Search

Abstract Background Extracranial traumatic cerebrovascular injury (TCVI) is present in 1-3% of all blunt force trauma patients. Although options for the management of patients with these lesions include anticoagulation, antiplatelet agents, and endovascular treatment, the optimal management strategy for patients with these lesions is not yet established. Objective Multidisciplinary survey of clinicians about current management of TCVI. Methods A six-item multiple-choice survey was sent by electronic mail to a total of 11,784 neurosurgeons, trauma surgeons, stroke neurologists, and interventional radiologists. The survey included questions about their choice of imaging, medical management, and the use of endovascular techniques. Survey responses were analyzed according to stated specialty. Results Seven hundred eighty-five (6.7%) responses were received. Overall, a total of 325 (42.8%) respondents favored anticoagulation (heparin and/or warfarin), 247 (32.5%) favored antiplatelet drugs, 130 (17.1%) preferred both anticoagulation and antiplatelet drugs, and 57 (7.5%) preferred stenting and/or embolization. Anticoagulation was the most commonly preferred treatment among vascular surgeons (56.9%), neurologists (50.2%) and neurosurgeons (40.7%), whereas antiplatelet agents were the most common preferred treatment among trauma surgeons (41.5%). Overall, 158 (20.7%) of respondents recommended treatment of asymptomatic dissections and traumatic aneurysms, 211 (27.7%) did not recommend it, and 39.4% recommended endovascular treatment only if there is worsening of the lesion on follow-up imaging. Conclusions These data demonstrate the wide variability of physicians' management of traumatic cerebrovascular injury, both on an individual basis, and between specialties. These findings underscore the need for multicenter, randomized trials in this field.

La tutela representa en las sociedades tradicionales una actividad de destacado relieve debido a las implicaciones personales y patrimoniales que, para el menor y la familia, se derivan de su ejercicio. A la luz de tal consideración ha de entenderse la importancia de la persona designada para esta responsabilidad y la creciente preocupación de los progenitores por disponer acerca de esta materia. Las conclusiones obtenidas del análisis de las fuentes empleadas en este trabajo -testamentos y escrituras de discernimiento de tutelas- permiten confirmar ambos extremos al tiempo que descubren otras significativas evoluciones. Así, la progresiva inquietud de los testadores por nombrar a los tutores de sus menores y la mayoritaria elección efectuada sobre los miembros del núcleo conyugal, evidencian tanto la aparición de una nueva sensibilidad hacia las circunstancias de los menores huérfanos y la necesidad de dotarlos de instrumentos de protección más fiables, como las transformaciones operadas en el seno de la familia, a la que se reconoce como medio óptimo para el desarrollo emocional y educativo de los menores. De tal modo, los viejos intereses de preservación del capital familiar y de cuidado personal de los pupilos se suman a las inquietudes surgidas a fines del Antiguo Régimen para propiciar, en último término, un clima de mayor bienestar y atención afectiva a los menores por medio de la persona señalada para atender a ambas funciones.

