The dramatic increase in sudden cardiac deaths and the alarming low survival: A global call to action to improve outcome with the engagement of tertiary education system.

The number of out-of-hospital cardiac arrests, cause of disability and death, has dramatically increased worldwide, but despite the progress, the incidence of survival does not appear to have increased significantly. Bystander cardiopulmonary resuscitation (CPR) remains the principal factor in saving out-of-hospital cardiac arrest victims. Analyzing the immense efforts produced by states and professional organizations to train people in CPR skills for immediate intervention in the occurrence of a cardiac arrest, the primary global strategy is centered on CPR education and training for schoolchildren. But the rate of CPR training remains low, with wide differences among communities. The concept of CPR training for schoolchildren to increase bystander CPR rates needs to be implemented. We suggest a global call to action for the tertiary education system for CPR learning and training, including all undergraduate students regardless of the degree course, as a possible method to improve the traditional CPR training today centered on the secondary education system. Extending CPR training courses to the university educational system could significantly increase the number of people educated in life-saving maneuvers. The final objective is to improve the survival rate of patients with out-of-hospital primary cardiac arrest, which has dramatically increased worldwide.

Medical simulation in pharmacology learning and retention: A comparison study with traditional teaching in undergraduate medical students.

The purpose of the study was to determine whether low-high fidelity medical simulation improves learning and long-lasting retention of pharmacology knowledge, compared to lecture alone, in undergraduate medical students. Ninety students, before a 45-minute lecture, were randomized into three groups - sham (S), low (LF), and high fidelity (HF) simulation - to participate in an interactive simulation session. To evaluate immediate and long-lasting retention, a 20-item structured questionnaire on inotropic agents was administered to 90 students before and after a 45-minute lecture, after simulation, and 3 months later. In all groups, the rate of correct answers increased after lecture, while no difference was observed between different groups (P = 0.543). After simulation, students in the HF group provided more correct answers compared to S or LF group (P > 0.001). After 3 months, a significant decrease in the number of correct answers was observed in S (P < 0.001) and LF (P < 0.001) groups, but not in the HF group (P = 0.066). Moreover, HF simulation resulted in an increased number of correct answers compared to the LF (P < 0.001) or S simulation (P < 0.001). These data suggest that advanced medical simulation teaching applied to pharmacology is associated with more effective learning and long-lasting retention compared to lecture alone.

A Novel Diagnostic and Prognostic Tool for Simple Decompression of Ulnar Nerve in Cubital Tunnel Syndrome.

BACKGROUND: Surgical decompression of the ulnar nerve (UN) is effective for treating cubital tunnel syndrome (CubTS). Nevertheless, the outcome is not always satisfying. Different surgical, clinical, and imaging findings have been claimed as outcome predictors, but there is no consensus in the literature. We analyzed the outcome-predicting role of ultrasonography (US) of the UN in patients with CubTS and its possible role for diagnosis and follow-up. METHODS: Patients with CubTS treated by simple UN decompression underwent US and electrodiagnotic (ED) studies of the UN at the elbow before and after surgery. Outcome was evaluated through the Bishop scale. A correlation analysis between pre- and postoperative clinical, US, and ED findings was performed. RESULTS: Thirty-six patients were enrolled. Preoperatively, we observed a negative correlation between the motor conduction velocity (MCV) and the transverse (TD) and anteroposterior diameters and cross-sectional area (CSA) of the UN at the precubital (P = 0.001, P = 0.001, P = 0.005) and cubital level (P = 0.02, P = 0.002, P = 0.001). Preoperative precubital TD and CSA were associated with outcome (P = 0.01, P = 0.006) and postoperative MCV (P = 0.004, P = 0.008). The cut-off values TD >6 mm and CSA >23.91 mm2 were predictors of poor outcome. Finally, postoperative cubital TD and CSA values were inversely correlated with outcome (P = 0.0002, P = 0.0007) and postoperative MCV (P = 0.0002, P = 0.0004). CONCLUSIONS: The US examination of the UN is useful for the management of patients with CubTS as an adjunct to clinical and ED evaluations. US measurements are correlated with pre- and postoperative ED findings and thus are useful for diagnosis and follow-up. Interestingly, specific precubital US measurements are good predictors of outcome.

Lack of the Nlrp3 Inflammasome Improves Mice Recovery Following Traumatic Brain Injury.

