Preliminary assessment of persistent organic pollutants (POPs) in tissues of Risso's dolphin (Grampus griseus) specimens stranded along the Italian coasts.

Ecotoxicological and pathological research on Grampus griseus (Cuvier, 1812) (Risso's dolphins) is scarce both globally and in the Mediterranean Sea. This species has been classified as "Vulnerable" by the International Union for Conservation of Nature (IUCN) in the Mediterranean Sea. To evaluate the presence of "persistent organic pollutants" (POPs), especially organochlorine compounds (OCs), in the animals, chemical analyses were performed on tissues and organs of Risso's dolphin stranded along the Italian coasts between 1998 and 2021. Toxic contaminants such as hexachlorobenzene (HCB), polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane and its metabolites (DDTs) were examined in the blubber, liver, muscle, and brain of 20 animals, and data was correlated with sex, age, and stranding locations.

Preoperative medication with oral morphine sulphate and postoperative pain.

BACKGROUND: The administration of an analgesic drug prior to nociceptive surgical stimulus could result in a better postoperative pain management. The aim of this study was to evaluate the effect of preoperative oral morphine sulphate on postoperative pain relief. METHODS: Sixty patients undergoing major abdominal surgery were randomly assigned to premedication with 0.5 mg/kg oral morphine sulphate (oral morphine group) or 0.05 mg/kg oral midazolam (active placebo group). Primary outcome was efficacy of morphine premedication on opioid administration of IntraVenous Patient Controlled Analgesia (IVPCA) doses, at 4, 24, and 48 hours after completion of surgery and reducing static and dynamic visual analogue scale (sVAS and dVAS) scores. Secondary outcome was the time needed for the recovery of canalization of the gastro-intestinal tract. It was also evaluated fentanyl intraoperative consumption. Statistical analysis was performed by linear regression and student t test. Values of P<0.05 were considered significant. RESULTS: The two groups were comparable with respect to patient characteristics. At 24 and 48 hours post surgery, administered IVPCA doses were reduced in the oral morphine group compared to the active placebo group (P<0.05). Values of sVAS and dVAS were significantly lower in the oral morphine group compared to the active placebo group at all assessment times (P<0.05). Fentanyl consumption was similar in both groups. Needs of a ketorolac rescue dose was greater in the ap versus the om group (21 patients in the ap vs 9 patients in the om group, P<0.001). Mean gastrointestinal canalization did not significantly differ between groups. CONCLUSIONS: In major abdominal surgery, premedication with oral morphine sulphate produces better postoperative pain control and has an opioid-sparing effect without delaying gastrointestinal canalization time.

Hyperlipidemic acute pancreatitis: a possible role of antiretroviral therapy with entecavir.

In most cases clinical profile of acute hyperlipidemic pancreatitis is a preexisting lipoprotein abnormality associated to second risk factors such as alcohol abuse, diabetes mellitus or medications that can induce hypertrygliceridemia. We report a case of a young male affected by chronic hepatitis B virus infection admitted to Emergency Department due to acute abdominal pain, vomiting and fever. The patient was in antiretroviral treatment with entecavir; moreover he was affected by diabetes mellitus and he presented a past history of alcohol abuse. Laboratory tests demonstrated hyperglycemia, severe metabolic acidosis and hypertriglyceridemia, whereas abdominal computed tomography scan revealed peripancreatic edema: hyperlipidemic pancreatitits was supposed and the patient was admitted to the intensive care unit. Considering its possible role in the pathogenesis of pancreatitis, entecavir was interrupted and total of 3 sections of plasmapheresis were performed, allowing clinical resolution and prevention of pancreatic damage. The possible pathogenetic role of entecavir is discussed.

Propriospinal myoclonus following intrathecal bupivacaine in hip surgery: a case report.

