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Summary Introduction. Healthcare associated infections (HAIs) are a cause of high morbidity, disability and reduced quality of life, as well as mortality and rising costs for health systems. Preventing the HAI risk by planning and implementing effective preventive strategies is important to safeguard patient health. Methods. The study aimed to evaluate the presence of procedures and protocols for infection control, to assess the adhesion to the different aspects of hand hygiene (HH) and hand washing technique by healthcare workers in six ICUs. A perspective observational study was conducted in six ICUs. In each ICU, the adherence by health care workers to both hand hygiene practices and standard precautions was assessed, as well as the presence of procedures and written protocols. Results. The findings showed that in all the involved ICUs, 73 of 142 required protocols and procedures were available. Specifically, 59 of 79 were available for general measure of risk control, 12 of 15 for hand hygiene, and 24 of 48 for standard precautions and isolation measures. Also, the results showed highly variable levels of adherence to the best hygiene practices in all the ICUs involved in the study, with compliance rates ranging from 3% to 100%, and 73 of 142 required protocols were available at the study time. Conclusions. Overall, the involved ICUs showed low levels of adherence to best hygiene practices. This suggests the need to implement immediate strategies for infection control in the ICUs. A multidisciplinary intervention could be effective in preventing and control the HAI risk.score was reached only by the third year students with regard to the proper HH. The level of knowledge about HAI was inadequate. A periodically check of nursing students' knowledge would be advisable in order to fill any gaps, improve training, reduce HAI and increase prevention measures compliance.

Aims: Tissue transglutaminase (tTG) was recently identified as the major autoantigen in coeliac disease. The aim of this multicentre study was to evaluate the impact of a new immunoenzymatic assay for the detection of IgA anti-tGT antibodies. Methods: Seventy four Italian and French clinical laboratories participated in this study; anti-tTG IgA with an enzyme linked immunosorbent assay (ELISA) method using guinea pig liver extract as the coating antigen, anti-endomysium IgA autoantibodies (EMA), and total serum IgA were determined in 7948 patients, 1162 of whom had coeliac disease (737 untreated cases and 425 on a gluten free diet). A proportion of the sera were then sent to a reference laboratory for anti-tTG retesting with an ELISA method using recombinant human tTG antigen. Results: Seven thousand four hundred and fifty eight (93.8%) sera were EMA/antiguinea pig tTG concordant (positive or negative); 490 (6.2%) were non-concordant. The sensitivity of EMA and antiguinea pig tTG in the 737 untreated patients with coeliac disease was 92.1% and 94.8%, respectively, and the specificity was 99.8% and 99.2%, respectively. Retesting of the discordant sera showed that of the 162 sera classified as EMA negative/antiguinea pig tTG positive, only 49 were positive for human recombinant anti-tTG, and that 39 of these were also EMA positive. Furthermore, of the 36 sera classified as EMA positive/antiguinea pig tTG negative, only two were confirmed as EMA positive. Conclusions: The antiguinea pig tTG assay is more sensitive but less specific than EMA, whereas the antihuman recombinant tTG assay is far more specific and just as sensitive as antiguinea pig tTG. Testing for EMA presents considerable interpretative problems and is difficult to standardise.

BACKGROUND AND OBJECTIVES: Clostridium difficile infection (CDI) accounts for the majority of nosocomial cases of diarrhea, and with recent upsurge of multidrug-resistant strains, morbidity and mortality have increased. Data on clinical impact of CDI come mostly from Anglo-Saxon countries, while in Italy only two studies address the issue and no economic data exist on costs of CDI in the in hospital setting. A retrospective cross-sectional study with pharmacoeconomic analysis was performed on the CDI series of the Policlinico Gemelli of Rome, a major 1400 bed Hospital. PATIENTS AND METHODS: The clinical charts of 133 patients in a 26 month period were reviewed. All costs of the involved resources were calculated and statistical analysis was carried out with means and standard deviations, and categorical variables as number and percentages. RESULTS: The results show the significant sanitary costs of CDI in an Italian hospital setting. The cost analysis of the various elements (exams, imaging studies, therapies, etc.) shows that none independently influences the high cost burden of CDI, but that it is the simple length of hospital stay that represents the most important factor. CONCLUSIONS: Prevention of CDI is the most cost-effective approach. The major break-through in cost reduction of CDI would be a therapeutical intervention or procedure that shortens hospital length of stay.