Treatment for traumatic brain injury (TBI) remains elusive despite compelling evidence from animal models for a variety of therapeutic targets. The activation of the NLRP3 (Nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3) inflammasome has been proposed as key point in the brain damage associated with TBI. NLRP3 was tested as potential target for reducing neuronal loss and promoting functional recovery in a mouse model of TBI. Male NLRP3-/- (n = 20) and wild type (n = 27) mice were used. A closed TBI model was performed and inflammatory and apoptotic markers were evaluated. A group of WT mice also received BAY 11-7082, a NLRP3 inhibitor, to further evaluate the role of this pathway. At 24 h following TBI NLRP3-/- animals demonstrated a preserved cognitive function as compared to WT mice, additionally brain damage was less severe and the inflammatory mediators were reduced in brain lysates. The administration of BAY 11-7082 in WT animals subjected to TBI produced overlapping results. At day 7 histology revealed a more conserved brain structure with reduced damage in TBI NLRP3-/- animals compared to WT. Our data indicate that the NLRP3 pathway might be exploited as molecular target for the short-term sequelae of TBI.

An update on anesthetics and impact on the brain.

INTRODUCTION: While anesthetics are indispensable clinical tools and generally considered safe and effective, a growing concern over the potential neurotoxicity of anesthesia or specific anesthetic agents has called into question the safety of general anesthetics, especially when administered at extremes of age. Areas covered: This article reviews and updates research findings on the safety of anesthesia and anesthetics in terms of long-term neurotoxicity, with particular focus on postoperative cognitive dysfunctions, Alzheimer's disease and dementias, developing brain, post-operative depression and autism spectrum disorder. Expert opinion: Exposure to general anesthetics is potentially harmful to the human brain, and the consequent long-term cognitive deficits should be classified as an iatrogenic pathology, and considered a public health problem. The fact that in laboratory and clinical research only certain anesthetic agents and techniques, but not others, appear to be involved, raises the problem on what is the safest and the least safe anesthetic to maximize anesthesia efficiency, avoid occurrence of adverse events, and ensure patient safety. New trends in research are moving toward the theory that neuroinflammation could be the hallmark of, or could have a pivotal role in, several neurological disorders.

Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient.

Sea drowning is a common cause of accidental death worldwide. Respiratory complications such as acute pulmonary oedema, which is often complicated by acute respiratory distress syndrome, is often seen. Noninvasive ventilation is already widely used as a first approach to treat acute respiratory failure resulting from multiple diseases. We report a case of a 45 year old man with a history of epilepsy, motor and mental handicap who developed acute respiratory failure secondary to sea water drowning after an epileptic crisis. We illustrate successful and rapid management of this case with noninvasive ventilation. We emphasize the advantages and limitations of using noninvasive ventilation to treat acute respiratory failure due to sea water drowning syndrome.

Anesthesia Issues in Central Nervous System Disorders.

Every year, millions of people affected by disorders of the central nervous system (CNS) undergo various diagnostic, therapeutic and surgical procedures requiring administration of anesthetic agents. Anesthetics exert their anesthetic, amnesic and analgesic effects by acting on multiple neuronal membrane proteins in the CNS. While some of the causal anesthetic targets have been identified, a large number of anesthetic targets remain unknown. The consequent longterm effect of anesthetic agents on expression of these various molecular targets has been implicated in mediating potentially long-lasting adverse effects. Recent work suggested that the effects of general anesthetics may not be entirely reversible, with animal studies demonstrating persistent changes in CNS protein expression post recovery from anesthesia. Age-associated or disease-induced alterations in the CNS can profoundly alter multiple aspects of brain structure, biochemistry, and function. Such maladaptive changes in the brain can render it increasingly vulnerable to the effects of various anesthetics. The selection of appropriate anesthesia drugs and protocol is mandatory, especially in individuals with pre-existing CNS disorders, so as to maximize anesthesia efficiency, avoid occurrence of adverse events, and ensure patient safety. This review aims to summarize and consider the effects and potential risks of commonly used anesthetic agents in patients with compromised CNS function. We provide a comprehensive review of the established as well as the implicated effects of anesthetic agents on the elderly as well as on the pathology and progression of common neurological conditions.

Nonfatal Cervical-Neck Lesion With a Wooden Foreign Body: Diagnosis and Management.

Penetrating cervical lesions caused by a foreign body are rare events. The neck is a complex and delicate body region, given the important vascular structures it holds. The most frequent fatal complications often involve vascular injuries, and as a consequence, the mortality rate increases by approximately 50%. Civilian patients are mainly victims of violence or motor vehicle accidents and rural accidents involving neck are not very common. When a cervical lesion is because of a wooden foreign body, infectious risk increases for its organic peculiarity. The authors report a rural nonfatal cervical lesion in a civilian, and its management.

