The Funnel: From the Skull Base to the Sacrum. New Trends and Technologies in Anaesthesia for the Adult Patient.

The management of children affected by neurosurgical pathologies is multidisciplinary and should be set on several fronts.The potential need for massive blood components transfusions, the prolonged anaesthesia in paediatric age that may be often complicated by various forms of syndrome-related problems, and airway management are often encountered.The problems may be divided schematically into three large groups: preoperative, intraoperative and postoperative problems.The aim of this work is to optimize and make paediatric neurosurgery safe by highlighting the most important aspects in the various perioperative phases.

Technologies in Anaesthesia for the Paediatric Patient.

Spine surgery is an increasingly frequent surgery and includes a wide range of procedures, from minor surgeries (removal of herniated discs, simple laminectomies) to major surgeries (arthrodesis, removal of spinal meningiomas, etc.).These surgeries commonly involve complex patients (elderly population, ASA II-III) and are sometimes performed in emergency settings (polytrauma, cauda syndrome, pathological fractures), which require specific positions (pronation or lateral decubitus), whereby there can be difficulty in airway management, especially in surgeries that concern the cervical tract.One of the main peculiarities of spine surgery involves the prone position.Patient positioning on the operating bed is an action that must be carried out under medical supervision, in particular by the anaesthetist who is supposed to supervise the regular positioning of the patient at the very moment in which it is performed. The correct positioning of the patient is one of the most important moments of the patient care process in the operating room, given that an error in this field may cause serious damage to the patient by giving rise to permanent and significant nerve damage.The prone position is associated with a variety of complications (Kwee et al., Int Surg 100(2): 292-303, 2015). The points of greatest compression during pronation are eyes, nose, breasts, genitals and neck veins.Therefore, the main risks that can derive from an incorrect position are visual disturbances from inappropriate orbital compression, brachial plexus stretching, ulnar nerve compression and lateral femur-cutaneous nerve stretching. In addition, an inappropriate compression of the abdominal organs in this position, may cause ischemia and consequent organ failure resulting in hospitalization prolongation, permanent disability and sometimes even death (Edgcombe et al., Br J Anaesth 100: 165-183, 2008).In addition to the mechanical effects on anatomical structures, there are also the physiological effects of the prone position, which can be divided into circulatory and respiratory effects.These effects are even more pronounced in elderly patients, cardiopaths or patients with respiratory diseases.

The Role of the Anesthesiologist and the Modern Intraoperative Echography in Ventriculoatrial Shunt for Hydrocephalus: From Hakim to Nowadays.

The introduction of US-guided venipuncture in clinical practice has greatly facilitated the surgical approach to patients with hydrocephalus. Especially in infants and children, where it results in a lower technical failure rate, less time and fewer complications than the traditional referral method, this technique has become a clinical protocol. This dynamic or "real time" technique has become one of the anesthetist's tools. This allowed the anesthesiologists to be part of the surgical team, so they not only dedicate themselves to inducing and maintaining general anesthesia but also to performing venipuncture of the central vein of the neck and to locating the tip of the catheter.The anesthetist's tools have made it possible to perform a simple and safe method, and the anesthesiologists have become an active part of the surgical team, charged with a specific role during the positioning of the ventricular atrial shunt.

Randomized, double-blind, placebo-controlled trial to evaluate the effect of Helicobacter pylori eradication on glucose homeostasis in type 2 diabetic patients.

BACKGROUND AND AIMS: Literature data suggest an association between Helicobacter pylori infection and glucose homeostasis. However, a causative link between them has not been demonstrated yet. The aim of this study is to investigate the effect of H. pylori eradication on glucose homeostasis in patients with type 2 diabetes. METHODS AND RESULTS: A randomized, double-blind, placebo-controlled trial was conducted to investigate the effect of H. pylori eradication on glucose homeostasis in 154 patients with type 2 diabetes and who tested positive for H. pylori infection (mean age (SD), 63.1 (8.1) years). Subjects were assigned to H. pylori eradication treatment or placebo. Metabolic and inflammatory parameters were measured in all subjects at baseline and 4 weeks after the treatment. H. pylori eradication led to an improvement in glucose homeostasis, measured by HOMA-IR (p < 0.001) and KITT (0 = 0.041), due to the decrease in fasting insulin levels (p = 0.004). The results also showed that lower levels of inflammatory parameters were present after eradication. CONCLUSION: To our knowledge this is the first randomized, double blind, controlled study where the effect of H. pylori eradication on glucose homeostasis in subjects with type 2 diabetes has been investigated. Our findings demonstrate that H. pylori eradication improves glucose homeostasis in patients with type 2 diabetes through a decrease in pro-inflammatory factors. TRIAL REGISTRATION NUMBER: ACTRN12609000255280 (https://www.anzctr.org.au/).

