The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery.

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

'Enhanced recovery after surgery' (ERAS) protocols have been recently applied in breast cancer patients in order to improve the postoperative course. However, the incidence of moderate to severe pain after breast surgery is frequent, and a multimodal approach is recommended. In this view, the interfascial plane blocks are advocated as a valid alternative to both paravertebral and epidural blockade. In this study, we evaluated the effects of these blocks on the postoperative course in patients undergoing breast surgery with ERAS protocols. We compared two patient groups: in the first, pectoral blocks were performed before general anesthesia, while in the second no block was carried out. We found that in the patient group receiving the blocks, postoperative opioid consumption (with essentially the same pain after surgery) and length of stay were significantly lower. Therefore, although more robust studies are needed to confirm our findings, these emerging locoregional techniques could favor a faster recovery in the context of ERAS in breast surgery. These results could have important clinical implications in terms of not only reducing healthcare costs but also ensuring a higher turnover of patients undergoing breast surgery.

The multidisciplinary audit in enhanced recovery after surgery (ERAS) colorectal surgery: experience in a single Italian center.

BACKGROUND: Current literature underlines the role of periodical feed-back to improve Enhanced Recovery After Surgery (ERAS) path adherence during implementation program. The aim of this retrospective study was to evaluate the clinical impact of an audit program in an ERAS path. METHODS: All elective patients submitted to elective colorectal surgery from November 2018 to January 2020 in our Institution were considered. The sample was divided into two study groups: group 1, including patients enrolled in the first sixth months of ERAS program until the first audit; group 2, patients enrolled in a time period of a six months after the first audit. RESULTS: The final analysis included 46 patients in group 1 and 64 in group 2. Group 2 showed a higher ASA Score (P<0.03), a higher prevalence of right hemicolectomy, and a lower prevalence of left hemicolectomy and anterior rectum resection (RAR) (P<0.016). Group 2 also had a lower prevalence of anastomotic leakage (AL) (P<0.004). Intraoperative normothermia (T>36 C°) in this group was achieved in a larger number of patients in comparison with group 1 (39% vs. 19.5%) (P<0.01). Group 2 experienced a higher average body temperature at admission in recovery room (RR) when compared to Group 1 (35.8 vs. 35.1 C°, P<0.01). CONCLUSIONS: Audit program may represent a useful tool to promote advantageous changes in clinical practice and to favor a better compliance to ERAS program.

The Role of the Recovery Room in Improving Adherence During an Enhanced Recovery After Surgery (ERAS) Implementation Program for Colorectal Surgery: A Single-Center Retrospective Analysis.

PURPOSE: The purpose of thisstudy was to evaluate the clinical impact of the Recovery Room (RR) in an Enhanced Recovery After Surgery (ERAS) pathway in colorectal surgery. DESIGN: Single-center retrospective study. METHODS: From November 2019 until September 2021, a total of 149 consecutive patients that underwent to colon-rectal surgery were enrolled. The patients were divided into two study groups: RR Group if admitted to RR after surgery, and no-Recovery Room (NRR) Group if monitored directly on the ward, bypassing the RR. The postoperative ERAS items adherence was assessed in the two study groups. FINDINGS: Final analysis included 119 patients in the RR Group and 30 patients in NRR Group. Patients that started clear liquid oral intake within two hours postoperatively were 118 in the RR group and 19 in the NRR group (99.1% vs 63.3%, P < .001). A total of 98 patients and 18 patients were mobilized on day 0 in the RR group and in NRR group, respectively (84.4% vs 15.5%, P < .05). In the RR group, postoperative adherence to the ERAS protocol components was higher in comparison with the NRR group (P < .003); adherence to the all protocol components was also higher (P < .004). CONCLUSIONS: Among patients undergoing colorectal surgery admitted to RR after surgery, the RR nurse guaranteed effective patient assistance and ensured appropriate compliance to the postoperative ERAS items.

Very early postoperative troponin increase and clinical outcome in patients admitted to the recovery room after noncardiac surgery with suspected cardiac events.

We assessed the prognostic meaning of very early (<6 h) troponin increase after noncardiac surgery in a population of patients admitted to the recovery room, for whom troponin measurements were taken because of a suspected cardiac event. Among a total of 296 patients, abnormal troponin was found in 24 (8.1%). Ten patients in this group (41.7%) and 27 among those with normal troponin (9.9%) experienced cardiovascular death, myocardial infarction, or decompensated heart failure at one month (p < 0.0001). Troponin was independently associated with a two-fold risk of events (p < 0.0001). In these patients, very early troponin measurement in the recovery room may help to identify patients at risk of cardiovascular events.

