THE D.A.M.A. PROJECT AT TERNI HOSPITAL, ITALY

Experience shows how difficult it is for a person with disabilities to cope with the reality of a hospital, especially if he or she has an intellectual disability. The difficulty in carrying out even simple diagnostic and therapeutic manoeuvres, the complexity of the pathologies, the difficulty in relating to the patient all make it a real risk that many medical problems of patients with disa bilities are overlooked or denied altogether. The person with a disability has the right to all care, not only that related to his or her pa rticular pathology, but also that required for other specialist or general pathologies. The UN Convention clearly states the rights of p ersons with disabilities. The Italian Republic has implemented the UN\u27s declaration with Law 18/2009. The rights enshrined in Article 25 of the UN Convention are also concretely applied in the European Charter of Patients\u27 Rights. The right of people with disabilities to be treated on an equal and non-discriminatory basis is also recalled by His Holiness Pope Francis in his latest encyclical. The DA MA (Disabled Advanced Medical Assistance) Hospital project was created to guarantee the right to health and care of people with disabilities, always, by remodelling its diagnostic and care procedures. The CAD/DAMA Service of the Terni Hospital since 2018 has adopted the DAMA project and also since 2018 has been collaborating with the Seraficio Institute of Assisi. The aim of the CAD/DAMA Service is also to promote and implement research in this area of care and training for healthcare professionals on disability and related issues

Population trends of the fan mussel Pinna nobilis from Portofino MPA (Ligurian Sea, Western Mediterranean Sea) before and after a mass mortality event and a catastrophic storm

Two Pinna nobilis populations thriving inside the borders of the Portofino Marine Protected Area (MPA) (Ligurian Sea, western Mediterranean Sea) were monitored before (2012) and after (September 2018) a dire mass mortality event that, since September 2016, spread through the whole Mediterranean Sea. In Portofino MPA, recorded mortality rates reached values of 91.29% and 43.94% in the two populations. The presence of a Haplosporidium protozoan parasite, considered to be the main cause of the mortality episodes, was confirmed from histological evidence: sporocysts and plasmodia were observed in all the tubules of the digestive glands of the collected specimens. Moreover, a catastrophic storm hit the Ligurian coasts at the end of October 2018, causing considerable damages both below and above the surface; a new survey conducted in November 2018 showed the complete annihilation of the two studied populations, as a probable combination of the continued parasite infections and the mechanical impacts caused by the storm. Finally, in June 2020 the sites were monitored again looking for traces of recovery, but no new specimens were recorded, indicating that P. nobilis became virtually absent from the MPA

Endocarditis of Native Valve due to Proteus mirabilis: Case Report and Literature Review

AbstractEndocarditis due to Proteus mirabilis is very uncommon and the optimal surgical and/or antibiotic treatment is not well defined. Guidelines from the AHA and ESC recommend prolonged courses of combined antibiotic therapy but information regarding the clinical presentation, the choice of treatment, the surgical management, and the duration of therapy can only be taken from clinical cases reported in literature. We describe a case of native valve endocarditis due to Proteus mirabilis, successfully treated with antibiotic therapy alone with a review of the relevant literature on this topic

Impact of antimicrobial stewardship interventions on appropriateness of surgical antibiotic prophylaxis. How to improve

Background and Objectives: Surgical Site Infections (SSIs) are the most common healthcare-associated infections and represent a major clinical problem in terms of mortality, morbidity, length of stay and overall costs. The appropriateness of Surgical Antibiotic Prophylaxis (SAP) is a key component to reduce the SSIs while the inappropriateness is a major cause of some emerging infections and selection of antibiotic resistance, therefore increasing healthcare costs. For this reasons international and national guidelines have been developed to guide clinicians in the optimal use of SAP. The The overall compliance to these guidelines is poor, with a high heterogeneity and as a consequence there is no universally recognized intervention to improve the appropriateness of SAP. The antimicrobial stewardship program is a systematic approach to improve appropriateness of antimicrobial use, to optimize the treatment of infections and to minimize the adverse effects associated with antibiotic use, like antimicrobial resistance, toxicity and costs. We describe a successfully Antimicrobial Stewardship (AMS) intervention on SAP appropriateness. Material and Methods: The prospective study was conducted at “Santa Maria” tertiary hospital in Terni, Umbria, in 12 main surgical units and was organized in three subsequent phases . The hospital defined evidence-based guidelines for optimal use of SAP, approved a new workflow to optimize the process of ordering, dispensing, administering and documenting SAP and created a satellite pharmacy in the operative block . Phase 1: we analysed 2059 elective surgical cases from January to June 2018 for 3 SAP parameters of appropriateness: indication, choice, dose. Phase 2: in July 2018 an audit was performed to analyse the result ; we reviewed 1781 elective surgical procedures from July to December 2018 looking for the same 3 SAP parameters of appropriateness. Results: The comparative analysis between phase 1 and 2 has demonstrated that the correct indication has a significant improvement (p-value 0.00128), moving from 73.63% in phase 1 to 77.82% in phase 2. The choice of antibiotic has not shown any significant improvement (p-value 0.4863) . The correct dose significantly improved (p-value< 2.2 1016 ), rising from 71.75% in phase 1 to 86.19% in phase 2. The overall compliance had a significant improvement (p-value <5.6 1012) passing from 40.21% in tphase 1 to 51.15% in phase 2. Conclusions: Our prospective study demonstrated a model of succesfully antimicrobial stewardship intervention that improves appropriateness of SAP

