Phylodynamic and Evolution of the Hemagglutinin (HA) and Neuraminidase (NA) Genes of Influenza A(H1N1) pdm09 Viruses Circulating in the 2009 and 2023 Seasons in Italy

The influenza A(H1N1) pdm09 virus, which emerged in 2009, has been circulating seasonally since then. In this study, we conducted a comprehensive genome-based investigation to gain a detailed understanding of the genetic and evolutionary characteristics of the hemagglutinin (HA) and neuraminidase (NA) surface proteins of A/H1N1pdm09 strains circulating in Italy over a fourteen-year period from 2009 to 2023 in relation to global strains. Phylogenetic analysis revealed rapid transmission and diversification of viral variants during the early pandemic that clustered in clade 6B.1. In contrast, limited genetic diversity was observed during the 2023 season, probably due to the genetic drift, which provides the virus with a constant adaptability to the host; furthermore, all isolates were split into two main groups representing two clades, i.e., 6B.1A.5a.2a and its descendant 6B.1A.5a.2a.1. The HA gene showed a faster rate of evolution compared to the NA gene. Using FUBAR, we identified positively selected sites 41 and 177 for HA and 248, 286, and 455 for NA in 2009, as well as sites 22, 123, and 513 for HA and 339 for NA in 2023, all of which may be important sites related to the host immune response. Changes in glycosylation acquisition/loss at prominent sites, i.e., 177 in HA and 248 in NA, should be considered as a predictive tool for early warning signs of emerging pandemics, and for vaccine and drug development.

Global Measles Surveillance: Trends, Challenges, and Implications for Public Health Interventions

Measles, a highly contagious disease primarily affecting children, carries serious health risks, including complications and mortality. Vaccination remains the most effective preventive measure against measles transmission. The COVID-19 pandemic has exacerbated challenges in surveillance and immunization efforts, leaving millions of people exposed to preventable diseases such as measles. Globally accelerated immunization campaigns are critical for achieving regional elimination goals and mitigating the risk of outbreaks. Our team has developed an open-access database for global measles monitoring, facilitating standardized data collection and analysis. The analysis of measles cases from 2011 to 2023 reveals fluctuating trends, with notable increases in Africa in 2019 and 2023, indicating potential gaps in control strategies. Using an automated signal detection tool developed by the European Centre for Disease Prevention and Control (ECDC) team, we identified significant variations between World Health Organization (WHO) regions, underscoring the importance of continuous monitoring to detect epidemiological changes early. These results underscore the need for robust surveillance systems and accelerated vaccination efforts to safeguard public health.

Mpox: An Overview of Pathogenesis, Diagnosis, and Public Health Implications

Mpox, caused by viruses of the genus Orthopoxvirus, is an emerging threat to human and animal health. With increasing urbanization and more frequent interaction between humans and wild animals, the risk of Mpox transmission to humans has increased significantly. This review aims to examine in depth the epidemiology, pathogenesis, and diagnosis of Mpox, with a special focus on recent discoveries and advances in understanding the disease. Molecular mechanisms involved in viral replication will be examined, as well as risk factors associated with interspecific transmission and spread of the disease in human populations. Currently available diagnostic methods will also be discussed, with a critical analysis of their limitations and possible future directions for improving the accuracy and timeliness of diagnosis. Finally, this review will explore the public health implications associated with Mpox, emphasizing the importance of epidemiological surveillance, vaccination, and emergency preparedness to prevent and manage possible outbreaks. Understanding the epidemiology and control strategies for Mpox is critical to protecting the health of human and animal communities and mitigating the risk of interspecific transmission and spread of the disease.

Changing and evolution of influenza virus: is it a trivial flu?

BACKGROUND

Influenza viruses are etiological agents which cause contagious respiratory, seasonal epidemics and, for Influenza A subtypes, pandemics. The clinical picture of Influenza has undergone continuous change over the years, due to intrinsic viral evolution as well as "reassortment" of its genomic segments. The history of Influenza highlights its ability to adapt and to rapidly evolve, without specific circumstances. This reflects the complexity of this pathology and poses the fundamental question about its assumption as a "common illness" and its impact on public health.

SUMMARY

The global influenza epidemics and pandemics claimed millions of deaths, leaving an indelible mark on public health, and showing the need for a better comprehension of the influenza virus. The clear understanding of genetic variations during the Influenza seasonal epidemics is a crucial point for developing effective strategies for prevention, treatment, and vaccine design. The recent advance in Next Generation Sequencing approaches, model systems to virus culture and bioinformatics pipeline played a key role in the rapid characterization of circulating Influenza strains. In particular, the increase of computational power allowed to perform complex tasks in healthcare setting through Machine Learning (ML) algorithms, which analyze different variables, such as medical and laboratory outputs, to optimize medical research and to improve public health systems. The early detection of emerging and re-emerging pathogens is of matter importance to prevent next pandemics.

KEY MESSAGES

The perception of influenza as a "trivial flu" or a more serious public health concern is a subject of ongoing debate, reflecting the multifaceted nature of this infectious disease. The variability in the severity of influenza shed the light on the unpredictability of the viral characteristics, coupled with the challenges in accurately predicting circulating strains. This adds complexity to the public health burden of Influenza and highlights the need of targeted interventions.

Monitoring Monkeypox: Safeguarding Global Health through Rapid Response and Global Surveillance

Monkeypox, a viral zoonotic disease, has emerged as a significant global threat in recent years. This review focuses on the importance of global monitoring and rapid response to monkeypox outbreaks. The unpredictable nature of monkeypox transmissions, its potential for human-to-human spread, and its high morbidity rate underscore the necessity for proactive surveillance systems. By analyzing the existing literature, including recent outbreaks, this review highlights the critical role of global surveillance in detecting, containing, and preventing the further spread of monkeypox. It also emphasizes the need for enhanced international collaboration, data sharing, and real-time information exchange to effectively respond to monkeypox outbreaks as a global health concern. Furthermore, this review discusses the challenges and opportunities of implementing robust surveillance strategies, including the use of advanced diagnostic tools and technologies. Ultimately, these findings underscore the urgency of establishing a comprehensive global monitoring framework for monkeypox, enabling early detection, prompt response, and effective control measures to protect public health worldwide.

