Comparative Evaluation of Two Different Post-Operative Analgesia after Hallux Valgus Correction in Day Surgery Patients.

INTRODUCTION: The aim of this study was the evaluation of two different techniques on post-operative analgesia and motor recovery after hallux valgus correction in one-day surgery patients. MATERIAL AND METHODS: We enrolled 26 patients scheduled for hallux valgus surgery and treated with the same surgical technique (SCARF osteotomy). After subgluteal sciatic nerve block with a short acting local anaesthetic (Mepivacaine 1.5%, 15ml), each patient received an ultrasound-guided Posterior Tibialis Nerve Block (PTNB) with Levobupivacaine 0.5% (7-8ml). We measured the postoperative intensity of pain using a Visual Analogue Scale (VAS), the consumption of oxycodone after operative treatment and the motor recovery. VAS was detected at baseline (time 0, before the surgery) and at 3, 6, 12 and 24 hours after the operative procedure (T1, T2, T3, T4 respectively). Control group of 26 patients were treated with another post-operative analgesia technique: local infiltration (Local Infiltration Anaesthesia, LIA) with Levobupivacaine 0.5% (15ml) performed by the surgeon. RESULTS: PTNB group showed a significant reduction of VAS score from the sixth hour after surgery compared to LIA group (p<0.028 at T2, p<0.05 at T3 and p<0.002 at T4, respectively). Instead, no significant differences were found in terms of post-operative oxycodone consumption and motor recovery after surgery.Conclusions: PTNB resulted in a valid alternative to LIA approach for post-operative pain control due to its better control of post-operative pain along the first 24 hours. In a multimodal pain management according to ERAS protocol, both PTNB and LIA should be considered as clinically effective analgesic techniques.

Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series.

Tibial shaft fractures are extremely common injuries. High rate of union, acceptable alignment in all planes, and a low complication rate have been reported when diaphyseal fractures are treated by intramedullary nailing. However, knee pain after tibial nailing has historically been problematic. While the exact aetiology of the knee pain is still unknown, surgical approach relative to the patellar tendon, nerve transection, violation of the fat pad or joint capsule as well as nail diameter and implant prominence have been claimed as possible causes. Therefore, establishing an appropriate starting point remains a crucial step in the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Literature is lacking on this topic, therefore the present article discusses clinical outcomes of 25 patients treated by suprapatellar nailing at 2 years follow up and a literature review.

Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study.

PURPOSE: Ventricular-arterial (V-A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV). METHODS: After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol. RESULTS: Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l(-1)), arterial dP/dt max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms(-1)), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg(-1) min(-1), p < 0.05). CONCLUSIONS: HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V-A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

A combined therapeutic approach in progressive idiopathic pulmonary fibrosis-pirfenidone as bridge therapy for ex vivo lung transplantation: a case report.

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrosing interstitial pneumonia of unknown etiology, which is associated with the histopathologic pattern of usual interstitial pneumonia (UIP) and leads to a progressive decrease of respiratory function. The present article describes a case of a 62-year-old ex-smoker referred to our hospital because of IPF. After 2 years of follow-up, the subject experienced a significant worsening of pulmonary function and was enrolled in a lung transplantation program. Afterward, a pharmacological treatment with pirfenidone was started, achieving a stabilization of respiratory function. The patient underwent a single lung transplantation by means of a normothermic ex vivo lung perfusion (EVLP) approach according to the Toronto model. At 20-month evaluation the subject's respiratory function was significantly improved, and quality of life was considerably ameliorated. We believe that an integrated multidisciplinary approach should be considered a key option for the treatment of individuals with IPF.

Network meta-analysis on the comparative effectiveness and safety of transcatheter aortic valve implantation with CoreValve or Sapien devices versus surgical replacement.

