Table of Contents
Editorial in Global Public Health
The key role of government national planning around the world for antimicrobial resistance: State of the art and perspectives
Author: Francesco Chirico1
1M.D., Health Service Department, State Police, Ministry of Interior, Italy.
Keywords: Drug resistance, microbial; global health; government; health policy; World Health Organization.
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Original Article in Critical Care Medicine
Physicians’ and nurses‘ knowledge and attitudes in management of sepsis: An Italian study
Authors: Gabriella Nucera1, Anna Esposito2, Naomi Tagliani3, Chiara Jane Baticos4, Pietro Marino1
1 M.D., Department of Emergency, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy
2 Prof, M.S.N., ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy. Faculty of Nursing Science, University of Milan, Milan, Italy
3 M.S.N., ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy. Faculty of Nursing Science, University of Milan, Milan, Italy
4 B.N., Faculty of Nursing Science, University of Milan, Italy
Introduction: Sepsis is one of the most deadly and costly conditions at hospitals. Our study aimed to study levels of knowledge and attitudes in management of sepsis among nurses and physicians employed at Fatebenefratelli hospital, Milano, North-Italy, with particular regard to the analysis of the effects of educational training.
Methods: A cross-sectional, quasi-experimental study was conducted between June 1 and October 30, 2017. Physicians and nurses from Intensive Care Unit (ICU) and non-ICU hospital wards were recruited. The study participants were invited to attend some educational workshops and, after 6 months, to fill out a questionnaire based on the 2016 Surviving Sepsis Campaign guidelines. Descriptive statistics were expressed with frequency and percentage (%). Chi-square and Student’s t-test were performed to compare the differences in awareness and knowledge between groups. P-values < 0.05 were considered statistically significant.
Results: Nurses and physicians reported both ‘good’ levels (> 75%) of knowledge of procedures that increase risk of sepsis, ‘fairly‘ (50-75%) levels of knowledge, attitudes and behaviour towards blood culture techniques, and ‘poor’ (< 50%) levels of knowledge concerning early identification, methods and scores for diagnosis and management of sepsis. However, with regard to this latter point, T Student test for sample independent confirmed a significant difference in the average percentages of correct answers between recently (~ 6 months) trained (74 ± 3.4%) nurses (n = 33) and physicians (n = 19) and not recently (> 1 years) or never trained (34.8 ± 7.4%) nurses (n = 99) and physicians (n = 30) (t(10) = 11.72, P = < 0.001).
Discussion and Conclusion: Our findings showed that levels of knowledge concerning methods and scores for early identification of sepsis can be significantly improved by educational training. A good knowledge of sepsis guidelines is essential to correct management of this condition.
Keywords: Education; knowledge and attitudes; Surviving Sepsis Campaign; SOFA; sepsis; qSOFA.
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Original Article in Infectious Diseases
Bacterial profile and antibiotic susceptibility pattern of adult lower respiratory tract infections in Colombo, Sri Lanka
Authors: Nadeesha Amarasinghe1, Muthulingam Athavan2, Deepal Jayamanne3, Yamuna Rajapakshe4, Aflah Sadikeen4, Kirthi Gunasekara4, Amitha Fernando4, Lilani Karunanayake5
1 M.D., Central Chest Clinic, Colombo, Sri Lanka
2 M.D., Senior Registrar in Respiratory Medicine, Central Chest Clinic, Colombo, Sri Lanka
3 M.D., Health Informatics, Ministry of Health, Colombo, Sri Lanka
4 M.D., Consultant Chest Physician, Central Chest Clinic, Colombo, Sri Lanka
5 M.D., Consultant Microbiologist, Medical Research Institute, Colombo, Sri Lanka
Introduction: Lower respiratory tract infections (LRTIs) remain the deadliest communicable disease around the world. This study was conducted to identify the bacterial etiology of LRTIs among patients who attended the Central Chest Clinic in city of Colombo, Sri Lanka and their antibiotic susceptibility profile to enable clinicians to take decisions on effective empirical antibiotics.
Methods: Sputum samples were collected from 1,372 patients over the age of 18 years with suspected LRTIs during the year 2015. The samples were collected and processed according to standard laboratory procedures at the microbiology laboratory of the Medical Research Institute of Sri Lanka.
