Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial.

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Force and pressure distribution using Macintosh and GlideScope laryngoscopes in normal and difficult airways: a manikin study.

BACKGROUND: The forces applied to the soft tissues of the upper airway may have a deleterious effect. This study was designed to evaluate the performance of the GlideScope compared with the Macintosh laryngoscope. METHODS: Twenty anaesthetists and 20 trainees attempted tracheal intubation of a Laerdal SimMan manikin. Forces and pressure distribution applied by both laryngoscope blades onto the soft upper airway tissues were measured using film pressure transducers. The minimal force needed to achieve a successful intubation, in the same simulated scenario, was measured; additionally, we considered the visualization score achieved by using the Cormack-Lehane grades. RESULTS: All participants applied, on average, lower force with the GlideScope than with the Macintosh in each simulated scenario. Forces [mean (sd)] applied in the normal airway scenario [anaesthetists: Macintosh 39 (22) N and GlideScope 27 (15) N; trainees: Macintosh 45 (24) N and GlideScope 21 (15) N] were lower than forces applied in the difficult airway scenario [anaesthetists: Macintosh 95 (22) N and GlideScope 66 (20) N; trainees: Macintosh 100 (38) N and GlideScope 48 (16) N]. All the intubations using the GlideScope were successful, regardless of the scenario and previous intubation experience. The average pressure on the blades was 0.13 MPa for the Macintosh and 0.07 MPa for the GlideScope, showing a higher uniformity for the latter. CONCLUSIONS: The GlideScope allowed the participants to obtain a successful intubation applying a lower force. A flatter and more uniform pressure distribution, a higher successful rate, and a better glottic view were observed with the GlideScope.

Assessing the Quality of in Silico Produced Biomolecules: The Discovery of a New Conformer.

The computational procedures for predicting the 3D structure of aptamers interacting with different biological molecules have gained increasing attention in recent years. The information acquired through these methods represents a crucial input for research, especially when relevant crystallographic data are not available. A number of software programs able to perform macromolecular docking are currently accessible, leading to the prediction of the quaternary structure of complexes formed by two or more interacting biological macromolecules. Nevertheless, the scoring protocols employed for ranking the candidate structures do not always produce satisfactory results, making difficult the identification of structures that are most likely to occur in nature. In this paper, we propose a novel procedure to improve the predictive performances of computational scoring protocols, using a maximum likelihood estimate based on topological and electrical properties of interacting biomolecules. The reliability of the new computational approach, enabling the ranking of aptamer-protein configurations produced by an open source docking program, has been assessed by its successful application to a set of antiangiopoietin aptamers, for which experimental data highlighting the sequence-dependent affinity toward the target protein are available. The procedure led to the identification of two main types of aptamer conformers involved in angiopoietin binding. Interestingly, one of these reproduces the arrangement of angiopoietin with its natural target, tyrosine kinase, while the other one is completely unexpected. The possible scenarios related to these results have been discussed. The methodology here described can be used to refine the outcomes of different computational procedures and can be applied to a wide range of biological molecules, thus representing a new tool for guiding the design of bioinspired sensors with enhanced selectivity.

A validation strategy for in silico generated aptamers.

The selection of high-affinity aptamers is of paramount interest for clinical and technological applications. A novel strategy is proposed to validate the reliability of the 3D structures of a group of anti- Angiopoietin-2 aptamers, produced in silico by using free software. In a previous literature these aptamers were processed both in vitro and in silico, by using an approach different from that here presented, and finally tested with a SPS experiment. Computational expectations and experimental outcomes did not agree. The procedure here proposed consists of three steps: a. the production of a large set of conformations for each candidate aptamer; b. the rigid docking upon the receptor; c. the topological and electrical characterization of the products. Steps a. and b. allow a global binding score of the ligand-receptor complexes based on the distribution of the "effective affinity", i.e. the sum of the conformational and the docking energies. Step c. employs a complex network approach (Proteotronics) to characterize the electrical properties of the aptamers and the ligand-receptor complexes. Finally, the results are discussed and compared with the literature on the same aptamers. The computational predictions are in good agreement with the known experimental measurements.

A completely automated CAD system for mass detection in a large mammographic database.

