Papers by Mariateresa Giglio
Pain and Therapy
Chronic low back pain is often due to L5S1 instability resulting in facet joint syndrome. Patient... more Chronic low back pain is often due to L5S1 instability resulting in facet joint syndrome. Patients suffering from low back pain may also have a gait pattern characterized by a reduced speed and a shorter, asymmetrical step in order to reduce pain. This case is of a patient with L5S1 instability that occurred after L1 to L5 lumbar stabilization who was treated with radiofrequency (RF) denervation of the medial branch of L5S1 bilaterally. RF ablation outcome was tested by comparing its impact on pain, function, quality of life, and on gait pattern, before and 1 month after the procedure. To objectify the impact of a good pain control on gait, a video recording was performed (see Video 1).
Cancer Control
Background In cancer patients with limited life expectancy, an implant of an intrathecal (IT) dru... more Background In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain. Methods Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC). Results Fifty patients, (16 F/34 M) we...
Search strategies. (DOCX 9 kb)
Table S2. The risk of bias assessment for each trial, according to the Cochrane domain-based eval... more Table S2. The risk of bias assessment for each trial, according to the Cochrane domain-based evaluation. (DOCX 17 kb)
Table S1. Data concerning RCTs morbidity/mortality risk definition, population and type of surger... more Table S1. Data concerning RCTs morbidity/mortality risk definition, population and type of surgery, tools and target used. (DOCX 23 kb)
Figure S4. Forest plot for postoperative acute kidney injury (AKI) (defined as the proportion of ... more Figure S4. Forest plot for postoperative acute kidney injury (AKI) (defined as the proportion of patients who developed postoperative worsening of renal function, whichever definition was used) including only those RCTs that showed a statistical difference between treatment versus control group during the perioperative period in the total amount of starch-based solutions (HES) administered. Size of squares for odds ratio reflects weight of trial in pooled analyses. Horizontal bars represent 95% confidence intervals. (TIFF 3072 kb)
Figure S3. Trial sequential analysis of postoperative acute kidney injury, including only low ris... more Figure S3. Trial sequential analysis of postoperative acute kidney injury, including only low risk of bias trials. A diversity adjusted information size of 9668 patients was calculated using α = 0.05 (two-sided), β = 0.20 (power 95%), an anticipated relative risk reduction of 2%, and an event proportion of 9% in the control arm. The blue cumulative z curve was constructed using a random effects model. (TIFF 3072 kb)
Figure S1. Flow chart summarizing the studies selection procedure for the meta-analysis. (TIFF 15... more Figure S1. Flow chart summarizing the studies selection procedure for the meta-analysis. (TIFF 1519 kb)
Cureus, 2021
Necrotizing Raynaud's phenomenon is a vascular clinical syndrome characterized by vasospasm of di... more Necrotizing Raynaud's phenomenon is a vascular clinical syndrome characterized by vasospasm of distal resistance vessels, usually triggered by cold temperatures or by psychological conditions such as anxiety and stress. Pain is the first reported symptom, related to insufficient oxygen delivery to the extremities that leads to ischemia of the peripheral tissues. The initial treatment is conservative, but if the symptoms persist, necrosis and distal amputation can occur. In selected patients, neuromodulation with spinal cord stimulation (SCS) can be an effective treatment by reducing pain and amputation rate. Recent evidence suggests that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause endotheliopathy with microvascular and macrovascular thrombotic events and can present as a systemic inflammatory vascular disease. We present a case of a severe necrotizing Raynaud's phenomenon successfully treated and controlled with SCS that abruptly reappeared during SARS-CoV-2 infection. The report of this case is suggestive for potential treatment in case of peripheral ischemia consequent to COVID-19 vasculopathy. The interaction between SCS and SARS-CoV-2-related endotheliopathy is unknown and would deserve further studies.
