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Introduction Perioperative antibiotic prophylaxis has proved to reduce the number of postoperative infections. In cardiac surgery, the infections in the surgical site are found to be around 0.4-4%. The most common bacterias causing surgical site infections in cardiac surgery are gram-positive. Our aim in to guide the reader in the decision of choosing the most adequate Perioperative Antibiotic Prophylaxis in each patient according to their characteristics and their environment. Methods The most recent bibliography was reviewed searching the most common antibiotics used in perioperative Antibiotic Prophylaxis in cardiac surgery. A bibliographic search was carried out in the PubMed-MEDLINE database. A peer review was performed and a total of 4 references of more than 30 were selected. Results There is no difference in the Surgical Site Infections between the use of 1st generation of Cephalosporin or Glycopeptides such as Vancomycin or Teicoplanin. On the other hand, 1st generation of Cephalosporin reduces the incidence of infections produced by Staphylococcus. Nevertheless, Glycopeptides are better at avoiding infection produced by Staphylococcus and Enterococcus resistant than Cephalosporin. Discussion Choosing Perioperative Antibiotic Prophylaxis must be individualized according to the bacterial flora in the environment, the different characteristics of the patients, and the type of cardiac surgery. Also, a high incidence of Staphylococcus Aureus methicillin-resistant must receive prophylaxis with Vancomycin and a second antibiotic should be considered.

Targeted intrathecal (IT) drug delivery systems (IDDS) are well established as an effective treatment of patients with chronic nonmalignant or malignant pain, and as a tool for management of patients with severe spasticity. The risk to benefit ratio of IDD makes it a relatively safe therapy for both cancer- and noncancer-related pain, but it is not free of risks, so it should be managed at specific centers. Recent technological advances, new therapeutic applications, reported complications, and the costs as well as maintenance required for this therapy require the need to stay up to date about new recommendations that may improve outcomes. This chapter reviews all technological issues regarding IDDS implantation with follow-up and pharmacological recommendations published during recent years that provide evidence-based decision-making process in the management of chronic pain and spasticity in patients.

This chapter describes the microanatomy of the spinal cord that is relevant to intrathecal drug delivery started with covering of the spinal cord that are pierced to enter the intrathecal space. The dural sac is mostly constituted by the outer layer of dura and the inner layer called arachnoid membrane, which regulates diffusion of drugs into the intrathecal space. The pia matter surrounding the spinal cord is a permeable structure allowing the passage of drugs through intercellular spaces. The relationship between nerve roots, CSF, and subarachnoid catheters determines the passage of an intrathecal catheter which can cause damage to nerve roots and spinal cord. Multiple factors may be involved in the mechanisms of drug diffusion across the membranes of the spinal cord, as well as in their dilution with the CSF, which will lead to the final drug distribution and availability at nerve roots and the spinal cord.

The descending pain modulatory system (DPMS) comprises a network of cortical and subcortical brain and brainstem regions that can inhibit nociceptive afferent brain input (Ossipov et al., 2010; Tracey, 2010; Zhuo and Gebhart, 1997). These pathways seem to be altered in several chronic pain syndromes such as knee osteoarthritis, fibromyalgia, painful diabetic neuropathy and low back pain (Brietzke et al., 2019; da Graca-Tarrago et al., 2019; Kong et al., 2018; Segerdahl et al., 2018). The DPMS network comprises the bilateral anterior insulae (AI), the anterior cingulate cortex (ACC), bilateral middle frontal gyri (mFG), both amygdalae (AMY), the rostral ventromedial medulla (RVM) and the periaqueductal gray (PAG) (Goksan et al., 2018; Schweinhardt and Bushnell, 2010). In the past, it has been suggested that traditional, paresthesia-generating Spinal Cord Stimulation (SCS) induces several changes in modulation circuits located in the cerebrum and brainstem. An inhibitory effect of traditional SCS on somatosensory evoked potentials, and potential mediators like the thalamus and the anterior cingulate cortex (ACC), could play a role in the mechanism of action (MOA) of SCS as well (Bentley et al., 2016; De Ridder and Vanneste, 2016; Moens et al., 2013, 2012). Several studies have provided evidence of the impact of SCS on the DPMS resulting in this inhibitory supraspinal effect (Sankarasubramanian et al., 2018; Schuh-Hofer et al., 2018). More recently, researchers have hypothesized similar influences on the DPMS by other paradigms of SCS such as high frequency SCS at 10 kHz and Burst SCS, as well as by other forms of neurostimulation e.g. occipital nerve field stimulation (Ahmed et al., 2018a, 2018c). Tonic SCS at sub-sensory threshold and at 500 Hz and pulse width 500μsec, so called high density or high dose SCS (HD-SCS), is a SCS form based on the impact of electrical charge delivery to the spinal cord (Chen et al., 2018; Linderoth and Foreman, 2017; Miller et al., 2016; Sweet et al., 2016; Wille et al., 2017). After some initial case series studies, researchers are still exploring the clinical effect and impact on chronic pain of HD-SCS (De Jaeger et al., 2017; Provenzano et al., 2017; Wille et al., 2017). In the past, several researchers have investigated the supraspinal effects of SCS by examining human cerebral circuits via different neuroimaging techniques (e.g. MR Spectroscopy (MRS), single photon emission computerized tomography (SPECT), positron emission tomography (PET), electroencephalography (EEG) and, functional magnetic resonance imaging (fMRI)) to capture alterations in modulation circuits (De Ridder and Vanneste, 2016; Kishima et al., 2010; Moens et al., 2013, 2012; Nagamachi et al., 2006). fMRI is especially interesting due to the robustness and test-retest reliability of the functional connectivity (FC) method in clinical applications (Apkarian, 2015; Shehzad et al., 2009). Additionally, the introduction of MRI-conditioned SCS devices enables further exploration of MOA of SCS, not only during trial period but also on long-term implanted devices. Based on this knowledge, we hypothesized, in this study, that HD-SCS may alter the DPMS and indirectly, might generate an inhibitory supraspinal effect. This hypothesis-driven pilot study aimed to investigate the influence of HD-SCS on FC within the DPMS, measured by resting state fMRI.

