Exploring the pros and cons of new approaches for gamete cross-border donation based on fresh and vitrified oocytes.

As highlighted by European statistics, the employment of donor oocytes is a growing option for women who cannot make use of their own gametes. As the potential recipients are continuously increasing in number, a donor programme which satisfies this demand is mandatory. Improvements in cryopreservation techniques, like oocyte and embryo vitrification, have led to the overcoming of the sequence of stimulation-retrieval-transfer both from a spatial and a temporal point of view, with the development of cryobanks of oocytes permitting crossborder donation. However, while some studies report comparable success when using vitrified and fresh oocytes we still need to investigate whether the use of fresh oocytes give higher live birth rate than cryopreserved ones, when the same number of oocytes are given. The performance of embryo cryopreservation, conversely, seems to be more reliable. A novel approach based on the shipment of frozen sperm from the recipient's country to the oocyte donor's one, where fresh oocytes are inseminated and the resulting embryos frozen and transported back to the referring IVF centre to perform a frozen embryo transfer may be a good strategy. We believe that the use of frozen embryos from fresh oocytes could be associated with a higher cumulative live birth rate per cycle, while favouring personalised oocyte recipient care with a flexible number of oocytes assigned and limiting the burden of travelling abroad.

Total intravenous anesthesia with superficial cervical block or morphine transition in patients undergoing carotid endarterectomy.

BACKGROUND: The aim of this study was compare the Aldrete score at 5 minutes of two groups of patients undergoing carotid endarterectomy with intravenous anesthesia, receiving either anesthetic superficial cervical plexus block or intravenous morphine as transition analgesia. METHODS: After Ethics Committee approval, this randomized, controlled, double-blind, single-center study was performed on patients undergoing carotid endarterectomy, who received total intravenous anesthesia with propofol and remifentanil infusion. After intubation, each patient was randomly assigned to Block (superficial cervical block with levobupivacaine before the surgical incision), or Morphine group (standardized dose of morphine 30 minutes before the end of surgery). In the recovery room, an investigator unaware of the patient randomization recorded time to extubation, Aldrete score, pain, nausea/vomiting, and shiver at T0 (time of extubation), and at 5 (T5), 10 (T10), and 30 minutes (T30) after extubation. RESULTS: Sixty-four patients were studied. Time to extubation was 11 ± 6 min for Block and 20 ± 10 min for Morphine group (P>0.001). Median Aldrete score at T0 was 9 in the Block and 6.5 in the Morphine group (P<0.001), at T5 it was 8.5 and 7.0 (P<0.001), respectively. At T5, 29 (90.6%) Block and 8 (25%) Morphine patients had an Aldrete score ≥ 8 (P<0.001). Systolic blood pressure was higher in the Block than in Morphine patients at T0 and T5. CONCLUSION: This study demonstrates shorter time to extubation and better emergence from anesthesia when total intravenous anesthesia is associated with superficial cervical block than with morphine as transition analgesia.

Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM).

OBJECTIVES: To define a set of indicators that could be used to improve quality in intensive care medicine. METHODOLOGY: An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes. RESULTS: A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes. CONCLUSION: This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

West Nile Virus encephalitis in intensive care: a small mosquito, a tremendous danger.

The authors describe two of three cases of West Nile virus (WNV) meningoencephalitis admitted to ICU in Ferrara (south of Po River) underlying the main common features. They focus on the difficulties in diagnosis, with key-points including seasonality (late summer in Italy), unspecific flu-like symptoms at the beginning, as hyperpyrexia, myalgia and asthenia, followed by neurological impairment, and use of steroids in the patient clinical history. Special attention is deserved to the poor outcome at both short and long term.

Validation of SAPS 3 Admission Score and comparison with SAPS II.

