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Background As delayed intubation may worsen the outcome of coronavirus disease 2019 (COVID-19) patients treated with continuous positive airway pressure (CPAP), we sought to determine COVID-specific early predictors of CPAP failure. Methods In this observational retrospective multicentre study, we included all COVID-19 patients treated with out-of-ICU CPAP, candidates for intubation in case of CPAP failure. From these patients, we collected demographic and clinical data. Results A total of 397 COVID-19 patients were treated with CPAP for respiratory failure, with the therapeutic goal of providing intubation in case of CPAP failure. Univariable analysis showed that, age, lactate dehydrogenase (LDH) and white cell counts were all significantly lower in patients with successful CPAP treatment compared to those failing it and undergoing subsequent intubation. The percentage changes between baseline and CPAP application in the ratio of partial pressure arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2), PaO2, respiratory rate and ROX index were higher in patients experiencing successful CPAP compared to those failing it. FiO2 and male gender were also significantly associated with intubation. Multivariable analysis adjusting for age, gender, Charlson comorbidity index, percentage change in PaO2/FiO2 or PaO2 and FiO2 separately, lactate, white blood cell count, LDH and C-reactive protein levels led to an area under the curve of 0.818 and confirmed that age, LDH and percentage increase in PaO2/FiO2 are predictors of intubation. Conclusions In COVID-19 patients requiring CPAP, age, LDH and percentage change in PaO2/FiO2 after starting CPAP are predictors of intubation.

Background The global burden of mental health conditions is increasing, especially in middle- and low-income countries and frequently the quality of mental health services is lower than the quality of services for other conditions. Disasters may increase this burden through their direct impact or due to secondary stressors, such as the preclusion of access to essential services. The aim of this study is to assess the impact of Mariana dam burst (Brazil) in November 2015, in the utilization of public mental health services by the population that experienced an interruption of water supply after the event. Methods We used data from DATASUS, the database of the Brazilian public health system, analyzing data from 34 months before to 36 months after the event. We defined as affected the population living in the municipalities of Minas Gerais state that had an interruption of water supply after the event and the rest of the state population as the comparison group. We designed an Interrupted time-series analysis to evaluate both immediate and gradual changes in use of mental health services after the accident. Results The affected population included 381,749 inhabitants and the comparison group 20,487,352 inhabitants. The monthly rate of mental health visits in the affected population in the beginning of the series was 296 (CI 182 to 409, p Discussion The results suggest that the event translated in a long-term increase in mental health services utilization. We believe that this study presents an innovative methodology on the assessment of mental health services after disasters and that it could be adapted to other contexts. Key messages Indirect impacts of disasters may be associated with long-term changes in the utilization of mental health services. Interrupted time series using routine data are useful tools for the assessment of health services utilization following disasters.

The anesthetic management of patients affected by myasthenia gravis is usually challenging in elective surgery and even more so in emergency procedures. The difficulties involved are several-fold, ranging from the choice of an appropriate muscle relaxant (i.e. one that enables safe and rapid airway management) to neuromuscular monitoring and normal muscular recovery. Additionally, optimizing patient conditions - either pharmacologically or with plasmapheresis - before intervention is well beyond the realm of possibility. We discuss the anesthetic management of two myasthenic patients undergoing emergency surgery (for sigmoid perforation and upper gastrointestinal bleeding respectively). In both cases, we opted for rapid-sequence induction with high-dose rocuronium to prevent inhalation of gastric contents. We also report on the implication of neuromuscular monitoring. We found that the rocuronium-sugammadex combination was a useful and effective option in the emergency setting.

Background Surgery in patients affected by amyotrophic lateral sclerosis (ALS) presents a particular anesthetic challenge because of the risk of post-operative pulmonary complications. Aims of the study We report on the use of non-invasive ventilation (NIV) to prevent post-operative pulmonary complications (PPCs) in nine patients affected by ALS enrolled in a phase-1 clinical trial with stem cell transplantation. Methods All patients were treated with autologous mesenchymal stem cells implanted into the spinal cord with a surgical procedure. Anesthesia was induced with propofol and maintained with remifentanil and sevoflurane. No muscle relaxant was used. After awakening and regain of spontaneous breathing, patients were tracheally extubated. Non-invasive ventilation through nasal mask was delivered and non-invasive positive pressure ventilation and continuous positive pressure ventilation were started. Results The average time on NIV after surgery was 3 h and 12 min. All patients regained stable spontaneous breathing after NIV discontinuation and had no episodes of respiratory failure until the following day. Conclusions Our case series suggest that the use of NIV after surgery can be a safe strategy to prevent PPCs in patients affected by ALS. The perioperative procedure we chose for these patients appeared safe even in patients with advanced functional stage of the disease.

