Sublingual sufentanil tablet system (SSTS) versus a single shot peri-nervous injection of ropivacaine for the management of postoperative pain after total knee arthroplasty: a single-center randomized trial.

INTRODUCTION: For several years, ropivacaine has been the standard-of-care for establishing postoperative femoral nerve block in total knee arthroplasty (TKA) setting and is still widely in use but new approaches such as the patient-controlled administration of sublingual sufentanil tablets system (SSTS) seem to offer good clinical results. Our aim is to compare the SSTS to single shot peri-nervous injection of ropivacaine (single shot) after TKA in terms of effectiveness in pain management and of time to recovery. MATERIALS AND METHODS: A total of 165 patients undergoing TKA were enrolled. Eighty-four patients were randomly allocated in the SSTS group and 81 patients in the single shot group. The primary objective of the study was to evaluate performance of Timed Up and Go test. Secondary objectives were to measure the length of stay, NRS pain scale, the adherence to the prescribed plan, the joint mobility, the frequency of rescue analgesic use, side effects and patients' satisfaction. RESULTS: Of all patients of the single shot group, 64 were withdrawn from the study as they unable to achieve pain control; only one patient was withdrawn from the SSTS group. Times for the "Timed Up and Go" test on the 3rd postoperative day were 8.4 ± 1.6 and 11.8 ± 3.6 in the SSTS group (n = 83) and single shot group (n = 17), respectively (p < .001). CONCLUSIONS: SSTS provides better pain management when compared to peri-nervous ropivacaine single shot injection after TKA.

Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy.

OBJECTIVE: Spinal anesthesia with local anesthetics is a viable alternative to general anesthesia in orthopedic surgery, and it is currently considered the standard of care for knee arthroscopy. The use of chloroprocaine may offer several potential advantages over other local anesthetics, including, above all, its rapid onset and short duration of action. The aim of the present retrospective study is to evaluate the post-surgical outcomes of patients who underwent knee arthroscopy using spinal anesthesia with chloroprocaine in an outpatient orthopedic setting. PATIENTS AND METHODS: Data from patients who underwent elective knee arthroscopy between January 2022 and December 2022 were collected for the present study. Spinal anesthesia with chloroprocaine 10 mg/mL was administered in the designated subarachnoid space (L3-L4 in the majority of patients). A dosage of 40 mg was used to obtain a satisfactory sensory and motor block. RESULTS: A total number of 302 patients met the inclusion criteria. No complications were reported during surgery in the present series of patients. None of the patients required bladder catheterization. In 84% of cases, the PADSS (Post-Anesthetic Discharge Scoring System) score at discharge was 10, whereas in 16% of cases, the PADSS score was 9. The mean time from anesthesia induction to first urination was 75±9.4 minutes, while the mean time from the anesthesia induction to the discharge from the hospital was 152±18.5 minutes. CONCLUSIONS: Spinal chloroprocaine for knee arthroscopy demonstrated a short motor block duration, resulting in a fast time to discharge. These limited data show that chloroprocaine may be safely and effectively applied in outpatient knee arthroscopy procedures. However, more studies, possibly with a randomized design, are required to confirm these findings.

A rapid recovery protocol for hip and knee replacement surgery: a report of the outcomes in a referral center.

OBJECTIVE: The number of joint replacements is expected to dramatically increase, and the optimization of the available resources is fundamental to maintain high clinical standards while providing an efficient treatment to an increasing number of patients. The present study describes the outcomes of the application of a rapid recovery (RR) protocol in a referral center for hip and knee replacement surgery. PATIENTS AND METHODS: The medical records of every patient undergoing primary hip or knee replacement in 2019 were identified and all the relevant data were retrospectively extracted and compared to those of year 2016 (the last year before the onset of the rapid recovery protocol). The following outcomes were considered: 1) length of stay (LOS); 2) total number of TKR and THR; 3) pre- and post-operative subjective questionnaires; 4) NRS for pain at day 1 following surgery; 5) mean hemoglobin value at discharge; 6) number of blood transfusion performed; 7) complications following surgery. RESULTS: The mean LOS was significantly lower for patients managed through the rapid recovery protocol: 5.1 ± 1.4 days vs. 10.4 ± 2.3 days (p < 0.0001). The earlier discharge of patients promoted an overall increase in the total number of joint replacement procedures performed (2,806 in year 2019 vs. 2,236 in year 2016; p < 0.0001). Higher hemoglobin values at discharge were found in the RR group (10.6 ± 1.4 g/dl vs. 9.6 ± 1.2 g/dl, p = 0.049). No difference was observed in terms of clinical scores and overall complication rate. CONCLUSIONS: The application of a multimodal RR protocol for THR and TKR patients was able to reduce the length of stay and optimize the use of blood products, without increasing the risk of complications or jeopardizing the functional recovery.

