The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Rethink analgo-sedation in digestive endoscopy: the role of scientific societies in tracing training path.

OBJECTIVE: The Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care Medicine (SIAARTI) and the Italian Society of Digestive Endoscopy (SIED) worked together to produce a joint Good Clinical Practice (GCP) on analgo-sedation in digestive endoscopy and launched a survey to support the document. The aim was to identify and describe the actual clinical practice of sedation in Italian digestive endoscopy units and offer material for a wider and more widespread discussion among anesthetists and endoscopists. SUBJECTS AND METHODS: A national survey was planned, in order to support the statements of the GCP. Twelve thousand and five hundred questionnaires were sent to the members of SIAARTI and SIED in June 2020. RESULTS: A total of 662 forms (5.3%) returned completed. Highly complex procedures are performed according to 70% of respondents; daily anesthesiologist's assistance is guaranteed in 26%, for scheduled sessions in 14.5% and as needed in 8%. 69% of respondents declared not to have a dedicated team of anesthesiologists, while just 5% reported an anesthesiologist in charge. A complete monitoring system was assured by 70% of respondents. Dedicated pathways for COVID-19-positive patients were confirmed in <40% of the answers. With regard to moderate/deep sedation, 90% of respondents stated that an anesthetist decides timing and doses. Propofol was exclusively administered by anesthetists according to 94% of answers, and for 6% of respondents the endoscopist is allowed to administer propofol in presence of a dedicated nurse, but with a readily available anesthetist. Only 32.8% of respondents reported institutional training courses on procedural analgo-sedation. CONCLUSIONS: The need to provide patients scheduled for endoscopy procedures with an adequate analgo-sedation is becoming an increasing concern, well-known in almost all countries, but many factors compromise the quality of patient care. Results of a national survey would give strength to the need for a shared GCP in gastrointestinal endoscopy. Training and certification of non-anesthetist professionals should be one of the main ways to center the objective.

Position paper of the Italian Association of Medical Oncology on the impact of COVID-19 on Italian oncology and the path forward: the 2021 Matera statement.

The coronavirus disease 2019 (COVID-19) pandemic has severely affected cancer care and research by disrupting the prevention and treatment paths as well as the preclinical, clinical, and translational research ecosystem. In Italy, this has been particularly significant given the severity of the pandemic's impact and the intrinsic vulnerabilities of the national health system. However, whilst detrimental, disruption can also be constructive and may stimulate innovation and progress. The Italian Association of Medical Oncology (AIOM) has recognized the impact of COVID-19 on cancer care continuum and research and proposes the '2021 Matera statement' which aims at providing pragmatic guidance for policymakers and health care institutions to mitigate the impact of the global health crisis on Italian oncology and design the recovery plan for the post-pandemic scenario. The interventions are addressed both to the pillars (prevention, diagnosis, treatment, follow-up, health care professionals) and foundations of cancer care (communication and care relationship, system organization, resources, research, networking). The priorities to be implemented can be summarized in the MATERA acronym: Multidisciplinarity; Access to cancer care; Telemedicine and Territoriality; Equity, ethics, education; Research and resources; Alliance between stakeholders and patients.

Cortical plasticity after hand prostheses use: Is the hypothesis of deafferented cortex "invasion" always true?

OBJECTIVE: To study motor cortex plasticity after a period of training with a new prototype of bidirectional hand prosthesis in three left trans-radial amputees, correlating these changes with the modification of Phantom Limb Pain (PLP) in the same period. METHODS: Each subject underwent a brain motor mapping with Transcranial Magnetic Stimulation (TMS) and PLP evaluation with questionnaires during a six-month training with a prototype of bidirectional hand prosthesis. RESULTS: The baseline motor maps showed in all three amputees a smaller area of muscles representation of the amputated side compared to the intact limb. After training, there was a partial reversal of the baseline asymmetry. The two subjects affected by PLP experienced a statistically significant reduction of pain. CONCLUSIONS: Two apparently opposite findings, the invasion of the "deafferented" cortex by neighbouring areas and the "persistence" of neural structures after amputation, could vary according to different target used for measurement. Our results do not support a correlation between PLP and motor cortical changes. SIGNIFICANCE: The selection of the target and of the task is essential for studies investigating motor brain plasticity. This study boosts against a direct and unique role of motor cortical changes on PLP genesis.

[Safety Walkround as a risk assessment tool: the first Italian experience]. / La Safety WalkRoundTM un'opportunità per l'assessment del rischio: la prima esperienza italiana.

