Diagnosed child, treated child: food challenge as the first step toward tolerance induction in cow's milk protein allergy.

BACKGROUND: Food challenge is required to assess tolerance in cow milk (CM) allergy. A positive challenge contraindicates the reintroduction of CM. Specific oral tolerance induction (SOTI) is a promising treatment. METHODS: All children admitted for a challenge were prospectively enrolled. To those tolerating between 2 and 150 ml a SOTI protocol was offered. Outcome, adverse reactions, parents' satisfaction were recorded. RESULTS: Out of 245 challenged patients, 175 reacted 122 out of 125, able to tolerate a minimum dose of 2 ml, underwent SOTI. After one year 75.4% were in an unrestricted diet, 16.1% tolerated between 5 and 150 ml, 8.5% stopped SOTI. Side effects were mild, parents' satisfaction was very high. CONCLUSIONS: The majority of children tolerating limited amounts of CM at the challenge acquires tolerance with SOTI without relevant side effects. Maintaining on an exclusion diet partially tolerant children should be considered debatable.

Burnout in teachers: an Italian survey.

Over the past 50 years, education has become more complex. The demand for quality and accountability in education had also increased. These demands have increased pressure on teachers, with the result that teaching is now regarded by teachers as highly stressful. The purpose of the study was to examine burnout among teachers in a region of Italy including the risk factors of burnout and the strategies used by teachers to prevent and deal with stress. The research was carried out on a sample of 508 teachers. The questionnaire incorporated the Maslach Burnout Inventory modified for Italian teachers--a 22 item questionnaire designed to assess the three aspects of burnout syndrome: emotional exhaustion, depersonalization and lack of personal achievement. The results highlight the presence of substantial levels of emotional exhaustion in a significant number of teachers. The rate of burnout among teachers is 19.7%. The data are lower than for a sample of Italy as a whole and than for European countries where rates of burnout range between 25% and 35%.

Impact of vaccinating HCWs on the ward and possible influence of avian flu threat.

BACKGROUND: The aim of the study was to evaluate the impact of a 2-year vaccination program on the compliance of healthcare workers (HCWs) employed in an acute care university hospital to influenza vaccination. MATERIALS AND METHODS: The study was carried out in October/November from 2004 to 2006 in a 286-bed acute care university hospital located in northern Italy employing 523 HCWs. The study cohort consisted of 473 HCWs continuously present in the hospital from 2004 to 2006. In 2005 and 2006, a vaccination campaign was made available in the wards that supplemented a pre-existing (2004) employee health service program. A personalized informative letter was sent to all HCWs explaining the risks and benefits of influenza vaccination for both patients and HCWs and indicating the scheduling of the additional vaccination service. RESULTS: The additional 2005 and 2006 campaigns produced significantly higher vaccination rates among HCWs than those achieved in previous years, from 10.4% in 2004 to 36.6% in 2005 and 23.2% in 2006. The year 2005 was characterized by an avian flu threat, which likely accounted for the highest vaccination rate of the 3-year study period. Physicians had the highest vaccination rates in the 3-year period (20.8%), while nurses in 2005 had the highest single vaccination rate (42.5%). CONCLUSIONS: Providing easy access to vaccination in the wards is a useful approach for improving vaccination rates among HCWs, but further tailored interventions are needed because overall vaccination rates remain too low. Subgroups, such as nurses and ancillary staff, should be considered as specific targets of such vaccination programs.

Application of Hazard Analysis Critical Control Points to control surgical site infections in hip and knee arthroplasty.

This study examined critical points linked to the increase of surgical site infections in patients undergoing joint replacement. With this type of infection, it is not always possible to detect specific causes, and it often is necessary to perform a systematic review of assistance processes. Using Hazard Analysis Critical Control Points methodology, 4 stages of patients' pathway were identified: preoperative assessment, surgical procedure, postoperative assistance, and discharge. Surgical site infection risk factors were identified for each stage and categorized as patient conditions, staff and procedures, equipment, and environment.