Complications of trauma patients admitted to the ICU in level I academic trauma centers in the United States.

BACKGROUND: The aims of this study were to evaluate the complications that occur after trauma and the characteristics of individuals who develop complications, to identify potential risk factors that increase their incidence, and finally to investigate the relationship between complications and mortality. METHODS: We did a population-based retrospective study of trauma patients admitted to ICUs of a level I trauma center. Logistic regression analyses were performed to determine independent predictors for complications. RESULTS: Of the 11,064 patients studied, 3,451 trauma patients developed complications (31.2%). Complications occurred significantly more in younger male patients. Length of stay was correlated with the number of complications (R = 0.435, P < 0.0001). The overall death rate did not differ between patients with or without complications. The adjusted odds ratio (OR) of developing complication for patients over age 75 versus young adults was 0.7 (P < 0.0001). Among males, traumatic central nervous system (CNS) injury was an important predictor for complications (adjusted OR 1.24). CONCLUSIONS: Complications after trauma were found to be associated with age, gender, and traumatic CNS injury. Although these are not modifiable factors, they may identify subjects at high risk for the development of complications, allowing for preemptive strategies for prevention.

Anesthetic techniques and cancer recurrence after surgery.

Many of the most common anesthetics are used in surgical oncology, yet effects on cancer cells are still not known. Anesthesia technique could differentially affect cancer recurrence in oncologic patients undergoing surgery, due to immunosuppression, stimulation of angiogenesis, and dissemination of residual cancer cells. Data support the use of intravenous anesthetics, such as propofol anesthesia, thanks to antitumoral protective effects inhibiting cyclooxygenase 2 and prostaglandins E2 in cancer cells, and stimulation of immunity response; a restriction in the use of volatile anesthetics; restriction in the use of opioids as they suppress humoral and cellular immunity, and their chronic use favors angiogenesis and development of metastases; use of locoregional anesthesia compared with general anesthesia, as locoregional appears to reduce cancer recurrence after surgery. However, these findings must be interpreted cautiously as there is no evidence that simple changes in the practice of anesthesia can have a positive impact on postsurgical survival of cancer patients.

Effects of anesthetics on mitochondrial signaling and function.

Mitochondria are considered the powerhouses of the cell playing an important role in energy metabolism. However, they are highly vulnerable to inhibition or uncoupling of the energy harnessing process and run a high risk of causing catastrophic damage to the cell. Several anesthetics or drugs commonly given during anesthesia interact with mitochondria and affect their structure or impair respiratory chain functioning with decreased ATP production. Mitochondria, in fact, are a potential site of action of general and local anesthetics. The purpose of this review is to update present knowledge and describe the effects and molecular mechanisms of the action of the most used drugs of anesthesia on mitochondria.

Genotoxic effects of anesthetic agents: an update.

INTRODUCTION: Exposure to anesthetics in the health environment may entail a health risk for patients and operating room personnel. Knowing the effects of anesthetic agents on genetic material could be a valuable basic support for anesthesia care providers to improve treatment performance, increase patient safety and reduce the risks for patients and staff in the operating room. AREAS COVERED: Relevant literature was identified using MEDLINE, CINAHL® and Cochrane Library databases. Over 200 abstracts for articles published from 1980 to 2010 were examined. Original articles were reviewed and relevant citations from these articles were also considered. EXPERT OPINION: Despite some conflicting results, the current available data indicate that exposure to anesthetics, especially nitrous oxide and halogenated agents, is associated with general and genotoxic risks, whereas intravenous agents, such as propofol and its metabolites are not associated with genotoxic effects. Moreover, given that different anesthetic drugs are used in combination it is, thus, very difficult to understand whether the observed effects or absence of effects are due to an individual agent action or linked to a synergy action of different anesthetics involved. Further clinical and experimental evidence is warranted.

Anaesthetic-related neuroprotection: intravenous or inhalational agents?

