Anesthesiologists ultrasound-guided regional anesthesia core curriculum: a Delphi consensus from Italian regional anesthesia experts

INTRODUCTION

The need for a standardized core curriculum in regional anesthesia has become essential, particularly with the integration of ultrasound revolutionizing and exponentially increasing clinical practice and possibilities. In fact, numerous novel techniques, often overlapping, can confuse practitioners. This study aims to establish a core curriculum for upper limb, lower limb, paraspinal and fascial plane blocks for residency training, addressing potential educational gaps caused by the multitude of techniques, through a Delphi consensus process involving recognized Italian regional anesthesia experts.

METHODS

A steering committee was formed in order to select a panel of experts in regional anesthesia. A three-round Delphi consensus was planned: two rounds of electronic voting and a final round of mixed electronic voting and round table discussion. The consensus was defined as ≥ 75% agreement for inclusion and lower than ≤ 25% agreement for exclusion from the core curriculum list. Techniques reaching the 50% threshold were included with low consensus.

RESULTS

Twenty-nine techniques were selected to be included in the ultrasound-guided regional anesthesia core curriculum. Twenty-two were included with strong consensus: Upper limb: interscalene brachial plexus block, supraclavicular brachial plexus block, infraclavicular brachial plexus block, axillary brachial plexus block, intermediate cervical plexus block Lower limb: femoral nerve block, pericapsular nerve group block, adductor canal block, sciatic nerve block (transgluteal approach, infragluteal approach, and at the popliteal fossa), ankle block Paraspinal/fascial plane blocks: erector spinae plane block, deep serratus anterior plane block, superficial pectointercostal plane block, interpectoral plane block, pectoserratus plane block, rectus sheath block, ilioinguinal iliohypogastric nerves block, transversus abdominis plane block (with subcostal and midaxillary approaches) The remaining seven techniques were included with low consensus: superficial cervical plexus block, lumbar plexus block, fascia iliaca block (suprainguinal approach), anterior quadratus lumborum block, lateral quadratus lumborum block, paravertebral block, and serratus anterior plane block.

CONCLUSIONS

This curriculum aims to standardize training and ensure that residents acquire the essential skills required for effective and safe practice regardless of the residents' subsequent specialization. By incorporating these techniques, educational programs can provide a structured and consistent approach to regional anesthesia, enhancing the quality of patient care and improving outcomes.

Affine diffractive beam dividers

Diffractive optical elements that divide an input beam into a set of replicas are used in many optical applications ranging from image processing to communications. Their design requires time-consuming optimization processes, which, for a given number of generated beams, are to be separately treated for one-dimensional and two-dimensional cases because the corresponding optimal efficiencies may be different. After generalizing their Fourier treatment, we prove that, once a particular divider has been designed, its transmission function can be used to generate numberless other dividers through affine transforms that preserve the efficiency of the original element without requiring any further optimization.

Tracking flowpaths in a complex karst system through tracer test and hydrogeochemical monitoring: Implications for groundwater protection (Gran Sasso, Italy)

Groundwater in karst aquifers is frequently tapped for drinking purposes, due to frequent huge volumes of resources. Unfortunately, vulnerability of these aquifers can be high, due to possible fast transfer of recharge water on springs by the karst network. On Gran Sasso Mountain regional aquifer, several springs are subjected to drinking withdrawal and an updated evaluation of their potential is now a fundamental issue to be considered, facing climate change effects, which reflect on variation of discharge regimen and values. To distinguish between different contribution of spring recharge, a tracer test has been carried out on the Vitella d'Oro spring, fed both by the regional aquifer and by a local system exposed to karst features developed in the Rigopiano Conglomerates formation. Thanks to hydrogeological, hydrogeochemical and isotopic data, a conceptual model of spring recharge has been proposed and subsequently validated by the tracer test results. All information confirms the superimposition on the regional base flow, by a relevant contribution of the karst network, influencing the spring discharge in recharge periods. In detail, a fast flow component is responsible for discharge peaks and frequently of turbidity events, having a mean velocity ranging from 30 to 70 m/h in the aquifer. Besides of this fast flow, an additional aliquot of the recharge is due to the same local aquifer, but slower flow clearly identifiable by hydrochemistry and isotopic data. Thanks to these findings, a renewed management of the spring has been suggested, considering the different degrees of aquifer vulnerability (turbidity occurrence) directly related to the discharge regimen.

The role of mesotherapy in the management of spinal pain. A randomized controlled study

Background

Mesotherapy is a technique through which active ingredients are administered into the thickness of the skin in order to increase the local analgesic effect.

Methods

141 patients with spinal pain not responding to systemic therapy with NSAIDs were randomized to receive one or more intra-cutaneous drugs on a weekly basis.

Results

All patients achieved a pain reduction of at least 50% compared to baseline, and all tolerated the therapy without having to resort to systemic drug dose increases.

Conclusions

The data from our study show that the active ingredients infiltrated into the skin induce a mesodermal modulation between the infiltrated liquid and the cutaneous nervous and cellular structures from which the typical drug-saving effect of mesotherapy arises. Although further studies are needed to establish how to integrate mesotherapy in various clinical settings, it appears to be a useful technique available to the practicing physician. This research is also useful in guiding future clinical research.

Three-dimensional polarization of fields radiated by partially coherent electromagnetic cylindrical sources

Partially coherent electromagnetic sources with cylindrical symmetry and infinite extent radiating outward are introduced. Their 3 × 3 cross-spectral density matrix is given through expansions of the field components in terms of basis functions related to the Hankel functions. The spectral density and the three-dimensional degree of polarization of such sources and the fields they radiate are examined. Several examples are presented and discussed. Among them, a class of cylindrical sources whose coherent vector modes coincide with the above basis functions is defined and studied.

Partially coherent spherical sources with spherical harmonic modes

A class of partially coherent spherical sources is introduced whose cross-spectral density across the surface has a modal expansion made up of spherical harmonics. For such sources, the solution of the propagation problem in all the outer spaces can be written through a series of the propagated modes, which maintains the spherical harmonic structure. The main features of this class of cross-spectral densities are derived illustrating their coherence properties with examples. Attention is paid to the properties of radial coherence. In particular, it is clearly shown that sources with perfect radial coherence exist with angular coherence that is only partial.

Cylindrical partially coherent scalar sources

Partially coherent scalar sources with cylindrical symmetry radiating outwards are introduced. Homogeneous cross-spectral densities are shown to possess angularly modulated Hankel modes, whose amplitudes are subject to a filtering process during propagation. Simple criteria for treating such sources are given. For the case of an incoherent cylinder, the number of effective modes is found and spatial coherence is shown to appear in the radiated light. The radial coherence of the radiated field is then examined. Non-homogeneous cylindrical sources are also introduced.

On-axis polarization of beams radiated by electromagnetic circularly coherent sources

On-axis spectral density and degree of polarization of beams radiated by electromagnetic (EM) sources with circular correlations are shown to be finely controlled by changing the source parameters. We reveal, in particular, that in this beam class, unlike for all previously known stationary beams, it is possible to control independently the dynamics of the on-axis spectral density and the degree of polarization. This was enabled by the obtained analytical expression for the on-axis polarization matrix, derived for general EM sources with circular coherence and Gaussian spectral density across the source plane. A simple experimental scheme for generating a broad class of EM circularly coherent sources is devised involving only a line source, a lens, and a transparency, possibly anisotropic.

Tailoring on-axis spectral density with circularly coherent light beams

The on-axis cross-spectral density (CSD) of a beam radiated by a stationary source with a circular coherence state and a Gaussian spectral density is obtained in the closed form. It is revealed that the on-axis CSD is expressed via the Laplace transform of the source's degree of coherence or the Hilbert transform of the corresponding pseudo-mode weighting function. Such relations enable efficient tailoring of the on-axis spectral density, as we show with a slew of numerical examples.

On z-coherence of beams radiated by Schell-model sources with Gaussian profile

The degree of coherence and the intensity distribution on the axis of the beam radiated by a planar partially coherent source of the Schell-model type are investigated. We present an expression for the on-axis cross-spectral density which is valid for a very general Schell-model source, with the only constraint that the intensity distribution across the source is Gaussian. Furthermore, we show that such an expression takes very simple analytical forms for several commonly used degrees of coherence of the source.

On z-coherence in self-focusing

Both the intensity distribution and the degree of coherence between pairs of points along the propagation axis (z-coherence) are derived in closed form for a phenomenon of self-focusing produced by circularly coherent light. The first confirms results previously obtained numerically, while the second exhibits new complex features. The physical interpretation is obtained by a suitable pseudo-modal expansion that suggests an analogy with a simple two-mode structure.

Intradermal therapy (mesotherapy): the lower the better

BACKGROUND

Intradermal therapy (mesotherapy) is a technique used to inject drugs into the surface layer of the skin. The intradermal micro deposit allows to modulate the kinetics of drugs, slowing down its absorption and prolonging the local mechanism of action. This technique is applied in the treatment of some forms of localized pain when a systemic drug-saving effect is useful, when it is necessary to synergize with other pharmacological or non-pharmacological thera-pies, when other therapies have failed or cannot be used.

AIM

The purpose of our study was to evaluate the effect of a mixture with respect to its lower concentration. We also wanted to evaluate the number of sessions needed to reach the therapeutic goal (50% reduction in pain from baseline) in patients with acute or chronic neck pain.

