Bloodstream infections in haematological cancer patients colonized by multidrug-resistant bacteria.

Infections by multidrug-resistant (MDR) bacteria are a worrisome phenomenon in hematological patients. Data on the incidence of MDR colonization and related bloodstream infections (BSIs) in haematological patients are scarce. A multicentric prospective observational study was planned in 18 haematological institutions during a 6-month period. All patients showing MDR rectal colonization as well as occurrence of BSI at admission were recorded. One-hundred forty-four patients with MDR colonization were observed (6.5% of 2226 admissions). Extended spectrum beta-lactamase (ESBL)-producing (ESBL-P) enterobacteria were observed in 64/144 patients, carbapenem-resistant (CR) Gram-negative bacteria in 85/144 and vancomycin-resistant enterococci (VREs) in 9/144. Overall, 37 MDR-colonized patients (25.7%) developed at least one BSI; 23 of them (62.2%, 16% of the whole series) developed BSI by the same pathogen (MDRrel BSI), with a rate of 15.6% (10/64) for ESBL-P enterobacteria, 14.1% (12/85) for CR Gram-negative bacteria and 11.1% (1/9) for VRE. In 20/23 cases, MDRrel BSI occurred during neutropenia. After a median follow-up of 80 days, 18 patients died (12.5%). The 3-month overall survival was significantly lower for patients colonized with CR Gram-negative bacteria (83.6%) and VRE (77.8%) in comparison with those colonized with ESBL-P enterobacteria (96.8%). CR-rel BSI and the presence of a urinary catheter were independent predictors of mortality. MDR rectal colonization occurs in 6.5% of haematological inpatients and predicts a 16% probability of MDRrel BSI, particularly during neutropenia, as well as a higher probability of unfavourable outcomes in CR-rel BSIs. Tailored empiric antibiotic treatment should be decided on the basis of colonization.

High incidence of post-transplant cytomegalovirus reactivations in myeloma patients undergoing autologous stem cell transplantation after treatment with bortezomib-based regimens: a survey from the Rome transplant network.

The incidence of cytomegalovirus (CMV) reactivations in patients with multiple myeloma (MM) receiving autologous stem cell transplantation (ASCT) is relatively low. However, the recent increased use of novel agents, such as bortezomib and/or immunomodulators, before transplant, has led to an increasing incidence of Herpesviridae family virus infections. The aim of the study was to establish the incidence of post-engraftment symptomatic CMV reactivations in MM patients receiving ASCT, and to compare this incidence with that of patients treated with novel agents or with conventional chemotherapy before transplant. The study was a survey of 80 consecutive patients who underwent ASCT after treatment with novel agents (Group A). These patients were compared with a cohort of 89 patients treated with VAD regimen (vincristine, doxorubicin, and dexamethasone) before ASCT (Group B). Overall, 7 patients (4.1%) received an antiviral treatment for a symptomatic CMV reactivation and 1 died. The incidence of CMV reactivations was significantly higher in Group A than in Group B (7.5% vs. 1.1%; P = 0.048). When compared with Group B, the CMV reactivations observed in Group A were significantly more frequent in patients who received bortezomib, whether or not associated with immunomodulators (9.4% vs. 1.1%; P = 0.019), but not in those treated with immunomodulators only (3.7% vs. 1.1%; P = 0.396). These results suggest that MM patients treated with bortezomib-based regimens are at higher risk of developing a symptomatic CMV reactivation after ASCT.

In vivo characterization of Zirconia Toughened Alumina material: a comparative animal study.

