Preoperative Echocardiographic Unknown Valvopathy Evaluation in Elderly Patients Undergoing Neuraxial Anesthesia during Major Orthopedic Surgery: A Mono-Centric Retrospective Study.

Background: The assessment of cardiac risk is challenging for elderly patients undergoing major orthopedic surgery with preoperative functional limitations. Currently, no specific cardiac risk scores are available for these critical patients. Echocardiography may be a reliable and safe instrument for assessing cardiac risks in this population. This study aims to evaluate the potential benefits of echocardiography in elderly orthopedic patients, its impact on anesthesiologic management, and postoperative Major Adverse Cardiac Events (MACEs). Methods: This is a retrospective, one-arm, monocentric study conducted at ''Federico II'' Hospital-University of Naples-from January to December 2023, where 59 patients undergoing hip or knee revision surgery under neuraxial anesthesia were selected. The demographic data, the clinical history, and the results of preoperative Echocardiography screening (pEco-s) were collected. After extensive descriptive statistics, the χ2 test was used to compare the valvopathies and impaired Left Ventricular Function (iLVEF) prevalence before and after echocardiography screening and the incidence of postoperative MACE; a p-value < 0.05 was considered statistically significant. Results: The mean age was 72.5 ± 6.9, and the prevalence of cardiac risk factors was about 90%. The cumulative prevalence of iLVEF and valvopathy was higher after the screening (p < 0.001). The pEco-s diagnosed 25 new valvopathies: three of them were moderate-severe. No patients had MACE. Conclusions: pEco-s evaluation could discover unknown heart valve pathology; more studies are needed to understand if pEco-s could affect the anesthetic management of patients with functional limitations, preventing the incidence of MACE, and assessing its cost-effectiveness.

Videolaryngoscopy versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: In recent years, videolaryngoscopy has increasingly been utilized as an alternative to fiberoptic bronchoscopy in awake intubation. Nonetheless, it remains uncertain whether videolaryngoscopy represents a viable substitute for fiberoptic bronchoscopy. We conducted this systematic review with a meta-analysis to compare videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. Methods: We systematically searched for all randomized controlled trials (RCTs) comparing videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically queried through August 2023. Our primary outcome measure was the duration of intubation. Secondary outcomes encompassed the rate of successful intubation on the initial attempt, failed intubation, patient-reported satisfaction, and any complications or adverse events potentially stemming from the intubation procedure. The Cochrane Risk of Bias Tool for RCTs was employed to evaluate all studies for evidence of bias. The GRADE approach was utilized to gauge the certainty of the evidence. Results: Eleven trials involving 873 patients were ultimately included in our review for data extraction. Meta-analysis demonstrated that videolaryngoscopy decreased the duration of intubation compared to fiberoptic bronchoscopy (SMD -1.9671 [95% CI: -2.7794 to -1.1548] p < 0.0001), a finding corroborated in subgroup analysis by the type of videolaryngoscope (SMD -2.5027 [95% CI: -4.8733 to -0.1322] p = 0.0385). Additionally, videolaryngoscopy marginally lowered the risk of experiencing a saturation below 90% during the procedure (RR -0.7040 [95% CI: -1.4038 to -0.0043] p = 0.0486). No statistically significant disparities were observed between the two techniques in terms of failed intubation, initial successful intubation attempt, or sore throat/hoarseness. With regard to patient-reported satisfaction, a pooled analysis was precluded due to the variability in evaluation methods employed across the trials to assess this outcome. Lastly, trial sequential analysis (TSA) conducted for intubation time (primary outcome) affirmed the conclusiveness of this evidence; TSA performed for secondary outcomes failed to yield conclusive evidence, indicating the necessity for further trials. Conclusions: Videolaryngoscopy for awake tracheal intubation diminishes intubation time and the risk of experiencing a saturation below 90% compared to fiberoptic bronchoscopy.

Dexamethasone versus Dexmedetomidine as Adjuvants in Ultrasound Popliteal Sciatic Nerve Block for Hallux Valgus Surgery: A Mono-Centric Retrospective Comparative Study.

