Transcontinental anaesthesia: a pilot study.

BACKGROUND: Although telemedicine is one of the key initiatives of the World Health Organization, no study has explored the feasibility and efficacy of teleanaesthesia. This bi-centre pilot study investigates the feasibility of transcontinental anaesthesia. METHODS: Twenty patients aged ≥ 18 yr undergoing elective thyroid surgery for ≥ 30 min were enrolled in this study. The remote and local set-up was composed of a master-computer (Montreal) and a slave-computer (Pisa). Standard Internet connection, remote desktop control, and video conference software were used. All patients received total i.v. anaesthesia controlled remotely (Montreal). The main outcomes were feasibility, clinical performance, and controller performance of transcontinental anaesthesia. The clinical performance of hypnosis control was the efficacy to maintain bispectral index (BIS) at 45: 'excellent', 'good', 'poor', and 'inadequate' control represented BIS values within 10, from 11 to 20, from 21 to 30, or >30% from target. The clinical performance of analgesia was the efficacy to maintain Analgoscore values at 0 (-9 to 9); -3 to +3 representing 'excellent' pain control, -3 to -6 and +3 to +6 representing 'good' pain control, and -6 to -9 and +6 to +9 representing 'insufficient' pain control. The controller performance was evaluated using Varvel parameters. RESULTS: Transcontinental anaesthesia was successful in all 20 consecutive patients. The clinical performance of hypnosis showed an 'excellent and good' control for 69% of maintenance time, and the controller performance showed an average global performance index of 57. The clinical performance of analgesia was 'excellent and good' for 92% of maintenance time, and the controller performance showed a global performance index of 1118. CONCLUSIONS: Transcontinental anaesthesia is feasible; control of anaesthesia shows good performance indexes. Clinical registration number NCT01331096.

Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine.

BACKGROUND: Reversal of the residual effect of rocuronium or cisatracurium by neostigmine may be slow and associated with side-effects. This randomized, safety-assessor-blinded study compared the efficacy of sugammadex, a selective relaxant binding agent for reversal of rocuronium-induced neuromuscular block, with that of neostigmine for reversal of cisatracurium-induced neuromuscular block. The safety of sugammadex and neostigmine was also evaluated. METHODS: Adult surgical patients (ASA class I-III) were randomized to sugammadex 2.0 mg kg(-1) for reversal of block induced by rocuronium 0.6 mg kg(-1), or neostigmine 50 microg kg(-1) for reversal of block induced by cisatracurium 0.15 mg kg(-1). Anaesthesia was induced and maintained using i.v. propofol and remifentanil, fentanyl, or sufentanil. Neuromuscular function was monitored using acceleromyography (TOF-Watch SX). Sugammadex or neostigmine was administered at reappearance of T(2). The primary efficacy variable was time for recovery of the train-of-four (TOF) ratio to 0.9. RESULTS: Eighty-four patients were randomized, 73 of whom received sugammadex (n=34) or neostigmine (n=39). Time from start of administration of reversal agent to recovery of the TOF ratio to 0.9 was 4.7 times faster with sugammadex than with neostigmine (geometric mean=1.9 vs 9.0 min, P<0.0001). Reversal of block was sustained in all patients. There were no serious adverse effects from either reversal agent and no significant changes in any measure of safety, except for similar elevations in urinary N-acetyl glucosaminidase in both groups. CONCLUSIONS: Sugammadex 2.0 mg kg(-1) administered at reappearance of T(2) was significantly faster in reversing rocuronium-induced blockade than neostigmine was in reversing cisatracurium-induced block.

Implicit and explicit memory formation: influence of gender and cultural habits.

The study was aimed to investigate whether impending surgery, considered as a stressful life event, might interfere with memory formation like other stress and anxiety conditions do. Results do not support the hypothesis. Implicit and explicit memory performance are both unaffected by presurgery condition and seem influenced, rather, by subjects gender, education and cultural habits. Females perform generally better than males and, regardless of age and sex, higher educated individuals score higher on the explicit memory task. The habits of reading books and doing crosswords are associated to best performance on explicit and implicit memory task respectively.

