delphi study, a multidisciplinary advisory board from Norway, Sweden, Finland, Iceland and Denmark, including ICU physicians, ICU nurses, palliative care specialists and a former ICU patient and family, developed potential end-of-life care domains of interest. Specialists with special competence/interest in end-of-life care and clinicians in all five countries were invited to rank these domains according to their importance and provide recommendations within each domain. The advisory board rephrased the recommendations into statements, which were sent out in the second round for participants to rate based on their level of agreement. Statements that did not achieve consensus in the second round were rephrased and redistributed in the third round. RESULTS:After the third Delphi round, 59 statements across 10 domains reached consensus. The domains were: 1. Communication at ICU admission, 2. Withholding and withdrawal of therapy and end-of-life care decisions in the ICU, 3. Meeting religious and spiritual needs and the needs of vulnerable patients in the ICU, 4. Extubation and termination of mechanical ventilation at the end of life in the ICU, 5. Management and monitoring of symptoms at the end of life in the ICU, 6. Continuous sedation at the end of life in the ICU, 7. Indicators for specialist palliative care consultations in the ICU, 8. Patient transfers from the ICU at the end of life, 9. Bereavement care and 10. Debriefing in the ICU following a patient's death. DISCUSSION:We developed core domains and consensus statements aiming at optimising end-of-life care that considers cultural and ethical nuances. The domains may help to shape end-of-life care guidelines in Scandinavian ICUs.

Background: Pain has detrimental consequences for individuals and is frequently reported in heart failure (HF). However, there is a lack of population studies investigating pain in HF. Objective: In this study, our aim was to investigate the prevalence and intensity of pain, including chronic musculoskeletalpain (CMSP), in individuals with HF compared with the general population, and to determine whether patients with HF had different levels of pain than people in the general population. Methods: In this cross-sectional population study we used data from the fourth wave of the Trøndelag Health Study in Norway (2017–2019), which included 56,041 individuals, of whom 1124 had HF. The HF diagnosis was ascertained by physicians. Outcomes in this study were overall pain, overall pain intensity, CMSP, and CMSP location. Prevalence of overall pain and overall pain intensity were assessed by an item in the Medical Outcomes Study Short Form health survey (SF-36), while prevalence and location of CMSP were evaluated by one item in the Standardised Nordic Questionnaire. We investigated whether individuals with HF reported more pain than individuals without HF, adjusted for potential confounders. Finally, we compared CMSP location among individuals with or without HF. Results: Heart failure was associated with a high prevalence of overall pain (50.5%) and CMSP (62.1%). Pain intensity (range: 0–5) was higher among individuals with HF compared with controls (2.1 vs. 1.8, P ≤ .001). Chronic musculoskeletal pain locations were similar across groups. When adjusted for age, sex, comorbidities, body mass index, level of education, living status, and smoking, the association between HF and pain was not evident. Conclusions: In this large population study, we found a high prevalence of overall pain and CMSP, and higher pain intensity in individuals with HF. The results suggest that healthcare personnel should incorporate pain assessment and tailored pain therapy during follow-up care of individuals with HF.

INTRODUCTION:Drug-drug interactions (DDIs) are among factors that may affect the efficacy and safety of opioid treatment. Data on clinically manifested DDIs are scarse, and recommendations that might guide physicians are presently lacking. The aim of this study was to update a systematic review (2015) on studies reporting clinically significant DDIs involving opioids used for pain treatment in adult patients with cancer. METHODS:Systematic literature searches in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from the start of the databases through 18 September 2023. RESULTS:Of the 1968 retrieved papers, 16 were included in the final analysis, together with five papers identified through hand-searching of reference lists. Nineteen publications were case reports or case series. Nine, sixteen, and eight patients presented adverse effects from opioids, impaired pain control, or opioid withdrawal, respectively. The main mechanisms underlying DDIs were alteration of cytochrome P450 3A4 activity and pharmacodynamic antagonism resulting from concurrent use of an opioid analgesic and a peripheral mu-opioid receptor antagonist (PAMORA). CONCLUSION:Knowledge about clinically significant DDIs associated with opioids in cancer patients is currently mostly based upon case reports. These cases give information about drug combinations that should be recognized as potentially harmful by physicians prescribing opioids. PROSPERO ID:CRD42023481103.

BACKGROUND:Physiological criteria are used to assess the potential severity of injury in the early phase of a trauma patient's care trajectory. Few studies have described the extent of abnormality in vital signs and different combinations of these at a national level. Aim of the study was to identify physiologic abnormalities in trauma patients and describe different combinations of abnormalities and changes between the pre-hospital and emergency department (ED) settings. METHOD:Norwegian Trauma Registry (NTR) data between 01.01.15 - 31.12.18, where evaluated on the prevalence and characteristics of abnormal physiologic variables. Primary outcome were rates of hypoventilation (respiratory rate [RR] < 10 breaths per min), hyperventilation (RR > 29 breaths per min), hypotension (systolic blood pressure [SBP] < 90 mmHg), and reduced level of consciousness (Glasgow Coma Scale [GCS] < 13). RESULTS:A total of 24,482 patients were included. Documented values for RR, SBP and GCS were 77.6%, 78.5% and 81.9% in the pre-hospital phase, and the corresponding percentages in the ED were 95.5%, 99.2% and 98.6%, respectively. In the pre-hospital phase, 3,615 (14.8%) patients had at least one abnormal vital sign, whereas the corresponding numbers in the ED, were 3,616 (14.8%) patients. The most frequent combination was low GCS and hyperventilation. A worsened RTS-score from pre-hospital phase to the ED was observed for RR, SBP and GCS in 3.9%, 1.2% and 1.9% of incidents, respectively. Overall 30-day mortality was 3.1% (n=752). Of these, 60.8% had abnormal vital signs, with decreased GCS as the most prevalent (61.3%). CONCLUSION:Most trauma patients had normal vital signs. According to the RTS-score, there were few deteriorations in RR, SBP and GCS between pre-hospital phase and the ED. The most frequent abnormality was low GCS, with a higher proportion in those who died within 30 days.

