Implementation and preliminary validation of a new score that predicts post-operative complications.

BACKGROUND: An accurate pre-operative risk assessment could reduce morbidity and mortality for high-risk surgical patients. The aim of the study was to implement and preliminary validate a new score that could predict the occurrence of post-operative complications (PoCs): the Anesthesiological and Surgical Postoperative Risk Assessment (ASPRA) score. METHODS: The ASPRA score was created through a literature's review; a score of 1-3 was given to each identified risk factor, according to its statistical correlation with PoC. ASPRA was retrospectively applied to a derivation set of 176 surgical patients. A receiver operating characteristic (ROC) analysis evaluated the discriminating ability of the score and cutoff value in predicting the occurrence of PoCs, according to the Clavien-Dindo classification of surgical complications. The statistical validation of the score and related cutoff values was prospectively ran within a validation set of 1928 surgical patients. RESULTS: Through ROC analysis, an ASPRA score of 7 was chosen as the cutoff value in the derivation set. In the validation set, 65.3% of patients presented a PoC (Clavien ≥ 1). In this group, ROC analysis showed an area under the curve (AUC) of 0.72, and although potentially related to the high rate of complications a high positive predictive value of 87.0% has been observed. No significant differences were found in ROC-AUC, sensitivity, specificity, or positive or negative predictive value between the derivation and validation sets (P > 0.05). CONCLUSION: The new ASPRA score has a high positive predictive value to predict the occurrence of PoCs. Further prospective studies are required to confirm these results.

Anatomical and biochemical studies of Spartium junceum infected by Xylella fastidiosa subsp. multiplex ST 87.

Spartium junceum L. is a typical species of Mediterranean shrubland areas, also grown in gardens and parks as an ornamental. In recent years in Europe, S. junceum has been recurrently found to be infected by different subspecies and genotypes of the quarantine regulated bacterium Xylella fastidiosa (Xf). This work presents for the first time the anatomy of S. junceum plants that we found, by means of genetic and immunochemistry analysis, to be naturally infected by Xf subsp. multiplex ST87 (XfmST87) in Monte Argentario (Grosseto, Tuscany, Italy), a new outbreak area within the EU. Our anatomical observations showed that bacteria colonized exclusively the xylem conductive elements and moved horizontally to adjacent vessels through pits. Interestingly, a pink/violet matrix was observed with Toluidine blue staining in infected conduits indicating a high content of acidic polysaccharides. In particular, when this pink-staining matrix was observed, bacterial cells were either absent or degenerated, suggesting that the matrix was produced by the host plant as a defense response against bacterial spread. In addition, a blue-staining phenolic material was found in the vessels and, at high concentration, in the pits and inter-vessels. SEM micrographs confirmed that polysaccharide and phenolic components showed different structures, which appear to be related to two different morphologies: fibrillary and granular, respectively. Moreover, our LM observations revealed bacterial infection in xylem conductive elements of green shoots and leaves only, and not in those of other plant organs such as roots and flowers.

Micromorphological and phytochemical survey of Ballota acetabulosa (L.) Benth.

Within the Open Science project entitled 'Botanic Garden, factory of molecules', a multidisciplinary study approach was applied to Ballota acetabulosa (L.) Benth., at the Ghirardi Botanic Garden (Toscolano Maderno, BS, Italy). Micromorphological and histochemical investigations were performed on the secreting structures of the vegetative and reproductive organs under light, fuorescence and electronic microscopy. Concurrently the characterization of the volatiles spontaneously emitted from leaves and flowers were examined. Four trichome morphotypes were identified: peltate and short-stalked, medium-stalked and long-stalked capitate trichomes, each with a specific distribution pattern. The histochemical analysis was confirmed using ultrastructural observations, with the peltates and long-stalked capitates as the main sites responsible for terpene production. The head-space characterization revealed that sesquiterpene hydrocarbons dominated both in leaves and flowers, with γ-muurolene, ß-caryophyllene and (E)-nerolidol as the most abundant compounds. Moreover, a comparison with literature data concerning the ecological roles of the main compounds suggested their dominant roles in defence, both at the leaf and flower level. Hence, we correlated the trichome morphotypes with the production of secondary metabolites in an attempt to link these data to their potential ecological roles. Finally, we made the obtained scientific knowledge available to visitors of the Botanic Garden through the realization of new labelling dedicated to B. acetabulosa that highlights the 'invisible', microscopic features of the plant.

