Does musical interaction in a jazz duet modulate peripersonal space?

Researchers have widely studied peripersonal space (the space within reach) in the last 20 years with a focus on its plasticity following the use of tools and, more recently, social interactions. Ensemble music is a sophisticated joint action that is typically explored in its temporal rather than spatial dimensions, even within embodied approaches. We, therefore, devised a new paradigm in which two musicians could perform a jazz standard either in a cooperative (correct harmony) or uncooperative (incorrect harmony) condition, under the hypothesis that their peripersonal spaces are modulated by the interaction. We exploited a well-established audio-tactile integration task as a proxy for such a space. After the performances, we measured reaction times to tactile stimuli on the subjects' right hand and auditory stimuli delivered at two different distances, (next to the subject and next to the partner). Considering previous literature's evidence that integration of two different stimuli (e.g. a tactile and an auditory stimulus) is faster in near space compared to far space, we predicted that a cooperative interaction would have extended the peripersonal space of the musicians towards their partner, facilitating reaction times to bimodal stimuli in both spaces. Surprisingly, we obtained complementary results in terms of an increase of reaction times to tactile-auditory near stimuli, but only following the uncooperative condition. We interpret this finding as a suppression of the subject's peripersonal space or as a withdrawal from the uncooperative partner. Subjective reports and correlations between these reports and reaction times comply with that interpretation. Finally, we determined an overall better multisensory integration competence in musicians compared to non-musicians tested in the same task.

Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia.

BACKGROUND: Driving pressure (ΔP) represents tidal volume normalised to respiratory system compliance (CRS) and is a novel parameter to target ventilator settings. We conducted a study to determine whether CRS and ΔP reflect aerated lung volume and dynamic strain during general anaesthesia. METHODS: Twenty non-obese patients undergoing open abdominal surgery received three PEEP levels (2, 7, or 12 cm H2O) in random order with constant tidal volume ventilation. Respiratory mechanics, lung volumes, and alveolar recruitment were measured to assess end-expiratory aerated volume, which was compared with the patient's individual predicted functional residual capacity in supine position (FRCp). RESULTS: CRS was linearly related to aerated volume and ΔP to dynamic strain at PEEP of 2 cm H2O (intraoperative FRC) (r=0.72 and r=0.73, both P<0.001). These relationships were maintained with higher PEEP only when aerated volume did not overcome FRCp (r=0.73, P<0.001; r=0.54, P=0.004), with 100 ml lung volume increases accompanied by 1.8 ml cm H2O-1 (95% confidence interval [1.1-2.5]) increases in CRS. When aerated volume was greater or equal to FRCp (35% of patients at PEEP 2 cm H2O, 55% at PEEP 7 cm H2O, and 75% at PEEP 12 cm H2O), CRS and ΔP were independent from aerated volume and dynamic strain, with CRS weakly but significantly inversely related to alveolar dead space fraction (r=-0.47, P=0.001). PEEP-induced alveolar recruitment yielded higher CRS and reduced ΔP only at aerated volumes below FRCp (P=0.015 and 0.008, respectively). CONCLUSIONS: During general anaesthesia, respiratory system compliance and driving pressure reflect aerated lung volume and dynamic strain, respectively, only if aerated volume does not exceed functional residual capacity in supine position, which is a frequent event when PEEP is used in this setting.

Early-goal directed therapy for septic shock: is it the end?

