COVID-19 and surgical training in Italy: Residents and young consultants perspectives from the battlefield

COVID-19 is seriously affecting Italy, putting the health system under extreme pressure. Training of medical students and residents is also suffering from this with the suspension of lectures and clinical rotations. What solutions have been taken to deal with the issue

Environmental impact of milk production in intensive farming systems: life cycle assessment approach

Life cycle assessment (LCA) has been shown to be a valuable method for the environmental evaluation of farming systems and has been applied to several agricultural products, particularly in Europe. In LCA the potential environmental impacts of a product are assessed by quantifying the resources consumed and the emissions, at all stages of its life cycle, from the extraction of resources, through the production and transport of materials, to the production process at the farm. The aim of the study was to evaluate the environmental impacts of milk production in intensive farming systems using LCA approach on a sample of 44 dairy farms in northern Italy. Impact categories were: Land use, Non-renewable energy use, Climate change, Acidification and Eutrophication. Functional units were: 1 kg of Fat and Protein Corrected Milk (FPCM); 1 ha of farm land. Data were collected by personal interview with the farmers. Farms involved in the study reared on average 145 (\ub191) cows, with a daily milk production of 28.0 (\ub13.32) kg FPCM/cow. Average farm land was 49.9 (\ub137) ha and stocking density 5.3 (\ub12.5) LU/ha. On average, 59% of the total dry matter of cow rations consisted of feed ingredients produced on the farm. The average results for the 5 LCA categories per kg of FPCM were: 2.84 (\ub11.02) m2 for Land use, 4.98 (\ub11.34) MJ for Energy use, 0.93 (\ub10.29) kg CO2-eq for Climate change, 18.2 (\ub14.2) g SO2-eq for Acidification and 12.0 (\ub13.1) g PO4-eq for Eutrophication. Impact indicators from this study are similar to those reported in recent European LC analyses on intensive dairy farms, although the comparison among LCA studies from different countries can be misleading because of local peculiarities and different methodologies. Within the study, LCA indicators allowed to compare environmental impacts of milk production among farms characterized by different levels of intensification (stocking density, milk production, feed self-supply)

Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock. a pilot study

Background: Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns. Methods: Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1–H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases. Results: Esmolol was infused 9 (6.4–11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34–0.83) to 0.78 (0.3–1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110–125) to 100 (92–103) beats/min and a decrease in cardiac index from 4.2 (3.1–4.4) to 2.9 (2.5–3.7) l/min/m−2. Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients. Conclusion: In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287)

Real world hypoglycaemia related to glucose variability and Flash glucose scan frequency assessed from global FreeStyle Libre data.

Flash glucose monitoring provides a range of glucose metrics. In the current study, we aim to identify those that indicate that glycaemic targets can be consistently met and contrast the total (t-CV) and within-day coefficient of variation (wd-CV) to guide the assessment of glucose variability and hypoglycaemia exposure. De-identified data from Flash readers were collected. The readers were sorted into 10 equally sized groups of scan frequency followed by quartiles of estimated A1c (eA1c). A similar grouping was performed for the total coefficient of variation (t-CV) and within-day coefficient of variation (wd-CV). In addition, analysis of the association of time below 54 mg/dl and glucose variability measured by t-CV and wd-CV was performed. The dataset included 1 002 946 readers. Readers sorted by 10 equal groups of scan rate and quartiles by eA1c, t-CV and wd-CV represented 25 074 readers per group. The association of lower eA1c with higher time in range and reduced time above range was clear. The correlation of eA1c quartiles and time below range was not consistent. An association between glucose variability and hypoglycaemia was found. Both wd-CV and t-CV were associated with time below range. For achieving the consensus target of <1% time below 54 mg/dl, the associated wd-CV and t-CV values were 33.5% and 39.5%, respectively. The type of CV reported by the different continuous glucose monitoring systems should be acknowledged. CV <36% might not be adequate to ensure low hypoglycaemia exposure. To our knowledge, the majority of continuous glucose monitoring reports the t-CV. Appropriate thresholds should be used to identify patients that would probably meet time below range targets (t-CV <40% or wd-CV <34%)

A simple method to assess the oxidative susceptibility of low density lipoproteins

BACKGROUND: Oxidative modification of low density lipoproteins (LDL) is recognized as one of the major processes involved in atherogenesis. The in vitro standardized measurement of LDL oxidative susceptibility could thus be of clinical significance. The aim of the present study was to establish a method which would allow the evaluation of oxidative susceptibility of LDL in the general clinical laboratory. RESULTS: LDL was isolated from human plasma by selective precipitation with amphipathic polymers. The ability of LDL to form peroxides was assessed by measuring thiobarbituric acid reactive substances (TBARS) after incubation with Cu(2+) and H(2)O(2). Reaction kinetics showed a three-phase pattern (latency, propagation and decomposition phases) which allowed us to select 150 min as the time point to stop the incubation by cooling and EDTA addition. The mixture Cu(2+)/H(2)O(2) yielded more lipoperoxides than each one on its own at the same time end-point. Induced peroxidation was measured in normal subjects and in type 2 diabetic patients. In the control group, results were 21.7 ± 1.5 nmol MDA/mg LDL protein, while in the diabetic group results were significantly increased (39.0 ± 3.0 nmol MDA/mg LDL protein; p < 0.001). CONCLUSION: a simple and useful method is presented for the routine determination of LDL susceptibility to peroxidation in a clinical laboratory

