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BACKGROUND: The role of positive end-expiratory pressure in mechanical ventilation during general anaesthesia for surgery remains uncertain. Levels of pressure higher than 0 cm H(2)O might protect against postoperative pulmonary complications but could also cause intraoperative circulatory depression and lung injury from overdistension. We tested the hypothesis that a high level of positive end-expiratory pressure with recruitment manoeuvres protects against postoperative pulmonary complications in patients at risk of complications who are receiving mechanical ventilation with low tidal volumes during general anaesthesia for open abdominal surgery. METHODS: In this randomised controlled trial at 30 centres in Europe and North and South America, we recruited 900 patients at risk for postoperative pulmonary complications who were planned for open abdominal surgery under general anaesthesia and ventilation at tidal volumes of 8 mL/kg. We randomly allocated patients to either a high level of positive end-expiratory pressure (12 cm H(2)O) with recruitment manoeuvres (higher PEEP group) or a low level of pressure (≤2 cm H(2)O) without recruitment manoeuvres (lower PEEP group). We used a centralised computer- generated randomisation system. Patients and outcome assessors were masked to the intervention. Primary endpoint was a composite of postoperative pulmonary complications by postoperative day 5. Analysis was by intention-to-treat. The study is registered at Controlled-Trials.com, number ISRCTN70332574. FINDINGS: From February, 2011, to January, 2013, 447 patients were randomly allocated to the higher PEEP group and 453 to the lower PEEP group. Six patients were excluded from the analysis, four because they withdrew consent and two for violation of inclusion criteria. Median levels of positive end-expiratory pressure were 12 cm H(2)O (IQR 12–12) in the higher PEEP group and 2 cm H(2)O (0–2) in the lower PEEP group. Postoperative pulmonary complications were reported in 174 (40%) of 445 patients in the higher PEEP group versus 172 (39%) of 449 patients in the lower PEEP group (relative risk 1·01; 95% CI 0·86–1·20; p=0·86). Compared with patients in the lower PEEP group, those in the higher PEEP group developed intraoperative hypotension and needed more vasoactive drugs. INTERPRETATION: A strategy with a high level of positive end-expiratory pressure and recruitment manoeuvres during open abdominal surgery does not protect against postoperative pulmonary complications. An intraoperative protective ventilation strategy should include a low tidal volume and low positive end-expiratory pressure, without recruitment manoeuvres. FUNDING: Academic Medical Center (Amsterdam, Netherlands), European Society of Anaesthesiology.

Alessandro Rizzardo,1 Luca Miceli,1 Rym Bednarova,2 Giovanni Maria Guadagnin,1 Rodolfo Sbrojavacca,3 Giorgio Della Rocca11Department of Anesthesia and Intensive Care, Academic Hospital of Udine, University of Udine, Udine, 2Pain Medicine and Palliative Care, Health Company Number 2, Gorizia, 3Emergency Department, Academic Hospital of Udine, Udine, ItalyBackground: Low-back pain (LBP) affects about 40% of people at some point in their lives. In the presence of “red flags”, further tests must be done to rule out underlying problems; however, biomedical imaging is currently overused. LBP involves large in-hospital and out-of-hospital economic costs, and it is also the most common musculoskeletal disorder seen in emergency departments (EDs).Patients and methods: This retrospective observational study enrolled 1,298 patients admitted to the ED, including all International Classification of Diseases 10 diagnosis codes for sciatica, lumbosciatica, and lumbago. We collected patients’ demographic data, medical history, lab workup and imaging performed at the ED, drugs administered at the ED, ED length of stay (LOS), numeric rating scale pain score, admission to ward, and ward LOS data. Thereafter, we performed a cost analysis.Results: Mean numeric rating scale scores were higher than 7/10. Home medication consisted of no drug consumption in up to 90% of patients. Oxycodone–naloxone was the strong opioid most frequently prescribed for the home. Once at the ED, nonsteroidal anti-inflammatory drugs and opiates were administered to up to 72% and 42% of patients, respectively. Imaging was performed in up to 56% of patients. Mean ED LOS was 4 hours, 14 minutes. A total of 43 patients were admitted to a ward. The expense for each non-ward-admitted patient was approximately €200 in the ED, while the mean expense for ward-admitted patients was €9,500, with a mean LOS of 15 days.Conclusion: There is not yet a defined therapeutic care process for the patient with LBP with clear criteria for an ED visit. It is to this end that we need a clinical pathway for the prehospital management of LBP syndrome and consequently for an in-hospital time-saving therapeutic approach to the patient.Keywords: low-back pain, health policies, emergency department, cost analysis

dopo una prima introduzione di carattere storico, il contributo pone in luce i profili di efficienza del credito documentario in una prospettiva EAL e analizza criticamente i differenti inquadramenti giuridici proposti in dottrina a proposito del credito documentario, soffermandosi ad esaminare le novità introdotte dalle NUU

The Bentham cypress is native of Mexico. As a wild tree it grows abundantly at elevations between 2400 and 3300 m asl in the central and north western part of Mexico. The distribution of Cupressus benthamii is really not well known. It appears to be generally sympatric with C. lusitanica but to have a more restricted natural distribution.

