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Healthcare students (HCSs) represent a target category for seasonal flu vaccination. This study aimed to examine adherence to flu vaccination campaigns from 2016 to 2019 among HCSs and to investigate knowledge and perception of and attitude toward influenza and flu vaccination. This cross-sectional study was conducted among the HCSs of a northern Italian university. Data on adherence, knowledge, perception, and attitude were investigated through an anonymous online self-administered questionnaire. The questionnaire was filled out by 352 out of 392 third-year HCSs (response rate = 90%). The main reason for refusal was the perception of influenza as non-threatening (24.4%), while self-protection was the main reason for adherence (87.5%). A univariate logistic regression analysis revealed some statistically significant associations with the adherence to the 2018-2019 campaign: being a nursing/midwifery student (OR: 4.14; 95% CI: 1.77-9.71) and agreeing with (OR: 19.28; 95% CI: 2.47-146.85) or being undecided (OR: 10.81; 95% CI: 1.33-88.27) about the obligation of vaccination in health facilities. The associations were also evaluated with a multiple logistic regression model. Despite the low vaccine uptake, good knowledge of the risks for HCSs and patients related to flu has emerged. Improving promotion strategies will be necessary to increase the adhesion of future healthcare workers.

Objectives: An adequate perioperative analgesia reduces neuroendocrine stress response and postoperative complica-tions. Opioids are the most effective parenteral drugs to control pain and stress response., Design: This is a prospective randomized double-blinded controlled study., Setting: Institutional tertiary level., Patients, Participants: Fifty patients underwent general anesthesia with desflurane for laparoscopic cholecystectomy., Main Outcome Measures: To compare two different doses of remifentanil (0.15 mcg/kg/min or 0.3 mcg/kg/min) in reducing markers of stress. Perioperative stress was assessed through the dosage of adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH), and prolactin (PRL). Three venous blood samples were collected from patients: before transferring the patient to the operating room (Time 0), at the trocar insertion (Time 1), and 1 hour after the end of the surgery (Time 2)., Results: Hemodynamic parameters showed no differences between the two groups. The authors observed an increase of GH and PRL in both groups at trocar insertion (Time 1) ( p = 0.473 and 0.754, respectively). ACTH and cortisol showed a decrease at Time 1 and an increase after surgery (p = 0.586). The modification of stress parameters levels showed no significant differences between the two groups., Conclusions: The results of our study showed that a lower dose of remifentanil is equally effective in controlling stress hormones during laparoscopic cholecystectomy.

Purpose: Postoperative cognitive dysfunction is a frequent complication occurring in geriatric patients. Type of anesthesia and the patient's inflammatory response may contribute to postoperative cognitive dysfunction (POCD). In this prospective randomized double-blinded controlled study we hypothesized that intraoperative remifentanil may reduce immediate and early POCD compared to fentanyl and evaluated if there is a correlation between cognitive status and postoperative inflammatory cytokines level., Methods: Six hundred twenty-two patients older than 60 years undergoing major abdominal surgery were randomly assigned to two groups and treated with different opioids during surgery: continuous infusion of remifentanil or fentanyl boluses. Twenty-five patients per group were randomly selected for the quantitative determination of serum interleukin (IL)-1β, IL-6, and IL-10 to return to the ward and to the seventh postoperative day., Results: Cognitive status and its correlation with cytokines levels were assessed. The groups were comparable regarding to POCD incidence; however, IL-6 levels were lower the seventh day after surgery for remifentanil group (P= .04). No correlation was found between POCD and cytokine levels., Conclusions: The use of remifentanil does not reduce POCD., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

In recent years there has been a wide use of the epidural technique not only during surgery to provide anesthesia and analgesia, but also for obstetric and trauma as well as acute, chronic and cancer pain states. Nowadays there is an increase in the number of the epidural drugs. Local anesthetics and opioids are still the pharmacological agents more widely used epidurally, nevertheless other drugs from different pharmacological classes are administered as adjuvant to local anesthetics and opioids or are in various early stages of investigation. Regarding to local anesthetics, the most recent literature focuses on the new enantiomers, ropivacaine and levobupivacaine, the efficacy of which is similar to that of bupivacaine with a reduced risk of cardiotoxicity. About opioids, the other class of drugs mainly used, the debate, in the last years, concerned the physicochemical properties of morphine and of the more recent lipophilic agents, fentanyl and sufentanil, in order to explain the main differences in efficacy and safety. Other categories of agents have been investigated for epidural administration, such as alpha(2)-adrenergic agonists clonidine and dexmedetomidine. They are being used increasingly as adjuvants to local anesthetics and opioids. Ketamine and neostigmine, the more recent studied drugs for epidural use, are still under investigation and are not part of routine clinical practice.

