Prehospital drugs for sedation in psychomotor agitation, friends or foes? An observational retrospective study

Altered mental status (AMS) describes an undifferentiated presentation of disorders of mentation. It represents a common problem for prehospital and hospital providers and may be found in 5% to 10% of patients admitted to the Emergency Department (ED). Psychomotor Agitation (PMA), a state of motor restlessness and mental tension associated with a variety of psychiatric conditions, is one of the most frequent manifestations of AMS. In this observational retrospective study we included all the patients who presented PMA, treated by the out-of-hospital Emergency Medical System (EMS), and transported to the ED of the University Hospital of Udine, Italy. The objectives were to determine the incidence of patients with PMA treated by EMS in the area of investigation, the evaluation of pharmacologically treated patients considering the most commonly administered drugs, the intubation rate, the fraction of inspired oxygen (FiO2) needs, the length of hospital stay (LOHS), the adverse drug reactions (ADRs), and the excited delirium syndrome (ExDS). From January 2017 to December 2018, 319 patients were enrolled. The prevalence of PMA was 2.5% and 0.5% were the cases of PMA managed by the EMS. The predominant drugs used for sedation were midazolam (19.75%) and ketamine (9.09%), alone or in association; patients with consistent PMA required more than one sedative. Statistically significant differences were found in FiO2 supplementation for ketamine-sedated psychiatric patients and midazolam-sedated psychiatric patients with chronic home therapy, in the LOHS >24 hours (h), with a longer stay in case of midazolam and ketamine use, and in LOHS and FiO2 supplementation due to polypharmacy administration with more than one sedative drug. PMA is a frequent and widespread phenomenon and in the prehospital setting requires rapid assessment and management. Therapeutical strategies with benzodiazepines, ketamine, and rarely associations of drugs are safe, do not increase hypoxia and intubation rate

Colonisation with Extended-Spectrum Cephalosporin-Resistant Enterobacterales and Infection Risk in Surgical Patients: A Systematic Review and Meta-analysis

Introduction: Limited evidence has been reported for surgical site infections (SSIs) in patients undergoing surgery who are carriers of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E). A systematic review and meta-analysis were conducted to evaluate the risk of postoperative infections in adult inpatients colonised with ESCR-E before surgery. Methods: The Medline, Embase and Cochrane databases were searched between January 2011 and April 2022, following PRISMA indications. Random effects meta-analysis was used to quantify the association between ESCR-E colonisation and infection. Results: Among the 467 articles reviewed, 9 observational studies encompassing 7219 adult patients undergoing surgery were included. The ESCR-E colonisation rate was 13.7% (95% CI 7.7–19.7). The most commonly reported surgeries included abdominal surgery (44%) and liver transplantation (LT; 33%). The SSI rate was 23.2% (95% CI 13.2–33.1). Pooled incidence risk was 0.36 (95% CI 0.22–0.50) vs 0.13 (95% CI 0.02–0.24) for any postoperative infection and 0.28 (95% CI 0.18–0.38) vs 0.17 (95% CI 0.07–0.26) for SSIs in ESCR-E carriers vs noncarriers, respectively. In ESCR-E carriers, the ESCR-E infection ratio was 7 times higher than noncarriers. Postoperative infection risk was higher in carriers versus noncarriers following LT. Sources of detected heterogeneity between studies included ESCR-E colonisation and the geographic region of origin. Conclusions: Patients colonised with ESCR-E before surgery had increased incidence rates of post-surgical infections and SSIs compared to noncarriers. Our results suggest considering the implementation of pre-surgical screening for detecting ESCR-E colonisation status according to the type of surgery and the local epidemiology

Cerebral fat embolism after traumatic bone fractures: a structured literature review and analysis of published case reports

