Differentiating typical tako tsubo syndrome from extensive anterior ST-elevation myocardial infarction: look behind the anterior wall

Funding Acknowledgements

Type of funding sources: None.

Tako-Tsubo Syndrome (TTS) consists in transient left ventricular dysfunction resembling in its typical form acute anterior ST-elevation myocardial infarction (STEMI). Early non-invasive differential diagnosis, crucial for therapeutic purposes, appears difficult according to available data.

Purpose

to systematically analyze LV function and ECG changes in patients with acute anterior STEMI and TTS, to identify parameters possibly useful for differential diagnosis.

Methods

this is a retrospective cohort study, with 2 groups: patients with anterior STEMI and extensive apical involvement at echocardiography (n = 22); patients with TTS (n = 22) and ECG changes diagnostic for anterior STEMI at presentation (n = 22). They underwent a comprehensive clinical and echocardiographic evaluation in acute phase, including 2D speckle tracking longitudinal strain. We created new indexes based on wall motion impairment of inferior and inferior-lateral walls: the Inferior apex ratio (IAR) and inferior-lateral apex ratio (ILAR) (see picture).

Results

TTS and STEMI patients were similar for age (74.7 ± 9.1 vs 73.4 ± 14.1 y), sex, and main biochemical data except for higher peak troponin I in STEMI (1323 ± 622 vs 377 ± 220 ng/L, p = 0.01). ST segment elevation in V1 (V1e) was significantly less common in TTS (p < 0.001) while increased ratio of ST segment elevation in V4-V6 to V1-V3 (∑Ste V4-V6/∑Ste V1-V3≥1) was more common in TTS (p < 0.001). Among ECG parameters, absence of V1e had the best sensitivity (86%) and specificity (86%) in predicting TTS. LVEF values were similar (means: 45% in both groups) with EDVI greater in TTS (55.5 ±12.3 vs 46.6 ± 11.0 ml/m2, p = 0.02). WMSI was greater in TTS patients (2.2 ± 0.1 vs 1.9 ± 0.1, p < 0.0001), mainly for greater scores of mid segments.  Global longitudinal strain was impaired in TTS (-8.1 ± 2.5 %) and in anterior STEMI (-7.9 ± 2.7, p = 0.8). By analyzing the single segments, strain was significantly more compromised in TTS in mid inferior (MI) (-4.3 ± 6.4 vs -9.9 ± 5.5 % in STEMI, p = 0.003) and mid inferior-lateral (MIL) segments (-5.4 ± 5.4 vs -9.6 ± 4.9 %, p = 0.009). Mean IAR was 0.7 ± 0.3 in TTS vs 1.8 ± 0.6 in STEMI, p < 0.0001; mean ILAR was 0.7 ± 0.1 in TTS vs 2.0 ± 0.9 in STEMI, p < 0.0001. ILAR was < I in all TTS patients, and > 1 in all STEMI cases. IAR < 1 showed 90% sensitivity and 95% specificity in predicting TTS. By multivariate linear regression analysis, strain values of MI and MIL segments were significantly associated with TTS (Beta: -0.98 and -0.97 respectively, p < 0.0001), independently from age, sex, and EDVI. IAR and ILAR values were significantly associated with TTS (Beta: -0.81 and -0.76 respectively, p < 0.0001) independently from the same co-variates as above.

Conclusions

evidence of impaired contractility extending beyond apex to mid inferior and inferior-lateral walls, assed by longitudinal strain or by IAR and ILAR, can help to discriminate TTS from extensive anterior STEMI, more accurately than ECG parameters. Abstract Figure. Examples of ILAR index  Abstract Figure. IAR and ILAR distributions

Phosphoproteomic Effects of Acute Depletion of PP2A Regulatory Subunit Cdc55

Protein phosphatase regulatory subunits are increasingly recognized as promising drug targets. In the absence of an existing drug, inducible degradation provides a means of predicting candidate targets. Here auxin-inducible degradation of Saccharomyces cerevisiae PP2A regulatory subunit Cdc55 in combination with quantitative phosphoproteomics is employed. A prevalence of hyperphosphorylated phosphopeptides indicates that the approach successfully identified direct PP2A^Cdc55 targets. PRM follow up of data-dependent acquisition results confirmed that vacuolar amino acid transporters are among the proteins most strongly affected by Cdc55 depletion.

Chemical Genetics of AGC-kinases Reveals Shared Targets of Ypk1, Protein Kinase A and Sch9

Protein phosphorylation cascades play a central role in the regulation of cell growth and protein kinases PKA, Sch9 and Ypk1 take center stage in regulating this process in S. cerevisiae To understand how these kinases co-ordinately regulate cellular functions we compared the phospho-proteome of exponentially growing cells without and with acute chemical inhibition of PKA, Sch9 and Ypk1. Sites hypo-phosphorylated upon PKA and Sch9 inhibition were preferentially located in RRxS/T-motifs suggesting that many are directly phosphorylated by these enzymes. Interestingly, when inhibiting Ypk1 we not only detected several hypo-phosphorylated sites in the previously reported RxRxxS/T-, but also in an RRxS/T-motif. Validation experiments revealed that neutral trehalase Nth1, a known PKA target, is additionally phosphorylated and activated downstream of Ypk1. Signaling through Ypk1 is therefore more closely related to PKA- and Sch9-signaling than previously appreciated and may perform functions previously only attributed to the latter kinases.

Target of rapamycin complex 2-dependent phosphorylation of the coat protein Pan1 by Akl1 controls endocytosis dynamics in Saccharomyces cerevisiae

Target of rapamycin complex 2 (TORC2) is a widely conserved serine/threonine protein kinase. In the yeast Saccharomyces cerevisiae, TORC2 is essential, playing a key role in plasma membrane homeostasis. In this role, TORC2 regulates diverse processes, including sphingolipid synthesis, glycerol production and efflux, polarization of the actin cytoskeleton, and endocytosis. The major direct substrate of TORC2 is the AGC-family kinase Ypk1. Ypk1 connects TORC2 signaling to actin polarization and to endocytosis via the flippase kinases Fpk1 and Fpk2. Here, we report that Fpk1 mediates TORC2 signaling to control actin polarization, but not endocytosis, via aminophospholipid flippases. To search for specific targets of these flippase kinases, we exploited the fact that Fpk1 prefers to phosphorylate Ser residues within the sequence RXS(L/Y)(D/E), which is present ∼90 times in the yeast proteome. We observed that 25 of these sequences are phosphorylated by Fpk1 in vitro We focused on one sequence hit, the Ark/Prk-family kinase Akl1, as this kinase previously has been implicated in endocytosis. Using a potent ATP-competitive small molecule, CMB4563, to preferentially inhibit TORC2, we found that Fpk1-mediated Akl1 phosphorylation inhibits Akl1 activity, which, in turn, reduces phosphorylation of Pan1 and of other endocytic coat proteins and ultimately contributes to a slowing of endocytosis kinetics. These results indicate that the regulation of actin polarization and endocytosis downstream of TORC2 is signaled through separate pathways that bifurcate at the level of the flippase kinases.

