Impact of COVID-19 pandemic on patients affected by peripheral arterial disease: an Italian single-center study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has evolved into a global pandemic, affecting a wide range of medical and surgical specialties. During COVID-19, we assisted in the reallocation of medical resources and services, as well as social distancing measures, and many patients with chronic diseases and comorbidities may have experienced difficulties in obtaining the correct medical care. The aim of the study was to investigate the impact of the COVID-19 pandemic on major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with peripheral arterial disease (PAD) and chronic limb-threatening ischemia (CLTI), compared to previous years. PATIENTS AND METHODS: We evaluated 1,335 hospital admissions of 877 patients with PAD admitted to Policlinico A. Gemelli Hospital between January 2017 and February 2020 and 368 hospital admissions of 272 patients with PAD admitted to the Policlinico A. Gemelli Hospital between March 2020 and March 2021. Data on demographic characteristics, comorbidities, symptoms, physical and radiological findings, laboratory tests, and routine visits before or after discharge were collected from electronic medical records. RESULTS: Emergency room (ER) admissions among PAD patients during COVID-19 were higher than before the pandemic [190 (51.63%) vs. 579 (43.37%), p = 0.01]. A MACE was found in 78 (5.84%) pre-pandemic hospitalizations and 126 (34.24%) pandemic hospitalizations (p < 0.01). A MALE was identified in 942 (70.56%) pre-pandemic hospitalizations and 331 (89.95%) pandemic hospitalizations (p < 0.01). Amputation rates during the pandemic were higher than before the pandemic [80 (21.74%) vs. 191 (14.31%), p < 0.01]. The number of in-hospital deaths did not differ between the pandemic and pre-pandemic periods [11 (2.99%) vs. 51 (3.82%), p = 0.55]. CONCLUSIONS: In patients with PAD and CLTI, the number of MACE, MALE, and amputations was higher during the COVID-19 period compared to the three years before the pandemic.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine.

BACKGROUND: The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia. METHODS: Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses. RESULTS: The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups. CONCLUSIONS: Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

Does clonidine 50 microg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study.

STUDY OBJECTIVE: To evaluate the effects of adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy (TEA). DESIGN: Randomized, double-blind study. SETTING: Departments of Anesthesia and Vascular Surgery of a university hospital. PATIENTS: 40 ASA physical status II and III patients undergoing elective TEA during superficial cervical plexus block. INTERVENTIONS: Superficial cervical plexus block was placed using 20 mL of 0.75% ropivacaine alone (Ropi group, n = 20) or with the addition of 50 microg clonidine (Ropi-Clonidine group, n = 20). If required, analgesic supplementation was given with local infiltration with 1% lidocaine and intravenous fentanyl (50-microg boluses). Nerve block profile, need for intraoperative analgesic supplementation, and time to first analgesic request were recorded. MEASUREMENTS AND MAIN RESULTS: Median (range) onset time was 10 minutes (5-25 min) in the Ropi group and 5 minutes (5-20 min) in the Ropi-Clonidine group (P < 0.05). Intraoperative consumption of both 1% lidocaine and fentanyl was higher in patients of the Ropi group (15 mL [0-25 mL] and 250 microg [50-300 microg]) than in patients of the Ropi-Clonidine group (8 mL [0-20 mL] and 0 microg [0-150 microg]; P < 0.05 and P < 0.05, respectively). First postoperative analgesic request occurred after 17 hours (10-24 hrs) in the Ropi group and 20 hours (10-24 hrs) in the Ropi-Clonidine group (P > 0.05). CONCLUSIONS: Adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia in patients undergoing elective TEA.

A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery.

BACKGROUND: The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain. METHODS: Forty-two ASA physical status II-III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5-10 mL h-1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h. RESULTS: The area under the curve of the visual analogue pain score during coughing over time was 192 (60-444) cm h-1 in group EPI and 228 (72-456) cm h-1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was -9 (0 to -9)% in group PVB and -17 (0 to -38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8-9.8) cm in group EPI and 9 (7.5-10) cm in group PVB (P = 0.65). CONCLUSIONS: Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.

Managing metabolic complications of peritoneal dialysis.

