Pattern of antibiotic use in the community: νon-adherence and self-prescription rates in an Italian urban population.

The aim of the present study was to assess the pattern of antibiotic use in a community setting of an urban area of Italy and identify factors that affect adherence to their use. By using a questionnaire-based survey, we collected 1,269 interviews and performed analysis on those patients who had their last course of antibiotic within the past 12 months (956 subjects). Among the subjects reporting that they had not followed their last antibiotic course as prescribed, 14.7% stopped therapy early, 5.4% modified the dosage, and 5% changed the prescribed antibiotic. Approximately 23% of the subjects declared that they self-prescribed antibiotics. After adjusting for all covariates, major predictors for the self-prescription of antibiotics were younger age, female gender and higher socioeconomic and educational status. Conversely, both low educational and socioeconomic status were associated with a higher risk of non-adherence to physician indications. The findings of this study assessed the widespread pattern of poor antibiotic-taking behavior and provides important implications for understanding the targets of future educational campaigns to control the use and misuse of antibiotics.

Anterior shoulder dislocation and injuries of the rotator cuff in patients aged over 40 years. Clinical and sonographic study.

A total of 39 patients with a mean age of 64 years (41 to 88) who had had anterior shoulder dislocation were followed-up an average of 2 years after trauma in order to evaluate the conditions of the rotator cuff. All of the patients were evaluated clinically, radiographically, and sonographically. Clinical evaluation revealed significant differences between the dislocated shoulders and the contralateral ones: the mean Constant score was 67 in the group with dislocated shoulders and 87 in the contralateral group. Ultrasound revealed partial injury of the cuff in 31% of cases and complete injury in 28%. Mean score was 81.4 in the group with a normal ultrasound, 67.1 in that with partial injury of the cuff, and 46.5 in that with complete injury of one or more tendons. These data confirm the high frequency of partial or complete injuries of the rotator cuff in patients aged over 40 years that have undergone anterior shoulder dislocation. Ultrasound confirms it is an excellent diagnostic method in the pathology of the rotator cuff, demonstrating good correlation with the clinical evaluation.

Circulating dendritic cells in early and advanced cancer patients: diminished percent in the metastatic disease.

Despite the well demonstrated fundamental role of dendritic cells (DC) in generating antitumor immunity in experimental conditions, to date there are only few preliminary studies which investigate the percent of DC in the peripheral blood of cancer patients. Several cell surface markers have now been described which are specific to cultured DC, however their expression in vivo is still controversial. Recently, however, two DC subsets, consisting of immature and mature DC, have been shown to be present in peripheral blood, which can be recognized as CD123+ and CD11c+ cells, respectively. On this basis, we decided to investigate the presence of both mature and immature DC in the peripheral blood of early or advanced cancer patients. The study included 40 solid tumor patients, 18 of whom had a locally limited disease, while the other 22 showed distant organ metastases. CD123+ and CD11c+ cells were detected by FACS using monoclonal antibodies, and expressed as the percent of total leukocytes. The control group consisted of 50 healthy subjects. The mean percent of both CD123+ and CD11c+ cells was significantly lower in cancer patients than in controls. Moreover, the mean percent of both DC subsets was significantly lower in metastatic patients than in the non-metastatic ones. This study, demonstrating significantly lower percents of both immature and mature DC in the peripheral blood of cancer patients, particularly in those with distant organ metastases, suggests that DC deficiency may play a role in inducing cancer-related immunosuppression. Therefore, the demonstration of a diminished percent of DC in peripheral blood may represent a new interesting biological marker predicting a poor prognosis in human neoplasms, as with lymphocytopenia, the unfavourable prognostic significance of which has been well demonstrated.

Daytime oxygen saturation does not predict nocturnal oxygen desaturation in patients with chronic obstructive pulmonary disease.

