Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke

BACKGROUND

Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF.

METHODS

The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed.

RESULTS

Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results.

CONCLUSION

MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.

Education in Urban Health: the experience of Public Health residents in an Italian high school

Background

Urban health has become an increasingly important aspect of Public Health curriculum for residents as people living in urban areas will substantially rise in the next 30 years so will their impact on health. Residents are both contributors and partners in creating sustainable solutions for their growing cities and can be involved in this aim as individual learners and also educators for younger students.

Objectives

A group of 15 Italian residents in Public Health were involved in creating and delivering 4 lessons on urban health to 319 students at Nomentano High School in Rome during spring 2022. After the 4th lesson, semi-structured interviews were conducted with the residents in order to assess perceptions, acceptance, barriers and facilitators of the experience. Data was gathered anonymously and analyzed using standard qualitative methods.

Results

All the residents answered the interview. Almost all reported the experience as highly impactful for training, team building, and increase in accountability. Most of residents also felt more confident on the topic of urban health and more involved in concrete actions for tackling pollution and climate change after delivering the lessons. Most perceived barriers mentioned were difficulties interacting with students, especially during the first two lessons, and their compliance. The opportunity to give lessons in the high school setting facilitated direct contact with students and better feedback was received.

Conclusions

Giving responsibility and leadership roles to Public Health residents and involving them in the education of younger students could improve their self-confidence and feelings of value and helpfulness, especially for urban health and climate change issues sensed by youth. Further experiences in other settings, specialties, and countries could be valuable to notice differences related to age groups and personal involvement.

Key messages

• The involvement of Public Health residents in education on urban health is highly impactful and well perceived for their personal growth.

• This kind of experience is applicable to other relevant topics in Public Health.

Increasing urban health awareness using an interactive approach: evidence from a school-based study

Issue

Urbanization is a cause of climate change, as cities are where these changes are most visible. Climate change also leads to significant inequalities and health issues in urban settings. In this context, urban health promotion is mandatory to increase adaptive capacity. Since the late 1980s the World Health Organization (WHO) has emphasized schools’ role in promoting health, as they can play a crucial role in increasing health awareness to future urban inhabitants.

Description

The objective of this pre/post-interventional study is to measure the awareness of urban health and green spaces among high school students and to rise it through an educational intervention. Four interactive sessions were delivered to 319 students from 13 to 18 years old in a high school in Rome, Italy during spring 2022. Data was gathered anonymously and analysed using descriptive and inferential statistics.

Results

A total of 192 (60%) students successfully completed the pre/post-intervention surveys. An increase in students’ knowledge of urban health and urban green areas was observed. Before the intervention 11.8% of participants were aware of urban health, whereas after the intervention 87.5% were aware. A rise across different areas appeared to be related to how many times the teachers repeated that concept during the intervention. For topics discussed in more than one session, the increase in correct answers averaged 13.9%. Two different trends emerged from the data analysis: one whose post-intervention test improved on most of questions and one whose post-intervention test remained unchanged.

Lessons

The results of the present study suggest that school-based interventions using interactive approaches on climate change and urban health are effective for increasing the knowledge level of scholars on these topics, and can be a useful way to promote health in an urban setting. This type of approach maintains high levels of concentration and interest in most students.

Key messages

• Urban health training activities in schools are needed to empower youth who live in urban settings.

• Interactive sessions keep student concentration high and improve their participation.

Training needs assessment of European healthcare workers on vaccinology and vaccine acceptance

Background

Healthcare workers (HCWs) are at the frontline of interaction with those that are taking decisions around vaccination. They need adequate training. The general aim of this systematic review is to assess HCWs’ training needs on vaccinology and vaccine acceptance. This work was performed for the European Centre for Disease Control (ECDC) under the specific contract No 1ECD.12108 ID.12922 implementing the framework contract number ECDC/2021/005.

Methods

The search was performed using MEDLINE, Scopus and Google Scholar databases in February 2022. The following inclusion criteria were used: date (from 01/01/2011 to 24/02/2022); language (English, Italian, Portuguese, Spanish, French and Romanian); geographic location of the study (Europe). Appraisal tool for Cross-Sectional Studies (AXIS checklist) was used to assess the methodological quality of the included papers.

Results

The scientific literature search retrieved 640 results on PubMed, 556 on Scopus and 15 on Google Scholar. In total, 1211 records were identified. After the duplicate removal and the title/abstract assessment, 132 publications were assessed for eligibility. Finally, after the full-text assessment, only 25 articles were included. As regards for the quality assessment, all studies were judged of moderate-good quality. The majority of studies stressed the need to deepen general knowledge of vaccine preventable diseases, vaccine efficacy, vaccination schedule and adverse effects of vaccines.

