Tapentadol prolonged release in association with analgesic radiofrequency for the treatment of chronic lumbar radicular pain: an observational, prospective study.

OBJECTIVE: Chronic pain is frequently irreversible, representing a major health problem. A survey has shown that 19% of European adults experience chronic pain which is not adequately managed. Innovative interventional techniques for the treatment of chronic pain have been developed, as a further step beyond the three-layer WHO analgesic ladder. Among these techniques, continuous and pulsed radiofrequency (RF) are very effective in the management of radicular pain syndrome. Usually, these techniques are associated with a pharmacologic approach with a wide-spectrum analgesic. Tapentadol has a double mechanism of action, as a µ-opioid receptor agonism (MOR) and noradrenaline reuptake inhibitor (NRI), contributing synergistically to its analgesic efficacy on both nociceptive and neuropathic pain. PATIENTS AND METHODS: We aimed to test the efficacy of tapentadol prolonged release (PR) combined with pulsed RF in improving neuropathic symptoms and disability in 50 patients with moderate-to-severe chronic pain due to lumbar radiculopathy. RESULTS: The responders to treatment, showing at least a 30% reduction in pain intensity on the Numerical Rating Scale (NRS), were 38 (76%). Both average NRS at rest and during loading were statistically significantly reduced compared with baseline (p<0.0001). Other parameters investigated (sleep quality, neuropathic symptoms, the degree of disability) were all statistically better with tapentadol PR. Patients requiring RF intervention dropped dramatically from 98% at baseline to 10% at the end of the study (p<0.01). Adverse events were reported in 14 patients (28%), four of which required therapy discontinuation. However, patients' satisfaction and overall tolerability of tapentadol PR treatment were high. CONCLUSIONS: Tapentadol PR is effective in reducing pain intensity at rest and during loading, with a favorable safety and tolerability profile. Moreover, the use of tapentadol PR decreases the degree and severity of disability, as well as the intensity of neuropathic symptoms.

No correlation between remifentanil blood, cerebrospinal fluid and cerebral extracellular fluid levels and TCI prediction: a pharmacokinetic study.

BACKGROUND: The aims of this paper were to elucidate the difference in concentration among remifentanil blood, cerebrospinal fluid and cerebral extracellular fluid levels, and to verify the presumable existence of a correlation between arterial and cerebral remifentanil. We used brain microdialysis to shed light on this aspect of the pharmacokinetic and to correlate these findings with Minto's model. METHODS: The study population was formed by 9 patients scheduled for elective intracranial surgery for cerebral supratentorial neoplasia. All patients received general anaesthetic; 100 microliters of dialysate were collected. Furthermore, arterial blood samples of 3 mL each were collected, respectively one at the beginning and one at the end of the sampling period. We determined the concentration of remifentanil and its main metabolite, remifentanil acid, in the blood and in the brain. The predictive performance of the Minto pharmacokinetic parameter set was evaluated by examining the performance error. RESULTS: The mean Performance Error was -45.13% (min -21.80, max -88.75) for the first series of arterial samples, -38.29% (min -6.57, max -79.17) for the second one and 67.73% (min 7, max -93.12) for the extra cellular fluid sample. The concentration of remifentanil set pumps was correlated with blood concentration for both series of samples. Neither the set concentration, nor the arterial samples were correlated with extra cellular fluid values. CONCLUSION: There was a wide interindividual variability with regard both to blood and cerebral remifentanil concentration. Moreover, the ratio between arterial blood and cerebral remifentanil was not consistent among our patients in spite of a stable infusion rate of remifentanil; at the end we found a trend of over prediction in the ratio between the various compartments examined.

Fatal subarachnoid hemorrhage from mycotic aneurysm ruptures in an immunocompetent patient with aspergillosis: a case report.

Cerebral aspergillosis is a rare condition usually encountered in severely immunodepressed patients. We review the case of an immunocompetent patient who developed a fulminant form of cerebral aspergillosis which led to death due to the rapid formation and rupture of multiple mycotic aneurysms in the cerebral arteries. We suggest the possible role of genetic factors in causing this unusual clinical history and we propose that cerebral aspergillosis should be taken into consideration early in the process of diagnosis in order to allow for timely treatment.

