Caregiver experiences of hospice dementia care: a systematic review and meta-ethnography

OBJECTIVES

Hospices are regarded as gold standard providers of end-of-life care. The term hospice, however, is broadly used, and can describe a type of care offered in a variety of health care services (e.g. nursing homes). It thus becomes complex for families to decide between services. We aimed to review the evidence around the experience of family carers of people with dementia accessing in-patient hospice settings for end-of-life care.

METHOD

We registered the review protocol on PROSPERO. We used PerSPE(C)TiF to systematically organise our search strategy. The evidence was reviewed across six databases: PubMed, EMBASE, PsycINFO, ASSIA, ISI Web, and CINAHL. We used meta-ethnography as per the eMERGe guidance for data interpretation.

RESULTS

Four studies were included. Two third-order constructs were generated through meta-ethnography: expectations of care and barriers to quality of care. We found that carers had expectations of care, and these could change over time. If discussion was not held with hospice staff early on, the carers could experience reduced care quality due to unmatched expectations. Unmatched expectations acted as barriers to care and these were found in terms of carers not feeling adequately supported, and/or having the person discharged from hospice, which would entail increased care responsibility for carers.

CONCLUSION

In view of an increase in new dementia cases over time and with hospice services being under pressure, integrating palliative care services within community-based models of care is key to reducing the risk of having inadequate and under resourced services for people with dementia.

A focus on the multiple interfaces between action and perception and their neural correlates

Successful behaviour relies on the appropriate interplay between action and perception. The well-established dorsal and ventral stream theories depicted two distinct functional pathways for the processes of action and perception, respectively. In physiological conditions, the two pathways closely cooperate in order to produce successful adaptive behaviour. As the coupling between perception and action exists, this requires an interface that is responsible for a common reading of the two functions. Several studies have proposed different types of perception and action interfaces, suggesting their role in the creation of the shared interaction channel. In the present review, we describe three possible perception and action interfaces: i) the motor code, including common coding approaches, ii) attention, and iii) object affordance; we highlight their potential neural correlates. From this overview, a recurrent neural substrate that underlies all these interface functions appears to be crucial: the parieto-frontal circuit. This network is involved in the mirror mechanism which underlies the perception and action interfaces identified as common coding and motor code theories. The same network is also involved in the spotlight of attention and in the encoding of potential action towards objects; these are manifested in the perception and action interfaces for common attention and object affordance, respectively. Within this framework, most studies were dedicated to the description of the role of the inferior parietal lobule; growing evidence, however, suggests that the superior parietal lobule also plays a crucial role in the interplay between action and perception. The present review proposes a novel model that is inclusive of the superior parietal regions and their relative contribution to the different action and perception interfaces.

Experiences of hospice dementia care: A qualitative study of bereaved carers and hospice clinicians

BACKGROUND

Nearly 50 million people worldwide have dementia and the increasing numbers requiring end-of-life and palliative care, has led to national efforts to define standards of care for this patient group. Little research, however, has been done to date about the experience of hospice care for people with dementia accessing these services. This study explores the views of hospice dementia care for bereaved carers of people with dementia and hospice clinicians.

METHODS

We used purposive sampling for participant recruitment. Semi-structured qualitative interviews were conducted with bereaved carers and hospice clinical staff. Interviews were audio recorded and the transcriptions were analysed through thematic analysis. A total of 12 participants were interviewed from one service in the Northwest region in the UK. All were female and white British.

RESULTS

Participants described their experience of hospice dementia care in three main themes: Pre-access to service, roles and responsibility within hospice care, ease and difficulty of last period of end-of-life care.

CONCLUSION

Rapid response teams delivering hospice home care could represent a better option to inpatient care and may be preferred by patients. This type of service, however, may require joined-up care with other community services, and this type of care needs to be considered and planned. Future studies should evaluate this type of community care.

Depth and direction effects in the prediction of static and shifted reaching goals from kinematics

The kinematic parameters of reach-to-grasp movements are modulated by action intentions. However, when an unexpected change in visual target goal during reaching execution occurs, it is still unknown whether the action intention changes with target goal modification and which is the temporal structure of the target goal prediction. We recorded the kinematics of the pointing finger and wrist during the execution of reaching movements in 23 naïve volunteers where the targets could be located at different directions and depths with respect to the body. During the movement execution, the targets could remain static for the entire duration of movement or shifted, with different timings, to another position. We performed temporal decoding of the final goals and of the intermediate trajectory from the past kinematics exploiting a recurrent neural network. We observed a progressive increase of the classification performance from the onset to the end of movement in both horizontal and sagittal dimensions, as well as in decoding shifted targets. The classification accuracy in decoding horizontal targets was higher than the classification accuracy of sagittal targets. These results are useful for establishing how human and artificial agents could take advantage from the observed kinematics to optimize their cooperation in three-dimensional space.

Improving Diagnosis of Intestinal Parasites Towards a Migrant-Friendly Health System

Purpose of Review

This study describes the results obtained by the World Health Organization (WHO) collaborating centre (CC) for the diagnosis of intestinal helminths and protozoa (WHO CC ITA-116) during the first 2 years of its activity on (i) the prevalence of intestinal parasites in migrants in southern Italy and (ii) the development and application of new diagnostic tools for intestinal helminths (e.g. FLOTAC, Mini-FLOTAC Kit 200 tests, Kubic FLOTAC microscope (KFM)).