Background Relative effects of dosage, volume and concentration of local anaesthetics used for postoperative thoracic epidural analgesia are still under debate. In this randomized, prospective, double-blinded study, we evaluated the incidence of side-effects such as changes in arterial pressure, postoperative nausea, vomiting, and pruritus in patients admitted for thoracic surgery during continuous thoracic epidural infusion using levobupivacaine and sufentanil mixture in three different volumes. Methods We studied 150 patients who underwent thoracotomy with a thoracic epidural catheter placed between T4 and T7. The patients were randomized into three groups which received 10 mg h−1 of levobupivacaine at three different concentrations (0.5%, 0.25%, and 0.15%), in combination with sufentanil at 2.6 μg h−1. Haemodynamic effects, pruritus, nausea, vomiting, sensory and motor block, pain score, additional analgesic requirement, sedation, and patient satisfaction were registered immediately after the surgical operation and on the first, second, and third postoperative days. Results We did not detect any differences in the incidence of side-effects such as changes in arterial pressure, and also postoperative nausea, vomiting, and pruritus. The three groups were also similar with regard to patient characteristics, sensory and motor block, pain score, analgesic rescue dose, sedation, and patient satisfaction. Conclusions The same dose of a mixture of levobupivacaine and sufentanil administered in three different volumes and concentrations during continuous thoracic epidural infusion for thoracotomy provided an equal incidence of adverse haemodynamic effects, nausea, vomiting, or pruritus.

Introduction:Currently, there is no widely available method to evaluate an emergency department disaster plan. Creation of a standardized patient data- base and the use of a virtual, live exercise may lead to a standardized and reproducible method that can be used to evaluate a disaster plan.Purpose:A virtual, live exercise was designed with the primary objective of evaluating a hospital's emergency department disaster plan. Education and training of participants was a secondary goal.Methods:A database (disastermed.ca) of histories, physical examination findings, and laboratory results for 136 simulated patients was created using information derived from actual patient encounters.The patient database was used to perform a virtual, live exercise using a training version of the emergency department's information system software.Results:Several solutions to increase patient flow were demonstrated during the exercise. Conducting the exercise helped identify several faults in the hospital disaster plan, including outlining the important rate-limiting step. In addition, a significant degree of under-triage was demonstrated. Estimates of multiple markers of patient flow were identified and compared to Canadian guidelines. Most participants reported that the exercise was a valuable learning experience.Conclusions:A virtual, live exercise using the disastermed.ca patient database was an inexpensive method to evaluate the emergency department disaster plan. This included discovery of new approaches to managing patients, delineating the rate-limiting steps, and evaluating triage accuracy. Use of the patient timestamps has potential as a standardized international benchmark of hospital disaster plan efficacy. Participant satisfaction was high.

The patients affected by critical limb ischemia (CLI) are patients generally considered difficult cases, destined to repeated approach to the sanitary structures. They are patients affected by many pathologies since years, that they know to be potentially lethal often have already faced many interventions, with partial and not long-lasting benefits, they go from one specialist to another and sometimes they entrust themselves to alternative medicine. Physicians have to take in charge not the pathology but to take in charge the patient. For the control of the pain it turns out essential, near the block of the perception of the pain, to act with psychological participation, in order to interfere with the perception of the pain and the meant one of the pain, modify the feelings associated to the pain, modify the behavior induced by pain.

Chronic pain is a symptom that inevitably goes along with a condition of critical ischemia of the lower limbs, termed also as "obstructive peripheral arteriopathy". This sometimes displays worsening, provoking difficult physical and psychological behaviors of the patients. The complexity of this kind of patients results in difficulties in their clinical management. A multidisciplinary team, namely the close and coordinated collaboration of various kinds of professionists, could give better results, than an individual approach, thanks to strategies of re-equilibrating the systemic homeostasis of the given patient.