Background and Aim: Ultrasound popliteal sciatic nerve block (UPSNB) is commonly performed in foot and ankle surgery. This study aims to assess the use of dexmedetomidine and dexamethasone as adjuvants in UPSNB for hallux valgus (HV) surgery, comparing their efficacy in producing motor and sensory block and controlling postoperative pain. The adverse event rate was also evaluated. Methods: This mono-centric retrospective study included 62 adult patients undergoing HV surgery: 30 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg and dexamethasone 4 mg (Group 1), whereas 32 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg, and dexmedetomidine 1 mcg/Kg (Group 2). At first, the visual analogue scale (VAS) was evaluated after 48 hours. The other outcomes were time to motor block regression, evaluation of the first analgesic drug intake, analgesic effect, adverse effects (hemodynamic disorders, postoperative nausea and vomiting (PONV)) and patient satisfaction. The continuous data were analyzed with student's t-test and the continuous one with χ2. Statistical significance was set at a p-value lower than 0.05. Results: No significant difference was found in VAS after 48 hours (4.5 ± 1.6 vs 4.7 ± 1.7, p = 0.621) to motor block regression (18.9 ± 6.0 vs 18.7 ± 6, p = 0.922). The number of patients that took their first analgesic drug in the first 48 h (p = 0.947 at 6 hours; p = 0.421 at 12 hours; p = 0.122 at 24 hours and p = 0.333 at 48 hours) were not significant. A low and similar incidence of intraoperative hemodynamic disorders was recorded in both groups (hypotension p = 0.593; bradycardia p = 0.881). Neither PONV nor other complication was found. Patients in Group 1 reported a lower degree of interference with sleep (p = 0.001), less interference with daily activities (P = 0.002) and with the affective sphere (P = 0.015) along with a more satisfactory postoperative pain management (p < 0.001) as compared to Group 2. Conclusion: No significant differences were observed in the duration of motor and sensory blockade between patients in both groups. Additionally, both groups showed good pain control with a low rate of adverse effects, even if there was no clinical difference between the groups. However, patients who received dexamethasone reported experiencing less interference with their sleep, daily activities and overall emotional well-being, and overall pain control.

The Effects of the Pericapsular Nerve Group Block on Postoperative Pain in Patients with Hip Fracture: A Multicenter Study.

BACKGROUND: An adequate early mobilization followed by an effective and pain-free rehabilitation are critical for clinical and functional recovery after hip and proximal femur fracture. A multimodal approach is always recommended so as to reduce the administered dose of analgesics, drug interactions, and possible side effects. Peripheral nerve blocks should always be considered in addition to spinal or general anesthesia to prolong postoperative analgesia. The pericapsular nerve group (PENG) block appears to be a less invasive and more effective analgesia technique compared to other methods. METHODS: We conducted multicenter retrospective clinical research, including 98 patients with proximal femur fracture undergoing osteosynthesis surgery within 48 h of occurrence of the fracture. Thirty minutes before performing spinal anesthesia, 49 patients underwent a femoral nerve (FN) block plus a lateral femoral cutaneous nerve (LCFN) block, and the other 49 patients received a PENG block. A non-parametric Wilcoxon-Mann-Whitney (α = 0.05) test was performed to evaluate the difference in resting and dynamic numerical rating scale (NRS) at 30 min, 6 h, 12 h, and 24 h. RESULTS: the PENG block administration was more effective in reducing pain intensity compared to the FN block in association with the LFCN block, as seen in the resting and dynamic NRS at thirty minutes and 12 h follow-up. CONCLUSION: the PENG block was more effective in reducing pain intensity than the femoral nerve block associated with the lateral femoral cutaneous nerve block in patients with proximal femur fracture undergoing to osteosynthesis.

Pregnant Patients with COVID-19 Admitted to an ICU: A Comparison with a Historical Cohort of Critical Pregnant Patients without COVID-19.

AIM OF THE STUDY: Maternal mortality and ICU admissions have increased during the COVID-19 pandemic. We reported a case-series of pregnant patients with COVID-19 admitted to an ICU and we compared them with a historical cohort of pregnant patients admitted to an ICU without COVID-19. METHODS: We included all pregnant patients with laboratory-confirmed COVID-19 infection admitted to our ICU in 2021. As a historical control group, we included all pregnant women who were admitted to our ICU between 1 January 2008 and 31 December 2013. RESULTS: In 2021, 11 pregnant patients (pts) with COVID-19 were admitted to an ICU, representing 2.87% of ICU admissions. We found that pregnant patients with COVID-19 (1) had a higher BMI (34.6 vs. 28.8, p = 0.04) and a lower gestational age (30.6 vs. 34 weeks, p = 0.03), (2) were mainly admitted for respiratory failure (100% vs. 2.7%; p = 0.001) and (3) required more days of invasive and non-invasive ventilations (54.5% vs. 5.2%, p = 0.002), a longer duration of stay at the ICU (21.9 vs. 4.8 days, p < 0.0001) and had a higher mortality rate (27.3% vs. 0%, p = 0.0192). CONCLUSIONS: Pregnant patients with COVID-19 represent a challenge for ICU physicians due to their different characteristics and outcomes when compared to pregnant patients without COVID-19.

