IMproved MAnagement (IM-MA study) in cancer-related pain: the value of a joint approach by an integrated team of radiotherapist and anesthetist.

PURPOSE: Purpose of this study was to retrospectively review our experience of multidisciplinary clinic providing a joint approach by radiation oncologist and anesthetist for patients with cancer pain to evaluate the adequacy and the IMprovement in MAnagement (IM-MA study) of this symptom. METHODS: A Team for Pain Management (TPM) represented by radiation oncologist and anesthetist weekly provided consultations to patient presenting cancer pain. TPM prospectively reported epidemiologic, symptomatic, and pharmacological data. TPM modified pain therapy and indicated antalgic radiotherapy. Patients were evaluated at baseline and after 4 weeks after intervention. RESULTS: From November 2015 to April 2016, 65 patients were evaluated by TPM. At the baseline, 18 patients (27.7%) were undertreated (i.e., receiving inadequate pain management); furthermore, 27 patients (41.5%) despite receiving strong opioids had uncontrolled pain. After 4 weeks from intervention, undertreated patients were reduced to 1.53%. For those patients undergone to radiotherapy, response at 34 weeks was scored as follows: complete response 28.8%, partial response 46.7%, pain progression 0.95%, indeterminate response 23.8%. CONCLUSIONS: A multidisciplinary Team for Pain Management improved the clinical management, optimizing pain control and increasing adequacy of pharmacological management. The TPM intervention seems particularly worth for patients presenting specific features including BTcP, neuropathic pain, severe pain due to bone metastases, and any potential candidate to radiotherapy. Larger series and QoL questionnaires are required to confirm these results.

Desflurane versus sevoflurane: a comparison on stress response.

BACKGROUND: Neurohumoral, immunologic and metabolic alteration characterize surgical procedures in relation with the intensity of injury, the total operating time and the anesthetic technique. We, therefore, compared the effects of desflurane versus sevoflurane anesthesia on intra and postoperative release of the stress hormones and inflammatory cytokines. METHODS: Fifty Caucasian women undergoing laparoscopic surgery for benign ovarian cysts were randomized to receive inhaled anesthesia with desflurane (DES group; N.=25) or sevoflurane (SEVO group; N.=25), with fentanyl bolus and remifentanil infusion. Plasma levels of noradrenaline, adrenaline, ACTH and cortisol were measured preoperatively (T1), 30 minutes after the beginning of surgery (T2), and 30 minutes, 2 and 4 hours after the end of surgery (T3, T4, T5 respectively). Interleukin 6 (IL-6), glucose and C-reactive protein (CRP) were measured at T1, T2,T3, T4, T5 and 12 hours after the end of surgery (T6). RESULTS: An increase of catecholamines during (T2) and immediately after surgery (T3) was observed in both groups. However, adrenaline and noradrenaline levels were significantly higher in the DES group compared to the SEVO group. Despite a drop of cortisol concentration was observed in both groups, only in the DES group there was a significant difference intraoperatively as compared to the baseline levels and to the SEVO group. While, the consequent increase of ACTH was significantly higher in the SEVO group at T2-T4. The preoperatory levels were restored at T5. Glucose, IL-6, CRP levels and postoperative pain did not show significant differences in timing within the same group and comparing DES vs SEVO group. CONCLUSION: In the present study we demonstrated that desflurane and sevoflurane produced a different stress response in the setting of laparoscopic surgery. The greater release of catecholamines during desflurane anesthesia could have adverse effects in patients with pre-existing cardiovascular disease. In low stress surgery desflurane, as compared to sevoflurane, was associated with a better control of intraoperative cortisol and ACTH response (T2). Moreover, the ACTH secretion resulted attenuated also postoperatively (T3-T4). Both gases did not influence the plasmatic levels of Il-6, CRP and glucose.

Influence of pneumoperitoneum on left ventricular filling pressures and NT-proBNP levels.