Three randomized clinical trials have recently provided data on the lack of effectiveness of "early-goal directed therapy" (EGDT) (i.e. optimization of tissue oxygenation in the first 6 hours since sepsis diagnosis using different therapeutic interventions based on the assessment of the central venous oxygen saturation to titrate such interventions) in the initial management of patients with septic shock. In a first trial including 31 US hospitals (the ProCESS study, N.=1341), three different therapeutic strategies (EGDT vs. protocol-based therapy vs. usual care) were compared and no difference in the primary endpoint (60-day mortality) was found (EGDT 21%, protocol-based therapy 18% and usual care 19%). No significant difference in death by 90 days or in other secondary outcomes, including serious adverse events, was found, as well. A second trial (ARISE, N.=1600), mostly conducted in Australia and New Zealand, randomized patients to EGDT or usual care. Ninety-day mortality was similar between groups (19% vs. 19%, respectively; P=0.90) and no other differences in secondary endpoints were recorded between the two groups. A third study (ProMISe, N.=1260) included patients in 56 hospitals across England, randomly assigned to EGDT or usual care. By 90 days, mortality was similar between groups (29% vs. 29%, respectively; P=0.90). Moreover, EGDT significantly increased costs and was associated with a longer hospital length of stay. We discussed some issues related to the differences between these studies and the pivotal paper from Rivers et al. and how EGDT should be still considered in the treatment of sepsis.

How to target temperature after cardiac arrest: insights from a randomized clinical trial.

Implementation of treatments able to improve survival and neurological recovery of cardiac arrest (CA) survivors is a major clinical challenge. More than ten years ago, two pivotal trials showed that application of therapeutic hypothermia (TH, 32-34 °C) to patients resuscitated from an out-of-hospital CA (OHCA) with an initial shockable rhythm significantly ameliorated their outcome. Since then, TH has been used also for non-shockable rhythms and for in-hospital CA to some extent, even if the quality of evidence supporting TH in such situations remained very low. The objective of this randomized, controlled, multicenter study (named "Targeted Temperature Management" TTM study) was to compare two different strategies of temperature control after CA; patients were randomized to be treated either at 33 °C or at 36 °C for 24 hours, while fever was accurately avoided for the first 3 days since randomization. Inclusion criteria were: Glasgow Coma Score <8, presumed cardiac origin of arrest, randomization occurring within the first 4 hours from the return of spontaneous circulation. Patients were excluded if they had an unwitnessed arrest with asystole as the initial rhythm, suspected or known acute intracranial hemorrhage or stroke, and a body temperature of less than 30 °C. A specific algorithm was used to decide for withdrawal of care in patients remaining comatose after 72 hours since normothermia was achieved. The primary outcome was 6-month mortality. After the enrollment of 939 patients, the authors did not find any significant difference between groups in primary outcome (235/473 [50%] and 225/466 [48%] of patients died in 33 °C and 36 °C group, respectively; HR for death if in the 33 °C group, 1.06 [95% CI 0.89 to 1.28; P=0.51]). Similarly, the analysis of the composite outcome of death or poor neurologic function yielded similar results between the two groups. This is the largest study evaluating the effects of two different strategies of temperature management after CA. Some important concerns have been raised on the real benefit of keeping CA patients at 33 °C and major changes in clinical practice are expected. We discussed herein the main differences with previous randomized trials and tried to identify possible explanations for these findings.

Esmolol for septic shock: more than just heart rate control?

Excessive adrenergic stimulation may be associated with several adverse events and contribute to increase mortality in critically ill septic patients. Few clinical data exist on the effects of adrenergic blockade in this setting. The objective of this study was to investigate the effect of a short acting b-blocker (esmolol) in septic shock patients. In a single-center, controlled, open-label, phase 2 trial (from November 2010 to July 2012), Morelli et al. randomized patients with a need of norepinephrine to maintain a mean arterial pressure above 65 mmHg to receive either esmolol or standard of care. Patients were included if, after 24 hours of initial resuscitation, hypovolemia was excluded (wedge pressure ≥12 mmHg or central venous pressure ≥8 mmHg) and heart rate was above 95 bpm. Patients were excluded if they were younger than 18 years, had previous b-blockers therapy, cardiac index was ≤2.2 L/min/m² with wedge pressure >18 mmHg, were diagnosed with significant cardiac valvular diseases or were pregnant. The primary outcome was the reduction in heart rate between 80 and 94 bpm over a 96-hr period. Secondary outcomes included norepinephrine requirement, hemodynamic changes, organ function, adverse events and 28-day mortality. A total of 154 patients, 77 for each group, were enrolled. Esmolol was more effective than standard treatment to reduce heart rate within target limits; also, b-blocker therapy was associated with an increased stroke volume and left ventricular work index when compared to the control group. These favorable hemodynamic effects were associated with a better control of lactate levels, a higher reduction in norepinephrine and fluids requirement. Mortality was 49.4% in the esmolol group and 80.5% in the control group (P<0.01). This is the first study showing an improvement in cardiac function and 28-day mortality in septic patients adding b-blockers to standard therapy. We discussed several statistical and methodological limitations that may influence the generability of these results.

