Evaluating the effect of COVID-19 incidence on Emergency Departments admissions. Results from a retrospective study in Central Italy during the first year of pandemic

Introduction

The COVID-19 pandemic has had a major impact on the Healthcare System, changing the patterns of Emergency Department access. In fact, accesses for trauma and less severe cases decreased significantly. This decline has generally been attributed to both the effects of the lockdown, imposed by the government, and the fear of being infected by SARS-CoV-2 in the hospital. However, the correlation between these elements is not yet clear, since the accesses to the Emergency Department did not increase either at the end of the lockdown or in the summer when the epidemiological situation was more favorable. Aim: To evaluate the association between trends of Emergency Department accesses and COVID-19 incidence in 2020.

Methods

Data on Emergency Department accesses, by month and severity triage code, from 14 hospitals in southeastern Tuscany (Italy) were obtained from hospitals' data warehouse. Official data on new cases of COVID-19 infection were used to calculate incidence. Hospitals were classified into 4 categories. Differences in Emergency Department access by month, triage code, and hospital type were investigated using Kruskal-Wallis analysis. Association between Emergency Department accesses and COVID-19 incidence was evaluated using a random-effect panel data analysis, adjusting for hospital type and triage code.

Results

The trend of 268,072 Emergency Department accesses decreases substantially at the first pandemic peak; thereafter, it increased and decreased again until the minimum peak in November 2020. COVID-19 incidence appeared to be overlapping with an inverse direction. Monthly differences were significant (p<0.01) except for most severe codes. There was a significant inverse association between Emergency Department accesses and COVID-19 incidence (Coef. =-0.074, p<0.001) except for most severe cases (triage code 1: Coef. =-0.028, p=0.154).

Conclusion

Emergency Department admissions trend followed the COVID-19 incidence, except for the most severe cases. Fear of infection seems to discourage patients from accessing Emergency Department for illnesses perceived as not serious.

Safer school with near-UV technology: novel applications for environmental hygiene

Systems capable of disinfecting air and surfaces could reduce the risk of infectious diseases transmission. Aim: to evaluate the effectiveness of near-UV LED ceiling lamps, with a wavelength of 405 nm, in improving environmental hygiene. Between November and December 2020, we conducted an experimental study having a pre-post design in a kindergarten room in Siena where 4 ceiling lamps with 405 nm LED technology were installed. Twice per day, sampling was performed before (T0) and after treatment with near-UV (T1). We used between 8 and 12 pairs of contact plates to sample at various random spots each day. Air samplings were also performed. The plates were incubated at 22 and 36 °C. Significance was set at 95% (p < 0.05). The mean level of Colony Forming Unit (CFU) at T(0) was 249 (95% CI 193.1 - 305.0) at 36 °C and 535.2 (374.3 - 696.1) at 22 °C. The reduction was significant at T(1): by 65% at 36 °C and, 72% at 22 °C. Also, for air contamination: 95.3% (98.4-92.3). A dose threshold of about 5 J/cm² was identified to have an 80% CFU abatement and remains nearly constant. The advantage of being able to use this technology in the presence of people is very important in the context of controlling environmental contamination.

Graphical abstract

Safer school with near-UVA technology: novel applications for Environmental Hygiene

Background

Schools are crowded places where outbreaks can occur. Systems capable of disinfecting air and surfaces could reduce the risk of transmission of infectious diseases.

Aim

to evaluate the effectiveness of a near-UVA (nUVA) LED ceiling lamp in improving environmental hygiene.

Methods

This cross-sectional study was conducted for 2 weeks between November and December 2020 in a kindergarten in Siena, Italy. Four ceiling lamps with LED wavelength of 405 nm were mounted on the room ceiling. The distance of the lamps from the floor was 2.70 m and 2.0 m from the desks. We preliminary selected 12 points in different sites of the room by measuring their irradiance values. We randomly sampled between 8 and 12 pairs of Petri Dishes (PD) daily during the study, incubated at 22 and 36C°, at different irradiation times: 8, 12 or 36 hours. Paired controls were used before using the lamps (at time T0), which were automatically switched ON overnight and compared with treatment (at time T1). Air sampling was also performed at T0 and T1. Statistical analysis was performed with Stata 14. Significance was set at 95% (p &lt; 0.05).

