Hydrothermal liquefaction of sewage sludge: use of HCOOH and KOH to improve the slurry pumpability in a continuously operated plant.

We studied the hydrothermal liquefaction (HTL) of digested sewage sludge (DSS) as model of waste biomass in batch and continuous reactors. HCOOH and KOH were used to improve the slurry pumpability. HTL experiments were conducted at the same kinetic severity factor in a batch reactor of 25 mL of volume and in a continuously operated tubular reactor with 350 mL of volume. The observed outcomes suggested that it was not possible to achieve the pumpability of native DSS when a high concentrated stream of suspended solid particles has been fed to the HTL continuous plant. Using acidic or basic homogeneous additives, as potassium hydroxide or formic acid, it was possible to enhance the pumpability of a concentrated slurry of DSS in the continuous plant achieving yields of heavy oil (fraction of biocrude) similar to those obtained in the batch reactor and with higher H/C ratios. Hence, we found that HCOOH and KOH are promising additives for the practical implementation of a continuous HTL process.

Sustainability of prevention practices at the workplace: safety, simplification, productivity and effectiveness.

Traditional full-time employment has evolved into various types of occupational situations, and, nowadays, new work organization strategies have been developed. Previously overlooked risk factors have emerged, such as traffic accidents while commuting or during work hours, poor work organization, and detrimental lifestyles (like alcohol and substance abuse, although recent statistics seem to show a declining trend for the latter). The global scenario shows greater attention to occupational risks, but also, to the reduced degree of protection. Moreover, the elevated costs, the unacceptably high fatal accident rates in some sectors, the complexity of the prevention systems, the lack of prevention training, the inadequate controls (despite the numerous independent supervisory bodies) and the obsolescence of certain precepts, call for a prompt review of the regulatory system. This is especially needed for general simplification, streamlining certification bodies and minimizing references to other provisions in the legislation that make it difficult for Italian and foreign workers to read and understand the rules "without legal interpreters". "New" occupational diseases and occupational risk factors have also been reported in addition to pollution. There are concerns for continued economic and social destabilization, unemployment, commuting, temporary and precarious contracts. All of these contribute to the lack of wellbeing in the working population. Thus, the timing, duration, and types of prevention training should be carefully assessed, making prevention more appealing by evaluating costs and benefits with a widespread use of indicators that make appropriate actions for health promotion "visible", thus encouraging awareness. Although reducing prevention is never justified, it should still be "sustainable" economically in order to avoid waste of resources. It is also essential to have laws which are easily and consistently interpreted and to work on the ethics of employers and employees to ensure that they conform to the standards of other European countries that currently operate with greater effectiveness and lower costs.

Geographic Differences in Endovascular Treatment and Retreatment of Cerebral Aneurysms.

BACKGROUND AND PURPOSE: Comparing outcomes between endovascular aneurysm coiling trials can be difficult because of heterogeneity in patients and end points. We sought to understand the impact of geography on aneurysm retreatment in patients enrolled in the Matrix and Platinum Science Trial. MATERIALS AND METHODS: Post hoc analysis was performed on data from the Matrix and Platinum Science trial. Patients were stratified as either North American or international. Baseline patient demographics, comorbidities, aneurysm characteristics, procedural complications, and clinical and angiographic outcomes were compared. RESULTS: We evaluated 407 patients from 28 North American sites and 219 patients from 15 international sites. Patient demographics differed significantly between North American and international sites. Aneurysms were well occluded postprocedure more often at international than North American sites (P < .001). Stents were used significantly more often at North American sites (32.7% [133 of 407]) compared with international sites (10.0% [22 of 219]; P < .001). At 455 days, there was no difference in the proportion of patients alive and free of disability (P = .56) or with residual aneurysm filling (P = .10). Ruptured aneurysms were significantly more likely to have been retreated at North American sites within the first year (P < .001) and at 2 years (P < .001). Among all patients for whom the treating physician believed there to be Raymond 3 aneurysm filling at follow-up, absolute rates of retreatment at international and North American sites were similar by 2-year follow-up. CONCLUSIONS: Data from the Matrix and Platinum Science Trial demonstrate that aneurysm retreatment occurs with different frequency and at different times in different regions of the world. This trend has critical value when interpreting trials reporting short-term outcomes, especially when judgment-based metrics such as retreatment are primary end points that may or may not take place within the defined study follow-up period. Though these variations can be controlled for and balanced within a given randomized trial, such differences in practice patterns must be accounted for in any attempt to compare outcomes between different trials. Despite these differences, endovascular-treated intracranial aneurysms around the world have similar clinical outcomes.