Results: Most of reports (58%) were from patients diagnosed with infective exacerbations of chronic lung diseases. Out of all sputum cultures processed, 404 (29.4%) resulted positive for pathogenic bacterial organisms. Coliforms (n = 176, 43.6%), and Pseudomonas aeruginosa (n = 117, 29%) were the most common isolated bacteria, followed by Moraxella (n = 47, 11.6%), Haemophilus influenzae (n = 23, 5.7%), and Streptococcus pneumoniae (n = 18, 4.4%). The two most common bacteria isolated showed a high sensitivity for co-amoxyclav, quinolones, 3rd generation cephalosporins, carbapenems and aminoglycosides, while coliforms were highly resistant (98%) to ampicillin. S. pneumoniae showed a high resistance for penicillin (67%) and erythromycin (61%), while Haemophilus showed a good sensitivity to co-amoxyclav (96%). There was no significant correlation between rainfall and proportions of coliforms (r = – 0.152, P = 0.638) and Pseudomonas (r = 0.271, P = 0.395) during the year.
Discussion and Conclusion: In our study, the most predominant pathogens recovered from LRTIs were P. aeruginosa and coliforms (Klebsiella spp.) as Gram negative, and S. pneumoniae as Gram positive bacteria. Co-amoxyclav, 3rd generation cephalosporins, quinolones and all second line antibiotics tested were the most efficient antibiotics in treatment of LRTIs, differently from ampicillin, erythromycin and penicillin that were not efficient antibiotics in treating this disease in our locality.
Keywords: Antibiotic susceptibility; antibiotic resistance; bronchiectasis, chronic obstructive pulmonary disease; lower respiratory tract infections; Sri Lanka.
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Original Article in Orthopaedics
Comparison of conventional versus robotic-assisted total hip arthroplasty using the Mako system: An Italian retrospective study
Authors: Roberta Banchetti1, Silvia Dari2, Maria Elisabetta Ricciarini3, Domenico Lup3, Francesco Carpinteri4, Fabio Catani5, Patrizio Caldora6
1 D.P.T., Prof, Department of Physical Rehabilitation, Santa Margherita Cortona Hospital, Arezzo, Italy. Faculty of Physical Therapy, University of Siena, Italy
2 Economist BEc, Faculty of Medicine, Department of Physical Therapy, La Sapienza University, Rome, Italy
3M.D., Department of Orthopaedics and Traumatology, Santa Margherita Hospital, Cortona and San Donato Hospital, Arezzo, Italy
4 M.D., Department of Physical Rehabilitation, San Donato Hospital, Arezzo, Italy
5 M.D., Prof, Department of Orthopaedics and Traumatology, University Hospital Polyclinic of Modena and Reggio Emilia, Modena, Italy
6 M.D., Prof, Department of Orthopaedics and Traumatology, Santa Margherita Hospital, Cortona and San Donato Hospital, Arezzo, Italy
Introduction: Our research aimed to evaluate differences in terms of length of hospital stay and clinical outcomes between robotic-arm assisted using MAKO system and standard manual implantation in a group of patients who underwent primary total hip arthroplasty (THA).
Methods: Our retrospective, cohort study was conducted between August 2014 and March 2016. From our target population of 376 patients from three hospitals of Tuscany Region, Italy, we randomly selected a sample of 220 patients, who was subdivided in two groups (MAKO system n = 100; Standard technique n = 120). Our evaluation was carried out before and after surgery at 24 months follow-up. Western Ontario and McMaster (WOMAC) Osteoarthritis Index, Harris Hip Modified Score (HHS), and Numeric Pain Rating Score (NPRS) scales were administered. One sample and independent sample T Student tests were used to assess eventual differences within and between groups for the continuous variables. The significance threshold was set up at P < 0.05.
Results: Rate of respondents was 48.6% (MAKO system n = 56, 56%; Standard technique n = 51, 42.5%). There was a significant difference in the length of hospital stay, expressed as number of days hospitalized, between the MAKO group (M = 5.14, SD = 1.98) and the standard group (M = 8.11, SD = 1.64) (t(105) = 15.30, P < 0.001). There were no significant differences in preoperative and post-operative scores between robotic-assisted and standard groups in all of the patient-reported outcome measures (PROMs), but we reported a statistically and clinically significant improvement in all of the post-operative PROMs scores for both surgical procedures (P < 0.001).
Discussion and Conclusion: Our findings showed that the MAKO™ robotic is a valuable technology that may innovate THA. However, further long-term studies are needed to justify additional costs.
Keywords: Arhroplasty, Hip Replacement; clinical outcomes; MAKO system; Patient Outcome Measures (PROMS) questionnaires.