Results

520 PDs were used in the study: 130 PDs at T0 matched at T1 incubated at 36 °C and as many at 22 °C. The mean level of contamination at T0 was respectively 249 CFU (95 % CI 193.1 - 305.0) at 36 °C and 535.2 CFU (374.3 - 696.1) at 22 °C. The reduction was significant (p &lt; 0.05) at T1: we had 87.4 CFU (56.3 - 118.6), equal to 65%, at 36C° and 149.6 CFU (83.7 - 215.4), equal to 72%, at 22C°. Different values were recorded stratifying for dose (irradiance per exposition time). A significant mean percentage reduction of air contamination was 95.3% (98.4 - 92.3).

Conclusions

The system was able to improve the environmental hygiene of the kindergarten. The advantage of using this technology in the presence of people is very important in the context of controlling environmental contamination.

Key messages

• Near-UVA are efficient in reducing the contamination level significantly in a real-life context, on the surfaces and of the air.

• Crowded places favour germ outbreaks. Hygiene control is essential to reduce the risk of transmission of infectious diseases.

COVID-19 incidence on Emergency Departments accesses. Health need and fear of infection, what wins?

Introduction

The COVID-19 pandemic has changed the patterns of access to the Emergency Department (ED), but it is unclear whether this change was due to COVID-19 incidence or the lockdown imposed by law.

Aim

To evaluate the association between trends of ED accesses and COVID-19 incidence in the period 1 January - 31 December 2020.

Material and methods

The data of accesses to the ED per month and severity triage code of 14 hospitals in the Southeast Tuscany (Italy, Provinces of Siena, Arezzo, Grosseto) were obtained from hospitals data warehouses. Data on new cases of COVID-19 infection (obtained by the Ministry of Health) for the 3 provinces were used to calculate the incidence of infection. Hospitals were classified in 4 categories based on beds number, medical specialties offered, services provided. Differences in ED accesses by month, triage code and hospital type were investigated by a Kruskal-Wallis analysis of variance. Association between ED accesses and COVID-19 incidence was evaluated using a random effect panel data analysis adjusting for hospital type and triage code.

Results

A total of 268,072 ED accesses have been studied. Their trends saw a strong decrease in correspondence of the first pandemic peak, subsequently they are increased and then decreased again until the minimum peak in November 2020. COVID-19 incidence appeared to overlap, but in the reverse direction, with ED admissions trends. Monthly differences of the ED accesses were significant (p &lt; 0.01) except for most severity code. There is a statistically significant inverse association between ED accesses and COVID-19 incidence (Coef. = -0.074, p &lt; 0.001) except for most severe cases (triage code 1: Coef. = -0.028, p = 0.154).

Conclusions

ED admissions trends followed the COVID-19 incidence independently from the period of lockdown except for the most severe cases. The fear to contract the infection seemed to discourage patients to access ED for diseases that were perceived as not serious.

Key messages

• The pandemic has changed the lifestyle of people worldwide, modifying even the perception that the patient has of own state of health and their access to Emergency Department.

• The decrease in accesses involved less severe cases. Reflect on both the adequacy of accesses in the pre-pandemic period and on what is the best setting to manage these cases in the pandemic period.

Improvement and standardization of disinfection in Hospital Theatre with UV-C technology

BACKGROUND

The level of disinfection between operating sessions is important to prevent cross-contamination risk in Operating Theatres (OTs). The aim was to assess the difference in microbial contamination between different disinfection levels (DLs), before T(0) and after T(1) application of a UVC Device (UVC-D).

METHODS

A cross-sectional study was conducted between December 2019 and August 2020 in a Clinic. Three DLs: no disinfection after surgery (DL0), after in-between cleaning (DL1), and after terminal cleaning (DL2), were compared to assess the reduction of microbial presence before T(0) and after T(1), the use of UVC-D that was used for 5-3 minutes per bedside. 260 Petri dishes (PD), divided into a preliminary phase followed by a probabilistic model-driven experiment, were used in 3 OTs, and Colony Forming Units (CFU) were counted. The Mann-Whitney test was performed in the preliminary phase to establish UVC exposure time. Using the probabilistic model, we calculated descriptive statistics and % and log₁₀ reduction. The MANOVA analysis for repeated measure was performed to verify the 95% statistical difference between T(0) and T(1), combined with the DLs and different OTs.