BACKGROUND--Smoking is the single most common cause of chronic bronchitis but the disease can also occur in non-smokers. Alterations in the lung responsible for the disease, such as oxidant/antioxidant and protease/antiprotease imbalance, have been investigated in smokers. The aim of our study was to evaluate local cellular and soluble factors (albumin, immunoglobulins, proteases, alpha 1-antitrypsin, and transferrin) that may be involved in the development of chronic bronchitis in subjects who have never smoked. METHODS--Sixteen clinically stable patients with chronic bronchitis who had never been smokers were studied and 17 healthy non-smokers served as controls. All subjects underwent bronchoalveolar lavage (BAL). Total and differential cell counts and concentrations of the main proteins (albumin, immunoglobulins, complement fractions, alpha 1-antitrypsin, and transferrin) were measured. Elastase-like activity was assessed in cells and supernatants. To estimate the oxidant burden the release of superoxide anion (O2-) from native cell populations was evaluated. RESULTS--Recovery of BAL fluid was reduced in older individuals in both the chronic bronchitis and control groups. There was no difference in total cell count, but neutrophil percentage count was higher in those with chronic bronchitis (median (range) 3.5 (1.6-14.2)) than in controls (1.3 (0.5-3.7)). These differences were most pronounced in the first recovery, representative of the bronchial lavage. There was no difference in bronchial epithelial cells. Total proteins and albumin levels were comparable and IgG, IgA, IgM, C3, C4, transferrin and alpha 1-antitrypsin values standardised to albumin did not show any significant differences. No differences in elastase-like levels in supernatants were detected. In cell lysates elastase-like activity x 10(7) cells (macrophages+neutrophils) was increased in patients with chronic bronchitis (0.25 (0.06-4.3) compared with controls 0.08 (0.03-0.9) micrograms PPEeq). The release of O2- both at baseline and after opsonised zymosan phagocytosis did not show any differences. Correlation analysis between FEV1 and BAL fluid data showed a negative correlation only with neutrophils/ml. CONCLUSIONS--Clinically stable non-smokers with chronic bronchitis show no alterations of local immune components, oxidant burden, and free elastase-like activity in BAL fluids, while the content of elastase-like activity in phagocytic cells is increased. As in smokers, bronchial neutrophilia is the most significant cellular modification which correlates with the degree of airflow obstruction.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Summary Background A potential approach to the treatment of morbid obesity is reduction of gastric emptying to achieve satiety. Botulinum toxin A (Btx-A) is a long-acting inhibitor of acetylcholine-mediated peristalsis, which is mainly responsible for gastric motility. Aim To investigate whether botulinum toxin A, injected in the antrum of obese patients, delays gastric emptying. Methods In a double_blind study, 18 healthy obese subjects (body mass index >30) were randomized into three groups (BTX133, BTX200 and Saline); they received Btx-A133U, Btx-A200U, or saline under endoscopic control. Gastric emptying was tested by scintigraphy before and 10 days after treatment. Body weight variations and appetite sensation were recorded after 5 weeks. Results Fourteen patients completed the study. The botulinum toxin A-treated groups showed weight reduction, which was not statistically significant. The effects on gastric emptying were variable. Most of the botulinum toxin A treated patients reported a reduced appetite. Conclusion This pilot clinical trial suggests potential activity of botulinum toxin A for the manipulation of appetite.

