Checking rounds for isolation precautions in the control of multidrug-resistant organisms: reduction achieved.

The objective of this investigation was to analyze the effectiveness of a quality improvement initiative in limiting the spread of multidrug-resistant organisms (MDROs) in the hospital setting. During the period 2011-2013, a multimodal intervention was activated at a tertiary care center in Italy. The intervention included: laboratory-based surveillance, interdisciplinary training sessions, monitoring the adoption of isolation precautions and daily supervision provided by infection control nurses, and a monthly feedback. Time series analysis was used to evaluate the trends and correlations between the MDROs rate, intensity of checking rounds, and hospital-wide data (i.e., transfer of patients, patients' days, site of isolation, etc.). A total of 149,251 patients were included in the study. The proportion of patients undergoing transmission-based isolation precautions within 24 h from a positive laboratory finding increased from 83% in 2011 to 99% in 2013 (p < 0.05). The wards appropriately adopting the correct isolation precaution increased from 83% in 2011 to 97.6% in 2013 (p < 0.05). The frequency of controls was significantly reduced after the observation of compliance in the appropriate wards (p < 0.05). After three years, the incidence rate changed from 5.8/1000 days of stay [95% confidence interval (CI) 5.6-6.1] in 2011 to 4.7 (95% CI 4.4-4.9) in 2013 (p < 0.0001). Moreover, microorganisms isolated from different types of specimens showed variable potential for transmission (i.e., skin as the most potential and urine the least). The results demonstrate the efficacy of the multimodal intervention, with sustained reduction of MDROs rate, besides check reduction, and highlight the long-term efficacy of checking rounds in changing professionals' behaviors.

Trans-physeal anterior cruciate ligament reconstruction in adolescents.

PURPOSE: The aim of the study was to evaluate, in a group of adolescents, the onset of varus-valgus deviations in the sagittal plane after performing a trans-tibial trans-epiphyseal technique of ACL reconstruction with a follow-up of at least 2 years. METHODS: Seventy-one patients aged 12-15 years old (Tanner scale 3 and 4) have undergone ACL reconstruction with STG using arthroscopy. All patients were evaluated clinically using the visual analogue scale (VAS), the Lysholm score and the Tegner activity score at the time of surgery. All patients were reevaluated after a follow-up period of at least 2 years (T1) using the VAS, the Lysholm score, the Tegner activity score and radiographic studies in order to compare the operated limb with the healthy control limb. RESULTS: Valgus difference exceeding 2° in the knee axis between the operated limb and the healthy control limb was observed only in three patients (4.2%: 95% CI 0.88-11.86%). The average difference was <1° (0.3°, 95% CI 0.0-0.55). CONCLUSION: The trans-tibial trans-epiphyseal technique of ACL reconstruction, according to the results obtained, seems to be a valid alternative procedure, when performed by a skilled orthopaedic surgeon, offering an excellent safety profile and at the same time very good clinical results. LEVEL OF EVIDENCE: IV.

High accuracy in knee alignment and implant placement in unicompartmental medial knee replacement when using patient-specific instrumentation.

PURPOSE: The influence of patient-specific instrumentations on the accuracy of unicompartmental medial knee replacement remains unclear. The goal of this study was to examine the ability of patient-specific instrumentation to accurately reproduce postoperatively what the surgeon had planned preoperatively. METHODS: Twenty consecutive patients (20 knees) who suffered from isolated unicompartmental medial osteoarthritis of the knee and underwent medial knee replacement using newly introduced magnetic resonance imaging-based patient-specific instrumentation were assessed. This assessment recorded the following parameters: (1) the planned and the postoperative mechanical axis acquired through long-leg AP view radiographies; (2) the planned and the postoperative tibial slope acquired by means of standard AP and lateral view radiographies; and (3) the postoperative fit of the implanted components to the bone in coronal and sagittal planes. The hypothesis of the study was that there was no statistically significant difference between postoperative results and preoperatively planned values. RESULTS: The study showed that (1) the difference between the postoperative mechanical axis (mean 1.9° varus ± 1.2° SD) and the planned mechanical axis (mean 1.8° varus ± 1.2° SD) was not statistically significant; (2) the difference between the postoperative tibial slope (mean 5.2° ± 0.6° SD) and the planned tibial slope (mean 5.4° ± 0.6° SD) was statistically significant (p = 0.008); and (3) the postoperative component fit to bone in the coronal and sagittal planes was accurate in all cases; nevertheless, in one knee, all components were implanted one size smaller than preoperatively planned. Moreover, in two additional cases, one size thinner and one size thicker of the polyethylene insert were used. CONCLUSIONS: This study suggests that overall patient-specific instrumentation was highly accurate in reproducing postoperatively what the surgeon had planned preoperatively in terms of mechanical axis, tibial slope and component fit to bone. LEVEL OF EVIDENCE: IV.

