Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review.

BACKGROUND: Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point. METHODS: In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used. RESULTS: Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001). CONCLUSION: Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ. LEVEL OF EVIDENCE: I systematic review of RCTs.

Functional alignment in robotic-assisted total knee arthroplasty: a systematic review.

PURPOSE: The present study systematically reviewed current evidence on functional alignment (FA) in robotic total knee arthroplasty (TKA), discussing advantages and limitations, possible pitfalls, and prospects. METHODS: This study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase with no additional filters or time constraints. All the clinical studies investigating functional alignment in robotic TKA were accessed. Only studies published in peer-reviewed journals were considered. The risk of bias was evaluated following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Non-randomized controlled trials (non-RCTs) were evaluated using the Risk of Bias in Nonrandomised Studies of Interventions (NRSI) (ROBINS-I) tool. RESULTS: Data from 1198 patients (seven studies) were retrieved. The mean length of the follow-up was 17.1 ± 6.4 months. The mean age was 67.2 ± 5.4 years, and the mean BMI was 30.9 ± 2.7 kg/m2. CONCLUSION: FA might improve resection accuracy, implant alignment, and gap balancing in TKA, and additional high-quality clinical trials are necessary to properly establish the superiority of FA to other alignment techniques in TKA. Long-term clinical trials are needed to investigate the impact of FA on implant survivorship. LEVEL OF EVIDENCE: Level IV, systematic review and meta-analysis.

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who have undergone total knee arthroplasty: a systematic review.

BACKGROUND: The present systematic review investigated the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) of several frequent and established PROMs used to assess patients who have undergone TKA. This study was conducted according to the 2020 PRISMA statement. METHODS: In September 2023, PubMed, Web of Science, and Embase were accessed with no time constraint All clinical studies investigating tools to assess the clinical relevance of PROMs used to evaluate patients having received TKA were accessed. Only studies which evaluated the MCID, PASS, or SCB were eligible. The PROMs of interest were the Forgotten Joint Score-12 (FJS-12), the Oxford Knee Score (OKS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and its related subscales activity of daily living (ADL), pain, quality of life (QoL), sports and recreational activities, and symptoms, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the Knee Society Score (KSS) and related function score, and the Short Form-12 (SF-12) and Short Form-36 (SF-36). RESULTS: Data from 29,737 patients were collected. The overall risk of bias was low to moderate. The great variability of thresholds for MCID, SCB and PASS between questionnaires but also between investigated aspects was noted, whereby MCIDs for the SF-36 appear lower than for knee-specific questionnaires. CONCLUSION: Despite its critical role from a patient's perspective, the dimension of SCB is still neglected in the literature. Moreover, thresholds for the different concepts need to be condition-specific. We encourage authors to specifically report such data in future studies and to adhere to previously reported definitions to allow future comparison. Level of evidence Level IV, systematic review and meta-analysis.

Level I of evidence does not support manual lymphatic drainage for total knee arthroplasty: a meta-analysis.

It is unclear whether manual lymphatic drainage (MLD) following primary total knee arthroplasty (TKA) is effective in reducing pain and swelling and improving knee function. The present study investigated the efficacy of MLD after TKA. The outcomes of interest are the range of motion (ROM), pain (visual analogue scale, VAS), and circumference of the lower leg. This meta-analysis was conducted according to the 2020 PRISMA statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase, with no time constraint. Only level I evidence studies, according to the Oxford Centre of Evidence-Based Medicine, were considered. All the randomised controlled trials (RCTs) comparing patients who have received MLD versus a group of patients who did not undergo MLD following primary TKA were accessed. Data from four RCTs (197 TKAs) were retrieved. 67% (132 of 197 patients) were women. The mean length of follow-up was 7.0 ± 5.8 weeks. The mean age of the patients was 69.6 ± 2.7 years, and the mean BMI was 28.7 ± 0.9 kg/m2. At baseline, between-group comparability was evidenced in the male:female ratio, mean age, mean BMI, knee flexion, and VAS. No difference was found in flexion (P = 0.7) and VAS (P = 0.3). No difference was found in the circumference of the thigh (P = 0.8), knee (P = 0.4), calf (P = 0.4), and ankle (P = 0.3). The current level I of evidence does not support the use of MLD in primary TKA.