Introduction: Venous catheters inserted in superficial femoral vein and with mid-thigh exit site have emerged as a feasible and safe technique for central or peripheral tip's venous access, especially in agitated, delirious patients. The spread of multidrug-resistant bacterial (MDR) strains is an emerging clinical problem and more and more patients are being colonized by these types of bacteria. The aim of this study is to evaluate the incidence of central line associated bloodstream infections (CLABSI) or catheter related bloodstream infections (CRBSI) in mid-thigh catheters in patients with positive rectal swabs to evaluate the safety of this procedure and the real infection risk., Methods: In this retrospective observational study, we analyzed data on patients with mid-tight catheters inserted from May 2021 to November 2022. All surveillance rectal swabs were recorded. In addition, to collect data on CLABSI and CRBSI, the results of all blood and catheter tip cultures performed during the hospital stay were acquired., Results: Six hundred two patients were enrolled, 304 patients (50.5%) had a rectal swab; 128 (42.1%) swabs were positive for MDR. Nine CLABSI (only two in patients with a positive rectal swab) and three CRBSI were detected. No statistical difference in the absolute number of CLABSI and CRBSI and in the number of infections per 1000 catheter days emerged between the overall population and patients with positive rectal swabs (respectively p  = 0.45 and p  = 0.53). Similarly, no statistical difference in the number of CLABSI and CRBSI was found among patients with a negative swab and patients with a positive one (respectively p  = 0.43 and p  = 0.51)., Conclusions: According to our data, cannulation of the superficial femoral vein represents a safe location in patients with positive rectal swabs., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Cardiovascular pathologies represent the first cause of death in uremic patients and are among the leading causes of mortality in patients with hereditary angioedema due to C1-inhibitor deficiency (HAE-C1INH). Before 2020, the most common treatment for long-term prophylaxis in HAE-C1INH patients in Italy was attenuated androgen, which may increase cardiovascular risk by multiple mechanisms., Case Description: We present a case report of a 56-year-old patient with HAE-C1INH type I affected by IgA nephropathy with severe kidney impairment. The patient experienced a first kidney transplant and, after late rejection, underwent a second kidney transplant. Further comorbidities included obesity, hypertensive cardiomyopathy, HCV liver disease, and dyslipidemia. His prophylactic therapy to prevent angioedema attacks had consisted of attenuated androgens for about 40 years. Since 2020, new modern targeted therapy for LTP, particularly lanadelumab, has shown promising results. The majority of patients with attenuated androgens have been successfully switched to lanadelumab, including our patient. Since introducing lanadelumab (300 mg subcutaneously every two weeks; after a six-month attack-free period, the dosing interval of lanadelumab was extended to four weeks), the patient has not experienced any acute HAE attack and did not report any adverse events. Moreover, we observed decreased total cholesterol, C-LDL, and body mass index, reducing the Matsushita et al. score for ten years of cardiovascular risk from 13.2% to 9.3%., Conclusion: lanadelumab is effective and safe in preventing hereditary angioedema attacks, as well as in reducing cardiovascular risk in an immunosuppressed patient with significant comorbidities. The successful outcomes of this case highlight the potential of lanadelumab as a promising prophylactic therapy., Competing Interests: AG received speaker/consultancy fees from CSL Behring and Takeda. MC received travel grants from CSL Behring, Menarini, Novartis, and Shire-Takeda, and consultancy fees from Biocryst, CSL Behring, and Shire-Takeda. AZ received speaker/consultancy fees from and/or was a member of advisory boards for BioCryst, CSL Behring, KalVista, Pharming, Pharvaris, and Takeda. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Gidaro, La Cava, Donadoni, Popescu Janu, Cogliati, Brucato, Zanichelli, Cancian and Bizzi.)

