Optimal bipolar system positioning to provide information about the trapezius activity associated with scapular retraction during shoulder exercises for resistance training

Objective. Recently, the use of EMG biofeedback to make subjects aware of the stabilizer activation associated with scapular retraction during exercise has been of interest, and challenges related to EMG detection have been addressed. Whether there is an optimal bipolar positioning that discriminates the stabilizer activation with retraction from a neutral scapular position during resistance exercises is an open issue that we address here by simultaneously mapping different positions using high-density surface electromyography (HD-sEMG).Approach. Sixteen resistance-trained males performed five pulling exercises with and without scapular retraction, namely barbell rows, dumbbell rows, pull-downs at a lat machine, seated rows, and TRX (total resistance exercises) system rows. HD-sEMG was acquired in a monopolar mode from the medial and lower trapezius (8 × 4 electrodes and inter-electrode distance (ied): 10 mm) and different bipolar systems were simulated in terms of positioning, interelectrode distance, and orientation with respect to the spine: longitudinal with three ieds (20 mm, 30 mm, and 40 mm), one transversal, and two diagonals (ied: 20 mm), totalling six EMG sets. To identify the optimal electrode pair that was able to distinguish between the presence or absence of scapular retraction, we computed: (i) the root mean square (RMS) map for each condition and the difference between them, obtaining a differential RMS map per subject; and (ii) the intersection of cumulative maps, by summing the differential (binary) maps from all subjects.Main results. For the lower trapezius, the results revealed that the diagonal direction (45 degrees; ied: 20 mm) obtained the greater occurrence of intersecting segments within and between exercises than the other electrode configurations, showing low variability for the optimal positioning across exercises. Electrode configuration varied within and between the pulling exercises for the medial trapezius.Significance. This study allows us to identify an optimal bipolar positioning (consistent across subjects and exercises) for lower trapezius activity assessment, representing a guideline for electrode positioning when EMG biofeedback is adopted for selective activation of the lower trapezius during pulling exercises.

Which is the best communication strategy, based on anti-tobacco ads, to impress teenagers? A multicenter cross-sectional study

BACKGROUND

Well-planned mass-media campaigns can increase health literacy and raise awareness about the consequences of tobacco use. This study aims to evaluate the emotions and opinions of adolescents about several anti-tobacco spots delivered by the mass media over the world.

STUDY DESIGN

Cross-sectional study.

METHODS

The study was conducted in Italy in 2016-2017 among students aged 13-17 years. Students expressed their emotions and opinions about seven anti-tobacco spots from all over the world on different topics and styles.

RESULTS

499 students attended. The video "Sponge" was found to be the most impressive (30.2%) and what they would have chosen if they had been responsible for campaign launched by the Minister of Health (40.5%). The "Icons" spot ranged second, with 19.2% and 17.4%, respectively.

CONCLUSIONS

In summary, this study showed that the communication strategies most effective, according to the students interviewed, are those that give clear messages with a scientific profile or that discover the false stereotypes, as in the video "Icons". However, further research is needed to investigate the effectiveness of TV campaigns against smoking, in terms of habits and knowledge in young people.

Methicillin-resistant Staphylococcus aureus: epidemiology and antimicrobial susceptibility experiences from the University Hospital 'Luigi Vanvitelli' of Naples

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the important pathogens worldwide showing resistance to several widely used antibiotics. This has made the treatment of MRSA infections harder, especially due to their prevalence in the hospital setting. We evaluated the antibiotic susceptibility patterns of healthcare-associated MRSA infections with a focus on Vancomycin Intermediate S. Aureus (VISA) and macrolide-licosamide-streptogramin B (MLS_B) phenotypes. A total of 417 Staphylococcus aureus (S. aureus) cases were isolated between January 2017 and December 2018, through several clinical specimens collected from the University Hospital 'Luigi Vanvitelli' of Naples. We identified bacterial strains using Matrix-Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) and antimicrobial susceptibility using Phoenix BD (Becton Dickinson, NJ, USA). Out of the total 417 S. aureus cases, 140 were MRSA (33.6%) and of these, 50% were soft tissue infections. All MRSA and Methicillin sensible S.aureus MSSA isolates were susceptible to linezolid and daptomycin. Two MRSA cases exhibited intermediate resistance to vancomycin and were of constitutive MLS_B phenotype. Among the MRSA strains, 11.4% were constitutive and 43.6% were inducible MLS_B phenotypes and 8.6% were macrolide-streptogramin B phenotype. This study characterized the epidemiological status, antibiotic resistance patterns, and current prevalent phenotypes of healthcare-associated MRSA. This knowledge can aid clinicians in improving the antimicrobial stewardship program by adapting appropriate guidelines for the proper use of MRSA antibacterial agents.

SARS-CoV-2: Sanitize a hospital

Issue

During the SARS-CoV-2 pandemic, several critical issues emerged. One of these was to identify which was the best terminal disinfection strategy for hospital rooms of a COVID-19. Description of the problem. Our University Hospital adopted ozone disinfection two years ago, recognized internationally as a 'safe gas' and is an excellent disinfectant for its characteristics of attacking and oxidizing each type of organic and inorganic compound and specifically also works against SARS-CoV-2.

