Emilia Prospero

Surveillance for surgical site infection after hospital discharge : A surgical procedure-specific perspective

OBJECTIVE To estimate the rate of surgical site infection (SSI) occurring after hospital discharge, to evaluate whether limiting surveillance to inpatients underestimates the true rate of SSI, and to select surgical procedures that should be included in a postdischarge surveillance program. DESIGN Prospective surveillance study. SETTING A surgical ward at a university teaching hospital in Italy. PATIENTS A total of 264 surgical patients were included in the study. RESULTS The global SSI rate was 10.6% (28 patients); 17 (60.2%) of patients with an SSI developed the infection after hospital discharge. The overall mean length of postoperative stay (+/-SD) for patients who acquired a postdischarge SSI was 4.9+/-3.7 days, and SSI was diagnosed a mean duration (+/-SD) of 11.5+/-4.5 days after surgery. Among procedures with postdischarge SSIs, those classified by the National Nosocomial Infections Surveillance system (NNIS) as herniorrhaphy, mastectomy, other endocrine system, and other integumentary system were associated with a mean postoperative stay that was less than the mean time between the operation and the onset of SSI. Four (36%) of in-hospital SSIs occurred after procedures with an NNIS risk index of 0, and 7 (64%) occurred after procedures with an NNIS risk index of 1 or higher. Of the 17 SSIs diagnosed after discharge, 14 procedures (82%) had an NNIS risk index of 0, compared with 3 procedures (18%) with an NNIS risk index of 1 or higher. CONCLUSIONS Our results revealed an increased risk of postdischarge SSI after some types of surgical procedures and suggest that there is an important need to change from generalized to NNIS operative category-directed postdischarge surveillance, at least for procedures locally considered to be high-risk.

Fish oil supplementation reduces cortisol basal levels and perceived stress: A randomized, placebo-controlled trial in abstinent alcoholics

Behavioral distress and dysfunctions of hypothalamic-pituitary-adrenocortical (HPA) axis play a central role in alcohol abuse. Omega-3 fatty acids are proposed as having antistress, regulatory effects on HPA responsiveness, but a possible protective role in ethanol addiction is unexplored.A randomized, doubleblind, placebo-controlled trial was performed in male alcoholics undergoing residential rehabilitation program, to evaluate the effects of 3-week supplementation with fish-oil providing eicosapentaenoic (60 mg/day) and docosahexaenoic acid (252 mg/day) on perceived stress/anxiety and HPA activity, assessed by measuring saliva basal cortisol levels at various daytimes (0730 h, 1130 h, 1600 h, 2000 h, and 2400 h) and the acute cortisol response to Trier Social Stress Test.Results showed that in supplemented subjects, before versus after decrease of stress/anxiety ratings was accompanied by reduction of cortisol basal levels throughout the day; no changes were observed in placebo group. At the end of intervention, amplitude, and duration of stress-evoked cortisol response did not differ between groups; however, the peak of cortisol response was temporally anticipated in supplemented subjects. In conclusion, an elevated omega-3 intake may reduce distress symptoms and basal cortisol secretion in abstinent alcoholics, thus providing a valid subsidiary measure to increase the efficacy of rehabilitation programs in ethanol addicts.

Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates.

The aims of this study were to determine adherence to the perioperative antibiotic prophylaxis (PAP) protocol used at a large Italian teaching hospital during a 6-year period, to assess the variables associated with inappropriate administration, and to measure the impact on surgical site infection (SSI) rates. There were 28 621 patients surveyed of which 74·6% received PAP. An improvement in adherence to the PAP protocol was registered for 58·8% of patients. Significant risk factors were an American Society of Anesthesiologists (ASA) score ≥ 2 [odds ratios (OR) from 1·28 (95% confidence interval (CI) 1·19-1·37) to 1·87 (95% CI 1·43-2·44)], prolonged duration of surgery (OR 1·68, 95% CI 1·56-1·82) and urgent surgery (OR 2·16, 95% CI 1·96-2·37). During the study period, a significant reduction in SSIs rates was detected. We concluded that the global reduction of inadequate PAP administration signifies the efficacy of a multidisciplinary quality improvement initiative on antimicrobial utilization, and this is supported by the observed reduction of the SSI rate.

