Implementation of enhanced recovery after surgery pathway for patients undergoing mastectomy.

BACKGROUND: Mastectomy is still a common treatment for breast cancer. The introduction of the Enhanced Recovery After Surgery pathway (ERAS) having proven its benefits for major surgeries has not yet been validated for mastectomy without reconstruction. Our study was conducted to investigate the effects of implementing an ERAS pathway for mastectomies, including the length of hospital stay, postoperative complications and patient satisfaction. METHOD: The study population included all patients who underwent mastectomy without immediate breast reconstruction in the gynecological surgery department of the Tours University Hospital during the year 2020. We compared patients who underwent an ERAS protocol with those who were managed in a standard manner. RESULTS: Of the 92 patients managed for mastectomy, 32 were managed in the ERAS group. The two groups were comparable. We found fewer postoperative complications with this protocol in multivariate analysis. We also obtained a 37% response rate to the satisfaction questionnaires. We did not find any significant difference between the 2 groups. CONCLUSION: There is a trend towards a decrease in the length of hospitalization associated with a decrease in postoperative complications thanks to the implementation of a ERAS protocol for the management of mastectomies. Future studies should focus on both objective clinical outcomes and patient-reported experiences to provide a comprehensive understanding of the effectiveness of ERAS protocols in mastectomy patients.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction after Mastectomy for cancer: A case-control study.

OBJECTIVE: The use of autologous fat grafting in the context of breast reconstruction is still a matter of controversy. The objective of this study was to compare the local relapse rate in women who had a fat grafting session in the context of breast reconstruction after breast cancer management, to those who had breast reconstruction without fat grafting. METHODS: We performed a retrospective, monocentric, case-control study from January 2007 to December 2017 in our hospital. The cases included women who underwent breast reconstruction with autologous fat grafting and controls, undergoing breast reconstruction without fat grafting. We compared survival and local recurrence between the two groups. RESULTS: 412 women were included: 109 (26.5%) in the lipofilling group and 303 women (73.5%) in the "no lipofilling" group. In the overall study population, lipofilling did not appear to be a predictive factor for recurrence, HR = 1.39 [0.63 - 3.06], p = 0.41; or a predictive factor for overall survival, HR = 0.84 [0.23 - 3.02], p = 0.79, or for distant metastases, HR = 1.10 [0.43 - 2.79], p = 0.84. In contrast, in the subgroup of women treated for invasive cancer, the multivariate analysis showed that lipofilling in this context was an independent predictive factor for local recurrence (HR= 5.06 [1.97 - 10.6], p = 0.04). CONCLUSION: we found an increased risk of local recurrence after lipofilling in women who were managed for invasive breast cancer. This suggests that special consideration should be given to women who have had invasive breast cancer before lipofilling.

Clinical comparison of oral administration and viscosupplementation of hyaluronic acid (HA) in early knee osteoarthritis.

PURPOSE: Osteoarthritis (OA) is a progressive, chronic and degenerative joint disease characterized by a loss of articular cartilage. Treatment of OA is largely palliative based on nonsteroidal anti-inflammatory drugs, opioids and injections of steroids. Regarding conservative treatment, intra-articular injections of hyaluronic acid (HA) can play a role in early symptomatic knee OA. MATERIALS AND METHODS: Between August 2015 and September 2015, sixty patients (32 males and 28 females) between 40 and 70 years old were randomly allocated into two groups: Half were treated with three weekly intra-articular injections of hyaluronic acid 1.6 % (group A), while the others were treated with Syalox 300 Plus® (hyaluronic acid 300 mg + Boswellia serrata extract 100 mg) 1 tab/die for 20 days and afterward Syalox 150® (hyaluronic acid 150 mg) 1 tab/die for other 20 days (group B). All patients were evaluated clinically with American Knee Society Score (AKSS) and visual analogue scale (VAS) for the pain before the treatment and after 3 months. RESULTS: AKSS of the patients in both groups was significantly increased by the treatment, and VAS score was significantly reduced. In both groups, two subgroups were created with patients older than 60 years and patients younger than 60 years. Better results are reported in younger patients of group A and older subjects in group B. CONCLUSIONS: Despite several limitations, the results of the study have shown that HA injection and oral administration may have beneficial therapeutic effects on patients with early osteoarthritis. Different outcomes in younger and older subject suggested a combined therapy first with local infiltrations and then with oral composition.

