Anaesthetic challenging in microsurgical flap reconstruction: a systematic review

Background: Anaesthetic management for microvascular reconstructive surgery is challenging and clearly affects the risk of major complications such as flap hypo-perfusion. In this systematic review we explore recent (last 7 years) clinical evidences related to perioperative management and anaesthetic controversy of patients undergoing microvascular reconstructive surgery, especially focused on head and neck surgery with free flaps (FF) and breast reconstructive surgery with deep inferior epigastric perforator flap (DIEP-flap). Methods: A literature search of published clinical studies between 2011 and 2018 was conducted, yielding a total of 4307 papers. Only 150 were eligible, according inclusion and exclusion criteria. Results: 62 studies were selected for this review and categorized in 3 groups: preoperative-intraoperative- postoperative anaesthetic management and areas of controversy for patients undergoing head and neck surgery with FF and breast reconstructive surgery with DIEP-flap. Discussion: Anaesthetic management for flap reconstructive surgery remains an open field of interest with limited evidences regarding a standard care. Main components of research currently are: the need to join standard multidisciplinary enhanced recovery pathways, as well as the necessity to develop a standard intraoperative management. In theatre, the recent hemodynamic parameter “Hypotension Probability Indicator” (HPI) is promising: the advantage to predict a drop in the mean arterial pressure can be more effective than a fluid therapy titrated to maintain SVV less than 13%. Prospective studies are necessary to clarify

Assessment of a stochastic downscaling methodology in generating an ensemble of hourly future climate time series

This study extends a stochastic downscaling methodology to generation of an ensemble of hourly time series of meteorological variables that express possible future climate conditions at a point-scale. The stochastic downscaling uses general circulation model (GCM) realizations and an hourly weather generator, the Advanced WEather GENerator (AWE-GEN). Marginal distributions of factors of change are computed for several climate statistics using a Bayesian methodology that can weight GCM realizations based on the model relative performance with respect to a historical climate and a degree of disagreement in projecting future conditions. A Monte Carlo technique is used to sample the factors of change from their respective marginal distributions. As a comparison with traditional approaches, factors of change are also estimated by averaging GCM realizations. With either approach, the derived factors of change are applied to the climate statistics inferred from historical observations to re-evaluate parameters of the weather generator. The re-parameterized generator yields hourly time series of meteorological variables that can be considered to be representative of future climate conditions. In this study, the time series are generated in an ensemble mode to fully reflect the uncertainty of GCM projections, climate stochasticity, as well as uncertainties of the downscaling procedure. Applications of the methodology in reproducing future climate conditions for the periods of 2000-2009, 2046-2065 and 2081-2100, using the period of 1962-1992 as the historical baseline are discussed for the location of Firenze (Italy). The inferences of the methodology for the period of 2000-2009 are tested against observations to assess reliability of the stochastic downscaling procedure in reproducing statistics of meteorological variables at different time scale

Randomized controlled trials and real-world data : differences and similarities to untangle literature data

Randomized controlled trials (RCTs) represent the gold-standard of medical evidence to assess the efficacy and safety of therapeutic interventions. However, the need to minimize bias and ensure the correct design to explore the study aims often affects the generalizability of results. As a consequence, the evidence derived from the most rigorous research strategy available is not always representative of the real-world settings for which this evidence is ultimately intended. Observational studies, in contrast, although affected by a number of potential confounders, can more effectively capture treatment characteristics and safety issues that had not been identified by previous RCTs, owing to the short duration of follow-up or highly selective inclusion criteria. The aim of this review is to provide a comparative summary of the main advantages and pitfalls of RCTs and real-world data, emphasizing the need for a constant integration of all available levels of evidence to provide the best care for patients

Histopathology of the synovial tissue : perspectives for biomarker development in chronic inflammatory arthritides

The histopathological and molecular analysis of the synovial tissue has contributed to fundamental advances in our comprehension of arthritis pathogenesis and of the mechanisms of action of currently available treatments. On the other hand, its exploitation in clinical practice for diagnostic or prognostic purposes as well as for the prediction of treatment response to specific disease-modifying anti-rheumatic drugs is still limited. In this review, we present an overview of recent advances in the field of synovial tissue research with specific reference to the methods for synovial tissue collection, approaches to synovial tissue analysis and current perspectives for the exploitation of synovial tissue-derived biomarkers in chronic inflammatory arthritides

Occurrence probability of moderate to large earthquakes in Italy based on new geophysical methods

We develop new approaches to calculating 30-year probabilities for occurrence of moderate-to-large earthquakes in Italy. Geodetic techniques and finite-element modelling, aimed to reproduce a large amount of neotectonic data using thin-shell finite element, are used to separately calculate the expected seismicity rates inside seismogenic areas (polygons containing mapped faults and/or suspected or modelled faults). Thirty-year earthquake probabilities obtained from the two approaches show similarities in most of Italy: the largest probabilities are found in the southern Apennines, where they reach values between 10% and 20% for earthquakes of M W ≥ 6.0, and lower than 10% for events with an M W ≥ 6.5

SERS, XPS and DFT study of xanthine adsorbed on citrate-stabilized gold nanoparticles

We have studied the adsorption of xanthine, a nucleobase present in human tissue and fluids that is involved in important metabolic processes, on citrate-reduced gold colloidal nanoparticles by means of surface-enhanced Raman scattering (SERS), absorption, and X-ray photoelectron spectroscopy (XPS) measurements, along with density functional theory (DFT) calculations. The citrate anions stabilize the colloidal suspensions by strongly binding the gold nanoparticles. However, these anions do not impair the adsorption of xanthine on positively-charged active sites present on the metal surface. We have obtained the Fourier transform (FT)-SERS spectra of adsorbed xanthine by laser excitation in the near infrared spectral region, where interference due to fluorescence emission does not usually occur. In fact, the addition of chloride ions to the Au/xanthine colloid induces the aggregation of the gold nanoparticles, whose plasmonic band is shifted to the near infrared region where there is the exciting laser line of the FT\u2013Raman instrument. Hence, this analytical approach is potentially suitable for spectroscopic determination of xanthine directly in body fluids, avoiding fluorescence phenomena induced by visible laser irradiation

Chronic pain : the burden of disease and treatment innovations

Musculoskeletal conditions are the most frequent cause of chronic pain and affect around 1 in 5 adults in Europe. When chronic pain occurs, it becomes disease itself, with substantial clinical, social and economic impact. Efficacy and tolerability problems are encountered with all therapeutic strategies available to treat musculoskeletal pain. This often limits effective analgesia and patients\u2019 long term compliance, with the result that chronic pain is persistently underestimated and undertreated. Tapentadol is a novel, centrally acting analgesic that has been recently commercialized for the treatment of chronic pain. This new molecule, by combining two distinct mechanisms of action, \u3bc-opioid receptor agonism (MOR) and noradrenaline reuptake inhibition (NRI), introduces a new pharmacological class called MOR-NRI. Several studies demonstrated promising results in the management of both nociceptive and neuropathic pain and good tolerability profile, particularly concerning side effects, compared to traditional opioids. This novel analgesic represents a possible therapeutic option also in the rheumatologic field, particularly in the treatment of osteoarthritis and low back pain