Conclusions

Considering their role in the community, especially as source of information and trust for vaccine acceptance, educational initiatives in vaccinology and vaccine hesitancy should be prioritized for HCWs, aimed at increasing their knowledge, awareness, and attitudes. An important heterogeneity of educational backgrounds, activities performed and training needs of the HCWs involved in vaccination at European level was one of the main critical issue to be addressed for future actions.

Key messages

Internuclear Ophthalmoplegia as an Isolated Symptom of Brainstem Wake-up Stroke Responsive to Intravenous Thrombolysis: Evidence from MRI

BACKGROUND

Internuclear ophthalmoplegia (INO) is a disorder of eye movements caused by a lesion involving the medial longitudinal fasciculus (MLF) within the brainstem, and it is characterized by adduction impairment combined with contralateral dissociated abduction nystagmus. The frequency of acute ischemic stroke (AIS) presenting with INO as a predominant symptom is very low, and many patients suffering from this brainstem AIS are precluded from intravenous thrombolysis (IVT).

OBJECTIVE

To provide for the first time a magnetic resonance imaging (MRI) evidence of response to the IVT in brainstem wake-up stroke presenting with INO as an isolated symptom.

METHODS

Here, we described a rare case of pons AIS presenting with INO as a unique symptom of awakening. In order to differentiate an ischemic stroke from other stroke mimics, and to determine whether the patient was within the therapeutic window for IVT (wake-up stroke), brain MRI including DWI and FLAIR sequences was acquired.

RESULTS

A left paramedian pontine DWI/FLAIR mismatch was detected and the patient was considered eligible for IVT. After IVT, the patient made a full recovery with complete resolution of INO. Follow-up MRI at 1 month demonstrates the absence of ischemic lesions.

CONCLUSION

Our case provides neuroradiological evidence of IVT efficacy in brainstem stroke, and it should prompt clinicians to rapidly perform MRI in wake-up onset INO and to just as quickly administer IVT, since INO is a functionally disabling deficit. Finally, this case demonstrates the value of MRI in diagnostic, prognostic, and therapeutic workup of posterior circulation wake-up stroke.

Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review

Introduction

Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment.

Methods

A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles.

Discussion

This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided.

Conclusions

Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.

Anthelmintic activity of Stevia multiaristata extract against Echinococcus granulosus sensu stricto

Cystic echinococcosis is a zoonotic disease caused by the larval stage of the parasite Echinococcus granulosus sensu lato. The available anti-parasitic treatment is mostly limited to a continuous administration of albendazole. However, due to its numerous side-effects and efficacy of around 50%, there is a need to find new drugs to improve the treatment for this disease. In the current study, the in vitro and in vivo efficacy of a Stevia multiaristata extract against E. granulosus sensu stricto (s.s.) was demonstrated. Stevia multiaristata extract (100 and 50 μg mL−1) caused a quick viability decrease on protoscoleces which was consistent with the observed tegumental alterations. Loss of turgidity was detected in 95 ± 3.4% of cysts incubated with S. multiaristata extract during 2 days (100 μg mL−1) and the collapse of the germinal layer was observed in 60 ± 9.3% of cysts treated with 100 μg mL−1 of the S. multiaristata extract during 4 days. The half maximal effective concentration value was 69.6 μg mL−1 and the selectivity index for E. granulosus s.s. cysts was 1.9. In this clinical efficacy study, the treatment of infected mice with the S. multiaristata extract (50 mg kg−1) caused a significant decrease in the weight of the cysts compared with the control group. These results coincided with the tissue damage observed in the cysts at the ultrastructural level. In conclusion, we observed high protoscolicidal and cysticidal effects, and significant reduction in the weight of the cysts in experimentally infected mice following treatment with the S. multiaristata extract.

Mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation and low baseline National Institute of Health Stroke Scale score: a multicenter retrospective matched analysis

BACKGROUND AND PURPOSE

The benefit of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and baseline mild neurological symptoms remains unclear. The purpose of this study was to evaluate the effectiveness of MT in this subgroup of patients.

METHODS

The databases of 9 high-volume Italian stroke centers were retrospectively screened for patients with LVO in the anterior circulation and a baseline National Institute of Health Stroke Scale (NIHSS) score ≤ 5 that received either immediate MT or best medical management (BMM) with the possibility of rescue MT upon neurological worsening. Primary outcome measure was a modified Rankin Scale score of 0-1 at 90 days. Propensity score matching (PSM) analysis was used to estimate the treatment effect of immediate MT compared to BMM/rescue MT.