Results

23 ozone generators were purchased, 20 ozonizers were assigned to departments with high environmental sanitation needs, 3 ozonizers supplied to the ozonator team. For the correct use of the equipment, 200 operators were trained in a certified way. The rooms are ozonated with pre-established frequency and whenever a COVID-19 patient is cared for. The ozonation team sanitizes rooms in wards that are not equipped but that may have hosted patients with carriers. Indications have been given in all the wards to create the ozonation room, that can be used as an ozone disinfection chamber, where it is possible to place garrisons and furnishings, even large-sized, that cannot be disinfected in other ways (in addition to sanitization with hypochlorite). The team also provides for the ozonation of ambulances with a predetermined periodicity or in the case of transport of patient carrying SARS-CoV-2. All activities are monitored with a special traceability card.

Lessons

Terminal disinfection of environments that have hosted patients with COVID-19. Terminal disinfection of the devices used on patients with COVID-19. Increased safety for operators carrying out environmental sanitation.

Key messages

Fight SARS-COV-2 with ozone.

Disinfecting with ozone is safety for everyone.

Which are the communication styles of anti-tobacco spots that most impress adolescents?

Objectives

To evaluate emotions and opinions of Italian adolescents aged 13-18 years old about different anti-tobacco spots delivered by the mass media campaigns over the world.

Methods

A multicenter cross-sectional study was conducted. Italian students from different regions were enrolled. A video that collected 7 anti-tobacco spots from all over the world. The spots describe the tobacco dependence, the health damages and the tobacco components using different communication styles (funny, scientific, dramatic, comedians, shocking, and sad). Information on age, gender, smoking status of family and peers were gathered. Descriptive and univariate analysis of emotional and cognitive reactions to spots were performed with respect to gender, smoking status of adolescents, their peers and parents.

Results

495 students were enrolled. 14% of them were current smokers. Two spots resulted to have most impressed the students: Sponge (29%) and Icons (18%). In the first spot the sponges represent human lungs, a pair of hands squeeze the tar from the sponge, revealing the cancer-producing tar that goes into the lungs of a pack-a-day smoker every year. The second one contrasts tobacco industry images such as a cowboy, a hip-hop DJ with a more accurate depiction of the repercussions of smoking: a dying man in a wheelchair who warns, ‘The reality is you can end up looking like this’. The reactions on these videos are disgust, reflection and sadness, respectively: Sponge 79%, 44% and 15%; Icons 60%, 3% and 20%. Univariate analysis showed differences by smoking status about video considered most impressive (p = 0.02) and by gender about the choice of spot in the role of the Minister of Health (p < 0.001).

Conclusions

The spot media campaigns that gave a clear and scientific message or that changed the “icon” of the smoker were preferred by adolescents. Further research is needed to study adolescents’ responses and smoking outcomes obtained by different anti-tobacco mass media campaigns.

Key messages

The study demonstrates the preference of adolescents for spot giving clear scientific messages or using strategies that fight manipulation of the tobacco industry and aimed at changing smoker’s icon. The present study underlines that it is necessary to monitor the effect of a multimedia campaign and to examine its longitudinal impact, especially its impact on smoking behavior.

Knowledge, experiences, and attitudes toward Mantoux test among medical and health professional students in Italy: a cross-sectional study

BACKGROUND

The World Health Organization's Action Framework for tuberculosis elimination in low-tuberculosis incidence countries includes the screening for active and latent tuberculosis in selected high-risk groups, including health care workers. In this context, medical and health profession students, exposed to nosocomial tuberculosis transmission during training and clinical rotations, are target populations for tuberculosis screening. No updated data are available on tuberculosis screening practice and knowledge of medical and health profession students in Italy.

METHODS

Within the activities Italian Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health, we carried out a multicentre cross-sectional study to assess knowledge, attitude and practices on tuberculosis prevention and control among Medical, Dentistry, Nursing and other health professions' students. Students were enrolled in the study on a voluntary basis and were administered a previously piloted structured questionnaire. Logistic regression models were applied to explore knowledge on tuberculosis prevention by selected socio-demographic variables and University-based tuberculosis prevention practice.

RESULTS

Students of seventeen Universities across Italy participated in the study, and 58.2% of them received compulsory tuberculin skin test either at enrollment or while attending clinical practice. A total of 5,209 students filled the questionnaire. 37.7% were medicine and dentistry students (Group 1), 44.9% were nursing students (Group 2) and 17.4% were other health professions' students (Group 3). Age and gender had different distributions by groups, as well as knowledge and practice on tuberculin skin test. 84.4% of the study population (95% CI = 83.3-85.3) was aware of the existence of the tuberculin skin test, 74.4% (95% CI = 73.2-75.6) knew what is the first-level screening test for latent tuberculosis and only 22.5% (95% CI = 21.4-23.6) knew how to proceed after a positive tuberculin skin test result. Overall, knowledge on tuberculosis prevention was higher in Group 2 and lower Group 3, as compared to Group 1.

