Gestione della cefalea post puntura durale (PDPH): dai trattamenti conservativi all'esecuzione dell'epidural blood patch come trattamento definitivo.

Nonostante i progressi nelle apparecchiature e nelle tecniche di anestesia locoregionale, la cefalea post-puntura durale (PDPH) rimane un problema persistente. In molti casi la cefalea è di media intensità e di breve durata, senza sequele significative, comunque non è sempre così. PDPH è occasionalmente severa abbastanza da lasciare i pazienti coricati a letto e spesso ritarda la dimissione dall’ospedale. PDPH può prolungarsi nel tempo con sintomi riportati che durano mesi o anche anni. Inoltre c’è evidenza che la puntura non intenzionale della dura con ago di Tuohy può portare allo sviluppo di cefalea cronica. PDPH non trattato può portare allo sviluppo di persistente paralisi dei nervi craniali e anche ematoma subdurale. In letteratura è stato descritto un vasto range sia di trattamenti conservativi che invasivi per PDPH, qualche volta con scarso supporto scientifico. Oltre ai trattamenti conservativi come rimanere coricati, l’idratazione, l’utilizzo di caffeina (orale o parenterale) esistono trattamenti invasivi come l’epidural blood patch, come trattamento riservato ai casi in cui i trattamenti conservativi non hanno avuto successo e in quei casi in cui i sintomi sono severi. Oltre ai vari trattamenti possibili per PDPH con particolare attenzione all’EBP, si focalizza l’attenzione sulla controversia se proprio l’EBP dovesse essere proposto a tutti i pazienti con una cefalea post-puntura durale e l’efficacia di questo trattamento nella gestione di PDPH. Inoltre si segnalano le complicazioni legate all’EBP: ematoma subdurale e aracnoidite (causa iniziale o effetto finale?). Per finire viene studiato un caso di trombosi del seno venoso cerebrale dopo una tentata epidurale, eseguita per analgesia per travaglio di parto, complicata da una puntura accidentale della dura e la conseguente cefalea trattata con EBP. Oltre al case report riportato da Ghatge e coll. nel Regno Unito, abbiamo trattato un caso analogo anche nell’ospedale di Lucca, pertanto viene focalizzata l’attenzione sulla gestione di questo caso trattato con successo con l’epidural blood patch

PONV negli interventi di tiroidectomia

Analisi di 300 pazienti sottosti a tiroidectomia, si va a esaminare quanti hanno sofferto di PONV. E' risultato che si sono avuti 93 casi di PONV, 75 per gli OPEN e 18 per le VIDEO

Evaluation of the Wharton׳s jelly poroelastic parameters through compressive tests on placental and foetal ends of human umbilical cords

The umbilical cord is a conduit between the developing foetus and the placenta. In physiological conditions it contains two arteries and one vein immersed in a mucoid tissue called Wharton׳s jelly. Although the extreme importance of such a structure is fully recognized, the umbilical cord and its components have been scarcely studied. A deep investigation on the biomechanics of the umbilical cord could help to understand if the pregnancy outcome is influenced by umbilical cord mechanical properties, however, detailed biomechanical data are still lacking. In the present study, the mechanical properties during compression of the human Wharton׳s jelly have been evaluated using a poroelastic approach. Multi-ramp stress-relaxation tests in both confined and unconfined configurations were performed on Wharton׳s jelly samples extracted from foetal and placental sides of twenty human umbilical cords. The Young modulus and Aggregate modulus were calculated at three strain levels and the hydraulic permeability was found by fitting the confined stress-relaxation data to the analytical solution and minimizing the stress least square differences. The Wharton׳s jelly exhibits a highly non linear and viscoelastic behaviour showing a dependence on the applied strain values and a ~90% and ~85% relaxation in unconfined and confined configuration, respectively. Moreover, equilibrium Young and Aggregate moduli resulted significantly higher and the permeability significantly lower at the foetal than the placental site, showing a dependence of the three material parameters on the location (foetal or placental) and, consequently, a non-homogeneity in the Wharton׳s jelly mechanical properties

Regional lung function and heterogeneity of specific gas volume in healthy and emphysematous subjects.

The aim of our study was to study regional lung function by standard computed tomography (CT) and characterise regional variations of density and specific gas volume (SVg) between different lung volumes. We studied 10 healthy and 10 severely emphysematous subjects. Corresponding CT images taken at high and low lung volumes were registered by optical flow to obtain two-dimensional maps of pixel-by-pixel differences of density (ΔHU) and SVg (ΔSVg) at slice levels near the aortic arch, carina and top diaphragm. In healthy subjects, ΔHU was higher at all levels (p<0.001) with higher variability expressed as interquartile range (p<0.001), largely due to its differences between dorsal and ventral regions. In patients, median ΔSVg values were 3.2 times lower than healthy volunteers (p<0.001), while heterogeneity of ΔSVg maps, expressed as quartile coefficient of variation, was 5.4 times higher (p<0.001). In all patients, there were areas with negative values of ΔSVg. In conclusion, ΔSVg is uniform in healthy lungs and minimally influenced by gravity. The significant ΔSVg heterogeneity observed in emphysema allows identification of areas of alveolar destruction and gas trapping and suggests that ΔSVg maps provide useful information for evaluation and planning of emerging treatments that target trapped gas for removal

On the need of a scale-dependent material characterization to describe the mechanical behavior of 3D printed Ti6Al4V custom prostheses using finite element models

Additive manufacturing is widely used in the orthopaedic industry for the high freedom and flexibility in the design and production of personalized custom implants made of Ti6Al4V. Within this context, finite element modeling of 3D printed prostheses is a robust tool both to guide the design phase and to support clinical eval-uations, possibly virtually describing the in-vivo behavior of the implant. Given realistic scenarios, a suitable description of the overall implant's mechanical behavior is unavoidable. Considering typical custom prostheses' designs (i.e. acetabular and hemipelvis implants), complex designs involving solid and/or trabeculated parts, and material distribution at different scales hinder a high-fidelity modeling of the prostheses.Moreover, uncertainties in the production and in the material characterization of small parts approaching the accuracy limit of the additive manufacturing technology still exist.While recent works suggest that the mechanical properties of thin 3D-printed parts may be peculiarly affected by specific processing parameters (i.e. powder grain size, printing orientation, samples' thickness) as compared to conventional Ti6Al4V alloy, the current numerical models make gross simplifications in describing the complex material behavior of each part at different scales.The present study focuses on two patient-specific acetabular and hemipelvis prostheses, with the aim of experimentally characterizing and numerically describing the dependency of the mechanical behavior of 3D printed parts on their peculiar scale, therefore, overcoming one major limitation of current numerical models. Coupling experimental activities with finite element analyses, the authors initially characterized 3D printed Ti6Al4V dog-bone samples at different scales, representative of the main material components of the investigated prostheses. Afterwards, the authors implemented the characterized material behaviors into finite element models to compare the implications of adopting scale-dependent vs. conventional scaleindependent approaches in predicting the experimental mechanical behavior of the prostheses in terms of their overall stiffness and the local strain distribution. The material characterization results highlighted the need for a scale-dependent reduction of the elastic modulus for thin samples compared to the conventional Ti6Al4V, which is fundamental to properly describe the overall stiffness and local strain distribution on the prostheses.The presented works demonstrate how an appropriate material characterization and a scale-dependent ma-terial description is needed to develop reliable FE models of 3D printed implants characterized by a complex material distribution at different scales

Electrical Impedance Tomography: From the Traditional Design to the Novel Frontier of Wearables

Electrical impedance tomography (EIT) is a medical imaging technique based on the injection of a current or voltage pattern through electrodes on the skin of the patient, and on the reconstruction of the internal conductivity distribution from the voltages collected by the electrodes. Compared to other imaging techniques, EIT shows significant advantages: it does not use ionizing radiation, is non-invasive and is characterized by high temporal resolution. Moreover, its low cost and high portability make it suitable for real-time, bedside monitoring. However, EIT is also characterized by some technical limitations that cause poor spatial resolution. The possibility to design wearable devices based on EIT has recently given a boost to this technology. In this paper we reviewed EIT physical principles, hardware design and major clinical applications, from the classical to a wearable setup. A wireless and wearable EIT system seems a promising frontier of this technology, as it can both facilitate making clinical measurements and open novel scenarios to EIT systems, such as home monitoring

A fully automated micro‑CT deep learning approach for precision preclinical investigation of lung fibrosis progression and response to therapy

: Micro-computed tomography (µCT)-based imaging plays a key role in monitoring disease progression and response to candidate drugs in various animal models of human disease, but manual image processing is still highly time-consuming and prone to operator bias. Focusing on an established mouse model of bleomycin (BLM)-induced lung fibrosis we document, here, the ability of a fully automated deep-learning (DL)-based model to improve and speed-up lung segmentation and the precise measurement of morphological and functional biomarkers in both the whole lung and in individual lobes. µCT-DL whose results were overall highly consistent with those of more conventional, especially histological, analyses, allowed to cut down by approximately 45-fold the time required to analyze the entire dataset and to longitudinally follow fibrosis evolution and response to the human-use-approved drug Nintedanib, using both inspiratory and expiratory μCT. Particularly significant advantages of this µCT-DL approach, are: (i) its reduced experimental variability, due to the fact that each animal acts as its own control and the measured, operator bias-free biomarkers can be quantitatively compared across experiments; (ii) its ability to monitor longitudinally the spatial distribution of fibrotic lesions, thus eliminating potential confounding effects associated with the more severe fibrosis observed in the apical region of the left lung and the compensatory effects taking place in the right lung; (iii) the animal sparing afforded by its non-invasive nature and high reliability; and (iv) the fact that it can be integrated into different drug discovery pipelines with a substantial increase in both the speed and robustness of the evaluation of new candidate drugs. The µCT-DL approach thus lends itself as a powerful new tool for the precision preclinical monitoring of BLM-induced lung fibrosis and other disease models as well. Its ease of operation and use of standard imaging instrumentation make it easily transferable to other laboratories and to other experimental settings, including clinical diagnostic applications

Multiparametric Analysis of Sniff Nasal Inspiratory Pressure Test in Middle Stage Amyotrophic Lateral Sclerosis

The relaxation rates and contractile properties of inspiratory muscles are altered with inspiratory muscle weakness and fatigue. This fact plays an important role in neuromuscular disorders patients and had never been extensively studied in amyotrophic lateral sclerosis (ALS). In this cross-sectional study, these parameters were investigated non-invasively through nasal inspiratory sniff pressure test (SNIP) in 39 middle stage spinal onset ALS subjects and compared with 39 healthy controls. ALS patients were also divided into three subgroups according to a decline in their percentage of predicted forced vital capacity (FVC%pred) as well as a decline in the ALS functional rating scale score and its respiratory subscore (R-subscore) in order to determine the best parameter linked to early respiratory muscle weakness. When compared with healthy subjects, middle stage ALS subjects exhibited a significantly lower (p 30 points in the ALS functional rating scale. In addition, 1/2RT (AUC 0.720, p = 0.01), FVC%pred (AUC 0.700, p = 0.03), τ (AUC 0.824, p < 0.0001), and MRPD (AUC 0.721, p = 0.01) were the parameters more sensitive in detecting a fall of three points in the R-subscore. On the other hand, MRPD (AUC 0.781, p < 0.001), τ (AUC 0.794, p = 0.0001), and percentage of predicted of SNIP (AUC 0.769, p = 0.002) were the parameters able to detect a fall in 30% of the FVC%pred in middle stage ALS patients. The contractile properties and relaxation rates of the diaphragm are altered in middle stage spinal onset ALS when compared with healthy subjects. These parameters are able to discriminate between those middle stage ALS subjects with early decline in inspiratory muscle function and those who not

Reduced probability of improving viro-immunological state in subjects with vertical transmission of HIV reaching adult age: A multicenter retrospective cohort study

Introduction: Young adults with vertical transmission (VT) of human immunodeficiency virus&nbsp;(HIV) represent a fragile population. This study evaluates factors associated with viro-immunological outcome of these patients. Methods: We performed a multicenter study including HIV-infected subjects with VT ≥ 18 years old from six Italian clinics. Subjects were observed from birth to death, lost to follow-up, or last visit until December 31, 2019. Condition of "optimal viro-immunological status" (OS) was defined as the simultaneous presence of HIV&nbsp;ribonucleic acid&nbsp;(RNA) &lt; 50 copies/mL, CD4+ &gt; 500 cells/mm3 , and CD4+/CD8+ ratio ≥ 1. Results: A total of 126 subjects were enrolled. At 18 years of age, 52/126 (44.4%) had HIV-RNA &gt; 50 copies/mL, 47/126 (38.2%) had CD4+ &lt; 500/mm3 , and 78/126 (67.2%) had&nbsp;CD4+/CD8+ &lt; 1; 28 subjects (23.7%) presented in the condition of OS. Having a CD4+/CD8+ ratio ≥ 1 at 18 years of age was related with an increased probability of shift from suboptimal viro-immunological status (SOS) to OS (HR: 7.7, 95% confidence interval [CI]: 4.23-14.04), and a reduced risk of shift from the OS to the SOS (HR: 0.49, 95% CI: 0.26-0.92). Acquired immunodeficiency syndrome (AIDS) diagnosis significantly reduced the probability of shift from a viro-immunological SOS to OS (HR: 0.09, 95% CI:&nbsp;0.03-0.30). Subjects who had not achieved an OS at 18 years of age had an increased risk of discontinuation of combination antiretroviral therapy (cART, p = .019). Conclusions: Only a small proportion of subjects with VT of HIV reached the adult age with "OS".&nbsp;Transition to the adult care with a compromised viro-immunological condition represents a negative driver for future optimal infection control, with a higher risk of discontinuation of cART and a reduced probability to improve the immunological status later in the years