Quality of sex life in endometriosis patients with deep dyspareunia before and after laparoscopic treatment.

PURPOSE: The present work aims at showing how dyspareunia linked to endometriosis can affect the life of fertile age women and how surgical treatment of endometriosis can relieve painful symptoms and consequently improve sex and social life. METHODS: From a cohort of 320 women with a clinical and instrumental diagnosis of pelvic endometriosis, 67 patients were selected. These patients had deep dyspareunia that underwent laparoscopic surgical treatment. All the patients had filled out a pre- and post-surgery questionnaire. RESULTS: Six months after laparoscopic treatment, a significant reduction of dyspareunia was recorded, per VAS scores. A statistically significant improvement in sex life was observed between the pre- and post-surgical condition: in particular, an increased number of coituses and of non-difficult coituses, a higher number of patients who declared that pain did not negatively affect sexual pleasure and of patients achieving orgasm. CONCLUSIONS: The quality of the sex life in patients with endometriosis and dyspareunia showed significant improvement 6 months after laparoscopic treatment. In view of the diagnostic delay characterizing this disease and confirmed by our results, it is essential to involve a multidisciplinary team to assess all the signs and symptoms of endometriosis that may appear in a women of fertile age. This clinical approach is able to ensure a treatment that is as personalized as possible and an appropriate follow-up also with the objective of preserving reproductive performance.

Towards a smoke-free hospital: how the smoking status of health professionals influences their knowledge, attitude and clinical activity. Results from a hospital in central Italy.

OBJECTIVES: In Italy, the prevalence of smoking among health professionals is higher than in the general population and this might hamper their role in the promotion of health. This study aimed to investigate how the smoking status of healthcare professionals might influence knowledge, attitudes and clinical practice in a hospital in central Italy in order to enforce effective tobacco control measures. METHODS: Physicians and professionals of the hospital were asked to complete an anonymous questionnaire which yielded epidemiological and environmental information on knowledge, attitude, clinical practice and quality of the hospital environments, in relation to smoking. RESULTS: Overall, among the employees of the hospital, the smoking prevalence was 47%, (42% among physicians and 43% among nurses); 30% admitted smoking in the hospital and three quarters of the smokers would like to quit. Some knowledge, opinions and attitudes differ statistically among the smoking categories. For example, only 35% of the smokers admitted that smoking is more dangerous to health than atmospheric and car pollution compared with 60% of the ex or never smokers (p=0.04). Fewer smokers realize that their behavior is seen as a role model by patients. A greater percentage of smokers state that patients (34%) and visitors (43%) often smoke in hospital and these percentages are significantly higher than those reported by ex or never smokers (p≤0.05). All smokers claim that they never smoke in patient rooms, infirmaries and clinics, whereas over 20% of ex or never smokers report that smoking sometimes occurs in these places (p=0.015). The mean concentration of PM 2.5 in the 25 rooms was 2.4 µg/m3 with a range from 1 to 7 µg/m3. CONCLUSIONS: This study implies that the prevalence of smoking among health professionals may be very high, and might be twice the rate observed in the general population. Generally, smokers report less knowledge compared with ex and never-smokers and it seems that they systematically underestimate the dangers related to smoking both in their knowledge and in their behavior, and try to socially "normalize" smoking. All this and the evidence of cigarette butts in hospital rooms and clinics, notwithstanding the good quality of the air thanks to the modern ventilation system, imply that there is still a long way to go towards a smoke-free hospital.

