Andrea A. Conti

The concept of quarantine in history: from plague to SARS.

Abstract The concept of ‘quarantine’ is embedded in health practices, attracting heightened interest during episodes of epidemics. The term is strictly related to plague and dates back to 1377, when the Rector of the seaport of Ragusa (then belonging to the Venetian Republic) officially issued a 30-day isolation period for ships, that became 40 days for land travellers. During the next 100 years similar laws were introduced in Italian and in French ports, and they gradually acquired other connotations with respect to their original implementation. Measures analogous to those employed against the plague have been adopted to fight against the disease termed the Great White Plague, i.e. tuberculosis, and in recent times various countries have set up official entities for the identification and control of infections. Even more recently (2003) the proposal of the constitution of a new European monitoring, regulatory and research institution has been made, since the already available system of surveillance has found an enormous challenge in the global emergency of the severe acute respiratory syndrome (SARS). In the absence of a targeted vaccine, general preventive interventions have to be relied upon, including high healthcare surveillance and public information. Quarantine has, therefore, had a rebound of celebrity and updated evidence strongly suggests that its basic concept is still fully valid.

Cardiac Troponin I and Q-wave perioperative myocardial infarction after coronary artery bypass surgery

OBJECTIVE To monitor cardiac troponin I (cTnI), a newly developed biochemical index for cardiac damage, in patients during and after coronary artery bypass surgery (CABS) to determine whether the measurement of the serum levels of this marker could be of value in formulating an early diagnosis of Q-wave perioperative myocardial infarction (PMI). DESIGN Prospective study with sequential measurements of biological markers in a selected surgical patient group. SETTING University research laboratory and general university hospital (Cardiac Surgery Unit and Anesthesiology and Reanimation Unit). PATIENTS Forty-two patients undergoing elective CABS without concomitant valvular replacement. INTERVENTIONS There were no interventions required for this study. However, patients entered into the study had CABS, sequential arterial blood samples, ECG recordings, and echocardiograms performed. MEASUREMENTS AND MAIN RESULTS Pre-, intra-, and postoperative (up to 48 hrs) measurements of cardiac troponin I, MB-CK, and total creatine kinase, as well as serial electrocardiograms and echocardiograms. Perioperative infarction was assessed as the development of new persistent regional wall motion abnormalities in echocardiography together with electrocardiographic alterations and MB-CK increases. Eight patients had Q-wave PMI. All PMI patients had elevated peak cTnI values (all >9.2 ng/mL), whereas the 34 nonPMI patients had peak values <9.0 ng/mL; therefore, sensitivity and specificity (with a 9.0 ng/mL cut-off value) are 100%. MB-CK measurement peak values did not demonstrate such a high specificity and sensitivity. CONCLUSIONS Because of its high specificity and sensitivity, serial measurements of cTnI provide a rapid and accurate method for confirming or excluding the diagnosis of perioperative myocardial injury. cTnI evaluation can therefore be used both as an independent prognostic marker for patients undergoing cardiac surgery and as a powerful tool for detecting smaller PMIs often missed with standard PMI diagnostic criteria.

Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up

Objective: To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain. Design: Randomized trial, 12-month follow-up. Setting: Outpatient rehabilitation department. Participants: 210 patients with chronic, non-specific low back pain, 140/210 women, age 59 ± 14 years. Interventions: Back school and individual physiotherapy scheduled 15 1-hour-sessions for 3 weeks. Back school included: group exercise, education/ ergonomics; individual physiotherapy: exercise, passive mobilization and soft-tissue treatment. Spinal manipulation, given according to Manual Medicine, scheduled 4 to 6 20’-sessions once-a-week. Outcome: Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6) were assessed at baseline, discharge 3, 6, and 12 months. Results: 205 patients completed the study. At discharge, disability score decreased by 3.7 ± 4.1 for back school, 4.4 ± 3.7 for individual physiotherapy, 6.7 ± 3.9 for manipulation; pain score reduction was 0.9 ± 1.1, 1.1 ± 1.0, 1.0 ± 1.1, respectively. At 12 months, disability score reduction was 4.2 ± 4.8 for back school, 4.0 ± 5.1 for individual physiotherapy, 5.9 ± 4.6 for manipulation; pain score reduction was 0.7 ± 1.2, 0.4 ± 1.3, and 1.5 ± 1.1, respectively. Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups (P<0.001); pain recurrences and drug intake were also reduced compared to back school (P <0.05) or individual physiotherapy (P <0.001). Conclusions: Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Early and Late Rehabilitation and Physical Training in Elderly Patients After Cardiac Surgery

