Antimicrobial neurotoxicity: an under-recognised cause of delirium.

Antimicrobial associated encephalopathy (AAE) is a well-documented, though under recognised, adverse event associated with antimicrobial use. Clinical manifestations of AAE are varied, ranging from myoclonus and seizure to an encephalopathy with cerebellar signs. The phenotypic presentation of the encephalopathy syndrome is, in general, governed by the antimicrobial in question. Given its apparent rarity in everyday clinical practice, awareness of AAE is crucial for physicians. We describe a reversible encephalopathy characterised by confusion, myoclonus and stupor in a 76 year old gentleman on antimicrobial therapy for a peri-rectal abscess.

A Survey of Latent Tuberculosis Screening and Treatment Practices in a Tertiary Centre.

Aim Knowledge of latent tuberculosis infection (LTBI) screening and treatment practices are lacking in Ireland, where LTBI is not programmatically surveyed or managed. The aim of this research was to describe current clinical practice when screening and treating patients for LTBI in a tertiary referral centre in Ireland. Methods A 17-question survey relating to LTBI screening and management practices with both open-ended questions and close ended multiple-choice questions was created using SurveyMonkey. The survey target sample was healthcare workers in the tertiary centre who direct LTBI screening and treatment for patients at risk of TB disease in their respective departments. Results The response rate to the survey was 45% (21/47). Seventy-one percent (15/21) of those surveyed responded to the question "What barriers exist to screening patients for latent TB in your clinical practice?". Fifty-three percent (8/15) said that they found it difficult to access LTBI testing and 27% (4/15) cited accessing the interferon-gamma release assay (IGRA) result as a barrier. Forty-three percent (9/21) responded that there was not a clear referral pathway for patients that they would like specialist input on when diagnosing and managing patients with LTBI. Conclusion Access to LTBI testing, LTBI test results, TB specialist services and the use of rifamycin-based regimens should be improved in this tertiary centre. Consideration should be given to developing a national LTBI education programme for healthcare professionals and updating national LTBI treatment guidelines.

National Guidelines on the Provision of Outpatient Parenteral Antimicrobial Therapy (OPAT).

Aim Outpatient parenteral antimicrobial therapy (OPAT) is an option in patients who require parenteral antimicrobial administration and are clinically well enough for hospital discharge. This is an update of the Irish National OPAT guidelines which were last reviewed in 2011. Methods The guideline was devised through a collaborative process with the national OPAT Working Group and a review of the literature. It is intended for clinicians who prescribe any intravenous (IV) antimicrobials outside of the inpatient setting in the Republic of Ireland. Results Patient care while on OPAT should be provided by a designated OPAT service, with clear managerial and clinical governance lines of responsibility. It should be conducted using a team approach with a clinical lead on each site either as an infection specialist, or a general medical physician with infection specialist input and an OPAT nurse. An antimicrobial pharmacist is also desirable. Several factors must be considered when assessing patient's suitability for OPAT including exclusion criteria, infection-specific factors, and patient specific factors such as physical, social and logistic criteria. Conclusion This updated guideline advocates a more individualised OPAT approach, with the recognition that specific antimicrobials and/or specific delivery models may be more appropriate for certain patient groups. Full guidelines are available through www.opat.ie.

Delivering precision antimicrobial therapy through closed-loop control systems.

Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.

Pilot study on the effects of high molecular weight sodium hyaluronate in the treatment of chronic pharyngitis.

Although several therapeutic approaches are available at present for the treatment of chronic pharyngitis, new therapeutic strategies acting on pharyngeal mucous function should be investigated in order to improve symptoms and quality of life. High-molecular weight hyaluronate performs important functions on mucociliary clearance, tissues hydration, defense against micro-organisms, and on tissue repair as well, but at present there is no clinical evidence of its exogenous use in patients with chronic pharyngitis. Our open, randomized controlled study was carried out to investigate efficacy, and tolerability of exogenous high molecular weight sodium hyaluronate (SH) at the dosage of 9 mg three times a day for a period of 30 days, in patients with chronic pharyngitis. Results show significant improvements of symptoms and cytology in active group (A, n = 10) vs. control group (B, n = 10). Good compliance and no adverse events were reported in group A. In conclusion, SH was effective and safe in patients with chronic pharyngitis.

Influenza and pneumococcal vaccination and varicella status in inflammatory arthritis patients.