The development of a new chromia-doped Zirconia Toughened Alumina (ZTA) material was previously reported as displaying mechanical properties suitable for implants with load bearing applications, such as orthopaedic and dental implants. This type of biomaterial is expected to be in contact with living tissues for a long period of time and its long-term toxicity must be carefully evaluated. In this study the suitability of this ZTA material as a candidate biomaterial for orthopaedic implants and dental devices was further investigated in vivo in comparison to alumina and zirconia, which are currently used in orthopaedic and dental surgery. Cylinders of the materials were implanted in vivo in white rabbits, and local and systemic tissue reactions were analyzed at different time intervals after surgery. Radiologic examinations displayed the absence of radiolucence around cylinders and no signs of implant loosening up to twelve months. No tumours developed in the animals either locally (at the site of implantation), or systemically in the peripheral organs. The results obtained suggest that this new ZTA material does not display any long term pathogenic effect in vivo. These findings extend our previous observations on the biocompatibility and the absence of any long-term carcinogenic effect in vitro of this material which displays interesting properties for biomedical applications. In conclusion, we report the in vivo characterization of a new chromia-doped ZTA material and confirm its suitability as a candidate biomaterial for orthopaedic implants and dental devices since it does not give any local nor systemic toxicity even after a long period of time after implantation.

Comparative Evaluation of Two Different Post-Operative Analgesia after Hallux Valgus Correction in Day Surgery Patients.

INTRODUCTION: The aim of this study was the evaluation of two different techniques on post-operative analgesia and motor recovery after hallux valgus correction in one-day surgery patients. MATERIAL AND METHODS: We enrolled 26 patients scheduled for hallux valgus surgery and treated with the same surgical technique (SCARF osteotomy). After subgluteal sciatic nerve block with a short acting local anaesthetic (Mepivacaine 1.5%, 15ml), each patient received an ultrasound-guided Posterior Tibialis Nerve Block (PTNB) with Levobupivacaine 0.5% (7-8ml). We measured the postoperative intensity of pain using a Visual Analogue Scale (VAS), the consumption of oxycodone after operative treatment and the motor recovery. VAS was detected at baseline (time 0, before the surgery) and at 3, 6, 12 and 24 hours after the operative procedure (T1, T2, T3, T4 respectively). Control group of 26 patients were treated with another post-operative analgesia technique: local infiltration (Local Infiltration Anaesthesia, LIA) with Levobupivacaine 0.5% (15ml) performed by the surgeon. RESULTS: PTNB group showed a significant reduction of VAS score from the sixth hour after surgery compared to LIA group (p<0.028 at T2, p<0.05 at T3 and p<0.002 at T4, respectively). Instead, no significant differences were found in terms of post-operative oxycodone consumption and motor recovery after surgery.Conclusions: PTNB resulted in a valid alternative to LIA approach for post-operative pain control due to its better control of post-operative pain along the first 24 hours. In a multimodal pain management according to ERAS protocol, both PTNB and LIA should be considered as clinically effective analgesic techniques.

Anaesthesia for total knee arthroplasty: efficacy of single-injection or continuous lumbar plexus associated with sciatic nerve blocks--a randomized controlled study.

Total knee arthroplasty (TKA) often results in marked postoperative pain. We compared in a randomized controlled study tramadol consumption, postoperative pain and patient satisfaction after primary TKA in patients who received a single injection lumbar plexus and sciatic nerve blocks or a continuous lumbar plexus and sciatic nerve blocks. Forty-four patients scheduled for unilateral total knee arthroplasty were allocated to the single shot group (group A) or to the catheter group (group B). All patients (in both groups) reported being satisfied with their anaesthetic management. Although pain scores and tramadol consumption appeared lower in the active infusion group, the differences did not reach statistical significance. This study confirms that either single injection or continuous infusion of Ropivacaine in lumbar plexus provides reliable and long-acting anaesthesia and analgesia.

The efficacy of the psoas compartment block versus the intrathecal combination of morphine, fentanyl and bupivacaine for postoperative analgesia after primary hip arthroplasty: a randomized single-blinded study.

