Postoperative cognitive worsening in seniors with an age above life expectancy: a prospective longitudinal study.

BACKGROUND: The growing number of elderly patients in hospitals is a challenge for healthcare systems. The main objective is to measure the postoperative change in the cognitive status at hospital discharge and one year after discharge in elderly patients undergoing planned or deferrable surgery. METHODS: We planned a prospective longitudinal study, single-center study: secondary care level hospital, enrolment from September 2018 to May 2019. We enroll elderly patients, aged above life expectancy in Italy, who underwent planned or deferrable surgery (men over 80.5 years old, women over 85.0 years old). In six months, we enrolled 76 eligible patients. We collected the scores of the clinical impairment scales Charlson Index, Barthel Index, and Six-Item Cognitive Impairment Test (6CIT). The primary endpoint was the postoperative worsening of the cognitive status at one-year follow-up. Secondary endpoints aimed to describe postoperative disabilities and complications, to investigate possible risk factors for cognitive worsening, and to measure the role of anesthesia in cognitive changes. RESULTS: We recorded an increased rate of pathological 6CIT values during the hospitalization period, rising from 39.47% to 55.26% (McNemar test, P=0.007), and this rate was still increased at 55.56% (P=0.021) one year after discharge. Anesthesia did not show any significant harmful effect on cognitive status. The preoperative hemoglobin value seems to be a risk factor for cognitive status and one-year mortality. CONCLUSIONS: Elderly patients had a significantly worse 6CIT value after planned surgery, which may derive in part from age and in part from hospitalization. It is difficult to determine if general anesthesia alone has no harmful effects on cognitive performance in patients at discharge and one year later. Further data are necessary.

Point-of-care pancreatic stone protein measurement in critically ill COVID-19 patients.

INTRODUCTION: Pancreatic stone protein (PSP) is a novel biomarker that is reported to be increased in pneumonia and acute conditions. The primary aim of this study was to prospectively study plasma levels of PSP in a COVID-19 intensive care unit (ICU) population to determine how well PSP performed as a marker of mortality in comparison to other plasma biomarkers, such as C reactive protein (CRP) and procalcitonin (PCT). METHODS: We collected clinical data and blood samples from COVID-19 ICU patients at the time of admission (T0), 72 h later (T1), five days later (T2), and finally, seven days later. The PSP plasma level was measured with a point-of-care system; PCT and CRP levels were measured simultaneously with laboratory tests. The inclusion criteria were being a critical COVID-19 ICU patient requiring ventilatory mechanical assistance. RESULTS: We enrolled 21 patients and evaluated 80 blood samples; we found an increase in PSP plasma levels according to mixed model analysis over time (p < 0.001), with higher levels found in the nonsurvivor population (p < 0.001). Plasma PSP levels achieved a statistically significant result in terms of the AUROC, with a value higher than 0.7 at T0, T1, T2, and T3. The overall AUROC of PSP was 0.8271 (CI (0.73-0.93), p < 0.001). These results were not observed for CRP and PCT. CONCLUSION: These first results suggest the potential advantages of monitoring PSP plasma levels through point-of-care technology, which could be useful in the absence of a specific COVID-19 biomarker. Additional data are needed to confirm these results.

Keyboard Contamination in Intensive Care Unit: Is Cleaning Enough? Prospective Research of In Situ Effectiveness of a Tea Tree Oil (KTEO) Film.

After the SARS-CoV-2 pandemic, disinfection practices and microbial load reduction have become even more important and rigorous. To determine the contamination of keyboard surface and the relative risk to transfer healthcare-associated pathogens to susceptible patients, as it frequently happens in Intensive Care Unit (ICU), a standard keyboard (SK), a cleanable keyless keyboard (KK) with smooth surface and a standard keyboard coated with a 3 M Tegaderm® film added with active essential oil (tea tree oil) (KTEO) were tested. S. aureus, including MRSA strains, were detected in ICU, with values ranging from 15% to 57%. Gram negative strains belonging to the Enterobacteriaceae family were also found with values ranging from 14% to 71%. Similar Gram positive and Gram negative strains were found on all surfaces, but with low percentage, and only environmental bacteria were detected using the settling plates method. The Microbial Challenge Test performed on KTEO showed high rates of decrease for all the pathogens with statistical significance both at 24 and 48 h (p = 0.003* and p = 0.040*, respectively). Our results suggest that the use of KTEO may be a feasible strategy for reducing the transmission of pathogens in health care setting and may be complementary to surface cleaning protocols.