Post-thoracotomy pain is one of the most severe types of postoperative pain. It can last up to 2 months and can become chronic in 30% of patients. Pain relief after thoracic surgery is of particular significance, not only for ethical considerations but also for reduction of postoperative pulmonary and cardiac complications. Because of the difficulty in pain control, many approaches have been suggested, but a multimodal therapeutic strategy that provides a central or peripheral block associated with nonsteroidal anti-inflammatory (NSAID) and adjuvant drugs is now the cornerstone of treatment, offering the possibility of reducing opioid requirements and side effects. Thoracic epidural analgesia with local anesthetics and opioids is regarded as the gold standard treatment for post-thoracotomy pain management because it results in early extubation, better ventilatory mechanisms and gas exchange, decreased incidence of atelectasis, pneumonia and chronic postoperative pain. When epidural analgesia is contraindicated or cannot be performed, other regional techniques of analgesia can be used. An alternative method of providing adequate pain relief is a thoracic paravertebral block: continuous paravertebral infusion of local anesthetic via a catheter placed percutaneously or under direct vision during thoracotomy. This is effective in controlling postoperative pain and in preserving pulmonary function. Other techniques, such as intercostal and interpleural blocks, are rarely utilized, whereas a single shot of intrathecal injection of a hydrophilic opioid, such as morphine, appears to be effective. Cryoanalgesia, which is successful in the immediate postoperative period, has been abandoned for its brief duration and increased incidence of chronic pain.

Thymoma is the most frequent type of tumor in the anterior-superior mediastinum. The presentation of thymomas is variable; most are asymptomatic and others present themselves with local compression syndrome or parathymic syndrome; rarely thymomas appear as an acute emergency. Surgery is the treatment of choice for thymic tumors and complete resection is the most important prognostic factor. Surgery with adjuvant radiation is recommended for invasive thymoma. The anaesthetic management of patients with mediastinal thymoma undergoing thymectomy is associated with several risks related to potential airway obstruction, hypoxia and cardiovascular collapse. Patients at high risk of perioperative complications can be identified by the presence of cardiopulmonary signs and symptoms. However, asymptomatic thymomas have been occurred with acute cardiorespiratory complications under general anaesthesia. A careful preoperative evaluation of signs, symptoms, chest X-ray, CT scan, MRI, cardiac echogram and venous angiogram should be helpful to investigate neoplasm presence and the area of invasion; moreover, an adequate airway and cardiovascular management, such as performing an awake intubation in the sitting position, allowing spontaneous and non-controlled ventilation, a rigid bronchoscope available and a standby cardiopulmonary bypass, is suggested to prevent the main life-threatening cardiorespiratory complications.

Myasthenia gravis (MG) is the prototype of antibody mediated autoimmune disease and results from the production of autoantibodies against the acetylcholine receptor (AChR) of the neuromuscular synapse. Adequate preoperative evaluation of the myasthenic patient must be carried out carefully. Age, sex, onset and duration of the disease as well as the presence of thymoma may determine the response to thymectomy. Specific attention should be paid to voluntary and respiratory muscle strength. The preoperative preparation of MG patients is essential for the success of surgery. It depends on the severity of clinical status and changes if myasthenic patients receive anticholinesterase therapy. Myasthenic patients may have little respiratory reserve, and hence depressant drugs for preoperative premedication should be used with caution and avoided in patients with bulbar symptoms. The anaesthetic management of myasthenic patient must be individualized in according to the severity of the disease and the type of surgery required. The use of regional or local anaesthesia seems warranted whenever possible. General anaesthesia can be performed safely when patient is optimally prepared and neuromuscular transmission is adequately monitored during and after surgery. Adequate postoperative pain control, pulmonary toilet, and avoidance of drugs that interfere with neuromuscular transmission will facilitate tracheal extubation. Myasthenia gravis is a disease with many implications for the safe administration of anaesthesia. The potential for respiratory compromise in these patients requires the anaesthesiologist to be familiar with the underlying disease state, as well as the interaction of anaesthetic and non-anaesthetic drugs with MG.

