Determinants of aggression against all health care workers in a large-sized university hospital

Background: The paper aims to describe the 3-year incidence (2015/17) of aggressive acts against all healthcare workers to identify risk factors associated to violence among a variety of demographic and professional determinants of assaulted, and risk factors related to the circumstances surrounding these events. Methods: A retrospective observational study of all 10,970 health workers in a large-sized Italian university hospital was performed. The data, obtained from the "Aggression Reporting Form", which must be completed by assaulted workers within 72 h of aggression, were collected for the following domains: Worker assaulted (sex, age class, years worked); profession (nurses, medical doctors, non-medical support staff, administrative staff, midwives); aggressive acts (activity type during aggressive acts, season, time and location of aggressive acts); and type of aggressive acts (verbal, non-verbal, consequences, aggressors). Results: Three hundred sixty-four (3.3%) workers experienced almost one aggression. The majority of the assaulted workers were female (77.5%), had worked for 6/15 years and were Nurses (64.3%). The majority of aggressive acts occurred during assistance and patient care (38.2%), in the spring and during the afternoon/morning shifts and took place in locations where patients were present (47.3%). The most prevalent aggression type was verbal (76.9%). The patient was the most common aggressor (46.7%). 56% of those assaulted experienced interruptions in their work. Being female, being < 50 years of age, having worked for 6-15 years were significant risk factors for aggression. Midwives suffered the highest risk of experiencing aggression (RR = 12.95). The risk analysis showed that non-verbally aggressive acts were related to assistance and patient care with respect to activity type, to the presence of patients and during the spring and afternoon/evening. Conclusions: The findings suggest the parallel use of future qualitative studies to clarify the motivation behind aggression. These suggestions are needed for the implementation of additional adequate prevention strategies on either an organizational or a personal level

Nutritional deficiency as a complex cause of reversible dementia and cutaneous manifestations in elderly: case report and review

Introduction: vitamin deficiency can be an important cause of cognitive impairment and cutaneous manifestations in elderly with a history of malnutrition. However, to understand the different etiologies and to choose the right one to proper disease management might not be an easy task, especially in individuals from this population with these findings, sometimes non-specific. Hypothesis of reversible dementia associated with pellagra and B12 vitamin are important. In the case of electrolytes deficiency, less likely, there is the hypothesis extrapontine osmotic demyelination syndrome. The following case discuss these findings together. Objective: to present a case of reversible dementia and cutaneous manifestations associated with vitamin deficiency in a context of neurological complication after untimely correction of sodium; to discuss pathophysiological processes relevant to the case. Case report: A 62-year-old woman in meat restriction for 1 year, with post-radioiodine hypothyroidism. Admitted to investigate well delimited erosions with scaling, hyperchromia and blisters in both hands and glabella. The major hypothesis at the time was pellagra. However, in few weeks she developed other clinical findings: food intolerance, pain and abdominal distension and some sort of cognitive impairment. Computed tomography (CT) of the abdomen showed fluid distention with air level throughout the colonic frame and distal segment of the ileum, without obstructive factors. There is loss of the usual haemorrhages of the sigmoid and descending colon, suggesting chronic alterations. Rectosigmoidoscopy was performed and parental feeding was introduced. There was evolution with improvement of cutaneous lesions and development of hyponatremia, followed by anemia, reduction of level of consciousness and hemodynamic instability. Magnetic resonance imaging presented changes suggestive of extra-pontine myelinolysis associated with hyponatremia. Laboratory tests revealed anti-parietal cell antibody with a 1/160 reagent result, upper digestive endoscopies compatible with atrophic gastritis and gastric polyps with absence of active or previous bleeding. Following the infirmary, the patient achieved a progressive improvement in the level of consciousness and dementia, resuming most of the cognitive functions. The hypothesis of extrapontine myelinolysis associated with the correction of hypernatremia and pellagra, secondary to the vegan diet was suggested by radiologists. Discussion: the case discussed is a probable reversible dementia associated with vitamin deficiency. Factors suggestive of this context were: dermatological lesion, restricted diet to meat, atrophic gastritis in upper digestive endoscopy and progressive dementia during hospitalization. As a confounding factor, there was an untimely correction of hyponatremia with findings suggestive of extrapontine myelinolysis according to the radiology team, which could have contributed to the dementia symptoms, though less likely. Conclusion: Pellagra and other nutritional deficiencies should be considered in the diagnosis of patients with restrictive diets, especially those with gastrointestinal tract disorders. The correction of hypernatremia, when present, should be adjusted with caution, aiming at the protection of the central nervous system

Thrombotic storm and malignancy in elderly woman: a case report

Introduction: Thrombotic storm is a state of hypercoagulability of relevance in the context of neoplasias, trauma, gestation, autoimmune diseases and deficiencies of coagulation proteins. The following case brings this topic associated with weight loss and a subsequent atypical primary site of neoplasm found in postmortem biopsy. Objectives: To present an atypical case of thrombosis in several sites in elderly women in a context of consumptive syndrome without definite primary cancer site; to discuss differentials and pathophysiological processes relevant to the case. Case report: A 74-year-old female patient, previously healthy, presented a constipation associated with weakness in right superior limb, edema and weakness of left lower limb, with difficulty in gait and subsequent bed restriction. It evolved with multiple thrombotic events (axillary arterial, segmental branches of the left pulmonary artery, hepatic, renal and splenic parenchymal infarction, deep venous thrombosis in the common femoral vein, superficial femoral vein and left femoral vein, and right superficial femoral vein thrombosis). Abdominal computed tomography (CT) showed hepatic nodules suggestive of metastases and lymph node enlargement up to 2.0 cm. Hepatic biopsy was performed by interventional radiology resulting inconclusive due to extensive areas of necrosis. Laboratory tests revealed hepatic enzymes, canalicular and direct bilirubin with increased and increasing values, normochromic normocytic anemia worsening and with increasing values of RDW and platelets. Ca19.9 accounted for &gt; 1,000 U / mL. FAN, anticardiolipin IgM and IgG, lupus anticoagulant, ANCA negative. Death verified 12 days after admission, despite intensive care. Necroscopic report showed adenocarcinoma centered in bile ducts involving gallbladder and extra and intrahepatic bile ducts with vascular dissemination (pulmonary and lymph node metastases) and extension to gastric wall and small intestine. Post-mortem diagnosis of cholangiocarcinoma was performed. Discussion: the case discusses is of multiple thrombotic events in unusual sites associated with non-specific findings at the beginning. The hypothesis of phospholipid antibody syndrome (APS) was proposed although it is unlikely in an elderly patient. Subsequent evaluation for thrombophilias was not done since weight loss and abdominal CT with multiple hepatic nodules suggested neoplasia of indeterminate site. Hence, SAF was discarded and the patient died without diagnosis of primary site due to the difficulty of the case. Conclusion: neoplasia of uncommon sites can be a disease of hard diagnosis and management especially in patients worsening in a short time. However they must be considered with proper investigation in patients with multiple thrombotic events due to the very known association with these findings