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Background Enhanced recovery after surgery ( ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery. Methods An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire. Results There were no differences in patient or disease characteristics between pre- ERAS (42 patients) and post- ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P < 0·001). Duration of hospital stay was shorter in the post- ERAS group (median 5 (i.q.r. 4-7) days versus 6 (5-7) days in the pre- ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (− US $333; −€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (− US $394; −€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation. Conclusion The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers. [ABSTRACT FROM AUTHOR]

The importance of the dynamic response of guyed towers for transmission lines (TLs) under wind loading is evaluated in this article. The objective is to verify if the simplified static-equivalent approach provided in the current TL codes is sufficient for this type of flexible tower. As a comparison, transient dynamic (TD) analyses were performed. Two different guyed tower configurations were investigated: (i) the direct current (DC) line and (ii) the alternating current (AC) line. Loading cases considering bare and iced TL structures were studied. It was found that, depending on the guyed tower configuration and the loading case, the static-equivalent approach may underestimate the possible dynamic response. In addition, a simplified method that allows a better prediction of the dynamic effects is proposed. [ABSTRACT FROM AUTHOR]

Background: Allergic rhinitis is an inflammatory disease often associated with bronchial asthma. Intranasal corticosteroids and oral antihistamines are the first-choice drugs. Patient training is relevant to asthma management, but little is known about its impact on rhinitis. We evaluated the role of patient training in the treatment of allergic rhinitis and its effects on nasal and bronchial symptoms. Methods: One hundred and one patients (M/F=62/39, age range 12–62 years) with pollen-induced rhinitis (32 with concomitant mild asthma) were enrolled. They were randomized into three groups: A (n=30) with drug therapy alone, B (n=35) with drug therapy plus training on the use of nasal spray, and C (n=36) the same as B plus a lesson on rhinitis and asthma. All patients received mometasone furoate nasal spray for 8 weeks as regular therapy, plus rescue medications on demand. Symptoms and drug consumption were evaluated during the pollen season. Results: The rate of noncompliance/dropout was highest in the untrained patients (P=0.001). No difference in nasal symptoms was seen among the three groups. On the other hand, group C had significantly fewer asthma symptoms (P=0.02) and less albuterol use (P=0.005) than group A. Moreover, the trained group globally used less rescue medication than the other groups (P=0.02). Conclusions: Detailed training of patients seems to improve compliance with treatment, reduce concomitant asthma symptoms, and reduce the use of symptomatic drugs. [ABSTRACT FROM AUTHOR]

Background Predictive tools assessing risk of transfusion have not been evaluated extensively among patients undergoing complex gastrointestinal surgery. In this study preoperative variables associated with blood transfusion were incorporated into a nomogram to predict transfusion following hepatopancreaticobiliary ( HPB) or colorectal surgery. Methods A nomogram to predict receipt of perioperative transfusion was developed using a cohort of patients who underwent HPB or colorectal surgery between January 2009 and December 2014. The discriminatory ability of the nomogram was tested using the area under the receiver operating characteristic ( ROC) curve and internal validation performed via bootstrap resampling. Results Among 4961 patients undergoing either a HPB (56·3 per cent) or colorectal (43·7 per cent) resection, a total of 1549 received at least 1 unit of packed red blood cells, giving a perioperative transfusion rate of 31·2 per cent. On multivariable analysis, age 65 years and over (odds ratio ( OR) 1·52), race ( versus white: black, OR 1·58; Asian, OR 1·86), preoperative haemoglobin 8·0 g/dl or less ( versus over 12·0 g/dl: OR 26·79), preoperative international normalized ratio more than 1·2 ( OR 2·44), Charlson co-morbidity index score over 3 ( OR 1·86) and procedure type ( versus colonic surgery: major hepatectomy, OR 1·71; other pancreatectomy, OR 2·12; rectal surgery, OR 1·39; duodenopancreatectomy, OR 2·65) were associated with a significantly higher risk of transfusion and were included in the nomogram. A nomogram was constructed to predict transfusion using these seven variables. Discrimination and calibration of the nomogram revealed good predictive abilities (area under ROC curve 0·756). Conclusion The nomogram predicted blood transfusion in major HPB and colorectal surgery. [ABSTRACT FROM AUTHOR]

Summary: Nasal cytology is an easy, cheap, non‐invasive and point‐of‐care method to assess nasal inflammation and disease‐specific cellular features. By means of nasal cytology, it is possible to distinguish between different inflammatory patterns that are typically associated with specific diseases (ie, allergic and non‐allergic rhinitis). Its use is particularly relevant when other clinical information, such as signs, symptoms, time‐course and allergic sensitizations, is not enough to recognize which of the different rhinitis phenotypes is involved; for example, it is only by means of nasal cytology that it is possible to distinguish, among the non‐allergic rhinitis, those characterized by eosinophilic (NARES), mast cellular (NARMA), mixed eosinophilic‐mast cellular (NARESMA) or neutrophilic (NARNE) inflammation. Despite its clinical usefulness, cheapness, non‐invasiveness and easiness, nasal cytology is still underused and this is at least partially due to the fact that, as far as now, there is not a consensus or an official recommendation on its methodological issues. We here review the scientific literature about nasal cytology, giving recommendations on how to perform and interpret nasal cytology. [ABSTRACT FROM AUTHOR]

