Postoperative cognitive worsening in seniors with an age above life expectancy: a prospective longitudinal study.

BACKGROUND: The growing number of elderly patients in hospitals is a challenge for healthcare systems. The main objective is to measure the postoperative change in the cognitive status at hospital discharge and one year after discharge in elderly patients undergoing planned or deferrable surgery. METHODS: We planned a prospective longitudinal study, single-center study: secondary care level hospital, enrolment from September 2018 to May 2019. We enroll elderly patients, aged above life expectancy in Italy, who underwent planned or deferrable surgery (men over 80.5 years old, women over 85.0 years old). In six months, we enrolled 76 eligible patients. We collected the scores of the clinical impairment scales Charlson Index, Barthel Index, and Six-Item Cognitive Impairment Test (6CIT). The primary endpoint was the postoperative worsening of the cognitive status at one-year follow-up. Secondary endpoints aimed to describe postoperative disabilities and complications, to investigate possible risk factors for cognitive worsening, and to measure the role of anesthesia in cognitive changes. RESULTS: We recorded an increased rate of pathological 6CIT values during the hospitalization period, rising from 39.47% to 55.26% (McNemar test, P=0.007), and this rate was still increased at 55.56% (P=0.021) one year after discharge. Anesthesia did not show any significant harmful effect on cognitive status. The preoperative hemoglobin value seems to be a risk factor for cognitive status and one-year mortality. CONCLUSIONS: Elderly patients had a significantly worse 6CIT value after planned surgery, which may derive in part from age and in part from hospitalization. It is difficult to determine if general anesthesia alone has no harmful effects on cognitive performance in patients at discharge and one year later. Further data are necessary.

[Clozapine-induced Tubulointerstitial Nephritis].

Tubulointerstitial nephritis is a common cause of acute renal failure, in two thirds of cases it is associated with drugs (mostly antimicrobials and NSAIDs), in 5-10% of cases it is associated with infections (bacterial/viral/parasitic), in 5-10% of cases it is idiopathic (this is the case of the TINU syndrome characterized by interstitial nephritis and bilateral uveitis, and the anti-glomerular basal membrane antibody syndrome), and finally in 10% of cases it is associated with systemic diseases (sarcoidosis, by Sjogren, LES). The pathogenesis is based on a cell-mediated immune response and in most cases removing the causative agent is the gold standard of therapy. However, a percentage of patients, in a variable range from 30% to 70% of cases, do not fully recover renal function, due to the rapid transformation of the interstitial cell infiltrate into vast areas of fibrosis. Clozapine is a second generation atypical antipsycothic usually used for the treatment of schizophrenia resistant to other types of treatment; it can cause severe adverse effects among which the best known is a severe and potentially fatal neutropenia, furthermore a series of uncommon adverse events are recognized including hepatitis, pancreatitis, vasculitis. Cases of acute interstitial tubular nephritis associated with the use of clozapine have been described in the literature, although this complication is rare. Medical personnel using this drug need to be aware of this potential and serious side effect. We describe the case of a 48-year-old man who developed acute renal failure after initiation of clozapine.

COVID-19 Biomarkers for Critically Ill Patients: A Compendium for the Physician.

BACKGROUND: SARS-CoV-2 clinical manifestation and progression are variable and unpredictable, hence the importance of considering biomarkers in clinical practice that can be useful for both diagnosis and prognostic evaluation. This review aims to summarize, for intensive care physicians, the most recent state of knowledge regarding known COVID-19 in critical patients. We searched PubMed® using the Boolean operators and identified all results on the PubMed® database of all studies regarding COVID-19 biomarkers. We selected studies regarding endothelium, cytokines, bacterial infection, coagulation, and cardiovascular biomarkers. METHODS: We divided the results into four essential paragraphs: "Cytokine storm", "Endothelium dysfunction and coagulation biomarkers in COVID-19", "Biomarker of sepsis", and Cardiovascular lung and new perspectives. RESULTS: The assessments of the severe COVID-19 prognosis should monitor, over time, IL-6, soluble Von Willebrand factor (VWF), P-selectin, sCD40L, thrombomodulin, VCAM-1, endothelin- Troponin, D-dimer, LDH, CRP, and procalcitonin. Metabolomic alterations and ACE2 receptors represent new perspectives. DISCUSSION AND CONCLUSIONS: Early identification of critically ill patients has been crucial in the first COVID-19 pandemic wave for the sustainability of the healthcare emergency system and clinical management. Only through the early identification of the most severe patients can they be provided with the most appropriate treatments.

