The challenge of perioperative pain management in opioid-tolerant patients

The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone

AB0844 HAND GRIP STRENGTH EVALUATION IN RHEUMATOLOGIC DISEASES

Background:Handgrip muscle strength test describes the strength of the hand muscles used to grasp or grip. Currently, hand grip evaluation is often used in clinical practice, as a marker of function and disability. In fact, it has already been applied as an outcome measure in arthritis rheumatoid clinical trials, to demonstrate the benefits of several treatments [1]. However, hand disability should also be considered in all other rheumatological diseases.Objectives:The main aim of this study is to assess the handgrip muscle strength test in a rheumatological cohort of patients as compared to a control group.Methods:This is a cross-sectional pilot study. We considered eligible 35 rheumatological consecutive female patients followed at our outpatients' clinic of Internal Medicine (I Policlinico of Naples) and 35 healthy control females (HC). Both groups included only right-handed individuals. Rheumatological patients were distributed as follows: 5 rheumatoid arthritis (14,3%), 9 psoriatic arthritis (25,7%), 4 systemic lupus erythematosus (11,4%), 10 systemic sclerosis (28,6%), 4 fibromyalgia (11,4%), 3 juvenile idiopathic arthritis (8,6%). The course of disease was under optimal treatment in all patients.The type of hand grip used is the power grip, in which an object is held firmly by wrapping the fingers around it, pressing the object against the palm, and using the thumb to apply counter-pressure. We considered as either right or left hand valid measure the mean of three consecutive tests per arm. Between-groups differences were tested both by a uni- and multivariable analysis.Results:The two subgroups were homogeneously distributed for age (median age 42 yrs. [IQR 33-48] vs. 36 yrs. [IQR 30-52] in HC; p=0.902). At univariate analysis, hand grip strength was significantly lower in the rheumatological patients, both at right hand (right 19.5 kg [IQR 13.6-24.8] vs. 24.5 kg [IQR 20.8-29] in HC; p=0.004) and left hand (18.5 kg [IQR 13.9-22.5] vs. 23.7 kg [IQR 19-27.3] in HC; p=0.002), as compared to HC. This finding was further confirmed at multivariable analysis only as for the left hand (OR 0.919, 95%CI: 0.858-0.984; p=0.016).Conclusion:Rheumatological diseases are burdened by hand disability, mostly affecting daily activities performance [2,3]. Beyond an optimal disease control, our pilot study shows a decrease in left hand strength as compared to healthy controls. This might be due to a reduced use of the non-dominant hand, which may lead over time to a higher deficit of strength. As such, these patients should be prescribed to a left hand exercise to improve both mobility and strength and, consequently, hand function.References:[1]Eberhardt K, Sandqvist G, Geborek P (2008) Hand function tests are important and sensitive tools for assessment of treatment response in patients with rheumatoid arthritis. Scand J Rheumatol 37(2):109–112.[2]Feced Olmos CM, Alvarez-Calderon O, Hervás Marín D, et al. Relationship between structural damage with loss of strength and functional disability in psoriatic arthritis patients. Clin Biomech (Bristol, Avon). 2019 Aug;68:169-174. doi: 10.1016/j.clinbiomech.2019.06.009.[3]Maddali-Bongi S, Del Rosso A, Mikhaylova S, et al. Impact of hand and face disabilities on global disability and quality of life in systemic sclerosis patients. Clin Exp Rheumatol. 2014 Nov-Dec;32(6 Suppl 86):S-15-20.Disclosure of Interests:None declare

Dean Emeritus Patrick J. Rohan

(Excerpt) Patrick J. Rohan’s connection to St. John’s reaches back more than half a century. He graduated from St. John’s University in 1954 and from the School of Law in 1956. Two years later, he joined the Law School faculty, where he served for fifty-two years until his retirement in June 2009. He died just a few months later, on November 26, 2009. The School of Law community mourns the passing of this man of St. John’s—Dean Emeritus, Professor of Law, alumnus, supporter, and friend

Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain

Purpose: The aim of the present study was to assess the long-term tolerability and efficacy of intranasal fentanyl (INFS) in opioid-tolerant patients with breakthrough cancer pain (BTP).Patients and methods: A 6 months, observational, prospective, cohort study design was employed to follow advanced cancer patients with BTP receiving INFS under routine clinical practice. Eligible adult cancer patients suffering from BTP had been prescribed INFS at effective doses. Data were collected at T0 and at month intervals for six months. The principal outcomes were the evaluation of possible serious adverse effects with prolonged use of INFS, the efficacy of BTP treatment with INFS, the quality of sleep, the rate of INFS discontinuation, and reasons for that.Results: Seventy-five patients were surveyed. Thirty-four patients (45.3 %) had a follow-up at 3 months, and twelve patients (16 %) were followed up at 6 months. The mean opioid doses, expressed as oral morphine equivalents, ranged 111\u2013180 mg/day, while the mean INFS doses were 87\u2013119 \u3bcg. Adverse effects were reported in a minority of patients and were considered to be associated with opioid therapy used for background pain. The quality of sleep significantly improved during the first 3\u20134 months. Finally, efficacy based on a general impression regarding the efficacy of INFS was good-excellent in most patients and statistically improved in time up to the third month.Conclusion: The long-term use of INFS in advanced cancer patients is effective and safe. No serious adverse effects were found up to six months of assessment. The level of quality of sleep and patients\u2019 satisfaction was relatively good, considering the advanced stage of disease

Microevolutionary traits and comparative population genomics of the emerging pathogenic fungus Cryptococcus gattii

Emerging fungal pathogens cause an expanding burden of disease across the animal kingdom, including a rise in morbidity and mortality in humans. Yet, we currently have only a limited repertoire of available therapeutic interventions. A greater understanding of the mechanisms of fungal virulence and of the emergence of hypervirulence within species is therefore needed for new treatments and mitigation efforts. For example, over the past decade, an unusual lineage of Cryptococcus gattii, which was first detected on Vancouver Island, has spread to the Canadian mainland and the Pacific Northwest infecting otherwise healthy individuals. The molecular changes that led to the development of this hypervirulent cryptococcal lineage remain unclear. To explore this, we traced the history of similar microevolutionary events that can lead to changes in host range and pathogenicity. Here, we detail fine-resolution mapping of genetic differences between two highly related Cryptococcus gattii VGIIc isolates that differ in their virulence traits (phagocytosis, vomocytosis, macrophage death, mitochondrial tubularization and intracellular proliferation). We identified a small number of single site variants within coding regions that potentially contribute to variations in virulence. We then extended our methods across multiple lineages of C. gattii to study how selection is acting on key virulence genes within different lineages. This article is part of the themed issue ‘Tackling emerging fungal threats to animal health, food security and ecosystem resilience’

Cardiovascular events and treatment of children with high risk medulloblastoma

Background: Children with high-risk medulloblastoma are treated with chemotherapeutic protocols which may affect heart function. We aimed to assesscardiovascular events (CVE) in children with medulloblastoma/primitive neuroectodermal tumors (PNET). Methods: We retrospectively collected data from a case series of 22 children with high-risk medulloblastoma/PNET admitted to the Santobono-Pausilipon Hospital, Naples, Italy from 2008 to 2016. All patients received the Milan HART protocol for high-risk brain malignancies as first line treatment (induction phase), followed by a consolidation phase with Thiotepa and hematopoietic stem cells transplantation, except for 1 patient who received the Milan HART as second line therapy. Four patients also received second line treatment, while 4 patients also received maintenance therapy. Patients underwent cardiac examination, including ECG, echocardiography and serum biomarkers, before antineoplastic treatment initiation and then when clinically needed. Six patients developed CVE (CVE group); 16 patients had no CVE (NO-CVE group). Findings: In the CVE group, 3 patients presented acute CVE during chemotherapy (2 patients with left ventricular (LV) dysfunction, 1 patient with arterial hypertension), while 3 patients presented chronic CVE after chemotherapy completion (2 patients with LV dysfunction, 1 patient with ectopic atrial tachycardia). After a 51 months median follow-up, 9 patients died: 4 from the CVE group (in 2 cases heart failure-related deaths) and 5 from the NO-CVE group (progression of disease). Interpretation: A relevant percentage of children treated for medulloblastoma/PNET develops CVE. Heart failure potentially due to chemotherapy may represent a cause of death. Hence, in these patients, strict cardiac surveillance is essential. Funding: No funding was associated with this study