Genetic and structural analyses reveal the low potential of the SARS-CoV-2 EG.5 variant

The severe acute respiratory syndrome coronavirus 2 EG.5 lineage is the latest variant under monitoring, and it is generating significant concern due to its recent upward trend in prevalence. Our aim was to gain insights into this emerging lineage and offer insights into its actual level of threat. Both genetic and structural data indicate that this novel variant presently lacks substantial evidence of having a high capacity for widespread transmission. Their viral population sizes expanded following a very mild curve and peaked several months after the earliest detected sample. Currently, neither the viral population size of EG.5 nor that of its first descendant is increasing. The genetic variability appear to be flattened, as evidenced by its relatively modest evolutionary rate (9.05 × 10-4 subs/site/year). As has been observed with numerous prior variants, attributes that might theoretically provide advantages seem to stem from genetic drift, enabling the virus to continually adjust to its host, albeit without a clear association with enhanced dangerousness. These findings further underscore the necessity for ongoing genome-based monitoring, ensuring preparedness and a well-documented understanding of the unfolding situation.

Integrative Genome-Based Survey of the SARS-CoV-2 Omicron XBB.1.16 Variant

The XBB.1.16 SARS-CoV-2 variant, also known as Arcturus, is a recent descendant lineage of the recombinant XBB (nicknamed Gryphon). Compared to its direct progenitor, XBB.1, XBB.1.16 carries additional spike mutations in key antigenic sites, potentially conferring an ability to evade the immune response compared to other circulating lineages. In this context, we conducted a comprehensive genome-based survey to gain a detailed understanding of the evolution and potential dangers of the XBB.1.16 variant, which became dominant in late June. Genetic data indicates that the XBB.1.16 variant exhibits an evolutionary background with limited diversification, unlike dangerous lineages known for rapid changes. The evolutionary rate of XBB.1.16, which amounts to 3.95 × 10-4 subs/site/year, is slightly slower than that of its direct progenitors, XBB and XBB.1.5, which have been circulating for several months. A Bayesian Skyline Plot reconstruction suggests that the peak of genetic variability was reached in early May 2023, and currently, it is in a plateau phase with a viral population size similar to the levels observed in early March. Structural analyses indicate that, overall, the XBB.1.16 variant does not possess structural characteristics markedly different from those of the parent lineages, and the theoretical affinity for ACE2 does not seem to change among the compared variants. In conclusion, the genetic and structural analyses of SARS-CoV-2 XBB.1.16 do not provide evidence of its exceptional danger or high expansion capability. Detected differences with previous lineages are probably due to genetic drift, which allows the virus constant adaptability to the host, but they are not necessarily connected to a greater danger. Nevertheless, continuous genome-based monitoring is essential for a better understanding of its descendants and other lineages.

Update on the Phylodynamic and Genetic Variability of Marburg Virus

The COVID-19 pandemic has not only strained healthcare systems in Africa but has also intensified the impact of emerging and re-emerging diseases. Specifically in Equatorial Guinea, mirroring the situation in other African countries, unique zoonotic outbreaks have occurred during this challenging period. One notable resurgence is Marburg virus disease (MVD), which has further burdened the already fragile healthcare system. The re-emergence of the Marburg virus amid the COVID-19 pandemic is believed to stem from a probable zoonotic spill-over, although the precise transmission routes remain uncertain. Given the gravity of the situation, addressing the existing challenges is paramount. Though the genome sequences from the current outbreak were not available for this study, we analyzed all the available whole genome sequences of this re-emerging pathogen to advocate for a shift towards active surveillance. This is essential to ensure the successful containment of any potential Marburg virus outbreak in Equatorial Guinea and the wider African context. This study, which presents an update on the phylodynamics and the genetic variability of MARV, further confirmed the existence of at least two distinct patterns of viral spread. One pattern demonstrates a slower but continuous and recurring virus circulation, while the other exhibits a faster yet limited and episodic spread. These results highlight the critical need to strengthen genomic surveillance in the region to effectively curb the pathogen's dissemination. Moreover, the study emphasizes the importance of prompt alert management, comprehensive case investigation and analysis, contact tracing, and active case searching. These steps are vital to support the healthcare system's response to this emerging health crisis. By implementing these strategies, we can better arm ourselves against the challenges posed by the resurgence of the Marburg virus and other infectious diseases.

Epidemic history and evolution of an emerging threat of international concern, the severe acute respiratory syndrome coronavirus 2

This comprehensive review focuses on the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its impact as the cause of the COVID-19 pandemic. Its objective is to provide a cohesive overview of the epidemic history and evolutionary aspects of the virus, with a particular emphasis on its emergence, global spread, and implications for public health. The review delves into the timelines and key milestones of SARS-CoV-2's epidemiological progression, shedding light on the challenges encountered during early containment efforts and subsequent waves of transmission. Understanding the evolutionary dynamics of the virus is crucial in monitoring its potential for adaptation and future outbreaks. Genetic characterization of SARS-CoV-2 is discussed, with a focus on the emergence of new variants and their implications for transmissibility, severity, and immune evasion. The review highlights the important role of genomic surveillance in tracking viral mutations linked to establishing public health interventions. By analyzing the origins, global spread, and genetic evolution of SARS-CoV-2, valuable insights can be gained for the development of effective control measures, improvement of pandemic preparedness, and addressing future emerging infectious diseases of international concern.

SARS-CoV-2 Recombinants: Genomic Comparison between XBF and Its Parental Lineages

Recombination events are very common and represent one of the primary drivers of RNA virus evolution. The XBF SARS-CoV-2 lineage is one of the most recently generated recombinants during the COVID-19 pandemic. It is a recombinant of BA.5.2.3 and BA.2.75.3, both descendants of lineages that caused many concerns (BA.5 and BA.2.75, respectively). Here, we performed a genomic survey focused on comparing the recombinant XBF with its parental lineages to provide a comprehensive assessment of the evolutionary potential, epidemiological trajectory, and potential risks. Genetic analyses indicated that although XBF initially showed the typical expansion depicted by a steep curve, causing several concerns, currently there is no indication of significant expansion potential or a contagion rate surpassing that of other currently active or previously prevalent lineages. BSP indicated that the peak has been reached around 19 October 2022 and then the genetic variability suffered slight oscillations until early 5 March 2023 when the population size reduced for the last time starting its last plateau that is still lasting. Structural analyses confirmed its reduced potential, also indicating that properties of NTDs and RBDs of XBF and its parental lineages present no significant difference. Of course, cautionary measures must still be taken and genome-based monitoring remains the best tool for detecting any important changes in viral genome composition.