In 2007 the Study Group "Clinical Risk Management" of the Italian Society of Anaesthesia and Intensive Care Unit (SIAARTI) performed a multicentric study in Intensive Care Unit (ICU) to assess the feasibility and efficacy of the Safety WalkRound (SWR) as a tool for the risk assessment. As the environment and organization of ICU are more complex than anaesthesia ones, mainly due to the severity of patients, high number of involved healthcare givers and different kinds of procedures, the Study Group decided that a check list is not fit for ICU and , after a careful review of the literature, chose to test the Safety WalkRound. in four Italian General ICUs. The SWR was born in 2003 when Frankel plans a structured interview of 15 questions (about 50% open) to collect operators' opinion about rate and type of errors, near misses, communication, problems regarding the report of adverse events and suggestions to increase patient safety. Consequently SWR is a tool of risk assessment alternative to the Incident Reporting which is marked by a diffuse underreporting of operators. Although the SWR is a new tool not validated in Italian language neither published in Italy on PubMed journals , the Study Group has decided that it might be fit for the organization of Italian Healthcare System. A back translation of the validated model of Joint Commission was provided and the translated version has been lightly changed to be employed in hospitals with and without Incident Reporting . The questions have been changed or introduced on the basis of the organization vulnerabilities detected with observational techniques or Focus Group. The interview performed in Italy contains 16 questions classified into five groups: a) error, b) error prevention, c) communication, teamwork and leadership, d) error discussion and e) relationship with patients and their families. The answers collected have been analyzed to detect the vulnerabilities in the organizations and specify the improvements to implement in every ICU. A statistical analysis was performed to verify the correlation between the answers collected and the results of the other techniques of risk assessment previously used ( observations and Focus Group ) . The value of k Pearson found ( mean value 0,976) has demonstrated this correlation and the efficacy of SWR in detecting system vulnerabilities already found with the other assessment techniques. The value of a Cronbach ( mean value 0,798) has demonstrated an internal consistency reliability. The results of this study have demonstrated that the Italian translation is fit for the model by Frankel and makes available a lot of information useful to improve patient safety. The study has demonstrated the sensibility, efficacy and efficiency of this tool in detecting the vulnerabilities in every ICU of the four ones. SWR is marked by feasibility, high compliance of operators and low costs; besides increases safety culture in the staff and demonstrating.

Characterization of multi-channel intraneural stimulation in transradial amputees.

Although peripheral nerve stimulation using intraneural electrodes has been shown to be an effective and reliable solution to restore sensory feedback after hand loss, there have been no reports on the characterization of multi-channel stimulation. A deeper understanding of how the simultaneous stimulation of multiple electrode channels affects the evoked sensations should help in improving the definition of encoding strategies for bidirectional prostheses. We characterized the sensations evoked by simultaneous stimulation of median and ulnar nerves (multi-channel configuration) in four transradial amputees who had been implanted with four TIMEs (Transverse Intrafascicular Multichannel Electrodes). The results were compared with the characterization of single-channel stimulation. The sensations were characterized in terms of location, extent, type, and intensity. Combining two or more single-channel configurations caused a linear combination of the sensation locations and types perceived with such single-channel stimulations. Interestingly, this was also true when two active sites from the same nerve were stimulated. When stimulating in multi-channel configuration, the charge needed from each electrode channel to evoke a sensation was significantly lower than the one needed in single-channel configuration (sensory facilitation). This result was also supported by electroencephalography (EEG) recordings during nerve stimulation. Somatosensory potentials evoked by multi-channel stimulation confirmed that sensations in the amputated hand were perceived by the subjects and that a perceptual sensory facilitation occurred. Our results should help the future development of more efficient bidirectional prostheses by providing guidelines for the development of more complex stimulation approaches to effectively restore multiple sensations at the same time.

Comparison of linear frequency and amplitude modulation for intraneural sensory feedback in bidirectional hand prostheses.

Recent studies have shown that direct nerve stimulation can be used to provide sensory feedback to hand amputees. The intensity of the elicited sensations can be modulated using the amplitude or frequency of the injected stimuli. However, a comprehensive comparison of the effects of these two encoding strategies on the amputees' ability to control a prosthesis has not been performed. In this paper, we assessed the performance of two trans-radial amputees controlling a myoelectric hand prosthesis while receiving grip force sensory feedback encoded using either linear modulation of amplitude (LAM) or linear modulation of frequency (LFM) of direct nerve stimulation (namely, bidirectional prostheses). Both subjects achieved similar and significantly above-chance performance when they were asked to exploit LAM or LFM in different tasks. The feedbacks allowed them to discriminate, during manipulation through the robotic hand, objects of different compliances and shapes or different placements on the prosthesis. Similar high performances were obtained when they were asked to apply different levels of force in a random order on a dynamometer using LAM or LFM. In contrast, only the LAM strategy allowed the subjects to continuously modulate the grip pressure on the dynamometer. Furthermore, when long-lasting trains of stimulation were delivered, LFM strategy generated a very fast adaptation phenomenon in the subjects, which caused them to stop perceiving the restored sensations. Both encoding approaches were perceived as very different from the touch feelings of the healthy limb (natural). These results suggest that the choice of specific sensory feedback encodings can have an effect on user performance while grasping. In addition, our results invite the development of new approaches to provide more natural sensory feelings to the users, which could be addressed by a more biomimetic strategy in the future.