Autologous collagen-induced chondrogenesis technique (ACIC) for the treatment of chondral lesions of the talus.

PURPOSE: Autologous collagen-induced chondrogenesis technique (ACIC) combines microfractures with the use of an injectable atelocollagen matrix that allows performing the whole cartilage repair treatment arthroscopically. The aim of this study was to evaluate the in vitro cytocompatibility of this biomaterial using human bone marrow mesenchymal stem cells and human chondrocytes. Moreover, the preliminary data of five patients affected by chondral lesion of the talus treated with the ACIC technique are shown. METHODS: Human bone marrow mesenchymal stem cells and human chondrocytes were seeded on solid and pre-solid atelocollagen scaffolds. Cell-scaffold constructs were cultured for 7 days and then prepared for histological analyses. Arthroscopic ACIC was performed in five patients affected by chondral lesions of the talus; they were clinically evaluated with AOFAS, VAS and Tegner score before and then after 6 months from surgery. RESULTS: In vitro results showed that both bone marrow mesenchymal stem cells and chondrocytes were able to efficiently colonize the whole construct, from the surface to the core, only when seeded on the pre-solid atelocollagen scaffold, but not on its solid form. No adverse events were observed in the patients treated with the ACIC technique; a significant improvement in VAS pain scale and in AOFAS score was found at 6 months follow up. CONCLUSION: Injectable atelocollagen can be considered a feasible scaffold for cartilage repair treatment, in particular if used in its pre-solid form. ACIC leads to good clinical results in the treatment for chondral lesions of the talus even if longer follow-up and a higher number of patients are necessary to confirm these data. LEVEL OF EVIDENCE: IV.

In vivo comparative efficacy of three surgical hand preparation agents in reducing bacterial count.

BACKGROUND: Besides objective efficacy, the choice between an antiseptic-based liquid soap, or an alcohol-based hand rub for surgical hand preparation technique is based on personal preference. Glycerol is often added to the formulations in order to enhance tolerability; however, it has been recently reported as a factor reducing the sustained effect of surgical hand rubs. AIM: To compare the efficacies of three commercial products for hand decontamination. METHODS: The in vivo efficacy of an alcohol-based hand rub (isopropyl alcohol 40%; N-propyl alcohol 25%; glycerin 1.74%; triethanolamine salt of carbomer <1%) was compared with other widely used products in surgical hand antisepsis (chlorhexidine and povidone-iodine). All products were used according to the manufacturers' instructions. FINDINGS: The best results were achieved with the alcohol-based hand rub and these were sustained for a period of 3h. Some volunteers experienced skin peeling off the hands when using alcohol-based hand rub; in this group of participants, the bacterial count was reduced only by 0.91 ± 1.67 log10 compared with 2.86 ± 1.22 log10 in the group who did not show this phenomenon. CONCLUSION: Besides confirming the importance of alcohol-based hand rubs for surgical hand decontamination, the results suggest the value of assessing the characteristics, and response of healthcare workers' skin, that may contribute to the development of skin peeling, and the subsequent possibility of a paradoxical overcolonization of hands after surgical preparation with alcohol-based hand rub.

Indications and limits of meniscal allografts.

Meniscal allograft transplantation has emerged as a useful treatment for carefully selected patients. The aim of this review of meniscal allograft transplantation is to put this procedure into a clinical perspective. Since there still is a lack of consensus on how the success of meniscal transplantation should be evaluated it is difficult to compare study outcomes. Nevertheless, almost all studies report an increase in patient satisfaction and improvement in pain and function. Clinical and functional outcome is improved in the majority of patients. Progression of cartilage degeneration according to MRI and radiological criteria was halted in a number of patients, indicating a chondroprotective effect. Joint space narrowing is only significantly progressive at long-term follow-up. On magnetic resonance imaging, shrinkage is seen after some years, but more in lyophilized allografts. Second-look arthroscopy usually shows good healing to the capsule. Overall, the clinical results of this type of surgery are encouraging and long-lasting in a well selected patient population who suffered a total meniscectomy. Meniscal allografting appears to becoming the golden standard therapy for these type of patients.

