How to reduce erroneous Emergency Department admissions for the frail elderly.

Background: Readmission after a first hospitalization is a common occurrence. It may be due to incomplete treatment, poor care for underlying problems or reflect bad coordination with health services at the time of discharge. The aim of this study was to identify the factors and classify the pathologies that expose elderly patients to erroneous access to the Emergency/Urgency Department (EUD). Study design: Retrospective observational study. Materials and methods: From January 2016 to December 2019 we studied patients who had at least one readmission to the EUD in the six months following discharge. All EUD accesses of the same patient that occurred for the problem treated during the previous hospitalization were identified. Data was provided by the University Hospital of Siena. Patients were stratified by age, gender, and municipality of residence. We used an ICD-9-CM coding system to describe health problems. Statistical analysis was carried out with Stata software. Results: We studied 1,230 patients (46.6% females) the mean age was 78.2 ± 14.3. Most of them, 721 (58.6%) were ≥80 years old, 334 (27.1%) were 65-79, 138 (11.2%) were 41-64, and only 37 (3.0%) were ≤40. Patients who lived in Municipality of Siena had a lower probability to return than to those living in other municipalities (OR 0.76; 95%CI: 0.62-0.93; p<0,05). The main causes of readmission for ≥65 years old were "symptoms, signs and ill-defined conditions" (18.3%), "respiratory diseases" (15.0%), "injury and poisoning" (14.1%), "cardiovascular diseases" (11.8%), "classification of factors influencing health status and contact with health services" (9.8%), "genitourinary diseases" (6.6%) and "digestive diseases (5.7%). Conclusions: We observed that patients residing a greater distance from the hospital facilitates the risk of readmission. The factors that were exposed could be used to identify frequent users and initiate measures to reduce their access.

Safer school with near-UV technology: novel applications for environmental hygiene.

Systems capable of disinfecting air and surfaces could reduce the risk of infectious diseases transmission. Aim: to evaluate the effectiveness of near-UV LED ceiling lamps, with a wavelength of 405 nm, in improving environmental hygiene. Between November and December 2020, we conducted an experimental study having a pre-post design in a kindergarten room in Siena where 4 ceiling lamps with 405 nm LED technology were installed. Twice per day, sampling was performed before (T0) and after treatment with near-UV (T1). We used between 8 and 12 pairs of contact plates to sample at various random spots each day. Air samplings were also performed. The plates were incubated at 22 and 36 °C. Significance was set at 95% (p < 0.05). The mean level of Colony Forming Unit (CFU) at T(0) was 249 (95% CI 193.1 - 305.0) at 36 °C and 535.2 (374.3 - 696.1) at 22 °C. The reduction was significant at T(1): by 65% at 36 °C and, 72% at 22 °C. Also, for air contamination: 95.3% (98.4-92.3). A dose threshold of about 5 J/cm2 was identified to have an 80% CFU abatement and remains nearly constant. The advantage of being able to use this technology in the presence of people is very important in the context of controlling environmental contamination.

Disinfecting Slush Machines by an Innovative Near Ultraviolet Light Emitting Diode (UV LED) Technological System.

Background: Microbial contamination of food and beverages is a topic of great interest. The most innovative technologies take advantage from UV light. This study aimed to evaluate a possible configuration of a nUV LED device at a wavelength of 405 nm installed on slush machines in order to reduce the microbial contamination. Study Design and Methods: Study Design and Methods. The study was conducted in the Department of Molecular and Developmental Medicine, University of Siena, Italy. A nUV LED device with 408 nm wavelength was installed and used on the slush machines. The inner walls of the machine tanks were fouled with contaminated slush, to evaluate the effectiveness of nUV radiation in reducing microbial contamination over time. Results: Experiment results on the slush machine showed a statistically significant logarithmic microbial reduction, in relation with the distance from the nUV LED light source. It has also been shown that the reduction of microbes is possible with a proper management of some parameters: the exposure time, the power and wavelength of the light source, the distance and the obstacles between the light source and the target to be irradiated. Conclusion: To reduce the incidence of foodborne diseases it is necessary to take all necessary precautionary measures, and the use of nUV technology has proved to be a crucial element in achieving this goal.

