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Abstract Background Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. Methods This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. Results A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. Conclusion This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Abstract Background The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. Methods Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. Results The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representatives' desires, and all decisions should be shared. Conclusions The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes. Graphical abstract

Abstract Background The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. Methods A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. Results A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). Conclusions This consensus provides practical recommendations to support a clinician’s decision making in the management of tSCI polytrauma patients.

Smooth muscle tumors of unknown malignant potential (STUMP) represent a group of heterogeneous uterine neoplasms showing worrisome histological features, raising concerns for a malignant behavior, but do not satisfy the diagnostic criteria for leiomyosarcoma. The existing literature remains scarce due to its rarity; therefore, there is no consensus regarding diagnostic criteria, malignant potential, treatment of choice, and follow-up. The authors report their case series to analyze the heterogeneous features of this poorly understood neoplasm. A retrospective, monocentric cohort study of all patients who underwent surgery diagnosed with STUMP at the Garibaldi-Nesima Hospital in Catania from February 2018 to August 2021 was conducted. Each patient’s age at diagnosis, symptoms, surgical treatment, tumor features, postoperative management, and follow-up were recorded. Nine STUMP cases were included. All patients reported menometrorrhagia and pelvic pain. In all women, the tumor lesion was single and intramural, and the mean diameter was 7.5 cm. Four women underwent laparotomic conservative surgery. The mean postoperative follow-up time was 36 months, and recurrences were observed in two patients. In conclusion, STUMP cases should be systematically discussed by tumor boards, pathologists with good expertise in gynecological diseases should examine the histological samples, and close surveillance is mandatory because of the possibility of recurrence or metastasis.

Abstract Background Postoperative analgesia in breast surgery is difficult due to the extensive nature of the surgery and the complex innervation of the breast; general anesthesia can be associated with regional anesthesia techniques to control intra- and post-postoperative pain. This randomized comparative study aimed to compare the efficacy of the erector spinae plane block and the thoracic paravertebral block in radical mastectomy procedures with or without axillary emptying. Methods This prospective randomized comparative study included 82 adult females who were randomly divided into two groups using a computer-generated random number. Both groups, Thoracic Paraverterbal block group and Erector Spinae Plane Block group (41 patients each), received general anesthesia associated with a multilevel single-shot thoracic paravertebral block and a multilevel single-shot erector spinae plane block, respectively. Postoperative pain intensity (expressed as Numeric Rating Scale), patients who needed rescue analgesic, intra- and post-operative opioid consumption, post-operative nausea and vomiting, length of stay, adverse events, chronic pain at 6 months, and the patient’s satisfaction were recorded. Results At 2 h (p

Abstract Background Erector spinae plane block is a locoregional anaesthetic technique widely used in several different surgeries due to its safety and efficacy. The aim of this study is to assess its utility in spinal degenerative and traumatic surgery in western countries and for patients of Caucasian ethnicity. Methods Patients undergoing elective lower-thoracic and lumbar spinal fusion were randomised into two groups: the case group (n = 15) who received erector spinae plane block (ropivacaine 0.4% + dexamethasone 4 mg, 20 mL per side at the level of surgery) plus postoperative opioid analgesia, and the control group (n = 15) who received opioid-based analgesia. Results The erector spinae plane block group showed significantly lower morphine consumption at 48 h postoperatively, lower need for intraoperative fentanyl (203.3 ± 121.7 micrograms vs. 322.0 ± 148.2 micrograms, p-value = 0.021), lower NRS score at 2, 6, 12, 24, and 36 h, and higher satisfaction rates of patients (8.4 ± 1.2 vs. 6.0 ± 1.05, p-value

The following paper sums up the history of Dr. Vincenzo Tiberio, a military physician from Italy, who lived around the second half of the past century. His life was dedicated to clinical research, particularly in the context of microorganism competition and mechanisms of transmission of infections. His scientific work, though significant and innovative, was adequately appreciated just many years after his death; a great loss for the scientific world since his discovery could have laid the groundwork for the development of antimicrobial drugs that can be used nowadays in the infection control strategies.