RESULTS

Two hundred and seventy-two patients received immediate MT (MT group). The BMM/rescue MT group included 41 patients. The primary outcome was achieved in 78.6% (n = 246) of overall patients, with a higher proportion in the MT group (80.5% vs. 65.9%, p = 0.03) in unadjusted analysis. After PSM, patients in the MT group had a 19.5% higher chance of excellent outcome at 90 days compared to the BMM/Rescue MT group with a similar risk of death from any cause.

CONCLUSIONS

Our experience is in favor of a potential benefit of MT also in patients with LVO and a NIHSS score ≤ 5 at the time of groin puncture. Nonetheless, this issue waits for a clear-cut recommendation in a dedicated clinical trial.

Diagnostic and therapeutic pathway for pain in a Continuing Care setting: a survey at an Italian Continuing Care Service

Background

Law no. 38 of 15 March 2010 ensures and governs the access to the palliative care and pain management network for patients who require it. The professional roles involved in the project have been identified by the law, with the specific experience and expertise in the field of palliative care and pain management, by allocating a meaningful role to general practitioners (GPs). For this reason, an important direct training plan has been drawn up that GPs can count on for dedicated refresher courses to increase and deepen their knowledge in this specific clinical field. If the role of the GPs in the pain management and palliative care network was well-defined by the law, we cannot say the same for the Continuing Care Physician (CCP), a role that only partially overlaps that of the GP. The study observed the response of a Continuing Care Service (CCS) to the demand for services from patients with pain-related problems. The role of the CCP is, therefore, outlined in the pain therapy care network by observing the services provided to patients experiencing pain that is understood as being a non-deferrable problem.

Methods

A survey was conducted at the CCSs site in Aquila, AS-01 Abruzzo. For this reason, the attending physician records the data of patients who consult the CCSs for pain-related problems on an appropriate questionnaire. The survey period covered a total of 68 days (1 January - 8 March 2020). Results. One hundred sixty five sheets were completed; females were more represented than males (57.6% v 42.4%) and the 36-65 age group appears most greatly represented (47.9%). One of the most frequent reasons for consulting the service is "musculoskeletal pain" (58.2%), followed by abdominal pain (15.8%). In the majority of patients, pain lasted from days (53.9%), with an average of approximately 3 days (3.1± 2.9), or hours in 40% of cases, with an average of over 6 hours (6.54±3.1). 88.5% of patients defined the level of pain experienced as "severe" (NRS=7-10), and the intensity of the pain associated with its repetitiveness (80.3% vs 92.6%) as "severe", with a statistically significant difference in relation to nonrepetitiveness cases (p=0.02). 66.1% of patients said that they had taken analgesics independently, with nonsteroidal anti-inflammatory drugs (NSAIDs) the most frequently taken (53.5%). Patients who turned to the CCS received a pharmacological prescription in almost all cases. NSAIDs, specifically, were the most prescribed medicines (64.8%), followed by muscle relaxants (29.7%). Tramadol was the most represented among opioids, which was prescribed in 7.9% of cases. Just 6.1% of patients were entered into the regional pain management network.

Conclusions

The results of the survey show that a large number of patients turn to the CCS to resolve painful symptoms of various natures. The study offers some food for thought concerning the role of CCPs and the importance of providing for their inclusion in the pain therapy clinical and training pathways provided for by Law 38/2010. This would ensure its more effective implementation and, therefore, better care for patients experiencing painful pathologies.

Public opinion on vaccines: the role of the scientific community in Italy

Background

After rising for years, vaccination rates in Italy fell until 2015 because of unfounded safety concerns, abetted by some government and court actions. Public education and a 2017 law on mandatory vaccination have boosted rates since then. So far only a few papers have examined the correlation between beliefs and attitudes towards vaccines and the level of trust in the scientific community regarding vaccinations in the general population.

Methods

Data were extracted from the Italian section of the last two editions of the European Social Survey (ESS), the first carried out between September and November 2017, the latter between December 2018 and March 2019. A descriptive analysis was conducted using survey data. In the two editions respectively 2,626 and 2,745 persons were interviewed. The main outcomes assessed was comparing the two surveys, so as to highlight the key changes in public opinion on vaccines.

Results

In the 2017 edition, 19% of the respondents believed in the harmfulness of vaccines, out of them 29% did not even have trust in the scientific community while those confident in the safety of vaccines were 50%. In the 2019 survey, the proportion of those who believed vaccines to be harmful fell to 15%, the undecided rose to 15%, those opposed to the idea that vaccines are harmful became 63%, not responding people were 8%. Correspondingly, trust in the scientific community about vaccines has increased from 57% in the first survey to 70% in the last one.

Conclusions

The scientific community and research bodies in the last years, in support of the Ministry of Health, have made a huge effort in the public debate on vaccines. This might play a role in increasing the public confidence in the safety of vaccines and the adherence to vaccination campaigns, changing the climate with regard to vaccination in general.