Improvement and standardization of disinfection in hospital theatre with ultraviolet-C technology.

BACKGROUND: The level of disinfection between operating sessions is important to prevent cross-contamination risk in operating theatres. AIM: To assess the difference in microbial contamination between different disinfection levels, before (T0) and after (T1) application of a UVC device (UVC-D). METHODS: A cross-sectional study was conducted between December 2019 and August 2020 in a clinic. Three disinfection levels - no disinfection after surgery, after in-between cleaning, and after terminal cleaning - were compared to assess the reduction of microbial presence at T0 and T1 according to the use of UVC-D for 3-5 min per bedside. A total of 260 Petri dishes, divided into a preliminary phase followed by a probabilistic model-driven experiment, were used in three operating theatres, and colony-forming units (cfu) were counted. The Mann-Whitney test was performed in the preliminary phase to establish UVC exposure time. Using the probabilistic model, descriptive statistics and percentage and log10 reduction were calculated. The multivariate analysis of variance (MANOVA) for repeated measures was performed to verify the 95% statistical difference between T0 and T1, combined with the disinfection levels and different operating theatres. FINDINGS: The Mann-Whitney test showed no cfu difference between 3 and 5 min of UVC exposure time; the MANOVA test showed no significant difference between disinfection levels in T0 - T1 cfu reduction with a mean cfu reduction of 72% (95% confidence interval: 61.7-84.9) regardless of the disinfection level applied previously. CONCLUSION: UVC-D has improved environmental disinfection in all initial conditions. Together with the classic sanitizing procedures already present, it improves and standardizes the level of environmental hygiene.

Promoting sport and physical activity in Italy: a cost-effectiveness analysis of seven innovative public health policies.

BACKGROUND: Inactive lifestyles are a key risk factor underpinning the development of many chronic diseases, yet more than half of the Italian population does not meet WHO thresholds for at least moderate physical activity. This study aims to make the economic case to upscale investments in policy actions to promote exercise and physical activity. STUDY DESIGN: Modelling-based cost-effectiveness analysis in Italy. METHODS: The study assesses the impact on health and healthcare expenditure of seven public health policies to promote exercise and physical activity against a business as usual scenario. Assessed policies include: promotion of active transport, workplace sedentarily interventions, investments in sports and recreation, mass media campaigns, prescription of physical activity in primary care, school-based interventions and mobile apps. RESULTS: Public policies to promote exercise have the potential to improve population health and produce savings in healthcare expenditure. Assessed policies can avoid hundreds of cases of cardiovascular diseases and diabetes per year and tens of cases of cancer resulting in gains in DALYs in the order of thousands per year. In the medium-term, the vast majority of policies show excellent cost-effectiveness ratio, below internationally recognized thresholds. CONCLUSIONS: Investing in policies to promote active lifestyles is a good investment for Italy.

Kocuria kristinae: an emerging pathogen in medical practice.

Introduction. Kocuria kristinae is becoming a growing public health challenge, especially for its ability to cause infections in immunocompromised patients. This bacterium is a Gram+coccus, catalase+, coagulase, and it is a common inhabitant of skin and oral mucosa.Aim. To investigate the spectrum of infections caused by K. K ristinae.Methodology. Between January-March 2018, we carried out a systematic search in PubMed utilizing the key search term 'Kocuria kristinae'. The selection criteria for studies were studies reporting cases of human infections due to K. kristinae, case-control and cohort studies and studies published in English or Spanish.Results. The literature search yielded 48 publications: after title, abstract and full-text analysis, 20 papers were consistent with the selection criteria. These studies were carried out in the period 2001-2017 in the USA, Japan, Taiwan, Hong Kong, Ukraine, Egypt, Bahrain, Serbia, India, Italy, Spain, Turkey and Mexico. K. kristinae was involved in 17 cases of central venous catheter-related bacteremia, four infective endocarditis, three acute peritonitis, one abdominal abscess, umbilical sepsis, acute cholecystitis and urinary tract infection. Additionally, K. kristinae was found in 40 % of carious cavities, although it is not clear whether they are directly involved in the development of caries. Antibiotic susceptibility testing has sometimes revealed multi-drug resistance.Conclusions. The clinical spectrum of K. kristinae infections has recently widened. The increasing spread of this underestimated bacterium and its resistance to antibiotics represent a new challenge for public health, which requires specific actions to limit it.