It is unclear whether shorter wave latencies of middle-latency-auditory-evoked-potentials may be associated to cognitive function other than nondeclarative memory. We investigated the presence of declarative, nondeclarative and dreaming memory in propofol-anaesthetized patients and any relationship to intraoperatively registered middle-latency-auditory-evoked-potentials. An audiotape containing one of two stories was presented to patients during anaesthesia. Patients were interviewed on dream recall immediately upon emergence from anaesthesia. Declarative and nondeclarative memories for intraoperative listening were assessed 24 h after awakening without pointing out positive findings. Six patients who reported dream recall showed an intraoperative Pa latency less than that of patients who were unable to remember any dreams (P<0.001). A high responsiveness degree of primary cortex was associated to dream recall formation during anaesthesia.

In critically ill patients, adequate sedation increases comfort, minimizes stress response and facilitates diagnostic and therapeutic procedures. Propofol (2-, 6-diisopropylphenol) is an intravenous sedative-hypnotic agent popular for sedation in the Intensive Care Unit. The favorable propofol pharmacokinetic, characterized by a three compartment linear model, allows rapid onset and short duration of action. The emergence time from sedation with propofol varies with the depth and the duration of sedation and the patient's bodyweight. Propofol causes hypotension, particularly in volume depleted patients, decreases cerebral oxygen consumption, reduces intracranial pressure and has potent anti-convulsant properties. It is a potent antioxidant, has anti-inflammatory properties and is a bronchodilator. As a consequence of these properties, propofol is being increasingly used in the management of traumatic head injury, status epilepticus, delirium tremens, status asthmaticus and in septic patients. Prolonged use (>48 h) of high doses of propofol (>66 mcg/Kg/min) has been associated with lactic acidosis, bradycardia, and lipidemia in pediatric patients. A rare complication firstly reported in pediatrics patients and also observed in adults is known as "propofol syndrome" characterized by myocardial failure, metabolic acidosis and rhabdomiolysis. Hyperkalemia and renal failure have also been associated with this syndrome. Hypertriglyceridemia and pancreatitis are uncommon complications. A large number of trials have compared the use of propofol with midazolam. Sedation with propofol is associated with adequate sedation in ICU patients, shorter weaning time and earlier tracheal extubation compared to midazolam, but not before ICU discharge.

Postoperative management after elective esophagectomy for cancer has not been standardized. Thoracoabdominal incision with associated pain, extended operative time with consequent extracellular fluid shifts, single lung ventilation, potential for prolonged postoperative mechanical ventilation and comorbidities in patients with esophageal cancer, all contribute to high perioperative risk. Respiratory problems remain the major cause of both mortality and morbidity after esophagectomy for cancer. A specific pulmonary disorder, acute respiratory distress syndrome (ARDS) occurs in 10-20% of patients after esophagectomy. ARDS mortality exceeds 50%. Atrial fibrillation, that complicates recovery in 20 to 25% of patients after esophagectomy, contributes to make outcome worse. Anesthesiologists should adopt strategies known to be able to optimize patient outcome. Decreased postoperative mortality and morbidity have been associated with epidural analgesia, bronchoscopy to clear persistent bronchial secretions, intraoperative fluid restriction and early extubation. It has been shown that setting up early respiratory physiotherapy and mobilitation may improve functional recovery.

Esophagectomy for carcinoma of the esophagus is associated with significant mortality and morbidity. Patients with esophageal cancer have frequently obstruction with dysphagia and they often develop malnutrition. In addition, patients can suffer from chronic aspiration leading to a poor preoperative respiratory status. Thorough preoperative evaluation is essential for assessing the operative risk in the individual patient. Respiratory and cardiac problems are the most common complications and assessment of surgical risk, preoperative performance status, particularly with regard to pulmonary and cardiac risk, is likely to be the most important factor. Clinical findings are more predictive of pulmonary complications than results of testing. Cardiac risk is evaluated according to the American College of Cardiology (ACC)/American Heart Association guidelines. With the identification of risk factors, patients undergoing esophageal surgery could be stratified. Appropriate preoperative risk-reduction strategies can be used to decrease morbidity and mortality rates associated with esophagectomy for cancer.

Continuous thoracic epidural analgesia with an opiod-local anaesthetic mixture is the most appropriate strategy to control postoperative pain in thoracic surgery. Levobupivacaine, the pure S(-) enantiomer of racemic bupivacaine, has less cardiotoxic and neurotoxic potential but similar anaesthetic properties of its native agent. There are no studies in thoracic surgery that had established the minimal efficient concentration of this anaesthetic when used with an epidural opioid. The advantages of administering opioids in addition to local anaesthetics in the epidural space are the possibility to decrease dose and consequently side-effects of each drug and to exploit the documented synergy between these different categories of drugs in producing segmental epidural analgesia. In our departmental study (unpublished data), 2 different concentration of levobupivacaine (Group A: 0.125% and Group B: 0.0625%) combined with sufentanil (1 mg/mL) were administered in continuous epidural post-thoracotomy infusion to investigate quality of analgesia, motor block and side-effects. An intravenous PCA system has been used in the postoperative period to evaluate rescue morphine consumption. Preliminary results showed that patients of each group reported similar VAS at rest although a better pain control during cough resulted in group A. Patients receiving levobupivacaine at 0.125% presented low incidence of nausea, vomiting and pruritus probably because of the smaller amount of rescue morphine administered. At the concentration of 0.125% epidural levobupivacaine in combination with sufentanil allowed to obtain a good pain control with no adverse effects and motor block at all.

