Pulmonologist-Administered Balanced Propofol Analgosedation during Interventional Procedures: An Italian Real-Life Study on Comfort and Safety.

Propofol-based sedation provides faster recovery than midazolam-based regimens with similar safety and comfort during video flexible bronchoscope (VFB) procedures. Pulmonologist-administered propofol "balanced" analgosedation (PAP-BAS) is still debated in Italy. In this real-life study, PAP-BAS safety and comfort during VFB procedures were investigated. We analysed prospectively the subjects undergoing elective VFB procedures in the Pulmonology and RICU of Arezzo Hospital between February and July 2019. PAP-BAS combined low propofol and meperidine doses titrated to achieve an RASS score between 0 and -3. The primary end-point was the complications' rate. Secondary end-points were as follows: the relation between propofol's dose and a subject's comfort assessed with a VAS, recovery time according to a modified Aldrete score ≥9, RASS, and subjects' will of undergoing the procedure again. We collected postprocedure symptoms' intensity too. Our 158 study patients (67 years; SD ± 14; 64% males) incurred in 25% of complication, fully resolved with medical therapy. Neither recourse to ventilator support nor death was reported. Intraprocedural comfort was good (94% of VAS score ≤2). Among postprocedural symptoms, cough was the most frequently reported, in 36% of the cases. Although half of subjects remembered the procedure, 90% of them would have repeated it, if necessary. 85% of them recovered from procedures within 10 minutes. Complications, VAS, and recovery time were not correlated with propofol dose. To our knowledge, this is the first Italian study showing that PAP-BAS to perform a VFB procedure is safe, well tolerated with a quick recovery. Randomised controlled trials are warranted to confirm these preliminary results.

Blue light exposure in the workplace: a case study of nail salons.

Fluorescent or LED nail lamps are used in manicure and pedicure salons to cure nail coatings. These are UV sources, but with significant blue light emissions. Most of the literature emphasizes skin damage and cancer risk from UV exposure rather than blue light-induced damage to visual photoreceptors. Nail technicians using the lamps routinely may have potentially greater exposure than customers. However, there are no data on blue light radiance levels combined with time activity patterns for exposure assessment. This research aimed to determine exposures through simulation experiments, informed by observational studies in seven nail salons. Typical and worst-case time activity patterns were established, and spectral radiance doses determined in the occupational visual field for two LED nail curing lamps. The results showed the effective spectral radiance dose were below the current guideline promulgated by the International Commission on Non-Ionising Radiation Protection. Interestingly, radiances at the corners of one LED nail curing lamp was higher than at the center, which shows the amount of exposure can differ depending on the viewing angle. This research is the first to determine spectral radiance doses. A covered design is highly recommended for blocking the emission of blue light from a nail lamp.

Work hazards and workers' mental health: an investigation based on the fifth European Working Conditions Survey.

BACKGROUND: Workplace hazards are a significant source of health impairment for workers and of financial losses for firms. EU directives on workers' health and safety standards significantly contributed to reduce reported occupational injuries, yet the incidence and prevalence of work-related mental illness is still very high. OBJECTIVES: We investigated the association between work-related hazards and individuals' perceived mental health. We reviewed the existing evidence on the channels through which task-related factors, adverse agents and psychosocial factors are expected to affect workers' health, with specific regard to mental health. METHODS: We used data from the fifth wave of the European Working Conditions Survey, covering over 40,000 face-to-face interviews with workers in 34 countries, which includes information on socio-demographic characteristics, firms and jobs attributes, employment status, as well as working conditions and health status. We carried out an empirical analysis with multivariate regression models in order to estimate the relationship between workers' mental health problems and workplace risk factors. RESULTS: 21,020 interviews were used in the multivariate analysis. We found strong correlations between hazards and various indicators of mental health. Among hazardous agents, low temperatures (ß=0.0287) and contact with infectious materials (ß=0.0394) were positively associated with mental health outcomes. Among task/sequence-related factors, tiring or painful positions (ß=0.0713), repetitive hand/arm movements (ß=0.0255), working with VDUs (ß=0.0301), repetitive tasks <10 min (ß=0.0859) and working in evenings (ß=0.00754) were positively associated with mental health. Various psychosocial risk factors related to both the content of the job (for example, frequent disruptive interruptions: ß=0.219, working in free time: ß=0.0759, poor work-life balance: ß=0.228) as well as the job context (for example, bad employment prospects: ß=0.177, low decisional autonomy: ß=0.245, bad social relations: ß=0.186, workplace violence: ß=0.411) were positively associated with mental health. The main results of the decomposition show that an important contribution to workers' overall mental distress at work is associated with psychosocial risk factors (up to 60% for depression/anxiety symptoms and sleep disorders), while the contribution of somatic factors is on average lower (up to 20% for overall fatigue). CONCLUSIONS: We argue that action is needed to improve workers' mental well-being, and reduce the economic costs for both the national health system and employers. Regulations and traditional economic measures are unlikely to prove successful in providing adequate standards of primary and secondary preventive measures in the work place without an appropriate and reliable Risk Assessment Procedure.

