Fine vita e decisioni etiche nelle emergenze anestesiologiche intraospedaliere.

Biomedical and biotechnological progress nowadays allowed doctors to prolong life through new and best therapies for many, once deathly, illnesses, and through new machine which can maintain vital functions in an artificial way; the therapeutic limit is always moved forward. Anesthesiologist usually manage emergency and urgencies in all hospitals\u2019 ward where the patients, especially during night and festive shift, can\u2019t always refer to their daily practitioner, who is not present in those context. If a CPR is necessary without the presence of the daily practitioner, bioethical problems, most of all due to the lack of medical deliveries regarding end of life decisions and clinical problems, grow exponentially. These conditions often lead to a wrong management with a start or a prosecution of treatments even when there shouldn\u2019t have been a proper indication; with a good communication and time to study the case, no one would have probably started CPR in many of those patients. Our goal was the evaluation of the management of these special cases, in a bioethical field, by visualizing retrospectively one year of intrahospital emergencies with an anaesthesiologist call, looking for basal datas regarding number and typology of emergencies and what is normally reported in medical records, then following results of these patients. Surely we can conclude that, if we want an improvement regarding ethical approach to CPR to patients with clinical history unknown by anesthesiologist, there should be a more codified decisional flowchart or medical delivery system in order to write and tell clearly ethical and clinical consideration

Fine vita e decisioni etiche nelle emergenze anestesiologiche intraospedaliere.

Biomedical and biotechnological progress nowadays allowed doctors to prolong life through new and best therapies for many, once deathly, illnesses, and through new machine which can maintain vital functions in an artificial way; the therapeutic limit is always moved forward. Anesthesiologist usually manage emergency and urgencies in all hospitals’ ward where the patients, especially during night and festive shift, can’t always refer to their daily practitioner, who is not present in those context. If a CPR is necessary without the presence of the daily practitioner, bioethical problems, most of all due to the lack of medical deliveries regarding end of life decisions and clinical problems, grow exponentially. These conditions often lead to a wrong management with a start or a prosecution of treatments even when there shouldn’t have been a proper indication; with a good communication and time to study the case, no one would have probably started CPR in many of those patients. Our goal was the evaluation of the management of these special cases, in a bioethical field, by visualizing retrospectively one year of intrahospital emergencies with an anaesthesiologist call, looking for basal datas regarding number and typology of emergencies and what is normally reported in medical records, then following results of these patients. Surely we can conclude that, if we want an improvement regarding ethical approach to CPR to patients with clinical history unknown by anesthesiologist, there should be a more codified decisional flowchart or medical delivery system in order to write and tell clearly ethical and clinical consideration

Biphenotypic sinonasal sarcoma: European multicentre case-series and systematic literature review [Sarcoma bifenotipico nasosinusale: case-series europeo multicentrico e revisione sistematica della letteratura]

Obiettivo: Il sarcoma nasosinusale bifenotipico (SNSB) è un raro tumore a basso grado, incluso a partire dalla 4° edizione WHO dei tumori testa-collo. L’obiettivo di questo studio è analizzare i tassi di sopravvivenza e i pattern di recidiva di questa neoplasia. Metodi: Revisione retrospettiva dei pazienti affetti da SNSB, trattati mediante approccio endoscopico in 6 centri di riferimento europei. È stata condotta inoltre una revisione sistematica della letteratura dal 2012 ad oggi, secondo le linee guida PRISMA. Risultati: . Sono stati inclusi 15 pazienti (approccio endoscopico endonasale in 7 casi, craniectomia endoscopica transnasale in 4 casi, approccio combinato transcranico in 4 casi). In 2 casi è stata somministrata radioterapia adiuvante. Dopo un periodo di follow-up medio di 27,3 mesi, è stato riscontrato un caso di metastasi a distanza; i tassi di 5-year Overall Survival e Disease-Free Survival erano 100% e 80 ± 17,9%, rispettivamente. Conclusioni: . Il SNSB è un tumore localmente aggressivo con un basso tasso di recidiva e tassi di sopravvivenza incoraggianti se trattato con asportazione chirurgica radicale con radioterapia adiuvante per casi selezionati. La chirurgia endoscopica ha dimostrato di essere sicura ed efficace come trattamento iniziale all’interno di un protocollo di cura multidisciplinare.Objective: Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade cancer that was included from the 4th edition of WHO classification of head and neck tumours. The purpose of this study is to analyse clinical behaviour, pattern of recurrences and survival outcomes of this neoplasm. Methods: Retrospective review of patients affected by BSNS who were treated via an endoscopic-assisted approach in 6 European tertiary-care referral hospitals. Cases of BSNS described in literature since 2012 to date were fully reviewed, according to PRISMA guidelines. Results: A total of 15 patients were included. Seven patients were treated via an endoscopic endonasal approach, 4 with endoscopic transnasal craniectomy, and 4 via a cranio-endoscopic approach. Adjuvant treatment was delivered in 2 cases. After a mean follow-up of 27.3 months, systemic metastasis was observed in 1 case; the 5-year overall survival and disease-free survival rates were 100% and 80 ± 17.9%, respectively. Conclusions: BSNS is a locally aggressive tumour with a low recurrence rate and encouraging survival outcomes if properly treated with surgical resection and free margins followed by adjuvant radiotherapy for selected cases. Endoscopic-assisted surgery is safe and effective as an upfront treatment within a multidisciplinary care protocol

