Cryoglobulinemia: the "cold" problem in cardiac surgery, a single-center experience and a literature review

Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures in order to perform surgery with a clear sight field.To safely perform surgery with CPB and preserve brain, kidney, and patient tissue from ischemic damage, cold cardioplegia, and mild to deep hypothermia are induced during the operation.Cryoglobulinemia is a hematological/infective-related disease (in certain cases idiopathic) in which temperature-dependent antibodies tend to aggregate and form emboli in the vascular system causing tissue damage if exposed to low temperature.The patient with cryoglobulinemia (known and unknown) can be at risk of a major ischemic event during CPB and induced hypothermia.This article's aim is to evaluate the present scientific literature in order to understand how, in years, the therapeutic or preventive approach, is evolving, and to analyze and make improvements to the management of a cryoglobulinemic patient who must undergo elective or emergency cardiac surgery.In the last part of our article, we expose our single-center experience during a 32-month-long period of survey.In all cases, our medical team (anesthesiologists, perfusionists, and cardiac surgeons) opted for a normothermic cardiopulmonary bypass to lower the risk of cryoglobulin-associated complications.In our experience, along with therapeutic intervention to lower the cryoglobulin titer, normothermic management of cardiopulmonary bypass is as safe as hypothermic management.Notwithstanding our results, further studies with a larger population are needed to confirm this perioperative management in a cardiac surgery setting.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry

Aims

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting.

Methods and results

In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72).

Conclusions

In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

Integrated lung ultrasound score for early clinical decision-making in patients with COVID-19: results and implications

Background and objectives

Lung Ultrasound Score (LUS) identifies and monitors pneumonia by assigning increasing scores. However, it does not include parameters, such as inferior vena cava (IVC) diameter and index of collapse, diaphragmatic excursions and search for pleural and pericardial effusions. Therefore, we propose a new improved scoring system, termed “integrated” lung ultrasound score (i-LUS) which incorporates previously mentioned parameters that can help in prediction of disease severity and survival, choice of oxygenation mode/ventilation and assignment to subsequent areas of care in patients with COVID-19 pneumonia.

Methods

Upon admission at the sub-intensive section of the emergency medical department (SEMD), 143 consecutively examined COVID-19 patients underwent i-LUS together with all other routine analysis. A database for anamnestic information, laboratory data, gas analysis and i-LUS parameters was created and analyzed.

Results

Of 143 enrolled patients, 59.4% were male (mean age 71 years) and 40.6% female. (mean age 79 years: p = 0.005). Patients that survived at 1 month had i-LUS score of 16, which was lower than that of non-survivors (median 20; p = 0.005). Survivors had a higher PaO2/FiO2 (median 321.5) compared to non-survivors (median 229, p < 0.001). There was a correlation between i-LUS and PaO2/FiO2 ratio (rho:-0.4452; p < 0.001), PaO2/FiO2 and survival status (rho:-0.3452; p < 0.001), as well as i-LUS score and disease outcome (rho:0.24; p = 0.005). In non-survivors, the serum values of different significant COVID indicators were severely expressed. The i-LUS score was higher (median 20) in patients who required non-invasive ventilation (NIV) than in those treated only by oxygen therapy (median 15.42; p = 0.003). The odds ratio for death outcome was 1.08 (confidence interval 1.02–1.15) for each point increased. At 1-month follow-up, 65 patients (45.5%) died and 78 (54.5%) survived. Patients admitted to the high critical ward had higher i-LUS score than those admitted to the low critical one (p < 0.003).

Conclusions

i-LUS could be used as a helpful clinical tool for early decision-making in patients with COVID-19 pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00264-8.

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

Effects of Different Levels of Variability and Pressure Support Ventilation on Lung Function in Patients With Mild-Moderate Acute Respiratory Distress Syndrome

Background: Variable pressure support ventilation (vPSV) is an assisted ventilation mode that varies the level of pressure support on a breath-by-breath basis to restore the physiological variability of breathing activity. We aimed to compare the effects of vPSV at different levels of variability and pressure support (ΔP_S) in patients with acute respiratory distress syndrome (ARDS).

