Helmet continuous positive airway pressure for patients' transport using a single oxygen cylinder: A bench study.

BACKGROUND: Continuous positive airway pressure (CPAP) is frequently used to treat patients with acute respiratory failure in out-of-hospital settings. Compared to a facemask, the helmet has many advantages for the patient but requires a minimum gas flow of 60 L/min to avoid CO2 rebreathing. The aim of the present bench study was to evaluate the performance of four Venturi devices, connected to a single oxygen cylinder, in delivering helmet-CPAP with clinically relevant gas flow, fraction of inspired oxygen (FiO2), and positive end-expiratory pressure (PEEP) values. METHODS: Three double-inlet Venturi systems (EasyVent, Ventuplus, Compact-HAR) were connected to full 5-L oxygen cylinders using a double flowmeter, and their oxygen requirements to reach different setups (flow 60-80 L/min; FiO2 0.4-0.5-0.6, PEEP 7.5-10-12.5 cmH2O) were tested. The fourth Venturi system (O2-MAX) was directly attached to the tank, and the flow and FiO2 delivered at preset FiO2 0.3 and 0.6 were recorded. The runtime of the cylinder was assessed. RESULTS: EasyVent, Ventuplus, and O2-MAX were able to deliver helmet-CPAP with clinically useful setups when connected to a single oxygen cylinder, while Compact-HAR did not. The runtime of the cylinders ranged between 28 and 60 minutes according to the preset flow and FiO2. The delivered gas flow decreased slowly and linearly with the drop in cylinder pressure until its exhaustion. CONCLUSIONS: Helmet-CPAP might be provided using portable Venturi systems connected to an oxygen cylinder, but not all of them are able to deliver it. The use of a double flowmeter allows delivery of both high flow and high FiO2 when double-inlet Venturi systems are used. Due to the flow drop observed during the cylinder consumption, a flow >60 L/min should be set when helmet-CPAP is started. Considering the flow drop phenomenon, the estimated duration of the tank runtime can be used with a margin of safety when planning patient transport.

A cyanoacrylate and silastic patch to reduce the risk of opening of the tumor: technical note.

BACKGROUND: Wide surgery is the main factor influencing survival in muscular skeletal tumor. Sometimes the margin can be very thin and the contamination risk can be very high because of manipulation of the mass. MATERIALS AND METHODS: A patch of cyanoacrylate and a silastic mesh are applied on tumor surface. In order to demonstrate the tumor sealing an histologic exam was performed. DISCUSSION: The application of protective patch can decrease the risk of accidental tumor rupture and neoplastic cells spreading.

Giant basal cell carcinoma of the skin: literature review and personal experience.

As the most common form of skin cancer, basal cell carcinoma (BCC) is typified by locally infiltrative growth and a very low risk of metastasis. On occasion, however, this otherwise indolent neoplasm may behave aggressively, demonstrating deep tissue invasion and a high rate of postsurgical recurrence. The pathogenesis and determinants of such tenacious growth are not completely understood. Only 1% of all BCC's achieve the status of 'giant', as defined in 1988 by the American Joint Committee on Cancer. In this article, the authors provide a comprehensive review of the scientific literature on giant basal cell carcinoma (GBCC) of the skin and report their experience with this rare tumour subtype.

Biological effects of low frequency high intensity ultrasound application on ex vivo human adipose tissue.

In the present work the effects of a new low frequency, high intensity ultrasound technology on human adipose tissue ex vivo were studied. In particular, we investigated the effects of both external and surgical ultrasound-irradiation (10 min) by evaluating, other than sample weight loss and fat release, also histological architecture alteration as well apoptosis induction. The influence of saline buffer tissue-infiltration on the effects of ultrasound irradiation was also examined. The results suggest that, in our experimental conditions, both transcutaneous and surgical ultrasound exposure caused a significant weight loss and fat release. This effect was more relevant when the ultrasound intensity was set at 100 % (~2.5 W/cm², for external device; ~19-21 W/cm2, for surgical device) compared to 70 % (~1.8 W/cm² for external device; ~13-14 W/cm2 for surgical device). Of note, the effectiveness of ultrasound was much higher when the tissue samples were previously infiltrated with saline buffer, in accordance with the knowledge that ultrasonic waves in aqueous solution better propagate with a consequently more efficient cavitation process. Moreover, the overall effects of ultrasound irradiation did not appear immediately after treatment but persisted over time, being significantly more relevant at 18 h from the end of ultrasound irradiation. Evaluation of histological characteristics of ultrasound-irradiated samples showed a clear alteration of adipose tissue architecture as well a prominent destruction of collagen fibers which were dependent on ultrasound intensity and most relevant in saline buffer-infiltrated samples. The structural changes of collagen bundles present between the lobules of fat cells were confirmed through scanning electron microscopy (SEM) which clearly demonstrated how ultrasound exposure induced a drastic reduction in the compactness of the adipose connective tissue and an irregular arrangement of the fibers with a consequent alteration in the spatial architecture. The analysis of the composition of lipids in the fat released from adipose tissue after ultrasound treatment with surgical device showed, in agreement with the level of adipocyte damage, a significant increase mainly of triglycerides and cholesterol. Finally, ultrasound exposure had been shown to induce apoptosis as shown by the appearance DNA fragmentation. Accordingly, ultrasound treatment led to down-modulation of procaspase-9 expression and an increased level of caspase-3 active form.

