Filadelfo Coniglione

Comparison of epidural, continuous femoral block and intraarticular analgesia after anterior cruciate ligament reconstruction

Background: The purpose of this study was to compare three locoregional techniques of pain management after arthroscopic anterior cruciate ligament reconstruction (ACLR).

White matter reduced streamline coherence in young men with autism and mental retardation

Background and purpose:  It has been proposed that white matter alterations might play a role in autistic disorders; however, published data are mainly limited to high‐functioning autism. The goal of this study was to apply diffusion tensor imaging (DTI) and fiber tractography (FT) to study white matter in low‐functioning autism and the relationship between white matter and cognitive impairment.

Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction

Background and Objectives: This prospective, randomized, clinical trial compared pain intensity and analgesic drug consumption after anterior cruciate ligament (ACL) reconstruction with patellar tendon under femoral-sciatic nerve block anesthesia in patients who received either a continuous femoral nerve block (CFNB) or continuous local anesthetic wound and intra-articular infusions. Methods: Fifty patients were randomized to CFNB (n = 25) or an ON-Q device (I-Flow Corp, Lake Forest, Calif) (n = 25). All patients received sciatic nerve block (25 mL of ropivacaine 7.5 mg/mL and clonidine 30 &mgr;g). The first group received a CFNB (2 mg/mL of ropivacaine at 7 mL/hr), and the second group received a single-shot femoral nerve block (both using 25 mL of ropivacaine 7.5 mg/mL and clonidine 30 &mgr;g). At the end of the intervention, an ON-Q device was positioned on the ON-Q patients to continuously infuse the patellar tendon wound and intra-articular cavity with ropivacaine 2 mg/mL at 2 mL/hr for each catheter. Data regarding demographic, hemodynamic, pain scores, adverse effects, and need for supplemental analgesia were registered in a 36-hr follow-up period. Results: The CFNB group reported lower visual analog scale values than the ON-Q group: at rest at 12 hrs (2.4 [SD, 2.2] vs 5.4 [SD, 3.1]; P < 0.001) and on movement at 12 (3.1 [SD, 2.5] vs 6.3 [SD, 2.9]; P < 0.001) and 24 hrs (2.7 [SD, 1.9] vs 4.6 [SD, 2.6]; P = 0.01) after surgery. The number of morphine and ketorolac boluses was lower in the CNFB group (morphine: 3.2 [SD, 2.2] vs 6.2 [SD, 2.5]; P < 0.001; ketorolac: 1.1 [SD, 1.0] vs 2.4 [SD, 0.9]; P < 0.001). Conclusion: Continuous femoral nerve block provides better analgesia than the continuous patellar tendon wound and intra-articular infusions after anterior cruciate ligament reconstruction with patellar tendon.

Long-term cognitive and behavioral therapies, combined with augmentative communication, are related to uncinate fasciculus integrity in autism.

Recent evidence points to white-matter abnormalities as a key factor in autism physiopathology. Using Diffusion Tensor Imaging, we studied white-matter structural properties in a convenience sample of twenty-two subjects with low-functioning autism exposed to long-term augmentative and alternative communication, combined with sessions of cognitive and behavioral therapy. Uncinate fasciculus structural properties correlated significantly with therapy length and early onset, as well as to clinical outcome, independently from IQ, age or symptoms severity at therapy onset. Moreover, adherence to therapy was linked with better clinical outcome and uncinate fasciculus structural integrity. The results point to the capability of a long-term rehabilitation of subjects with low-functioning autism to produce white-matter structural modifications, which could thus play a role in the rehabilitative outcome.

Intraoperative haemodynamic monitoring: A pilot study on integrated data collection, processing and modelling for extracting vital signs and beyond

In this paper we illustrate an ongoing project focused on intraoperative monitoring of haemodynamic stability and cardiorespiratory interactions, and present an example analysis of vital signs recorded synchronously from multiple monitoring devices through a LabView©-based acquisition software termed “Global Collect”. We present two moving average models for the black box estimation of the gains of the cardiopulmonary baroreflex control of arterial resistance and of ventricular contractility, based on invasive, continuous measurements of arterial blood pressure and central venous pressure. As a proof-of-concept, we analyze the effects of a fluid-challenge maneuver performed during major surgery, quantifying the mechanisms through which such maneuvers are able to increase cardiac performance and hence enhance venous return. These preliminary results of a pilot case study demonstrate the potential of investigating autonomic nervous system control of circulation under general anesthesia in advancing intraoperative patient monitoring and aiding maintenance of haemodynamic stability in patients undergoing major surgery.

