Gastrointestinal Issues in Depression, Anxiety, and Neurodegenerative Diseases: A Systematic Review on Pathways and Clinical Targets Implications

INTRODUCTION

Multiple illnesses commonly involve both the Central Nervous System (CNS) and the Gastrointestinal Tract (GI) simultaneously. Consistent evidence suggests that neurological disorders impair GI tract function and worsen the symptomatology and pathophysiology of digestive disorders. On the other hand, it has been proposed that early functional changes in the GI tract contribute to the genesis of several CNS illnesses. Additionally, the role played by the gut in these diseases can be seen as a paradigm for how the gut and the brain interact.

METHODS

We mentioned significant GI symptoms and discussed how the GI tract affects central nervous system illnesses, including depression, anxiety, Alzheimer's disease, and Parkinson's disease in this study. We also explored potential pathophysiological underpinnings and novel targets for the creation of future therapies targeted at gut-brain connections.

RESULTS & DISCUSSION

In this situation, modulating the gut microbiota through the administration of fecal microbiota transplants or probiotics may represent a new therapeutic option for this population, not only to treat GI problems but also behavioral problems, given the role that dysbiosis and leaky gut play in many neurological disorders.

CONCLUSION

Accurate diagnosis and treatment of co-existing illnesses also require coordination between psychiatrists, neurologists, gastroenterologists, and other specialties, as well as a thorough history and thorough physical examination.

Geraniol accelerates the gastric healing, minimizes ulcers recurrence, and reduces anxiolytic-like behavior in ulcerated rodents by oral or inhaled route

BACKGROUND

Geraniol (GE) is dietary acyclic monoterpene alcohol found in essential oils from aromatic plants with therapeutic value against gastric ulcers already described.

HYPOTHESIS/PURPOSE

To assess whether oral GE accelerates gastric healing or prevents ulcer recurrence, and to evaluate the hypothesis that GE promotes antiulcer effects by the inhaled route and that promotes changes in the behavior of ulcerated rodents.

METHODS

Gastric healing effects, underlining mechanisms, and behavioral changes were measured in80% acetic acid-induced gastric ulcer model in rats receiving GE by oral (30 mg/kg) or inhaled route (1 mg/L of air/min); whereas the effects of GE to avoid ulcer recurrence was evaluated in mice submitted to 10% acetic acid plus IL-1β ulcer.

RESULTS

GE administered by both routes accelerates gastric healing, increasing mucin and GSH levels, CAT, and GST activities, and reducing MPO activity. Moreover, oral, and inhaled GE minimized ulcer recurrence reducing gastric TNF and IL-6 levels and preserving mucin levels. Interestingly, the inhalation or oral intake of GE promotes anxiolytic-like effects in ulcerated rats.

CONCLUSION

Data altogether suggest that the GE accelerates gastric healing through the strengthening of protective factors of the gastric mucosa, promoting a quality healing that reduces the recurrence of the lesion. Besides, the anxiolytic-like effect of GE may also contribute to its gastric healing action since anxiety is recognized as one of the etiologic agents of ulcers.

Dual role of eugenol on chronic gastric ulcer in rats: Low-dose healing efficacy and the worsening gastric lesion in high doses

This study evaluated the gastric healing activity of eugenol, the main bioactive compound from clove (Syzygium aromaticun) essential oil. Five groups of female Wistar rats were submitted to acetic acid-induced ulcer model and treated with Vehicle (1 mL/kg, p.o.), eugenol (1, 10 or 100 mg/kg, p.o) or omeprazole (20 mg/kg, p.o), twice a day, by seven or fourteen days. Macroscopic, microscopic and biochemical analyses were performed in the ulcerated site. Eugenol (1 mg/kg, p.o) administered by 7 or 14 days accelerated the gastric healing process by 33% and 52%, respectively. The healing actions of eugenol were accompanied by the rescue on the histological architecture and the normalization of the superoxide dismutase and catalase activity. Moreover, eugenol (1 mg/kg, p.o) reduced the gastric mucosal myeloperoxidase activity and increased the mucin secretion. In contrast, eugenol at a dose of 100 mg/kg administered by 7 days enhanced 49% the ulcerated area, but at 10 mg/kg did not change the ulcer area after 7 or 14 days of treatment. Thus, despite the undesirable results due to the worsening of the gastric lesion with the use of eugenol in high doses, the antiulcer potential of this compound is evident and manageable in an adequate dose.

Gastroprotective activity of hydroalcoholic extract of the leaves of Urera baccifera in rodents

ETHNOPHARMACOLOGICAL IMPORTANCE

The species Urera baccifera (L.) Gaudich. ex Wedd. (Urticaceae) is native to the Americas and is distributed widely throughout Brazil, where it is known as urtiga-brava, urtiga-vermelha, or urtigão. The leaves are often used as anti-inflammatory and antirheumatic agents and for the treatment of gastric disorders. However, the pharmacological mode of action underlying the gastroprotection induced by this species has not been investigated.

AIM OF THE STUDY

To contribute to the knowledge of the gastroprotective mode of action of the hydroalcoholic extract of U. baccifera (HEU) leaves.