Recent Findings

Almost 23.3% of migrants examined were positive for at least one intestinal parasite. Moreover, a significant correlation was found between the duration of stay in Italy and positivity for intestinal parasites. The results of the comparison between diagnostic techniques showed a perfect agreement between FLOTAC and Mini-FLOTAC Kit 200 tests whereas no statistically significant differences were found between the count of helminth eggs obtained by Mini-FLOTAC with optical microscope and KFM.

Summary

The results obtained by WHO CC ITA-116 during the first 2 years of its activity provide important information on innovations in parasitological diagnosis and add data to the parasitological scenario of migrants arriving in southern Italy, highlighting the importance of regular parasitological monitoring.

The role of personality assessment in forensic driving license renewal procedures. A study supported by the MMPI-2 test

The main function of the medical-psychological assessment to evaluate fitness to drive (FTD) is to safeguard the community against risks posed by drivers who, owing to psycho-physical disease, personality disturbances, abuse of psychotropic substances or drugs, can be a hazard to safety on the roads. In the context of psychodiagnostic investigations, the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) test is the gold standard tool supporting clinical assessments conducted to evaluate a subject's capacity to predict her/his own actions, attitudes, risk propensity, level of conformity to social norms. Other important features of the tool include the specific scales aimed at individuating behaviors adopted with the intent to elude or hide existing personality problems. These behaviors are very frequent in the field of medicolegal, psychological and psychiatric assessments, including FTD evaluations. In this study, the MMPI 2 test was administered to 154 subjects for whom Driving Licence (DL) Medical Commissions based in the south of Italy had required specific personality assessments, compared to a control group of 186 subjects with no clinical or psychodiagnostic problems. The question posed in our study was to understand whether the test was able to detect differences between the personalities of the subjects belonging to the two groups. The results obtained demonstrated significant differences between the experimental group and the controls, shown by the MMPI-2 variables, in particular the clinical Hs scale,the supplementary scales: GF, Re, AAS, APS and the content scales DEP and TRT, as well as the PSY-5 Disc and Nege scales.

Laboratory evidence that dinotefuran, pyriproxyfen and permethrin combination abrogates Leishmania infantum transmissibility by sick dogs

Dogs are reservoir hosts of leishmaniasis caused by Leishmania infantum and transmitted by phlebotomine vectors. The effect of dinotefuran, pyriproxyfen and permethrin spot-on solution (Vectra®3D, Ceva Santé Animale, Libourne, France) on Leishmania transmissibility by naturally infected dogs via reared Phlebotomus perniciosus, was assessed. Dogs affected by leishmaniasis were submitted to xenodiagnosis and 6 infecting >10% of insects were treated topically on day 0. Antifeeding, insecticidal and anti-transmissibility effects were evaluated through xenodiagnoses performed on days 1, 7 and 28, using individual pre-treatment parameters as control. Feeding and mortality rates were assessed at 24 h, whereas promastigote infection, maturation and burden were assessed up to 96 h post blood meal (potentially infectious rate). On day 1, the anti-feeding efficacy was >95% in 4 dogs, insecticidal efficacy 100% in 4 dogs, and anti-transmissibility effect 100% in 6 dogs. Efficacy rates recorded on day 7 were very similar to day 1. On day 28, anti-feeding and insecticidal efficacy values were much broader, ranging 32.6-100% and 7.7-94.4%, respectively. Potentially infectious insects were recorded from two dogs, with sharp decrease in transmissibility rate as compared with pre-treatment condition. Altogether, Vectra®3D abrogated by >98% the potential Leishmania transmissibility by the examined pool of infected dogs over 1 month.

Fusobacterium nucleatum and alteration of the oral microbiome: from pregnancy to SARS-COV-2 infection

OBJECTIVE

The human being has evolved in close symbiosis with its own ecological community of commensal, symbiotic and pathogenic bacteria. After the intestinal microbiome, that of the oral cavity is the largest and most diversified. Its importance is reflected not only in local and systemic diseases, but also in pregnancy since it would seem to influence the placental microbiome.

MATERIALS AND METHODS

This is a literature review of articles published in PubMed about Fusobacterium Nucleatum and both its implications with systemic and oral health, adverse pregnancy outcomes, flavors perception and its interference in the oral-nasal mucosal immunity.

RESULTS

It is in maintaining the microbiome's homeostasis that the Fusobacterium nucleatum, an opportunistic periodontal pathogen of the oral cavity, plays a crucial role both as a bridge microorganism of the tongue biofilm, and in maintaining the balance between the different species in the oral-nasal mucosal immunity also by taste receptors interaction. It is also involved in the flavor perception and its detection in the oral microbiome of children from the first days of life suggests a possible physiological role. However, the dysbiosis can determine its pathogenicity with local and systemic consequences, including the pathogenesis of respiratory infections.

CONCLUSIONS

It is interesting to evaluate its possible correlation with Sars-CoV-2 and the consequences on the microflora of the oral cavity, both to promote a possible broad-spectrum preventive action, in favor of all subjects for whom, by promoting the eubiosis of the oral microbiome, a defensive action could be envisaged by the commensals themselves but, above all, for patients with specific comorbidities and therefore already prone to oral dysbiosis.

Tele-rehabilitation for people with dementia in the COVID-19 pandemic: A case-study

Introduction

The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic.

Objectives

This qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges.

Methods

Interviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis.

Results

Video delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources.

Conclusions

The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.