Why should you stay one night? Prospective observational study of enhanced recovery in elderly patients.

BACKGROUND: Delirium is a severe condition that can arise in many contexts during hospitalization. The aim of this research was to measure the incidence of postoperative delirium in patients aged 75 years or older, with the exclusion of those with preexisting neurocognitive disorders (NCD), who underwent fast-track, moderate surgery. METHODS: We conducted a prospective cohort study with patients ≥ 75 years of age who were eligible for fast-track, moderate surgery, without severe dementia, with a planned hospitalization of 24 h and with a physical status varying from very fit to vulnerable. The 4-item confusion assessment method (CAM4) was used to measure delirium. RESULTS: Of the 209 eligible patients, 195 subjects were enrolled in the study. The percentage of the population with a CAM4 score above 0 before surgery was 2.56%; after surgery, the percentage was 10.25%; and on the following day, the percentage was 4.61%. There was a statistically significant difference in the CAM4 scores between immediately after surgery and at 24 h after surgery (p = 0.0172). CONCLUSION: The data from this study support an enhanced recovery approach for elderly patients, in which after a minor surgical procedure with anaesthesia, a recovery period of one night in the hospital can contribute to normalizing the CAM4 score and reducing the incidence of delirium.

Hemoadsorption cartridge and coronavirus disease 2019 infections: A case report and brief literature review.

The cytokine storm has been frequently reported to occur in patients with severe coronavirus disease 2019 (COVID-19). Data from the literature suggest that elevated levels of inflammatory mediators, such as interleukin (IL)-6, IL-8, and tumor necrosis factor, indicate a severe course or the fatality of the disease. Several therapeutic options have been employed to treat critically ill patients, including hemoadsorption of inflammatory mediators. We here present a case of severe acute respiratory syndrome caused by COVID-19 and acute renal failure. The patient was admitted to our intensive care unit and treated with mechanical ventilation, renal replacement therapy, and hemoadsorption to reduce the cytokine release syndrome, which plays a fundamental role in the clinical presentation of COVID-19 patients. We also discuss the potential advantages of reducing cytokine plasma levels using a hemoadsorption cartridge.

Propofol: a safe anaesthetic drug in experimental cardiac surgery in rabbits.

ACKGROUND: Experimental surgery needs a pharmacological approach that can interfere with cardiac function. CASE REPORT: In a animal model of regenerative medicine of myocardium we use an anaesthesiological protocol that included Propofol, a benzodiazepine (Midazolam) and an alpha-2 adrenergic agent. RESULTS: In a group of 15 rabbits undergoing cardiac surgery we reported 1 arrhythmic complication during stem cell injection. DISCUSSION: The functional cardio- respiratory depressor activity of Propofol was compensated by alpha-2 adrenergic drugs, avoiding serious complications. We hypothesize that the functional cardio-respiratory depressor of different anaesthesiological drugs can be reversed by the contemporary administration of with adrenergic agents. KEY WORDS: Arrhythmias, Cardiac ischemia, Cardiovascular toxicity, Propofol.

Does stem cell therapy induce myocardial neoangiogenesis? Histological evaluation in an ischemia/reperfusion animal model.

BACKGROUND: In an experimental model in the rabbit, a myocardial ischemia-reperfusion injury was obtained. Subsequently, the effects of homologous bone marrow stem cell (BMSC) administration were studied. METHODS: In 21 New Zealand adult rabbits, ischemia/reperfusion damage was induced by temporary occlusion of the anterior descending coronary artery. Homologous BMSCs were isolated, cultured and re-suspended for injection at the level of the ischemic zone. We evaluated the proangiogenetic effect of intramyocardial injections of BMSC at the peri-infarcted area. Histological evaluations were made after 20 days from the surgical procedure. RESULTS: In rabbits treated with intramyocardial BMSC administration, we demonstrated histologically capillary neoangiogenesis, without signs of tissue immunological reaction or of generation of new myocardial cells. On the contrary, only minimal neovascular supply was detected in rabbits treated with intravenous administration of BMSC. Only typical signs of ischemic myocardium injury were observed in the control group. CONCLUSION: These observations suggest that the effect of direct BMSC administration in ischemic myocardium could promote a capillary neoangiogenesis, which helps to prevent ischemic myocardial damage.

An unusual case of enoxaparin induced thrombocytopenia in intensive care unit.