CONCLUSION

In Italy, the knowledge on tuberculosis screening among University students is generally good. To reduce some of the criticalities found among the different study courses, it would be appropriate to harmonize both the regulations on tuberculosis screening practices for admission to University courses, and the educational activities on the topic of tuberculosis, to be extended to all workers involved in health care setting.

Shared and task-specific muscle synergies of Nordic walking and conventional walking

Nordic walking is a form of walking that includes a poling action, and therefore an additional subtask, with respect to conventional walking. The aim of this study was to assess whether Nordic walking required a task-specific muscle coordination with respect to conventional walking. We compared the electromyographic (EMG) activity of 15 upper- and lower-limb muscles of 9 Nordic walking instructors, while executing Nordic walking and conventional walking at 1.3 ms^-1 on a treadmill. Non-negative matrix factorization method was applied to identify muscle synergies, representing the spatial and temporal organization of muscle coordination. The number of muscle synergies was not different between Nordic walking (5.2 ± 0.4) and conventional walking (5.0 ± 0.7, P = .423). Five muscle synergies accounted for 91.2 ± 1.1% and 92.9 ± 1.2% of total EMG variance in Nordic walking and conventional walking, respectively. Similarity and cross-reconstruction analyses showed that 4 muscle synergies, mainly involving lower-limb and trunk muscles, are shared between Nordic walking and conventional walking. One synergy acting during upper limb propulsion is specific to Nordic walking, modifying the spatial organization and the magnitude of activation of upper limb muscles compared to conventional walking. The inclusion of the poling action in Nordic walking does not increase the complexity of movement control and does not change the coordination of lower limb muscles. This makes Nordic walking a physical activity suitable also for people with low motor skill.

Cross-country skiing movement factorization to explore relationships between skiing economy and athletes' skills

We investigated the relationships between the biomechanics of the double poling (DP) technique in cross-country skiing, its economy, and athletes' skill. To this aim, skiers' motion has been factorized into components through principal component analysis (PCA). Eight high-level (HL) and eight regional level (RL) male cross-country skiers performed a 5-minute submaximal DP trial while roller skiing on a treadmill at 14 km h^-1 and 2° incline. Whole-body kinematics was recorded with a motion capture system. PCA was applied to markers coordinates to extract principal movements (PM_k ), which were ranked by their variance. Energy cost (EC) of locomotion was calculated from ergospirometric measurements. Results showed that 96.7%±0.6% of total skiing pattern variance can be described with the first three PM_k. (Shoulder and trunk flexion-extension are described PM₁ and PM₂ and elbow flexion-extension are mainly represented in PM₂ and PM_3. The variance of further components, consisting of residual movements (eg, slow postural changes or high-frequency vibrations), was greater for the RL than the HL skiers (4.0%±0.5% vs 2.6%±0.3%; P<.001) and was positively correlated with EC (R² =.646; P<.001). PCA permitted to describe the biomechanics of the DP technique through a limited set of principal movements. Skiing skills and economy appeared to be related to a skier's ability to simplify movement complexity, suggesting that an efficient skier is better able to reduce superfluous movement components during DP.

Central and peripheral fatigue in knee and elbow extensor muscles after a long-distance cross-country ski race

Although elbow extensors (EE) have a great role in cross-country skiing (XC) propulsion, previous studies on neuromuscular fatigue in long-distance XC have investigated only knee extensor (KE) muscles. In order to investigate the origin and effects of fatigue induced by long-distance XC race, 16 well-trained XC skiers were tested before and after a 56-km classical technique race. Maximal voluntary isometric contraction (MVC) and rate of force development (RFD) were measured for both KE and EE. Furthermore, electrically evoked double twitch during MVC and at rest were measured. MVC decreased more in KE (-13%) than in EE (-6%, P = 0.016), whereas the peak RFD decreased only in EE (-26%, P = 0.02) but not in KE. The two muscles showed similar decrease in voluntary activation (KE -5.0%, EE -4.8%, P = 0.61) and of double twitch amplitude (KE -5%, EE -6%, P = 0.44). A long-distance XC race differently affected the neuromuscular function of lower and upper limbs muscles. Specifically, although the strength loss was greater for lower limbs, the capacity to produce force in short time was more affected in the upper limbs. Nevertheless, both KE and EE showed central and peripheral fatigue, suggesting that the origins of the strength impairments were multifactorial for the two muscles.

From directive to practice: are pictorial warnings and plain packaging effective to reduce the tobacco addiction?

OBJECTIVES

Tobacco packaging represents an important form of promotion of tobacco products and for this reason plain packaging (PP) can be considered an additional tobacco control measure. In Italy the current tobacco packaging is branded with textual warnings. The study investigated the perception of PP with textual warnings (PPTWs) and pictorial warnings (PPPWs) in Italy.

STUDY DESIGN

Cross-sectional.

METHODS

The study was conducted on adults who were current, never and former smokers. The participants watched out three types of packages (current packaging, PPTWs and PPPWs) and eight pictorial warnings, and indicated which they considered the most effective ones to motivate smoking cessation or reduction and to prevent the onset.