A campaign aimed at increasing seasonal influenza vaccination coverage among post graduate medical residents in an Italian teaching hospital.

We analysed the impact of several strategies aimed at increasing influenza immunisation rates among Medical Residents (MRs) of an Italian teaching Hospital. During the 2015-16 and 2016-17 influenza seasons we carried out several interventions: ambulatory doubling where vaccination was offered, ambulatory opening hour extension, email invitations, informative materials, forum theatre and vaccination campaign conference. In addition, during the 2016-17 the OSV was carried out: MRs who go to specific wards where they perform influenza immunisation counselling and eventually vaccinate the personnel. 99/1041 (9.5%) and 184/1013 (18.2%) MRs received the vaccine in 2015-16 and in 2016-17 respectively (p < 0.0001). Significant difference was found among three specialisation areas (medicine, surgery, "services"; p < 0.001) and among years of residency (p < 0.001). The highest coverage was found among Infectious Diseases, Paediatrics, Haematology and Hygiene MRs (80%, 67%, 52% and 52% respectively) in 2016-2017 season. The highest coverage increase was found among MRs in Pneumology and Geriatrics (566% and 268%, respectively). The coverage rate has increased even though important differences among specialties persist. The study shows a significant increase in immunisation rate among MRs after the implementation of these strategies.

[A rare cardiomegaly]. / Una rara cardiomegalia.

We present the case of a patient who came to our attention for enlargement of the cardiac silhouette on chest X-ray. Echocardiography showed moderate diastolic overload of both ventricles with enhanced cardiac output without valvular disease or cardiac shunt that could account for this cardiomegaly. A subsequent abdominal echocardiographic exploration showed an angiomatous transformation of the liver due to diffuse lacunar enlargement of hepatic portal vein branches and arterial-venous shunts. Computed tomography and magnetic resonance imaging confirmed the echocardiographic findings. The imaging findings coupled with cutaneous and nasopharyngeal lesions were suggestive of hereditary hemorrhagic telangiectasia (HHT) and the diagnosis was confirmed after the identification of a mutation in the ACVRL1 gene on chromosome 12. HHT is a rare but underestimated vascular disease that can affect different organs, in particular the liver, leading to organ failure requiring transplantation as occurred in our patient. Echocardiography is a useful imaging tool to exclude cardiac abnormalities as a cause of cardiomegaly and to guide the correct diagnosis of a peripheral origin of high cardiac output.

[Unexpected early obstruction of a biological aortic valve prosthesis]. / Un'inattesa ostruzione precoce di protesi biologica aortica.

A 64 years old male was submitted to the surgical substitution of a deteriorated biological aortic valve prosthesis with a new Hancock II biological prosthesis. The implantation was not followed by an anticoagulation or antiaggregation therapy. Two months later he was checked at our Institution because he complained symptoms and developed echocardiographic indexes suggestive of an aortic prosthesis obstruction by a clot. Both symptoms and the echocardiographic indexes of prosthesis obstruction faded away after giving warfarin; they arose again when the anticoagulation therapy was stopped and was replaced by aspirin. The following permanent use of warfarin normalized both clinic and echocardiographic aspects. The present case report underlines the utility of early controls after a biological prosthesis, yet aortic, implantation, when it is not followed by an anticoagulant therapy, also in subjects free from thrombosis high risk factors.