Socioeconomic determinants of influenza vaccination among older adults in Italy

Abstract Objectives Seasonal influenza represents a major threat to public health but vaccination campaigns are strongly recommended to reduce the risks of serious complications and mortality among community-dwelling elderly persons. We investigated on potential social predictors of influenza vaccination among older adults in Italy. Methods Data analysis was based on the national survey “Health and use of health care,” which was carried out in 2004/2005 and reached a sample of 25,183 elderly persons. After initial univariate and bivariate statistics, we used multivariate logistic regression to evaluate potential independent predictors of influenza immunization. Results 62.6% of the recruited subjects declared to be vaccinated against influenza. At bivariate analysis, significative differences in immunization rates arose by each socioeconomic variable investigated. Logistic regressions confirmed that individuals in lower social classes have higher chances of being vaccinated. Moreover, older age and chronic disease were associated with higher likelihood of immunization. Conversely, reporting good health predicted a lower uptake. Conclusion In our analysis we found several independent predictors of influenza vaccination. Surprisingly, individuals belonging to lower social classes have higher chances of being vaccinated. These results suggest that vaccination policies have a positive effect in preventing socioeconomic inequalities in access to this service in Italy.

Maternal dietary loads of α-tocopherol depress protein kinase C signaling and synaptic plasticity in rat postnatal developing hippocampus and promote permanent deficits in adult offspring.

Vitamin E (α-tocopherol) supplementation has been tested as prophylaxis against gestational disorders associated with oxidative damage. However, recent evidence showing that high maternal α-tocopherol intake can adversely affect offspring development raises concerns on the safety of vitamin E extradosages during pregnancy. Besides acting as an antioxidant, α-tocopherol depresses cell proliferation and modulates cell signaling through inhibiting protein kinase C (PKC), a kinase that is deeply involved in neural maturation and plasticity. Possible effects of α-tocopherol loads in the maturing brain, where PKC dysregulation is associated to developmental dysfunctions, are poorly known. Here, supranutritional doses of α-tocopherol were fed to pregnant and lactating dams to evaluate the effects on PKC signaling and morphofunctional maturation in offspring hippocampus. Results showed that maternal supplementation potentiates hippocampal α-tocopherol incorporation in offspring and leads to marked decrease of PKC phosphorylation throughout postnatal maturation, accompanied by reduced phosphorylation of growth-associated protein-43 and myristoylated alanine-rich C kinase substrate, two PKC substrates involved in neural development and plasticity. Although processes of neuronal maturation, synapse formation and targeting appeared unaffected, offspring of supplemented mothers displayed a marked reduction of long-term synaptic plasticity in juvenile hippocampus. Interestingly, this impairment persisted in adulthood, when a deficit in hippocampus-dependent, long-lasting spatial memory was also revealed. In conclusion, maternal supplementation with elevated doses of α-tocopherol can influence cell signaling and synaptic plasticity in developing hippocampus and promotes permanent adverse effects in adult offspring. The present results emphasize the need to evaluate the safety of supranutritional maternal intake of α-tocopherol in humans.

