Neurological pupil index and its association with other prognostic tools after cardiac arrest: A post hoc analysis.

INTRODUCTION: We evaluated the concordance of the Neurological pupil Index (NPi) with other predictors of outcome after cardiac arrest (CA). METHODS: Post hoc analysis of a prospective, international, multicenter study including adult CA patients. Predictors of unfavorable outcome (UO, Cerebral Performance Category of 3-5 at 3 months) included: a) worst NPi ≤ 2; b) presence of discontinuous encephalography (EEG) background; c) bilateral absence of N20 waves on somatosensory evoked potentials (N20ABS); d) peak neuron-specific enolase (NSE) blood levels > 60 mcg/L; e) myoclonus, which were all tested in a subset of patients who underwent complete multimodal assessment (MMM). RESULTS: A total of 269/456 (59 %) patients had UO and 186 (41 %) underwent MMM. The presence of myoclonus was assessed in all patients, EEG in 358 (78 %), N20 in 186 (41 %) and NSE measurement in 228 (50 %). Patients with discontinuous EEG, N20ABS or high NSE had a higher proportion of worst NPi ≤ 2. The accuracy for NPi to predict a discontinuous EEG, N20ABS, high NSE and the presence of myoclonus was moderate. Concordance with NPi ≤ 2 was high for NSE, and moderate for discontinuous EEG and N20ABS. Also, the higher the number of concordant predictors of poor outcome, the lower the observed NPi. CONCLUSIONS: In this study, NPi ≤ 2 had moderate to high concordance with other unfavorable outcome prognosticators of hypoxic-ischemic brain injury. This indicates that NPi measurement could be considered as a valid tool for coma prognostication after cardiac arrest.

The use of automated pupillometry in critically ill cirrhotic patients with hepatic encephalopathy.

PURPOSE: To evaluate whether pupillary abnormalities would correlate with the severity of encephalopathy in critically ill cirrhotic patients. METHODS: In this retrospective study, we enrolled adult cirrhotic patients admitted to the Intensive Care Unit undergoing automated pupillometry assessment within the first 72 h since ICU admission. Encephalopathy was assessed with West-Haven classification and Glasgow Coma Scale. Pupillometry-derived variables were also correlated with biological variables, including ammonium, renal function or inflammatory parameters, measured on the day of pupillary assessment. RESULTS: A total of 62 critically ill cirrhotic patients (Age 61 [52-68] years; 69% male) were included. Median GCS and West-Haven classification were 14 [11-15] and 1 [0-3], respectively. There was a significant although weak correlation between GCS and constriction velocity (CV; R2 = 0.1; p = 0.017). We observed significant differences in CV and DV values among different levels of West-Haven classification. When only patients with encephalopathy (n = 42) or severe HE (n = 18) were considered, a weak correlation between GCS and worst CV was observed. When patients receiving sedatives or opioids were excluded, no significant correlation between pupillometry and clinical variables was observed. CONCLUSIONS: Pupillary function assessed by the automated pupillometry was poorly associated with encephalopathy scales in cirrhotic patients.

Quality of targeted temperature management and outcome of out-of-hospital cardiac arrest patients: A post hoc analysis of the TTH48 study.

BACKGROUND: No data are available on the quality of targeted temperature management (TTM) provided to out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. METHODS: Post hoc analysis of the TTH48 study (NCT01689077), which compared the effects of prolonged TTM at 33 °C for 48 h to standard 24-h TTM on neurologic outcome. Admission temperature, speed of cooling, rewarming rates, precision (i.e. temperature variability), overcooling and overshooting as post-cooling fever (i.e. >38.0 °C) were collected. A specific score, ranging from 1 to 9, was computed to define the "quality of TTM". RESULTS: On a total of 352 patients, most had a moderate quality of TTM (n = 217; 62% - score 4-6), while 80 (23%) patients had a low quality of TTM (score 1-3) and only 52 (16%) a high quality of TTM (score 7-9). The proportion of patients with unfavorable neurological outcome (UO; Cerebral Performance Category of 3-5 at 6 months) was similar between the different quality of TTM groups (p = 0.90). Although a shorter time from arrest to target temperature and a lower proportion of time outside the target ranges in the TTM 48-h than in the TTM 24-h group, quality of TTM was similar between groups. Also, the proportion of patients with UO was similar between the different quality of TTM groups when TTM 48-h and TTM 24-h were compared. CONCLUSIONS: In this study, high quality of TTM was provided to a small proportion of patients. However, quality of TTM was not associated with patients' outcome.

Development of primary superficial venous insufficiency: the ascending theory. Observational and hemodynamic data from a 9-year experience.