Laparoscopic hysterectomy (LH), one of the most common surgeries among women, results in moderate-to-severe postoperative pain. The use of the transversus abdominis plane (TAP) block for pain management in LH has been evaluated but with conflicting results. The erector spinae plane (ESP) block has emerged as an effective and safe technique for relieving visceral pain. This study aimed to compare the analgesic efficacy of posterior TAP block versus ESP block following LH. We conducted a prospective, randomised, multicentre study. Seventy-six patients (American Society of Anesthesiologists I–III) scheduled for elective LH were included in the final analysis. The interventions performed were posterior TAP block (TAP group) and ESP block at T8 (ESP group). We adopted numerical rating scale (NRS) scores for pain at different time points, intraoperative remifentanil need, rescue analgesic requirements, incidence of postoperative nausea and vomiting in the first 36 postoperative hours, and days of hospitalisation as criteria of evaluetion. At nearly all time points, NRS scores did not significantly differ between the TAP and ESP groups. The TAP group had higher NRS scores for pain in the immediate postoperative period (p=0.008). The need for intraoperative remifentanil was higher in the TAP group (p=0.0018). When needed, remifentanil was infused at slower maximum infusion rates in the ESP group than in the TAP group (mean±SD: 0.02±0.04 vs. 0.04±0.05, respectively; p=0.006). The total rescue analgesic requirements in the first 36 postoperative hours did not significantly differ between the two groups. We conclude that following LH, the posterior TAP and ESP blocks can achieve similar levels of pain management.

Acinetobacter baumannii is commonly known to cause infection in immunocompromised patients. During COVID-19 pandemic, outbreaks of multidrug-resistant organisms, including Acinetobacter, have been well documented in acute care hospitals, particularly among critically ill patients. In the case reported, a woman was admitted to our ICU because of a severe COVID-19 pneumonia. During her stay, she worsened due to Acinetobacterrelated lung cavitations and only after proper antibiotic treatment she eventually recovered. To our knowledge, very few cases have been reported pointing to Acinetobacter as a causal agent for the acute development of lung cavities, especially in COVID-19 patients.

When I was younger, I had the privilege of seeing the greatest player in the history of soccer play live: Diego Armando Maradona. Maradona was able to win matches and tournaments just on his own. In contrast, in third millennium medicine, no physician can expect to defeat complex diseases requiring high-intensity care without the support of a team. The inherent complexity of precision medicine, the abundance of treatment options, and the need to set up long-term treatment pathways with different intensities of care, are driving toward a win-win approach of patient management by Multidisciplinary Teams (MDT). This is the whole reason Acute Care Medicine Surgery and Anaesthesia (AMSA) was born: ranging from the name of the journal to the composition of the editorial board, our interest in critically ill and surgical patients is clearly visible. [...]

IntroductionPatients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage.MethodsWe conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT.ResultsWe observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance.DiscussionThe low number of observed complications might be related to our organizational strategy, all based on a dedicated “tracheo-team” implementing both PDT following a strictly defined protocol and accurate follow-up.

Abstract Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is usually performed in cases of severe respiratory failure in which conventional and advanced mechanical ventilation strategies are ineffective in achieving true lung-protective ventilation, thus triggering ventilatory-induced lung injury. If circulatory failure coexists, veno-arterial ECMO (VA-ECMO) may be preferred over VV-ECMO because of its potential for circulatory support. In VA-ECMO, the respiratory contribution is less effective and the complication rate is higher than in the VV configuration. Case presentation The authors present a case in which VV-ECMO was performed in an emergency setting to treat a 68-year-old White male patient who experienced acute respiratory failure after massive aspiration. Despite intubation and intensive care unit admission, multiple organ failure occurred suddenly, thus prompting referral to a level-1 trauma center with an ECMO facility. The patient’s condition slowly improved with VV-ECMO support along with standard treatment for hemodynamic impairment. VV-ECMO was discontinued on day 8. The patient was extubated on day 14 and discharged home fully recovered 34 days after the event. Conclusions Attention was focused on the decision to initiate VV-ECMO support even in the presence of severe hemodynamic derangement, although VA-ECMO could have provided better hemodynamic support but less effective respiratory support.

