Enhanced recovery protocol in esophagectomy, is it really worth it? A cost analysis related to team experience and protocol compliance.

Application of enhanced recovery protocols (ERP) in esophageal surgery seems to lead an advantage in terms of length of hospital staying and outcomes, but only few data exist on its cost effectiveness. Previous literature analyzed pre- and post-ERP groups, finding a cost reduction with the introduction of the pathway. We aimed to study the influence on costs of accumulating experience and compliance in an ERP group. Seventy-one patients have been treated at our institution from January 2014 to June 2017 with our ERP for Ivor-Lewis esophagectomy. Direct costs were divided into subcategories and were analyzed as a function of calendar year and compliance. Factor affecting costs were searched. Univariable analysis highlighted a significant reduction in costs over time. Increase in compliance led to a progressive cost reduction for each ERP item completed (€14 852-€11 045). While age was not found to significantly influence the cost (p = 0.341), complications seemed to nullify the effect of experience: the median was €11 507 in uncomplicated patients, and increased to €13 791 in Clavien-Dindo 3-4 (CD3-4) patients. Compliance and CD3-4 remained significant also in multivariable analysis, accomplished by quantile regression, while year of surgery lost its significance. Our results evidence how accumulating experience in ERP led to a cost reduction over time, which was mainly mediated by an increase in compliance. Indeed, compliance was the main factor in reducing ERP cost while CD3-4 complications were the most important factor in cost increasing, nullifying the benefit of compliance.

Subjective measures of health and all-cause mortality - the Rotterdam Study.

BACKGROUND: Subjectively assessed health is related to mortality. Various subjective indicators of health have been studied, but it is unclear whether perceived physical functioning or mental health best accounts for the relation with mortality. METHOD: We studied the relation of subjective measures of health with all-cause mortality in 5538 participants of age 55 to 96 years at baseline from the Rotterdam Study. Various instruments of subjectively assessed health were used, that included basic activities of daily living (BADL), instrumental activities of daily living (IADL), quality of life (QoL), positive affect, somatic symptoms and negative affect. All participants completed questionnaires for each subjective measure of health and were followed for mortality for a mean of 12.2 (s.e. = 0.09) years. Cox regression analysis was conducted in the total sample. RESULTS: In this cohort, 2021 persons died during 48 534 person-years of follow-up. All measures of subjective health were related to mortality after adjusting for age, gender, education, cognition, prevalent chronic diseases and cardiovascular risk [BADL hazard ratio (HR, calculated per Z-score) = 1.35, 95% confidence interval (CI) 1.29-1.41; IADL HR = 1.27, 95% CI 1.22-1.32; QoL HR = 0.85, 95% CI 0.81-0.89; positive affect HR = 0.92, 95% CI 0.88-0.96; somatic symptoms HR = 1.11, 95% CI 1.06-1.16; and negative affect HR = 1.05, 95% CI 1.01-1.10]. In the mutually adjusted model, only BADL (HR = 1.24, 95% CI 1.16-1.32) and IADL (HR = 1.10, 95% CI 1.04-1.17) remained independently associated with mortality. CONCLUSIONS: Measures of subjectively assessed health are important indicators of mortality. Our study shows that of the different measures of subjective health, perceived physical health predicts mortality over and above mental health. Conversely, the association between mental health and mortality may partly be explained by poor perceived physical health.

Cognition, structural brain changes and complicated grief. A population-based study.