MATERIALS AND METHODS

Antiulcerogenic effect of HEU against ethanol-induced acute gastric ulcer was evaluated in rats and mice at doses of 3-300 mg/kg. NO-synthase inhibitor (L-NAME), SH blocker (NEM), cyclooxygenase inhibitor (indomethacin) and alpha 2-adrenergic receptor antagonist yohimbine were used to evaluate the participation of cytoprotective factors in HEU gastroprotection. Moreover, the levels of reduced gluthatione (GSH) and cytokines (TNF, IL-6, IL4 and IL-10), as well as the enzymatic activity of gluthatione S-transferase (GST), myeloperoxidase (MPO), superoxide dismutase (SOD) and catalase (CAT) were measure. Moreover, the samples were analyzed histologically and the antisecretory capability of HEU were quantified using pylorus ligated rats.

RESULTS

The phytochemical analysis of HEU (UPLC/ESI-IT-MS) identified the flavonoids diosmetin and apigenin glucuronide. Furthermore, HEU decreased the occurrence of ethanol-induced ulcers at 30 and 300 mg/kg by 57% and 66%, respectively, compared with the vehicle. The gastroprotective effects were accompanied by increased GSH levels and GST and SOD activity as well as by reduced MPO activity in vivo and in vitro, revealing antioxidant effects and inhibition of neutrophil infiltration. The beneficial effects of 30 and 300 mg/kg HEU were also observed upon histological analyses. Regarding the mode of action, the gastroprotective effect of HEU was abolished by the pre-administration of L-NAME, NEM, indomethacin or yohimbine. Moreover, HEU was able to decrease the IL-6, IL-4 and IL-10 in ulcerated tissue, as well as the pepsin activity of the gastric juice in pylorus-ligated rats.

CONCLUSION

Together, the results confirmed that the gastroprotection elicited by HEU was due reduction in oxidative damage, neutrophil migration, and peptic activity. This work validates the popular use of U. baccifera to treat gastric disorders and supports important future research for the identification of gastroprotective molecules from this species.

Gastroprotective properties of Lupeol-derived ester: Pre-clinical evidences of Lupeol-stearate as a potent antiulcer agent

Lupeol (1) was isolated from hexane branch extract of Maytenus salicifolia and the Lupeol stearate (2), Lupeol palmitate (3), Lupeol myristate (4), Lupeol laurate (5) and Lupeol caprylate (6) were obtained reacting 1 with an adequate carboxylic acid. Swiss mice were treated with vehicle, carbenoxolone or Lupeol esters before administration of ethanol/HCl or indomethacin. Additionally, the involvement of nitric oxide (NO), sulfhydryl compounds (NP-SH), α-2 adrenergic receptors (α2-AR) and prostaglandins (PGE) in antiulcer effects was investigated using appropriate inhibitors or antagonist. Oxidative and inflammatory parameters were measured after euthanasia and anti-secretory effects was evaluated in pylorus-ligated rats. Ethanol/HCl ulcerated the gastric mucosa by 64.45 ± 6.58 mm², which the oral treatment with 1, 4 and 6 (10 mg/kg), and 3 and 5 (30 mg/kg) reduced the lesion area. Interestingly, 2 reduced the gastric ulcer by oral route in a potent and dose-dependent manner (ED₅₀ = 0.40 mg/kg), which was accompanied by the increase in reduced glutathione levels and by the reduction of lipids peroxidation and myeloperoxidase and superoxide dismutase activities. Moreover, 2 (0.1 mg/kg) also prevented the ulcerogenesis by intraperitoneal route. The participation of NO, NP-SH, α2-AR and PGE in 2-mediated gastroprotection was confirmed. In indomethacin-induced ulcer, 2 (1 mg/kg, p.o) also reduced the ulcer area and increased the PGE₂ levels. However, 2 did not alter the gastric acid secretion. Therefore, these findings indicate that the obtention of 2 potentiated the antiulcer activity of 1 and that this compound can elicit gastroprotective action due a diversified mode of action.

Role of the antioxidant properties in the gastroprotective and gastric healing activity promoted by Brazilian green propolis and the healing efficacy of Artepillin C