RESULTS

1065 subjects were recruited. The PPPWs were considered the most effective in motivating to quit, reduce and prevent the smoking habits (ranged 83.4%-96.1%) in all tobacco users and age groups (≤40/>40 years) (P < 0.005). In general PP does not seem to be very effective in quitting for three-quarters of the smokers and 60% declared that they would have still started smoking with PP. The younger group believed less than the older one that PP gives a motivation to quit (29.4% vs 39.1%, P = 0.002). The pictures perceived as most effective in communicating the smoking effects were lung cancer and gangrene (about one-third of the sample).

CONCLUSIONS

The textual warnings on tobacco products are a measure of control now outdated. Countries still using them should consider the idea of replace them with pictorial warnings that seem to be more effective. It is also desirable in the near future that these countries introduce the PPPWs.

The association of coeliac disease in childhood with functional gastrointestinal disorders: a prospective study in patients fulfilling Rome III criteria

BACKGROUND

An association between coeliac disease (CD) and functional gastrointestinal disorders (FGIDs) has at present only been demonstrated in adults.

AIMS

To assess the prevalence of FGIDs at 1 year and the role of psychological aspects on the development of FGIDs in CD children.

METHODS

One-hundred consecutive CD children (36M and 64F) were followed up for 1 year. Fifty-six children (25M and 31F) represented the control group. All children and/or their parents completed validated questionnaires for GI symptoms, depression, and anxiety. GI symptoms at diagnosis and after 1 year of gluten-free diet (GFD) were compared.

RESULTS

Twenty-three/82 (28%) CD patients followed up prospectively, on GFD from at least 1 year, fulfilled the Rome III criteria for FGIDs compared with 5/56 (8.9%) controls (P = 0.008; χ² = 6.8; OR: 3.97; 95% CI: 1.40-11.21). Children complaining with GI symptoms alone [21/52 (40.3%)] more likely fulfilled Rome III criteria for FGIDs after 1 year of GFD than children with extra-intestinal symptoms (P = 0.045). CD children with FGDIs presented significantly higher anxiety and depression compared to CD children without FGIDs and controls (P = 0.02).

CONCLUSIONS

This study demonstrates that children with CD on a GFD for a year have a much higher prevalence of functional GI symptoms than do controls. Whether the risk is due to the residua of a chronic inflammatory process, and/or due to psychological factors remains to be further tested.

Irritable bowel syndrome in childhood: visceral hypersensitivity and psychosocial aspects

Visceral hypersensitivity is often considered to play a major etiologic role in the pathophysiology of irritable bowel syndrome in adults, and some authors argue that this increased sensitivity is mainly due to psychological factors. In contrast, there are no data in children with irritable bowel syndrome which confirm this relationship. The aim of the study was to evaluate the relationship between psychosocial aspects and sensorymotor function in children affected by irritable bowel syndrome. Ten children fulfilling the Rome II criteria for irritable bowel syndrome and seven healthy controls were enrolled. We studied the thresholds and the perception of visceral stimuli in the rectum by means of an electronic barostat (isobaric phasic distentions, 3 mmHg/1 min, interval 1 min) and a validated questionnaire. Personality features were evaluated by means of the Big Five Questionnaire for Children. Sleep, mood disturbance, anxiety and individual performance (missed school days, school results and social activities) were also evaluated. Children with irritable bowel syndrome showed significantly lower thresholds for discomfort (14.8 +/- 3.5 vs 22.3 +/- 6.9 mmHg, P = 0.010) and a higher cumulative perception score (28.2 +/- 11.1 vs 12.3 +/- 8.0, P = 0.005) compared with healthy controls. A higher emotional instability (57.8 +/- 7.0 vs 48.7 +/- 10.1, P = 0.047), sleep disturbance (7.2 +/- 1.0 vs 9.3 +/- 0.5, P = 0.004) and anxiety (6.3 +/- 2.0 vs 2.3 +/- 1.7, P = 0.009) were observed in irritable bowel syndrome patients. Moreover, in a multivariate analysis, the cumulative perception score was significantly related to emotional instability (P = 0.042). In conclusion children with irritable bowel syndrome exhibit visceral hypersensitivity and psychosocial impairment. Emotional instability, as a personality feature in these children, seems to modulate the perception response to visceral stimulations.

[Pediatric functional gastrointestinal disorders: a questionnaire on pediatric gastrointestinal symptoms based on Rome III criteria]

Functional Gastrointestinal Disorders (FGIDs) are defined as a variable combination of chronic or recurrent gastrointestinal symptoms, age dependent, not explained by structural or biochemical abnormalities. Recurrent gastrointestinal disorders, especially abdominal pain, are one of the most common reasons for medical consultation among children and adolescents. A population-based study demonstrated that 28-46% of school age children complain of abdominal pain each week. Only in 10% of the cases an organic cause can be identified, while most of the children and adolescents who present these symptoms have a functional disorder without any evidence of disease. FGIDs significantly influence the quality of life of affected children and have a big social impact related to socialization, school absences and could have long-term psychological implications. A complete understanding of the pathophysiology of FGIDs remains elusive. FGIDs are a multifactorial condition and diverse pathophysiologic mechanisms appear to contribute to them, including altered motility, visceral hyperalgesia, brain-gut disturbances, genetic and environmental factors, and psychosocial upsets, among others. In 2006 the new version of the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) based on Rome III Criteria (QPGS-RIII) was created, in order to validate such criteria and to facilitate the diagnosis of FGDIs in children and adolescents. The Italian translation of the QPGS-RIII has been realized by our research group to spread a valid and universal method to screen the children potentially affected by FGDIs.