BACKGROUND: Several psychosocial risk factors for complicated grief have been described. However, the association of complicated grief with cognitive and biological risk factors is unclear. The present study examined whether complicated grief and normal grief are related to cognitive performance or structural brain volumes in a large population-based study. METHOD: The present research comprised cross-sectional analyses embedded in the Rotterdam Study. The study included 5501 non-demented persons. Participants were classified as experiencing no grief (n = 4731), normal grief (n = 615) or complicated grief (n = 155) as assessed with the Inventory of Complicated Grief. All persons underwent cognitive testing (Mini-Mental State Examination, Letter-Digit Substitution Test, Stroop Test, Word Fluency Task, word learning test - immediate and delayed recall), and magnetic resonance imaging to measure general brain parameters (white matter, gray matter), and white matter lesions. Total brain volume was defined as the sum of gray matter plus normal white matter and white matter lesion volume. Persons with depressive disorders were excluded and analyses were adjusted for depressive symptoms. RESULTS: Compared with no-grief participants, participants with complicated grief had lower scores for the Letter-Digit Substitution Test [Z-score -0.16 v. 0.04, 95% confidence interval (CI) -0.36 to -0.04, p = 0.01] and Word Fluency Task (Z-score -0.15 v. 0.03, 95% CI -0.35 to -0.02, p = 0.02) and smaller total volumes of brain matter (933.53 ml v. 952.42 ml, 95% CI -37.6 to -0.10, p = 0.04). CONCLUSIONS: Participants with complicated grief performed poorly in cognitive tests and had a smaller total brain volume. Although the effect sizes were small, these findings suggest that there may be a neurological correlate of complicated grief, but not of normal grief, in the general population.

Self-Reported Early and Later Life Weight and the Risk of All-Cause Mortality in Older Adults.

OBJECTIVES: The extent to which body weight in early adulthood is associated with late-life mortality risk is unclear. This study aimed to determine the association between body mass index (BMI) in early adulthood (at 18 years of age) and older age (70 years and over), and the risk of mortality in later life. DESIGN: Secondary analysis of the ASPREE Longitudinal Study of Older Persons (ALSOP). SETTING, PARTICIPANTS: Data were from 14,853 relatively healthy community-dwelling Australians aged ≥ 70 years when enrolled in the study. MEASUREMENTS: Self-reported weight at age ≥ 70 years and recalled weight at age 18 years were collected at ALSOP study baseline. Height was measured with a stadiometer and was used for calculation of BMI at both timepoints. BMI at each timepoint was defined as: underweight, normal weight, overweight and obese. Individuals were categorised into one of five 'lifetime' BMI groups: normal weight (BMI between 18.5 and 24.9 at both times), overweight (25.0-29.9 at either or both times), obesity to non-obese (≥30.0 at age 18 and <30.0 ≥ 70 years), non-obese to obesity (<30.0 at age 18 and ≥30.0 at age ≥ 70 years), and early and later life obesity (≥30.0 at both times). RESULTS: During a median 4.7 years follow-up, 715 deaths occurred. Obesity at 18 years, but not in older age (p=0.44), was significantly associated with the risk of mortality in later life, even after accounting for current health status (HR: 2.35, 95% CI: 1.53-3.58, p<0.001). Compared with participants with normal BMI at both time points, being obese at both time points was associated with increased mortality risk (HR=1.99, 95% CI: 1.04-3.81, p=0.03), and the risk was even greater for individuals who were obese at 18 years but were no longer obese in older age (HR=2.92, 95% CI: 1.65-5.16, p<0.001), in fully adjusted models. Participants who were normal weight at 18 years and were obese in later life, did not have an increased mortality risk (p=0.78). CONCLUSIONS: Obesity in early adulthood, and obesity in both early and later life, were associated with increased mortality risk in later life. This highlights the importance of preventing obesity in early adulthood and maintaining a normal weight over an adult lifespan.

Self-reported oral health status, edentulism and all-cause mortality risk in 12 809 Australian older adults: a prospective cohort study.

