Aetiology of pneumonia following isolated closed head injury

AbstractPatients undergoing mechanical ventilation (MV) after an isolated closed head injury (ICHI) have often been found to develop hospital-acquired pneumonia (HAP) well before subjects who require MV for different reasons. In a prospective study of patients receiving MV after an ICHI, 38 subjects (out of 65 with clinically suspected HAP) had a bacteriological diagnosis established on the basis of correspondence between cultures made from bronchoalveolar lavage and protected specimen brush (with quantitative thresholds of 104 and 103 cfu ml−1, respectively). Patients were separated according to the time of onset of HAP, with 20 subjects who developed HAP within 4 days of the start of MV (early onset pneumonia, EOP) and 18 subjects who developed HAP after the fourth day (late onset pneumonia, LOP). In those who had LOP, an expected spectrum of organisms was found, with Gram-negatives (especially Pseudomonas sp.) accounting for the majority of isolates. However, in EOP cases, Gram-positive bacteria (especially Staphylococcus sp. and Streptococcus pneumoniae) were found to largely predominate (P = 0·0000026). This confirms the high incidence of staphylococcal pneumonia in neurosurgery patients, and also provides evidence that the vast majority of such staphylococcal pneumonia are EOP. Unlike most previous reports, the microbiological findings from the present study suggest that a cut-off point of 4 days successfully distinguishes between EOP and LOP. Since these two clinical entities differ significantly in terms of pathogenesis and aetiology, preventive measures and therapeutical protocols have to be tailored accordingly

Prolonged hospitalisation for immigrants and high risk patients with positive smear pulmonary tuberculosis.

Background and objective. Tuberculosis (TB) occurring in immigrants and resistance to drugs are major problems for TB control in Western countries. Directly observed therapy (DOT) reduces disease transmission, but this approach may have poor results among illegal immigrants. Our aim was to evaluate a prolonged hospitalisation programme to improve early outcome of TB treatment in high risk patients. Methods. All the consecutive adult patients with sputum smear-positive pulmonary TB admitted to 2 Italian referral TB Centres were evaluated. Hospital-based DOT was provided to high risk patients up-to smear conversion. Demographic, microbiological and clinical conditions, as potential factors associated with confirmed smear conversion at 60 and 90 days of anti-tuberculous therapy were evaluated. Results. 122 patients were studied, 45.9% of them were immigrants (20% illegal) from high-prevalence TB countries. HIV testing was negative in all cases. Twelve patients had M. tuberculosis resistant to ≥ 1 first-line anti-tuberculous agents. The rate of defaulting from TB treatment was 7.3%. Sputum smear became negative in 84.4% cases after 60 days and 93.3% cases after 90 days. At such time, smear conversion rates were similar among different high risk subgroups such as illegal immigrants (95.9%), legal foreign-born (92.5%) and Italian persons (94.8%). Persistent sputum smear positivity was independently correlated with the extent of pulmonary lesions at 60 (p<0.0001) and 90 days (p=0.038) of hospital-based DOT. Conclusions. These findings suggest that prolonged hospitalisation for illegal immigrants and high risk TB patients, may positively influence the early outcome of TB treatment despite of drug resistance and legal status

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Traumatic brain injury and peripheral immune suppression: primer and prospectus

Nosocomial infections are a common occurrence in patients following traumatic brain injury (TBI) and are associated with an increased risk of mortality, longer length of hospital stay and poor neurological outcome. Systemic immune suppression arising as a direct result of injury to the central nervous system (CNS) is considered to be primarily responsible for this increased incidence of infection, a view strengthened by recent studies that have reported novel changes in the composition and function of the innate and adaptive arms of the immune system post TBI. However, our knowledge of the mechanisms that underlie TBI-induced immune suppression is equivocal at best. Here, after summarising our current understanding of the impact of TBI on peripheral immunity and discussing CNS-mediated regulation of immune function, we propose roles for a series of novel mechanisms in driving the immune suppression that is observed post TBI. These mechanisms, which have never been considered before in the context of TBI-induced immune paresis include the CNS-driven emergence into the circulation of myeloid derived suppressor cells and suppressive neutrophil subsets, and the release from injured tissue of nuclear and mitochondria-derived damage associated molecular patterns. Moreover, in an effort to further our understanding of the mechanisms that underlie TBI-induced changes in immunity, we pose throughout the review a series of questions, which if answered would address a number of key issues such as establishing whether manipulating peripheral immune function has potential as a future therapeutic strategy by which to treat and/or prevent infections in the hospitalised TBI patient