Prevalence of atopy in children with chronic constipation

OBJECTIVES

To evaluate the prevalence of chronic constipation (CC) in unselected children, its association with atopy and the efficacy of a cow's milk protein (CMP) elimination diet on refractory constipation.

STUDY DESIGN

The study was conducted by six primary care paediatricians, serving a population of 5113 children aged from birth through to 12 years; only 2068 children were 6 months to 6 years. During a 3-month period, prevalence of CC was determined for the entire study population, ages 0-12 years. In the second part of the study, all patients aged 6 months to 6 years with CC, and age- and sex-matched controls, were evaluated for atopy and its association with CC. A questionnaire was completed including personal and family history of atopy and bowel-movement characteristics. Patients were tested for atopy by specific serum IgE and/or skin-prick tests. Constipated patients, refractory to osmotic laxatives, underwent a 4-week CMP elimination diet.

RESULTS

91 (1.8%) children had CC, and 69 (3.3%) of the 6 months to 6 years age group fell into the atopy study age range. All 69 constipated children (mean age 34.9 (18.0) months) and 69 controls completed the questionnaire. Twelve of the 69 constipated children (17.3%) and 13 out of the 69 control children (18.8%) had a diagnosis of atopy. Eleven out of 69 (15.9%) constipated children were refractory to constipation treatment, and three (27.3%) of these had atopy. The 4-week trial of dietary elimination did not result in improvement in any of these 11 children.

CONCLUSIONS

In our study group, prevalence of atopy among children with CC is similar to that in the general population. The level of refraction of CC does not seem to be related to cow's milk allergy.

Surveillance of nosocomial infections: a preliminary study on yeast carriage on hands of healthcare workers

Hospital-acquired fungal infection is increasing. The aim of this preliminary study was to evaluate the frequency and distribution of yeast carriage on the hands of healthcare workers (HCW) from different departments. The study was conducted in three departments (Surgery, Intensive Care Unit, Obstetrics and Gynaecology) of a hospital in Campania, southern Italy. Over a six-month period, 50 healthcare workers were randomly tested. Imprints of palms and fingertips were taken monthly during the morning shift. The plate with yeast was counted and Candida species were identified. Risk factors for hand contamination were determined. Hand carriage of yeast and Candida species in the three departments were found in the following percentages: Surgery (50% and 49%); Intensive Care Unit (61% and 57%); Obstetrics and Gynaecology (65% and 59%). No significant difference in the frequency or distribution of yeast and Candida sp. recovered in the three departments was ascertained by comparing every two months' data, the hand carriage of yeast and Candida species found in the three departments; this varied - min to max - according to the following percentages: Surgery [(45%-54%) and (42%-58%)]; Intensive Care Unit [(53%-66%) and (56%-59%)]; Obstetrics and Gynaecology [(62%-69%) and (57%-63%)]. The only factor associated with yeast carriage on the hands of healthcare workers was the absence of gloving during healthcare procedure (p = 0.0192). We conclude that in our study yeast carriage on the HCWs' hands is common in the three departments investigated, but its causes are unclear. Careful use of gloving may reduce pathogenic yeast on hands.

Segmental characteristics of oesophageal peristalsis in paediatric patients

High-resolution manometry (HRM) in adults identifies a sequential chain of pressure segments that together form normal oesophageal peristalsis. HRM was performed in 40 neonates, infants/toddlers and children (age 1 day-14 years) to see if a similar segmental pattern could be identified in paediatric subjects. A chain of three pressure segments was found with inter-segmental troughs at 27.4 +/- 1.1%, 62.6 +/- 1.3% and 94.9 +/- 0.8% oesophageal length. The first and second pressure troughs were similarly distributed along the oesophagus across age groups; the third was 7.6-8.9% oesophageal length further from the lower oesophageal sphincter in neonates (P < 0.05 compared with other age groups). There were no significant differences in trough locations between subjects with or without oesophageal disease, controlling for age. Consistent presence of all three segments was less common in neonates, primarily because of fewer swallows demonstrating the first (proximal) and third (distal) segments compared with children. HRM in paediatric patients demonstrates, from neonates to children, the distinctive chain of pressure events that also characterizes oesophageal peristalsis in adults. The segmental character to oesophageal peristalsis should be taken into consideration in manometric investigation of all age groups - for example, in testing pharmacological responses and evaluating clearance mechanisms.