Khosta: A Genetic and Structural Point of View of the Forgotten Virus

Bats are well-known to be natural reservoirs of various zoonotic coronaviruses, which have caused outbreaks of severe acute respiratory syndrome (SARS) and the COVID-19 pandemic in 2002 and 2019, respectively. In late 2020, two new Sarbecoviruses were found in Russia, isolated in Rhinolophus bats, i.e., Khosta-1 in R. ferrumequinum and Khosta-2 in R. hipposideros. The potential danger associated with these new species of Sarbecovirus is that Khosta-2 has been found to interact with the same entry receptor as SARS-CoV-2. Our multidisciplinary approach in this study demonstrates that Khosta-1 and -2 currently appear to be not dangerous with low risk of spillover, as confirmed by prevalence data and by phylogenomic reconstruction. In addition, the interaction between Khosta-1 and -2 with ACE2 appears weak, and furin cleavage sites are absent. While the possibility of a spillover event cannot be entirely excluded, it is currently highly unlikely. This research further emphasizes the importance of assessing the zoonotic potential of widely distributed batborne CoV in order to monitor changes in genomic composition of viruses and prevent spillover events (if any).

Genome-based survey of the SARS-CoV-2 BF.7 variant from Asia

The SARS-CoV-2 BF.7 variant represents one of the most recent subvariant under monitoring. At the beginning of the 2023 if caused several concerns especially in Asia because of a resurge in COVID-19 cases. Here we perform a genome-based integrative approach on SARS-CoV-2 BF.7 in order to shed light on this emerging lineage and produce some consideration on its real dangerousness. Both genetic and structural data suggest that this new variant currently does not show evidence of an high expansion capability. It is very common in Asia, but it appears less virulent than other Omicron variants as proved by its relatively low evolutionary rate (5.62 x 10^-4 subs/sites/years). The last plateau has been reached around December 14, 2022 and then the genetic variability, and thus the viral population size, no longer increased. As already seen for several previous variants, the features that may be theoretically related to advantages are due to genetic drift that allows to the virus a constant adaptability to the host, but is not strictly connected to a fitness advantage. These results have further pointed that the genome-based monitoring must continue uninterruptedly in order to be prepared and well documented on the real situation. This article is protected by copyright. All rights reserved.

Molecular In-Depth on the Epidemiological Expansion of SARS-CoV-2 XBB.1.5

Since the beginning of the pandemic, the generation of new variants periodically recurs. The XBB.1.5 SARS-CoV-2 variant is one of the most recent. This research was aimed at verifying the potential hazard of this new subvariant. To achieve this objective, we performed a genome-based integrative approach, integrating results from genetic variability/phylodynamics with structural and immunoinformatic analyses to obtain as comprehensive a viewpoint as possible. The Bayesian Skyline Plot (BSP) shows that the viral population size reached the plateau phase on 24 November 2022, and the number of lineages peaked at the same time. The evolutionary rate is relatively low, amounting to 6.9 × 10−4 subs/sites/years. The NTD domain is identical for XBB.1 and XBB.1.5 whereas their RBDs only differ for the mutations at position 486, where the Phe (in the original Wuhan) is replaced by a Ser in XBB and XBB.1, and by a Pro in XBB.1.5. The variant XBB.1.5 seems to spread more slowly than sub-variants that have caused concerns in 2022. The multidisciplinary molecular in-depth analyses on XBB.1.5 performed here does not provide evidence for a particularly high risk of viral expansion. Results indicate that XBB.1.5 does not possess features to become a new, global, public health threat. As of now, in its current molecular make-up, XBB.1.5 does not represent the most dangerous variant.

The stress response of intensive care unit medical doctors facing repeated severe emergencies

Objectives

This study assesses the psychopathological distress experienced by doctors working in an Intensive care unit (ICU) during the COVID-19 pandemic. These doctors were the same who faced the consequences of a previous natural disaster, a severe 6.3 magnitude earthquake. A second objective is to evaluate their current mental attitude, professional performances and coping strategies adopted in the pandemic in relation to the conditioning effect of that first emergency, the earthquake.

Methods

Thirty-seven ICU medical doctors were recruited and assessed using Rapid Stress Assessment (RSA) rating scale, Symptom Checklist-90 Revised (SCL-90-R), Zung Self-Rating Anxiety Scale, Beck Depression Inventory, Beck Hopelessness Scale, Millon Clinical Multiaxial Inventory III. Comparison between exposure to the earthquake and COVID pandemic has been made in terms of professional role and psychological burden.

Results

Comparison between 2009 earthquake catastrophe and COVID pandemic conditions evidenced relevant changes in professional role, team, environment, shifts, and work organization.

Conclusion

The doctors, who already experienced the 2009 earthquake reported a feeling of greater insecurity facing this latter catastrophe, the COVID pandemic, as well as perception of greater concern for their family and the global situation. However, having participated in the medical management of another emergency (the 2009 earthquake) appears to have contributed to limiting demoralization and psychological distress. The feeling of having greater decision-making possibilities and participation in the organization of work, strengthen coping skills in the face of the emergency.

The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature

The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.

Human Immunodeficiency Virus Type 2: The Neglected Threat

West Africa has the highest prevalence of human immunodeficiency virus (HIV)-2 infection in the world, but a high number of cases has been recognized in Europe, India, and the United States. The virus is less transmissible than HIV-1, with sexual contacts being the most frequent route of acquisition. In the absence of specific antiretroviral therapy, most HIV-2 carriers will develop AIDS. Although, it requires more time than HIV-1 infection, CD4+ T cell decline occurs more slowly in HIV-2 than in HIV-1 patients. HIV-2 is resistant to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and some protease inhibitors. Misdiagnosis of HIV-2 in patients mistakenly considered HIV-1-positive or in those with dual infections can cause treatment failures with undetectable HIV-1 RNA. In this era of global integration, clinicians must be aware of when to consider the diagnosis of HIV-2 infection and how to test for this virus. Although there is debate regarding when therapy should be initiated and which regimen should be chosen, recent trials have provided important information on treatment options for HIV-2 infection. In this review, we focus mainly on data available and on the insight they offer about molecular epidemiology, clinical presentation, antiretroviral therapy, and diagnostic tests of HIV-2 infection.