Intensive care complications in liver and multivisceral transplantation.

The complications concerning liver and intestinal transplant surgery have relevance for the field of intensive care because they share some characteristics with those following complex long-term surgery. Thus, in this article we shall try to describe complications that are specific to liver and multivisceral transplants. A review of the existing literature on this topic reveals a large number of studies dedicated to early as well as late surgical complications, and immunosuppressive treatment, while there are far fewer contributions describing complications exclusively concerning intensive care. We shall thus attempt to focus on certain aspects where, besides the literature data, we have personal experience. In particular we want to underline the implications of failure in the functional recovery of the graft; alterations in water, electrolyte, and glycemic balance; as well as neurological, respiratory, renal, nutritional, and infective complications.

Transversus abdominis plane block for analgesia after Cesarean delivery. A systematic review.

Cesarean delivery is a major surgical procedure, after which a woman can experience substantial postoperative discomfort or pain. Inadequate postoperative analgesia is one of the most common reasons for poor patient satisfaction following cesarean delivery. Although spinal or systemic opioids are currently the gold standard to achieve effective analgesia, they are often associated with side effects. In the last few years there has been growing interest in abdominal plane blocks, with promising data on their efficacy. The transversus abdominis plane (TAP) block is a regional analgesic technique which is gaining acceptance in postoperative analgesia for lower abdominal surgeries. In this systematic review of articles published as of 31 December 2013, we searched the principal medical databases for randomized controlled trials that assessed the efficacy of ultrasound (US)-guided TAP block following cesarean delivery and reported on postoperative opioid consumption and pain score, opioid-related side-effects and patient satisfaction. Although controversy surrounds the utility of US-guided TAP block in cesarean section, evidence suggests that when correctly executed as part of a multimodal analgesic regimen, TAP block may reduce postoperative opioid consumption and opioid-related side effects, improving postoperative pain control and patient satisfaction. Further studies are necessary to explore this field of research.

Haemodynamic and volumetric monitoring during haemorrhagic shock in swine.

Various studies have been performed concerning haemodynamics in the shock state. The aim of this study was to examine if a haemodynamic approach based on volumetric indices can offer a new method of evaluation. Volumetric measurements of ventricular filling and cardiac function were compared with classical haemodynamic variables during induced haemorrhagic shock in swine. Twelve hybrid swine were anaesthetized and underwent arteriectomy to induce haemorrhagic shock. Blood was collected in ACD treated bags and reinfused via the same vein after a shock period of 90 min. Haemodynamic and volume measurements were evaluated. Seven swine survived to complete the protocol and reached the final experimental time (90 min after reinfusion), while the remaining five died 1 h after reinfusion. Concerning the haemodynamics, afterload changes characterized the haemorrhagic shock period, while blood volume distribution dictated ventricular filling and ventricular kinetics during the post-reinfusion period. Systemic vascular resistance was different in the two groups. This study suggests that blood volumetric evaluations can offer better comparative data than pulmonary catheterisation for a precise assessment of cardiac output. Preload values have turned out to be of greater relevance than traditional pressure variables.

Role of intensive therapy in liver transplant recipients: experience in blood purification and biosynthetic techniques.

The severity of the clinical situation for patients awaiting liver transplant depends on the conditions induced by the liver disease, which trigger a series of extrahepatic system alterations requiring prompt correction to improve the patient's preoperative condition. In the pre-terminal stage of liver cirrhosis, the patient's general condition is partly due to toxemia caused by loss of blood purification functions and also to liver synthetic deficits. In this study we describe our experience with extracorporeal support techniques, both from the blood purification standpoint and from biosynthesis. This experience represents an historic overview of the techniques involved in for construction of an "artificial liver." The aim of this work was to provide a summary of our clinical findings and current methods in extracorporeal liver support with the goal of improving the clinical status potential transplant patients.

Reliability of ultrasound screening of liver and kidney donors: a retrospective study.