Background: Midazolam (MZ) is commonly used in critically ill neurosurgical patients. Neuro-penetration of MZ and its metabolite, 1-hydroxy-midazolam (1-OH-MZ), is not well characterized., Objective: This study evaluated correlations between serum and cerebrospinal fluid (CSF) concentrations of MZ and 1-OH-MZ and assessed implications on patient sedation., Methods: Adults in the neurosurgical intensive care unit (ICU) with external ventricular drains receiving MZ via continuous infusion were prospectively studied. Serum and CSF samples were obtained 12-24 h and 72-96 h after initiation, and concentrations were determined in duplicate by high-performance liquid chromatography with tandem mass spectrometry. Bivariate correlation analyses used Pearson coefficient., Results: A total of 31 serum and CSF samples were obtained from 18 subjects. At sampling, mean MZ infusion rate was 3.9 ± 4.4 mg/h, and previous 12-h cumulative dose was 51.4 ± 78.2 mg. Mean concentrations of MZ and 1-OH-MZ in serum and CSF were similar between timepoints. Similarly, ratios of 1-OH-MZ to MZ in serum and CSF remained stable over time. Serum MZ (126.2 ± 89.3 ng/mL) showed moderate correlation (r 2 = 0.68, P < 0.001) with serum 1-OH-MZ (17.7 ± 17.6 ng/mL) but not CSF MZ (3.9 ± 2.5 ng/mL; r 2 = 0.24, P = 0.005) or CSF 1-OH-MZ (2.5 ± 0.6 ng/mL; r 2 = 0.47, P = 0.30). CSF MZ did not correlate with CSF 1-OH-MZ (r 2 = 0.003, P < 0.001). Mean serum ratio of 1-OH-MZ to MZ (0.14 ± 0.2 ng/mL) did not correlate with CSF ratio (1.06 ± 0.83 ng/mL; r 2 = 0.06, P = 0.19). Concentrations and ratios were unrelated to MZ infusion rate or 12-h cumulative dose. Sedation was weakly correlated with CSF 1-OH-MZ, but not with serum MZ, serum 1-OH-MZ, or CSF MZ., Conclusion and Relevance: Continuous infusions of MZ result in measurable concentrations of MZ and 1-OH-MZ in CSF; however, CSF concentrations of MZ and 1-OH-MZ poorly represent serum concentrations or dosages. Accumulation of MZ and 1-OH-MZ in serum or CSF over time was not evident. Concentrations of MZ and 1-OH-MZ do not predict sedation levels, reinforcing that pharmacodynamic assessments are warranted., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Short peripheral catheters (SPCs) are affected by a high complication rate that leads to catheter failure. Currently, the Visual Infusion Phlebitis score (VIP) is the most used tool to verify the presence of inflammatory complications (phlebitis and thrombophlebitis). However, ultrasound signs (US) may be an attractive alternative., Objective: This study aims to evaluate the sensitivity and specificity of US and VIP score = 1 in identifying and recognizing early signs of SPC failure. The time to positivity for US and VIP scores was assessed as a secondary outcome., Methods: An observational prospective study was conducted. In each patient, US (subcutaneous edema; fibroblastic sleeve; thrombophlebitis) and VIP of the exit site were performed every 24 h until 96 h after insertion. Compared to catheter failure, Sensitivity, Specificity, and Predictive values in both US and VIP were calculated., Results: Two hundred patients were enrolled. The presence of ultrasonic pattern suggestive of edema at 72 h ( p  = 0.018), fibroblastic sleeve at 24, 48, 72, and 96 h ( p <  0.001), thrombosis at 48 ( p <  0.001) and 72 h ( p  = 0.005), and at least one of an abovementioned US at all checkpoints ( p <  0.001) were highly significant predictors of complications. Both US and VIP effectively detect inflammatory events; however, the US showed better sensitivity in overall checkpoints and earlier predictive ability than VIP (1.9 vs 0.47 days)., Conclusions: An ultrasound inflammatory pattern is correlated with SPC failure. An ultrasound protocol-requiring minimal training-is more effective than VIP in recognizing early signs of device failure., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Long peripheral catheters (LPCs) role in Difficult IntraVenous Access (DIVA) patients admitted to the emergency department has already been studied, resulting in a rapid, safe, and cost-effective procedure. Although their use in outpatient settings is established, there is a lack of studies assessing their benefits. In particular, rheumatologic outpatients affected by scleroderma, especially those affected by digital ulcers, are often treated with intravenous infusions of prostaglandin I 2 (PGI 2 ) analog (IV-PGI 2 A)., Objective and Methods: From 1 October 2021 to 31 March 2024, we conducted a prospective study enrolling DIVA outpatients affected by systemic sclerosis or undifferentiated connective tissue disease who needed IV-PGI 2 A therapy at L. Sacco Hospital in Milan (Italy). Each treatment cycle consisted of four consecutive days of infusion of iloprost or alprostadil. The primary aim was to assess the efficacy and potential complications associated with LPCs for IV-PGI 2 A., Results: Twenty-six patients were enrolled 23 were females (88.5%), and the median age was 72 years (IQR 56-78.7). In total, 97 LPCs were inserted, with a mean number of insertions per patient/year of 2.3. An increase in LPCs insertion during the 30 months of the enrollment period was observed. Eighteen patients required more than one LPC placement, and in 61% of them, the second venipuncture was executed at a different site. No procedural complications were registered (accidental puncture of the brachial artery, accidental median nerve puncture, bleeding) nor late complications (Catheter-Related Thrombosis, Catheter-Related Bloodstream Infections, Accidental Removal)., Conclusions: Our experience shows that LPCs could be valuable and safe for rheumatologic outpatients. The increased number of insertions and new and total patients enrolled each year defines the satisfaction of patients and health care professionals., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Myeloproliferative neoplasms (MPNs) are often associated with splanchnic vein thrombosis (SVT). Not all the factors involved in the thrombotic tendency are currently known., Objectives: This study aims to evaluate a possible association between ADAMTS13, von Willebrand factor (VWF), platelet microvesicles (MV), and factor VIII activity (FVIII:C) with thrombotic events in MPN patients., Materials and Methods: In total, 36 consecutive MPN patients with SVT were enrolled. The MPNs were diagnosed based on clinical characteristics and one or more gene mutations among JAK-2, CALR, and MPL. As controls, 50 randomly selected patients with MPN without thrombosis, 50 patients with deep vein thrombosis without MPNs, and 50 healthy blood donors were evaluated. Complete blood count, ADAMTS13, VWF, MV, and FVIII:C in plasma were measured in all the subjects., Results: The JAK-2 mutation was found in 94% of the patients with SVT, but none were triple-negative for genetic mutations (JAK2 V617F, CALR, MPL, and exon 12). Compared to the normal subjects, in all the MPN patients (with or without SVT), the levels of ADAMTS13 were found to be significantly lower ( p < 0.001) and the MV concentrations were significantly higher ( p < 0.001). Among the MPN patients, the VWF and FVIII:C levels were significantly higher in the patients with SVT than those without thrombosis ( p = 0.007 and p = 0.04, respectively). Splenomegaly was present in 78% of MPN patients with SVT and in 30% of those without SVT ( p < 0.001). The ADAMTS13/VWF ratio was reduced in all the patients, but not in the healthy blood donors ( p < 0.001)., Conclusions: The significant increase in circulating MV, VWF, and FVIII:C in the MPN patients and in the patients with thrombosis supports the role of endothelium damage in promoting thrombotic events. In particular, a significant increase in VWF and FVIII:C levels was found in the MPN patients with SVT.