Methods: This study was a crossover randomized clinical trial. We included patients with mild to moderate ARDS already ventilated in conventional pressure support ventilation (PSV). The study consisted of two blocks of interventions, and variability during vPSV was set as the coefficient of variation of the ΔP_S level. In the first block, the effects of three levels of variability were tested at constant ΔP_S: 0% (PSV_0%, conventional PSV), 15% (vPSV_15%), and 30% (vPSV_30%). In the second block, two levels of variability (0% and variability set to achieve ±5 cmH₂O variability) were tested at two ΔP_S levels (baseline ΔP_S and ΔP_S reduced by 5 cmH₂O from baseline). The following four ventilation strategies were tested in the second block: PSV with baseline ΔP_S and 0% variability (PSV_BL) or ±5 cmH₂O variability (vPSV_BL), PSV with ΔP_S reduced by 5 cmH₂O and 0% variability (PSV₋₅) or ±5 cmH₂O variability (vPSV₋₅). Outcomes included gas exchange, respiratory mechanics, and patient-ventilator asynchronies.

Results: The study enrolled 20 patients. In the first block of interventions, oxygenation and respiratory mechanics parameters did not differ between vPSV_15% and vPSV_30% compared with PSV_0%. The variability of tidal volume (V_T) was higher with vPSV_15% and vPSV_30% compared with PSV_0%. The incidence of asynchronies and the variability of transpulmonary pressure (P_L) were higher with vPSV_30% compared with PSV_0%. In the second block of interventions, different levels of pressure support with and without variability did not change oxygenation. The variability of V_T and P_L was higher with vPSV₋₅ compared with PSV₋₅, but not with vPSV_BL compared with PSV_BL.

Conclusion: In patients with mild-moderate ARDS, the addition of variability did not improve oxygenation at different pressure support levels. Moreover, high variability levels were associated with worse patient-ventilator synchrony.

Clinical Trial Registration:www.clinicaltrials.gov, identifier: NCT01683669.

Iatrogenic Acute Aortic Dissection in the Era of Minimally Invasive Cardiac Surgery - Experience of a Center and Review of Literature

Introduction

Iatrogenic acute aortic dissection (IAAD) type A is a rare but potentially fatal complication of cardiac surgery.

Methods

The purpose of this article is to review the literature since the first reports of IAAD in 1978, examining its clinical characteristics and describing operative details and surgical outcomes. Moreover, we reviewed the recent literature to identify current trends and risk factors for IAAD in minimally invasive cardiac surgery procedures, often related to femoral artery cannulation for retrograde perfusion.

Results

We found that IAAD ranges from 0.04 to 0.29% of cardiac patients in overall trials and ranged from 0.12 to 0.16% between 1978-1990, before the minimally invasive surgical era. And we concluded that since the first cases to the recent reports, the incidence of IAAD has not significantly changed. As minimally invasive procedures are on the rise, some authors think that the incidence of IAAD could increase in the future; we think that using all the precaution - such a strict monitoring of perfusion pressure throughout the intervention, avoiding extremely high jet pressures using vasodilators, repositioning of arterial cannula, or splitting perfusion in both femoral arteries -, this complication can be extremely reduced. Finally, we describe a very singular case occurring during mitral valve replacement followed by spontaneous dissection of left anterior descending artery one month later.

Conclusion

The present article adds to the literature a more detailed clinical picture of this entity, including patients' characteristics, the mechanism, timing, and localization of the tear, and mortality details.

A simple prognostic score based on troponin and presepsin for COVID-19 patients admitted to the emergency department: a single-center pilot study

BACKGROUND

The need to determine prognostic factors that can predict a particularly severe or, conversely, the benign course of COVID-19 is particularly perceived in the Emergency Department (ED), considering the scarcity of resources for a conspicuous mass of patients. The aim of our study was to identify some predictors for 30-day mortality among some clinical, laboratory, and ultrasound variables in a COVID-19 patients population.

METHODS

Prospective single-center pilot study conducted in an ED of a University Hospital. A consecutive sample of confirmed COVID-19 patients with acute respiratory failure was enrolled from March 8th to April 15th, 2020.

RESULTS

143 patients were enrolled. Deceased patients (n = 65) were older (81 vs. 61 years, p <0.001), and they had more frequently a history of heart disease, neurological disease, or chronic obstructive pulmonary disease (p-values = 0.026, 0.025, and 0.034, respectively) than survived patients. Troponin I and presepsin had a significant correlation with a worse outcome. Troponin achieved a sensitivity of 77% and a specificity of 82% for a cut-off value of 27.6 ng/L. The presepsin achieved a sensitivity of 54% and a specificity of 92% for a cut-off value of 871 pg/mL.

CONCLUSION

In a population of COVID-19 patients with acute respiratory failure in an ED, presepsin and troponin I are accurate predictors of 30-day mortality. Presepsin is highly specific and could permit the early identification of patients who could benefit from more intensive care as soon as they enter the ED. Further validation studies are needed to confirm this result.

QTc interval prolongation and life-threatening arrhythmias during hospitalization in patients with COVID-19. Results from a multi-center prospective registry

Background

Prolonged QTc interval and life-threatening arrhythmias (LTA) are potential drug induced complications previously reported with antimalarial, antivirals and antibiotics.

Objectives

To evaluate prevalence and predictors of QTc interval prolongation and incidence of LTA during hospitalization for COVID-19 among patients with normal admission QTc.

Methods

110 consecutive patients were enrolled in a multicenter international registry. 12-lead ECG was performed at admission, after 7 and 14 days; QTc values were analyzed.

Results

Fifteen (14%) patients developed a prolonged-QTc (pQT) after 7 days (mean QTc increase 66±20msec, +16%, p<0.001); these patients were older, had higher basal heart rates, higher rates of paroxysmal atrial fibrillation, lower platelet count. QTc increase was inversely proportional to baseline QTc levels and leukocyte count and directly to basal heart rates(p<0.01).At multivariate stepwise analysis including age, male gender, paroxysmal atrial fibrillation, basal QTc values, basal heart rate and dual antiviral therapy, age(OR 1.06, 95% C.I. 1.00-1.13, p<0.05), basal heart rate(OR 1.07, 95% C.I. 1.02-1.13, p<0.01) and dual antiviral therapy(OR 12.46, 95% C.I. 2.09-74.20, p<0.1) were independent predictors of QT-prolongation.Incidence of LTA during hospitalization was 3.6%. One patient experienced cardiac arrest and three non-sustained ventricular tachycardia. LTAs were recorded after a median of 9 days from hospitalization and were associated with 50% of mortality rate.

Conclusions

After 7 days of hospitalization, 14% of patients with Covid-19 developed pQTc; age, basal heart rate and dual antiviral therapy were found as independent predictor of pQTc. Life threatening arrhythmias have an incidence of 3.6% and were associated with poor outcome.

Intrapartum ultrasound monitoring of malposition and malrotation during labor neuraxial analgesia: maternal outcomes

Objective: This study analyzes the important role of ultrasonography (IUS) related to the maternal outcomes in women with fetal persistent occiput posterior position (POPP) and asynclitism (A) in labor neuraxial analgesia (LNA).Study design: Prospective assessment of 148 primiparous women diagnosed with the prolonged second stage of labor. Transabdominal and transperineal IUS were used to detect fetal head position and to evaluate the angle of progression (AOP) and pubic arch angle (PAA). Statistical data about maternal aspects, modalities of delivery and maternal outcomes were observed.Results: In all parturients included in the study, the operative delivery rate was 73%. In patients delivered via cesarean section, the PAA was ≤ of 96.5°. There was statistical correlation between doses of LNA and Apgar score at first minute (r0.8).Conclusions: There is a greater frequency of Fetal POPP and asynclitism related with maternal complications. The results of our study confirmed the importance of determination of angle of progression (AoP) and PAA in the prolonged second stage of labor. Unfavorable AoP and PAA, in presence of POPP and A, are related with high percentage of operative delivery. If the prolonged labor and delivery in these patients exceed time limit proposed by American College of Obstetricians and Gynecologists guidelines, it may be viewed as a possible malpractice. In cases of POPP with asynclitism, in the second stage of labor detected by IUS it is advisable to discontinue the anesthetic drugs administration in LNA; because the labor pain is related to the dystocia, an operative delivery is necessary to avoid maternal and fetal complications.

Congenital Aorto-Right Ventricular Fistula Associated with Pulmonary Hypertension in an Old Female Patient

We report a late clinical presentation of an aorto-right ventricular fistula (RVF) extending from the right sinus of Valsalva into the RV outflow tract with significant left-to-right shunt and severe pulmonary hypertension. A three-dimensional transesophageal echocardiogram and a chest-computed tomography scans were performed to better characterize the abnormality. Aorto- RVF can be either congenital or acquired, secondary to endocarditis, Valsalva aneurysm rupture, chest trauma, or aortic dissection.

Effect of age on the performance of bispectral and entropy indices during sevoflurane pediatric anesthesia: a pharmacometric study

BACKGROUND

Bispectral index (BIS) and entropy monitors have been proposed for use in children, but research has not supported their validity for infants. However, effective monitoring of young children may be even more important than for adults, to aid appropriate anesthetic dosing and reduce the chance of adverse consequences. This prospective study aimed to investigate the relationships between age and the predictive performance of BIS and entropy monitors in measuring the anesthetic drug effects within a pediatric surgery setting.

METHODS

We concurrently recorded BIS and entropy (SE/RE) in 48 children aged 1 month-12 years, undergoing general anesthesia with sevoflurane and fentanyl. Nonlinear mixed effects modeling was used to characterize the concentration-response relationship independently between the three monitor indicators with sevoflurane. The model's goodness-of-fit was assessed by prediction-corrected visual predictive checks. Model fit with age was evaluated using absolute conditional individual weighted residuals (|CIWRES|). The ability of BIS and entropy monitors to describe the effect of anesthesia was compared with prediction probabilities (P_K ) in different age groups. Intraoperative and awakening values were compared in the age groups. The correlation between BIS and entropy was also calculated.

RESULTS

|CIWRES| vs age showed an increasing trend in the model's accuracy for all three indicators. P_K probabilities were similar for all three indicators within each age group, though lower in infants. The linear correlations between BIS and entropy in different age groups were lower for infants. Infants also tended to have lower values during surgery and at awakening than older children, while toddlers had higher values.

CONCLUSIONS

Performance of both monitors improves as age increases. Our results suggest a need for the development of new monitor algorithms or calibration to better account for the age-specific EEG dynamics of younger patients.

Effects of ventilator settings, nebulizer and exhalation port position on albuterol delivery during non-invasive ventilation: an in-vitro study

Background

Few studies have investigated the factors affecting aerosol delivery during non-invasive ventilation (NIV). Our aim was to investigate, using a bench-top model, the effect of different ventilator settings and positions of the exhalation port and nebulizer on the amount of albuterol delivered to a lung simulator.

Methods

A lung model simulating spontaneous breathing was connected to a single-limb NIV ventilator, set in bi-level positive airway pressure (BIPAP) with inspiratory/expiratory pressures of 10/5, 15/10, 15/5, and 20/10 cmH₂O, or continuous positive airway pressure (CPAP) of 5 and 10 cmH₂O. Three delivery circuits were tested: a vented mask with the nebulizer directly connected to the mask, and an unvented mask with a leak port placed before and after the nebulizer. Albuterol was collected on a filter placed after the mask and then the delivered amount was measured with infrared spectrophotometry.

Results

Albuterol delivery during NIV varied between 6.7 ± 0.4% to 37.0 ± 4.3% of the nominal dose. The amount delivered in CPAP and BIPAP modes was similar (22.1 ± 10.1 vs. 24.0 ± 10.0%, p = 0.070). CPAP level did not affect delivery (p = 0.056); in BIPAP with 15/5 cmH₂O pressure the delivery was higher compared to 10/5 cmH₂O (p = 0.033) and 20/10 cmH₂O (p = 0.014). Leak port position had a major effect on delivery in both CPAP and BIPAP, the best performances were obtained with the unvented mask, and the nebulizer placed between the leak port and the mask (p < 0.001).

Conclusions

In this model, albuterol delivery was marginally affected by ventilatory settings in NIV, while position of the leak port had a major effect. Nebulizers should be placed between an unvented mask and the leak port in order to maximize aerosol delivery.

Acute abdomen as a consequence of an unusual suicide attempt: intra-abdominal injection of sulfuric acid

Caustic ingestion is a common cause of life-threatening upper gastrointestinal tract injuries. It mostly happens in children as accidental exposure, but may occur in adults as a result of suicide attempt. We present a case of an acute abdomen that occurred after a peculiar way of self-administration of sulfuric acid as a suicide attempt in an adult psychiatric male patient, already known for self-harm with caustic agents in the previous years. In a few hours, the patient developed diffuse peritonitis, pneumoperitoneum, and a rapid hemodynamic deterioration, as a consequence of ileum and sigmoid necrosis, requiring an emergency surgery with the application of a damage control strategy. The patient was then transferred to intensive care unit for hemodynamic stabilization, and definitive surgical correction of the abdominal lesions was performed after 3 days with Hartmann procedure. Thirty-nine days after hospital admission, the patient was discharged. In conclusion, to our knowledge, never has been reported in the literature a case of intra-abdominal self-administration of caustic substance causing a rapid evolution of clinical conditions and requiring the application of damage control strategy.

[Coffee consumption in depressive disorders: it's not one size fits all]

Caffeine is considered the world's most popular psychoactive substance. Its actions on the central nervous system, mainly mediated by antagonism of adenosine receptors and subsequent modulation of dopaminergic activity, would be particularly sought by depressed patients, as an attempt of self-medication. However, published data suggested that coffee consumption may worsen psychopathological conditions in mood disorders. Thus, we reviewed available evidence in the literature that investigated the effects of coffee consumption on clinical development of underlying psychopathology. Literature research was done by typing on Medline/PubMed and PsychINFO the key words "coffee AND major depression", "coffee AND dysthymia". The research was limited to English language publications and to studies conducted exclusively on humans. Although literature data are conflicting, extensive follow-up studies indicate a significant caffeine effect on risk reduction of developing clinical depression symptoms. Clinical worsening was observed mainly in cases of postpartum depression and comorbid panic disorder. Taking in account the study limitations, we observed a biphasic profile in caffeine psychostimulant effect: low to moderate doses may correlate with a reduction in depressive risk in healthy subjects and an improvement of many clinical symptoms (attention, arousal, psychomotor performance) in depressed patients, whereas the assumption of high doses may result in thymic dysregulation, favor mixed affective states and worsen circadian profiles and anxiety symptoms.

Effects of Nebulizer Position, Gas Flow, and CPAP on Aerosol Bronchodilator Delivery: An In Vitro Study

BACKGROUND

The aim of this study was to investigate the effects of different delivery circuit configurations, nebulizer positions, CPAP levels, and gas flow on the amount of aerosol bronchodilator delivered during simulated spontaneous breathing in an in vitro model.

METHODS

A pneumatic lung simulator was connected to 5 different circuits for aerosol delivery, 2 delivering CPAP through a high-flow generator tested at 30, 60, and 90 L/min supplementary flow and 5, 10, and 15 cm H2O CPAP and 3 with no CPAP: a T-piece configuration with one extremity closed with a cap, a T-piece configuration without cap and nebulizer positioned proximally, and a T-piece configuration without cap and nebulizer positioned distally. Albuterol was collected with a filter, and the percentage amount delivered was measured by infrared spectrophotometry.

RESULTS

Configurations with continuous high-flow CPAP delivered higher percentage amounts of albuterol compared with the configurations without CPAP (9.1 ± 6.0% vs 6.2 ± 2.8%, P = .03). Among configurations without CPAP, the best performance was obtained with a T-piece with one extremity closed with a cap. In CPAP configurations, the highest delivery (13.8 ± 4.4%) was obtained with the nebulizer placed proximal to the lung simulator, independent of flow. CPAP at 15 cm H2O resulted in the highest albuterol delivery (P = .02).

CONCLUSIONS

Based on our in vitro study, without CPAP, a T-piece with a cap at one extremity maximizes albuterol delivery. During high-flow CPAP, the nebulizer should always be placed proximal to the patient, after the T-piece, using the highest CPAP clinically indicated.

Implementation of epidural analgesia for labor: is the standard of effective analgesia reachable in all women? An audit of two years

BACKGROUND

Social and cultural factors combined with little information may prevent the diffusion of epidural analgesia for pain relief during childbirth. The present study was launched contemporarily to the implementation of analgesia for labor in our Department in order to perform a 2 years audit on its use. The goal is to evaluate the epidural acceptance and penetration into hospital practice by women and care givers and safety and efficacy during childbirth.

PATIENTS AND METHODS

This audit cycle measured epidural analgesia performance against 4 standards: (1) Implementation of epidural analgesia for labor to all patients; (2) Acceptance and good satisfaction level reported by patients and caregivers. (3) Effectiveness of labor analgesia; (4) No maternal or fetal side effects.

RESULTS

During the audit period epidural analgesia increased from 15.5% of all labors in the first trimester of the study to 51% in the last trimester (p < 0.005). Satisfaction levels reported by patients and care givers were good. A hierarchical clustering analysis identified two clusters based on VAS (Visual Analogue Scale) time course: in 226 patients (cluster 1) VAS decreased from 8.5±1.4 before to 4.1±1.3 after epidural analgesia; in 1002 patients (cluster 2) VAS decreased from 8.12±1.7 before (NS vs cluster 1), to 0.76±0.79 after (p < 0.001 vs before and vs cluster 2 after). No other differences between clusters were observed.

CONCLUSIONS

Present audit shows that the process of implementation of labor analgesia was quick, successful and safe, notwithstanding the identification of one cluster of women with suboptimal response to epidural analgesia that need to be further studies, overall pregnant womens'adhesion to labor analgesia was satisfactory.

[Internet addiction disorder and social networks: statistical analysis of correlation and study of the association with social interaction anxiousness]

INTRODUCTION

Internet Addiction Disorder (IAD) is an emerging psychiatric disorder, assimilable to impulse control problems and related to maladaptive use of new networks and social and virtual technologies.

AIM

Our study aims to analyze the presence of IAD among adolescents and to study the correlation with social interaction anxiousness. We investigated also the possibility that the Social Network (SN) represent a source of risk for the development of IAD.

MATERIALS AND METHODS

The test group was composed of 250 subjects, aged between 14 and 18 years. They were administered: Young's IAT; IAS (Interaction Anxiousness Scale), AAS (Audience Anxiousness Scale) and SISST (Social Interaction Self-Statement Test) to analyze the dimension of social interaction anxiousness.

RESULTS

We found a rate of 2% of the IAD. The SN are the most common use of the Net in our sample, but not the most clicked sites by subjects with IAD. It should be noted, finally, a correlation between social interaction anxiety and IAD, but not a significant difference in scores of social anxiousness scales based on the SN use/non-use.

CONCLUSIONS

The use of SN intended as single variable doesn't correlate with increased risk for IAD, or for increased social interaction anxiousness. However, if associated with prolonged use of the net for 5-6 hours or more, or concomitant use of chat rooms and/or net gambling, we find a more significant risk of psychopathology. The data presented require further investigations, in order to guide new pathogenetic models and appropriate intervention strategies.

Weight loss in obese children carrying the proopiomelanocortin R236G variant

To acquire more information relative to the course of obesity in conditions of food restriction in subjects carrying mutations in the melanocortin signaling pathway, 710 obese children (mean age: 9.5+/-2.1 yr; mean z-score body mass index: 3.63+/-1.6) were genotyped for the proopiomelanocortin (POMC) R236G substitution, a variant which has been associated to early onset obesity, by restriction fragment length polymorphism (RFLP) analysis. Three children were heterozygotes for the R236G variant (0.4%). One of them had the metabolic syndrome. This variant was not found in 400 controls. The 3 probands followed a hypocaloric balanced diet and, after about 12 months, normalized their weight as well as fat mass and insulin resistance. The patient with the metabolic syndrome reversed this condition. These results show that a) the R236G substitution of POMC gene, although not a major cause of obesity among Italian obese children and adolescents, is associated with early onset obesity, and that b) inherited alterations of the melanocortin signaling pathway, independently of the degree of obesity, do not preclude the possibility to lose weight in mutated individuals following a hypocaloric diet.

Molecular screening of the ghrelin gene in Italian obese children: the Leu72Met variant is associated with an earlier onset of obesity

OBJECTIVE

To test whether ghrelin variants could play a role in modulating some aspects of the obese phenotype during childhood.

DESIGN

We screened the ghrelin gene in 300 Italian obese children and adolescents (mean age 10.5+/-3.2 y; range 4-19 y) and 200 controls by using the single-strand conformation polymorphism and the restriction fragment length polymoprhism analysis.

RESULTS

No mutations were detected with the exception of two previously described polymorphisms, Arg51Gln and Leu72Met. For both variations, allelic frequencies were similar between patients and controls. Interestingly, we showed that the Leu72Met polymorphism was associated with differences in the age at obesity onset. Patients with the Met72 allele became obese earlier than homozygous patients for the wild Leu72 allele. The logrank test comparing the plots of the complement of Kaplan-Meier estimates between the two groups of patients was statistically significant (P<0.0001).

CONCLUSION

It is unlikely that ghrelin variations cause the obesity due to single-gene mutations. The Leu72Met polymorphism of the ghrelin gene seems to play a role in anticipating the onset of obesity among children suggesting, therefore, that ghrelin may be involved in the pathophysiology of human adiposity.

Low frequency of melanocortin-4 receptor (MC4R) mutations in a Mediterranean population with early-onset obesity

BACKGROUND

Melanocortin-4 receptor (MC4R) mutations have been reported as the most common single genetic cause of obesity in some populations and it has been suggested that they may be responsible for more than 4% of early-onset obesity.

OBJECTIVES

To verify the presence of mutations of the MC4R coding region in children from southern Italy with early-onset obesity.

SUBJECTS AND METHODS

Two-hundred and eight unrelated obese children and adolescents were included in the study. The average age at obesity onset was 4.5+/-2.6 y. MC4R coding region was screened using both single-strand conformation polymorphism (SSCP) analysis and denaturing high-performance liquid chromatography (DHPLC). Automatic sequencing of PCR products of all individuals that showed an aberrant SSCP and/or DHPLC pattern was performed.

RESULTS

One novel missense mutation and one previously described polymorphism (Vall03Ile) were identified. The missense mutation C142T, resulting in the substitution of proline with serine at codon 48, within the first MC4R transmembrane domain, was detected at the heterozygous state in a 15-y-old obese girl (body mass index (BMI)=35 kg/m(2)) who has been obese since she was 8 y old. The mutation co-segregated with the obesity phenotype for over three generations and was not found in the control population.

CONCLUSIONS

Our data show MC4R obesity causing mutations in less than 0.5% of the patients (ie 1 out of 208 patients) and therefore indicate a low prevalence of MC4R variants in the obese population from southern Italy. The specific genetic background of the Mediterranean population could make it difficult for MC4R mutations to produce an essentially polygenic trait such as common obesity, at least during childhood.