Adult patients in the intensive care unit (ICU) often experience pain resulting from acute and chronic illness, as well as from standard positioning and maneuverers in the ICU. In recent years, the need for effective pain control in intensive care has emerged strongly. Partial or ineffective control is associated with multiple complications, such as agitation, delirium, inability to adapt to mechanical ventilation, increased length of stay, and post-traumatic stress disorder. Recent guidelines and studies suggest multimodal strategies for effective pain control, also re-evaluating the use of locoregional anesthesiological techniques. Oncological pain in critically ill patients represents a particular challenge for medical staff, being closely linked to the concept of palliative care. We present a case of refractory pain and agitation in an oncologic patient following an emergency exploratory laparotomy. Through the use of an intrathecal catheter, we provided effective analgesia to control pain and agitation, allowing weaning from mechanical ventilation before, and once the terminal state of the tumor was established, providing palliative care to ensure dignity and satisfaction of the patient.

Abstract Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (

Abstract There is the urgent need to study the effects of immunomodulating agents as therapy for Covid-19. An observational, cohort, prospective study with 30 days of observation was carried out to assess clinical outcomes in 88 patients hospitalized for Covid-19 pneumonia and treated with canakinumab (300 mg sc). Median time from diagnosis of Covid-19 by viral swab to administration of canakinumab was 7.5 days (range 0–30, IQR 4–11). Median PaO2/FiO2 increased from 160 (range 53–409, IQR 122–210) at baseline to 237 (range 72–533, IQR 158–331) at day 7 after treatment with canakinumab (p

Abstract Background A large proportion of patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure requiring admission to the intensive care unit (ICU) and about 80% of them need mechanical ventilation (MV). These patients show great complexity due to multiple organ involvement and a dynamic evolution over time; moreover, few information is available about the risk factors that may contribute to increase the time course of mechanical ventilation. The primary objective of this study is to investigate the risk factors associated with the inability to liberate COVID-19 patients from mechanical ventilation. Due to the complex evolution of the disease, we analyzed both pulmonary variables and occurrence of non-pulmonary complications during mechanical ventilation. The secondary objective of this study was the evaluation of risk factors for ICU mortality. Methods This multicenter prospective observational study enrolled 391 patients from fifteen COVID-19 dedicated Italian ICUs which underwent invasive mechanical ventilation for COVID-19 pneumonia. Clinical and laboratory data, ventilator parameters, occurrence of organ dysfunction, and outcome were recorded. The primary outcome measure was 28 days ventilator-free days and the liberation from MV at 28 days was studied by performing a competing risks regression model on data, according to the method of Fine and Gray; the event death was considered as a competing risk. Results Liberation from mechanical ventilation was achieved in 53.2% of the patients (208/391). Competing risks analysis, considering death as a competing event, demonstrated a decreased sub-hazard ratio for liberation from mechanical ventilation (MV) with increasing age and SOFA score at ICU admission, low values of PaO2/FiO2 ratio during the first 5 days of MV, respiratory system compliance (CRS) lower than 40 mL/cmH2O during the first 5 days of MV, need for renal replacement therapy (RRT), late-onset ventilator-associated pneumonia (VAP), and cardiovascular complications. ICU mortality during the observation period was 36.1% (141/391). Similar results were obtained by the multivariate logistic regression analysis using mortality as a dependent variable. Conclusions Age, SOFA score at ICU admission, CRS, PaO2/FiO2, renal and cardiovascular complications, and late-onset VAP were all independent risk factors for prolonged mechanical ventilation in patients with COVID-19. Trial registration NCT04411459