Early enteral feeding with human milk for VLBW infants.

In a NICU early enteral feeding is usually possible only when the newborn clinical conditions permit it. Because of the frequent need of umbilical/central catheters, they usually start with parenteral feeding and/or with minimal enteral feeding (trophic feeding). This kind of management is even more frequent in VLBWIs, in which the risk of NEC is very high. In this work we describe a model of early enteral exclusive feeding (EEEF) based on the use of banking human milk followed by mother milk. In the Centre of Neonatology of Trento, as in other Centers, the newborns weighing less than 750g or with a GE< 27 weeks, are treated with parenteral nutrition and minimal enteral feeding. The newborn weighing 750-1249g and with GE > 26 weeks define a group in which we find critical neonates, who can not be treated with enteral feeding, and neonates whose clinical conditions permit EEEF. In particular, in a period of 16 years (1994-2009) in Trento, 308 newborns weighing 750-1249 g and GE > than 26 weeks were admitted. The 90,9 % has been treated with prenatal steroids, the 91,9 % was inborn, the 96,1% survived. In the 59,1 % of the cases (175) we gave EEEF. We could continue with a complete EEEF in the 40,2 % of the total (119 cases). The characteristics of these neonates and our centre management, based mainly on early use of banking human milk and mother milk, are detailed described.

Change Pain: changing the approach to chronic pain.

In Italy, chronic pain has a prevalence of about 26%, a rate that warrants efforts by specialists and primary care physicians to improve its treatment. From a study of various treatment systems, it is clear that a radical change in the approach to pain pathology is needed. To this end, the Change Pain International Advisory Board*, an international panel of experts, highlighted the limits to current treatment schemes and proposed new strategies. Among the criticalities are poor or inadequate communication between physician and patient, difficulty in qualitative and quantitative measurement of pain, management of adverse effects, and the "vicious circle" generated by current therapies, often the cause of poor compliance with pain treatment or discontinuation of analgesic therapy. A further limitation to current therapeutic practice is to consider pain intensity as the sole reference parameter in its treatment. In light of these considerations, the Advisory Board has drawn up a strategy to improve outcomes of pain therapy: 1) a shared therapeutic pact between physician and patient based on efficacious communication rather than on information alone; 2) identification of defined therapeutic objectives that allow for reaching a balance between reduction of pain and occurrence of adverse effects; 3) adoption of drug therapies that respond at least in part to an approach based on the pathogenic mechanism of pain rather than on pain intensity alone.

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.

Pharmacological treatment of chronic pain - the need for CHANGE.

BACKGROUND: Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management. SCOPE: Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts. FINDINGS: It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a 'vicious circle' that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community's understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians' knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable. CONCLUSIONS: To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

Clinical uses of low-dose ketamine in patients undergoing surgery.

Ketamine acts mainly as a N-methyl-D-aspartate receptor (NMDAr) antagonist. Originally developed as a general anesthetic, it is now seldom employed as such in richer countries due to the relatively high risk of psychotomimetic adverse effects. Recently, low-dose regimens in the range of 0.25-0.5 mg/kg as an initial bolus followed by 50-500 kappag/kg/h have been proposed as an adjuvant for postoperative analgesia and for the reduction of exogenous opioid-induced hyperalgesia. In this review, we examine the evidence for clinical usefulness of perioperative ketamine infusion and its role in the context of general and/or regional anesthesia.

Updating postoperative pain management: from multimodal to context-sensitive treatment.

Although a wealth of evidence exists on effective postoperative pain (POP) treatment, surgical patients still suffer from inadequate analgesic regimens, and outcomes have been shown to improve only within the context of tightly controlled, randomized trials. The pathophysiology of pain seems to suggest that analgesic regimens aimed at inhibition of neurotransmission and neuroplastic phenomena should be instituted immediately before the painful stimuli are applied. Several protocols have been proposed, but the final choice should be made according to patients' needs, surgical indications, and institutional resources. Optimal POP management may succeed in improving outcomes only when combined with hospital-wide protocols for early rehabilitation and recovery; in the absence of adequate monitoring, equipment, motivation and coordination, even state-of-the-art techniques may fail to show results in terms of returning to daily life. Analgesic efficacy should always be balanced against safety and the ability to monitor patients in order to reduce complications that may actually impair recovery. A ''context-sensitive'' approach to POP, therefore, is suggested. Context-sensitive analgesia should be instituted as early as deemed necessary to avoid persistent pain, and it should be continued, with different modalities, until full recovery from surgery. In this way, it should constitute a ''bridge'' therapy from surgery to full healing. The use of neuroprotective agents to reduce the risk of postoperative hyperalgesia and other sensory disturbances should be considered in the context of specific surgical interventions.

