A Bilateral Lumbar Multidermatomal Herpes Zoster in an Elderly Woman with Chronic Kidney Disease

n/

Candida Colonization Index in Patients Admitted to an ICU

Multiple-site colonization with Candida spp. is commonly recognized as a risk factor for invasive fungal infection in critically ill patients. We carried out a study to determine the relationship between Candida colonization and invasive infection in neurological patients admitted to an ICU. At admission (T0) and every three days for two weeks, different samples (pharynx swab, tracheal secretions, stomach contents, etc.) were collected for mycological surveillance. Candida mannan antigen and Candida anti-mannan antibodies were assayed. The Colonization Index (CI) and Corrected Colonization Index were calculated for each time point. Of all patients 70% was already colonized by Candida spp. at T0 and six of them had CI ≥ 0.5. Three patients developed candidemia; they had CI ≥ 0.5 before infection. Positive values of Candida mannan antigen and anti-mannan antibodies were found only in the patients with candidemia. The sensitivity and specificity of the Candida mannan test were 66.6% and 100%, respectively, while the sensitivity and specificity of the anti-mannan antibody test were 100%. In accordance with other authors, we find the surveillance cultures are useful to monitor the Candida colonization in ICU patients. In addition, the sequential observation of anti-mannan antibodies could contribute to early diagnosis of candidiasis more than Candida mannan antigen in immunocompetent patients

Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis

Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury

Opioid therapy for chronic non cancer pain: how to make the right choice

The WHO analgesic ladder provides an approach for managing patients with malignant pain. In clinical practice, this ladder is often applied to nonmalignant chronic pain, although its application in this setting is limited by its original design for a malignant pain model and omission of pain etiology and biological mechanism in symptom assessment. The WHO analgesic ladder directs therapy based on pain severity and persistence, with drug therapy recommendations which extends from nonopioids (e.g., NSAIDs and paracetamol) for mild pain followed by weak (e.g., codeine) and strong opioids (e.g., morphine) for moderate to severe pain, and adjuvant therapies if appropriate. However, a Cochrane analysis found long-term opioid therapy was either ineffective or poorly tolerated by a third of patients with nonmalignant chronic pain. This lack of evidence for long-term therapy is also problematic for nonopioid therapy. Short-term opioid therapy has been associated with adverse effects (e.g., nausea, constipation, somnolence, dizziness and pruritus) in 50-80 percent of patients. Additional concern are tolerance and addiction to opioids during long- term opioid therapy. This short review will highlight the issues of chronic opioid therapy and propose how to optimize it

Complete Relief of a Severe Feet and Hand Necrotising Raynaud’s Phenomenon with Double Epidural Cervical and Dorsal Spinal Cord Stimulation

Several evidences suggest that Spinal Cord Stimulation (SCS) can effectively treat vascular disorders. Raynaud’s phenomenon is a vasospastic condition affecting primarily the distal resistance vessels, triggered by cold temperatures, or by emo- tions such as anxiety and stress. High levels of sympathetic activity seem to be related to Raynaud’s phenomenon as well as low levels of calcitonin gene-related peptide expression in the local sensory fibers. Patients with pain due to vascular disease initially receive conservative and pharmacological therapy to treat the underlying cause. If the symptoms persist, amputation could be necessary. We present a case of a severe necrotising Raynaud’s phenomenon involving one hand and both feet successfully treated with epidural cervical and thoracic SC

Gut Microbiota Modulation and Its Implications on Neuropathic Pain: A Comprehensive Literature Review