An integrated approach to control Cystic Echinococcosis in southern Italy

Cystic echinococcosis (CE) is a severe zoonosis, caused by the larval stage of the tapeworm Echinococcus granulosus. This helminth infection is of increasing public health and socio-economic concern due to the considerable morbidity rates that cause economic losses both in the public health sector and in the livestock industry. Control programmes against E. granulosus are considered long-term actions which require an integrated approach and high expenditure of time and financial resources. Since 2010, an integrated approach to control CE has been implemented in a highly endemic area of continental southern Italy (Campania region). Innovative procedures and tools have been developed and exploited during the control programme based on the following strategies: i) active and passive surveillance in livestock (using geospatial tools for georeferencing), ii) diagnosis in dogs (using the FLOTAC techniques and molecular analysis), iii) targeted treatment of farm dogs (using purpose-built confinement cages), iv) early diagnosis in livestock (by ultrasonography), v) surveillance in humans (through hospital discharge records analysis), vi) monitoring the food chain (analysing raw vegetables), vii) outreach activities to the general public (through dissemination material, e.g. brochures, gadgets, videos, virtual reality). Over eight years, the integrated approach and the new strategies developed have resulted in a noteworthy reduction of the parasite infection rates in livestock (e.g. up to 30 % in sheep). The results obtained so far highlight that using a one health multidisciplinary and multi-institution effort is of pivotal importance in preparing CE control programmes at regional level and could be extended to other endemic Mediterranean areas.

Perineurioma of the colon: an uncommon tumor with an unusual location. Report of a case and review of the literature

Perineurioma is a relatively rare benign peripheral nerve sheath tumor composed of cells resembling to normal perineurium. Although this tumor may arise in the context of a nerve (intraneural perineurioma), extraneural perineurioma does occur, frequently involving the soft tissues of the lower and upper extremities, trunk and head and neck. Rarely it has also been reported in visceral organs, including gastrointestinal tract. We herein describe the clinicopathologic features of a rare case of a perineurioma presenting as a polypoid lesion of the sigmoid colon, emphasizing the pathologic diagnostic clues.

Papillary thyroid microcarcinoma in super obese patient

Papillary thyroid microcarcinoma (PTMC) typically has an indolent behavior with a good prognosis but it is not always completely harmless. Surgical treatment varies from thyroid lobectomy to total thyroidectomy eventually associated with lymph node dissection and radioiodotherapy. The ability to identify patients with aggressive PTMCs from the majority of low risk patients is critical to planning proper clinical management. Several studies don't report any statistically significant differences about recurrence and mortality among patients undergone lobectomy and patients undergone total thyroidectomy. Recently, higher body mass index (BMI) has been associated with aggressive pathologic features of papillary thyroid carcinoma. For differentiated thyroid cancers, an elevated BMI has been linked to a higher incidence of thyroid cancer in some cohorts. The risk factors for a more aggressiveness of PTMC don't yet clearly defined such as their biological features enable to condition the surgical treatment. In order to elucidate the precise mechanism contributing to the relationship between obesity and thyroid cancer aggressiveness, future studies must be performed.

Update on sutureless thyroidectomy

INTRODUCTION

The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay.

PATIENTS AND METHODS

250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used.

RESULTS

The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study.

CONCLUSIONS

We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Protection against maternal infection-associated fetal growth restriction: proof-of-concept with a microbial-derived immunomodulator

Infection-associated inflammatory stress during pregnancy is the most common cause of fetal growth restriction and/or miscarriage. Treatment strategies for protection of at-risk mothers are limited to a narrow range of vaccines, which do not cover the bulk of the common pathogens most frequently encountered. Using mouse models, we demonstrate that oral treatment during pregnancy with a microbial-derived immunomodulator (OM85), currently used clinically for attenuation of infection-associated airway inflammatory symptoms in infants-adults, markedly reduces risk for fetal loss/growth restriction resulting from maternal challenge with bacterial lipopolysaccharide or influenza. Focusing on LPS exposure, we demonstrate that the key molecular indices of maternal inflammatory stress, notably high levels of RANTES, MIP-1α, CCL2, KC, and G-CSF (granulocyte colony-stimulating factor) in gestational tissues/serum, are abrogated by OM85 pretreatment. Systems-level analyses conducted in parallel using RNASeq revealed that OM85 pretreatment selectively tunes LPS-induced activation in maternal gestational tissues for attenuated expression of TNF, IL1, and IFNG-driven proinflammatory networks, without constraining Type1-IFN-associated networks central to first-line antimicrobial defense. This study suggests that broad-spectrum protection-of-pregnancy against infection-associated inflammatory stress, without compromising capacity for efficient pathogen eradication, represents an achievable therapeutic goal.

A Writing Program with Word Prediction for a Young Man with Multiple Disabilities: A Preliminary Assessment

This study assessed a writing program with word prediction, which completed the writing of a word and spoke it out only when there was certainty that such a word was the correct one. The assessment was carried out with a young man with multiple disabilities, who typically used a word-processing program without word prediction. The two programs were compared on the time required by the participant for writing general sentences, through a social validation assessment, and eventually a check on the participant's preference. Analysis showed the program with word prediction was significantly more effective in terms of the writing time, which was halved, and was deemed preferable by 40 raters (psychology students) involved in the social validation assessment and by the participant himself. Implications of the findings are discussed.

