Ultrasound in spinal anaesthesia - is there a place?

L'anestesia subaracnoidea è una tecnica ampiamente diffusa e praticata. La tecnica generalmente viene eseguita alla “cieca”; tramite la palpazione cutanea della regione dorso lombare si identificano i reperi anatomici, i processi spinosi, e si procede all’introduzione dell’ago atraumatico alla ricerca dello spazio subaracnoideo. La non sempre facile identificazione dei reperi anatomici di riferimento, come ad esempio nel paziente obeso, la presenza di patologia del rachide (scoliosi, artrosi, etc) ed esiti di interventi chirurgici (laminectomia, stabilizzazione vertebrale) possono talvolta rendere difficile l’esecuzione di tale tecnica; gli eventuali ripetuti tentativi costituiscono da un lato un aumento del disagio per il paziente e dall’altro un aumento del rischio di complicanze quali parestesie, cefalea postpuntura durale, ematomi spinali. La tecnica con ultrasuoni è ecoassistita, ovvero l’anestesia subaraconoidea viene eseguita dopo aver effettuato uno scanning della regione dorso-lombare al fine di identificare gli elementi anatomici. La possibilità di identificare ecograficamente la posizione della dura madre tra le due vertebre e la sua profondità può rendere l'esecuzione della tecnica più sicura e più semplice da eseguire, anche in condizioni particolari con ovvi vantaggi conseguenti. La letteratura inerente all’argomento è crescente e non ancora dirimente sul fatto che gli ultrasuoni possano effettivamente giovare all’esecuzione della anestesia subaracnoidea nella pratica quotidiana. Mentre gli ultrasuoni sono ormai ampiamente utilizzati in tutti gli ospedali per eseguire i blocchi nervosi periferici ed esiste abbondante letteratura che ne suggerisce l’impiego routinario, non esiste ad oggi una letteratura conclusiva sul loro utilizzo nell’anestesia neuro assiale

Analgesia post-operatoria mediante due differenti anestetici locali per via peridurale

Il posizionamento del catetere peridurale, oltre che migliorare la tecnica anestesiologica durante un intervento chirurgico, risulta vantaggioso anche per il controllo del dolore post-operatorio. Con la PCEA (Patient Controlled Epidural Analgesia) la terapia del dolore diviene allo stesso tempo terapia continua e terapia al bisogno: la prima viene attuata mediante una pompa che consente l'infusione nello spazio peridurale di una miscela di farmaci ad effetto analgesico; la seconda è resa possibile dalla presenza di un pulsante, mediante il quale il paziente può autosomministrarsi un bolo aggiuntivo qualora avvertisse dolore. I farmaci impiegati sono generalmente un'associazione di un oppioide con un anestetico locale; il loro uso, tuttavia, non è esente da effetti collaterali, tra i quali prurito, blocco motorio, nausea, vomito, ritenzione urinaria, ipotensione, depressione respiratoria. Confrontare i due anestetici locali Ropivacaina e Levobupivacaina, che vengono imipiegati nella pratica clinica in associazione all'oppioide Sufentanil, ha permesso di valutare se ci siano differenze nell'incidenza di effetti collaterali e nel controllo del dolore tra i due farmaci in modo da poter ottimizzare i protocolli terapeutici del dolore acuto post-operatorio

Propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa Representaciones Malca E.I.R.L. Utcubamba 2017