Medical errors and clinical risk management: state of the art.

Medical errors represent a serious public health problem and pose a threat to patient safety. All patients are potentially vulnerable, therefore medical errors are costly from a human, economic, and social viewpoint. The present report aims not only to provide an overview of the problem on the basis of the published literature, but also to stress the importance of adopting standard terminology and classifications, fundamental tools for researchers to obtain valid and reliable methods for error identification and reporting. In fact, agreement on standard definitions allows comparison of data in different contexts. Errors can be classified according to their outcome, the setting where they take place (inpatient, outpatient), the kind of procedure involved (medication, surgery, etc.) or the probability of occurring (high, low). Error categories are analysed taking into consideration their prevalence, avoidance and associated factors as well as the different strategies for detecting medical errors. Incident reporting and documentation of near-misses are described as useful sources of information, and Healthcare Failure Mode Effect Analysis (HFMEA) and Root Cause Analysis (RCA) are seen as powerful methods for process analysis. Furthermore, means to increase patient safety are considered in the broader context of clinical risk management. New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rate. A system approach and a blame-free environment, aimed at better organizational performances, lead to much better results than focusing on individuals. Furthermore, use of technology, information accessibility, communication, patient collaboration and multi-professional team-work are successful strategies to reach the goal of patient safety within healthcare organizations.

Catheter sepsis from infusate contamination.

Ten patients harboring an indwelling CVC with contamination of the infusate are described. Six patients developed sepsis, which was resolved in all patients except one who died from misdiagnosed septic shock. The majority of microorganisms responsible for the infusate contamination were opportunistic pathogens and in five cases were S. epidermidis. There was no apparent correlation between contamination rate of the infusate and subsequent sepsis of the patients. Reasons for the high prevalence of Staphylococcus epidermidis include ubiquitous diffusion of this microorganism, marked affinity for prosthetic devices, especially by the slime-producing strains, and increased susceptibility of debilitated cancer patients to infection. Recognition that the possibility exists for infusate contamination during compounding should alert all members of the Nutritional Support Team to use aseptic technique when preparing and handling the intravenous solutions. Infusate-related sepsis is a potentially lethal but preventable event.

Laparoscopic repair of a Morgagni-Larrey hernia.

The authors report a case of a large Morgagni hernia treated by laparoscopy. The patient complained of dyspnea, cough, and a sensation of tightness in the chest 1 month prior to admission. Preoperative diagnosis was made by chest x-ray, CT scan, and MRI, which showed a large right paracardiac mass consisting of an omentum and transverse colon. By reducing the hernial content, a 6 x 10-cm defect was revealed; the repair was performed with a Marlex mesh sutured by a hernia stapler. Postoperative recovery was uneventful, and 3 months after surgery the patient is well. Laparoscopic treatment of a Morgagni hernia provides an excellent view of the surgical field and ease of execution, joined with a minimal surgical trauma with rapid recovery for the patient.

[Indications for splenectomy in the surgical treatment of gastric cancer]. / Indicazioni alla splenectomia nel trattamento chirurgico del cancro gastrico.

The extent of lymphadenectomy in the treatment of gastric cancer is still a matter of debate. Splenectomy, which has to be performed using the common surgical techniques to remove the lymph nodes of the splenic hilus, is part of this problem. The indications for splenectomy in the treatment of gastric cancer are examined, considering the results in terms of operative mortality and morbidity and long term survival. The Authors analyze a consecutive series of 129 patients who underwent total gastrectomy with D2 or D3 lymphadenectomy for gastric cancer. Forty-seven splenectomies were performed among 79 patients submitted to total gastrectomy. Splenectomy did not influence the perioperative mortality. Morbidity was higher in the patients who underwent splenectomy (33.3%) than in the patients without splenectomy (28.12%). This difference was not statistically significant. Five-year survival was higher in the group that did not undergo splenectomy (37.6% vs 27%) without any significant difference. Also considering the results in literature, splenectomy is associated with an increase in morbidity, and, for some authors, also in mortality, without any significant improvement in long-term survival. The indication for splenectomy in gastric cancer is based on an accurate evaluation of the localization and the depth of the parietal infiltration of the tumor.