Coenzyme Q10 supplementation in infertile men with low-grade varicocele: an open, uncontrolled pilot study.

Many conditions associated with male infertility are inducers of oxidative stress, including varicocele. Antioxidants, such as coenzyme Q10, may be useful in this case. To evaluate the antioxidant capacity of seminal plasma of infertile men with varicocele before and after an oral supplementation with coenzyme Q10 , 38 patients were recruited from a pilot clinical trial. A standard semen analysis was also performed at baseline and 3 months after an oral supplementation with exogenous coenzyme Q10 100 mg per die. Seminal plasma antioxidant capacity was measured using a spectroscopic method. Coenzyme Q10 therapy improved semen parameters and antioxidant status. This study highlights the importance of oxidative stress in the pathogenesis of male infertility, namely in varicocele, and strengthens the possibility of the usefulness of the antioxidant therapy.

[Cumulative exposure to polychlorodibenzo-p-dioxins (PCDDS), polychlorodibenzofurans (PCDFS) and polychlorobiphenyls (PCB) in the metallurgic workers and the general population in Brescia province, northern Italy]. / Esposizione cumulativa a policlorodibenzodiossine (PCDD), policlorodibenzofurani (PCDF) e policlorobifenili (PCB) in lavoratori metallurgici e nella popolazione generale della provincia di Brescia.

High temperature metallurgical processes may significantly contribute to the release of polychlorodibenzo-p-dioxins (PCDDs) and polychlorodibenzofurans (PCDFs) into the environment. Aim of this study was to evaluate the exposure to PCDDs, PCDFs, dioxin-like PCBs (DL-PCBs) and non dioxin-like PCBs (NDL-PCBs) in a sample of 300 workers of metallurgical plants operating in the Brescia area and in a control group of 113 men. Serum samples were grouped in pools of 10 and analyzed for their concentration of PCDDs and PCDFs, DL- and NDL-PCBs. Metallurgical workers show serum concentrations of NDL-PCBs similar to those observed in non-occupationally exposed living in Brescia, except in the case of some congeners, such as PCBs 28, 52, 101 which result to be significantly higher in metallurgical workers. Their concentrations range of "dioxins" was of 32.5 - 84.8 pgTEQ g(-1) lb. No significant difference was found between metallurgical workers and the control group on the whole, but the difference became significant when comparing metallurgical workers with the group of the 47 subjects living in remote non industrialised areas. In conclusion, concentrations of total PCBs observed in metallurgy workers are comparable with those observed in the control group, with the exception of a few, more volatile, congeners which resulted to be higher in metallurgy workers. Concentrations of PCDDs and PCDFs showed a range of values similar to that observed in the general population of Brescia not professionally exposed. However, concentrations of PCDDs and PCDFs observed in subjects resident in "remote" areas were significantly lower than those assessed in metallurgy workers and subjects living in the town of Brescia. On the whole, men living in the town of Brescia show levels of PCBs, PCDDs and PCDFs higher than those observed in other groups of the Italian general population, this reflecting the intense industrial activity of the town.

Evaluation of antioxidant systems in pituitary-adrenal axis diseases.

