Simulation-Based Medical Education and Training Enhance Anesthesia Residents' Proficiency in Erector Spinae Plane Block.

Background: Advances in regional anesthesia and pain management led to the advent of ultrasound-guided fascial plane blocks, which represent a new and promising route for the administration of local anesthetics. Both practical and theoretical knowledge of locoregional anesthesia are therefore becoming fundamental, requiring specific training programs for residents. Simulation-based medical education and training (SBET) has been recently applied to ultrasound-guided regional anesthesia (UGRA) with remarkable results. With this in mind, the anesthesia and intensive care residency program of the University of Milano-Bicocca organized a 4-h regional anesthesia training workshop with the BlockSim® (Accurate Srl, Cesena) simulator. Our study aimed to measure the residents' improvement in terms of reduction in time required to achieve an erector spinae plane (ESP) block. Methods: Fifty-two first-year anesthesia residents were exposed to a 4-h training workshop focused on peripheral blocks. The course included an introductory theoretical session held by a locoregional anesthetist expert, a practical training on human models and mannequins using Onvision® (B. Braun, Milano) technologies, and two test performances on the BlockSim simulator. Residents were asked to perform two ESP blocks on the BlockSim: the first without previous practice on the simulator, the second at the end of the course. Trainees were also also asked to complete a self-assessment questionnaire. Results: The time needed to achieve the block during the second attempt was significantly shorter (131 [83, 198] vs. 68 [27, 91] s, p < 0.001). We also observed a reduction in the number of needle insertions from 3 [2, 7] to 2 [1, 4] (p = 0.002), and an improvement aiming correctly at the ESP from 30 (58%) to 46 (88%) (p < 0.001). Forty-nine (94%) of the residents reported to have improved their regional anesthesia knowledge, 38 (73%) perceived an improvement in their technical skills and 46 (88%) of the trainees declared to be "satisfied/very satisfied" with the course. Conclusions: A 4-h hands-on course based on SBET may enhance first-year residents' UGRA ability, decrease the number of punctures and time needed to perform the ESP block, and improve the correct aim of the fascia.

The Role of Regional Anesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects.

The severe acute respiratory syndrome coronavirus SARS-CoV2 is spreading over millions of people worldwide, leading to thousands of deaths, even among the healthcare providers. Italy has registered the deaths of 337 physicians and more than 200 nurses as of March 14, 2021. Anesthesiologists are at higher risk as they are the care providers in both ICU and operating rooms.Although the vaccination of healthcare providers has been the prioirity, physicians are still continually exposed to the virus and potentially risk contagion and must thus protect themselves and their patients from the risks of infection while providing the best care to their surgical patients.Regional anesthesia allows for a reduction in airway manipulation, reducing environmental contamination as a result. Furthermore, regional anesthesia reduces the opioid requirements as well as the muscle paralysis due to muscle-relaxants and should be recommended whenever possible in COVID-19 patients. Our aim is to evaluate the advantages and criticisms of regional anesthesia in the management of surgical patients in the pandemic age.

Genome, Environment, Microbiome and Metabolome in Autism (GEMMA) Study Design: Biomarkers Identification for Precision Treatment and Primary Prevention of Autism Spectrum Disorders by an Integrated Multi-Omics Systems Biology Approach.

Autism Spectrum Disorder (ASD) affects approximately 1 child in 54, with a 35-fold increase since 1960. Selected studies suggest that part of the recent increase in prevalence is likely attributable to an improved awareness and recognition, and changes in clinical practice or service availability. However, this is not sufficient to explain this epidemiological phenomenon. Research points to a possible link between ASD and intestinal microbiota because many children with ASD display gastro-intestinal problems. Current large-scale datasets of ASD are limited in their ability to provide mechanistic insight into ASD because they are predominantly cross-sectional studies that do not allow evaluation of perspective associations between early life microbiota composition/function and later ASD diagnoses. Here we describe GEMMA (Genome, Environment, Microbiome and Metabolome in Autism), a prospective study supported by the European Commission, that follows at-risk infants from birth to identify potential biomarker predictors of ASD development followed by validation on large multi-omics datasets. The project includes clinical (observational and interventional trials) and pre-clinical studies in humanized murine models (fecal transfer from ASD probands) and in vitro colon models. This will support the progress of a microbiome-wide association study (of human participants) to identify prognostic microbiome signatures and metabolic pathways underlying mechanisms for ASD progression and severity and potential treatment response.

[Nontherapeutic international normalized ratio results in hospital emergency patients on vitamin K antagonists: prevalence and associated factors]. / Prevalencia y factores asociados a un International Normalized Ratio (INR) fuera de rango en pacientes en tratamiento con antivitamina K atendidos en servicios de urgencias hospitalarios.