Changes in chemical and biological soil properties as induced by anthropogenic disturbance: A case study of an agricultural soil under recurrent flooding by wastewaters.

Monitoring the environmental impact of anthropogenic disturbance on soil ecosystem is of great importance for optimizing strategies for soil use, conservation and remediation. The aim of this study was to assess whether and to what extent a long-term, human-induced disturbance could have affected main chemical and biological properties in an agricultural soil. The study site was a hazel (Corylus avellana L.) orchard located in the area surrounding the volcanic apparatus of Somma-Vesuvius (Southern Italy). For the last two decades, the site has been repeatedly subjected to floodings by wastewaters containing not only alluvial sediments but also potentially hazardous compounds from illegally disposed wastes. Soil disturbance was assessed by a multitechnique approach, which combined chemical, biochemical and physiological (Biologs) methods together with community fingerprinting by denaturing gradient gel electrophoresis (DGGE) and amplified ribosomal DNA restriction analysis (ARDRA). A hazel site never subjected to flooding provided the control soil. Soil sampling was repeated three times over a 1-year period. The effect of flooding by wastewaters, sampling time and their interaction were statistically evaluated. Under wastewater flooding, soil pH and most organic matter-related pools, i.e. total organic C, total N, and active soil C-resources such as basal (SBR) and substrate-induced respiration (SIR) and microbial biomass C (MBC) were all increased; whereas sampling time mostly affected two active-N pools, namely K2SO4-extractable N (Extr-N) and potentially mineralizable N that varied unconcurrently in tested soils. Also the electrical conductivity varied across samplings. Parameters related to microbial maintenance energy (ATP and qCO2) were higher in the flooded soil, even though they were not statistically affected by wastewater flooding or by sampling time. The Biologs method evidenced that under recurrent flooding, soil microbial populations became functionally more uniform when compared to the control soil. Molecular fingerprinting of PCR-amplified 16S rDNA targets revealed that, along with seasonal shifts, a marked change in the genetic structure of total bacterial community occurred in the flooded soil. Furthermore, compositional shifts in the actinomycete community were less marked and mostly influenced by seasonal effects. Yet, a decreased genetic diversity in the ammonia-oxidizing bacteria community was evidenced in the flooded soil by ARDRA. Thus both the genetic and the functional structure of native soil bacterial populations were changed under repeated flooding by wastewaters. Repeated sampling over a 1-year period allowed us to reveal soil disturbance effects beyond seasonal variations

Effect of preoperative inflammatory status and comorbidities on pain resolution and persistent postsurgical pain after inguinal hernia repair

Poor acute pain control and inflammation are important risk factors for Persistent Postsurgical Pain (PPSP). The aim of the study is to investigate, in the context of a prospective cohort of patients undergoing hernia repair, potential risk factors for PPSP. Data about BMI, anxious-depressive disorders, neutrophil-tolymphocyte ratio (NLR), proinflammatory medical comorbidities were collected. An analysis for correlation between comorbidities and PPSP was performed in those patients experiencing chronic pain at 3 months after surgery. Tramadol resulted less effective in pain at movement in patients with a proinflammatory status. Preoperative hypertension and NLR > 4 were correlated with PPSP intensity. Regional anesthesia was significantly protective on PPSP when associated with ketorolac. Patients with pain at 1 month were significantly more prone to develop PPSP at 3 months. NSAIDs or weak opioids are equally effective on acute pain and on PPSP development after IHR, but Ketorolac has better profile in patients with inflammatory background or undergoing regional anesthesia. Drug choice should be based on their potential side effects, patient's profile (comorbidities, preoperative inflammation, and hypertension), and type of anesthesia. Close monitoring is necessary to early detect pain conditions more prone to progress to a chronic syndrome

Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients

Abstract Spinal anesthesia is considered safe and reliable for most surgical procedures involving the lower part of the body, but its use in the ambulatory setting requires drugs with rapid onset and regression of the motor and sensory block-like prilocaine. The purpose of this study is to retrospectively analyze data from 3291 procedures recorded in our institutional database, to better define the safety profile of spinal prilocaine and the incidence of complications and side effects. All clinical data, prospectively collected from 2011 to 2019 in an Italian tertiary hospital, of patients treated with spinal anesthesia performed with 40 mg of hyperbaric 2% prilocaine, according to our internal protocol of day surgery, were analyzed. Surgical procedures included saphenectomy (28.5%, n = 937), knee arthroscopy (26.8%, n = 882), proctologic surgery (15.16%, n = 499), and inguinal canal surgery (14.9%, n = 491). Anesthesia-related complication was represented by urinary retention (1.09%, n = 36), lipotimia (0.75%, n = 25), and postoperative nausea (0.33%, n = 11); arrhythmic events were uncommon (0.18%, n = 6). One case of persistent hypotension and 2 cases of persistent hypertension were reported. Persistent motor or sensory block (lasting more than 5 h) was experienced by 7 patients. One patient (0.03%), who underwent knee arthroscopy, experienced pelvic pain lasting for 6 h, compatible with a transient neurological symptom. Proctologic surgery was a factor associated with unplanned admission due to anesthesia-related complications (OR = 4.9; 95% CI: 2–14%). The number of complications related to the method was low as well as the need for hospitalization. This drug is valid and safe for the most performed day surgery procedures; however, further trials are needed to investigate the incidence of complications in the days following the procedure

Effect of Preoperative Inflammatory Status and Comorbidities on Pain Resolution and Persistent Postsurgical Pain after Inguinal Hernia Repair

Poor acute pain control and inflammation are important risk factors for Persistent Postsurgical Pain (PPSP). The aim of the study is to investigate, in the context of a prospective cohort of patients undergoing hernia repair, potential risk factors for PPSP. Data about BMI, anxious-depressive disorders, neutrophil-tolymphocyte ratio (NLR), proinflammatory medical comorbidities were collected. An analysis for correlation between comorbidities and PPSP was performed in those patients experiencing chronic pain at 3 months after surgery. Tramadol resulted less effective in pain at movement in patients with a proinflammatory status. Preoperative hypertension and NLR > 4 were correlated with PPSP intensity. Regional anesthesia was significantly protective on PPSP when associated with ketorolac. Patients with pain at 1 month were significantly more prone to develop PPSP at 3 months. NSAIDs or weak opioids are equally effective on acute pain and on PPSP development after IHR, but Ketorolac has better profile in patients with inflammatory background or undergoing regional anesthesia. Drug choice should be based on their potential side effects, patient's profile (comorbidities, preoperative inflammation, and hypertension), and type of anesthesia. Close monitoring is necessary to early detect pain conditions more prone to progress to a chronic syndrome

Effect of postoperative analgesia on acute and persistent postherniotomy pain: a randomized study.

STUDY OBJECTIVE: The study objective is to identify differences in postoperative pain management according to different analgesic treatments, targeting 2 main pathways involved in pain perception. DESIGN: The design is a randomized, parallel groups, open-label study. SETTING: The setting is in an operating room, postoperative recovery area, and surgical ward. PATIENTS: There are 200 patients undergoing open inguinal hernia repair (IHR) with tension-free technique (mesh repair). INTERVENTIONS: The intervention is a randomization to receive ketorolac (group K) or tramadol (group T) for 3 days after surgery. MEASUREMENTS: The measurements are differences in analgesic efficacy (numeric rating scale [NRS]) in the postoperative (up to 5 days) period, chronic pain incidence (1 and 3 months), side effects, and complications. MAIN RESULTS: We found no differences in analgesic efficacy (NRS value ≥4 in the first 96 hours: 26% in group K vs 32% in group T, P = .43); the proportion of patients with NRS ≥4 was similar in both groups, and the time trajectories were not significantly different (P for interaction = .24). Side effects were higher (12% vs 6%) in the tramadol group, although not significantly (P = .14), with a case of bleeding in the ketorolac group and higher incidence of constipation in tramadol group. One patient in each group developed chronic pain. CONCLUSIONS: Ketorolac or weak opioids are equally effective on acute pain and on persistent postsurgical pain development after IHR, and drug choice should be based on their potential side effects and patient's comorbidities. Further studies are needed to standardize the most rational approach to prevent persistent postsurgical pain after IHR. TRIAL REGISTRATION: ClinicalTrials.gov NCT01345162

Risk factors for post-operative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND: Pars Plana Vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following Pars Plana Vitrectomy (PPV) in a selected population of patients with non-painful eye disease, receiving regional anaesthesia and moderate sedation with benzodiazepines, without use of narcotics.METHODS: Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the aetiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.RESULTS: Eye pain (NRS > 3) was present in 3 patients (0.7%) at operating room discharge, 59 (13.2%) at 6 and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at 6 hours. Scleral buckling was selected for eye pain at 24 hrs.CONCLUSIONS: A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade