Microbiological surveillance of endoscopes and implications for current reprocessing procedures adopted by an Italian teaching hospital.

BACKGROUND: Hospital acquired infections have been associated with the contamination of flexible endoscopes caused by a failure of the reprocessing procedure. Microbiological surveillance of endoscope reprocessing is valuable for assessing contamination by pathogens. The aim of this study is to evaluate microbiological contamination of endoscopes after reprocessing, and the involvement of reprocessing procedures adopted in endoscopy units of an Italian teaching-hospital. METHODS: The study was carried out, on several dates in 2014, in 11 endoscopic operation units equipped with 100 endoscopes (18 bronchoscopes, 41 gastroduodenoscopes, 29 colonoscopes, 12 laryngoscopes) and 9 Automated Endoscope Reprocessors. Presence/absence of common pathogens and indicator micro-organisms (including multi-drug resistant bacteria) and Total Microbiological Count (TMC) were obtained from the biopsy channels of endoscopes after reprocessing, from final rinse water of automated endoscope reprocessors and from tap water applying standard microbiological culture methods. Following the European Guidelines for quality assurance in reprocessing, the post-reprocessing criteria were "absence of indicator micro-organisms and absence of TMC in samples obtained from endoscopes' channels". RESULTS: A total of 180 samples were collected (143 endoscopes, 25 Automated Endoscope Reprocessors and 12 water supply). Compliance to the European Guidelines was achieved for 112 out of the 180 (62.2%) samples analyzed. Presence of indicator micro-organisms (mainly Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and other Gram-negative non-fermenting bacteria) was found in 51 out of 143 endoscopes (35.7%). Multi-drug resistant bacteria were also found. Presence of pathogen micro-organisms was statistically associated with the increase of TMC level, but not with time after reprocessing. CONCLUSION: The study provides information about the microbiological quality of endoscope reprocessing procedures adopted by different endoscopic operation units. The high prevalence of contaminated endoscopes provides evidence of the need to improve the quality of reprocessing.

Prevalence of diabetes and/or ischaemic heart disease in classes of increasing carotid artery atherosclerosis: an ultrasonographic study.

AIMS: To evaluate the prevalence of non-diabetic subjects and diabetic patients, with or without ischaemic heart disease (IHD), in different classes of increasing carotid atherosclerotic damage. METHODS: Using high-resolution B-mode ultrasound, we studied 598 subjects without known cardiovascular disease (CVD) or diabetes, 74 diabetic patients without CVD, 74 non-diabetic subjects with IHD and 36 patients with both diabetes and IHD. Carotid atherosclerosis was classified as: normal; thickened intima-media; non-stenotic plaque; stenotic plaque. RESULTS: Compared with subjects without diabetes or CVD, the frequency of patients with diabetes without known CVD increased significantly from 'normal' to 'stenotic plaque' (4.1%, 6.4%, 13%, 14.8% for normal, thickened intima-media, non-stenotic plaque and stenotic plaque, respectively; P = 0.0057). The same figures were 6%, 7.6%, 10.2%, 23.3% (P = 0.0007) for non-diabetic subjects with IHD, and 0%, 2%, 5.6%, 15.9% (P < 0.0001) for diabetic patients with IHD. No difference was found comparing subjects with diabetes without CVD with non-diabetic patients with IHD (P = 0.56). Using polychotomous logistic regression analysis, diabetic patients without CVD and non-diabetic subjects with IHD showed a similar association with the increasing degree of carotid atherosclerosis (P = 0.59), but significantly stronger compared with subjects without diabetes or CVD (P < 0.03 for both). CONCLUSIONS: Diabetic patients without known CVD show an advanced degree of carotid atherosclerotic damage similar to non-diabetic subjects with IHD and significantly higher compared with non-diabetic subjects without CVD. Our data support the need for an aggressive early prevention of CVD in diabetic subjects.

Reproducibility of heart rate measured in the clinic and with 24-hour intermittent recorders.