Nocturnal hypoxemia occurs commonly in patients with chronic obstructive pulmonary disease (COPD). Because pulmonary hypertension and cardiac arrhythmias are associated with this phenomenon, the detection and treatment of nocturnal hypoxemia should be part of the management of COPD patients. The ability to predict nocturnal hypoxemia by evaluating an awake patient would be desirable economically and logistically because continuous nocturnal oximetry is not widely available and because it is costly and labor intensive. We sought to determine whether awake oximetry would be precise enough to be clinically useful in predicting the degree of nocturnal oxygen desaturation in patients with COPD. We studied 71 patients with COPD. During sleep, the arterial oxygen saturation (SaO2) decreased by an average of 9% with a maximum decrease of 21% (awake SaO2 93.0 +/- 0.4% vs nocturnal lowest SaO2 84.0 +/- 0.7%, p = 0.0001). The nocturnal oxygen desaturation in each patient, however, was poorly predicted from awake SaO2. The standard error of estimate was large with a value of 5.3%. These data suggest that awake SaO2 is not a good predictor of nocturnal oxygen desaturation in individual patients. The lack of a simple relationship between awake SaO2 and nocturnal SaO2 is due to a complex interplay of various physiologic and pathologic mechanisms involved in the control of breathing and oxygenation during sleep.

Incidence and nature of dysphagia in polio survivors.

Questionnaires pertaining to swallowing function were mailed to 220 members of postpolio support groups in Connecticut. Of the 109 responses, 80 individuals reported having no difficulty with swallowing, while 29 reported having either intermittent or consistent swallowing problems. Twenty-one of the 29 were seen for videofluoroscopic swallowing studies and pulmonary function testing. The swallowing studies showed that 43% of these individuals had difficulty with bolus control, 19% with delayed swallow response, and 81% with decreased pharyngeal transit. Although none of these individuals were observed to aspirate, two were judged to be at significant risk. Incidence of dysphagia within the group of polio survivors was estimated to be approximately 18%. Seventeen of the 20 postpolio subjects with dysphagia also demonstrated decreased breathing capacity. Although moderately to severely depressed values in the pulmonary function measures accompanied moderate dysphagia in certain postpolio individuals, reduced values in these same measures were also present in individuals with minimal swallowing dysfunction. Therefore, although impaired breathing may complicate swallowing dysfunction and vice versa, it does not appear that one can be predicated from the other. Management of dysphagia in postpolio individuals is discussed.

Nutrition for the respiratory insufficient patient.

Malnutrition is fairly common in patients with chronic obstructive pulmonary disease, the more severe the airway obstruction the more severe the nutritional status. The consequences of nutritional depletion on respiratory and immune systems are ventilatory compromise and susceptibility to infection. Diaphragm muscle mass and thickness is decreased in patients with COPD. This results in decreased maximum voluntary ventilation and diminished inspiratory pressure. Malnutrition is one of the causes of failure to wean in patients with respiratory failure. Malnutrition also has profound effects on cell-mediated immune response and humoral immunity with reduced levels of secretory IgA. In patients with COPD, colonization of respiratory tract bears a direct relationship with parameters of nutritional status. Patients with significant nutritional impairment have more tracheal cell bacteria adhered to and the tracheas were more frequently colonized by Pseudomonas species. The improvement of nutrition in these patients resulted in less bacterial cell binding to tracheal epithelial cells.

Weaning from mechanical ventilation: adjunctive use of inspiratory muscle resistive training.

We used inspiratory resistive training (IRT) in an effort to improve the respiratory muscle endurance of 27 patients with respiratory failure who had failed repeated weaning attempts using standard techniques. Seven patients had primary neuromuscular diseases; the other 20 had primary lung diseases. All patients had stable respiratory failure, without gross malnutrition or electrolyte disorders. Their best initial T-piece duration averaged 6.4 +/- 8.4 (SD) h, with pHa 7.33 +/- 0.09 and PCO2 63 +/- 4 torr at the end of the T-piece trial. We provided a mean of five weekly training sessions of spontaneous breathing through an adjustable nonlinear resistor, with gradually increasing duration and resistance. When initial T-piece tolerance was less than 2 h, two to ten breaths of mechanical ventilation were provided during IRT sessions. No training session exceeded 30 min, and mechanical ventilation was provided between IRT sessions. Under this regimen, maximal inspiratory pressure improved from -37 +/- 15 to -46 +/- 15 cm H2O (p less than .001) and vital capacity improved from 561 +/- 325 to 901 +/- 480 ml (p less than .001). Twelve of the 27 patients were successfully weaned after 10 to 46 days; five more were weaned to nocturnal ventilation, for a total of 63%. We conclude that IRT can improve respiratory muscle strength and endurance in patients with respiratory failure, and can allow many of them to be weaned from mechanical ventilation.