El objetivo general de la presente investigación fue elaborar una propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa Representaciones Malca E.I.R.L. Utcubamba 2017, considerando como hipótesis que: si se implementa una propuesta de estrategias en las cuentas por cobrar entonces se mejorará la liquidez de la empresa Representaciones Malca E.I.R.L. Utcubamba 2017. La metodología se basó en una investigación de tipo descriptivo, propositivo de diseño no experimental, transversal, así mismo, se utilizó el método deductivo inductivo y el método del análisis para llegar a las conclusiones generales de la investigación; la recolección de datos se realizó a través de un cuestionario y análisis financiero. Los resultados evidenciaron que durante el año 2016 existió un mayor nivel de liquidez en comparación con el año actual, lo que demuestra la tendencia negativa de la empresa en el manejo de sus recursos económicos y financieros, así como la disminución de sus ingresos en comparación con sus obligaciones internas y externas, por otra parte se logró determinar que la empresa durante el 2017 no logra cubrir sus deudas, pues por cada sol de deuda dispone de S/0.38 para pagarlo, es decir, no está en condiciones de pagar la totalidad de sus pasivos a corto plazo. Se concluye que el diseño de una propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa Representaciones Malca E.I.R.L, es necesaria pues actualmente no existe una planificación ni mucho menos una serie de acciones estratégicas que se enfoquen en recuperar las cuentas por cobrar, el estudio demuestra que la empresa carece de políticas estandarizadas de otorgamiento de créditos, no dispone de personal suficiente para el área de recuperación de cuentas por cobrar, carece de una planificación y responsables de las ventas al crédito, lo que influye en su bajo nivel de liquidez

Propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa Representaciones Malca E.I.R.L. Utcubamba 2017

El objetivo general de la presente investigación fue elaborar una propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa RepresentacionesMalca E.I.R.L. Utcubamba 2017, considerando como hipótesis que: si se implementa una propuesta de estrategias en las cuentas por cobrar entonces se mejorará la liquidez de la empresa Representaciones Malca E.I.R.L. Utcubamba 2017. La metodología se basó en una investigación de tipo descriptivo, propositivo de diseño no experimental, transversal, así mismo, se utilizó el método deductivo inductivo y el método del análisis para llegar a las conclusiones generales de la investigación; la recolección de datos se realizó a través de un cuestionario y análisis financiero. Los resultados evidenciaron que durante el año 2016 existió un mayor nivel de liquidez en comparación con el año actual, lo que demuestra la tendencia negativa de la empresa en el manejo de sus recursos económicos y financieros, así como la disminución de sus ingresos en comparación con sus obligaciones internas y externas, por otra parte se logró determinar que la empresa durante el 2017 no logra cubrir sus deudas, pues por cada sol de deuda dispone de S/0.38 para pagarlo, es decir, no está en condiciones de pagar la totalidad de sus pasivos a corto plazo. Se concluye que el diseño de una propuesta de estrategias en las cuentas por cobrar para mejorar la liquidez de la empresa Representaciones Malca E.I.R.L, es necesaria pues actualmente no existe una planificación ni mucho menos una serie de acciones estratégicas que se enfoquen en recuperar las cuentas por cobrar, el estudio demuestra que la empresa carece de políticas estandarizadas de otorgamiento de créditos, no dispone de personal suficiente para el área de recuperación de cuentas por cobrar, carece de una planificación y responsables de las ventas al crédito, lo que influye en su bajo nivel de liquidez

Effective targeting of breast cancer stem cells by combined inhibition of Sam68 and Rad51

: Breast cancer (BC) is the second cause of cancer-related deceases in the worldwide female population. Despite the successful treatment advances, 25% of BC develops resistance to current therapeutic regimens, thereby remaining a major hurdle for patient management. Current therapies, targeting the molecular events underpinning the adaptive resistance, still require effort to improve BC treatment. Using BC sphere cells (BCSphCs) as a model, here we showed that BC stem-like cells express high levels of Myc, which requires the presence of the multifunctional DNA/RNA binding protein Sam68 for the DNA-damage repair. Analysis of a cohort of BC patients displayed that Sam68 is an independent negative factor correlated with the progression of the disease. Genetic inhibition of Sam68 caused a defect in PARP-induced PAR chain synthesis upon DNA-damaging insults, resulting in cell death of TNBC cells. In contrast, BC stem-like cells were able to survive due to an upregulation of Rad51. Importantly, the inhibition of Rad51 showed synthetic lethal effect with the silencing of Sam68, hampering the cell viability of patient-derived BCSphCs and stabilizing the growth of tumor xenografts, including those TNBC carrying BRCA mutation. Moreover, the analysis of Myc, Sam68 and Rad51 expression demarcated a signature of a poor outcome in a large cohort of BC patients. Thus, our findings suggest the importance of targeting Sam68-PARP1 axis and Rad51 as potential therapeutic candidates to counteract the expansion of BC cells with an aggressive phenotype