Background: Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation., Methods: A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado., Results: In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement., Conclusion: Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Introduction: Situations involving increased workloads and stress (i.e., the COVID-19 pandemic) underline the need for healthcare professionals to minimize patient complications. In the field of vascular access, tunneling techniques are a possible solution. This systematic review and meta-analysis aimed to compare the effectiveness of tunneled Peripherally Inserted Central Catheters (tPICCs) to conventional Peripherally Inserted Central Catheters (cPICCs) in terms of bleeding, overall success, procedural time, and late complications., Methods: Randomized controlled trials without language restrictions were searched using PUBMED ® , EMBASE ® , EBSCO ® , CINAHL ® , and the Cochrane Controlled Clinical Trials Register from August 2022 to August 2023. Five relevant papers (1238 patients) were included., Results: There were no significant differences in overall success and nerve or artery injuries between the two groups ( p = 0.62 and p = 0.62, respectively), although cPICCs caused slightly less bleeding (0.23 mL) and had shorter procedural times (2.95 min). On the other hand, tPICCs had a significantly reduced risk of overall complications ( p < 0.001; RR0.41 [0.31-0.54] CI 95%), catheter-related thrombosis ( p < 0.001; RR0.35 [0.20-0.59] IC 95%), infection-triggering catheter removal ( p < 0.001; RR0.33 [0.18-0.61] IC 95%), wound oozing ( p < 0.001; RR0.49 [0.37-0.64] IC 95%), and dislodgement ( p < 0.001; RR0.4 [0.31-0.54] CI 95%)., Conclusions: The tunneling technique for brachial access appears to be safe concerning intra-procedural bleeding, overall success, and procedural time, and it is effective in reducing the risk of late complications associated with catheterization.

The migration of Twitter users to Mastodon following Elon Musk's acquisition presents a unique opportunity to study collective behavior and gain insights into the drivers of coordinated behavior in online media. We analyzed the social network and the public conversations of about 75,000 migrated users and observed that the temporal trace of their migrations is compatible with a phenomenon of social influence, as described by a compartmental epidemic model of information diffusion. Drawing from prior research on behavioral change, we delved into the factors that account for variations of the effectiveness of the influence process across different Twitter communities. Communities in which the influence process unfolded more rapidly exhibit lower density of social connections, higher levels of signaled commitment to migrating, and more emphasis on shared identity and exchange of factual knowledge in the community discussion. These factors account collectively for 57% of the variance in the observed data. Our results highlight the joint importance of network structure, commitment, and psycho-linguistic aspects of social interactions in characterizing grassroots collective action, and contribute to deepen our understanding of the mechanisms that drive processes of behavior change of online groups., (© 2023. The Author(s).)

Background: Catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality among hospitalized patients. Different studies suggest that the use of disinfectant caps (DCs) significantly reduces the rate of CRBSIs. The first purpose of this study is to analyze, through an in-vitro -model, the antiseptic effect of DCs produced by two manufacturers; the second aim is to assess potential differences in terms of effectiveness between the two manufacturers' products., Methods: A know concentration of thirteen different microorganisms was incubated with the sponge drenched in antimicrobial fluid inside DCs and cultured through several assays to investigate the disinfectant effectiveness of some commercially available caps. Disinfectant properties were evaluated under two different conditions: baseline (DCs placed on the needle-free connectors (NFCs) and stress test (DCs directly applied to the catheter hub)., Results: Both manufacturers overcame the basal tests (fourteen different assays). Regarding stress tests: the only significant bacterial load was found for Serratia marcescens (10 4 CFU/mL in ICU Medical™), both at 90 and 180 minutes after incubation; due to the low load, MDR Acinetobacter baumannii was not considered significant (<10 3 CFU/mL in BD PureHub™)., Conclusions: Our results confirm what was reported in BD PureHub™ datasheet and add data not previously shown by ICU Medical™. Moreover, no difference was observed between the two manufacturers products: the use of both DCs on NFCs was able to reclaim the catheter lumen. These findings support the routine use of DCs with NFCs, as part of a structured bundle of interventions, to reduce the incidence of CRBSIs., Competing Interests: Conflict of interest: The Authors declare no conflicts of interest.