Background:Systemic inflammation is crucial in cancer cachexia, but the optimal measurement method remains unclear. This study compares markers of systemic inflammation (MoSI) in predicting weight loss in patients with metastatic cancer. Methods:This prospective, observational multi-center study involved patients undergoing radiotherapy for bone metastases. Baseline assessments included demographics, clinical characteristics, previous weight loss, and appetite loss. MoSI included: C-reactive protein (CRP), albumin, white blood cells, neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, interleukin-6 (IL-6), modified Glasgow Prognostic Score (mGPS), and Prognostic Nutritional Index. Body weight was recorded at baseline, 3, and 8 weeks post-radiotherapy. Multiple linear regression assessed MoSI's predictive ability for weight loss, adjusting for previous weight loss, appetite loss, and primary tumour type. Goodness-of-fit was assessed using adjusted R2. Results:Out of 574 recruited patients, 540 and 470 were analyzed at 3 and 8 weeks, respectively. The median age (IQR) was 67 (15), 330 (61%) were male, and 397 (74%) had a Karnofsky performance status ≥70. In a base model without MoSI, significant predictors of weight loss at 3 weeks were appetite loss and urological, lung, and gastrointestinal cancer (adjusted R2 of 0.064), while at 8 weeks, urological and lung cancer were significant (adjusted R2 of 0.035). At 3 weeks, all MoSI significantly improved the base model, with adjusted R2 between 0.078 and 0.091. At 8 weeks: CRP, mGPS, albumin and IL-6 improved the model; however only CRP and mGPS retained an adjusted R2 of ~0.09. Conclusions:All MoSI predicted weight loss, but CRP and mGPS were the most optimal.

Opioids are the mainstay therapy for patients affected by moderate to severe cancer pain, yet in about 10–20% of the cases, patients do not benefit from the received analgesic treatment or experience side effects. Genetic variability might account for the variation in individual responses to opioids, both in terms of efficacy and toxicity. The aim of this genome-wide association study (GWAS) was to identify new genetic markers of opioid toxicity in terms of nausea-vomiting. Cancer patients receiving morphine, oxycodone, buprenorphine, and fentanyl were recruited from different European cancer centers. Data about toxicity (nausea-vomiting score, NVS) and other relevant clinical information were collected. DNA samples were genotyped using Axiom Precision Medicine Research Arrays. Linear regression between genotypes of 2,059 patients and NVS was performed, using the REGENIE pipeline. Sex, age, study, and country were included in the model as covariates. We found 68 variants associated with NVS (P-value < 1.0 x 10− 6). Of note, 15 intronic variants on chromosome 2 were located in the NPAS2 gene, encoding a circadian transcription factor reported to play a role in another opioid side effect, the alteration of sleep. Some of these variants were previously identified as splicing quantitative trait loci of the NPAS2 gene. This is the first GWAS, performed in more than two thousand individually genotyped patients treated with opioids for cancer pain, that investigated the genetic bases of opioid-induced nausea-vomiting. Although further studies are needed to confirm our findings and to characterize the functional role of the identified variants, our results emphasize the importance of performing large pharmacogenomic studies to identify germline variants associated with opioid response, with the ultimate goals of improving personalization of cancer pain therapies.

Background: Bone metastases (BMs) are a common complication in patients with cancer, often leading to significant pain that adversely affects quality of life, necessitating effective pain management strategies. This study aims to evaluate the effectiveness of pain management in patients with BMs undergoing palliative radiotherapy and to identify determinants of pain management adequacy. Methods: We conducted an observational analysis of 560 patients from the Palliative Radiotherapy and Inflammation Study (PRAIS) trial across several European centers, focusing on the Pain Management Index (PMI) for assessing pain management adequacy. Key predictors examined included Karnofsky Performance Status (KPS), treatment setting, primary tumor type, and site of BMs. Results: Our findings indicate that 19.0% of patients experienced inadequate pain management (PMI < 0). Specifically, patients with KPS ⩾ 90 had a notably lower rate of adequate analgesic therapy (59.3%) compared with those with a KPS < 90 (85.0%). Among outpatients, 23.7% reported inadequate pain management, contrasted with a significantly lower inadequacy rate (3.8%) in palliative care or hospice settings. In addition, in outpatients, pain management adequacy varied with the primary tumor type, showing improved outcomes for patients with lung cancer (89.2%) versus other primary tumors (79.1%). Moreover, in non-outpatients, pain management was less effective for patients receiving radiotherapy on pelvic BMs (89.5%) compared with other sites (95.7%). Conclusion: Although overall rates of inadequate pain management were lower than seen in previous studies, significant variability exists based on patient health status, care setting, primary tumor type, and site of BMs. These results underscore the need for personalized pain management approaches and highlight specific areas for improvement in outpatient settings and among patients with generally good health but significant pain from BMs.