What is the central question of this study? Although different studies have attempted to find factors that influence the expression of aquaporins (AQPs) in the lung in different situations, to date no research group has explored the expression of AQP1 and AQP5 jointly in rats mechanically ventilated with different tidal volumes in a model of ventilator-induced lung injury. What is the main finding? Mechanical ventilation with a high tidal volume causes lung injury and oedema, increasing lung permeability. In rats ventilated with a high tidal volume, the pulmonary expression of AQP1 decreases. We analysed the expression of aquaporins 1 and 5 and its relation with tidal volume in a model of ventilator-induced lung injury. Forty-two rats were used. Six non-ventilated animals were killed (control group). The remaining rats were ventilated for 2 h with different tidal volumes (group 7ML with 7 ml kg

Opioid analgesics are important therapeutic options for chronic non-cancer pain (CNCP), recognized as a major public health issue with high social and economic burden. The increasing therapeutic opioid use for CNCP, misuse and abuse of prescription opioids have become matters of severe concern in USA. The recent position paper of the American Academy of Neurology (AAN) about the use of opioids in USA expresses growing alarms about opioid misuse/abuse, and has alerted physicians worldwide to rethink about their prescription practice. Current US practice in opioid prescription has been associated with morbidity and mortality of epidemic proportions: over 100,000 people directly or indirectly died from prescribed opioids in USA in the last twenty years, reaching 16,651 deaths in 2010. The actually alarming data from US have initiated pain physicians and researchers to re-evaluate their prescribing policies and attitudes for long-term treatment of non-cancer patients with opioids. In this position paper it is explained that any change in clinical behavior should not be based on an uncritical generalization of the US data that do not reflect the European situation. The primary objective of pain physicians remains to adequately treat chronic pain. Opioids are and will continue to remain an essential part of the "armamentarium against pain"; physicians should use them in the best way, i.e. after thorough diagnosis, assessment of alternative therapeutic options in the context of a multimodal treatment concept, and with repeated careful re-evaluations of the proper indication by a close long-term follow-up of any chronic opioid patient.

Because of the characteristics of direct oral anticoagulants (DOA), the lack of an antidote to completely reverse their anticoagulant effects, the absence of standardization in monitoring of their effects, and limited experience of their use, specific recommendations for their management in the perioperative period or in emergencies are required. In elective surgery, in patients with normal renal function and low hemorrhagic/ thrombotic risk, DOA should be withdrawn 2 days before the intervention; when the hemorrhagic/ thrombotic risk is higher, bridge therapy with a low molecular weight hepatin beginning 5 days before the intervention is proposed as an alternative. In emergency surgery, systematic administration of hemostatic drugs as prophylaxis is not recommended. In DOA-related acute hemorrhage, administration of prothrombin complex concentrate, fresh plasma or factor VIIa should be evaluated, and general measures to control bleeding should be implemented.