Bilateral diaphragmatic paralysis: clinical spectrum, prognosis, and diagnostic approach.

In a retrospective review of the clinical course of five patients with nontrauma-related bilateral diaphragmatic paralysis, we found that the diagnosis is generally delayed (median delay: two years) in the presence of moderate to severe respiratory insufficiencies. Orthopnea out of proportion to the underlying cardiopulmonary status and thoracoabdominal paradoxus in the supine position are the clues to the diagnosis. Pulmonary function tests showed a typical restrictive ventilatory defect, and arterial blood gas showed chronic respiratory acidosis. Failure to recognize the diaphragmatic impairment led to cardiopulmonary decompensations such as cor pulmonale and acute respiratory failure. However, with the institution of appropriate therapy, adverse effects resolved and all five patients are alive and continue to lead independent lives. We conclude that nontrauma-related bilateral diaphragmatic paralysis is an underrecognized and underdiagnosed condition. The results also indicate that early diagnosis and treatment can minimize morbidity and mortality, and that excellent long-term, good-quality survival can be expected.

Diaphragmatic dysfunction in siblings with hereditary motor and sensory neuropathy (Charcot-Marie-Tooth disease).

Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth disease) is characterized by chronic degeneration of peripheral nerves and roots, resulting in distal muscle atrophy, beginning in the feet and legs and later involving the hands. The association of this disease with diaphragmatic dysfunction has not been reported. We studied a patient with hereditary motor and sensory neuropathy type 1 (Charcot-Marie-Tooth disease) and type 2 diabetes mellitus who had severe diaphragmatic impairment. Some of the clinical findings are similar to the sleep apnea syndrome, which could lead to incorrect diagnosis and delay in the administration of appropriate therapy. Transdiaphragmatic pressure studies on the subject's brother, who also has Charcot-Marie-Tooth disease and type 2 diabetes mellitus, revealed subclinical impairment of diaphragmatic function. These findings suggest that phrenic nerve involvement may be part of the spectrum of polyneuropathy in Charcot-Marie-Tooth disease in association with diabetes mellitus.

Further specification and evaluation of a new clinical index for dyspnea.

When breathlessness is described in conventional clinical indexes-such as the Pneumoconiosis Research Unit score or the Medical Research Council index-the ratings depend only on the magnitude of the most taxing task that the patient can perform. No attention is given to the patient's effort in performing tasks or to the functional impairment produced by dyspnea in everyday activities. To improve the effectiveness and scope of the assessment, the patient's magnitude of effort and task, as well as functional impairment, were combined in a recently developed new index of dyspnea. In the current research, this new index has been further improved and tested. The ratings have been cited with more precise criteria, and the results of the Modified Dyspnea Index created by the new criteria have been compared with results of the conventional Pneumoconiosis Research Unit score, and with physiologic measurements of pulmonary function. For 32 patients with stable chronic obstructive pulmonary disease (COPD), the Modified Dyspnea Index had a moderate correlation with the Pneumoconiosis Research Unit score (Spearman rho = -0.62) and with the FEV1 (Pearson r = 0.71) and FVC (Pearson r = 0.69). Among patients with the same Pneumoconiosis Research Unit score, however, the Modified Dyspnea Index scores showed a substantial gradient. Ratings with both the previous and the modified new dyspnea indexes correlated most strongly with respiratory muscle strength, supporting the idea that dyspnea is mediated by alteration of respiratory muscle function.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial adherence to respiratory tract cells. Relationships between in vivo and in vitro pH and bacterial attachment.