OBJECTIVES: To present a case of heparin induced thrombocytopenia in a patient treated with enoxaparin. METHODS: A case of heparin-induced thrombocytopenia was examinated with a detailed platelet count analysis over the time and with detection of platelets antibodies. RESULTS: The detection of platelet antobodies and the recovery of platelet count after cessation of enoxaparin strongly support the diagnosis of heparin-induced thrombocytopenia (HIT). CONCLUSION: HIT is a severe side effects of heparin administration. It is more frequent in patients treated with unfractionated heparin however can also be induced by low molecular weight heparin. Guideline suggests the cessation of heparin administration and the treatment of patients with fondaparinux. KEY WORDS: Enoxaparin, Heparin induced thrombocytopenia, Thrombocytopenia.

NDP-α-MSH attenuates heart and liver responses to myocardial reperfusion via the vagus nerve and JAK/ERK/STAT signaling.

Melanocortin peptides afford cardioprotection during myocardial ischemia/reperfusion via janus kinases (JAK), extracellular signal-regulated kinases (ERK) and signal transducers/activators of transcription (STAT) pathways. Here we investigated whether melanocortin-induced modulation of the JAK/ERK/STAT signaling occurs via the cholinergic anti-inflammatory pathway, focusing our study on cardiac and hepatic responses to prolonged myocardial ischemia/reperfusion. Ischemia was produced in rats by ligature of the left anterior descending coronary artery for 30min; effects of ischemia/reperfusion were evaluated using Western blot of heart and liver proteins. Intravenous treatment, during coronary artery occlusion, with the melanocortin analog (Nle(4), D-Phe(7))α-melanocyte-stimulating hormone (NDP-α-MSH) induced a left ventricle up-regulation of the cardioprotective transcription factors pJAK2, pERK1/2 and pTyr-STAT3 (JAK-dependent), and a reduction in the levels of the inflammatory mediators tumor necrosis factor-α (TNF-α) and pJNK (a transcription factor also involved in apoptosis), as assessed at the end of the 2-h reperfusion period. Further, these beneficial effects of NDP-α-MSH were associated with heart over-expression of the pro-survival proteins heme oxygenase-1 (HO-1) and Bcl-XL, and decrease of ventricular arrhythmias and infarct size. In the liver NDP-α-MSH induced a decrease in the pJAK2 and pTyr-STAT3 levels, and strongly reduced pERK1/2 expression. In the liver of ischemic rats NDP-α-MSH also blunted pJNK activity and TNF-α expression, and up-regulated Bcl-XL. Bilateral cervical vagotomy prevented all effects of NDP-α-MSH, both in the heart and liver. These results indicate that melanocortins inhibit heart and liver damage triggered by prolonged myocardial ischemia/reperfusion likely, as main mechanism, via the vagus nerve-mediated modulation of the JAK/STAT/ERK signaling pathways.

Ibuprofen timing for hand surgery in ambulatory care.

OBJECTIVE: To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care. METHODS: Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h. RESULTS: Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085). CONCLUSION: Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

Ibuprofen timing for hand surgery in ambulatory care

OBJECTIVE: To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care. METHODS: Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h. RESULTS: Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085). CONCLUSION: Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

Neural damage biomarkers during open carotid surgery versus endovascular approach.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard for treating severe carotid artery stenosis, whereas carotid artery stenting (CAS) represents an endovascular alternative. The objective of this study was to assess the potential neural damage following open or endovascular carotid surgery measured by peripheral blood concentration of 3 biomarkers: S100ß, matrix metalloproteinase-9 (MMP-9), and d-dimer. METHODS: Data for this prospective investigation were obtained from the Carotid Markers study (January 2010-2011), which sought to measure the levels of specific biomarkers of neuronal damage and thrombosis on candidates to CEA or CAS presenting at the Department of Vascular Surgery of the Nuovo Ospedale S. Agostino Estense of Modena (Italy) at baseline and at 24 hr after surgery. Relevant medical comorbidities were noted. RESULTS: A total of 113 consecutive patients were enrolled in the study, 41 in the endarterectomy group and 72 in the endovascular group. The baseline levels of the studied biomarkers did not show any statistically significant difference between the groups with the exception of MMP-9, which showed higher concentrations in the endovascular group (median 731 vs. 401, P = 0.0007), while 24 hr after surgery the endarterectomy group featured significantly higher peripheral blood concentrations of MMP-9, S100ß, and d-dimer. Conversely, no significant difference was detected in the endovascular group except the d-dimer level. CONCLUSIONS: Neural damage biomarkers demonstrated a substantial difference between open and endovascular carotid surgery, which, if performed in selected patients, may become a less invasive alternative to CEA.