Demolition activities in a healthcare facility: results from a fungal surveillance after extraordinary preventive measures.

OBJECTIVES: Aspergillus spp could be responsible of nosocomial aspergillosis in immunocompromised patients. In 2018, it was decided to demolish a building of Careggi Hospital (Florence, Italy), the Chief Medical Officer ordered a 9-months-long air and surface microbiological sampling and extraordinary preventive measures. STUDY DESIGN: A 9-months-long prospective study. METHODS: After mapping the at-risk areas, air and surface samples were collected in different locations: in corridors, in rooms (high efficiency particulate air filter (HEPA) filtered or not), and outdoors. The samples were collected during the critical phases of the demolition. Air temperature and weather conditions were determined and recorded at the beginning of each sampling. RESULTS: Seventy-eight air samples and 72 surface samples were collected. The results showed highest contamination at time zero (before extraordinary preventive measures) and in the wards without HEPA filtered air. No specific prophylaxis strategy was implemented at our hospital for immunocompromised patients, and no cases of aspergillosis were recorded. CONCLUSIONS: Our results showed that extraordinary protective measures, the use of air treatment systems, and a continuous monitoring could be associated with decreased Aspergillus air contamination during construction, renovation, or demolition works.

Human Trichinellosis in Italy: an epidemiological review since 1989.

OBJECTIVES: Trichinellosis is a worldwide zooantroponosis caused by a nematode of the genus Trichinella that can pose a risk to human health. Among the species of Trichinella, T. Spiralis is the most common represented. The main source of human infection is the consumption of raw or undercooked meat (especially from pigs, wild boars and horses). Infection with Trichinella was one of the most frequent parasitic diseases in Italy until 1959 when obligatory screening for these parasites in slaughtered swines was introduced. As the last review on this topic was performed in 1989, the aim of our study was to describe the epidemiology of Trichinellosis in Italy from 1989 to 2017. STUDY DESIGN: We performed a systematic research in Pubmed (MEDLINE). METHODS: We included in our review studies that were published in the peer reviewed literature using the MESH terms "Trichinellosis" and "Italy". The only restrictions were the language (articles should be in English, Italian, Spanish or French) and the date of publication: from 1989 to March 2017. We excluded all the articles which referred to trichinellosis in the animals or which focused only on molecular biology of trichinella or on diagnostic techniques. RESULTS: We found 56 studies, but only 8 were considered eligible. During the study period, 764 cases of Trichinellosis occurred in Italy: 13.7% caused by T. Britovi and 84.4% by T. spiralis; in 14 cases the identification of the parasite was not performed. The outbreaks occurred in Umbria, Piedmont, Apulia (500 cases in 1990, by T. spiralis), Basilicata, Tuscany, Abruzzo, Emilia Romagna, Sardinia. In 2001 and in 2008 two outbreaks occurred in Lazio and Veneto respectively, but imported from abroad. The most important sources of infections were: horse meat (82.2%); wild boar meat (11.9%); pig meat (5.9%). CONCLUSIONS: Trichinellosis is still present in Italy, but often forgotten by general practitioners and infectious diseases specialists. It's pivotal to improve awareness about this parasitic disease in Physicians and veterinarians. A strict surveillance, especially on meat products from endemic countries or from wild animals is necessary to considerably reduce the risk of acquiring the infection.