Night blindness in cystic fibrosis : the key role of vitamin A in the digestive system

Vitamin A is a fundamental micronutrient that regulates various cellular patterns. Vitamin A deficiency (VAT) is a worldwide problem and the primary cause of nocturnal blindness especially in low income countries. Cystic fibrosis (CF) is a known risk factor of VAD because of liposoluble vitamin malabsorption due to pancreatic insufficiency. We describe a case of a 9-year-old girl who experienced recurrent episodes of nocturnal blindness due to profound VAD. This little girl is paradigmatic for the explanation of the key role of the gut\u2013liver axis in vitamin A metabolism. She presents with meconium ileus at birth, requiring intestinal resection that led to a transient intestinal failure with parenteral nutrition need. In addition, she suffered from cholestatic liver disease due to CF and intestinal failure-associated liver disease. The interaction of pancreatic function, intestinal absorption and liver storage is fundamental for the correct metabolism of vitamin A

CIAO: the CNR-IMAA advanced observatory for atmospheric research

Long-term observations of aerosol and clouds are of crucial importance to understand the weather climate system. At the Istituto di Metodologie per l'Analisi Ambientale of the Italian National Research Council (CNR-IMAA) an advanced atmospheric observatory, named CIAO, is operative. CIAO (CNR-IMAA Atmospheric Observatory) main scientific objective is the long term measurement for the climatology of aerosol and cloud properties. Its equipment addresses the state-of-the-art for the ground-based remote sensing of aerosol, water vapour and clouds including active and passive sensors, like lidars, ceilometers, radiometers, and a radar. This paper describes the CIAO infrastructure, its scientific activities as well as the observation strategy. The observation strategy is mainly organized in order to provide quality assured measurements for satellite validation and model evaluation and to fully exploit the synergy and integration of the active and passive sensors for the improvement of atmospheric profiling. Data quality is ensured both by the application of protocols and dedicated quality assurance programs mainly related to the projects and networks in which the infrastructure is involved. The paper also introduces examples of observations performed at CIAO and of the synergies and integration algorithms (using Raman lidar and microwave profiler data) developed and implemented at the observatory for the optimization and improvement of water vapour profiling. CIAO database represents an optimal basis to study the synergy between different sensors and to investigate aerosol-clouds interactions, and can give a significant contribution to the validation programs of the incoming new generation satellite missions

Comparison of Astrand VO2 Max Prediction to a Graded Leg Ergometry VO2 Max Test in Endurance Athletes

Please refer to the pdf version of the abstract located adjacent to the title

The invasive cell coat at the microsporidian Trachipleistophora hominis-host cell interface contains secreted hexokinases

Funding: Wellcome Trust (Grant Number: 089803/D/09/Z), 600th anniversary studentship from the University of St Andrews.Microsporidia are obligate intracellular parasites causing significant disease in humans and economically important animals. In parallel to their extreme genetic reduction, Microsporidia have evolved novel mechanisms for exploiting host metabolism. A number of microsporidians confer secretion of otherwise cytosolic proteins by coding for signal peptides that direct entry into the endoplasmic reticulum. The human pathogen Trachipleistophora hominis encodes for four hexokinases, three of which have signal peptides at the N‐terminus. Here, we localized hexokinase 2 and hexokinase 3 through developmental stages of T. hominis using light and electron microscopy. Both proteins were concentrated in an extracellular coat previously termed the plaque matrix (PQM). The PQM (containing hexokinases) was morphologically dynamic, infiltrating the host cytoplasm predominantly during replicative stages. Throughout development the PQM interacted closely with endoplasmic reticulum that was demonstrated to be active in membrane protein biosynthesis and export. The impact of hexokinase on the host metabolism was probed using the fluorescent analog of glucose, 2‐NBDG, which displayed spatially restricted increases in signal intensity at the parasite/vacuole surface, coincident with hexokinase/PQM distribution. Gross metabolic aberrations, measured using metabolic profiling with the Seahorse XF Analyzer, were not detectable in mixed stage cocultures. Overall, these results highlight a role for the extended cell coat of T. hominis in host–parasite interactions, within which secreted hexokinases may work as part of a metabolic machine to increase glycolytic capacity or ATP generation close to the parasite surface.Publisher PDFPeer reviewe