Effect of autonomic nervous system dysfunction on sudden death in ischemic patients with anginal syndrome died during electrocardiographic monitoring in Intensive Care Unit

AIM

The aim of this study was to investigate the role of sympathovagal imbalance in patients with ''ischemic'' sudden death (arrhythmic death preceded by ST segment shift). Although heart rate variability is a powerful tool for risk stratification after myocardial infarction, the mechanism precipitating sudden death is poorly known.

METHODS

We analyzed the records of 10 patients who had ischemic sudden death during ECG Holter monitoring. Thirty patients with angina and transient myocardial ischemia during Holter monitoring served as control subjects. Arrhythmias, ST segment changes and heart rate variability were analyzed by a computed interactive Holter system.

RESULTS

In 8 patients the sudden death was induced by ventricular fibrillation; in 2 by atrioventricular block followed by sinus arrest. All 10 patients showed ST segment shift. ST depression (maximal change 0.54+/-0.16 mV) occurred in 6 patients and ST elevation (maximal change 0.65+/-0.24 mV) in 4. The standard deviation of normal RR intervals (SDNN) was 92+/-30 ms during total Holter monitoring period vs 70+/-10 ms and 46+/-8 ms in epoch 1 and epoch 2 respectively. The SDNN was lower before the occurrence of ischemic sudden death: 54+/-12 ms (P< 0.005) in epoch 3 and 26+/-5 (P<0.005) in epoch 4 (i.e. 5 min before the onset of fatal ST segment shift). In controls the SDNN was 108+/-30 ms during total Holter monitoring period, whereas is measured 58+/-28 ms 5 min before the most significant episode of ST shift vs 26+/-5 in the group with sudden death (P<0.001).

CONCLUSION

Sympathovagal imbalance, as detected by a marked decrease in heart rate variability, is present in the period (5 min) immediately preceding the onset of the ST shift precipitating ischemic sudden death. These findings suggest that transient autonomic dysfunction may facilitate, during acute myocardial ischemia, fatal arrhythmias precipitating in sudden death.

Functional gastrointestinal disorders in migrainous children: efficacy of flunarizine

The aim of this study was to evaluate the prevalence of functional gastrointestinal disorders (FGIDs) in children with migraine headache and the effects of flunarizine on gastrointestinal manifestations. We studied 50 migrainous children (mean age 8.63 years). The clinical pattern and the diagnosis of FGIDs were obtained from structured questionnaires. All subjects underwent measurement of total gastric emptying time (TGEt) performed by real-time ultrasonography of the gastric antrum at baseline (T0). In the second part of the study, we evaluated 10 migrainous children (mean age 9.8 years) with associated FGIDs. In these 10 patients, repeated TGEt evaluation together with a detailed symptom history was obtained after 1 (T1) and 2 months (T2) of treatment with flunarizine. Control groups were composed of 10 migrainous children without FGIDs (mean age 9.2 years) and nine sex- and age-matched healthy children. Gastrointestinal disorders were present in 70% of the patients. Migrainous children with FGIDs had significantly (P < 0.01) more prolonged TGEt than subjects without FGIDs. Prior to therapy, all migrainous children with FGIDs had prolongation of TGEt compared with controls (P < 0.05). Patients on flunarizine had a significant decrease in TGEt at both 1 (P < 0.01) and 2 months (P = 0.002) of therapy. The mean frequency of abdominal pain per month was significantly (P < 0.001) reduced at T1 compared with T0. The mean frequency of vomiting per month was significantly decreased at T1 (P < 0.05) and even more so at T2 (P < 0.01). Finally, the mean frequency of headache per month was significantly reduced only at T2 (P < 0.05), whereas the mean duration of headache was significantly decreased at T1 (P < 0.01) with no difference between T1 and T2. Most children with migraine report FGIDs, associated with a delayed gastric emptying. Flunarizine decreases the frequency and duration of migrainous episodes as well as the gastrointestinal symptoms.

Surveillance of nosocomial infections: a preliminary study on hand hygiene compliance of healthcare workers

The observance of hand hygiene compliance is important to reduce cross-infection by micro-organisms. The aim of this preliminary study was to evaluate the level of hand hygiene in healthcare workers from different departments, with particular emphasis on transient flora. The study was conducted in three departments (Surgery, Intensive Care Unit, Obstetrics and Gynecology) of a hospital in Campania, southern Italy. Over a six-month period, 50 healthcare workers were randomly tested. Imprints of palms and fingertips were taken monthly during the morning shift. The number of colonies per plate was counted and transient pathogens were identified. Risk factors for hand contamination were determined. Total flora was found in the following CFU means per palm and per five fingertips (95% CI): Obstetrics and Gynecology [palms 130 CFUs (95% CI 85-180); fingertips 125 CFUs (95% CI 92-160)]; ICU [palms 80 CFUs (95% CI 58-99); fingertips 62 CFUs (95% CI 45-82)]; Surgery [palms 75 CFUs (95% CI 41-120); fingertips 70 CFUs (95% CI 52-90)] Transient flora was found on 39% of healthcare workers' hands. The only factor associated with hand contamination by transient flora was the absence of gloving during healthcare procedure (P = 0.02).