Key messages

Italians changed their opinions on vaccines between two ESS surveys. The scientific community had a relevant role in the public debate on vaccines.

Italian health workers’ knowledge, attitudes and behaviours towards COVID-19 vaccination

Background

Vaccine hesitancy is the reluctance or refusal to be vaccinated. While it has been widely studied for various contagious diseases, there is still a lack of knowledge about this phenomenon for COVID-19, especially if health workers' hesitancy is considered.

Methods

An extensive review of the literature was conducted to identify the main determinants of vaccine hesitancy in health workers, as well as to find already validated surveys to evaluate the knowledge, attitudes and behaviors (KAB) of health workers towards vaccination, both in general and with specific regard to COVID-19. Building on the available information, a new survey was developed to assess the KAB of Italian health care workers towards COVID-19 vaccination after validation with a pilot study in a diverse sample of 30 Italian health workers.

Results

A new survey was validated to assess the KAB of health workers towards COVID-19 vaccination in Italian health workers. The survey requires about 6 minutes to complete and is composed of 30 questions, investigating different domains: socio-demographic and professional characteristics (6); health status (2); attitudes (11); behaviors (6); knowledge (4). The survey will be administered to a representative sample of at least 385 Italian health workers through the web platform SurveyMonkey in the period June-September 2021. Preliminary results will be available by the end of October 2021.

Conclusions

By analyzing KAB towards COVID-19 vaccination with a new tool, the magnitude and determinants of health worker's COVID-19 vaccine hesitancy will be evaluated to understand how to improve health workers' perception towards COVID-19 vaccination and, consequently, foster their positive influence on the general population.

Key messages

We explore the knowledge, attitudes and behaviors towards COVID-19 vaccination in all categories of health workers operating on the Italian territory to understand the reasons of vaccine hesitancy.

Understanding the determinants of COVID-19 vaccine hesitancy in Italian health workers is necessary given their influence on the perception of the general population in Italy.

Fournier's gangrene secondary to locally advanced prostate cancer: case report and review of the Literature

Fournier's gangrene is a rare and potentially lethal condition. Previously described as an idiopathic process, this necrotising fasciitis is secondary to infection and in 95% of cases the cause arises from ano-rectum (30-50%), uro-genitalia (20-40%) or genital skin (20%). Cancer could lead to a Fournier's gangrene thanks a Romacompromised host immunity condition. In the past the rate of death was high ranging from 20% to 80%, while currently mortality is decreasing to 10%. We report a case of a 76-years-old man with Fournier's Gangrene due to locally advanced prostate cancer. The multimodal therapeutic management included broad-spectrum antibiotic therapy, intravenous fluid resuscitation and surgical debridement that was delayed by the will of the patient. To our knowledge, this is the first case of Fournier's gangrene caused by prostate cancer without common predisposing factors. In order to improve the knowledge about this rare disease, we performed a narrative review of the literature.

Delivery of selective internal radiation therapy complicated by variant hepatic vascular anatomy

“Difficult vascular anatomy” is a challenge for Interventional Radiologists especially in liver directed therapies such as trans arterial radio embolization.

Trans arterial radio embolization is a long and difficult procedure in which the basic knowledge of hepatic and gastro-enteric vascularization, with its high degree of variations, is very important in order to correctly administer the therapeutic drug selectively.

In this report, we present a case of an atypical patient affected by an unresectable hepatocellular carcinoma, candidate for Radio-embolization treatment.

His vascular anatomy was very difficult to manage, but the Interventional Radiologist was not only able to go over the “difficult anatomy,” but also to take advantage of it.

Climatic variables drive temporal patterns of α and β diversities of dung beetles

Understanding the mechanisms underpinning spatiotemporal diversity patterns of biological communities is a major goal of ecology. We aimed to test two ecological hypotheses: (i) temporal patterns of β-diversity will mostly be driven by nestedness, with a loss of species from summer to winter, and (ii) nestedness values will correlate with climatic variables instead of turnover values, indicating either a loss of species during winter or a gain of species during summer. We sampled dung beetles using standardized sampling protocols along a year in four Atlantic forest sites: two at the northwest and two at the central region of Rio Grande do Sul state, southern Brazil. We partitioned temporal patterns of β-diversity into turnover and nestedness in order to investigate if community changes are driven by species substitution or gain/loss across time. Our results highlighted five main findings: (i) dung beetle composition varied more with sites than site geographic position; (ii) there was almost one and a half 'true' dung beetle assemblages regarding the spatial distribution of species weighed by abundance; (iii) we found a positive influence of mean temperature and a negative influence of relative humidity on both species richness and abundance; (iv) both spatial and temporal dissimilarity among sites were dominated by species replacement, while the relative importance of nestedness was higher in temporal than spatial patterns; (v) there was an effect of precipitation and relative humidity on temporal patterns of β-diversity components, but these effects were site-dependent. Contrary to our expectations, the β-diversity component of turnover dominated both spatial and temporal patterns in dung beetle dissimilarity among sites and months. Distinct climatic variables affected differently the α-diversity and β-diversity components of dung beetle assemblages. Partitioning β-diversity into temporal components is a promising approach to unveil patterns of the community dynamics and to produce insights on mechanisms underlying such patterns.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Magnetic resonance arthrography accuracy in the detection of labral tears in young patients with chronic unstable shoulder: correlation with arthroscopy