Stent-assisted coiling versus coiling alone in unruptured intracranial aneurysms in the matrix and platinum science trial: safety, efficacy, and mid-term outcomes.

BACKGROUND AND PURPOSE: Stent-assisted coiling may result in less aneurysm recanalization but more complications than coiling alone. We evaluated outcomes of coiling with and without stents in the multicenter Matrix and Platinum Science Trial. MATERIALS AND METHODS: All patients in the Matrix and Platinum Science Trial with unruptured intracranial aneurysms treated per protocol were included. Baseline patient and aneurysm characteristics, procedural details, neurologic outcomes, angiographic outcomes, and safety data were analyzed. RESULTS: Overall, 137 of 361 (38%) patients were treated with a stent. Stent-coiled aneurysms had wider necks (≥4 mm in 62% with stents versus 33% without, P < .0001) and lower dome-to-neck ratios (1.3 versus 1.8, P < .0001). Periprocedural serious adverse events occurred infrequently in those treated with and without stents (6.6% versus 4.5%, P = .39). At 1 year, total significant adverse events, mortality, and worsening of mRS were similar in treatment groups, but ischemic strokes were more common in stent-coiled patients than in coiled patients (8.8% versus 2.2%, P = .005). However, multivariate analysis confirmed that at 2 years after treatment, prior cerebrovascular accident (OR, 4.7; P = .0089) and aneurysm neck width ≥4 mm (OR, 4.5; P = .02) were the only independent predictors of ischemic stroke. Stent use was not an independent predictor of ischemic stroke at 2 years (OR, 1.1; P = .94). Stent use did not predict target aneurysm recurrence at 2 years, but aneurysm dome size ≥10 mm (OR, 9.94; P < .0001) did predict target aneurysm recurrence. CONCLUSIONS: Stent-coiling had similar outcomes as coiling despite stented aneurysms having more difficult morphology than coiled aneurysms. Increased ischemic events in stent-coiled aneurysms were attributable to baseline risk factors and aneurysm morphology.

Current update on the endovascular management of intracranial aneurysms.

Rapid technological advances in the endovascular field has revolutionized the treatment of intracranial aneurysms. Since the Food and Drug Administration approval of Guglielmi detachable coils in 1995, a variety of newer coils with different design and physical properties such as complex coils, stretch resistant and bioactive coils, have become available promising to increase packing density and decrease aneurysmal recurrence and recanalization rates. Treatment of wide neck intracranial aneurysms has improved with availability of compliant balloons and newer intracranial assist devices. Emerging technology such as flow diverters hold promise in treatment of large and difficult to treat intracranial aneurysms. Liquid embolic agent (Onyx HD 500) offer a novel, safe and effective adjunctive treatment option when used in combination with coils with stent and/or balloon assist technique. Endovascular treatment options have vastly expanded the armamentarium of neurosurgeons allowing safe and durable treatment of aneurysms previously amenable to clipping only.

Endovascular therapy of acute ischemic stroke: report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery.

OBJECTIVE: To summarize and classify the evidence for the use of endovascular techniques in the treatment of patients with acute ischemic stroke. METHODS: Recommendations previously published by the American Heart Association (AHA) (Guidelines for the early management of adults with ischemic stroke (Circulation 2007) and Scientific statement indications for the performance of intracranial endovascular neurointerventional procedures (Circulation 2009)) were vetted and used as a foundation for the current process. Building on this foundation, a critical review of the literature was performed to evaluate evidence supporting the endovascular treatment of acute ischemic stroke. The assessment was based on guidelines for evidence based medicine proposed by the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM). Procedural safety, technical efficacy and impact on patient outcomes were specifically examined.