Non-Fungible Tokens (NFTs) have emerged as the most representative application of blockchain technology in recent years, fostering the development of the Web3. Nonetheless, while the interest in NFTs rapidly boomed, creating unprecedented fervour in traders and creators, the demand for highly representative and up-to-date data to shed light on such an intriguing yet complex domain mostly remained unmet. To pursue this objective, we introduce a large collection of NFT transactions and associated metadata that correspond to trading operations between 2021 and 2023. Our developed dataset is the most extensive and representative in the NFT landscape to date, as it contains more than 70 M transactions performed by more than 6 M users across 36.3 M NFTs and 281 K collections. Moreover, this dataset boasts a wealth of metadata, including encoded textual descriptions and multimedia content, thus being suitable for a plethora of tasks relevant to database systems, AI, data science, Web and network science fields. This dataset represents a unique resource for researchers and industry practitioners to delve into the inner workings of NFTs through a multitude of perspectives, paving the way for unprecedented opportunities across multiple research fields., (© 2023 The Author(s).)

Most antimicrobial drugs need an intravenous (IV) administration to achieve maximum efficacy against target pathogens. IV administration is related to complications, such as tissue infiltration and thrombo-phlebitis. This systematic review aims to provide practical recommendations about diluent, pH, osmolarity, dosage, infusion rate, vesicant properties, and phlebitis rate of the most commonly used antimicrobial drugs evaluated in randomized controlled studies (RCT) till 31 March 2023. The authors searched for available IV antimicrobial drugs in RCT in PUBMED EMBASE ® , EBSCO ® CINAHL ®, and the Cochrane Controlled Clinical trials. Drugs' chemical features were searched online, in drug data sheets, and in scientific papers, establishing that the drugs with a pH of <5 or >9, osmolarity >600 mOsm/L, high incidence of phlebitis reported in the literature, and vesicant drugs need the adoption of utmost caution during administration. We evaluated 931 papers; 232 studies were included. A total of 82 antimicrobials were identified. Regarding antibiotics, 37 reach the "caution" criterion, as well as seven antivirals, 10 antifungals, and three antiprotozoals. In this subgroup of antimicrobials, the correct vascular access device (VAD) selection is essential to avoid complications due to the administration through a peripheral vein. Knowing the physicochemical characteristics of antimicrobials is crucial to improve the patient's safety significantly, thus avoiding administration errors and local side effects.

Introduction: Critically ill hospitalized patients are at increased risk of infection so we assessed the immunogenicity of 23-valent pneumococcal polysaccharide vaccine (PPSV23) administered within six days of injury., Methods: This prospective observational study compared the immunogenicity of PPSV23 among critically ill burn and neurosurgical patients at a tertiary, academic medical center. Patients received PPSV23 vaccination within six days of ICU admission per standard of care. Consent was obtained to measure concentrations of vaccine-specific IgG to 14 of 23 serotype capsule-specific IgG in serum prior to and 14-35 days following PPSV23. A successful immunologic response was defined as both a ≥2-fold rise in capsule-specific IgG from baseline and concentrations of >1 mcg/mL to 10 of 14 measured vaccine serotypes. Immunologic response was compared between burn and neurosurgical patients. Multiple variable regression methods were used to explore associations of clinical and laboratory parameters to immunologic responses., Results: Among the 16 burn and 27 neurosurgical patients enrolled, 87.5% and 40.7% generated a successful response to the vaccine, respectively (p = 0.004). Both median post-PPSV23 IgG concentrations (7.79 [4.56-18.1] versus 2.93 [1.49-8.01] mcg/mL; p = 0.006) and fold rises (10.66 [7.44-14.56] versus 3.48 [1.13-6.59]; p<0.001) were significantly greater in burn compared with neurosurgical patients. Presence of burn injury was directly and days from injury to immunization were inversely correlated with successful immunologic response (both p<0.03). Burn injury was associated with both increased median antibody levels post-PPSV23 and fold rise to 14 vaccine serotypes (p<0.03), whereas absolute lymphocyte count was inversely correlated with median antibody concentrations (p = 0.034)., Conclusion: Critically ill burn patients can generate successful responses to PPSV23 during acute injury whereas responses among neurosurgical patients is comparatively blunted. Further study is needed to elucidate the mechanisms of differential antigen responsiveness in these populations, including the role of acute stress responses, as well as the durability of these antibody responses.