Generous breastfeeding: an observational retrospective study of milk donor's characteristics in the province of Siena, Italy.

BACKGROUND: Breastfeeding is definitely one of the measures capable of improving not only children's but also mother's health. Human milk banks are institutions providing human milk to babies with limited access to breastfeeding for various reasons. STUDY DESIGN: The aim of this observational retrospective study was to examine principal characteristics of breast milk donors in the province of Siena and to identify variables influencing Milk Quantity (MQ) and Length of donation period (LD). METHODS: Information was extracted from medical records of Human Milk Bank of Siena, all women that donated their breast milk during the period from January 2010 until August 2017 were included. Examined variables were: age, place of birth (Italy/outside Italy), residence (Siena city/Siena province), education, profession, type of labor (preterm/in-term) and type of delivery (vaginal/cesarean section), gestational age, number of children, previous donations (blood, milk), quantity of donated milk and length of donation. RESULTS: A total of 304 donors were included: 75.7% of Italian nationality. The mean age was 32.4±5.2, Italian donors were older (33.5±5.0 vs. 28.7±4.2; Mann-Whitney; p<0.001). Socio-economic situation of Italian donors was better compared to non-Italian donors (chi-squared; p<0.005). Non-Italian donors had more probability to go through preterm labor (OR=3.68; p<0.001). Average length of donation was 2.7±1.8 months. Mean quantity of donated milk was 4.8±7.6l. From multiple linear regression, preterm birth (p<0.005) and length of donation (p<0.001) emerged as a variable that can predict higher quantity of donated milk. CONCLUSIONS: Preterm babies are usually recovering in a neonatology intensive therapy unit, with mothers staying close to them, which facilitates the whole donation process. Mothers of premature babies have a higher perception of the meaningfulness of donation and a need of adequate nutrition for fragile infants.

Microbiological surveillance of flexible bronchoscopes after a high-level disinfection with peracetic acid: preliminary results from an Italian teaching hospital.

BACKGROUND: Flexible bronchoscopes are heat labile, complex and difficult to clean, and some nosocomial outbreaks related to bronchoscopy have been reported in literature. The aim of our study was to determine, through a systematic monitoring, whether bronchoscopes' cleaning and disinfection procedures have been correctly adopted by health operators. METHODS: We conducted a 19 months-long prospective study in the Unit of Pulmonology at Careggi Teaching Hospital (Florence, Italy), analyzing endoscopes that were reprocessed through a high-level disinfection procedure. Samples collection was performed weekly by two trained operators. Results were organized in a database and then exported for descriptive and inferential statistical analysis. RESULTS: From February 2016 to September 2017 we collected 218 samples from bronchoscopes' valves (N=109) and from their inner channels (N=109). Staphylococci were found in 34 samples (15.69% of all samples). Pseudomonas was found in 11 samples (5.04% of all samples). Pseudomonas aeruginosa wasn't found in any sample. CONCLUSIONS: Our results came out to be better than similar studies in literature and demonstrated that a correct endoscopes' hygiene should be part of a more complex strategy of surveillance and control of healthcare-associated infections. However, a continuous monitoring of endoscopes could provide a wider view about this problem, and more reliable results.

Developing a new predictor of health expenditure: preliminary results from a primary healthcare setting.