Society of NeuroInterventional Surgery Standards of Practice: general considerations.

This is the first in a set of documents intended to standardize techniques, procedures, and practices in the field of endovascular surgical neuroradiology. Standards are meant to define core practices for peer review, comparison, and improvement. Standards and guidelines also form the basic dialogue, reporting, and recommendations for ongoing practices and future development.

Microvascular decompression for trigeminal neuralgia: visualization of results in a 3D stereoscopic virtual reality environment.

BACKGROUND: This study employs 3D stereoscopic virtual reality technology to demonstrate the surgical results of microvascular decompression (MVD) for trigeminal neuralgia. PATIENTS/MATERIAL AND METHODS: 3D models were rendered by fusing CTA and MRI fast imaging employing steady state acquisition (FIESTA) modalities of both pre- and post-operative scans. The brainstem, trigeminal nerve root and relevant vasculature were extracted, superimposed, and co-registered to bony and ventricular anatomy. RESULTS: 3 clinically successful MVD cases were evaluated for superior cerebellar artery (SCA) vessel displacement. Qualitative parameters included translational and rotational shift of the SCA, and distance decompressed from the trigeminal nerve root entry zone. Parameters were met in each case, with demonstration of vessel displacement and decompression of the nerve root. CONCLUSION: The 3D virtual-reality environment with stereoscopic visualization offers a method through which to visualize the results of MVD, and a potential reference point to evaluate cases of treatment failure or relapse.

Computational fluid dynamic simulation to assess flow characteristics of an in vitro aneurysm model.

BACKGROUND: Modifications of in vitro aneurysm modeling to study the effects of morphology on flow dynamics are time consuming, costly and analysis tends to be more qualitative than quantitative. This study develops a virtual two-dimensional flow model replicating an in vitro aneurysm model and analyzes how changes in morphology modify flow characteristics. METHODS: Using finite volume analysis, a two-dimensional saccular aneurysm model was created with a configuration matching a published, experimental, in vitro model. Qualitative comparisons were made determining whether a two-dimensional fluid dynamic model can replicate the results of an in vitro model. Quantitative changes in flow patterns, wall shear stress, dynamic pressure and maximum velocities were assessed by modifying the shape of the neck and proximal dome without modifying the overall size of the aneurysm. RESULTS: A two-dimensional computational fluid dynamic model reproducing the shape of a published aneurysm demonstrated excellent qualitative fidelity to an in vitro flow model. Additional information regarding dynamic pressure, shear stress and velocity along the aneurysm neck and within the aneurysm dome were determined. Although all dimensions were kept constant, slight modifications of the neck and proximal dome resulted in quantitative changes in studied parameters, such as wall shear stress and dynamic pressure. CONCLUSIONS: Computer generated aneurysm flow models, when carefully developed, reproduce flow events within in vitro aneurysms providing objective data on biophysical parameters. Effective flow modeling of aneurysms depends on flow input, size of the parent vessel and aneurysm, and other factors. These data suggest that neck and proximal dome configuration, independent of size, are important characteristics of flow.

Isolated progressive visual loss after coiling of paraclinoid aneurysms.