Determinants of influenza vaccination uptake among Italian healthcare workers

We analyzed seasonal influenza vaccination coverage among the Italian healthcare workers (HCW) in order to identify socio-demographic and clinical determinants of vaccination. We used data from the survey “Health and health care use in Italy,” which comprised interviews of 5,336 HCWs For each respondent, information on socioeconomic, health conditions, self-perceived health and smoking status were obtained. After bivariate analysis, we used multilevel regression models to assess determinants of immunization. Overall 20.8% of HCWs (95%CI 19.7–21.9) reported being vaccinated against seasonal influenza. After controlling for potential confounders, multilevel regression revealed that older workers have a higher likelihood of vaccine uptake (OR = 6.07; 95% CI 4.72–7.79). Conversely, higher education was associated with lower vaccine uptake (OR = 0.65; 95% IC 0.50–0.83). Those suffering from diabetes (OR = 2.07; 95% CI 1.19–1.69), COPD (OR = 1.95; 95% CI 1.31–2.89) and cardiovascular diseases (OR = 1.48 95% CI 1.11–1.96) were more likely to be vaccinated. Likewise, smokers, or former smokers receive more frequently the vaccination (OR = 1.40; 95% CI 1.15–1.70; OR = 1.54; 95% CI 1.24–1.91, respectively) compared with never-smokers as well as those HCWs reporting fair or poor perceived health status (ORs of 1.68, 95% CI 1.30–2.18). Vaccine coverage among HCWs in Italy remains low, especially among those with no comorbidities and being younger than 44 y old. This behavior not only raises questions regarding healthcare organization, infection control in healthcare settings and clinical costs, but also brings up ethical issues concerning physicians who seem not to be very concerned about the impact of the flu on themselves, as well as on their patients. Influenza vaccination campaigns will only be effective if HCWs understand their role in influenza transmission and prevention, and realize the importance of vaccination as a preventive measure

Surveillance of acute flaccid paralysis in the Marches region (Italy): 1997–2007

BackgroundThe last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982, however, it is important to guarantee a high quality surveillance as there is a risk of importation of cases from areas where polio is endemic. Stopping poliovirus transmission is pursued through a combination of high infant immunization coverage and surveillance for wild poliovirus through reporting and laboratory testing of all cases of acute flaccid paralysis (AFP) among children under fifteen years of age. The aim of this study was to describe and to evaluate 11 years of active surveillance in the Marches (Italy) in terms of: incidence, aetiology and clinical manifestation of AFP cases.MethodsThe active Acute Flaccid Paralysis surveillance has been carried out in the Marches region since February 1997 by the Chair of Hygiene which established a regional hospital network. Active surveillance involves 15 hospital centres.ResultsIn the considered period, 0–15 years population varied between 187,051 in 1997 to 201,625 in 2007, so the number of AFP expected cases is 2 per year. From February 1997 to October 2007, 27 cases were found with rates of 1.0/100,000 in 1997; 2.0/100,000 in 1998; 1.0/100,000 in 1999; 0.5/100,000 in 2000; 2.5/100,000 in 2001; 1.0/100,000 in 2002; 0 in 2003; 0.5/100,000 in 2004; 1.5/100,000 in 2005; 2.0/100,000 in 2006; 1.5/100,000 in 2007. In 29.6% of cases two stool samples were collected in 14 days from the symptoms onset. The 60-days follow-up is available for 23 out of 27 cases reported. In 44.5% of cases the definite diagnosis was Guillain Barrè syndrome.ConclusionIn general, the surveillance activity is satisfactory even if in presence of some criticalities in biological samples collection. The continuation of surveillance, in addition to the maintenance of current levels of performance, will tend to a further and more detailed sensitization of all workers involved, in order to obtain spontaneous and prompt reporting, and to achieve the optimal standards recommended by the WHO both in the collection of biological samples and the availability of 60 days follow-up, with the goal of eradicating polio from all countries.