PURPOSE: Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques. METHODS: Forty patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine, 0.015 mg fentanyl and 15 mg hyperbaric bupivacaine (Group I, n = 20) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 20). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's satisfaction and acceptance of the postoperative analgesic technique were also recorded. RESULTS: During the first 24 hr, pain scores (12 +/- 27 vs 24 +/- 25 at H + 12, 12 +/- 46 vs 20 +/- 26 mm at H + 24, 16 +/- 19 vs 20 +/- 29 mm at H + 36) and tramadol consumption (30 +/- 70 vs 210 +/- 400 mg at H + 12, 180 +/- 120 vs 320 +/- 100 mg at H + 24) were slightly lower in Group I than in Group II, but there were no statistically significant differences. Itching was the most frequent side-effect occurring in 45% of cases in Group I vs 10% in Group II (P < 0.05). No major complication occurred. There was no difference in satisfaction scores between the two groups. CONCLUSION: Intrathecal administration of a combination of morphine, fentanyl and bupivacaine and single-shot psoas compartment block both provide very good postoperative analgesia after primary hip arthroplasty.

[Correlation between exhaled benzene and environmental exposure in refinery workers]. / Correlazione tra il dosaggio del benzene nell'aria alveolare ed i livelli ambientali nei lavoratori di una raffineria.

Benzene is still present in various working processes. Many methods are available for the biological monitoring of benzene exposure. The Authors present a study concerning a series of 23 workers of a refinery exposed to benzene. The measurement of benzene in alveolar air was preferred to quantify exposure. In this paper, adopting an original, simple and reliable device to collect the samples of alveolar air, a good correlation was found between the levels of benzene in the alveolar air and the environmental individual sampling.

Intravenous infusion of magnesium sulfate and postoperative analgesia in total knee arthroplasty.

BACKGROUND: The effectiveness of combining magnesium (Mg) administration with both general and spinal anesthesia to reduce postoperative pain and analgesic consumption is still debated. We evaluated the effects of an intravenous (IV) infusion of Mg sulphate on analgesic consumption and postoperative pain score after total knee arthroplasty performed under spinal anesthesia. METHODS: We studied 40 patients who underwent spinal anesthesia with bupivacaine plus morphine. Patients were randomly assigned to two groups, each of 20 patients, who received either treatment (i.e., intravenous Mg sulphate 40 mg kg(-1) followed by an infusion of 10 mg kg(-1) h(-1)), or the same amounts of isotonic saline (controls). Irrespective of the group of randomization, all patients received postoperative paracetamol, ketorolac, and patient-controlled analgesia with morphine. RESULTS: The Mg postoperative blood level was 0.85 ± 0.02 mmol/L and 1.25 ± 0.11 mmol/L for C and Mg groups, respectively (P<0.001). Sensory level of the spinal block, height of spinal block, mean time to first pain and incidence of PONV were similar in the two groups. Morphine consumption did not show any statistically significant difference between the two groups. The pain score was not significantly different between the two groups. No severe adverse effects were recorded after Mg infusion. CONCLUSION: IV perioperative administration of Mg did not influence postoperative pain control and analgesic consumption after total knee arthroplasty. More studies should be performed with different intra and postoperative pain protocols to enhance the potential anti-nociceptive effect of Mg.

Haploidentical, G-CSF-primed, unmanipulated bone marrow transplantation for patients with high-risk hematological malignancies: an update.