Tetraplegia and respiratory failure following mild cervical trauma in a child with Cornelia De Lange syndrome.

Here we report a 6-year-old female patient with Cornelia de Lange syndrome who developed tetraplegia and respiratory failure after a seemingly trivial spinal trauma due to an spinal malformation that has not yet been described.

Remifentanil vs fentanyl with a target controlled propofol infusion in patients undergoing craniotomy for supratentorial lesions.

AIM: Remifentanil hydrochloride is an ultra-short acting m-opioid receptor agonist. This study compared the use of remifentanil with that of fentanyl during elective supratentorial craniotomy in a target controlled infusion (TCI)-propofol anesthesia regimen and evaluated the quality of recovery from anesthesia. METHODS: After written informed consent for this prospective study, 40 adult patients were randomly divided into 2 groups: in group F analgesia was provided with fentanyl 2-3 mg kg(-1) h(-1) and in group R with remifentanil 0.25 mg kg(-1) h(-1). Anesthesia was induced with thiopental and pancuronium bromide, and maintained with propofol-TCI, pancuronium, air and oxygen and fentanyl (group F) or remifentanil (group R), respectively. After tracheal intubation, infusion rate of remifentanil was reduced and then adjusted to maintain stable hemodynamics. Hemodynamics and recovery time were monitored for 60 min after surgery. Analgesic requirements, propofol intraoperative consumption, nausea and vomiting in postoperative period were monitored. Recovery was evaluated according to a modified Aldrete score. RESULTS: Baseline hemodynamics were similar in both groups. Mean arterial pressure differed between the 2 groups (P<0.05) with the greatest decrease in group R during dura opening (P<0.001). Postoperative mean arterial pressure was higher in group R. Patients in group R exhibited a faster recovery. The incidence of nausea and vomiting was similar in the 2 groups. Noteworthy, there was a reduction in the amount of propofol used in group R. CONCLUSIONS: Remifentanil appears to be a reasonable alternative to fentanyl during elective surgery of supratentorial lesions.

Propofol EEG burst suppression in carotid endarterectomy.

BACKGROUND: The results of randomized trials indicate that carotid endarterectomy, performed with a low morbidity-mortality perioperative risk, is the best therapeutic option both for patients with high-grade symptomatic and asymptomatic stenosis. Since the main operative risk is represented by embolic or hemodynamic cerebral ischemia, it appears necessary to maintain an adequate intraoperative cerebral blood flow and to carry out a meticulous endarterectomy. METHODS: On the basis of these considerations we prospectively studied a series of 100 consecutive patients operated on for high-grade carotid stenosis, by using a protocol based on: 1) an accurate selection of patients for surgery; 2) meticulous surgical technique without any shunt; 3) perioperative cerebral protection by barbiturate or propofol; 4) pre- and postoperative medical treatment of risk factors. All patients of our series performed preoperatively brain CT scan, transcranial Doppler, carotid duplex scanning, four vessel angiography, brain 99mTc-HMPAO SPECT. Eighty-two patients had symptomatic carotid stenosis ranged between 70 and 90%, 18 had carotid stenosis higher than 90%. RESULTS: In this series there have been one postoperative death due to myocardial infarction and one major stroke. CONCLUSIONS: We think that this protocol can significantly minimize risks of endarterectomy and probably maximize the benefits of surgery, also in patients with asymptomatic high-grade carotid stenosis.

Hypertonic saline solution: a safe alternative to mannitol 18% in neurosurgery.