Green propolis is a resinous substance used in folk medicine given its anti-inflammatory, antibacterial, and anti-ulcer effects. Our research group has already confirmed the gastroprotective activity of hydroalcoholic extract from green propolis (HEGP), as well as of its main isolated compounds. In continuity, this study evaluated the antioxidant mode of action involved in the preventive effect induced by HEGP, and its therapeutic gastric healing potential on installed ulcers. In addition, the healing effect of its main compound Artepillin C was also investigated. Acute and chronic ulcers were induced in rats by given ethanol or acetic acid, respectively. In acute model, the rats were orally pre-treated with vehicle (water plus 1% Tween, 1 mL/kg), HEGP (30-300 mg/kg), or carbenoxolone (200 mg/kg) 1 h prior the ulcer induction. In the chronic ulcer protocol, the rats received vehicle (water plus 1% Tween, 1 mL/kg), HEGP (300 mg/kg), or omeprazole (20 mg/kg) twice a day by 7 days, whereas groups of mice received vehicle (water plus 1% Tween, 1 mL/kg), Artepillin C (18 mg/kg), or ranitidine (20 mg/kg) twice a day by 4 days. Ulcerated tissue was collected for histological, histochemical, immunostaining, oxidative, and inflammatory analyses. The in vitro scavenger activity of HEGP was also verified using the DPPH assay. The oral pre-treatment with HEGP (100 and 300 mg/kg) prevented the gastric epithelial damage promoted by ethanol. Besides, HEGP (100 and 300 mg/kg) reduced SOD activity about 11% and 26%, respectively, and increased the activity of GST around 20% and CAT in 80%. HEGP (300 mg/kg) also reduced the production of reactive oxygen species, as well as lipoperoxidation levels in the ethanol-ulcerated tissue. In the acetic acid-induced chronic ulcer, the daily treatment with HEGP (300 mg/kg) accelerates the healing process by 71%. In this model, HEGP normalized SOD and CAT activity and increased GST activity by 109% when compared to non-ulcerated rats. In both models, the extract administration increased the mucin PAS staining and reduced the myeloperoxidase activity at the ulcer site. Moreover, the treatment with HEGP enhanced the PCNA immunostaining, but did not alter the concentration of collagen in the acetic acid-ulcerated tissue. The extract had a direct DPPH radical-scavenging ability (LogIC₅₀: 0.56). Besides, as expected, HPLC analysis showed Artepillin C as a major compound and its administration at 18 mg/kg also accelerated the gastric healing ulcer process in mice. Our findings confirm that HEGP displays both gastroprotective and gastric healing properties, contributing to the validation of its popular use as preventive and therapeutic approaches. These actions occur through the increase in mucin production and the reestablishment of the oxidative balance due to a reduction in gastric inflammation.

Hydroalcoholic extract of Tagetes erecta L. flowers, rich in the carotenoid lutein, attenuates inflammatory cytokine secretion and improves the oxidative stress in an animal model of ulcerative colitis

Given the role of oxidative stress in ulcerative colitis (UC) etiology, and the amount of lutein (a carotenoid with antioxidant properties) in the dry hydroalcoholic extract of Tagetes erecta flowers (DHETE), this study investigated the intestinal anti-inflammatory properties of DHETE in an animal model of UC. The amount of lutein in the extract was determined by ¹H-nuclear magnetic resonance spectroscopy, and total phenols, radical scavenger capability, cytotoxicity, and effects on reactive oxygen species and nitric oxide production were evaluated in vitro. Experimental UC was established by adding 5% dextran sulfate sodium (DSS) to drinking water, with the effects of DHETE (30-300 mg/kg, once a day for 7 days) on the morphological (colon length and weight), clinical (disease activity index and body weight loss), microscopic (histological score and mucin levels), and biochemical parameters analyzed. The lutein concentration found in DHETE was 8.2%, and DHETE scavenged 2,2-diphenyl-1-picrylhydrazyl radicals at 1000 μg/mL The exposure of intestinal epithelial cells to DHETE did not change its viability but reduced reactive oxygen species and nitric oxide production after lipopolysaccharide stimulation. In vivo, DHETE (300 mg/kg) attenuated weight loss, disease activity index, colon shortening, and histopathological changes promoted by DSS intake. Moreover, DHETE increased mucin colonic staining. The treatment with DHETE decreased myeloperoxidase activity as well as tumor necrosis factor and interleukin-6 levels. The extract also increased reduced glutathione levels and catalase activity and normalized superoxide dismutase and glutathione-S-transferase activities. In conclusion, DHETE reduced colitis severity by attenuating inflammatory cytokine secretion and improved the endogenous antioxidant defense in DSS-induced UC in mice.

Intestinal perforation after surgical treatment for incisional hernia: iatrogenic or idiopathic?

Intestinal perforation (IP) is a life-threatening gastroenterological condition requiring urgent surgical care, which may present itself as an uncommon complication following incisional hernia repair surgery, most often because of iatrogenic traumatism occurring during the procedure. However, we report a case where a spontaneous onset can be hypothesised. A 60-years-old patient underwent repair of an abdominal laparocele, through rectus abdominis muscle plasty, 5 years after development of an incisional hernia due to exploratory laparotomy for the treatment of acute appendicitis. Xipho-pubic scar was excised and umbilicus and supra-umbilical hernia sac dissected, a linear median incision was performed along the sub-umbilical linea alba, reaching preperitoneal plane to assess any intestinal loop adherence to the abdominal wall. After limited viscerolysis, abdominal wall defect was corrected by ‘rectus abdominis muscle plasty’ and umbilicus reconstruction by Santanelli technique. Postoperative course was uneventful until Day 29, with sudden onset of epigastric pain, fever and bulge. Sixty cubic centimeter pus was drained percutaneously and cavity was rinsed with a 50% H2O2 and H2O V-V solution until draining clear fluid. Symptoms recurred two days later, while during rinsing presented dyspnoea. X-Ray and CT scan diagnosed IP, and she underwent under emergency an exploratory laparotomy, leading to right hemicolectomy extended to last ileal loops and middle third of the transverse, right monolateral salpingo-ovariectomy and a temporary ileostomy by general surgeon. Twenty-three days later an ileostomy reversal surgery was performed and 8 days after she was discharged. At latest follow-up patient showed fair conditions, complaining abdominal pain and diarrhoea, attributable to the extensive intestinal resection. IP following incisional hernia repair, is reported as uncommon and early postoperative complication. In our case, the previous regular postoperative course with late onset lead us to hypothesise a possible idiopathic etiopathogenesis, because of a strangulation followed by gangrene and abscess formation, which might begin before the incisional hernia repair and unnoticed at the time surgery was performed.