Objective: The characteristics, diagnosis, and preferred management strategies for distal posterior inferior cerebellar artery (PICA) aneurysms associated with cerebellar arteriovenous malformation (AVMs) are poorly understood. We present a case series with attention to aneurysm angioarchitecture, diagnostic imaging, treatment approaches, and a thorough review of the literature. With this information, we demonstrate a specific anatomical pattern for these aneurysms, an underreported need for conventional digital subtraction angiography (DSA) during evaluation, along with the utility of endovascular treatment with liquid embolic agents., Methods: Neurosurgical patients from 2005 to 2016 were reviewed to identify PICA aneurysms along with distal PICA aneurysms. Details of their presentation, imaging studies, associated AVMs and treatment were recorded. A thorough literature search of previous case series and case reports of distal PICA aneurysms with and without associated small cerebellar AVMs was performed with PubMed and Google Scholar., Results: Thirty-four patients with PICA aneurysms were identified at our institution, 12 of which were in a distal segment. All 12 of these patients underwent DSA as a part of their evaluation. Of the 12 patients with distal PICA aneurysms, 9 presented with subarachnoid hemorrhage and intraventricular hemorrhage. Five of these patients had a small occult cerebellar AVM. All nine patients presenting with a ruptured distal PICA aneurysm had a Fischer grade 4 subarachnoid hemorrhage. Of the five patients with a small occult cerebellar AVM, the AVM nidus was missed on computed tomography angiogram (CTA) interpretation but easily visualized with DSA. CTA followed by DSA with concurrent endovascular treatment was performed in 9 of the 12 patients with distal PICA aneurysms. Two of the 12 patients were treated with microsurgical clip ligation, and one mycotic aneurysm was identified and treated with antibiotics. Parent vessel sacrifice was used distal to the aneurysm in all 5 associated AVM cases with liquid embolic agents as well as AVM embolization in 3 of the 5 cases. Fifty-one well-described case reports of distal PICA aneurysms associated with small cerebellar AVMs have been reported in the literature. A total of 12 well-described case series of distal PICA aneurysms that comment on associated AVMs describe an associated small cerebellar AVM incidence of 4%-50%. In our case series, the incidence of an associated small cerebellar AVM with a distal PICA aneurysm was 42%., Conclusions: In cases of distal PICA aneurysms, there is a frequent association of a small cerebellar AVM. In our series, CTA was an inadequate diagnostic study to identify the associated AVM, and DSA was necessary to definitely visualize the AVM nidus. Endovascular treatment of the aneurysm and AVM with the use of liquid embolic agents was a feasible and useful management strategy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Target plasma level achievement has remained a challenge in neurosurgical intensive care unit patients receiving intravenous vancomycin. We evaluated continuous infusion (CI) and intermittent vancomycin dosing strategies in these patients., Methods: This retrospective cohort compared CI vancomycin (target random levels, 20-30 mg/L) to intermittent vancomycin (target troughs, 15-20 mg/L) in regards to achievement of target plasma levels, nephrotoxicity, pharmacodynamic target attainment, and cost savings in 130 patients., Results: Continuous infusion resulted in greater achievement of goal plasma concentrations at the first steady-state level (40 vs 21.5%, P = .02), more rapid achievement of goal plasma concentrations (2.04 vs 3.76 days, P < .0001), and increased time within therapeutic range (55% vs 34%, P < .0001) but no significant difference in nephrotoxicity (15.4% vs 21.5%, P = .5). Continuous infusion improved pharmacodynamic target attainment (92.3% vs 30.8%, P < .0001) and also reduced levels drawn (3.8 vs 5.7, P = .0007), dose adjustments (1.4 vs 2.4, P = .0006), days of therapy (10.4 vs 14.1, P = .01), and mean total daily dose requirements (33 vs 35.7 mg/kg, P < .0001) per patient., Conclusions: Continuous infusion appears beneficial for improving attainment of target plasma concentrations, pharmacodynamic goals, and financial burden, without increasing risk of acute kidney injury., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves., Design: Case report (Canadian Task Force classification III)., Setting: Private practice hospital in São Paulo, Brazil., Patient: A 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0-10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm., Interventions: Standard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4., Measurements and Main Results: The surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0-10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves., Conclusion: Laparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: To assess the utility of previously developed scoring systems, we compared SEDAN, named after the components of the score (baseline blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign on admission computed tomography scan, Age, and National Institutes of Health Stroke Scale on admission), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-arterial Therapy (HIAT), and HIAT-2 scoring systems among patients receiving systemic (intravenous [IV] tissue plasminogen activator [tPA]) and endovascular (intra-arterial [IA]) treatments., Methods: We retrospectively reviewed all IV tPA and IA patients presenting to our center from 2008-2011. The scores were assessed in patients who were treated with IV tPA only, IA only, and a combination of IV tPA and IA (IV-IA). We tested the ability of THRIVE to predict discharge modified Rankin scale (mRS) 3-6, HIAT and HIAT-2 discharge mRS 4-6, and SEDAN symptomatic intracerebral hemorrhage (sICH)., Results: Of the 366 patients who were included in this study, 243 had IV tPA only, 89 had IA only, and 34 had IV-IA. THRIVE was predictive of mRS 3-6 in the IV-IA (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.30-2.91) and the IV group (OR, 1.71; 95% CI, 1.43-2.04), but not in the IA group. HIAT was predictive of mRS 4-6 in the IA (OR, 3.55; 95% CI, 1.65-7.25), IV (OR, 3.47; 95% CI, 2.26-5.33), and IV-IA group (OR, 6.48; 95% CI, 1.41-29.71). HIAT-2 was predictive of mRS 4-6 in the IA (OR, 1.39; 95% CI, 1.03-1.87) and IV group (OR, 1.36; 95% CI, 1.18-1.57), but not in the IV-IA group. SEDAN was not predictive of sICH in the IA or the IV-IA group, but was predictive in the IV group (OR, 1.54; 95% CI, 1.01-2.36)., Conclusions: Our study demonstrated that although highly predictive of outcome in the original study design treatment groups, prediction scores may not generalize to all patient samples, highlighting the importance of validating prediction scores in diverse samples., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