Propriospinal myoclonus is a rare disorder characterized by sudden, shock-like, involuntary jerks that arise from the axial muscles and spread both rostrally and caudally to other myotomes through slow polysynaptic pathways. It can be idiopathic or secondary to intrinsic and extrinsic spinal cord lesions; additionally, it can develop as an adverse effect to the administration of several drugs, including neuraxial local anesthetics. This article describes a case of transient propriospinal myoclonus in a 77-year-old woman undergoing surgery for hip replacement who received 12 mg of 0.5% normobaric bupivacaine administered by a 25-G spinal needle. On postoperative day 1, the patient presented with spinal myoclonus, defined by clinical and electrophysiologic studies. Valproate and clonazepam controlled the symptoms, and on day 4 the myoclonus completely disappeared. Few cases of myoclonus induced by intrathecal bupivacaine administration have been reported in the literature, but systematic reviews written to clarify the global incidence and the physiopathology of this complication are still lacking.

Efficacy and safety of quinine-artesunate in an HIV-positive patient with severe falciparum malaria.

Severe falciparum malaria is a medical emergency that is associated with a high rate of mortality, even when treated in an Intensive Care Unit. Until recently, intravenous quinine was the standard treatment; however, artemisin derivatives are now regarded as the first-line treatment for multidrug-resistant falciparum malaria. Although several studies have demonstrated the superiority of Artesunate, this drug is not licensed in many countries. This article describes the case of an HIV-positive patient, who returned from Africa and presented with 10% parasitemia and clinical signs of severe falciparum malaria; this individual was successfully treated with a combination of artesunate and quinine. Artesunate was imported from the foreign market, and written consent for its administration was obtained in advance. Parasite clearance was rapidly achieved; however, on day IV, the patient developed acute respiratory distress syndrome that required mechanical ventilation. The patient was extubated on day XIV and discharged on day XXV. Due to its rapid action, artesunate was likely responsible for the good clinical outcome in this case; however, in order to clarify the role of this new combination therapy, further studies are required.

Propofol sedation in a colorectal cancer screening outpatient cohort.

AIM: Colorectal cancer screening colonoscopies require sedation for both anxiety and pain. Propofol is used worldwide and allows for rapid and profound sedation with quick recovery after cessation of infusion. However, there is still a debate about whether it should be administered by anesthetists, gastroenterologists, or trained nurses. The aim of the study was to assess the number and proportion of patients who might benefit from the quality and safety of sedation under propofol during colonoscopies in a cohort of colorectal cancer screening outpatients. METHODS: Patients' genders, ages, numbers of operative procedures, and prior experience with colonoscopies were recorded, and differences were tested between sedated and unsedated patients. The need for mask ventilation and the rate of anesthetically, medically, or surgically related complications were compared between sedated and unsedated patients. The number of complete colonoscopies, length of the procedures, and time to reach the ileocecal valve were compared between sedated and unsedated patients. RESULTS: Of 135 colonoscopies, 101 were performed under sedation. All sedated patients underwent complete endoscopic examinations, while 8.9% of unsedated patients had their examination stopped due to excessive discomfort or pain. Colonoscopies tended to be shorter in sedated than unsedated patients. No anesthesia-related complications occurred. In 3/135 patients, a short period (<3 min) of mask ventilation was necessary. One surgical complication occurred among the sedated patients. One unsedated patient suffered a medical complication (dyspnea and ST-T elevation). CONCLUSIONS: Propofol sedation can be safely applied to colorectal cancer screening outpatients. Sedation was managed by a dedicated anesthetic staff and no patient suffered anesthesia-related complications.

Changes in auditory evoked potentials induced by postsurgical sepsis.