Multiple representation of reaching space in the medial posterior parietal area V6A

During foveal reaching, the activity of neurons in the macaque medial posterior parietal area V6A is modulated by both gaze and arm direction. In the present work, we dissociated the position of gaze and reaching targets, and studied the neural activity of single V6A cells while the eyes and reaching targets were arranged in different spatial configurations (peripheral and foveal combinations). Target position influenced neural activity in all stages of the task, from visual presentation of target and movement planning, through reach execution and holding time. The majority of neurons preferred reaches directed toward peripheral targets, rather than foveal. Most neurons discharged in both premovement and action epochs. In most cases, reaching activity was tuned coherently across action planning and execution. When reaches were planned and executed in different eye/target configurations, multiple analyses revealed that few neurons coded reaching actions according to the absolute position of target, or to the position of target relative to the eye. The majority of cells responded to a combination of both these factors. These data suggest that V6A contains multiple representations of spatial information for reaching, consistent with a role of this area in forming cross-reference frame representations to be used by premotor cortex.

Three-dimensional eye position signals shape both peripersonal space and arm movement activity in the medial posterior parietal cortex

Research conducted over the last decades has established that the medial part of posterior parietal cortex (PPC) is crucial for controlling visually guided actions in human and non-human primates. Within this cortical sector there is area V6A, a crucial node of the parietofrontal network involved in arm movement control in both monkeys and humans. However, the encoding of action-in-depth by V6A cells had been not studied till recently. Recent neurophysiological studies show the existence in V6A neurons of signals related to the distance of targets from the eyes. These signals are integrated, often at the level of single cells, with information about the direction of gaze, thus encoding spatial location in 3D space. Moreover, 3D eye position signals seem to be further exploited at two additional levels of neural processing: (a) in determining whether targets are located in the peripersonal space or not, and (b) in shaping the spatial tuning of arm movement related activity toward reachable targets. These findings are in line with studies in putative homolog regions in humans and together point to a role of medial PPC in encoding both the vergence angle of the eyes and peripersonal space. Besides its role in spatial encoding also in depth, several findings demonstrate the involvement of this cortical sector in non-spatial processes.

The bias, accuracy and precision of faecal egg count reduction test results in cattle using McMaster, Cornell-Wisconsin and FLOTAC egg counting methods

The faecal egg count reduction test (FECRT) is the recommended method to monitor anthelmintic drug efficacy in cattle. There is a large variation in faecal egg count (FEC) methods applied to determine FECRT. However, it remains unclear whether FEC methods with an equal analytic sensitivity, but with different methodologies, result in equal FECRT results. We therefore, compared the bias, accuracy and precision of FECRT results for Cornell-Wisconsin (analytic sensitivity = 1 egg per gram faeces (EPG)), FLOTAC (analytic sensitivity = 1 EPG) and McMaster method (analytic sensitivity = 10 EPG) across four levels of egg excretion (1-49 EPG; 50-149 EPG; 150-299 EPG; 300-600 EPG). Finally, we assessed the sensitivity of the FEC methods to detect a truly reduced efficacy. To this end, two different criteria were used to define reduced efficacy based on FECR, including those described in the WAAVP guidelines (FECRT <95% and lower limit of 95%CI <90%) (Coles et al., 1992) and those proposed by El-Abdellati et al. (2010) (upper limit of 95%CI <95%). There was no significant difference in bias and accuracy of FECRT results across the three methods. FLOTAC provided the most precise FECRT results. Cornell-Wisconsin and McMaster gave similar imprecise results. FECRT were significantly underestimated when baseline FEC were low and drugs were more efficacious. For all FEC methods, precision and accuracy of the FECRT improved as egg excretion increased, this effect was greatest for McMaster and least for Cornell-Wisconsin. The sensitivity of the three methods to detect a truly reduced efficacy was high (>90%). Yet, the sensitivity of McMaster and Cornell-Wisconsin may drop when drugs only show sub-optimal efficacy. Overall, the study indicates that the precision of FECRT is affected by the methodology of FEC, and that the level of egg excretion should be considered in the final interpretation of the FECRT. However, more comprehensive studies are required to provide more insights into the complex interplay of factors inherent to study design (sample size and FEC method) and host-parasite interactions (level of egg excretion and aggregation across the host population).

T-cell activation genes differentially expressed at birth in CD4+ T-cells from children who develop IgE food allergy

BACKGROUND

Presymptomatic immaturity in neonatal T-cell function is a consistent antecedent of allergic disease, including reduced responsiveness to polyclonal activation.

METHODS

To elucidate the underlying mechanisms, we examined for differences in T-cell gene expression in longitudinal samples collected at birth and at 1 year of age in children with (n = 30) and without IgE-mediated food allergy (n = 30). We employed a low-level soluble anti-CD3 stimulus to activate the T-cell receptor (TCR) and surveyed gene expression by DNA microarray in purified CD4(+) T-cells. Allergen-specific responses were assessed in parallel functional studies.

RESULTS

At birth, the allergic group showed a reduced number of genes up regulated in response to anti-CD3 treatment on the microarray and a reduced lympho proliferative capacity, suggesting clear differences in T-cell signalling pathways. Polymerase chain reaction (PCR) validation of candidate genes confirmed significantly lower expression of a number of genes in the allergic group including RELB, NFKB2, LIF and FAS. By 12 months of age, there were marked changes in the anti-CD3 response in all infants, culminating in upregulation of cytokine genes (IL-5, IL-13, IL-17 and IL-22). Neonatal differences were no longer apparent. Instead, the allergic group, all symptomatic by this age, showed differential expression of T-cell lineage pathways including GATA-3, MAL and FcER1 in unstimulated T-cells. Allergen stimulation induced significantly higher cytokines production (IL-5, IL-13 and IFNγ) in the allergic group.