This study was undertaken to assess the reproducibility of office versus ambulatory heart rates in 839 hypertensive subjects participating in the Hypertension and Ambulatory Recording Venetia Study (HARVEST). A 24-hour heart rate was recorded twice; this procedure was repeated three months later. Reproducibility was better for ambulatory than for office measurement, and was greater for 24-hour than for daytime heart rate, and lowest for night-time heart rate. Reproducibility of office heart rate was impaired above 85 bpm, and was poorer in subjects with more severe office hypertension. A small but significant decrease in average daytime (-1 bpm, P < 0.0001) and virtually no change in night-time heart rate (-0.3 bpm, NS) were observed at repeat recording. Heart rate reproducibility indices were related to the extent of the heart rate and blood pressure white-coat effect, but did not vary according to age, gender, body mass index, day-night blood pressure difference, or alcohol or tobacco use. Results indicate that heart rate recorded over the 24 hours has a better reproducibility than office heart rate, and could thus be a better prognostic indicator than traditional measurement of resting heart rate in the hospital setting.

White-coat hypertension: a selection bias? Harvest Study Investigators. Hypertension and Ambulatory Recording Venetia Study.

BACKGROUND: Results of several studies have shown that subjects with white-coat hypertension (WCH) have more target-organ damage than do normotensive controls with similar ambulatory blood pressures. OBJECTIVE: To investigate whether this is due to a selection bias. SETTING: Seventeen hypertension clinics in northeast Italy. MAIN OUTCOME MEASURES: Echocardiographic data in relation to WCH status. PATIENTS AND METHODS: Mild hypertensive subjects from the HARVEST (n = 565) who underwent two ambulatory blood pressure monitorings 3 months apart and M-mode echocardiography, and 95 normotensive control subjects. RESULTS: From first ambulatory monitoring, 90 hypertensive subjects were classified as having WCH (mean daytime blood pressure < 130/80 mmHg). Their 24 h blood pressure was similar to that of the normotensive subjects, but their left ventricular mass index was greater. From second ambulatory monitoring, only 38 of the 90 subjects still had WCH, whereas 24 h blood pressure in the other 52 had risen beyond the limit of WCH. Left ventricular mass index (89.2 +/- 2.4 g/m2), wall thickness (18.1 +/- 0.3 mm), and relative wall thickness (0.359 +/- 0.006%) of the 38 subjects with WCH at both recordings were still greater than those of the normotensive subjects (82.4 +/- 1.5 g/m2, P = 0.02; 17.2 +/- 0.2 mm, P = 0.002; and 0.337 +/- 0.004%, P = 0.025) and similar to those of the 52 subjects who no longer had WCH (88.5 +/- 2.0 g/m2, 18.7 +/- 0.2 mm, and 0.375 +/- 0.005%, all NS). CONCLUSIONS: Owing to regression toward the mean, over 50% of the subjects with WCH could no longer be classified as such from repeated ambulatory monitoring, indicating that the current diagnosis of WCH is subject to selection bias. Cardiac remodeling was present also in the subjects confirmed to have WCH by repeated blood pressure recording, suggesting that the effect of WCH has an actual impact on target organs.

[Long term treatment of moderate to severe hypercholesterolemia with low dose statin. Comparison of simvastatin and pravastatin]. / Trattamento a lungo termine dell'ipercolesterolemia di grado moderato-severo con statine a picole dosi. Comparazione tra simvastatina e pravastatina.

Sixty-seven subjects with primary hypercholesterolemia were enrolled in an open study with "low dosages" of inhibitors of 3-hydroxy-3methylglutaril coenzyme A reductase. Patients were randomized in comparative and parallel study with simvastatin 10 mg (30 subjects) and pravastatin 20 mg (27 subjects) once in the evening for a treatment period of 12 months. At the end of the treatment the plasma concentrations of total and LDL cholesterol were reduced respectively by 21% (p < 0.001) and 29% (p < 0.001), plasma triglyceride concentration was reduced by 16%, high density lipoprotein (HDL) was increased by 2.9%. The efficacy of drugs was increasing during the study: at the third month 63% of subjects and at the twelfth month 89% of subjects showed a LDL < 160 mg/dL. In this study the drugs were well-tolerated, but 11 subjects showed a slight and transitory increase of CK. A treated group with simvastatin showed a similar decrease of the total cholesterol and LDL as that one treated with pravastatin. Pravastatin in comparison with simvastatin reduced significantly plasma triglycerides. There was no significant difference between the groups in the frequency of drug-related adverse effects. In conclusion "low dosages" of simvastatin and pravastatin in long term treatment were very efficacious in the reduction of total and LDL cholesterol. In our study, the decrease of total and LDL cholesterol was time-dependent, with the greatest reduction after sixth months. There were no significant differences between 10 mg of simvastatin and 20 mg of pravastatin on reduction of total and LDL cholesterol levels. Triglycerides decreased significantly only with pravastatin.