BACKGROUND: Clinical examination may be less sensitive than electrophysiological methods in the diagnosis of sepsis-associated encephalopathy. The aim of this study was to evaluate the changes in A-line Autoregression Index (AAI) induced by postsurgical sepsis. METHODS: The study involved patients admitted to the University High Dependency Unit (HDU) after major abdominal surgery. Patients that later developed sepsis entered the septic group (SG), and the other patients formed the control group (CG). The SG underwent measurements of AAI and tests for bedside mental status, consciousness abnormalities, heart rate, blood pressure, respiratory rate, tympanic temperature and white blood cell concentration at HDU admission (T1) and within 6 hours after the diagnosis of sepsis was confirmed (T2). The CG was evaluated at T1 and at day 4 of the HDU stay. All measured variables were compared between CG and SG at T1 and T2 using the Mann Whitney test with a significance cut-off of P<0.001. RESULTS: The CG and SG included 30 and 24 patients, respectively. There was no difference between the CG and SG at T1. At T2, the median AAI was significantly higher in the CG than in the SG. Significant differences were found also for reactive protein C and body temperature. CONCLUSION: The occurrence of sepsis significantly reduces AAI. Measurement of AAI thus has the potential to be a reliable diagnostic test to identify subclinical sepsis-associated encephalopathy.

Acute left ventricular dysfunction due to Tako-tsubo syndrome after induction of general anesthesia.

Tako-tsubo cardiomyopathy is a recently described form of transient ventricular dysfunction that is not associated with coronary vessels obstruction, although its clinical manifestations are often similar to those of myocardial ischemia. This syndrome is possibly due to an excess of catecholamines, and it is associated with emotional and physical stress and surgery. However, the pathophysiological relation to anaesthesia has not yet been clarified. We report a case of Tako-tsubo cardiomyopathy that ensued immediately after induction of general anaesthesia for elective surgery in a patient submitted to laparoscopic cholecystectomy. The patient was first treated as if affected by myocardial ischemia, but a rapidly performed emergency coronary angiography showed normal epicardial coronary vessels with a significant reduction of left ventricular function. The coronary angiography ruled out the diagnosis of typical myocardial ischemia and allowed for the arrival at the correct diagnosis. The transient ventricular ballooning was attributed to the recently described Tako-tsubo syndrome. Prompt treatment allowed control of symptoms, and the patient was safely treated and discharged on day 15. Although it is difficult to identify the cause of this syndrome, it may be argued that, during general anaesthesia and particularly at induction, the imperfect control of catecholamine excess may induce cardiac damage in predisposed subjects.

State entropy and bispectral index: correlation with end tidal sevoflurane concentrations.

AIM: Aim of this study was to evaluate the difference between the correlations of state entropy (SE) and bispectral index (BIS) with different end tidal concentrations (Et) of sevoflurane. METHODS: A total of 40 ASA I/II patients submitted to abdominal surgery were enrolled in the study. After premedication with fentanyl, anesthesia was induced with propofol and atracurium and maintained with sevoflurane in oxygen and air. The values of Et sevoflurane, SE and BIS were recorded during the operating room stay. The mean Et sevoflurane was calculated and the correlations of SE and BIS with Et sevoflurane were determined with Pearson test separately at values of Et sevoflurane below and higher the mean Et sevoflurane. Student's t-test was used to verify if the difference between the correlations was significant (P<0.05). RESULTS: The mean Et sevoflurane was 1.5%. During anesthesia the correlation with Et sevoflurane was -0.75 for SE and -0.70 for BIS. At Et sevoflurane higher than 1.5% the correlation with Et sevoflurane was -0.41 for SE and -0.14 for BIS. At Et sevoflurane below 1.5% the correlation with Et sevoflurane was -0.65 for SE, and -0.8 for BIS. The difference between the correlations of Et sevoflurane with SE and BIS resulted statistically significant. CONCLUSION: During sevoflurane anesthesia SE shows a better correlation than BIS with Et sevoflurane. Although at low Et sevoflurane the correlation is better with BIS, at high Et sevoflurane the correlation is better with SE.

Bispectral Index compared to Ramsay score for sedation monitoring in intensive care units.