Role of transoesophageal echocardiography in evaluating the effect of catheter ablation of atrial fibrillation on anatomy and function of the pulmonary veins.

AIMS: Radiofrequency ablation (ABL) of pulmonary veins (PVs) is an effective treatment of atrial fibrillation (AF). The aim of this study was to evaluate the possible morphological and functional consequences of this procedure on PV during a 12-month follow-up. METHODS AND RESULTS: Ninety-six patients underwent transoesophageal echocardiography (TEE) before ABL, and 48 h, 3, and 12 months later. The peak velocity, mean velocity, mean/peak flow velocity, and diameter of each vein were measured at every follow-up examination. All patients also underwent multidimensional computer tomography (MCT) 3 months after ABL. At the first control, a 5% reduction in PV diameters and an increase in the peak velocity, mean velocity, and mean/peak velocity (34.3, 42.2, and 6.9, respectively: P < 0.000) of their Doppler flow were observed. Later follow-up examinations revealed no further significant increase in PV narrowing or flow velocities. MCT showed PV stenoses (>50%) in four PVs, while TEE showed a >100% increase over basal values in flow velocities and a plateau configuration of the pulsed-wave Doppler spectrum. CONCLUSION: ABL of AF reduces the diameter and increases the flow velocities of PV. However, critical stenosis is rare and can be diagnosed by TEE through a marked change in the velocities and in the configuration of the Doppler flow.

Role of anticoagulation therapy after pulmonary vein antrum isolation for atrial fibrillation treatment.

BACKGROUND: Atrial fibrillation (AF) increases the risk of atrioembolic stroke. However, the role of anticoagulation therapy (OAT) in preventing cerebrovascular accidents (CVA) after intracardiac echocardiography-guided pulmonary vein antrum isolation (ICE-PVAI) is still unclear. In the present study, we evaluated the incidence of CVA following the interruption of OAT 3 months after ICE-PVAI. METHODS: Between September 2002 and March 2004, 85 consecutive patients (72 men, mean age 62 +/- 7 years) underwent ICE-PVAI for symptomatic drug-refractory AF. Heart disease was present in 61 patients (72%) (left ventricular ejection fraction = 58 +/- 6%, LA diameter 44 +/- 6 mm). Eighty-five consecutive patients who underwent electrical cardioversion (EC) for AF, matched for age, sex and heart disease, served as a control group. After 3 months, OAT was stopped unless one of the following conditions was observed: (i) AF-recurrence; (ii) severe pulmonary vein stenosis; (iii) non-good atrial contractility on transesophageal echocardiography; or (iv) other indications for OAT. RESULTS: In the study group, OAT was stopped after 3 months in 77 patients (90%) and no CVA occurred during the remaining follow-up (15 +/- 7 months). In the control group, 1 month after EC, OAT was stopped by the referring physician in 29 patients (34%). A stroke occurred in five patients (6%) (P = 0.09; mean P = 0.059) during follow-up. In two of these (2%), the stroke was fatal. CONCLUSIONS: Stopping OAT 3 months after ICE-PVAI seems to be safe in patients without AF recurrences after the first 3 months following ablation. Further randomized-controlled studies are needed to confirm these preliminary data.

Sport and arrhythmias: summary of an international symposium.

This article is the report of an International Symposium endorsed by the European Society of Cardiology, held within the Venice Arrhythmias 2007: 10 International Workshop on Cardiac Arrhythmias (Venice, October 2007). The topics of the Symposium are the following: how to stratify the risk of sudden death in athletes; the role of different diagnostic examinations in the risk stratification of sudden death in athletes; controversies on arrhythmias and sport; and exercise prescription in patients with arrhythmias.

Hemodynamic effects of atrial septal pacing in cardiac resynchronization therapy patients.

