Epidemiology and complications of late-onset sepsis: an Italian area-based study

BACKGROUND: Most studies regarding late-onset sepsis (LOS) address selected populations (i.e., neonates with low birth weight or extremely preterm neonates). Studying all age groups is more suitable to assess the burden of single pathogens and their clinical relevance. METHODS: This is a retrospective regional study involving paediatric departments and NICUs in Emilia-Romagna (Italy). Regional laboratory databases were searched from 2009 to 2012. Records of infants (aged 4 to 90 days) with a positive blood or cerebrospinal fluid (CSF) culture were retrospectively reviewed and analysed according to acquisition mode (whether hospital- or community-acquired). RESULTS: During the study period, there were 146,682 live births (LBs), with 296 patients experiencing 331 episodes of LOS (incidence rate: 2.3/1000 LBs). Brain lesions upon discharge from the hospital were found in 12.3% (40/296) of cases, with death occurring in 7.1% (23/296; 0.14/1000 LBs). With respect to full-term neonates, extremely preterm or extremely low birth weight neonates had very high risk of LOS and related mortality (> 100- and > 800-fold higher respectively). Hospital-acquired LOS (n = 209) was significantly associated with very low birth weight, extremely preterm birth, pneumonia, mechanical ventilation, and death (p< 0.01). At multivariate logistic regression analysis, catecholamine support (OR = 3.2), central venous line before LOS (OR = 14.9), and meningitis (OR = 44.7) were associated with brain lesions or death in hospital-acquired LOS (area under the ROC curve 0.81, H-L p = 0.41). Commonly identified pathogens included coagulase-negative staphylococci (CoNS n = 71, 21.4%), Escherichia coli (n = 50, 15.1%), Staphylococcus aureus (n = 41, 12.4%) and Enterobacteriaceae (n = 41, 12.4%). Group B streptococcus was the predominant cause of meningitis (16 of 38 cases, 42%). Most pathogens were sensitive to first line antibiotics. CONCLUSIONS: This study provides the first Italian data regarding late-onset sepsis (LOS) in all gestational age groups. Compared to full-term neonates, very high rates of LOS and mortality occurred in neonates with a lower birth weight and gestational age. Group B streptococcus was the leading cause of meningitis. Excluding CoNS, the predominant pathogens were Escherichia coli and Staphylococcus aureus. Neonates with hospital-acquired LOS had a worse outcome. Antibiotic associations, recommended for empirical treatment of hospital- or community-acquired LOS, were adequate

Group B Streptococcus early-onset disease and observation of well-appearing newborns

Background International guidelines lack a substantial consensus regarding management of asymptomatic full-term and late preterm neonates at risk for early-onset disease (EOS). Large cohorts of newborns are suitable to increase the understanding of the safety and efficacy of a given strategy. Methods This is a prospective, area-based, cohort study involving regional birth facilities of Emilia-Romagna (Italy). We compared cases of EOS (at or above 35 weeks\u2019 gestation) registered in 2003\u20132009 (baseline period: 266,646 LBs) and in 2010\u20132016, after introduction of a new strategy (serial physical examinations, SPEs) for managing asymptomatic neonates at risk for EOS (intervention period: 265,508 LBs). Results There were 108 cases of EOS (baseline period, n = 60; intervention period, n = 48). Twenty-two (20.4%) remained asymptomatic through the first 72 hours of life, whereas 86 (79.6%) developed symptoms, in most cases (52/86, 60.5%) at birth or within 6 hours. The median age at presentation was significantly earlier in the intrapartum antibiotic prophylaxis (IAP)exposed than in the IAP-unexposed neonates (0 hours, IQR 0.0000\u20130.0000 vs 6 hours, IQR 0.0000\u201315.0000, p<0.001). High number of neonates (n = 531) asymptomatic at birth, exposed to intrapartum fever, should be treated empirically for each newborn who subsequently develops sepsis. IAP exposed neonates increased (12% vs 33%, p = 0.01), age at presentation decreased (median 6 vs 1 hours, p = 0.01), whereas meningitis, mechanical ventilation and mortality did not change in baseline vs intervention period. After implementing the SPEs, no cases had adverse outcomes due to the strategy, and no cases developed severe disease after 6 hours of life. Conclusions Infants with EOS exposed to IAP developed symptoms at birth in almost all cases, and those who appeared well at birth had a very low chance of having EOS. The risk of EOS in neonates (asymptomatic at birth) exposed to intrapartum fever was low. Although definite conclusions on causation are lacking, our data support SPEs of asymptomatic newborns at risk for EOS. SPEs seems a safe and effective alternative to laboratory screening and empirical antibiotic therapy

Antifungal Activity of Some Essential Oils against Multi-Resistant Candida Strains