BACKGROUND: We recently demonstrated that pneumoperitoneum affects diastolic echocardiographic findings in healthy women scheduled for gynaecologic laparoscopy. No reports have been conducted in order to assess the echocardiographic consequences in hypertensive subjects during laparoscopic procedures. AIM: The aim of this study was to evaluate Left Ventricular filling pressures in hypertensive women with and without diastolic dysfunction, combining the tissue Doppler imaging technique and the plasmatic levels of amino terminal proBNP. MATERIALS AND METHODS: Doppler recordings of mitral inflow, tissue Doppler imaging of mitral annulus and N-terminal-proBNP plasmatic levels were obtained in 40 hypertensive women with or without diastolic dysfunction. Measurements were executed in awake patients (T0), after the induction of anesthesia (T1), 10 and 20 minutes after the creation of the pneumoperitoneum (T2 and T3, respectively) and at the end of the surgery (T4). Furthermore, we collected the last blood sample after 12 hours (T5). RESULTS: The E/Ea ratio for the evaluation of left ventricular filling pressures were higher in the diastolic dysfunction group than in the non diastolic dysfunction and significantly increased after pneumoperitoneum. Pneumoperitoneum increased the plasmatic levels of natriuretic peptide in both groups. At the end of the procedure we did not observe any further significant alteration. CONCLUSIONS: Pneumoperitoneum produces a consistent increase of ventricular filling pressures in a population of hypertensive patients with and without diastolic dysfunction. Moreover, there is a significant but transient rise in NT-proBNP after gas insufflation in both groups, most accentuated in the diastolic dysfunction group.

Primary stenting for renal fibromuscular-dysplastic stenosis: a case report.

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vascular disease that has been reported in renal and internal carotid arteries and in almost every arterial bed, primarily affecting young to middle-aged people, mainly female individuals. These patients may be asymptomatic or may present with hypertension. A 29 year-old hypertensive woman was referred for a renal color Doppler ultrasound (CDU) scan because of a suspicion of renovascular hypertension and we revealed the presence of three separate stenosis on the right renal artery. Digital selective angiography (DSA) and percutaneous transluminal angioplasty (PTA) were performed but an incomplete dilation of the vessel was obtained. Because of the suboptimal result, it was decided to stent the lesions during two different procedures. Percutaneous transluminal renal angioplasty is the primary treatment of renal FMD, but should not be excluded primary stent implantation as an alternative technique to surgical revascularization.

Altered Cx43 expression during myocardial adaptation to acute and chronic volume overloading.

Gap-junctions are specialized regions of intercellular contacts allowing electrical impulse propagation among adjacent cardiomyocytes. Connexin43 (Cx43) is the predominant gap-junction protein in the working ventricular myocardium and its reduced expression has been extensively implicated in the genesis of conduction abnormalities and re-entry arrhythmia of chronically hypertrophied hearts. In contrast, data on the role played by this protein during cardiac remodeling and early phases of developing hypertrophy are lacking. Therefore, in the present study, we investigated this issue using an experimental model of pig left ventricle (LV) volume overloading consisting in the creation of an aorto-cava fistula. At scheduled times (6, 24, 48, 96, 168 h, and 2, 3 months after surgery) echocardiographic and haemodynamic measurements were performed and myocardial biopsies were taken for the morphological and biochemical analyses. When faced with the increased load, pig myocardium underwent an initial period (from 6 up to 48 h) of remarkable tissue remodeling consisting in the occurrence of cardiomyocyte damage and apoptosis. After that time, the tissue developed a hypertrophic response that was associated with early dynamic changes (up-regulation) in Cx43 protein expression, as demonstrated by Western blot and confocal immunofluorescence analyses. However, an initial transient increase of this protein was also found after 6 h from surgery. With the progression of LV hypertrophy (from 168 hr up to 3 months), a reduction in the myocardial Cx43 expression was, instead, observed. The increased expression of Cx43 protein during acute hypertrophic response was associated with a corresponding increase in the levels of its specific mRNA, as detected by RT-PCR. We concluded that up-regulation of Cx43 gap-junction protein could represent an immediate compensatory response to support the new working conditions in the early stages of ventricular overloading.

Meralgia paresthetica as a complication of laparoscopic appendectomy.

Laparoscopy is becoming a current approach for appendectomy. The technique is considered safe with few complications. We observed a young woman affected by meralgia paresthetica that developed after laparoscopic appendectomy. The femorocutaneous lateral nerve probably was damaged by insertion of a trocar in the right abdominal quadrant too close to the nerve course. Although meralgia paresthetica is not considered a frequent complication of laparoscopic appendectomy, it should be taken into account to avoid nerve lesion.