BACKGROUND: To evaluate the usefulness of hypertonic saline solutions (HTS) as an alternative to mannitol in neurosurgery. METHODS: Thirty patients subjected to craniotomy for supratentorial cerebral tumors were randomly divided in to three Groups: M: had mannitol 0.5 g.kg-1 as bolus at the start of skin incision, and postoperatively 0.5 g.kg-1 daily three times a day for 3 days (72 hrs); HM: had mannitol 0.25 g.kg-1 as bolus at the start of skin incision plus 3% HTS, 20 ml.h-1 intraoperatively and mannitol 0.25 g.kg-1 daily three times a day for 3 days plus HTS in the concentration of 3% in the first day and 2% and 1% the second and the third day after surgery; H: had 3% HTS 3.5 ml kg-1 as bolus at the start of skin incision plus 3% HTS, 20 ml hr-1 intraoperatively and 3% HTS, 20 ml h-1 on the first day and 2% and 1% the second and the third day after surgery. FR, MAP, ICP, CVP and diuresis were continuously monitored intraoperatively and postoperatively for 72 hrs. ICP was monitored intraoperatively until dural opening and in the postoperative period for 72 hrs at least. RESULTS: Diuresis was increased in the first and second Group (M and HM) more than in the H Group especially in the postoperative period, but this change was not a significative one (35.31 ml.kg-1.h-1+/-4.57 and 36.56+/-3.92 vs 3.23 ml.kg-1.h-1). Mean serum Na+ values declined in the postoperative period, in Groups M and MH and remained stable in the postoperative period in the Group H (137.6+/-7 mEq.l-1 and 136.5+/-6.5 mEq.l-1 vs 139.2+/-5 mEq.l-1). Serum osmolality increased significantly in the postoperative period in group H and remained unchanged in the same period in Group M and MH. Potassium values declined significantly during the whole period in all groups but remained in a normal clinical range. CVP values decreased in Groups M and MH in the postoperative period, and increased although not significantly in the postoperative period in the Group H patients. Ht values declined significantly in all groups without differences among the groups although the reduction was greater in group H. CONCLUSIONS: HTS can safely be used in humans they obtain a reduction of ICP without reducing CVP, serum osmolality and Na+ serum values. Our data underline the possibility of their use as an alternative to mannitol in the treatment of patients scheduled for intracranial surgery, especially when multiple doses are needed.

The tuberous breast syndrome.

The tuberous breast syndrome is the result of a complex series of defects with various degrees of expression. However, much confusion has been generated in the literature by the use of often inadequate terminology, which is partly the cause of multiplicity of managements being proposed that mainly aim to correct the major defect and not the entire syndrome. The surgical approach adopted by our group stems from the improvement of classic techniques, consisting essentially of a combination of periareolar mastopexis, additive mastoplasty, and gland base enlargement by cross incision. Our results were fully satisfying both aesthetically and functionally. We achieved a correct shape, resolved ptosys and reduced areolas with no double-fold effect, and attained good symmetry in more complex unilateral cases.

[The measurement of osmolality in neurologic intensive care]. / La misurazione dell'osmolalità in neurorianimazione. Nota tecnica.

Serum osmolality is one of the end-points in the management of neurologic intensive care patient. Its leading role in the concept of cerebrovascular homeostasis is underlined. Normal plasma osmolality is generally 285 mOsm kg-1, a value determined almost entirely by small molecules and ions (Na+, K+, urea and lactate). The plasma osmolality value is determined by measuring the changes in freezing point related to the zero value of a sample of distilled water. The measurement of plasma osmolality is very easy and inexpensive; its widely use could be very useful in the neurologic intensive care units to improve the treatment of neurological critical patient. According to the authors the monitoring of plasma osmolality should be mandatory to evaluate the effectiveness of treatment of brain edema.

The impact of genetics on Crohn's disease.

BACKGROUND/AIMS: Reports focusing on the familiarity and "pedigree" of patients with Crohn's Disease (CD) are increasing. The study of the role of genetics as a predisposing factor in providing the ideal milieu upon which environmental agents and immuno-inflammatory responses may act, could be paramount in finding the pith of the etiopathogenesis of this disease. METHODOLOGY: In order to determine the impact of familiarity on CD, a series of 187 patients, managed between January 1965 and January 1997, was subdivided into two groups. In group I (145 pts.), the family history relied only on direct information from the patient, while in group II (42 pts.) a prospective study was carried out involving both close and distant relatives who were interviewed and, in some cases, clinically investigated. RESULTS: In this study, relatives with suspected CD were 9 out of 122 in group I patients (7.4%), while in the more detailed assessment of group II, 18 out of 42 cases (43%) had an ascertained CD familiarity. CONCLUSIONS: The importance of familiarity in the pathogenesis of CD may be higher than expected if properly sought for. Reports on the possibility that the onset of CD may be strongly influenced by genetics, favor our hypothesis that the true etiology may find its base in a hemolymphatic disorder of the mesentery followed by superimposed inflammatory responses.