Macchi C, Fattirolli F, Molino Lova R, Conti AA, Luisi MLE, Intini R, Zipoli R, Burgisser C, Guarducci L, Masotti G, Gensini GF: Early and late rehabilitation and physical training in elderly patients after cardiac surgery. Am J Phys Med Rehabil 2007;86:826–834. Objective:Few randomized trials have enrolled patients who have undergone cardiac surgery, and even fewer have included patients aged 75 yrs or more. Furthermore, the optimal timing of cardiac rehabilitation for postsurgical patients has not yet been codified. The aim of this study was to verify whether rehabilitation outcomes are also favorable in postsurgical patients aged 75 yrs or more and whether an early rehabilitation program is as effective and safe as a late one. Design:Three hundred patients who underwent cardiac surgery, 27.7% of whom were at least 75 yrs old, were randomly assigned to a rehabilitation program starting within the second week after operation or within the fourth week. All events occurring during the rehabilitation program or in the following year were recorded. Results:During the rehabilitation program, new-onset atrial fibrillation was significantly more frequent in the early rehabilitation group, independent of age class, and anemia was significantly more frequent in older patients, independent of rehabilitation timing. At the end of the rehabilitation program, more than 90% of patients showed significant increases in walking distance, and during the follow-up, no significant difference was found with regard to mortality, nonfatal events, functional ability, or control of cardiovascular risk factors, independent of rehabilitation timing and age class. Conclusions:This study provides evidence that in selected patients who have undergone cardiac surgery, rehabilitation outcomes are also favorable in patients aged 75 yrs or more, and an early rehabilitation program is as effective and safe as a traditionally late one.

S-100 Protein and Neuron-Specific Enolase as Markers of Subclinical Cerebral Damage after Cardiac Surgery: Preliminary Observation of a 6-Month Follow-Up Study

Cerebral damage remains one of the hazards related to cardiac surgery with cardiopulmonary bypass. The use of biochemical markers of cerebral injury may be of practical value. We investigated the plasma release patterns of S-100 protein and neuron-specific enolase (NSE) during the intervention and their relationship with the development of neuropsychological deficits assessed 6 months after the intervention in 16 patients undergoing elective cardiac surgery with cardiopulmonary bypass. Both S-100 and NSE significantly increased peri- and postoperatively. Significant correlations were found between values measured at several time points and impaired performance in a few tests at the 6-month follow-up. A stratification into two age subgroups led to the hypothesis that age might have a confounding or a modifying effect on the association between S-100 and NSE levels, and cognitive impairment.

Electrophysiologic procedures and activation of the hemostatic system

BACKGROUND Thromboembolism occurs in 0.4% to 2% of the subjects undergoing radiofrequency ablation (RFA), but its mechanisms remain unclear. Our aim was to evaluate several parameters of the hemostatic system in relation to the electrophysiologic procedure. METHODS Thirty consecutive patients were enrolled in the study. Fifteen underwent electrophysiologic study and 15 underwent radiofrequency ablation. Before the ablation procedure, all subjects were given an intravenous heparin bolus (2500 IU). Blood samples were drawn immediately before, at the end of, and 24 hours after the procedures. Spontaneous platelet aggregation in whole blood and in platelet-rich plasma, markers of clotting activation (prothrombin fragment 1+2 and the thrombin-antithrombin complex) and the fibrinolytic system (plasminogen activator inhibitor and D-dimer) levels were evaluated. RESULTS At the end of the procedure, spontaneous platelet aggregation in whole blood, prothrombin fragment 1+2, thrombin-antithrombin complex, and D-dimer levels increased significantly in all patients. The hemostatic changes were more marked after RFA than after electrophysiology. Spontaneous aggregation in whole blood, prothrombin fragment 1+2, and thrombin-antithrombin complex levels at 24 hours after the procedure were similar to those observed before the procedure in both groups; D -dimer levels were still elevated with respect to preprocedure levels, with a trend toward higher levels in patients undergoing RFA rather than electrophysiology. A significantly more marked activation of coagulation (prothrombin fragment 1+2, P <.005) was found in patients in whom the mean duration of energy application was higher than 23.5 seconds. CONCLUSIONS Our data suggest that antithrombotic prevention with a prolonged administration of heparin and/or the association of antiplatelet agents should be considered in patients undergoing RFA.

Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany

Background: Despite the importance of hand hygiene in reducing infection, healthcare worker compliance with hand hygiene recommendations remains low. In a previous study, we found a generally low level of compliance at baseline, with substantial differences between doctors and nurses and between hospital units. We describe here the results of our multimodal intervention intended to improve levels of healthcare worker hand hygiene. Methods: A 6-month, before-and-after, multimodal interventional study in five hospital units in Florence, Italy. We used direct observation to assess hand hygiene rates for doctors and nurses, focusing on hygiene before touching the patient. We explored reasons for unit variability via interviews of doctor and nurse leaders on the units. Results: Overall healthcare worker hand hygiene increased from 31.5% to 47.4% (p<0.001). Hand hygiene adherence among nurses increased from 33.7% to 47.9% (p<0.001); adherence among doctors increased from 27.5% to 46.6% (p<0.001). Improvement was statistically significant in three out of five units, and units differed in the magnitude of their improvement. Based on the interviews, variability appeared related to the “champion” on each unit, as well as the level of motivation each physician leader exhibited when the preintervention results were provided. Conclusions: Although overall healthcare worker adherence with hand hygiene procedures before patient contact substantially increased after the multimodal intervention, considerable variability—for both nurses and doctors and across the 5 units—was seen. Although adherence substantially increased, overall hand hygiene in these units could still be greatly improved.