Abstract Background Iron metabolism and immune response to SARS-CoV-2 have not been described yet in intensive care patients, although they are likely involved in Covid-19 pathogenesis. Methods We performed an observational study during the peak of pandemic in our intensive care unit, dosing D-dimer, C-reactive protein, troponin T, lactate dehydrogenase, ferritin, serum iron, transferrin, transferrin saturation, transferrin soluble receptor, lymphocyte count and NK, CD3, CD4, CD8 and B subgroups of 31 patients during the first 2 weeks of their ICU stay. Correlation with mortality and severity at the time of admission was tested with the Spearman coefficient and Mann–Whitney test. Trends over time were tested with the Kruskal–Wallis analysis. Results Lymphopenia is severe and constant, with a nadir on day 2 of ICU stay (median 0.555 109/L; interquartile range (IQR) 0.450 109/L); all lymphocytic subgroups are dramatically reduced in critically ill patients, while CD4/CD8 ratio remains normal. Neither ferritin nor lymphocyte count follows significant trends in ICU patients. Transferrin saturation is extremely reduced at ICU admission (median 9%; IQR 7%), then significantly increases at days 3 to 6 (median 33%, IQR 26.5%, p value 0.026). The same trend is observed with serum iron levels (median 25.5 μg/L, IQR 69 μg/L at admission; median 73 μg/L, IQR 56 μg/L on days 3 to 6) without reaching statistical significance. Hyperferritinemia is constant during intensive care stay: however, its dosage might be helpful in individuating patients developing haemophagocytic lymphohistiocytosis. D-dimer is elevated and progressively increases from admission (median 1319 μg/L; IQR 1285 μg/L) to days 3 to 6 (median 6820 μg/L; IQR 6619 μg/L), despite not reaching significant results. We describe trends of all the abovementioned parameters during ICU stay. Conclusions The description of iron metabolism and lymphocyte count in Covid-19 patients admitted to the intensive care unit provided with this paper might allow a wider understanding of SARS-CoV-2 pathophysiology.

Introduction: The management of complex trauma patient with concomitant brain injury and extra-cranial lesions is challenging since the requirement of a low pressure to limit the bleeding clashes with the need to maintain an adequate cerebral perfusion and to obtain a brain CT-scan.Here we present the use of REBOA as a bridge to CT scan in complex head and torso trauma. Case presentation: A 59 years old male patient involved in a road traffic crash was admitted to our hospital after a car accident. He had a GCS of 3 with a left fixed pupil anisocoria. Despite right-sided chest decompression for pneumothorax and massive transfusion protocol for haemoperitoneum, blood pressure remained low; to temporally stabilize the patient and perform a brain CT scan a zone 1 REBOA was inserted and systolic blood pressure rose up from 60 mmHg to 110 mmHg. A brain CT scan highlighted a right subdural hematoma with a 8-mm midline shift. The patient went to the operating room to perform damage control surgery and, subsequently, a decompressive craniotomy. After 96 days of hospital stay, the patient was discharged at home with a complete neurological recovery. Conclusions: The achievement of a rapid brain CT scan in traumatic brain injury is often crucial and has a deep impact in changing surgical management; moreover, duration of cerebral herniation is associated with worse outcome and increased mortality.In the light of this, the use of REBOA in selected cases of complex head and torso trauma could allow to gain time to go to the CT room in safe conditions.

ObjectiveIsolated torsion of a fallopian tube is a rare event and it is extremely difficult to be diagnosed in pregnancy. The aim of this study is to present a clinical case report that occurred in our department and to summarize the latest evidence about tubal torsion in pregnancy.MethodsWe reported data, ultrasonographic features and an intra-operative image of a case report of tubal torsion in a term pregnancy. Then a review of the literature was performed following the PRISMA statement: we searched all the articles related to tubal torsion in pregnancy in the last 10 years from the international electronic bibliographic database PUBMED. We collected data regarding population characteristics, clinical features, treatment, and feto-maternal outcomes.ResultsAccording to our search strategy, 10 articles were included. The main clinical symptoms were abdominal pelvic pain (100%), nausea, and vomiting (30%). The mean gestational age at the diagnosis was 36 weeks after the last menstrual period in 50% of cases. Ultrasound images showed a cystic lesion in the adnexal area in 70% of cases. In most of the cases, a cesarean section with a contextual salpingectomy was performed. No cases of maternal and fetal death were respectively reported.ConclusionIsolated torsion of the fallopian tube is a rare obstetric condition but it should be considered in case of acute lower abdominal pain presentation during pregnancy. Depending on gestational age, surgical treatment as soon as possible could prevent a salpingectomy.

