COVID-19 diagnosis and management: a comprehensive review.

Severe acute respiratory syndrome coronavirus (SARS-CoV)-2, a novel coronavirus from the same family as SARS-CoV and Middle East respiratory syndrome coronavirus, has spread worldwide leading the World Health Organization to declare a pandemic. The disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), presents flu-like symptoms which can become serious in high-risk individuals. Here, we provide an overview of the known clinical features and treatment options for COVID-19. We carried out a systematic literature search using the main online databases (PubMed, Google Scholar, MEDLINE, UpToDate, Embase and Web of Science) with the following keywords: 'COVID-19', '2019-nCoV', 'coronavirus' and 'SARS-CoV-2'. We included publications from 1 January 2019 to 3 April 2020 which focused on clinical features and treatments. We found that infection is transmitted from human to human and through contact with contaminated environmental surfaces. Hand hygiene is fundamental to prevent contamination. Wearing personal protective equipment is recommended in specific environments. The main symptoms of COVID-19 are fever, cough, fatigue, slight dyspnoea, sore throat, headache, conjunctivitis and gastrointestinal issues. Real-time PCR is used as a diagnostic tool using nasal swab, tracheal aspirate or bronchoalveolar lavage samples. Computed tomography findings are important for both diagnosis and follow-up. To date, there is no evidence of any effective treatment for COVID-19. The main therapies being used to treat the disease are antiviral drugs, chloroquine/hydroxychloroquine and respiratory therapy. In conclusion, although many therapies have been proposed, quarantine is the only intervention that appears to be effective in decreasing the contagion rate. Specifically designed randomized clinical trials are needed to determine the most appropriate evidence-based treatment modality.

Breast implant capsule flaps and grafts: a review of the literature.

BACKGROUND: A breast implant capsule forms as a physiological response to the foreign material. Over the past decades, authors started to consider the breast implant capsule as a new source of tissue, thus describing several capsular flaps and grafts. The aim of this article is to provide an overview of the applications and indications for the use of capsular tissue flaps and grafts in reconstructive and aesthetic surgery. METHODS: A review of the literature on breast implant capsule grafts and flaps was conducted. The reported surgical techniques were described and compared for indications and complications. The studies were evaluated and compared for number of patients and follow-up. RESULTS: The search yielded a total of 21 citations. Patient population was reported in 11 studies for capsular flaps and 2 articles for capsular grafts. Between 1997 and 2012, a total of 74 patients underwent surgery with the use of capsular tissue. Among these, 60 patients had a capsular flap (81 %) and 14 (19 %) had a capsular graft. Complications were experienced in 5 patients (6.7 %). CONCLUSIONS: Capsular flaps and grafts are indicated mainly to address breast implant-related problems. The breast implant capsule represents a versatile and reliable source of tissue for both aesthetic and reconstructive surgery. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Factors to consider for fascial plane blocks' success in acute and chronic pain management.

The outcome of fascial plane blocks (FPBs) has a certain variability that may depend on many factors, which can be divided into three main categories: operator-related, patient-related and drug-related. Operator-related factors include personal skills, choice of needle and injection modalities. Patient variables include anthropometric features, the type of targeted fascia, anatomical variants, patient positioning, muscle tone and breathing. Ultimately, efficacy, onset, and duration of fascial blocks may be affected by characteristics of the injected solution, including the type of local anesthetic, volume, concentration, pH, temperature and the use of adjuvants. In this article, we investigated all the factors that may influence the outcome of FPBs from a generic perspective, without focusing on any specific technique. Also, we provided suggestions to optimize techniques for everyday practitioners and insights to researchers for future studies.

Anesthesiologists ultrasound-guided regional anesthesia core curriculum: a Delphi consensus from Italian regional anesthesia experts.