SARS-CoV-2 shifting transmission dynamics and hidden reservoirs potentially limit efficacy of public health interventions in Italy

We investigated SARS-CoV-2 transmission dynamics in Italy, one of the countries hit hardest by the pandemic, using phylodynamic analysis of viral genetic and epidemiological data. We observed the co-circulation of multiple SARS-CoV-2 lineages over time, which were linked to multiple importations and characterized by large transmission clusters concomitant with a high number of infections. Subsequent implementation of a three-phase nationwide lockdown strategy greatly reduced infection numbers and hospitalizations. Yet we present evidence of sustained viral spread among sporadic clusters acting as "hidden reservoirs" during summer 2020. Mathematical modelling shows that increased mobility among residents eventually catalyzed the coalescence of such clusters, thus driving up the number of infections and initiating a new epidemic wave. Our results suggest that the efficacy of public health interventions is, ultimately, limited by the size and structure of epidemic reservoirs, which may warrant prioritization during vaccine deployment.

Evolution patterns of SARS-CoV-2: Snapshot on its genome variants

An acute respiratory syndrome (COVID-19), caused by a novel coronavirus (SARS-CoV-2) with a high rate of morbidity and elevate mortality, has emerged as one of the most important threats to humankind in the last centuries. Rigorous determination of SARS-CoV-2 infectivity is very difficult owing to the continuous evolution of the virus, with its single nucleotide polymorphism (SNP) variants and many lineages. However, it is urgently necessary to study the virus in depth, to understand the mechanism of its pathogenicity and virulence, and to develop effective therapeutic strategies. The present contribution summarizes in a succinct way the current knowledge on the evolutionary and structural features of the virus, with the aim of clarifying its mutational pattern and its possible role in the ongoing pandemic.

Assessment of Pain and Associated Comorbidities: A Survey of Real Life Experiences Among Nurses in Italy

PURPOSE

Pain is a symptom that should be evaluated along with its comorbidities in order to plan an effective holistic treatment strategy involving specific pharmacological interventions, side effect management, psychological support, control of therapeutic effects over time, and dialogue with the patient and their relatives. In this holistic process of caring for patients with pain, nurses play a central role as they deal with suffering patients directly and continuously. The purpose of this study was to evaluate the types of pain identified by nurses in their daily clinical practice and the associated comorbidities (anamnestic history taking) by geographical region and to evaluate the pharmacological strategies used.

METHODS

A cross-sectional survey was performed among 696 registered nurses in Italy. Data were collected using an online questionnaire.

RESULTS

There was a significant difference between geographical regions in terms of reports of acute and chronic pain: acute pain was more frequently reported in the South (63.5%), while chronic pain was more frequent in the Central region (32.3%; p=0.0008). Additionally, chronic oncological pain was more frequent in the Northeast (29.6%), while chronic non-oncological pain was more frequently reported in the Central region (33.9%; p=0.0001). The underlying pain disorders reported were also different between geographical regions; rheumatic pain (21.8%) and neurological pain (18.6%) were more frequent in the Central region, while musculoskeletal pain was significantly more frequent in the South (43.4%; p=0.004). Anxiety, sleep disorders and somatization were found in acute pain (60.82%, 43.56% and 53.12%), while depression and mood disorders were more frequently detected in chronic pain condition (p<0.001).

CONCLUSION

Our study showed differences among Italian regions in pain assessment. Specific education on pain management nursing is essential for nurses. Promotion of optimal nursing care for people affected by pain is the main focus of pain management nursing. Nowadays, nurses should focus on personalized complex care and research in order to improve the patient's quality of life.

The 2019-new coronavirus epidemic: Evidence for virus evolution

There is a worldwide concern about the new coronavirus 2019-nCoV as a global public health threat. In this article, we provide a preliminary evolutionary and molecular epidemiological analysis of this new virus. A phylogenetic tree has been built using the 15 available whole genome sequences of 2019-nCoV, 12 whole genome sequences of 2019-nCoV, and 12 highly similar whole genome sequences available in gene bank (five from the severe acute respiratory syndrome, two from Middle East respiratory syndrome, and five from bat SARS-like coronavirus). Fast unconstrained Bayesian approximation analysis shows that the nucleocapsid and the spike glycoprotein have some sites under positive pressure, whereas homology modeling revealed some molecular and structural differences between the viruses. The phylogenetic tree showed that 2019-nCoV significantly clustered with bat SARS-like coronavirus sequence isolated in 2015, whereas structural analysis revealed mutation in Spike Glycoprotein and nucleocapsid protein. From these results, the new 2019-nCoV is distinct from SARS virus, probably trasmitted from bats after mutation conferring ability to infect humans.

Abstract P2-09-14: Surveillance program for women carrying BRCA1/BRCA2 genetic predisposition

Between January 2003 and January 2015, women at genetic risk of developing breast and/or ovarian cancer were selected for a surveillance program. The monitoring strategy consisted of the association of breast ultrasound (US), every six months, and Rx-mammography (XM) and breast MRI (MRI) to be performed annually. To date, 29 women have been included in the surveillance program: BRCA1 mutation carriers, 18; BRCA2 mutation carriers, 11.

Eight women (28%) had already developed breast and/or ovarian cancer, while 21 (72%) were unaffected carriers.

At a median surveillance time of 33 months (range 0-144), 4 incidental breast cancers were diagnosed in 4 BRCA1/2 mutation carriers (4/29, 14%), 2 BRCA1+ and 2 BRCA2+; 3/21 (14%) unaffected carriers and 1/8 (13%) previously affected carriers. Two cancers (50%) were detected by all three diagnostic tools; 2 (50%) were identified only by US and MRI in patients aging 33 and 43, respectively.

Characteristics of patients with breast cancer diagnosed during surveillanceagemutated geneprevious cancerUSXMMRIhistologysurveillance time (months)33BRCA2-+-+ductal74+43BRCA2-+-+ductal40+45BRCA1-+++ductal60+40BRCA1yes+++ductal74+

One of these four patients, affected by breast cancer, died at 31 months of overall survival; three underwent surgery, chemotherapy and radiotherapy and are still disease free, in follow-up at 59, 28 and 26 months, respectively.