[Subarachnoid hemorrhage and systemic arterial pressure. Physiopathology and perioperative management]. / Emorragia subaracnoidea e pressione arteriosa sistemica. Fisiopatologia e gestione perioperatoria.

A correct assessment of arterial pressure state during subarachnoid haemorrhage (SAH) is one of most critical issue in neurologic intensive care and in neuroanesthesia. It is important to evaluate two different clinical conditions during SAH: before and after aneurysmal clipping or embolization. Before clipping it is mandatory to evaluate a possibility of rebleeding and so it is important to maintain systolic pressure at lower level. Otherwise after clipping it can be useful to maintain systolic pressure at higher level to prevent vasospasm and related ischemia. In this review the Authors examine the pathophysiology of SAH and SAH complications as rebleeding, vasospasm and ischemia. According to international data, they propose pressure parameters appropriated for SAH according to timing of treatment so as to prevent and treat SAH complications.

Hepatic growths mimicking adrenal tumors.

BACKGROUND/AIMS: The upper district of the perirenal space is widely open and compliant, especially on the right side. Hepatic growths can, therefore, easily invade the adrenal gland area, mimicking adrenal tumors and vice-versa for adrenal and renal tumors. Data on the nature and exact origin of a mass in this region are important for appropriate preoperative management, surgical approach and prognosis but, sometimes, even modern imaging fails in this design. METHODOLOGY: The records and imaging documentation of 42 patients with a mass exceeding 6 cm in the hepatorenal space, have been retrospectively reviewed and compared with surgical and histological findings. RESULTS: Among the 14 patients with "non-functioning adrenal tumors," the preoperative diagnosis had been accurate in all but 2 cases where the suspected adrenal lesion turned out, intraoperatively, to be liver growths. These 2 cases are discussed in detail. CONCLUSIONS: The distinction between an intrahepatic and extrahepatic mass challenges modern imaging techniques, and even invasive procedures sometimes fail. A deceptive diagnosis may lead to inappropriate preoperative management and surgical procedures.

Surgery in Crohn's disease: when, where and why the recurrences?

One frustrating feature in the surgical management of Crohn's disease is the high recurrence rate which may lead to reoperation. It is common opinion that relapses occur haphazardly both in time and in site, and the causes remain unknown. When does a recurrence really arise after surgery? Is the site of recurrence determined by definite causes? Is there a relapsing factor? Between 1965 and 1995, 177 patients underwent surgery for Crohn's disease. The procedures performed in 145 cases were those popular at the time, while a recent series of 20 selected patients was managed following a new approach based on epiploonplasty. This strategy stems from the strong conviction that Crohn's disease is not a primary bowel disease but the result of stasis and superimposed infection due to a primary hemolymphatic disorder of the mesentery. The five-year recurrence rate was 62% in patients operated on according to standard procedures, while no recurrences were reported in the epiploonplasty group. Among 12 remaining patients with recurrent disease, two cases are reported in detail because they provide evidence in favor of the hemolymphatic theory. This study also maintains that recurrences, viewed with the hemolymphatic disorder in mind, occur immediately after surgery, while the superimposed intestinal inflammatory process and stricturing events may appear clinically at different time intervals during follow-up. The site of recurrences usually corresponds to the mesenteric region subjected to compression. Altered mesenteric microcirculation appears to be the true essence of the disease.

[Appropriate arterial pressure management for subarachnoid hemorrhage ]. / Regime pressorio arterioso appropriato per l'ESA.

A correct assessment of arterial pressure state during SAH is one of most critical issue in neurologic intensive care. It is important to evaluate two different clinical conditions: a) during SAH when the aneurysm is open, b) after aneurysmal clipping or embolization. The authors propose pressure parameters appropriated for SAH according to the timing of treatment so as to prevent and treat SAH complications.

A new approach in the management of Crohn's disease: observations in 20 consecutive cases.