Clinical efficacy of implementing a Patient Blood Management (PBM) Protocol in joint replacement surgery: a retrospective cohort study in a national referral center.

OBJECTIVE: The aging of population has dramatically broadened the total number of Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) performed worldwide. To optimize the number of blood transfusions performed, a multimodal and multidisciplinary approach was introduced, called Patient Blood Management (PBM). The aim of the present retrospective study is to evaluate the feasibility and clinical outcomes of a PBM protocol applied in a national referral center for joint replacement surgery. PATIENTS AND METHODS: Clinical reports of 9,635 patients undergoing primary THA or TKA, from 2014 to 2019, were screened. The trends of hemoglobin value at admission and at day 4 after surgery were analyzed. Furthermore, the trend of blood bags' requests and blood transfusions was longitudinally evaluated to assess the efficacy of our PBM protocol and its potential impact in reducing the length of stay in the hospital. RESULTS: In 2014, mean hemoglobin (Hb) levels at postoperative day 4 were 10.3 g/dl and 10.2 g/dl for TKA (unilateral and bilateral, respectively), and in 2019 were 11.3 g/dl and 11.6 g/dl (unilateral and bilateral, respectively, p=0.001). Total requested red blood cell (RBC) transfusions by each surgery over time have decreased for THA (277 in 2014 vs. 120 in 2019, p=0.001).  A correlation matrix analysis between Hb level, body mass index (BMI), age, days spent in orthopedic (OR) ward and number of requested transfusions showed that RBC bags transfusions were related to the length of the hospital stay. CONCLUSIONS: A timely application of a PBM protocol in the perioperative period of TKA and THA was significantly associated to the reduction of blood transfusions and total length of hospital stay, with clear benefits for both the patients and the hospital.

Effect of intravenous ferric carboxymaltose supplementation in non-anaemic iron deficient patients undergoing hip and knee arthroplasty.

Preoperative anaemia and non-anaemic iron deficiency are independent risk factors for perioperative blood transfusion, morbidity, and mortality. Although the efficacy to treat anaemia with iron infusion before elective surgery has been widely studied, the literature offers few data about the efficacy of treating iron deficient, non-anaemic patients before elective surgery. This retrospective study assessed the effect of preoperative ferric carboxymaltose (FC) administration on the concentration of Haemoglobin (Hb) in iron deficient, non-anaemic individuals following total knee or hip arthroplasty. A treatment group of 83 non-anaemic iron deficient individuals scheduled for arthroplasty were administered a 1000mg FC infusion over 15 minutes 4 weeks prior to surgery. In the control group (n=62) FC was not administered preoperatively. No individual from either group was given any iron supplement following the pre-operative visit. Blood tests were performed and analysed 4-weeks before surgery, on admission, and then 2-days, 4-days and 4-weeks postoperatively. Number of blood transfusions performed and adverse events were recorded. Hb concentration did not change substantially after iron supplementation prior to surgery. No difference in the number of blood transfusions was observed. In the treatment, group postoperative Hb concentration recovered significantly more quickly compared to control (p=0.0047). No adverse event was reported. The administration of FC in non-anaemic iron deficient individuals quickens the restoration of Hb concentration following THA or TKA procedures.

Sufentanil Sublingual Tablet System: from rationale of use to clinical practice.

The control of post-operative pain in Italy and other western countries is still suboptimal. In recent years, the Sufentanil Sublingual Tablet System (SSTS; Zalviso; AcelRx Pharmaceuticals, Redwood City, CA, USA), which is designed for patient-controlled analgesia (PCA), has entered clinical practice. SSTS enables patients to manage moderate-to-severe acute pain during the first 72 postoperative hours directly in the hospital setting. However, the role of SSTS within the current framework of options for the management of post-operative pain needs to be better established. This paper presents the position on the use of SSTS of a multidisciplinary group of Italian Experts and provides protocols for the use of this device.

Single-shot epidural-spinal anesthesia followed by oral oxycodone/naloxone and ketoprofen combination in patients undergoing total hip replacement: analgesic efficacy and tolerability.

