Exposure to psychotropic medications and COVID-19 course after hospital admission: Results from a prospective cohort study.

OBJECTIVE: There is evidence of a bidirectional association between COVID-19 disease and psychiatric disorders. We aimed to assess whether exposure to psychotropic medications prior to hospitalization was associated with mortality or discharge within 30 days after hospital admission. METHODS: In this prospective study, we included all individuals with a laboratory-confirmed COVID-19 infection who were admitted to the Bologna University Hospital between 1st March 2020 and 31st January 2021. We collected data about pre-existing psychiatric disorders and the use of psychotropic medications at the admission. As univariate analyses, we estimated cumulative incidence functions for 30-day mortality and discharge stratifying by exposure to each of the psychotropic medication classes. Finally, we fitted Cox regression models to estimate cause-specific Hazard Ratios (HR) of 30-day mortality and discharge. Results were adjusted for sociodemographic (age, sex), clinically relevant variables (comorbidity, c-reactive protein levels, severity of disease at presentation, history of smoking, study period), and psychiatric variables (psychiatric disorder diagnosis, number of psychotropic medications). RESULTS: Out of a total of 1238 hospitalized patients, 316 were prescribed psychotropic medications at the time of admission. Among these, 45 (3.6%) were taking a first-generation antipsychotics (FGA) and 66 (5.3%) a second generation antipsychotic (SGA). Exposure to SGA was associated with increased rates of 30-day mortality (HR = 2.01, 95%CI = 1.02-3.97) and exposure to FGA was associated with decreased rates of 30-day discharge (HR = 0.55, 95%CI = 0.33-0.90). CONCLUSION: Patients with COVID-19 infection exposed to FGA and SGA may have worse COVID-19 infection outcomes.

Twenty-month Performance of a Universal Bonding System on Simulated-challenged Dentin Substrates Pretreated with Chlorhexidine.

OBJECTIVES: Since the use of dentin antiproteolytic agents with universal adhesives (UAs) can potentially degrade the bonding interface, this study evaluated bond strengths with and without chlorhexidine (CHX) on variously altered dentin surfaces for up to 20 months. METHODS: Human molar specimens (n=20) were categorized by substrates as S=sound, E=eroded, and C=carious, and by pretreatment as W=water or CHX. These specimens were subjected to micro-tensile bond strength (µTBS) testing at 24 hours, 6 months, and 20 months, after 30 seconds of pretreatment with CHX or W, followed by self-etching and bonding (Adper Single Bond Universal, 3M ESPE). Modes of failure were assessed using optical microscopy (40×) and scanning electron microscopy (SEM), and the results were analyzed by 3-way ANOVA and Tukey's statistical tests (α=0.05). RESULTS: Substrate (p<0.001), pre-treatment (p=0.0413), and time (p<0.0001) were statistically significant. The sound-dentin group in initial time (W=39.27/CHX=40.55) yielded the higher µTBS values (MPa) in comparison with altered substrates pre-treated with CHX (E-CHX=19.84; C-CHX=18.24) after 20 months, which showed the lowest values. Under SEM analysis, heterogeneous patterns appeared in the hybrid layer of the CHX-treated group, particularly in the altered substrates. CONCLUSIONS: Bond strength to dentin decreased over a period of 20 months using UA with 10-methacryloyloxydecyl-dihydrogen phosphate (MDP) in self-etching mode. Substrates altered by erosion or caries have impaired adhesion and associated clinical use of UA with MDP and CHX should be avoided.

Performance of a Universal Bonding System Associated With 2% Digluconate Chlorhexidine in Carious and Eroded Dentin.

CLINICAL RELEVANCE: Carious and eroded dentin represent clinical challenges. The use of a universal bonding system, in a self-etching mode, associated with chlorhexidine (CHX) seems to not improve its longevity. This may be attributed to the competition for calcium between the bonding agent functional monomer and CHX.

Adapted Three-step Restorative Technique: Recovering Dental Substrate Compromised by Complex Erosive Wear in a Young Patient.