Potential Role of Focal Microvibration (Equistasi®) in the Management of Chronic Pain: A Pilot Study.

INTRODUCTION: Chronic pain is one of the leading causes of medical consultation with a dramatic psychophysical and socioeconomic impact. Focal microvibration (Equistasi®) is a revolutionary technology that converts the thermal energy of the skin into vibration. Equistasi® was shown to be effective in the treatment of gait and balance dysfunction in many pathological conditions such as Parkinson's disease and multiple sclerosis. Our aim was to explore the efficacy of focal microvibration in the management of chronic pain. METHODS: We randomized 60 patients with pain of different origin into two groups: an experimental group (group E) treated with Equistasi, and a control group (group C) treated with standard pharmacological therapy. Pain, disability, and working capacity were evaluated by Brief Pain Inventory (BPI), Oswestry Disability Index (ODI), and Work Ability Index (WAI) at the baseline and after 7 (T7), 15 (T15), 30 (T30), 60 (T60), and 90 (T90) days. RESULTS: According to BPI, average and worst pain in the last 24 h significantly decreased in group E at T15 and this result persisted up to T90; pain interference on general activity, mood, waling ability, normal work, relations with other people, sleep, and enjoyment of life decreased in group E with a significant improvement from T15. Lifting activity and work ability in relation to demands also significantly improved in group E. No significant changes in BPI, ODI, and WAI scores were recorded in group C during the follow-up. CONCLUSIONS: Focal microvibration can be an effective tool for managing chronic pain in combination with other therapies.

The PATIENT Approach: A New Bundle for the Management of Chronic Pain.

BACKGROUND: Chronic pain is one of the most challenging diseases for physicians as its etiology and manifestations can be extremely varied. Many guidelines have been published and many therapeutic options are nowadays available for the different types of pain. Given the enormous amount of information that healthcare providers must handle, it is not always simple to keep in mind all the phases and strategies to manage pain. We here present the acronym PATIENT (P: patient's perception; A: assessment; T: tailored approach; I: iterative evaluation; E: education; N: non-pharmacological approach; T: team), a bundle which can help to summarize all the steps to follow in the management of chronic pain. METHODS: We performed a PubMed search with a list of terms specific for every issue of the bundle; only English articles were considered. RESULTS: We analyzed the literature investigating these topics to provide an overview of the available data on each bundle's issue; their synthesis lead to an algorithm which may allow healthcare providers to undertake every step of a patient's evaluation and management. DISCUSSION: Pain management is very complex; our PATIENT bundle could be a guide to clinicians to optimize a patient's evaluation and treatment.

Interleukin-6 and Its Soluble Receptor Complex in Intensive Care Unit COVID-19 Patients: An Analysis of Second Wave Patients.

In December 2019, a SARS-CoV-2 virus, coined Coronavirus Disease 2019 (COVID-19), discovered in Wuhan, China, affected the global population, causing more than a million and a half deaths. Since then, many studies have shown that the hyperinflammatory response of the most severely affected patients was primarily related to a higher concentration of the pro-inflammatory cytokine interleukin-6, which directly correlated with disease severity and high mortality. Our study analyzes IL-6 and its soluble receptor complex (sIL-6R and sgp130) in critically ill COVID-19 patients who suffered severe respiratory failure from the perspective of the second COVID wave of 2020. A chemiluminescent immunoassay was performed for the determination of IL6 in serum together with an enzyme-linked immunosorbent assay to detect serum levels of sIL-6R and sgp130, which confirmed that the second wave's serum levels of IL-6 were significantly elevated in the more severe patients, as with the first 2019 COVID-19 wave, resulting in adverse clinical outcomes. At present, considering that no specific treatment for severe COVID-19 cases in its later stages exists, these molecules could be considered promising markers for disease progression, illness severity, and risk of mortality.