OBJECTIVE: To investigate the association between oral health status and all-cause mortality in older adults using prospective cohort study design. SETTING AND PARTICIPANTS: In total, 12 809 adults aged ≥70 years (54.3% females) were participants of the ASPREE Longitudinal Study of Older Persons (ALSOP). METHODS: Participants self-reported the presence of natural teeth and oral health status. The association of self-reported oral health, edentulism and the integrative measure of the two with all-cause mortality were explored using the Cox-regression models adjusted for age, gender, socio-economic status, health-related behaviours, weight status, aspirin and polypharmacy. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. RESULTS: In total, 22.2% of participants reported edentulism and 13.8% had fair/poor oral health. After adjustment for confounders, risk of all-cause mortality was higher among those with edentulism (vs. no edentulism) HR (95% CI) 1.43 (1.18, 1.73); and those with edentulism and reporting poor/fair oral health HR (95% CI) 1.69 (1.02, 2.82), or with no edentulism but reporting poor/fair oral health HR (95% CI) 1.46 (1.19-1.80) vs. no edentulism and reporting good/very good/excellent oral health. No association was observed between self-reported oral health alone and all-cause mortality. CONCLUSIONS: The risk of all-cause mortality was 69% higher among older adults reporting both edentulism and poor/fair oral health compared with those with teeth and more favourable self-reported oral health. © 2023 Australian Dental Association.

Rhodium nanoparticles stabilized by ferrocenyl-phosphine ligands: synthesis and catalytic styrene hydrogenation.

A series of ferrocenylphosphine-stabilized rhodium nanoparticles has been prepared in one pot from the organometallic [Rh(η3-C3H5)3] precursor. This complex has been decomposed by hydrogen treatment (3 bar) in dichloromethane in the presence of five different ferrocene-based phosphine ligands. Very small rhodium nanoparticles in the size range of 1.1-1.7 nm have been obtained. These nanoparticles have shown activity in a model catalytic reaction, namely the hydrogenation of styrene. These results evidence that the metal surface is not blocked despite the steric bulk of the stabilizing ligands. Moreover, certain selectivity has been observed depending on the ligand employed. To the best of our knowledge, such a type of compound has not yet been used for stabilizing metal nanoparticles and our findings highlight the interest to do so.

Crosstalk Reduction in Epimysial EMG Recordings from Transhumeral Amputees with Principal Component Analysis.

Electromyographic (EMG) recordings of muscle activity using monopolar electrodes suffer from poor spatial resolution due to the crosstalk from neighbouring muscles. This effect has mainly been studied on surface EMG recordings. Here, we use Principal Component Analysis (PCA) to reduce the crosstalk in recordings from unipolar epimysial electrodes implanted in three transhumeral amputees. We show that the PCA-transformed signals have, on average, a better signal-tonoise ratio than the original unipolar recordings. Preliminary investigations show that this transformation is stable over long periods of time. If the latter is confirmed, our results show that the combination of PCA with unipolar electrodes allows for a higher number of muscles to be targeted in an implant (compared with bipolar electrodes), thus facilitating 1-to-1 proportional control of prosthetic hands.

Recovery of the 3-D shape of the left ventricle from echocardiographic images.

A computational method is reported which allows the fully automated recovery of the three-dimensional shape of the cardiac left ventricle from a reduced set of apical echo views. Two typically ill-posed problems have been faced: 1) the detection of the left ventricle contours in each view, and 2) the integration of the detected contour points (which form a sparse and partially inconsistent data set) into a single surface representation. The authors' solution to these problems is based on a careful integration of standard computer vision algorithms with neural networks. Boundary detection comprises three steps: edge detection, edge grouping, and edge classification. The first and second steps (which are typical early-vision tasks not involving specific domain-knowledge) have been performed through fast, well-established algorithms of computer vision. The higher level task of left ventricle-edge discrimination, which involves the exploitation of specific knowledge about the left ventricle silhouette, has been performed by feedforward neural networks. Following the most recent results in the field of computer vision, the first step in solving the problem of recovering the ventricle surface has been the adoption of a physically inspired model of it. Basically, the authors have modeled the left ventricle surface as a closed, thin, elastic surface and the data as a set of radial springs acting on it. The recovery process is equivalent to the settling of the surface-plus-springs system into a stable configuration of minimum potential energy. The finite element discretization of this model leads directly to an analog neural-network implementation. The efficiency of such an implementation has been remarkably enhanced through a learning algorithm which embeds specific knowledge about the shape of the left ventricle in the network. Experiments using clinical echographic sequences are described. Four apical views (each with a different rotation of the probe) have been acquired during a heartbeat from a set of seven normal subjects. These images have been utilized to set the various processing modules and test their capabilities.