Modified autologous matrix-induced chondrogenesis (AMIC) for the treatment of a large osteochondral defect in a varus knee: a case report.

This paper presents a case report of a 27-year-old male patient affected by a large osteochondral defect of the medial femoral condyle (6 cm(2)) in a varus knee. He was treated with a combined approach consisting of high tibial osteotomy and autologous matrix-induced chondrogenesis technique enhanced by a bone marrow-enriched bone graft. Twelve months after surgery, the patient reported considerable reduction in pain and significant increase in his quality of life. A hyaline-like cartilage completely covered the defect and was congruent with the surrounding condyle cartilage as revealed by MRI and by a second-look arthroscopy. Level of evidence IV.

Trend of hospital utilization for encephalitis.

Encephalitis generally results in a serious illness requiring hospitalization. The aim of this study was to describe the epidemiology of hospitalization for encephalitis in Italy, taking into account the geographical distribution, aetiology, seasonality and evolution of hospitalization rates over recent years. The mean hospitalization rate was 5·88/100 000. For most of these hospitalizations (n=13 119, 55·6%), no specific cause of encephalitis was reported. The most common aetiological category was 'viral', which accounted for 40·1% (n=4205) of such hospitalizations (rate 1·05/100 000). Within this category, herpes virus was the leading causative agent (n=1579, 0·39/100 000). This report highlights a significant increase of 'viral encephalitis not otherwise specified' (ICD-9 code 049·9) vs. a reduction of all other causes. A seasonal pattern was noted in people aged ≥65 years in this group. Specific surveillance of encephalitis without known origin should be reinforced in order to identify the potential role of emerging pathogens and to design preventive interventions.

Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates.

The aims of this study were to determine adherence to the perioperative antibiotic prophylaxis (PAP) protocol used at a large Italian teaching hospital during a 6-year period, to assess the variables associated with inappropriate administration, and to measure the impact on surgical site infection (SSI) rates. There were 28 621 patients surveyed of which 74·6% received PAP. An improvement in adherence to the PAP protocol was registered for 58·8% of patients. Significant risk factors were an American Society of Anesthesiologists (ASA) score ≥ 2 [odds ratios (OR) from 1·28 (95% confidence interval (CI) 1·19-1·37) to 1·87 (95% CI 1·43-2·44)], prolonged duration of surgery (OR 1·68, 95% CI 1·56-1·82) and urgent surgery (OR 2·16, 95% CI 1·96-2·37). During the study period, a significant reduction in SSIs rates was detected. We concluded that the global reduction of inadequate PAP administration signifies the efficacy of a multidisciplinary quality improvement initiative on antimicrobial utilization, and this is supported by the observed reduction of the SSI rate.

Extended-spectrum beta-lactamases Klebsiella pneumoniae: multimodal infection control program in intensive care units.

INTRODUCTION: The aims of our study were to investigate a nosocomial spread of an extended-spectrum fl-lactamases-Klebsiella pneumoniae cluster at a University teaching hospital in Italy, to describe, and to monitor the implementation of a multimodal infection control program in two mixed ICUs. METHODS: During the 1 October 2005-30 September 2006 period, 79 colonized patients have been identified. Isolates were genotyped by pulsed-field gel electrophoresis (PFGE). A mutimodal infection control program with monitoring of alcohol-based hand rub was performed in Intensive Care Units (ICU A and ICU B). RESULTS: The epidemiological investigation and PFGE showed a horizontal transmission of the same PFGE genotype, with the isolation of the outbreak strain on the hand of one healthcare operator. Alcohol based hand rub was adopted in ICUA on 18 March 2006, in addition to hand washing with plain or antiseptic soap. ICU B did not change its hand hygiene habits. Following the implementation of the program, the incidence density rate (IDR) in ICU A fell down from 4.50 to 1.68/1000 patient days. DISCUSSION AND CONCLUSIONS: Our findings confirm the important role of personnel in cross-transmission. Moreover the inbuilt control group involuntarily offered by the delaying of the intervention in ICU B has given the opportunity to verify the epidemiological association between the actual implementation of infection control practices and the outbreak control.