Electromagnetic navigation bronchoscopy (ENB) was reported to increase diagnostic yield in pulmonary nodules (PNs). The aim of this study was to assess if rapid on site evaluation (ROSE) associated with ENB could improve diagnostic accuracy in PNs after non-diagnostic fluoroscopy-guided bronchoscopy added to ROSE.Forty patients with PNs suspected for lung cancer underwent to ENB + ROSE after non-diagnostic Fluoroscopy-guided Bronchoscopy + ROSE. Each lesion was studied with reference to size, location, presence of bronchus sign on CT. All lesions were sampled by needle and brush; if negative, by forceps and bronchoalveolar lavage. All patients were followed-up until achievement of definitive diagnosis.Twenty-nine out of 41 lesions (70.7%) had a definitive diagnosis. ENB sensitivity for malignancy was 76.5%, with higher rate in presence of bronchus sign on CT (86.2%) and in case of lesions located in the upper and middle lobes (87.5%).ENB is a useful tool in the evaluation of PNs. High diagnostic accuracy may be related to sampling (transbronchial needle aspiration), ROSE, location and presence of bronchus sign.

In lizards, tail loss transects spinal nerves and the cut axons elongate in the regrowing tail, providing a natural paradigm of robust regenerative response of injured spinal motoneurons. We previously ascertained that these events involve nitric oxide synthase induction in the axotomized motoneurons, suggesting a correlation of this enzyme with regeneration-associated gene expression. Here we investigated, in lizards, whether the cell death repressor Bcl-2 protein and growth-associated protein-43 (GAP-43) were also induced in motoneurons that innervate the regenerated tail in the first month post-caudotomy. Single and multiple immunocytochemical techniques, and quantitative image analysis, were performed. Nitric oxide synthase, GAP-43 or Bcl-2 immunoreactivity was very low or absent in spinal motoneurons of control lizards with intact tail. Nitric oxide synthase and GAP-43 were induced during the first month post-caudotomy in more than 75% of motoneurons which innnervate the regenerate. Bcl-2 was induced in approximately 95% of these motoneurons at five and 15 days, and in about 35% at one month. The intensity of Bcl-2 and GAP-43 immunostaining peaked at five days, and nitric oxide synthase at 15 days; immunoreactivity to these proteins was still significantly high at one month. Immunofluorescence revealed co-localization of nitric oxide synthase, GAP-43 and Bcl-2 in the vast majority of motoneurons at five and 15 days post-caudotomy. These findings demonstrate that co-induction of nitric oxide synthase, Bcl-2 and GAP-43 may be part of the molecular repertoire of injured motoneurons committed to survival and axon regeneration, and strongly favor a role of nitric oxide synthase in motoneuron plasticity.

Perspective study in order to estimate the incidence of TURP-Syndrome, in spinal anesthesia (SA) with volemic expansion with sodium chloride solution 0.9 % vs 3%. Materials and Methods Two groups (gr) of patients (pt) A (n=20) and B (n=20) in SA have received like respective 500 ml of NaCl 0.9% and 250 ml. of NaCl 3%. The bladder was irrigated with a solution containing 1.5% glycine (1). We estimated: weight of prostate adenoma and weight of removed tessue, Sodium (Na) preop - intraop - postop. and after 24 hours, Ammonium (NH4+) pre - postop, volumes (V) of dropped solutions, V of dropped glycine (gl), operation time, core body temperature intraop and postop, mental state intra and postop., osmolarity. Results We found no significant difference in weight of adenoma and removed tessue. We have not observed any differences in the V of infusive solutions in the periop. We have not observed any difference in the values of Na preop. and postop, in those of NH4+ preop and postop, in operation time and in the V of gl. During procedure 5 pz. (S group) showed: visual disturbances, mental confusion (TURP-Syndrome) and hypertention (2). No pz. have any Na and NH4+ intraop.values altered. Time of TURP appeared bigger in non symptomatic patients (69 mn gr S. vs 48.43 gr.A and 47.26 gr. B). The V of instilled gl. has appeared meaningfully more elevated in gr. S (21.4 / vs 12 in gr.A and 12.31 in gr. B). The Na and NH4+ postop., Na after 24 hours and core body temperature have turned out statistically omogenee in all pt. In the 5 symptomatic pt the osmolarity values entered in normality ranges and they did not show differences between the groups considered. Conclusions We have not noticed any differences in using of the NaCl solution 0.9% versus NaCl 3% like volemic prefilling; the symptomatic patients have endured one longer procedure and greater amount of irrigating solution; their values of Na and NH4+ were in the limits of the normality; for this reasons perhaps the cause of symptoms in our patients would be searched in direct toxicity of glycine as inhibitory neurotrasmitter in CNS.

The Novara 118 emergency medical system (EMS) dispatch center manages medical emergency calls coming from a region that spreads out over 1,400 km2 and includes 88 towns and a population of 385,000 people; inhabitant density is 275 inhabitants/km2.

