Mini-Open Surgical Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Adolescents.

OBJECTIVE: Evaluate treatment and outcome of mini-open fasciotomy (MOF) in a population of adolescent motorcycling racers affected by forearm chronic exertional compartment syndrome (CECS). DESIGN: Prospective case series. SETTING: University hospital/private practice. PATIENTS: Nine professional motorcycling adolescents were diagnosed with forearm CECS. All were treated with MOF between 2007 and 2012 and followed for a minimum of 5 years (range 5-10 years). Age, sex, body mass index, laterality, and profession were recorded. INTERVENTIONS: A MOF to obtain decompression of all compartments was performed in all patients. MAIN OUTCOME MEASURES: Visual analog scale; a subjective scale to measure strength; and Quick-DASH functional scores. Time to resume full riding capacities as the short-term evaluation. RESULTS: A significant decrease in visual analog scale (P < 0.001) and Quick-DASH (P < 0.001) scores was observed in the first 3 months, stabilizing during follow-up (P = 0.521; P = 0.217). Average time to return to sport was 2.8 ± 1 week. No symptom recurrence was reported, but one patient suffered a minor complication. There were no cases of infection, hematoma, or peripheral nerve injury. CONCLUSIONS: We assess that MOF can be a valid alternative for the treatment of forearm CECS in adolescent competitive motorcycling racers, as demonstrated by the good success rate and minimal incidence of complications during follow-up. LEVEL OF EVIDENCE: IV, case series.

Long-Term Outcome of Mini-Open Surgical Decompression for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Riders.

OBJECTIVE: To evaluate results of mini-open fasciotomy (MOF) in high-level motorcycling or motocross riders with chronic exertional compartment syndrome (CECS) at long-term follow-up (minimum 5 years). DESIGN: Case series. LEVEL OF EVIDENCE: IV. SETTING: University Hospital/Private Practice. PATIENTS: Fifty-four professional motorcycling riders treated with MOF for a CECS of the forearm from January 2006 to June 2011. Inclusion criteria comprised: high-level motorcycling or motocross riders, clinical symptoms of CECS for at least 6 months, diagnosis confirmed using preoperative compartment hydrostatic pressure measurement and/or magnetic resonance imaging of the forearm, minimum follow-up of 5 years. INTERVENTIONS: A MOF to obtain decompression of all compartments was performed in all patients. MAIN OUTCOME MEASURES: Visual analog scale; a subjective scale to measure strength; QuickDash functional scores. Time to resume full riding capacities as short-term evaluation. RESULTS: A total of 54 patients who underwent 77 MOF procedures overall (23 bilateral) were included. The mean age was 23.6 ± 5.2 years. Mean Visual Analog Scale decreased from a preoperative value of 68.2 to a 3-month postoperative value of 26 (P < 0.001). Mean QuickDash scale was 84 at preoperative registration, falling to 20, 3 months after surgery (P < 0.001) and down to 12 at 1-year follow-up (P = 0.017). The average time to return to full riding capacities was 3.5 ± 1 week. CONCLUSIONS: Mini-open fasciotomy resulted safe and effective for the treatment of chronic exertional compartment syndrome in high-level motorcycling or motocross riders. The good outcome at follow-up resulted stable at 5 years and the incidence of complications remained low. Our data demonstrate that the resolution of symptoms is reliable and durable. Pain recovery was immediate after surgery, instead functional scores showed a more gradual recovery throughout the 12 months after surgery. CLINICAL RELEVANCE: Mini-open fasciotomy is a reliable treatment for CECS of the forearm in professional motorcycling riders. This treatment should also be considered in young riders due to the absence of tardive relapse reported in this study.

Management of intersection syndrome in professional motorcycle rider: a case report.

BACKGROUND AND AIM OF THE WORK: Intersection syndrome is an uncommon and underdiagnosed condition, especially found in sport overuse. This case report describes the treatment of a professional motor biker who presented intense wrist pain and swelling after training sessions. METHODS: The athlete was treated with rest, the use of a wrist splint combined with NSAIDs, physical therapy, including pulsed Nd-YAG laser therapy and exercise, such as stretching and release, massage and eccentric training. RESULTS: The applied therapeutic protocol was successful and allowed the biker to completely resolve the symptoms and return to training session and professional races at full power. The results are durable at 5 months post injury follow up. CONCLUSIONS: This experience suggests that pulsed Nd-YAG laser therapy can be an additional useful tool in the global approach treatment for intersection syndrome, contributing with splint and manual therapy, to full recovery even in mechanically stressful conditions. (www.actabiomedica.it).