How does dexamethasone influence surgical outcome after laparoscopic Nissen fundoplication? A randomized double-blind placebo-controlled trial.

Laparoscopic floppy Nissen fundoplication (LFNF) is an effective treatment for gastroesophageal reflux disease. The duration of convalescence, after noncomplicated LFNF, may depend on several factors of which pain, fatigue and sociocultural factors are the most important. Nausea and vomiting occur mainly on the day of operation. Glucocorticoids are well known for their analgesic, anti-inflammatory, immune-modulating and antiemetic effects. We therefore undertook the present study to investigate whether preoperative dexamethasone could improve surgical outcome in patients undergoing uncomplicated laparoscopic floppy Nissen fundoplication. From March 2005 to April 2008, 82 patients were randomized to receive dexamethasone (8 mg) intravenously, 90 min before skin incision or saline (placebo). Patients received a similar standardized anesthetic, surgical and multimodal analgesic treatment. The primary end points were pain and fatigue. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein (CRP), interleukin-6 and 1 (IL-6, IL-1), pain scores and nausea, and the number of vomiting episodes were registered. Dexamethasone significantly reduced postoperative levels of CRP (p = 0.01), IL-6 and IL-1 (p < 0.05), fatigue (p = 0.01) and overall pain during the first 24 postoperative hours (p < 0.05) and the total requirement of analgesic (ketorolac) (p < 0.05). Dexamethasone also reduced nausea and vomiting on the day of operation (p < 0.05). Preoperative dexamethasone (8 mg) reduced pain, fatigue, nausea and vomiting in patients undergoing uncomplicated LNF when compared with placebo.

Effects of phosphatidylcholine and sodium deoxycholate on human primary adipocytes and fresh human adipose tissue.

Recent studies introduced the novel concept of chemical lipolysis where phosphatidylcholine (PC), an active component of commercial preparations, plays a pivotal role. Other studies suggested that sodium deoxycholate (DOC), an excipient contained in medical preparations, could be the real active component performing an adipocytolytic action. We investigated the effects of PC and DOC on human primary adipocyte cultures and on human fresh adipose tissue. Human adipocytes isolated by Rodbell's method, were cultured onto type I collagen-coated glass coverslips, placed into 24-well tissue culture plates. Cells were incubated with or without DOC (5-7-9%), PC (5%) or DOC/PC mixture and observed under phase contrast microscope. After incubation, cells were stained with Oil Red-O and with acridine orange/ethidium bromide to observe necrotic cells with phase contrast microscope and fluorescent microscope, respectively. Histological specimens from adipose tissue biopsies were observed with phase contrast microscopy and with scanning electron microscopy. To investigate the lipid pattern variability in the different experimental conditions, culture medium obtained from the different treatments was subjected to lipid extraction and subsequently to thin layer chromatography (TLC). Microscopic observation of adipocytes showed that DOC treatment led to a detrimental morphological effect in a dose-dependent manner. PC treatment did not significantly affect adipocyte viability. On the contrary, results from experiments aimed to analyze the effects of PC/DOC combined treatment suggested a PC protective role against the DOC harmful effects on adipocytes. Results indicated that clinical effects, observed in local treatment with pharmaceutical preparation, could be due only to DOC, a detergent inducing nonspecific lysis of cell membranes following adipocyte necrosis. On the other hand, PC could likely be incorporated in the lipid bilayer, thus strongly reducing the disruptive DOC effects.

[Early diagnosis of dysmorphophobia and others dysmorphic disorders: a possible operative model]. / Dismorfofobia e diagnosi precoce: un modello operativo possibile.