BACKGROUND: Many patients undergoing hip replacement have inadequate postoperative pain control, leading to suboptimal recovery. Oxycodone is effective in controlling pain, but is associated with adverse events such as postoperative nausea and vomiting (PONV). In patients with chronic pain, oral oxycodone-naloxone combination (OXN) provides comparable analgesia with fewer side effects. This retrospective, single-centre study evaluated analgesic effectiveness and tolerability of single-shot epidural spinal anaesthesia followed by OXN after total hip replacement. METHODS: Consecutive patients received perioperative spinal-epidural anaesthesia, OXN 10/5 mg and oral ketoprofen 100 mg q 12h for 4 days. Efficacy and tolerability were assessed on the evening post surgery and days 1-3 after. Efficacy endpoints included pain intensity at rest and upon movement (Numerical Rating Scale [NRS] Score), rescue analgesia and patient satisfaction (0-3 point scale). RESULTS: Two hundred eighty-two patients were included in the observation (57.2% women, mean age 62.9±12 years). After surgery, pain intensity remained well controlled, both at rest (mean NRS: 1.1, 1.1, 1.2 and 1.2 on days 0-3 respectively; P=ns) and upon movement (2.1, 2.4, 2.1 and 2.0; P=ns). No patient reported severe pain throughout the observation. Rescue paracetamol was required on days 0-3 in 17.0%, 18.4%, 12.4% and 12.1% of patients, respectively (P<0.009); no patient required additional intravenous rescue morphine. Seventy-two percent of patients were 'very satisfied' with postoperative pain therapy. CONCLUSION: Single-shot epidural spinal anaesthesia followed by OXN-based analgesia after hip replacement provided effective pain management, with high patient satisfaction rates.

Effects of bandage configuration on paw pad pressure in dogs: a preliminary study.

Seven bandage configurations were placed on the right forepaw of six English pointer dogs to evaluate the effects that configurations have on reducing pad pressure. The "clam shell" configuration resulted in less pressure being applied to all palmar pad surfaces. For the major weight-bearing pad, a basic paw bandage with an intermediate compressible foam sponge that had a hole under the major weight-bearing pad, combined with a metal splint paw cup under the sponge, resulted in a significantly lower pressure recording than for other bandage configurations. Digital pads 3 and 5 had the greatest pressure in a basic bandage configuration. Based on pressures on these pads, a basic paw bandage with an intermediate compressible foam sponge under the major weight-bearing pad, with or without a metal splint paw cup under the sponge, helped elevate the digits to relieve pressure on them. Placing a foam sponge pad, with or without a splint paw cup under the palmar paw surface, also provided less pressure on these pads.

Evaluation of fibrin sealants in cutaneous wound closure.

Human fibrin sealant (HFS) and bovine fibrin sealant (BFS) were delivered as preformulated fibrinogen-thrombin mixtures that are light activated. These formulations were evaluated in the healing of incised cutaneous wounds in beagle dogs. Four groups were differentiated by sealant type and study duration with group: BFS for 10 days, HFS for 10 days, BFS for 30 days, and HFS for 30 days. Healing was evaluated by noting incidences of open wounds, laser Doppler perfusion imaging (LDPI), planimetry, breaking strength, and histopathology. In the absence of tension, both sealants tended to hold wound edges together; however, HFS tended to be better than its controls and BFS. Both sealants augmented suture closure, necessitating fewer sutures for wound closure. At 5 and 30 days BFS wounds had more perfusion than HFS wounds, indicating more inflammation. At 10 and 30 days BFS wounds had larger scar areas than their controls, while scar areas of HFS wounds were smaller than either BFS wounds or controls. Breaking strengths indicated that HFS wounds were stronger than their controls and BFS wounds. Histologically, mild to moderate chronic-active inflammation was observed in wounds receiving either sealant, and this persisted longer in BFS wounds. Overall, HFS had positive qualities, thus showing potential for functional and cosmetic wound closure.

Evaluation of treatment with a pulsed electromagnetic field on wound healing, clinicopathologic variables, and central nervous system activity of dogs.

OBJECTIVE: To evaluate effects of treatment with a pulsed electromagnetic field (PEMF) on healing of open and sutured wounds, clinicopathologic variables, and CNS activity of dogs. ANIMALS: 12 adult female Beagles. PROCEDURE: Open and sutured wounds were created in the skin of the trunk of the dogs. Dogs were divided into 2 groups. One group received PEMF treatment and 1 group served as untreated (control) dogs. The PEMF-treated dogs received treatment twice a day starting the day before surgery and lasting through day 21 after surgery. Wounds were evaluated by use of tensiometry, planimetry, laser Doppler perfusion imaging, and histologic examination. Clinicopathologic variables and electroencephalographic tracings were also evaluated. RESULTS: Use of PEMF treatment resulted in significantly enhanced epithelialization of open wounds 10 and 15 days after surgery. Five days after surgery, wounds of control dogs had a negative value for wound contraction, whereas PEMF-treated wounds had a positive value. The PEMF treatment did not cause significant changes in short-term planimetric, perfusion, tensiometric, histologic, clinicopathologic, or electroencephalographic results. CONCLUSIONS: The PEMF treatment enhanced wound epithelialization in open cutaneous wounds and provided indications of early contraction without significant short-term changes in other variables.