AIMS: The purposes of this paper are: to report our experience employing a comprehensive, multifaceted treatment program to improve the metabolic disturbances of dyslipidemia, hyperglycemia and weight gain observed in our peritoneal dialysis patients, and by post-hoc analysis to demonstrate how the routine clinical lipid profile can be manipulated arithmetically to estimate levels of atherogenic low-density lipids and thereby achieve a more sophisticated clinical analysis of dyslipidemia and its response to therapy. METHODS: Data are reported for 56 patients who were stable on peritoneal dialysis for at least 6 months and who had metabolic data available prior to beginning peritoneal dialysis. Metabolic complications of peritoneal dialysis were treated by a comprehensive strategy involving diet, glycemic control and lipid-lowering medications with an emphasis on weight control and exercise. From the measured lipid profile (total cholesterol (TC), high-density lipoprotein (HDL) and triglyceride (TG)), levels of atherogenic low-density lipids (low-density lipoprotein (LDL), non-HDL, very-low-density lipoprotein (VLDL) and intermediate-low-density lipoprotein (IDL) were calculated. RESULTS: Before initiation of peritoneal dialysis therapy, the most common lipid abnormalities were low levels of HDL (59%) and elevated levels of triglyceride (41%) with infrequent elevations of total cholesterol (9%) and low-density lipoprotein (23%). After initiation of peritoneal dialysis therapy, all lipid levels, except HDL, increased significantly, and hyperlipidemia, hyperglycemia and obesity, singly or in combination, occurred in 84% of patients. With treatment, elevated lipid levels decreased significantly with reversal of the adverse cardiovascular risk profile of lipids that developed during peritoneal dialysis therapy, and HDL levels increased significantly. On peritoneal dialysis therapy, all diabetic patients required insulin, and glycemic control was achieved in most patients (79%). Excessive weight gain (10-24% body weight) occurred in 20% of peritoneal dialysis patients. Diabetic patients had a higher incidence of being overweight and obese. Post-hoc analysis revealed that levels of VLDL and IDL frequently were elevated both before (57-61%) and during (68-84%) peritoneal dialysis and that target levels of these atherogenic low-density lipoproteins infrequently (22-26%) were achieved. CONCLUSIONS: The metabolic complications of peritoneal dialysis are responsive to a comprehensive treatment strategy. Controlling weight gain on peritoneal dialysis therapy maybe a difficult challenge for some patients, particularly those who are diabetic. Patients with renal failure and on dialysis, especially peritoneal dialysis, frequently have elevated levels of the atherogenic lipoproteins fragments VLDL and IDL. Future clinical trials should focus on the efficacy and safety of aggressive therapy to achieve target levels of these atherogenic lipids.

Teaching group treatment in doctoral programs for counseling psychology.

We surveyed the 71 doctoral programs in counseling psychology approved by the American Psychological Association to examine whether and how group counseling or therapy was taught. Responses from 31 programs listed at least one graduate course in group counseling; over half offered more than one. In most cases the introductory course was required. Analysis also indicated that introductory courses often included an in-class or an out-of-class experiential component, focused either primarily or exclusively on outpatient therapy and used Yalom's interpersonal approach. Discussion focused on the importance of courses in group interventions in doctoral programs in counseling psychology and the differences and similarities in academic training of group interventions in programs in counseling and clinical psychology.

An insulin sensitizer improves the free radical defense system potential and insulin sensitivity in high fructose-fed rats.

Recently there has been growing interest in the effects of antioxidants on insulin activity. In the present study, we investigated the effect of metformin on free radical activity and insulin sensitivity in high fructose-fed rats, a diet that leads to insulin resistance. The animals were divided into four groups (n = 16 per group; experiment duration = 6 weeks): the control (C) group received a standard diet; the control metformin (CM) group was fed a control diet and received metformin (200 mg x kg(-1) x day(-1) in water); the fructose control (FT) group was fed a diet in which fructose composed 56.8% of the total carbohydrates; and the fructose metformin (FM) group received high-fructose diet and metformin (200 mg x kg(-1) x day(-1) in water). The glucose clamp technique was used to determine insulin sensitivity in eight animals per group. Metabolic and oxidative stress parameters were measured in the remaining rats. In the FT rats, insulin resistance, lower red cell CuZn superoxide dismutase activity and lower blood reduced glutathione were observed. Metformin treatment improved both the insulin activity and the antioxidant defense system. In the CM group, metformin had no effect on metabolic parameters, but improved red cell antioxidant enzyme activities and the blood GSH level, which suggests that it has an antioxidant activity independent of its effect on insulin activity.

Academic training in group psychotherapy in clinical psychology doctoral programs.

We surveyed 185 clinical psychology doctoral programs accredited by the American Psychological Association to examine whether and how group psychotherapy was taught. While respondents of all Psy.D: programs to the survey offered a course in group psychotherapy, less than one-third of Ph.D. programs offered one. Among programs that offered a course in group psychotherapy, less than half required that students take it. Most instructors had an in-class experiential component, focused either primarily or exclusively on outpatient therapy and used Yalom's interpersonal approach. Discussion focused on the importance of making group psychotherapy a higher priority and the suggestion that courses include a variety of theoretical approaches and important specialty groups such as psychiatric inpatients.

Vitamin E improves the free radical defense system potential and insulin sensitivity of rats fed high fructose diets.