MicroTools enables automated quantification of capillary density and red blood cell velocity in handheld vital microscopy

Direct assessment of capillary perfusion has been prioritized in hemodynamic management of critically ill patients in addition to optimizing blood flow on the global scale. Sublingual handheld vital microscopy has enabled online acquisition of moving image sequences of the microcirculation, including the flow of individual red blood cells in the capillary network. However, due to inherent content complexity, manual image sequence analysis remained gold standard, introducing inter-observer variability and precluding real-time image analysis for clinical therapy guidance. Here we introduce an advanced computer vision algorithm for instantaneous analysis and quantification of morphometric and kinetic information related to capillary blood flow in the sublingual microcirculation. We evaluated this technique in a porcine model of septic shock and resuscitation and cardiac surgery patients. This development is of high clinical relevance because it enables implementation of point-of-care goal-directed resuscitation procedures based on correction of microcirculatory perfusion in critically ill and perioperative patients

The endogenous cannabinoid system in the gut of patients with inflammatory bowel disease

Activation of cannabinoid receptors (CBs) by endocannabinoids impacts on a number of gastrointestinal functions. Recent data indicate that CB1 agonists improve 2,4-dinitrobenzene sulfonic acid-induced colitis in mice, thus suggesting a role for the endocannabinoid agonist anandamide (AEA) in protecting the gut against inflammation. We here examined the gut endocannabinoid system in inflammatory bowel disease (IBD) patients, and investigated the ex vivo and in vitro effects of the non-hydrolysable AEA analog methanandamide (MAEA) on the mucosal proinflammatory response. The content of AEA, but not of 2-arachidonoyl-glycerol and N-palmitoylethanolamine, was significantly lower in inflamed than uninflamed IBD mucosa, and this was paralleled by lower activity of the AEA-synthesizing enzyme N-acyl-phosphatidylethanolamine-specific phospholipase D and higher activity of the AEA-degrading enzyme fatty acid amide hydrolase. MAEA significantly downregulated interferon-γ and tumor necrosis factor-α secretion by both organ culture biopsies and lamina propria mononuclear cells. Although these results are promising, further studies are needed to determine the role of cannabinoid pathways in gut inflammation. © 2011 Society for Mucosal Immunology

Role of Continuous Glucose Monitoring in Clinical Trials: Recommendations on Reporting.

Thanks to significant improvements in the precision, accuracy, and usability of continuous glucose monitoring (CGM), its relevance in both ambulatory diabetes care and clinical research is increasing. In this study, we address the latter perspective and derive provisional reporting recommendations. CGM systems have been available since around the year 2000 and used primarily in people with type 1 diabetes. In contrast to self-measured glucose, CGM can provide continuous real-time measurement of glucose levels, alerts for hypoglycemia and hyperglycemia, and a detailed assessment of glycemic variability. Through a broad spectrum of derived glucose data, CGM should be a useful tool for clinical evaluation of new glucose-lowering medications and strategies. It is the only technology that can measure hyperglycemic and hypoglycemic exposure in ambulatory care, or provide data for comprehensive assessment of glucose variability. Other advantages of current CGM systems include the opportunity for improved self-management of glycemic control, with particular relevance to those at higher risk of or from hypoglycemia. We therefore summarize the current status and limitations of CGM from the perspective of clinical trials and derive suggested recommendations for how these should facilitate optimal CGM use and reporting of data in clinical research

Clinical factors affecting short- and long-term mortality in older patients with COVID-19: a retrospective cohort study

The majority of fatal cases of SARS-CoV-2 was concentrated among older patients. We aimed at assessing risk factors contributing to mortality in this population. A retrospective study including 584 COVID-19 patients aged &gt;= 80 years hospitalized between October 10th 2020 to May 4th 2021 at Ospedale di Circolo (Varese, Italy) and Ospedale Galmarini (Tradate, Italy) was conducted. Evaluation of risk factors associated with in-hospital mortality was the primary endpoint. 509 patients were considered. Median age was 86 [82-89] years. Almost half of the patients (n=241) suffered from &gt;= 3 comorbidities. Overall in-hospital mortality was 39.7% (n=202). Age, chronic kidney disease (CKD), peripheral oxygen saturation at admission, and high-flow oxygen during hospital stay independently predicted in-hospital mortality. Overall mortality at 6 months was 57.8% (n=294) and increased with increasing age and number of comorbidities (P&lt;0.05). Age, CKD, and dementia independently predicted 6-month mortality. Age and comorbidities predicted short- and long-term mortality in older patients (&gt;= 80 years). Stratification of patients according to age and comorbidities might provide critical information for a better management of elderly patients