Clinical comparison of oral administration and viscosupplementation of hyaluronic acid (HA) in early knee osteoarthritis

PURPOSE

Osteoarthritis (OA) is a progressive, chronic and degenerative joint disease characterized by a loss of articular cartilage. Treatment of OA is largely palliative based on nonsteroidal anti-inflammatory drugs, opioids and injections of steroids. Regarding conservative treatment, intra-articular injections of hyaluronic acid (HA) can play a role in early symptomatic knee OA.

MATERIALS AND METHODS

Between August 2015 and September 2015, sixty patients (32 males and 28 females) between 40 and 70 years old were randomly allocated into two groups: Half were treated with three weekly intra-articular injections of hyaluronic acid 1.6 % (group A), while the others were treated with Syalox 300 Plus^® (hyaluronic acid 300 mg + Boswellia serrata extract 100 mg) 1 tab/die for 20 days and afterward Syalox 150^® (hyaluronic acid 150 mg) 1 tab/die for other 20 days (group B). All patients were evaluated clinically with American Knee Society Score (AKSS) and visual analogue scale (VAS) for the pain before the treatment and after 3 months.

RESULTS

AKSS of the patients in both groups was significantly increased by the treatment, and VAS score was significantly reduced. In both groups, two subgroups were created with patients older than 60 years and patients younger than 60 years. Better results are reported in younger patients of group A and older subjects in group B.

CONCLUSIONS

Despite several limitations, the results of the study have shown that HA injection and oral administration may have beneficial therapeutic effects on patients with early osteoarthritis. Different outcomes in younger and older subject suggested a combined therapy first with local infiltrations and then with oral composition.

Early enteral feeding with human milk for VLBW infants

In a NICU early enteral feeding is usually possible only when the newborn clinical conditions permit it. Because of the frequent need of umbilical/central catheters, they usually start with parenteral feeding and/or with minimal enteral feeding (trophic feeding). This kind of management is even more frequent in VLBWIs, in which the risk of NEC is very high. In this work we describe a model of early enteral exclusive feeding (EEEF) based on the use of banking human milk followed by mother milk. In the Centre of Neonatology of Trento, as in other Centers, the newborns weighing less than 750g or with a GE< 27 weeks, are treated with parenteral nutrition and minimal enteral feeding. The newborn weighing 750-1249g and with GE > 26 weeks define a group in which we find critical neonates, who can not be treated with enteral feeding, and neonates whose clinical conditions permit EEEF. In particular, in a period of 16 years (1994-2009) in Trento, 308 newborns weighing 750-1249 g and GE > than 26 weeks were admitted. The 90,9 % has been treated with prenatal steroids, the 91,9 % was inborn, the 96,1% survived. In the 59,1 % of the cases (175) we gave EEEF. We could continue with a complete EEEF in the 40,2 % of the total (119 cases). The characteristics of these neonates and our centre management, based mainly on early use of banking human milk and mother milk, are detailed described.

Change Pain: changing the approach to chronic pain

In Italy, chronic pain has a prevalence of about 26%, a rate that warrants efforts by specialists and primary care physicians to improve its treatment. From a study of various treatment systems, it is clear that a radical change in the approach to pain pathology is needed. To this end, the Change Pain International Advisory Board*, an international panel of experts, highlighted the limits to current treatment schemes and proposed new strategies. Among the criticalities are poor or inadequate communication between physician and patient, difficulty in qualitative and quantitative measurement of pain, management of adverse effects, and the "vicious circle" generated by current therapies, often the cause of poor compliance with pain treatment or discontinuation of analgesic therapy. A further limitation to current therapeutic practice is to consider pain intensity as the sole reference parameter in its treatment. In light of these considerations, the Advisory Board has drawn up a strategy to improve outcomes of pain therapy: 1) a shared therapeutic pact between physician and patient based on efficacious communication rather than on information alone; 2) identification of defined therapeutic objectives that allow for reaching a balance between reduction of pain and occurrence of adverse effects; 3) adoption of drug therapies that respond at least in part to an approach based on the pathogenic mechanism of pain rather than on pain intensity alone.

A Systematic Investigation of Strain Relaxation, Surface Morphology and Defects in Tensile and Compressive InGaAs/InP Layers

The results of a systematic investigation by transmission electron microscopy (TEM), cathodoluminescence (CL), Rutherford backscattering (RBS), X-ray diffraction and topography and scanning force microscopy (SFM) techniques on several InGaAs/InP compressive and tensile strained layers covering the misfit range from −2.3 to 1.5×10−2 and grown by the metal organic vapor phase epitaxy (MOVPE) technique are reported. In compressively strained films the same dependence for the residual strain vs the film thickness as for the InGaAs/GaAs is found whereas a different strain release rate and different extended defects are found in tensile stressed InGaAs alloy. In particular in tensile stressed samples, grooves, planar defects and cracks are present in addition to the interfacial network of misfit dislocations. The correlation between the observed planar defects and the mechanisms of strain relaxation in the case of tensile strained layers is discussed.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

Pharmacological treatment of chronic pain - the need for CHANGE

BACKGROUND

Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management.

SCOPE

Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts.

FINDINGS

It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a 'vicious circle' that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community's understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians' knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable.

CONCLUSIONS

To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

Updating postoperative pain management: from multimodal to context-sensitive treatment

Although a wealth of evidence exists on effective postoperative pain (POP) treatment, surgical patients still suffer from inadequate analgesic regimens, and outcomes have been shown to improve only within the context of tightly controlled, randomized trials. The pathophysiology of pain seems to suggest that analgesic regimens aimed at inhibition of neurotransmission and neuroplastic phenomena should be instituted immediately before the painful stimuli are applied. Several protocols have been proposed, but the final choice should be made according to patients' needs, surgical indications, and institutional resources. Optimal POP management may succeed in improving outcomes only when combined with hospital-wide protocols for early rehabilitation and recovery; in the absence of adequate monitoring, equipment, motivation and coordination, even state-of-the-art techniques may fail to show results in terms of returning to daily life. Analgesic efficacy should always be balanced against safety and the ability to monitor patients in order to reduce complications that may actually impair recovery. A ''context-sensitive'' approach to POP, therefore, is suggested. Context-sensitive analgesia should be instituted as early as deemed necessary to avoid persistent pain, and it should be continued, with different modalities, until full recovery from surgery. In this way, it should constitute a ''bridge'' therapy from surgery to full healing. The use of neuroprotective agents to reduce the risk of postoperative hyperalgesia and other sensory disturbances should be considered in the context of specific surgical interventions.