RESULTS

The Mann-Whitney showed no CFU difference between 3-5 minutes of UVC exposure time; the MANOVA test for showed no significant difference between DLs in T(0)-T(1) CFU reduction with a mean CFU reduction of 72% (CI95% 61.7 - 84.9%) regardless of the DL applied before.

CONCLUSION

UVC-D enhanced environmental disinfection under any initial conditions. In concert with sainting procedures improves and standardizes the level of environmental hygiene.

[An integrated approach for better contamination control in hospital settings]

Disinfection of hospital environments is a cornerstone of intervention strategies to reduce the risk of hospital-associated infections. Many studies show that standard cleaning procedures are not sufficient for proper disinfection of hospital environments and that the addition of no-touch technologies, such us ultraviolet light, can provide deeper sanitisation. This study aims to test whether the application of ultraviolet light after standard procedures improves hygiene levels in the shortest possible time and shows the degree of contamination before and after irradiation. A cross-sectional study was conducted in a real clinical setting in rehabilitation rooms of a contracted clinic "Rugani Hospital" in Monteriggioni (SI), Italy, between December 2019 and August 2020.the study was carried out according to the following protocol: i) quantization of contamination of 12 selected target points in room; ii) attribution to the points of a probability of contamination risk; iii) sampling of a subset of 6 points with probabilistic assignment; iv) evaluation of the pre-post disinfection environmental hygiene using a UV-C system. For the pre-post statistical analysis the non-parametric Wilcoxon test was used; the multivariate MANOVA was used to verify the role of different confounders, with post hoc Bonferroni test. Probabilistic calculations minimised the samplings required to conclude that the application of the ultraviolet light device reduced the level of contamination in a statistically significant manner (p &lt; 0.01) when comparing pre- and post-exposure, with less irradiation time than indicated by the manufacturer.

Six ultraviolet minutes for cleaner operating theatres

Background

Sanitizing the operating theatres (OT) is important to minimize risk of post-operative infections. Disinfection procedures between one operation and another is less aggressive than final cleaning procedures, at the end of the day. Aim was assessing the difference of contamination: i) between different levels of disinfection; ii) before and after the use of a UVC Device (UVC-D).

Methods

Between December 2019/February 2020 a cross sectional study was conducted in OT in a real clinical context. 94 Petri dishes (PD) were used in 3 OT. Three different sanitation levels (SL1-3) were compared pre- and post-use of UVC-D: i) No cleaning after surgery (SL1); ii) after in-between cleaning (SL2); iii) after terminal cleaning (SL3). UVC-D was employed for 6 minutes, 3 minutes per bed side. PD were incubated at 36 °C and colony forming unit (CFU) counted at 48h. Descriptive statistic, Wilcoxon and Mann-Whitney tests were performed to assess the contamination levels in total, pre/post use of UVC-D, and between different sanitation levels, respectively.

Results

In total we had a mean of 3.39 CFU/PD (C.I. 2.05 - 4.74) and a median of 1 CFU/PD (Min. 0 - Max. 39), after UVC-D use we had a mean of 2.20 CFU/PD (C.I. 0.69 - 5.09) and a median of 0 CFU/PD (Min. 0 - Max. 133). The UVC-D led to a significant reduction of CFU (p &lt; 0.001). Without UVC-D we had a significant CFU drop (p &lt; 0.05) between SL1 and SL3. Using UVC-D, we observed significant reductions of contamination (p &lt; 0.05) between SL3 and SL1. Comparing SL1 (median 0) post UVC-D use vs SL2 pre UVC-D use (median 0.5), and SL2 post UVC-D use (median 0) vs SL3 pre UVC-D use (median 1) we had a significant reduction of contamination (p &lt; 0.05).

Conclusions

UVC-D improved environmental contamination in any of the three sanitation levels. Furthermore, the use of UVC-D alone was better than in-between and terminal cleaning. Although these encouraging results, the cleaning procedures executed by dedicated staff has to be considered.