WITHDRAWN: Ccpdma by combined centripetal and centrifugal parotidectomy for face dermatofibrosarcoma protuberans: case report and review of the literature

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Conservative Surgical Approach for Reduction of Macrocheilitis Caused by Massive Injection of Liquid Silicone

Cosmetic lip augmentation, regardless of the filling agent, is nowadays one of the most requested aesthetic procedures. Liquid silicone injections were used in the past, but after reports of severe late complications their use has been discontinued, ending with a permanent ban in most western countries. In this report we describe clinical presentation, diagnostic pathways and surgical reconstruction of six patients presenting with macrocheilia due to previous liquid silicone augmentation. Patients showed chronic inflammation of the lower third of the face, lip eversion, various degrees of asymmetry and functional impairment of the lips. All patients underwent preoperative soft tissue High Frequency Ultrasound (HFUS) and Magnetic Resonance Imaging (MRI) of the of the face to obtain evidence of the filler material and to ascertain its diffusion within the soft tissues of the perioral region. Conservative surgery was carried out to remove foreign material and to restore symmetric aesthetically pleasing lips. Histology confirmed the siliconoma diagnosis. HFUS and RMI allowed to clearly identify the silicone within the soft tissues. The conservative surgery restored the harmonious relationship between the lips, with an improvement in lip functionality at long term follow-up. Healing was complete and uneventful in all of the patients.

Human herpesvirus 8 and human herpesvirus 2 infections in prison population

Incarcerated persons have high rates of infectious diseases. Few data on the prevalence of sexually transmitted diseases in prisoners are available. This multi-center cross-sectional study enrolled 973 inmates from eight Italian prisons. Demographic and behavioral data were collected using an anonymous standardized questionnaire and antibodies to HIV, HCV, HBV, HSV-2, and HHV-8 were detected in a blood sample obtained from each person at the time of the enrollment in the study. Two hundred and two out of the 973 subjects (20.7%) had antibodies against HHV-8. HHV-8-seropositive subjects were more likely to be older than 30 years with a higher educational level. HHV-8 infection was associated significantly with HBV (P < 0.001) and HSV-2 (P = 0.004) seropositivity and with previous imprisonments. Multivariate analysis showed that HHV-8 infection in Italian inmates was associated with HBV (P < 0.001) and HSV-2 (P = 0.002) seropositivity otherwise among foreigners inmates HHV-8 was significantly associated with HBV infection (P = 0.05). One hundred and eighty-six (21.2%) prisoners had anti-HSV-2 antibodies. At multivariate analysis HSV-2-positivity was significantly associated with HIV (P < 0.001) and HHV-8 infections (P = 0.003), whereas it was inversely associated with HCV infection (0.004). A relatively high seroprevalence of HHV-8 and HSV-2 among Italian prison inmates was found. The association of HHV-8 and HSV-2 infections suggest sexual transmission of these viruses among Italian prison inmates.

Increasing proportion of late testers among AIDS cases in Italy, 1996–2002

In recent years, the proportion of individuals who are unaware of being infected with HIV when diagnosed with AIDS (defined as 'late testers') has dramatically increased in several European countries, including Italy. We evaluated the extent and determinants of late testing and its impact in terms of AIDS-defining illnesses among AIDS cases reported to the Italian National AIDS Registry since 1996. Late testers were defined as those persons whose first positive HIV test result was within six months of the AIDS diagnosis. Late testers were more likely to be heterosexual contacts or MSWM, as opposed to IDUs. They were also more likely to come from low prevalence areas of Italy or from foreign countries. At AIDS diagnosis, late testers were less likely to be undergoing HAART or prophylaxis against PCP/toxoplasmosis, compared to non-late testers. The mean CD4 cell count at AIDS diagnosis was significantly lower among late testers. PCP, toxoplasmosis and Kaposi's sarcoma were more frequently diagnosed as an AIDS-defining illness in late testers, who also had a significantly higher risk of presenting with multiple concomitant AIDS-defining illnesses. In conclusion, late testing results in missed opportunities for preventing and treating HIV infection, leading to an increased risk of developing preventable opportunistic infections and death.