Point-of-care pancreatic stone protein measurement in critically ill COVID-19 patients.

INTRODUCTION: Pancreatic stone protein (PSP) is a novel biomarker that is reported to be increased in pneumonia and acute conditions. The primary aim of this study was to prospectively study plasma levels of PSP in a COVID-19 intensive care unit (ICU) population to determine how well PSP performed as a marker of mortality in comparison to other plasma biomarkers, such as C reactive protein (CRP) and procalcitonin (PCT). METHODS: We collected clinical data and blood samples from COVID-19 ICU patients at the time of admission (T0), 72 h later (T1), five days later (T2), and finally, seven days later. The PSP plasma level was measured with a point-of-care system; PCT and CRP levels were measured simultaneously with laboratory tests. The inclusion criteria were being a critical COVID-19 ICU patient requiring ventilatory mechanical assistance. RESULTS: We enrolled 21 patients and evaluated 80 blood samples; we found an increase in PSP plasma levels according to mixed model analysis over time (p < 0.001), with higher levels found in the nonsurvivor population (p < 0.001). Plasma PSP levels achieved a statistically significant result in terms of the AUROC, with a value higher than 0.7 at T0, T1, T2, and T3. The overall AUROC of PSP was 0.8271 (CI (0.73-0.93), p < 0.001). These results were not observed for CRP and PCT. CONCLUSION: These first results suggest the potential advantages of monitoring PSP plasma levels through point-of-care technology, which could be useful in the absence of a specific COVID-19 biomarker. Additional data are needed to confirm these results.

Health Care Management during a Major Planned Event in Italy.

Events involving a high number of participants should be planned and implemented with the primary objective of guaranteeing the highest possible level of safety, which is ever more essential in the recent years due to the risk of terrorism, violence, and highly transmissible pathogens like coronavirus disease 2019 (COVID-19).The aim of this study was describing health care management of the Vasco Modena Park July 1, 2017 concert by the artist Vasco Rossi that involved 220,000 participants, more than doubling the population of Modena (Italy), the city hosting the event.Data were retrospectively collected from all health care registers used during the concert. Descriptive data regarding the event were recorded, as well as the medical records generated by the advanced medical posts.For analysis, patients were divided into two groups: the LOW-Severity (admission code green) and HIGH-Severity (admission codes yellow and red). The number of patients within the inclusion period was 1,088; there were 953 green discharge codes (97.74%), 16 yellow (1.64%), and six red (0.61%). Patients who needed a second-level assessment were 5.85% (57 events). HIGH-Severity patients needed to be further evaluated in 45.45% of the cases versus 4.93% of the LOW-Severity patient group (P value <.001).The health care management proved adequate to the number of participants and the severity of patients. Descriptive data reported add the mass-gathering database useful for further events.

On-chip magnetophoretic capture in a model of malaria-infected red blood cells.

The search for new rapid diagnostic tests for malaria is a priority for developing an efficient strategy to fight this endemic disease, which affects more than 3 billion people worldwide. In this study, we characterize systematically an easy-to-operate lab-on-chip, designed for the magnetophoretic capture of malaria-infected red blood cells (RBCs). The method relies on the positive magnetic susceptibility of infected RBCs with respect to blood plasma. A matrix of nickel posts fabricated in a silicon chip placed face down is aimed at attracting infected cells, while healthy cells sediment on a glass slide under the action of gravity. Using a model of infected RBCs, that is, erythrocytes with methemoglobin, we obtained a capture efficiency of about 70% after 10 min in static conditions. By proper agitation, the capture efficiency reached 85% after just 5 min. Sample preparation requires only a 1:10 volume dilution of whole blood, previously treated with heparin, in a phosphate-buffered solution. Nonspecific attraction of untreated RBCs was not observed in the same time interval.

Intensive Care Patients from the First COVID-19 Wave: One-Year Survival after Tocilizumab Treatment.