BACKGROUND: The objective of this study was to validate the Simplified Acute Physiology Score SAPS 3 Admission Score (SAPS 3) and to compare its fit with that of SAPS II in an independent sample of patients admitted to a single-centre intensive care unit (ICU). METHODS: The data for all adult patients consecutively admitted to an eight-bed ICU of a 700-bed university hospital between 1 January 2006 and 2 September 2007 were collected. SAPS II and SAPS 3 were computed, as well as the predicted hospital mortality. The calibration of SAPS II and SAPS 3, according to the general equation (GE), and equations for Southern Europe and Mediterranean countries (SE&MC), and Central and Western Europe (C&WE), were assessed by the goodness-of-fit Hosmer-Lemeshow H and C statistics. Standardized mortality ratios (SMR) with 95% confidence interval (95% CI) were computed for SAPS II and SAPS 3 equations. RESULTS: Six hundred and eighty-four patients were studied (males 63%). The median age was 73 (quartiles 65-80) years. The fit of SAPS 3 using the C&WE equation (H 13.49, P=0.095; C 12.73, P=0.121) as well as that of SAPS II was acceptable (H 6.02, P=0.644; C12.08, P=0.147), while SAPS 3 GE (H 23.36, P=0.002; C 22.37, P=0.004) and S&MC (H 25.73, P=0.001; C 26.19, P=0.001) did not fit well. SAPS 3 GE, SAPS 3 SE&M Countries and the SAPS II significantly over estimated the mortality. Only 95% CI of SMR for SAPS 3 C&WE included 1 (SMR 0.97; 95% CI 0.89-1.05). CONCLUSION: Each ICU should identify the SAPS 3 equation most suitable for its case mix. The SAPS II model tended to overestimate the mortality.

Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care.

OBJECTIVE: This prospective observational study was designed to explore the relationships between post-traumatic stress disorder (PTSD), patients' memories of the intensive care unit (ICU) and sedation practices. DESIGN: Prospective multi-centre follow-up study out to 3 months after ICU discharge. SETTING: Two district general hospitals and three teaching hospitals across Europe. PATIENTS AND PARTICIPANTS: Two hundred and thirty-eight recovering, post-ventilated ICU patients. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Assessment of patients' memories of ICU was undertaken at 1-2 weeks post ICU discharge. Patients' psychological recovery was assessed by examining the level of PTSD-related symptoms and rate of PTSD by 3 months post ICU. The rate of defined PTSD was 9.2%, ranging from 3.2% to 14.8% in the different study ICUs. Independent of case mix and illness severity, the factors found to be related to the development of PTSD were recall of delusional memories, prolonged sedation, and physical restraint with no sedation. CONCLUSION: The development of PTSD following critical illness is associated with a number of different precipitating factors that are in part related to how patients are cared for within intensive care. This study raises the hypothesis that the impact of care within the ICU has an impact on subsequent psychological morbidity and therefore must be assessed in future studies looking at the way patients are sedated in the ICU and how physical restraint is used.

Emotional and interpersonal factors are most important for patient satisfaction with anaesthesia.

BACKGROUND: Questionnaires to evaluate patient satisfaction with anaesthesia mainly consider physiological aspects. This study was performed to identify the items of value for patients having anaesthesia (pilot phase) and to validate the questionnaire built on these findings in a new group of inpatients. METHODS: In the pilot phase, 100 surgical patients were interviewed and asked whether each of the 23 items selected by a panel of providers was relevant (score 1) and to rank these from 1 (additional score 6) to 5 (additional score 2). The resulting 10-item final instrument was administered to 219 consecutive inpatients by interview, after recent anaesthesia, asking them how much of each item they received (item received) and the level of satisfaction with the same item, using Numerical Rating Scales (range 0-10). RESULTS: In the pilot phase, gender, age, education and surgery did not influence the score enough to change the first 10 rank-ordered items. The 219 patients subsequently studied did not differ from those missing the questionnaire administration. The patients aged less than 55 years showed lower satisfaction scores than those aged 55 years or more (P = 0.019). In all items, except 'feeling anxious/frightened', the item received was significantly associated with the satisfaction reported. 'Kindness/regard of caregivers' together with 'information given by anaesthetist' and 'feeling safe' predicted 47% of the variance in total patient satisfaction. CONCLUSIONS: Inpatients value highly those elements of care that pertain to emotional and interpersonal relationships.

Post-traumatic stress disorder-related symptoms after intensive care.