Surgical resection remains the mainstay of treatment in lung cancer patients. Stratification of preoperative risk should be based on the functional status of pulmonary and cardiac systems usually damaged by cigarette smoking. Preoperative pulmonary evaluation should be performed taking into consideration the specific characteristics of the single patient and the type of surgery planned. Spirometry only may be required or oxygen consumption determination is necessary. Cardiac assessment should be based on clinical and instrumental examinations while invasive tests should be limited to high-risk patients. The potential difficulties in endotracheal intubation and lung isolation, the risk for desaturation during one-lung ventilation, and postoperative pain control should be analyzed.

Auditory evoked potentials (AEPs) are an electrical manifestation of the brain response to an auditory stimulus. Mid-latency auditory evoked potentials (MLAEPs) and the coherent frequency of the AEP are the most promising for monitoring depth of anaesthesia. MLAEPs show graded changes with increasing anaesthetic concentration over the clinical concentration range. The latencies of Pa and Nb lengthen and their amplitudes reduce. These changes in features of waveform are similar with both inhaled and intravenous anaesthetics. Changes in latency of Pa and Nb waves are highly correlated to a transition from awake to loss of consciousness. MLAEPs recording may also provide information about cerebral processing of the auditory input, probably because it reflects activity in the temporal lobe/primary cortex, sites involved in sounds elaboration and in a complex mechanism of implicit (non declarative) memory processing. The coherent frequency has found to be disrupted by the anaesthetics as well as to be implicated in attentional mechanism. These results support the concept that the AEPs reflects the balance between the arousal effects of surgical stimulation and the depressant effects of anaesthetics. However, AEPs aren't a perfect measure of anaesthesia depth. They can't predict patients movements during surgery and the signal may be affected by muscle artefacts, diathermy and other electrical operating theatre interferences. In conclusion, once reliability of the AEPs recording became proved and the signal acquisition improved it is likely to became a routine feature of clinical anaesthetic practice.

Clinical, electrocardiographic, radiological, hemodynamic and angiocardiographic data of 12 patients with ventricular septal defect (VSD) associated to aortic regurgitation (AR) have been analyzed. The trend of evolution of the AR has been evaluated and angiographic criteria to make a correct diagnosis have been pointed out. Nine patients have been followed up for a mean of 3.8 years. The severity of AR seemed to increase only in three cases: this demonstrates that AR associated to VSD is not always a progressive disease. The usefulness of various radiological views in evidencing the anatomy of both VSD and aortic valve has been discussed and findings of left ventriculogram and aortogram are detailedly described. The site of VSD and the type of lesion of the aortic valve may be crucial for indicating surgical intervention and its type. Indication for surgery is briefly discussed. Surgical technics are shortly summarized.

16 cases of left ventricular-right atrial communication are reported. The most consistent clinical features, suggestive of this condition, were: auscultatory findings of V.S.D., electrocardiographic patterns of right atrial enlargement and biventricular hypertrophy, considerable right atrial enlargement coexisting with signs of left-sided cardiac enlargement and increased polmonary vascularity to Xray examination, echocardiographic fluttering of the tricuspid valve. Cardiac catheterization revealed an increased oxygen content in the right atrial or ventricular blood without the passage of the catheter through an A.S.D. The definitive diagnosis was established by left ventricular angiocardiography which demonstrated immediate opacification of a dilated right atrium through a septal defect; the location of the septal defect in the cardiac septum was attempted. In patients who suffered from a large left to right shunt were recommended for surgical treatment also in view of the relatively bad tolerance of this defect and low operative risk. There were two deaths: one baby died of early congestive failure. 9 cases were operated upon with one immediate postoperative death. The remaining, controlled by clinic follow-up, had good results.