A torso model comparison of temperature preservation devices for use in the prehospital environment.

BACKGROUND: Hypothermia is an independent predictor of increased morbidity and mortality in patients with trauma. Several strategies and products have been developed to minimise patients' heat loss in the prehospital arena, but there is little evidence to inform the clinician concerning their effectiveness. METHODS: We used a human torso model consisting of two 5.5-litre fluid bags to simultaneously compare four passive (space blanket, bubble wrap, Blizzard blanket, ambulance blanket) and one active (Ready-Heat II blanket) temperature preservation products. A torso model without any temperature preservation device provided a control. For each test, the torso models were warmed to 37°C and left outdoors. Core temperatures were recorded every 10 min for 1 h in total; tests were repeated 10 times. RESULTS: A significant difference in temperature was detected among groups at 30 and 60 min (F (1.29, 10.30)=103.58, p<0.001 and F (1.64, 14.78)=163.28, p<0.001, respectively). Mean temperature reductions (95% CI) after 1 h of environmental exposure were the following: 11.6 (10.3 to 12.9) °C in control group, 4.5 (3.9 to 5.1) °C in space blanket group, 3.6 (3 to 4.3) °C in bubble-wrap group, 2.1 (1.7 to 2.5) °C in Blizzard blanket group, 6.1 (5.8 to 6.5) °C in ambulance blanket group and 1.1 (0.7 to 1.6) °C in Ready-Heat II blanket group. CONCLUSIONS: In this study, using a torso model based on two 5 L dialysate bags we found the Ready-Heat II heating blanket and Blizzard blanket were associated with lower rates of heat loss after 60 min environmental exposure than the other devices tested.

Fall from height: a case report.

The manuscript reports the case of a 16-year-old boy who fell from a height of 15 meters while having a cellphone conversation. Surprisingly, only minor injuries were reported. Prognostic factors related to falls from height are still debated; the present case is a further contribution to the discussion.

Improving laboratory test ordering can reduce costs in surgical wards.

Background and Aim Laboratory blood tests for hospitalized patients are often overused. Excessive costs and no proof of benefit suggest re-evaluating the current approach to laboratory test ordering. The aim of the study is to improve the decision-making process of test ordering and to investigate what effect a rational, evidence-based use of laboratory test ordering in surgical wards would have on costs and healthcare resources. Methods Three-phase experimental prospective study carried out at the tertiary referral teaching hospital of Parma. Phase 1 (baseline status). The baseline status of laboratory test ordering was evaluated by recording the number of biochemical tests requested for patients undergoing elective surgery. Laboratory tests were grouped in "recommended" (RT) and "non recommended" (nRT) tests on the basis of pertinent literature. Phase 2 (improvement action): new guidelines were introduced into clinical practice. Phase 3 (feedback): Prospective data collection for first and second feedback was performed with no advance notice. Results A highly significant reduction in test ordering was found on occasion of the phases 2 and 3 of the study. The overall number of tests decreased, largely due to a decrease in the use of nRT. Conclusions Analysis was justified by the fact that most test requests proved not to be supported by clinical evidence. Inappropriate ordering of laboratory tests results in an unnecessarily high number of requests, which do not in turn improve patient management. Moreover, more appropriate, evidence-based laboratory test ordering for patients undergoing elective surgery may produce a significant reduction in costs, particularly in high-cost settings. (www.actabiomedica.it).

Comparison of two different approaches to hypotension following spinal anaesthesia for Caesarean delivery: effects on neonatal and maternal wellbeing.