Relationship between albumin excretion rate, ambulatory blood pressure and left ventricular hypertrophy in mild hypertension.

OBJECTIVE: To study the relationship of urinary albumin excretion to ambulatory blood pressure and other cardiovascular risk factors in borderline to mild hypertension. PATIENTS AND METHODS: We studied 779 patients with borderline to mild hypertension (mean +/- SEM age 33 +/- 0.3 years; mean +/- SEM office blood pressure 146 +/- 0.4/94 +/- 0.2 mmHg) at 17 hypertension clinics in northeast Italy. Office and 24-h blood pressures were recorded with simultaneous urine collection for albumin measurement. In 510 subjects, left ventricular mass was measured by echocardiography. RESULTS: Subjects with overt (> or = 30 mg/24 h) and borderline (16-29 mg/24 h) microalbuminuria had similar 24-h blood pressure levels, higher than those in the subjects without microalbuminuria. In the univariate and multiple regression analyses the albumin excretion rate was closely correlated with 24-h systolic blood pressure and not related to age, body mass index, metabolic parameters, lifestyle factor and degree of left ventricular hypertrophy. CONCLUSIONS: Borderline values of urinary albumin excretion (16-29 mg/24 h) may be clinically relevant in subjects with borderline to mild hypertension. Renal and cardiac damage do not develop in parallel in the initial phases of hypertension.

Factors affecting ambulatory blood pressure reproducibility. Results of the HARVEST Trial. Hypertension and Ambulatory Recording Venetia Study.

To assess the reproducibility of ambulatory blood pressure, we recorded 24-hour blood pressure twice 3 months apart in 508 hypertensive subjects participating in the HARVEST trial using a noninvasive technique. Blood pressure was measured every 10 minutes during the daytime and 30 minutes during the nighttime. Reproducibility was better for ambulatory than for office blood pressure. It was greater for 24-hour than for daytime blood pressure and lowest for nighttime blood pressure. The reproducibility of blood pressure variability (standard deviation) was poorer than that of the average values. A small but significant decrease in average daytime blood pressure (-0.8/-1.0 mm Hg) and virtually no change in nighttime blood pressure (+0.5/+0.1 mm Hg) were observed at repeat recording. Reducing the sampling rate by 50% caused only a small impairment of the reproducibility indexes of both the average values and variability. Blood pressure reduction was greater during the first and last hours of the recordings, indicating an effect of the hospital environment on the between-monitoring difference. Changes in body weight (-0.7 kg, P = .006, at repeat recording) were related to those of 24-hour diastolic blood pressure (P < .05). In conclusion, patient reaction to medical environment and changes of body weight seem to account for most of the change in 24-hour blood pressure that occurs over a 3-month period.

Sigmoid volvulus in west Africa: a prospective study on surgical treatments.

To evaluate the efficacy of different types of surgery, we performed a prospective, randomized trial in 31 consecutively hospitalized patients with sigmoid volvulus. These patients represented 8 percent of 377 cases of emergency surgery. At the time of surgery, the patients were divided into two groups according to the absence (Group A) or presence (Group B) of bowel gangrene. At random, each group was assigned two surgical treatments. Seventeen patients entered Group A and underwent mesosigmoidopexy (seven patients) or resection and primary anastomosis (10 patients). Fourteen patients entered Group B and underwent Hartmann's procedure (eight patients) or resection and primary anastomosis (six patients). Overall mortality was four patients among 31 (13 percent), with a significant prevalence in the group with gangrene (21.4 percent vs. 5.8 percent). In Group A, the rate of success in patients treated with resection-anastomosis was higher than that in patients undergoing mesosigmoidopexy (90 percent vs. 71.5 percent). In Group B, a meaningful difference was observed between the rate of success of patients undergoing Hartmann's procedure and that of those undergoing resection and primary anastomosis (87.5 percent vs. 50 percent). The mortality rates were 12.5 percent and 33.3 percent, respectively. The results of our study show that the therapeutic approach to sigmoid volvulus should be diversified according to the absence or presence of gangrenous colon. The treatment of choice seems to be resection with primary anastomosis in patients with viable colon and Hartmann's procedure in patients with gangrenous colon.