To investigate the mechanisms underlying ventilator-dependence in patients with chronic obstructive pulmonary disease (COPD), and to assess the effects of the combination of positive end-expiratory pressure (PEEP) and pressure-support ventilation (PSV) on inspiratory muscle effort, we investigated respiratory mechanics in eight ventilator-dependent COPD patients. The patients' breathing pattern, lung mechanics, diaphragmatic effort (PTPdi), diaphragmatic tension-time index (TTdi), and arterial blood gases were measured during both spontaneous breathing (SB) and ventilatory assistance consisting of PSV alone (15, 20, and 25 cm H2O) and PSV combined with a PEEP of 5 cm H2O (reducing PSV to 10, 15, and 20 cm H2O, respectively, to maintain equivalent inspiratory pressure). The different levels of ventilatory support were delivered in a randomized sequence. Maximal inspiratory (MIP), esophageal (PpImax) and transdiaphragmatic (Pdi(max)) pressures and respiratory drive (P(0.1)) were measured at the beginning of the procedure during SB. We found a high P(0.1) (6.1 +/- 1.7 cm H2O), which seemed to rule out an impairment of respiratory-center output. Apparently, inspiratory muscle strength was compatible with successful weaning (38.5 +/- 8.8, 50.9 +/- 9.7, and 51.8 +/- 9.5 cm H2O for MIP, PPImax and Pdi(max), respectively). However, abnormal respiratory mechanics (particularly an intrinsic positive end-expiratory pressure (PEEPi) of 8.3 +/- 1.9 cm H2O and pulmonary resistance 24.7 +/- 9.5 cm H2O/L/s imposed an excessive load on the inspiratory muscles, as indicated by a high PTPdi (499 +/- 122 cm H2O x s). Increasing levels of PSV progressively and significantly unloaded the patients' inspiratory muscles, although at pressures above 20 cm H2O uncoupling occurred between patient and ventilator respiratory frequency. Application of PEEP during PSV improved ventilatory assistance by further reducing the inspiratory effort (by 17% on average) and by ameliorating patient-ventilator interaction. We conclude that the excessive mechanical load, and in particular the high PEEPi, is the major determinant of ventilator-dependence in COPD patients. Application of PEEP improves the efficiency of PSV in unloading these patients' inspiratory muscles, and can sometimes improve patient-ventilator interaction.

To evaluate the additional information provided by the determination of cholesterolemia to the Acute Physiology and Chronic Health Evaluation (APACHE) II score.Retrospective evaluation of patients admitted to the intensive care unit (ICU).ICUs in a university hospital.638 consecutive critically ill surgical patients.Surgical and medical therapy according to clinical status.Two indices were devised: DELCUPOS and DELCUNEG (cubed absolute value of the difference between measure cholesterol and the value of 190 mg/dl when cholesterolemia was, respectively, over and under 190 mg). The first estimation of cholesterolemia was taken upon admission to the ICU. The APACHE II score was computed from teh worst values obtained during the first 24h of the ICU stay, including the pre-operative period for patients transferred from the operating theatre. Mortality (24.4%) over the whole time of hospitalization has been considered. A stepwise linear logistic regression on APACHE II, DELCUPOS, DELCUNEG, and on interactions among these three factors has been carried out. A U-shaped relationship between cholesterolemia and morality was demonstrated. The significance of DELCUPOS (p = 0.0021) and DELCUNEG (p = 0.0002), considered together with the APACHE II score, has demonstrated an additive information content with respect to the APACHE score for the prediction of mortality.Both hyper- and hypocholesterolemia have a highly significant relationship to mortality. Cholesterolemia improves the prognostic power of the APACHE II score. This result could be used to create a more powerful prognostic index.