[Evolution of electronic fetal monitoring in labor]. / Evoluzione della cardiotocografia fetale in travaglio.

Intrapartum fetal hypoxia remains an important cause of neonatal permanent handicap and death, and in many cases it is related to lack of optimal fetal surveillance. In the last 40 years cardiotocography (CTG) has been routinely used for fetal monitoring yet this technique lacks reproducibility and its interpretation by healthcare professionals remains an important variable. Indeed, this technology not only does not improve clinically important outcomes, but also, on the contrary, leads to an increase in the number of caesarean sections carried out. Recent research has focused the attention on specific components of electronic fetal monitoring (EFM) tracings, such as ST-segment analysis (STAN) or fetal pulse oximetry (FPO). Fetal ST-segment analysis and pulse oximetry provide important parameters when used in addition to CTG, but their combined use obviously does not eliminate CTG interpretation limits. Although continuous electronic fetal monitoring is now ubiquitously utilized in modern practice, risks and benefits associated with its use are worth analysing. The analysis of the research and clinical practices carried out in the past several decades may provide useful insights into the current use of electronic fetal monitoring and new system associated procedures (STAN and FPO), which have influenced what has now become a routine modern obstetric practice.

Sedation after cardiac arrest and during therapeutic hypothermia.

Mild therapeutic hypothermia (MTH) has improved neurological outcome of comatose patients after cardiac arrest (CA). Since the first clinical studies performed in this setting, sedation has always been associated with cooling procedures. The use of sedative drugs during MTH is required because it allows faster achievement and better maintenance of target temperature. Further studies are necessary to prove any potential neuroprotective effects of sedation after CA. No differences in clinical outcomes have been found among different drugs, except for those related to their intrinsic pharmacological properties: the association propofol/remifentanil provides a faster recovery of consciousness than midazolam/fentanyl but is associated with the need of more vasopressors to maintain stable hemodynamic. Moreover, pharmacokinetic properties of these drugs are often altered during MTH so that standard drug regimens could result in overdosing because of reduced clearance. Neuromonitoring could be helpful to titrate drugs' effects and detect earlier complications (i.e. seizure), while a wake-up test should be avoided during the first 24 hours after CA.

Immunohistochemical study of the nervous system of the tunicate Thalia democratica (Forsskal, 1775).

Thalia democratica is a cosmopolitan tunicate belonging to the Thaliacea class. To further investigate the anatomy of this species, immunohistochemical labelling was performed using anti-tubulin and anti-serotonin antibodies on specimens collected in the Mediterranean Sea. The anti-tubulin antibody stained the cilia of the endostyle, the pericoronal bands and of the gill bar, enabling a detailed description of these structures. Moreover, immunolabelling of the nervous system showed the presence of eight pairs of nerve fibres emerging from the neural ganglion. Serotonergic cells were observed in the distal tract of the intestine, along the pericoronal bands, and in the placenta of gravid blastozooids, as well as in the neural ganglion. The presence of serotonin in the central nervous system has also been reported in the larvae of ascidians and may be linked to the planktonic life of these animals, a condition shared by adult thaliaceans and ascidian larvae. This work improves our knowledge of the anatomy of T. democratica and demonstrates the presence of a complex serotonergic system.