AIM: To determine the incidence of Post Traumatic Stress Disorder (PTSD) related symptoms in a population of intensive care unit (ICU) admitted patients and the relationship between PTSD-related symptoms and memories of ICU. METHODS: Adults consecutively admitted to an ICU of a University hospital during 1 year, who stayed in the ICU at least 3 days, were prospectively studied. A questionnaire (ICU memory tool) was administered to 84 patients 1 week after ICU discharge and to 63 of them after 3 months. Past medical history and clinical variables present during ICU stay were collected. RESULTS: At the 1st interview, 5 patients (5.9%) did not remember to have been in ICU. Of the remaining 79 patients (males 59.5%, median age 69 years, SAPS II 34, APACHE II 14 and ICU stay 5 days), 4 reported intrusive memories and none panic attacks. The Impact of Events Scale (IES), available in 3 of them, scored in medium/high levels. Only the median number of factual memories reported by the patients with and without intrusive memories was significantly different (4 interquartile range 2-5 vs 8 interquartile range 6-10; p=0.002). The patients with intrusive memories at the 1st interview did not report them at the 2nd interview. Two patients not having panic or intrusive memories at the 1st interview reported PTSD-related symptoms after 3 months. CONCLUSIONS: In a general ICU population, few patients (5%) have PTSD-related symptoms and those who present those symptoms report less factual memories of ICU stay.

The effect of volatile anesthetics on respiratory system resistance in patients with chronic obstructive pulmonary disease.

We examined the effect of isoflurane and sevoflurane on respiratory system resistance (Rmin,rs) in patients with chronic obstructive pulmonary disease (COPD). The diagnosis of COPD rests on the presence of airway obstruction, which is only partially reversible after bronchodilator treatment. Ninety-six consecutive patients undergoing thoracic surgery for peripheral lung cancer were enrolled. They were divided into two groups: preoperative forced expiratory volume in 1 s/forced vital capacity ratio <70% or >70%. Rmin,rs was measured after 5 and 10 min of maintenance anesthesia by using the constant flow/rapid occlusion method. Maintenance of anesthesia was randomized to thiopental 0.30 mg . kg(-1) . min(-1) or 1.1 minimum alveolar anesthetic concentration end-tidal isoflurane or sevoflurane. Eleven patients were excluded: two because anesthesia was erroneously induced with propofol and nine because of an incorrect tube position. Maintenance with thiopental failed to decrease Rmin,rs, whereas both volatile anesthetics were able to decrease Rmin,rs in patients with COPD. The percentage of patients who did not respond to volatile anesthetics was larger in those with COPD as well. In conclusion, we have demonstrated that isoflurane and sevoflurane produce bronchodilation in patients with COPD.

Analgesia, sedation, and memory of intensive care.

PURPOSE: The purpose of this article was to investigate the relationship between analgesia, sedation, and memory of intensive care. PATIENTS AND METHODS: One hundred fifty-two adult, cooperative intensive care unit (ICU) patients were interviewed 6 months after hospital discharge about their memory of intensive care. The patient was considered to be cooperative when he/she was aware of self and environment at the interview. The patients were grouped as follows: A (45 patients) substantially no sedation, B (85) morphine, and C (22) morphine and other sedatives. RESULTS: The patients having no memory of intensive care were 38%, 34%, and 23% respectively, in the three groups. They were less ill, according to SAPS II (P <.05), and had a shorter ICU stay (P <.01). Group C patients were more seriously ill according to SAPS II, duration of mechanical ventilation, and length of stay in ICU and in hospital (P <.001). The incidence of factual, sensation, and emotional memories was not different among the three groups. Females reported at least one emotional memory more frequently than males (odds ratio 4.17; 95% CI 10.97-1.59). CONCLUSIONS: The patients receiving sedatives in the ICU are not comparable with those receiving only opiates or nothing, due to the different clinical condition. The lack of memory of intensive care is present in one third of patients and is influenced more by length of stay in ICU than by the sedation received. Sedation does not influence the incidence of factual, sensation, and emotional memories of ICU admitted patients. Females have higher incidences of emotional memories than males.

Quality of life before intensive care admission: agreement between patient and relative assessment.