CLINICAL RELEVANCE: This article presents the dental restoration of a young female patient complaining of erosive dental wear using a three-step restorative technique, an alternative approach with some novel adjustments. SUMMARY: For successful tooth wear treatment, determining the etiological systemic and local factors is the main priority before deciding on effective and long-term preventive and/or therapeutic restorative approaches. In addition to professional intervention, achieving optimal outcomes requires patients to control their diet and/or gastric issues, thus minimizing the wear process. However, continuous wear constitutes the most challenging scenario, mainly when it affects young patients' dentitions. This article describes the dental restoration of posterior teeth with reestablishment of occlusal vertical dimension before treating the anterior teeth, while educating the patient and providing medical monitoring. The three-step restorative technique seems to be properly applicable in cases of significant dental compromise due mainly to erosive wear and is based on direct procedures, which can assure a reliable and feasible approach.

Bloodstream infections in patients living with HIV in the modern cART era.

Retrospective multicentre study aiming at analysing the etiology, characteristics and outcome of bloodstream infections (BSI) in people living with HIV (PLWHIV) in an era of modern antiretroviral therapy. Between 2008 and 2015, 79 PLWHIV had at least 1 BSI, for a total of 119 pathogens isolated. Patients were mainly male (72.1%), previous intravenous drug users (55.7%), co-infected with HCV or HBV (58.2%) and in CDC stage C (60.8%). Gram-positive (G+) pathogens caused 44.5% of BSI, followed by Gram-negative (G-), 40.3%, fungi, 10.9%, and mycobacteria, 4.2%. Candida spp. and coagulase-negative staphylococci were the most frequent pathogens found in nosocomial BSI (17% each), while E.coli was prevalent in community-acquired BSI (25%). At the last available follow-up, (mean 3.2 ± 2.7 years) the overall crude mortality was 40.5%. Factors associated with mortality in the final multivariate analysis were older age, (p = 0.02; HR 3.8, 95%CI 1.2-11.7) CDC stage C (p = 0.02; HR 3.3, 95%CI 1.2-9.1), malignancies, (p = 0.004; HR 3.2, 95%CI 1.4-7.0) and end stage liver disease (p = 0.006; HR 3.4, 95%CI 1.4-8.0). In conclusion, the study found high mortality following BSI in PLWHIV. Older age, neoplastic comorbidities, end stage liver disease and advanced HIV stage were the main factors correlated to mortality.

A toolkit for the management of infection or colonization by extended-spectrum beta-lactamase producing Enterobacteriaceae in Italy: implementation and outcome of a European project.

Among European countries, prevalence rates of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are particularly high in those bordering the Mediterranean. This is the case for Italy, with 26% of Escherichia coli displaying resistance to the 3rd generation cephalosporins in 2013. An ESBL-E toolkit designed to assist clinicians in managing patients harboring ESBL-E was favorably implemented in Southern France. In a context of lack of specific Italian recommendations, its extension to an adjacent region of Italy was made possible through a cross-border EU cooperation program. Italian infectious disease (ID) specialists, microbiologists, and community-based general practitioners from three districts in Liguria were offered a toolkit consisting in a warning system and detailed procedures for the management of patients harboring ESBL-E, including seeking advice from an ID specialist, and were trained during 52 video conferences by an experienced French team. Indications and trends in antimicrobial prescription were studied following implementation of the toolkit. Between November 2013 and November 2014, 476 patients were identified as harboring ESBL-E and expert advice was sought for 364 of these; all patients and/or their caregivers were advised on appropriate hygiene measures and 209/341 with documented management received antimicrobial treatment, while asymptomatic carriers (39%) were not prescribed antibiotics. The ESBL-E toolkit was well received by the healthcare staff. A specific, simple tool consisting in a care-bundle approach to manage ESBL-E carriers can restrict antimicrobial prescription to symptomatic patients while raising awareness among caregivers of the importance of seeking expert advice and implementing appropriate hygiene measures.

Role of Proteolytic Enzyme Inhibitors on Carious and Eroded Dentin Associated With a Universal Bonding System.