Key messages

UVC are efficient to decrease contamination in operating theatres regardless of sanitation levels. The additional use of UVC technology to standard cleaning procedures significantly improves sanitation levels.

Analytical approach for a better control of environmental contamination

Background

The environment of hospital rooms plays a role on Hospital Acquired Infections. Objects may be repository of germs and have a role on cross contamination, mainly in high-touch surfaces. Proper sanitation and disinfection procedures are needed.

Aims

i) to highlight the different probabilities of microbial contaminations in Hospital, ii) to assess whether the use of a UVC device (UVC-D), after standard disinfection procedures, improves the level of hygiene.

Methods

Between November 2019 and February 2020 a cross sectional study in a real clinical context was conducted. Investigations were carried out in double rehabilitation rooms with patients admitted for at least 48h. 16 preliminary Petri dishes (PD) were used in one rehabilitation room and bathroom, to assess the contamination level after deep disinfection procedures (T0). Matched comparisons were made after the use of UVC-D, 3 points/room and 1 point/bathroom, 3 minutes each(T1). At T0 we estimated the probability of contamination to select the following sampling. Six rooms and bathrooms were investigated using randomized spots. PD were incubated at 36 °C and colony forming unit (CFU) counted at 48h. Descriptive statistic and Wilcoxon test were performed to assess the levels of contamination between (T0) and (T1).

Results

At T0 we have a mean of 5.83 CFU/PD (CI 3.79-7.86) and a median of 1.0 CFU/PD (min 0 - max 118); at T1 mean is 0.28 CFU/PD (CI 0.15-0.40) and median of 0 CFU/PD (min 0-max 5). Significant reduction of contamination was achieved between T0 and T1 (p &lt; 0.001). 83,33% of the contamination sites had 0 CFU/PD after using UVC-D.

Conclusions

The probability approach has driven the selection of the highest contaminations spots. Standard disinfection, followed by using UVC-D, significantly reduces contamination assuring a lower probability of cross contamination and risk of infection.

Key messages

Analytical approach to assess the contamination level of room to address with greater precision the points with higher risk of cross contamination. The UVC technology assures better results when associated with standard sanitation procedure decreasing the risk of hospital acquired infections.

Organ donation and transplantation in migrants: Piedmont reality from 2004 to 2011

BACKGROUND

Over the last 20 years, an increasing number of people have immigrated into Italy. On January 1, 2011, there were 4,570,317 foreign residents in Italy, including 398,910 in the Piedmont region (Italian National Statistics Institute data). The Romanian community was the largest, followed by the Moroccan and Albanian ones. The numbers are even layer if we consider illegal immigrants. As a result, the number of foreign people with brain death has increased, as well as the number of foreign people needing organ transplantations.

METHODS

The Piedmont Regional Coordination Agency of Tissue and Organ Procurement has analyzed our 1781 brain death situations between January 2004 and December 2011, including 126 (7%) in people not born in Italy (migrants).

RESULTS

Non-refusal for donation occurred in 79 cases (62.7%). The agency also analyzed each community looking at number of brain deaths and non-refusals of donation. We utilized 61 donors, for 174 transplantations. Migrants in Italy are not only potential tissue and organ donors, but also potential tissue and organ recipients. Between 2004 and 2011, 222 patients who had not been born in Italy had been transplanted with: a liver (n = 66), a kidney (n = 130), a heart (n = 21) or a lung (n = 5).

Fine tuning of protein kinase C (PKC) isoforms in cancer: shortening the distance from the laboratory to the bedside

The serine/threonine protein kinase C (PKC) family was first identified as intracellular receptor(s) for the tumor promoting agents phorbol esters. Thirty years after the discovery of PKC, the role of specific PKC isoforms has been described in relationship with an altered pattern of expression in different types of cancer and a good number of small molecule inhibitors (inhibitory peptides, antisense oligonucleotides or natural compounds) targeting PKC are now available. Despite all these achievements and a huge amount of basic research studies on the biochemical regulation of PKC, there has been a delay in clinical trials with drugs targeting PKC function. This delay is easily explained taking into account the extreme biological complexity of the PKC family of isoforms and the incomplete understanding of the specific role of each PKC isozyme in different types of cancers. Some of the difficulties in developing pharmacological compounds selectively tuning the different PKCs have started to be overcome. In this review, the growing evidences of the role of the PKC isoforms α, βII, δ, ε, ζ and ι is in promoting or counteracting tumor progression will be discussed in relationship with promising therapeutic perspectives.