Using PET-CT in the restaging of primitive mediastinal B-cell lymphoma (PMBCL) after chemotherapy: which criteria should we use?

AIM: Primitive mediastinal B-cell lymphoma (PMBCL) is a relatively rare form of non-Hodgkin lymphoma (NHL), typically concerning the youngster, with an aggressive course and poor prognosis. The therapy generally consists of high dose chemotherapy followed by radiotherapy. PET-CT is used at staging, restaging after chemotherapy and after radiotherapy, or when relapse is suspected. Aim of the study was to compare different criteria in the evaluation of response to chemotherapy in this setting. METHODS: Thirty-eight patients with PMBCL (15 M, 23 F, median age 33 yrs [range 18-79]), all treated with chemo-immunotherapy and radiotherapy, who had undergone baseline (b-PET) and end of chemotherapy (f-CHT-PET) 18F-FDG-PET-CT scans at our institution between July 2004 and September 2014 were retrospectively re-evaluated; the median follow-up was 42 months (range 4-109), at which 4/38 (11%) had died, 5/38 (13%) were in partial response (PR) and 29/38 (76%) were in complete response (CR). The primary endpoint was progression-free survival (PFS), while the secondary one was overall survival (OS), according to the Cheson criteria. SUV max of the mediastinal disease mass at staging, of the residual mass at CT after chemo-immunotherapy, SUV max of the liver and of the mediastinal blood pool (MBP) were calculated for all patients. RESULTS: In our population, we observed that: 1) visual criteria performs better when positivity-negativity threshold is set at point 3 of the 5-point scale (5-PS); 2) semiquantitative approach by use of Δ SUV max performs better when the threshold is set at 66% decrease: in fact, at Δ SUV max analysis with 66% decrease, 9 patients resulted positive at the test (Δ SUV max ≤66%), 29 negative (Δ SUV max >66%). CONCLUSION: In our population Δ SUV max could be working well in these patients because the baseline values are very high and very homogeneous. Our data, though limited in numerosity of patients and events, suggests that in this particular setting the use of the 5-PS reporting system could not be the best tool available; on the other hand, Δ SUV max could prove to be reliable in the evaluation of response to chemotherapy.

Comparison between cardiac output measured by thermodilution technique and calculated by O2 and modified CO2 Fick methods using a new metabolic monitor.

OBJECTIVE: To calculate cardiac ouptut from dual oximetry with carbon dioxide production (VCO2) and oxygen consumption (VO2) measured by a new metabolic monitor, and to compare these values with measurements made simultaneously using the thermodilution method during the steady state condition. DESIGN: Prospective, comparative clinical study. SETTING: The adult postsurgical intensive care unit (ICU) of a University Hospital. PATIENTS: Twenty mechanically ventilated postsurgical patients (70.7 +/- 7.8 years of age; range 50-84). MEASUREMENTS AND RESULTS: A new metabolic monitor (Puritan-Bennett 7250, Carlsbard, USA) connected to a ventilator (Puritan-Bennett 7200) was used to measure VCO2 and VO2. Measurements of arterial (SaO2) and mixed venous (SvO2) oxygen saturations were made using pulse and venous fiberoptic oximeters. Cardiac output starting from VCO2 (COVCO2) was obtained according to Mahutte's formula: COVCO2 = VCO2/[k (SaO2-SvO2)], where k represents a constant. The value for each patient was determined from the initial measurements of thermodilution cardiac output (COtd), VCO2, SaO2 and SvO2. COVCO2 calculated from the previous equation was compared to the COtd. Cardiac output calculated from the traditional O2 Fick equation (COVO2) was compared to the COtd. All patients were studied over a period of 120 min at 15-min intervals in reasonably stable conditions. COVCO2 was closely related to COtd (r = 0.94; SEE = 0.79; p = 0.0001; n = 180) with a bias of -0.10 and a precision of 0.45 l/min. The mean percent difference between the two methods was -2.2 +/- 8.3%. COVO2 was related to COtd (r = 0.77; SEE = 0.79; p = 0.0001; n = 180) with a bias of -0.57 and precision of 0.86 l/min. The mean percent difference between the two methods was -10.8 +/- 16.0%. CONCLUSIONS: In stable patients, cardiac output measurements obtained from dual oximetry with VO2 and VCO2 measured by this new metabolic monitor, show good correlation with measurements made using the thermodilution method. The values of cardiac output calculated from VCO2 are more accurate and precise than values from VO2. The validity of these measurements in hemodynamically unstable patients and during various modes of mechanical ventilation seems warranted.