[Chronic diseases and risk of symptomatic COVID-19: results of a case-population study on a sample of patients in the Local Health Unit 'Toscana Centro' (Tuscany Region, Central Italy)]. / Malattie croniche e rischio di ammalarsi di COVID-19 sintomatica: risultati di uno studio case-population su un campione di casi in AUSL Toscana Centro.

BACKGROUND: the COVID-19 pandemic represents a challenge for health systems around the world, with just under 10,000 cases in Tuscany Region (Central Italy) and about 4,500 in the Local Health Unit (LHU) 'Toscana Centro', updated on 11 May 2020. The risk factors reported are several, including age, being male, and some chronic diseases such as hypertension, diabetes, respiratory and cardiovascular diseases. However, the relative importance of chronic diseases is still to be explored. OBJECTIVES: to evaluate the role of chronic diseases on the risk to develop clinically evident (at least mild symptomatic) forms of SARS-CoV-2 infection in the population of the LHU Toscana Centro. DESIGN: case-population study. SETTING AND PARTICIPANTS: 'case' is a subject with SARS-CoV-2 positive swab with at least mild clinical status, who lives in the LHU Toscana Centro area; 'controls' are all people residing in the LHU Toscana Centro area at 1 January 2020. People aged under 30 and patients living in nursing care homes are excluded from the analysis. MAIN OUTCOME MEASURES: the analysis assesses the effect of gender, age, neoplasm, and the main chronic diseases on the onset of an infection with at least mild symptoms by calculating odds ratios (OR) by multivariate logistic regression models (to produce adjusted OR by potential confounders). RESULTS: among the 1,840 cases, compared to the general population, the presence of males and over-60-year-old people is greater. Almost all the considered chronic diseases are more frequent among the cases, compared to the general population. A chronic patient has a 68% greater risk to be positive with at least mild symptoms. Many of the considered diseases show an effect on the risk of getting COVID-19 in a symptomatic form, which remains even adjusting by other comorbidities. The main ones include heart failure, psychiatric disorders, Parkinson's disease, and rheumatic diseases. CONCLUSIONS: these results confirm evidence already shown in other studies on COVID-19 patients and add information on the chronic diseases attributable risk in the population, referred to the symptomatic forms and adjusted by age, gender or the possible copresence of more diseases. These risk estimates should guide prevention interventions by health services in order to protect the chronic patients affected by the pathologies most at risk.

Giant isolated intracardiac thrombus presenting as acute heart failure secondary to right ventricular outflow tract obstruction in a patient with renal carcinoma.

Right-sided intracardiac thrombi are potential causes of right ventricular (RV) failure, particularly when tricuspid or pulmonary obstruction occurs. In most cases, RV thrombus develops in patients with RV dysfunction and concomitant thrombosis in the systemic veins. However, RV thrombosis can rarely present as an isolated mass and despite preserved RV function, particularly in patients with thrombophilic states. In this report, we describe an unusual case of giant isolated RV thrombus presenting with acute RV failure secondary to dynamic RV outflow tract obstruction in a patient with renal carcinoma. Bedside echocardiography allowed a rapid assessment of the hemodynamic effects of the mass. The possibility of a thrombotic RV outflow obstruction should be considered in patients with acute RV failure, even in those with no evidence of thrombosis in the venous district. This may be particularly important in patients with prothrombotic states, where the effectiveness of routine thromboembolic prophylaxis could be reduced.

Clinical impact of recovery room on post-operative walking performance in elderly patients submitted to hip surgery: a real-world analysis.

BACKGROUND: Strategies aimed at favouring functional recovery after surgery for hip fracture may be of clinical importance. AIMS: To test the clinical utility of a recovery room (RR) in terms of postoperative walking performance in an elderly population submitted to hip fracture surgery. METHODS: Postoperative walking performance at rollator was assessed in 242 consecutive orthogeriatric patients able to follow the institutional physiotherapy protocol starting on day 1 after hip surgery. Group 1 (n = 186, age 86.0 ± 9.3 years, 24.7% male) was admitted to the RR for postoperative monitoring, whereas Group 2 (n = 56, age 85.2 ± 5.7 years, 23.2% male) was directly admitted to the ward. The best performance observed during the first three postoperative days was considered. RESULTS: Group 1 showed a better walking performance than Group 2, with a 50% lower probability of walking < 5 m (relative risk 0.51, p = 0.0005) and a two-fold higher probability of walking > 10 m (relative risk 2.10, p = 0.0005). Multivariable analysis confirmed a favourable independent effect of the RR stay on walking performance (ß = 0.205, p = 0.005). DISCUSSION: Admission to the RR in elderly patients submitted to hip fracture surgery could have an independent beneficial effect on postoperative walking functional recovery. This beneficial effect could probably depend on the possibility of ensuring a more rapid management of postoperative issues CONCLUSIONS: These findings support the clinical utility of a RR implementation in facilities where hip surgery in elderly subjects is routinely performed.

