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Francesco Mongelli,1 Massimo Lucchelli,2 Davide La Regina,3 Dimitri Christoforidis,1 Andrea Saporito,4 Alberto Vannelli,5 Matteo Di Giuseppe3 1Department of Surgery, Ospedale Regionale di Lugano, Lugano, Switzerland; 2Financial Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 3Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 4Department of Anesthesia, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 5Department of Surgery, Ospedale Valduce, Como, ItalyCorrespondence: Francesco MongelliOspedale Regionale di Lugano, via Tesserete 46, Lugano, 6900, SwitzerlandTel +41764706297Fax +41918119066Email francesco.mongelli@mail.comBackground: Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.Methods: From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.Results: Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482± 386 vs 613± 543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606± 816 vs 2769± 1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of − 243 ± 881 EUR/pain unit on the VAS.Conclusion: Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.Keywords: pudendal nerve, nerve block, cost-benefit analysis, postoperative pain, hospital costs

Background: The aim of this retrospective and observational study was to analyse the impact of the introduction of a goal directed transfusion (GDT) strategy based on a viscoelastic test (ROTEM®) and specific procoagulant products in a patient blood management (PBM) Program on blood product use and perioperative bleeding in a single cardiac surgery centre. Study Design and Methods: Patient population underwent cardiac surgery from 2011 to 2021 was divided in two groups based on PBM protocol used (G#11–14, years 2011–2014, G#15–21, years 2015–2021) and compared for the following variables: intraoperative and postoperative transfusions of packed red blood cell and any procoagulant products, postoperative drain blood loss volume and rate of re‐exploration surgery. The second program was defined after the introduction of a GDT protocol based on viscoelastic tests and specific procoagulant products. Results: After the introduction of a GDT protocol, about 80% less amongst patients were transfused with fresh frozen plasma and any procoagulant product (p < 0.001 for both phases). Moreover, similar results were obtained with PRBC transfusions (p < 0.001) and drain blood loss volume (p = 0.006) in the postoperative phase. The main factors affecting the use of any procoagulant and PBRC transfusion in the multivariate logistic regression analysis was Group (2 versus 1, OR 0.207, p < 0.001) and preoperative haemoglobin (OR 0.728, p < 0.001), respectively. Discussion: In our experience, a GDT strategy for the diagnosis and treatment of the coagulopathy in patients undergone cardiac surgery led to a significant reduction in bleeding and transfusion. [ABSTRACT FROM AUTHOR]

Objectives: The immunologic profile and opportunistic viral DNA increase were monitored in Italian patients with COVID-19 in order to identify markers of disease severity. Methods: A total of 104 patients infected with SARS-CoV-2 were evaluated in the study. Of them, 42/104 (40.4%) were hospitalized in an intensive care unit (ICU) and 62/104(59.6%) in a sub-intensive care unit (SICU). Human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV), Parvovirus B19 and Human Herpesvirus 6 virus reactivations were determined by real-time PCR, and lymphocyte subpopulation counts were determined by flow cytometry. Results: Among opportunistic viruses, only EBV was consistently detected. EBV DNA was observed in 40/42 (95.2%) of the ICU patients and in 51/61 (83.6%) of the SICU patients. Comparing the two groups of patients, the EBV DNA median level among ICU patients was significantly higher than that observed in SICU patients. In parallel, a significant reduction of CD8 T cell and NK count in ICU patients as compared with SICU patients was observed (p

Robots have been used for many years in therapeutic activities with people with Autism Spectrum Disorder. However, most robots presented in the literature have limited or no mobility, are made of rigid materials, or are too expensive for many care centers. We share the choices and the design rationale of the latest version of a soft, mobile, low-cost, autonomous robot that has successfully been used for 3 years in a care center for activities that include both free play and structured games. Moreover, the kind of activities that can be performed with this robot, and the feedback obtained from therapists about its application are reported.