BackgroundThis study aimed to describe an innovative and functional method to deal with the increased COVID-19 pandemic-related intensive care unit bed requirements.MethodsWe described the emergency creation of an integrated system of internistic ward, step-down unit, and intensive care unit, physically located in reciprocal vicinity on the same floor. The run was carried out under the control of single intensive care staff, through sharing clinical protocols and informatics systems, and following single director supervision. The intention was to create a dynamic and flexible system, allowing for rapid and fluid patient admission/discharge, depending on the requirements due to the third Italian peak of the COVID-19 pandemic in March 2021.ResultsThis study involved 142 COVID-19 patients and 66 non-COVID-19 patients who were admitted; no critical patient was left unadmitted and no COVID-19 severe patients referring to our center had to be redirected to other hospitals due to bed saturation. This system allowed shorter hospital length-of-stay in general wards (5.9 ± 4 days) than in other internistic COVID-19 wards and overall mortality in line with those reported in literature despite the peak raging.ConclusionThis case report showed the feasibility and the efficiency of this dynamic model of hospital rearrangement to deal with COVID-19 pandemic peaks.

Background: Trauma is a leading cause of death and disability. Patients with trauma undergoing invasive mechanical ventilation (IMV) are at risk for ventilator-associated events (VAEs) potentially associated with a longer duration of IMV and increased stay in the intensive care unit (ICU). Methods: We conducted a retrospective cohort study aimed to evaluate the incidence of infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (PVAP), and their characteristics among patients experiencing severe trauma that required ICU admission and IMV for at least four days. We also determined pathogens implicated in PVAP episodes and characterized the use of antimicrobial therapy. Results: In total, 88 adult patients were included in the main analysis. In this study, we observed that 29.5% of patients developed a respiratory infection during ICU stay. Among them, five patients (19.2%) suffered from respiratory infections due to multi-drug resistant bacteria. Patients who developed IVAC/PVAP presented lower total GCS (median value, 7; (IQR, 9) vs. 12.5, (IQR, 8); p = 0.068) than those who did not develop IVAC/PVAP. Conclusions: We observed that less than one-third of trauma patients fulfilling criteria for ventilator associated events developed a respiratory infection during the ICU stay.

Abstract Background Major trauma patients experience a 20% mortality rate overall, and many survivors remain permanently disabled. In order to monitor the quality of trauma care in the Trauma System, outcomes assessment is essential. Quality indicators on outcome can be expressed as quality of life, functional outcome, and others. The trauma follow-up system was created within the Romagna Trauma System (Italy) in order to monitor the trauma network and assess its long-term outcomes. The aim of this paper is firstly to evaluate the existence of correlations between epidemiological data, severity of injury, and clinical assessment characterizing the acute phase and the long-term outcomes in trauma patients and secondly, to explore the association between outcome variables have been modified. Methods We conducted a cross-sectional study over a 10-year period, including patients with severe trauma who survived and were discharged from the intensive care unit. The outcome measures were assessed with the use of the Extended Glasgow Outcome Scale and the Euro Quality of Life scale 5 dimension. Demographic data and clinical severity descriptors versus functional outcome were tested in a binary logistic regression model. Results In all, 428 major trauma patients participated in the study. At 1 year, 50.8% of trauma patients included had a good recovery and 49.2% had some degree of disability. The median value of quality of life was 0.725. At the multivariate analysis, variables showing significant impact on functional outcome were age (p = 0.052, OR 1.025), injury severity score (p = 0.001, OR 1.025), and Glasgow coma scale ≤ 8 (p = 0.001, OR 3.509) The Spearman’s Rank correlation coefficient showed a strong correlation between the global level of function variables and quality of life at one year (Spearman’s Rho Correlation Coefficient 0.760 (p < 0.0001)). Conclusions Increased age, increased injury severity score, and severe traumatic brain injury are predictors of long-term disability. Most of these trauma patients show impairments that affect not only the level of functional state but also the quality of life. The degree of functional independence has the greatest positive impact on quality of life. According to our results, after the recovery a prompt recognition of physical and psychological problems with systematic follow-up screening programs can help patients and doctors in defining specific therapeutic-rehabilitation pathways tailored to meet individual requirements.

Abstract Background Trauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries. Case presentation The first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards. Conclusions The outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.