In conclusion, 29 BRCA1/2 carriers have been included in the surveillance program, the median age was 42.5 months (range 27-68) and the median surveillance time was 33 months (range 0-144). Our preliminary data confirm the 3% expected rate of diagnosed cancers and the effectiveness of performing the triple diagnostic surveillance with US, XM and MRI.

Citation Format: Sidoni T, Cocciolone V, Cannita K, Di Giacomo D, Ciccozzi A, Bafile A, Pizzorno L, Resta V, Marsecano C, Ferrari F, Di Cesare E, Ficorella C, Ricevuto E. Surveillance program for women carrying BRCA1/BRCA2 genetic predisposition. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-14.

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.

Bradykinin B2 Receptor Antagonist off Label Use in Short-Term Prophylaxis in Hereditary Angioedema

Hereditary angioedema type I (HAE-C1-INH) is an inherited disorder characterized by repeated severe angioedema attacks mostly triggered by traumas, emotional stress, increased estrogen levels or surgical procedures, in particular, odontostomatological interventions. Icatibant, a bradykinin B2 receptor antagonist, has been approved for treatment of HAE attacks. In this paper we describe the “off label” administration of icatibant as short-term prophylaxis of dental extraction in a patient with HAE with the aim of preventing perioperative angioedema attacks. The drug showed an effective and safe profile. Thus, a short-term prophylaxis of angioedema attacks in patients with HAE may be arranged on a multidisciplinary basis, according to the clinical history of each single patients.

Regional anaesthesia techniques for carotid surgery: the state of art

PURPOSE

This review will analyse some aspects of regional anaesthesia (RA) for carotid endarterectomy (CEA), a surgical procedure which requires a strict monitoring of patient's status. RA remains an important tool for the anaesthesiologist. Some debates remain about type and definition of regional anaesthesia, efficacy and safety of the different cervical block techniques, the right dose, concentration and volume of local anaesthetic, the use of adjuvants, the new perspectives: ultrasonography, the future directions.

METHODS

A literature search was performed for journal articles in English language in the PubMed Embase and in The Cochrane Library database, from January 2000 to December 2013. The electronic search strategy contained the following medical subject headings and free text terms: local anaesthesia versus general anaesthesia for endarterectomy, superficial and deep cervical block, complications of cervical nerve block, ultrasound guidance of superficial and deep cervical plexus block.

CONCLUSIONS

The gold standard for RA will be achieved after overcoming a number of limitations by a more extensive use of ultrasonography, by combining general and regional anaesthesia, including conscious anaesthesia, by defining the appropriate volume, concentration and dosage of local agents and by addition of adjuvants.

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.

Low back pain in a natural disaster

Low back pain is usually self-limited. The transition from acute to chronic LBP is influenced by physical and psychological factors. Identification of all contributing factors, in a mass emergency setting, differentiating primary and secondary life-threatening forms of LBP, is the best approach for success. Aims of the present report were to estimate the prevalence of LBP in population afferent to four advanced medical presidiums (AMPs) during postseismic emergency period and to evaluate frequency of use, types of pain killers administered to patients and short-term efficacy of them.

METHODS

Study was carried out in four AMPs during the first 5 weeks after the earthquake. Site, type of eventual trauma, pain intensity during LBP episode by Verbal Numerical Rating Scale (vNRS) were registered. Diagnosis of primary or secondary LBP was made on the basis of clinical features and therapeutic treatment was also analyzed.

RESULTS

The prevalence of acute LBP was 4.9% (95%, IC 3.7 to 6.4), among 958 first accesses to AMP, representing 14.1% (95%, IC 10.8 to 18.3) of cases on the total of 322 patients treated for all pain conditions. Episodes of relapsed LBP in chronic pre-existing LBP represented the 40% (n = 19) of cases, while the first episode was present in 60% of patients (n = 28). Pain treatment was effective with a significant reduction in vNRS in short term evaluation.

CONCLUSIONS

The emotional stress induced by natural disaster tends to heighten norepinephrine and sympathetic nervous system activity, which may further amplify nociception through peripheral or central mechanisms that result in consistent prevalence of primary NSLBP and become potential risk factor for pain chronicization.

High dose of buprenorphine in terminally ill patient with liver failure: efficacy and tolerability

Pain in terminally ill patients with cancer can be often hard to manage, due to the unpredictable kinetics of drugs caused by progressive kidney and liver dysfunction. Plasma concentrations of active metabolites-also a cause of dangerous side effects--could be difficult to estimate. This case report holds the idea that buprenorphine, a partial agonist of m-receptors, even at high dosage, may be effective and safe to use in terminally ill patients with significant liver and kidney impairment.

Pain after earthquake

INTRODUCTION

On 6 April 2009, at 03:32 local time, an Mw 6.3 earthquake hit the Abruzzi region of central Italy causing widespread damage in the City of L Aquila and its nearby villages. The earthquake caused 308 casualties and over 1,500 injuries, displaced more than 25,000 people and induced significant damage to more than 10,000 buildings in the L'Aquila region.

OBJECTIVES

This observational retrospective study evaluated the prevalence and drug treatment of pain in the five weeks following the L'Aquila earthquake (April 6, 2009).

METHODS

958 triage documents were analysed for patients pain severity, pain type, and treatment efficacy.

RESULTS

A third of pain patients reported pain with a prevalence of 34.6%. More than half of pain patients reported severe pain (58.8%). Analgesic agents were limited to available drugs: anti-inflammatory agents, paracetamol, and weak opioids. Reduction in verbal numerical pain scores within the first 24 hours after treatment was achieved with the medications at hand. Pain prevalence and characterization exhibited a biphasic pattern with acute pain syndromes owing to trauma occurring in the first 15 days after the earthquake; traumatic pain then decreased and re-surged at around week five, owing to rebuilding efforts. In the second through fourth week, reports of pain occurred mainly owing to relapses of chronic conditions.

CONCLUSIONS

This study indicates that pain is prevalent during natural disasters, may exhibit a discernible pattern over the weeks following the event, and current drug treatments in this region may be adequate for emergency situations.