Ninety-seven patients affected by high-risk hematological malignancies underwent G-CSF primed, unmanipulated bone marrow (BM) transplantation from a related, haploidentical donor. All patients were prepared with an identical conditioning regimen including Thiotepa, Busilvex, Fludarabine (TBF) and antithymocyte globulin given at myeloablative (MAC = 68) or reduced (reduced intensity conditioning (RIC) = 29) dose intensity and received the same GvHD prophylaxis consisting of the combination of methotrexate, cyclosporine, mycofenolate-mofetil and basiliximab. Patients were transplanted in 1st or 2nd CR (early phase: n = 60) or in > 2nd CR or active disease (advanced phase: n = 37). With a median time of 21 days (range 12-38 days), the cumulative incidence (CI) of neutrophil engraftment was 94 ± 3%. The 100-day CI of III-IV grade acute GvHD and the 2-year CI of extensive chronic GvHD were 9 ± 3% and 12 ± 4%, respectively. Overall, at a median follow-up of 2.2 years (range 0.3-5.6), 44 out of 97 (45%) patients are alive in CR. The 5-year probability of overall survival (OS) and disease-free survival (DFS) for patients in early and advanced phase was 53 ± 7 vs 24 ± 8% (P = 0.006) and 48 ± 7 vs 22 ± 8% (P = 0.01), respectively. By comparing MAC with RIC patient groups, the transplant-related mortality was equivalent (36 ± 6 vs 28 ± 9%) while the relapse risk was lower for the MAC patients (22 ± 6 vs 45 ± 11%), who showed higher OS (48 ± 7 vs 29 ± 10%) and DFS (43 ± 7 vs 26 ± 10%). However, all these differences did not reach a statistical significance. In multivariate analysis, diagnosis and recipient age were significant factors for OS and DFS. In conclusion, this analysis confirms, on a longer follow-up and higher number of patients, our previous encouraging results obtained by using MAC and RIC TBF regimen as conditioning for G-CSF primed, unmanipulated BM transplantation from related, haploidentical donor in patients with high-risk hematological malignancies, lacking an HLA-identical sibling or unrelated donor and in need to be urgently transplanted.

Wake-up test during major spinal surgery under remifentanil balanced anaesthesia.

Damage to spinal cord and subsequent neurological deficit is a recognised complication of major spinal surgery. It may be produced by a number of causes, not last excessive stretching when surgical instrumentation is positioned; it is easy to understand that early intraoperative warning of potential damage is highly desiderable. Wake-up test is a simple, safe and reliable method of recognition of such a complication, allowing rapid neurological recovery by reduction of spinal distraction. Remifentanil belongs to a new pharmacokinetic class of opioids (EMO: Esterase Metabolised Opioid) undergoing rapid biotransformation to minimally active metabolites, showing a short and predictable duration of action with no effect of accumulation. Authors describe a first 10 patient series subjected to wake-up-test during spinal surgery under remifentanil balanced anaesthesia. The protocol the authors set up allowed a very rapid intraoperative neurological examination (in average less than 5 min), without pain and/or disagreement for the patient and no complication related to the test was observed. Authors conclude that the use of Remifentanil for intraoperative awakening during major spinal surgery seems to be a safe, reliable and pratictical method to detect very quickly any potential neurological damage during the operation.

Anaesthesia for shock wave therapy in musculoskeletal disorders: a preliminary report.

The potential for using external applied energy to rectify or ameliorate musculoskeletal disorders has been explored for decades. A shock wave is a pressure disturbance: tissue effect is cavitation, producing microtrauma or microfracture and haematoma formation, inducing, as to date is thought, increase in vascularization, increased soft callus and faster enchondral ossification. Anaesthesiological interest in this field is focused in non-union or delayed osseous union, joint stiffness or osteochondrosis and femoral head necrosis in adults. Actually, because of the pain associated with high energy extracorporeal shock wave therapy on bones, anaesthesia is necessary, but, since almost all patients have no complaint after treatment, there is no need of postoperative analgesia. Therefore, short duration anaesthetic techniques and agents should be preferred. Loco-regional anaesthesia or general anaesthesia are both suitable to the purpose. Fifty patients have been treated nowadays in our Institution with shock wave therapy needing anaesthesia. 18 patients (36%) received general anaesthesia. Since patient's stay in hospital was expected to be short, short duration agents have been used, avoiding those causing unpleasent side effects, first emesis. We used Propofol or Remifentanil by continuous infusion, titrated to maintain stable haemodynamics and an appropriate level of anaesthesia. The short duration of action of Propofol depends on its rapid elimination, whereas Remifentanil undergoes rapid biotransformation to minimally active metabolites. 32 patients (64%) received regional anaesthesia. We avoided long acting agents or high concentration drugs. Spinal blocks have been performed with 0.5% hyperbaric bupivacaine; brachial plexus blocks, sciatic-femoral blocks and an epidural block have been performed with 0.5-1% xylocaine or 1% mepivacaine. Shock Wave Therapy has been done during a 3-day hospital stay. With suitable anaesthesiological treatment and preparation, almost all patients could be treated as outpatients or with an overnight hospital stay.