Resistance to oral antifungal drugs, such as fluconazole, ketoconazole, itraconazole for example, becomes a problem when the drugs are used or as prophylaxis or for frequent short-term exposures. Candida is a common fungus that is normally controlled by the immune system, but when immune system is suppressed, Candida can grow on mucous membranes or elsewhere in the body, causing symptoms known as candidiasis. HIV positive and HIV negative people may experience candidiasis and more and more strains become resistant to antifungal drugs. Very recent studies (Luqman et al.,2007) demonstrate that rosemary oil is a potential alternative compound to treat drug-resistant infections. Zambonelli (2004) demonstrated the fungicidal activity of Thymus vulgaris essential oil and the data is confirmed by the Italian Society of Gynecology and Obstetrics. In the present study we performed a screening on a series of essential oils with the aim to find new antifungal agents. Materials and Methods: Essential oils from Anethus graveolens, Mentha piperita, Rosmarinus officinalis and Thymus vulgaris were tested against multi-resistant strains of Candida (albicans, parapsilosis, krusei, glabrata, tropicalis, dubliniensis and guillermondi) from clinical specimens from HIV-seropositive subjects kindly supplied by the Department of Medicine Laboratory-Ospedale Policlinico-Modena. Qualitative analysis of the essential oils was performed by a gas chromatograph 6890-N, quantitative analysis by a gas chromatograph DANI 86-10 and a flame ionization detector (FID). Strains were cultured in Sabouraud Dextrose Liquid Medium (pH 5,6 ± 0,2 at 25°C). Fluconazole was chosen as reference drug. Sensitivity tests were performed in according with the NCCLS method for agar dilution and MIC values (minimal inhibitory concentration) were calculated. Results: Essential oils, characterized by variable percentages of p-cymene, gamma therpinene, tymol, sabinene and 1-8 cyneol, were diluted, added to Sabouraud dextrose liquid medium and evaluated for the antifungal activity in comparison with fluconazole (dilution from 200 to 0.1 mg/l). Thymus, Mentha and Rosmarinus appear to be the most active oils since the antifungal activity is maintained with very low dilution (>1000 of the mother solution) over 24 h and against the most of strains but in particular against C. albicans, C. tropicalis and C. krusei this latter responsible of fungal infections in newborns and small infants. On the same strains, fluconazole MIC is >100mg/l thus showing the presence of strong resistance to the drug. The very high percentage of 1-8 cyneol (14-25%), in Rosmarinus oil could represent a safety index in that the molecule is non toxic on Vero cell cultures, but the data is referred to the isolated compound. Conclusion: At the present we are unable to identify a compound responsible of the anti-fungal activity. No compound is present at the same percentage in all the oils we studied. The results we observed may be due or to the phytocomplex or to a molecule present even at very low concentration. The phytocomplex could reduce the toxicity of isolated compounds as camphora, camphene or alpha pynene. The interesting result is the very good antifungal activity exerted at very low dilutions. Further studies are to be performed to investigate both on the mechanism of action and to the presence of side effects

PARA-PARESI: UN RARO ESORDIO DI LINFOMA DI HODGKIN.

Il linfoma di Hodgkin (LH) è una patologia linfoproliferativa a cellule B, con peculiari caratteristiche cliniche, istologiche e immunofenotipiche. La patologia può diffondere dai linfonodi paravertebrali attraverso i forami intervertebrali in regione toracica o addominale causando compressione spinale. In casi rari può esordire con dolore, indebolimento degli arti inferiori e deficit sensitivi con successiva perdita del controllo degli sfinteri e para-paresi. Tale sintomatologia è più frequente nel decorso di malattia. Queste forme sono altamente resistenti alla chemioterapia

Solo febbre e tosse?

Anche situazioni molto comuni e banali, come un’infezione delle vie aeree associata a tosse insistente, in assenza di fattori predisponenti evidenti tranne, come nel nostro caso, una lassità ligamentosa degli arti inferiori, possono accompagnarsi a PMS e necessitare di attento follow-up per il rischio di sviluppo di complicanze, come pneumomediastino tensivo, pneumotorace e pneumopericardio, che, sebbene rare, possono richiedere procedure invasive d’urgenza. Raccomandazioni follow-up: limitazioni immediate, no voli aerei per 6 mesi o sport o attività fisiche violente; limitazioni potenzialmente a vita, attività con variazioni pressorie repentine, subacquea, paracadutismo ecc

Una strana addominalgia

L’angioedema ereditario è una rara patologia autosomica dominante causata da deficit congenito dell’inibitore di C1 esterasi. Questo deficit porta ad aumento del rilascio locale di mediatori vasoattivi, soprattutto la bradichinina, con maggior permeabilità dei piccoli vasi, accumulo di liquido extravascolare e quindi edema. Caratteristica dell’angioedema è il ripetersi di episodi che interessano il sottocute (estremità, volto, tronco e genitali) o la sottomucosa (intestino e laringe). L’episodio acuto può essere scatenato da un trauma, uno stato d’ansia, o insorgere spontaneamente. Quando è colpito il tratto gastrointestinale i pazienti presentano nausea, vomito e dolore addominale