Improvement of the ventilator associated pneumonia rate with infection control practices in an Italian ICU.

BACKGROUND: To assess the impact of an intervention to improve respiratory infection control practices and reduce the ventilator associated pneumonia (VAP) rate in an intensive care unit, at the request of the ICU staff. DESIGN: prospective surveillance before-after study. Baseline VAP rates were determined over a 4-month period of active surveillance without an infection control program (period 1) and compared to VAP rates following implementation of an infection control program (period 2). The ICU staff requested the implementation of infection control practices. SETTING: Intensive Care Unit (ICU) at a university teaching hospital in Italy. PATIENTS: A total of 185 patients admitted to the ICU were included in the study. RESULTS: PATIENTS assessed during period 1 were similar to patients assessed during period 2 with regard to age, sex, origin, type of admission and mortality. PATIENTS who were admitted during period 2 had significantly lower simplified acute physiology scores (SAPS) II and acute physiology and chronic health evaluation (APACHE) II scores than patients admitted during period 1 (P<0.05). During period 1, there were 27 cases of VAP, and the incidence rate was 36.9/1000 MV-days. During period 2, the VAP rate decreased significantly (P=0.049): there were only 17 cases of VAP, and the incidence rate was 22.5/1,000 MV-days, with a rate-ratio of 0.61. CONCLUSION: Despite our short study period, the results appear to be encouraging and show a measurable impact on the incidence of VAP.

[Report on the incidence of accidents and occupational diseases in the sector of waste disposal]. / Rapporto sulla frequenza degli infortuni e delle malattie professionali nel settore smaltimento dei rifiuti.

Waste management is continuously evolving, moreover, lack of resources and environmental hygiene issues have given more importance to recycling, establishing the basis of an increased risk in these workers. The aim of this study was to provide a description of occupational health of Italian waste workers in order to highlight key points for ad hoc interventions. Data about injuries and professional disease were extracted from the Italian National Labour Insurance Institute (INAIL) Waste work is a well-known cause of occupational accidents, however occupational disease appear to be less-known with many "unclassified" events. While new researches are needed in order to clarify these emerging issues, education could be the key to assure the waste workers health safety.

[Body mass index in shift workers: relation to diet and physical activity]. / BMI nei lavoratori a turni in relazione alle abitudini alimentari ed all'attività fisica.

UNLABELLED: Many studies investigated adverse effects of rotating shift work, deriving from modifications of circadian rhythms and alimentary behaviours. This may cause the disregulation of glycolipidic metabolism and of insulin secretion, and the development of central obesity. We conducted the present study in order to assess the differences in body mass index (BMI) between day and shift workers, in relation to diet quality and physical activity. DESIGN AND METHODS: The study included 341 male subjects (165 day workers and 176 shift workers). Body weight, height, BMI, waist and hip circumferences were measured. Physical activity and diet quality were assessed by self-reported questionnaires. RESULTS: Shift workers had higher BMI than day workers (27.6 +/- 3.9 vs 26.7 +/- 3.6), and this correlation persisted after adjustment for age. The diet quality was better in shift workers and the level of physical activity was similar in the two groups. DISCUSSION: The results of this study indicate that shift work is an independent risk factors in the development of overweight and central obesity. In fact, although the diet quality was even better in shift workers, and the level of physical activity was similar between day and shift workers, we found that shift workers had higher BMI.

Surveillance for surgical site infection after hospital discharge: a surgical procedure-specific perspective.