We aimed to assess whether Internet addiction (IA) severity was related to alexithymia scores among high school students, taking into account the role of gender differences and the possible effect of anxiety, depression, and age. Participants in the study were 600 students (ages ranging from 13 to 22; 48.16% girls) recruited from three high schools in two cities from Southern Italy. Participants completed a sociodemographic questionnaire, the Toronto Alexithymia Scale, the Internet Addiction Test, the Hamilton Anxiety Scale, and the Hamilton Depression Scale. The findings of the study showed that IA scores were associated with alexithymia scores, over and above the effect of negative emotions and age. Students with pathological levels of alexithymia reported higher scores on IA severity. In particular, results showed that difficulty in identifying feelings was significantly associated with higher scores on IA severity. No effect of gender was found. Implications for clinicians were discussed.

Aims: To assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes., Methods: Twenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists' Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools., Results: The final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (± 13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%)., Discussion and Conclusions: Our results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients' psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders.

Cervical ectopic pregnancy is a rare and dangerous event that can be life and reproductive threatening. Years ago, the only treatment available were hysterectomy, resulting in a 50% of maternal mortality. In the present, ultrasound technologies let us make early diagnosis raising the possibilities of a conservative treatment in several ways. Cervical ectopic pregnancy represent a big challenge for the obstetrician, requiring great diagnostic and therapeutic skills in order to preserve the reproductive capacity, specially because this kind of ectopic pregnancy is more frequent in assisted reproductive techniques like intrauterine insemination, and in couples seeking fertility treatments, the reproductive capacity is an extremely important issue. By now, there's no plenty scientific evidence about this problem to write diagnostic and therapeutic guidelines. Today, personalized treatment is the only viable option for this patient. We report the case of a 31-year-old woman who arrived to our emergency room with a profuse vaginal bleeding, and with a history of conservative treatment for a cervical ectopic pregnancy.

Background and Purpose: Hypercapnia can induce intracranial blood-flow steal from ischemic brain tissues, and early initiation of noninvasive ventilator correction (NIVC) may improve cerebral hemodynamics in acute ischemic stroke. We sought to determine safety and tolerability of NIVC initiated on hospital admission without polysomnography study., Subjects and Methods: Consecutive acute ischemic stroke patients were evaluated for the presence of a proximal arterial occlusion, daytime sleepiness, or history of obstructive sleep apnea, and acceptable pulse oximetry readings while awake (96%-100% on 2 to 4 L supplemental oxygen delivered by nasal cannula). NIVC was started on hospital admission as standard of care when considered necessary by treating physicians. NIVC was initiated using bilevel positive airway pressure at 10 cmH(2)O inspiratory positive airway pressure and 5 cmH(2)O expiratory positive airway pressure in combination with 40% fraction of inspired oxygen. All potential adverse events were prospectively documented., Results: Among 356 acute ischemic stroke patients (median NIHSS score, 5; interquartile range, 2-13), 64 cases (18%) received NIVC (median NIHSS score, 12; interquartile range, 6-17). Baseline stroke severity was higher and proximal arterial occlusions were more frequent in NIVC patients compared to the rest (P<0.001). NIVC was not tolerated by 4 patients (7%). Adverse events in NIVC included vomiting (n=1), aspiration pneumonia (n=1), respiratory failure/intubation (n=1), hypotension requiring pressors (n=1), and facial skin breakdown (n=3). The in-hospital mortality rate was 13% in NIVC patients and 8% in the rest (P=0.195). Neurological improvement during hospitalization tended to be greater in the NIVC group (median NIHSS score decrease, 2 points; interquartile range, 0-4) compared to the rest (median NIHSS score decrease, 1; interquartile range, 0-2; P=0.078)., Conclusions: In acute ischemic stroke patients with proximal arterial occlusion and excessive sleepiness or obstructive sleep apnea, NIVC can be initiated early with good tolerability and a relatively small risk of serious complications.