Left ventricular hypertrophy or storage disease? the incremental value of speckle tracking strain bull's-eye.

Left ventricular hypertrophy (LVH) develops in response to a variety of physical, genetic, and biochemical stimuli and represents the early stage of ventricular remodeling. In patients with LVH, subclinical left ventricular (LV) dysfunction despite normal ejection fraction (EF) may be present before the onset of symptoms, which portends a dismal prognosis. Strain measurement with two-dimensional speckle tracking echocardiography (STE) represents a highly reproducible and accurate alternative to LVEF determination. The present review focuses on current available evidence that supports the incremental value of STE in the diagnostic and prognostic workup of LVH. When assessing the components of LV contraction, STE has an incremental value in differentiating between primary and secondary LVH and in the differential diagnosis with storage diseases. In addition, STE provides unique information for the stratification of patients with LVH, enabling to detect intrinsic myocardial dysfunction before LVEF reduction.

Left Atrial Mass Invasion from Pulmonary Neoplasm Extension via the Right Upper Pulmonary Vein Presenting as Ipsilateral Stroke.

Left atrial invasion by lung cancer via haematogenous pathways is a relatively uncommon but potentially life-threatening event. While several cardiac complications of cardiac involvement have been previously described, the evolution towards cerebral stroke has been rarely reported. In this case report, we describe an atypical case of haematogenous metastatic invasion of the left atrium from pulmonary neoplasm extension presenting as an ipsilateral stroke whose ASCO classification changed during the clinical management.

Near-zero x-ray in arrhythmia ablation using a 3-dimensional electroanatomic mapping system: A multicenter experience.

BACKGROUND: Radiation exposure related to conventional tachyarrhythmia radiofrequency catheter ablation (RFCA) carries small but not negligible stochastic and deterministic effects on health. These effects are cumulative and potentially more harmful in younger individuals. Nonfluoroscopic mapping systems can significantly reduce the radiological exposure and in some cases it can completely eliminate it. OBJECTIVE: The aim of this study was to assess the safety, feasibility, and efficacy of a complete nonfluoroscopic approach for RFCA compared with ablation procedures performed under fluoroscopic guidance. METHODS: RFCA was performed in 442 consecutive patients (mean age 58 ± 19 years). The first 145 patients (group 1) were treated only under fluoroscopic guidance, and the following 297 patients (group 2) were treated using a nonfluoroscopic electroanatomic mapping system (EnSite Velocity). RFCA was completely performed without fluoroscopy in 255 of 297 patients in group 2 (86%). RESULTS: The acute success rate did not differ between group 1 and group 2 (97% vs 96%; P = .46), and there were no differences in either procedure time (87 ± 57 minutes vs 91 ± 52 minutes; P = .41) or complication rate. Fluoroscopic exposure in group 2 was significantly reduced in comparison with group 1 (14 ± 6 seconds vs 1159 ± 833 seconds; P < .0001). CONCLUSION: Compared with the conventional fluoroscopic technique, the near-zero radiation (RX) approach provides similar outcomes and may significantly reduce or eliminate ionizing radiation exposure in RFCA. These reductions are achieved without altering the duration or compromising the safety and effectiveness of the procedure.

Clinical utility of an undersized nurse-operated recovery room in the postoperative course: results from an Italian community setting.

PURPOSE: In Europe, standardized criteria for recovery room (RR) requirements have not been established. The purpose of this study was to examine the clinical utility of an undersized nurse-operated RR in an Italian community hospital. DESIGN: Single-center observational study. METHODS: A total of 1,945 consecutive surgical patients admitted to the RR at the study institution between September 31, 2009, and August 31, 2011, were included in the study. A control group of surgical patients not admitted to the RR, matched for age, gender, American Society of Anesthesiologists score, and type of surgery were also considered. The prevalence of early adverse events occurring within 3 hours of the end of surgery was compared between the two groups. FINDINGS: Patients admitted to the RR (mean age, 73.6 ± 14.2 years; 42.2% male; and 76.3% having major surgery) showed lower prevalences of hypotension (P < .0001), hypertensive response (P < .0001), new arrhythmias requiring intervention (P = .0036), and oxygen desaturation (P < .0001) in comparison with the control group. No differences in the proportions of patients experiencing postoperative nausea and vomiting, shivering, bleeding, and respiratory events were found. The Numeric Rating Scale for pain was also significantly lower at 2 hours in the study group as compared to the control group (1 [0 to 5] vs 3 [1 to 7]; P < .0001). CONCLUSION: In this Italian community setting, an undersized nurse-operated RR contributed to a reduced prevalence of adverse postoperative events.