Metabolic control during total parenteral nutrition: use of an artificial endocrine pancreas.

The metabolic impact of total parenteral nutrition (TPN) was evaluated in nine subjects who underwent esophagogastroplasty for esophageal carcinoma. On the second day after operation all subjects were connected to an artificial endocrine pancreas. In four patients only glucose was infused (5.5 mg/kg X min). The remaining five subjects received glucose (4.0 mg/kg X min), amino acid (0.5 mg/kg X min), and lipid emulsion (0.6 mg/kg X min). Plasma glucose concentration was kept constant over 24 hours. However, both insulin requirement (111 +/- 15 v 70 +/- 2 mU/kg X h) and plasma insulin level (99 +/- 15 v 30 +/- 7 microU/mL; P less than .01) were higher during combined TPN. Blood lactate concentration was higher during glucose infusion (P less than .05). No difference was found in blood concentrations of pyruvate, alanine, and ketone bodies. Both glycerol and FFA were higher during combined TPN. The ratio between glucose infusion rate and the average plasma insulin level was calculated as an index of insulin-mediated glucose metabolism; G/I X 100 was markedly reduced during combined TPN (4.5 +/- 0.8 v 20.7 +/- 3.7; P less than .05). Plasma FFA levels were positively correlated with plasma insulin concentration (r = .76) and inversely correlated to G/I X 100 (r = -.73; both P less than .05). In conclusion, during combined TPN a state of insulin resistance is induced and more insulin is required to achieve a normal glucose utilization.

Moyamoya syndrome in only one of two identical twins. Case report.

The authors describe moyamoya syndrome in only one of two identical twins. The clinical and angiographic data suggest that it may be an acquired form, but the cause of the pathology remains obscure.

Critical evaluation of the hemispheric perfusion brain scanning using Tc99m labeled human albumin microspheres in cerebral ischemic disorders. Preliminary report.

Twentytwo patients, 11 with Completed Stroke and 11 with Transitory Ischemic Attacks, were submitted to the Perfusional Brain Scanning (PBS). In all cases the PBS demonstred a pathologic pattern. The test explored the conditions of the arteriolar tree and acquainted us with the degree of the ischemic damage and the functional value of the interhemispheric arterial collateral circle. Further informations on the morphology, site and extension of the lesion were obtained. The pathophysiologic aspects of the procedure are discussed and its safety assessed.

Third ventricle intrinsic craniopharingioma. Case report.