Development of END-of-Life ScorING-System to identify critically ill patients after initial critical care who are highly likely to die: a pilot study.

BACKGROUND: High quality palliative care should be provided for the dying patients in the intensive care unit (ICU). The aim of this pilot study is to develop a scoring system, the "END-of-Life ScorING-System" (ENDING-S), that may help to identify ICU patients at very high risk of dying after initial response to the intensive treatments and which could be used to facilitate palliative care. METHODS: The characteristics of longer-term ICU patients (>4 days) who are at very high risk of dying were identified through an analysis of the literature and developed in a retrospective cohort of patients. ENDING-S Score was developed through a multivariate analysis. Model accuracy was tested through ROC and Hosmer-Lemeshow analysis for model discrimination and calibration respectively. Cross validation was used to provide internal model validation. RESULTS: Potential predictors of death were identified and applied to 80 ICU patients. Significant variables in the multivariate analysis were the ratio of the ICU days in which the patient needs mechanical ventilation or vasoactive drugs divided by the total ICU days, the total ICU length of stay, and current sepsis. Analysis of accuracy showed a ROC-AUC equals to 0.98 (95% CI, 0.97 to 1), and agreement between the predicted probability and the observed frequency of death in the ICU was observed (P>0.05 at Hosmer-Lemeshow test). The internal validation confirms these results. CONCLUSION: In these preliminary results, ENDING-s shows acceptable calibration and discrimination properties. ENDING-S may raise awareness among ICU physicians about the importance of integrating palliative care into ICU daily practice.

Spin-trappers and vitamin E prolong endurance to muscle fatigue in mice.

The involvement of free radicals in endurance to muscle effort is suggested by experimental and clinical data. Therefore, experiments have been performed to observe the effect of trapping free radicals on endurance to swimming in mice. Animals were injected intraperitoneally with each of three spin-trappers [N-tert-Butyl-alpha-Phenyl-Nitrone (PBN),alpha-4-Pyridyil-1-Oxide-N-tert-Butyl-Nitrone (POBN) and 5,5-Dimethyl-1-Pirrolyn-N-Oxide (DMPO): 0.2 ml of 10(-1) molar solution]. Each mouse was submitted to a swimming test to control resistance to exhaustion a) without any treatment, b) after administration of each spin-trapper in a random order c) after saline. Control experiments were performed with saline and with vitamin E. Endurance to swimming was greatly prolonged by pretreatment with all the spin-trappers (DMPO less than 0.0001; POBN less than 0.0001; PBN less than 0.001) and with Vitamin E. Experiments state that compared to treatment with spin-trappers or Vitamin E, administration of saline alone did not enhance time to exhaustion so that the increase in time to exhaustion with the various free radical scavengers was not the effect of training. Therefore, free radicals could be considered as one of the factors terminating muscle effort in mice.

Role of patient posture during puncture on successful unilateral spinal anaesthesia in outpatient lower abdominal surgery.