Botulinum toxin is a neurotoxin that has been widely used in chronic pain for the treatment of multiple conditions with a component of localized muscle spasm. Recent studies suggest that botulinum toxin is effective in the treatment of neuropathic pain syndromes such as post-herpetic neuralgia.We report the case of a 67-year-old man who underwent atypical segmentectomy of a right lower lobe lung nodule. The patient was referred to our pain management department with a of 2-year history persistent pain along the thoracotomy scar having a predominantly neuropathic component, refractory to standard treatments. He was successfully treated with subcutaneous botulinum toxin type A.On the basics of our own experience and on the analysis of the reports published in the literature, fractioned subcutaneous injections of botulinum toxin may be useful for the treatment of various chronic localized pain conditions including chronic post-thoracotomy pain.

Internal infusion pumps are implantable and programmable systems that have been widely used for years in the management of chronic pain. During the past few years, these devices have had an increasingly prominent role given the possibility of insulin infusions in patients with diabetes mellitus because they provide patients with higher autonomy in the management of their disease, despite the fact that they are expensive systems and require surgery for implantation. These features make internal infusion pumps a suitable therapeutic option for those patients who need to use artificial tears continuously because of severe dry eyes. We report a case of severe eye pain due to xerophthalmia in a patient with CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome who was treated with an implanted pump reservoir.

4 pages.-- Final full-text version of the paper available at: http://dx.doi.org/10.1111/j.1551-2916.2007.02034.x., Fly Ash Belite Cement (FABC) pastes with and without nanosilica additions have been prepared and maintained in sulfate solutions (Na2SO4 0.5M) for 180 days. The mechanical performance and the changes in microstructure have been monitored at 28, 90, and 180 days by compressive strength, X-ray diffraction (XRD), and 29Si MAS NMR measurements. We have found that, unexpectedly, and contrary to what happens in Ordinary Portland Cements (OPC), the addition of nanosilica particles induces an initial decline in the compressive strength of the samples. Only in samples maintained for a long time (180 days) does the nanosilica addition improve the mechanical properties. Our XRD and 29Si NMR experiments have revealed that although nanosilica additions trigger the consumption of Belite phases, this is not always accompanied by formation of longer calcium–silicate–hydrate (C–S–H) gel structures. Only at a long time (180 days), and due to a mechanism that seems to be controlled by the pH of the samples, do the nanosilica additions lead to high-polymerized C–S–H gels., This work was financially supported by the Spanish Government (Projects no. MAT 2002-04023-CO1-CO2-CO3 and MAT2005-03890).

Growing interest in the effect of hemostasis-altering medications on regional anesthetic techniques was analyzed recently in a review article suggesting certain safety measures, by Llau and colleages in Revista Española de Anestesiología y Reanimación. Since that review, however, it has become necessary to extend the discussion of clinical issues, based on information presented at the Eighth Local Meeting of the European Society for Regional Anesthesia (ESRA) of May 2002. There, participants debated the most controversial aspects, with attention to practical questions such as temporal safety margins and approaches to take given certain platelet antiaggregants, fibrinolytics or drug combinations. This paper faithfully presents the suggestions made by participants at the meeting. As most anesthesiologists expressed the need to set guidelines for fibrinolytics, the main issues related to those drugs in regional anesthesia are reviewed.

Sin resumen

Stroke is the main cause of admission to Neurology departments and cardioembolic stroke (CS) is one of the most common subtypes of stroke.A multicentre prospective observational study was performed in 5 Neurology departments in public hospitals in the Region of Madrid (Spain). The objective was to estimate the use of healthcare resources and costs of acute CS management. Patients with acute CS at48h from onset were recruited. Patients' socio-demographic, clinical, and healthcare resource use data were collected during hospitalisation and at discharge up to 30 days after admission, including data for rehabilitation treatment after discharge.During an 8-month recruitment period, 128 patients were recruited: mean age, 75.3±11.25; 46.9% women; mortality rate, 4.7%. All patients met the CS diagnostic criteria established by GEENCV-SEN, based on medical history or diagnostic tests. Fifty per cent of the patients had a history of atrial fibrillation and 18.8% presented other major cardioembolic sources. Non-valvular atrial fibrillation was the most frequent cause of CS (33.6%). Data for healthcare resource use, given a mean total hospital stay of 10.3±9.3 days, are as follows: rehabilitation therapy during hospital stay (46.9%, mean 4.5 days) and after discharge (56.3%, mean 26.8 days), complications (32%), specific interventions (19.5%), and laboratory and diagnostic tests (100%). Head CT (98.4%), duplex ultrasound of supra-aortic trunks (87.5%), and electrocardiogram (85.9%) were the most frequently performed diagnostic procedures. Average total cost per patient during acute-phase management and rehabilitation was €13,139. Hospital stay (45.0%) and rehabilitation at discharge (29.2%) accounted for the largest part of resources used.Acute CS management in the Region of Madrid resulted consumes large amounts of resources (€13,139), mainly due to hospital stays and rehabilitation.