A case of craniopharingioma developed and situated in the cavity of the third ventricle with no connections with the base of the skull is reported. The patient was a thirty-year-old man, who within a few months had developed a diencephalic syndrome followed by psychic disorders and intracranial hypertension. Cerebral scan: large area of accumulation in the supra and retrosellar region. Bilateral carotid angiogram: no pathological staining but the venous angle and the internal cerebral vein were elevated and shifted posteriorly. Pneumoencephalogram: free and normal basal cisterns; the third ventrical is almost totally filled by a mass; small dilatation of the lateral ventricles. Operation: right trans ventricular approach to the third ventricle. The tumour was the size of an apricot encapsulated with a smooth surface, and adherent to the wall of the third ventricle only in the region of the infundibulum. There was little bleeding and no cystic component. Total removal was performed except for a few millimeters of capsule in the infundibular region. The postoperative course was complicated by an irreversible diencephalic insufficiency with death on the 27th postoperative day. Autopsy clearly showed that the inferior surface of the brain in the diencephalic region was not involved by the mass which hystologically was doubtless a craniopharingioma. Only two other cases of craniopharingioma of the third ventricle were so far reported in the literature by Cashion and Young in 1971.

Critical evaluation of a new water soluble contrast medium (Iopamidolo) in cervical myelograms.

The Authors report the preliminary results in 96 cervical myelograms performed by percutaneous subarachnoid injection at the level C1-C2 of a new water soluble contrast medium (Iopamidolo*). Compared to other water soluble contrast media Iopamidolo offers some advantages: (1) it is a time stable solution ready for immediate use; (2) it gives an ideal density for the study of the cervical spinal canal; (3) it provides high quality radiograms suitable for magnification of anatomical details which give a more accurate surgical diagnosis; (4) it is well tolerated without significant sequelae; no delayed complications were reported up to 15 months. This contrast medium gives valuable results also in myelograms performed by lumbar route.

Intramedullary spinal cord metastases.

The authors report 5 cases of intramedullary metastases, observed in the last 5 years. In 2 cases, the way of spreading was via the CSF, in 2 cases via the systemic circulation, and in 1 case along the perineural sheaths. A comparison with similar studies in the literature is followed by a brief discussion on treatment and prognosis.

Single versus multiple drug therapy in the combined treatment of malignant gliomas. A multicenter study.

The best treatment of malignant gliomas has been considered to be surgery followed by irradiation and chemotherapy with nitrosourea compounds. Our controlled and randomized trial was designed in 1982 to analyze the effectiveness of multiple-drug versus single-drug therapy in patients bearing malignant gliomas. After 3 weeks from surgery and histopathological diagnosis 173 patients were randomly assigned to receive one of the three chemotherapy regimens: CCNU alone, CCNU plus VM-26 or CCNU plus VM-26 plus 5-FU. Radiotherapy was administered whole-brain (40-45 Gy) and coned-down focal (15-20 Gy) irradiation for a total of 60 Gy (1700 rets) in conjunction with the first course of chemotherapy. 150/173 patients are evaluable. Statistical analysis of results shows a better quality of life and survival for patients treated with polychemotherapy using a three drug combination than two drug or single drug therapy (13.8 vs 14.7 vs 18.2 months MST; P less than 0.01) but with a higher incidence of toxicity problems. An analysis of prognostic factors and their distribution in each arm of the protocol will be made in the near future.

Transcerebellar biopsy in the posterior fossa: 12 years experience.

Utilizing the Leksell stereotactic system, the transcerebellar approach was used for posterior fossa biopsies. During a period of 12 years, a total of 29 patients were operated on by this technique, among them 12 children. In the adult, the procedure was carried out with the patient awake and sitting upright; the pediatric patients required general anesthesia and the head was supported either manually or by a clamp. Representative specimens were obtained in all cases but one, showing a wide diagnostic spectrum. As a rule, the procedures were performed smoothly, with no serious side effects. Stereotactic biopsies in the posterior fossa, hitherto seldom performed, open new diagnostic perspectives, one of which is for use in obscure brain stem lesions. The transcerebellar approach has been proven to be easy, direct, and safe provided an appropriate technique is used, such as that described in the present paper.

High-dose interstitial brachytherapy for glioblastoma multiforme.

