Learning a palliative care approach during the COVID-19 pandemic: A case study in an Infectious Diseases Unit.

BACKGROUND: Hospital palliative care is an essential part of the COVID-19 response, but relevant data are lacking. The recent literature underscores the need to implement protocols for symptom control and the training of non-specialists by palliative care teams. AIM: The aim of the study was to describe a palliative care unit's consultation and assistance intervention at the request of an Infectious Diseases Unit during the COVID-19 pandemic, determining what changes needed to be made in delivering palliative care. DESIGN: This is a single holistic case study design using data triangulation, for example, audio recordings of team meetings and field notes. SETTING/PARTICIPANTS: This study was conducted in the Palliative Care Unit of the AUSL-IRCCS hospital of Reggio Emilia, which has no designated beds, consulting with the Infectious Diseases Unit of the same hospital. RESULTS: A total of 9 physicians and 22 nurses of the Infectious Diseases Unit and two physicians of the Palliative Care Unit participated in the study.Our Palliative Care Unit developed a feasible 18-day multicomponent consultation intervention. Three macro themes were identified: (1) new answers to new needs, (2) symptom relief and decision-making process, and (3) educational and training issues. CONCLUSION: From the perspective of palliative care, some changes in usual care needed to be made. These included breaking bad news, patients' use of communication devices, the limited time available for the delivery of care, managing death necessarily only inside the hospital, and relationships with families.

Postoperative pain management of liver transplantation in cystic fibrosis: Is it time to start US-guided neuraxial blocks?

Cystic fibrosis (CF) is the most common life-limiting genetic disease in Caucasians. Declining lung function is the principal cause of death, but liver involvement can lead to the need for liver transplantation. General anesthesia has detrimental effects on pulmonary function, increasing perioperative morbidity and mortality in CF patients. Regional anesthetic techniques improve outcomes by reducing anesthetic drugs and administration of opioids, and hastening extubation, awakening, and restarting respiratory of physiotherapy. There is a growing evidence that thoracic epidural anesthesia is feasible in pediatric patients. Concerns about coagulopathy and immunosuppression have limited its use in liver transplantation. Ultrasonography is becoming an adjunct tool in neuraxial blocks, allowing faster and easier recognition of the epidural space, and reducing vertebral touch and number of attempts. In pediatric patients, it is still debated whether anesthesia has detrimental effects on cognitive development. Efforts to make regional techniques easier and safer by ultrasonography are ongoing. We report the first case of continuous thoracic epidural analgesia after pediatric liver transplantation in a 10-year-old boy affected with CF with macronodular cirrhosis. Despite a challenging coagulation profile, the echo-assisted procedure was safely performed and allowed extubation in the odds ratio, postoperative awakening and comfort, and quick resumption of respiratory physiotherapy.

Anesthetic management of totally robotic right lobe living-donor hepatectomy: new tools ask for perioperative care.

Living donor transplantation is an accepted clinical practice in select transplant centers in Western countries to increase the availability of organs, while is standard practice in East Asian transplant programs. Living-donor right hepatic lobe resection is a particularly risky operation, with two mandatory outcomes: no serious complications for the donor, and an optimal graft-recipient body weight ratio. The use of robotic surgery has increased worldwide thanks to its minimally invasive approach, and is now becoming suitable for living donor procurement. From the anesthetic point of view, robotic surgery reveals itself to be extremely challenging, and requires diverse capacities in teamwork and planning of anesthetic management. We report what we believe is the first case of anesthetic management of a totally robotic right lobe resection in a living donor, and describe the steps taken by the anesthetists, in concert with the surgical team, to ensure delivery of the safest patient care.

A 12-month follow-up for neurological complication after subarachnoid anesthesia in a parturient affected by multiple sclerosis.

Multiple sclerosis is common among women of childbearing age. Neuraxial blocks have been administered to them with reluctance because of the hypothetical risk that local anesthetics might be more histotoxic to neural tissue already compromised by multiple sclerosis. In spite of the lack of uniform guidelines on disorders in pregnancy like multiple sclerosis, and of the published data that sometimes contrast each other, experience gained in recent years has indicated that regional anesthesia is safe even in these patients, but there aren't many published cases. We describe the case of a pregnant woman affected by multiple sclerosis in which we administered spinal anesthesia for a cesarean section, and we analyzed the aspects that literature defines as critical points in this group of patients. The results were favorable with regard to the level, intensity and duration of anesthesia. No neurological exacerbations were recognized during the hospital stay, nor during the follow-up that lasted 12 months.

Cotrel-Dubousset instrumentation for the treatment of severe scoliosis.

In a multicentric study, 36 cases (40 curves) of severe scoliosis were analysed; 19 were idiopathic and 17 neurological, Cobb angles ranged from 70 degrees to 145 degrees, all had undergone three-rod Cotrel-Dubousset (CD) instrumentation. The correction on the frontal plane achieved more than 50% of the preoperative angle (53.9% for idiopathic curves and 55.6% for neurological ones). On the sagittal plane the pathological shape of the spine was reduced and distinctly ameliorated. In ten patients, the authors successfully applied a technique, alternative to the original one, which was based on the use of two or three screws in the lumbar area, one supplementary pedicle transverse claw on the cranial area and two rods connected by a domino, instead of a single rod (the longer one applied on the concave side). The main complications were: one case of infection, three of vascular compression of the duodenum, one of crank-shaft phenomenon and one laminar hook displacement. The excellent result achieved in both, idiopathic and neurological severe and stiff scoliosis shows the efficacy, reliability and versatility of CD three-rod instrumentation.