Mass localization plays a crucial role in computer-aided detection (CAD) systems for the classification of suspicious regions in mammograms. In this article we present a completely automated classification system for the detection of masses in digitized mammographic images. The tool system we discuss consists in three processing levels: (a) Image segmentation for the localization of regions of interest (ROIs). This step relies on an iterative dynamical threshold algorithm able to select iso-intensity closed contours around gray level maxima of the mammogram. (b) ROI characterization by means of textural features computed from the gray tone spatial dependence matrix (GTSDM), containing second-order spatial statistics information on the pixel gray level intensity. As the images under study were recorded in different centers and with different machine settings, eight GTSDM features were selected so as to be invariant under monotonic transformation. In this way, the images do not need to be normalized, as the adopted features depend on the texture only, rather than on the gray tone levels, too. (c) ROI classification by means of a neural network, with supervision provided by the radiologist's diagnosis. The CAD system was evaluated on a large database of 3369 mammographic images [2307 negative, 1062 pathological (or positive), containing at least one confirmed mass, as diagnosed by an expert radiologist]. To assess the performance of the system, receiver operating characteristic (ROC) and free-response ROC analysis were employed. The area under the ROC curve was found to be Az = 0.783 +/- 0.008 for the ROI-based classification. When evaluating the accuracy of the CAD against the radiologist-drawn boundaries, 4.23 false positives per image are found at 80% of mass sensitivity.

Effects of overweight and obesity on motor and mental development in infants and toddlers.

BACKGROUND: A consequence of childhood obesity may be poor developmental outcomes. OBJECTIVES: This study aimed to examine the relationship between weight and developmental delays in young children. METHODS: We conducted a secondary analysis of the Early Childhood Longitudinal Study Birth Cohort data. Logistic regression models quantified the association between different weight statuses (normal weight <85th, overweight ≥90th, obese ≥95th percentile for weight) and delays in motor and mental development. RESULTS: Children classified as overweight in both waves had higher percentages of delays in wave 2 (motor [7.5 vs. 6.2-6.4%], mental [8.6 vs. 5.9-6.7%]), as well as wave 1 and/or wave 2 (motor [14.8 vs. 10.9-13.0%], mental [11.9 vs. 9.0-10.1%]), compared with other children. This association was also found in children who were obese at both time points in wave 2 (motor delay [8.9 vs. 4.9-7.3%], mental delay [10.3 vs. 6.0-7.2%]), as well as wave 1 and/or wave 2 (motor delay [14.5 vs. 10.9-12.9%], mental delay [14.1 vs. 9.4-10.1%]). In the adjusted models, children classified as always obese were more likely to have a mental delay in wave 2 (adjusted odds ratio [aOR] 1.89, 95% confidence interval [CI]: 1.21-2.95) as well as wave 1 and/or wave 2 (aOR 1.56, 95% CI: 1.08-2.26). These children were also more likely to have motor delay (aOR 1.47, 95% CI: 1.02-2.13) in wave 1 and/or wave 2. CONCLUSION: Overweight children are more likely than their normal-weight peers to have motor and mental developmental delays. Preventing obesity during infancy may facilitate reducing developmental delays in young children.

Mitoxantrone versus daunorubicin in induction-consolidation chemotherapy--the value of low-dose cytarabine for maintenance of remission, and an assessment of prognostic factors in acute myeloid leukemia in the elderly: final report. European Organization for the Research and Treatment of Cancer and the Dutch-Belgian Hemato-Oncology Cooperative Hovon Group.

PURPOSE AND METHODS: Optimization of remission-induction and postremission therapy in elderly individuals with acute myeloid leukemia (AML) was the subject of a randomized study in patients older than 60 years. Remission-induction chemotherapy was compared between daunomycin (DNR) 30 mg/m2 on days 1, 2, and 3 versus mitoxantrone (MTZ) 8 mg/m2 on days 1, 2, and 3, both plus cytarabine (Ara-C) 100 mg/m2 on days 1 to 7. Following complete remission (CR), patients received one additional cycle of DNR or MTZ chemotherapy and were then eligible for a second randomization between eight cycles of low-dose (LD)-Ara-C 10 mg/m2 subcutaneously every 12 hours for 1 2 days every 6 weeks or no further treatment. RESULTS: A total of 242 patients was randomized to DNR and 247 to MTZ. Median age of both study groups was 68 years. Secondary AML was documented in 26% and 25% of patients in either arm. The probability of attaining CR was greater (P = .069) with MTZ (47%) than with DNR (38%). Median duration of neutropenia was 19 (DNR) and 22 days (MTZ). The greater response rate to MTZ therapy correlated with reduced occurrence of chemotherapy resistance (32% v 47%, P = .001). With a median follow-up of 6 years, 5-year disease-free survival (DFS) is 8% in each arm. Overall survival estimates are not different between the groups (6% v 9% at 5 yrs). Poor performance status at diagnosis, high WBC count, older age, secondary AML, and presence of cytogenetic abnormalities all had an adverse impact on survival. Secondary AML and abnormal cytogenetics predicted for shorter duration of CR. Among complete responders, 74 assessable patients were assigned to Ara-C and 73 to no further therapy. Actuarial DFS was significantly longer (P = .006) for Ara-C-treated (13% [SE = 4.0%] at 5 years) versus nontreated patients (7% [SE = 3%]), but overall survival was similar (P = .29): 18% (SE = 4.6%) versus 15% (SE = 4.3%). Meta-analysis on the value of Ara-C postremission therapy confirms these results. CONCLUSION: In previously untreated elderly patients with AML, MTZ induction therapy produces a slightly better CR rate than does a DNR-containing regimen, but it has no significant effect on remission duration and survival. Ara-C in maintenance may prolong DFS, but it did not improve survival.