High-resolution X-ray diffractionin situstudy of very small complexes: the case of hydrogenated dilute nitrides

In this work it is demonstrated howin situhigh-resolution X-ray diffraction (HRXRD), performed during thermal annealing and employing a conventional laboratory source, can be used to obtain information on the evolution kinetics of very small complexes formed in an epitaxial layer. HRXRD allows the measurement of changes in the lattice parameter of the layer (i.e.the layer strain) with different annealing strategies (by linear temperature ramp or isothermal annealing). On the basis of these data and using an appropriate model, the dissolution energy values of the complexes can be extracted. The underlying idea is that every type of complex present in the layer gives a specific lattice strain which varies under annealing, allowing their evolution to be traced accurately. As an example, this methodology is applied to the study of N–H complexes formed in hydrogen-irradiated GaAs1−xNx/GaAs layers.

Pain after minimally invasive videoassisted and after minimally invasive open thyroidectomy--results of a prospective outcome study

BACKGROUND

Substantial modifications in surgical treatment of thyroid disease have changed the postoperative management of thyroidectomized patients. The reduction of postoperative pain permit a short-stay surgery.

MATERIALS AND METHODS

We have analyzed the patients treated in our Unit from July 2006 to December 2006, with minimally invasive cervicotomy and mini-invasive video-assisted thyroidectomy. We have registered the postoperative pain applying an evaluation protocol numeric scale. The results were analyzed by t test.

RESULTS

One hundred thirteen patients were divided in two groups: group A, minimally invasive cervicotomy (15 male and 46 female patients); group B, mini-invasive video-assisted thyroidectomy (9 male and 43 female patients). Upon returning to the ward, the pain scale group A vs B was 2.77 +/- 1.16 vs 2.5 +/- 0.762 (p = 0.22) .At 24 h after surgery, the pain scale in group A was 1.82 +/- 1.258 vs 1.031 +/- 0.8608 (p < 0.005).

CONCLUSIONS

Both methods are safe, but mini-invasive video-assisted thyroidectomy gives not only a better cosmetic result but a reduction of postoperative pain especially at 24 h.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine

BACKGROUND

The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia.

METHODS

Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses.

RESULTS

The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups.

CONCLUSIONS

Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

Quantification of energy expenditure during gait in children affected by cerebral palsy

AIM

Children affected by cerebral palsy (CP) are generally characterised by some movement limitations and abnormalities that compromised gait pattern. These disabilities during deambulation may lead to excessive energy cost and so to a compromised energy efficiency.

METHODS

In this study oxygen expenditure was evaluated during walking in 20 children affected by CP and in 20 healthy children, using Cosmed K4b2 (Cosmed, Italy). From obtained data about energy consumption, some parameters (heart rate, energy expenditure index, oxygen consumption, oxygen cost) were extracted, first in order to quantify energy cost during gait in pathological and healthy subjects and then to underline differences between the 2 groups of children.

RESULTS

In particular, the results obtained revealed that heart rate (bpm) and oxygen consumption (mL/kg/min) mean values didn't differ significantly between normal subjects and those with CP; instead, energy expenditure index (b/m) and oxygen cost (mL/kg/m) presented higher mean values rather than control group at a statistically level and so they revealed to be significant parameters, in order characterized energy expenditure in children affected by CP.

CONCLUSIONS

This inefficiency characteristic of CP deambulation is probably directly connected to the presence of simultaneous contraction of agonist and antagonist muscle in these patients.

Sildenafil reduces L-NAME-induced severe hypertension and worsening of myocardial ischaemia-reperfusion damage in the rat

BACKGROUND AND PURPOSE

Phosphodiesterase-5 inhibitors are beneficial in pulmonary hypertension and congestive heart failure, the two conditions associated with coronary heart disease and ischaemia. We investigated whether sildenafil counteracts the cardiovascular alterations induced by N -nitro-L-arginine methyl ester (L-NAME) in the rat.

EXPERIMENTAL APPROACH

Sildenafil was given orally to rats at doses of 0.37, 0.75 or 1.5 mg kg-1day-1 for four weeks, either alone or with L-NAME (35-40 mg kg-1 day-1 in the drinking water). Systolic blood pressure and urinary parameters (6-keto-prostaglandin F1alpha, thromboxane B2, 8-isoprostane-prostaglandin F2 and nitrite/nitrate) were measured in conscious rats. Isolated hearts were subjected to low flow ischaemia-reperfusion, and myocardial levels of guanosine 3', 5'cyclic monophosphate (cGMP) were determined. Endothelial vascular dysfunction was examined in aortic rings.

KEY RESULTS

Sildenafil dose-dependently prevented the rise in systolic blood pressure in L-NAME-treated rats. This activity was associated with a normalization of urinary 8-isoprostane-prostaglandin F2alpha and other biochemical parameters. In perfused hearts, the post-ischaemic ventricular dysfunction was worse in preparations from L-NAME-treated rats than in controls. Sildenafil dose-dependently reduced this effect, and creatine kinase and lactate dehydrogenase release were lower too. cGMP levels, which were low in myocardial tissue from L-NAME-treated rats, were restored by sildenafil. In noradrenaline-precontracted aortic rings from L-NAME-treated rats acetylcholine lost its vasorelaxant effect, and sildenafil restored it.

CONCLUSION AND IMPLICATIONS

In a rat model of chronic nitric oxide deprivation, where hypertension and aggravation of post-ischaemic ventricular dysfunction are associated with loss of vascular endothelium-relaxant function, sildenafil provided significant cardiovascular protection, primarily by maintaining tissue cGMP levels.

Quantitative analysis of gait pattern and energy consumption in children with cerebral palsy

The measurement of oxygen consumption during walking allows the quantification of gait expenditure, mainly in patients with musculoskeletal disabilities, as in cerebral palsy (CP). In this study, first, an experimental set up for the acquisition of energy consumption during gait analysis (GA) was proposed; secondly, some parameters of energy expenditure were analyzed to characterize pathological gait from an energetic point of view. Twenty CP children and 20 healthy children were evaluated during two consecutive sessions (session 1: only GA was performed; session 2: K4b2 was used during GA acquisition). The results revealed that the experimental set up was comfortable for all subjects. The absence of any differences in GA values between the two sessions showed that the use of a device for energy acquisition does not modify gait pattern. Energy expenditure index and oxygen cost presented abnormal values in comparison with normality and they were significant to quantify energy expenditure in CP children.