Background: Cyclins drive cell-cycle progression by associating with their kinase partners, cyclin-dependent kinases (CDK). We investigated cyclin D1/CDK6, cyclin E/CDK2 complexes, and the cell-cycle negative regulators p15 and p27 in an incisional skin wound model., Methods: Wounds were produced on the back of female diabetic mice and their normoglycemic littermates. Animals were treated with polydeoxyribonucleotide (PDRN, 8 mg/kg/i.p.), an agonist of adenosine A2(A) receptors, or its vehicle daily. Granulation tissue proliferation by Ki67 immunostaining, cyclin D/CDK6 and cyclin E/CDK2 complexes, and p21 and p16 proteins (Western blot analysis), and the histologic changes were assessed at different days (3, 6, and 12 days after injury)., Results: Numerous Ki67 positive cells were observed at day 3 and day 6 in the granulation tissue of normoglycemic mice. Ki67 positive cells were fewer in diabetic than in normoglycemic mice. PDRN increased Ki67 positive cells in diabetic mice. Normoglycemic mice showed the greatest upregulation of cyclin D1, CDK6, cyclin E, and CDK2 at day 6. Diabetic mice had a markedly lower expression of cyclin D1, CDK6, cyclin E, and CDK2 at day 6. They also showed a greater expression of p15 and p27 at day 6. PDRN administration in diabetic mice increased cyclin D1/CDK6 and cyclin E/CDK2 expression and reduced p15 and p27 inhibitors at day 6 after injury; moreover, it improved the impaired wound healing at day 12., Conclusion: Our results suggest that adenosine A2(A) receptor activation by PDRN might represent a therapeutic strategy to overcome the diabetes-impaired cell-cycle machinery., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background and Purpose: Intra-arterial (IA) rescue procedures are increasingly used to treat acute ischemic stroke. We implemented continuous transcranial Doppler (TCD) monitoring during these procedures to detect any potentially harmful flow changes. Here, we report diagnostic criteria and yield of TCD monitoring., Methods: We studied consecutive acute stroke patients who underwent IA reperfusion procedures. TCD flow signatures during these procedures were analyzed and any abnormal findings were documented., Results: Patients were included only if there was successful insonation through the skull; of 56 eligible patients, 51 were included. IA procedures included IA tissue plasminogen activator, use of the Merci retriever, the Penumbra system, balloon angioplasty, and stenting. On TCD monitoring, contrast injections produced high-intensity signals and increased the mean flow velocity (MFV). Deployment of the Merci device appeared as high-intensity, short-duration signals with a transient MFV decrease of 11.5%. The Penumbra system produced lower-intensity signals with a greater transient decrease in MFV during aspiration. IA tissue plasminogen activator significantly increased MFV by 7.5% over Merci and Penumbra flow velocity changes. Power motion Doppler-TCD detected reocclusion in 13 patients, artery-to-artery embolization in 2 patients, air embolism in 2 patients, and hyperperfusion in 6 patients. Overall, the yield of TCD monitoring was positive in 23 (49%) patients who received IA reperfusion procedures., Conclusions: Our velocity, intensity, and flow signatures criteria for TCD monitoring of IA reperfusion procedures detect reocclusion, hyperperfusion, or thromboembolism and air embolism in nearly half of all procedures. This hemodynamic information can be particularly helpful when neurological assessment is limited or delayed.

In a brief introduction, methods for collecting urine and diagnosis criteria are reviewed. Data relative to a study of about 10,000 samples of urine from patients admitted to various departments of the Milan Ca' Granda Hospital in 1975 are then reported. The frequencies of the various species of bacteria isolated in cases of bacteriuria are reported. Those occurring most frequently were Proteus (40.7%) of whose four species, Proteus mirabilis and Proteus rettgeri cover almost all cases, and Escherichia coli (26.1%). As for individual isolated microrganisms, the sensitivity to 13 chemotherapeutic agents was tested. E. coli, Klebsiella and Enterococcus demonstrated a high degree of sensitivity with respect to the majority of antibiotics considered.

The sensitivity of two tests recently proposed for the classification of pathogen staphylococci were evaluated: --production of DNA-ase with the modified method of Lachica et al.; --production of lisozyme. The two above tests were studied with other six tests on 1,000 strains of staphylococci showing a very high specificity. The Authors propose that the DNA-ase production and the lisozyme production, also for their very simple execution, should become routine tests to identify the strains of pathogenic staphylococci.