[Surgical treatment of stomach cancer: analysis of our personal experience]. / La terapia chirurgica del cancro dello stomaco: analisi dell'esperienza personale.

The "curative" treatment of gastric carcinoma includes the complete removal of the tumour and of the nodes involved without any macroscopic residual of disease (RO). Out of 326 patients with gastric cancer observed, a series of 114 consecutive patients underwent surgical resection (total gastrectomy or subtotal distal gastrectomy) with D2 or D3 lymphadenectomy. Overall operative mortality was 5.3%. Since 1988 no postoperative death occurred. Overall morbidity was 15.8%, specific morbidity 10.5%, reduced after 1988 to 6.6%. No significant differences in operative mortality and need of blood transfusions were recorded between D2 and D3 lymphadenectomy. Overall 5-year survival was 32%. Univariate and multivariate analysis showed that only T and N stages are significant prognostic factors, whereas tumour location, total or subtotal gastrectomy in antral cancers, extent of lymphadenectomy (D2 vs D3) and histology were not significantly related to survival. Since most studies have clearly shown that T and N stages are the most important prognostic factors in gastric cancer, the present aim should be to plan the extent of surgical resection according to the T and N stages characteristics of the neoplasm.

[Dunbar syndrome: apropos of a case (review of the literature)]. / Sindrome di Dunbar: a proposito di un caso (revisione della Letteratura).

The authors report a case of the uncommon and still discussed "coeliac artery compression syndrome". On the basis of the literature's review and of their own observation they conclude that Dunbar's Syndrome is a real clinical entity. The section of the arcuate ligament and the subadventitial removal of the pericoeliac tissue, or, whenever indicated, an aorto-coeliac by-pass, seems to be the "gold standard" in the surgical treatment.

[The role of the environment in postoperative infections]. / Ruolo dell'ambiente nelle infezioni postoperatorie.

The infections are a common complication after surgical procedures, ranging from wound to peritoneal infections. The authors compared the results, in terms of wound infection, of the same equipment in two hospitals, one of which of modern concept. They analysed 1202 operations equally distributed between the two hospitals classifying them in four kinds of operations: I (clean), II (clean-contaminated), III (contaminated), IV (septic). The difference, with less infections in the new hospital, appeared to be already evident if the global results were considered. Considering instead each kind of operations the difference was not statistically meaningful only in the clean operations. The role of antibiotic prophylaxis brought a modest improvement, also statistically not meaningful. Many authors in the past reported different results in terms of wound infections especially if the role of the environment was considered. Gillquist for instance, reported a reduction of wound infections after clean operations that was not present in the research of Bergman and Leissner. The great importance of the environment in preventing wound infections appear clearly in this research, together with the concept that many other factors play an important role.

[Preoperative transhepatic biliary drainage in the jaundiced patient: our experience]. / Il drenaggio biliare transepatico preoperatorio nel paziente itterico: nostra esperienza.

The authors assessed the efficacy of PTBD in a group of 72 patients with obstructive jaundice due to lithiasis or malignant obstruction, that underwent preoperatively PTBD procedure. They analysed the early and late complications and its effectiveness in decreasing the bilirubin levels. The results, in agreement with the most recent reports, suggest the uselessness of the preoperative PTBD in the treatment of the patients with a jaundice due to a biliary lithiasis. Concerning the patients with a neoplastic jaundice, this procedure seems to be more effective in the patients with a biliary obstruction due to pancreatic head or distal choledochus carcinoma: in the patients with a far advanced cancer, the PTBD procedure could be the first step to the insertion of biliary endoprosthesis; on the other hand, in the patients that may undergo a curative treatment, PTBD could be useful preoperatively both to reach an adequate water-electrolyte [correction of hydroelectrolithic] balance and nutritional status both to complete the diagnostic procedure.