OBJECTIVES: Risk adjustment is a widely used tool for health expenditure prediction and control. Early approaches for estimating health expenditure were based on patient demographic variables alone, whereas more recent models incorporate patient information, such as chronic medical conditions, clinical diagnoses, and self-reported health status. Many studies have investigated the health expenditure predictive capacity of single demographic, morbidity, or health-related quality of life measures, but the best models prove to be those that include them all. The aim of this study was to develop an index that combines measures of perceived health and disease severity and to compare its efficacy in predicting health expenditure with that of the measures taken individually. STUDY DESIGN: This is a linked cross-sectional study. METHODS: In 2009 and 2010, the health-related quality of life questionnaire SF-36 (8 scales, two indices: Physical Component Summary [PCS] and Mental Component Summary [MCS]) was distributed to 886 patients of general practitioners in the Province of Siena, Italy. Severity of diseases was calculated for each patient using the Charlson Index (CH-I) and Cumulative Illness Rating Scale Severity Index (CIRS-SI). Siena Local Health Unit 2012 data on health expenditure were obtained for each patient. Multivariate linear regression was applied to test the performance of severity (CH-I, CIRS-SI) and perceived health (PCS and MCS) measures in predicting health expenditure. The indexes that predicted health expenditure best were then combined in a new tool, and its expenditure predictive capacity was tested. RESULTS: The best health expenditure predictors proved to be PCS and SI (R2 = 0.15 and R2 = 0.17, respectively). When combined in a new index (PCS-SI), better predictive capacity of health expenditure was obtained than with the two single measures separately (R2 = 0.19). CONCLUSIONS: A multidimensional indicator proved to be a better predictor of healthcare expenditure than single health measures.

Effects of anticoagulation therapy with vitamin K antagonists on hospitalizations and emergency room accesses in Grosseto (Italy).

INTRODUCTION: A lot of drug groups are associated with preventable drug-related admissions. Coumarin derivatives, prescribed for the treatment and prevention of deep vein thrombosis or pulmonary embolism or prevention of systemic embolism or stroke in patients with prosthetic heart valves or atrial fibrillation, are often associated with bleeding. The aim of our study was to analyze how the anticoagulant therapy with VKAs could affects the hospitalizations and the visits to emergency room in the elderly population (> 65 years old). METHODS: In 2013 we conducted a cross sectional study analyzing the database of all pharmaceutical prescriptions, selecting patients living in Grosseto (Italy), which received at least two prescriptions of coumarin derivatives in 2012. We analyzed the admissions to hospital and the accesses to the emergency rooms (ERs) made by each patient, focusing especially on those related to bleeding. For each access to ER we recorded the date, time of stay, diagnosis and outcome. For each hospitalization the information we recorded were the date of admission and discharge diagnosis. RESULTS: 3684 patients were included in our study. 261 (7.1%) patients visited the emergency room for bleeding; 37 (1%) for intracranial bleeding. The accesses made by men were higher than those made by women. The average time of stay in ER was 349 minutes. The admissions to hospital were 96 (2.6%); 42 (1.1%) were admitted to hospital with a diagnosis of major vascular event. 53 patients (20.3%), accessed to the ER more than one time. The 11.5% was admitted to the hospital more than one time. CONCLUSIONS: Our study showed that VKAs are responsible of an increase of the accesses to ER and of the admissions to hospital. However, it would be interesting to enlarge the sample size including patients living in other provinces or in other regions, with a lower age and treated also with TSOACs, in order to evaluate the real cost-effectiveness of anticoagulant therapy.

Attitudes towards compulsory vaccination in Italy: Results from the NAVIDAD multicentre study.

BACKGROUND: Vaccine hesitancy is a considerable issue in European countries and leads to low coverage rates. After a long debate, Italy has made vaccination mandatory for admission to its schools. METHODS: In the NAVIDAD study (a cross-sectional multicentre study), a 63-item questionnaire was administered to 1820 pregnant women from 15 Italian cities. The questionnaire assessed the interviewee's opinion on mandatory vaccines, as well as their socioeconomic status, sources of information about vaccines, confidence in the Italian National Healthcare Service (NHS), and intention to vaccinate their newborn. RESULTS: Information sources play a key role in determining the opinion on restoration of mandatory vaccines; in particular, women who obtained information from anti-vaccination movements are less likely to accept the vaccines (OR: 0.35, 95% CI: 0.21-0.58, p < 0.001). Women who had confidence in healthcare professional information agreed more on mandatory vaccination than did the other women (OR: 2.66, 95% CI: 1.62-4.36, p < 0.001); those who perceived that healthcare professionals have economic interest in child immunization and who declared that healthcare providers inform only on vaccinations benefits not on risks were less likely to agree on compulsory vaccination (OR: 0.66, CI 95%: 0.46-0.96, p = 0.03; OR: 0.66, CI 95%: 0.46-0.95, p = 0.03, respectively). CONCLUSION: Information sources and confidence towards health professionals are the main determinants of acceptance of mandatory vaccine restoration. To increase the acceptability of the restoration and reduce vaccine hesitancy, these aspects need to be strengthened.