Patients with inflammatory arthritis are at increased risk of vaccine preventable infections. This risk is increased by immunomodulatory therapies. Vaccination for influenza and pneumococcal disease reduces the risk. Severe cases of varicella infection have occurred in patients on biologic therapies. We sought to identify vaccination rates for commonly acquired infections and to ascertain varicella immune status in patients with inflammatory arthritis. 100 patients with inflammatory arthritis were administered a standardised questionnaire. Data collected included age, diagnosis, vaccination history, history of varicella, treatment and the presence of other indications for vaccination. 58 patients (58%) had not received the influenza vaccine in the past year. Only 19 patients (19%) had ever received pneumococcal vaccine. Anti TNF use did not predict vaccination (p = .46). An increasing number of co morbid conditions predicted both pneumococcal (p < 0.003) and influenza vaccine (p < 0.03) administration. Nineteen patients (19%) gave no history of varicella infection, none having had varicella titres checked pre treatment. Immunisation rates in patients with inflammatory arthritis on immunosuppressive therapies are low. Immunisation schedules should be available for each patient during rheumatology and general practice consultations.

Primary pleural haemangioendothelioma in an Italian female patient: a case report and review of the literature.

Primary epithelioid haemangioendothelioma (EHE) of the pleura is a rare vascular tumour that occurs mainly in men. Pleural effusion and thickening are the most common clinical presentations. A 58 year old female, nonsmoking patient presented to us with dry cough, dyspnoea and left chest pain for several weeks (no asbestos exposure). Standard chest X-ray and contrast enhanced multislice computed tomography revealed a large-size lobulated mass originating from the pleura which was diagnosed as primary pleural haemangioendothelioma (PHE) by histology and immunohistochemistry (reactivity for vimentin, CD31, CD34, Factor VIII and ulex europeaus). No metastases were detected. The patient refused treatment and died three months later due to the onset of acute and progressive respiratory failure. Despite the lack of high-grade malignancy, primary PHE displays a poor prognosis while curative therapies are actually not available. To our knowledge, this is the first case of primary PHE in a female patient occurring in Italy and the third one to have been reported in English literature. Difficulties in diagnosis and treatment management are discussed below.

Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study.

Background: Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice. Methods: We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 - May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy. Results: Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine. Conclusions: Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.

Lung cancer metastatic cells detected in blood by reverse transcriptase-polymerase chain reaction and dot-blot analysis.

PURPOSE: We analyzed the blood of patients with lung cancer at different stages of presentation for the presence of carcinoembryonic antigen (CEA) mRNA detected by reverse transcriptase-polymerase chain reaction (RT-PCR) combined with the dot-blot procedure as an indicator of micrometastatic malignant cells. PATIENTS AND METHODS: We studied 24 lung cancer patients (10 with distant metastases and 14 with no evidence of distant metastases), eight age- and sex-matched patients affected by nonneoplastic respiratory diseases (four smokers), and eight healthy subjects. We used immunohistochemistry and RT-PCR dot-blot analysis to evaluate CEA expression in the neoplastic tissue, and the RT-PCR dot-blot procedure to analyze CEA mRNA in circulating cells. RESULTS: The RT-PCR dot-blot procedure was highly sensitive aspecific: it detected CEA mRNA in samples of RNA from lung cancer diluted 10(6)-fold with RNA extracted from normal blood cells, and sequence analysis confirmed that the amplified product was CEA. CEA mRNA was found in circulating cells from eight of 10 lung cancer patients with distant metastases (diagnostic sensitivity, 80%) and in four of 14 patients with no evidence of distant metastases. Two of the latter had distant metastases within 6 months of analysis. Thus, the diagnostic specificity of the analysis toward lung cancer without distant metastases was 86%. The analysis was negative in the eight nonneoplastic patients and in the eight healthy controls. CONCLUSION: The RT-PCR dot-blot analysis of CEA mRNA in blood cells seems to be a promising tool for the early detection of micrometastatic circulating cells in patients with lung cancer.

Vivências de sofrimento e adoecimento em ambiente de trabalho: uma análise do cotidiano profissional de enfermeiras e enfermeiros num contexto pandêmico em dois centros de referência no atendimento a pacientes de Covid-19 / Experiences of suffering and illness in a work environment: an analysis of nurses daily professional life in a pandemic context in two reference centers in the care of Covid-19 patients

Este artigo promove um debate que orbita em torno de conceitos, tais como: risco e sofrimento; subjetividade e experiência; cotidiano e memória; vulnerabilidade e precarização. Buscamos compreender as vivências em ambiente de trabalho de enfermeiros e enfermeiras que atuam desde o início da pandemia de Covid-19 (Coronavirus Disease 2019) em dois hospitais públicos de Goiânia, referências no atendimento a indivíduos vitimados pela doença em questão. Destacamos que a realização das entrevistas teve como pano de fundo um contexto de aprofundamento da precarização e da flexibilização das condições e relações de trabalho desses profissionais, associadas ao vertiginoso aumento do número de casos e óbitos entre esses. Com base na história oral temática, constatamos que esses profissionais - embora essenciais no enfrentamento à pandemia - se encontram atualmente ainda mais vulnerabilizados, individual e coletivamente. Ainda que homens e mulheres nessa categoria de trabalhadores experimentem de forma muito diferente o sofrimento e o adoecimento em seus respectivos cotidianos laborais. Particularmente, em função das desigualdades de gênero no mercado de trabalho.