[PATHOS study on postoperative pain management in Europe: French data]. / Enquête européenne sur la prise en charge de la douleur et de l'analgésie postopératoires (PATHOS) : les résultats français.

INTRODUCTION: Relief of postoperative pain is a major topic of public health and has been repeatedly shown to be inadequate. STUDY DESIGN: A questionnaire survey performed in seven European countries (postoperative analgesic therapy observational survey) in 746 health structures--which perform more than 80% of the total number of surgical procedures of each country--has demonstrated significant improvement when compared with previous surveys, particularly regarding increased use of multimodal analgesia and regular administration of analgesic drugs. The present study describes specific results for the 178 French health care institutions surveyed and 345 questionnaires collected. Preoperative patient information is given on a regular basis for 84% of respondents. RESULTS: Multimodal analgesia is used after major surgery in 87% of cases and prescribed on a regular basis for 84% of respondents. Written protocols are available in 36% of responding institutions. Pain scores are measured several times a day in 65% of institutions. An acute pain service (or any other structure with a similar aim) is found in 52% of institutions. Regular on-site training courses on pain control are delivered to 30% of anaesthesiologists, to 6% of surgeons, to 57% of recovery-room nurses and to 63% of ward nurses. Overall, the study suggests an improvement of current practices but also highlights remaining insufficiencies. CONCLUSION: Important efforts remain to be done, particularly in the field of initial and continuous education of all healthcare categories as this is believed to be the only real way to obtain long-term results.

Pain after minimally invasive videoassisted and after minimally invasive open thyroidectomy--results of a prospective outcome study.

BACKGROUND: Substantial modifications in surgical treatment of thyroid disease have changed the postoperative management of thyroidectomized patients. The reduction of postoperative pain permit a short-stay surgery. MATERIALS AND METHODS: We have analyzed the patients treated in our Unit from July 2006 to December 2006, with minimally invasive cervicotomy and mini-invasive video-assisted thyroidectomy. We have registered the postoperative pain applying an evaluation protocol numeric scale. The results were analyzed by t test. RESULTS: One hundred thirteen patients were divided in two groups: group A, minimally invasive cervicotomy (15 male and 46 female patients); group B, mini-invasive video-assisted thyroidectomy (9 male and 43 female patients). Upon returning to the ward, the pain scale group A vs B was 2.77 +/- 1.16 vs 2.5 +/- 0.762 (p = 0.22) .At 24 h after surgery, the pain scale in group A was 1.82 +/- 1.258 vs 1.031 +/- 0.8608 (p < 0.005). CONCLUSIONS: Both methods are safe, but mini-invasive video-assisted thyroidectomy gives not only a better cosmetic result but a reduction of postoperative pain especially at 24 h.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine.

BACKGROUND: The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia. METHODS: Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses. RESULTS: The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups. CONCLUSIONS: Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

Sildenafil reduces L-NAME-induced severe hypertension and worsening of myocardial ischaemia-reperfusion damage in the rat.