Systolic anterior motion causing hemodynamic instability and pulmonary edema during bleeding.

Systolic anterior motion (SAM) of mitral valve is the prolapse of a mitral leaflet into the left ventricle outflow tract (LVOT) during systole, causing LVOT obstruction and mitral valve regurgitation. We report the case of a patient who developed SAM-induced hemodynamic instability during bleeding with a clinical picture resembling pulmonary edema. A 77-year-old woman was admitted to our emergency room for abdominal bleeding in polycystic renal disease. Upon arrival, she was normotensive, despite being anuric and acidotic. After infusion of fluids and packed red blood cells (total 3 680 mL in 6 hours) she developed atrial fibrillation and clinical and radiological signs of pulmonary edema. Sedation and non-invasive ventilation brought to immediate severe hypotension. A transesophageal echocardiogram showed an "empty" hypertrophic hypercontractile left ventricle, SAM with LVOT obstruction (intraventricular gradient 154 mmHg) and moderate-to-severe mitral regurgitation. With further fluid infusion hemodynamic stability and sinus rhythm were recovered. SAM, LVOT obstruction and mitral regurgitation disappeared. SAM is a rare but dangerous cause of hemodynamic instability. It has been described in patients with and without left ventricular hypertrophy, in presence of hypovolemia and sympathetic stimulation. In our case it presented with a misleading clinical picture of pulmonary edema simulating fluid overload in an actually hypovolemic patient. In fact, SAM-associated mitral regurgitation together with diastolic dysfunction and tachycardia induced a pulmonary edema whose treatment worsened hypovolemia and precipitated LVOT obstruction and hypotension. Further fluid infusion was resolutive. Echocardiography was fundamental for diagnosis and treatment.

A randomized openly comparative study between rifaximin suspension versus rifaximin pills for the eradication of Helicobacter pylori.

BACKGROUND: It has been recently shown that Rifaximin, although given as a suspension, plus omeprazole, may be a promising antibiotic against Helicobacter pylori (H pylori) and worthy of further study. AIM: We have therefore evaluated Rifaximin suspension versus Rifaximin pills, in a randomly openly allocated fashion study, in H pylori positive patients. METHODS: Twenty patients with upper gastrointestinal symptoms (M/F: 13/7, age range 28-68; mean 49.6 yrs) were found to have H. pylori associated gastritis. They were allocated in an open randomized study to two different treatment groups for two weeks: (A) Rifaximin suspension 1800 mg three times a day plus Omeprazole 20 mg twice a day (n = 10), (B): Rifaximin pills 1800 mg three times a day plus Omeprazole twice a day (n = 10). Symptoms such as pirosis, bloating, epigastric pain and nausea were recorded by diary card and were evaluated before and four weeks after stopping treatment. Patients were assessed by endoscopy, histology and urease testing at entry and four weeks after stopping treatments. All the twenty patients were available four weeks after stopping treatment. RESULTS: A statistically significant improvement of the symptoms were found overall after Rifaximin treatments for pirosis, bloating, epigastric pain (p < 0.001 respectively). A significant difference in the symptom's score at the end of the two treatments were recorded between the two groups for bloating alone (p < 0.070). A different and major fall in the neutrophils, between the two treatments was observed with Rifaximin pills compared to Rifaximin suspension. The same observation was obtained according to the intensity of H. pylori reaching an eradication rate of 40% and 60% for Rifaximin suspension versus Rifaximin pills plus omeprazole respectively. In conclusion, these data suggest that Rifaximin pills may be an effective antibiotic against H pylori and worthy of further study.

Endoscopic removal of foreign bodies in the large bowel.

Endoscopic removal of foreign bodies from the intestinal tract is an extremely useful method. In our series, foreign bodies passing down from the upper intestinal tract were removed endoscopically from the rectum and colon of 13 patients. No complications were observed. It can be concluded that endoscopy is a simple, safe and effective method which, in many cases, avoids surgical procedures.