The aim of this study is to determine the diagnostic performance of Magnetic Resonance Arthrography (MRA) in evaluating lesions of the glenoid labrum, in young active patients with chronic unstable shoulder, compared to shoulder arthroscopy. We retrospectively considered 65 MRA examinations, performed between December 2011 and January 2018. Among them, thirty-five patients (31 men, 4 women; mean age, 27.3 years; range, 16-53 years; 4 patients with a previous arthroscopy of the same shoulder) underwent shoulder arthroscopy after MRA. Arthroscopic reports were collected and analyzed for the correlation with MRA results.

Graphene-Induced Improvements of Perovskite Solar Cell Stability: Effects on Hot-Carriers

Hot-carriers, that is, charge carriers with an effective temperature higher than that of the lattice, may contribute to the high power conversion efficiency (PCE) shown by perovskite-based solar cells (PSCs), which are now competitive with silicon solar cells. Hot-carriers lose their excess energy in very short times, typically in a few picoseconds after excitation. For this reason, the carrier dynamics occurring on this time scale are extremely important in determining the participation of hot-carriers in the photovoltaic process. However, the stability of PSCs over time still remains an issue that calls for a solution. In this work, we demonstrate that the insertion of graphene flakes into the mesoscopic TiO₂ scaffold leads to stable values of carrier temperature. In PSCs aged over 1 week, we indeed observe that in the graphene-free perovskite cells the carrier temperature decreases by about 500 K from 1800 to 1300 K, while the graphene-containing cell shows a reduction of less than 200 K after the same aging time delay. The stability of the carrier temperature reflects the stability of the perovskite nanocrystals embedded in the mesoporous graphene-TiO₂ layer. Our results, based on femtosecond transient absorption measurements, show that the insertion of graphene can be beneficial for the design of stable PSCs with the aim of exploiting the hot-carrier contribution to the PCE of the PSCs.

Osteoid osteoma treated with radiofrequency ablation in non-operating room anesthesia. A different way of approaching ablative therapy on osteoid osteoma

OBJECTIVE

The purpose of this study is to verify the effectiveness and complications occurrence of radiofrequency ablation (RFA) in the treatment of osteoid osteoma (OO) in non-operating room anesthesia (N.O.R.A.).

PATIENTS AND METHODS

From 2014 to 2017, 61 patients affected by OO (40 men and 21 women) with an age of 20.7 years on average (range, 4-51 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency ablation (RFA) in N.O.R.A. (Non-Operating Room Anesthesia). Lesion sites treated were: femur (27), tibia (22), pelvis (2), talar bone (3), distal radius (1), and humerus (6). Mean follow-up time was 36 months. In each case, anesthesiologic support followed a new protocol (N.O.R.A. protocol), approved by our Institute. Primary success rate, complications, symptom-free intervals, and follow-up results were evaluated.

RESULTS

Pain relief (evaluated with Visual Analogue Scale - VAS) was significant in 97% of patients; it disappeared within 24 hours of the procedure in 44 patients, within 3 days in 10 patients, and within 7 days in 7 patients. After 6 months of observation time, 60 of 61 patients were successfully treated and had no more complaints. In 2 patients, two major complications were found: infection of the site treated, healed with antibiotics, and a nerve lesion, healed with steroid therapy. No other complications were observed.

CONCLUSIONS

RFA is a highly effective, efficient, minimally invasive and safe method for the treatment of OO following N.O.R.A.

PROTOCOL

Plasmon Controlled Shaping of Metal Nanoparticle Aggregates by Femtosecond Laser-Induced Melting

In this work, we show how to control the morphology of femtosecond laser melted gold nanosphere aggregates. A careful choice of both laser fluence and wavelength makes it possible to selectively excite different aggregate substructures to produce larger spherical nanoparticles, nanorods, and nanoprisms or necklace-like 1D nanostructures in which the nanoparticles are interlinked by bridges. Finite integral technique calculations have been performed on the near-field concentration of light in the nanostructures which confirm the wavelength dependence of the light concentration and suggest that the resulting localized high intensities lead to nonthermal melting. We show that by tuning the wavelength of the melting light it is possible to choose the spatial extension of the ensembles of NPs heated thus allowing us to exhibit control over the morphology of the nanostructures formed by the melting process. By a proper combination of this method with self-assembly of chemically synthesized nanoparticles, one can envisage the development of an innovative high-throughput high-resolution nanofabrication technique.