Therapeutic Advances in Musculoskeletal Disease, 2021
Musculoskeletal pain (excluding bone cancer pain) affects more than 30% of the global population ... more Musculoskeletal pain (excluding bone cancer pain) affects more than 30% of the global population and imposes an enormous burden on patients, families, and caregivers related to functional limitation, emotional distress, effects on mood, loss of independence, and reduced quality of life. The pathogenic mechanisms of musculoskeletal pain relate to the differential sensory innervation of bones, joints, and muscles as opposed to skin and involve a number of peripheral and central nervous system cells and mediators. The interplay of neurons and non-neural cells (e.g. glial, mesenchymal, and immune cells) amplifies and sensitizes pain signals in a manner that leads to cortical remodeling. Moreover, sex, age, mood, and social factors, together with beliefs, thoughts, and pain behaviors influence the way in which musculoskeletal pain manifests and is understood and assessed. The aim of this narrative review is to summarize the different pathogenic mechanisms underlying musculoskeletal pain ...
Best Practice & Research Clinical Anaesthesiology, 2020
procedures have been reduced or interrupted during the COVID-19 pandemic in order to reduce the r... more procedures have been reduced or interrupted during the COVID-19 pandemic in order to reduce the risk of viral spread. The shutdown of pain services jointly to the home lockdown imposed by governments has affected chronic pain management worldwide with additional impact on patients' psychological health. Therefore, the aim of this review is to analyze the impact of COVID-19 pandemic on chronic pain treatment and to address what types of strategies can be implemented or supported in order to overcome imposed limitations in delivery of chronic pain patient care.
Advances in Therapy, 2020
Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. ... more Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are ''non-responders'' to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholaminesparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients.
Pain and Therapy, 2020
Herpes zoster (HZ) is a painful rash caused by the reactivation of the varicella-zoster virus (VZ... more Herpes zoster (HZ) is a painful rash caused by the reactivation of the varicella-zoster virus (VZV) permanently latent within the cranial or dorsal root ganglia. Usually the rash presents in only one side of the body, in a single dermatome or restricted to a part of it. In immunocompromised patients, more than one contiguous unilateral dermatome, called multidermatomal HZ, has been described, usually in cervical dermatomes. Bilateral rash is rare. Besides immunosuppression, the major risk factors for virus reactivation are older age and female gender. This is a case of a bilateral lumbar multidermatomal HZ in an elderly woman with chronic renal failure.
Pain and Therapy, 2020
Introduction: In cancer-related pain refractory to systemic opioids, intrathecal (IT) administrat... more Introduction: In cancer-related pain refractory to systemic opioids, intrathecal (IT) administration of morphine can be a useful strategy. In clinical practice, IT morphine is usually combined with other drugs with different mechanisms of action, in order to obtain a synergistic analgesic effect. However, the discussion on efficacy and safety of IT combination therapy is still ongoing. The aim of this observational study was to report the effects of an IT combination of low doses of ziconotide, morphine, and levobupivacaine in end-stage cancer refractory pain. Methods: Sixty adult patients, 21 females and 39 males, were enrolled to an IT device implant. The mean visual analogue scale of pain intensity (VASPI) score was 88 ± 20 mm. All patients started with a triple combination therapy: the initial IT dose of morphine was calculated for each patient based on the equivalent daily dose of morphine; an oral/IT ratio of 400/1 was used. For ziconotide, a standard slow titration schedule was started at 1.2 lg/day and the initial dose of levobupivacaine was 3 mg/day. Results: The initial IT mean doses of morphine, ziconotide, and levobupivacaine were 0.8 ± 0.3 mg/day, 1.2 mcg/day and 3 mg/day, respectively. At day 2, a significant reduction in VASPI score was registered (49 ± 17, p \ 0.001), and this significant reduction persisted at 56 days (mean VASPI score 44 ± 9, p \ 0.001), with mean doses of morphine 2 ± 1 mg/day, ziconotide 2.8 ± 1 mcg/day, and levobupivacaine 3.8 ± 2 mg/day. Very few adverse effects (AEs) were observed. Patients' satisfaction was very high during the entire study period. Conclusions: Our results, within the limit of the study design, suggest that the IT combination of ziconotide, morphine, and levobupivacaine, at low doses, allows safe and rapid control of refractory cancer pain, with high levels of patient satisfaction.