[Management of breast cancer in geriatric age; observations on 164 cases]. / La terapia del cancro della mammella in età geriatrica: considerazioni su 164 casi osservati.

Progressive increasing of the life expectancy and the ever more frequent finding of breast cancer in elderly women have focused the attention on the treatment of this pathology in the elderly women. Today most studies support a more aggressive locoregional and systemic therapy in older patients in good physical condition. Authors analyze retrospectively a series of 164 women with breast cancer aged over 69 years treated with combined modality therapy regarding the stage of disease and the status of the patient. Survival by stage, tumor characteristics, node involvement have been compared with a series of patients less than 70 years treated on the same period. Survival curves were not significantly different between the two groups, except for T1 which showed a better survival in younger patients. Also survival according to node involvement did not show significant differences between the two groups. in conclusion, older women should be treated with the same surgical procedures, according to stage, of the younger patients, if they are not too frail to undergo surgery. Only the definitive results of prospective randomized trials will better define the indications and limits of a further reduction of the extent of surgical excision.

[The multidisciplinary management of acute pancreatitis: a review of 244 cases]. / Il trattamento multidisciplinare della pancreatite acuta: considerazioni su 244 casi.

BACKGROUND: Acute pancreatitis (AP) has still a high mortality rate; therefore the accuracy of the predictors of severity actually employed and the therapeutic choices are under debate. The aim of this work is to valuate the accuracy of the prognostic factors actually employed and the results of a multidisciplinary treatment of the AP. METHODS: A consecutive series of 244 patients affected by AP (168 mild, 76 severe) is analysed. Mean age 64.4 years (range 17-94 years old). As regard as aetiology is concerned, 166 are biliary pancreatitis, 42 alcoholic, 27 idiopathic, 9 iatrogenic. Ranson's score, Balthazar criteria, and ASA are employed to assess the high-risk patients. The treatment is medical and in severe AP the patient is admitted in ICU. 80 patients affected biliary AP undergo an ERCP. An endoscopic papillotomy is performed in 55 cases and in 49 biliary stones are removed. 90 patients underwent a delayed colcistectomy. 11 patients underwent a surgical treatment: 9 for infected necrotic pancreatitis, 1 for a hemorrhagic shock, 1 for peritonitis. The overall mortality, the mortality related to the severity of the AP, the prognostic evaluation of the etiology, the ASA index, the Ranson and Balthazar scores are evaluated. RESULTS: The overall mortality rate is 2.8% (0.6% in the mild AP and 7.8% in the severe AP). In the surgical group the mortality rate is 18.1%. The Ranson's score is the only independent factor in the multivariate analysis (p<0.0374) while also the Balthazar classification is significant in the univariate analysis. CONCLUSION: As regard as the prognostic factors in AP are concerned, the Ranson's score and Balthazar criteria are reliable even if many other predictors of severity are tested to make progress in the early detection of the complications. As regard as the therapy is concerned, the endoscopic papillotomy and the endoscopic removal of the biliary stones is the gold standard in the treatment of the biliary AP. In the other cases of AP medical treatment shall be started as early as possible with intensive care management in the severe AP. In patients with infected pancreatic necrosis or haemorrhage or peritonitis, surgery is the only therapeutic choice while the surgical treatment in case of sterile pancreatic necrosis with MODS unresponsive to medical therapy is still under debate.

Laparoscopic treatment or a nonparasitic splenic cyst: case report.

The authors describe a case of nonparasitic splenic cyst treated by laparoscopic fenestration. The patient complained of left upper quadrant pain that increased during the prior 3 months. Computed tomography scan revealed a large cyst of the inferior pole of the spleen. The patient was submitted to laparoscopic wide fenestration of the cystic wall. The postoperative course was unremarkable and the patient was discharged with complete relief of symptoms. Laparoscopic technique provides the same results in terms of effectiveness and safety as traditional surgery, linked to the benefits of the mininvasive approach; thus, the laparoscopic fenestration can be considered the ideal treatment of nonparasitic splenic cysts.