1) to evaluate the long-term efficacy of nocturnal IPPV either via tracheostomy (tIPPV) or a nasal mask (nIPPV) as a means to improve alveolar ventilation in patients with chronic severe hypercapnia caused by kyphoscoliosis; and 2) to assess the effect of MV on hospitalizations and life-style. Twenty six patients with kyphoscoliosis in chronic respiratory failure were enrolled in the study. Patients were divided into two groups. The first group comprised 13 subjects who had been clinically stable for at least 1 month (arterial carbon dioxide tension (Pa,CO2) 81 +/- 1.5 kPa (60.8 +/- 10.9 mmHg), arterial oxygen tension (Pa,O2) 7.3 +/- 0.8 kPa (54.6 +/- 6.1 mmHg)). The second group comprised 13 patients who were either suffering or recovering from an episode of acute respiratory insufficiency (Pa,CO2 9.0 +/- 1.8 kPa (67.8 +/- 13.3 mmHg), Pa,O2 6.8 +/- 1.1 kPa (51.2 +/- 8.2 mmHg), breathing supplemental oxygen in seven cases). Patients in the first group were treated with nocturnal IPPV via a nasal mask, whilst those in the second received nocturnal IPPV via tracheostomy. Similar improvements in arterial blood gases (ABGs) were achieved with both methods. Despite the differences in the degree of severity at baseline, after 1 month, ABG values were: Pa,CO2 6.2 +/- 0.6 kPa (46.6 +/- 4.4 mmHg), Pa,O2 9.0 +/- 1.3 kPa (67.5 +/- 9.6 mmHg) (nIPPV patients); Pa,CO2 6.1 +/- 0.9 kPa (46.1 +/- 6.8 mmHg), Pa,O2 9.8 +/- 1.3 kPa (73.6 +/- 9.8 mmHg) (tIPPV patients). After 1 yr, this improvement was still evident. Days of hospitalization were significantly reduced in both groups during the first year of MV. We conclude that both tIPPV and nIPPV are effective in the long-term treatment of respiratory failure in patients with kyphoscoliosis. It would appear from our data that if nIPPV is initiated early in the evolution of chronic respiratory failure in patients with kyphoscoliosis it will delay the necessity to use an invasive technique; however, long-term follow-up studies and larger case series are needed to demonstrate this.

Bacterial extracts can act as immune stimulants and in some instances have been used, rather empirically, to prevent recurrent infections in the nonimmunocompromised host. Some agents are administered via oral route with the goal to increase airways immune defenses. In animal models and in normal humans, gut-associated lymphoid tissue (GALT) stimulation is able to induce a generalized response by the whole mucosal-associated lymphoid tissue (MALT). The aim of this placebo-controlled, double-blind, parallel-group study was to evaluate whether the stimulation of the GALT through oral administration of a polyvalent bacterial extract (BE) could lead to significant immune modifications either systemically or locally in the respiratory tract in patients suffering from chronic bronchitis. We selected 20 subjects (5 nonsmokers, 6 smokers, and 9 ex-smokers) for at least 3 years. According to a balanced-block randomization method, ten patients received active treatment and ten received placebo. Either drug or placebo was to be taken as one capsule daily the first 10 days of 3 consecutive months. Each capsule of the active product contained 7 mg of a BE obtained from eight different bacterial strains. On entry (T0) and 90 days after beginning of treatment (T90), all patients underwent bronchoalveolar lavage (BAL) and peripheral blood withdrawal to assay BAL fluids and serum samples for immune parameters. The BAL recoveries, cellularity, cell differentials, and lymphocyte subsets (CD19, CD3, CD4, CD8) did not show significant differences. IgG/albumin and IgA/albumin values were not significantly different, but IgA/albumin was significantly increased in the treatment (T0 = 0.14, 0.01 to 0.27, median and range, T90 = 0.15, 0.08 to 0.45, p = 0.028) vs the placebo group when data from current smokers were excluded. Functional tests on alveolar macrophages (AM) (leading front stimulated motility and superoxide anion-O2(-)-release) showed a significant increase of random migration (T0 = 10.6, 7.0 to 23.6, T90 = 13.4, 8.1 to 28.8 microns, p = 0.02) and of stimulated motility after FMLP 10(-7) M (T0 = 13.2, 8.3 to 46.4, T90 = 18.3, 8.4 to 49.6 microns, p = 0.04), a significant increase of O2- release in basal conditions (T0 = 6.0, 1.7 to 30.5 nM/10(6) AM/10', T90 = 11.1, 5.5 to 24.5, p = 0.05) and after stimulation with opsonized zymosan (T0 = 17.7, 4.7 to 35.2, T90 = 22.1, 13.8 to 53.3, p = 0.009) in the treatment group only. Data were not significantly different in the placebo group between T0 and T90. No modifications in systemic immunity were ever observed.(ABSTRACT TRUNCATED AT 400 WORDS)