INTRODUCTION: The need for a standardized core curriculum in regional anesthesia has become essential, particularly with the integration of ultrasound revolutionizing and exponentially increasing clinical practice and possibilities. In fact, numerous novel techniques, often overlapping, can confuse practitioners. This study aims to establish a core curriculum for upper limb, lower limb, paraspinal and fascial plane blocks for residency training, addressing potential educational gaps caused by the multitude of techniques, through a Delphi consensus process involving recognized Italian regional anesthesia experts. METHODS: A steering committee was formed in order to select a panel of experts in regional anesthesia. A three-round Delphi consensus was planned: two rounds of electronic voting and a final round of mixed electronic voting and round table discussion. The consensus was defined as ≥ 75% agreement for inclusion and lower than ≤ 25% agreement for exclusion from the core curriculum list. Techniques reaching the 50% threshold were included with low consensus. RESULTS: Twenty-nine techniques were selected to be included in the ultrasound-guided regional anesthesia core curriculum. Twenty-two were included with strong consensus: Upper limb: interscalene brachial plexus block, supraclavicular brachial plexus block, infraclavicular brachial plexus block, axillary brachial plexus block, intermediate cervical plexus block Lower limb: femoral nerve block, pericapsular nerve group block, adductor canal block, sciatic nerve block (transgluteal approach, infragluteal approach, and at the popliteal fossa), ankle block Paraspinal/fascial plane blocks: erector spinae plane block, deep serratus anterior plane block, superficial pectointercostal plane block, interpectoral plane block, pectoserratus plane block, rectus sheath block, ilioinguinal iliohypogastric nerves block, transversus abdominis plane block (with subcostal and midaxillary approaches) The remaining seven techniques were included with low consensus: superficial cervical plexus block, lumbar plexus block, fascia iliaca block (suprainguinal approach), anterior quadratus lumborum block, lateral quadratus lumborum block, paravertebral block, and serratus anterior plane block. CONCLUSIONS: This curriculum aims to standardize training and ensure that residents acquire the essential skills required for effective and safe practice regardless of the residents' subsequent specialization. By incorporating these techniques, educational programs can provide a structured and consistent approach to regional anesthesia, enhancing the quality of patient care and improving outcomes.

Ultrasound predictors of difficult spinal anesthesia: a prospective single-blind observational study.

BACKGROUND: Ultrasound showed to improve the precision and efficacy of spinal anesthesia (SA) through the identification of specific structures surrounding the intrathecal space, such as the anterior and posterior complex of dura mater (DM). The aim of this study was to verify the efficacy of ultrasonography in predicting difficult SA trough the analysis of different ultrasound patterns. METHODS: This prospective single-blind observational study involved 100 patients undergoing orthopedic or urological surgery. A first operator chose by landmarks the intervertebral space where he wanted to perform SA. Then a second operator recorded the visibility of DM complexes at ultrasound. Subsequently, the first operator, blinded to the ultrasound evaluation, performed SA, defined as "difficult" in case of failure, change of intervertebral space, operator exchange, duration >400 seconds or more than 10 needle passes. RESULTS: The ultrasound visualization of only posterior complex or the failure in visualization of both complexes showed a positive predictive value of 76% and 100%, respectively, towards difficult SA vs. 6% when both complexes were visible; P<0.001. A negative correlation was found between the number of visible complexes and both patients' age and BMI. Landmark-guided evaluation underestimated the intervertebral level in 30% of cases. CONCLUSIONS: Ultrasound showed a high accuracy in detecting difficult spinal anesthesia and its use should be recommended in the daily clinical practice in order to increase success rate and minimize patient discomfort. The absence of both DM complexes at ultrasound should lead the anesthetist to evaluate other intervertebral levels or consider alternative techniques.

Epicardial and pericardial fat analysis on CT images and artificial intelligence: a literature review.

The present review summarizes the available evidence on artificial intelligence (AI) algorithms aimed to the segmentation of epicardial and pericardial adipose tissues on computed tomography (CT) images. Body composition imaging is a novel concept based on quantitative analysis of body tissues. Manual segmentation of medical images allows to obtain quantitative and qualitative data on several tissues including epicardial and pericardial fat. However, since manual segmentation requires a considerable amount of time, the analysis of adipose tissue compartments based on AI has been proposed as an automatic, reliable, accurate and fast tool. The literature research was performed on March 2021 using MEDLINE PubMed Central and "adipose tissue artificial intelligence", "adipose tissue deep learning" or "adipose tissue machine learning" as keywords for articles search. Relevant articles concerning epicardial adipose tissue, pericardial adipose tissue and AI were selected. The evaluation of adipose tissue compartments can provide additional information on the pathogenesis and prognosis of several diseases, including cardiovascular. AI can assist physicians to obtain important information, possibly improving the patient's quality of life and identifying patients at risk of developing variable disorders.