AIMS: Body Dismorphic Disorder interest the 1-2% of the general population. It is characterized by an unfavorable prognosis and an elevated comorbidity with others psychiatric disorders. Approximately 6-15% of people with body image disorder refer for aesthetic surgery without any benefit indeed the outcome is, often, to request others surgery procedure. The aim of study has been to investigate the presence of dismorphophobia, others dismorphic disorders and psychiatric symptoms in a sample of patients candidates to aesthetic surgery procedure. MATERIALS AND METHODS: It has been recruited 109 patients of mean age 27.21 years, coming to the department of Plastic Surgery of L'Aquila (Italy). To all the patients have been delivered a questionnaire for socio-demographic data and two clinical standardized instruments: Self-report Symptom Inventory-Revised (SCL-90) and the Body Uneasiness Test (BUT). The psychometric and clinical evaluations have been performed by SMILE center (Service for Monitoring and early Intervention against psychoLogical and mEntal suffering in young people), the mission of which is to reduce the burden of mental suffering in young people by of an earlier recognition of signs and symptoms of psychiatric disorders. RESULTS: 42.67% of sample showed positive results to BUT, while 57.33% reported negative results. Moreover, BUT-positive subjects achieved significantly higher results in all SCL-90 items. CONCLUSIONS: A liaison between psychiatrists and plastic surgery equipe is essential for an early diagnosis of Dismorphophobia and others Dismorphic Disorders, to begin an eventual treatment and to supply indications for the surgical candidability. Our study confirm the high prevalence of body image disorders and the presence of other psychiatric symptoms and diseases in patients who demand aesthetic procedure. The detection of early signs of any psychiatric and psychological apparent discomfort represent a priority because this correlate, in most cases, with late diagnosis and intervention because awareness of these types of disease is usually very low and therefore the possibility that subjects with this type of problems are requested to psychiatric services is rare.

Silicone gel mammary prostheses: immune pathologies and breastfeeding.

Augmentation mammoplasty is the most frequent request among esthetic surgery procedures but numerous controversies have been raised about the security of the silicone gel prostheses. Today a new question needs an answer: is the prosthesis a risk factor for pregnancy? In this paper the results of a hematochemical study performed on a group of patients with term pregnancies and silicone gel breast implants (group A) compared with a control group without implants (B) are described. For laboratory screening the valuation of antibody (TRIM) and silicone concentrations in blood and maternal milk and in neonate blood was performed.

Gorlin syndrome associated with basal cell carcinoma of the vulva: A case report.

Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome (NBCCS), is a hereditary condition transmitted as an autosomal dominant trait with high penetrance and variable expressivity. The syndrome is characterized by numerous manifestations: basal cell carcinomas (BCCs) and odontogenic keratocysts (OKCs) are the leading ones. In this article a typical Gorlin syndrome case associated with basal cell carcinoma of the vulva is described.

Achievements and new directions in continuous renal replacement therapies.

The evolution of renal replacement therapy has permitted the treatment of critically ill patients with acute renal failure. In intensive care settings, continuous renal replacement therapies have been shown to be better tolerated and clinically useful. Continuous hemofiltration is now performed with blood pumps and double-lumen venous catheters, thus avoiding the complications found in previous arteriovenous treatments. The use of countercurrent dialysate flow has overcome problems related to low treatment efficiency. High clearances can now be obtained during continuous hemodialysis or hemodiafiltration, and adequate blood purification can be achieved even in severely catabolic patients. New replacement solutions allow for a more effective correction of acidosis and electrolyte imbalances. Finally, newly designed machines permit continuous therapies while minimizing staff workload. Continuous therapies are today moving toward newer indications and applications. The ability to remove proinflammatory substances by filtration and/or adsorption has opened a series of potential indications. The concept that renal support and protection take place during hemofiltration suggests that very early use of this technique is desirable, even before the onset of oliguria or azotemia.

Comparative evaluation of the haemodynamic effects of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in mechanically ventilated trauma patients.

OBJECTIVE: To compare the haemodynamic effects of identical values of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in a group of mechanically ventilated patients. SETTING: General ICU, Vicenza Hospital, Italy. PATIENTS: 15 consecutive patients, admitted after road accident trauma. METHODS: We compared the haemodynamic effects of ZEEP, 10 cmH2O of PEEP, and 10 cmH2O CNEP, applied in random order, in 15 head trauma patients under going controlled mechanical ventilation; 9 had associated thoracic trauma, while 6 did not have lung involvement. CNEP was obtained with a "poncho". RESULTS: We observed a significant increase in CI during CNEP, compared with both ZEEP and PEEP 10 cmH2O. Accordingly the oxygen delivery index significantly increased during CNEP, compared with PEEP 10 cmH2O. Conversely, Qs/Qt decreased with CNEP, if compared with PEEP, both in patients with and without lung damage. CONCLUSION: CNEP can significantly increase CI in mechanically ventilated patients in patients with and without associated lung damage.