OBJECTIVES: The aim of this study was to evaluate the effect of proteolytic inhibitors on the bond strength of a universal adhesive system (etch-and-rinse mode) applied to artificial carious and eroded dentin. METHODS: Ninety molars were prepared and randomly divided into three groups according to the substrate: N, no challenges; ACD, artificial carious dentin simulation and ERO, artificial erosion simulation with orange juice. All groups were redivided into three subgroups according to the dentin pretreatment: W, water; CHX, 2% digluconate chlorhexidine; and E-64 (trans-epoxysuccinyl-L-leucylamido-[4-guanidino] butane), 5 µM E-64 inhibitor. They constituted a total of nine groups (n=10): N-W, N-CHX, N-E64, ACD-W, ACD-CHX, ACD-E64, ERO-W, ERO-CHX, and ERO-E64. All specimens were restored with Adper Single Bond Universal/Filtek Z250. Beams (0.64 mm2) were obtained and subjected to the microtensile test (µTBS) in a universal testing machine at 0.5 mm/min. The failure mode of the interfaces was determined by optical microscopy (40× magnification). Data were statistically analyzed by three-way analysis of variance and Tukey tests (p<0.05). RESULTS: All individual factors (p<0.0001) and the interaction between substrate and treatment (p=0.0011) and between substrate and time (p=0.0003) were statistically significant. The caries substrate contributed negatively to bond strength. Chlorhexidine reduced bond strength for normal and eroded conditions. Only the normal substrate was negatively affected by time despite the pretreatment. CONCLUSIONS: The universal bonding system appears to be a promising bonding strategy for the maintenance of bond strength to affected dentin. E-64 did not affect bonding to the dentin in contrast to the use of chlorhexidine, which, when associated with the universal system, did affect the microtensile bond strength for artificial carious dentin.

A SOA-Based Platform to Support Clinical Data Sharing.

The eSource Data Interchange Group, part of the Clinical Data Interchange Standards Consortium, proposed five scenarios to guide stakeholders in the development of solutions for the capture of eSource data. The fifth scenario was subdivided into four tiers to adapt the functionality of electronic health records to support clinical research. In order to develop a system belonging to the "Interoperable" Tier, the authors decided to adopt the service-oriented architecture paradigm to support technical interoperability, Health Level Seven Version 3 messages combined with LOINC (Logical Observation Identifiers Names and Codes) vocabulary to ensure semantic interoperability, and Healthcare Services Specification Project standards to provide process interoperability. The developed architecture enhances the integration between patient-care practice and medical research, allowing clinical data sharing between two hospital information systems and four clinical data management systems/clinical registries. The core is formed by a set of standardized cloud services connected through standardized interfaces, involving client applications. The system was approved by a medical staff, since it reduces the workload for the management of clinical trials. Although this architecture can realize the "Interoperable" Tier, the current solution actually covers the "Connected" Tier, due to local hospital policy restrictions.

A SOA-Based Platform to Support Clinical Data Sharing

The eSource Data Interchange Group, part of the Clinical Data Interchange Standards Consortium, proposed five scenarios to guide stakeholders in the development of solutions for the capture of eSource data. The fifth scenario was subdivided into four tiers to adapt the functionality of electronic health records to support clinical research. In order to develop a system belonging to the "Interoperable" Tier, the authors decided to adopt the service-oriented architecture paradigm to support technical interoperability, Health Level Seven Version 3 messages combined with LOINC (Logical Observation Identifiers Names and Codes) vocabulary to ensure semantic interoperability, and Healthcare Services Specification Project standards to provide process interoperability. The developed architecture enhances the integration between patient-care practice and medical research, allowing clinical data sharing between two hospital information systems and four clinical data management systems/clinical registries. The core is formed by a set of standardized cloud services connected through standardized interfaces, involving client applications. The system was approved by a medical staff, since it reduces the workload for the management of clinical trials. Although this architecture can realize the "Interoperable" Tier, the current solution actually covers the "Connected" Tier, due to local hospital policy restrictions.

Quality of life in an Italian cohort of people living with HIV in the era of combined antiretroviral therapy (Evidence from I.A.N.U.A. study-investigation on antiretroviral therapy).