Predicting difficult spinal anesthesia: development of a neuraxial block assessment score.

BACKGROUND: Spinal anesthesia is a commonly performed procedure with unpredictable difficulty. The objective of this study was to predict a difficult lumbar spinal anesthesia with clinical elements that are easy to collect. METHODS: A questionnaire-based, observational study named NBA, conducted from February 2018 to June 2018. The questions regarded clinical elements and the eventual spinal anesthesia difficulty encountered. A total of 427 questionnaires were filled by the operators. The clinical elements were selected upon literature search and have been integrated with new ones. All the answers were recorded from the anesthesiologist performing the procedure. RESULTS: The NBA Score was derived from a total number of 427 questionnaires. Among them, 26 patients had "previous history of difficult spinal anesthesia;" 277 had "spinous processes not visible;" 83 had "spinous processes not palpable;" 77 had "spinal deformities" and 28 had "previous spinal surgery" in the puncture area; 138 patients received lumbar spinal anesthesia in lateral position. There were 328 (76.8%) single puncture successes. Seventy-nine (18.5%) patients required more than one skin puncture to obtain a successful spinal anesthesia. 20 (4.7%) required an alternative anesthesia technique (general anesthesia). Multivariate analysis indicated that each element is a risk factors for difficult spinal anesthesia, except for previous spinal surgery. CONCLUSIONS: The combination of more than one element increased the chance of a second skin puncture of more than 50%. This work proposes a simple clinical scoring system predicting the probability of a difficult spinal anesthesia.

Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study.

Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle-nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle-nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings.

Pericapsular nerve group block: an overview.

INTRODUCTION: The PENG block is a recently described ultrasound-guided technique for the blockade of the sensory nerve branches to the anterior hip joint capsule. It was described as an analgesic block for the acute pain management after hip fracture, while subsequent studies expanded the original indication. The aim of this narrative review was to summarize the existing knowledge about the PENG block from the anatomical bases and to provide an up-to-date description of the technique, applications and effects. EVIDENCE ACQUISITION: We reviewed the following medical literature databases for publications on PENG block: PubMed, Google Scholar, EMBASE, and Web of science until August 31st, 2020. Data regarding anatomy, indications, drugs and technique were also collected, reported and discussed. EVIDENCE SYNTHESIS: From our search result we selected 57 relevant publications. Among them, 36 were case reports or case series and 12 publication were letters or correspondence; no RCT was identified. The main indication is the hip-related analgesia. The most commonly injected drug is a 20ml long-acting local anesthetic. There are some cases of femoral and obturator nerve block, but no major complication such as hematoma/bleeding or needle-related organ injury has been reported yet. CONCLUSIONS: The PENG block is a promising technique. Randomized controlled trials of high methodological quality are required to further elaborate the role of this block.

Beyond selective spinal anesthesia: A flow pattern analysis of a hyperbaric dye solution injected in a lower-density fluid.

INTRODUCTION: Spinal anesthesia is a technique performed since more than a century and the introduction of hyperbaric anesthetics allowed the anesthesiologists to be more selective when using this technique. The aim of this study is to show the in vitro flow patterns of a hyperbaric dye solution through 27 G Quincke and Sprotte spinal needles, injected at different speeds, in a lower-density fluid. METHODS: A simulator was made using a gummy-like sponge and a disposable plastic urine glass, filled with saline solution, which has a similar density to cerebrospinal fluid (CSF). A hyperbaric dye solution was composed by mixing 3 ml of plain methylene blue with 1 ml of glucose 33%. We used both 27 G Quincke and Sprotte spinal needles to perform a bevel up and a bevel down injection with both slow (15 s) and fast (4 s) injection speed of 0.5 mL hyperbaric dye solution. All the injections were performed using a preset syringe pump and recorded by a camera. RESULTS: The least selectivity was observed after a bevel up-fast injection through the 27 G Sprotte needle, followed by both bevel up and down fast injections through the 27 G Quincke needle. On the contrary, the best selectivity was observed after a bevel down-slow injection through the 27 G Sprotte needle, followed by both bevel up and down slow injections through the 27 G Quincke needle. CONCLUSION: When a 27 G Sprotte needle is used to inject a hyperbaric solution in a lower-density fluid-like CSF, the spread depends on both the bevel direction and the injection speed.

Continuous PENG block for hip fracture: a case series.