: Neuropathic pain (NP) is a chronic pain disorder arising from somatosensory nervous system impairment. Extensive evidence supports the notion that the gut microbiota (GM) is crucial in maintaining human health by performing vital tasks. At the same time, its disruption has been linked to the emergence and advancement of an expanding range of disorders, including NP, in which GM could play a role in its pathophysiology. The crosstalk between the nervous system and GM happens through immune mediators, metabolites, and nervous structures and involves both central and peripheral nervous systems. This literature review aims to thoroughly investigate the function of modulating GM in the treatment of NP. It will achieve this by integrating existing knowledge, identifying underlying mechanisms, and evaluating the possible clinical consequences of exploiting the gut-brain axis. We will cover the main therapeutic applications of the described GM-modulators, such as probiotics, faecal microbiota transplantation, dietary supplements and emotional support, to the main kinds of NP in which any evidence, even if only pre-clinical, has been unravelled in recent years. The explored NP areas include chemotherapy-induced peripheral neuropathy, diabetic neuropathy, trauma-induced neuropathic pain, trigeminal neuralgia, postherpetic neuralgia and low back pain

Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study

In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain

Microbial Symphony: Exploring the Role of the Gut in Osteoarthritis-Related Pain. A Narrative Review

One of the most common musculoskeletal disorders, osteoarthritis (OA), causes worldwide disability, morbidity, and poor quality of life by degenerating articular cartilage, modifying subchondral bone, and inflaming synovial membranes. OA pathogenesis pathways must be understood to generate new preventative and disease-modifying therapies. In recent years, it has been acknowledged that gut microbiota (GM) can significantly contribute to the development of OA. Dysbiosis of GM can disrupt the "symphony" between the host and the GM, leading to a host immunological response that activates the "gut-joint" axis, ultimately worsening OA. This narrative review summarizes research supporting the "gut-joint axis" hypothesis, focusing on the interactions between GM and the immune system in its two main components, innate and adaptive immunity. Furthermore, the pathophysiological sequence of events that link GM imbalance to OA and OA-related pain is broken down and further investigated. We also suggest that diet and prebiotics, probiotics, nutraceuticals, exercise, and fecal microbiota transplantation could improve OA management and represent a new potential therapeutic tool in the light of the scarce panorama of disease-modifying osteoarthritis drugs (DMOADs). Future research is needed to elucidate these complex interactions, prioritizing how a particular change in GM, i.e., a rise or a drop of a specific bacterial strain, correlates with a certain OA subset to pinpoint the associated signaling pathway that leads to OA

Is perioperative goal-directed therapy able to reduce surgical complications in different surgical settings? A meta-analytic study

Introduction: Goal directed therapy (GDT) is a method aiming at optimizing doses and timing of fluids, inotropes and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications in high risk patients, and a recent trial suggests its significant effect also in low-moderate risk patients. The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications, in both high and low risk patients. Moreover, we stratified the effect of GDT in different kind of surgical procedures. Methods: Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with a least one postoperative complication. A subgroup- analysis was also performed including RCTs with a mortality rate in control group <10%, and considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery and so on. Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs). Results: In 47 RCTs, 2329 patients developed at least one complication: 1030 out of 2781 (37%) were randomized to perioperative GDT, and 1299 out of 2772 (47%) were randomized to control. Pooled OR was 0.58 and 95% CI was 0.47-0.70. The sensitivity analysis confirmed main result. The subgroup analysis including only studies in which the mortality rate in the control group was higher than 10% showed significant results (OR 0.51, 95% CI 0.35-0.74, p=0.004, 10 RCTs), as well as a statistical significant effect was observed in those RCTs with a mortality rate in control group <10% (OR 0.59, 95% CI 0.47-0.74, p<0.0001, 37 RCTs). The subgroup analysis enrolling major abdominal patients showed a significant result (OR 0.69, 95% CI 0.57- 0.83,p <0.0001, 29 RCTs, 3881 patients) as well as a significant effect was observed in those RCTs enrolling exclusively orthopedic (OR 0.48, 95% CI 0.30-0.79,p=0.004, 6 RCTs, 501 patients) and neurosurgical procedures (OR 0.40, 95% CI 0.21-0.78, p=0.008, 2 RCTs, 208 patients). Conclusions: The present meta-analysis suggests that GDT can reduce postoperative complication rate in high risk as well as in low risk patients. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. However, heterogeneity was found in some subgroups, reducing the strength of the results. Several well-designed RCTs are needed to further explore the effect of GDT in low risk patient and in different kind of surgeries