The aims of this study were to assess the Health Related Quality of Life (HRQoL) of People Living with HIV/AIDS (PLWHA) who attend outpatient services in Genoa, Italy, and to evaluate the relationship between HRQoL and clinical factors, primarily: CD4+ cell count, viral load and HIV-Hepatitis C Virus (HCV) coinfection. A cross-sectional study was performed involving a sample of 943 consecutive patients. Firstly the EuroQol-Five Dimensions-Three Level (EQ-5D-3L) self-reported questionnaire was used to evaluate HRQoL, while socio-demographic information was collected using a separate self-administered questionnaire. Descriptive statistical analysis was then used to show the socio-demographic and clinical characteristics of the sample. Having characterized the sample, Pearson's correlation technique was used to assess the relationship between HRQoL and socio-demographic and clinical characteristics. Finally, multivariable linear regression was used to determine factors associated with HRQOL. The median EQ-Visual analogue scale (EQ-VAS) score was 75.4 (SD 18.4). We found statistically significant associations between the EQ-VAS score and age, coinfection with HCV+, education, other drugs taken over cART, hospitalization due to HIV and a CD4+ cell count <200 mm3 compared with CD4+ cell count >500 mm3. Factors independently associated with lower HRQoL were: older age, coinfection with HCV+, other drugs used in addition to cART, hospitalization due to HIV and CD4+ cell count <200 mm3 compared with CD4+ cell count >500 mm3.

Effectiveness, safety, durability and immune recovery in a retrospective, multicentre, observational cohort of ART-experienced, HIV-1-infected patients receiving maraviroc.

The aim of this retrospective, multicentre, observational study was to assess the durability, safety, immune recovery and effectiveness on viral suppression of antiretroviral therapy (ART) in a maraviroc (MVC)-based cohort. We collected clinical, demographical, immunological and virological parameters of adult HIV patients who were infected by CCR5-tropic virus and started an ART regimen containing MVC from 2005 to 2012. We created a longitudinal mixed model to assess the change over time of data. We enrolled 126 drug-experienced patients; the median duration of MVC treatment was 25 months. The probability of stopping ART at one year was 13.3%, and at three years was 27.3%. Statistically significant changes were observed for CD4+ cell count increase ( p < 0.001), HIV-RNA decrease ( p < 0.001) and total cholesterol decrease ( p = 0.005). Ninety-four patients (79.7%) had CD4 ≥ 200 cells/mm3 at baseline while nine of them reached this threshold at nine months (7.6%), 17 (13%) after nine months and six (5%) remained below 200 cells/mm3 at the end of the study. Overall, 114 patients (90.5%) achieved an HIV-RNA ≤ 50 cp/ml. A majority of patients maintained CD4 cell counts of ≥ 200 cells/mm3 and achieved an undetectable HIV viral load within three months. MVC-containing regimens are safe and appear to be a feasible therapeutic option for ART.

Metabolomic and Genome-wide Association Studies Reveal Potential Endogenous Biomarkers for OATP1B1.

Transporter-mediated drug-drug interactions (DDIs) are a major cause of drug toxicities. Using published genome-wide association studies (GWAS) of the human metabolome, we identified 20 metabolites associated with genetic variants in organic anion transporter, OATP1B1 (P < 5 × 10-8 ). Of these, 12 metabolites were significantly higher in plasma samples from volunteers dosed with the OATP1B1 inhibitor, cyclosporine (CSA) vs. placebo (q-value < 0.2). Conjugated bile acids and fatty acid dicarboxylates were among the metabolites discovered using both GWAS and CSA administration. In vitro studies confirmed tetradecanedioate (TDA) and hexadecanedioate (HDA) were novel substrates of OATP1B1 as well as OAT1 and OAT3. This study highlights the use of multiple datasets for the discovery of endogenous metabolites that represent potential in vivo biomarkers for transporter-mediated DDIs. Future studies are needed to determine whether these metabolites can serve as qualified biomarkers for organic anion transporters. Quantitative relationships between metabolite levels and modulation of transporters should be established.

Experiences of patient-centredness with specialized community-based care: a systematic review and qualitative meta-synthesis.