Correlates of HIV, HBV, and HCV infections in a prison inmate population: results from a multicentre study in Italy

A cross-sectional study was undertaken on the correlates of infection for the human immunodeficiency virus (HIV) and hepatitis viruses B and C (HBV and HCV) in a sample of inmates from eight Italian prisons. A total of 973 inmates were enrolled [87.0% males, median age of 36 years, 30.4% intravenous drug users (IDUs), 0.6% men who have sex with men (MSWM)]. In this sample, high seroprevalence rates were found (HIV: 7.5%; HCV: 38.0%; anti-HBc: 52.7%; HBsAg: 6.7%). HIV and HCV seropositivity were associated strongly with intravenous drug use (OR: 5.9 for HIV; 10.5 for HCV); after excluding IDUs and male homosexuals, the HIV prevalence remained nonetheless relatively high (2.6%). HIV prevalence was higher for persons from Northern Italy and Sardinia. The age effect was U-shaped for HIV and HCV infections; HBV prevalence increased with age. Tattoos were associated with HCV positivity (OR: 2.9). The number of imprisonments was associated with HIV infection, whereas the duration of imprisonment was only associated with anti-HBc. The probability of being HIV-seropositive was higher for HCV-seropositive individuals, especially if IDUs. In conclusion, a high prevalence of HIV, HCV, and HBV infections among inmates was observed: these high rates are in part attributable to the high proportion of IDUs. Frequency of imprisonment and tattoos were associated, respectively, with HIV and HCV positivity. Although it is possible that the study population is not representative of Italy's prison inmate population, the results stress the need to improve infection control measures users was prisons.

Correlates of Mycobacterium tuberculosis infection in a prison population

Prisons represent a crucial setting for tuberculosis control. Currently, there is scarce information concerning Mycobacterium tuberculosis (MT) infection in European prisons, and no data are available for Italy. This study aims to describe the prevalence and correlates of MT infection in an Italian prison population. In this multicentre cross-sectional study, 1,247 inmates from nine prisons were recruited and asked to undergo questioning regarding socio-economic and demographic variables, tuberculin skin testing (TST), chest radiographs and testing for HIV, hepatitis B and hepatitis C virus infection. TST was positive in 17.9% of the 448 evaluable subjects. With multivariate logistic regression (performed among male inmates), MT infection was correlated with age (adjusted odds ratio (OR) 4.12 for inmates aged 31-40 yrs; 3.78 for those aged >40 yrs), being foreign-born (OR = 4.9), education < or =5 yrs (OR = 1.88) and length of detention (increased risk per yr: 11%). As with elsewhere in the world, the prison system in Italy features a population with an increased rate of Mycobacterium tuberculosis infection and at-risk rate for Mycobacterium tuberculosis transmission. Improved tuberculosis surveillance and control measures are deemed necessary in correctional facilities nationwide, especially for subjects with the above risk factors and those who are HIV infected, in whom the tuberculin skin testing can be misleading. The screening of entrants is particularly important to avoid undiagnosed smear-positive tuberculosis cases.

A population based seroepidemiological survey of Chlamydia pneumoniae infections in schoolchildren

AIM

A serosurvey was carried out in schoolchildren from a northeastern area of Italy to define the burden of Chlamydia pneumoniae infection.

METHODS

A sample of 649 schoolchildren underwent a simplified version of the International Study of Asthma and Allergies in Childhood questionnaire and IgG and IgA antibodies were investigated using an enzyme immunoassay, followed by a microimmunofluorescence assay in reactive sera.

RESULTS

Of the children examined, 29% and 19.7% had IgG and IgA antibodies, respectively. The IgG prevalence increased with age. No other sociodemographical variable was related to C pneumoniae infection. An association was established between IgA prevalence and previous otitis media.

CONCLUSIONS

A mesoendemic (intermediate between high and low endemic level) pattern of C pneumoniae infection is present in schoolchildren from this area and the prevalence rate is related to age. Moreover, this is the first epidemiological evidence of the role of C pneumoniae in otitis.

Giant pleomorphic adenoma of the submandibular gland. Case report

Salivary glands are sites for a great variety of tumors. The parotid gland is the most common site followed by the submandibular gland. The pleomorphic adenoma represents the 60-70% of all tumors involving the major salivary glands, while the submandibular gland is involved in 8% of cases. The pleomorphic adenoma of the submandibular gland is rare and can present difficulty in diagnosis. The heterogeneous histology, a possible malignant transformation, an incomplete capsule that can determine a recurrence, are the most important characteristics of pleomorphic adenoma. A complete surgical removal of the tumor is the treatment of choice. In the case presented, the mass showed an unusual vascularization and remarkable dimensions.

[Techniques for administering inhalation anesthetic agents, professional exposure, and early neurobehavioral effects]

BACKGROUND

Occupational exposure to high concentrations of anaesthetic gases can cause neurobehavioral effects in operating room personnel. The measures taken to reduce waste gas exposures, including the installation of active scavenging devices and airconditioning systems, are not effective, so that the NIOSH recommendations for maximum exposure are currently unattainable in practice.

OBJECTIVES

The aim of the present study was to measure operating room pollution and neurobehavioral functions in a group of anaesthesiologists during open-system and low-flow anaesthesia.

METHODS

Environmental concentrations of N2O and isoflurance were measured by an infrared gas analyzer (Brüel & Kjaer) in open system and in low flow anaesthesia. Under the same stress condition, but with different exposure levels to anaesthetic gases, psychomotor vigilance and response speed were evaluated four times with the Reaction Time Test at the beginning and at the end of the first weekday shift and at the beginning and at the end of the last weekday shift. Exclusion criteria were considered excessive alcohol and coffee intake and use of CNS medication.