Loop electrosurgical excision procedure and risk of miscarriage

OBJECTIVE To evaluate the risk of miscarriage in the subsequent pregnancy after a loop electrosurgical excision procedure (LEEP), also considering time elapsed from LEEP to pregnancy. DESIGN Multicenter, retrospective cohort study. SETTING Tertiary care university hospitals. PATIENT(S) Women who had undergone LEEP from January 2000 to December 2011. Women with histologic assessment of low-grade cervical dysplasia, not requiring subsequent surgical treatment, constituted the control group. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The first pregnancy after the procedure was evaluated, and only women with singleton spontaneous pregnancies were considered. Women with time intervals of <12 months and women with intervals of ≥12 months or more from LEEP to pregnancy were then compared, to identify adjusted odds ratios for miscarriage. RESULT(S) In women previously treated with LEEP, a total of 116 cases of miscarriage (18.1%) was reported. The mean time interval from LEEP to pregnancy for women with miscarriage compared with women without miscarriage was significantly shorter (25.1 ± 11.7 months vs. 30.1 ± 13.3 months). A higher rate of miscarriage in women with a LEEP-to-pregnancy interval of <12 months compared with controls emerged (28.2% vs. 13.4%; adjusted odds ratio 2.60, 95% confidence interval 1.57-4.3). No significant difference in the rate of miscarriage in women with a LEEP-to-pregnancy interval of ≥12 months compared with controls emerged. CONCLUSION(S) Women with a time interval from LEEP to pregnancy of <12 months are at increased risk for miscarriage.

Caesarean delivery in South Italy: women without choice. A cross sectional survey.

Background In spite of the World Health Organization’s recommendations to maintain caesarean delivery (CD) between 5% and 15% of total births, the rates of CD continue to rise in countries with routine access to medical services. As in Italy CD rate reached 38% in 2008, the highest at EU level, we evaluated socioeconomic and clinical correlates of “elective” and “non programmed” CD in the Country. We performed a stratified analysis in order to verify whether the effect of such correlates differed among women with an “a priori” preference for natural and caesarean delivery respectively. Methods and Findings We analyzed cross-sectional data from the Italian National Statistics Institute (ISTAT) survey on health condition. Socio-demographic variables, information on maternal care services use and health conditions during pregnancy, as well as maternal preferences on delivery, were available for a representative sample of 2,474 primiparous women. After an initial bivariate analysis, we used logistic regressions to evaluate factors associated to the study outcomes. Overall CD accounted for 35.5% of the total births in our sample (CI 33.6–37.4%); moreover, 30.7% (CI 28.6–32.6%) of women preferring natural delivery actually delivered with a CD. Elective CD rate is higher among women over 35 years (22.9%, CI 18.8–27.4%), and those living in the South (26.2%, CI 23.0–29.6%). The multivariate analysis showed that, even adjusting for several confounders, women in the South, receiving care in the private sector had higher chances of CD, also in case of preference for natural delivery. Conclusion Policy interventions are required to reduce the rate of undesired CD, e.g. increasing women knowledge regarding delivery in order to favour aware choices. An effective strategy to reduce CD rate should address the Southern Regions, as women here appear to have a very limited control over the delivery, in spite of a widespread preference for natural delivery.

Determinants of influenza vaccination among the adult and older Italian population with chronic obstructive pulmonary disease: a secondary analysis of the multipurpose ISTAT survey on health and health care use.

We analyzed seasonal flu vaccination rates among the Italian population suffering from Chronic Obstructive Pulmonary Disease (COPD) in order to identify socio-demographic and clinical determinants for vaccination. We used data from the survey “Health and health care use in Italy”, which interviewed 5,935 persons (age 15 – 102 years) suffering from COPD in the period 2004-2005. For each respondent, information on socioeconomic and health conditions, smoking status and patterns of health care utilization were retrieved. After bivariate analysis, we used two multilevel regression models to assess determinants of vaccination among the adult and the older Italian population. Overall 30.5% of adults (N=670) and 74.8% (N=2,796) of older people reported being vaccinated against seasonal flu. After controlling for potential confounders, older age increases the odds of vaccine uptake. Single marital status among the older people, smoking and not having contact with GPs in both age groups, are factors associated with non vaccination. Higher-educated elderly are less likely to be vaccinated, while coverage is higher among the wealthier adults. Vaccine coverage among adults with COPD in Italy remains low, especially among those with no comorbidities, and aged less than 44 years. It is only in older age that vaccination rates increase substantially. We found several risk factors for non vaccination, such as smoking, single marital status, and not having contacts with GPs, which should be considered in developing strategies to increase the coverage of influenza vaccine among people with COPD in Italy.