Expiratory flow limitation in intensive care: prevalence and risk factors

Expiratory flow limitation (EFL) is characterised by a markedly reduced expiratory flow insensitive to the expiratory driving pressure. The presence of EFL can influence the respiratory and cardiovascular function and damage the small airways; its occurrence has been demonstrated in different diseases, such as COPD, asthma, obesity, cardiac failure, ARDS, and cystic fibrosis. Our aim was to evaluate the prevalence of EFL in patients requiring mechanical ventilation for acute respiratory failure and to determine the main clinical characteristics, the risk factors and clinical outcome associated with the presence of EFL

Psychological treatments and psychotherapies in the neurorehabilitation of pain. Evidences and recommendations from the italian consensus conference on pain in neurorehabilitation

BACKGROUND: It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams. OBJECTIVES: To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases. METHODS: A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions. RESULTS: The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache. CONCLUSIONS: Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the pape

What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian consensus conference on pain in neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

Experimental analysis of the dynamic behaviour of a real water distribution system

Water distribution networks are traditionally modelled, designed and managed assuming steady flow conditions considering at most Extended Period Simulation (EPS) approach. However, water distribution systems are actually subject to unsteady flow phenomena. The resulting pressure oscillations can potentially cause structural damage to the systems as well as water quality problems due to the intrusion of contaminants or untreated water. Consequently, it is crucial a reliable evaluation of the unsteady flow phenomena in order to assure the pipe system integrity and security. However, examples of experimental analyses of the dynamic behaviour of a real water distribution network are very limited to date and mainly focused on the impact of important operations such as valves or pumps manoeuvres. This paper shows the results of the monitoring and analysis of the dynamic behaviour of a real water distribution network, Gorino Ferrarese (FE, Italy), under ordinary operational conditions. Both pressure and flow were monitored for two days. The dynamic behaviour of the system is thus characterized by an analysis of the pressure fluctuations in the measurement sections. The analysis highlights that all the system is characterized by some predominant low frequencies, related to the network geometry and characteristics. On the other hand, very short pressure oscillations were observed at the measurement sections: they differ according to both the location of the measurement sections – characterized by different density of user connections – and the time of day. These high-frequency pressure signal components can be related to the system management and user demand

Experimental analysis of the dynamic behaviour of a real water distribution system

Water distribution networks are traditionally modelled, designed and managed assuming steady flow conditions considering at most Extended Period Simulation (EPS) approach. However, water distribution systems are actually subject to unsteady flow phenomena. The resulting pressure oscillations can potentially cause structural damage to the systems as well as water quality problems due to the intrusion of contaminants or untreated water. Consequently, it is crucial a reliable evaluation of the unsteady flow phenomena in order to assure the pipe system integrity and security. However, examples of experimental analyses of the dynamic behaviour of a real water distribution network are very limited to date and mainly focused on the impact of important operations such as valves or pumps manoeuvres. This paper shows the results of the monitoring and analysis of the dynamic behaviour of a real water distribution network, Gorino Ferrarese (FE, Italy), under ordinary operational conditions. Both pressure and flow were monitored for two days. The dynamic behaviour of the system is thus characterized by an analysis of the pressure fluctuations in the measurement sections. The analysis highlights that all the system is characterized by some predominant low frequencies, related to the network geometry and characteristics. On the other hand, very short pressure oscillations were observed at the measurement sections: they differ according to both the location of the measurement sections – characterized by different density of user connections – and the time of day. These high-frequency pressure signal components can be related to the system management and user demand

Exploring the impacts of tourism and weather on water consumption at different spatiotemporal scales: evidence from a coastal area on the Adriatic Sea (northern Italy)