The role of adrenal steroids in antioxidant regulation is not known. Previously, we demonstrated some Coenzyme Q(10) (CoQ(10)) alterations in pituitary diseases, which can induce complex pictures due to alterations of different endocrine axes. Therefore we determined CoQ(10) and Total Antioxidant Capacity (TAC) in pituitary-dependent adrenal diseases: 6 subjects with ACTH-dependent adrenal hyperplasia (AH); 19 with secondary isolated hypoadrenalism (IH), 19 with associated hypothyroidism (multiple pituitary deficiencies, MPH). CoQ(10) was assayed by HPLC; TAC by the system metmyoglobin-H(2)O(2), which, interacting with the chromogenous 2,2(I)-azinobis-(3-ethylbenzothiazoline-6-sulphonate), generates a spectroscopically revealed radical compound after a latency time (Lag) proportional to the antioxidant content. CoQ(10) levels were significantly lower in IH than AH and MPH, with a similar trend when adjusted for cholesterol. Also TAC was lower in IH than in AH and MPH, suggesting that adrenal hormones can influence antioxidants. However, since thyroid hormones modulate CoQ(10) levels and metabolism, when thyroid deficiency coexists it seems to play a prevalent influence.

Hormones and antioxidant systems: role of pituitary and pituitary-dependent axes.

Oxidative stress, a condition defined as unbalancing between production of free radicals and antioxidant defenses, is an important pathogenetic mechanism in different diseases. Despite the abundant literature, many aspects of hormone role in regulating antioxidant synthesis and activity still remain obscure. Therefore, we reviewed experimental data, in vivo and in vitro, about the effects of the different pituitary- dependent axes on antioxidant levels, trying to give a broad view from hormones which also have antioxidant properties to the classic antioxidants, from the lipophilic antioxidant Coenzyme Q10, strictly related to thyroid function, to total antioxidant capacity, a measure of non-protein non-enzymatic antioxidants in serum and other biological fluids. Taken together, these data underline the importance of oxidative stress in various pituitary-dependent disorders, suggesting a possible clinical usefulness of antioxidant molecules.

[Pulmonary concentration of asbestos fibers in steel workers with pleural mesothelioma]. / Concentrazione polmonare di fibre di amianto in lavoratori siderurgici affetti da mesotelioma pleurico.

The asbestos fibre burden of the lung has been used in the past as a biological indicator of cumulative exposure to the mineral so much so that in 1997 reference limits even for non-occupationally exposed people have been proposed. This kind of analysis was performed on groups of workers of different type of industries and allowed to achieve a qualitative-quantitative estimate of past exposure to asbestos, even in absence of exposure estimates by environmental monitoring. An important example is the steel industry where asbestos was widely used in the past, but for which there are not available exposure estimates of workers. Among the mesothelioma cases collected by the Mesothelioma Registry of the Province of Brescia from 1980 to present there are 55 workers who spent at least 5 years in steel industry, on a total of 289 cases classified as asbestos exposed (19%). For 8 subjects who worked in steel mills and production of electrical steel pipes, of which 4 in the same plant, lung tissue samples were available for the asbestos fibres burden analysis (7 samples coming from autopsies and 1 from extra-pleural pneumonectomy). In all cases the diagnosis was given with histological analyses supplemented with immunohistochemistry. In 7 cases autopsied the diagnosis was confirmed. The work histories have been reconstructed in detail through the interview process, inclusive of details of duties performed. The asbestos fibre burden analyses showed a range of concentrations between 260,000 and 11,000,000 ff per grams of dry tissue; the concentration of amphiboles was much higher than that of chrysotile. The highest body burden was detected in the maintenance workers of the same plant in witch a cluster of malignant mesothelioma was observed. In conclusion, this study illustrates the results of asbestos fibres burden analyses in subjects where exposure to asbestos is sure but not quantifiable. The results showed also that these concentrations can reach values that overlap with those found in asbestos-cement workers and in asbestos-textile workers. These data suggest to consider the cases of mesothelioma occurred in the steel workers at least as "possible" exposure, even in the absence of adequate information on the circumstances of contact with asbestos. This study, although based on a small number of cases, is the only one ever held in Italy on workers in this sector.

[Malignant mesothelioma in garment sewing-machine workers]. / Mesoteliomi maligni nelle confezioni abbigliamento: un'ulteriore fonte di esposizione ad amianto.