Catatonia is a complex identifiable clinical syndrome characterized primarily by psychomotor symptoms. In recent decades, some authors have considered that catatonia can be presented as a catatonic syndrome in several pathologies such as bipolar disorder, schizophrenia and other psychotic disorders and not only in schizophrenia. Prior to DSM 5, there were two conceptions of catatonia: one in which clinical characterization seemed to play a determining role (a categorical view) and another in which a dimensional perspective advocated the existence of catatonia as a clinical entity in its own right, detached from the underlying pathology. Although there are no definitive consensus guidelines for the treatment of catatonia, some studies show that in the schizophrenic form of catatonia, benzodiazepines are partially effective, as well as treatment with ECT. We present the case of a 24-year-old man with severe catatonia and psychotic symptoms, resistant to lorazepam treatment, who achieved complete remission with clozapine treatment according to our diagnostic hypothesis of schizophrenia.

Autism Spectrum Disorder (ASD) is defined by the copresence of two core symptoms: alteration in social communication and repetitive behaviors and/or restricted interests. In ASD children and adults, irritability, self-injurious behavior (SIB), and Attention Deficit and Hyperactivity Disorders- (ADHD-) like symptoms are regularly observed. In these situations, pharmacological treatments are sometimes used. Selective Serotonin Reuptake Inhibitors- (SSRI-) based treatments have been the subject of several publications: case reports and controlled studies, both of which demonstrate efficacy on the symptoms mentioned above, even if no consensus has been reached concerning their usage. In this article four clinical cases of children diagnosed with ASD and who also present ADHD-like symptoms and/or SIB and/or other heteroaggressive behaviors or irritability and impulsivity treated with low doses of fluoxetine are presented.

Background: LV unloading strategies during VA-ECMO support are still based on local expertise. The aim of this retrospective observational study is to investigate the current LV unloading indications and strategies. Methods: Among 2012 to 2021, patients receiving VA-ECMO associated with any LV unloading strategy were enrolled in 15 ICUs (14 located in Italy, one in the Netherlands). Data on the VA-ECMO management, unloading strategy and related applied techniques were collected. Results: 425 patients (mean age 53,8±15,9 years old, 72,6 % males, BMI 24,8,±6,92 kg/m2) were supported with VA-ECMO (6,7±5,8 days) and concomitantly received any unloading strategy (14,9%). The VA-ECMO indications were either refractory cardiogenic shock, CS (64,1 %, SCAI-class: A-B,1,6%; C,17,1%; D,44,2%; E,37,2%) or cardiac arrest, CA (35,9%). The CS indications were mainly acute coronary syndromes (35,6%), post CA (29,8%), post-cardiotomy shocks (29,6%) and acute heart failure, accounting for one fifth of CS (20,9%). At the time of LV unloading, mean arterial pressure was 60,4±21,6 mmHg, heart rate 89,9±30,3 bpm mainly in sinus rhythm (71,2%). Almost all patients were treated with inotropes/vasopressor (90,1%). LV overload was mainly defined on bed-side echocardiogram (71,2 %), arterial line pulseless (19,2%), X-ray (10,7%) and pulmonary artery catheter (2,2%). Among the echocardiographic parameters, the LV unloading interventions restored the AV opening in half of patients (52%), reverted smoke like effect in the overwhelming majority (86,3%) and effectively reduced LA and LV distension (82,8% and 85,4%, respectively). Overall, the discharge survival rate was 37,2%, mainly with a mild-moderate LV dysfunction (mean ejection fraction 48,6±13,7%). Almost one out of ten patients were bridged to Heart Transplantation (8,3%) and 5,2% bridged to LVAD. The survival of patients supported with VA-ECMO experiencing LV overload is very poor. This retrospective observational study clearly showed the crucial role of bedside echocardiogram in the LV unloading decision making. [ABSTRACT FROM AUTHOR]