AIM: Continuous monitoring is of paramount importance in order to obtain a correct level of sedation in ICU patients. Clinical scoring systems, although simple and inexpensive, are often inadequate in evaluating the patient level of consciousness. Among instrumental tools for sedation monitoring, Bispectral Index (BIS) is now widely used due to its reliability and applicability. Nevertheless some doubts still exist regarding its usefulness in ICU. METHODS: Sedation, obtained with propofol or midazolam, was monitored with Ramsay scale and BIS in 40 patients admitted in ICU for postoperative monitoring after major abdominal or vascular surgery. A correlation between Ramsay score and BIS values was searched using Pearson test. RESULTS: A good correlation between Ramsay score and BIS values was observed. At the deeper levels of sedation a wide range of BIS values corresponds to Ramsay score 6, indicating various levels of central nervous system depression that are not identified by clinical evaluation. CONCLUSIONS: BIS monitoring is useful in ICU patients and allows a finest differentiation of sedation level in deeply sedated ICU patients.

A-line autoregression index monitoring to titrate inhalational anaesthesia: effects on sevoflurane consumption, emergence time and memory.

BACKGROUND: A-line autoregression index (AAI) is a parameter derived from auditory evoked potentials proposed as depth of anaesthesia monitor. We evaluated the effects of AAI guidance on sevoflurane consumption, emergence time, explicit and implicit memory. METHODS: One hundred patients submitted to major abdominal surgery were randomized into two groups. In group A (n = 50), sevoflurane was titrated according to AAI (target = 20 +/- 5), in group B (n = 50) according to clinical signs. Anaesthesia was induced with fentanyl, propofol, atracurium and maintained with sevoflurane. The mean value of sevoflurane consumption (g/min) and emergence time has been assessed in both groups. After emergence, A test of explicit memory was administered. We assessed implicit memory using a category generation test. RESULTS: In group A, mean sevoflurane consumption was significantly (P = 0.0001) reduced by 20.4% and mean emergence time was significantly (P = 0.00012) shorter by 2 min with respect to group B. No patients experienced explicit memory while the difference between the two groups in implicit memory results was not significant (P = 0107). CONCLUSIONS: AAI titration of anaesthesia allows a significant reduction in sevoflurane consumption and emergence time without significant effects on the incidence of explicit and implicit memory. Nevertheless the relationship between AAI and memory requires studies in larger groups of patients.

Sepsis associated encephalopathy.

A diffuse cerebral dysfunction is often present in sepsis and may ensues even before signs of other organ failure. It is better defined as ''Sepsis Associated Encephalopathy'' (SAE), in order to stress the absence of direct infection of the central nervous system. The main sign of SAE is an altered mental status. Electroencephalography is the more sensitive diagnostic test, and allows the grading of the severity of cerebral dysfunction that is related to outcome. SAE is potentially reversible, but it always worsens the prognosis. Pathophysiology of SAE is not still completely understood, and it is probably multifactorial. Indeed, brain dysfunction in sepsis may be related to action of micro-organisms toxins, to the effects of inflammatory mediators, to metabolic alterations and to abnormalities in cerebral circulation. At this moment a specific treatment for SAE does not exist and outcome relies upon prompt and appropriate treatment of sepsis as a whole.

Genetic variants of alpha-1-antitrypsin (AAT).

This paper reviews the genetic variants of alpha-1-antitrypsin (AAT) which have been sequenced with special emphasis on the s.c. deficiency variants. These result in AAT low plasma levels via three main mechanisms: 1) intracellular storage; 2) intracellular degradation; 3) lack of synthesis. Intracellular storage occurs with the classical Z variant and with a few variants called M-like, because of their isoelectric focusing (IF) pattern. The storage phenomenon causes liver damage and can be demonstrated at both light and electron microscopic level with the help of immunohistochemistry. We report a new deficiency variant of AAT (M-Cagliari) characterized by very low plasma levels, massive storage of AAT and liver cirrhosis. By using immunohistochemical techniques and DNA analysis we could demonstrate that M-Cagliari has antigenic and genetic properties other than the Z AAT.