The reliability of abdominal ultrasound in screening liver and kidney donors was assessed by correlating ultrasound findings with the suitability of organs for transplantation as determined by direct examination of the organs. We evaluated 100 multiorgan donors (100 livers, 200 kidneys) during a 15-month period. Abdominal ultrasound showed the following results for liver and kidney, respectively: specificity, 95.6% and 98.9%; sensitivity, 62.5% and 66.6%; and accuracy, 93% and 97%. These results show that abdominal ultrasound is a valuable tool for determining suitability of organs for transplantation when the ultrasound findings are normal. When ultrasound findings are abnormal, further studies are necessary to determine the suitability of the organs for transplantation.

Organ donation and transplantation as health programs in Italy.

Organ and tissue donation and transplantation have a role in public health programs as organizational projects designed by public health departments to increase the quality and number of donations and transplantations. These programs serve as communication projects to inform public opinion on cerebral death, organ and tissue shortages, procurement and allocation rules, and the quality of life of transplanted patients. The health department of Emilia-Romagna created a regional law and a multimedia communication program for these purposes, resulting in a 95% increase of cadaver donor in 4 years. In 1995, regional activity reached the European mean level and afterwards surpassed it. In 1997, the bone bank was activated, followed in 1998 by the heart valve and vascular segment bank. The regional health department now considers transplant activities a primary goal; human and professional relations between intensive care units and the transplant reference center are considered crucial; cooperation among health departments, medical teams involved in organ procurement and transplant activities has been fostered, and the local coordination network has been active and efficient. The public information campaign has proven important in providing information both to professionals and citizens.

[The transplant coordinator]. / Il coordinatore ai prelievi.

Spain was the first European country adopting a strategy of organ procurement based on a specific health professional named transplant coordinator, who was first established in Catalunya in the middle eighties. In principle, the transplant coordinator is a doctor with hospital experience who is involved full time in organ procurement. The transplant coordination activity is available without interruption, due to a team work. Transplant coordination is based on four main functions: clinical, research, training and communication, management. The principles of transplant coordination according to the Spanish model are reported in the recently approved Italian law on transplantation (law 91/1999), indicating the coordinator's specific functions: a) communication to the regional reference centre of the data concerning the possible organ donors, b) preparation of the documents needed, c) relationship with the donors' family, d) information and education of the population on transplantation issues.

Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is a common disease which increases the risk of perioperative complications. The aim of this study is to assess the clinical utility of preoperative screening for OSA in determining the prevalence of patients at high risk of OSA in a surgical population, the incidence of difficult airway management and the incidence of perioperative complications. METHODS: We conducted a multisite, prospective observational study on adult patients scheduled for elective surgery. All patients completed a STOP-Bang questionnaire as a part of their preoperative evaluation. Collected data included: demographic data, type of surgery, ASA class, postoperative course, complications within 48 hours, difficult intubation (DI) and difficult mask ventilation (DMV) rates. RESULTS: A total of 3452 consecutive patients were recruited; 2997 (87%) were identified as low OSA risk patients and 455 (13%) were identified as high OSA risk patients; 113 (3%) postoperative complications, 315 (9%) cases of DMV and 375 (11%) of DI were observed. The percentage of postoperative complications in patients with HR-OSA was 9%, while the percentage of DI was 20% and the percentage of DMV was 23%. High risk for OSA and higher BMI (≥30 Kg m-2) were independently associated with risk for perioperative complications. CONCLUSION: In conclusion, this study demonstrates that the prevalence of high OSA risk patients in the surgical population is high. The increase in the rates of perioperative complications justifies the implementation of perioperative strategies that use the STOP-Bang as a tool for triage.

The Helsinki Declaration on Patient Safety in Anesthesiology: a way forward with the European Board and the European Society of Anesthesiology.

Anesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, emergency medicine and pain therapy, is acknowledged as the leading medical specialty in addressing issues of patient safety, but there is still a long way to go. Several factors pose hazards in Anesthesiology, like increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, as well as new drugs and devices. To better design educational and research strategies to improve patient safety, the European Board of Anesthesiology (EBA) and the European Society of Anesthesiology (ESA) have produced a blueprint for patient safety in Anesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anesthesiology, was endorsed together with the World Health Organization (WHO), the World Federation of Societies of Anesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. It was signed by several Presidents of National Anesthesiology Societies as well as other stakeholders. The Helsinki Declaration on Patient Safety in Anesthesiology represents a shared European view of what is necessary to improve patient safety, recommending practical steps that all anesthesiologists can include in their own clinical practice. The Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Care (SIAARTI) is looking forward to continuing work on "patient safety" issues in Europe, and to cooperating with the ESA in the best interest of European patients.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version.

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.