Genetic design of optimum linear and nonlinear QRS detectors.

This paper describes an approach to the design of optimum QRS detectors. We report on detectors including a linear or nonlinear polynomial filter, which enhances and rectifies the QRS complex, and a simple, adaptive maxima detector. The parameters of the filter and the detector, and the samples to be processed are selected by a genetic algorithm which minimizes the detection errors made on a set of reference ECG signals. Three different architectures and the experimental results achieved on the MIT-BIH Arrhythmia Database are described.

Extravasation of contrast medium from cerebral aneurysmal rupture during angiography (remarks on four cases).

The authors report four cases of contrast material extravasation during carotid angiography from cerebral aneurysmal rupture. The thesis of a coincidental event not due to an increase in the intraarterial pressure, is supported. The poor prognosis of these bleedings, detectable on angiography, is underlined and the questionable toxic effect of contrast material in the subarachnoidal space is discussed.

Extracranial bleeding and extravasation of contrast medium after penetrating head injury. Case report.

The Authors report a case of extravasation from deep and small cerebral arteries associated with traumatic thrombosis of the left anterior cerebral artery following penetrating head injury. The rareness of this event is asserted. The event related to the hemorrhage extravasation are discussed.

Recording of intracranial pressure and daily drainage in pseudotumor cerebri. A preliminary study.

After long-term recording of intracranial pressure (ICP) in four cases of pseudotumor cerebri, a volumetric rather than a pressure-dependent device was proposed to drain a given amount of cerebrospinal fluid at each maneuver by external finger pressure according to preoperative ICP recordings. Some of the advantages of this method are discussed.

Daytime circulating melatonin levels in smokers.

AIMS AND BACKGROUND: Melatonin secretion is required to be a potential inhibitor of the development and growth of tumors, and cigarette smoking is a well established risk factor for cancer at various sites. METHODS: Circulating melatonin levels of 20 smokers and 20 non smokers (controls), sampled at the same hour from awaking in order to obtain a comparable circadian synchronization, were compared. RESULTS: Our data showed higher melatonin circulating levels in smokers (17.44 +/- 1.8 pg/ml) than in nonsmokers (9.77 +/- 1.4 pg/ml). CONCLUSIONS: The causes, mechanism and meaning of this phenomenon are still unknown. The most attractive hypothesis considers higher melatonin levels in smokers as an attempt to counterbalance cellular growth stimulus, a natural "brake" mechanism to restrain the proliferation of normally differentiated tissues: smoke is a prominent risk factor for several different tumors.

Clinical aspects of fatigue in multiple sclerosis.

We studied 100 multiple sclerosis outpatients in order to assess the frequency of fatigue and to detect its relationships with other clinical findings. Fatigue was quantified by fatigue severity scale (FSS; range 1-7); current clinical neurological status and disability level were respectively scored by Kurtzke's functional systems and expanded disability status scale (EDSS). FSS mean score was 4.12; fatigue was totally absent in 3% of the patients. Fatigue started before onset of the disease in 7 patients, at onset in 12 and within the first year in 7. Fatigue intensity and frequency were related to each other. FSS mean scores were significantly higher in the patients with fatigue worsened by heat (p < 0.01), with chronic progressive disease (p < 0.0001), with motor symptoms (p < 0.0001) and with EDSS > or = 3.5 (p < 0.0001). Multiple regression analysis showed a significant effect of EDSS on fatigue (p < 0.0001), not attributable to differences in duration of the disease.