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases

BACKGROUND

When the conservative treatment is not recommended, Nipple Sparing Mastectomy (NSM) is proposed more and more frequently for the surgical treatment of breast cancer. The risk of local recurrence behind the nipple areolar complex (NAC) is the main limiting factor of the NSM procedure. To minimize such risk, we proposed in 2002 a intraoperative radiotherapy of the preserved NAC.

PATIENTS AND METHODS

From March 2002 to November 2006, 579 cases (in 570 patients) of NSM were performed for carcinoma. The median follow up time was 19 months (Range: 1-60). The subcutaneous mastectomy was performed through an incision removing a portion of the skin overlying the tumour. An extemporaneous histological examination was performed on the retroareolar glandular tissue. If the histology was positive the patient was not considered eligible. Then an intraoperative radiotherapy with electrons (ELIOT) of 16 Gy in one shot was delivered on the NAC area. An immediate breast reconstruction was done using implants in most cases and in several cases a musculocutaneous flaps, usually in large breast. The number of local recurrences was recorded and the correlation between their occurrence and the clinical and histological criteria were analysed using the Gray test statistical method in a competing framework.

RESULTS

In 516 cases the negative retroareolar frozen section biopsy was confirmed by the final histology, while in 63 cases, the final histology showed foci of carcinoma. Seven out of these 63 cases underwent a secondary NAC removal. In the 56 cases which preserved areolas we did not observe any local recurrence after 19 months follow up. The probability of retro areola positive histology increases with the tumour size. and was not related to the nodal status. The rate of local relapses was 0.9% per year. We didn't find any significant difference in the local relapse rate according to different patient's and tumour's features. Most relapses were located close to the tumour bed but never in the NAC area.

CONCLUSION

Our study confirms that the local recurrence rate in the NSM completed with local radiotherapy on the NAC is not higher than the usual rate observed in the literature and the preservation of the NAC does not increase the risk. The absence of local recurrence in the region where a portion of glandular tissue has been purposely preserved is a good argument in favour of ELIOT.

[The role of skin expansion: giant nevi of the hand]

The Authors, after considering the epidemic and evolution of giant nevi, present their surgical protocol for giant melanocitic nevi of the hand. Their experience is based on 2 cases, but the rarity of these lesions of the hand, the reconstructive technique used and the results obtained justify the report in detail. The Authors used in both cases an expanded groin flap to repair the postexcisional wound. Skin expansion allowed both to obtain flaps, which were wide and reliable, and to close primarily the donor areas. The definitive resorption of the subcutaneous fat caused by the expansion allowed to obtain thin and adaptable flaps, which ensured excellent results also in areas of primary functional value, such as the hand. In both cases, the expanded going flap was used to repair the dorsum of the hand. In one case the lateral and medial parts of the fingers were repaired with skin grafts.

[Prosthetic rehabilitation with endosseous implants in fibular free flaps reconstructed mandibles]

Mandibular defect following neoplasm resection involves severe alterations in morphology. Today, however, these alterations can be repaired with the use of revascularized free flaps. Chewing can be returned to normal, or at least to an acceptable level, thanks to the insertion of endosseous implants, used both to support the fixed prosthesis and the mobile prosthesis (overdenture). The present work reports the Authors' experience with 5 patients who underwent compound mandibular resection and reconstruction with revascularized fibula free flaps. In all cases the mandible was totally toothless and rehabilitation called for the insertion of a total prosthesis held by a bar secured to the endosseous implant. In 2 cases the implants were inserted at the time of reconstruction. Four patients completed the rehabilitation program, with a 93% (14/15) implant success rate. All were able to return to a normal diet. Likewise the aesthetic results were valid. The main problem was to achieve an adequate interface between the soft tissues and the implants.