Head, acetabular liner composition, and rate of revision and wear in total hip arthroplasty: a Bayesian network meta-analysis.

Total hip arthroplasty (THA) is a common procedure for patients suffering from hip pain e.g. from osteoarthritis, osteonecrosis, or hip fractures. The satisfaction of patients undergoing THA is influenced by the choice of implant type and material, with one key factor being the selection of the appropriate material combination for the bearing surface. In this Bayesian network meta-analysis, we investigated the impact of material combinations for the bearing surface on the longevity of hip implants. The wear penetration rate per year and the total wear penetration in the liner resulting from different material combinations, as well as the survival rate at last follow-up, were examined. We analyzed a total of 663,038 THAs, with 55% of patients being women. Mean patient age was 59.0 ± 8.1 years and mean BMI 27.6 ± 2.6 kg/m2. The combination of an aluminium oxide (Al2O3) head and an Al2O3 liner demonstrated the lowest wear penetration at last follow-up and the lowest rate of wear penetration per year. Additionally, the combination of a crosslinked polyethylene (XLPE) liner and a zircon oxide (ZrO2) head demonstrated the lowest rate of revision at last follow-up. These findings underscore the importance of careful material selection for hip implant bearing surfaces to optimize their longevity and patient satisfaction after THA.

Long-Term Monitoring of Dolphin Biosonar Activity in Deep Pelagic Waters of the Mediterranean Sea.

Dolphins emit short ultrasonic pulses (clicks) to acquire information about the surrounding environment, prey and habitat features. We investigated Delphinidae activity over multiple temporal scales through the detection of their echolocation clicks, using long-term Passive Acoustic Monitoring (PAM). The Istituto Nazionale di Fisica Nucleare operates multidisciplinary seafloor observatories in a deep area of the Central Mediterranean Sea. The Ocean noise Detection Experiment collected data offshore the Gulf of Catania from January 2005 to November 2006, allowing the study of temporal patterns of dolphin activity in this deep pelagic zone for the first time. Nearly 5,500 five-minute recordings acquired over two years were examined using spectrogram analysis and through development and testing of an automatic detection algorithm. Echolocation activity of dolphins was mostly confined to nighttime and crepuscular hours, in contrast with communicative signals (whistles). Seasonal variation, with a peak number of clicks in August, was also evident, but no effect of lunar cycle was observed. Temporal trends in echolocation corresponded to environmental and trophic variability known in the deep pelagic waters of the Ionian Sea. Long-term PAM and the continued development of automatic analysis techniques are essential to advancing the study of pelagic marine mammal distribution and behaviour patterns.

A 24-Hour Postintensive Care Unit Transition-of-Care Model Shortens Hospital Stay.

BACKGROUND: Patients discharged early from the medical intensive care unit (MICU) are at risk of deterioration, MICU readmission, and increased mortality. An earlier discharge to a medical ward is desirable to reduce costs but it may adversely affect outcomes. To address this problem, a new model for the MICU transition of care was implemented at our academic center: The MICU team continued to manage all patients transferred from the MICU to the medical ward for at least 24 hours. METHODS: Data were collected for all MICU patients admitted 1 year before and 1 year after the intervention. Hospital length of stay (LOS) after transfer from the MICU, readmission rate, and mortality rate were compared before and after the intervention. A nonparsimonious propensity model based on 30 factors was used to identify matched preintervention and postintervention cohorts. RESULTS: A total of 618 of the 848 patients admitted to the MICU were transferred to medical ward during the year prior to the implementation of the new model, and 600 of the 883 patients were transferred during the following year. Pre- and postintervention cohorts were well matched (n = 483 patients in each group). Poisson regression analysis showed a decrease in the hospital LOS after MICU transfer by 1.17 days (P < .001) without a significant change in adjusted mortality (lower by 1.9%, P = .181) and MICU readmission rates (lower by 2%, P = .264). CONCLUSION: A new model for the post-MICU transition of care, with the MICU team continuing to manage all patients transferred to the medical ward for at least 24 hours, significantly decreased duration of hospital stay after MICU transfer without affecting MICU readmission and mortality rate. The implementation of this model may lower medical costs and make transition of care safer without adverse outcomes.

Size Distribution of Sperm Whales Acoustically Identified during Long Term Deep-Sea Monitoring in the Ionian Sea.

The sperm whale (Physeter macrocephalus) emits a typical short acoustic signal, defined as a "click", almost continuously while diving. It is produced in different time patterns to acoustically explore the environment and communicate with conspecifics. Each emitted click has a multi-pulse structure, resulting from the production of the sound within the sperm whale's head. A Stable Inter Pulse Interval (Stable IPI) can be identified among the pulses that compose a single click. Applying specific algorithms, the measurement of this interval provides useful information to assess the total length of the animal recorded. In January 2005, a cabled hydrophone array was deployed at a depth of 2,100 m in the Central Mediterranean Sea, 25 km offshore Catania (Ionian Sea). The acoustic antenna, named OνDE (Ocean noise Detection Experiment), was in operation until November 2006. OνDE provided real time acoustic data used to perform Passive Acoustic Monitoring (PAM) of cetacean sound emissions. In this work, an innovative approach was applied to automatically measure the Stable IPI of the clicks, performing a cepstrum analysis to the energy (square amplitude) of the signals. About 2,100 five-minute recordings were processed to study the size distribution of the sperm whales detected during the OνDE long term deep-sea acoustic monitoring. Stable IPIs were measured in the range between 2.1 ms and 6.4 ms. The equations of Gordon (1991) and of Growcott (2011) were used to convert the IPIs into measures of size. The results revealed that the sperm whales recorded were distributed in length from about 7.5 m to 14 m. The size category most represented was from 9 m to 12 m (adult females or juvenile males) and specimens longer than 14 m (old males) seemed to be absent.

Annual Acoustic Presence of Fin Whale (Balaenoptera physalus) Offshore Eastern Sicily, Central Mediterranean Sea.

In recent years, an increasing number of surveys have definitively confirmed the seasonal presence of fin whales (Balaenoptera physalus) in highly productive regions of the Mediterranean Sea. Despite this, very little is yet known about the routes that the species seasonally follows within the Mediterranean basin and, particularly, in the Ionian area. The present study assesses for the first time fin whale acoustic presence offshore Eastern Sicily (Ionian Sea), throughout the processing of about 10 months of continuous acoustic monitoring. The recording of fin whale vocalizations was made possible by the cabled deep-sea multidisciplinary observatory, "NEMO-SN1", deployed 25 km off the Catania harbor at a depth of about 2,100 meters. NEMO-SN1 is an operational node of the European Multidisciplinary Seafloor and water-column Observatory (EMSO) Research Infrastructure. The observatory was equipped with a low-frequency hydrophone (bandwidth: 0.05 Hz-1 kHz, sampling rate: 2 kHz) which continuously acquired data from July 2012 to May 2013. About 7,200 hours of acoustic data were analyzed by means of spectrogram display. Calls with the typical structure and patterns associated to the Mediterranean fin whale population were identified and monitored in the area for the first time. Furthermore, a background noise analysis within the fin whale communication frequency band (17.9-22.5 Hz) was conducted to investigate possible detection-masking effects. The study confirms the hypothesis that fin whales are present in the Ionian Sea throughout all seasons, with peaks in call detection rate during spring and summer months. The analysis also demonstrates that calls were more frequently detected in low background noise conditions. Further analysis will be performed to understand whether observed levels of noise limit the acoustic detection of the fin whales vocalizations, or whether the animals vocalize less in the presence of high background noise.

The effect of flow trigger on rapid shallow breathing index measured through the ventilator.

BACKGROUND: The rapid shallow breathing index (RSBI) has the best predictive value to assess readiness for weaning from mechanical ventilation. At many institutions, this index is conveniently measured without disconnecting the patient from the ventilator, but this method may be inaccurate. Because modern ventilators have a base flow in the flow trigger mode that may provide a substantial help to the patient, we hypothesized that the RSBI is significantly decreased when measured through the ventilator with flow trigger even without continuous positive airway pressure (CPAP) and pressure support (PS). METHODS: The RSBI was calculated using the values of minute ventilation and respiratory rate obtained either through the digital display of the ventilator or from a digital ventilometer. The RSBI was measured using 3 different methods: method 1, CPAP and PS both 0 cm H2O with flow trigger; method 2, CPAP and PS both 0 cm H2O without flow trigger; and method 3, using digital ventilometer. RESULTS: A total of 165 measurements per method were obtained in 80 adult patients in the medical intensive care unit (MICU). The RSBI (breaths/min/L) values were 70.2 ± 26.5 with method 1, 85.4 ± 30.3 with method 2, and 80.1 ± 30.3 with method 3. The RSBI was significantly decreased using mechanical ventilation with flow trigger as compared with mechanical ventilation without flow trigger (P < .0001) or digital ventilometer (P < .0001). When method 1 was compared with methods 2 and 3, the RSBI decreased by 17% and 12%, respectively. CONCLUSIONS: The RSBI measurement is significantly decreased by the base flow delivered through modern ventilators in the flow trigger mode. If RSBI is measured through the ventilator in the flow trigger mode, the difference should be considered when using RSBI to assess readiness for weaning from mechanical ventilation.

Critical airway management: a suggested modification to the rigid fiber-optic stylet based on 301 novice intubations.

BACKGROUND: Emergent airways in critically ill patients outside the operating room (critical airways) are often difficult airways frequently managed by intensivists. Current advanced airway management tools have not been adequately evaluated for critical airways and are not specifically designed for intensivists. The rigid fiber-optic stylet has the potential to fill this niche as it is an established difficult intubation technique very similar to bronchoscopy. The purpose of this study was to evaluate the rigid fiber-optic stylet and identify characteristics that would affect its use for critical airway management by intensivists. METHODS: A retrospective, single-center, observational study was performed in the setting of a tertiary care university teaching hospital. A total of 301 consecutive elective surgery patients underwent endotracheal intubation attempted by a novice using a rigid fiber-optic stylet. RESULTS: Novices could successfully intubate >95% patients using the rigid fiber-optic stylet. Most patients were intubated within 2 attempts (93%) in a median time of 73 seconds. In all the cases of intubation failure by novices, the staff anesthesiologist could successfully intubate the patient in his first attempt with an average time of 32 seconds. By studying unsuccessful attempts, we identified an important barrier to the adaptation of this tool for critical airway management-the absence of working channels, which does not allow suctioning, oxygenation, or instillation of lidocaine. CONCLUSIONS: A multilumen sheath designed with 2 working channels has the potential to overcome all identified barriers to the use of rigid fiber-optic stylet as a critical airway management device by intensivists. This modification should be evaluated in a clinical study.

Comparison of 3 different methods used to measure the rapid shallow breathing index.

PURPOSE: Rapid shallow breathing index (RSBI) is conveniently measured through the ventilator. If continuous positive airway pressure (CPAP) is used, it may change the RSBI value. We measured the RSBI with a handheld spirometer and through the ventilator, with and without CPAP, to assess differences. MATERIALS AND METHODS: Rapid shallow breathing index was measured in 3 ways: (1) CPAP 0 cm H(2)O and fraction of inspired oxygen (Fio(2)) 0.4, (2) CPAP 5 cm H(2)O and Fio(2) 0.4, and (3) ventilator disconnected and Fio(2) 0.21. Tidal volume and respiratory frequency were recorded from ventilator monitor values in methods 1 and 2, and from a handheld spirometer and observed respiratory frequency, in method 3. RESULTS: A total of 170 measurements, each using all 3 methods, were obtained from 80 patients admitted to a medical intensive care unit. The mean RSBI values for methods 1, 2, and 3 were 98.1 ± 58.7, 87.6 ± 51.2, and 108.3 ± 65.3, respectively (P < .001). The RSBI decreased by 9.4% when using CPAP 0 cm H(2)O and by 19.1% when using CPAP 5 cm H(2)O. CONCLUSIONS: The RSBI values measured through the ventilator with CPAP 5 cm H(2)O are much lower than the values measured with a handheld spirometer. Even the RSBI values measured with CPAP 0 cm H(2)O are significantly lower. This is attributable to the base flow delivered by some ventilators. The difference must be taken into account during weaning assessment.

A new endotracheal tube designed to enable a single operator to perform percutaneous dilatational tracheostomy while maintaining the airway, providing continuous bronchoscopic guidance, and minimizing procedural complications: demonstration of feasibility on a mannequin and a cadaver.

BACKGROUND: : We designed a double-lumen endotracheal tube (the EZ [Easy] Tracheostomy [EZT]) to enable a single operator to safely perform percutaneous dilatational tracheostomy (PDT) at the bedside while providing continuous bronchoscopic guidance. The EZT design also aims to ensure uninterrupted mechanical ventilation during most of the PDT procedure via a secure airway. It aims to significantly minimize hypoxia, hypoventilation, auto-positive end-expiratory pressure, airway loss, posterior wall laceration, and damage to the endoscope related to the current methodology. METHOD: : We demonstrated the feasibility of our method on a mannequin model and a cadaver. RESULTS: : Single operators successfully performed the modified PDT on their first attempt with excellent visualization and no obvious complications. The potential for minimal interruption in ventilation, low risk of airway loss or malpositioning, and significant reduction in other PDT-related complications were clearly demonstrated. The procedure was found to be easier to perform when compared with conventional PDT. CONCLUSIONS: : It is feasible for a single operator to perform PDT with continuous bronchoscopic guidance when using the EZT on cadaver and mannequin models. Clinical studies are warranted to evaluate this new tool.

Coccidioidomycosis in nonendemic area: case series and review of literature.

Four cases of coccidioidomycosis, diagnosed in New Orleans, are described to illustrate the varied clinical presentation of this infection. The first is an immunocompromised elderly patient presenting with a cavitary lung lesion after travel to Utah. The second, a young immunocompetent patient presenting with acute respiratory distress syndrome after moving from Arizona. The third and fourth, young Hispanic immigrants with acquired immunodeficiency syndrome presenting with respiratory distress and sepsis. These are examples of different presentations, depending on immune competency, and illustrate the challenges in making this diagnosis in non-endemic areas. For two of the three patients who died an autopsy was obtained. We present the cases, show radiographic and pathological findings, and review the current literature on coccidioidomyocosis.

A 63-year-old man with recurrent pulmonary infections: a case of Swyer-James Macleod syndrome.

Swyer-James Macleod syndrome is a rare disorder that leads to recurrent respiratory infections. The fibrosis and obstruction of the terminal and respiratory bronchioles, likely caused by respiratory infections in early childhood, prevents normal development of the alveolar bud. Organisms that have been associated with this syndrome include adenovirus, measles, bordetella pertussis, mycobacterium spp, influenza A and mycoplasma. The syndrome is an acquired cause of unilateral emphysema. The diagnosis of the syndrome can be made in infancy or early childhood, but in asymptomatic individuals can be delayed until adulthood and rarely in the elderly. Chest radiographs and computed tomographic (CT) scan can confirm the diagnosis and exclude other possibilities. A case of Swyer- James Macleod syndrome diagnosed at age 63 in a patient with recurrent respiratory infections and a history of childhood pertussis is presented.