Intra-articular analgesia following arthroscopic surgery of the shoulder.

Shoulder surgery is very often followed by severe postoperative pain. Loco-regional anaesthesia has greatly contributed as a solution of this problem. Nevertheless most of surgery is still performed under general anaesthesia. In this case many different methods have been proposed in order to mitigate postoperative pain. Intra-articular administration of local anaesthetics after shoulder surgery is not yet in routinely clinical practice. In this study efficacy of intra-articular administration of Ropivacaine versus Bupivacaine has been evaluated. Analysis of results showed both drugs to share the same effectiveness within four hours postoperatively. In subsequent period (6-24 hours) Ropivacaine demonstrated to provide a statistically significant better postoperative pain relief. Furthermore Ropivacaine group patients needed postoperative analgesics to a lesser extent than Bupivacaine group. The long-losting satisfactory level of analgesia, particularly with Ropivacaine, could recommend the use of intra-articular analgesia even for day-hospital or one-day surgery procedures.

Pediatric neuroanesthesia computerized monitoring system.

The authors describe the development of a computerized on-line monitoring system and its application during major pediatric neurosurgical procedures. The system acquires from monitor by serial communication the values of heart rate, systemic pressures, intracranial and central venous pressures, peripheral and central body temperatures and stores all these data on hard-disk. The system allows the collecting of clinical information, and other data concerning the metabolic and hemodynamic perioperative status of the patient. It also calculates in real time many derived parameters and stores all the measured data, the therapeutical administrations and their temporal relationship with the various surgical procedures on disk for statistical evaluation.

Recombinant alpha interferon in the treatment of low-grade non-Hodgkin's lymphoma: results of a cooperative phase II trial in 31 patients.

Thirty-one patients with advanced stage of favorable histology non-Hodgkin's lymphomas were entered into a multicenter phase II trial with recombinant alpha A interferon as single agent. Interferon was administered intramuscular in doses of 6 x 10(6)/IU/m2 three times per week for 12 weeks. Dose escalation was applied, in the absence of toxicities greater than WHO grade II, in patients not responding after 4 weeks. In responding patients treatment was continued at the same dose with a weekly maintenance schedule for 12 additional weeks. Objective responses (4 complete, 10 partial) were obtained in 14 of the 27 evaluable patients (52%). Median time to progression was 15 months for partial responders, while none of the complete responders has relapsed up to the present time. Toxicity was generally moderate and manageable. Treatment was discontinued in three patients because of side effects, and one patient refused therapy after 3 weeks. Our study shows that recombinant alpha A interferon has antitumor activity in patients with favorable histology non-Hodgkin's lymphoma.

Lack of prognostic significance of the pretreatment labeling and mitotic indices of marrow blasts in acute nonlymphocytic leukemia (ANLL).

The prognostic significance of the pretreatment growth characteristics of marrow blasts was examined in 37 patients with acute nonlymphocytic leukemia (ANLL) treated with a similar therapeutic regimen. Initial mitotic index (MI) and in vitro 3H-thymidine labeling index (LI) were broadly distributed showing no correlation to other initial variables, such as age or absolute blast count. No relationship whatsoever was observed between the pretreatment LI, MI and either the likelihood of achieving a complete remission or the remission and survival length. We conclude that the initial growth characteristics of marrow blasts do not play a significant role in predicting the therapeutic response in ANLL; age, modality of therapy and, possibly, the dynamic perturbations of the proliferative activity of the blast cells induced by treatment should be regarded as more reliable prognostic indicators in ANLL.