CONCLUSION

Although transient, suboptimal neonatal T-cell activation pathways that signal through the NF-κB complex may affect the developmental transition of T-cell phenotypes in the periphery shortly after birth and may increase the risk of food allergy.

[Bilio-intestinal bypass in the treatment of metabolic syndrome in obese patient]

INTRODUCTION

obesity (O) is a chronic patologic condition, evolutive and relapsing, with multifactorial etiopathogenesis, consisting in an alteration of the body's composition characterized by a relative and absolute excess of fat, that gets worse the life quality and causes complications that can lead to death.

PATIENTS AND METHODS

experience concerns twenty-five diabetic obese patients underwent bilio-intestinal by-pass between January 2006-December 2007. All these patients, before the surgical operation, underwent a rigorous clinical and laboratory examination. Besides, a precise rate control of laboratory, overlap with those performed in the pre-operative period of operation, was required for each patient: the first after one month, the second after six months and the third after twelve months.

RESULTS

the average weight loss was about 40 kg and, more important, these data show that the BMI is reduced, until to become stable, after 12 months from surgical operation, about values 34-31 Kg/m², obtaining, in this way, an improvement of values in the development metabolic syndrome and, above all, heart rate and ventricular repolarization.

CONCLUSIONS

the data obtained by our study support the hypothesis to suggest the operations of bariatric malassorbing surgery, in particular bilio-intestinal by-pass, as prophylactic methods for dismetabolics diseases, with reduction of cardiovascular risk in obese patient.

[Prevention of psychosocial issues and drug addiction in workers employed in building great infrastructures: first outcomes of an experience in the Florence area]

The research on stress, mobbing, and substance dependence in workers employed in the building of the great infrastructures is part of the project Euridice-Ten. The 75% of the workers employed took part in the research through an anonymous and structured questionnaire. The Clinica del Lavoro of the University of Milan elaborated the data. They point out a high risk of stress, a low level of control, a marked risk of mobbing, a high chronic fatigue in the most exhausting jobs, sleep disorders, problems in the social life as well as at home, in nourishment and at work. Many workers drink too much alcohol and the 9% of the workers know workers who use cocaine.

Epstein-Barr virus is associated with grey matter atrophy in multiple sclerosis

OBJECTIVE

The aim of the study was to determine whether the presence of anti-Epstein-Barr virus (EBV) antibodies is associated with MRI measures of brain injury and neurodegeneration in patients with multiple sclerosis (MS).

METHODS

135 patients with MS (86 women, 49 men) underwent brain MRI and testing for antibodies against EBV. MRI measurements included gadolinium enhancing lesion volume, T1 and T2 lesion volumes and fractions of whole brain parenchyma (BPF), white matter and grey matter (GMF). The anti-EBV panel included anti-EBV early antigen IgG, anti-EBV nuclear antigen IgG and anti-EBV viral capsid antigen (VCA) IgG levels. The relationships between antibody levels and MRI measurements were assessed in regression analysis. Repeat measurements of anti-EBV VCA IgG and MRI measures were available for a subset of 50 patients after a mean follow-up of 3.1 years.

RESULTS

GMF (R(2) = 0.24 for overall model, p = 0.002) and BPF (R(2) = 0.39 for overall model, p<0.001) showed negative associations with anti-EBV-VCA IgG levels. A greater decline in BPF over 3 years was significantly associated with increased 3 years prior time point anti-EBV VCA IgG levels (p<0.001).

CONCLUSIONS

The results suggest that the presence of anti-EBV antibodies is associated with MRI markers of GM atrophy in MS and with increased loss of brain volume over 3 years.

Enabling a young man with minimal motor behavior to manage independently his leisure television engagement

Persons with severe spastic tetraparesis and minimal motor behavior may be confined to a wheelchair or bed and have virtually no chances of constructive engagement with their immediate environment. A possible way to modify this situation may involve the use of technology. The present study (a) assessed specific technology to enable a young adult to manage his leisure television engagement independently and (b) carried out a social validation assessment of the technology-supported performance involving 90 teacher trainees as raters. The intervention period with the new technology included 67 sessions, during which the participant performed independently 392 of the 408 television-management responses, i.e., turning on the television, finding a channel with a preferred program, setting the volume, and turning off the television. He also indicated preference for using the technology as opposed to not using it. The raters provided relatively high (positive) scores for the technology-supported performance compared to the baseline performance. Implications of the findings are discussed.

Spontaneous bilateral Achilles tendon rupture in a patient treated with oral levofloxacin

A case of bilateral rupture of the Achilles tendon in a patient treated with levofloxacin for cystitis is reported. A 76-year-old woman suddenly developed painful ankles one day after levofloxacin treatment. Drug therapy was switched to amoxicillin/clavulanate on the fourth day. Sonography revealed a serious condition of tendinosis with complete bilateral full-thickness rupture on day 6. Tendons were both repaired in the same surgical session. Pathological anatomy of the specimens reported fatty tissue lobules with panniculitis and histiocytosis. Ankles were immobilized postoperatively with a plaster cast. Achilles tendon rupture may occur as an adverse side effect of short-term use of levofloxacin, a fluoroquinolone antibiotic. This adverse effect is a rare and poorly understood complication of this antibiotic therapy. A review of the literature is provided.