The cypress wood of Fontegreca is located in the Matese National Park, across Molise and Campania. Its presence is documented since 1500, though its origin is uncertain. Also known as 'Bosco degi Zappini', this uneven-aged, native-like cypress stand has been the subject of scientific projects aimed at promoting its ecological, and genetic value and to explore its potential for the local economy and tourism. In 2011 a clonal orchard was set up to obtain selected and certified seed for the production of valuable timber, the protection of slopes and the recovery of deteriored sites. The valorization of this site should be continued through a comprehensive and structured plan.

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Cupressus remains a conservative genus, now mostly represented by relict populations with comparatively little morphological variation. Silba reduced the varieties of C. chengiana to its synonyms because of lack of botanical features and distribution distinguishing them properly. In 1964, Cupressus chengiana was described by Shin Ying Hu as a new species of cypress. This species was named "chengiana" in honor of the forestry professor Rong Cheng (1888-1971), who discovered four different cypress taxa in China in collaboration with Dr. L. G. Fu. C. chengiana occupies an area of around 2000 km2 distributed in about 9 natural areas. This species is considered vulnerable and in continuing decline in the number of mature trees. The declining Cheng cypress population is due above all to the past and recent exploitation for its timber of high quality. Natural populations are now mostly restricted to more inaccessible sites such as canyons and exposed cliffs.

S Ussai,1,2 L Miceli,3 F E Pisa,4 R Bednarova,5 A Giordano,1,2 G Della Rocca,3 R Petelin6 1Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; 2Sbarro Institute for Cancer Research andMolecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University,Philadelphia, PA, USA; 3Department of Anesthesiology andIntensive Care Medicine, 4Institute of Hygiene and Clinical Epidemiology, University Hospital ofUdine, 5Department of Palliative Care andPain Medicine, Health Company n.5, Bassa Friulana, Italy; 6School of Management, Santa Clara University, Santa Clara, CA, USA Abstract: Pain remains one of the main reasons for medical consultation worldwide: moderate- to severe-intensity pain occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use and a careful surveillance to monitor for toxicity and efficacy is critical. This study aims to assess: 1) the pattern of use of NSAIDs and opioids in a population covered by a cloud-based pharmacovigilance surveillance system; and 2) potential inappropriate use. A retrospective 18-months systematic analysis on patients’ pain treatment was performed. The primary endpoint was evaluating the prevalence of NSAIDs and opioids use and the duration of therapy regimen. The secondary endpoint was to investigate the prevalence of NSAIDs taken for >21 consecutive days concomitant with drugs for peptic ulcer and gastroesophageal reflux disease (GORD) or antiplatelet drugs. The yearly cost for individual users of concomitant NSAIDs for more than 21 consecutive days and of GORD medications has been estimated. A total of 3,050 subjects with chronic pain were enrolled; 97% of them took NSAIDs for >21 consecutive days; about one-fourth of these users also received drugs for peptic ulcer and GORD (Anatomical Therapeutic Chemical code A02B). The yearly cost foran individual who uses NSAIDs for >21 consecutive days as well as concomitant GORD medications is 61.23 euros. In total, 238 subjects (8%) using NSAIDs for >21 days also received one antiplatelet agent. About 11% of subjects received opioids at least once and only 2% of them carried on the therapy for more than 90 consecutive days. In evaluating the escalation in dosage as a proxy of dependence risk, this study shows no dosage escalation in our cohort of chronic pain population - that is to say we show no risk of dependence. Keywords: pain therapy, economic impact, dependence

Luca Miceli,1 Rym Bednarova,2 Alessandro Rizzardo,1 Valentina Samogin,1 Giorgio Della Rocca1 1Department of Anesthesia and Intensive Care Medicine, University of Udine, 2Department of Pain Medicine and Palliative Care, Hospital of Latisana, Latisana, Udine, Italy Objective: Italian Road Law limits driving while undergoing treatment with certain kinds of medication. Here, we report the results of a test, run as a smartphone application (app), assessing auditory and visual reflexes in a sample of 300 drivers. The scope of the test is to provide both the police force and medication-taking drivers with a tool that can evaluate the individual’s capacity to drive safely. Methods: The test is run as an app for Apple iOS and Android mobile operating systems and facilitates four different reaction times to be assessed: simple visual and auditory reaction times and complex visual and auditory reaction times. Reference deciles were created for the test results obtained from a sample of 300 Italian subjects. Results lying within the first three deciles were considered as incompatible with safe driving capabilities. Results: Performance is both age-related (r>0.5) and sex-related (female reaction times were significantly slower than those recorded for male subjects, P

Il contributo procede al riesame critico della legislazione sull'usura, rivisitandone i presupposti economici e e le conseguenze sul piano della regolamentazione del credito e pervenendo a risultati originali