BACKGROUND: Specialized community-based care (SCBC) endeavours to help patients manage chronic diseases by formalizing the link between primary care providers and other community providers with specialized training. Many types of health care providers and community-based programs are employed in SCBC. Patient-centred care focuses on patients' psychosocial experience of health and illness to ensure that patients' care plans are modelled on their individual values, preferences, spirituality, and expressed needs. OBJECTIVES: To synthesize qualitative research on patient and provider experiences of SCBC interventions and health care delivery models, using the core principles of patient-centredness. DATA SOURCES: This report synthesizes 29 primary qualitative studies on the topic of SCBC interventions for patients with chronic conditions. Included studies were published between 2002 and 2012, and followed adult patients in North America, Europe, Australia, and New Zealand. REVIEW METHODS: Qualitative meta-synthesis was used to integrate findings across primary research studies. RESULTS: Three core themes emerged from the analysis: patients' health beliefs affect their participation in SCBC interventions;patients' experiences with community-based care differ from their experiences with hospital-based care;patients and providers value the role of nurses differently in community-based chronic disease care. LIMITATIONS: Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across several qualitative studies builds an increasingly robust understanding that is more likely to be transferable. The diversity of interventions that fall under SCBC and the cross-interventional focus of many of the studies mean that findings might not be generalizable to all forms of SCBC or its specific components. CONCLUSIONS: Patients with chronic diseases who participated in SCBC interventions reported greater satisfaction when SCBC helped them better understand their diagnosis, facilitated increased socialization, provided them with a role in managing their own care, and assisted them in overcoming psychological and social barriers. PLAIN LANGUAGE SUMMARY: More and more, to reduce bed shortages in hospitals, health care systems are providing programs called specialized community-based care (SCBC) to patients with chronic diseases. These SCBC programs allow patients with chronic diseases to be managed in the community by linking their family physicians with other community-based health care providers who have specialized training. This report looks at the experiences of patients and health care providers who take part in SCBC programs, focusing on psychological and social factors. This kind of lens is called patient-centred. Three themes came up in our analysis: patients' health beliefs affect how they take part in SCBC interventions; patients' experiences with care in the community differ from their experiences with care in the hospital; patients and providers value the role of nurses differently. The results of this analysis could help those who provide SCBC programs to better meet patients' needs.

Patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis.

BACKGROUND: Depression and anxiety are highly prevalent in patients with chronic disease, but remain undertreated despite significant negative consequences on patient health. A number of clinical groups have developed recommendations for depression screening practices in the chronic disease population. OBJECTIVES: The objective of this analysis was to review empirical qualitative research on the experiences of patients with chronic disease (e.g., COPD, diabetes, heart disease, stroke) and comorbid depression or anxiety, and to highlight the implications of the screening and management of anxiety and/or depression on chronic disease outcomes. REVIEW METHODS: We performed literature searches for studies published from January 2002 to May 2012. We applied a qualitative mega-filter to nine condition-specific search filters. Titles and abstracts were reviewed by two reviewers and, for the studies that met the eligibility criteria, full-text articles were obtained. Qualitative meta-synthesis was used to integrate findings across relevant published primary research studies. Qualitative meta-synthesis produced a synthesis of evidence that both retained the original meaning of the authors and offered a new, integrative interpretation of the phenomenon through a process of comparing and contrasting findings across studies. RESULTS: The findings of 20 primary qualitative studies were synthesized. Patients tended to experience their chronic conditions and anxiety or depression as either independent or inter-related (i.e., the chronic disease lead to depression/anxiety, the depression/anxiety lead to the chronic disease, or the two conditions exacerbated each other). Potential barriers to screening for depression or anxiety were also identified. LIMITATIONS: A wider array of issues might have been captured if the analysis had focused on broader psychological responses to the chronic disease experience. However, given the objective to highlight implications for screening for anxiety or depression, the more narrow focus seemed most relevant. CONCLUSIONS: Chronic disease and anxiety or depression can be independent or inter-related. Patients may be reluctant to acknowledge depression or anxiety as a separate condition, or may not recognize that the conditions are separate because of overlapping physical symptoms. More qualitative research is needed to specifically address screening for depression or anxiety. PLAIN LANGUAGE SUMMARY: Depression is a common complication of chronic disease. It may worsen the disease, and it may also affect the self-management of the disease. Screening for depression earlier, and then treating it, may reduce distress and improve symptoms of the chronic disease, leading to better quality of life.