INTRODUCTION: Surgical replacement for aortic stenosis is fraught with complications in high-risk patients. Transcatheter techniques may offer a minimally invasive solution, but their comparative effectiveness and safety is uncertain. We performed a network meta-analysis on this topic. METHODS: Randomized trials on transcatheter aortic valve replacement vs surgery were searched. The primary outcome was all cause death. Risk estimates were obtained with Bayesian network meta-analytic methods. RESULTS: Four trials with 1,805 patients were included. After a median of 8 months, risk of death and myocardial infarction was not different when comparing surgery versus transcatheter procedures, irrespective of device or access. Conversely, surgery was associated with higher rates of major bleeding (odds ratio vs CoreValve=3.03 [95% credible interval: 2.23-4.17]; odds ratio vs transfemoral Sapien =1.82 [1.21-2.70]; odds ratio vs transapical Sapien =2.08 [1.20-3.70]), and acute kidney injury (odds ratio vs CoreValve =2.08 [1.33-3.32]; odds ratio vs transapical Sapien =2.78 [2.21-99.80]), but lower rates of pacemaker implantation (odds ratio vs CoreValve =0.41 [0.28-0.59]), and moderate or severe aortic regurgitation (odds ratio vs CoreValve =0.06 [0.02-0.27]; odds ratio vs Sapien=0.17 [0.02-0.76]). Strokes were less frequent with CoreValve than with transfemoral Sapien (odds ratio =0.32 [0.13-0.73]) or transapical Sapien (odds ratio =0.33 [0.10-0.93]), whereas pacemaker implantation was more common with CoreValve (odds ratio vs surgery =2.46 [1.69-3.61]; odds ratio vs transfemoral Sapien =2.22 [1.27-3.85]). CONCLUSIONS: Survival after transcatheter or surgical aortic valve replacement is similar, but there might be differences in the individual safety and effectiveness profile between the treatment strategies and the individual devices used in transcatheter aortic valve implantation.

Epicatechin and catechin modulate endothelial activation induced by platelets of patients with peripheral artery disease.

Platelet activation contributes to the alteration of endothelial function, a critical initial step in atherogenesis through the production and release of prooxidant mediators. There is uncertainty about the precise role of polyphenols in interaction between platelets and endothelial cells (ECs). We aimed to investigate whether polyphenols are able to reduce endothelial activation induced by activated platelets. First, we compared platelet activation and flow-mediated dilation (FMD) in 10 healthy subjects (HS) and 10 patients with peripheral artery disease (PAD). Then, we evaluated the effect of epicatechin plus catechin on platelet-HUVEC interaction by measuring soluble cell adhesion molecules (CAMs), NOx production, and eNOS phosphorylation (p-eNOS) in HUVEC. Compared to HS, PAD patients had enhanced platelet activation. Conversely, PAD patients had lower FMD than HS. Supernatant of activated platelets from PAD patients induced an increase of sCAMs release and a decrease of p-eNOS and nitric oxide (NO) bioavailability compared to unstimulated HUVEC. Coincubation of HUVEC, with supernatant of PAD platelets patients, pretreated with a scalar dose of the polyphenols, resulted in a decrease of sCAMs release and in an increase of p-eNOS and NO bioavailability. This study demonstrates that epicatechin plus catechin reduces endothelial activation induced by activated platelets.

Clinical and functional outcomes of internal fixation with intertrochanteric antegrade nail in older patients with proximal extracapsular femoral fractures.

PURPOSE: The intertrochanteric Trigen Intertan(®) nail (Smith & Nephew, Memphis, TN) is a popular fixation device for proximal extracapsular femoral fractures (PEFFs). We evaluated clinical and functional outcomes in patients with PEFFs treated with Trigen Intertan(®) nail. METHODS: In a single-site, prospective observational study, clinical and functional parameters were recorded for all patients admitted to the Emergency Department with PEFFs from June 2008 through June 2011. Patients with severe cognitive impairment, severe disability, neoplastic pathological fractures, or suffering from terminal illnesses were not eligible for the study. Fractures were classified according to the AO/OTA classification system. Preoperative physical fitness was assessed via the American Association of Anaesthetists (ASA) score. The Barthel index was used to quantify the level of physical function before fracture and at follow-up. RESULTS: One-hundred thirty-five patients with PEFFs were eligible for inclusion during the 3-year survey (mean age 83.2 ± 9.5 years; 82 % females). Fracture type distribution was as follows: A1.1 = 18 %, A1.2 = 7 %, A1.3 = 5 %, A2.1 = 44 %, A2.2 = 21 %, A2.3 = 5 %. All patients were treated with Trigen Intertan(®) nail. Two patients experienced a fracture of the femoral shaft during the insertion of a long nail for an A2.3 fracture. Weight-bearing was allowed between the third and tenth postoperative day depending on pain tolerance and general conditions. No loss of reduction, collapse of the femoral neck, nonunion or fixation failure were observed. Two patients died within 10 days postoperatively, and nine within 6 months after surgery. Functional status 1 month after surgery was lower than pre-fractural levels, and improved over follow-up. At 6 months, functional status was comparable to the pre-fractural level. CONCLUSIONS: Trigen Intertan(®) produces highly satisfactory clinical and functional results in older patients with PEFFs. Complete functional recovery is obtained on average 6 months after surgery.