BACKGROUND: Hemodynamic principles suggest that primary venous insufficiency follows the hydrostatic column of venous pressure of the limbs, and therefore, venous reflux begins at the lower points and rises upwards. To test the hypothesis of an "ascending development" of reflux, we carried an observational study to analyze the natural evolution of lower limb venous insufficiency. METHODS: During 9-year period patients with primary superficial venous disease who refused treatment were followed prospectively with 6-month scheduled clinical and duplex ultrasound examinations. Localization, stage, and evolution of the venous patterns were compared. RESULTS: A total of 104 limbs in 99 patients were analyzed (12 males, 92 female; mean age 48.7 years). Prevalence of reflux was (p < 0.001) more frequent along great-saphenous and its tributaries (78/104, 75%) than nonsaphenous veins. The time of re-examination ranged from 1 to 13 years (mean 4 +/- 3.1 years). With the exception of six remaining stable, all the veins showed a progression of insufficiency (94%); 47 involved deep circulation. In all the worsened refluxes, an extension to reach one or more venous segments at an upper level, uninvolved before, was found. There was no downward oriented pattern of progression. There was no significant difference in age, gender, and type of vein between the stable and progressive diseases. CONCLUSIONS: Natural history of primary venous insufficiency is that of a progressive disease, which begins at lower levels of the limbs and develops in an antegrade manner as venous stasis is higher where force of gravity is higher. This data do not support the aggressive and widespread treatment of terminal valve as first approach, but need to be supported by larger studies.

Influences of postural alterations on the hemodynamic of the gait in patients with saphenous incompetence. A preliminary study.

OBJECTIVES: The aim of this study is to verify whether the postural alterations can influence the development of the varicose disease with unilateral and bilateral saphenous incompetence. MATERIALS AND METHODS: 39 patients suffering from saphenous incompetence diagnosed by hemodynamic study with eco-color doppler (20 patients with bilateral venous insufficiency (VI), 19 patients with unilateral VI) have performed the gait analysis though wireless inertial sensor and baropodometry to assess the plantar pressure distribution both statically and dynamically. RESULTS: The 68% and the 60% of subjects suffering from unilateral or bilateral VI present a plantar pressure dysfunction a single foot or both feet in static and/or in dynamic. In 63% of subjects with unilateral VI the propulsion is reduced on the lower limb damaged. The number of asymmetries in walking and dysfunctions in planar pressure in both groups has been calculated. The average number of asymmetries in walking in the group of patients with unilateral VI is significantly greater (p-value=0.0075) compared to the group of patients with bilateral VI. CONCLUSIONS: Plantar pressure and increased valvo-muscular pump pressure (VMPP) are not the main etiological factors that modify the hemodynamic in walking. In unilateral cases the postural alterations may contribute to worsening or to appearance of the varicose veins. Postural disorders treatment in children of phlebopaths during the childhood could maintain the mild condition of varicose disease silent. The treatment in adults suffering from unilateral VI may reduce or prevent the appearance of relapses KEY WORDS: Gait analysis, Hemodynamic of the gait, Postural alterations, Saphenous incompetence, Venous insufficiency.

[Linee guida flebo-linfologiche SIF-SICVE 2016 della Società Italiana di Flebologia e della Società Italiana di Chirurgia Vascolare ed Endovascolare].

Phlebology is not a specialty for its own in Italy. Phlebological patients are treated by vascular and general surgeons, dermatologists, phlebologists, angiologists, internists and even general practitioners. Even tough guidelines present a series of recommendations based on evidence-based medicine, guidelines may also be a tool to unify the diagnostic and therapeutic approach in a vast medical field like phlebology. Since vascular surgeons and phlebologists are particularly involved in phlebology-related pathologies the scientific societies of the Italian Society of Phlebology (SIF) and the Italian Society for Vascular and Endovascular Surgery (SICVE) decided to cooperate for the preparation of phlebo-lymphological guidelines. These guidelines comprehend also an important chapter dealing with the lymphology of the lower extremities; phlebological active physicians are often faced with lymphatic pathologies and a good differential diagnosis can be sometimes very helpful. Sclerotherapy and Surgery as the major therapeutical alternatives are extensively analyzed, but also the compression therapy, the medical and physical therapy are presented under the critical view of evidence based analyses. Separate chapters deal with the treatment alternatives for superficial and deep venous thromboses and the recommendations for the treatment of venous ulcers. The current scientific evidences were confronted with the experiences of Italian specialists and the particular practice and reality in Italy. They represent therefore the actual valid positions and recommendations in Italy which shall be updated regularly.

Echo-sclerosis hemodynamic conservative: a new technique for varicose vein treatment.

Treatment of venous insufficiency has been revolutionized by introduction of various less invasive procedures. The echo-sclerosis hemodynamic conservative (ESEC) technique is a completely new treatment of varicose veins that combines ultrasound-monitored sclerosis, innovative sclerotherapy findings, and hemodynamic principles. The objective of venous stasis suppression is achieved by the ESEC technique through a conservative and functional approach that preserves venous drainage and saphenous vessel integrity. The technique is efficient, simple, safe, in-office manageable, and easily repeatable, although it obviously requires training and skill. It may be considered as the primary treatment for most varicose patients. Evaluation of long-term results, with regard to comparison with other techniques, should assess cost efficacy from a lifelong point of view.