Uno strano “ballo”

La malattia reumatica (MR) è in fase di recrudescenza a partire dagli anni ottanta. Insorge dopo 2 settimane da un episodio di faringite streptococcica, per danno anticorpale da anticorpi diretti contro la proteina M del SBA che cross reagiscono con proteine delle articolazioni, endocardio, e SNC. La diagnosi della MR si basa tutt’oggi sui criteri di Jones (revisionati nel 1992), mentre l’ecocardiografia costituisce il principale strumento per monitorare le lesioni valvolari mitraliche e aortiche che costituiscono la più grave complicanza della MR, pur essendo ancora controverso il ruolo dell’ecocardiografia nella diagnosi di lesioni non clinicamente evidenti. La terapia si basa sulla profilassi primaria con trattamento della faringite e sulla profilassi secondaria con benzatin-penicillina, la cui durata è variabile a seconda dell’entità dell’interessamento cardiaco da 5 anni a tutta la vita

Quando il vomito persiste

Le stenosi duodenali in età pediatrica sono più frequentemente di origine congenita, possono essere complete (atresia) o incomplete. Nelle incomplete si ha un restringimento del lume duodenale di natura intrinseca o estrinseca. Le cause più frequenti sono il diaframma duodenale, il difetto di rotazione, le briglie di Ladd e il pancreas anulare. Il pancreas anulare è caratterizzato da una banda di tessuto pancreatico che circonda la seconda parte del duodeno in continuità con la testa del pancreas restringendo il lume intestinale a tale livello. La sintomatologia principale è rappresentata dal vomito che si manifesta precocemente nelle stenosi complete; nelle forme incomplete la sintomatologia può essere più sfumata e tardiva quindi la diagnosi può rimanere misconosciuta a lungo. Di fronte alla presenza di vomito persistente è quindi importante, una volta escluse le cause più frequenti per età, proseguire con le indagini al fine di escludere quadri malformativ

Integrating Biological and Radiological Data in a Structured Repository: a Data Model Applied to the COSMOS Case Study

Integrating the information coming from biological samples with digital data, such as medical images, has gained prominence with the advent of precision medicine. Research in this field faces an ever-increasing amount of data to manage and, as a consequence, the need to structure these data in a functional and standardized fashion to promote and facilitate cooperation among institutions. Inspired by the Minimum Information About BIobank data Sharing (MIABIS), we propose an extended data model which aims to standardize data collections where both biological and digital samples are involved. In the proposed model, strong emphasis is given to the cause-effect relationships among factors as these are frequently encountered in clinical workflows. To test the data model in a realistic context, we consider the Continuous Observation of SMOking Subjects (COSMOS) dataset as case study, consisting of 10 consecutive years of lung cancer screening and follow-up on more than 5000 subjects. The structure of the COSMOS database, implemented to facilitate the process of data retrieval, is therefore presented along with a description of data that we hope to share in a public repository for lung cancer screening research

Three-point checklist of dermoscopy: A new screening method for early detection of melanoma

Background: Dermoscopy used by experts has been demonstrated to improve the diagnostic accuracy for melanoma. However, little is known about the diagnostic validity of dermoscopy when used by nonexperts. Objective: To evaluate the diagnostic performance of nonexperts using a new 3-point checklist based on a simplified dermoscopic pattern analysis. Methods: Clinical and dermoscopic images of 231 clinically equivocal and histopathologically proven pigmented skin lesions were examined by 6 nonexperts and 1 expert in dermoscopy. For each lesion the nonexperts assessed 3 dermoscopic criteria (asymmetry, atypical network and blue-white structures) constituting the 3-point method. In addition, all examiners made an overall diagnosis by using standard pattern analysis of dermoscopy. Results: Asymmetry, atypical network and blue-white structures were shown to be reproducible dermoscopic criteria, with a kappa value ranging from 0.52 to 0.55. When making the overall diagnosis, the expert had 89.6% sensitivity for malignant lesions (tested on 68 melanomas and 9 pigmented basal cell carcinomas), compared to 69.7% sensitivity achieved by the nonexperts. Remarkably, the sensitivity of the nonexperts using the 3-point checklist reached 96.3%. The specificity of the expert using overall diagnosis was 94.2% compared to 82.8 and 32.8% achieved by the nonexperts using overall diagnosis and 3-point checklist, respectively. Conclusion: The 3-point checklist is a valid and reproducible dermoscopic algorithm with high sensitivity for the diagnosis of melanoma in the hands of non-experts. Thus it may be applied as a screening procedure for the early detection of melanoma. Copyright (C) 2004 S. Karger AG, Basel