Abstract
In patients intubated for hypoxemic acute respiratory failure (ARF) related to novel coronavirus disease (COVID-19), we retrospectively compared two weaning strategies, early extubation with ...immediate non-invasive ventilation (NIV) versus standard weaning encompassing spontaneous breathing trial (SBT), with respect to IMV duration (primary endpoint), extubation failures and reintubations, rate of tracheostomy, intensive care unit (ICU) length of stay and mortality (additional endpoints). All COVID-19 adult patients, intubated for hypoxemic ARF and subsequently extubated, were enrolled. Patients were included in two groups, early extubation followed by immediate NIV application, and conventionally weaning after passing SBT. 121 patients were enrolled and analyzed, 66 early extubated and 55 conventionally weaned after passing an SBT. IMV duration was 9 6–11 days in early extubated patients versus 11 6–15 days in standard weaning group (
p
= 0.034). Extubation failures 12 (18.2%) vs. 25 (45.5%),
p
= 0.002 and reintubations 12 (18.2%) vs. 22 (40.0%)
p
= 0.009 were fewer in early extubation compared to the standard weaning groups, respectively. Rate of tracheostomy, ICU mortality, and ICU length of stay were no different between groups. Compared to standard weaning, early extubation followed by immediate NIV shortened IMV duration and reduced the rate of extubation failure and reintubation.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
BackgroundEnhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their ...implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention.MethodsA large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items.ResultsOf 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of −0.58 days (95% CI −1.07, −0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68).ConclusionImplementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. Trial registration number NCT04037787.
Objective
To evaluate the effectiveness of implementing the Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing elective hysterectomy in a network of regional hospitals, supported ...by an intensive audit‐and‐feedback (A&F) approach.
Design
A multi‐centre, stepped‐wedge cluster randomised trial (ClinicalTrials.gov NCT04063072).
Setting
Gynaecological units in the Piemonte region, Italy.
Population
Patients undergoing elective hysterectomy, either for cancer or for benign conditions.
Methods
Twenty‐three units (clusters), stratified by surgical volume, were randomised into four sequences. At baseline (first 3 months), standard care was continued in all units. Subsequently, the four sequences implemented the ERAS protocol successively every 3 months, after specific training. By the end of the study, each unit had a period in which standard care was maintained (control) and a period in which the protocol, supported by feedback, was applied (experimental).
Main outcome measures
Length of hospital stay (LOS), without outliers (>98th percentile).
Results
Between September 2019 and May 2021, 2086 patients were included in the main analysis with an intention‐to‐treat approach: 1104 (53%) in the control period and 982 (47%) in the ERAS period. Compliance with the ERAS protocol increased from 60% in the control period to 76% in the experimental period, with an adjusted absolute difference of +13.3% (95% CI 11.6% to 15.0%). LOS, moving from 3.5 to 3.2 days, did not show a significant reduction (−0.12 days; 95% CI −0.30 to 0.07 days). No difference was observed in the occurrence of complications.
Conclusions
Implementation of the ERAS protocol for hysterectomy at the regional level, supported by an A&F approach, resulted in a substantial improvement in compliance, but without meaningful effects on LOS and complications. This study confirms the effectiveness of A&F in promoting important innovations in an entire hospital network and suggests the need of a higher compliance with the ERAS protocol to obtain valuable improvements in clinical outcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
: To check the efficacy of a reverse thermosensitive gel (poloxamer P407) for intracoronary shunt sealing in off-pump coronary artery bypass surgery to stop residual bleeding from the shunt and avoid ...the use of blowers.
: Nineteen coronary anastomoses were performed on five patients who underwent off-pump coronary artery bypass surgery. Intracoronary shunting was adopted in all procedures. All the shunts were sealed into the coronary lumen with the injection of a reverse thermosensitive gel. Before tying the sutures, a piece of ice was applied on the anastomotic sites to dissolve the gel. Bleeding from the coronary lumen was always checked after shunt removal.
: Bleeding was stopped or reduced and anastomoses performed without blower use. In one case, bleeding started again after shunt manipulation, and the shunt sealing procedure needed to be repeated. No intraoperative surface electrocardiogram and regional motion changes were detected. All patients showed normal creatine kinase-MB (CK-MB) levels in the postoperative period. All patients were free from adverse cardiovascular events at 4 months from operation.
: The use of a thermosensitive polymer for intracoronary shunt sealing was effective in controlling bleeding, eliminated the necessity for blower use, and was not associated to operative complications.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
6.
Un monastero sul mare Bianchi, Giovanna; Gelichi, Sauro; Cristina Rossi, Maria ...
2016., 2016, Volume:
24
eBook
Open access
The remains of the monastery of San Quirico stand on the slopes of Poggio Tondo, a hill not far from the ancient city of Populonia. They overlook the Tyrrhenian Sea, dotted with the islands of the ...Tuscan archipelago. Field research at this site, carried out in the first decade of the new millennium by two different teams, from Siena University and Venice’s Ca’ Foscari University, respectively, was part of ongoing efforts to expand the Baratti-Populonia Archeological Park, and to further explore the features present within it. This volume contains the results of this research work: a scientific publication of the excavation, and a critical analysis of the material found. Processing of the data collected during these investigations, together with a re-reading of written documentation, has made it possible to piece together the complex history of this important monastery, in a totally new narration. In this narration, the history of the monastery, and of the features which existed prior to it, are closely interwoven with the history of the promontory of Populonia and the surrounding area, ultimately producing a new overview which sets out the historical boundaries of this area, between Late Antiquity and the modern era.
I resti del monastero di San Quirico si trovano sulle pendici del poggio Tondo, a poca distanza dall’antica città di Populonia, rivolti verso lo specchio del mare Tirreno costellato dalle isole dell’arcipelago toscano. Le ricerche archeologiche in questo sito, realizzate nel primo decennio del nuovo millennio da due differenti équipe, rispettivamente dell’Università di Siena e Ca’ Foscari di Venezia, si sono svolte nell’ambito degli interventi di ampliamento e di valorizzazione del parco archeologico di Baratti-Populonia. Questo volume contiene i risultati di quelle ricerche: l’edizione scientifica dello scavo e l’analisi critica dei materiali rinvenuti. La rielaborazione dei dati raccolti durante tali indagini, unita ad una rilettura della documentazione scritta, ha poi permesso di ricomporre le complesse vicende di questo importante monastero, in una nuova ed inedita narrazione. In tale narrazione le vicende del cenobio e delle sue preesistenze si intrecciano con quelle del promontorio di Populonia e dei territori limitrofi fino a delineare un quadro di sintesi che ridisegna i confini storici di questo territorio tra la Tarda Antichità e l’Età Moderna.
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