BACKGROUND AND PURPOSE: The proximity of the paraclinoid segment of the internal carotid artery to the visual pathways may result in visual deficits when patients present with aneurysms in this segment. Although surgical clip ligation of these aneurysms has been the standard of care for decades, the advent of coil embolization has permitted endovascular therapy in those aneurysms with favorable dome-to-neck ratios. Although immediate nonprogressive visual loss after coil embolization of paraclinoid aneurysms has been well described, isolated progressive visual loss immediately or shortly following coil embolization, to our knowledge, has not. We have identified 8 patients who experienced progressive loss of vision, unassociated with any other neurologic deficits, developing immediately or shortly after apparently uncomplicated coil embolization of a paraclinoid aneurysm. MATERIALS AND METHODS: This study is a retrospective case series of 8 patients seen at 4 separate academic institutions. Inpatient and outpatient records were examined to determine patient demographics, previous ocular and medical history, and ophthalmic status before endovascular embolization. In addition, details of the primary endovascular therapy and subsequent surgical and nonsurgical interventions were recorded. Follow-up data, including most recent best-corrected visual acuity, postoperative course, and duration of follow-up were documented. RESULTS: Eight patients developed progressive visual loss in 1 or both eyes immediately or shortly after apparently uncomplicated coiling of a paraclinoid aneurysm. MR imaging findings suggested that the visual loss was most likely caused by perianeurysmal inflammation related to the coils used to embolize the aneurysm, enlargement or persistence of the aneurysm despite coiling, or a combination of these mechanisms. Most patients experienced improvement in vision, 2 apparently related to treatment with systemic corticosteroids. CONCLUSION: Patients in whom endovascular treatment of a paraclinoid aneurysm is contemplated should be warned about the potential for both isolated nonprogressive and progressive visual loss in 1 or both eyes. Patients in whom progressive visual loss occurs may benefit from treatment with systemic corticosteroids.

[Emergent pathology in occupational medicine: the mobbing]. / Patologie emergenti in Medicina del Lavoro: il mobbing.

Mobbing constitutes a phenomenon not yet clearly defined. The activity, located in the II Faculty of Medicine and Surgery, is specifically dedicated to such phenomenon, which is the outcome of cooperation. The examined population is composed by a light prevalence of men (51.3%) respect to women (48.6%), aged around 42 years and employees (71.6%), workers (28.4%). All patients have been submitted to working anamnesis before being subjected to a psychiatric examination and psycodiagnostic tests. The emerged data underline a trouble of adaptation 55.4% of the cases, 40.5% is affected by psychiatric pathologies, 4.1% of the patients do not show mental disorders. A certification of compatibility with mobbing has been possible to be verified in 49% of the cases. Nevertheless, it is necessary a connection between a physician and business medical service. We hope a necessary enactment of a specific regulation.

[Moral and psychological violence at work: assessment and certification]. / Violenza morale e psichica sul lavoro: valutazione e certificazione.

Mobbing constitutes a phenomenon not yet clearly defined. The activity, located in the H Faculty of Medicine and Surgery, is specifically dedicated to such phenomenon, which is the outcome of cooperation. The examined population is composed by a light prevalence of women (54%) respect to men (46%), aged around 44 years and employees (73%), workers (27%). All patients have been submitted to working anamnesis before being subjected to a psychiatric examination and psycodiagnostic tests. The emerged data underline a trouble of adaptation 63% of the cases (to which we have released a certification of compatibility with mobbing), 28% is affected by psychiatric pathologies, 9% of the patients do not show mental disorders. Nevertheless, it is necessary a connection between a physician and business medical service.

Anti-Ri-associated paraneoplastic opsoclonus-ataxia syndrome in a man with transitional cell carcinoma.

BACKGROUND: There are several case reports describing paraneoplastic syndromes in patients with various forms of bladder carcinoma. Current immunologic analyses have enabled the identification of the antineuronal autoantibodies associated with specific syndromes. METHODS: A patient with a history of bladder carcinoma presented with opsoclonus and myoclonus. RESULTS: Workup confirmed the presence of anti-Ri antibodies in the patient's serum and cerebrospinal fluid. The target Ri antigen was found to be expressed by the tumor. CONCLUSIONS: To the authors' knowledge, there are few reports in the literature describing the long-term clinical follow-up and postmortem evaluation in a patient with this form of paraneoplastic syndrome. More important, the authors believe the current study represents the first time that the presence of anti-Ri antibodies has been noted in a paraneoplastic syndrome associated with transitional cell carcinoma of the bladder.