How diet modification challenges are magnified in vulnerable or marginalized people with diabetes and heart disease: a systematic review and qualitative meta-synthesis.

BACKGROUND: Diet modification is an important part of self-management for patients with diabetes and/or heart disease (including coronary artery disease, heart failure, and atrial fibrillation). Many health care providers and community-based programs advise lifestyle and diet modification as part of care for people with these conditions. This report synthesizes qualitative information on how patients respond differently to the challenges of diet modification. Qualitative and descriptive evidence can illuminate challenges that may affect the success and equitable impact of dietary modification interventions. OBJECTIVES: To (a) examine the diet modification challenges faced by diabetes and/or heart disease patients; and (b) compare and contrast the challenges faced by patients who are members of vulnerable and nonvulnerable groups as they change their diet in response to clinical recommendations. DATA SOURCES: This report synthesizes 65 primary qualitative studies on the topic of dietary modification challenges encountered by patients with diabetes and/or heart disease. Included papers were published between 2002 and 2012 and studied adult patients in North America, Europe, and Australia/New Zealand. REVIEW METHODS: Qualitative meta-synthesis was used to integrate findings across primary research studies. RESULTS: Analysis identified 5 types of challenges that are common to both vulnerable and nonvulnerable patients: self-discipline, knowledge, coping with everyday stress, negotiating with family members, and managing the social significance of food. Vulnerable patients may experience additional barriers, many of which can magnify or exacerbate those common challenges. LIMITATIONS: While qualitative insights are robust and often enlightening for understanding experiences and planning services in other settings, they are not intended to be generalizable. The findings of the studies reviewed here--and of this synthesis--do not strictly generalize to the Ontario (or any specific) population. This evidence must be interpreted and applied carefully, in light of expertise and the experiences of the relevant community. CONCLUSIONS: Diet modification is not simply a matter of knowing what to eat and making the rational choice to change dietary practices. Rather, diet and eating practices should be considered as part of the situated lives of patients, requiring an individualized approach that is responsive to the conditions in which each patient is attempting to make a change. Common challenges include self-discipline, knowledge, coping with everyday stress, negotiating with family members, and managing the social significance of food. An individualized approach is particularly important when working with patients who have vulnerabilities. PLAIN LANGUAGE SUMMARY: Health care providers often encourage people with diabetes and/or heart disease to change their diet. They advise people with diabetes to eat less sugar, starch, and fat. They advise people with heart disease to eat less fat and salt. However, many patients find it difficult to change what they eat. This report examines the challenges people may face when making such changes. It also examines the special challenges faced by people who are vulnerable due to other factors, such as poverty, lack of education, and difficulty speaking English. Five themes were common to all people who make diet changes: self-discipline, knowledge, coping with stress, negotiating with family members, and managing the social aspect of food. Members of vulnerable groups also reported other challenges, such as affording fresh fruit and vegetables or understanding English instructions. This report may help health care providers work with patients more effectively to make diet changes.

Chronic disease patients' experiences with accessing health care in rural and remote areas: a systematic review and qualitative meta-synthesis.