Left-ventricular function and physical performance on the 6-min walk test in older patients after inpatient cardiac rehabilitation.

Polcaro P, Molino Lova R, Guarducci L, Conti AA, Zipoli R, Papucci M, Garuglieri S, Raimo D, Fattirolli F, Macchi C, Gensini GF: Left-ventricular function and physical performance on the 6-min walk test in older patients after inpatient cardiac rehabilitation. Am J Phys Med Rehabil 2008;87:46–55. Objective:The 6-min walk test (6mWT) is widely used to assess physical performance in cardiac rehabilitation settings. Factors affecting the walked distance before starting physical training have been described, whereas information on factors affecting the increase of the walked distance after physical training is still scant. The aim of this study was to verify, in a large sample of elderly patients soon after cardiac surgery, the role of left-ventricular function (LVF) in increases in distances walked after an intensive rehabilitation program. Design:We enrolled 459 patients (300 males and 159 females, mean [±SD] age 70 ± 11 yrs). According to the echographic ejection fraction, patients were classed into two categories, LVF ≥ 40% and LVF < 40%. All patients performed the 6mWT at the beginning and end of the rehabilitation program. Results:Longer walked distances before and after the rehabilitation program were significantly associated with preserved or moderately depressed LVF, whereas greater relative increases of the distance walked after the rehabilitation program were significantly associated with poor LVF (P < 0.001 for all). Conclusions:Among elderly patients admitted as inpatients to an intensive rehabilitation program soon after cardiac surgery, those with poor LVF are most likely to respond more favorably to physical training. Therefore, instead of considering poor LVF a risk for starting physical training in these patients, it should be considered a strong indication, to avoid further physical deconditioning and disability.

Systematic reviews of diagnostic test accuracy and the Cochrane collaboration

Since Cochrane’s Corner focuses on Cochrane systematic reviews, it is important that readers be informed about new publication types within the Cochrane Library (http://www. thecochranelibrary.com), for example systematic reviews of diagnostic test accuracy (DTA). This commentary serves to explain that research on diagnostic test efficacy and impact has recently begun to be based on an expanding set of complex methodological rules. These rules may still be unfamiliar to doctors who rely on and use tests for clinical decisions. A historical perspective

Frailty and resilience from physics to medicine.

Medicine makes use of an extremely ample and flexible range of terms, reshaping existing concepts and deriving others from scientific and popular sectors. The well known and widely used term ‘‘stress” is a good example and, more recently, other terms deriving from physics are becoming more and more employed in biomedicine and in medical humanities. Frailty and resilience are two of them. According to the (on-line) Longman Dictionary of Contemporary English [1] frailty is ‘‘the lack of strength or health”. The term frailty has not yet been included in the MeSH controlled vocabulary of the Medline database, but the number of hits encountered when inserting it in Medline as a free text term is on the increase [2]. They were 1777 (as at October 14, 2009), of which only 44 (2.5%) date back to before the nineties. Therefore, this term deriving from physics has gained ground in medicine essentially in the last two decades, in particular in the field of geriatrics, where it now indicates a not infrequent biological and clinical syndrome of the elderly. This complex is characterized by a lowering of reserves in many human organs and apparatuses, usually developing progressively and appearing as the incapacity of declining body functional mechanisms to respond to excess external and internal needs [3]. On the contrary resilience is, always according to the same dictionary, ‘‘the ability to become strong, happy, or successful again after a difficult situation or event” and ‘‘the ability of a substance such as rubber to return to its original shape after it has been pressed or bent” [1]. Resilience is a MeSH term (‘‘the human ability to adapt in the face of tragedy, trauma, adversity, hardship, and ongoing significant life stressors”) introduced in 2009 [2], and only 142 of 3193 (4.4%) hits detectable inserting it as a free text expression in Medline date back to before 1990 (as at October 14, 2009). First adopted in physics to indicate the capacity of materials to retrieve their initial shape following exposition to external pressure (flexibility and elasticity), in the last few years its use has been extended to the biological and medical sciences, and it defines the intrinsic ability of individuals to cope negative events and difficulties and to recover and regain health after them [4]. This capacity may now be referred not only to single subjects but also to whole communities. It is perhaps not by chance that the old universal term ‘‘stress” now appears connected with both the terms here presented, frailty and resilience. No longer isolated, it now keeps good company.