In designing the anaesthetic plan for patients undergoing surgery, the choice of anaesthetic agent may often appear irrelevant and the best results obtained by the use of a technique or a drug with which the anaesthesia care provider is familiar. Nevertheless, in those surgical procedures (cardiopulmonary bypass, carotid surgery and cerebral aneurysm surgery) and clinical situations (subarachnoid haemorrhage, stroke, brain trauma and post-cardiac arrest resuscitation) where protecting the CNS is a priority, the choice of anaesthetic drug assumes a fundamental role. Treating patients with a neuroprotective agent may be a consideration in improving overall neurological outcome. Therefore, a clear understanding of the relative degree of protection provided by various agents becomes essential in deciding on the most appropriate anaesthetic treatment geared to these objectives. This article surveys the current literature on the effects of the most commonly used anaesthetic drugs (volatile and gaseous inhalation, and intravenous agents) with regard to their role in neuroprotection. A systematic search was performed in the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINHAL®) and Cochrane Library databases using the following keywords: 'brain' (with the limits 'newborn' or 'infant' or 'child' or 'neonate' or 'neonatal' or 'animals') AND 'neurodegeneration' or 'apoptosis' or 'toxicity' or 'neuroprotection' in combination with individual drug names ('halothane', 'isoflurane', 'desflurane', 'sevoflurane', 'nitrous oxide', 'xenon', 'barbiturates', 'thiopental', 'propofol', 'ketamine'). Over 600 abstracts for articles published from January 1980 to April 2010, including studies in animals, humans and in vitro, were examined, but just over 100 of them were considered and reviewed for quality. Taken as a whole, the available data appear to indicate that anaesthetic drugs such as barbiturates, propofol, xenon and most volatile anaesthetics (halothane, isoflurane, desflurane, sevoflurane) show neuroprotective effects that protect cerebral tissue from adverse events--such as apoptosis, degeneration, inflammation and energy failure--caused by chronic neurodegenerative diseases, ischaemia, stroke or nervous system trauma. Nevertheless, in several studies, the administration of gaseous, volatile and intravenous anaesthetics (especially isoflurane and ketamine) was also associated with dose-dependent and exposure time-dependent neurodegenerative effects in the developing animal brain. At present, available experimental data do not support the selection of any one anaesthetic agent over the others. Furthermore, the relative benefit of one anaesthetic versus another, with regard to neuroprotective potential, is unlikely to form a rational basis for choice. Each drug has some undesirable adverse effects that, together with the patient's medical and surgical history, appear to be decisive in choosing the most suitable anaesthetic agent for a specific situation. Moreover, it is important to highlight that many of the studies in the literature have been conducted in animals or in vitro; hence, results and conclusions of most of them may not be directly applied to the clinical setting. For these reasons, and given the serious implications for public health, we believe that further investigation--geared mainly to clarifying the complex interactions between anaesthetic drug actions and specific mechanisms involved in brain injury, within a setting as close as possible to the clinical situation--is imperative.

Peri-operative risk management in patients with Alzheimer's disease.

The aim of this review is to identify an evidence-based perioperative management for patients affected by Alzheimer's disease (AD) that are scheduled to undergo surgery. This will minimize the negative effects of anesthesia and postoperative sedation and correct those perioperative variables possibly responsible for a decline in cognitive status and a worsening of AD. We here gather evidence on the importance of correct preoperative assessment regarding cognitive and functional status and the presence of preoperative delirium. The potential role of anesthesia, surgery, and postoperative analgosedation as risk factors for development of delirium are herein outlined. Finally, pain assessment instruments, as well as principles of management strategies for postoperative delirium in subjects with AD, are suggested.

Postoperative cognitive dysfunction: toward the Alzheimer's disease pathomechanism hypothesis.

Alzheimer's disease (AD), a chronic and progressive deterioration of memory and other cognitive domains, is the most common form of dementia. Because of related health and social impact, there is growing interest in assessing potential relationship between anesthesia and the onset and progression of chronic neurodegenerative disorders, including AD. Currently, preclinical and clinical research is addressed to identify underlying pathomechanisms, patient risk factors, and the use of the least provocative drugs and techniques, to minimize the incidence of chronic neurodegenerative disorders. Preclinical studies are providing an increasing body of evidences on some of the mechanisms that link anesthetics to neuronal programmed cell death (apoptosis) and accumulation of misfolded proteins in the aging brain. Therefore, risk factors and pathomechanisms of chronic neurodegenerative disorders, including AD, and persistent postoperative-postanesthesia cognitive dysfunction may overlap.

Cholinergic central system, Alzheimer's disease, and anesthetics liaison: a vicious circle?

Alzheimer's disease (AD) is a neurodegenerative disorder characterized by the accumulation and aggregation of amyloid-ß peptide and loss of forebrain cholinergic neurons, resulting in progressive loss of memory and irreversible impairment of higher cognitive functions. Several studies have accounted for the close relationship between AD and the central cholinergic system, suggesting that a dysfunction of acetylcholine containing neurons in the brain contributes significantly to the cognitive deficit of individuals with AD. The aim of the present review is to survey current literature on this topic in order to provide a clear understanding of the role of the cholinergic system in the development and neurodegenerative process of AD. The implications for anesthesia are also discussed. This knowledge could be valuable to improve anesthesia performance and patient safety.