Multicasualty triage is the process of establishing the priority of care among casualties in disaster management. Recent mass casualty incidents (MCI) revealed that health personnel are unfamiliar with the triage protocols. The objective of this study is to compare the relative impact of two simulation-based methods for training medical students in mass casualty triage using the Simple Triage and Rapid Treatment (START) algorithm.

Emergencies and disasters can occur anywhere in the world, affecting human health and lives and the infrastructure built to support them. Chemical releases arising from technological incidents, natural disasters, and conflict and terrorism are common [1]. The International Federation of Red Cross and Red Crescent Societies has estimated that between 1998 and 2007, there were nearly 3,200 technological disasters with approximately 100,000 people killed and nearly 2 million people affected. Unfortunately, the threat of major events involving chemicals is predicted to increase worldwide for three main reasons. First, the chemical industry is rapidly growing, and the number of chemicals available in the market is increasing [2]. Second, chemical incidents may have an impact beyond their original location, in some cases crossing national borders. Third, there is concern regarding the deliberate use of chemicals for terrorist purposes [3].

Gli Autori, ritenendo che una cattiva divulgazione scientifica nuoccia al dibattito pubblico sulla c.d. "morte cerebrale", si addentrano nel concetto biologico di morte notando come le discussioni e le confusioni in merito riguardano fondamentalmente due punti: 1. l'identificazione della morte cerebrale con la morte della persona; 2. i criteri che devono essere accettati per una diagnosi corretta di morte cerebrale. Lo studio si propone successivamente di chiarire i possibili equivoci terminologici e concettuali nella difficile materia. Vengono, inoltre, presi in esame i meccanismi, i correlati anatomici e quelli clinici della morte cerebrale, illustrandone, infine, anche le procedure di accertamento (da quelle classiche a quelle più avanzate) sia nell'adulto che in età pediatrica.

Altered cardiovascular and respiratory function is uncommonly encountered in multiple sclerosis, though it may appear late in the course of the disease [4]. Episodes of acute ventilatory failure due to autonomic and/or voluntary respiratory function paralysis have already been described. These episodes are often accompanied by a focal neurological deficit which expresses lesion at the level of the medulla [6]. A demyelinating bulbar lesion leading to altered cardiovascular function is likewise infrequent but when it happens, bradycardia, postural hypotension [2], or acute pulmonary edema without heart failure may occur [1]. We present a case of non cardiogenic acute pulmonary edema which had neither a toxic insult nor an infective agent as etiology, but appeared as the initial manifestation of a multifocal demyelinating syndrome.

Introduction:Although most hospitals have an emergency department disas- ter plan, most never have been implemented in a true disaster or been tested objectively. Computer simulation may be a useful tool to predict emergency department patient flow during a disaster.Purpose:The aim of this study was to compare the accuracy of a computer simulation in predicting emergency department patient flow during a masscasualty incident with that of a real-time, virtual, live exercise.Methods:History, physical examination findings, and laboratory results for 136 simulated patients were extracted from the disastermed.ca patient database as used as input into a computer simulation designed to represent the emergency department at the University of Alberta Hospital.The computer simulation was developed using a commercially available simulation software platform (2005, SimProcess, CACI Products, San Diego CA). Patient flow parameters were compared to a previous virtual, live exercise using the same data set.Results:Although results between the computer simulation and the live exercise appear similar, they differ statistically with respect to many patient benchmarks. There was a marked difference between the triage codes assigned during the live exercise and those from the patient database; however, this alone did not account for the differences between the patient groups. It is likely that novel approaches to patient care developed by the live exercise group, which are difficult to model by computer software, contributed to differences between the groups. Computer simulation was useful, however, in predicting how small changes to emergency department structure, such as adding staff or patient care areas, can influence patient flow.Conclusions:Computer simulation is helpful in defining the effects of changes to a hospital disaster plan. However, it cannot fully replace participant exercises. Rather, computer simulation and live exercises are complementary, and both may be useful for disaster plan evaluation.

Dynamic predictors of fluid responsiveness (FR) perform poorly in ICU patients receiving partial ventilatory assistance. Because these modes of partial support are increasingly used, FR dynamic indexes are applicable only in a few ICU patients [1]. To overcome these limitations, novel approaches for testing FR in ICU have been proposed, such as the passive leg raising and the end-expiratory occlusion. These tests, however, may not always be applicable [2]. During controlled mechanical ventilation, Pulse Pressure (PP) and left ventricle stroke volume are coupled; their variations are due to the reduction of right ventricle stroke volume consequent to ventilator insufflation and are either proportional to the tidal volume and closely related to preload dependence.