INTRODUCTION: Spontaneous or pacing-induced interatrial conduction delay may affect the outcome of heart failure patients treated with cardiac resynchronization therapy (CRT). The objective of this study was to evaluate the impact of the atrial pacing site (right atrial appendage, RAA; and low interatrial septum, LIS) during biventricular (BV) pacing on the left ventricular (LV) systolic function in candidates for CRT. METHODS AND RESULTS: Fifteen heart failure patients with left bundle branch block and LV ejection fraction < or =35% were enrolled. Electrodes were placed at the RAA, LIS, right ventricular apex, and LV free wall. A DDD protocol was tested, which consisted of 50 beats in AAI mode from the RAA followed by 50 beats in BV DDD mode with atrial pacing at the RAA (DDD_RAA) or at the LIS (DDD_LIS) at four AV delays. The average (+/-SD)%LV+dP/dtmax increase during DDD_RAA and DDD_LIS pacing with respect to baseline was 24 +/- 16% and 21 +/- 15%, respectively (P < 0.01), and average percentage change in aortic pulse pressure during DDD_RAA and DDD_LIS with respect to baseline (%PP) was 13 +/- 8% and 13 +/- 7% (ns). CONCLUSIONS: Our results show a significant hemodynamic improvement with both DDD_RAA and DDD_LIS biventricular pacing compared to AAI pacing. However DDD_LIS pacing was not superior to DDD_RAA pacing in acute hemodynamic responses.

A critical appraisal of current knowledge and future directions of ergophthalmology: consensus document of the ICOH Committee on 'Work and Vision'.

In the past, occupational health gave scant attention to the visual apparatus. Studies on issues relating to 'work and vision' have predominantly addressed industrial accidents and the toxic effects of exposure to chemical and physical agents, with secondary prevention being more common than primary prevention. In recent years, the huge transformations implemented in workplaces, mainly due to computer-based technologies, demand a progressively higher efficiency of the eye and the related nervous system components that co-ordinate eye movements and accommodation. At the moment these aspects are managed by medical, psychosocial and a variety of technical disciplines, without any shared criteria, terminology and method. Objectives of the Committee are: to investigate holistically the many possible hazards associated to the occupational visual performance; to come to a consensus on terminology, risk assessment and health surveillance procedures. The present status of research and practice in ergophthalmology does not allow for clear-cut decision about health risk and nor is there a clear direction on the prevention of work-related ocular and visual disturbances and disorders. Specifically, at least three determinants must be objectively considered, namely: (a) visual effort; (b) environmental agents; (c) individual characteristics. Although criteria exist for the evaluation of some of these determinants, a greater refinement is necessary 'for a good working life' of the visual apparatus. The ICOH Scientific Committee on 'Work and Vision' is seeking to systematically develop this matter, yielding a more rational and complete approach to the relationship between work and vision.

[Thrombocytopenia associated with massive cardiac thrombosis during treatment with non-fractionated heparin: description of a clinical case]. / Trombocitopenia associata a trombosi cardiaca massiva in corso di trattamento con eparina non frazionata: descrizione di un caso clinico.

Thrombosis associated with a drop in the platelet count may occur in 33-50% of the patients who develop heparin-induced thrombocytopenia (HIT) during treatment with unfractionated heparin; the deep veins are commonly involved while cardiac thrombosis is considered as a rare complication. We report the case of a 64-year-old woman who was treated with unfractionated heparin following a myocardial infarction and an episode of deep vein thrombosis which occurred 13 days after myocardial revascularization including triple coronary artery bypass grafting; a drop in the patient's platelet count was documented and a transesophageal echocardiogram revealed massive thrombosis of the four cavities of her heart. The diagnosis of HIT was supported by high blood levels of PF4-antiheparin antibodies. Heparin infusion was stopped and the patient was started on sodium warfarin therapy; the platelet count promptly returned to normal and the size of the clots slowly decreased, although they were still detectable 1 month later. Aspirin (325 mg daily) was then prescribed as an adjunct to warfarin and 6 months later we documented the total disappearance of the thrombotic masses without embolic complications.