Does clonidine 50 μg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study

STUDY OBJECTIVE

To evaluate the effects of adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy (TEA).

DESIGN

Randomized, double-blind study.

SETTING

Departments of Anesthesia and Vascular Surgery of a university hospital.

PATIENTS

40 ASA physical status II and III patients undergoing elective TEA during superficial cervical plexus block.

INTERVENTIONS

Superficial cervical plexus block was placed using 20 mL of 0.75% ropivacaine alone (Ropi group, n = 20) or with the addition of 50 microg clonidine (Ropi-Clonidine group, n = 20). If required, analgesic supplementation was given with local infiltration with 1% lidocaine and intravenous fentanyl (50-microg boluses). Nerve block profile, need for intraoperative analgesic supplementation, and time to first analgesic request were recorded.

MEASUREMENTS AND MAIN RESULTS

Median (range) onset time was 10 minutes (5-25 min) in the Ropi group and 5 minutes (5-20 min) in the Ropi-Clonidine group (P < 0.05). Intraoperative consumption of both 1% lidocaine and fentanyl was higher in patients of the Ropi group (15 mL [0-25 mL] and 250 microg [50-300 microg]) than in patients of the Ropi-Clonidine group (8 mL [0-20 mL] and 0 microg [0-150 microg]; P < 0.05 and P < 0.05, respectively). First postoperative analgesic request occurred after 17 hours (10-24 hrs) in the Ropi group and 20 hours (10-24 hrs) in the Ropi-Clonidine group (P > 0.05).

CONCLUSIONS

Adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia in patients undergoing elective TEA.

Endoparasites of chub (Leuciscus cephalus) in two rivers of the Abruzzo region of Italy

The relationship between communities of chub endoparasites (Leuciscus cephalus) fished in the Orta and Pescara Rivers in the Abruzzo region of Italy, and the quality of the water in which they are caught, were studied in surveys designed to evaluate the feed quality of fish in the inland waters of the Abruzzo. Samples were taken monthly from October 2000 to September 2001 in the Orta River (Buscesi District) and the Pescara River (near the Villareia bridge); a total of 86 chub were caught. During periods of low and moderate flow in both rivers, benthonic macroinvertebrates were sampled at the fish sampling sites to classify the water quality using the extended biotic index (EBI) method. The Orta River was moderately polluted and the Pescara River slightly more polluted than the Orta. A parasitological study of the fish was conducted using conventional methods. A morphological study of the parasites led to the identification of seven species of endoparasites. Five of these (Allocreadium isoporum, Caryophyllaeus brachycollis, Caryophyllaeides fennica, Rhabdocona denudata and Pomphorhyncus laevis) were found at both sampling sites, while Acanthocephalus clavula was found only in the Pescara River and Neoechinorhynchus rutili was found only in the Orta River.

Fast-track anaesthesia for laparoscopic cholecystectomy: a prospective, randomized, multicentre, blind comparison of desflurane-remifentanil or sevoflurane-remifentanil

BACKGROUND AND OBJECTIVE

To evaluate the effects of sevoflurane and desflurane in combination with intravenous remifentanil on time for discharge from the postanaesthesia care unit and need for postanaesthesia care unit management after elective laparoscopic cholecystectomy.

METHODS

231 ASA Grade I-II patients, undergoing elective laparoscopic cholecystectomy in seven University teaching hospital, were randomly allocated to receive a desflurane-remifentanil (n = 105) or sevoflurane-remifentanil (n = 126) anaesthetic. A blinded observer recorded times for emergence and postanaesthesia care unit discharge (achievement of an Aldrete score > or =9), number of patients eligible for postanaesthesia care unit discharge when exiting the operating room and occurrence of adverse events.

RESULTS

Intraoperative cardiovascular stability was similar in the two groups. Emergence, response and extubation occurred earlier after desflurane (5.4 +/- 3 min, 5.5 +/- 3 min and 7.5 +/- 4 min) than sevoflurane (6.6 +/- 3.5 min, 7.2 +/- 4 min and 9.1 +/- 4.2 min) (P = 0.0005, 0.05 and 0.003, respectively). Postanaesthesia care unit bypass was possible in 44 desflurane-remifentanil patients (41%) and 55 sevoflurane- remifenatnil patients (43%) (P = 0.69), while postanaesthesia care unit discharge occurred after 46 min (25th-75th percentiles: 18-40 min) with desflurane and 64 min (25th-75th percentiles: 20-50 min) with sevoflurane (P = 0.04). Postoperative nausea and vomiting was observed in 40 desflurane-remifentanil patients (36%) and 53 sevoflurane-remifentanil patients (42%) (P = 0.42).

CONCLUSIONS

Both the desflurane-remifentanil and sevoflurane-remifentanil combinations provide a similarly adequate intraoperative cardiovascular stability. Emergence and postanaesthesia care unit discharge were faster with desflurane-remifentanil than sevoflurane-remifentanil, but this was not associated with a larger proportion of postanaesthesia care unit bypass, confirming that no clinically relevant differences are present between the two agents.

Intracellular interleukin-1 receptor antagonist type 1 antagonizes the stimulatory effect of interleukin-1α precursor on cell motility

Interleukin (IL)-1alpha, a proinflammatory cytokine, is produced as a 33 kDa protein precursor (preIL-1alpha) which is cleaved to generate the 17 kDa C-terminal mature IL-1alpha (mIL-1alpha) and the 16kDa N-terminal IL-1alpha propiece (NIL-1alpha). The biological effect of IL-1alpha is regulated by the IL-1 receptor antagonist (IL-1Ra), its naturally occurring inhibitor. Four different isoforms of the IL-1Ra have been described, one secreted (sIL-1Ra) and three intracellular (icIL-1Ra1, 2, 3). Whether the icIL-1Ra1 isoform can antagonize some of the biological effects of intracellular IL-1alpha is still unknown. The aim of this study is to investigate effects of preIL-1alpha and icIL-1Ra1 on cell motility in stably transfected ECV304 cells. We show that expression of preIL-1alpha in ECV304 cells significantly increases cell motility. Furthermore, transfection with NIL-1alpha propiece also increases cell motility whereas this stimulatory effect was not observed by addition of exogenous mIL-1alpha, suggesting an intracellular effect of preIL-1alpha mediated by NIL-1alpha propiece. Co-transfection of ECV304 cells with icIL-1Ra1 completely antagonizes the stimulatory effect of preIL-1alpha and NIL-1alpha propiece on cell motility. In conclusion, NIL-1alpha propiece increases ECV304 cell motility and icIL-1Ra1 exerts intracellular functions regulating this stimulatory effect.

Use of histopathological indicators on chub (Leuciscus cephalus) and brown trout (Salmo trutta fario) in evaluating river environments

A multidisciplinary study was conducted on water from two rivers in the Abruzzo region of Italy. The study highlighted the importance of histopathological investigations in the evaluation of the environmental impact on fish. Brown trout (Salmo trutta fario) from the Aterno river and chub (Leuciscus cephalus) from the Vomano river were sampled in winter and then again in spring. Histopathological investigations of gills, kidneys and livers revealed inflammatory and degenerative lesions, early warning signals of environmental stress. Lesions were evaluated semi-quantitatively and findings were ranked. The histopathological features were compared with results obtained from the analysis of water samples and macroinvertebrates collected in the two rivers (extended biotic index). All results confirmed alterations of the environment.

Comparative analysis of the expression of ERBIN and Erb-B2 in normal human skin and cutaneous carcinomas

BACKGROUND

ERBIN is a binding partner of Erb-B2, an orphan receptor within the Erb-B family critically involved in the regulation of cell growth and differentiation. Although its function remains unclear, ERBIN is thought to affect the polarity of epithelial cells and cell growth via the Ras signalling pathway.

OBJECTIVES

To examine and compare the tissue distribution and the expression levels of ERBIN and Erb-B2 in normal skin and in cutaneous carcinomas.

METHODS

Fifteen cases of basal cell carcinoma (BCC), 12 cases of squamous cell carcinoma (SCC) and five cases of keratoacanthoma (KA) were analysed by immunohistochemistry on paraffin-embedded sections using anti-ERBIN and anti-Erb-B2 antibodies.

RESULTS

ERBIN and Erb-B2 had a similar distribution in normal human skin. They were primarily localized at the plasma membrane in differentiated keratinocytes and in duct cells from eccrine glands, whereas they were localized diffusely in the cytoplasma of basal keratinocytes. In both SCC and KA the subcellular distribution of ERBIN and Erb-B2 remained unchanged, whereas both proteins were redistributed from the plasma membrane into cytosolic aggregates in BCC.

CONCLUSIONS

The subcellular localization of ERBIN in normal human skin is similar to that of Erb-B2 and varies with cell differentiation. Based on our findings and on the biological activities of Erb-B2, it is conceivable that disturbed expression or functioning of ERBIN and Erb-B2 is implicated in the development of the malignant phenotype of BCC.

Hydrolyzed milk-serum peptides reduce body weight and fat content of dietary obese rats ameliorating their antioxidant status and liver functions

AIM

Recent studies suggested that weight reduction under energy restriction required protein supplementation. Moreover, a significant decrease in serum cholesterol and triglycerides was observed when milk-serum proteins and, in particular, their hydrolyzed peptides were compared to milk casein.

METHODS

Six Sprague-Dawley rats were fed with the standard diet for 8 weeks. Eighteen rats were fed with the obesity- producing diet for 4 weeks. After this period and for the remaining 4 weeks, these rats were divided into 3 groups, the 1st was fed with the obesity-diet, the 2nd and the 3rd were fed with the casein--and with the hydrolyzed milk-serum peptides--restricted diet, respectively.

RESULTS

Treatment with the obesity-diet, compared to standard-diet, induced an increase in the body weight and fat content, with a decrease in protein mass and dehydration state. There was also an increase in blood levels of cholesterol, triglycerides and glucose. The lipoperoxides content in the plasma, heart, brain and liver had also increased, while the content of glutathione and ATP and the membrane fluidity in the liver had significantly decreased. The administration of the restricted caloric diet, in particular the one containing the hydrolyzed peptides were capable of an improvement of all these parameters.

CONCLUSIONS

The metabolic modifications induced by the hydrolyzed peptides-restricted diet contribute to control better the over-weight thus reducing the risk of the onset of the dismetabolic pathologies correlated to it.

Interleukin-1 plays a major role in vascular inflammation and atherosclerosis in male apolipoprotein E-knockout mice

OBJECTIVE

To examine the role of the balance between interleukin (IL)-1 and IL-1 receptor antagonist (IL-1Ra) in atherosclerosis and vascular inflammation.

METHODS

Transgenic (Tg) mice overexpressing either secreted IL-1Ra or intracellular IL-1Ra1 as well as IL-1Ra-deficient mice (IL-1Ra -/-) were crossed with apolipoprotein E-deficient mice (ApoE -/-).

RESULTS

In males fed a cholesterol-rich diet for 10 weeks, average atherosclerotic lesion area within aortic roots was significantly decreased in ApoE -/- secreted IL-1Ra Tg (-47%) and ApoE -/- intracellular IL-1Ra1 Tg (-40%) mice as compared to ApoE -/- non-Tg controls. The extent of sudanophilic lesions was reduced within the thoraco-abdominal aorta in ApoE -/- secreted IL-1Ra (-53%) and ApoE -/- intracellular IL-1Ra1 (-67%) Tg mice. In parallel experiments, we observed early mortality and illness among double deficient mice, whereas ApoE -/- IL-1Ra +/+ and ApoE +/+ IL-1Ra -/- mice were apparently healthy. After 7 weeks of diet, ApoE -/- IL-1Ra -/- mice exhibited massive aortic inflammation with destruction of the vascular architecture, but no signs of atherosclerosis. ApoE -/- IL-1Ra +/+ had atherosclerosis and a moderate inflammatory reaction, whereas ApoE +/+ IL-1Ra -/- mice were free of vascular lesions. Macrophages were present in large amounts within inflammatory lesions in the adventitia of ApoE -/- IL-1Ra -/- mice.

CONCLUSION

Our results demonstrate that the IL-1/IL-1Ra ratio plays a critical role in the pathogenic mechanisms leading to vascular inflammation and atherosclerosis in ApoE -/- mice.

0.2% ropivacaine with or without sufentanil for patient-controlled epidural analgesia after anterior cruciate ligament repair

AIM

The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia (PCEA) on the quality of postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction.

METHODS

Twenty ASA physical status I-II patients, scheduled to have elective ACL repair were studied. Combined spinal-epidural anesthesia was performed at the L3-L4 or L4-L5 interspace using a needle-through-needle technique. Spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine. Postoperative epidural analgesia was started at the end of surgery using a continuous epidural infusion of 0.2% ropivacaine alone (n=10) or 0.2% ropivacaine/0.5 mg mL(-1) sufentanil (n=10). The degree of pain was evaluated at 1, 8, 16, 24 and 48 hours after surgery; at the same observation times the degree of motor block, sedation, oxygen saturation, total consumption of PCEA solution and incremental doses given to the patient were also recorded.

