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Introduction As well known, infrastructure endowment influences competitiveness of a region since the characteristics of a transport system in terms of capacity, connectivity, speeds, etc. determine the advantages/disadvantages of an area compared to other locations. This article attempts to investigate the potential impacts on rail accessibility across Europe when different possible operational enhancement scenarios are simulated. Methods The simulations are carried out by means of a combination of the TRANSTOOLS rail network and Traffic Analyst, the post-processing analyses are implemented in Matlab and the results for each zone (at NUTS3 level) are reported both in tabular form and in easy-to-read ArcGIS maps. Several accessibility measures are evaluated including two Data Envelopment Analysis (DEA) approaches aiming to construct a composite index for embracing all the complementary information provided by ‘partial’ accessibility sub-indicators; to better evaluate and understand the results either sensitivity and robustness analyses are performed for both the aggregate indicators. Results The outcomes provide insight into where major benefits in terms of accessibility can be expected; in particular the current infrastructure endowment already benefits many regions but improvements in speed could still increase significantly rail accessibility across Europe (mainly outside the core area as in Poland, Bulgaria, Romania, Slovakia, etc.). Furthermore both the proposed global indexes, although associating different ‘endogenous’ weights to the various sub-indicators, appear to be worthy and robust against uniform random noise. Conclusions Ultimately the results provide information useful for the prioritization of investment needs; moreover even if the interpretation of the partial accessibility indicators is clear and useful for policy-makers, the evaluation of a composite measure could allow planners not only to compare or fully rank the level of accessibility for different regions but even to control for eventual confusing and/or incomplete results that may appear when using only a partial approach.

BACKGROUND: Laparoscopic cholecystectomy is the most common surgical procedure performed in the Western world. While it is performed with minimally invasive procedures, patients often complain of moderate to severe postoperative pain, and the role of the anesthesiologist for its effective management remains crucial. Modern anesthesiology practices have embraced trunk blocks which can contribute to perioperative, multimodal analgesia. There is emerging literature about the favorable effect of erector spinae plane block in the reduction of pain after laparoscopic cholecystectomy.OBJECTIVE: The aim of this study was to explore the efficacy of preoperative bilateral erector spinae plane block when dexmedetomidine is added in the local anesthetic mixture in patients undergoing elective laparoscopic cholecystectomy.STUDY DESIGN: This study is a double-blind, randomized, controlled, prospective study.SETTING: Georgios Papanikolaou General Hospital of Thessaloniki, Greece.METHODS: After Local Ethics Committee approval (No: 1146/7.10.2019, October 2019) and in accordance with the principles outlined in the Declaration of Helsinki, the study was submitted to clinicaltrials.gov with reference number: NCT04587973. Sixty patients were randomized into 3 equal groups. Erector spinae plane block was performed in Group C with normal saline (N/S) 0.9%, in Group DR with ropivacaine 0.375% and dexmedetomidine 1 mcg/kg, and in Group R with ropivacaine 0.375%. The perioperative opioid consumption, pain intensity, time of first mobilization, hospitalization days, and satisfaction score of patients were recorded. Statistical analysis was performed with ANOVA, Kruskal-Wallis and Spearman test, as appropriate.RESULTS: The perioperative opioid consumption was significantly lower in Groups R and DR as compared to Group C (P < 0.001). The median numerical rating scale (NRS) scores of patients at all time points were statistically different between Groups C and DR, as well as between groups C and R. Satisfaction score was significantly higher in Group DR as compared to Group C (P < 0.001), and mobilization time was significantly shorter in group DR in comparison to Group C as well as in Group R as compared to Group C (P = 0.015 and P = 0.035, respectively). Intraoperative remifentanil consumption was lower in Group DR in comparison to Group R (P < 0.001). There was no difference in postoperative nausea and vomiting and duration of hospital stay of patients.LIMITATIONS: The limitation of the study is the small sample size of the patients recruited, which may be the reason why no statistically significant differences were found in postoperative morphine consumption and postoperative NRS scores between Groups R and DR and in postoperative nausea and vomiting among the 3 groups.CONCLUSION: Erector spinae plane block performed either with ropivacaine or with a combination of ropivacaine and dexmedetomidine is a novel and safe method, which was found to be more effective compared to standard analgesia protocols in patients undergoing laparoscopic cholecystectomy and thus, it can improve the quality of perioperative analgesia.