Transplantation of human endothelial cell monolayer on artificial vascular prosthesis: the effect of growth-support surface chemistry, cell seeding density, ECM protein coating, and growth factors.

The failure rates of synthetic vascular grafts, when placed in low blood flow environments in humans, are not acceptable. Thus, endothelial cell (EC) seeding technology of vascular grafts was developed to prepare prostheses lined with a human monolayer expressing optimal thromboresistant properties. In a clinical setting, endothelialization of a graft can be achieved using higher cell seeding densities, or by creating a surface on which EC can adhere and grow to confluence. But, human endothelial cells show little or no proliferation on the currently available graft materials. In this study, surface modification of PTFE and ePTFE by ammonia plasma treatment was carried out to enhance its interactions with ECM protein, EC growth factors, and with EC harvested from human umbilical vein (HUVEC), and from human saphenous veins (HSVEC). Our data shows that various vascular graft materials generated from ammonia plasma treated PTFE and ePTFE exhibited statistically significant improvements in HUVEC and HSVEC growth when compared to their respective controls (p values < 0.001). Growth of HSVEC on ammonia plasma treated ePTFE without ECM protein coating was also found to be statistically significant in comparison to that on fibronectin coated ePTFE (p < 0.001). The final HSVEC cell densities found on various ePTFE surfaces prepared from ammonia plasma treated ePTFE, suggests that transplantation of HSVEC monolayers on vascular prostheses can be established within clinically relevant times. Ammonia plasma treatment process provides an unique opportunity to surface modify prosthetic materials of various construct to transplant mammalian cells including those that have undergone ex vivo gene transfer, and to deliver angiogenic molecules to a target area for tissue development.

High-efficiency transformation of human endothelial cells by Apo E-mediated transfection with plasmid DNA.

Endothelial cells, because of their proximity to the blood stream, provide an attractive system for gene transfer and delivery of gene products that control foci of vascular disease processes. We describe a simple, new methodology to achieve highly efficient transformation of cultured human endothelial cells derived from umbilical veins (HUVEC). A plasmid pCH110 containing coding region for beta-galactosidase driven by SV 40 early promoter region was employed to transfect HUVEC. The developed protocol exploits the role of apolipoprotein E (Apo E) in the metabolism of Apo E-containing lipoproteins and its high affinity binding to LDL receptors. DNA transfection of cultured HUVEC was carried out using standard transfection methods including calcium phosphate precipitation, polybrene mediated transfection, and lipofection. The new methodology of transfecting HUVEC employed Apo E adsorbed lipofection reagent-DNA complex, and was found to be the most efficient procedure to transform HUVEC in comparison to the standard methods used in this study.

Patients dropping out of treatment in Italy.

The aim of this study was to explore the extent and the specific features of drop-out for patients having a first contact with an university psychiatric outpatient clinic in Italy over the course of 1 year and to determine which variables were associated with early termination of treatment. Of the 158 patients selected for this study, there was an overall 3-month drop-out rate following the first visit of 63%. Of the 59 patients who had returned once after the initial contact, 28 interrupted subsequently the treatment, although the therapist's plan included further visits. The overall drop-out rate at 3 months was thus 82%. The only 2 variables associated with drop-out rates were the patients' perception of the severity of their disorder and the psychiatric history: continuing patients were more frequently in agreement with the clinician's judgment as compared with those who dropped out and were more likely to have already been in psychiatric treatment.

Enhanced attachment and growth of human endothelial cells derived from umbilical veins on ammonia plasma modified surfaces of PTFE and ePTFE synthetic vascular graft biomaterials.

Ammonia plasma generated by electrical discharge at low pressure was employed for the surface modification of PTFE and ePTFE. A new chemistry at the plasma treated surfaces is reported. X-ray photoelectron spectroscopy studies showed the incorporation of C-N, C-O, C = O etc functional groups on the plasma treated surfaces. Human endothelial cells derived from umbilical veins (HUEC) were used to seed the plasma treated PTFE and ePTFE surfaces to assess the attachment and growth. Enhanced attachment and growth of HUEC was observed on the plasma treated surfaces. In addition, the performance of these surfaces in this respect was found to be considerably superior to human collagen or human fibronectin or collagen-fibronectin coated PTFE. HUEC attachment and growth on these plasma treated surfaces was further enhanced by immobilizing collagen or fibronectin or collagen-fibronectin. Ammonia plasma treated and untreated ePTFE vascular graft samples were seeded with 3.6 X 10(4) cells/sample. At 24 hrs after seeding, HUEC cell attachment was studied. Although, HUEC attachment on collagen or fibronectin coated ePTFE was improved, but there was no significant difference between the number of cells attached to these surfaces when compared with those adhered to plasma treated ePTFE without collagen or fibronectin coating. Collagen or fibronectin coated plasma treated surfaces showed better performance over their respective controls.