Midwives in England and in Italy: two realities compared.

BACKGROUND: Midwives have the responsibility to provide assistance to pregnant women for non-complicated deliveries. The aim of this study was to identify the distinctive features of midwives in Italy and in England in order to provide interesting comparisons. METHODS: From September to October 2015 we administered an online questionnaire to groups of Italian and English midwives. The questionnaire was composed by a part trying to collect the sociodemographic information and a second part to define the attitudes of care and the type of approach to birth and degree of attained professional autonomy. The questions were used to create a score for 5 macro areas: "Midwifery: who is the midwife?", "Education: how much does the midwife know?", "Responsibility: what does the midwife do?", "Ethics: how does the midwife act?", "Social acknowledgment: the midwife and the other people". Results were loaded in a database and analyzed using the using STATA. RESULTS: 183 Midwives (100 Italian and 83 English) completed the questionnaire. 92% of Italian respondents said to have a "Bachelor", 6% a "University Diploma" and only 2% a "Diploma". 80% of British midwives had a "Midwifery Degree" and 8% attended a "Midwifery Short Program", a degree course in Nursing with an additional specialization of a year and a half in Midwifery. 34% of the Italian claimed to have also a "1st level Master", 16% a "Full Degree" and the remaining 50% attended post degree training courses. Only 23% of the English sample had a "Master of Science" and the remaining 67% reported to have "other" general qualifications. 72% of Italian midwives declared to work and, in particular, in a "III level point of birth" (35%), "II level point of birth" (25%), "I level point of birth" (17%), or in "private health facilities" (4%), in "professional offices" (6%) or "counseling ambulatories" (5%). 46% of the English midwives who participated in the study worked in hospitals; 21% as employees of the NHS in territorial structures. 12% worked in birth centers and 11% had a private profession. There was a statistically significant difference between Italian and English Midwives, for all the macro areas (except for the first), with better results for English Midwives. CONCLUSION: English Midwives tend to consider their professional role and their professional skills more acknowledged and appreciated than Italian Midwives. Actually Italians tend to be not very satisfied. However, the Midwives of both countries feel very close to women and have the same conception of themselves and of their profession.

Effectiveness of ATP bioluminescence to assess hospital cleaning: a review.

INTRODUCTION: Contamination of hospital surfaces plays an important role in the transmission of several healthcare-associated microorganisms, therefore methods for evaluating hospital surfaces' cleaning gain particular importance. Among these, there are visual inspection, quantitative microbiology, fluorescent markers and adenosine triphosphate (ATP) bioluminescence. The latter seems to provide interesting features, detecting the presence of ATP on surface (as Relative Light Units, RLU), a proxy of organic matter and microbial contamination. Several studies have investigated the effectiveness of this technology; with this research, we aim to summarize the most significant results. METHODS: A systematic review was conducted. The keywords (namely, "ATP", "bioluminescence", "hospital" and "surfaces") were searched in PubMed/MEDLINE and Scopus databases, in order to find relevant data, from January 2000 to October 2014. After the selection, we globally considered 27 articles. RESULTS: Most of the studies were conducted in United Kingdom and in USA. Different threshold RLU benchmark values were identified by analyzed studies. Fourteen of these researches compared the ATP bioluminescence with microbiological methods, 11 identified a significant correlation between the two methods, although poor or not complete for 5. DISCUSSION: ATP bioluminescence is not a standardized methodology: each tool has different benchmark values, not always clearly defined. At the moment, we can say that the technique could be used to assess, in real time, hospital surfaces where cleanliness is required, but not sterility.