Coronary spasm during selective coronary angiography have multiple explanation. In some instances there is no true pathological implication (catether induced spasm), in other instances, instead, a clear relationship with "functional" angina and myocardial infarction exists. Moreover, in few occasions may only be a false positive radiologic image (apparent spasm). The angiographic features of coronary spasm, however, are always the same, indipendently from its clinical significance and pathophysiologic mechanism. In this paper the Authors are not limiting their experience to the morphologic description of this event, rather describe the clinical criteria which, together with angiographic picture, may be useful in the interpretation of the physiopathology of the coronary artery spasm.

Ten cases of total abnormal pulmonary venous connection are described: 5 cases with supracardiac drainage, 4 with sub-diaphragmatic drainage and one with intracardiac drainage, 3 cases with supradiaphragmatic drainage, and 4 with subdiaphragmatic drainage have undergone surgical treatment. Some developmental, embryological and pathophysiological signs of this malformation are reported. The more significant clinical and instrumental data arising from our personal cases and from review data are discussed. In the clinical description a distinction is made between cases with venous obstruction and those without venous obstruction. The importance of hemodinamic tests, which allow us to identify the type of connection present, and whether or not there are associated malformations, are underlined. The natural history is conditioned by the presence of venous obstruction, by the value of the pulmonary hyper-flow and by the possibility of communication between the two circulatory districts. The prognosis of the cases with marked obstruction, and of those with irreversible cardiac failure is one of rapid deterioration: surgical correction in the first months of life is the only therapeutic possibility, even if the death risk is high. The cases without venous obstruction, and with fairly normal weight and circulation, are corrected surgically at a later age with much more favourable results.

60 patients with clinical signs of coronary artery disease who had a hemodynamic examination were studied. The study of the regional dynamics using the deformation as a vectorial time-dependent parameter and the pressure-length loops, was carried out on a total of 420 parietal regions of the left ventricle: the basal ventriculography, the post-extrasystolic potentiation and the ventriculography after nitroglycerin were evaluated. The dynamic regional pattern was correlated with clinical-enzimatic signs of necrosis in the electrocardiogram. The possibility of correlating signs of necrosis with particular patterns of hypokinesia, akinesia, dyskinesia which differ from corresponding "static" forms of asynergy in active pressure development and deformation (even in a brief systolic interval) seems to confirm the physiopathologic interpretation of the regional phenomenon based on the ratio between viable not viable myocardium -- as primary cause.

One thousand coronary arteriography performed in the catheterization laboratory of the Department of Cardiology (University of Padua) from 1973 to 1978 were reviewed. Indication to perform a coronary arteriography was established in 668 patients with clinically suspected coronary artery disease and in 332 patients affected by different heart disease in whom the study of coronary arteries was judged to be usefull. The percutaneous technique was usually employed. The overall mortality rate was 0.2%; there were no death in the last three years. The overall morbility was 3.5% (2.3 from 1976 to 1978). The anterior descending artery appeared to be the most frequently and precociously affected area. There was a good correlation between severity of the atherosclerotic lesions and age or sex of the patients. We could recognize coronary disease, when present, on the basis of clinical evaluation in patients without different heart disease.

The angiographic findings of 10 cases with azygos (AC) or hemiazygos (HC) continuation of the inferior vena cava (IVC), associated with other congenital heart disease (0.5%), are described. Abdominal situs solitus was present in 7 cases, left isomerism in 3. In 5 cases IVC was to the left to the spine, bilateral in one. In 6 cases there was AC, HC in 2; in one both types of continuation were documented. It is important that this venous anomaly be diagnosed before cardiac catheterization; manipulation of the probe may be very difficult when saphenous approach is used. The correct use of the terms "Azygos", "Hemiazygos" and "Accessory Hemiazygos" are discussed.

Three cases of traumatic tricuspid insufficiency are reported. The most consistent clinical and noninvasive cardiovascular findings were: previous nonpenetrating thorax trauma; non holosystolic murmur which increased slightly during inspiration on standing; electrocardiographic patterns of right atrial enlargement and right bundle branch block; unusual bulge along the mid-left heart border, seen on chest x-ray examination suggesting ventricular aneurysm; striking right ventricular dilatation wit paradoxical movement of the ventricular septum on ECHO. Cardiac catheterization led to definitive diagnosis by demonstrating a massive tricuspid valve incompetence with "ventricularisation" of the right atrial pressure. Some dyskinetic areas of the right ventrice, most likely due to the full-thickness contusion of the miocardial wall, seen on the right cineangiography, confirmed the diagnosis. The long-term clinical and haemodynamic follow-up was useful for monitoring the evolution of the disease. Surgery should be recommended in the presence of right-sided heart failure not relieved by adequate medical treatment, in view of the low operative risk.