Two-years surveillance of fungal contamination in three hospital departments in Campania region

A two-years (2003-2005) fungal environmental surveillance was carried out in three departments of a hospital in Campania region (Surgery, Intensive Care Unit, Obstetrics and Gynaecology). Four operating theatres rooms and their relative areas of service and support, 4 patient rooms of intensive care unit, 1 delivery room, 1 labour room and 1 nursery of Obstetrics and Gynaecology were checked. A total of 12,120 surfaces and 2,904 air samples were collected in 24 monthly determinations. A seasonal variation in the fungal development was observed, in particular the lowest level of air and surface fungi contamination was found in winter and autumn whereas it was higher in spring and summer. In this study 30 fungal species were identified and, among these, the most frequent specie isolated was the Aspergillus spp. The results show an air contamination, expressed in percentage of positive determinations for Aspergillus spp, and the other fungi in the following percentages: Obstetrics and Gynaecology (25% and 33,3%); Intensive Care Unit (17% and 25%); Surgery (12.5% and 21%). For surfaces contamination it was found: Obstetrics and Gynaecology (67% and 75%); Intensive Care Unit (63% and 71%); Surgery (58.3% and 67%). This study shows that in the departments observed environmental fungi contamination is always present and therefore it would be necessary to apply environmental surveillance procedure and monitor the effectiveness.

Fertility of male workers of the italian mint

Fertility among workers exposed to metal fumes and solvents in the Italian mint (stampers, founders, and other technical workers) was compared to the reproductive experience of the administrative staff. Data on the reproductive history and time to pregnancy were collected by interview. For workers with children, data on the time to pregnancy (TTP) for the first pregnancy was assessed in relation to occupational risk factors. The groups with the highest prevalence of pregnancy delay beyond 6 months were stampers (21%) and those exposed to solvents (21.5%). Logistic regression did not show a significant association of these job exposures with pregnancy delay, but the power of the study to show an important difference was low. The data are not inconsistent with the hypothesis that male exposure to solvents and metal fumes is associated with an increase in the TTP.

A normal gastrointestinal motility excludes chronic intestinal pseudoobstruction in children

Gastrointestinal manometry has gained wide acceptance in the approach to patients with suspected enteric neuromuscular disorders. However, performing gastrointestinal manometry in these subjects without a previous exhaustive diagnostic evaluation is unjustified. Twelve children (median age: 7.0 years; range: 8 months-13 years), with clinical and x-ray features suggesting chronic intestinal pseudoobstruction, were referred to our unit for gastrointestinal manometry. The latter was performed with a perfused catheter for 5 hr in the fasting state and for 90 min after feeding. Data were compared with those recorded in eight age-matched controls. In all patients and controls, interdigestive motor complexes with propagated phases III were detected; a regular postprandial antroduodenal motor activity was also recorded. Patients and controls did not differ for fed antral and duodenal motility indexes, fed antroduodenal coordination, and length of duodenal phase III. Most of the patients showed short or prolonged bursts of nonpropagated activity in the fasting and/or fed states; in four cases fasting and/or fed sustained phasic activity was recorded. Manometric evidence of migrating motor complexes and postfeeding activity did not support the diagnosis of intestinal pseudoobstruction and suggested redirecting the diagnostic evaluation. Final diagnoses were: Munchausen syndrome-by-proxy (four cases), celiac disease (two cases), intestinal malrotation (two cases), Crohn's disease (two cases), multiple food intolerance (one case), and congenital chloride-losing diarrhea (one case). It is concluded that in children with suspected chronic intestinal pseudoobstruction manometric evidence of migrating motor complexes and fed motor activity excludes an enteric neuromuscular disorder and suggests a reassessment of the diagnostic work-up. Furthermore, if gastrointestinal manometry shows migrating motor complexes and postfeeding motor activity, qualitative abnormalities of the manometric tracings do not indicate an underlying enteric neuromuscular disorder and must not be overemphasized. Patients referred for gastrointestinal manometry should previously undergo an extensive diagnostic investigation to exclude disorders mimicking chronic intestinal pseudoobstruction.

Gestational maturation of electrical activity of the stomach

Gestational maturation of gastrointestinal motility is a key factor in readiness of the preterm neonates for enteral nutrition. Since gastric motility mainly depends on the electrical activity of the smooth muscle cells, it was of interest to investigate the developmental aspects of electrical activity of the stomach. The latter was recorded weekly through cutaneous electrogastrography in 27 preterm infants (aged 29-34 weeks of gestation). Recordings were done for 1 hr before and 1 hr after meal. The electrogastrographic variables measured were: percentage of normal gastric rhythm, ie, 2-4 cpm; percentage of tachygastria (>4 cpm); the fed-to-fasting ratio of the dominant electrogastrographic power; and the instability coefficient of the dominant frequency. Data were compared with those measured in 10 full-term infants. Peaks of normal electrical activity (2-4 cpm) were present in most of the recordings at all the gestational ages; however, percentages of both normal electrical rhythm and tachygastria in preterm infants were similar to those measured in full-term infants (mean +/- SD) (normal rhythm; fasting: 70.2 +/- 3.8, fed: 72.2 +/- 5.0; tachygastria: fasting: 24.6 +/- 4.0, fed: 19.1 +/- 3.5) by 35 weeks of gestation (normal rhythm; fasting: 67.5 +/- 2.0, fed: 69.6 +/- 4.4; tachygastria: fasting: 27.1 +/- 4.0, fed: 25.6 +/- 4.1). The coefficient of instability of the dominant frequency in preterm infants was also similar to the value measured in full-term infants by 35 weeks of gestation, whereas the EGG power showed a significant increase in the postprandial state at all the gestational ages. We conclude that a maturation pattern of the electrical activity of the stomach can be detected by means of a noninvasive tool such as cutaneous electrogastrography: a normal electrical rhythm can be detected at very early gestational ages; however, this activity becomes dominant at around the 35 weeks of gestational age. In preterm infants developmental changes of gastric electrical activity are a function of advancing postnatal age.