Latency-aware composition of Virtual Functions in 5G

The adoption of the virtualization paradigm in both computing and networking domains portends a landscape of heterogeneous service capabilities and resources pervasively distributed and interconnected and deeply integrated through the 5G network infrastructure. In this service ecosystem, dynamic service demand can be flexibly and elastically accomplished by composing heterogeneous services provisioned over a distributed and virtualized resource infrastructure. Indeed, with the term Virtual Functions we refer to virtual computing as well as network service capabilities (e.g., routers and middlebox functions provided as Virtual Network Functions). In order to cope with the increasingly resource intensive demand, these virtual functions will be deployed in distributed clusters of small-scale datacenters typically located in current exchanges at the network edge and will supplement those deployed in traditional large cloud datacenters. In this work we formulate the problem of composing, computing and networking Virtual Functions to select those nodes along the path that minimizes the overall latency (i.e. network and processing latency) in the above mentioned scenario. The optimization problem is formulated as a Resource Constrained Shortest Path problem on an auxiliary layered graph accordingly defined. The layered structure of the graph ensures that the order of VFs specified in the request is preserved. Additional constraints can be also taken into account in the graph construction phase. Finally, we provide a use case preliminary evaluation of the proposed model

Listeria monocytogenes Brain Abscess: Controversial Issues for the Treatment—Two Cases and Literature Review

Listeria monocytogenes (LM) is an opportunistic pathogen, and the most common central nervous system manifestation is meningitis while listerial brain abscesses are rare. We describe 2 cases of brain abscess due to LM and a literature review. Only 73 cases were reported in the literature from 1968 to 2017. The mean age was 51.9, and the mortality rate was 27.3%. In 19% of cases, no risk factors for neurolisteriosis were identified. Blood cultures were positive in 79.5% while CSF or brain abscess biopsy material was positive in 50.8%. In 40% was started a monotherapy regimen while in 60% a combination therapy without substantial differences in mortality. Fifty-two percent underwent neurosurgery while 45.3% has been treated only with medical therapy. The mortality rates were, respectively, 13% and 38.2%. Only 25% of patients who were treated for ≤6 weeks underwent neurosurgery, while 80% of those who were treated for ≥8 weeks were operated. The mortality rates were, respectively, 12.5% and 0%, suggesting that a combined approach of surgery and prolonged medical therapy would have an impact on mortality. We believe that it is essential to carry out this review as brain abscesses are rare, and there are no definitive indications on the optimal management, type, and duration of therapy

THE D.A.M.A. PROJECT AT TERNI HOSPITAL, ITALY

Experience shows how difficult it is for a person with disabilities to cope with the reality of a hospital, especially if he or she has an intellectual disability. The difficulty in carrying out even simple diagnostic and therapeutic manoeuvres, the complexity of the pathologies, the difficulty in relating to the patient all make it a real risk that many medical problems of patients with disa bilities are overlooked or denied altogether. The person with a disability has the right to all care, not only that related to his or her pa rticular pathology, but also that required for other specialist or general pathologies. The UN Convention clearly states the rights of p ersons with disabilities. The Italian Republic has implemented the UN\u27s declaration with Law 18/2009. The rights enshrined in Article 25 of the UN Convention are also concretely applied in the European Charter of Patients\u27 Rights. The right of people with disabilities to be treated on an equal and non-discriminatory basis is also recalled by His Holiness Pope Francis in his latest encyclical. The DA MA (Disabled Advanced Medical Assistance) Hospital project was created to guarantee the right to health and care of people with disabilities, always, by remodelling its diagnostic and care procedures. The CAD/DAMA Service of the Terni Hospital since 2018 has adopted the DAMA project and also since 2018 has been collaborating with the Seraficio Institute of Assisi. The aim of the CAD/DAMA Service is also to promote and implement research in this area of care and training for healthcare professionals on disability and related issues

Impact of Antimicrobial Stewardship Interventions on Appropriateness of Surgical Antibiotic Prophylaxis: How to Improve

Surgical site infections (SSIs) are the most common healthcare-associated infections. The appropriate use of Surgical Antibiotic Prophylaxis (SAP) is a key component to reduce SSIs, while its inappropriate application is a major cause of some emerging infections and selects for antibiotic resistance. We describe an Antimicrobial Stewardship (AMS) intervention on SAP appropriateness. The prospective study was conducted in an Italian hospital, in 12 main surgical units, and was organized in three subsequent phases, as follows. Phase 0: Definition of hospital evidence-based guidelines and a new workflow to optimize the process of ordering, dispensing, administering and documenting the SAP. Phase 1: We analysed 2059 elective surgical cases from January to June 2018 for three SAP parameters of appropriateness: indication, choice and dose. Phase 2: In July 2018, an audit was performed to analyse the results; we reviewed 1781 elective surgical procedures from July to December 2018 looking for the same three SAP appropriateness parameters. The comparative analysis between phases 1 and 2 demonstrated that the correct indication, the correct dose and the overall compliance significantly improved (p-value 0.00128, p-value < 2.2·1016 and p-value < 5.6·1012 respectively). Our prospective study demonstrates a model of successful antimicrobial stewardship intervention that improves appropriateness on SAP

Antimicrobial Stewardship Program, COVID-19, and Infection Control: Spread of Carbapenem-Resistant Klebsiella Pneumoniae Colonization in ICU COVID-19 Patients. What Did Not Work?

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the “daily-ICU round strategy” and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4–5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization

Antimicrobial stewardship program, COVID-19, and Infection control. Spread of carbapenem-resistant klebsiella pneumoniae colonization in ICU COVID-19 patients. What did not work ?

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the “daily-ICU round strategy” and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4–5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization