Central venous accesses in prone position during the pandemic period: A narrative review

The unprecedented challenges posed by the global COVID-19 pandemic have magnified the significance of managing intensive care patients in prone positions, particularly those requiring mechanical ventilation. Central venous access is crucial for delivering essential therapies to patients, particularly in intensive care settings. However, the shift in patient management during the pandemic, necessitating prone positioning for improved oxygenation, presented unique hurdles in maintaining and establishing central venous access. Before the pandemic, scant literature detailed the insertion of vascular access devices in prone or unconventional positions. Limited case reports and letters highlighted the feasibility of procedures like ultrasound-guided central catheter placement in patients undergoing surgery or with specific clinical needs. During the pandemic, a surge in case reports and series illuminated the complexities faced by clinicians in maintaining vascular access during pronation procedures. These reports delineated critical scenarios, ranging from rapid clinical deterioration necessitating immediate interventions to challenges with vascular access device (VAD) malfunctions or misplacements during prone maneuvers. Patient selection and device types emerged as critical considerations. Various scenarios, including patients transitioning to prone position from non-invasive ventilation and those requiring additional access for therapies like dialysis, posed challenges in device selection and placement. Successful VAD insertion techniques in prone patients encompassed multiple anatomical sites, including the internal jugular, brachial, femoral, and popliteal veins. However, challenges persisted, particularly with respect to anatomical variations and technical complexities in cannulation. Further research, standardized protocols, and randomized studies are needed to refine and validate the proposed strategies in both pandemic and non-pandemic settings.

Lateral Femoral Cutaneous Nerve Block or Wound Infiltration Combined with Pericapsular Nerve Group (PENG) Block for Postoperative Analgesia following Total Hip Arthroplasty through Posterior Approach: A Randomized Controlled Trial

Background: Pericapsular nerve group (PENG) block, although effective for pain management following total hip arthroplasty (THA), does not cover skin analgesia. In this randomized controlled trial, we compared the effectiveness of PENG block combined with lateral femoral cutaneous nerve (LFCN) block or wound infiltration (WI) on postoperative analgesia and functional outcomes. Methods: Fifty patients undergoing posterior-approached THA under spinal anesthesia were randomly allocated to receive LFCN block with 10 mL of 0.5% ropivacaine or WI with 20 mL of 0.5% ropivacaine. In both groups, PENG block was performed by injecting 20 mL of 0.5% ropivacaine. Primary outcomes were static and dynamic pain scores (0-10 numeric rating scale) measured in the first 24 h after surgery. Secondary outcomes included postoperative opioid consumption, functional assessment and length of hospital stay. Results: Postoperative static NRS of patients receiving LFCN was higher than that of patients receiving WI at 6 h but lower at 24 h, with a median (IQR) of 3 (2-4) vs. 2 (1-2) (p < 0.001) and 2 (2-3) vs. 3 (3-4) (p = 0.02), respectively. Static pain scores at 12 h did not show significant differences, with an NRS of 3 (2-4) for WI vs. 3 (3-4) for LFCN (p = 0.94). Dynamic pain and range of movement followed a similar trend. No significant differences were detected in other outcomes. Conclusions: LFCN block was not inferior to WI for postoperative analgesia and functional recovery in association with PENG block during the first postoperative day, although it had worse short-term pain scores. Based on these results, it is reasonable to consider LFCN block as a valid alternative to WI or even a complementary technique added to WI to enhance skin analgesia during the first 24 h after THA. Future studies are expected to confirm this hypothesis and find the best combination between PENG block and other techniques to enhance analgesia after THA.

Emergence of Long-Range Angular Correlations in Low-Multiplicity Proton-Proton Collisions

This Letter presents the measurement of near-side associated per-trigger yields, denoted ridge yields, from the analysis of angular correlations of charged hadrons in proton-proton collisions at sqrt[s]=13  TeV. Long-range ridge yields are extracted for pairs of charged particles with a pseudorapidity difference of 1.4<|Δη|<1.8 and a transverse momentum of 1 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Epstein-Barr virus, Cytomegalovirus, and Herpes Simplex-1/2 reactivations in critically ill patients with COVID-19

OBJECTIVES

To assess the incidences of Herpes Simplex-1 and 2 (HSV-1, HSV-2), Cytomegalovirus (CMV), Epstein-Barr Virus (EBV) reactivations in critically ill COVID-19 patients. To determine the association between viral reactivation and in-hospital mortality, Intensive Care Unit Bloodstream infection (ICU-BSI), ventilator-associated pneumonia (VAP).

DESIGN

Observational retrospective cohort study.

SETTING

COVID-19 Intensive Care Unit.

PATIENTS

From November 2020 to May 2021, one hundred and twenty patients with COVID-19 severe pneumonia were enrolled and tested for HSV-1, HSV-2, CMV and EBV at the admission in ICU and weekly until discharge or death. The presence of VAP and ICU-BSI was evaluated according to clinical judgement and specific diagnostic criteria.

MEASUREMENTS AND MAIN RESULTS

One hundred and twenty patients were enrolled. Multiple reactivations occurred in 75/120 (63%) patients, single reactivation in 27/120 patients (23%). The most reactivated Herpesvirus was EBV, found in 78/120 (65%) patients. The multivariate analysis demonstrated that viral reactivation is a strong independent risk factor for in-hospital mortality (OR = 2.46, 95% CI 1.02-5.89), ICU-BSI (OR = 2.37, 95% CI 1.06-5.29) and VAP (OR = 2.64, 95% CI 1.20-5.82).

CONCLUSIONS

Human Herpesviruses reactivations in critically ill patients with COVID-19 severe Pneumonia are associated with mortality and with a higher risk to develop both VAP and ICU-BSI.

First Measurement of the |t| Dependence of Incoherent J/ψ Photonuclear Production

The first measurement of the cross section for incoherent photonuclear production of J/ψ vector mesons as a function of the Mandelstam |t| variable is presented. The measurement was carried out with the ALICE detector at midrapidity, |y|<0.8, using ultraperipheral collisions of Pb nuclei at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. This rapidity interval corresponds to a Bjorken-x range (0.3-1.4)×10^{-3}. Cross sections are given in five |t| intervals in the range 0.04<|t|<1  GeV^{2} and compared to the predictions by different models. Models that ignore quantum fluctuations of the gluon density in the colliding hadron predict a |t| dependence of the cross section much steeper than in data. The inclusion of such fluctuations in the same models provides a better description of the data.

Extracorporeal Membrane Oxygenation in Acute Respiratory Failure due to Hemorrhagic Alveolitis in a Patient with Acute Myeloblastic Leukemia

Introduction. Extracorporeal membrane oxygenation (ECMO) support for severe acute respiratory distress syndrome (ARDS) is nowadays widely used with notable results on the overall survival as reported in the ELSO registry near to 55% at 90 days. This is the reason why ECMO teams force the use of this extreme technique to several populations, even though there is still a lack of data about its use on hematological patients. Case Report. A 39-year-old woman without a history of previous diseases, but a new diagnosis of acute myeloblastic leukemia (AML) was admitted to intensive care unit (ICU) for worsening hypoxia and respiratory acidosis, presenting an ARDS with PaO2/FiO2 < 100 in spontaneous breathing treated with noninvasive ventilation via full-face mask. Meanwhile, chemotherapy was started leading to a severe bone marrow aplasia that was managed with multiple blood and platelet transfusions. These conditions did not allow physicians to start any invasive approaches. After 14 days, ARDS worsened whereas bone marrow recovered, making possible the beginning of an invasive mechanical ventilation, with low positive end-expiratory pressure and a low tidal volume. Moreover, an immediate extracorporeal CO2 removal (ECCO2R) therapy was added. Despite these efforts, no improvement was achieved, and that is why venovenous ECMO throughout femoral-jugular cannulation was applied. A full protective lung ventilation by ultralow tidal volumes was guaranteed. After 2 weeks of ECMO, a gradual weaning from ECMO support was started and completed after two days. No ECMO-related complications were registered. In the end, the patient started her weaning from the mechanical ventilation and reached 12 hours of spontaneous ventilation in oxygen therapy. Discussion. ECMO is used as a rescue therapy in patients affected by severe respiratory failure with life-threatening hypoxia and respiratory acidosis nonresponsive to other maneuvers. However, immunosuppression and coagulopathies of hematological malignancies are considered relative contraindications for ECMO, while long-lasting respiratory failure represents another relative contraindication to extracorporeal support. ECMO could be a valid option to improve the survival of hematological patients with severe ARDS and thrombocytopenia, and management could change case by case, even if high incidence of recurrency.

Selective Bias Virtual Screening for Discovery of Promising Antimalarial Candidates targeting Plasmodium N-Myristoyltransferase

Malaria remains a significant public health challenge, with Plasmodium vivax being the species responsible for the most prevalent form of the disease. Given the limited therapeutic options available, the search for new antimalarials against P. vivax is urgent. This study aims to identify new inhibitors for P. vivax N-myristoyltransferase (PvNMT), an essential drug target against malaria. Through a validated virtual screening campaign, we prioritized 23 candidates for further testing. In the yeast NMT system, seven compounds exhibit a potential inhibitor phenotype. In vitro antimalarial phenotypic assays confirmed the activity of four candidates while demonstrating an absence of cytotoxicity. Enzymatic assays reveal LabMol-394 as the most promising inhibitor, displaying selectivity against the parasite and a strong correlation within the yeast system. Furthermore, molecular dynamics simulations shed some light into its binding mode. This study constitutes a substantial contribution to the exploration of a selective quinoline scaffold and provides valuable insights into the development of new antimalarial candidates.

Evaluation of condylar and mandibular movements on the upper airway during the use of mandibular advancement device for obstructive sleep apnea treatment

OBJECTIVES

To evaluate the temporomandibular joint (TMJ), condylar and mandibular movements in obstructive sleep apnea (OSA) patients treated with mandibular advancement device (MAD) and to identify the influence of these anatomic factors on upper airway (UA) volume and polysomnographic outcomes after treatment.

MATERIALS AND METHODS

Twenty OSA patients were prospectively treated with MAD. Clinical examinations, cone-beam computed tomography, and polysomnography were performed before MAD treatment and after achieving therapeutic protrusion. Polysomnographic variables and three-dimensional measurements of the TMJ, mandible, and upper airway were statistically analyzed.

RESULTS

Condylar rotation, anterior translation, and anterior mandibular displacement were directly correlated with total UA volume, while vertical mandibular translation was inversely correlated with the volume of the inferior oropharynx. MAD treatment resulted in an increase in the volume and area of the superior oropharynx. There was no statistically significant correlation between condylar rotation and translation and polysomnographic variables. With MAD, there was a significant increase in vertical dimension, changes in condylar position (rotation and translation), and mandibular displacement. The central and medial lengths of the articular eminence were inversely correlated with condylar rotation and translation, respectively. The lateral length of the eminence was directly correlated with condylar translation, and the lateral height was directly correlated with condylar rotation and translation.

CONCLUSION

Condylar and mandibular movements influenced UA volume. The articular eminence played a role in the amount of condylar rotation and translation.

CLINICAL RELEVANCE

Individualized anatomical evaluation of the TMJ proves to be important in the therapy of OSA with MAD.

ψ(2S) Suppression in Pb-Pb Collisions at the LHC

The production of the ψ(2S) charmonium state was measured with ALICE in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV, in the dimuon decay channel. A significant signal was observed for the first time at LHC energies down to zero transverse momentum, at forward rapidity (2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial

OBJECTIVES

The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required.

DESIGN

In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia).

PARTICIPANTS

All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled.

SETTING

The study was conducted to the University of Campus Bio-Medico Hospital of Rome.

METHODS

Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed.

LIMITATIONS

The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks.

RESULTS

A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p < 0.01). Moreover, a significant reduction of LOS (45.97 ± 9.87 vs. 65.08 ± 17.32 h; p < 0.01) and PONV was observed in the LRA group, as well as a better level of patient satisfaction at discharge (9.43 ± 0.94 vs. 8.26 ± 1.19; p < 0.01), compared to the N-LRA group.

CONCLUSIONS

US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients' post-operative recovery.

Factors to consider for fascial plane blocks' success in acute and chronic pain management

The outcome of fascial plane blocks (FPBs) has a certain variability that may depend on many factors, which can be divided into three main categories: operator-related, patient-related and drug-related. Operator-related factors include personal skills, choice of needle and injection modalities. Patient variables include anthropometric features, the type of targeted fascia, anatomical variants, patient positioning, muscle tone and breathing. Ultimately, efficacy, onset, and duration of fascial blocks may be affected by characteristics of the injected solution, including the type of local anesthetic, volume, concentration, pH, temperature and the use of adjuvants. In this article, we investigated all the factors that may influence the outcome of FPBs from a generic perspective, without focusing on any specific technique. Also, we provided suggestions to optimize techniques for everyday practitioners and insights to researchers for future studies.

Condylar Position in the Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device: A Pilot Study

Objective  To evaluate, through a tomographic analysis, the positional changes of the condyle when using a mandibular advancement device (MAD) for the treatment of obstructive sleep apnea (OSA), and to assess if the condylar positions influence OSA polysomnographic patterns. Materials and Methods  Ten OSA patients underwent treatment with an MAD, and polysomnographic and tomographic examinations were performed before therapy (T0) and after MAD placement (T1). Results  By comparing the T0 and T1 measurements, we observed advancement and extrusion of the condyles in all patients ( p  < 0.001), as well as a decrease in the apnea-hypopnea index (AHI) ( p  < 0.001), increases in the mean ( p  = 0.001) and minimum ( p  < 0.001) oxyhemoglobin saturation, and a significant correlation between the anterior displacement of the right ( p  = 0.003) and left ( p  = 0.015) condyles. Discussion  Condylar advancement was directly correlated with OSA improvement: the greater the advancement, the better the AHI.

The effect of Zostera noltei recolonization on the sediment mercury vertical profiles of a recovering coastal lagoon

Mercury's extreme toxicity and persistence in the environment justifies a thorough evaluation of its dynamics in ecosystems. Aveiro Lagoon (Portugal) was for decades subject to mercury effluent discharges. A Nature-based Solution (NbS) involving Zostera noltei re-colonization is being tested as an active ecosystem restoration measure. To study the effect of Zostera noltei on the sediment contaminant biogeochemistry, seasonal (summer/winter) sediment, interstitial water and labile mercury vertical profiles were made in vegetated (Transplanted and Natural seagrass meadows) and non-vegetated sites (Bare-bottom area). While no significant differences (p > 0.05) were observed in the sedimentary phase, Zostera noltei presence reduced the reactive/labile mercury concentrations in the top sediment layers by up to 40% when compared to non-vegetated sediment, regardless of season. No differences were found between vegetated meadows, highlighting the fast recovery of the contaminant regulation ecosystem function provided by the plants after re-colonization and its potential for the rehabilitation of historically contaminated ecosystems.

Thoughts and concerns of patients at hospital discharge after lumbar spine surgery. A qualitative study

PURPOSE

The increased rate of surgical interventions point to the necessity to investigate the patient's experience from a biopsychosocial perspective. The aim of this study was to investigate the thoughts and concerns of patients undergoing spinal surgery for lumbar degenerative disease at the time of their discharge from hospital.

METHODS

Semi-structured interviews were conducted with 28 patients. The questions investigated possible concerns associated to discharging them home. A content analysis was performed by a multidisciplinary group to identify the main themes that emerged from the interviews.

RESULTS

The patients were satisfied with the surgeons' preoperative explanations and description of expected prognosis. However, they were disappointed with the lack of information at hospital discharge, in particular regarding practical and behavioral recommendations. The patients expressed clear concerns about being left alone to deal with possible complications or difficulties they may encounter when returning home.

CONCLUSION

This study underlined the patients' need for a comprehensive psychological guidance and possibly a person of reference during the post-operative process. Discussing discharge with the patient was emphasized as an important issue to improve patients' compliance to the recovery process itself. Putting these elements into practice should help spine surgeons to manage better hospital discharge.IMPLICATIONS FOR REHABILITATIONA comprehensive discussion with the patient at the time of hospital discharge is clearly stressed as an important issue to improve patients' adherence to the recovery process.The patients complained of a lack of information when returning home, in particular regarding practical and behavioral recommendations.The patients expressed clear concerns about possible complications or difficulties they may encounter when returning home and they expressed their need to know whom they can contact for help if needed.A better understanding of the thoughts and concerns of patients undergoing spinal surgery at the time of their discharge from hospital should help spine surgeons to improve the management of hospital discharge and the post-operative recovery.

Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

Ultrasound predictors of difficult spinal anesthesia: a prospective single-blind observational study

BACKGROUND

Ultrasound showed to improve the precision and efficacy of spinal anesthesia (SA) through the identification of specific structures surrounding the intrathecal space, such as the anterior and posterior complex of dura mater (DM). The aim of this study was to verify the efficacy of ultrasonography in predicting difficult SA trough the analysis of different ultrasound patterns.

METHODS

This prospective single-blind observational study involved 100 patients undergoing orthopedic or urological surgery. A first operator chose by landmarks the intervertebral space where he wanted to perform SA. Then a second operator recorded the visibility of DM complexes at ultrasound. Subsequently, the first operator, blinded to the ultrasound evaluation, performed SA, defined as "difficult" in case of failure, change of intervertebral space, operator exchange, duration >400 seconds or more than 10 needle passes.

RESULTS

The ultrasound visualization of only posterior complex or the failure in visualization of both complexes showed a positive predictive value of 76% and 100%, respectively, towards difficult SA vs. 6% when both complexes were visible; P<0.001. A negative correlation was found between the number of visible complexes and both patients' age and BMI. Landmark-guided evaluation underestimated the intervertebral level in 30% of cases.

CONCLUSIONS

Ultrasound showed a high accuracy in detecting difficult spinal anesthesia and its use should be recommended in the daily clinical practice in order to increase success rate and minimize patient discomfort. The absence of both DM complexes at ultrasound should lead the anesthetist to evaluate other intervertebral levels or consider alternative techniques.

Dipropyl ammonium ionic liquids to prepare Ti/RuO2-Sb2O4 anodes at different calcination temperatures

The development of technologies capable of producing efficient and economically viable anodes is essential for the electrochemical treatment of water contaminated with complex organic pollutants. In this context, the use of ionic liquids as solvents to prepare mixed metal oxide (MMO) anodes has proven to be an up-and-coming alternative. Here, we analyze the influence of the temperature of calcination (300, 350, and 400 ºC) on the production of Ti(RuO2)0.8-(Sb2O4)0.2 anodes made using the thermal decomposition method using three ionic liquids (IL) as solvents: dipropyl ammonium acetate (DPA-Ac), dipropyl ammonium propionate (DPA-Pr), and dipropyl ammonium butyrate (DPA-Bu). The decomposition temperature for all IL, accessed by thermogravimetry, is below 200 ºC. Physical and electrochemical analyses demonstrate that the calcination temperature of the anodes is decisive for their durability and electrochemical properties. Anodes prepared with DPA-Bu at 350 ºC show higher stability (around 35 h) than those made with other ILs at temperatures of 300 and 400 ºC and improved results in terms of 4-NP mineralization, where 97% of TOC removal was achieved in 120 min. It could be verified that the calcination temperature and IL employed had a decisive influence on the characteristics of the presented anodes. Therefore, the anode prepared with DPA-Bu at 350 ºC is promising for application in the degradation of organic compounds.

Measurement of the Lifetime and Λ Separation Energy of _{Λ}^{3}H

The most precise measurements to date of the _{Λ}^{3}H lifetime τ and Λ separation energy B_{Λ} are obtained using the data sample of Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV collected by ALICE at the LHC. The _{Λ}^{3}H is reconstructed via its charged two-body mesonic decay channel (_{Λ}^{3}H→^{3}He+π^{-} and the charge-conjugate process). The measured values τ=[253±11(stat)±6(syst)]  ps and B_{Λ}=[102±63(stat)±67(syst)]  keV are compatible with predictions from effective field theories and confirm that the _{Λ}^{3}H structure is consistent with a weakly bound system.

Measurement of the J/ψ Polarization with Respect to the Event Plane in Pb-Pb Collisions at the LHC

We study the polarization of inclusive J/ψ produced in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC in the dimuon channel, via the measurement of the angular distribution of its decay products. We perform the study in the rapidity region 2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

First Measurement of Antideuteron Number Fluctuations at Energies Available at the Large Hadron Collider

The first measurement of event-by-event antideuteron number fluctuations in high energy heavy-ion collisions is presented. The measurements are carried out at midrapidity (|η|<0.8) as a function of collision centrality in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV using the ALICE detector. A significant negative correlation between the produced antiprotons and antideuterons is observed in all collision centralities. The results are compared with a state-of-the-art coalescence calculation. While it describes the ratio of higher order cumulants of the antideuteron multiplicity distribution, it fails to describe quantitatively the magnitude of the correlation between antiproton and antideuteron production. On the other hand, thermal-statistical model calculations describe all the measured observables within uncertainties only for correlation volumes that are different with respect to those describing proton yields and a similar measurement of net-proton number fluctuations.

Enhanced Deuteron Coalescence Probability in Jets

The transverse-momentum (p_{T}) spectra and coalescence parameters B_{2} of (anti)deuterons are measured in p-p collisions at sqrt[s]=13  TeV for the first time in and out of jets. In this measurement, the direction of the leading particle with the highest p_{T} in the event (p_{T}^{lead}>5  GeV/c) is used as an approximation for the jet axis. The event is consequently divided into three azimuthal regions, and the jet signal is obtained as the difference between the toward region, that contains jet fragmentation products in addition to the underlying event (UE), and the transverse region, which is dominated by the UE. The coalescence parameter in the jet is found to be approximately a factor of 10 larger than that in the underlying event. This experimental observation is consistent with the coalescence picture and can be attributed to the smaller average phase-space distance between nucleons in the jet cone as compared with the underlying event. The results presented in this Letter are compared to predictions from a simple nucleon coalescence model, where the phase-space distributions of nucleons are generated using pythia8 with the Monash 2013 tuning, and to predictions from a deuteron production model based on ordinary nuclear reactions with parametrized energy-dependent cross sections tuned on data. The latter model is implemented in pythia8.3. Both models reproduce the observed large difference between in-jet and out-of-jet coalescence parameters, although the almost flat trend of the B_{2}^{Jet} is not reproduced by the models, which instead give a decreasing trend.

Three-dimensional comparison between the effects of mandibular advancement device and maxillomandibular advancement surgery on upper airway

BACKGROUND

The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA.

METHODS

The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation.

RESULTS

Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region.

CONCLUSIONS

The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations

In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.

Sinus rhythm endocardial mapping for channels identification in ischemic ventricular tachycardia using a modified electrophysiological triad

Background

In a previous study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients. This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps.

Purpose

This study aimed to prospectively assess the ability of a modified electrophysiological triad to identify and localize the ventricular tachycardia's (VT) channels and entrance zones during sinus rhythm mapping.

Methods

Prospective analysis of a unicentric registry of individuals who underwent ischemic VT ablation with Carto® EAM, all in sinus rhythm. All patients with non-ischemic etiology, lack of high-density EAM or lack of mapping in any of the left ventricle walls or structures were excluded. Areas of late potentials and possible channels of re-entry were compared to a modified electrophysiological triad constituted by: areas of low-voltage (&lt;0.5mV), a site of deep histogram valley (LAT-Valley) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the total activation time mapped. We also assessed the relationship between the pre-valley bar (the LAT histogram bar immediately before the prolonged LAT-Valley) and the channel entrances.

Results

A total of 14 patients (14 men, median age 70 IQR 64–78 years) were included. All patients presented with ischemic VT and 86% had a previous inferior myocardial infarction. The median number of collected points were 1733 (IQR 1363–2729). All sinus rhythm maps presented with at least 1 LAT-Valley in the analysed histograms. All arrhythmias were effectively treated after undergoing radiofrequency in the LAT-Valley location, either by blocking the channel entrances or scar homogenization ablation strategy. Also, the pre-valley bar in the histogram marked all the channel entrances in the scar borders. No patient had relapse after a clinical follow up of over 6 months.

Conclusion

In a prospective analysis, a modified electrophysiological triad was able to identify the scar channels in sinus rhythm in all patients. The pre-valley bar in the histogram disclosed the channel entrances. Further studies are needed to assess the usefulness of this algorithm to simplify catheter ablation and improve clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Novel dual-reflection design applied for ITER core x-ray spectrometer

A novel dual-reflection configuration is introduced for the International Tokamak Experimental Reactor (ITER) core x-ray spectrometer to fit the allocated space where it will be placed accompanied by moving the detectors backward to reduce the incident radiation dose. The highly oriented pyrolytic graphite, which has a mosaic structure of microscopic crystallites, is chosen for the front reflector motivated by higher x-ray throughput and stronger misalignment tolerance compared to the perfect crystal reflector. In the ITER core x-ray spectrometer, a combination of several reflector-deflected Lines of Sight (LOSs) and a direct LOS is proposed for the first time named X-Ray Crystal Spectroscopy Core (XRCS-Core). The system is optimized to observe lines from externally seeded xenon and the intrinsic tungsten impurity, meeting both port integration needs and measurement requirements. Its spectral performance is simulated using an analytical-raytracing mixed code--XRSA, showing good imaging quality with a spectral resolution higher than 8000. The XRCS-Core system is thought to be applicable in various ITER scenarios through the assessment taking into account the spectrometers' specifications and the chosen lines' emissivity in different plasma parameters.

Hypertriton Production in p-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The study of nuclei and antinuclei production has proven to be a powerful tool to investigate the formation mechanism of loosely bound states in high-energy hadronic collisions. The first measurement of the production of _{Λ}^{3}H in p-Pb collisions at sqrt[s_{NN}]=5.02  TeV is presented in this Letter. Its production yield measured in the rapidity interval -1<y<0 for the 40% highest-multiplicity p-Pb collisions is dN/dy=[6.3±1.8(stat)±1.2(syst)]×10^{-7}. The measurement is compared with the expectations of statistical hadronization and coalescence models, which describe the nucleosynthesis in hadronic collisions. These two models predict very different yields of the hypertriton in charged particle multiplicity environments relevant to small collision systems such as p-Pb, and therefore the measurement of dN/dy is crucial to distinguish between them. The precision of this measurement leads to the exclusion with a significance larger than 6.9σ of some configurations of the statistical hadronization model, thus constraining the theory behind the production of loosely bound states at hadron colliders.

Depression among Endometrial Cancer hospitalizations - Preliminary results of a nationwide retrospective study

Introduction

Uterine cancer is the most common gynecologic malignant neoplasm in developed countries. While depression is up to 3-5 times more common in patients with cancer than in the general population, literature is still limited regarding the relation between Endometrial Cancer and depression.