BACKGROUND: Rurality can contribute to the vulnerability of people with chronic diseases. Qualitative research can identify a wide range of health care access issues faced by patients living in a remote or rural setting. OBJECTIVE: To systematically review and synthesize qualitative research on the advantages and disadvantages rural patients with chronic diseases face when accessing both rural and distant care. DATA SOURCES: This report synthesizes 12 primary qualitative studies on the topic of access to health care for rural patients with chronic disease. Included studies were published between 2002 and 2012 and followed adult patients in North America, Europe, Australia, and New Zealand. REVIEW METHODS: Qualitative meta-synthesis was used to integrate findings across primary research studies. RESULTS: Three major themes were identified: geography, availability of health care professionals, and rural culture. First, geographic distance from services poses access barriers, worsened by transportation problems or weather conditions. Community supports and rurally located services can help overcome these challenges. Second, the limited availability of health care professionals (coupled with low education or lack of peer support) increases the feeling of vulnerability. When care is available locally, patients appreciate long-term relationships with individual clinicians and care personalized by familiarity with the patient as a person. Finally, patients may feel culturally marginalized in the urban health care context, especially if health literacy is low. A culture of self-reliance and community belonging in rural areas may incline patients to do without distant care and may mitigate feelings of vulnerability. LIMITATIONS: Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across a number of qualitative studies builds an increasingly robust understanding that is more likely to be transferable. Selected studies focused on the vulnerability experiences of rural dwellers with chronic disease; findings emphasize the patient rather than the provider perspective. CONCLUSIONS: This study corroborates previous knowledge and concerns about access issues in rural and remote areas, such as geographical distance and shortage of health care professionals and services. Unhealthy behaviours and reduced willingness to seek care increase patients' vulnerability. Patients' perspectives also highlight rural culture's potential to either exacerbate or mitigate access issues. PLAIN LANGUAGE SUMMARY: People who live in a rural area may feel more vulnerable--that is, more easily harmed by their health problems or experiences with the health care system. Qualitative research looks at these experiences from the patient's point of view. We found 3 broad concerns in the studies we looked at. The first was geography: needing to travel long distances for health care can make care hard to reach, especially if transportation is difficult or the weather is bad. The second concern was availability of health professionals: rural areas often lack health care services. Patients may also feel powerless in "referral games" between rural and urban providers. People with low education or without others to help them may find navigating care more difficult. When rural services are available, patients like seeing clinicians who have known them for a long time, and like how familiar clinicians treat them as a whole person. The third concern was rural culture: patients may feel like outsiders in city hospitals or clinics. As well, in rural communities, people may share a feeling of self-reliance and community belonging. This may make them more eager to take care of themselves and each other, and less willing to seek distant care. Each of these factors can increase or decrease patient vulnerability, depending on how health services are provided.

Intraspecific diversity of Edwardsiella ictaluri isolates from diseased freshwater catfish, Pangasianodon hypophthalmus (Sauvage), cultured in the Mekong Delta, Vietnam.

A molecular epidemiology study was conducted on 90 Edwardsiella ictaluri isolates recovered from diseased farmed freshwater catfish, Pangasianodon hypophthalmus, cultured in the Mekong Delta, Vietnam. Thirteen isolates of E. ictaluri derived from diseased channel catfish, Ictalurus punctatus, cultured in the USA were included for comparison. All the E.ictaluri isolates tested were found to be biochemically indistinguishable. A repetitive (rep)-PCR using the single (GTG)(5) primer was shown to possess limited discriminatory power, yielding two similar DNA profiles categorized as (GTG)(5) -PCR group 1 or 2 among the Vietnam isolates and (GTG)(5) -PCR group 1 within the USA isolates. Macrorestriction analysis identified 14 and 22 unique pulsotypes by XbaI and SpeI, respectively, among a subset of 59 E. ictaluri isolates. Numerical analysis of the combined macrorestriction profiles revealed three main groups: a distinct cluster formed exclusively of the USA isolates, and a major and minor cluster with outliers contained the Vietnam isolates. Antibiotic susceptibility and plasmid profiling supported the existence of the three groups. The results indicate that macrorestriction analysis may be regarded as a suitable typing method among the E. ictaluri species of limited intraspecific diversity. Furthermore, the findings suggest that E. ictaluri originating from Vietnam may constitute a distinct genetic group.

Data collection and advanced statistical analysis in phytotoxic activity of aerial parts exudates of Salvia spp

In order to define the phytotoxic potential of Salvia species a database was developed for fast and efficient data collection in screening studies of the inhibitory activity of Salvia exudates on the germination of Papaver rhoeas L. and Avena sativa L.. The structure of the database is associated with the use of algorithms for calculating the usual germination indices reported in the literature, plus the newly defined indices (Weighted Average Damage, Differential Weighted Average Damage, Germination Weighted Average Velocity) and other variables usually recorded in experiments of phytotoxicity (LC50, LC90). Furthermore, other algorithms were designed to calculate the one-way ANOVA followed by Duncan's multiple range test to highlight automatically significant differences between the species. The database model was designed in order to be suitable also for the development of further analysis based on the artificial neural network approach, using Self-Organising Maps (SOM).