Commonly, Disaster Medicine educational issues are often related to the Emergency Medicine domain, even though in Europe there is no clear definition about these two subjects. Yet, following the extraordinary succession of natural and technological disasters in Europe during the past several years (e.g. Chernobyl, flooding, forest fires), the governments belonging to the European Union are putting increasing pressure on national entities (ministries, universities, hospitals, local governments, etc.) to develop official plans, protocols, and guidelines that can be implemented in case the regular ‘pathways’ fail at any level. The study of disaster situations is included in the core curriculum of many schools at the undergraduate and post-graduate level (ranging from Architecture to Computer Science to Economics), and the possibility of short-, medium-, and long-term chain-reaction effects involving the environment and affected population are being examined. At least in Europe, the body of knowledge belonging to the study of Medicine, despite being very rich and formally exhaustive, is mostly oriented to the ideal situation of doctor and patient, rather than to the occurrence of any type of system failure causing a massive number of casualties and the need to provide treatment, even in hostile environments and over time. Two core subjects, Epidemiology and Occupational Medicine, offer students the possibility to think in terms of hundreds to millions of patients.

Traumatic injury and trauma deaths have been worldwide considered a major health problem [1]. The World Health Organization estimates that 16 000 people die everyday from trauma injuries, and for every person who dies, several thousands more are injured, many of them with permanent sequelae. Injury accounts for 16% of the global burden of disease [2].

In Italy (130,000 new strokes in the general population per year) ischemic stroke is the third cause of death, after cardiovascular disease and neoplastic disease with a prevalence of 6.5%. Different physicians are involved in the emergent evaluation and treatment of the acute ischemic stroke. As other acute events, the initial evaluation must be addressed to assess the patient's airway and breath-ing and cardiocirculatory conditions. The neurological examination must not be exhaustive and it should be completed in 5-10 minutes and a particular attention should be given to clinical findings leading to the suspect of an intracranial hemorrhages. A plain CT scan of the brain is the most important initial diagnostic study. Emergency therapy must be mainly directed to the correction of hypovolemia, hypoxia and the treatment of severe hypertension, hypoglycemia, intracranial hypertension and seizures. The goal is to achieve and to maintain an adequate cerebral perfusion by lowering the intracranial pressure (treating the cerebral oedema) and by increasing the mean arterial pressure, with an appropriate volemic expansion and/or with inotropic or vasopressor drugs. The thrombolytic therapy with intravenous recombinant tessutal plasminogen activator (r-TPA) when not specifically contraindicated, is recommended within 3 hours of onset of ischemic stroke. The benefit of intravenous r-TPA for acute ischemic stroke beyond 3 hours from the onset has never been proved.

During the last 20 years many trauma-scoring indexes have been developed and their applicability seems to be important mainly because they could allow [1]: comparisons of the efficacy of different therapeutic interventions and outcome quick triage during the pre-hospital phases as well as priority treatments.

Noninvasive ventilation through a mask is commonly applied in pressure support ventilation (nPSV). Recent studies showed that noninvasive neurally adjusted ventilatory assist (nNAVA) improves patient-ventilator interaction and synchrony. More recently we described a new setting for nNAVA (nNAVA15) able to reduce the peak of electrical activity of the diaphragm (EAdipeak) and dyspnea (assessed by a visual analogue scale, VASd), compared with both nPSV and nNAVA, in patients undergoing NIV through a helmet, by improving the rate pressurization. We therefore designed a physiological study to evaluate and compare the effects of nNAVA15 with nPSV and nNAVA on VASd, EAdipeak, pressurization rate and arterial blood gases (ABGs).

Noninvasive neurally adjusted ventilatory assist by helmet (hNAVA) was shown to improve, compared with pressure support ventilation by helmet (hPSV), patient-ventilator interaction and synchrony in patients with acute respiratory failure without affecting peak electrical activity of the diaphragm (EAdipeak) [1]. Recently, a new helmet is available, which improves pressurization during hPSV. We propose a new setting of hNAVA (hNAVA15) to achieve further improvement. We compare hPSV, hNAVA and hNAVA15, all delivered using the new helmet, with respect to patient's dyspnea, assessed by a visual analogue scale (VASd), arterial blood gases (ABGs), EAdipeak, rate of ventilator pressurization and triggering performance.