[Isolated ACTH deficiency: description of a clinical case]. / Deficit isolato di ACTH: descrizione di un caso clinico.

A 34-year man was admitted to the hospital with symptoms of hypoglycemia. The endocrine investigations indicated adrenocortical insufficiency secondary to isolated ACTH deficiency: low ACTH and cortisol plasma levels, significant increase of cortisol following prolonged stimulation with depot tetracosactrin, normal secretory reserve of other anterior pituitary hormones. The absence of ACTH-response after corticotropin releasing hormone and insulin tolerance tests suggested a primary impairment of corticotropin cells.

[A computerized support system for the ambulatory treatment of patients with arterial hypertension]. / Un sistema computerizzato di supporto al trattamento ambulatoriale del paziente con ipertensione arteriosa ("AGAPE").

AGAPE (Computer-based Outpatients' Clinic Programme) is a programme for IBM-compatible microcomputers realised by physicians for the management of hypertensive patients. The programme is planned to make the operators' work complete and expeditious while, at the same time, respecting the standard formulation of the clinical approach to the patient. The collection, organisation, recording and communication of data are handled on line by the programme under the operator's control. Special attention has been given to the control of the quality of the data collected as well as to their easy use for clinical, research and statistical purposes. This programme was used for 52 months in a hypertension clinic where physicians and nurses work jointly. Up to April 1989, 1924 new patient visits and 10,639 control visits together with 3,375 groups of lab tests were inserted. The mean training time for new operators was 3.2 hours; the mean data insertion time was 12.5 minutes for the first visit, 3 minutes for the subsequent visits and 2.5 minutes for lab tests. The drop-outs, evaluated at one-year follow-up on each 250 patients before and after the introduction of the computerized system, were 84/250 and 64/250 respectively (p less than 0.05), with a trend to wards the better control of hypertension (diastolic blood pressure less than 90 mmHg, 128/250 vs 143/250, n.s.).

[Effects of somatostatin peridurally administered in the treatment of postoperative pain]. / Effetti della somministrazione della somatostatina per via peridurale nel trattamento del dolore post-operatorio.

Somatostatin (SMS), a hormone extensively found within the CNS, has shown to have a powerful analgesic effects administered either via the epidural or subdural route. The aim of the present study was to evaluate the efficacy of SMS administered epidurally compared with placebo, for the treatment of post-operative pain in patients receiving epidural anaesthesia for surgery. Of the 86 patients observed, 58 entered the study and were randomized to receive either SMS or placebo in a double blind fashion. They were also divided into 3 groups according to the site of the operation (group A: procto-anal; group B: inguino-crural; group C: other), 28 of them receiving SMS and 30 placebo. The post-operative pain evaluation was obtained via VAS at the moment of request of treatment (basal) and after an hour. Twenty-eight of the 86 observed (32.5%) didn't complain of pain that necessitated analgesic treatment. A statistically significant difference in reduction of intensity of pain was observed in the somatostatin treated group (6.42 +/- 0.37 vs 3.64 +/- 0.59) and in the somatostatin treated subgroup A and B (6.4 +/- 0.4 vs 3.8 +/- 0.7 and 6.3 +/- 0.8 vs 3.0 +/- 0.6 respectively). No adverse reactions of any kind were observed. SMS has shown to be a safe and effective drug, reducing by 50% the intensity of pain in patients undergone procto-anal or inguino-crural surgery.

Calcitonin and prolactin serum levels in heroin addicts: study on a methadone treated group.

Serum calcitonin (CT) and prolactin (PRL) levels were determined in 21 heroin addicts in hospital treatment with methadone. After withdrawal of heroin the values of CT 112.4 +/- 62.9 pg/ml, and PRL 19.1 +/- 10.1 ng/ml were both significantly higher (P less than 0.001) than in normal controls (62.2 +/- 43.8 pg/ml and 9.1 +/- 3.5 ng/ml, respectively). After withdrawal of methadone, i.e. 12 +/- 3.7 days after heroin withdrawal, CT values were 76.6 +/- 32.7 ng/ml (a significant level of P less than 0.02 towards initial values). No correlation was noted between CT and PRL values.