OBJECTIVE: To estimate the rate of surgical site infection (SSI) occurring after hospital discharge, to evaluate whether limiting surveillance to inpatients underestimates the true rate of SSI, and to select surgical procedures that should be included in a postdischarge surveillance program. DESIGN: Prospective surveillance study. SETTING: A surgical ward at a university teaching hospital in Italy. PATIENTS: A total of 264 surgical patients were included in the study. RESULTS: The global SSI rate was 10.6% (28 patients); 17 (60.2%) of patients with an SSI developed the infection after hospital discharge. The overall mean length of postoperative stay (+/-SD) for patients who acquired a postdischarge SSI was 4.9+/-3.7 days, and SSI was diagnosed a mean duration (+/-SD) of 11.5+/-4.5 days after surgery. Among procedures with postdischarge SSIs, those classified by the National Nosocomial Infections Surveillance system (NNIS) as herniorrhaphy, mastectomy, other endocrine system, and other integumentary system were associated with a mean postoperative stay that was less than the mean time between the operation and the onset of SSI. Four (36%) of in-hospital SSIs occurred after procedures with an NNIS risk index of 0, and 7 (64%) occurred after procedures with an NNIS risk index of 1 or higher. Of the 17 SSIs diagnosed after discharge, 14 procedures (82%) had an NNIS risk index of 0, compared with 3 procedures (18%) with an NNIS risk index of 1 or higher. CONCLUSIONS: Our results revealed an increased risk of postdischarge SSI after some types of surgical procedures and suggest that there is an important need to change from generalized to NNIS operative category-directed postdischarge surveillance, at least for procedures locally considered to be high-risk.

[International review of health educational programs for nutrition in the elderly]. / Rassegna internazionale sugli interventi di educazione sanitaria per la nutrizione in età geriatrica.

Progressive increase of the elderly may well explain the interest to educational programs at this age. Different chronic conditions such as cardiovascular diseases, diabetes and osteoporosis may be controlled and prevented by proper educational campaigns. In our review, the role of nutritional educational on quality of life has been evaluated, either in healthy subjects or in those with chronic disease. Evaluation tools and outcome index have been described. It is emphasized that applying specific projects may improve nutritional attitudes and lifestyle even in older adults. Proper educational intervention should be implemented, but socio-cultural characteristics of the target population should be taken into account.

Factors influencing hospital infection control policies in Italian hospitals.

A study was undertaken to determine the resources available in Italian hospitals for the control of nosocomial infections and the factors favouring a successful approach. During January-May 2000 a questionnaire about infection control was sent to the hospital health director of all Italian National Health System hospitals treating acute patients and with more than 3500 admissions in 1999. An active programme was defined as a hospital infection control committee (HICC) meeting at least four times in 1999, the presence of a doctor with infection control responsibilities, a nurse employed in infection control and at least one surveillance activity and one infection control guideline issued or updated in the past two years. There was a response rate of 87.5% (463/529). Almost fifteen percent (69/463) of hospitals had an active programme for Infection Control and 76.2% (353/463) had a HICC. Seventy-one percent (330/463) of the hospitals had a hospital infection control physician and 53% (250/463) had infection control nurses. Fifty-two percent (242/463) reported at least one surveillance activity and 70.8% (328/463) had issued or updated at least one guidance document in the last two years. The presence of regional policies [odds ratio (OR) 8.7], operative groups (OR 4.2), at least one full-time nurse (OR 4.6) and a hospital annual plan which specified infection control (OR 2.1) were statistically associated with an active programme in the multivariate analysis.

Evaluation of a transit first-aid station providing emergency care to former Yugoslavian war victims evacuated in Ancona, Italy.

BACKGROUND: A first-aid station was implemented in Falconara Marittima airport (Ancona, Italy). It provided medical emergency care to war victims evacuated from former Yugoslavia in transit for further treatment. MATERIALS AND METHODS: A descriptive analysis of the displaced population arriving at the first-aid station was performed using three independent datasets for administrative information, of which one included medical information. The implemented resources were also evaluated. RESULTS: From August 1993 to March 1995, 2272 displaced persons were registered at the first-aid station, out of which 54.2% were accompanying family members. Among those needing medical intervention (45.8% of total), most frequent diagnoses were traumatisms and burns (59.8%), neoplasms (15.6%), and congenital malformations (13.2%). The medical care provided at the first-aid station was most often basic: a medical examination alone was performed on 77.0% of the patients, and a minor dressing on 17.3%. Median length of stay was 1 day. Patients were sent to 30 different countries and 8% were forwarded to the local regional hospital. Deployed logistical resources exceeded by far actual needs but a lack of psychological assistance was observed, mainly for children. The agencies involved did not coordinate data sharing and follow-up information. CONCLUSIONS: The medical assistance to the war victims was efficient regarding provided care and timeliness. Effectiveness of such a programme could be improved by a better coordination between partners, allowing more adequate logistics according to appropriate epidemiological information.