Anxiolysis and postoperative pain in patients undergoing spinal anesthesia for abdominal hysterectomy

AIM

The relationship between pain and psychological factors is well known. The aim of the study was to evaluate the influence of lorazepam, given before total abdominal hysterectomy, on postoperative pain control.

METHODS

Sixty patients, enrolled in the study, were defined as either anxious or not anxious when the State/Trait Anxiety Inventory (STAI) score was =/>51 or =/< 50, respectively. The anxious patients were randomly assigned to receive oral lorazepam 0.035 mg/kg the night and 2 h before surgery (Group A), or placebo at the same time (Group B). The not anxious patients were assigned to receive oral lorazepam 0.035 mg/kg the night and 2 h before surgery (Group C), or placebo at the same time (Group D). Anesthesia was performed with subarachnoidal block. Ketorolac was used for postoperative pain. As rescue drug, tramadol was administered using a patient controlled analgesia (PCA) modality. Postoperative pain was assessed during the 24 h after surgery by tramadol consumption.

RESULTS

Tramadol consumption was significantly greater in Group B (216.3+/-58.9 mg) than in Groups A, C and D respectively (150.9+/-28.9 mg; 153.6+/-39.9 mg; 154.4+/-39.9 mg). Group B showed a significantly higher pain score compared to the other groups during the first 8 h. No difference in patient satisfaction with perioperative treatment was noted.

CONCLUSION

Preoperative lorazepam reduced perioperative anxiety. This could explain the better postoperative pain control in patients undergoing hysterectomy, a very stressful surgical procedure.

Cervical pain and headache in patients with facial asymmetries: the effect of orthognathic surgical correction

AIM

Facial asymmetries are often associated with cervicobrachial pain and headache. The aim of the study was to evaluate the influence of surgical orthognathic correction of facial asymmetries on the intensity of cervicobrachial pain and headache in the short and long term.

METHODS

Thirty-two patients affected by maxillomandibular asymmetries associated with pain referred to occipital, cervical, dorsal and scapulohumeral areas who were undergoing orthodontic surgical correction were enrolled in the study. The pain intensity at rest and on fibromyalgia trigger points was assessed using a 0-10 Visual Analogue Scale (VAS) preoperatively (T(0)) and 5 days (T(1)), 6 months (T(2)) and 12 months (T(3)) after surgery. Functional limitation was evaluated by the same method at T(0),T(2) and T(3).

RESULTS

VAS scores at rest were significantly lower at T(1), T(2) and T(3) compared to T0 in every area to which pain was referred. After 12 months (T(3)), pain at rest was completely absent in 23 patients (71.8%) in the occipital region, in 23 patients (71.8%) in the cervical area, in 22 patients (68.7%) in the dorsal area, and in 28 patients (87.5%) in the scapulohumeral area. In the other patients, the pain scores in all areas were < 1 (0.77, 0.83, 0.95, 0.5 in the occipital, cervical, dorsal, and scapulohumeral areas respectively). The VAS at neck fibromyalgia points were significantly reduced at T(1), T(2), T(3) and functional limitation was improved at T(3) and T(4) (P=0.00).

CONCLUSION

This study appears to demonstrate the utility of orthognathic surgery when facial asymmetry is associated with cranial-cervicobrachial pain syndrome, presumably through a new musculoskeletal rearrangement of stomatognathic apparatus. Indeed, the surgical correction has resulted in morphological, functional and symptomatic effects.

Parenteral nutrition in ventilated patients with chronic obstructive pulmonary disease: long chain vs medium chain triglycerides

AIM

The aim of this study was to assess the usefulness of a lipid formulation containing a physical mixture of medium (MCT) and long chain triglycerides (LCT) compared with a long chain triglycerides emulsion in patients affected by chronic obstructive pulmonary disease with acute respiratory failure.

METHODS

Twenty-four patients requiring mechanical ventilation were randomly selected in 2 groups and received total parenteral nutrition. Twelve patients received a MCT/LCT emulsion (50:50), the others used a 100% LCT emulsion. Nutritional status, metabolic rate, time of ventilatory support and weaning were evaluated.

RESULTS

Both groups showed an improvement of all nutritional parameters evaluated; oxygen uptake, carbon dioxide output and respiratory gas exchange ratio were similar in both groups. The duration of mechanical ventilation was not significantly different; however, the time of weaning in the MCT/LCT group was significantly shorter. The longer weaning time in the LCT group patients could be related to vasoactive intermediates deriving from long chain fatty acids. The T-cell subsets, which were evaluated for both groups, showed a significant decrease of T helper-T suppressor ratio in the LCT group.

CONCLUSION

MCT/LCT emulsion is an effective lipid supplementation and should be considered the therapy of choice in COPD patients; however, the relationship between lipid emulsions administered and length of weaning requires further investigations.

Use of strong opioids in advanced cancer pain: a randomized trial

The World Health Organization (WHO) guidelines for the treatment of cancer pain recommend nonopioid analgesics as first-line therapy, so-called "weak" analgesics combined with nonopioid analgesics as second-line therapy, and so-called "strong" opioids (with nonopioid analgesics) only as third-line therapy. However, these guidelines can be questioned with regard to the extent of efficacy as well as the rationale for not using strong opioids as first-line treatment, especially in terminal cancer patients. The purpose of this randomized study was to prospectively compare the efficacy and tolerability of strong opioids as first-line agents with the recommendations of the WHO in terminal cancer patients. One hundred patients with mild-moderate pain were randomized to treatment according to WHO guidelines or to treatment with strong opioids. Evaluated outcomes included pain intensity, need for change in therapy, quality of life, Karnofsky Performance Status, general condition of the patient, and adverse events. No between-treatment differences were observed for changes in quality of life or performance status, but patients started on strong opioids had significantly better pain relief than patients treated according to WHO guidelines (P=0.041). Additionally, patients started on strong opioids required significantly fewer changes in therapy, had greater reduction in pain when a change was initiated, and reported greater satisfaction with treatment than the comparator group (P=0.041). Strong opioids were safe and well-tolerated, with no development of tolerance or serious adverse events. These data suggest the utility of strong opioids for first-line treatment of pain in patients with terminal cancer.