Alterations in in vitro pH have been shown to have a significant effect on the bacterial binding capacity of epithelial cells for certain organisms. We investigated the effect of in vivo pH and in vitro changes in pH on the adherence of Pseudomonas aeruginosa to buccal and tracheal cells of 19 chronic tracheostomy patients. In addition, airway pH was measured in 5 normal volunteers. Oropharyngeal and endobronchial pH were measured with a flexible electrode that could be passed through a bronchoscope under direct visualization. In vitro adherence of Pseudomonas to respiratory epithelial cells was determined at pH 6.5 and 7.2. Colonization status of the patients was determined by culture of oropharyngeal and tracheal secretions. The pH value of each site in the respiratory tract and its secretions were different in the tracheostomy patients (buccal pH 6.3; tracheal, 6.9; sputum, 7.5). No difference was noted in pH of the 2 sites in control subjects (buccal, 6.7; tracheal, 6.7). Changes in in vitro pH had a significant effect (p less than 0.004) on bacterial binding to epithelial cells from both sites. The pH had its greatest effect on tracheal cells of patients colonized with Pseudomonas. Increased in vitro binding of these organisms was noted at the more alkaline pH. The magnitude of the effect of in vitro pH alteration on bacterial binding correlated directly with the degree of binding. These results demonstrated that pH has a significant effect on in vitro Pseudomonas adherence and the effect is most marked on cells obtained from the lower respiratory tract of patients colonized with this organism.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutritional status and bacterial binding in the lower respiratory tract in patients with chronic tracheostomy.

Patients with chronic tracheostomy often develop tracheobronchial colonization with enteric gram-negative bacilli, especially Pseudomonas aeruginosa, but pathogenic mechanisms are largely unknown. To examine this problem, we measured in-vitro bacterial adherence to airway epithelial cells from the tracheal surfaces of 15 patients with chronic tracheostomy and 18 healthy, noncolonized controls without tracheostomy. Patients with tracheostomy had more tracheal cell adherence (7.3 +/- 0.4 [SE] bacteria/cell) than controls (4.8 +/- 0.7 bacteria/cell; p = 0.008), but patients colonized by Pseudomonas species had even more binding (9.0 +/- 0.06 bacteria/cell) than those without this finding (5.8 +/- 0.8 bacteria/cell; p = 0.008). Differences between patients in lower airway cell binding of bacteria were largely related to a multifactorial assessment of patient nutritional status, the prognostic nutritional index (r = 0.67, p = 0.005). Thus, nutritional status may account in part for the common problem of tracheobronchial colonization with gram-negative bacteria in patients with chronic tracheostomy.

Respiratory infection complicating long-term tracheostomy. The implication of persistent gram-negative tracheobronchial colonization.

Colonization of the lower respiratory tract by enteric Gram-negative bacilli (EGNB) has been a frequent finding in patients with long-term tracheostomies; however, the association of hospitalization and certain features of serious illness with this phenomenon has not been clearly established. Because such factors can render the oropharynx more susceptible to EGNB colonization, we sought to discover whether they can also have this effect on the tracheobronchial tree and its microflora. Thus, we collected serial paired culture samples from these two mucosal sites in 15 subjects with long-term tracheostomies and examined patterns and rates of colonization and related these findings to clinical parameters. In 49 sets of cultures, we found that EGNB (especially Pseudomonas species) were present in significantly fewer upper-airway cultures (36.7 percent) than lower-airway cultures (75.5 percent) (p = 0.009). At the tracheobronchial site, seven subjects had persistent EGNB colonization, all with Pseudomonas species, while only one subject had this finding at the oropharyngeal site (p = 0.015). Patients with persistent tracheobronchial colonization were more ill than those without this finding. They were treated with higher doses of prednisone (p = 0.06), received antibiotics more often, and developed purulent tracheobronchitis more often (100 percent vs 25 percent) than patients without persistent colonization. In addition, in the month following the culture survey, four subjects developed pneumonia, and three of these had previous persistent tracheobronchial colonization.(ABSTRACT TRUNCATED AT 250 WORDS)

Nerve conduction impairment in patients with respiratory insufficiency and severe chronic hypoxemia.

Sixteen patients with chronic respiratory insufficiency and severe hypoxemia were studied to determine the effect of chronic respiratory insufficiency on peripheral sensory and motor nerve conduction. When matched with a control group, a statistically significant slowing (from p less than 0.02 to p less than 0.001) of nerve conduction was noted in the motor median, ulnar peroneal, and tibial nerves and also in the sensory median nerve. The peripheral neuropathy was probably due to chronic hypoxemia.