[Ultra-low laparoscopic rectal resection and colo-anal anastomosis. Experimental study on swine]

Nowadays oncologic surgery is defining new criteria in the treatment of rectal cancer: preservation of sfincterial function, ultra-low resections with distal margin at only 2 cm distally to the tumor, role of mesorectum as preferential site of lymphatic diffusion, preservation of lombo-aortic and pelvic nerves. Laparoscopy is showing good results in bowel surgery so as previously got on biliary tract: less visceral manipulation, less stimulation of immunologic system, less pain, early resumption of peristalsis and food intake, better recovery, less hospital stay. We experimented on pig ultra-low laparoscopic resection of the rectum, with preservation of sfincterial function, and mechanical anastomosis at the upper edge of the sfincterial ring. The evaluation of surgical technique, post-operative supervision, and follow-up instrumental control (anal manometry, endo-rectal ultrasonography, sfincterial electtromanometry, Rx barium enema) show technical feasibility and confirm a better recovery with regular defecatory function.

[Roux-en-Y reconstruction with defunctionalized jejunal loop, after gastric resection]

Authors report their personal experience on Roux-en-Y reconstruction, after partial gastric resection. They have considered 39 patients: 24 of them had been operated for a peptic ulcer of the lesser gastric curve and 15 for a pyloric cancer for which a partial gastric resection had been adopted for various reasons (age, stage or else). The follow-up lasted on an average of 42 months (4 to 68). Controls concerned secretory activity and motility. A prolonged stasis of solids, in the gastric stump or in the isolated loop, has been observed in two of the long controlled patients, together with superficial ulcers of the digiunal mucosa. Alcaline reflux was absent or very small; inflammatory changes of the gastric mucosa were hardly evident. In conclusion the authors regard the partial gastric resection, followed by the reconstruction with a digiunal isolated loop, as a valid surgical technique, for peptic ulcers of lesser gastric curve and for gastric cancers for which total gastrectomy seems not indicate.

[Segmental liver transplantation. Experimental studies in swine]

Authors report the results of an experimental application of one of the more recent techniques of liver transplantation, which has the preparation ex situ as a basilar step of the procedure. 18 pig were operated on, from september 1991 to march 1993; they were divided in two groups: the first (group A) underwent an auxiliary segmental autotransplantation of left lobe to heterotopic subdiaphragmatic location; in group B an orthotopic segmental autotransplantation of right lobe after ex situ preparation of the liver according the technique of Pichlmayr was performed. The results show that a bigger application of ex situ surgery may help to find a resolution to the problem of the small number of liver donation.

[The criteria of choice in the palliative therapy of cancer of the pancreas]

Explorative laparotomy and palliative surgery keep on having the leadership, in the treatment of exocrine tumours of the pancreas, in spite of important diagnostic and surgery progress. The authors have looked at international literature and their own experience, to simplify the choice of better treatment for each patient. They compared the reliability of various diagnostic technologies and different surgery options. Metastasis and lymphatic invasion are limiting factors for surgery; the first lymphatic stage and duodenum fixation still consent curative surgery. Biliary decompression through external catheter or transpapillary endoscopic prosthesis has a primary role in the diagnostic therapeutic decision. The authors preferred to reserve gastro-jejunostomy to patients with duodenum obstruction. They choose an anterior trans-mesocolic gastro-jejunostomy with Roux-en-y reconstruction, with an upper bilio-enteroanastomosis. Pain relief is one of the most important goal in pancreas' cancer: anaesthetic and surgery techniques lead to good and long-standing results. Explorative laparotomy is often the only technique that leads to the final decision about a therapeutic plan, because it shows size, location and characteristic of the tumour and his metastasis in lymphatic and anatomic structures. The integration of metasurgery therapy (chemo-, radio-, hormono ...) allows, together with pain treatment, to improve the results above all the quality of life in carcinoma of the pancreas.

Recurrent dislocation of the shoulder: twenty-five years experience with the Delitala method

The authors report the clinical and radiographic results of 57 patients operated on for recurrent dislocation of the shoulder by the Delitala method. The age at operation ranged from 16 to 45 years. The follow-up was an average of 10 years (minimum 1, maximum 25 years) and the results were good or excellent in most of the cases. The failures included one case of recurrence and two of stiffness.