RESULTS

No differences in the quality of intraoperative anesthesia was observed, and in no case general anesthesia was required to complete surgery. Patients receiving the combination of ropivacaine and sufentanil showed lower levels of VAS from 16 hours after surgery as compared with ropivacaine group (P=0.02). However, no differences in the degree of pain were observed between the 2 groups during continuous passive mobilization.

CONCLUSION

Adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia improved pain control at rest but did not result in significant improvement of postoperative analgesia during continuous passive mobilization.

Acute Pain Service and multimodal therapy for postsurgical pain control: evaluation of protocol efficacy

AIM

The institution of a postoperative Acute Pain Control Service is mandatory to improve the control of pain induced by surgical injury. Treatment of postoperative pain may be achieved using a combination of analgesic agents and techniques, reducing the incidence of side effects owing to the lower doses of the individual drugs. In 1997 we established an Acute Pain Service (APS) at the San Raffaele Hospital in Milan. The aim of this study was to assess the efficacy and safety of our APS both in terms of treatment protocols and organisational issues.

METHODS

In this prospective observational study we included 592 patients undergoing abdominal, gynecological, or orthopedic surgery with severe expected pain. According to general guidelines on pain treatment, the patients were assigned to different treatment protocols based on the kind of operation. All protocols were based on the multimodal therapy, with the association of nonsteroidal anti-inflammatory drugs (NSAIDS), opioids and regional anesthesia techniques. During the first 48 h of the postoperative period we recorded vital signs, level of pain and occurrence of any side effect.

RESULTS

Our analgesic protocols proved to be effective and safe (low incidence of side effects) for every surgery. The incidence of postoperative nausea and vomiting was higher in patients receiving patient-controlled morphine than that with continuous epidural or nerve block. After lower abdominal surgery, pain at movement at 24 h was significantly lower in the epidural group than in the Patient Control Analgesia group. Nausea and vomiting, numbness and paresthesias at the lower limbs were higher in gynecological patients. A larger percentage of orthopedic patients in the epidural group reported numbness and paresthesias at the lower limbs in comparison with patients receiving continuous peripheral nerve block.

CONCLUSION

In agreement with previous literature, this study confirmed that a multimodal approach to pain treatment provides an adequate control of postoperative pain, minimizing side effects.

Spinal block or total intravenous anaesthesia with propofol and remifentanil for gynaecological outpatient procedures

BACKGROUND AND OBJECTIVE

The aim of this prospective, randomized study was to compare the preparation and discharge times, the side-effects and patient satisfaction after gynaecological outpatient procedures performed using either spinal block or total intravenous anaesthesia with propofol and remifentanil.

METHODS

With Ethics Committee approval and written informed consent, 40 healthy females scheduled for hysteroscopic ablation of endometrial neoplasm were randomly allocated to receive either a spinal block with bupivacaine 0.5% hyperbaric solution 10 mg (n = 20) or total intravenous anaesthesia with propofol and remifentanil (n = 20). Preparation and discharge times, as well as occurrence of untoward events and anaesthesia-related costs, were recorded.

RESULTS

The median (range) preparation time was 7 (7-10) min with general anaesthesia, and 11 (7-21) min with spinal block (P = 0.00005). No differences in discharge time from the postanaesthesia care unit and incidence of hypotension or bradycardia, or both, were reported between the two groups. Hospital discharge times were 156 (101-345) min after general anaesthesia and 296 (195-720) min after spinal anaesthesia (P = 0.0005). Acceptance of the anaesthesia technique was better after general (100%) than after spinal anaesthesia (75%) (P = 0.04). No differences in total costs were reported between spinal block ([symbol: see text] 155 ([symbol: see text] 117-[symbol: see text] 224)) and propofol-remifentanil general anaesthesia ([symbol: see text] 143 ([symbol: see text] 124-[symbol: see text] 203) (P = 0.125)).

CONCLUSIONS

Accurate titration of short-acting intravenous anaesthetic drugs such as propofol and remifentanil results in shorter preparation times and earlier home discharge after outpatient gynaecological procedures compared with spinal anaesthesia with hyperbaric bupivacaine 10 mg, with better patient acceptance and no increased costs.

Randomized comparison of remifentanil-propofol with a sciatic-femoral nerve block for out-patient knee arthroscopy

BACKGROUND AND OBJECTIVE

To evaluate preparation and discharge times as well as the anaesthesia-related costs of out-patient knee arthroscopy performed with a combined sciatic-femoral nerve block, or a propofol-remifentanil general anaesthetic.

METHODS

With Ethics Committee approval and written informed consent, 40 healthy patients were pre-medicated with intravenous midazolam (0.05 mg kg(-1)) and ketoprofen (50 mg). They were then randomly allocated to receive either a combined sciatic-femoral nerve block with 25 mL mepivacaine 2% (15 mL for the femoral nerve, 10 mL for the sciatic nerve) (PNB group, n = 20), or a general anaesthetic with a continuous intravenous infusion of remifentanil (0.1-0.3 microgkg(-1) min(-1)) and propofol (target plasma concentration 2-4 microg mL(-1)) with a laryngeal mask airway (GA group, n = 20).

RESULTS

The median (range) preparation time was 16 (10-28)min in the PNB group and 13 (8-22)min in the GA group (P = 0.015). Ten PNB patients were directly discharged to the day-surgery unit after the procedure as compared with one GA patient (P = 0.003). Discharge from the postanaesthesia care unit (PACU) required 5 (5-20) min in the PNB group and 23 (7-95) min in the GA group (P = 0.001). Home discharge criteria were fulfilled after 277 (150-485) min in the PNB group and 170 (100-400) min in the GA group (P = 0.005). Costs related to the time spent in the PACU were lower for the PNB group (1.10 euro, range Euro 0-22 euro) compared with the GA group (30 euro, range 0-176 euro) (P = 0.0005). There were no differences in total costs: PNB group 158 euro (range 105-194 euro) versus GA group 160 euro (range 101-238 euro) (P = 0.61).

CONCLUSIONS

In patients undergoing out-patient knee arthroscopy, the length of stay in the PACU can be shorter after a sciatic-femoral nerve block with a small volume of mepivacaine 2% compared with a propofol-remifentanil anaesthetic, and there is an increased likelihood that they will bypass the first phase of the postoperative recovery.

[Spinal cord stimulation and quality of life in patients with refractory angina]

BACKGROUND

Spinal cord stimulation (SCS) is a treatment that exploits the antalgic and vasodilatory effects on the microcirculation produced by a stimulating electrode positioned in the peridural space. This therapy has been used for years in the treatment of refractory angina pectoris. The aim of this study was to monitor the clinical effectiveness of the technique in terms of symptomatic benefits and, above all, improved quality of life in angina patients undergoing SCS.

METHODS

From November 1998 to December 2000 we used SCS to treat 17 patients with refractory angina (functional class III or IV Canadian Cardiovascular Society) with onset more than one year earlier. All patients had undergone one or more traditional revascularisation procedures and were receiving maximum drug therapy. Patients were assigned to SCS because it was not technically possible to perform other revascularisation procedures. Quality of life was measured before and after treatment using a multidimensional index (QL Spitzer's index). We also noted the mortality, acceptance and morbidity of the procedure during a follow-up lasting 10 months on average. Lastly, the number of weekly anginal pain attacks, weekly nitrate consumption and CCS functional class were recorded before treatment and 1, 3 and six months after therapy.

RESULTS

SPC was effective in 13 patients out of 17 (76.47%). In responders the quality of life improved by 70%: in these patients, the number of weekly angina attacks reduced from 11.76+/-7.56 to 2.14+/-2.54, and the functional class from 3.30+/-0.75 to 1.5+/-0.53. No major periprocedural complications were reported. The annual mortality rate was 6.6%. The technique was easy to use.

CONCLUSIONS

The results of this study show that SCS is effective, safe, easy to use and well tolerated by patients with refractory angina who fail to respond to traditional revascularisation. This technique substantially improves the quality of life of patients suffering from refractory angina.

[Peripheral blocks for the lower limb: lumbar plexus]

BACKGROUND

The techniques of continuous peripheral blockades have shown to be efficient in postoperative pain control, in the various orthopaedic procedures of the limbs. The aim of this study is to evaluate the existing data about the use of a continuous blockade of the lumbar plexus or femoral nerve, together with the indications for technique and therapy.

METHODS

We considered the principal results of prospective, randomised studies described in literature about the assessment of a continuous peripheral blockade of the lumbar plexus or the femoral nerve in limb surgery. Furthermore we described the principal techniques for positioning the perinerval catheters in the considered sites, and the advised dosage regimen.

RESULTS

The various studies report an adequate costs/benefits relation concerning the used techniques. The analysed studies not only report an adequate efficacy of the postoperative pain control, but often show an important benefit in terms of functional recovery of the operated limbs and on final outcome of the patient.

CONCLUSIONS

The use of continuous blockades of the lumbar plexus or femoral nerve shows to be an important and effective instrument not only in terms of positive effects on postoperative pain control, but also in terms of relevant advantages concerning final outcome after surgery. Nevertheless these techniques should not be considered as the only approach to postoperative pain in the orthopaedic patient, but have to be included in a global, multidisciplinary and multimodal approach.

[Systemic analgesia after peripheral block]

Over the past few years, increasing emphasis has been placed on the need to improve the management of acute pain. Despite a growing trend in acute pain management, many difficulties are still present for the treatment of postoperative pain. Loco-regional techniques together with an effective pain management should accelerate rehabilitation, decrease risk of postoperative complications and speed return to normal activities. A multimodal approach should be used for a reduction of pharmacological side effects, improving pain reduction. The association between NSAIDs and opioids permits reduction of full dose opioids with better pain relief and less side effects. If NSAIDs are contraindicated, acetaminophen is an alternative, though considered by someone to be an NSAID It's action is believed to result from inhibition of prostaglandin synthesis within the central nervous system. It doesn't cause gastrointestinal ulceration or bleeding, but we have to note that large amounts may lead to hepatic necrosis. Newer NSAIDs (COX-2 inhibitors), affect mainly COX-2, and appear to be associated with less adverse effect. Rofecoxib showed a reduction of morphine consuming after spinal fusion and has been admitted by FDA for the treatment of post operative pain. Newer methods of pain relief, as patient controlled analgesia (PCA), can provide excellent and safe pain relief. When high-tech options such as PCA are used, patients need a management by an anesthesiologist-based acute pain service (APS), allowing a better pain relief with less side effects compared to patients supervised by less experienced medical staff.

Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine

BACKGROUND

The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 1 microg. kg-1 fentanyl to ropivacaine 7.5 mg. ml-1 for axillary brachial plexus anaesthesia.

METHODS

With Ethics Committee approval and written consent, 30 ASA physical status I-II in-patients, scheduled for orthopaedic hand procedures were randomly allocated to receive axillary brachial plexus block with 20 ml of either ropivacaine 7.5 mg. ml-1 (n=15) or ropivacaine 7.5 mg. ml-1+1 microg. ml-1 fentanyl (n=15). Nerve blocks were placed using a nerve stimulator with the multiple injection technique. A blinded observer recorded the time to onset of surgical block (loss of pinprick sensation in the innervation areas of the hand (C6-C8) with concomitant inability to flex the wrist against gravity and move the fingers when squeezing the hand) and first request for pain medication after surgery.

RESULTS

No differences in demography, degree of sedation or peripheral oxygen saturation were observed between the two groups. Median (range) time required to achieve readiness for surgery was 15 min (5-36 min) with ropivacaine alone and 15 min (5-40 min) with the ropivacaine-fentanyl mixture. No differences in the intraoperative quality of nerve block were reported between the two groups. Four patients receiving ropivacaine plain and two patients receiving the ropivacaine-fentanyl mixture did not require analgesics during the first 24 h after surgery (P=0.62). The degree of pain experienced at first analgesic request in those patients asking for pain medication, as well as median consumption of postoperative analgesics, were similar in the two groups. First postoperative analgesic request was made at 11 h (25th-75th percentiles: 9.1-14 h) in patients receiving ropivacaine alone and at 11.8 h (25th-75th percentiles: 9.8-15 h) in patients receiving the ropivacaine-fentanyl mixture (P=0.99).

CONCLUSION

The addition of fentanyl 1 microg. ml-1 to ropivacaine 7.5 mg. ml-1 does not improve the nerve block characteristics of axillary brachial plexus anaesthesia for orthopaedic procedures involving the hand.