Reports of new wing color polymorphism and taxonomic information to cercopids (Auchenorrhyncha: Cercopidae) from upland rice crop, Pará State, Brazil

Abstract Cercopidae is one of the largest families of the spittlebug superfamily Cercopoidea. Most spittlebugs species are characterized by bright color patterns. Thus, this study evaluated for the first time the Cercopidae species collected in rice crops, Novo Progresso, Pará state, Brazil. Insects were collected weekly between November/2010 and March/2011 from areas without (WA) and with agrochemical applications (AA). Four species were recorded: Deois incompleta (Walker, 1851) (71 specimens in WA area and 50 in AA area); Mahanarva spectabilis (Distant, 1909) (39 specimens in WA area and 39 in AA area); Mahanarava tristis (Fabricius, 1803) (26 specimens in WA area and 20 in AA area); Zulia pubescens (Fabricius, 1803) (11 specimens in WA area and four in AA area). The species collected displayed pronounced color polymorphism when compared with the color patterns of the same species from other regions. This makes correct identification more difficult for these species. Therefore, taxonomic and diagnostic informations provided in this study will help in the correct identification, control and monitoring of these insects in future studies. Besides that, we recommend monitoring in rice fields and further study of the biology and ecology of cercopids in Brazil to assess the potential of these species as rice pests.

Care strategies and therapeutic pathways for chronic pain patients in Abruzzo Region, Italy

BACKGROUND

Chronic pain is considered to be among the most disabling and costly diseases in North America, Europe and Australia. A large survey was conducted on chronic pain in Europe, called Pain in Europe. Italy ranks third in Europe in terms of prevalence, with 26% of the population suffering from chronic pain at some point. In 2010 Italy passed Law 38/2010, to ensure treatment for pain control in patients with oncological diseases as well as in patients with chronic non-cancer pain through a network of care services. This study aims to provide preliminary information regarding the application of L.38/2010 in the Abruzzo region of Italy.

METHODS

A descriptive study was conducted on a non-probabilistic sample of people who attended pain therapy centres of the local health service in 2014. The patients (129) were interviewed by centre staff using a validated questionnaire. Recruitment was carried out by enrolling consecutive cases over a three-month period (February to April).

RESULTS

Almost two-thirds of the patients had visited several physicians before requesting help. The initial visit to the pain therapy centre was made after some months in 37.2% of cases, and in 38% of patients it was made years after the onset of pain. The reasons given for this long wait before seeking specialist medical treatment for chronic pain reveal a wait-and-see attitude on the part of patients, who controlled their pain by taking painkillers. Responsibility for this delay in requesting assistance can however also be attributed 'externally' to the fact that patients were not aware that this kind of centre was available.

CONCLUSION

The results of the study describe, in a regional context, a situation in which L.38/2010 is hard to apply. The study showed how the care pathway for these patients is still characterised by difficulty in accessing the network of local services. Clearly, more effort needs to be directed towards an effective application of L.38/2010, with increased availability of resources to develop and strengthen the network of services at regional level.

Minocycline hydrochloride as a soft sclerotizing agent for symptomatic simple renal and hepatic cysts

OBJECTIVE

To present the results of our ten-year case series in simple hepatic and renal cysts sclerosis using minocycline hydrochloride as a sclerotizing agent, evaluating the effectiveness, the safety and the feasibility of this agent for percutaneous sclerotherapy for symptomatic cysts.

PATIENTS AND METHODS

We retrospectively evaluated our archives of patients treated (54 patients with 60 renal cysts, 21 patients with 24 hepatic cysts) for symptomatic abdominal cysts. These patients were treated with ultrasound guided drainage and subsequent minocycline hydrochloride instillation. In large or recurrent cysts, we repeated the treatment for the second time. The patients were evaluated at 6 and 12 months; some patients underwent later, additional examinations and we also reviewed these exams for any eventual long-term relapse.

RESULTS

The percentage of sclerosis success was found to be 100% for hepatic cysts and 86% for renal cysts. We also found that minimal complications were encountered.

CONCLUSIONS

Minocycline hydrochloride has proven to be an effective sclerotizing agent. In our cases, symptoms disappeared in 100% of patients with hepatic cysts and in 93% of patients with renal cysts. It is also a safe sclerotizing agent, as demonstrated by the few complications encountered. Percutaneous sclerosis with Minocycline hydrochloride is a very effective and promising nonsurgical treatment for patients with symptomatic simple cysts, and it can be performed without major complications.

