Katia Rossi

Changing trends in acute upper-GI bleeding: a population-based study.

BACKGROUND Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear. OBJECTIVE To analyze the time trends of UGIB in 2 different management eras. DESIGN Prospective observational study. SETTING General university-affiliated hospital. PATIENTS AND INTERVENTIONS A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period. RESULTS The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%). LIMITATIONS A single-center study and a potential lack of generalizability. CONCLUSIONS From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.

Group B Streptococcal Infections in a Northern Region of Italy

BACKGROUND. Group B streptococcus is a leading cause of neonatal bacterial infections. Despite adoption of preventive strategies, cases of infection continue to occur and there is concern that widespread antimicrobial prophylaxis might delay rather than prevent disease onset, increasing the rates of late-onset diseases. OBJECTIVES. The purpose of this study was to determine the incidence and clinical features of early- and late-onset group B streptococcus disease in a northern region of Italy where a screening-based approach had been proposed. METHODS. A population-based study was prospectively conducted in Emilia-Romagna, Italy. Infections that occurred during 2003–2005 in infants aged <3 months were analyzed. RESULTS. Among 112933 live births, 56 cases of invasive disease (30 early- and 26 late-onset disease) were observed, giving an annual group B streptococcus disease incidence of 0.50 per 1000 live births. Eleven infants with early-onset disease showed no signs of illness or were mildly ill, whereas 19 had moderate-to-severe symptoms, and culture-proven meningitis was found in 2. Risk factors were detected in 12 women. Twenty-two mothers had antenatal screening; 5 were group B streptococcus colonized, but 17 were culture-negative. Prophylaxis was administered in 3 women. Three infants with late-onset diseases were mildly ill, whereas 23 had moderate-to-severe symptoms. Risk factors were found in 7 mothers. Late-onset diseases were clinically more severe than early-onset diseases; meningitis was diagnosed in 12 infants, and 4 of 26 died. CONCLUSIONS. The incidence of early-onset disease was low. Some early infections were still observed because of negative screening results or missed opportunity for prevention. Late-onset diseases accounted for most meningitis cases and deaths. Strict adherence to protocols and adoption of optimal culture methods would further improve prevention of early-onset disease, but the aim of future strategies should be the prevention of all invasive diseases.

Metabolic and respiratory effects of theophylline in the preterm infant

BACKGROUND Methylxanthines are often administered to preterm infants for the treatment of apnoea. AIMS To study the effects of theophylline on energy metabolism, physical activity, and lung mechanics in preterm infants. METHODS Indirect calorimetry was performed for six hours before and after administration of a bolus of theophylline (5 mg/kg) in 18 preterm infants while physical activity was recorded with a video camera. Lung mechanics measurements were performed at baseline and 12 and 24 hours after theophylline treatment. RESULTS Theophylline increased mean (SEM) energy expenditure by 15 (5) kJ/kg/day and augmented carbohydrate utilisation from 6.8 to 8.0 g/kg/day, but fat oxidation was unchanged. After theophylline treatment, preterm infants had faster respiration, lower transcutaneous CO2, and improved static respiratory compliance without increased physical activity. CONCLUSIONS A bolus of 5 mg/kg theophylline increased energy expenditure independently of physical activity, increased carbohydrate utilisation, and improved respiratory compliance. The increased energy expenditure could be detrimental to the growth of the preterm infant.

Maternal anaphylaxis and fetal brain damage after intrapartum chemoprophylaxis.

Abstract We report a case of maternal anaphylaxis following intrapartum chemoprophylaxis. The term fetus developed severe brain damage as a consequence of intrapartum asphyxia. The lesions resulted from maternal hypotension following anaphylaxis. We discuss the feto-maternal risks and the controversial treatment of such a condition. The increasing number of penicillin-treated parturients will result in further cases of maternal anaphylaxis than previously found.

Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non-valvular atrial fibrillation

Essentials Anticoagulation in the elderly is still a challenge and suspension of warfarin is common. This is an observational study reporting reasons and consequences of warfarin suspension. Vascular disease, age, time in therapeutic range, and bleedings are associated with suspension. After suspension for bleeding or frailty, patients remain at high‐risk of death or complications.

Absence of neonatal streptococcal colonization after planned cesarean section

According to CDC recommendations, women colonized with group B streptococcus (GBS), delivering by planned cesarean section (CS) with intact membranes, do not require intrapartum chemoprophylaxis (IAP) (1). These recommendations are based on scanty literature, mainly on a single paper where maternal colonization status was unknown (2). We studied neonatal colonization, with the aim to know if after planned CS mother-to-infant GBS transmission can occur.

Are postnatal ampicillin levels actually related to the duration of intrapartum antibiotic prophylaxis prior to delivery? A pharmacokinetic study in 120 neonates

Objective To assess ampicillin levels according to the duration of intrapartum antibiotic prophylaxis (IAP). Design Prospective cohort single-centre study. Setting Tertiary care centre (Modena, Italy). Patients 120 neonates≥35 weeks’ gestation exposed to IAP. Interventions Neonates were divided into four groups, according to the duration of IAP prior to delivery: group 1 (n=30; <1 hour), group 2 (n=30; ≥1 and <2 hours), group 3 (n=30; ≥2 and <4 hours) and group 4 (n=30; ≥2 doses, ≥4 hours). Main outcome measures Blood samples were collected at delivery (from the umbilical cord) and at age 4 hours (from a peripheral vessel). Results Median duration of IAP was 121 min (range 7–2045 min). Median ampicillin levels in umbilical cord blood were 10.4 µg/mL (IQR 6.4–14.9) and in peripheral blood were 4.7 µg/mL (IQR 2.8–6.4µg/mL). Umbilical cord blood levels reached a peak approximately 30 min after IAP and then declined significantly (p<0.001). Peripheral blood levels did not differ among study groups. Neonates exposed to a full loading dose (n=115) had peripheral blood levels 2.5–70 times higher than the minimal inhibitory concentration for group B streptococcus. There was no relationship between neonatal ampicillin concentrations and the duration of IAP prior to delivery (β=−0.0003, 95% CI −0.02 to 0.001, p=0.680). Conclusions Ampicillin levels reach a peak in the umbilical cord blood within 30 min of intrapartum administration. After a full loading dose, bactericidal levels persist for at least 4 hours after birth and seem independent of the duration of IAP prior to delivery.

46 MEDIUM CHAIN TRIGLYCERIDES (MCT) IN INFANT FORMULAS: METABOLIC INTERCONVERSION AND INFLUENCE ON ESSENTIAL FATTY ACIDS (EFA)

Limited information exist on (a) the metabolic inter conversions of MCT and on (b) the influence of these processes on EFA metabolism. The effect the MCT content of two infant formulas, on plasma fatty acids (FA) were studied in preterm infants. The MCT formula (MCTF) contained 46 mol% octanoic+decanoic acids and roughly half the palmitic, stearic and oleic acids of the long-chain triglyceride formula (LCTF) (4.8 mol% octanoic+decanoic). Both had similar amounts of linoleic and linolenic acids. The FA composition of plasma lipids was determined by gas-chromatography at birth and on day 28. The groups (MCTF n=8, LCTF n=12) had similar clinical characteristics, infants were fed solely the formulas from birth and did not receive parenteral lipids. Selected FA of plasma triglycerides (TG) and phospholipids (PL) (day 28) are in tables.In spile of striking dietary differences, palmitic and stearic were not different indicating that MCT are elongated or converted into saturated fatty acids. Oleic was lower in MCTF possibly because the Δ9 desaluralion is limiting. Notwithstanding similar dielary and plasma linoleic and linolenic, docosahexaenoic was lower in PL of the MCTF fed infants. EFA metabolism may be influenced by the non essential FA fed concurrently.