RESULTS

Concentrations of N2O and isoflurane in the operating room were 4.83 ppm and 0.4 ppm respectively, which are lower compared with open systems: 301 ppm and 11.1 ppm respectively. The mean of the Reaction Time was significantly higher (p < 0.01) during work with the open system compared to work in low flow at the end of the first weekday shift and at the end of the last weekday shift.

CONCLUSIONS

Low-flow anaesthesia appears to be effective in reducing waste gas exposure: lower flows produced lower values and protect the integrity of neurobehavioral functions.

[Environmental monitoring of occupational exposure to glutaraldehyde at a hospital]

BACKGROUND

To evaluate the air pollution in operating theatres of a Sicily Hospital produced by 2% alkaline solutions of glutaraldehyde, which is used to disinfect flexible endoscopy units, filling tanks and cleaning surfaces. Personnel reported subjective symptoms as: headache, dizziness, anxiety, drowsiness on the job, loss of attention, irritation of the skin and respiratory tract.

METHODS

Environmental valuation of glutaraldehyde was made by infrared photoacustic spectroscopy.

RESULTS

The final results is not very comforting infact we found value of glutaraldehyde which exceeded the upper limit value (0.05 ppm) due to behavioral rules, to not well ventilated workplaces and to not automated washing units.

Low rates of antimicrobial resistance in respiratory pathogens from a pediatric population in north-eastern Italy

BACKGROUND

Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes are the main agents of bacterial upper respiratory tract infections in infants and children. In the past decades, the proportion of patients infected with drug-resistant organisms has increased; surveying at a regional level is important for understanding the size of the problem and elaborating therapeutic guidelines based on local epidemiology.

METHODS

Since 1997, all isolates of Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes have been surveyed for antimicrobial resistance.

RESULTS

In our zone, we found 3.5% penicillin-resistant and 18% macrolide-resistant Streptococcus pneumoniae, 15.8% ampicillin-resistant Haemophilus influenzae and 24.8% erythromycin-resistant Streptococcus pyogenes.

CONCLUSIONS

Penicillin-resistant Streptococcus pneumoniae (PRSP) in our area does not represent a real concern; conversely, macrolide resistance in Streptococcus pneumoniae is relatively frequent. Resistance to ampicillin in Haemophilus influenzae in our area seems relatively low, due to beta-lactamase production. Even for Streptococcus pyogenes, macrolide resistance rates in our region are relatively low if compared with other countries and other italian regions. In conclusion, in our area penicillins are still the first choice drugs, at least in noncomplicated or not recurrent infections.

Case report: Salmonella panama osteomyelitis in a Ghanaian child with sickle cell disease

Sickle cell disease is a rare condition in italian patients and even rarer are its complications, in particular Salmonella osteomyelitis. We describe a case of a Ghanaian child with sickle cell disease who developed osteomyelitis due to Salmonella panama, treated successfully with surgical debridement, followed by a prolonged period of specific antibiotic therapy.

[Occupational exposure to formaldehyde at a service of pathologic anatomy]

OBJECTIVE

Aim of the present study is to evaluate the air pollution produced by formaldehyde in pathological anatomy.

METHODS

This study was made with instrumental approach based on environmental evaluation of 10% formaldehyde used in pathological anatomy, by an infrared gas analyser (Brüel & Kjaer), and clinical approach of pathological anatomy personnel.

RESULTS

The final result is not very comforting because we found values of formaldehyde during specific activities which exeeded the current limits proposed by industrial hygienist, infact we found in a different settings 1.81 ppm, 3.78 ppm, 8.3.05 ppm. The personnel exposed reported subjective symptoms as reactive airway symptoms, headache, skin problems.

CONCLUSIONS

To reduce air pollution we have indicated technical precautions as forced ventilation which is a major engineering control for reducing risk from chemical agents, use of personal protective equipment (PPE) as last resort for protection, behavioral rules and health surveillance.

[Suspected glutaraldehyde poisoning: a case report]

AIMS

To report a case of anxiety, possibly due to glutaraldehyde poisoning in a female anaesthesiologist working in an operating room and exposed to 2% solution of glutaraldehyde, the only chemical used for disinfection of flexible endoscopic instruments.

METHODS

A clinical evaluation was made and neurobehavioural functions were explored by sensitive neuropsychological testing: testing included a simple and complex reaction time and examination of the autonomic nervous system. The atmospheric concentration of glutaraldehyde was measured by means of a Brüel & Kjaer Multigas Monitor type 1302 analyzer.

RESULTS

Adverse neurobehavioural effects, including headache, loss of attention, dizziness, anxiety, drowsiness on the job, alteration of homeostatic reflexes, were observed, and sensitive neuropsychological testing confirmed neurobehavioural impairment. No blood alterations related to exposure were found. Very high levels of glutaraldehyde were detected in the operating theatre. After ten days away from exposure to glutaraldehyde no symptoms and no behavioral effects on the central and autonomic nervous systems were detectable.