Family history and ethnicity influencing clinical presentation of type 1 diabetes in childhood

BACKGROUND

A different clinical presentation of type 1 diabetes (T1DM) could be supposed in children belonging to different ethnicities, with or without family history of autoimmunity.

OBJECTIVE

This study investigates the effect of ethnicity and family history of T1DM on clinical characteristics at presentation in a group of T1DM children.

METHODS

One hundred ninety-six T1DM children <18 years, consecutively diagnosed during the years 2011-2014, were studied including 91 % of Caucasians of Italian ancestry and 9 % of non-Caucasian origin.

RESULTS

Children with 1st or 2nd degree relatives affected by T1DM were younger at disease onset (p = 0.005) and showed lower HbA1C levels (p = 0.002), and higher IAA levels (p = 0.01). Non-Caucasian children were younger at disease onset (p = 0.029), and showed more severe hyperglycemia (p = 0.008) and ketoacidosis (pH p < 0.001). HbA1C levels were negatively related to positive family history of T1DM (p = 0.01), fasting C-peptide levels (p = 0.003), IAA levels (p = 0.03), and IA-2 levels (p = 0.003). The level of pH was positively influenced by fasting C-peptide (p = 0.004), and negatively impacted by C-reactive protein (p = 0.01) and non-Caucasian ethnicity (p = 0.03).

CONCLUSION

The milder metabolic decompensation in children with a positive family history of T1DM is probably explained by the awareness of the families in terms of early symptoms of T1DM, while the younger age at onset and the higher levels of autoantibodies may suggest a stronger genetic susceptibility, associated with a more aggressive autoimmune process. The younger age in non-Caucasian children is probably explained by the higher genetic susceptibility in subjects belonging to ethnic groups with a low T1DM incidence. Social aspects and poor living conditions probably predominate in determining the increased severity of metabolic decompensation at onset in children from non-Caucasian ethnicities.

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC)

BACKGRAUND

Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment.

METHODS

An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting.

RESULTS

The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness.

CONCLUSION

The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Anaesthesia Management in Patients with Multiple Chemical Sensitivity Syndrome

Multiple Chemical Sensitivity (MCS) is characterised by the appearance of numerous and sometimes severe symptoms, when subjects are in contact with various chemicals and medicinal substances. Currently there are no useful guidelines for managing clinical issues and, specifically, anaesthesia for patients with MCS. This case report describes anaesthesia management in a patient affected by clinically documented MCS and a latex allergy, a candidate for a laparoscopic cholecystectomy operation.

Circulating anti-nuclear antibodies in uveitis

Uveitis represents the inflammatory process of uvea being caused by an autoimmune mechanism. Similarly, systemic connective tissue diseases (CTDs) present as well an autoimmune pathogenesis and numerous are the reports of a correlated association of the two different conditions, according to their serological characteristics. In this work, we have studied a number of subjects affected by uveitis as well as a number of subjects affected by CTDs associated with uveitis (14.2%). Only one significant correlation has been observed here, and it is the one between uveitis and the Systemic Lupus Erythematosus (SLE, 42.8%). The observation has been made up to through a time-lapse of 18 months during which, the signs of uveitis showed a clear trend to faintly diminish till completely disappearing. At the same time, the presence of uveitis has not stressed out any correlation either with the general positivity for the autoantibodies, nor with the titration or the pattern of single fluorescent antibodies. This study seems to confirm the presence of a weak association between uveitis and CTDs (SLE excluded), where the research of antinuclear antibodies does not seem to give any useful element in terms of diagnostics and clinics, able to value the risk of developing CTDs when uveitis is already stated.

Hydromorphone does not influence the immune response in patients affected by chronic pain

Hydromorphone (HMP) is a semisynthetic opioid that has been widely used over many years in the treatment of chronic moderatesevere pain. A number of studies have demonstrated the use of HMP in patients with cancer pain as safe and affective, and more recently HMP has been also utilised in the treatment of chronic degenerative pain (CDP). Then, some opioids are able to influence several immune parameters. Aim of our study was to assess HMP in patients with CDP in terms of safety and efficacy, to evaluate effects of HMP, within 2 months of observation, on cutaneous cell-mediated immunity (CCMI) as well as other basic immune parameters, and the production of interleukin-2 (IL-2) and interleukin-6 (IL-6). Results have shown that HMP does not influence CCMI nor the sieric levels of immunoglobulins or other immune parameters. Furthermore, it also has no effects on the 3rd and 4th complement fractions, on white blood cells count and T-lymphocyte subpopulations, on presence of seric autoantibodies, nor on production of IL-2 and IL-6. Therapy with HMP has not effects on the studied parameters of the immune system and does not seem to have any influence on the immune competence and immune response in patients with chronic pain.