In the transport sector, where change comes with inertia and investments are made with a long term perspective, decision makers need to consider how the future may look like in the very long term. The work presented in this paper is a scenario analysis focusing on the evolution of transport demand towards 2050, aiming to identify related challenges for European industrial and policy players. It follows up on the work of other recent attempts to study the future of transport from a European perspective, integrating findings from these studies, updating new trends and applying a specific scenario analysis methodology relying also on expert consultation. The diversity of the scenarios created unfolds aspects of the future transport system with rather different outcomes on issues like the volume of transport, travel motives, the prevalent spatial scales of transport and logistics, people’s preferences towards different transport attributes, the relevancy of the State versus the private initiative in transport production, the level of competition, or the relative importance of environment and resource scarcity in setting an agenda for innovation and regulations. Beyond the subsequent challenges and opportunities identified in this work, the scenarios developed may be a useful basis for individual actors of distinct backgrounds to build their own specific futures, supporting them in defining strategies for the future.

Background and AimsQuality of Recovery (QoR) of patients after major abdominal surgeries is a field of concern for anesthesiologists. In this study we evaluated the efficacy of continuous, bilateral Erector Spinae Plane Block (ESPB) in enhancing QoR and satisfaction of patients undergoing elective laparoscopic (LC) or open colectomy (OC).MethodsThis study is a double-blinded, randomized, controlled, prospective study, submitted to clinicaltrials.gov (NCT04879004). 30 patients scheduled for OC and LC were randomized into 4 equal groups. If the patient was randomized in Group RL or RO, Ropivacaine 0.375% (20 ml) was infused at each side 30 minutes before induction of GA and 0.2% (20 ml) 12, 24, 36 and 48 hours after surgery. If the patient was randomized in Group CL or CO, N/S 0.9% (20 ml) was infused in the same manner. We recorded QoR score on the 3d postoperative day, satisfaction score and discharge time of patients. Statistical analysis was performed with JamoviVersion1.6.18.0, using MannWhitneyU test.ResultsAll groups were similar. No statistically significant differences were found between groups RL and CL regarding QoR, satisfaction score and discharge time of the patients (p=0.061, p=0.061, p=0.704 respectively). Regarding OC, QoR score and satisfaction score of the patients were significantly higher in Group RO when compared to CO (p=0.002 and p=0.042 respectively). There was found no statistically significant difference between these groups regarding discharge time of the patients (p=0.122).ConclusionsIn this study, we confirmed that ESPB is an effective method which contributes to the improvement of QoR and satisfaction score of patients undergoing OC.

Background and AimsLaparoscopic cholecystectomy (LC) is one of the most common procedures performed by general surgeons. Postoperative pain can be moderate to severe, requiring administration of large doses of opioids. Erector Spinae Plane block (ESPB) is a trunk block performed as a method of postoperative analgesia in various surgical procedures. Its analgesic efficacy in LCs when dexmedetomidine is added in the local anesthetic mixture, has not been proven yet. In this study, we explored its efficacy as a perioperative analgesic method in patients undergoing LC.MethodsThis study was designed as a double-blinded, randomized, controlled, prospective study. 60 patients were randomized into Group C: ESPB N/S 0,9%, Group D: ESPB ropivacaine 0,375%, dexmedetomidine 1 mcg/kg, Group R: ESPB ropivacaine 0,375%. ESPB was performed bilaterally before the induction of general anesthesia, with ultrasound guidance. Statistical analysis was performed with ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis, Spearman test.ResultsAll patients remained hemodynamically stable and no major complications were observed. Total intraoperative remifentanil was statistically different between the three groups. Median 24h morphine consumption, median NRS scores at all time points and mobilization time, were statistically different between Groups C and D, Groups C and R, but insignificant between Groups R and D. Satisfaction score was found to be statistically significant between Group C and D.Abstract 1 Figure 1ConclusionsESPB performance with ropivacaine or ropivacaine/dexmedetomidine in patients scheduled for LC is a novel, safe and simple method, which can help improve the quality of analgesia, avoid the complications of opioid administration and thus achieve pre-emptive, multimodal and ‘opioid-free analgesia’.

Background and AimsInternal Jugular Vein Catheterization (IJVC) in oncology patients can be challenging, as most of these patients have undergone multiple painful procedures and fear of pain. This study aims to determine whether intermediate cervical plexus block (ICPB) is superior to conventional local anesthesia in terms of satisfaction of the patient for IJVC.Methods30 oncology patients, ASA III, were randomly divided into two groups. In Group A (n=18), ICPB with lidocaine 2% (5 ml) was administered to the patients, 5 minutes before the placement of the central venous catheter (CVC). In Group B (n=12), conventional local anesthesia with lidocaine 2% (5 ml) was administered at the site of the catheterization, 5 minutes before the placement of CVC. The procedure in both groups was ultrasound-guided. The duration, complications and VAS score of the procedure along with patient’s satisfaction of the procedure were recorded. Patient’s vital signs were recorded throughout the procedure.ResultsNo complications were reported in both Groups. The mean duration of the procedure was not statistically significant between the two groups. VAS scores and Satisfaction Scores were found to be statistically significant between the two groups.ConclusionsIn this study, the performance of ICPB in oncology patients undergoing IJVC was found to provide superior analgesia and comfort to the patients when compared to conventional local anesthesia. To the authors’ concern there are no studies exploring the superiority of ICPB as a means of analgesia to patients undergoing IJVC. Certainly, more studies should be performed for further confirmation of these findings.