I nterferon beta-1a slows progression of brain atrophy in relapsing-remitting multiple sclerosis predominantly by reducing gray matter atrophy

Background Brain atrophy, as assessed by magnetic resonance imaging (MRI), has been correlated with disability in patients with multiple sclerosis (MS). Recent evidence indicates that both white matter (WM) and gray matter (GM) are subject to atrophy in patients with MS. Although neurological deficiencies in MS are primarily due to loss of WM, the clinical significance of GM atrophy has not been fully explored in MS.

Methods We have undertaken a three-year, open-label study, comparing 26 patients who elected to receive intramuscular interferon beta-1a (IFN β-1a) therapy, with 28 patients who elected not to receive therapy. Both groups had quantitative cranial MRI scans at study entry and after three years, and standardized clinical assessments every six months. Brain parenchymal fraction (BPF), GM fraction (GMF), and WM fraction (WMF) percent changes were calculated, and T2- and T1-lesion volumes (LVs) assessed.

Results After three years, mean percent (%) change in BPF favored the IFN β-1a treatment group (IFN β-1a —1.3% versus the control group —2.5%, P=0.009), as did the mean percent change in GMF (+0.2 versus —1.4%, P=0.014), and the mean percent change in T1-LV (—9.3 versus +91.6%, P=0.011). At the end of the study, there was a significant within-patient decrease in BPF for both groups (P=0.02 for the IFN β-1a treatment group, and P<0.001 for the control group), a significant within-patient decrease in WMF for the IFN β-1a treatment group (P=0.01), and a significant decrease in GMF for the control group (P=0.013) when compared with baseline.

Conclusion Over a three-year period, treatment with IFN β-1a significantly slowed the progression of whole-brain and GM atrophy, and of T1-hypointense LV accumulation, when compared with the control group. Multiple Sclerosis 2007; 13: 490-501. http://msj.sagepub.com

Prevalence of home artificial nutrition in Italy in 2005: A survey by the Italian Society for Parenteral and Enteral Nutrition (SINPE)

AIM

To determine the prevalence (cases per million inhabitants) of home artificial nutrition (HAN), enteral (HEN) and parenteral (HPN), in Italy, grouped according to administrative regions, patient age and primary disease, and to analyze the impact both of the presence of an HAN regional regulation and of demographic characteristics.

METHODS

In April 2005, the Regional Coordinators of the Italian Society for Parenteral and Enteral Nutrition (SINPE) recorded all the ongoing cases of HAN using a structured questionnaire and were asked to estimate the representativeness of the collected sample with respect to the total expected HAN.

RESULTS

A total of 6955 cases of HAN (93.5% adults, 6.5% pediatric patients < or = 18 years) were recorded in 16 of the 20 Italian regions (80% of the Italian population; sample representativeness 78%). HAN prevalence 152.6 (83.9% HEN, 16.1% HPN); the HAN range among the regions was: prevalence 28.1-519.8; oncological disease 13.8-75.7%, neurological disease 15.5-79.9%, intestinal failure 1.3-14.0%. An HAN regulation was present in 11 regions. A positive association (P=0.012) was found between the number of years since the regulation was issued and the HAN prevalence, and also between the % neurological patients and the population density (P=0.130) and the % inhabitants > or = 75 years (P=0.040).

CONCLUSIONS

The need for HAN regards a great number of patients throughout the country; there are substantial differences between the regions with respect to both the prevalence and the use of HAN in various disease categories. A specific regulation may favor the development of HAN.

Comparative study between nadolol and 5-isosorbide mononitrate vs. endoscopic band ligation plus sclerotherapy in the prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial

BACKGROUND

After variceal bleeding, cirrhotic patients should receive secondary prophylaxis.

AIM

To compare nadolol plus 5-isosorbide mononitrate (5-ISMN) with endoscopic band ligation. The end points were rebleeding, treatment failure and death.

METHODS

One hundred and nine cirrhotic patients with a recent variceal bleeding were randomized: nadolol plus 5-ISMN in 57 patients and endoscopic band ligation in 52 patients.

RESULTS

The mean follow-up was 17 and 19 months in nadolol plus 5-ISMN and endoscopic band ligation groups, respectively. No differences were observed between groups in upper rebleeding (47% vs. 46%), variceal rebleeding (40% vs. 36%), failure (32% vs. 22%), major complications (7% vs. 13.5%) and death (19% vs. 20%), respectively. The actuarial probability of remaining free of rebleeding, failure and deaths were similar in both groups. Time to rebleeding shows that endoscopic band ligation patients had an early rebleed, with a median of 0.5 month (95% CI: 0.0-4.2) compared with patients from nadolol plus 5-ISMN, 7.6 months (95% CI: 2.9-12.3, P < 0.013). Multivariate analysis indicated that outcome-specific predictive factor(s) for rebleeding was Child A vs. B + C (P < 0.01); for failure was Child A vs. B + C (P < 0.02); and for death ascites (P < 0.01) and rebleeding (P < 0.02).

CONCLUSION

This trial suggests no superiority of endoscopic band ligation over nadolol plus 5-ISMN mononitrate for the prevention of rebleeding in cirrhotic patients.

Extending the evaluation of a computer system used as a microswitch for word utterances of persons with multiple disabilities

BACKGROUND

Micro-switches can be vital tools to help individuals with extensive multiple disabilities acquire control of environmental stimulation. This study was aimed at extending the evaluation of a computer system used as a microswitch for word utterances with three participants with multiple disabilities.

METHOD

Sets of 7 or 12 word utterances were used for the participants. The utterances were divided into three groups, which were exposed to intervention successively. During the intervention and a 2-month post-intervention check, the participants' emission of the target utterances led the system to present favourite, matching stimuli (i.e. provided that it recognized the utterances).