Impact of Ultrasound-Assisted Method on Success Rate of Spinal Anesthesia Performed by Novice Trainees: A Retrospective Comparative Study.

In current practice, single-shot spinal anesthesia has traditionally been performed using the conventional surface-anatomic-Landmark-Guided technique. This "blind" technique has significant critical issues such as a high risk of complications due to the numerous attempts at spinal needle placement and the negative impact on the learning curve of the trainees. Ultrasound-Assisted spinal anesthesia could reduce these critical issues and allow trainees to perform the procedure more easily and with fewer complications for the patient. We performed a before-and-after monocentric retrospective comparative study at the University of Naples "Federico II" (Naples, Italy). Inclusion criteria were as follows: patients aged 18 years or older; ASA physical status between I and IV; and elective orthopedic surgery under single-shot spinal anesthesia performed by supervised trainees between January 2022 and December 2022. In the selected cohort, 88 patients were included in group A (Landmark-Guided spinal anesthesia) and 91 in group B (Ultrasound-Assisted spinal anesthesia). The number of attempts by trainees (p-value < 0.005), procedure performing time (<0.001), and patient discomfort (<0.001) were significantly lower in group B than in group A. Ultrasound-Assisted single-shot spinal anesthesia performed by novice trainees reduces the number of attempts, complication rate, periprocedural pain, and patient discomfort.

Low serum 25­hydroxy-vitamin D levels are associated with cognitive impairment in multiple sclerosis.

BACKGROUND: Cognitive impairment frequently affects people with multiple sclerosis (MS). Low vitamin D has been associated with cognitive dysfunction in different neurodegenerative diseases, and, in MS, with motor disability and disease activity. We aim to investigate associations between vitamin D and cognitive status in MS. METHODS: In this cross-sectional study, we included 181 MS patients, recruited consecutively at the MS Unit of the Policlinico Federico II University Hospital of Naples, Italy, between January and April 2022, with serum 25­hydroxy (25-OH) vitamin D measurements using Chemiluminescence-ImmunoAssay, and cognitive assessment using the Brief International Cognitive Assessment for MS (BICAMS), which includes Symbol Digit Modalities Test (SDMT), California Verbal Learning Test-II (CVLT-II) and Brief Visuospatial Memory Test-Revised (BVMT-R). We collected demographics (age, sex, education), and clinical variables (disease duration, disease subtype, expanded disability status scale (EDSS), disease modifying treatment, relapses in previous 12 months, vitamin D supplementation, comorbidities). For a subset of patients (n = 41, 23.2% of the total sample), we collected Beck Depression Inventory-II, Beck Anxiety Inventory, and Modified Fatigue Impact Scale. RESULTS: At univariable linear regression models, serum 25-OH-vitamin D levels were 0.9 ng/mL higher for each unit increase of SDMT adjusted scores (Coeff=0.93; 95%CI=0.81, 1.04; p<0.01), 0.7 ng/mL higher for each unit increase of CVLT-II adjusted scores (Coeff=0.68; 95%CI=0.53, 0.83; p<0. 01), 0.6 ng/mL higher for each unit increase of BVMT-R adjusted scores (Coeff=0.58; 95%CI=0.43, 0.73; p<0.01), -9.63 ng/mL lower for each impaired BICAMS test (Coeff=-9.63; 95%CI=-11.48, -7.79; p<0.01), and -2.2 ng/mL lower for each unit increase of EDSS (Coeff=-2.16; 95%CI=-3.57, -0.75; p<0.01). At multivariable linear regression models, we confirmed associations between 25-OH-vitamin D and EDSS (Coeff=-2.09; 95%CI=-4.45, -0.43; p<0.01), SDMT (Coeff=0.75; 95%CI=0.60, 0.90; p<0.01), and CVLT-II (Coeff=0.14; 95%CI=0.01, 0.28; p = 0. 04). Results remained unchanged when including depression, anxiety and fatigue scores. CONCLUSIONS: Lower serum 25-OH-vitamin D was associated with worse cognitive function in MS. Future studies should consider longitudinal variations in cognitive function in relation to vitamin D supplementation.

Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis.