Prolactin and thyrotropin pituitary response to thyrotropin releasing hormone in young female heroin addicts.

Prolactin (PRL) and thyrotropin (TSH) serum levels were determined in a group of young female heroin addicts treated in hospital with methadone in tapered doses. At admission, from 24 to 3 h after the last dose of 'street' heroin, basal PRL values were 21 +/- 2.6 ng/ml, i.e. significantly higher (P less than 0.001) than in controls: 9.8 +/- 0.7; there was no significant differences of basal TSH values between heroin addicts and normal subjects: 2.5 +/- 0.2 vs. 2.2 +/- 0.1 mu units/ml, respectively. The day after admission, when methadone treatment was begun, the PRL and TSH pituitary response to thyrotropin releasing hormone (TRH) 200 micrograms i.v. in 12 patients was studied. The PRL response was significantly reduced (P less than 0.001) in heroin addicts vs. controls, the mean values of highest percent increments over basal were 368 +/- 41.8 and 847 +/- 80.7, respectively. The TSH response in the two groups was similar, the mean highest per cent increment over basal 393 +/- 53.4 in heroin addicts vs. 367 +/- 39.2 in controls. The increase of the PRL basal concentration and its decreased pituitary response following TRH were probably related to a change in the tuberoinfundibolar dopaminergic system (TIDA) because of a chronic intake of opiates whereas the impaired function of the dopaminergic system did not alter the thyrotropin pituitary secretion.

Long-term captopril therapy at low doses reduces albumin excretion in patients with essential hypertension and no sign of renal impairment.

The aim of the present study was to evaluate changes in urinary micro-albumin and in serum and urinary beta 2-microglobulin during treatment with captopril at low doses in a group of hypertensive outpatients without any sign of renal impairment. Thirty-four patients with essential hypertension entered the study, all having been treated for at least one year with beta-blockers and diuretics. None had proteinuria (by Albustix) and creatinine clearance was normal. The patients were randomly allocated to two groups: the first group was maintained on the previous regimen (group BD) and the second received captopril 50 mg twice daily instead of the beta-blocker (group CD). During the year of observation blood pressure values and serum and urinary beta 2-microglobulin were not significantly different between the two groups. There was, however, a significant reduction in albumin excretion rate (AER) in the CD group at both 3 and 6 months. Since arterial measures did not differ between the two groups, it is proposed that the reduction of AER was due to a diminution of the transcapillary hydraulic pressure due to the inhibition of the intrarenal angiotensin II induced by captopril.

[Arterial hypertension induced by an excess of mineralocorticoids caused by abuse of nasal spray. Report of a case]. / Ipertensione arteriosa da eccesso di mineralcorticoidi dovuta ad abuso di spray nasale. Descrizione di un caso.

Among the various syndromes caused by excess mineralocorticoids, the factitious syndrome produced by excessive 9-alpha-fluorprednisolone inhalations is more common than might be expected, especially in places where the drug is easily obtained without a doctor's prescription. A fairly typical case of addiction to a nasal spray containing ephedrine hydrochloride and an imidazoline compound as well as the steroid is described. The diagnosis of the case is analysed with details of certain differences from similar cases reported in the literature and the modifications to clinical and instrumental parameters achieved after over two months' treatment with spironolactone are described.

[Acute herpes simplex hepatitis with favorable outcome in an otherwise healthy adult]. / Epatite acuta da Virus Herpes Simplex a decorso favorevole in un adulto normale.

A non fatal case of Human Herpes Simplex hepatitis is presented, and the features of 15 previously reported cases are briefly reviewed. The patient, an otherwise normal middle-aged woman, presented as acutely ill, with typical mucocutaneous lesions, but recovered in a few days. Liver biopsy showed multiple focal areas of cellular necrosis with marked inflammatory infiltration, but without evidence of intranuclear eosinophilic inclusions. The possible underestimation of cases of Herpes Simplex hepatitis is proposed.