Effectiveness of bortezomib in cardiac Al amyloidosis: a report of two cases.

Cardiac involvement is a major prognostic determinant in patients with primary AL amyloidosis. The clinical results of standard therapeutic approaches are suboptimal. It has been recently shown that bortezomib, an inhibitor of the proteasome, can induce rapid favourable responses in AL amyloidosis improving cardiac function and survival. Herein we report on two patients with cardiac amyloidosis treated by bortezomib who experienced partial or total remission of hematologic disease and of cardiac involvement. However, death of one patient, suffering from chronic kidney disease stage 5, due to fulminant respiratory syndrome suggests the need for caution in bortezomib use if patients have this comorbid condition.

Clinical outcome, valve dysfunction, and progressive aortic dilation in a pediatric population with isolated bicuspid aortic valve.

The aim of this study was to explore the medium-term clinical outcome and the risk of progression of aortic valve disease and aortic dilation in pediatric patients with isolated bicuspid aortic valve (BAV). 179 pediatric patients with isolated BAV were prospectively followed from January 1995 to December 2010. Patients with severe valve dysfunction at baseline were excluded. Clinical outcome included cardiac death, infective endocarditis, aortic complications, cardiac surgery and percutaneous valvuloplasty. Echocardiographic endpoints were: progression of aortic stenosis (AS) or regurgitation (AR) and progressive aortic enlargement at different levels of the aortic root, evaluated as z-score. The median age at diagnosis was 7.8 [2.7-12.0] years. After a median followup of 5.4 [2.3-9.2] years, all patients were alive. The clinical endpoint occurred in 4 (2.2 %) patients (0.41 events per 100 patient-years). A progression of AS and AR was observed in 9 (5.0 %) and 29 (16.2 %) patients, respectively. The z-scores at the end of follow-up were not significantly different from baseline at the annulus, Valsalva sinuses and sinotubular junction, whereas a slight increase was observed at the level of the ascending aorta (1.9 vs 1.5, p = 0.046). Significant progressive aortic dilation occurred in a minority of patients (10.6, 5.6, 9.5, and 19.0 % respectively). The clinical outcome in pediatric patients with isolated BAV is favourable and the progression of aortic valve dysfunction and aortic dilation is relatively slow. These findings may be taken into account to better guide risk assessment and clinical follow-up in these patients.

Subclavian steal syndrome presenting as recurrent pulmonary oedema associated with acute left ventricular diastolic dysfunction.

Subclavian steal syndrome typically presents as angina in patients with internal mammary artery grafts. Atypical clinical presentations have been rarely described. We report an unusual case of subclavian steal syndrome presenting as pulmonary oedema with acute left ventricular diastolic dysfunction and preserved ejection fraction in a patient with internal mammary artery graft and severe stenosis of the proximal left subclavian artery. After successful angioplasty and stenting of subclavian artery, the patient remained asymptomatic for six months, but then experienced acute diastolic dysfunction and recurrent pulmonary oedema associated with critical subclavian in-stent restenosis with stent deformation. This report points out that, in patients with internal mammary-to-LAD grafts, subclavian steal syndrome may present as acute left ventricular diastolic dysfunction and pulmonary oedema even in the presence of normal ejection fraction.

Left ventricular twist in clinically stable heart transplantation recipients: a speckle tracking echocardiography study.

BACKGROUND AND AIM: Cavity twist is an integral part of LV function and its pattern in transplanted hearts is not well known. This study aimed at exploring LV twist in clinically stable heart transplant (HT) recipients with no evidence for rejection. METHODS: We studied 32 HT patients (54 ± 24 months after HT), 34 other cardiac surgery (CS) patients and compared them with 35 health controls using speckle tracking echocardiography, measuring peak twist angle, time-to-peak twist, and untwist rate. RESULTS: LV twist angle was smaller in the HT group (6.2 ± 3.3°) in comparison with the CS group and controls (13.2 ± 3.5° and 13.1 ± 4.5°, respectively; p<0.0001 for all) and untwist rate was reduced (HT group: -74 ± 30°/s; CS group: -118 ± 43°/s; controls: -116 ± 39°/s; p<0.0001 for all). Time-to-peak twist was not different between groups. Time after HT was the main independent predictor of both LV twist angle and untwist rate (ß=0.8, p<0.0001). CONCLUSION: Though clinically stable, LV twist dynamics are significantly impaired in HT recipients, even in comparison with patients who underwent other cardiac surgery.