Management of residual dysplastic vessels after cerebral arteriovenous malformation resection: implications for postoperative angiography.

OBJECTIVE: The verification of surgical resection of cerebral arteriovenous malformations (AVMs) relies on angiography. Abnormal vasculature often is identified after removal of the AVM. Differentiation of dysplastic feeding vessels that resemble the neovascularity of moyamoya disease, as distinct from residual AVM, is crucial for preserving critical brain areas. We review a large experience with immediate postoperative angiography after AVM resection and discuss the implications for management of abnormal dysplastic vessels discovered after AVM resection. METHODS: Beginning in 1992, 86 consecutive patients with AVMs underwent operations by standard protocol for immediate postoperative angiography under the same general anesthetic. Angiographic interpretation dictated admission to the intensive care unit or return to the operating room for further resection. RESULTS: In 78 patients, the angiogram revealed complete resection. Two patients were returned to the operating room, one for residual malformation with an early draining vein, and one for resection of residual dysplastic vessels. There was one postoperative hemorrhage in a patient whose postoperative angiogram was falsely negative for AVM. Six patients with residual dysplastic vessels mimicking residual AVM, but without an early draining vein, were managed conservatively. Delayed follow-up angiography demonstrated spontaneous involution of these abnormal vessels in all of these patients. CONCLUSION: Residual dysplastic feeding vessels resembling the neovascularity of moyamoya disease but not associated with an early draining vein do not necessarily represent residual malformation after AVM resection. The abnormal vessels will proceed to complete spontaneous resolution. Given the difficulty of interpreting intraoperative angiography, immediate postoperative angiography may be a viable alternative after AVM resection.

Targeted inhibition of intrinsic coagulation limits cerebral injury in stroke without increasing intracerebral hemorrhage.

Agents that restore vascular patency in stroke also increase the risk of intracerebral hemorrhage (ICH). As Factor IXa is a key intermediary in the intrinsic pathway of coagulation, targeted inhibition of Factor IXa-dependent coagulation might inhibit microvascular thrombosis in stroke without impairing extrinsic hemostatic mechanisms that limit ICH. A competitive inhibitor of native Factor IXa for assembly into the intrinsic Factor X activation complex, Factor IXai, was prepared by covalent modification of the Factor IXa active site. In a modified cephalin clotting time assay, in vivo administration of Factor IXai caused a dose-dependent increase in time to clot formation (3.6-fold increase at the 300 micrograms/kg dose compared with vehicle-treated control animals, P < 0.05). Mice given Factor IXai and subjected to middle cerebral artery occlusion and reperfusion demonstrated reduced microvascular fibrin accumulation by immunoblotting and immunostaining, reduced 111In-labeled platelet deposition (42% decrease, P < 0.05), increased cerebral perfusion (2.6-fold increase in ipsilateral blood flow by laser doppler, P < 0.05), and smaller cerebral infarcts than vehicle-treated controls (70% reduction, P < 0.05) based on triphenyl tetrazolium chloride staining of serial cerebral sections. At therapeutically effective doses, Factor IXai was not associated with increased ICH, as opposed to tissue plasminogen activator (tPA) or heparin, both of which significantly increased ICH. Factor IXai was cerebroprotective even when given after the onset of stroke, indicating that microvascular thrombosis continues to evolve (and may be inhibited) even after primary occlusion of a major cerebrovascular tributary.

Dysarthria during basilar artery balloon occlusion.

A 49-year-old woman presenting with recurrent, reversible brainstem symptoms and a distal basilar artery aneurysm underwent balloon test occlusion. Five minutes after balloon inflation she developed a reversible isolated dysarthria. Despite failing the test occlusion (and after an additional brainstem event), the patient underwent surgery with placement of a clip across the basilar artery. The operation was tolerated without complication. The authors conclude that 1) pure dysarthria may be a symptom of temporary basilar artery occlusion and 2) balloon testing may overestimate the risk of basilar artery clipping.