The growth of tourism in the last decades has left behind a significant footprint on water resources, which is particularly evident in the regions affected by water scarcity or consistent seasonal population fluctuations. However, only limited efforts were spent in evaluating the effects of tourism on water consumption with regard to specific non-residential users such as bathing facilities. The current work aimed at providing an insight into the effects of seaside tourism on water consumption in a case study coastal area in northern Italy that is typically subjected to high tourist fluctuations throughout the year. Analyses were carried out at multiple spatiotemporal scales—from urban to user level, and from yearly to daily scale—by exploiting hourly flow data collected at the inflow points of the area and at some touristic users (i.e. nine bathing facilities and a holiday home). In addition, the impact of weather—temperature and rainfall—on water use was explored. The study revealed consistent inflow fluctuations in the area concerned based on tourism (with a ratio between the maximum and minimum monthly average inflow of about 15.7) and demonstrated that the touristic component of water inflow was considerably higher than the residential component at the height of tourist season (i.e., 176 L/s against 42 L/s). Moreover, significant variations in the water inflow due to tourism and weather were also observed on a daily scale, along with considerable water consumption fluctuations in bathing facilities

Experimental analysis of the water consumption effect on the dynamic behaviour of a real pipe network

This paper presents the results of the monitoring and analysis of the dynamic behaviour of the Gorino Ferrarese (Ferrara, Italy) water distribution system. The network is subjected to ordinary operational conditions, (i.e. no manoeuvres on pumps or valves are considered), the aim being to show that user demand may generate frequent and not negligible pressure variations. Pressure and discharge were monitored for two days in different sections of the network. The dynamic behaviour of the system is then characterized by analysing the pressure changes at the measurement sections in the time and frequency domains. Such analyses highlight that pressure signals are characterized by long-term changes (low-frequency) on which shorter period (high-frequency) ones overlap. Long-term oscillations show a similar trend at all measurement sections and are characterized by certain dominant frequencies, linked to the topological and mechanical characteristics of the network. Instead, high-frequency pressure fluctuations related to user activity vary in amplitude both spatially and temporally

Heterogeneity of regional inflection points from pressure-volume curves assessed by electrical impedance tomography

Background: The pressure-volume (P-V) curve has been suggested as a bedside tool to set mechanical ventilation; however, it reflects a global behavior of the lung without giving information on the regional mechanical properties. Regional P-V (PVr) curves derived from electrical impedance tomography (EIT) could provide valuable clinical information at bedside, being able to explore the regional mechanics of the lung. In the present study, we hypothesized that regional P-V curves would provide different information from those obtained from global P-V curves, both in terms of upper and lower inflection points. Therefore, we constructed pressure-volume curves for each pixel row from non-dependent to dependent lung regions of patients affected by acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Methods: We analyzed slow-inflation P-V maneuvers data from 12 mechanically ventilated patients. During the inflation, the pneumotachograph was used to record flow and airway pressure while the EIT signals were recorded digitally. From each maneuver, global respiratory system P-V curve (PVg) and PVr curves were obtained, each one corresponding to a pixel row within the EIT image. PVg and PVr curves were fitted using a sigmoidal equation, and the upper (UIP) and lower (LIP) inflection points for each curve were mathematically identified; LIP and UIP from PVg were respectively called LIPg and UIPg. From each measurement, the highest regional LIP (LIPr MAX ) and the lowest regional UIP (UIPr MIN ) were identified and the pressure difference between those two points was defined as linear driving pressure (ΔP LIN ). Results: A significant difference (p < 0.001) was found between LIPr MAX (15.8 [9.2-21.1] cmH 2 O) and LIPg (2.9 [2.2-8.9] cmH 2 O); in all measurements, the LIPr MAX was higher than the corresponding LIPg. We found a significant difference (p < 0.005) between UIPr MIN (30.1 [23.5-37.6] cmH 2 O) and UIPg (40.5 [34.2-45] cmH 2 O), the UIPr MIN always being lower than the corresponding UIPg. Median ΔP LIN was 12.6 [7.4-20.8] cmH 2 O and in 56% of cases was < 14 cmH 2 O. Conclusions: Regional inflection points derived by EIT show high variability reflecting lung heterogeneity. Regional P-V curves obtained by EIT could convey more sensitive information than global lung mechanics on the pressures within which all lung regions express linear compliance. Trial registration: Clinicaltrials.gov, NCT02907840. Registered on 20 September 2016