RESULTS

Intervention data showed that (1) the participants increased the frequencies of the target utterances and (2) the computer system recognized approximately 80% of those utterances. These findings were maintained at the post-intervention check. An analysis of the levels of occurrence of individual utterances showed statistically significant differences among them, in line with the notions of preference and choice.

CONCLUSIONS

The computer system was useful as a microswitch to enable access to favourite stimuli. There is a need to improve the accuracy of the system with respect to its recognition of the participants' utterances.

Long-term effects of intravenous high dose methylprednisolone pulses on bone mineral density in patients with multiple sclerosis

To determine the effects of high dose methylprednisolone (HDMP) pulses on bone mineral density (BMD) in patients with multiple sclerosis (MS), we studied 25 MS patients who received regular pulses of HDMP as well as pulses of HDMP for relapses, 18 MS patients who received HDMP at the same dose schedule only for relapses, and 61 healthy controls. We measured BMDs at lumbar spine and femoral neck and we assessed biochemical markers of bone metabolism and turnover. The average lifetime dosage of MP was 75.4 (SD 11.9) g in the pulsed HDMP group and 28.6 (SD 18.3) g in the HDMP for relapses group (P < 0.0001). Two MS patients (4.7%) and four controls (6.6%) had osteoporosis (P = NS), whereas 25 patients with MS (58.1%) and 21 controls (34.4%) had osteopenia (P = 0.016). BMDs measured at lumbar spine and femoral neck and biochemical indices of bone metabolism did not differ in MS patients and controls. BMD measures were not associated with lifetime methylprednisolone dosage. In partial correlation analysis, controlling for age, gender and menopausal status there was a significant inverse correlation between BMD at femoral neck and Expanded Disability Status Scale (EDSS) score (r = -0.31, P = 0.05). In conclusion, treatment with repeated HDMP pulses was not associated with osteoporosis in patients with MS who participated in a trial of methylprednisolone. However, osteopenia was observed more frequently in MS patients than healthy controls. Our data are reassuring, as them suggest that repeated pulses of methylprednisolone do not result in substantially increased risk of osteoporosis in MS patients. Moreover, osteopenia was found only in patients treated for relapses, who had a significantly higher EDSS score than patients in the HDMP group, suggesting that decreased mobility may contribute to bone loss more than corticosteroid use. BMD should be monitored in patients with MS, regardless of the use of methylprednisolone.

Risk factors of multiple sclerosis: a case-control study

We assessed the risk of multiple sclerosis (MS) associated with a series of putative risk factors. We studied 140 patients (90 women) with MS (mean age, 42.1 years; SD= 10.2 years; disease duration, 10.9 years, SD= 7.5 years) and 131 sex-and age-matched controls. Using a structured questionnaire, we collected information related to demographic data, socio-economic status, education, ethnicity, changes of domiciles, migration, occupation, environmental, nutritional and hormonal factors, exposure to various bacterial and viral agents, vaccinations, and family history of diseases. In multiple logistic regression analysis, we found independent risk factors of MS to be: familiarity for MS (OR= 12.1; 95% CI, 1.3-110.7), autoimmune diseases (OR= 3.8; 95% CI, 2.0-7.1) and migraine (OR= 8.7; 95% CI, 1.0-75.4); comorbidity with autoimmune disease (OR= 6.8; 95% CI, 1.4-32.0) and migraine (OR= 13.5; 95% CI, 1.5-116.6); and vaccination against measles (OR= 92.2; 95%, 12.1-700.2). Familial susceptibility to MS, autoimmune diseases and migraine, and vaccination to measles are associated with an increased risk of MS. The data collected in this study are confirmatory and support the hypothesis that etiology of MS constitutes the effect of interplay between genetic and environmental risk factors. However, the relatively small number of cases and controls prevents firm conclusions.

(2+1)-dimensional soliton formation in photorefractive Bi12SiO20 crystals

(2+1)-dimensional spatial solitons in Bi12SiO20 (BSO) photorefractive crystals with large optical activity are experimentally demonstrated. The soliton formation when a Gaussian beam is injected at the input has been previously analyzed numerically and then experimentally investigated. We demonstrate analytically, numerically, and experimentally that by applying static electric biases of high values, the polarization rotation accelerates: this acceleration prevents the beam from broadening if the polarization rotation period becomes shorter than the diffraction length. Contemporary to this nonlinear optical activity, an induced birefringence affects the beam polarization state. Analysis of the polarization dynamics shows that the polarization changes nonuniformly across the beam (with a field dependent speed) until about 30-35 kV/cm; above this limit, the whole beam has just one polarization state. Representation on the Poincaré sphere of the polarization dynamics reveals the existence of a stable polarization trajectory closed around a polarization attractor that depends on the linear optical activity and on the photorefractive nonlinearity. The experimental soliton is well described by the analytical solutions already obtained [Fazio et al., Phys. Rev. E 66, 016605 (2002)].