Genetic subtypes of smoldering multiple myeloma are associated with distinct pathogenic phenotypes and clinical outcomes

Smoldering multiple myeloma (SMM) is a precursor condition of multiple myeloma (MM) with significant heterogeneity in disease progression. Existing clinical models of progression risk do not fully capture this heterogeneity. Here we integrate 42 genetic alterations from 214 SMM patients using unsupervised binary matrix factorization (BMF) clustering and identify six distinct genetic subtypes. These subtypes are differentially associated with established MM-related RNA signatures, oncogenic and immune transcriptional profiles, and evolving clinical biomarkers. Three genetic subtypes are associated with increased risk of progression to active MM in both the primary and validation cohorts, indicating they can be used to better predict high and low-risk patients within the currently used clinical risk stratification models

Construindo uma reflexão coletiva sobre a noção de sustentabilidade a partir de percepções de agroecologia e agricultura familiar

Fruto de anos de reflexão com apoio do CNPq (Edital REPENSA 22/201 0), um grupo dedocentes e pesquisadores de várias regiões brasileiras buscaram sintetizar reflexões e oentorno de um dos temas mais polissêmicos da contemporaneidade – Sustentabilidade e suas imbricações com as lógicas familiares de produção. Outro aspecto importante que sepode ressaltar é o uso do Marco para la Evaluación de Sistemas de Manejo de Recursos Naturales incorporando Indicadores de Sustentabilidad (MESMIS) em distintas realidades e regiões na perspectiva sistêmica. Tal “utopia”, quem sabe, pode nos dar essa resposta, pois, como dizem Fernando Birri e Eduardo Galeano, ela é como o horizonte: nós o vemos, ao longe, porém nunca o alcançaremos; mas serve para que continuemos sempre a caminhar. Talvez a sustentabilidade seja assim: significa o próprio processo da caminhada por um ideal que nos motiva a caminhar incessantemente por sua afirmação. O objetivo do presente ensaio foi o de apresentar uma noção de sustentabilidade capaz de contemplar não só as diferentes experiências de ensino, pesquisa e extensão dos autores, como, também, que retrate as diferentes realidades da agricultura familiar de base ecológica inseridas em diferentes regiões brasileiras

EBF1, MYO6 and CALR expression levels predict therapeutic response in diffuse large B-cell lymphomas

BackgroundDiffuse large B-cell lymphoma (DLBCL) is a hematological malignancy representing one-third of non-Hodgkin’s lymphoma cases. Notwithstanding immunotherapy in combination with chemotherapy (R-CHOP) is an effective therapeutic approach for DLBCL, a subset of patients encounters treatment resistance, leading to low survival rates. Thus, there is an urgent need to identify predictive biomarkers for DLBCL including the elderly population, which represents the fastest-growing segment of the population in Western countries.MethodsGene expression profiles of n=414 DLBCL biopsies were retrieved from the public dataset GSE10846. Differentially expressed genes (DEGs) (fold change >1.4, p-value <0.05, n=387) have been clustered in responder and non-responder patient cohorts. An enrichment analysis has been performed on the top 30 up-regulated genes of responder and non-responder patients to identify the signatures involved in gene ontology (MSigDB). The more significantly up-regulated DEGs have been validated in our independent collection of formalin-fixed paraffin-embedded (FFPE) biopsy samples of elderly DLBCL patients, treated with R-CHOP as first-line therapy.ResultsFrom the analysis of two independent cohorts of DLBCL patients emerged a gene signature able to predict the response to R-CHOP therapy. In detail, expression levels of EBF1, MYO6, CALR are associated with a significant worse overall survival.ConclusionsThese results pave the way for a novel characterization of DLBCL biomarkers, aiding the stratification of responder versus non-responder patients

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research