INTRODUCTION: An infection by COVID-19 triggers a dangerous cytokine storm, so tocilizumab has been introduced in Italy as an agent blocking the cytokine storm. This paper aims to describe the one-year survival of ICU patients treated with tocilizumab. METHODS: This observational study enrolled all patients confirmed to be infected by COVID-19 who were admitted to the ICU in our center. We offered tocilizumab to all non-septic patients if they did not present any contraindications. RESULTS: We enrolled 68 ICU patients in our center on 72 occasions during the enrollment period; we excluded four patients due to study criteria. The one-year mortality hazard ratio of treated patients was 0.64, with a confidence interval of 0.31 to 1.19, with p = 0.169. Among the survivors, 32 of 35 patients answered the phone interview (14 patients in the treated group and 18 in the untreated group); overall, the effect of COVID-19 on quality of life was 58.14%. These effects were lower in the tocilizumab group, with p = 0.016 *. CONCLUSIONS: Our observational data follow the most relevant largest trial. Patients treated with tocilizumab had lower rates of new-onset symptoms later COVID-19 ICU hospitalizations. As reported by recent medical literature, the presence of these symptoms suggests that a follow-up program for these types of patients could be useful.

How Artificial Intelligence and New Technologies Can Help the Management of the COVID-19 Pandemic.

The COVID-19 pandemic has worked as a catalyst, pushing governments, private companies, and healthcare facilities to design, develop, and adopt innovative solutions to control it, as is often the case when people are driven by necessity. After 18 months since the first case, it is time to think about the pros and cons of such technologies, including artificial intelligence-which is probably the most complex and misunderstood by non-specialists-in order to get the most out of them, and to suggest future improvements and proper adoption. The aim of this narrative review was to select the relevant papers that directly address the adoption of artificial intelligence and new technologies in the management of pandemics and communicable diseases such as SARS-CoV-2: environmental measures; acquisition and sharing of knowledge in the general population and among clinicians; development and management of drugs and vaccines; remote psychological support of patients; remote monitoring, diagnosis, and follow-up; and maximization and rationalization of human and material resources in the hospital environment.

A prognostic risk score for major amputation in dialysis patients with chronic limb-threatening ischemia after endovascular revascularization.

BACKGROUND: Almost 38% of all patients with end-stage chronic kidney disease (CKD) have peripheral arterial disease of the lower limbs that can lead to chronic limb threatening ischemia (CLTI). The aim of this study was to assess the impact of several factors to conduct a stratification of the amputation risk in CKD patients with CLTI receiving endovascular revascularization. METHODS: Observational, retrospective, single-center study of patients treated from 2010 to 2016. The primary endpoint was the major amputation. The study included adult CKD dialysis patients affected by CLTI (rest pain and/or trophic lesions) with indication to endovascular revascularization and excluded for open repair. RESULTS: A total of 82 patients were considered (58 men [70.7%], 24 women [29.3%] mean age 70.4±15.0 years). The number of major amputations was 28 (34.1%). The arterial lesion severity (TASC II-classification) and the trophic lesions extension (WIfI classification) were significantly associated with major amputation (OR and 95%CI, 1.20 [1.07-1.34], P=0.001; 2.65 [1.49-4.72], P=0.001; respectively). Based on the above-mentioned characteristics, a prognostic score was proposed to predict the major amputation risk. A score ≥23 was associated with a 67.6% probability of amputation in the following 12 months. CONCLUSIONS: The CLTI revascularization is associated with poor outcomes in CKD patients. The present clinical score provided a pragmatic tool to calculate the major amputation risk. An elevated score could facilitate the decision-making process in order to perform an endovascular treatment vs. conservative approach.

The effects of the general anesthetic sevoflurane on neurotransmission: an experimental and computational study.