AIMS AND BACKGROUND: The long-term prognosis for survival of patients with inoperable glioblastoma multiforme (GBL) is very poor. Conventional external radiotherapy gives only transitory result. This severe prognosis led us to elaborate a high-dose rate (HDR), after-remote-loading brachytherapy treatment protocol: our aim was both therapeutic and psychologic. METHODS: Five patients with GBL (T1 G4 UICC) were treated with stereotactic biopsy followed by HDR brachytherapy. A unique coaxial after-loading catheter was stereotactically inserted through the center of the target volume. The treatment schedule considered 5 fractions, 5 Gy/fraction at the dose specification surface, 2 fractions per day. RESULTS: The treatment was well tolerated. Tumor progression started again at the 8th to the 16th week from the end of the treatment. ECOG performance status at the 8th week was better than before the therapy in 2 of 5 patients and was stable in 2 of 5 patients. Order neuroperformance status was stable in 2 patients at 8 weeks. At the 16th week there was neurologic deterioration. The average survival was 21 weeks. CONCLUSIONS: Our approach seems to be of some interest for the palliation of GBL, and it offers some advantages, in particular regarding the short treatment period. Our procedure can be improved: a multi-catheter implant and a more fractionated schedule could be taken into account.

High-dose-rate brachytherapy for poor-prognosis, high-grade glioma: (phase II) preliminary results.

AIMS AND BACKGROUND: The purpose of this study was to investigate the palliative effectiveness of an interstitial fractionated high-dose-rate (HDR) brachytherapy regimen in patients with poor-prognosis, high-grade glioma. METHODS: An after-remote-loading microSelectron HDR lr-192 370 GBq unit was used. A unique coaxial after-loading catheter was stereotactically inserted through the center of the target volume. The treatment schedule was: 5 fractions, 5 Gy per fraction, or alternatively 7 fractions, 3.85 Gy per fraction, at the dose specification surface, 2 fractions per day. Twenty-four patients have been treated: in 17 of them (T1 G3-4) the catheter was implanted during stereotactic biopsy procedure; in the other 7 cases (T2 G3-4), subjected to partial resection and reduced to yT1, the catheter was implanted following surgery with a mean delay of 15 days. RESULTS: The treatment was feasible and well tolerated. The complete course takes no more than 7 days. The acute complication rate (2/24) seems to be acceptable. The median survival was 8 months. No less than 45% of the patients had a WHO grade 2 score or better at any time of follow-up. At 4 months of follow-up, functional status, assessed using a verbally administered Barthel index, had improved from the pretreatment level in 29.1% of the 18 surviving patients and remained stable in another 22.2%. A minimal response or stable disease, according to CT scan, was obtained in about half of the assessable survivors at any time of follow-up. CONCLUSIONS: The short course of brachytherapy provides a good palliation in terms of functional improvement in a high proportion of patients, with low and acceptable toxicity.

Effects of repeated exposures to xenon on rat adrenal cortex ultrastructure.

Xenon has many properties of the ideal anaesthetic and it has been proposed to replace classic volatile anaesthetics. Although some studies demonstrated that xenon does not induce gross morphological changes in major organs, little is known on its possible ultrastructural effects. The present study investigates the subcellular effects of repeated exposures to 70% xenon on rat adrenal cortex in comparison with N2O. Animals were divided into four groups: xenon-exposed, N2O-exposed, sham-exposed and controls. Exposed rats were placed into a sealed cage to breathe the respective gas mixture for 2.5 h/day for a week. Specimens of adrenal cortex for electron microscopy and blood samples for determination of corticosterone plasma levels were taken at the end of the last exposure or one week after the last exposure (recovery). Adrenal cortex from N2O- and sham-exposed rats mainly showed dilation of endoplasmic reticulum, whereas xenon-exposed rats also exhibited several cells with lipid droplets appearing subdivided into smaller droplets, irregular in shape and size. In all experimental groups, corticosterone plasma levels increased in comparison to controls. Both ultrastructural and hormonal changes were not detected anymore after one week from the last exposure. These findings indicate that xenon is able to induce subcellular changes in rat adrenal cortex, mainly at the level of lipid structures. The transient changes induced by xenon suggest that this gas can be regarded as a safer anaesthetic.