BACKGROUND: Maternal hypotension during spinal anaesthesia for Caesarean delivery is a common event, with potential detrimental consequences. We led a prospective, randomized study to compare the effects of two strategies on neonatal and maternal wellbeing. METHODS: Parturients scheduled for elective Caesarean section in spinal anaesthesia were preoperatively studied with a supine stress test. Those with a positive test were enrolled in the study and received a solution of 0.5% hyperbaric bupivacaine 12.5 mg and 0.02% morphine 200 µg intrathecally. Patients received a 37.5 mg/h preventive intravenous (IV) infusion of ephedrine (Pharmacologic Group), or a 15° left lateral tilt (Non-Pharmacologic Group). In Pharmacolgic Group hypotension was treated for 20% drops in systolic blood pressure; in Non-Pharmacolgic Group only severe hypotension - defined as a 40% drop in systolic blood pressure - was treated. RESULTS: Thirty-six patients were studied. Study groups were statistically similar in terms of demographic variables and intraoperative times. No statistical differences were found in terms of umbilical arterial blood base excess [-1.4 (-3.7 to -0.3) mEq/l Pharmacologic Group vs. -1.7 (-2.7 to -1.0) mEq/l Non-Pharmacologic Group; p=0.815] and other umbilical blood gas values. Apgar scores were statistically similar between study groups. Treatment for hypotension was required by 13 (72.2%) patients in Pharmacologic Group and 9 (50%) patients in Non-Pharmacologic Group (p=0.171). No differences were found at the analysis of serial changes in vital signs. CONCLUSIONS: Both studied strategies guaranteed a comparable safe outcome in terms of maternal and neonatal wellbeing. (www.actabiomedica.it).

The learning curve for laryngoscopy: Airtraq versus Macintosh laryngoscopes.

PURPOSE: Airtraq use by inexperienced personnel has been evaluated in simulator studies, but little is known about the learning process in real patients. This prospective study was designed to compare learning curves for laryngoscopy with the Airtraq or Macintosh laryngoscopes in patients under general anesthesia. METHODS: Ten medical students with no prior experience in airway management were recruited on a voluntary basis and underwent training in Macintosh and Airtraq laryngoscopy. Patients with no difficult intubation criteria were enrolled after consent. Each student performed laryngoscopy with either device on ten consecutive patients. Success was defined as Cormack-Lehane grading ≤2. We also recorded subjective difficulty scores on an 11-point numerical rating scale. Learning curves were drawn using cumulative success rates and 95% confidence intervals calculated with bootstrap procedures. RESULTS: The mean (95% CI) success rates for the procedures were 86.0% (76.7-93.3%) for the Airtraq and 64.0% (52.0-75.0%) for the Macintosh laryngoscope. Differences in success rate were significant from the fourth attempt and were 22.0% (8.2-36.5%) after the tenth. Seven students achieved success rates ≥90% using the Airtraq, versus one using the Macintosh (P = 0.022). Median (25th-75th percentile) difficulty scores were 2 (1-4) and 4 (2-6), respectively (P < 0.001). CONCLUSION: Students achieved higher success rates using the Airtraq laryngoscope during early training on live patients. The Airtraq may be a useful choice for teaching advanced airway management, especially to professionals who will not perform laryngoscopy on a regular basis.

Gender differences in case mix and outcome of critically ill patients.

INTRODUCTION: The potential for gender-related bias in the provision of medical treatments has gained increased interest in recent years. The aim of this retrospective, observational study was to evaluate the association between gender and clinical outcome in an Italian mixed medical-surgical ICU population. METHODS: Data on 1978 patients admitted to the ICU during a 3-year period were analyzed. Demographics, diagnosis, and hospital stay details were recorded. RESULTS: Male ICU admissions were predominant over female ones (64% vs 36%). Neither ICU survival rate (80% in group male, 79% in group female; P = 0.602) nor hospital survival rate (72% in group male, 72% in group female; P = 0.820) showed gender-related differences. A statistically significant difference was found in terms of mean (SD) age (57 [19] years in group male, 62 [18] years in group female; P < 0.001), ICU length of stay (7.0 [9.1] days in group male, 5.7 [7.7] days in group female; P < 0.001) and length of mechanical ventilation (6.3 [8.4] days in group male, 5.3 [7.5] days in group female; P = 0.001). Severity of illness, measured through the simplified acute physiology score II, was not statistically different between gender groups; nor was the incidence of infective complications. After stratifying for diagnostic subgroups a few gender differences were pointed out, but none of them affecting ICU and hospital survival rates. A Kaplan-Meier 30-day ICU survival analysis revealed no differences between the male and female groups of the study population. CONCLUSIONS: According to our results, mortality among critically ill patients was not influenced by gender. Despite a higher frequency of men admitted, women were older than men. Moreover, men were treated for a longer period of time than women. Limitations of the study were the inability to establish causal relations and to account for variables with important effects on the reported associations. Moreover, the sample size was small if compared to similar multicenter studies.

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers.

STUDY OBJECTIVE: To evaluate the effects on systemic hemodynamics of sequential pneumatic compression of the lower limbs in healthy volunteers. DESIGN: Prospective, self-controlled, volunteer study. SETTING: University teaching hospital. PATIENTS: 11 healthy volunteers, aged 25 +/- 1.3 years. INTERVENTIONS AND MEASUREMENTS: After volunteers underwent a 6-hour period of fasting and 15 minutes of rest in the supine position, baseline systemic hemodynamics were assessed using transthoracic electrical bioimpedance. Peripheral venous pressure was measured using a 16-gauge intravenous cannula inserted in the forearm and connected to a pressure monitor. Then sequential pneumatic compression of the lower limbs was activated for a 30-minute period, and systemic hemodynamic measurements were repeated. In each volunteer, measurements were repeated twice in two consecutive days, and average values were calculated for each volunteer. MAIN RESULTS: After activation of sequential pneumatic compression of the lower limbs, mean arterial blood pressure increased from 90 mmHg (79-107 mmHg) to 95 mmHg (79-129 mmHg) (P = 0.02), whereas heart rate decreased from 79 bpm (51-94 bpm) to 75 bpm (53-90 bpm) (P = 0.02). This was associated with a significant increase in peripheral vascular resistance index (from 545 [440-1066] to 613 [369-1280] dynes s cm(-5) m(-2) [P = 0.013]) and reduction in cardiac index (from 3.4 [2.7- 4.5] to 3.2 [2.5-4.0] L/min per m2 [P = 0.034]). CONCLUSIONS: The application of sequential pneumatic compression to the lower limbs is associated with minor increases in mean arterial blood pressure, with moderate reduction of cardiac output and heart rate.

Effects of baricity of 0.5% or 0.75% levobupivacaine on the onset time of spinal anesthesia: a randomized trial.

PURPOSE: Levobupivacaine has been extensively evaluated for spinal anesthesia. Its pharmacologic properties are similar to those of bupivacaine, but differences in density between two commercially-available preparations of plain levobupivacaine might lead to different block profiles. We examined the characteristics of spinal anesthesia using the same dose of 0.5% and 0.75% plain levobupivacaine. METHODS: In this randomized, controlled, double-blind clinical trial, 60 ASA I-III patients, scheduled for hip fracture surgery, were randomly allocated to receive spinal anesthesia with 15 mg of either 0.5% (group Levo-0.5), or 0.75% (group Levo-0.75) plain levobupivacaine. Onset time (primary outcome), sensory block height level by pinprick, motor block using a modified Bromage scale, and hemodynamic variables were recorded. RESULTS: In group Levo-0.5 (n = 29), surgical anesthesia was obtained within 15 (10-20) min, compared to 12 (7-21) min in group Levo-0.75 (n = 31) (p = 0.409). The highest sensory block level was T11 (T6-T12) in group Levo-0.5, and T10 (T8 - T12) in group Levo-0.75 (p = 0.759). Mean duration of anesthesia was 285 (224-303) min in group Levo-0.5, and 318 (243-375) min in group Levo-0.75 (p = 0.117). The groups were similar in regards to the number of failed blocks requiring general anesthesia, and the number of patients requiring vasopressors. CONCLUSIONS: In this population of elderly patients, spinal anesthesia with 15 mg of either 0.5% or 0.75% plain levobupiva-caine resulted in similar onset of pharmacological actions, and outcomes. Potential differences in baricity did not appear to be clinically relevant in this setting.