CONCLUSIONS

Although conclusions cannot be drawn from a single case, exposure to a high level of glutaraldehyde, subjective symptoms, alteration of neurobehavioural performance, no consumption of CNS medication, no neurological or psychiatric disorders, no coffee consumption and alcohol intake, no exposure to other neurotoxic agents, complete recovery after removal from exposure to glutaraldehyde, are indicative of glutaraldehyde poisoning.

Changes in incidence and risk factors of Mycobacterium avium complex infections in patients with AIDS in the era of new antiretroviral therapies

The aim of the study presented here was to determine the incidence, risk factors and prognostic indicators of Mycobacterium avium complex (MAC) infection in HIV-infected subjects prior to and after the introduction of highly active antiretroviral therapy (HAART). In the HAART era, the incidence of MAC infection decreased significantly from 3.7 to 0.9 per 100 person-years. Using logistic regression analysis, a high acute physiology and chronic health evaluation (APACHE) III score, a low number of CD4+ cells/ mm3 and a high level of HIV viremia were found to be independent predictors of the risk to develop MAC disease; however, a high APACHE III score was the only prognostic indicator associated with an unfavourable outcome of a disseminated MAC infection. These results indicate that MAC infections, although considerably less frequent in the HAART era, are still responsible for cases of severe disease.

Effect of highly active antiretroviral therapy on the incidence of bacterial pneumonia in HIV-infected subjects

The aim of the study was to assess the incidence of hospital and community acquired bacterial pneumonia in HIV-infected subjects prior to and after the introduction of highly active antiretroviral therapy (HAART). We studied 266 patients with bacterial pneumonia over two separate periods, 154 in the first period and 112 in the second period. A statistically significant difference in the incidence of bacterial pneumonia in the two study periods was observed ranging from 13.1 to 8.5 episodes per 100 persons. The incidence of community-acquired bacterial pneumonia decreased from 10.7 to 7.7 (P=0.01), while that of nosocomial episodes decreased from 2.4 to 0.8 episodes (P=0.003). Low levels of peripheral CD(4+) cells (<100/mm(3)) and intravenous drug abuse (IVDA) were significantly associated with the development of community-acquired bacterial pneumonia, while an increasing value of APACHE III score and prolonged hospitalisation increased the risk of nosocomial bacterial pneumonia in both study periods.

Urinary tract infection in diabetic patients

AIM

The aim of the study was to compare the epidemiological, microbiological and clinical features of diabetic patients with urinary tract infection (UTI) to those of nondiabetic ones.

METHODS

A prospective study was performed on 490 consecutive patients with proven UTI. The patients were studied on the basis of a specific questionnaire and hospital records.

RESULTS

Of 490 enrolled patients, 89 (18.1%) had diabetes mellitus. The mean age of diabetics and nondiabetics was respectively 64.9 +/- 13.2 (SD) and 54.4 +/- 23.3 years. Most diabetics had asymptomatic bacteriuria and had undergone bladder catheterization more frequently than the nondiabetics. The most frequent causative agents of UTI in diabetics and nondiabetics were: E. coli (respectively, 56.1 vs. 56.8%), Proteus sp. (7.9% vs. 7.2%), Pseudomonas sp. (6.7 vs. 8.2%), Enterococcus sp. (6.7 vs. 7.2%). More than 50% of the isolated Pseudomonas sp. strains in both groups were resistant to gentamicin, piperacillin and norfloxacin. Both diabetics (52.8%) and nondiabetics (42.2%) had recurrent UTI during the follow-up period; the difference in the incidences did not reach statistical significance.

CONCLUSION

No significant differences in epidemiological, clinical and microbiological evaluated features of diabetics and nondiabetics were pointed out, except for the higher frequency of bladder catheterization of diabetics than nondiabetics. However, the eradication of UTI seemed to be more difficult in diabetics than in nondiabetics.

Bloodstream infections in HIV-positive patients: a review of sixty-eight episodes

A retrospective review of all episodes of bloodstream infection (BSI) in HIV-positive patients admitted to the Infectious Diseases Unit at the Pisa General Hospital from 1991 to 1994 was performed. Sixty-eight episodes of BSI were recorded in 61 patients (5.8% of all patients admitted for HIV infection). BSI was community-acquired in 64.7% of cases. The patients were mainly male and i.v. drug abusers with a mean age of 33.8 yrs +/- 5.6 S.D. Sixty-four episodes occurred in AIDS patients (CDC criteria). CD4 count was less than 100 in 49 patients. The most frequent isolates were coagulase-negative staphylococci 33, S. aureus 7, Pseudomonas spp 7, fungi 1, non-typhoidal Salmonella 4. The most common sources of BSI were the skin or subcutaneous tissue infections and intravascular catheters. The overall mortality associated with BSI was 27.3%. Vancomycin and teicoplanin were active in vitro against all but one of the staphylococcal isolates.