OBJECTIVE: To assess the agreement between patients and relatives concerning the formers' quality of life (QOL) before intensive care unit (ICU) admission. DESIGN: Prospective study involving direct interviews of patients and relatives during ICU stay. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: A hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h, and their relatives were interviewed. The instruments used were two questionnaires suitable for ICU patients: QOL-IT and QOL-SP. Interobserver reproducibility was investigated in 36 patients. RESULTS: Interobserver reproducibility was nearly perfect (weighted Kappa 0.99 for QOL-IT and QOL-SP). Considering global scores, weighted Kappa was 0.78 for QOL-IT and 0.82 for QOL-SP, with the mean difference between patients and relatives lower than 0.3 for both scores but with limits of agreement wider than 4. Among the items, concordance was excellent in the areas of physical activity and social life for both questionnaires. Gender, living together with the patient and the degree of relationship of relatives did not influence the agreement. CONCLUSIONS: The relatives give global scores for both instruments which can be regarded as acceptable substitutes for those given by patients. However, the wide limits of agreement should make investigators cautious in analysing together scores generated by patients and by relatives. The emotional dimension seems to be assessed less accurately by relatives than the physical one.

Validation of two quality of life questionnaires suitable for intensive care patients.

OBJECTIVE: To validate two instruments measuring quality of life (QOL) suitable for patients admitted to the intensive care unit (ICU): QOL-IT and QOL-SP. DESIGN: Prospective study using patient interviews. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: One hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h were interviewed. One year after hospital discharge, 84 survivors were interviewed again. Inter-observer reproducibility was investigated in 36 patients. To validate the instruments, the QOL-IT and QOL-SP scores reported by patients were considered according to the functional limitation evaluated by the interviewer. Moreover, the theoretical prediction that patients with chronic diseases should have a worse QOL before ICU admission than patients with only acute illness was tested. QOL-IT and QOL-SP scores given 1 year after hospital discharge were compared with those recorded at the first interview. RESULTS: Inter-observer reproducibility was excellent. The possible range of QOL-IT is 0-20 and that of QOL-SP 0-29. According to the functional limitation (absent, mild or severe), the median QOL-IT score increased from 3 to 6 to 13 and QOL-SP from 2 to 6 to 12 (p< 0.0001). The patients with chronic diseases gave scores significantly higher than the patients with only acute illness (median QOL-IT 8 versus 3, p< 0.013; QOL-SP 8 versus 4, p< 0.004). The median QOL-IT score changed from 3 to 4 one year after hospital discharge, a difference which is statistically (p< 0.001), but not clinically, significant. The median QOL-SP score was 3 and did not change. CONCLUSIONS: QOL-IT and QOL-SP are instruments able to discriminate between different health states.

Predictors of weaning outcome in chronic obstructive pulmonary disease patients.

Several threshold values for predicting weaning outcome from mechanical ventilation have been proposed. These values, however, have been obtained in nonhomogeneous patient populations. The aim of the present study was to determine the threshold values in chronic obstructive pulmonary disease (COPD) patients and compare them to those reported for nonhomogeneous patient populations. The initial weaning trial included 81 COPD patients. Fifty-three of them underwent a successful weaning trial, whereas 28 failed it. The latter were enrolled into the present investigation, and were restudied during a subsequent successful trial. The weaning indices used were those reported in the literature. The threshold values obtained were within 10% of those reported for a nonhomogeneous patients population only for tidal volume and effective compliance. The classification error was <20% for maximal inspiratory pressure (MIP), occluded inspiratory pressure swing (deltaPI)/MIP, rapid and shallow breathing (respiratory frequency/tidal volume), and compliance, rate, oxygenation, pressure index (CROP), whereas the area under the receiver operating characteristic curves was >0.9 only for deltaPI/MIP and CROP. In conclusion, the threshold values obtained in chronic obstructive pulmonary disease patients who failed the first weaning attempt differed from those previously reported. Although a gold standard weaning index is not available for chronic obstructive pulmonary disease patients, the occluded inspiratory pressure swing/ maximal inspiratory pressure and compliance, rate, oxygenation, pressure index may be candidates for such a role.

Presumptive delayed gas embolism after laparoscopic cholecystectomy.