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Original Article in Pulmonary Medicine
Role and sensitivity of Positron Emission Tomography with [18F]Fluorodeoxyglucose in diagnosis and follow-up of patients affected by chronic pulmonary aspergillosis (CPA)
Authors: Gianfranco Schiraldi1, Cristina Elena Popescu2, Michele Chiericozzi3, Salvatore Lo Cicero3, Flavio Allegri4, Franco Mosca5, Claudio Rossetti6
1M.D., Prof., Department of Pneumology, IRCCS Auxologico, Milan, Italy
2M.D., Department of Nuclear Medicine, Niguarda Cà Granda Hospital, Milan, Italy
3M.D., Department of Pneumology, Niguarda Cà Granda Hospital, Milan, Italy
4M.D., Department of Pneumology, National Center Cancer, Milan, Italy
5M.D., Health Service Department, State Police, Ministry of Interior, Rome, Italy
6M.D., Prof., Department of Nuclear Medicine, Niguarda Cà Granda Hospital, Milan, Italy
Introduction: PET/CT is considered as a powerful tool to diagnose, stage, and monitor patients with a variety of diseases. In this study, we assessed the sensitivity and the degree of agreement between 18F-FDG PET/CT and serological tests in diagnosis and follow-up of patients affected by chronic pulmonary aspergillosis (CPA).
Methods: Thirty-seven adult patients (21 males and 16 females) affected by CPA were recruited during the study period (2010 – 2017). At the time of first diagnosis, we compared sensitivity of 18F-FDG PET/CT and serologic tests (i.e., identification of Aspergillus-specific IgE and IgG antibodies using IFA and ELISA). 12 months after the treatment, we repeated tests only in patients with possible active disease to make a comparison between serological tests and 18F-FDG PET/CT. Sensitivity was calculated as the proportion of positive results obtained with the index test among cases. The agreement between diagnostic techniques was assessed using the Kappa coefficient. The level of significance was set at 5% (P < 0.05).
Results: At the time of first diagnosis, agreement between 18F-FDG PET/CT and serologic tests was ‘almost perfect’ (88%, Kappa = 0.846, P < 0.05), whereas it was ‘good’ at 12 months follow-up (81%, Kappa = 0.684, P < 0.05). At first diagnosis, serological test had a higher sensitivity (94.59%, 95% Confidence Interval [CI] 81.81% to 99.34%) in comparison with 18F-FDG PET/CT (83.78%, 95% CI 67.99% to 93.81%). Conversely, at 12-month follow-up, 18F-FDG PET/CT showed higher sensitivity (93.75, 95% CI 69.77% to 99.84%) than serological test group (75%, 95% CI 47.62% to 92.73%).
Discussion and Conclusion: Our findings demonstrate that both methods are suitable and have almost equivalent sensitivity in diagnosis and follow-up of patients affected by CPA with active disease. 18F-FDG PET/CT scan is a reliable support tool for clinical and serological data in the diagnosis and follow-up of aspergillosis infection, providing additional information on metabolic activity, accurate anatomic localization and extent of disease.
Keywords: Diagnosis; pulmonary aspergillosis; Positron Emission Tomography; sensitivity; serological tests.
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Original Article in Sociology of Health
Education as a key determinant of health: A case study from rural Anhui, China
Authors: Adam Mursal1, Weizhen Dong2
1 MA, Department of Sociology and Legal Studies, University of Waterloo, Waterloo, Canada
2 PhD, Department of Sociology and Legal Studies, University of Waterloo, Waterloo, Canada
Introduction: Recent attention has focused on the emergence and causes of substantial health disparities between rural and urban residents in China. This study aims to identify which social determinants contribute to the poor health status of rural Chinese.
Methods: Quantitative analysis (multivariate logistic regression) of survey data was utilized to determine significant social determinants of health affecting the health of adult people from the rural province of Anhui, China. Diagnosis of chronic diseases was the main measure of health used as the outcome variable. Predictor variables included in the statistical model were major social determinants of health (education, income, sex, age, occupation, as well as health behaviours related to smoking, drinking, and exercise).
Results: Our findings indicated education had the largest impact on chronic disease diagnoses in rural Anhui. Generally, as education level increases, incidence of chronic disease diagnosis decreases.
Discussion and Conclusion: Healthcare reform in Anhui China should focus on increasing the education level of rural residents, particularly for vulnerable groups such as farmers, women, the elderly, and homemakers.