BACKGROUND: Many RCTs have evaluated the influence of intraoperative tidal volume (tV), PEEP, and driving pressure on the occurrence of postoperative pulmonary complications, cardiovascular complications, and mortality in adult patients. Our meta-analysis aimed to investigate the association between tV, PEEP, and driving pressure and the above-mentioned outcomes. METHODS: We conducted a systematic review and meta-analysis of RCTs from inception to May 19, 2022. The primary outcome was the incidence of postoperative pulmonary complications; the secondary outcomes were intraoperative cardiovascular complications and 30-day mortality. Primary and secondary outcomes were evaluated stratifying patients in the following groups: (1) low tV (LV, tV 6-8 ml kg-1 and PEEP ≥5 cm H2O) vs high tV (HV, tV >8 ml kg-1 and PEEP=0 cm H2O); (2) higher PEEP (HP, ≥6 cm H2O) vs lower PEEP (LP, <6 cm H2O); and (3) driving pressure-guided PEEP (DP) vs fixed PEEP (FP). RESULTS: We included 16 RCTs with a total sample size of 4993. The incidence of postoperative pulmonary complications was lower in patients treated with LV than with HV (OR=0.402, CI 0.280-0.577, P<0.001) and lower in DP than in FP group (OR=0.358, CI 0.187-0.684, P=0.002). Postoperative pulmonary complications did not differ between HP and LP groups; the incidence of intraoperative cardiovascular complications was higher in HP group (OR=1.385, CI 1.027-1.867, P=0.002). The 30-day mortality was not influenced by the ventilation strategy. CONCLUSIONS: Optimal intraoperative mechanical ventilation is unclear; however, our meta-analysis showed that low tidal volume and driving pressure-guided PEEP strategies were associated with a reduction in postoperative pulmonary complications.

The Twenty-Five Most Cited Articles About Adductor Canal Block: A Bibliometric Analysis from 1980 to 2022.

Introduction: Loco-regional anesthesia role is increasingly important in surgery, especially in postoperative pain control. Using ultrasound-guided techniques has made the loco-regional approach increasingly safe and manageable, guaranteeing excellent analgesic results and patient compliance. This bibliometric research aimed to identify the most influential papers on the adductor canal blocks and outline their characteristics. Methods: All articles published from 1980 to 2022 were included in the Web of Science, PubMed, and Scopus databases and found using the keywords "Adductor canal block" or "Saphenous nerve block" or "Peripheral nerve block" or "Hunter canal block" or "Subsartorial canal block" or "ACB" or "Knee" or "TKR" or "TKA" or "Analgesia" or "Arthroplasty" or "Replacement" in the title section had bibliometric analysis performed. The first 25 papers were selected and analyzed by the number of citations. The correlation between numerical variables was evaluated using the Pearson Correlation coefficient. Results: Literature screening found 252 publications. One hundred ten were only about the adductor canal block. Of these, 25 articles were selected for our bibliometric study, published in 8 different journals and with a total number of citations equal to 1.457. "Regional Anesthesia and pain medicine" journal - with 9 articles - was the one that produced the most. There was a significant strong correlation between the n. of citations and the citation rate (R = 0.84, p < 0.001). Conclusion: The purpose of this study is to be a guide on regional anesthesia and, particularly, on adductor canal block, making the most effective as well as the most cited articles available to anesthesiologists or other researchers interested in this topic.

Robot-Assisted versus Laparoscopic Gastrointestinal Surgery: A Systematic Review and Metanalysis of Intra- and Post-Operative Complications.

BACKGROUND: The use of robotic surgery is attracting ever-growing interest for its potential advantages such as small incisions, fine movements, and magnification of the operating field. Only a few randomized controlled trials (RCTs) have explored the differences in perioperative outcomes between the two approaches. METHODS: We screened the main online databases from inception to May 2023. We included studies in English enrolling adult patients undergoing elective gastrointestinal surgery. We used the following exclusion criteria: surgery with the involvement of thoracic esophagus, and patients affected by severe heart, pulmonary and end-stage renal disease. We compared intra- and post-operative complications, length of hospitalization, and costs between laparoscopic and robotic approaches. RESULTS: A total of 18 RCTs were included. We found no differences in the rate of anastomotic leakage, cardiovascular complications, estimated blood loss, readmission, deep vein thrombosis, length of hospitalization, mortality, and post-operative pain between robotic and laparoscopic surgery; post-operative pneumonia was less frequent in the robotic approach. The conversion to open surgery was less frequent in the robotic approach, which was characterized by shorter time to first flatus but higher operative time and costs. CONCLUSIONS: The robotic gastrointestinal surgery has some advantages compared to the laparoscopic technique such as lower conversion rate, faster recovery of bowel movement, but it has higher economic costs.