BACKGROUND: Due to poor information collected through patient interviews, a considerable number of malignant mesothelioma (MM) cases still remain classified as "unknown" asbestos exposure in the Italian Mesotelioma Registry (Re.Na.M). At the same time, some occupational asbestos exposures, which were previously unknown, have been demonstrated in certain types of work, i.e., in agriculture and in the textile industry. OBJECTIVES: The aim of this research was to investigate the possible past occupational exposure to asbestos in clothing workers using sewing-machines. METHODS: The MM cases were collected from the Mesothelioma Registry of Brescia. Work histories were obtained via a standardized questionnaire. Investigations were conducted in sewing-machine maintenance workshop in order to collect information regarding the possible use of asbestos parts. In addition, the use of asbestos friction materials and the use of insulated asbestos materials was checked in the clothing divisions by interviewing the management and maintenance workers of two companies where cases of MM were observed. RESULTS: The Mesothelioma Registry of Brescia identified and collected 10 MM cases with past work in the clothing industry: 6 used sewing-machines and 4 were self-employed tailors. The search for asbestos materials gave positive results as the use of friction materials had been widespread since the 1950's in all types of sewing-machines; in addition, asbestos materials were used to insulate some parts of the ironing equipment and the steam pipelines. CONCLUSION: The results of this investigation suggest assigning at least "possible occupational asbestos exposure" to those cases employed in clothing manufacture since the 1950's, who used sewing-machines or pressing machines, according to the Re.Na.M guidelines. Other possible occupational exposures to asbestos in this working sector cannot be excluded; when the simple interview of patients does not reveal such exposures further investigations are needed in order to demonstrate all the possible circumstances of exposure.

[Cluster of malignant mesothelioma cases in a thermostat manufacturing industry]. / Cluster di casi di mesotelioma maligno in una azienda produttrice di termostati.

BACKGROUND: Malignant mesothelioma is a rare disease and the identification of a cluster of cases suggests a possible presence of an asbestos contamination source. OBJECTIVES: To describe 3 cases of malignant mesothelioma (2 pleural and 1 peritoneal) that occurred in workers employed in the same thermostat factory. METHODS: Since this occupational sector is not traditionally known for asbestos exposure the Lombardy Mesothelioma Registry proposed to Local Occupational Health Unit to investigate this industry. RESULTS: From the first inspection of the plant, an environmental asbestos contamination (ropes covering oven handle and gasket) was found. But the greatest source of exposure was identified in the melamine resin reinforced with asbestos that constituted some internal parts of thermostats and that were sheared and perforated by the workers. So the 3 cases were defined as occupational diseases and legal procedures were initiated. CONCLUSION: The results underline the importance of a close cooperation within Local Occupational Health Units and Mesothelioma Registry in the identification and evaluation of asbestos occupational exposure otherwise not recognized, determining thus the loss of precious information.

[Pleural mesothelioma in cotton spinning workers]. / Mesoteliomi pleurici in lavoratori tessili addetti alla filatura del cotone.

BACKGROUND: Cases of malignant mesothelioma (MM) in the non-asbestos textile industry have recently been described, but asbestos exposure in spinning and looming has seldom been reported. Nevertheless, on a national level the Italian Mesothelioma Registry (Re.Na.M) contains numerous cases of MM with past non-asbestos textile work but classified as "unknown" exposure due to poor information. OBJECTIVES: The aim of this research was to investigate possible past occupational exposure to asbestos in this specific industrial sector. METHODS: The MM cases were collected from the Mesothelioma Registry of Brescia. Work histories were obtained via a standardized questionnaire. Investigations were conducted in textile machinery manufacturing plants in order to collect information regarding the possible use of asbestos parts; at the same time, the use of asbestos friction materials and the use of sprayed asbestos for noise abatement purposes or thermal insulation was checked in the cotton industry by interviewing the management of two companies where a cluster of MM was observed. RESULTS: The Mesothelioma Registry of Brescia retrieved and collected 15 MM cases with past work in the cotton spinning industry, 4 of them employed in the same company. Further search of asbestos use gave positive results as the use of friction materials has been widespread since the fifties, while sprayed asbestos was not found anywhere in the cotton industry. On the other hand, half of the cases were employed during the thirties and forties, when friction materials appear to have been asbestos-free. Therefore the other hypothesis of exposure could be direct manufacture of asbestos yarn. CONCLUSION: The results of this investigation indicate the attribution, at least, of possible asbestos exposure"for those cases employed in textile industries since the fifties, according to the Re.Na.M guidelines; for those cases employed before that period the same classification can be attributed on an epidemiological basis. Previous work periods need further investigation in order to demonstrate the circumstances of the occupational asbestos exposure, given the heterogeneity of work processes and machinery characteristic of this industrial sector.