Construction of a weight-bearing surface on a dog's distal pelvic limb.

A one-year-old, neutered female boxer presented with a self-inflicted pandigital amputation following complications of a left hind footpad laceration repair. A meshed skin graft was placed distally over the exposed granulation tissue of the affected limb. In two surgical procedures, a total of five 6 by 8-mm and three 8 by 10-mm digital pad grafts were transplanted into recessed sites in the granulation tissue over the distal aspect of the metatarsal bones. A newly designed pressure relief bandage/ splint was used to assist maturation of the grafts. The result was a weight-bearing surface over an area of maximum tissue stress.

Worldwide blindness.

Blindness affects approximately 42 to 52 million people worldwide. This article examines the major causes of blindness, including cataract, trachoma, glaucoma, onchocerciasis, nutritional deficiencies, and ocular trauma. Numerous case studies supplement the text.

Endocrine involvement in children with beta-thalassaemia major. Transverse and longitudinal studies. I. Pituitary-thyroidal axis function and its correlation with serum ferritin levels.

Thyroid function was investigated by a TRH test in 24 clinically prepubertal children, 3-15 years old with beta-thalassaemia major; in 7 of them the test was repeated once and in 2 twice at intervals of at least 12 months. Basal T4, T3, TBG and TSH levels and the TSH levels during a TRH test were determined and correlated with age and serum ferritin levels. Basal serum T4, T3 and TBG levels were lower and serum TSH levels were higher during the test and in the basal state in thalassaemia major children than in control children. These results show a compensated sub-clinical primary hypothyroidism. The transversal study did not show any significant correlation between the hormonal parameters studied and chronological age or serum ferritin levels. In contrast, the longitudinal study showed a significant correlation between pituitary-thyroidal axis function and siderosis (positive correlations between the variations of TSH levels as delta, peak, 30 and 45 min values and the variations of serum ferritin levels). The thyroid impairment seems not to be correlated with serum ferritin levels in the transversal study because of the presence of an individual different sensitivity of the gland to the iron overload. The ferritin dependence of this impairment is shown only by longitudinal studies where individual differences in sensitivity of the gland are absent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Investigation on the psychosomatic and clinical causes in cases of amenorrhea after a voluntary interruption of pregnancy]. / Indagine sulle cause psicosomatiche e cliniche nei casi di amennorrea post-I.V.G.

PIP: Authors report on data gathered as a result of an investigation aimed at evaluating the presence of psychosomatic causes or contributing factors in the onset of amenorrhea after a voluntary interruption of pregnancy (VPI). The investigation, carried out at the Little Obstetrics and Gynaecologic Surgery Dept. at the University of Rome, where law 194 concerning VPI is implemented, has provided data that, for the most part, corroborates this assumption. However, there exists a pool of patients on whom further causes will require investigation in order to completely eradicate post-VPI amenorrhea. (author's modified)^ieng

[Prevention of iatrogenic pathology in voluntary abortions]. / La prevenzione della patologia iatrogena nella interruzione volontaria della gravidanza.

PIP: With reference to the increasingly widespread practice of abortion, the authors review the possible consequences of voluntary abortion, both by examining the data available in the literature and from their own personal parctice. (author's modified)^ieng

[Contraception before and after induced abortion (author's transl)]. / Contraccezione prima e dopo l'I.V.G.

PIP: This document presents data on contraception gathered on 1000 women who underwent voluntary induced abortion at the Minor Obstetric Surgery and Gynecologic Ward of the University of Rome, Italy. 33.4% of women were from outside of Rome; 61.3% were between 18-30, and only 6.2 were minors; 50.3% were unmarried and 49.7% were married; more than 50.8% had a high school education; 79.2% of requests for abortion were urgent, and most were done between the 7th and 9th week of gestation. Prior to the abortion only 40% of women had sometimes used an effective contraceptive method, i.e. 308 women had used the pill, 28 the IUD, and 25 the diaphragm. Of the remaining women 20%, or 210, had never used contraception, and 40%, or 421 women, relied on coitus interruptus, which remains the method of choice. 84 women used the Ogino-Knaus method, 60 used spermicidal agents, and 85 the condom. 841 women came back for a control visit; after appropriate counseling, medical and psychological, 203 women chose the IUD and 141 the pill as a contraceptive method. 116 women did not accept any contraception at all. These data show that knowledge about contraception is not widespread as it should be, and that efforts must be made by the medical and paramedical personnel.^ieng