Minimum local anesthetic volume blocking the femoral nerve in 50% of cases: a double-blinded comparison between 0.5% ropivacaine and 0.5% bupivacaine

Recent studies demonstrated that ropivacaine was nearly 40% less potent than bupivacaine in the first stage of labor, but contrasting results have been reported. We, therefore, conducted a prospective, randomized, double-blinded study to determine the effects of the ropivacaine/bupivacaine potency ratio on the minimum volume of local anesthetic required to produce effective block of the femoral nerve in 50% of patients. Fifty adults premedicated with IV midazolam, 0.05 mg/kg, undergoing elective knee arthroscopy received femoral nerve blocks with a multiple-injection technique with a nerve stimulator (contractions of vastus medialis, vastus intermedius, and vastus lateralis were elicited with a 0.5-mA stimulating current). Patients randomly received either 0.5% ropivacaine (n = 25) or 0.5% bupivacaine (n = 25). The anesthetic volume was decided according to Dixon's up-and-down method, starting from 12 mL and being equally divided among the three elicited twitches. Successful nerve block was loss of pinprick sensation in the femoral nerve distribution with concomitant block of the quadriceps muscle within 20 min after injection, as assessed by a blinded observer. Positive or negative responses determined a 3-mL decrease or increase for the next patient, respectively. According to the up-and-down sequences, the minimum local anesthetic volume providing successful nerve block in 50% of cases was 14 +/- 2 mL in the ropivacaine group (95% CI: 12-16 mL) and 15 +/- 2 mL (95% CI: 13-17 mL) in the bupivacaine group (P: = 0.155). We conclude that the volume of 0.5% ropivacaine required to produce effective block of the femoral nerve in 50% of patients is similar to that required when using 0.5% bupivacaine.

IMPLICATIONS

Considering the risk for drug-related systemic toxicity, the equipotency ratio between ropivacaine and bupivacaine is crucial for daily practice. Despite the 40% reduction in the analgesic potency of ropivacaine reported during epidural analgesia for labor pain, results of this prospective, randomized, double-blinded study demonstrated that the same volume of 0.5% ropivacaine or 0.5% bupivacaine is required to produce an effective block of the femoral nerve in 50% of cases.

Transesophageal echocardiography as predictor of mitral valve repair

BACKGROUND AND AIM OF THE STUDY

Mitral valve repair has recently emerged as the treatment of choice in patients presenting with insufficiency due to valve prolapse. The study aims were to evaluate: (i) the clinical presentation in a consecutive series of patients with mitral valve prolapse undergoing surgical repair; (ii) the correlation between pre- and intraoperative echocardiographic features and surgical findings in these patients; and (iii) whether clinical and echocardiographic data may predict surgical outcome.

METHODS

Between March 1997 and May 2000, 152 patients (110 men, 42 women; mean age 59+/-13 years) were recruited into the study. All patients had myxomatous mitral valve disease causing severe regurgitation and underwent systematic examination by transesophageal echocardiography (TEE) for clear delineation of the three scallops of the posterior leaflet and juxtaposed segments of the anterior leaflet.

RESULTS

In 119 patients (78%) a flail valve was documented by TEE and confirmed on surgical inspection; an anterior leaflet chordal rupture was not visualized by TEE in one case. In 15 cases (10%) there was flail of the anterior leaflet, and in 105 cases (69%) flail of the posterior leaflet. A bileaflet complex prolapse without chordal rupture was found in 32 cases. On the basis of TEE evaluation, mitral valve replacement was performed electively in 10 patients (7%); the other 142 (93%) underwent mitral valve repair. Adequate repair was obtained in 93% of cases; residual mitral regurgitation (eight cases; grade 3+) and mitral stenosis (one case) were documented by intraoperative TEE, and nine patients (6%) underwent valve replacement.

CONCLUSION

The majority of patients with myxomatous mitral valve prolapse and severe regurgitation undergoing valve repair have chordal rupture of the posterior mitral leaflet, a condition in which results of valve repair are excellent. TEE provides a powerful means to define the mechanisms of mitral regurgitation and to identify the suitability of patients for valvuloplasty.

Study of the effect of lactobacillus GG supplementation in combination with and without arginine aspartate on lipoproteins and liver peroxidation in cholesterol-fed rats

The effect of diet integration with lactobacillus GG and arginine aspartate administered singly or together to rats submitted to a cholesterol-enriched diet have been evaluated by measuring both the changes in the levels of cholesterol and triglycerides and the variations of the most indicative parameters of peroxidation in plasma lipoproteins and livers. The administration of lactobacillus GG alone is able to induce a significant hypocholesterolaemic effect while the arginine aspartate singly or together with the lactobacillus does not seem to promote any significant hypocholesterolaemic effect. The cholesterol levels (expressed as mg x dL-1) are in fact: 45.5 for the control diet; 185.4 for the cholesterol-enriched diet; 131.1 for the cholesterol-enriched diet + lactobacillus; 178.2 for the cholesterol enriched diet + arginine aspartate and 122.4 for the cholesterol-enriched diet + lactobacillus + arginine aspartate. On the contrary, the co-administration of lactobacillus and arginine aspartate gives rise to a very high preventive activity against the cholesterol-induced peroxidation damages both in the plasma lipoproteins and in the liver. Such preventive activity is higher by far than that obtainable when lactobacillus or arginine aspartate are administered singly to the rats.

A comparison of remifentanil and sufentanil as adjuvants during sevoflurane anesthesia with epidural analgesia for upper abdominal surgery: effects on postoperative recovery and respiratory function

We compared the recovery profile and postoperative SpO(2) after the administration of general anesthesia with either sevoflurane-remifentanil or sevoflurane-sufentanil in 30 healthy patients undergoing upper abdominal surgery. They were randomly allocated to receive general anesthesia with sevoflurane and small doses of either remifentanil (n = 15) or sufentanil (n = 15), followed by postoperative epidural analgesia. The median sevoflurane minimum alveolar anesthetic concentration-hour was 2.3 (1.2-6.3) in group Remifentanil and 2.6 (1.4-5.2) in group Sufentanil (P: = 0.39), while the median consumption of remifentanil was 1.3 mg (0.7-3.4 mg) and sufentanil 0.09 mg (0.05-0.6 mg). Tracheal extubation required 10 min (6-18 min) with remifentanil and 14 min (8-24 min) with sufentanil (P: = 0.05); however, no differences in time to discharge from the recovery area were reported (24 min [12-75 min] with remifentanil and 30 min [12-135 min] with sufentanil; P: = 0. 35). From the first to seventh hour after surgery, SpO(2) was decreased more in the sufentanil than in the remifentanil group (P: = 0.001), and seven patients in the sufentanil group showed at least one episode with SpO(2) < or = 90% for more than 1 min (P: = 0.006) (median: 1 episode; range: 0-17 episodes; P: = 0.003). When added to sevoflurane, remifentanil is as effective as sufentanil during the intraoperative period, but provides shorter time to tracheal extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.

IMPLICATIONS

In this double-blinded study, we evaluated the effects of adding small infusions of either remifentanil or sufentanil to sevoflurane in combination with postoperative epidural analgesia for upper abdominal surgery. We demonstrated that remifentanil is as effective as sufentanil during the intraoperative period, but that it provides shorter time to extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.