Although the "modern history" of Crohn's disease dates back to 1932, the etiology is still nebulous, the medical treatment inefficient and resective surgery results in a high recurrence rate. Twenty consecutive patients with terminal ileitis underwent ileo-cecal resection and mesenteric-epiploonplasty to enhance collaterals and lymphatic drainage. This approach was advised by experimental observations (the ligation of colonic lymphatic ducts in rabbits), by the intraoperative use of optics to better appreciate the details of the diseased bowel before and after injecting dye and by the angiographic results in one patient. In rabbit experiments, the obliteration of lymphatic drainage led to Crohn's disease-like macroscopic and microscopic patterns, while diffusion of the dye injected in the diseased segment showed altered lymph flow. The angiographic study in one patient confirmed the presence of vascular anomalies. Direct observation through optics revealed large vessels in the serosa with milky contents and the oozing of sticky exudate. In the 8 patients who underwent this procedure over 5 years ago, there were no recurrences. We strongly believe in the vasculo-lymphatic etiology of Crohn's disease and in mesentery-epiploonplasty as the only actual indirect approach to resolve hemolymphatic obstructions.

Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma.

BACKGROUND: Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. METHODS: One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. RESULTS: Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). CONCLUSIONS: Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

[Total intravenous anesthesia in neurosurgery. Our clinical experience]. / Anestesia endovenosa totale in neurochirurgia. Nostra esperienza clinica.

BACKGROUND: The quality of a "neuroanesthetic" technique is the result of its pharmacokinetics, of its effect on intracerebral homeostasis and metabolism, of its antinociceptive and neuroprotective features. Aim of this study is to test the effectiveness of TIVA as the technique of choice in neurosurgical patients throughout a retrospective analysis of 1982 patients scheduled for brain tumors, neurovascular surgery and spine lesions. METHODS: 1982 patients (1023 F, 959 M), ASA I-IV, aging 15-80 yrs scheduled for neurosurgery were studied. Hemodynamic and electrophysiological parameters were monitored carefully. Time of recovery was evaluated although this parameter is influenced by perioperative clinical status and by area and kind of brain damage. RESULTS: A good hemodynamic stability was observed. Recovery time was quick, related with brain damage and time of surgery. Incidence of postoperative nausea, vomiting and seizures was very low. Two cases of awareness were noted. CONCLUSIONS: 1982 neurosurgical operations were carried out in TIVA without major complications and side effects: the authors are therefore sure that TIVA can be considered the anesthetic technique "of choice" in neurosurgical patients.

Early percutaneous endoscopic gastrostomy (PEG). A safe and effective enteral feeding technique in neurologic intensive care unit.

Enteral feeding by percutaneous gastrostomy is recommended as the "best choice" in NICU patients. It allows us to obtain early gut activation and to prevent physiopathologic events leading to multiorgan failure syndrome. In this retrospective study the Authors describe their experience related to 76 patients admitted in NICU between January 1992 and April 1994. In these patients percutaneous gastrostomy was easily and safety performed at the bedside with early enteral nutrition and drug administration and a related low incidence of infections complicating central and peripheral vein catheterization. Moreover the authors underline the avoidance of nasogstric tube and its side effects and a good compliance of patients and nurses that seems to be a real advantage of this technique. The authors suggest their 13 guidelines to improve management of enteral nutrition by gastrostomy and to avoid its short-comings.

[Surgical treatment of rectal cancer: comparison of anterior resection and abdominoperineal excision]. / Trattamento chirurgico del cancro del retto: resezione anteriore e amputazione addomino-perineale a confronto.

From 1987 to 1992, 91 rectal neoplasms were operated in the Istituto di Patologia Speciale Chirurgica of the University of Bologna: 50 anterior resections and 41 abdomino-perineal amputations. The local recurrence rate shows no significant difference between the two groups. The mortality rate is 7.6% in anterior resections and 14.2% in abdomino-perineal amputations. Our results and literature review show that local recurrence and mortality rates depend more from the tumor stage than from the surgical procedure.

[Primary gastric lymphoma. Diagnostic and therapeutic considerations on 30 cases]. / Il linfoma gastrico primitivo. Considerazioni diagnostico-terapeutiche su 30 casi.

From 1987 to 1992, 30 cases of Primary Gastric Lymphoma were operated in the Institute of Patologia Speciale Chirurgica of the University of Bologna. Clinical features, diagnostic findings, therapeutic procedures and histologic characteristics are reported. The results are discussed after a brief literature review.