Giant right atrial thrombus in hepatocellular carcinoma: real-time characterization by cardiac magnetic resonance and real time three-dimensional echocardiography.

Hepatocellular carcinoma (HCC) with extension to the right atrium is an uncommon form of cardiac involvement. We report a case of a 67-year-old man admitted to our Department for the incidental findings of a mass in the right atrium. Physical examination revealed leg edema, distention of external jugular vein and ascites. The anamnestic collection revealed HCC occurred on post-alcoholic liver cirrhosis 3 years earlier. Transthoracic echocardiography revealed a dilated RA containing a mass, with superficial apposition of a thrombotic material. Bi-dimensional echocardiography is the most commonly used noninvasive tool for evaluating intracardiac masses. Although MRI is considered the gold standard, real-time three-dimensional echocardiography has the capability to obtain the entire volume reconstruction of an intracardiac mass, even with an irregular shape. Moreover, it permits an hemodynamic evaluation of the potential obstructive effects visualized from different angles and planes.

Commercial and laboratory extracts from artichoke leaves: estimation of caffeoyl esters and flavonoidic compounds content.

Artichoke leaf extracts are widely used alone or in association with other herbs for embittering alcoholic and soft drinks and to prepare herbal teas or herbal medicinal products. Despite this wide diffusion, the European Pharmacopoeia does not report an official method for the determination of the active principles of artichoke leaf extracts. This work reports a quali-quantitative determination by HPLC/DAD and HPLC/MS techniques of both cynnamic acids and flavonoids present in some artichoke leaf commercial extracts (Com) compared with two different laboratory extracts (Lab). Most of the commercial extracts showed a similar quali-quantitative pattern with a single exception having five-six times higher value. The quantitative data from the Italian Pharmacopoeia(IP) official method does not evaluate the flavonoidic fraction and showed an overestimation of the caffeoyl esters with respect to the HPLC/DAD results. The proposed HPLC/DAD method was able to completely characterize and quantify this matrix and represents a contribution to better quality control of these herbal extracts.

Highly active antiretroviral therapy restores in vitro mitogen and antigen-specific T-lymphocyte responses in HIV-1 perinatally infected children despite virological failure.

To analyse the effect of highly active antiretroviral therapy (HAART) on T-lymphocyte functions we selected seven HIV-1 perinatally infected children (CDC immunological category 1 or 2) who had neither a fall in their plasma HIV-1 RNA levels nor a significant rise in CD4+ lymphocyte counts while receiving HAART. Clinical signs and symptoms were monitored monthly. Plasma viral load, CD4+, CD8+, CD19+ lymphocyte counts and in vitro T-lymphocyte proliferative responses to mitogens (anti-CD3, phytohaemoagglutinin, concanavalin A and pokeweed mitogen) and recall antigens (Candida albicans and tetanus toxoid) were tested at baseline and after 1, 3, 6 and 12 months of HAART. Twenty-two healthy age-matched children were studied as controls. A gain in body weight, no worsening of the disease and no recurrence of opportunistic infections were observed. At baseline, the majority of the children had low responses to mitogens, and all of them had a defective in vitro antigen-specific T-lymphocyte response (<2 standard deviations below the mean result for controls). During HAART, a significant increase in the response to mitogens and antigens was observed in all the patients. The T-lymphocyte response was restored more consistently against antigens to which the immune system is constantly exposed (Candida albicans, baseline versus 12 months: P < 0.001) compared with a low-exposure antigen (tetanus toxoid, baseline versus 12 months: P < 0.01). HAART restores in vitro T-lymphocyte responses even in the absence of a significant viral load decrease and despite any significant increase in CD4+ lymphocyte counts. It implies that a direct mechanism might be involved in the overall immune recovery under HAART.

Evidence for a T-lymphocyte dependent mechanism involving proinflammatory cytokines in anticonvulsant hypersensitivity syndrome: a case report.