OBJECTIVES: To determine the prevalence of international normalized ratio (INR) findings outside the normal range in hospital emergency department patients on vitamin K antagonists (VKAs). To identify factors associated with abnormal anticoagulant levels in these patients. MATERIAL AND METHODS: Observational, cross-sectional, multicentric study in 4 hospital emergency departments. We included a convenience sample of patients on VKA treatment for whom INR levels were on record and who had sought emergency care for complications unrelated to anticoagulant treatment. RESULTS: We included 376 patients with a mean (SD) age of 76.8 (10.1) years; 50.3% were women and 86.7% had atrial fibrillation. We found that 60.4% (95% CI, 55.3%-65.2%) had INRs outside the reference range. Multivariate analysis showed that changes in the patients' other long-term medications were independently associated with nontherapeutic INR results (odds ratio, 1.6; 95% CI, 1.02-2.79; P=.035). CONCLUSION: Over 60% of patients on VKA treatment who come to hospital emergency departments with complaints unrelated to anticoagulant therapy have INR values outside the normal range. Changes in a patient's usual medications are significantly associated with nontherapeutic INR findings.

OBJETIVO: Determinar la prevalencia de un International Normalized Ratio (INR) fuera de rango entre los pacientes que acuden a los servicios de urgencias hospitalarios (SUH) y se encuentran en tratamiento con fármacos antivitamina K (AVK). Identificar los factores que se asocian con unos valores inadecuados de anticoagulación en estos pacientes. METODO: Estudio multicéntrico, observacional y transversal en cuatro SUH. Se incluyeron pacientes en tratamiento con AVK a los que se les realizó una analítica con determinación de INR, que no acudían por complicaciones asociadas al tratamiento anticoagulante. La inclusión se realizó mediante un muestreo de oportunidad. RESULTADOS: Se incluyeron en el estudio un total de 376 pacientes. Edad media de 76,8 (10,1) años, 50,3% fueron mujeres. El 86,7% de los pacientes presentaban fibrilación auricular. El 60,4% (IC 95%: 55,3%-65,2%) de los pacientes tuvieron un INR fuera de rango. El análisis multivariado demostró que los cambios en los medicamentos habituales con odss ratio (OR) de 1,6 (IC 95%: 1,02-2,79; p = 0,035) se asociaron de forma independiente a la presencia de un INR fuera de rango. CONCLUSIONES: El 60,4% de los pacientes en tratamiento con AVK que acuden a un SUH sin complicaciones asociadas al tratamiento anticoagulante presenta un INR fuera de rango. Los cambios en el tratamiento habitual del paciente se relacionaron significativamente con un INR fuera de rango.

Clinical and prognostic significance of a reverse dipping pattern on ambulatory monitoring: An updated review.

Reverse or inverted dipping (ie, the phenomenon characterized by higher nighttime compared with daytime blood pressure values) is an alteration of circadian blood pressure rhythm frequently documented in hypertension, type 2 diabetes mellitus, chronic kidney disease, and sleep apnea syndrome, and generally regarded as a harmful condition. Available literature on the clinical and prognostic implications of reverse dipping is scanty. The present article will review a number of relevant issues concerning reverse dipping, in particular: (1) its possible mechanisms; (2) prevalence and clinical correlates, (3) concomitant cardiac and extracardiac subclinical organ damage; (4) association with acute and chronic cardiovascular diseases; (5) prognostic value in predicting cardiovascular events and mortality; and (6) therapeutic interventions aimed at reverting this abnormal circadian blood pressure rhythm.

Prevalencia y factores asociados a un International Normalized Ratio (INR) fuera de rango en pacientes en tratamiento con antivitamina K atendidos en servicios de urgencias hospitalarios / Nontherapeutic international normalized ratio results in hospital emergency patients on vitamin K antagonists: prevalence and associated factors

Objetivos: Determinar la prevalencia de un International Normalized Ratio (INR) fuera de rango entre los pacientes que acuden a los servicios de urgencias hospitalarios (SUH) y se encuentran en tratamiento con fármacos antivitamina K (AVK). Identificar los factores que se asocian con unos valores inadecuados de anticoagulación en estos pacientes. Método: Estudio multicéntrico, observacional y transversal en cuatro SUH. Se incluyeron pacientes en tratamiento con AVK a los que se les realizó una analítica con determinación de INR, que no acudían por complicaciones asociadas al tratamiento anticoagulante. La inclusión se realizó mediante un muestreo de oportunidad. Resultados: Se incluyeron en el estudio un total de 376 pacientes. Edad media de 76,8 (10,1) años, 50,3% fueron mujeres. El 86,7% de los pacientes presentaban fibrilación auricular. El 60,4% (IC 95%: 55,3%-65,2%) de los pacientes tuvieron un INR fuera de rango. El análisis multivariado demostró que los cambios en los medicamentos habituales con odss ratio (OR) de 1,6 (IC 95%: 1,02-2,79; p = 0,035) se asociaron de forma independiente a la presencia de un INR fuera de rango. Conclusiones: El 60,4% de los pacientes en tratamiento con AVK que acuden a un SUH sin complicaciones asociadas al tratamiento anticoagulante presenta un INR fuera de rango. Los cambios en el tratamiento habitual del paciente se relacionaron significativamente con un INR fuera de rango (AU)