BACKGROUND AND OBJECTIVE: Unilateral spinal anaesthesia is a useful anaesthesia technique in lower abdominal surgery, especially in an outpatient setting. Patient posture is pivotal in the achievement of unilateral anaesthesia. Nevertheless, no studies have elucidated the influence of patient posture during the anaesthetic injection on unilaterality. Thus, the aim was to compare the effect of patient posture, during the induction phase of spinal anaesthesia, on block characteristics. METHODS: Eighty patients, ASA I-II, scheduled for unilateral hernioplasty were randomized into two groups. Anaesthesia was performed in lateral position in Group 1 (G1) with operative side down and in sitting position in Group 2 (G2) whose patients were then immediately turned on their lateral side. All patients were maintained for 20 min in lateral position with their operative side down. Hyperbaric bupivacaine 1% 10 mg were used. RESULTS: Unilateral anaesthesia was seen in 80% (32/40) and 12.5% (5/40) of G1 and G2, respectively. The readiness for surgery was faster in G1 (P < 0.0001). The motor block in the non-operative side was stronger in G2 (P < 0.0001). The offset of sensory block was faster in G1 (P = 0.0001). The offset of motor block was slower in G1 (P = 0.0008). The time for voiding was shorter in G1, although not significant. CONCLUSIONS: Lateral posture during the induction of spinal anaesthesia is pivotal for a higher success of unilateral block, a fast readiness to surgery, and a fast recovery. Therefore, this technique can be considered feasible and time-saving for lower abdominal surgery.

Exogenous glutathione increases endurance to muscle effort in mice.

Many data suggest an involvement of toxic oxygen radicals in the termination of endurance to muscle fatigue. Being reduced glutathione (GSH), an efficient intracellular physiological antioxidant, experiments have been performed to discover whether exogenous GSH modifies endurance to exhaustive swimming in mice. GSH was administered to mice as a single dose (250, 500, 750 or 1000 mg/kg i.p.) or as repeated doses (250 mg/kg i.p. once a day during 7 days) 10 min before a swimming test to exhaustion. GSH 500, 750 and 1000 mg/kg, increased endurance to swimming by respectively 102.4%, 120.0% and 140.7%. GSH 250 mg/kg did not affect endurance when injected in a single dose but increased it by 103.7% when injected once a day for 7 days.

[Reduced glutathione and L-cysteine in endotoxic shock in the rat]. / Glutatione ridotto e L-cisteina nello shock endotossinico nel ratto.

BACKGROUND: Reduced Glutathione (GSH) is a well known physiological antioxidant, that would protect against lethal effects of endotoxin. However, the site of the action of GSH can be intracellular (transmembrane passage of constitutive amino acids) or extracellular (membrane thiols). AIM OF THE WORK: To search if L-cysteine (one of three constitutive amino acids of GSH) protects against endotoxin as GSH and to search if inhibition of transmembrane passage of GSH and L-cysteine by Probenecid affects that protection. MATERIALS AND METHODS: Rats injected (n = 99) with a lethal dose of endotoxin (BACTO, DIFCO lab. 0111:B4 10 mg/kg ip) immediately after received: (a) Saline solution; (b) GSH 500 mg/kg; (c) L-Cysteine 0.25 g/kg; (d) Probenecid 25 mg/kg in 20% Ethanol plus GSH 500 mg/kg; (e) Probenecid 25 mg/kg in 20% Ethanol; (f) 20% Ethanol. The administration of Saline solution, GSH, L-cysteine was repeated two hours later. Injection volume was 0.5 ml ip. Survival rate of each group of rats was evaluated 6, 12 and 24 hours after endotoxin injection. Survival was compared with that of the control group by Fisher test. RESULTS: GSH and L-cysteine significantly increase survival if compared to all other treatments (respectively p < 0.002 and p < 0.001 at 12 hours; p < 0.005 and p < 0.0002 at 24 hours). Probenecid nullifies the survival increase caused by GSH. Probenecid alone or Ethanol alone show a survival rate not significantly different in respect to control group. CONCLUSIONS: Protection exerted by GSH against fatal effects of endotoxin is also provided by one of its constituent amino acids (L-cysteine) and is inhibited by Probenecid. So we can infer that such an antioxidant action happens at an intracellular site. Need of high doses of GSH and L-cysteine can be due to the necessity of a strong concentration gradient between extra and intracellular sites.