The anticonvulsant drug hypersensitivity syndrome (AHS) is a potentially fatal drug reaction associated with aromatic antiepileptic drugs, the pathogenic mechanisms of which are still unclear. We studied a 2-year-old female affected with AHS after phenobarbital treatment. In vitro experiments showed a T-lymphocyte response to the drug and an increased, dose-related, IL-6 production after drug incubation. These findings suggest that AHS may be caused by a T-lymphocyte dependent mechanism, involving pro-inflammatory cytokines.

Inhibition of natural killer cell cytotoxicity and interferon gamma production by the envelope protein of HIV and prevention by vasoactive intestinal peptide.

Natural killer (NK) cell dysfunction is common in human immunodeficiency virus (HIV)-infected subjects, although its mechanisms are poorly understood. A direct effect of HIV envelope glycoprotein gp120 may be involved. We investigated the in vitro effects of gp120 on the major NK cell effector functions, natural cytotoxicity and cytokine production. In addition, the ability of the vasoactive intestinal peptide (VIP) to modulate these effects was investigated. Our results indicated that gp120 inhibits NK natural cytotoxicity and showed, for the first time, that the inhibition affects also the production of the proinflammatory cytokine interferon-gamma (IFN-gamma). Interestingly, the inhibitory effect on NK cell functions was obtained with gp120 at concentrations within the range measured in the serum of HIV-infected subjects. Furthermore, we showed that the inhibitory activity of gp120 can be prevented by coincubation with VIP, even if VIP has no stimulatory activity by itself. Taken together these data suggest that (1) an inhibitory effect of gp120 may account for the NK cell dysfunction in HIV-infected subjects; (2) the gp120-mediated decrease in IFN-gamma production by NK cells may contribute to the cytokine imbalance observed in HIV infection; and (3) VIP counteracts the inhibitory effect of gp120 on NK cell functions.

Statistical analysis of the effect of high dilutions of arsenic in a large dataset from a wheat germination model.

This paper describes the statistical analysis of a series of experiments using a simple biological model (wheat germination in vitro), where a large number of wheat seeds were treated with homeopathic potencies of Arsenic trioxide. Some potencies, such as As2O3 40x, 42x and 45x, have repeatedly shown a significant stimulating effect on germination compared to controls, whereas As2O3 35x has a significant inhibiting effect. In some experiments the seeds were stressed before the experiment with a sublethal dose of the same substance. We performed a statistical analysis, both for stressed and non-stressed seed groups, using Poisson distribution as a suitable model for representing the number of non-germinated seeds in a standard experiment with 33 seeds in the same Petri dish. Finally, we have considered the most repeated potencies (30x and 45x), computing the sample odds ratio (OR) and a 95% confidence interval (CI) for the population OR. Our results show significant reproducible effects of some As2O3 decimal potencies, particularly As2O3 45x. In stressed seeds, even decimal potencies of water seem to give significant results compared to control, whereas high dilutions of As2O3 without potentization never show significant effects.

Statistical analysisof the effect of high dilutions of arsenic in a large dataset from a wheat germination model

This paper describes the statisticalanalysis of a series of experiments using a simple biological mosdel (wheat germination in vitro), where a large number of wheat seeds were treated with homeopathic potencies of Arsenic trioxide. Some potencies, such as As2O3 40x, 42x and 45x, have repeatedly shown a significant stimulating effect on germination compared to controls, whereas As2O335x has a significant inhibiting effect. In some experiments the seeds... (AU)

Determination of phenoxyalkanoic acids and other herbicides at the ng/ml level in water by solid-phase extraction with poly(divinylbenzene-co-N-vinylpyrrolidone) sorbent and high-performance liquid chromatography--diode-array detection.

A method for the determination of phenoxyalkanoic acids and other polar compounds in environmental water samples without pH adjustment before extraction has been developed. Recoveries were calculated from 500 ml of milliQ water spiked at the level of 0.5 ng/ml using solid-phase extraction (SPE) and HPLC-DAD. Different SPE materials (RP-C18, ENV+, ENV+-C8, SAX and Oasis HLB) were tested. After method optimization, 15 of the 16 compounds studied could be extracted with recoveries better than 70% on the most suitable copolymeric poly(divinylbenzene-co-N-vinylpyrrolidone) material (Oasis HLB cartridges).