Surgical approach to intramyocardial administration of bone marrow stem cells in an animal model.

AIM: The aim of the study was to evaluate the surgical approach to intramyocardial (i.m.) injection of Bone Marrow Stem Cells (BMSCs) in a pre-clinical model and its complications. MATERIAL OF STUDY: In New Zealand rabbits an ischemia reperfusion injury lasting 20 min was induced by temporary ligation of anterior descending coronary artery during cardiac surgical procedure. Homologous BMSCs were isolated from the posterior iliac crest, cultured and re-suspended for injection. BMSC were injected at the peri-infarcted area and side effects were evaluated. A control group with myocardial infarction was treated with i.m. injections of saline, to evaluate possible side effects of injection. Comparison of ventricular premature contractions (VPC), ventricular tachycardia and ventricular fibrillation were recorded during surgery and after 7 and 21 days. RESULTS: Seven rabbits developed intractable ventricular fibrillation during the experimental protocol, three during coronary ligation but before cell injections and four following i.m. injections. At day 7, hourly PVC were more frequent in the groups of animals that received i.m. injections of BMSCs (132 ± 19 beats) compared to saline injections. (54 ± 14). CONCLUSIONS: Intramyocardial injections of BMSCs induced an electrical instability as shown by a high number of PVC as compared with intramyocardial injections of saline.

Tuna cornea as biomaterial for cardiac applications.

Among available biomaterials, cornea is almost completely devoid of cells and is composed only of collagen fibers oriented in an orderly pattern, which contributes to low antigenicity. Thunnus thynnus, the Atlantic bluefin tuna, is a fish with large eyes that can withstand pressures of approximately 10 MPa. We evaluated the potential of this tuna cornea in cardiac bioimplantation. Eyes from freshly caught Atlantic bluefin tuna were harvested and preserved in a fixative solution. Sterilized samples of corneal stroma were embedded in paraffin and stained with hematoxylin and eosin, and the histologic features were studied. Physical and mechanical resistance tests were performed in comparison with bovine pericardial strips and porcine mitral valves. Corneal material was implanted subcutaneously in 7 rats, to evaluate in vivo calcification rates. Mitral valves made from tuna corneal leaflets were implanted in 9 sheep. We found that the corneal tissue consisted only of parallel collagen fibers without evidence of vascular or neural structures. In tensile strength, the tuna corneal specimens were substantially similar to bovine pericardium. After 23 days, the rat-implanted samples showed no calcium or calcium salt deposition. Hydrodynamic and fatigue testing of valve prototypes yielded acceptable functional and long-term behavioral results. In the sheep, valvular performance was stable during the 180-day follow-up period, with no instrumental sign of calcification at the end of observation. We conclude that low antigenicity and favorable physical properties qualify tuna cornea as a potential material for durable bioimplantation. Further study is warranted.

Heat wave in Italy and hyperthermia syndrome.

In the city of Modena, Italy, daily temperatures registered during the year 2003 showed a higher mean increase of 3 degrees C compared with the previous three years, with average temperature of 26.1 degrees C, compared with 22.8 degrees C. The reported ambient temperature was higher than 32.3 degrees C in 84% of the recorded days, and daily values exceeded 35.1 degrees C in 62% of the days. During the summer, four heat waves occurred (June 11-15, July 21-23, August 3-15 and August 17-24). Nine patients affected by hyperthermia syndrome with a mean body temperature of 41.4 +/- 1.3 degrees C were admitted to the Intensive Care Unit (ICU) of the Modena Teaching Hospital. Another patient with similar clinical features was not admitted to ICU, but to a general ward, and eventually died a few hours later. Mortality reached 80% and the mean survival time was 4.2 days with median values of one day. All patients except for one were admitted during one of the four above-mentioned heat waves, and in particular, 7 patients were admitted during the period from August 3rd to 15th. A common feature among 8 of the 10 patients was the chronic consumption of psychoactive drugs. According to these observations, it is important to identify a population at risk in case of bioclimatological alarm, to find prevention strategies. It is extremely important in patients with hyperthermia to lower body temperature levels in the early hours to influence the malignant evolution of this severe pathologic process.