[Emergence and postoperative course after anesthesia with sevoflurane versus propofol]. / Risveglio e decorso postoperatorio dopo anestesia con sevoflurano versus anestesia con propofol.

BACKGROUND: To compare the postoperative period, with particular regard to occurrence of adverse effects at the time of emergence from anaesthesia, recovery parameters, any post-surgical analgesia requirements and laboratory tests changes in 80 ASA I and II patients undergoing sevoflurane or propofol anaesthesia for elective extracavity surgery. DESIGN: A prospective randomized clinical trial. METHODS: Patients were randomly allocated into two groups: in the first group, thiopentone was administered for induction of anaesthesia and sevoflurane for maintenance; the second group received propofol either for induction of anaesthesia and maintenance. All patients received vecuronium for neuromuscular blockade and fentanyl as needed. At the end of surgery, the occurrence of adverse effects, recovery parameters, time of discharge from recovery area, any post-surgical analgesia requirements, time of walking resumption and any laboratory tests changes were recorded. RESULTS: In the sevoflurane group times of discharges from recovery area were significantly faster. In both groups total bilirubin increase was recorded until 72 hours after the end of anaesthesia. CONCLUSIONS: Significant differences of postoperative adverse effects and laboratory tests changes were not recorded in both groups of anaesthetics.

[Anesthesia with sevoflurane vs propofol in elective extracavity surgery]. / Anestesia con sevoflurano vs propofol nella chirurgia d'elezione extracavitaria.

OBJECTIVE: To compare the cardiovascular effects and recovery characteristics of sevoflurane and propofol anesthesia in 80 ASA I and II patients undergoing elective extracavity surgery expected to last at least one hour. DESIGN: A prospective randomized clinical trial. METHODS: After meperidine and atropine premedication, the patients were randomly allocated into two groups: in the sevoflurane group thiopentone was administered for induction of anesthesia and sevoflurane for maintenance; the propofol group received propofol either for induction of anesthesia or maintenance. All patients received N2O, vecuronium, artificial ventilation and fentanyl as needed. Vital parameters were monitored during anesthesia and two hours later. Recovery times were recorded after anesthesia. Statistical analysis was performed with SAS (Statistical Analysis System). RESULTS: In the sevoflurane group, heart rate and diastolic pressure were slightly higher than in the propofol group. Recovery time was faster after sevoflurane anesthesia.

[Light-guided intubation using Trachlight]. / Intubazione luce-guidata mediante Trachlight.

BACKGROUND: A new intubating transilluminated device (Trachlight) has been recently proposed as an alternative to tracheal intubation with direct laryngoscopy. OBJECTIVE: 1) To evaluate Trachlight device in orotracheal intubation and to assess its operation and complications. 2) To compare the time consumption of transillumination intubation in respect to direct laryngoscopy on the same patients. METHODS: The first study was performed on 50 patients undergoing elective surgery and submitted to Trachlight intubation alone; speed of intubation, number of attempts and all complications were recorded and related to Mallampati classes. In the second study 16 patients undergoing to elective surgery were enrolled. Each patient was classified according to both the Mallampati classes and the Cormack classes. Each patient was submitted to two tracheal intubations: the first with the Trachlight and the second with conventional direct laryngoscopy performed by the same anesthesiologist. The time to intubation and the number of attempts were recorded and related to the Mallampati and Cormack classes. RESULTS: In the first study time of intubation with Trachlight was 20.93 +/- 13.02s (mean +/- SD) without statistical differences in respect to the Mallampati classes. In the second study the times to intubation were without any statistical difference independently of the technique of intubation and of the Mallampati or Cormack classes. CONCLUSIONS: Orotracheal intubation using Trachlight appears to be an effective and easy to learn technique, being also easy, safe and fast to carry out. The comparison with direct laryngoscopy showed the same speed and effectiveness even on patients with difficult intubation.