Correlation of sexual dysfunction and brain magnetic resonance imaging in multiple sclerosis

Sixty-two patients (40 women and 22 men) with multiple sclerosis (MS) were examined with 1.5 tesla magnetic resonance imaging (MRI) of the brain. Information on sexual and sphincteric disturbances has been collected, and data on disability, independence, cognitive performances and psychological functioning have been assessed. Calculations of T1- and T2-lesion load (LL) of total brain, frontal lobes and pons have been performed using a reproducible semiautomated technique. Whole brain, frontal and pontine atrophies were estimated using a normalized measure, the brain parenchymal fraction (BPF), obtained with a computerized interactive program. When comparing patients with and without sexual dysfunction (SD), there were no differences in total brain, frontal and pontine T1- and T2-LL, as well as in measures of whole brain and frontal atrophy. The only significant difference was in the pontine BPF (P = 0.026). In linear multiple regression analysis, SD was associated with depression (R = 0.56, P < 0.001) and, after adjusting for depression and anxiety, with bladder dysfunction (R = 0.43, P = 0.003) and pontine BPF (R = 0.56, P < 0.001). No association between SD and any of the measures of T1- and T2-LL was found. The findings showed a relationship between SD and pontine atrophy, confirmed the correlation of SD with bladder dysfunction and highlighted the role of psychological factors in determining SD.

Latex symptoms and sensitisation in health care workers

BACKGROUND

Natural rubber latex has become an important occupational health concern, particularly among health care workers, who for protection are required to wear latex gloves when at work. This study evaluated the prevalence of latex-related symptoms and sensitisation among a large group of health care workers in Trieste hospitals.

METHODS

We evaluated the prevalence of latex-related symptoms in 1,165 health care workers, by means of a questionnaire, a medical examination, skin prick tests and IgE-specific evaluation. We determined atopy and latex sensitivity by skin prick tests using a battery of common inhalant allergens, a commercial latex extract (Lofarma Allergeni, Milan) and individual skin puncture tests for each of the vegetables immunologically related to latex (potato, tomato, chestnut, banana, kiwi fruit). Associations between potential risk factors for latex allergy were assessed.

RESULTS

Glove-related symptoms were noticed on 17.2% of the nurses (200) the majority of symptoms being mild dermatitis with itching and erythema (120 subjects, 11.1%). Symptoms suggestive of IgE-mediated latex allergy were found in 51 subjects: 35 (3%) complained of contact urticaria and 16 (2.2%) complained of asthma and/or rhinitis. The resulting symptoms were significantly related to skin prick tests that were positive to latex (odds ratio (OR) = 11.89; 6.40-22.2), to personal atopy (OR = 2.15; 1.47-3.12), to familiar atopy (OR = 2.12; 1.48-3.03), to skin prick test positivity to related fruit (OR = 2.01; 1.16-3.46) but not to prick test positivity to common inhalant allergens (OR = 1.00; 0.71-1.39). Symptoms increased as a direct function of the time-usage of latex gloves and were more prevalent in operating room staff.

CONCLUSION

In this large cross-sectional study, glove-related symptoms and latex skin sensitisation appear to be substantial among health care workers, and are related to common signs of atopy. We stress the need of preventive measures to avoid latex exposure when health care workers are at risk of developing allergy symptoms.

Regulation of dendritic cell recruitment into resting and inflamed airway epithelium: use of alternative chemokine receptors as a function of inducing stimulus

Dendritic cells (DC) were purified by flow cytometry from rat tracheal mucosa; they exhibited the phenotypic characteristics of immature DC including high endocytic activity, low CD80/86 expression, and in vitro responsiveness to a broad range of CC chemokines. Daily treatment of adult rats with the selective CCR1 and CCR5 antagonist Met-RANTES reduced baseline numbers of tracheal intraepithelial DC by 50-60%, and pretreatment of animals with Met-RANTES before inhalation of aerosol containing heat-killed bacteria abolished the rapid DC influx into the epithelium that occurred in untreated controls, implicating CCR1 and CCR5 and their ligands in recruitment of immature DC precursors into resting airway tissues and during acute bacterial-induced inflammation. Comparable levels of DC recruitment were observed during airway mucosal Sendai virus infection and after aerosol challenge of sensitized animals with the soluble recall Ag OVA. However, Met-RANTES did not affect these latter responses, indicating the use of alternative chemokine receptors/ligands for DC recruitment, or possibly attraction of different DC subsets, depending on the nature of the eliciting stimulus.

Orbital abscess: management and outcome

PURPOSE

To discuss the diagnosis, management and outcome of various types of orbital abscess.

METHODS

The medical records of 13 patients diagnosed and treated for orbital abscess were reviewed. The sources of infection included: paranasal sinusitis (n = 5), odontogenic origin of infection (n = 4), one each, temporal fossa abscess, palatal abscess, furuncle on the nose, and secondary to retrobulbar injection of steroid. Computed tomographic scans revealed the presence of an abscess in all 13 cases. Associated findings on CT scan included: sinus disease (n = 8), cavernous sinus thrombosis (n = 2) and subdural empyema (n = 2). All patients were treated with intensive, multiple, intravenous antibiotics and early surgical drainage.

RESULTS

Purulent material collected surgically from the orbit cultured Staphylococcus aureus (n = 3), two each Pseudomonas aeruginosa, Proteus mirabilis, Acinetobacter species and one each beta-haemolytic Streptococci, Citrobacter frundi and Enterobacter. Final visual acuity was good in 6 patients (6/12-6/6) and no light perception in 6 others. Visual acuity could not be recorded in the infant. The other complications were intracranial abscess (n = 4), cavernous sinus thrombosis (n = 2) and restricted ocular motility (n = 1).

CONCLUSIONS

A high index of suspicion is necessary, along with early institution of appropriate diagnostic imaging, and aggressive medical and surgical treatment for a favourable outcome in cases of orbital abscess.