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.

Open and laparoscopic colorectal surgeries, while essential in the management of various colorectal pathologies, are associated with significant postoperative pain. Effective perioperative pain management strategies remain an anesthesiologic challenge. The erector spinae plane block (ESPB), a novel peripheral nerve block, has gained attention for its potential in providing analgesia for a wide variety of surgeries. This study aimed to evaluate the effectiveness of continuous, bilateral ultrasound-guided ESPB in perioperative pain management of patients undergoing colectomy. This prospective, randomized, controlled, double-blind trial included 40 adult patients scheduled for elective open or laparoscopic colectomy. Patients undergoing open colectomy as well as patients undergoing laparoscopic colectomy were randomly allocated into two groups: the ESPB group (n = 20) and the control group (n = 20). All patients received preoperatively ultrasound-guided, bilateral ESPB with placement of catheters for continuous infusion. Patients in the ESPB group received 0.375% ropivacaine, while patients in the control group received sham blocks. All patients received standardized general anesthesia and multimodal postoperative analgesia. Pain scores, perioperative opioid consumption, and perioperative outcomes were assessed. Patients in the ESPB group required significantly less intraoperative (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and postoperative opioids (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and had higher quality of recovery scores on the third postoperative day (p = 0.002 for open and laparoscopic colectomies). Patients in the ESPB group did not exhibit lower postoperative pain scores compared to those in the control group (p > 0.05 at various time points), while patients in both groups reported comparable satisfaction scores with their perioperative pain management (p = 0.061 for open colectomies, and p = 0.078 in laparoscopic colectomies). No complications were reported. ESPB is a novel and effective strategy in reducing perioperative opioid consumption in patients undergoing colectomy. This technique, as part of a multimodal analgesic plan and enhanced recovery after surgery protocols, can be proven valuable in improving the comfort and satisfaction of patients undergoing colorectal surgery.

We present a new method that allows a separation of the attribution of human influence in extreme events into changes in atmospheric flows and changes in other processes. Assuming two data sets of model simulations or observations representing a natural, or 'counter-factual' climate, and the actual, or 'factual' climate, we show how flow analogs used across data sets can provide quantitative estimates of each contribution to the changes in probabilities of extreme events. We apply this method to the extreme January precipitation amounts in Southern UK such as were observed in the winter of 2013/2014. Using large ensembles of an atmospheric model forced by factual and counterfactual sea surface temperatures, we demonstrate that about a third of the increase in January precipitation amounts can be attributed to changes in weather circulation patterns and two thirds of the increase to thermodynamic changes. This method can be generalized to many classes of events and regions and provides, in the above case study, similar results to those obtained in Schaller et al (2016 Nat. Clim. Change 6 627-34) who used a simple circulation index, describing only a local feature of the circulation, as in other methods using circulation indices (van Ulden and van Oldenborgh 2006 Atmos. Chem. Phys. 6 863-81).

The neurophysiological mechanisms underlying NGF-induced masseter muscle sensitization and sex-related differences in its effect are not well understood in humans. Therefore, this longitudinal cohort study aimed to investigate the effect of NGF injection on the density and expression of substance P, NMDA-receptors and NGF by the nerve fibers in the human masseter muscle, to correlate expression with pain characteristics, and to determine any possible sex-related differences in these effects of NGF. The magnitude of NGF-induced mechanical sensitization and pain during oral function was significantly greater in women than in men (P < 0.050). Significant positive correlations were found between nerve fiber expression of NMDA-receptors and peak pain intensity (r s  = 0.620, P = 0.048), and expression of NMDA-receptors by putative nociceptors and change in temporal summation pain after glutamate injection (r s  = 0.561, P = 0.003). In women, there was a significant inverse relationship between the degree of NGF-induced mechanical sensitization and the change in nerve fiber expression of NMDA-receptors alone (r s  = − 0.659, P = 0.013), and in combination with NGF (r s  = − 0.764, P = 0.001). In conclusion, women displayed a greater magnitude of NGF-induced mechanical sensitization that also was associated with nerve fibers expression of NMDA-receptors, when compared to men. The present findings suggest that, in women, increased peripheral NMDA-receptor expression could be associated with masseter muscle pain sensitivity.