Hemodynamic variations during thoracic and abdominal stop-flow regional chemotherapy

AIMS

The aim of this study was to study hemodynamic modifications during thoracic and abdominal stop-flow regional chemotherapy and to evaluate the need for routine hemodynamic monitoring during such kind of procedures.

METHODS

Thirty patients, aged 17-67 years, ASA physical status II-III, scheduled for thoracic (group A, n = 15), and abdominal (group B, n = 15) stop-flow regional chemotherapy were enrolled. Heart rate (HR), electrocardiogram lead I and V(5), end tidal carbon dioxide (ETCO(2)), arterial oxygen saturation (SaO(2)), systolic, diastolic and mean arterial pressure (SBP, DBP, MAP), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), cardiac output (CO), stroke volume (SV), stroke index (SI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), left cardiac work (LCW), right cardiac work (RCW), left cardiac work index (LCWI), right cardiac work index (RCWI), cardiac index (CI), and body O(2) consumption (VO(2)) were recorded.

RESULTS

After aortic and inferior vena cava endovascular occlusion (T(1)), a significant reduction of CO and SV, associated with an increase of CVP, MAP, PAPM and PCWP were observed. A concomitant reduction of CI and increase of SVR and PVR were registered. The VO(2) was significantly reduced compared to basal values in both groups. After deflating aortic and vena cava balloons (T(2)), CO, SV and CI increased with respect to basal value p < 0.05) whereas MAP, CVP, PAPM, PCWP and calculated parameters (SVR, PVR) showed a significant reduction compared to T(1). The oxygen consumption was significantly higher than that of basal values p < 0.05. After hemofiltration (T(3)), all hemodynamic variables were comparable with the basal values. Modifications of direct and calculated parameters, during the stop-flow period, showed a similar trend in both study groups, without any statistically significant difference. No ST modifications at ECG were noted during all perioperative period.

CONCLUSIONS

The results of this study have confirmed in both groups, the safety of stop-flow regional chemotherapy procedure, despite endovascular occlusion of the aorta and inferior cava vein. The hemodynamic and oxygenation changes are reversible and did not produce any ST modifications at ECG during all perioperative period. Routine pulmonary artery catheterization is thus unnecessary, except in high cardiac risk patients.

[Diagnosis and treatment of non-palpable breast lesions: from the biopsy to the microhistology results. Our experience]

The aim of modern senology lies in the diagnosis and treatment of non-palpable breast lesions (NPBLs). Through the diffusion of regional mammography screening the lesions being observed are continuously smaller, thus calling for more and more accurate methodology. Our experience in this area is based on the use of certain methods for retrieval and removal of NPBLs, such as Kopan's sec. philo-guide, ultrasound and advanced breast biopsy instrumentation. In our opinion methods allowing total removal of lesions in order to obtain complete histopathological characterization and enabling adequate therapeutic programs are to be preferred. In reviewing case studies a noteworthy increase of initial carcinoma (DCIS or LCIS), from 19.5% to 57.1%, has been observed in the last three years due to the extensive use of the aforementioned methods.

[Clinical use of spinal or epidural steroids]

Steroids, drugs with potent antiinflammatory properties on the damaged nervous roots, have been especially used as adjuvants of local anesthetics, by spinal route, in the treatments of low-back pain. Spinal route was chosen to obtain a higher local concentration of drug, with few systemic side effects and to improve drug's action mechanism. Steroids seem to interact with GABA receptors and thus control neural excitability through a stabilising effect on membranes, modification of nervous conduction and membrane hyperpolarization, in supraspinal and spinal site. Epidural steroids are especially used in the treatment of low back pain due to irritation of nervous roots. They have been administered alone or in association with local anesthetics and/or saline solution. Slow release formulations have been generally used (methylprednisolone acetate, and triamcinolone diacetate). Other indications of epidural steroids are: postoperative hemilaminectomy pain, prevention of post herpetic neuralgia, degenerative ostheoartrithis. Intra-thecal steroids have been frequently used in the treatment of lumbar radiculopathy due to discopathy, as an alternative treatment when epidural administration is ineffective. Positive results have been obtained with methylprednisolone acetate, alone or in association with local anesthetics. Complications related to intraspinal steroids injections are due to execution of the block and side effects of drugs. Complications associated with intrathecal steroids are more frequent and severe than epidural injections and include: adhesive arachnoiditis, aseptic meningitis, cauda equina syndrome. Steroidal toxicity seems to be related to the polyethylenic glycole vehicle. Anyway, slow release formulations contain less concentrated polyethylenic glycole. The epidural administration, a correct dilution of steroid with local anesthetics solution and/or saline solution, and a limited number of injections (no more than three) allows a significant reduction of steroid neurotoxicity.

Clonidine for treatment of postoperative pain: a dose-finding study

The aim of this double-blind randomized study was to evaluate the optimal intravenous dose of clonidine administrated during the peri-operative period, after lumbar hemilaminectomy for herniated disk repair. The "optimal intravenous dose" was defined as that providing minimal analgesic request, stable haemodynamic profile and a minimal sedation score during 12h after extubation. Eighty adult patients, ASA physical status I-II, undergoing lumbar hemilaminectomy for herniated disk (L(4)-L(5), L(5)-S(1)) were included in the study. All the patients were randomly assigned to one of four study groups (A, B, C, D), 20 patients each. The same standardized general anaesthesia was performed for each group. Thirty minutes before the end of surgery, group A, B and C patients received three different loading doses of intravenous clonidine (5 microg/kg, 3 microg/kg, 2 microg/kg respectively), followed by the same infusion of intravenous clonidine (0.3 microg/kg per hour). Group D patients received a bolus dose and a continuous infusion of NaCl 0.9%. In the recovery unit, postoperative pain was treated by a patient-controlled analgesia device, containing morphine. Pain relief was evaluated by the total morphine requirement during the postoperative period. Systolic blood pressure (SBP), heart rate and sedation were also noted during the first 12h postoperatively. Intravenous clonidine decreased morphine requirements in a dose-dependent manner. Group A, B, C and D patients requested 5 +/- 2, 11 +/- 3, 19 +/- 4 and 29 +/- 8 doses of morphine respectively. Clonidine also affected SBP in a dose-related manner. Group A, B and C patients had an SBP decrease respectively of 26 +/- 3%, 7 +/- 4% and 2 +/- 2% compared with basic values while, at the same time, in group D patients no SBP variation was registered. In conclusion, this study demonstrates that, when sedation and analgesic effect of clonidine is required, 3 microg/kg bolus dose followed by a continuous infusion of 0.3 microg/kg per hour has to be considered the optimal intravenous dose. The higher dose of intravenous clonidine (5 microg/kg) produced better analgesia but the degree of hypotension and sedation was more severe and longer lasting; it required ephedrine administration and careful monitoring of the patient. On the other hand, the bolus of intravenous clonidine 2 microg/kg (group C) was less effective in terms of pain relief but with similar side-effects to the 3 microg/kg dosage (group B).