METHOD

We analyzed retrospectively data from 62 patients with cervicobrachial pain treated with intradermal drugs. Group A received a mixture of drugs; group B received half the dose of drugs.

RESULTS

Patients who received a lower concentration of drugs achieved similar results to those who received a higher dose. The therapeutic goal was achieved on average with 3.5 + 1.7 sessions on a weekly basis (min 1; max 9). Subjects in group A required 4+1.7 treatments (min 1; max 9), while subjects in group B required 3+1.5 treatments (min 1; max 7).

CONCLUSIONS

Our study confirms that even a lower dose of drugs can induce a clinically useful result. This study confirms that the useful effect of mesotherapy is only partly due to the pharmacological action. Further randomized prospective studies are needed to standardize the technique in the various pain syndromes, but it is recommended to follow the guidelines of the Italian Society of Mesotherapy to ensure patients receive appropriate treatment.

A Call to Action by the Italian Mesotherapy Society on Scientific Research

Mesotherapy (local intradermal therapy, LIT) is a technique used to slowly spread drugs in tissues underlying the site of injection to prolong the pharmacological effect with respect to intramuscular injection. Recommendations for proper medical use of this technique have been made for pain medicine and rehabilitation, chronic venous disease, sport medicine, musculoskeletal disorders, several dermatological conditions, skin ageing, and immune-prophylaxis. Although mesotherapy is considered a valid technique, unresolved questions remain, which should be answered to standardize methodology and dosing regimen as well as to define the right indications in clinical practice. New randomized controlled trials are needed to test single products (dose, frequency of administration, efficacy and safety). Even infiltration of substances for dermo-cosmetic purposes must be guided by safety and efficacy tests before being proposed by mesotherapy. In this article, we put forth a preclinical and clinical research plan and a health technology assessment as a call to action by doctors, researchers and scientific societies to aid national health authorities in considering mesotherapy for prevention, treatment and rehabilitation paths.

Evidence based recommendations on mesotherapy: an update from the Italian society of Mesotherapy

INTRODUCTION

Mesotherapy, also known as local intradermal therapy, widely used all over the world, is a technique used to inject substances into the surface layer of the skin. There are no international guidelines for the correct use of this technique and in many countries, it is still applied empirically without valid patient consent. The Italian society of mesotherapy has planned a study to assess the rationale and clinical applications based on current evidence.

METHODS

An independent steering committee, based on the available scientific literature, has formulated a series of clinical questions. 21 experts responded by writing an evidence-based document. From this document 30 statements were obtained which were presented to 114 experts using the Delphi method.

RESULTS

28 statements reached a broad agreement on definition, technique, pharmacological rationale, indications and some crucial ethical aspect.

CONCLUSIONS

Although further studies are needed to establish the clinical role of this technique in each field of application, our statements recommend the correct application according to the needs of the individual patient in full respect of ethics.

Association of Neutrophil Activation, More Than Platelet Activation, With Thrombotic Complications in Coronavirus Disease 2019

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 infection is associated with hypercoagulability, which predisposes to venous thromboembolism (VTE). We analyzed platelet and neutrophil activation in patients with coronavirus disease 2019 (COVID-19) and their association with VTE.

METHODS

Hospitalized patients with COVID-19 and age- and sex-matched healthy controls were studied. Platelet and leukocyte activation, neutrophil extracellular traps (NETs), and matrix metalloproteinase 9, a neutrophil-released enzyme, were measured. Four patients were restudied after recovery. The activating effect of plasma from patients with COVID-19 on control platelets and leukocytes and the inhibiting activity of common antithrombotic agents on it were studied.

RESULTS

A total of 36 patients with COVID-19 and 31 healthy controls were studied; VTE developed in 8 of 36 patients with COVID-19 (22.2%). Platelets and neutrophils were activated in patients with COVID-19. NET, but not platelet activation, biomarkers correlated with disease severity and were associated with thrombosis. Plasmatic matrix metalloproteinase 9 was significantly increased in patients with COVID-19. Platelet and neutrophil activation markers, but less so NETs, normalized after recovery. In vitro, plasma from patients with COVID-19 triggered platelet and neutrophil activation and NET formation, the latter blocked by therapeutic-dose low-molecular-weight heparin, but not by aspirin or dypiridamole.

CONCLUSIONS

Platelet and neutrophil activation are key features of patients with COVID-19. NET biomarkers may help to predict clinical worsening and VTE and may guide low-molecular-weight heparin treatment.