A 50-year-old woman, with a history of arterial hypertension treated with beta-blocker and Ca-antagonist, presented cardiac arrest 6 hours after elective laparoscopic cholecystectomy. During surgical intervention, arterial hypotension without any respiratory change was observed. Dyspnea, asthenia and anxiety were the clinical signs appearing approximately 2 hours before cardiac arrest. After resuscitation, myocardial infarction, dissecting thoracic aortic aneurysm and major pulmonary thromboembolism were excluded. The signs of increased resistance to the right ventricular outflow and the relevant alteration of coagulation tests, lasting only a few hours, suggested venous gas embolism. Subsequently, the patient presented a cortical blindness, persisting at hospital discharge. The anesthetists should be aware about the complication that we observed after laparoscopic surgery. The least sign of cardiorespiratory instability appearing in the postoperative period must be taken into account and signal the need for increased monitoring.

Validation of severity scoring systems SAPS II and APACHE II in a single-center population.

OBJECTIVE: To validate two severity scoring systems, the Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE II), in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a two four-bed multidisciplinary ICUs of a teaching hospital. PATIENTS AND METHODS: Data were collected in ICU over 4 years on 1,721 consecutively admitted patients (aged 18 years or older, no transferrals, ICU stay at least 24 h) regarding SAPS II, APACHE II, predicted hospital mortality, and survival upon hospital discharge. RESULTS: At the predicted risk of 0.5, sensitivity was 39.4 % for SAPS II and 31.6 % for APACHE II, specificity 95.6 % and 97.2 %, and correct classification rate 85.6 % and 85.5 %, respectively. The area under the ROC curve was higher than 0.8 for both models. The goodness-of-fit statistic showed no significant difference between observed and predicted hospital mortality (H = 7.62 for SAPS II, H = 3.87 for APACHE II; and C = 9.32 and C = 5.05, respectively). Observed hospital mortality of patients with risk of death higher than 60 % was overpredicted by SAPS II and underpredicted by APACHE II. The observed hospital mortality was significantly higher than that predicted by the models in medical patients and in those admitted from the ward. CONCLUSIONS: This study validates both SAPS II and APACHE II scores in an ICU population comprised mainly of surgical patients. The type of ICU admission and the location in the hospital before ICU admission influence the predictive ability of the models.

Multistage dispersion compensator using ring resonators.

A compact, multichannel dispersion-compensating filter is demonstrated with D=-4200 ps/nm, a +/-5-ps group delay ripple, <3-dB loss, and a 4.5-GHz passband width out of a 12.5-GHz free spectral range. We show that multistage designs can achieve a substantial increase in passband width and peak dispersion for a given group-delay ripple compared with single-stage designs. The dispersion-compensation effectiveness was demonstrated in a 320-km, seven-channel nonlinear system simulation for OC48 signals.

Plasma dopamine concentration and effects of low dopamine doses on urinary output after major vascular surgery.

To evaluate plasma dopamine concentration and the effects of low doses infusion on urinary output after abdominal vascular surgery in patients with renal function impairment we performed a prospective clinical study. Twenty hemodynamically stable patients (mean age 66.6 years), with serum creatinine concentration < 2 mg %, who undergoing general anesthesia for major vascular surgery participated. A low dose of dopamine (3 micrograms/kg/min) was administrated to patients with postoperative protracted urinary output < 0.5 ml/kg/hr for at least eight hours. Plasmatic determinations were taken at T0 (no dopamine administration), when urinary output began to increase, or if not, after two hours (T1), at eight (T2), and 24 (T3) hours after the beginning of infusion. After 24 hours the dopamine infusion was stopped and the patient's plasmatic level was measured four hours later (T4). Dopamine plasma concentrations were measured using high-performance liquid chromatography. Plasma dopamine concentration increased in all patients and reached a steady state at T2 (T2 = 76.41 +/- 16.84 ng/ml). Dopamine induced a concentration-dependent increase in urinary output (T0 = 0.45 +/- 0.14; T1 = 1.49 +/- 1.11; T2 = 2.34 +/- 1.44; T3 = 1.57 +/- 0.57; T4 = 0.85 +/- 0.7 ml/kg/hr). Three patients did not have an enhanced urinary output after dopamine infusion; they did have a prolonged clamping time and operation time (162 +/- 24 and 570 +/ 30 min, respectively). We conclude that low dose dopamine induces a dose-dependent increase of urinary output. This phenomenon also has been found in patients when their plasma concentration had not yet reached the steady-state. Lack of responsiveness to dopamine suggests a renal function impairment probably due to the prolonged aortic clamping time.