Background: Use of the immune checkpoint inhibitor ipilimumab is sometimes complicated by ipilimumab-associated colitis (Ipi-AC), an immune-mediated colitis that mimics inflammatory bowel disease.Objective: We sought to characterize the histopathologic and immunophenotypic features of Ipi-AC and to directly compare these features to ulcerative colitis (UC).Methods: This is a retrospective cohort study of 22 patients with Ipi-AC, 12 patients with treatment-naïve UC and five controls with diarrhoea but normal endoscopic findings. Immunohistopathologic features were described, and quantitative immunohistochemistry (IHC) was performed for CD4, CD8, CD20, CD138 and FOXP3.Results: Endoscopic findings in both the Ipi-AC and UC groups included ulcerated, oedematous and erythematous mucosa. Involvement of the GI tract was more diffuse in Ipi-AC. As compared to UC, a smaller proportion of Ipi-AC biopsies had basal plasmacytosis (14% for Ipi-AC vs. 92% for UC, P < 0.0001) and crypt distortion (23% for Ipi-AC vs. 75% for UC, P = 0.003), whereas Ipi-AC biopsies had more apoptotic bodies in the left colon (17.6 ± 15.3 for Ipi-AC vs. 8.2 ± 4.2 for UC, P = 0.011). Cryptitis, ulcerations and crypt abscesses were common in both groups. Biopsy specimens from Ipi-AC had a lower density of CD20-positive lymphocytes than UC (275.8 ± 253.3 cells mm-2 for Ipi-AC vs. 1173.3 ± 1158.2 cells mm-2 for UC, P = 0.022) but had a similar density of CD4, CD8, CD138 and FOXP3-positive cells.Conclusions: Ipi-AC is a distinct pathologic entity with notable clinical and histopathological differences compared to UC. These findings provide insights into the pathophysiology of immune-related adverse events (iAEs) from ipilimumab therapy. [ABSTRACT FROM AUTHOR]

Background Although frailty is a known determinant of poor postoperative outcomes, it can be difficult to identify in patients before surgery. The authors sought to develop a preoperative frailty risk model to predict mortality among patients aged 65 years or more. Methods Clinical and morphometric data including total psoas area ( TPA), total psoas volume ( TPV) and psoas density (Hounsfield unit average calculation, HUAC) were collected for patients undergoing hepatopancreaticobiliary ( HPB) surgery between 2012 and 2014. Multivariable Cox proportional hazards regression was used to identify preoperative risk factors associated with 1-year mortality. Results The median age of the 518 patients included in the study was 72 (i.q.r. 68-76) years; 55·6 per cent of patients were men, and half of the cohort had multiple co-morbidities (Charlson co-morbidity index ( CCI) of 4 or more, 55·6 per cent). TPA cut-offs to define sarcopenia were 552·7 mm2/m2 in women and 702·9 mm2/m2 in men; cut-offs for TPV were 18·2 cm3/m2 in women and 26·2 cm3/m2 in men, whereas HUAC cut-offs were 31·1 HU in women and 33·3 HU in men. The overall 1-year mortality rate was 14·1 per cent. In multivariable analysis, risk factors associated with 1-year mortality included CCI of 4 or above (hazard ratio ( HR) 2·91, 95 per cent c.i. 1·47 to 5·77; P = 0·002), malignant disease ( HR 3·94, 1·17 to 13·30; P = 0·027) and sarcopenia by HUAC ( HR 1·85, 1·10 to 3·10; P = 0·021). A weighted 25-point composite score was developed to stratify patients at risk of 1-year postoperative mortality. The 1-year mortality rate was noted to be 2·5 per cent among patients scoring 0-10 (low risk), 17·3 per cent among patients scoring 11-20 (intermediate risk) and 29·2 per cent among those scoring between 21 and 25 (high risk) ( P < 0·001). Conclusion Clinical and morphometric measures of frailty accurately predict the risk of 1-year mortality following HPB surgery in elderly patients, and can be used to risk-stratify patients appropriately. [ABSTRACT FROM AUTHOR]