Acute inflammatory bowel disease complicating chronic alcoholism and mimicking carcinoid syndrome.

We report the case of a woman with a history of chronic alcohol abuse who was hospitalized with diarrhea, severe hypokalemia refractory to potassium infusion, nausea, vomiting, abdominal pain, alternations of high blood pressure with phases of hypotension, irritability and increased urinary 5-hydroxyindoleacetic acid and cortisol. Although carcinoid syndrome was hypothesized, abdominal computed tomography and colonoscopy showed non-specific inflammatory bowel disease with severe colic wall thickening, and multiple colic biopsies confirmed non-specific inflammation with no evidence of carcinoid cells. During the following days diarrhea slowly decreased and the patient's condition progressively improved. One year after stopping alcohol consumption, the patient was asymptomatic and serum potassium was normal. Chronic alcohol exposure is known to have several deleterious effects on the intestinal mucosa and can favor and sustain local inflammation. Chronic alcohol intake may also be associated with high blood pressure, behavior disorders, abnormalities in blood pressure regulation with episodes of hypotension during hospitalization due to impaired baroreflex sensitivity in the context of an alcohol withdrawal syndrome, increased urinary 5-hydroxyindoleacetic acid as a result of malabsorption syndrome, and increased urinary cortisol as a result of hypothalamic-pituitary-adrenal axis dysregulation. These considerations, together with the regression of symptoms and normalization of potassium levels after stopping alcohol consumption, suggest the intriguing possibility of a alcohol-related acute inflammatory bowel disease mimicking carcinoid syndrome.

Hypertension and acute myocardial infarction: an overview.

History of hypertension is a frequent finding in patients with acute myocardial infarction (AMI) and its recurring association with female sex, diabetes, older age, less frequent smoking and more frequent vascular comorbidities composes a risk profile quite distinctive from the normotensive ischemic counterpart.Antecedent hypertension associates with higher rates of death and morbid events both during the early and long-term course of AMI, particularly if complicated by left ventricular dysfunction and/or congestive heart failure. Renin-angiotensin-aldosterone system blockade, through either angiotensin-converting enzyme inhibition, angiotensin II receptor blockade or aldosterone antagonism, exerts particular benefits in that high-risk hypertensive subgroup.In contrast to the negative implications carried by antecedent hypertension, higher systolic pressure at the onset of chest pain associates with lower mortality within 1 year from coronary occlusion, whereas increased blood pressure recorded after hemodynamic stabilization from the acute ischemic event bears inconsistent relationships with recurring coronary events in the long-term follow-up.Whether antihypertensive treatment in post-AMI hypertensive patients prevents ischemic relapses is uncertain. As a matter of fact, excessive diastolic pressure drops may jeopardize coronary perfusion and predispose to new acute coronary events, although the precise cause-effect mechanisms underlying this phenomenon need further evaluation.

Dilated cardiomyopathy and inclusion body myositis.

Inclusion body myositis (IBM) is the most common inflammatory myopathy after 50 years of age. In contrast to polymyositis and dermatomyositis, in which cardiac involvement is relatively common, current evidences indicate that IBM is not associated with cardiac disease. We report the case of a patient with biopsy-proven IBM who developed heart failure and major ventricular arrhythmias secondary to dilated cardiomyopathy few months after the clinical onset of IBM, and in whom no pathophysiologic causes explaining cardiac enlargement and dysfunction were found by laboratory and instrumental investigations. The hypothesis of a pathophysiologic association between the two conditions is discussed.

Isolated papillary muscle rupture complicating acute pancreatitis.

Papillary muscle rupture in the absence of coronary stenoses is a rare event. An isolated infarction of the papillary muscle is involved in most cases, but the pathogenesis is still debated. We describe an anterolateral papillary muscle rupture complicating acute pancreatitis in a patient without significant coronary stenoses and with evidence of coronary spasm. This suggests that an increased susceptibility to coronary spasm and thrombosis, triggered by an acute systemic inflammatory response, may represent a mechanism of selective papillary muscle infarction.