Increased prevalence of cardiac arrhythmias and transient episodes of myocardial ischemia in hypertensives with left ventricular hypertrophy but without clinical history of coronary heart disease

To evaluate the behavior of cardiac arrhythmias (CA) and transient episodes of myocardial ischemia (TEMI), in relation to the circadian pattern of blood pressure in patients suffering from arterial hypertension, with or without echocardiographically ascertained left ventricular hypertrophy (LVH), we studied 128 patients, 87 men (M) and 41 women (F), aging from 21 to 76 years, subdivided into two groups: Group I, including 66 patients with LVH (45 M and 21 F; mean age of 53.7 +/- 9.1 years; Group II, including 62 patients without LVH (42 M and 20 F; mean age of 49.7 +/- 9.5 years). Office blood pressure (OBP) as well as nighttime ambulatory blood pressure (ABP) were higher in patients with LVH (P < .05 and P < .01). CA were present in a higher number of patients of Group I (P < .001): premature supraventricular beats (PSVB) 22.7 v 4.8%, supraventricular couplets (SVC) 36.4 v 16.1%, supraventricular tachycardia runs (SVT runs) 27.3 v 12.9%, ventricular ectopic beats (VEB) 25.6 v 8.0%, ventricular couplets (VC) 30.3 v 12.9%, ventricular tachycardia runs (VT runs) 12.1 v 3.2%. The absolute number of ectopic beats was also significantly higher in patients of Group I. Ventricular arrhythmias were significantly related to ASBP (r = 0.83, P < .01), to ADBP (r = 0.74, P < .01) and to heart rate (r = 0.87, P < .01) in patients of Group I. TEMI were more frequent in patients of Group I (73 v 41 episodes, 39.39% v 25.8% of patients, P < .01) and were related to ABP peaks. In fact, in both groups of patients all TEMI without heart rate increase and most TEMI with heart rate increase were registered between 6:00 and midnight, hours in which ABP values were higher. We conclude that hypertensives with LVH, but without clinical history of coronary heart disease, have a higher prevalence of ventricular arrhythmias and of transient episodes of myocardial ischemia in relation to the circadian pattern of ABP.

Effects of captopril and ticlopidine, alone or in combination, in hypertensive patients with intermittent claudication

Twenty four male hypertensive patients suffering also from peripheral obstructive arterial disease were randomly subdivided in two groups and after a period of farmacological wash-out of one month Group I was treated with Captopril (C 50 mg bid) or Ticlopidine (T 250 mg bid) for three months and then with the association C plus T for three months again. After placebo administration for one month, patients were further treated with C plus T at low doses (25 mg bid and respectively 250 mg daily). In the first part of the study, patients of Group II received an inverse sequence of the drugs (before Ticlopidine 250 mg bid and then Captopril 50 bid). In both groups of patients C induced a significant decrease of blood pressure and an increase of PFWD, TWD, and WI. T did not modify blood pressure but slightly increased PFWD, TWD, and WI. The improvement was more evident during administration of C plus T, whereas placebo administration induced a trend toward baseline values. Finally, the chronic administration of C plus T for twelve months induced a further improvement of all considered parameters. In conclusion, chronic administration of C plus T may be useful in the treatment of hypertensive patients suffering from intermittent claudication, improving significantly PFWD and TWD.

[Silent myocardial ischemia: prevalence, prognostic significance, diagnosis]

Silent myocardial ischemia (SMI) has been demonstrated in 2 to 5% of subjects in totally asymptomatic population, in 30% of patients with history of previous myocardial infarction and in 60 to 100% of patients with stable or unstable angina pectoris. In these patients, 60 to 80% of transient episodes of ischemia are silent and SMI is induced by daily activities and so can be registered during continuous ECG monitoring. The finding of SMI during an exercise testing or during ambulatory monitoring has an unfavourable prognostic significance both in apparently asymptomatic subjects and in patients suffering from stable or unstable angina pectoris or survivors to a myocardial infarction. Stress testing and Holter monitoring are the most used non invasive tests to detect SMI. The sensitivity and specificity of ergometer test can be improved by 201-Tl myocardial scintigraphy. Moreover, the ergometer test can be used as a provocative test to induce changes in regional wall kinesis and so these alterations can be evaluated by using echocardiogram and radioisotopic or contrast ventriculography. The echocardiogram allows to evaluate the presence of kinesis changes induced by stress test or by pharmacological stimulation with dipyridamole or dobutamine. SMI can be also detected through the study of metabolic alterations during cardiac catheterism.

Using the critical incident survey to assess hospital service quality

This survey was designed to determine "standards of excellence" in hospital services as defined by (a) former patients, (b) physicians, (c) hospital employees, and (d) corporate insurance subscribers. One hundred forty-seven (147) patients, 188 employees, and 20 corporate subscribers were interviewed by telephone, and 52 physicians were interviewed in their offices. The interview consisted of a single question: "Can you think of a time when, as a patient/employee/employer/physician, you had a particularly satisfying or dissatisfying experience with a local hospital?" Reported incidents were reviewed, and 239 "critical incidents" were identified. These incidents were classified into 12 descriptive categories relating to the underlying factors in the incident reports. Six focus groups were later held with participants segregated by the population pool they represented. These groups were asked to develop definitions of "excellence" in hospital service quality and standards for service which would "exceed expectations." The focus groups created 122 standards of excellence, which were classified into 43 categories. Overall, the largest percentages of corporate, physician, and employee critical incidents were classified as "Administrative Policy" issues. Patients most often reported "Nurturing" incidents as critical to their perceptions of hospital service quality.