This article discusses concepts such as: risk and suffering, subjectivity and experience; everyday life and memory; vulnerability and precariousness. We analyze the work environment experiences of nurses working since the beginning of the Covid-19 pandemic in two public hospitals in Goiânia, reference hospitals in the care of individuals afflicted by the pathogen in question. The interviews were conducted against a background of deepening in the precariousness and flexibility of working conditions and relationships of these professionals, associated with the vertiginous increase in the number of cases and deaths among them. Based on thematic oral history, we found that these professionals - although essential in facing the pandemic - are currently even more vulnerable individually and collectively, and that men and women of this field experience suffering and illness differently in their respective daily work.

Influence of glass composition on the properties of glass polyalkenoate cements. Part III: influence of fluorite content.

The influence of fluorite content of the glass on the formation and properties of glass polyalkenoate cements was investigated. A series of glass powders based on 1.5SiO2 x 0.5P2O5 x Al2O3 x CaO x XCaF2 were synthesised. The glass transition temperature of the glass fell with increasing fluorite content. Setting and working times of the cement pastes decreased with increasing fluorite content of the glass. Compressive strength and un-notched fracture strength increased with increasing fluorite content of the glass. Fracture toughness and toughness of the cements were relatively insensitive to fluorite content.

Influence of alkali metal ions on the fracture properties of glass polyalkenoate (ionomer) cements.

The influence of substituting sodium for calcium on the properties of glass polyalkenoate cements was investigated. Two series of glass compositions based on PSiO2 x QAl2O3 x 0.75P2O5 x (1 - Z)CaO x XCaF2ZNa2O were studied. The fluorine content was fixed at X = 0.50 and 0.75 and the sodium content varied by altering Z. The glass polyalkenoate cements formed from these glasses were characterized using a linear elastic fracture mechanics (LEFM) approach. In addition, compressive strengths of the cements were determined. The properties of the cements based on the high fluorine content glasses (X = 0.75) were relatively insensitive to sodium content. The Young's modulus, un-notched fracture strength and fracture toughness of the cements produced with the lower fluorine content glasses (X = 0.5) reduced with sodium content, which was consistent with sodium acting to disrupt ionic cross-linking in the polyacrylate matrix. The compressive strength was not as dependent on sodium content as the LEFM parameters.

Involvement of calcium in the cardiac depressant actions of a garlic dialysate.

In order to elucidate a possible role for calcium on the negative cardiotropic effects of a garlic (Allium sativum L., Liliaceae) dialysate in rat atria we studied: (a) the effects of our extract 15 min after preincubation with high and low concentrations of extracellular calcium ([Ca2+]o) on left and right activity of rat atria. The negative inotropism of garlic dialysate increased with calcium 0.75 mM; in contrast, high level of calcium (4.5 mM) induced a significant reduction of this depressant effect. None of these treatments modified the negative chronotropism of garlic; (b) nifedipine (10(-9) to 10(-7) M, verapamil (10(-9) to 10(-7) M) and diltiazem (10(-9) to 10(-7) M) induced a concentration-dependent synergism of the log concentration-effect of garlic dialysate on left atria. Verapamil and diltiazem (10(-7)M), but not nifedipine increased the inhibitory chronotropism of garlic in right atria; (c) negative inotropic and chronotropic effects demonstrated by nifedipine (1 x 10(-10) to 1.1 x 10(-6) M) were antagonized as expected by preincubation with Bay K-8644. Depressant actions of garlic were not modified with this pretreatment. These results suggest that the negative inotropic effect of our garlic dialysate is related to [Ca2+]o availability. It is possible that a restriction of intracellular calcium contributes to this effect. However, the negative chronotropic effect of garlic is scarcely affected by these modifications.

Complete regression of laryngeal involvement by classic Kaposi's sarcoma with low-dose alpha-2b interferon.

We report the case of an 82-year old Italian female with laryngeal involvement of classic Kaposi's sarcoma. We obtained a complete regression of laryngeal lesion with low-dose alpha-2b interferon.

Fibromatosis of the larynx in the adult.

We describe the fourth case of aggressive fibromatosis of the larynx arising in an adult. Most cases of laryngeal fibromatosis have been described in children. In the larynx it may behave the same as in other sites, with local aggressiveness but without metastasis. The possible differential diagnoses are discussed.