Objectives

To analyze Depression among Endometrial Cancer hospitalizations in mainland Portuguese public hospitals (2008-2015).

Methods

A retrospective observational study was conducted using administrative data from all hospitalizations in Portuguese mainland public hospitals between 2008-2015. All women’s hospitalizations(≥18 years) with a primary diagnosis of Endometrial Cancer (ICD-9-CM 182.x) were selected. Secondary diagnosis of depression was identified with ICD-9-CM 296.2x, 296.3x and 311x codes. Surgical procedures codes 68.4x, 65.6x, 40.3x, 40.5x, 68.6x, 68.9x and 68.8x were used to divide the hospitalizations into surgical vs non-surgical. Groups were compared with Pearson Chi-square test and crude odds ratio(OR) was used to estimate the association between surgery and depression.

Results

From 10227 hospitalizations with a primary diagnosis of Endometrial Cancer, 533 had a registry of depression(5.2%). Annual depression frequency rose from 2.0% (2008) to 8.3% (2015). Among patients with a record of depression, 73.2% had surgery. Women who had surgery were significantly more likely to have registered depression (p<0.001). The OR for depression in surgical vs non-surgical patients was 1.73 (95%IC:1.42-2.10).

Conclusions

Patients hospitalized due to Endometrial Cancer and submitted to surgery had almost two-fold more risk of having a registry of depression. This trend reinforces the importance of early depression screening of these patients, enabling the implementation of timely therapeutic strategies before and after surgery.

Disclosure

No significant relationships.

Anatomical Computerized Exploration to Excise Malignancies in Deep Facial Compartments: An Advanced Virtual Reality Protocol for a Tailored Surgical Approach

Objective/Hypothesis

This study describes the design and application of a novel advanced protocol for virtual three-dimensional anatomical reconstruction of the deep facial compartments, aiming to improve the preoperative understanding and the intraoperative assistance in complex resective surgeries performed for malignant diseases which extend in complex spaces, including the pterygomaxillopalatine fossa, the masticator space, and the infratemporal fossa.

Methods

This study is a non-profit, retrospective, and single-institution case series. The authors clearly describe in detail imaging acquisition protocols which are suitable to segment each target, and a multilayer reconstruction technique is presented to simulate anatomical structures, with particular focus on vascular networks. Virtual surgical planning techniques are individually designed for each case to provide the most effective access to the deep facial compartments. Intraoperative guidance systems, including navigation and virtual endoscopy, are presented, and their role is analyzed.

Results

The study included seven patients with malignant disease located in the deep facial compartments requiring radical resection, and all patients underwent successful application of the protocol. All lesions, except one, were subject to macroscopically radical resection. Vascular structures were identified with overall reconstruction rates superior to 90% for major caliber vessels. Prominent landmarks for virtual endoscopy were identified for each case.

Conclusions

Virtual surgical planning and multilayer anatomical reconstruction are valuable methods to implement for surgeries in deep facial compartments, providing the surgeon with improved understanding of the preoperative condition and intraoperative guidance in critical phases for both open and endoscopic phases. Such techniques allow to tailor each surgical access, limiting morbidity to strictly necessary approaches to reach the disease target.

Polarization of Λ and Λ[over ¯] Hyperons along the Beam Direction in Pb-Pb Collisions at sqrt[s]_{NN}=5.02 TeV

The polarization of the Λ and Λ[over ¯] hyperons along the beam (z) direction, P_{z}, has been measured in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV recorded with ALICE at the Large Hadron Collider (LHC). The main contribution to P_{z} comes from elliptic flow-induced vorticity and can be characterized by the second Fourier sine coefficient P_{z,s2}=⟨P_{z}sin(2φ-2Ψ_{2})⟩, where φ is the hyperon azimuthal emission angle and Ψ_{2} is the elliptic flow plane angle. We report the measurement of P_{z,s2} for different collision centralities and in the 30%-50% centrality interval as a function of the hyperon transverse momentum and rapidity. The P_{z,s2} is positive similarly as measured by the STAR Collaboration in Au-Au collisions at sqrt[s_{NN}]=200  GeV, with somewhat smaller amplitude in the semicentral collisions. This is the first experimental evidence of a nonzero hyperon P_{z} in Pb-Pb collisions at the LHC. The comparison of the measured P_{z,s2} with the hydrodynamic model calculations shows sensitivity to the competing contributions from thermal and the recently found shear-induced vorticity, as well as to whether the polarization is acquired at the quark-gluon plasma or the hadronic phase.