Transactivation activity and nucleocytoplasmic transport of ß-catenin are independently regulated by its C-terminal end.

The key protein in the canonical Wnt pathway is ß-catenin, which is phosphorylated both in absence and presence of Wnt signals by different kinases. Upon activation in the cytoplasm, ß-catenin can enter into the nucleus to transactivate target gene expression, many of which are cancer-related genes. The mechanism governing ß-catenin's nucleocytoplasmic transport has been recently unvealed, although phosphorylation at its C-terminal end and its functional consequences are not completely understood. Serine 646 of ß-catenin is a putative CK2 phosphorylation site and lies in a region which has been proposed to be important for its nucleocytoplasmic transport and transactivation activity. This residue was mutated to aspartic acid mimicking CK2-phosphorylation and its effects on ß-catenin activity as well as localization were explored. ß-Catenin S6464D did not show significant differences in both transcriptional activity and nuclear localization compared to the wild-type form, but displayed a characteristic granular nuclear pattern. Three-dimensional models of nuclei were constructed which showed differences in number and volume of granules, being those from ß-catenin S646D more and smaller than the wild-type form. FRAP microscopy was used to compare nuclear export of both proteins which showed a slightly higher but not significant retention of ß-catenin S646D. Altogether, these results show that C-terminal phosphorylation of ß-catenin seems to be related with its nucleocytoplasmic transport but not transactivation activity.

Technology for patient care assessment, documentation, and education.

Computer technology plays a big role in health care systems and information management. As technology continues to evolve, its role will become even more prevalent and important. Among the trends seen in technology products are better integration and compatibility of systems and accessories, enhanced performance and speed, smaller size and portability, improved user-friendliness, and affordability. All of these trends favor increased use in the health care environment. Selection of a product requires consideration of the desired goals and needs. An assessment should be made of existing technologies, particularly if interfacing will be required. Furthermore, most products have a life of only 10-18 months due to the rapid development of newer and better technologies.

The seeing stylet: a new device for tracheal intubation.

A new tracheal intubation device is available. The 'Shikani Seeing Stylet' is a new, inexpensive, reusable high resolution endoscope with a malleable stainless-steel sheath which can be inserted through a tracheal tube allowing intubation to be performed under direct vision. We have assessed this new device on 20 patients (ASA I-II; age 25-67) scheduled to undergo elective surgery with tracheal intubation. We measured heart rate (HR), non invasive blood pressure (NIBP), oxygen saturation (SpO(2)) and end tidal carbon dioxide (ETCO(2)) at three different times: T(0) (induction of anesthesia), T(1) (beginning of intubation procedure), T(2) (end of intubation procedure); we also recorded the time interval between T(1) and T(2). All patients were successfully intubated with the device. Eleven patients were intubated at the first attempt (T(1)-T(2) mean time=8. 65 s); three patients were intubated at the first attempt using cricoid pressure (T(1)-T(2) mean time 11.6 s); four patients were intubated at the second attempt (T(1)-T(2) mean time=36.5 s); two patients were intubated at the third attempt (T(1)-T(2) mean time=54. 5 s). The HR, NIBP, SpO(2) and ETCO(2) remained fairly stable. On the basis of our preliminary experience with 20 patients, the 'Shikani Seeing Stylet' seems to be a promising adjunct for airway management.

COPA as an aid for tracheal intubation.

The purpose of this study is to verify the usefulness of the cuffed oropharyngeal airway (COPA) as a device to guide a tracheal tube using a semiblind technique with a lightwand. Ten anaesthetised patients (ASA I-II, aged 35-67) undergoing to an elective surgery were analysed. We selected and positioned a correct size of COPA for each patient. A lightwand (Trachlight) was then inserted into the COPA to confirm correct placement of this device. The lightwand was then removed and the first portion of a tube exchanger (TE) was inserted and connected by a 15-mm connector with the breathing circuit and its position was confirmed by End Tidal CO(2) values during ventilation. The patients were then paralysed and ventilation through the first portion of the TE reconfirmed. The COPA was removed, and the second portion of the TE was connected and used as a guide for a tracheal intubation. This combined technique had a success rate of six out of ten patients and could be used for airway management if a fibre optic scope or other devices such as a Combitube, LMA or LMA Fastrach were not available. The preliminary data from this study are not indicative of the statistical validity of this technique. Further studies should be performed to verify the statistical reliability of the technique.