Critical Care, 2019
Background: Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, ... more Background: Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury. Main body: Randomized controlled trials enrolling adult patients undergoing major surgery were considered. GDT was defined as perioperative monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluids alone or with inotropes. Trials comparing the effects of GDT and standard hemodynamic therapy were considered. Primary outcome was acute kidney injury, whichever definition was used. Meta-analytic techniques (analysis software RevMan, version 5.3) were used to combine studies, using random-effect odds ratios (OR) and 95% confidence intervals (CI). Trial sequential analyses were performed including all trials and considering only low risk of bias trials. Sixty-five trials with an overall sample of 9308 patients were included. OR for the development of renal injury was 0.64 (95% CI, 0.62-0.87; p = 0.0003), with no statistical heterogeneity. Trial sequential analyses and sensitivity analysis including studies with low risk of bias confirmed the main results. A significant decrease in renal injury rate was observed in studies that adopted cardiac output and oxygen delivery as hemodynamic target and that used both fluids and inotropes. The postoperative kidney injury rate was significantly lower in trials enrolling "high-risk" patients and major abdominal and orthopedic surgery. Short conclusion: The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery.
Reducing Mortality in Acute Kidney Injury, 2016
Acute kidney injury is a serious complication in surgical and critical care patients and carries ... more Acute kidney injury is a serious complication in surgical and critical care patients and carries an increased risk of mortality and additional hospital costs. Hemodynamic optimization to reduce mortality in critically ill patients with or at risk for AKI is supported by high-level evidence. However, several points of debate are still open, including the type of fluid to be used to reach the hemodynamic targets, the inotropic support, the choice of the monitoring tool, as well as of the hemodynamic variables to be targeted, and which subgroup of the high-risk surgical population could benefit most from a goal-directed therapy approach.
Minerva anestesiologica, Jan 13, 2016
Recent data found that perioperative goal directed therapy (GDT) was effective only in higher con... more Recent data found that perioperative goal directed therapy (GDT) was effective only in higher control mortality rate (>20%) with a relatively high heterogeneity that limited the strength of evidence. The aim of the present meta- analysis was to clearly understand which high risk patients may benefit of GDT. Systematic review of randomised controlled trials with meta-analyses, including a meta regression technique. MEDLINE, EMBASE, and The Cochrane Library databases were searched (1980-January 2015). Trials enrolling adult surgical patients and comparing the effects of GDT versus standard haemodynamic therapy were considered. The primary outcome measure was mortality. Data synthesis was obtained by using Odds Ratio (OR) with 95% confidence interval (CI) by random- effects model. 58 studies met the inclusion criteria (8171 participants). Pooled OR for mortality was 0.70 ( 95% CI 0.56-0.88, p=0.002, no statistical heterogeneity ). GDT significantly reduced mortality when it is >1...
Critical care (London, England), 2014
Dynamic predictors of fluid responsiveness, namely systolic pressure variation, pulse pressure va... more Dynamic predictors of fluid responsiveness, namely systolic pressure variation, pulse pressure variation, stroke volume variation and pleth variability index have been shown to be useful to identify in advance patients who will respond to a fluid load by a significant increase in stroke volume and cardiac output. As a result, they are increasingly used to guide fluid therapy. Several randomized controlled trials have tested the ability of goal-directed fluid therapy (GDFT) based on dynamic parameters (GDFTdyn) to improve post-surgical outcome. These studies have yielded conflicting results. Therefore, we performed this meta-analysis to investigate whether the use of GDFTdyn is associated with a decrease in post-surgical morbidity. A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through September 2013 was conducted. Data synthesis was obtained by using odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) by ran...
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Papers by Mariateresa Giglio