perioperative hyperglycemia is common in patients undergoing cardiac surgery and it is associated with increased risks of mortality and morbidity1. The pathogenesis of perioperative dysglycemia is a complex interaction between underlying patient's condition (diabetes, metabolic syndrome) and surgical stress. This study evaluates an intraoperative glucose control protocol designed according to the European Association for Cardio-Thoracic Surgery (EACTS) guidelines2 to manage blood glucose levels during surgery. we developed an intraoperative blood glucose (BG) control protocol (figure 1) with a target of BG <180 mg/dL. Patients were divided into three risk categories: very high (HH) for type 1 diabetes, high (H) for insulin-dependent or non-insulin- dependent diabetes, metabolic syndrome, or chronic steroid therapy, and low (L) for patients without these conditions. BG was measured first after general anesthesia induction, subsequently every 30-40 minutes, the last measurement was at ICU admission. Insulin therapy was started at BG>180 mg/dL for H and L groups, and BG>110 mg/dL for HH group. Patients with urgent or emergent surgeries were treated as H group regardless their comorbidities. 1-year retrospective analysis (March, 2023 – March, 2024). Data were analyzed by Sigmastat 11 (SPSS inc. Chicago, IL) and presented as mean ± SD or median [interquartile range], t-test was used for comparisons. 495 patients were treated with this protocol. Data from 442 patients (HH=1; H=266; L=175) were analyzed, while 53 patients (10%) were excluded due to incorrect protocol application. Overall 180 (41%) patients underwent glycemic control protocol as described above (HH n=1, 100%, H n=125, 46% and L n=54, 31%).344 patients underwent elective surgery and 35% of these (n=120; group L n= 53, 44%; group H n= 67, 56%) needed insulin protocol. Urgent surgeries showed a higher prevalence of hyperglycemia, affecting 60 of 97 patients (62%). Figure 2 describes intraoperative BG (off-pump surgery n=16, 3%; on-pump surgery n=426, 96% with CPB time = 107 [88-128] minutes). At the end of surgery, BG was on average under 180 mg/dl in all groups and urgent surgery. In the elective group BG at ICU admission was 145±40 mg/dL in patients with intraoperative insulin protocol, versus 136±25 mg/dL in patients who did not require insulin (p=0.010). A higher difference (<0.01) was observed in BG at ICU admission between patients that required insulin protocol and who did not (165±59 versus 129±24 mg/dL). Mild hypoglycemia was observed in 3 cases, all during elective surgery. Two patients in group H (BG 69 and 66 mg/dL) and one patient in group L (BG 57 mg/dL), treated without any complication. The protocol showed to be effective in managing intraoperative hyperglycemia, as reflected by a good glycemic control at ICU admission. The stratification of patients by risk allowed a more tailored approach which optimal BG control and minimal hypoglycemia risk. Furthermore, urgent surgery remains a significant trigger for hyperglycemia, resulting in more patients requiring the protocol application with less efficacy than the elective group. [ABSTRACT FROM AUTHOR]

Shallow landslides are very dangerous phenomena, widespread all over the world, which could provoke significant damages to buildings, roads, facilities, cultivations and, sometimes, loss of human lives. It is then necessary assessing the most prone zones in a territory which is particularly susceptible to these phenomena and the frequency of the events, according to the return time of the triggering events, which generally correspond to intense and concentrated rainfalls. Susceptibility and hazard of a territory are usually assessed by means of physically-based models, that quantify the hydrological and the mechanical responses of the slopes according to particular rainfall amounts. Whereas, these methodologies could be applied in a reliable way in little catchments, where geotechnical and hydrological features of the materials affected by shallow failures are homogeneous. Moreover, physically-based models require, sometimes, significant computation power, which limit their implementations at regional scale. Data-driven models could overcome both of these limitations, even if they are generally built up taking into only the predisposing factors of shallow instabilities. Thus, they allow usually to estimate the susceptibility of a territory, without considering the frequency of the triggering events. It is then required to consider also triggering factors of shallow landslides to allow these methods to estimate also the hazard. This work presents the preliminary results of the development and the implementation of data-driven model able to estimate the hazard of a territory towards shallow landslides. The model is based on a Genetic Algorithm Model (GAM), which links geomorphological, hydrological, geological and land use predisposing factors to triggering factors of shallow failures. These triggering factors correspond to the soil moisture content and to the rainfall amounts, which are available for entire a study area thanks to satellite measures. The methodological approach is testing in different catchments of 30−40 km2 located in Oltrepò Pavese area (northern Italy), where detailed inventories of shallow landslides occurred during past triggering events and corresponding satellite soil moisture and rainfall maps are available. This work was made in the frame of the ANDROMEDA project, funded by Fondazione Cariplo.