The aim of the study was to determine whether intermittent positive pressure ventilation (IPPV), delivered either by nasal mask or by tracheostomy, is able to improve alveolar gas exchange in kyphoscoliotic patients with respiratory failure. We evaluated 17 patients, 10 females and 7 males, aged 52 +/- 12 (mean +/- SD) yrs. Eight had severe respiratory failure (arterial oxygen tension (PaO2) 53.2 +/- 9.3 mmHg (7.1 +/- 1.2 kPa); arterial carbon dioxide tension (PaCO2) 73.3 +/- 12.5 mmHg (9.7 +/- 1.6 kPa), breathing supplemental oxygen), and were put on IPPV via tracheostomy (TIPPV). The others (PaO2 54.5 +/- 5.5 mmHg (7.3 +/- 0.7 kPa); PaCO2 57.9 +/- 7 mmHg (7.7 +/- 0.9 kPa), breathing air), were put on IPPV via nasal mask (NIPPV). Home mechanical ventilation (HMV) was performed at night (7 +/- 1 h) by means of a volume-cycled pressure respirator in control mode. The frequency was adapted to the patient's spontaneous respiratory rate, and then eventually modified according to blood gases. A silicone mask was moulded onto the patient's nose. Supplemental oxygen (to maintain arterial oxygen saturation (SaO2)90%) was used only for tracheostomized patients, whereas NIPPV was performed with fractional inspiratory oxygen (FIO2) 21%. Arterial blood samples were obtained for all patients in steady-state condition, 8 +/- 1 h from the withdrawal, breathing air, after 1 and 6 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of the present study was to verify the effectiveness of procaterol, a recent and specific beta-2-adrenoceptor stimulant, in preventing exercise-induced asthma (EIA). Twelve asthmatic patients were selected aged 18.6 +/- 5.6 years with a positive response to EIA and a basal forced expiratory volume of the first second (FEV1) better than 80% of predicted. The patients underwent four bronchoprovocation challenges on four consecutive days. On the first day they performed an inclusion test, and, on the three subsequent days, they were submitted, to three identical standardized challenges according to a randomized design. Fifteen minutes before, procaterol (20 mcg), salbutamol (200 mcg) and a placebo were administered as metered aerosol. No pharmacological treatment was given for 24 h (48 h for antihistamines) before each challenge. The test was carried out running on treadmill (10% grade) for 7 min. Room temperature (20-25 degrees C) and relative humidity (40-55%) were maintained constant. At baseline, 15 min before, 5, 10, 15, 30 and 60 min after the exercise, lung function was assessed. Basal mean values of FEV1 were 94.7, 94.9, 90.7 and 91.5% of predicted for the inclusion and the three protected tests, respectively, without significant differences. The FEV1 mean values showed a mild bronchodilation 15 min after salbutamol (+13.2%, p less than 0.006) and procaterol (+8%, NS). At every considered time all indices showed a significant gap (p less than 0.01) between drugs and the placebo with no appreciable differences between procaterol and salbutamol.

Eight patients who were subjected to colorectal surgery received 1500 mg metronidazole and another 8 patients 1600 mg tinidazole. The two groups of patients were comparable in respect to age, body size, diagnoses, types of operations, premedication, and anaesthesia. Concentrations of the parent compounds and hydroxy-metronidazole were determined by high pressure liquid chromatography in serum and tissues (subcutaneous fat, rectus abdominal muscle, peritoneum, greater omentum, distal ileum, colon, appendix). The serum and tissue concentrations of metronidazole and tinidazole were within overlapping ranges. Hydroxy-metronidazole but not hydroxy-tinidazole was detected. The total area under the serum curves was 505 (SD: +/- 181) mg . h/l for metronidazole, 137 (+/- 38) mg . h/l for hydroxy-metronidazole, and 810 (+/- 286) mg . h/l for tinidazole. The serum half-life values in the same order were 8.5, 11.2, and 14.2 hours. The distribution volume (Vd,area) were 30.1 liter for metronidazole and 38.8 liter for tinidazole. The range of tissue concentrations were completely overlapping. The two regimens can, consequently, be assessed as pharmacokinetically similar.

An 83-year-old woman was found unconscious several hours after she had fallen and fractured her lower limbs in a very cold cellar. On admission she was in shock and had metabolic acidosis, anemia and hypokalemia; her axillary and rectal temperature was 23 degrees C. Her initial ECG showed atrial fibrillation with slow ventricular response and a prominent J wave on the left precordial leads. These changes reverted to normal when body temperature returned to 37 degrees C. Moreover a transient, hypothermia-associated increase of QRS voltage was noted.