[Platysma myocutaneous flap in oral cavity reconstruction]

Repairing soft oral tissues which have been removed for oncological reasons is as dauting as it is important. Currently there are many, often sophisticated, methods available but any search for the best possible results must also cause the least patient trauma. The pedicled myocutaneous platysma flap is not new to oral cavity reconstruction although it is not very widespread. We have occasionally used this surgical anatomy, the cases are presented. This flap was performed in 10 cases and proved quite effective; there was no case of total failure as indicated by an orocutaneous fistula. Cutaneous necrosis, partial or total, was seen in 4 cases although it did healed by second intention. The other reconstructive methods are then discussed along with the indications and contraindications as well as some technical insight. One can conclude that the myocutaneous platysma flap is a relatively simple, highly versatile solution although reliability is not the best. The Authors conclude that it is advisable for the surgeon to include the myocutaneous platysma flap as part of his therapeutic arsenal.

[Gallstone ileus]

Gallstone ileus is a rare condition whose diagnosis may be difficult. From January 1976 to December 1991 4 cases of gallstone ileus were treated in our hospital, representing 1% of all patients admitted with mechanical bowel obstruction during that period. Three patients were treated by enterolithotomy alone to remove the impacted stone. In one patient intestinal resection of the bowel tract was associated followed by end to end anastomosis. One patient died (33%) seven days after surgery for cardiopulmonary failure. In one patient the obstruction resolved with the passage of a stone per rectum. The Authors conclude that enterolithotomy alone should be the standard procedure for gallstone ileus. The repair of cholecyst-enteric fistula should be done later only if there are continuing or recurrent symptoms.

[Bilateral pneumonia caused by Chlamydia psittaci. Description of a clinical case]

A mortal case of atypical pneumonia due to Chlamydia psittaci with acute respiratory distress, septic shock and multiple organ failure is described. Infection has been caused by an ill parrot imported clandestinely. Antibody titration with the immunofluorescence technique allowed diagnosis.

A sensitive immunochemiluminescence assay for human serum amyloid A protein

We describe an immunochemiluminescence assay for human plasma serum amyloid A protein (SAA) in which specific rabbit polyclonal antibodies against synthetic peptides are used. The detection of the antigen-antibody reaction at 425 nm is based on a brief emission of light by a luminophor component (signal) in response to chemical energy. The working range of the assay covers plasma SAA concentrations from 5 to 100 micrograms/L. The lower detection limit is 5 micrograms/L, the within- and between-assay CVs are less than 12%. Bilirubin, cholesterol and triglyceride in final concentrations of up to 220 mumol/L, 8.1 mmol/L and 2.68 mmol/L, respectively, do not interfere with the assay. Results were correlated with those obtained by the enzyme-linked immunosorbent assay using the same antibodies (r = 0.95; p less than 0.001; n = 50). This method is inexpensive, simple and easily automated.

[5 patients in irreversible coma in which it was not possible to remove the organs for therapeutic transplant]

The special committee consisting of a neurologist, an anaesthesist and a forensic doctor, refused transplantation permission since spinal reflexes were present. These reflexes persisted until cardiac death occurred. Brain death was diagnosed by instrumental techniques and was confirmed by necropsies.

[Holter's ECG monitoring in esophagogastroduodenoscopy. Premedication with tiropramide. Preliminary notes]

Endoscopy of the upper digestive tract with flexible instruments is presently a safe, widely used technique in gastrointestinal pathology. Some cases of changes in cardiac rhythm, ventricular fibrillation, ischaemia and cardiac arrest, have, however, been observed during EGDS. The incidence of arrhythmias during EGDS in 41 patients, monitored during the examination with Holter's ECG, has been observed. The results obtained confirm that EGDS does not bring noteworthy cardiovascular changes sufficient to suspend the examination. The absence of parasympathicomimetic effects makes it possible to consider thyropramide one of the drugs of choice in medication before EGDS.

[Antipollution system for operating rooms. Critical assessment and testing of a new system]

Following a rapid review of equipment available for the depolluting of operating theatres, new equipment which does not interfere with anaesthesia circuit pressures is presented; experimental data obtained during use of this equipment are also reported and compared with standard data.