Keywords: China; education; health policy; SDoH (social determinants of health).
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Original Article in Infectious Diseases
Impact of diet on vitamin D status in a Sri Lanka-based sample of pregnant women
Authors: Kaneshapillai Anusha1, Liyanage Guwani2, Hettiaratchi Usha3, Gunasekera Dulanie4
1 Bsc, Research Assistant and Clinical Nutritionist, Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
2 M.D., Senior Lecturer, Department of Paediatrics, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
3 PhD, Senior Lecturer, Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
4 M.D., Professor, Department of Paediatrics, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
Introduction: Vitamin D deficiency is common during pregnancy in Asian countries. However, there is little knowledge about vitamin D status of pregnant mothers and, therefore, supplements are not routinely provided in public clinics and government hospitals in Sri Lanka. Therefore, aim of this study was to assess vitamin D status and adequacy of vitamin D intake in a sample of pregnant mothers.
Methods: This was a secondary analysis of existing data from a prospective cohort study. A convenience sample of 89 healthy and non-vitamin D supplemented Sri Lanka-based pregnant mothers was recruited during the third trimester of their pregnancy. Dietary vitamin D intake was assessed through a food frequency questionnaire, while serum was analysed for vitamin D, parathyroid hormone (PTH) and other markers of bone biochemistry.
Results: In our sample, average daily dietary intake of vitamin D was 1,289.4 ± 1,225.6 IU/day (range: 56 – 5400 IU). A significant proportion of mothers (45%) consumed < 600 IU of vitamin D per day. More than half of our sample (56.9%) received vitamin D though fortified milk powder and 36% from fish consumption. Most of mothers (69%) consumed small fish and none of them received vitamin D supplementation. There was a significant positive correlation between dietary vitamin D and serum 25-hydroxyvitamin D (25(OH)D) (r = 0.355, P < 0.01). 12.4%, 50.6% and 37% of the mothers were vitamin D deficient, insufficient and sufficient, respectively. We showed a significant difference in levels of dietary vitamin D intake between serum 25(OH)D deficient/insufficient (dietary vitamin D: 1,083.6 ± 1,026.4 IU/day) and 25(OH)D sufficient (dietary vitamin D: 1,638.5 ± 1,456.1 IU/day) groups.
Discussion and Conclusion: Dietary intake of vitamin D was inadequate in Sri Lankan non-vitamin D supplemented mothers. Further evaluation of vitamin D status and requirement for supplementation in a nationally representative sample is essential.
Keywords: Bone; calcium; diet; parathyroid hormone; pregnancy; vitamin D; Sri Lanka.
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Case Report in Internal Medicine
Levofloxacin-induced visual hallucinations: A case report and review of the literature
Authors: Valentina Raffaelli1, Giulia Cantoni1, Gabriella Nucera1, Pietro Marino1
1 M.D., Department of Emergency, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy
A 52-year-old female, nonalcoholic, with no significant past medical history, was empirically treated with intravenous administration of levofloxacin (LVFX, 750 mg/day) for bronchopneumonia. On day 2, she reported seeing people who are not there (visual hallucinations). She had no history of psychiatric disorders or any family history of mental illness. The patient underwent EEG and brain magnetic resonance imaging (MRI), which resulted normal. Hence, psychiatric and neurological examinations excluded delirium, encephalitis, meningitis, structural neurological lesions. Any endocrine dysfunction (e.g., hypoglyvemia, dyselectrolytemia, diabetic ketoacidosis) or toxic ingestion were also excluded. However, the possibility of levofloxacin-induced acute psychosis was considered and, on day 3, levofloxacin was discontinued with a complete resolution of the patient’s visual hallucinations by her sixth day of hospitalization. The Naranjo Probability Scale (NPS) for determining the likelihood of whether an adverse drug reaction (ADR) is actually due to the drug rather than the result of other factors was calculated as + 6 (‘probable’). In literature, the association between psychiatric adverse events and assumption of fluoroquinolones is known, but only a few cases after assumption of levofloxacin have been reported. However, the true prevalence of levofloxacin-induced neuropsychiatric adverse effects could be underestimated. Therefore, physicians and psychiatrists should consider neuropsychiatric adverse effects when prescribing levofloxacin or other fluoroquinolones.
Keywords: Drug-related side effects and adverse reactions; fluoroquinolones; levofloxacin; hallucinations, visual.
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