Open comparison study of oxidative stress markers between patients with chronic renal failure in conservative therapy and patients in haemodialysis

AIMS

Oxidative stress is defined as tissue damage caused by an imbalance between the excessive production of the oxidant components and an insufficient defence mechanism. It has been observed, as in patients with chronic kidney failure, that there exists a pro-oxidant state characterised by a higher level of reactive oxygen species (ROS), and that oxidative stress in dialysis patients can be aggravated by the activation of neutrophils associated with the production of free radicals. In patients undergoing dialysis even the molecules other than those of cytokines can accumulate and provoke an inflammatory response. This study proposes an analysis based on the total antioxidant capacity (TAC), thiol concentration (TC) and pro-oxidant capacity (POC) in the serum of various groups of patients: one group of dialysis subjects who had been undergoing substitutive treatment for more than ten years at the time of the study; one group of subjects with chronic renal insufficiency in its pre-terminal stage and subjected to conservative therapy; and the control group consisting of healthy volunteers.

MATERIALS AND METHODS

Three types of tests were employed to assess the level of oxidative stress: oxy-adsorbent test, d-ROMS test, and SHp- test. Thirty-three subjects were selected: 11 undergoing haemodialysis for over then years; 14 patients with chronic kidney failure in its pre-terminal stage, and 8 normal subjects. In patients undergoing renal substitutive treatment, the serum levels (mean±sd) of TAC were 272.98±20.54; TC, 249.19±92.48, and POC, 95.06±15.70. In patients with chronic renal insufficiency in its pre-terminal stage and undergoing conservative treatment, the value of TAC was 226.5±27.89; TC, 336.42±102.08; and POC, 80.78±15.69. The levels of TAC in the serum of the controls were 335.62±46.35; TC, 434.09±22.23; and POC, 56.31±7.41.

CONCLUSION

The analysed data suggest that in dialysis the patients with chronic kidney failure, whether undergoing conservative therapy during its pre-terminal stage or in substitution treatment during its terminal stage, there is a reduction in the antioxidant defence (in terms of TAC and thiolic barrier) and an increase in POC compared to the healthy subjects in the control group. Uraemia and haemodialysis increase the inflammatory response: an initial signal provokes the inflammatory state with the production of cytokines and free radicals or reactive oxygen, so that the lack of an antioxidant defence mechanism can bring about a vicious circle with the continual production of other free radicals.

Assessment of the oxidative stress markers in patients with chronic renal insufficiency undergoing dialysis treatment

AIMS

Uraemia is a disease characterised by a significant oxidative stress, and it is a wide agreement that oxidative stress which accompanies uraemia, increases the inflammatory state and promotes the alterations of tiny molecules such as amino acids, proteins, lipids, and carbohydrates. There are numerous records of how ROS are connected to the pathology of end stage renal disease (ESRD). The aim of this study is to assess the Total Antioxidant Capacity (TAC), the Thiolic Capacity (TC) and the Pro-Oxidant Capacity (POC) in the serum of patients undergoing dialysis treatment.

MATERIALS AND METHODS

Forthy-six patients have been recruited (32 men, 14 women; mean age 68.5±15.8) who received hemodialytic treatment triweekly. Three methods have been used: oxy adsorbent test (mmol/l) to determine TAC values; d-ROM test (mg/100 mg/H₂O₂) to determine POC; SHp-test (mmol/l) to determine TC.

RESULTS

In patients who underwent hemodialysis, TAC levels were: pre-dialysis, 265.9±30.5; post-dialysis, 300.0±40.6; TC levels: pre-dialysis, 267.4±59.1; post-dialysis, 303.2±116.7; POC levels: predialysis, 86.2±16.9; post-dialysis, 98.6±17.0; NS: TAC, 335.6±46.3; TC, 434.0±22.2; POC, 56.3±7.4. TAC in both pre- and post-dialysis is reduced compared to the NS (p < 0.05); moreover TAC increases after dialysis (p < 0.05). Pre- and post-dialysis TC is reduced compared to NS (p < 0.05); available TC increases after dialysis, although not statistically significant. Pre- and post-dialysis POC in patients undergoing dialysis is increased compared to the NS (p < 0.05); moreover, POC tends to increase after dialysis ( p < 0.05). The data obtained from our study also show that the TAC is reduced in the patients subjected to hemodialysis compared to the NS, both before and after dialysis treatment; TAC increased after dialysis, even though it did not reach the level of the control group.

CONCLUSION

Our study has demonstrated that exists a profound imbalance between antioxidants and the production of ROS in ESRD patients, which determines oxidative stress and eventually leads to atherosclerosis and cardiovascular complications. This, in turn, represents the major cause of morbidity and mortality in these patients.