Background The present study aimed to develop a short validated patient-completed questionnaire, the Rhin Asthma Patient Perspective ( RAPP), to assess the health-related quality of life ( HRQo L) in patients with asthma and comorbid allergic rhinitis in clinical practice. Methods A provisional RAPP questionnaire was formed from candidate items identified through retrospective analysis of 333 RHINASTHMA questionnaires. This was then tested on 150 asthma patients with allergic rhinitis. Results Psychometric analyses identified eight items fitting a unidimensional model to form RAPP. Internal consistency ( Cronbach's alpha coefficient > 0.8) and agreement with RHINASTHMA ( r = −0.31, P = 0.0001) were excellent. Criterion, discriminant, and convergent validity were good. Reliability in 47 stable patients was very good (intra-class and concordance correlation coefficients were 0.90 and 0.89, respectively). Responsiveness in 103 patients with health improvement or deterioration was significantly associated with changes in Global Rating Scale ( r = −0.4965, P < 0.01), Rhinitis Visual Analogue Scale ( r = 0.5722, P < 0.01) and asthma control test ( r = −0.6483, P < 0.01). Minimal clinical difference in the analyzed population was 2. Conclusion Rhin Asthma Patient Perspective is a simple eight-question questionnaire with good measurement properties and sensitivity to health changes, which will provide a valid, reliable and standardized HRQo L measurement in patients with asthma and comorbid allergic rhinitis in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Horses play a significant role in people's leisure time in Italy and other countries, but few data are available on IgE-mediated sensitization to horse allergens in patients without occupational exposure. We assessed, in a multicentric survey, the prevalence of horse sensitization in atopic subjects and its clinical characteristics. Methods: Allergists from the whole Italian territory were required to collect the results of skin prick tests from at least 100 consecutive subjects. Those patients with a positive skin test to horse dander underwent a detailed interview concerning clinical history, pet ownership and possible exposure. Results: Data from 3,235 outpatients were collected and 2,097 had at least 1 skin positivity. Among them, 113 (5.38%) were sensitized to horse dander (9 monosensitized). Thirty patients reported direct horse contact (4 owners and 26 for riding or occasional contact), 23 patients were sometimes in contact with horse owners and 60 subjects denied any direct or indirect exposure. Among 9 horse monosensitized patients, 6 had intermittent and mild rhinitis and 3 persistent moderate/severe rhinitis plus asthma. Three of them were horse owners or riders and the remaining had no contact with the animal. Conclusions: Our data evidence that the rate of sensitization to horse dander is not negligible and probably underestimated. In susceptible, not occupationally exposed individuals, horse contact, but also indirect or no apparent exposure, may induce sensitization. We recommend inclusion of horse allergen in the routine panel for the diagnosis of respiratory allergy. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Reports the use of alternative medicine in treating allergic respiratory diseases. Effect of alternative medicine on disease management; Application of chi-square test in the distribution analysis; Preference of using alternative medicine among the women population.

Background: A growing use of complementary alternative medicine (CAM) has been found in Europe as well in Italy for chronic diseases, including the allergic rhinitis. The study aims at investigating the prevalence and the pattern of use of CAM amongst patient with allergic rhinitis. Methods: A 12-item questionnaire was developed by a panel of experts and administered to patients with moderate/severe allergic rhinitis consecutively referring during the study time-frame to seven allergy clinics placed all around Italy. The items covered several topics including reason for choosing CAM, its clinical efficacy, schedule of treatment, costs, type of therapy. Results: Overall 359 questionnaires were analysed. 20% of patients declared CAM use. A significant correlation between the use of CAM and female sex (p < 0.01) and with a higher level of education (p < 0.01) was observed. CAM users were adults (36% in the range between 20 and 40 years and 32% between 41 and 60 years). Youngsters (< 20 years) (7%) and elderly (> 60) (25%) less frequently used CAM.The most used type of CAM was homoeopathy (77% of patients). 60% of users would recommend CAM despite a poor clinical efficacy according to 67% of them. Conclusions: Although no evidence supports CAM efficacy and safety, the number of patients who relies on it is not negligible. As allergic rhinitis is not a trivial disease, the use of CAM as the only treatment for it should be discouraged at any level, but by general practitioner and specialist in particular. [ABSTRACT FROM AUTHOR]

Background: The query “are there animals at home?” is usually administered for collecting information on anamnesis. This modality to consider exposure to pet allergens constitutes a potential bias in epidemiological studies and in clinical practice. The aim of our study was to evaluate/quantify different modalities of exposure to cat/dog in inducing allergic sensitization. Methods: Thirty Italian Allergy units participated in this study. Each centre was required to collect the data of at least 20 consecutive outpatients sensitized to cat/dog allergens. A standardized form reported all demographic data and a particular attention was paid in relieving possible modalities of exposure to cat/dog. Results: A total 723 patients sensitized to cat/dog were recorded, 359 (49.65%) reported direct pet contact, 213 patients (29.46%) were pet owners, and 146 subjects (20.19%) were exposed to pets in other settings. Other patients were sensitized by previous pet ownership (150–20.75%) or indirect contact (103–14.25%), in 111 subjects (15.35%) any contact was reported. Conclusions: Only 213 patients (29.46%) would be classified as “exposed to animals” and 510 (70.54%) as “not exposed” according to usual query. Our classification has shown that many “not-exposed” subjects (399–55.19%) were “really exposed”. The magnitude of exposure to pet allergens at home is not related exclusively to pet ownership. These considerations should be taken into account during the planning of epidemiological studies and in clinical practice for the management of pet allergic individuals. [ABSTRACT FROM AUTHOR]