BACKGROUND AND PURPOSE: Phosphodiesterase-5 inhibitors are beneficial in pulmonary hypertension and congestive heart failure, the two conditions associated with coronary heart disease and ischaemia. We investigated whether sildenafil counteracts the cardiovascular alterations induced by N -nitro-L-arginine methyl ester (L-NAME) in the rat. EXPERIMENTAL APPROACH: Sildenafil was given orally to rats at doses of 0.37, 0.75 or 1.5 mg kg-1day-1 for four weeks, either alone or with L-NAME (35-40 mg kg-1 day-1 in the drinking water). Systolic blood pressure and urinary parameters (6-keto-prostaglandin F1alpha, thromboxane B2, 8-isoprostane-prostaglandin F2 and nitrite/nitrate) were measured in conscious rats. Isolated hearts were subjected to low flow ischaemia-reperfusion, and myocardial levels of guanosine 3', 5'cyclic monophosphate (cGMP) were determined. Endothelial vascular dysfunction was examined in aortic rings. KEY RESULTS: Sildenafil dose-dependently prevented the rise in systolic blood pressure in L-NAME-treated rats. This activity was associated with a normalization of urinary 8-isoprostane-prostaglandin F2alpha and other biochemical parameters. In perfused hearts, the post-ischaemic ventricular dysfunction was worse in preparations from L-NAME-treated rats than in controls. Sildenafil dose-dependently reduced this effect, and creatine kinase and lactate dehydrogenase release were lower too. cGMP levels, which were low in myocardial tissue from L-NAME-treated rats, were restored by sildenafil. In noradrenaline-precontracted aortic rings from L-NAME-treated rats acetylcholine lost its vasorelaxant effect, and sildenafil restored it. CONCLUSION AND IMPLICATIONS: In a rat model of chronic nitric oxide deprivation, where hypertension and aggravation of post-ischaemic ventricular dysfunction are associated with loss of vascular endothelium-relaxant function, sildenafil provided significant cardiovascular protection, primarily by maintaining tissue cGMP levels.

Quantification of energy expenditure during gait in children affected by cerebral palsy.

AIM: Children affected by cerebral palsy (CP) are generally characterised by some movement limitations and abnormalities that compromised gait pattern. These disabilities during deambulation may lead to excessive energy cost and so to a compromised energy efficiency. METHODS: In this study oxygen expenditure was evaluated during walking in 20 children affected by CP and in 20 healthy children, using Cosmed K4b2 (Cosmed, Italy). From obtained data about energy consumption, some parameters (heart rate, energy expenditure index, oxygen consumption, oxygen cost) were extracted, first in order to quantify energy cost during gait in pathological and healthy subjects and then to underline differences between the 2 groups of children. RESULTS: In particular, the results obtained revealed that heart rate (bpm) and oxygen consumption (mL/kg/min) mean values didn't differ significantly between normal subjects and those with CP; instead, energy expenditure index (b/m) and oxygen cost (mL/kg/m) presented higher mean values rather than control group at a statistically level and so they revealed to be significant parameters, in order characterized energy expenditure in children affected by CP. CONCLUSIONS: This inefficiency characteristic of CP deambulation is probably directly connected to the presence of simultaneous contraction of agonist and antagonist muscle in these patients.

Quantitative analysis of gait pattern and energy consumption in children with cerebral palsy.

The measurement of oxygen consumption during walking allows the quantification of gait expenditure, mainly in patients with musculoskeletal disabilities, as in cerebral palsy (CP). In this study, first, an experimental set up for the acquisition of energy consumption during gait analysis (GA) was proposed; secondly, some parameters of energy expenditure were analyzed to characterize pathological gait from an energetic point of view. Twenty CP children and 20 healthy children were evaluated during two consecutive sessions (session 1: only GA was performed; session 2: K4b2 was used during GA acquisition). The results revealed that the experimental set up was comfortable for all subjects. The absence of any differences in GA values between the two sessions showed that the use of a device for energy acquisition does not modify gait pattern. Energy expenditure index and oxygen cost presented abnormal values in comparison with normality and they were significant to quantify energy expenditure in CP children.

Does clonidine 50 microg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study.