[Sino-nasal inverted papillomas and occupational etiology]. / Papillomi invertiti naso-sinusali ed eziologia occupazionale.

The sino-nasal inverted papilloma is a rare benign tumour with certain aggressive features because of frequent relapses and the high probability of malignant degeneration. For these reasons, several studies have been made to evaluate the efficacy of the different courses of treatment, but only afew studies have been carried out to establish the etiology of this tumour, which is still uncertain. Although it is believed that viral infection, chronic inflammation and cigarette smoking can play an important etiological role, it has recently been suggested that occupational risk factors, such as those involved in malignant epithelial sino-nasal cancer (SNC), can also be involved in causing sino-nasal inverted papilloma. A group of 70 patients was examined who have been diagnosed with inverted papilloma from 1991 to 2003; the occupational history, collected via the standardized questionnaire, showed that risk factors like wood and leather dusts, chromium and nickel vapours or fumes and formaldehyde were associated with only 5% of all cases. This proportion is much lower than that established for SNC in several epidemiological studies. Although occupational environmental pollution can be a source of chronic sino-nasal mucosa irritation, on the basis of our results we believe that a causal relationship between exposure to occupational risk factors and inverted papilloma is not likely, differently from the suggestions made in other studies. Consequently, an epidemiological surveillance of inverted papilloma as a "sentinel" tumour, as has been proposed in Italy for SNC, is not considered necessary. Among the possible non-occupational risk factors we observed that 75% of the male patients were smokers and 40% of all patients suffered from chronic sinusitis and sino-nasal polyps. Lastly, among the 70 cases of inverted papilloma, we observed 5 with malignant degeneration.

[Epithelial naso-sinusal cancer incidence and the role of work in 100 cases diagnosed in the Province of Brescia (northern Italy), in the period 1978-2002]. / Incidenza dei tumori naso-sinusali epiteliali ed attività lavorative in 100 casi diagnosticati in provincia di Brescia dal 1978 al 2002.

BACKGROUND: Naso-sinusal cancers (NSC) cover a group of rare tumours in Italy for which the role of occupational risk has been established. The systematic survey of NSC in the province of Brescia made it possible to analyse the jobs of the cases occurring in the area. OBJECTIVES: The aims of the research were: estimation of epithelial NSC incidence both in the general population and among wood and leather workers, description of the frequency and type of occupational exposure to substances or manufacturing processes. METHODS: The epithelial type cases were obtained from the Naso-sinusal Cancer Register (population-based) operating in the Province of Brescia since 1994. Work histories were obtained via a standardized questionnaire. RESULTS: The annual incidence ofepithelial NSC (for 100,000) in the entire population (1,090,000 inhabitants, ISTAT census 1991) from 1993 to 1997 and from 1998 to 2002 was nearly the same, 0.82 and 0.90 for men, 0.37 and 0.37 for women, respectively. The nasal cavity was the most affected anatomic site (45%) and squamous cell carcinoma was the most frequent histotype (44%) among the first 100 cases whose case histories were appropriate; in the ethmoidal sinus adenocarcinoma represented 62% of the cases; 25% of all cases were exposed to occupational carcinogens (list A) and particularly to wood dust (17%), even if only of softwood species (30%), and leather dusts (7%) especially in the shoe repair. The average latency period was 47 years (SD 7.4) and 44 years (SD 5.6) respectively; 71% of these epithelial NSC cases involved the ethmoid and 85% were adenocarcinomas. Only 1% of the cases was exposed to chromium and nickel and occurred in galvanization processes. Among the exposures to occupational risks with limited epidemiological evidence (list B) there was one case exposed to formaldehyde and 42 cases occurring in the building, agricultural, metallurgic and textile sectors. Thus all the exposures to occupational risks, both certain and probable (lists A and B) reached 84% among men and 17% among women. Epithelial NSC annual incidence rates (for 100,000) estimated among the wood and leather workers for the period 1985-2002 were 13 and 6.5 respectively. CONCLUSION: The results confirm the meaning of sentinel event for these tumours in occupational health and justify maintaining an active surveillance programme for the cases occurring in the area.