Fluid responsiveness in liver surgery: comparisons of different indices and approaches

The expected response to fluid infusion is an increase of cardiac output (CO), and this response depends mostly on the current cardiac function of the patient. The importance of the prediction of fluid responsiveness (FR) is based on the fact that fluid loading in hemodynamic unstable patients may be hazardous and dangerous, e.g., by exposing them to the risk of developing pulmonary edema. The objective of this work is to improve the knowledge about the performance of the indices of FR prediction in association with different classification approaches in a particular setting, i.e., liver surgery. The specific aims are (1) the comparison of different CO estimators from invasive arterial blood pressure (ABP) measurement with particular attention to the assessment of CO variation after fluid administration and (2) the comparison of several indices for the prediction of FR to maneuvers classified from the CO measurements provided by a commercial monitor (PiCCO™, Pulsion Medical System, Munich, Germany). The main finding of this work is that pulse pressure variation (PPV) indices are more reliable and computationally feasible than stroke volume variation (SVV) indices. The PPV provided by PiCCO has the best performance in terms of area under curve, sensitivity, and specificity (0.92, 0.88, and 0.86, respectively), when the maneuvers are classified according to the maximum values of CO variation estimated during the second and third minutes after infusion. Moreover, PPVPiCCO is significantly correlated with the CO variation after infusion (rho = 0.51, p value < 0.05). The threshold values produced by the PPV indices (PPV = 13.9% and PPVPiCCO = 14.4%) are in agreement with the literature. From these observations, we conclude that the PPV index can be considered most suitable for the prediction of FR in liver surgery.

Comparisons of predictors of fluid responsiveness in major surgery

The majority of studies on fluid responsiveness is focused on volume expansion maneuvers in intensive care unit (ICU), while fewer studies have analyzed the same problem during major surgery. Among them, the results are contrasting. The aim of this work was to compare the performance of different hemodynamic indices in the prediction of cardiac output variations following fast fluid infusion. The study was limited to a particular type of major surgery, i.e. liver transplantation and hepatectomy. Our results showed that pulse pressure variation (PPV) estimated according to the definition, i.e. within single respiratory cycles, and PPV estimated by PiCCO monitor system are coherent and very similar. Moreover, PPV and stroke volume variation (SVV) produced good values of sensitivity and specificity in separating the subjects into responsive and non responsive to maneuvers.

Arterial blood pressure regulation following aorta clamping and declamping during surgery

In this paper, we propose the use of black box models for the system identification of the cardiopulmonary baroreflex control of arterial resistance and of ventricular contractility and of arterial baroreflex control of heart rate (HR) from invasive, continuous measurements of arterial blood pressure (ABP) and central venous pressure (CVP), and non invasive, continuous recordings of ECG and respiration. Two crucial phases of the abdominal aortic aneurism (AAA) repair were investigated: the clamping and declamping of aorta. The objective of the present work is to evaluate and to test the ability to monitor baroreflex responses to clamping and declamping maneuvers preceding and following aneurism removal.

Prediction of postoperative outcomes using intraoperative hemodynamic monitoring data

Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44–0.78). By using intraoperative features, performance improved significantly to 0.82 (95% CI: 0.56–0.91, P = 0.001). Similarly, including intraoperative features (AUC = 0.82; 95% CI: 0.66–0.94) in ARF prediction improved performance over preoperative features (AUC = 0.72; 95% CI: 0.50–0.85), though not significantly (P = 0.32). We conclude that inclusion of intraoperative hemodynamic features significantly improves prediction of postoperative events in OLT. Features strongly associated with occurrence of both outcomes included greater intraoperative central venous pressure and greater transfusion volumes.

Meynert’s Nucleus Complex White Matter Abnormalities in Autism Spectrum Disorders: An MRI Study

Introduction : Cholinergic dysfunction has been proposed to play a role in autistic symtomatology. However, to date, its structural correlates are poorly understood. Methods : Twenty-five low-functioning, non-verbal males with Autism Spectrum Disorders (ASD) and 25 controls were enrolled in the study. All underwent MR T1-weighted 3D Structural Imaging and Diffusion Tensor Imaging. Grey and white matter components of the Meynert’s Nucleus Complex were then identified on MR images, and both grey matter density and white matter mean Fractional Anisotropy in the Meynert’s Nucleus region of interest were quantified for each subject. Non-verbal IQ was assessed in all subjects with ASD. Results : We showed reduced white matter Fractional Anisotropy in the bundles surrounding the Meynert’s Nucleus in ASD subjects compared to controls. Fractional Anisotropy in these bundles was positively associated with non-verbal IQ, independently from whole brain white matter mean Fractional Anisotropy. ASD subjects did not show significant abnormalities in Meynert’s Nucleus grey matter density. Conclusions : Our findings suggest that white matter abnormalities in the Meynert’s Nucleus might be involved in the cholinergic deficits of ASD.