The purpose of this study was to investigate the effects of vitamin E in rats fed a high fructose diet which leads to insulin resistance, on some components of the free radical defense system and on insulin sensitivity. The rats (postweaning, 50 g) were divided into three groups: the control group (C, n = 16), which received a purified diet containing 60 g/100 g carbohydrates, the high fructose-fed group (FT, n = 16),fed a diet in which 56.8% of the carbohydrate as fructose, and a high fructose and vitamin E-fed group (FVE, n = 16), fed the FT diet supplemented with 3.4 g vitamin E/kg diet (vs. 0.17 g/kg in C and FT groups). The duration of the treatment was 6 wk. Insulin sensitivity was determined in half of the rats in each group using the euglycemic hyperinsulinic glucose clamp technique. The remaining rats were investigated for plasma glucose, insulin, triglyceride and fructosamine concentrations and for components of the free radical defense system. The FT group had a significantly lower insulin sensitivity than the C group. Basal glycemia was not different among the groups. In comparison with the C group, the FT group had a greater lipid peroxidation, as indicated by the higher concentrations of plasma thiobarbituric acid reactive substances (TBARS) and blood disulfide glutathione (GSSG) and the lower Cu-Zn superoxide dismutase (Cu-Zn SOD) activity. These markers approached the values of the controls after addition of vitamin E. Moreover, the FVE group had a higher insulin sensitivity than the FT group, but it remained lower than in the C group. These results show that a high fructose diet in rats leads to insulin resistance and a defect in the free radical defense system. Vitamin E supplementation improves insulin sensitivity in fructose-fed rats.

Intellectual functioning of inpatients with dissociative identity disorder and dissociative disorder not otherwise specified. Cognitive and neuropsychological aspects.

The intellectual functioning of 105 inpatients with multiple personality disorder and dissociative disorder not otherwise specified was assessed using the Wechsler Adult Intelligence Scale-Revised as part of a comprehensive research protocol. There were no significant intellectual differences between the groups on any major intelligence quotient summary score or any of the age-adjusted empirical factor scores. The anecdotal but widely accepted hypotheses that dissociative patients either have above average premorbid intelligence or that their current intellectual functioning is deleteriously affected by their fluctuant psychiatric disorder were not supported in this sample. A significant subsample of the multiple personality disorder group manifested abnormal interest scatter on the Wechsler Adult Intelligence Scale-Revised verbal subtests, and this variability was attributed to subtle neuropsychological deficits on the Memory/Distractibility factor. We speculate that dissociative patients might need to be evaluated for attention deficit disorder in addition to the range of dissociative symptoms in a comprehensive evaluation.

Temporal consistency and stability of three scales for measuring stress in adults.

We investigated the 30-min. temporal consistency and temporal stability of three focal scales for measuring stress: the Cognitive Anxiety Scale-State, the Focusing Inventory Scale-State, and the Somatic Symptom Scale-State. These scales are applicable for individually measured reduction in stress in research on outcome with older adolescents and adults. All possess excellent internal consistency. All manifested significant temporal consistency and good to excellent temporal stability over 30 min. in a nonclinical sample of 60 undergraduates. Small significant differences in means on the Cognitive Anxiety Scale-State and the Somatic Symptom Scale-State were noted. The phenomenological states associated with stress were stable and consistent over 30 min., the optimal time interval used in research on stress.

Retrospective self-reported symptoms of attention-deficit hyperactivity disorder: reliability of the Wender Utah Rating Scale.

We measured the internal consistency and four-week temporal consistency and temporal stability of the Wender Utah Rating Scale and its 25-item short form. The Wender scale is a rationally constructed retrospective self-report rating scale for symptoms of Attention-deficit Hyperactivity Disorder. Both scales manifested excellent internal consistency. Over one month, both versions manifested significant temporal consistency and good temporal stability in the nonclinical sample of 83 successful young adults most likely to be referred for an evaluation of suspected Attention-deficit Hyperactivity Disorder. The collegiate group had a considerably higher Wender score than the original normative group, calling into question the adequacy of the limited normative data. However, both forms of the scale are reliable and comprehensive validation research is advocated.

[Tracheal and main bronchial disruptions after blunt chest trauma]. / Le lacerazioni tracheo-bronchiali da trauma chiuso del torace.

Tracheobronchial disruption is one of the less common injury associated with blunt thoracic trauma and the diagnostic evaluation is often misleading. Early diagnosis and repair of these injuries are essential to minimize the risk of patient's death and his future respiratory performances. Mechanisms of injury, clinical presentation, diagnosis and management of 5 our patients are reviewed. The good results achieved encourage an aggressive approach in these disruptions that can be life threatening.

Zinc prevents the structural and functional properties of free radical treated-insulin.

