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Summary. Background and aim of the work: Patients undergoing elective primary total hip replacement and spinal anesthesia may encounter significant hemodynamic instability. Objective: The study is aimed at observing the haemodynamic modifications after spinal anaesthesia during total hip replacement in patients managed to “preload independence” with goal directed fluid therapy (GDFT) and monitored non-invasively with Clearsight. Methods: Thirty patients, aged 50-80 years, with an American Society of Anaesthesiologists’ (ASA) score II-III, undergoing elective primary total hip replacement and spinal anaesthesia were enrolled. Patients were monitored with the EV1000 platform and the Clearsight finger-cuff and managed with a goal directed fluid therapy. Results: The 79% of the population showed preload independence at baseline. After spinal, the 93% did not show a significant mean arterial pressure reduction. In our population, 79% reported a decrease >10% of the stroke volume during surgery, while 66% in the Recovery Room. Patients showed an improvement in mean arterial pressure, systemic vascular resistances indexed (SVRI), stroke volume (SV) and stroke volume indexed (SVI) at spinal resolution compared to baseline. Conclusions: Our cohort population showed hemodynamic stability throughout the study period, with increased SV and decreased SVRI at spinal resolution compared to basal values. Further randomized prospective studies are advocated in the same setting. (www.actabiomedica.it).

The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis.This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery.A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours.The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery.Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.Questo studio si pone come obiettivo l’identificazione della variabilità nell’approccio alla colecistite acuta ed alla colelitiasi e di identificare eventuali trend nell’outcome di questi malati.Lo studio è un ampio studio di coorte retrospettivo, basato su dati estratti dai database amministrativi della Regione Emilia Romagna raccolti tra il 2002 ed il 2012 e con un periodo di follow-up fino a 11 anni, che compara l’efficacia e l’efficienza dell’attività chirurgica confrontando la colecistectomia laparoscopica (LC) con l’approccio open (OC). Sono stati analizzati: parametri demografici e caratteristiche dei pazienti, durata della degenza, modalità di ricovero e mortalità. Sono stati considerati come indicatori di outcome la mortalità (ospedaliera e successiva al ricovero in analisi), le riammissioni con colecistite acuta o colelitiasi come diagnosi principale ed il tempo intercorso prima del trattamento chirurgico.Nel periodo 2002-2012 sono state eseguite 84.628 colecistectomie su 123.061 ricoveri con diagnosi principale di colecistite acuta o colelitiasi. L’approccio laparoscopico è stato utilizzato in 69.842 pazienti. La mortalità ad un anno per i pazienti sottoposti a OC ha mostrato un differenza statisticamente significativa se comparata con quella di pazienti sottoposti a LC. Solamente una minoranza dei pazienti è stata operata entro 72 ore dall’insorgenza dei sintomi, al contrario di quanto raccomandano le linee guida.L’analisi di dati amministrativi è un potente strumento di supporto per la gestione della sanità a livello regionale, consentendo di migliorare la qualità delle cure e di valutare l’appropriatezza dell’approccio diagnostico-terapeutico ai pazienti. È fondamentale rilevare la minor durata della degenza per i malati trattati con tecnica laparoscopica (50% in meno rispetto ai malati trattati con approccio open): questa riduzione dei tempi di degenza porta ad un significativo vantaggio economico. Inoltre, la mortalità è significativamente maggiore per la chirurgia open per la colecistite acuta; è interessante sottolineare come questo dato sia confermato anche a 30 giorni ed 1 anno di followup, essendo probabilmente dovuto ad un maggior numero di comorbidità presente nei pazienti sottoposti a chirurgia open.

The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure.In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV.Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P0.001. According to logistic regression model, a SAPS II29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI.The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.