Haemodynamic effects of intravenous clonidine on propofol or thiopental induction

The study evaluated the effects of premedication with intravenous clonidine on thiopental or propofol requirements for induction and haemodynamic changes associated with both induction and endotracheal intubation. Clonidine administered intravenously before induction of anaesthesia reduced propofol or thiopental requirements. The association of clonidine and propofol caused, after injection of the induction drug, a decrease in mean arterial pressure which was significantly greater than with thiopental. Moreover, a major haemodynamic stability was registered before and after laryngoscopy in the clonidine-thiopental group. These findings might contraindicate the clonidine-propofol combination in patients with cardiovascular disease.

[Use of remifentanil in ambulatory obstetric-gynecologic surgery. A dose-effect study]

BACKGROUND

Remifentanil, a recently commercialised opioid, is characterised by a predictable and non cumulative effect which vanishes rapidly without determining side effects in the long term. These characteristics make remifentanil an ideal opioid in continuous infusion for the ambulatory surgery setting. Aim of this study was to assess the ideal dose of remifentanil, administered in bolus before propofol, in patients undergoing uterine curettage and assisted by mask ventilation in 100% oxygen.

METHODS

Sixty patients, ASA status I-II, scheduled for uterine curettage, were divided into three study groups according to the bolus dose of remifentanil received before the induction agent: group A (n = 20) 1 microgram/kg; group B (n = 20) 2 micrograms/kg; group C (n = 20) 2 micrograms/kg. All patients were assisted by 100% oxygen ventilation with facial mask. During surgery the following were recorded: time to spontaneous ventilation (in case of post induction apnea); incidence of somatic and autonomic responses to surgical stress (treated with remifentanil in bolus). At the end of surgery the times to response to simple verbal commands, to discharge from the recovery room (by Aldrete score every 5') and to discharge from hospital (by PADSS score every 30') were registered.

RESULTS

All patients presented post-induction apnea with a significantly more rapid return to spontaneous ventilation in group A. Six patients of group A responded to surgical stress while in groups B and C there was no need for supplementary boluses (p < 0.05). Five patients of group C were treated with atropine for bradycardia, in four of group C it was necessary to administer succinylcholine for thoracic rigidity. No significant differences regarding the anesthesia recovery times were observed. All patients were discharged from the recovery room after 10' from the end of surgery. Overall, the qualification for discharge from hospital was obtained at the second PADSS score control, except for one group A patient who incurred in metrorrhagia.

CONCLUSIONS

The administration in bolus of remifentanil, before the inducing agent, permits short-term surgery in ambulatory surgery settings thanks to the rapid recovery of vital functions. Compared to the other doses, the 1.5 micrograms/kg dose guaranteed a good control over surgical stress without influencing the speed of awakening and without determining uncomfortable side effects.

Intra-articular buprenorphine after knee arthroscopy. A randomised, prospective, double-blind study

BACKGROUND

Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra-articular administration of buprenorphine after knee arthroscopy.

METHODS

In a double-blind randomised trial, 48 patients were assigned to four groups: group A patients received buprenorphine 100 micrograms i.a. and NaCl 0.9% i.m., group B patients received bupivacaine 0.25% 50 mg i.a. and NaCl 0.9% i.m., group C patients received NaCl 0.9% i.a. and buprenorphine 100 micrograms i.m., and group D patients received NaCl 0.9% i.a. and NaCl 0.9% i.m. Intensity of postoperative pain was evaluated by VAS at recovery (T0) and 1, 3, 6, 12, 24 h after operation (T1, T2, T3, T4, T5), at rest and during passive 10 degrees knee flexion. Total analgesic requirements and side effects related to study drugs were recorded.

RESULTS

The VAS scores were significantly higher in groups C and D than in group A and B patients. The differences were significant at T0, T1, T2 and T3. At T1, group C and D patients had greater analgesic requirement than groups A and B. No patients developed side effects.

CONCLUSION

Intra-articular buprenorphine and i.a. bupivacaine, both produced equally good postoperative pain control and allowed a significant reduction of analgesic requirement after knee arthroscopy.

[MR characterization of breast pathology using inversion recovery sequence]

As yet, a valid tissue characterization of human breast diseases has not been possible with conventional MR techniques. On the basis of the experimental thesis according to which fibroadenomas and carcinomas have a slight, though significant, difference in T1 relaxation times, we employed specific inversion recovery sequences at the T null of the breast glandular and adipose tissues, to enhance the differences in the signal intensities of the various pathologies. We examined 16 (6 cystic dysplasias, 5 fibroadenomas, 3 carcinomas, and 1 phylloid fibroadenoma) selected patients with the above-mentioned sequences in addition to the routine T1- and T2-weighted spin echo sequences. The following conclusions were reached by evaluating the characteristic signal intensities: MR spin echo sequences allow solid lesions to be distinguished from cystic ones; MR inversion recovery sequences allow fibroadenomas to be distinguished from carcinomas with 88% accuracy.

[Magnetic resonance of the breast. Clinical experience with a dedicated coil]

MR Imaging was performed on 10 healthy volunteers and 86 patients, using a 0.5 T superconducting magnet and a dedicated coil to image both breasts simultaneously. The patients were selected by the presence of nodules at clinical examination. Final diagnoses were made either at histology--in the patients who underwent surgery--or at cytology, with fine needle biopsy. The MR findings of the different breast diseases are discussed. In spite of an improved spatial resolution and of a very good natural contrast between different tissues, MR Imaging does not allow a satisfactory characterization of the lesions; its use is thus limited to the staging of cancers which need a better therapeutic planning.