Development of chicken embryos in a pulsed magnetic field.

Six independent experiments of common design were performed in laboratories in Canada, Spain, Sweden, and the United States of America. Fertilized eggs of domestic chickens were incubated as controls or in a pulsed magnetic field (PMF); embryos were then examined for developmental anomalies. Identical equipment in each laboratory consisted of two incubators, each containing a Helmholtz coil and electronic devices to develop, control, and monitor the pulsed field and to monitor temperature, relative humidity, and vibrations. A unipolar, pulsed, magnetic field (500-microseconds pulse duration, 100 pulses per s, 1-microT peak density, and 2-microseconds rise and fall time) was applied to experimental eggs during 48 h of incubation. In each laboratory, ten eggs were simultaneously sham exposed in a control incubator (pulse generator not activated) while the PMF was applied to ten eggs in the other incubator. The procedure was repeated ten times in each laboratory, and incubators were alternately used as a control device or as an active source of the PMF. After a 48-h exposure, the eggs were evaluated for fertility. All embryos were then assayed in the blind for development, morphology, and stage of maturity. In five of six laboratories, more exposed embryos exhibited structural anomalies than did controls, although putatively significant differences were observed in only two laboratories (two-tailed Ps of .03 and less than .001), and the significance of the difference in a third laboratory was only marginal (two-tailed P = .08). When the data from all six laboratories are pooled, the difference in incidence of abnormalities in PMF-exposed embryos (approximately 25 percent) and that of controls (approximately 19 percent), although small, is highly significant, as is the interaction between incidence of abnormalities and laboratory site (both Ps less than .001). The factor or factors responsible for the marked variability of inter-laboratory differences are unknown.

Properties of acetylcholine-receptor activation in human Duchenne muscular dystrophy myotubes.

In human myotubes cultured from biopsies of normal subjects and dystrophic patients we investigated, with the patch-clamp technique, the activation properties of the nicotinic acetylcholine receptor (AChoR) in the presence of acetylcholine and suberyldicholine. The single-channel conductance and the lifetime of the openings were not found to differ. In contrast, the average frequency of openings was about four times higher in Duchenne muscular dystrophy (DMD) myotubes in the presence of equal amounts of acetylcholine, but not of suberyldicholine. The most reasonable conclusion from this observation is that the behaviour of the AChoR is not altered in DMD cells but that there is a greater average concentration of ACho molecules present around AChoRs. This leads to the tentative conclusion that the activity of the enzyme acetylcholinesterase (AChoE) is impaired by some unknown mechanism in the dystrophic myotube.

Dystrophin immunocytochemistry in muscle culture: detection of a carrier of Duchenne muscular dystrophy.

Dystrophin is the gene product which is affected in Duchenne muscular dystrophy (DMD). We studied differentiating clonal muscle cultures derived from normal muscle and from the mother of a DMD patient by immunocytochemistry, using anti-dystrophin antibody. While clonal cultures derived from normal muscle expressed dystrophin in all myotubes, two populations of myogenic cells could be demonstrated in muscle from this possible DMD carrier; in 13 clones the myotubes expressed dystrophin and in 7 clones dystrophin was undetectable. No DNA deletion, duplication or rearrangement was detected by Southern blot analysis of DNA from this family using cDNA probes. Thus, immunocytochemical analysis of clonal muscle cultures may be a useful method to determine whether mothers of DMD patients are carriers of the DMD mutation, especially in the absence of demonstrable gene defects.

Immunocytochemical study of dystrophin in muscle cultures from patients with Duchenne muscular dystrophy and unaffected control patients.

Using immunocytochemical methods, the localization of dystrophin, the gene product affected in Duchenne muscular dystrophy (DMD) in aneural, differentiating human muscle cultures, was studied. Dystrophin was not demonstrable in undifferentiated myoblasts from control patients and from two patients with DMD. After myoblast fusion, the protein was found in circumscribed sarcoplasmic patches, in the perinuclear area, and along the surface of all normal multinucleate myotubes, with more mature myotubes showing predominantly sarcolemmal distribution. There was no staining in myotubes from one DMD patient and only faint diffuse fluorescence in myotubes from the second affected boy, however. These data provide further evidence that dystrophin is a sarcolemma-associated protein, that it is developmentally regulated, and that it is absent or greatly reduced in quantity in skeletal muscle cultures from patients with DMD.

Transposition of the pronator radio teres muscle to the radial extensors of the wrist, in infantile cerebral paralysis. An improved operative technique.

In the majority of cases of infantile cerebral paralysis, the upper limb is found to be in an attitude of pronation of the forearm, flexion and adduction of the wrist, and flexion of the fingers. The modified surgical technique practiced by the writers enables the pronation of the forearm and the flexion of the wrist to be corrected at the same time, by transposing the pronator teres muscle to the radial extensors of the wrist after passing it around the radius through the interosseous membrane, thus giving it a supinating action.