Risk Factors for Pneumocystis jirovecii Pneumonia in Non-HIV Patients Hospitalized for COVID-19: A Case-Control Study.

BACKGROUND: Very few cases of Pneumocystis jirovecii pneumonia (PJP) have been reported in COVID-19 so far, and mostly in patients with concomitant HIV infection or in solid-organ transplant recipients. Despite COVID-19 being associated with lymphopenia and the use of steroids, there are no studies specifically aimed at investigating the risk factors for PJP in COVID-19. METHODS: A retrospective case-control study was performed. We matched PJP cases with controls with a 1:2 ratio, based on age ± 10 years, solid-organ transplantation (SOT), hematological malignancies, and in the setting of PJP development (ICU vs. non-ICU). A direct immunofluorescence assay on bronchoalveolar lavage fluid was used to diagnose PJP. RESULTS: We enrolled 54 patients. Among 18 cases of PJP, 16 were diagnosed as "proven". Seven of the eighteen cases were immunocompromised, while the other patients had no previous immunological impairment. Patients with PJP had significantly lower median lymphocyte values (p = 0.033), longer COVID-19 duration (p = 0.014), a higher dose of steroid received (p = 0.026), higher CRP values (p = 0.005), and a lower SARS-CoV-2 vaccination rate than the controls (p = 0.029). Cumulative steroid dose is the independent risk factor for PJP development (OR = 1.004, 95%CI = 1-1.008, p = 0.042). CONCLUSIONS: PJP develops in COVID-19 patients regardless of immunosuppressive conditions and the severity of disease, and it is correlated to the corticosteroid dose received.

Trends for Percutaneous Tracheostomy in Italian Acute Care Setting over a 5-Year Period.

Background: Tracheostomy is a widespread procedure usually performed with a percutaneous approach for prolonged mechanical ventilation. Little is known about the population-based trends for percutaneous tracheostomies (PT). The aim of this study was to evaluate the order to analyze the characteristics, rates, and costs of PTs performed in Italy from 2009 to 2014. Methods: We analyzed 102,646 PTs performed in Italy between 2009 and 2014. We obtained the data of patients from the section of the discharge report of the Italian Ministry of Health (National Archive for Hospital Discharge Form, Ministry of Health) about age, gender, length of stay (LOS), hospital types, and hospital region for code 541 and 542 for the years 2009, 2010, 2011, 2012, 2013 and 2014. Our additional source of data was the Annual Discharge Reports of the Italian Ministry of Health. Results: In this study, including 102,646 PTs performed from 2009 to 2014, we found that (1) the rates of PTs significantly decreased over time; (2) PTs were mostly performed in patients aged less than 65 years and hospitalized in ICUs for less than 40 days; and (3) the costs of PTs severely decreased over time, with a breakpoint between 2011 and 2012. Conclusions: Percutaneous tracheostomy is still a procedure frequently performed in the setting of acute care. Although percutaneous tracheostomy still results in high medical care reimbursement, it is a safe and cost-saving procedure.

Tetra-block: ultrasound femoral, lateral femoral-cutaneous, obturator, and sciatic nerve blocks in lower limb anesthesia: a case series.

BACKGROUND: The gold standard anesthesiologic procedure for urgent femur fracture surgery is Spinal Anesthesia. It is not always feasible because of patients' severe comorbidities and difficulties in optimizing drug therapy in the appropriate time frame such as discontinuation of anticoagulant drugs. The use of four peripheral nerve blocks (tetra-block) can be a winning weapon when all seems lost. CASE PRESENTATION: We present, in this case series, three Caucasian adult femur fractures (an 83-year-old woman, a 73-year-old man, and a 68-year-old woman) with different and major comorbidities (cardiac or circulatory disorders on anticoagulants therapy that were not discontinued on time; breast cancer and others) underwent the same anesthesiologic approach in the urgent setting. Ultrasound peripheral nerve blocks, that is femoral, lateral femoral cutaneous, obturator, and sciatic with parasacral approach were successfully performed in all patients who underwent intramedullary nailing for intertrochanteric fracture. We evaluated the adequacy of the anesthesia plane, postoperative pain control with the VAS scale, and the incidence of postoperative side effects. CONCLUSIONS: Four peripheral nerve blocks (Tetra-block) can be alternative anesthesiologic management in urgent settings, in patients where drug therapy cannot be optimized, as in antiplatelet and anticoagulant therapy.