An algorithm for real-time vessel enhancement and detection.

In this paper we present an algorithm for the real-time enhancement and detection of blood vessels in medical images. The algorithm is based on a set of linear filters sensitive to vessels of different orientation and thickness. Such filters are obtained as linear combinations of properly shifted Gaussian kernels. The output of multiple oriented vessel-enhancing filters can be integrated to obtain images in which vessels are highly enhanced independently of their direction and thickness. To avoid spurious responses in the presence of step edges or to enhance the skeletons of vessels, the output of directional filters can be validated before integration. Skeleton detection and vessel segmentation can be performed via thresholding with hysteresis. Experimental results on synthetic images and real coronary arteriograms are reported.

[Therapy of insomnia]. / La terapia dell'insonnia.

The authors review the neurochemical and electrophysiological features of insomnia, together with the results obtained by various substances. The literature data show that the benzodiazepines (BZ) should be administered for short periods of time, in order to avoid addiction and withdrawal symptoms. For this reason, the authors suggest that, before starting a therapy with such substances, an accurate clinical evaluation should be made and a good knowledge of the pharmacokinetics of the various BZ is essential.

[Epidemics of musculotendinous pathologies of the upper limbs (cumulative trauma disorders) in a group of assembly line workers]. / Epidemia di patologie muscolo tendinee degli arti superiori (CTD) in un gruppo di addetti al montaggio di passeggini.

The study was prompted by a report concerning a group of assembly line workers in a factory producing prams who had developed various muscular and tendinous disorders of the upper limbs that can be classified under the larger category of Cumulative Trauma Disorders (CTD). The study first concentrated on the working conditions with analysis of the main factors responsible for overloading of the upper limbs during work. This analysis revealed high frequency and repetitiveness of upper limb movements together with a marked inadequacy of the length and distribution of pauses. In a significant part of the operations the workers also performed movements in positions that over loaded the wrist and hand. A parallel clinical and instrumental study carried out in collaboration with specialists in orthopedics, brain surgery and neurophysiology on all 40 workers in the shop showed that 90% of the subjects suffered from a form of CTD of the upper limbs: in particular, 40% were affected with carpal tunnel syndrome (12.5% bilateral), and there were high prevalence of tenosynovitis (32% Trigger Finger, 17% De Quervain's syndrome) and epicondylitis (20% medial or lateral). The results of the study once again emphasize the need for greater attention of occupational health practitioners in Italy for muscular and tendinous disorders of the upper limbs due to repeated strain, which Italian law defines, albeit controversially, as occupational.

Increasing body weight and risk of limitations in activities of daily living: a systematic review and meta-analysis.

This study examined the relationship between normal weight, overweight and obesity class I and II+, and the risk of disability, which is defined as impairment in activities of daily living (ADL). Systematic searching of the literature identified eight cross-sectional studies and four longitudinal studies that were comparable for meta-analysis. An additional four cross-sectional studies and one longitudinal study were included for qualitative review. Results from the meta-analysis of cross-sectional studies revealed a graded increase in the risk of ADL limitations from overweight (1.04, 95% confidence interval [CI] 1.00-1.08), class I obesity (1.16, 95% CI 1.11-1.21) and class II+ obesity (1.76, 95% CI 1.28-2.41), relative to normal weight. Meta-analyses of longitudinal studies revealed a similar graded relationship; however, the magnitude of this relationship was slightly greater for all body mass index categories. Qualitative analysis of studies that met the inclusion criteria but were not compatible for meta-analysis supported the pooled results. No studies identified met all of the pre-defined quality criteria, and subgroup analysis was inhibited due to insufficient comparable studies. We conclude that increasing body weight increases the risk of disability in a graded manner, but also emphasize the need for additional studies using contemporary longitudinal cohorts with large numbers of obese class III individuals, a range of ages and with measured height and weight, and incident ADL questions.