Aims: To determine the prevalence of international normalized ratio (INR) findings outside the normal range in hospital emergency department patients on vitamin K antagonists (VKAs). To identify factors associated with abnormal anticoagulant levels in these patients. Methods: Observational, cross-sectional, multicentric study in 4 hospital emergency departments. We included a convenience sample of patients on VKA treatment for whom INR levels were on record and who had sought emergency care for complications unrelated to anticoagulant treatment. Results: We included 376 patients with a mean (SD) age of 76.8 (10.1) years; 50.3% were women and 86.7% had atrial fibrillation. We found that 60.4% (95% CI, 55.3%-65.2%) had INRs outside the reference range. Multivariate analysis showed that changes in the patients' other long-term medications were independently associated with nontherapeutic INR results (odds ratio, 1.6; 95% CI, 1.02-2.79; P=.035). Conclusions: Over 60% of patients on VKA treatment who come to hospital emergency departments with complaints unrelated to anticoagulant therapy have INR values outside the normal range. Changes in a patient's usual medications are significantly associated with nontherapeutic INR findings (AU)

Decompensated porto-pulmonary hypertension in a cirrhotic patient with thrombosis of portocaval shunt.

We report a case of decompensated porto-pulmonary hypertension closely associated with the development of intra-portocaval shunt thrombosis. A woman with Laennec's cirrhosis was hospitalized because of severe dyspnea and edema. She underwent surgical portocaval anastomosis ten years ago. Imaging studies showed massive intra-shunt thrombosis, portal hypertension, ascites, pleuro-pericardial effusions and enlargement of right cardiac cavities. Cardiac catheterization allowed to rule out coronary and left-sided heart abnormalities and led to the diagnosis of pre-capillary pulmonary hypertension. Antithrombotic treatment with low molecular weight heparin was instituted. The management also included ACE inhibitors, spironolactone, low-salt diet and lactulose. The patient was discharged and three months later we observed the disappearance of edema, ascites and pleuro-pericardial effusions, a marked body weight reduction and improved dyspnea and liver function tests. A possible link between the development of intra-shunt thrombosis and clinical decompensation in our patient was hypothesized. In fact, it has been demonstrated that the increased portal pressure, caused by occlusion of portosystemic shunt, reduces renal plasma flow and increases systemic endothelin-1 concentration. In our patient the disappearance of edematous state and improved dyspnea observed after recanalization of the shunt strongly support this hypothesis.

Insulin resistance causes impaired vasodilation and hypofibrinolysis in young women with polycystic ovary syndrome.

INTRODUCTION: Insulin resistance, a novel cardiovascular risk factor, is often associated with increased plasminogen activator inhibitor-1 levels and impaired vasodilation. Insulin infusion in the forearm induces plasminogen activator inhibitor-1 and tissue plasminogen activator expression and endothelium-dependent vasodilation in normal subjects. The present study explores the relationship between insulin-induced vasodilatory and fibrinolytic properties of the endothelium in women with polycystic ovary syndrome, frequently affected by insulin resistance and early atherosclerosis. MATERIALS AND METHODS: Metabolic, hormonal and fibrinolytic parameters were evaluated in 64 patients with polycystic ovary syndrome (19 insulin-resistant and 45 insulin-sensitive) and in 25 controls. In 16 women with polycystic ovary syndrome, 8 insulin-resistant and 8 insulin-sensitive, blood flow, plasminogen activator inhibitor-1 and tissue plasminogen activator expression were evaluated during insulin infusion into the forearm. RESULTS: Elevated basal plasminogen activator inhibitor-1 levels were found in women with polycystic ovary syndrome, correlating directly with insulin levels. Plasminogen activator inhibitor-1 expression increased during insulin infusion in all women with polycystic ovary syndrome, but was delayed and sustained in insulin-resistant patients (p<0.01). Vasodilatory response to insulin was blunted (p<0.01) and tissue plasminogen activator expression abolished in insulin-resistant patients (p<0.01). CONCLUSION: Our study demonstrates that women with polycystic ovary syndrome and insulin resistance show a blunted endothelial-dependent vasodilation. The impaired endothelial release of tissue-plasminogen activator and the sustained plasminogen activator inhibitor-1 release during insulin infusion suggest a hypofibrinolytic state in PCOS patients with insulin resistance. This hemodynamic and fibrinolytic derangement may contribute to the pathogenesis of early atherosclerosis in insulin resistance.