INTRODUCTION: The pericapsular nerve group (PENG) block is a novel regional technique indicated for analgesia for hip joint pain. We administered PENG blocks and performed catheter insertion for continuous infusions in patients with femur fractures on hospital admission. In this case series, we describe our initial experience of pain management in 10 patients with continuous infusion and its associated adverse events. CASE SERIES: The PENG block was administered with an introducer needle. The catheter was then inserted 3 cm beyond the needle tip. In three patients, blood aspiration through the catheter occurred. In each patient, the catheter was repositioned 0.5-1.0 cm more medially. No blood aspiration or visible hematoma occurred subsequently. The presence of any vascular structure deep to the iliopsoas muscle was excluded postoperatively based on a Doppler color flow scan. DISCUSSION: Overall, eight patients had femoral neck fractures, and two patients had intertrochanteric fractures. All 10 patients reported good pain relief. The median (IQR) Numerical Rating Scale (NRS) score decreased from 7 (6-7) before the block to 2 (2-2.75) 20 min after PENG catheter placement. The median (IQR) NRS score after 12, 24 and 48 hours were 2 (2-3), 2 (2-3), and 2 (0.25-2), respectively. Patients underwent surgery 24-48 hours following catheter placement. Catheters were removed by an Acute Pain Service nurse 72 hours postinsertion. We want to highlight the potential for intravascular catheter placement in this anatomical region. Further studies are required to confirm if this is a technical error or an associated complication of continuous PENG blocks.

Neck fat volume as a potential indicator of difficult intubation: A pilot study.

BACKGROUND: Direct laryngoscopy is the gold standard of the airway management in patients without predicted difficulties. If unpredicted difficulties are encountered instead, different algorithms to follow have been developed. To date, no single predictor is sufficiently valid. In clinical practice, it is used a combination of them to enhance the estimate, and despite the variety of parameters used, not all the difficult intubations are predicted. The aim of this work is to retrospectively analyze neck computed tomography scans of 37 patients who have had tracheal intubation and search for anatomic neck fat compartments that correlate with the intubation difficulty, and eventually find a suitable, clinical parameter that can potentially enhance the prediction of a difficult airway when used in combination of the preexisting scores. MATERIALS AND METHODS: the patients are divided by direct laryngoscopy view into two groups: Group A (n = 31): Normal airway, with a Cormack Lehane, Score I or II; Group B (n = 6): Difficult airway, with a Cormack Lehane Score III or IV. In the zone of interest, it was measured the neck volume parameter and other subparameters. RESULTS: Despite a positive trend is shown for anterior fat volume (AFV) (P = 0.23) and fat volume (FV) (P = 0.28), statistically significant differences (P < 0.05) were not found between Group A and B in any of the measurements acquired. CONCLUSIONS: According to the literature, our results confirmed that there is still no single element that can predict a difficult intubation. Although no statistical significance was found, the AFV and FV have shown to have a potential predictive role for difficult intubation. Further studies with bigger samples are advisable to confirm this encouraging result.

Medial thigh lift in post-bariatric patients: Our encouraging experience.

BACKGROUND: A high rate of postoperative complications following inner thigh lift is reported in the medical literature. The authors present the results of a study on the validity of inner thigh contouring, with liposuction and concomitant skin excision, in postbariatric patients. METHODS: This study examined the charts of 46 postbariatric female patients, who underwent medial thigh lift with a 'T' scar technique and concomitant liposuction, between February 2010 and February 2013. Complications were recorded. A questionnaire was administered to the patients at the 1-year follow-up visit. Preoperative and 1-year postoperative photographs were compared, superimposed, and analysed. RESULTS: This study did not observe major systemic complications, haematoma, seroma, infection, skin necrosis, lymphoceles, or lymphoedema. Minor complications were three cases of wound dehiscence and two cases of deepithelialisation. At the 1-year follow-up visit, caudal scar migration, genital distortion, recurrent ptosis, or deformity of the inner thigh contour were not observed. Questionnaires and a comparison of pre- and 1-year postoperative pictures showed encouraging results. CONCLUSIONS: The medial thigh lift technique described and assessed in this article is a straightforward surgical procedure, with considerable functional and aesthetic results. Liposuction, early mobilisation, and appropriate postoperative management are pivotal to reduce postoperative downtime and complications.