Effects of depth of neuromuscular block on surgical operating conditions in women undergoing gynecologic laparoscopic surgery: a randomized clinical trial.

BACKGROUND: In recent years, the relationship between the advantages and disadvantages of a deep neuromuscular block (DNMB), compared to a moderate block (MNMB) in laparoscopic surgery, has been increasingly studied. OBJECTIVE: Evaluate the effect of D-NMB compared to M-NMB in gynecological laparoscopic surgery. METHODS: This was a parallel-group, double-blind, randomized clinical trial, conducted at a single center in Italy between February 2020 and July 2020. American Society of Anesthesiologist (ASA) I-II risk class patients scheduled for elective gynecological laparoscopic surgery were randomized into a 1:1 ratio to either experimental or control group. The first one included DNMB with a rocuronium bolus at the starting dose of 1.2 mg/kg and a maintenance dose (0.3-0.6 mg/kg/h). The second one included MNMB with a rocuronium bolus at the starting dose of 0.6 mg/kg, and a maintenance dose in boluses (0.15-0.25 mg/kg). The primary outcome was the intraoperative surgical condition assessed every 15 min by the surgeon as a 5-point scale. The secondary outcome was the time needed to discharge patients from post-anesthesia care unit (PACU). The tertiary outcome was the assessment of the intra-operative hemodynamic instability. A sample size of 50 patients was planned. RESULTS: One hundred five patients were assessed for eligibility, 55 were excluded. Fifty patients met the inclusion criteria and were enrolled. The average score for the operative field was 4 for the D-NMB group and 3 for the M-NMB group (p value < 0.01). The length of stay in PACU was 13 min for the DNMB group and 22 min for the MNMB group (p value = 0.02). CONCLUSIONS: Deep neuromuscular block improves intraoperative surgical condition during gynecological laparoscopic surgery. TRIAL REGISTRATION: clinicalTrials.gov NCT03441828.

Propensity score matched analysis of postoperative nausea and pain after one anastomosis gastric bypass (MGB/OAGB) versus sleeve gastrectomy (SG).

The aim of our study was to assess and compare postoperative nausea and pain after one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (LSG). Patients undergoing OAGB and LSG at our institution between November 2018 and November 2021 have been prospectively asked to report postoperative nausea and pain on a numeric analogic scale. Medical records were retrospectively reviewed to collect scores of these symptoms at the 6th and 12th postoperative hour. One-way analysis of variance (ANOVA) was used to evaluate effect of type of surgery on postoperative nausea and pain scores. To adjust for baseline differences between cohorts, a propensity score algorithm was used to match LSG patients to MGB/OAGB patients in a 1:1 ratio with a 0.1 tolerance. A total number of 228 (119 SGs and 109 OAGBs) subjects were included in our study. Nausea after OAGB was significantly less severe than after LSG both at the 6th and 12th hour assessment; pain was less strong after OAGB at the 6th hour but not after 12 h. Fifty-three individuals had a rescue administration of metoclopramide after LSG and 34 after OAGB (44.5% vs 31.2%, p = 0.04); additional painkillers were required by 41 patients after LSG and 23 after OAGB (34.5% vs 21.1%, p = 0.04). Early postoperative nausea was significantly less severe after OAGB, while pain was comparable especially at the 12th hour.

Concomitant diagnosis of multiple sclerosis and human immunodeficiency virus (HIV) infection: case report and the review of literature.

BACKGROUND: To date, few cases of multiple sclerosis (MS) patients with concomitant Human Immunodeficiency Virus (HIV) infection have been described. However, none of the previously described cases has been treated with Natalizumab, probably due to the increasing risk of progressive multifocal leukoencephalopathy (PML). CASE: We report the case of a patient concomitantly diagnosed for HIV infection and MS treated with combined antiretroviral therapy (cART) and Natalizumab for 19 months, without clinical or radiological MS activity. CONCLUSIONS: Our case might suggest considering Natalizumab in patients with concomitant HIV infection, especially for those with significant disease activity requiring a high efficacy disease modifying treatment.