Measurement of the Groomed Jet Radius and Momentum Splitting Fraction in pp and Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

This article presents groomed jet substructure measurements in pp and Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector. The soft drop grooming algorithm provides access to the hard parton splittings inside a jet by removing soft wide-angle radiation. We report the groomed jet momentum splitting fraction, z_{g}, and the (scaled) groomed jet radius, θ_{g}. Charged-particle jets are reconstructed at midrapidity using the anti-k_{T} algorithm with resolution parameters R=0.2 and R=0.4. In heavy-ion collisions, the large underlying event poses a challenge for the reconstruction of groomed jet observables, since fluctuations in the background can cause groomed parton splittings to be misidentified. By using strong grooming conditions to reduce this background, we report these observables fully corrected for detector effects and background fluctuations for the first time. A narrowing of the θ_{g} distribution in Pb-Pb collisions compared to pp collisions is seen, which provides direct evidence of the modification of the angular structure of jets in the quark-gluon plasma. No significant modification of the z_{g} distribution in Pb-Pb collisions compared to pp collisions is observed. These results are compared with a variety of theoretical models of jet quenching, and provide constraints on jet energy-loss mechanisms and coherence effects in the quark-gluon plasma.

Opioid-free anesthesia in oncologic surgery: the rules of the game

BACKGROUND

Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.

MAIN BODY

This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.

CONCLUSIONS

Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Pressure monitoring devices may undetect epidural space: a report on the use of Compuflo® system for epidural injection

Lumbar epidural infiltration (EI) is a feasible procedure performed in pain therapy. Even though epidural analgesia is widely applied, it remains a blind technique, based on the operator's hand sensations, and it is associated with significant failure rate and several potential complications. Compuflo® (Compuflo, Milestone Scientific, Livingston, NJ) is a computerized injection pump which precisely detects the real time pressure at the tip of a Tuohy needle when placed in human tissues, thanks to a continuous fluid path. In our institution, we usually perform EI for chronic back pain guided by the Compuflo device, especially for expected difficult procedures. However, we report 6 false negative cases on a total number of 60 procedures in which the Compuflo system didn't meet the criteria of epidural space entry, even though the epidural space was actually reached. A mild pressure decrease (less than 50%) which lasted for more than 5 s was reported on the monitor, and the acoustic signal changed in a little bit lower sound, without a clear indication on stopping or not the needle advancement. This unspecific drop in monitored pressure gives false negatives using the Compuflo® system and may lead to excessive advancing of the needle. In conclusion, we consider the epidural pressure monitoring device Compuflo as a tool which may be able to ease the correct positioning of an epidural needle. The percentage of 10% false negative identifications of the epidural space in our case series however suggests more investigations on adequate or specific settings for this epidural system. In the meantime, in chronic pain patients, this anesthetic technique should only be used by experienced hands.

Selective spinal anesthesia with hyperbaric prilocaine provides better perioperative pain control than local anesthesia for ambulatory inguinal hernia repair without affecting discharging time: a randomized controlled trial

PURPOSE

Local anesthesia is the most used anesthetic technique for inguinal hernia repair, despite its unpredictability. Selective spinal anesthesia with a short-term local anesthetic guarantees rapid recovery, predictable duration and low incidence of side effects. We tried to assess the efficacy of this neuraxial technique in ambulatory setting.

METHODS

One hundred thirty-two ASA I-III, aged > 18 patients scheduled for inguinal hernia repair have been randomized into two groups receiving unilateral spinal anesthesia with 40 mg of hyperbaric prilocaine (group A) or local anesthesia with mepivacaine (group B).

PRIMARY ENDPOINT

intraoperative and post-operative NRS. Other outcomes: sensory block onset, need for opiates and deep sedation, surgery duration, and time to discharge.

RESULTS

Group A: intraoperative NRS was 0 in 100% of patients; post-operative maximum NRS was > 3 in 12.12% of patients. Group B: mean intraoperative NRS was 4; mean post-operative NRS was 2.5. Spinal anesthesia resulted superior in controlling both intraoperative and post-operative pain (p < 0.00001; p = 0.008). Mean time of the motor block resolution in group A was 98 ± 2 min. Mean time to discharge was not significantly different between groups. Surgical time was significantly different between the two groups (mean time of 37 ± 3.2 min group A; 54 ± 6 min group B-p < 0.00001).

CONCLUSION

Spinal anesthesia group patients had significantly less pain than local anesthesia group, both intraoperatively and post-operatively, without differences in time to discharge, incidence of complications and with improvement of surgical time. More randomized controlled trials are needed to confirm this hypothesis.

TRIAL REGISTRATION

NCT05136534 . Registered November 29, 2021-Retrospectively registered.