Primary neurological injury due to any kind of insult (traumatic, ischaemic, hypoxic, metabolic) can be followed by a chain of pathological events, that can worsen or perpetuate the primary lesion within minutes, hours or days. This group of derangements is traditionally defined as secondary damage, and its principal determinant, regardless of the producing cause, is ischaemia-anoxia.

The lizard tail regenerates after amputation, which severs the spinal cord and spinal nerves. Dorsal root ganglia (DRGs) do not regenerate in the regrowing tail, which is innervated by DRGs rostral to the amputation. With Nissl staining, NADPH-diaphorase histochemistry and nitric oxide synthase (NOS) immunohistochemistry, we investigated NOS expression and its relationship with structural changes in DRG neurons of caudotomized lizards. First, by horseradish peroxidase retrograde tracing we here provided evidence that the sensory innervation of the regenerated tail derives only from the three pairs of DRGs rostral to the amputation plane. These ganglia were then analyzed in control animals with original intact tail, at 5, 15 and 30 days after caudotomy, and at 8 months in lizards with mature regenerates. Caudotomy elicited in DRG neurons marked hypertrophy that persisted after tail regeneration. In control ganglia, most neurons were lightly NADPH-diaphorase-positive, a few were unstained or intensely stained. Tail transection elicited marked staining up-regulation, and an increase in the proportion of intensely positive neurons. The staining intensity peaked in DRG neurons at 15 days and was still significantly increased in respect to controls several months after complete tail regeneration. NOS immunoreactivity in DRGs matched the histochemical findings. NADPH-diaphorase positivity was also enhanced in the dorsal horn superficial laminae of the corresponding spinal segments. We demonstrate that transection of the lizard spinal nerves, provoked by tail loss, elicits in the axotomized primary sensory neurons marked NOS enhancement, which accompanies axon elongation in the regrowing tail and persists after the end of this process.

To study the impact of severe head injury on both basal pituitary hormone secretion and the response to exogenous synthetic hypothalamic releasing factors (TRH and GHRH) in order to evaluate sequential changes in the central control of hypophyseal secretion in the days following head injury.Prospective clinical study21 comatose male patients with head injuries, each intubated and ventilated, intensively monitored and having no previous endocrine problems.AND RESULTS The GH and PRL responses to TRH (200 microg iv), and the GH and PRL responses to GHRH (50 microg iv) were evaluated, respectively, on the days 1 and 16 and on days 2, 7and 15 after admission. Daily blood samples were also collected for GH, PRL, TSH, T3 and T4 evaluation. In the basal samples taken on days 2, 7 and 15, IGF-I and cortisol were also determined. Nitrogen balance was assessed daily. On the day 1, TRH increased GH levels from 9.8 +/- 2.2 to 22.4 +/- 6.5 mU/l but failed to induce GH release on day 16. The PRL response to TRH was normal. The GH peak response to GHRH was normal on the day 2 (35.7 +/- 13.9 mU/l), but was increased on days 7 and 15 (68.3 +/- 10.7 mU/l on day 7; 73.8 +/- 9.2 mU/l on day 15, P0.01 vs. day 2). We found a significant PRL response to GHRH during the whole period of observation. In the daily evaluation, nitrogen balance was negative in all patients from the day 1 to 5. On average, all patients reached a positive nitrogen balance on the day 8. Compared to the day 2, a statistical increase in IGF-I concentration was observed on days 7 and 15.The evaluation of pituitary dynamics in the acute phase of a severe injury demonstrates an alteration of GH and PRL secretion, which correlate with the aminergic and/or peptidergic derangements. Taken together, our data suggest augmented tone of both GHRH and somatostatin in the very acute phase, while an imbalance of releasing factors is hypothesized in the following days. The metabolic consequences of this neuroendocrine pattern could be advantageous in the rapid recovery from the cascade of events produced by the trauma, as documented by the increase in IGF-1 levels and the positive nitrogen balance.

We evaluated cerebral variation in oxyhemoglobin, deoxyhemoglobin, and cytochrome oxidase before and after transcranial magnetic and electrical stimulation in ten healthy volunteers using near-infrared spectroscopy. Immediately after magnetic but not after electric stimulation a significant increase in oxyhemoglobin and a decrease in cytochrome oxidase were observed (P < 0.05). Our data suggest that repetitive transcranial magnetic stimulation induces metabolic activation of the cerebral cortex together with an increase in cerebral blood flow.