Study of the oxygen reduction reaction by scanning tunnelling microscopy measurements in electrochemical set-up on Co, Ni and Zn octaethylporphyrins

openLo studio di catalizzatori per la reazione di riduzione dell'ossigeno (ORR) è di fondamentale importanza per lo sviluppo di celle a combustibile, batterie metallo aria e sensori elettrochimici. In particolare nelle celle a combustibile la ORR è la reazione catodica caratterizzata da una cinetica particolarmente lenta che perciò limita quella della reazione complessiva. Ad oggi i catalizzatori con migliori prestazioni sono quelli che utilizzano il platino con lo svantaggio di essere una materia prima critica e costosa, per cui gli sforzi della ricerca sono diretti verso nuovi catalizzatori che utilizzino materiali non preziosi. In questo particolare studio a carattere strettamente fondamentale si sono indagate le proprietà elettrocatalitiche di siti attivi a singolo atomo costituiti da metalli di transizione. In particolar modo sono state considerate e studiate come sistemi modello, in grado di mimare il comportamento di centri single site, octaetilporfirine metallate con centro metallico M = Zn, Ni e Co. Questo è stato fatto al fine di costruire una scala di reattività. Le metallo-porfirine sono state studiate attraverso misure in operando di microscopia a scansione ad effetto tunnel e mediante voltammetria ciclica e polarizzazione su elettrodo a disco rotante del tipo RRDE.The study of catalysts for oxygen reduction reaction (ORR) is crucial for the development of fuel cells, metal-air batteries and electrochemical sensors. In particular fuel cells utilizes ORR as a cathodic reaction, however its sluggish kinetic limits the overall reaction one. Nowadays platinum based catalysts show the best performance with the drawback of being expensive and critical raw materials, therefore research efforts are focused on new non precious catalysts. Here are investigated, in a foundamental research perspective, the electrocatalytic properties of transition metal based single-atom active sites. Metal octaethylporphyrins, with metal center M= Zn, Ni and Co, are used as model catatalysts, with the final pourpose of building a reactivity scale. Metal porphyrins are studied by in operando scanning tunneling microscopy, cyclic voltammetry and RRDE polarization technique

Invecchiamento del sistema cardiovascolare

L’età è un fattore di rischio indipendente per patologie cardiovascolari. L’elevata prevalenza di patologie quali ipertensione arteriosa, cardiopatia ischemica e scompenso cardiaco potrebbe essere determinata sia da un processo intrinseco di invecchiamento dell’apparato cardiovascolare che comporta una riduzione della riserva funzionale degli organi che lo compongono, che da una più lunga esposizione ad altri fattori di rischio

Invasive pulmonary aspergillosis complicating allergic bronchopulmonary aspergillosis

Invasive pulmonary aspergillosis is a frequent complication in immunocompromised patients. The role of the prolonged use of steroids in predisposing to invasive aspergillosis has been recognized, but exceptionally described in asthmatic patients. We report the case of a 59-year-old woman with bronchial asthma treated with steroid therapy for a long time, who developed an invasive pulmonary aspergillosis with an unusual combination of invasive and allergic disease. It seems reasonable to think that allergic disease due to allergic bronchopulmonary aspergillosis (ABPA) preceded the terminal invasive process. Adjunctive therapy with antifungal agents in patients with ABPA is considered, since there is the risk of an invasive pulmonary aspergillosis