Search for SARS-CoV-2 RNA in platelets from COVID-19 patients

The frequent finding of thrombocytopenia in patients with severe SARS-CoV-2 infection (COVID-19) and previous evidence that several viruses enter platelets suggest that SARS-CoV-2 might be internalized by platelets of COVID-19. Aim of our study was to assess the presence of SARS-CoV-2 RNA in platelets from hospitalized patients with aconfirmed diagnosis of COVID-19. RNA was extracted from platelets, leukocytes and serum from 24 COVID-19 patients and 3 healthy controls, real-time PCR and ddPCR for viral genes were carried out. SARS-CoV-2 RNA was not detected in any of the samples analyzed nor in healthy controls, by either RT-PCR or ddPCR, while RNA samples from nasopharyngeal swabs of COVID-19 patients were correctly identified. Viral RNA was not detected independently of viral load, of positive nasopharyngeal swabs, or viremia, the last detected in only one patient (4.1%). SARS-CoV-2 entry in platelets is not acommon phenomenon in COVID-19 patients, differently from other viral infections.

Evidence of Air Trapping During Ex Vivo Lung Perfusion: A Swine Experimental Lung Imaging and Mechanics Study

Ex vivo lung perfusion (EVLP) allows the ventilation and perfusion of lungs to evaluate their viability for transplantation. The aim of this study is to compare the mechanical, morphologic and functional properties of lungs during EVLP with values obtained in vivo to guide a safe mechanical ventilation strategy. Lungs from 5 healthy pigs were studied in vivo and during 4 hours of EVLP. Lung compliance, airway resistance, gas exchange, and hemodynamic parameters were collected at positive end-expiratory pressure (PEEP) of 5 cm H₂O. Computed tomography was performed at PEEP 0, PEEP 5, and total lung capacity (TLC). Lung pressure-volume (PV) curves were performed from PEEP 0 to TLC. Lung compliance decreased during EVLP (53 ± 5 mL/cm H₂O vs 29 ± 7 mL/cm H₂O, P < .05), and the PV curve showed a lower inflection point. Gas content (528 ± 118 mL vs 892 ± 402 mL at PEEP 0) and airway resistance (25 ± 5 vs 44 ± 9 cmH₂O/L∗s^-1, P < .05) were higher during EVLP. Alveolar dead space (5% ± 2% vs 17% ± 6%, P < .05) and intrapulmonary shunt (9% ± 2% vs 28% ± 13%, P < .05) increased ex vivo compared to in vivo, while the partial pressure of oxygen to inspired oxygen fraction ratio (PO₂/FiO₂) did not differ (468 ± 52 mm Hg vs 536 ± 14 mm Hg). In conclusion, during EVLP lungs show signs of air trapping and bronchoconstriction, resulting in low compliance and increased alveolar dead space. Intrapulmonary shunt is high despite oxygenation levels acceptable for transplantation.

Effectiveness and safety of lidocaine patch 5% to treat herpes zoster acute neuralgia and to prevent postherpetic neuralgia

Herpes zoster is often associated to acute neuralgia and postherpetic neuralgia (PHN). Their therapeutic management is still challenging: among therapeutic options, lidocaine patch 5% was rarely used in acute neuralgia on lesional skin, and its efficacy to prevent PHN was never studied. The efficacy and tolerability of lidocaine patch 5% was evaluated in 38 patients with acute neuralgia (19) and PHN (19). Pain intensity was investigated using DN4 questionnaire and NRS-11 scale at baseline and at week 2, 4, and 8. The use of rescue therapy was also evaluated. A significant reduction of DN4 and NRS-11 was observed already at W2, with further improvement at W4 and W8. A complete response to treatment (DN4 and NRS-11 = 0) at week 8 was higher in patients with acute neuralgia (63.2%) than PHN (31.6%). Rescue therapy gradually decreased in acute neuralgia patients from week 2 (57.9%) to week 8 (10.5%), with only two patients needing neuroleptics. In PHN patients rescue therapy remained stable (68.4%). According to our results, lidocaine patch 5% applied on lesional skin was well tolerated and ensured a rapid pain relief in acute neuralgia; if early used, it prevented PHN in almost all patients.

Choice and management of vascular access in the context of COVID-19 outbreak in Italy: Recommendations from clinical practice

On April 2020, during the outburst of the COVID-19 pandemic in Italy, the SIAARTI ("Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva") Research Group on Vascular Access has formulated some essential recommendations for the optimization of the selection, insertion, and maintenance of the vascular access devices, with the aim of guarantee the operator safety, ensure the effectiveness of the maneuvers, and reduce the risk of complications. Here we describe the key elements of clinical management of vascular access in patients affected by COVID-19.

Choice and management of vascular access in the context of COVID-19 outbreak in Italy: Recommendations from clinical practice

On April 2020, during the outburst of the COVID-19 pandemic in Italy, the SIAARTI ("Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva") Research Group on Vascular Access has formulated some essential recommendations for the optimization of the selection, insertion, and maintenance of the vascular access devices, with the aim of guarantee the operator safety, ensure the effectiveness of the maneuvers, and reduce the risk of complications. Here we describe the key elements of clinical management of vascular access in patients affected by COVID-19.