Even with encouraging recipient outcomes, transplantation using donation after circulatory death (DCD) is still limited. A major barrier to this type of transplantation is the consequences of warm ischemia on graft survival; however, preservation techniques may reduce the consequences of cardiac arrest and provide better organ conservation. Furthermore, DCD in trauma patients could further expand organ donation. We present five cases in which organs were retrieved and transplanted successfully using normothermic regional perfusion (NRP) in trauma patients. Prompt critical care support and surgical treatment allowed us to overcome the acute phase. Unfortunately, owing to the severity of their injuries, all of the donors died. However, the advanced and continuous organ-specific supportive treatment allowed the maintenance of general clinical stability and organ preservation. Consequently, it was possible to retrieve and transplant the donors’ organs. Death was ascertained in accordance with cardio-circulatory criteria, which was followed by NRP. We consider that DCD in trauma patients may represent an important source of organs.

Subarachnoid hemorrhage (SAH) represents a medical emergency. Unfortunately, diagnosis can be delay due to cardiogenic abnormalities often associated with SAH. Cardiac manifestations are heterogeneous and common in patients with SAH. This phenomenon has not to be underestimated taking into account the devastating consequences of misdiagnosis and delay in the correct diagnosis and in a specific treatment, with serious and life-threatening consequences. We present a case report of an out of hospital ST elevation in a patient with Glasgow coma score of 6. He was primarily managed as an acute coronary syndrome case. However, coronary angiography was normal. After performing a computed tomography scan, the diagnosis of SAH was made.

Rhabdomyolysis is an uncommon complication of the coronavirus disease 2019 (COVID-19) infection. Previous reports have described its management and treatment in medical units, but have not discussed confirmatory tests or differential diagnosis. We report a case of a 58 year-old male patient, who was admitted for COVID-19 pneumonia and subsequently developed severe weakness, inability to move limbs, acute renal failure, significantly elevated myoglobin and creatinine kinase, and was diagnosed with rhabdomyolysis. Continuous renal replacement therapy, the treatment modality of choice over hyperhydration due to ongoing mechanical ventilation, was effective in resolving symptoms. No direct viral invasion of muscles was noted on biopsy. Here, we describe his symptoms, electromyography, and muscular biopsy results, and further discuss the possible differential diagnoses. Neuromuscular symptoms related to COVID-19 require careful clinical analysis. In addition, detailed reports of patients’ course of illness and diagnoses will assist in improving care for affected patients.

An amendment to this paper has been published and can be accessed via the original article.

Background and aims: Septic complications represent the predominant cause of late death in poly-trauma patients. The necessity to differentiate septic from non septic patients is more relevant at the early stage of the illness in order to improve the clinical outcome and to reduce the mortality. The identification of a sensitive and specific, clinically reliable, biomarker capable to early recognize incoming septic complications in trauma patients whose expression is not influenced by concomitant traumatic injuries, is still a challenge for the researchers in the field. Materials and methods: A retrospective analysis on 48 adult patients (9 females and 39 males, mean age 47.6±19 years) with multiple trauma was performed. The inclusion criterion was to suffer from acute trauma since no more than 24 hours and the exclusion criteria were the following: antibiotic treatment on admission and maintained for more than 48 hours; on-going infection on admission not associated with trauma; treatment with immunosuppressors/ immunomodulants; age Results and conclusions: In patients with SIRS, the mean presepsin concentration was 917,08 (±69.042) ng/L vs 980,258 (±1951.32) ng/L in patients without SIRS (P=0.769). In the infected patients, the mean presepsin concentration was 1513.25 (±2296.54) ng/L vs 654.21 (±511,068) ng/L (P

Gait recovery is one of the main goals of post-stroke rehabilitation and Robot-Assisted Gait Training (RAGT) has shown positive outcomes. However, there is a lack of studies in the literature comparing the effects of different devices. This paper aims to study the effects, in terms of clinical and gait outcomes, of treadmill-based and overground RAGT, compared to conventional gait training in stroke subjects. The results showed a significant improvement of clinical outcomes in both robotic treatments and in conventional therapy. The performance of locomotor tasks was clinically significant in the robotic groups only. The spatio-temporal gait parameters did not reveal any significant difference. Results suggest future multicentre studies on a larger number of subjects.

Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated.We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues.With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was "very low", with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by "high" quality evidence according to the GRADE classification but was downgraded to "moderate" for external validity issues.Tranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.