Dehydroepiandrosterone sulfate levels are not suppressible by glucocorticoids before adrenarche.

We measured dehydroepiandrosterone sulfate (DHEA-S) levels in children before and after high dose prednisone therapy. In older children (postadrenarchal), there was a 70% decrease in DHEA-S levels after 1 week. However, even after a month of therapy, DHEA-S was detectable in serum. In contrast, in younger (preadrenarchal) children, the low initial DHEA-S levels were not decreased by prednisone therapy. These findings suggest that there are two distinct regulatory pathways leading to DHEA-S, one of which is independent of ACTH.

Lorenz-like systems and classical dynamical equations with memory forcing: an alternate point of view for singling out the origin of chaos.

An alternate view for the emergence of chaos in Lorenz-like systems is presented in this paper. For such purpose, the Lorenz problem is reformulated in a classical mechanical form and it turns out to be equivalent to the problem of a damped and forced one-dimensional motion of a particle in a two-well potential, with a forcing term depending on the "memory" of the particle past motion. The dynamics of the original Lorenz system in the proposed particle phase space can then be rewritten in terms of a one-dimensional first-exit-time problem. The emergence of chaos turns out to be due to the discontinuous solutions of the transcendental equation ruling the time for the particle to cross the intermediate potential wall. The whole problem is tackled analytically deriving a piecewise linearized Lorenz-like system that preserves all the essential properties of the original model.

Seminal antioxidants in humans: preoperative and postoperative evaluation of coenzyme Q10 in varicocele patients.

Coenzyme Q10 in seminal fluid shows a direct correlation with seminal parameters except in patients with varicocele. To evaluate whether surgical treatment of varicocele could revert CoQ10 abnormalities, we have studied CoQ10 distribution in thirty-three VAR patients, before and 6-8 months after varicocelectomy, twenty patients with idiopathic oligozoospermia, eleven with isolated asthenozoospermia and sixteen normal fertile men. CoQ10 was assayed in total seminal fluid, plasma or cell pellet by HPLC. A significantly higher CoQ10 proportion in seminal plasma in VAR vs. controls (mean +/- SEM: 61.68 +/- 2.41 vs. 41.60 +/- 1.99%, respectively) was present; total CoQ10 correlated with sperm motility in controls, but not in VAR; an inverse correlation between cellular CoQ10 and motility was present in VAR, but not in controls. Postoperatively, a partial reversion was observed, since the plasma-to-total CoQ10 ratio decreased, but the correlation between total CoQ10 and motility was not restored. On the contrary, the peculiar correlation between cellular CoQ10 and motility was no more detectable in postoperative VAR patients. A partial postoperative reversal of abnormalities in CoQ10 distribution and correlation with seminal parameters was therefore present. As seminal plasma CoQ10 reflects an interchange between intracellular and extracellular compartments, its different distribution could cause a greater sensitivity to peroxidative damage and a reduced utilization for energetic purpose.

The use of an oxygen dissociation curve analyzer in transfusion therapy.

Two automatic apparatuses utilizing a dual wave-length spectrophotometric method were developed to perform oxygen dissociation curves on microsamples of blood. This method provides a complete printout of an oxygen dissociation curve in 15 to 20 minutes and the P50 values obtained agree closely with those obtained by classical methods. This technique was used as part of a routine clinical evaluation in assessing oxygen delivery in anemic patients. These apparatuses allowed identification of patients with well-compensated anemia, patients with no compensatory decrease in oxygen affinity, and several patients with a paradoxical increase in oxygen affinity. Knowledge of the oxygen-releasing capacity of the blood permits a more thorough evaluation of oxygen transport in anemic patients than the hemoglobin level and a more precise assessment of the need for transfusion therapy. The ready availability of an oxygen dissociation curve by this method is feasible for routine clinical evaluation and permits more judicious use of blood products.