Awake use of a new laryngeal mask prototype in a non-fasted patient requiring urgent peripheral vascular surgery.

This case illustrates that a new prototype laryngeal mask with high seal pressures can be placed in the awake patient with minimal cardiorespiratory changes and that it facilitates passage of a nasogastric tube.

Pulse oximetry with the laryngeal mask airway.

This study evaluated the accuracy of pulse oximetry measured by a modified laryngeal mask airway (LMA). Ten anaesthetized patients (ASA I-II, aged 18-45) undergoing elective knee arthroscopies (mean-duration 40 min) were studied. A transmission pulse oximeter probe/sound OHMEDA was attached on the back of LMA (sizes 4 and 5) in an area in contact with the floor of the laryngeal part of the pharynx. Pharyngeal pulse oximetry as well as LMA cuff pressure were monitored and recorded every 5 min from the time of insertion (T0) to removal (T8) and were compared to simultaneous finger pulse oximeter readings. At T2 the cuff was over-inflated to obtain a 100 cm H2O intracuff pressure. At T3 the cuff pressure was decreased at 60 cm H2O. Pharyngeal pulse oximetry correlated with finger pulse oximetry throughout the study and was not effected by over-inflation of the LMA. This modification of the LMA provides an accurate method of measuring pulse oximetry which may be of use in a variety of circumstances.

A modified laryngeal mask in the endoscopic management of an esophageal tumor.

The laryngeal mask airway (LMA) can be used for gastroscopy, but its use can result in loss of the seal and/or displacement of the cuff. We describe an LMA that was specifically modified for gastroscopy and report its use in a patient with an esophageal tumor. The modified LMA has (a) a second tube that allows instruments to be directed toward the esophagus and (b) a second cuff mounted on the dorsal surface that increases the efficacy of the seal with the larynx. A 78-year-old man weighing 65 kg presented with a large mediastinal adenocarcinoma that was infiltrating the lateral wall of the thoracic esophagus. An esophagoscopy under anesthesia was planned to debulk the tumor. The modified LMA was inserted easily following induction with propofol. Anesthesia was maintained with propofol and 50% O2 in air and spontaneous ventilation. A lubricated 10.5-mm external diameter gastroscope was inserted into the second tube and passed easily into the esophagus. The tumor was successfully debulked using a polypectomy snare and an argon plasma coagulator. There was no loss of seal or displacement of the cuff, and the patient was stable throughout the procedure. We conclude that gastroscopy is feasible with the modified LMA. The device has a potential application in patients who require ventilatory support during gastroscopy.

Comparison of morphine and ropivacaine following knee arthroscopy.

PURPOSE: The purpose of this study was to compare the effectiveness of ropivacaine, a new local amidic anesthetic, compared with morphine as an intra-articular drug in controlling pain in patients after arthroscopic knee surgery. TYPE OF STUDY: Randomized trial. METHODS: We enrolled 90 patients scheduled to undergo elective knee arthroscopy. Patients were homogenous regarding demographic data and ASA physical status. Procedures included were diagnostic arthroscopies, lateral and medial meniscectomies, meniscal repair, and removal of loose bodies. All cases were treated by the same surgeon, under general anesthesia, using the same procedure. Patients were randomly divided into 3 groups. The first group received ropivacaine 75 mg in 20 mL of saline solution, the second group received 2 mg morphine in 20 mL of saline solution, and the third group received 20 mL of saline solution. No other oral or injectable analgesic administration was allowed. A blind observer assessed the patients' postoperative pain using a 10-cm visual analogue scale (VAS), ranging from no pain (0) to unbearable pain (10). Scores were taken at 0, 1, 4, 6, 12, and 24 hours after drug injection. VAS scores were analyzed using analysis of variance; significance was set at P <.005. RESULTS: None of the patients treated with ropivacaine or morphine needed administration of any other oral or injectable analgesic. No adverse reaction was noted in ropivacaine group. VAS score analysis in the first 4 postoperative hours showed greater effectiveness for ropivacaine versus morphine or placebo with highly significant results (P <.001). In the first 24 postoperative hours, the ropivacaine group versus the morphine group showed no significant differences (P =.207). CONCLUSIONS: Although its cost is very high compared with morphine, ropivacaine is a safe, site-specific, and long lasting anesthetic drug with an earlier onset than morphine and almost the same duration, covering the whole postoperative period (24 hours).