The brain functions can be reversibly modulated by the action of general anesthetics. Despite a wide number of pharmacological studies, an extensive analysis of the cellular determinants of anesthesia at the microcircuits level is still missing. Here, by combining patch-clamp recordings and mathematical modeling, we examined the impact of sevoflurane, a general anesthetic widely employed in the clinical practice, on neuronal communication. The cerebellar microcircuit was used as a benchmark to analyze the action mechanisms of sevoflurane while a biologically realistic mathematical model was employed to explore at fine grain the molecular targets of anesthetic analyzing its impact on neuronal activity. The sevoflurane altered neurotransmission by strongly increasing GABAergic inhibition while decreasing glutamatergic NMDA activity. These changes caused a notable reduction of spike discharge in cerebellar granule cells (GrCs) following repetitive activation by excitatory mossy fibers (mfs). Unexpectedly, sevoflurane altered GrCs intrinsic excitability promoting action potential generation. Computational modelling revealed that this effect was triggered by an acceleration of persistent sodium current kinetics and by an increase in voltage dependent potassium current conductance. The overall effect was a reduced variability of GrCs responses elicited by mfs supporting the idea that sevoflurane shapes neuronal communication without silencing neural circuits.

Why should you stay one night? Prospective observational study of enhanced recovery in elderly patients.

BACKGROUND: Delirium is a severe condition that can arise in many contexts during hospitalization. The aim of this research was to measure the incidence of postoperative delirium in patients aged 75 years or older, with the exclusion of those with preexisting neurocognitive disorders (NCD), who underwent fast-track, moderate surgery. METHODS: We conducted a prospective cohort study with patients ≥ 75 years of age who were eligible for fast-track, moderate surgery, without severe dementia, with a planned hospitalization of 24 h and with a physical status varying from very fit to vulnerable. The 4-item confusion assessment method (CAM4) was used to measure delirium. RESULTS: Of the 209 eligible patients, 195 subjects were enrolled in the study. The percentage of the population with a CAM4 score above 0 before surgery was 2.56%; after surgery, the percentage was 10.25%; and on the following day, the percentage was 4.61%. There was a statistically significant difference in the CAM4 scores between immediately after surgery and at 24 h after surgery (p = 0.0172). CONCLUSION: The data from this study support an enhanced recovery approach for elderly patients, in which after a minor surgical procedure with anaesthesia, a recovery period of one night in the hospital can contribute to normalizing the CAM4 score and reducing the incidence of delirium.

Keyboard Contamination in Intensive Care Unit: Is Cleaning Enough? Prospective Research of In Situ Effectiveness of a Tea Tree Oil (KTEO) Film.

After the SARS-CoV-2 pandemic, disinfection practices and microbial load reduction have become even more important and rigorous. To determine the contamination of keyboard surface and the relative risk to transfer healthcare-associated pathogens to susceptible patients, as it frequently happens in Intensive Care Unit (ICU), a standard keyboard (SK), a cleanable keyless keyboard (KK) with smooth surface and a standard keyboard coated with a 3 M Tegaderm® film added with active essential oil (tea tree oil) (KTEO) were tested. S. aureus, including MRSA strains, were detected in ICU, with values ranging from 15% to 57%. Gram negative strains belonging to the Enterobacteriaceae family were also found with values ranging from 14% to 71%. Similar Gram positive and Gram negative strains were found on all surfaces, but with low percentage, and only environmental bacteria were detected using the settling plates method. The Microbial Challenge Test performed on KTEO showed high rates of decrease for all the pathogens with statistical significance both at 24 and 48 h (p = 0.003* and p = 0.040*, respectively). Our results suggest that the use of KTEO may be a feasible strategy for reducing the transmission of pathogens in health care setting and may be complementary to surface cleaning protocols.

Novel Coronavirus (2019-nCov) do you have enough Intensive Care Units? / Nuevo coronavirus (2019-nCov): ¿tiene suficientes unidades de cuidados intensivos?

No disponible

Overview of the main challenges in shared decision making in a multicultural and diverse society in the intensive and critical care setting.