STUDY OBJECTIVE: To evaluate the effects of adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy (TEA). DESIGN: Randomized, double-blind study. SETTING: Departments of Anesthesia and Vascular Surgery of a university hospital. PATIENTS: 40 ASA physical status II and III patients undergoing elective TEA during superficial cervical plexus block. INTERVENTIONS: Superficial cervical plexus block was placed using 20 mL of 0.75% ropivacaine alone (Ropi group, n = 20) or with the addition of 50 microg clonidine (Ropi-Clonidine group, n = 20). If required, analgesic supplementation was given with local infiltration with 1% lidocaine and intravenous fentanyl (50-microg boluses). Nerve block profile, need for intraoperative analgesic supplementation, and time to first analgesic request were recorded. MEASUREMENTS AND MAIN RESULTS: Median (range) onset time was 10 minutes (5-25 min) in the Ropi group and 5 minutes (5-20 min) in the Ropi-Clonidine group (P < 0.05). Intraoperative consumption of both 1% lidocaine and fentanyl was higher in patients of the Ropi group (15 mL [0-25 mL] and 250 microg [50-300 microg]) than in patients of the Ropi-Clonidine group (8 mL [0-20 mL] and 0 microg [0-150 microg]; P < 0.05 and P < 0.05, respectively). First postoperative analgesic request occurred after 17 hours (10-24 hrs) in the Ropi group and 20 hours (10-24 hrs) in the Ropi-Clonidine group (P > 0.05). CONCLUSIONS: Adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia in patients undergoing elective TEA.

Fast-track anaesthesia for laparoscopic cholecystectomy: a prospective, randomized, multicentre, blind comparison of desflurane-remifentanil or sevoflurane-remifentanil.

BACKGROUND AND OBJECTIVE: To evaluate the effects of sevoflurane and desflurane in combination with intravenous remifentanil on time for discharge from the postanaesthesia care unit and need for postanaesthesia care unit management after elective laparoscopic cholecystectomy. METHODS: 231 ASA Grade I-II patients, undergoing elective laparoscopic cholecystectomy in seven University teaching hospital, were randomly allocated to receive a desflurane-remifentanil (n = 105) or sevoflurane-remifentanil (n = 126) anaesthetic. A blinded observer recorded times for emergence and postanaesthesia care unit discharge (achievement of an Aldrete score > or =9), number of patients eligible for postanaesthesia care unit discharge when exiting the operating room and occurrence of adverse events. RESULTS: Intraoperative cardiovascular stability was similar in the two groups. Emergence, response and extubation occurred earlier after desflurane (5.4 +/- 3 min, 5.5 +/- 3 min and 7.5 +/- 4 min) than sevoflurane (6.6 +/- 3.5 min, 7.2 +/- 4 min and 9.1 +/- 4.2 min) (P = 0.0005, 0.05 and 0.003, respectively). Postanaesthesia care unit bypass was possible in 44 desflurane-remifentanil patients (41%) and 55 sevoflurane- remifenatnil patients (43%) (P = 0.69), while postanaesthesia care unit discharge occurred after 46 min (25th-75th percentiles: 18-40 min) with desflurane and 64 min (25th-75th percentiles: 20-50 min) with sevoflurane (P = 0.04). Postoperative nausea and vomiting was observed in 40 desflurane-remifentanil patients (36%) and 53 sevoflurane-remifentanil patients (42%) (P = 0.42). CONCLUSIONS: Both the desflurane-remifentanil and sevoflurane-remifentanil combinations provide a similarly adequate intraoperative cardiovascular stability. Emergence and postanaesthesia care unit discharge were faster with desflurane-remifentanil than sevoflurane-remifentanil, but this was not associated with a larger proportion of postanaesthesia care unit bypass, confirming that no clinically relevant differences are present between the two agents.

Endoparasites of chub (Leuciscus cephalus) in two rivers of the Abruzzo region of Italy.

The relationship between communities of chub endoparasites (Leuciscus cephalus) fished in the Orta and Pescara Rivers in the Abruzzo region of Italy, and the quality of the water in which they are caught, were studied in surveys designed to evaluate the feed quality of fish in the inland waters of the Abruzzo. Samples were taken monthly from October 2000 to September 2001 in the Orta River (Buscesi District) and the Pescara River (near the Villareia bridge); a total of 86 chub were caught. During periods of low and moderate flow in both rivers, benthonic macroinvertebrates were sampled at the fish sampling sites to classify the water quality using the extended biotic index (EBI) method. The Orta River was moderately polluted and the Pescara River slightly more polluted than the Orta. A parasitological study of the fish was conducted using conventional methods. A morphological study of the parasites led to the identification of seven species of endoparasites. Five of these (Allocreadium isoporum, Caryophyllaeus brachycollis, Caryophyllaeides fennica, Rhabdocona denudata and Pomphorhyncus laevis) were found at both sampling sites, while Acanthocephalus clavula was found only in the Pescara River and Neoechinorhynchus rutili was found only in the Orta River.