We have previously reported that zinc deficiency could increase in vivo lipid peroxidation and decrease rat insulin sensitivity. In the present paper, we address the hypothesis of the role of zinc on insulin molecule in relation to free radical damage. From native recombinant human insulin, we prepared a zinc-depleted insulin. Both preparations were subjected to controlled free radical attack by incubation in the presence of 2,2'-azobis(2-amidinopropane) hydrochloride (AAPH). To obtain minimally oxidized insulin, the oxidation process was monitored by measuring the intrinsic fluorescence of the insulin preparations. For 2.5 mM of AAPH, the autofluorescence of zinc-depleted insulin markedly decreased as compared to that of native insulin. These data are in favor of conformational changes of the insulin molecule which were further studied by quenching of fluorescence by means of potassium iodide. Using the euglycaemic hyperinsulinic glucose clamp technique in rats, the in vivo activities of the different insulin preparations, showed that oxidized zinc-depleted insulin had a marked reduced activity as compared to oxidized native insulin. From our results, we suggest that structural modification of the insulin molecule took place after zinc depletion and free radical treatment. Moreover, zinc depletion appeared to increase the susceptibility of insulin to free radicals.

[A comparison between propafenone and amiodarone in the conversion to sinus rhythm of atrial fibrillation of recent onset]. / Confronto tra propafenone ed amiodarone nella conversione al ritmo sinusale della fibrillazione atriale di recente insorgenza.

The effectiveness of propafenone versus amiodarone for conversion to sinus rhythm of paroxysmal atrial fibrillation was compared. Fifty-four consecutive adult patients affected by recent onset atrial fibrillation (< 7 days) were randomized to treatment with intravenous propafenone (27 patients) and amiodarone (27 patient). Sinus rhythm was restored respectively in 74.1% and 70.4% (p = ns); within 5 hours was obtained reconversion in 65% of propafenone and in 15.8% of amiodarone group (p < 0.05); the mean conversion time was 3.5 and 16.6 hours (p < 0.01). In conclusion propafenone seems to be as effective and safe as amiodarone, but is significantly fast in converting recent onset atrial fibrillation to sinus rhythm.

The Trail Making Test A and B: a technical note on structural nonequivalence.

The major structural aspect of the Trail Making Test, length of drawn lines needed to complete the tests, was measured and compared for the adult and school-aged child versions. Trail Making B is a markedly longer test than Trail Making A, 32% for adults and 27% for school-aged children. The interpretive assumptions that Trail Making B differs from Trail Making A only in terms of the cognitive skills needed to complete the test and the implicit interpretive bias toward minimizing the motor component of the tests were challenged in this technical note.

Verapamil used in lung transplantation: could it have a cytoprotective effect during the ischemic phase of pulmonary preservation? Study on alveolar type II cells.

It has been shown that Verapamil (V) improves lung preservation, but it is not clear whether the effect is due to vasodilation, with a more homogeneous cooling effect during hypothermic preservation, or a direct cytoprotection. Attempting to verify this, we studied the cellular viability of rats' pneumocytes type II primary cultures separately incubated in the first experiment for 6 hours in Ringer Lactate (RL) +/- V (10 mg/l) at 25 degrees C and at 4 degrees C, and in the second experiment for the same period in RL, EuroCollins (EC) and Collins (CL) solution +/- V (10 mg/l) at 4 degrees C. We analyzed the influence of the drug using two methods: the total protein content in each culture and the metabolic function of the cells using the rate of protein synthesis by means of 35 S methionine uptake assay. All data showed that there were no significant statistical difference (Student t-test, p > 0.05) in the use of verapamil during alveolar type II cells either in normothermic or hypothermic preservation. Thus we conclude that the protection of this calcium channel blocker during lung preservation is probably due to the effect on pulmonary vessels rather than to a direct cytoprotective effect on the lung cells.

The Bender-Gestalt psychopathology scale: failure to infer validity in a school-aged sample.

The concurrent validity of Hutt's (1977) empirical psychopathology scale of the Bender Visual-Motor Gestalt Test was evaluated among three groups of younger school-aged children within the 7-to-10- year age range (M = 109.1): adjustment disordered, conduct disordered, and nonclinical controls (n = 40/group). Excellent interscorer reliability was achieved with approximately 2 hr of self-study of the scoring manual. Although the conduct-disordered group was significantly more immature on Koppitz' Developmental Scoring System, there were no significant differences among groups on the psychopathology scale when visual-motor development was covaried (M = 50.5). This was an unexpected result, given Hutt's initial validation study among school-aged children. The psychopathology scale was not inferred to be valid among adolescents in the only known concurrent validation study. Pending supportive validation research, the psychopathology scale should not be employed in the clinical assessment of younger school-aged children.

Contralateral spontaneous pneumothorax after single lung transplantation for fibrosis.

The authors report the treatment of a case of contralateral spontaneous pneumothorax during single lung transplantation. This is a unusual complication that must be treated to avoid life-threatening problems. There is no consensus of opinion on therapeutic procedures. This work underline the success obtained with a simple thoracostomic drainage.