[Cases of acute poisoning hospitalized in the Veneto region. Preliminary results in 1721 cases]. / Le intossicazioni acute ospedalizzate nella regione Veneto. Risultati preliminari su 1721 casi.

An epidemiological study has been made of acute poisoning cases hospitalised in the Veneto region in 1978 and 1979 and the present paper reports an initial sizeable group of 1721 cases. Young people are most affected (60% of cases below the age of 30), particularly in the first decade of life. The male sex is mainly involved in poisoning due to voluntary substances (alcohol, heroin) while females are most affected by psychoactive drugs. The commonest toxic substances are: psychoactive drugs (26%), alcohol (20%), domestic products (19%), heroin (10%), non-narcotic analgesics (4%), agricultural products (3%) and cardiovascular drugs (2%). In 3% of cases it proved impossible to identify the compound in question and in 13% of poisonings different drugs and substances were involved. The average duration of admission was 41/2 days and support treatment was carried out regularly. Mortality was 0.4% (7 cases), 4 of them due to poisoning by domestic products.

Esophagogastric anastomotic leakage.

Anastomotic leakage of esophagogastric anastomoses can be prevented by administering adequate preoperative nutritional support and by employing mechanical circular staplers. In a series of 299 intrathoracic anastomoses, 35 leakages were observed, 11 of which gave asymptomatic radiological findings. In a series of 46 cervical anastomoses, nine leakages were observed. In the majority of cases conservative treatment was adopted. This is based upon external drainage of septic collections, gastric emptying, antibiotics and intensive nutritional care. The mortality rate in cases of anastomotic fistulas was 1.74% (6 patients) in the patients with esophagogastric anastomoses.

Reversal of profound and "deep" residual rocuronium-induced neuromuscular blockade by sugammadex: a neurophysiological study.

BACKGROUND: Sugammadex is the first of a new class of selective relaxant binding drugs developed for the rapid and complete reversal of neuromuscular blockade (NMB) induced by the aminosteroid neuromuscular blocking drugs rocuronium and vecuronium. Neuromuscular blocking drugs block the transmission from the peripheral nerve to the muscle units, with reduction and disappearance of the evoked electromyographic activity. Usually, neuromuscular monitoring for the investigational reversal drug is performed by calibrated acceleromyography. The efficacy of sugammadex in reversing profound and "deep" residual rocuronium-induced NMB using myogenic motor evoked potentials (mMEPs) monitoring was evaluated. METHODS: In this prospective trial, 30 consenting patients undergoing propofol-remifentanil anesthesia for spine surgery were enrolled and divided into two groups: Group 1, reversal of profound NMB (sugammadex 16 mg/Kg, 3 minutes after rocuronium 1.2 mg/Kg) and Group 2, reversal of "deep" residual NMB (sugammadex 4 mg/Kg, 15 minutes after rocuronium 0.6 mg/Kg). Myogenic MEPs registrations of upper and lower limbs and the diaphragm were performed, as well as TOF monitoring. RESULTS: After injection of 4 mg/Kg of sugammadex, the means of recovery time of the basal mMEPs amplitudes (diaphragm, and lower limbs and upper limbs) were 124±9.6, 143±163, 151±207 sec, respectively whereas after 16 mg/Kg of sugammadex the times were 109±13.8, 124±0.6, and 135±14.1 sec. Times to TOF ratio 0.9 were 114±75 and 186±105 sec in Group 1 and 2, respectively. No serious adverse effects related to sugammadex and to electrical stimulation were reported. No reoccurrence of neuromuscular block was observed. CONCLUSION: Neurophysiological monitoring using mMEPs confirmed that sugammadex provided a complete recovery from profound and "deep" residual rocuronium-induced neuromuscular blockade.