Background: The incidence of cerebral fat embolism (CFE) ranges from 0.9\u201311%, with a mean mortality rate of around 10%. Although no univocal explanation has been identified for the resulting fat embolism syndrome (FES), two hypotheses are widely thought: the \u2018mechanical theory\u2019, and the \u2018chemical theory\u2019. The present article provides a systematic review of published case reports of FES following a bone fracture. Methods: We searched MEDLINE, Web of Science and Scopus to find any article related to FES. Inclusion criteria were: trauma patients; age\ua0 65\ua018 years; and the clinical diagnosis of CFE or FES. Studies were excluded if the bone fracture site was not specified. Results: One hundred and seventy studies were included (268 cases). The male gender was most prominent (81.6% vs. 18.4%). The average age was 33 years (\ub118). The mean age for males (29 \ub1 14) was significantly lower than for females (51 \ub1 26) (p < 0.001). The femur was the most common fracture site (71% of cases). PFO was found in 12% of all cases. Univariate and multivariate regression analyses showed the male gender to be a risk factor for FES: RR 1.87 and 1.41, respectively (95%CI 1.27\u20132.48, p < 0.001; 95%CI 0.48\u20132.34, p < 0.001). Conclusions: FES is most frequent in young men in the third decades of life following multiple leg fractures. FES may be more frequent after a burst fracture. The presence of PFO may be responsible for the acute presentation of cerebral embolisms, whereas FES is mostly delayed by 48\u201372 h

Garantismo y crisis de la justicia

Esta obra representa una importante reflexión teórica producto de la labor investigativa de sus autores, en torno a uno de los problemas de mayor actualidad en la sociedad contemporánea, cual es, la tensión permanente que se presenta entre la necesidad que tiene el Estado de garantizar un orden o control social y al mismo tiempo, la exigencia actual de la garantía y protección de los derechos fundamentales

Factors associated with the development of septic shock in patients with candidemia: A post hoc analysis from two prospective cohorts

Background: Almost one third of the patients with candidemia develop septic shock. The understanding why some patients do and others do not develop septic shock is very limited. The objective of this study was to identify variables associated with septic shock development in a large population of patients with candidemia. Methods: A post hoc analysis was performed on two prospective, multicenter cohort of patients with candidemia from 12 hospitals in Spain and Italy. All episodes occurring from September 2016 to February 2018 were analyzed to assess variables associated with septic shock development defined according to The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3). Results: Of 317 candidemic patients, 99 (31.2%) presented septic shock attributable to candidemia. Multivariate logistic regression analysis identifies the following factors associated with septic shock development: age > 50 years (OR 2.57, 95% CI 1.03-6.41, p = 0.04), abdominal source of the infection (OR 2.18, 95% CI 1.04-4.55, p = 0.04), and admission to a general ward at the time of candidemia onset (OR 0.21, 95% CI, 0.12-0.44, p = 0.001). Septic shock development was independently associated with a greater risk of 30-day mortality (OR 2.14, 95% CI 1.08-4.24, p = 0.02). Conclusions: Age and abdominal source of the infection are the most important factors significantly associated with the development of septic shock in patients with candidemia. Our findings suggest that host factors and source of the infection may be more important for development of septic shock than intrinsic virulence factors of organisms

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study)

Background: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. Methods: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. Results: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). Conclusions: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. Trial registration: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021)

Nonlinear analysis of intervertebral disk under dynamic load.

This study pertains to the response of intervertebral joint under dynamic axial load. The numerical model represents two vertebral bodies with an interposed disk and uses three-dimensional elements. A transversely isotropic material law is adopted for cortical bone and an isotropic law for cancellous bone. Annulus collagen fibers are modelled using truss elements with no compressive resistance. The disk material is assumed hyperelastic, using a mixed finite element approach, allowing a representation of the disk involving the incompressibility characteristics for the material. The analysis considers finite displacement and strain fields under dynamic load. Intensity, trend and distribution of loads on the vertebral body are deduced from the literature. The problem is investigated with reference to different compressibility levels of disk material related to disk degenerationn phenomena

La magia nell'Europa moderna. Tradizioni e mutamenti, Atti del convegno (Firenze, 2-4 ottobre 2003)

Muovendo dagli esiti più fecondi e stimolanti del vivace dibattito novecentesco intorno alla presenza e al significato della magia nella cultura filosofica della prima età moderna, nei saggi inclusi nel volume vengono approfonditi, con un'impostazione interdisciplinare, le varie posizioni dottrinali e i diversi livelli della pratica magica che, a partire dalla seconda metà del '400 e lungo i due secoli successivi, toccano e coinvolgono ambiti diversi del sapere: dalla filosofia alla religione, dalla medicina alla scienza giuridica