BACKGROUND: In shared decision making, health care professionals and patients collaborate in making health-related choices. This process is based on autonomy and constitutes one to the elements of patient-centered care. However, there are situations where shared decision making is more difficult, if not impossible, due to barriers, which may be related to language, culture, education, or mental capacity and external factors like the state of emergency or the availability of alternative sources of information. AIM: The aim of this paper is to identify some of the main obstacles to the adoption of shared decision making in an intensive and critical care scenario and discuss potential ways to facilitate its implementation. METHODS: We conducted a literature review on shared decision making from the perspective of intensive and critical care specialists. DISCUSSION: Although the health care context is complex and the variety of situation that can arise makes it impossible to prepare professionals for every occurrence, shared decision making process should be structured at an organization level, engaging health care professionals, experts of communication, and patient representatives coming from different cultural backgrounds, languages, and education to assemble for all the main procedures, where shared decision making is involved, the specific information packages health care professionals will use in order to guide them through the process and ensuring all patients receive a comparable level of engagement. Shared decision making should not become a hindrance for the health care professional but on the contrary a way to strengthen their relationship with the patient. CONCLUSION: The implementation of the shared decision making approach at an organization-wide level improves its quality and effectiveness.

Propofol: a safe anaesthetic drug in experimental cardiac surgery in rabbits.

ACKGROUND: Experimental surgery needs a pharmacological approach that can interfere with cardiac function. CASE REPORT: In a animal model of regenerative medicine of myocardium we use an anaesthesiological protocol that included Propofol, a benzodiazepine (Midazolam) and an alpha-2 adrenergic agent. RESULTS: In a group of 15 rabbits undergoing cardiac surgery we reported 1 arrhythmic complication during stem cell injection. DISCUSSION: The functional cardio- respiratory depressor activity of Propofol was compensated by alpha-2 adrenergic drugs, avoiding serious complications. We hypothesize that the functional cardio-respiratory depressor of different anaesthesiological drugs can be reversed by the contemporary administration of with adrenergic agents. KEY WORDS: Arrhythmias, Cardiac ischemia, Cardiovascular toxicity, Propofol.

The burden of not-weighted factors - Nursing workload in a medical Intensive Care Unit.

OBJECTIVES: Body weight and infection status affect nursing workload and are not accounted for in the Therapeutic Intervention Scoring System 28 (TISS-28) and Nine Equivalents of Nursing Manpower Use Score (NEMS). The objective of this study was to analyse the correlation between weight and infection status with TISS 28 and NEMS in a cohort of medical Intensive Care Unit patients. RESEARCH METHODOLOGY: A retrospective observational trial was conducted on the nursing records of 26 randomly selected patients over a 12-month period. TISS-28 and NEMS were calculated for each day of ICU stay. Infectious status was determined based on positive cultures to multi-resistant organisms while overweight and obesity were based on Body Mass Index. RESULTS: A total of 809 nursing shifts' activity records were analysed. There were 12 infected patients that required isolation, 14 overweight patients and 3 obese: 9 patients presented both conditions. Only the presence of both conditions was statistically associated with an increase in workload (TISS-28p-value = 0.041 and NEMS p-value = 0.011). CONCLUSIONS: Although TISS-28 and NEMS do not specifically consider body weight and infection status, their integration into nursing workload scores may improve the accuracy as management tools, increasing the quality of the cares provided.

Response by Twin Italian Hub Hospitals in a Double Seismic Event: A Retrospective Observational Investigation.

INTRODUCTION: The objectives of this study were to compare prevalence rates of different pathologies, ambulance system and emergency department management times, and patient survival and hazard ratios for codes 2 and 3 in two hub hospitals in Modena in the 36-month period across the stages of two major earthquakes in short sequence in Northern Italy in 2012. METHODS: Clinical records pertaining to the emergency care of patients were analyzed and only those assigned status codes 2 and 3 by ambulance professionals were included (if the assessment was confirmed by emergency department triage). The statistical analysis of data was divided by three time periods studied: before, during/between, and after the earthquakes. RESULTS: Among the 2,278 retained records, there were no statistically significant differences in the prevalence of the main pathologies presented at the two hubs in the studied period. A Cox regression model was used to analyze the survival of patients in the different stages of the emergency; there were no statistically significant differences in the hazard ratios of death before, during, and after the earthquake. The study found a significant increase in emergency department treatment times. DISCUSSION: Redundancies in the Modena medical system were found to have compensated for damaged hospital facilities. In particular, they helped emergency systems reorganize themselves faster in order to bring medical assistance to people during and around seismic events with as a minimal amount of disruption as possible. CONCLUSION: The Modena medical system was redundant and ensured that disrupted emergency systems were reorganized and put back online while damaged hospital facilities were compensated for/reproduced elsewhere.