Appraising Hospital Performance by Using the JCHAO/CMS Quality Measures in Southern Italy

Objectives

The main objective of the present study was to estimate the uptake to quality indicators that reflect the current evidence-based recommendations and guidelines.

Methods

A retrospective review of medical records of patients admitted to two hospitals in the South of Italy was conducted. For the purposes of the analysis, a sets of quality indicators has been used from the Joint Commission on Accreditation of Hospital Organizations and Centers for Medicare & Medicaid Services. Four areas of care were selected: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical care improvement project (SCIP). Frequency or median was calculated, as appropriate, for each indicator. A composite score was calculated to estimate the overall performance for each area of care.

Results

A total of 1772 medical records were reviewed. The adherence rates showed a wide-ranging variability among the selected indicators. The use of aspirin and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for AMI, the use of ACEI or ARB for HF, the use of appropriate thromboembolism prophylaxis and appropriate hair removal for surgical patients almost approached optimal adherence. At the other extreme, rates regarding adherence to smoking-cessation counseling in AMI and HF patients, discharge instructions in HF patients, and influenza and pneumococcal vaccination in pneumonia patients were noticeably intangible. Overall, the recommended processes of care among eligible patients were provided in 70% for AMI, in 32.4% for HF, in 46.4% for PN, and in 46% for SCIP.

Conclusions

The results show that there is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. Improvement initiatives should be focused more on domains of healthcare than on specific conditions, especially on the area of preventive care.     

Potentially Pathogenic Acanthamoeba Isolated from a Hospital in Brazil

Studies on free-living amoebae (FLA), has been increased in recent years, especially related to the genus Acanthamoeba, because these organisms are widely found in the environment. The present work isolated and characterized this organism from biofilms and dust in hospital environment. 135 samples were collected in 15 different environments in a hospital at the south of Brazil. Thirty-one (23%) isolates were identified as morphologically belonging to the Acanthamoeba genus and 10 of these were submitted to temperature and osmotolerance tests as criterion for evaluation of the viability and pathogenicity. The tests indicate that four (40%) of these isolates could be potentially pathogenic because grew at high temperature (40°C) and osmolarity (mannitol 1 M). Some isolates genotypes were determined after ribosomal DNA sequencing. These data revealed that three dust isolates belong to T4, two biofilm isolates to T5 and one dust isolate to T3 genotype. Therefore, Acanthamoeba found in the hospital environment represents a risk for people that circulate there.     

Saint cults and political alignments in Southern Italy

Conclusion People are seldom able to account for the meanings implied in the particulars of the rituals, but the most important element in the interaction with the saint seems to be of a reciprocal character-exchange of gifts for miracles or protection. The saint cult can be seen as part of a total social phenomenon which articulates the symmetrical reciprocity in the interpersonal relationships in the social structure and asymmetrical relationships in the clientela system. The feasts amount to a popular gathering with multiple functions where all the activities that are being performed renew and confirm networks that constitute village solidarity. The saint cult also joins all these functions and meanings in a complex cultural-personal metaphor that relates expressions of reciprocity as instances of the underlying forms of the society.The saint cult does not merely express a metaphor.A metaphor uses imagery from one domain or level of experience to illuminate relationships, objects and processes in a different domain or at a different level. It follows from this that the domain of thought or experience which is being explicated by metaphor is that which metaphor is used to illuminate, not that from which the idioms of metaphor is fetched .There is also a formal similarity between the gift-giving to a patron saint and to a profane patron. But the rituals in the saint cults do not account for a divine justification of the order in the substantial world. On the contrary, the rituals of the saint cults use a known and common language of reciprocity to get hold of a difficult and inexplicable world. I thus argue that the rituals of the saint cults use idioms similar to the profane political and social relations to express the quality of the relationship between saint and devotee, but this in no way implies that the two domains are substantively confounded. The forms are part of the same world view that emphasizes reciprocity as the basis for social solidarity; receiving evokes obligations for return giving, a favor for a gift. Ritual is not a substitute for the world or displacement of action in it; it is part of, an expression of, a world articulated by those values/views of reciprocity. Consequently, the saint cults which have been analyzed here do not represent an alternative to political or other activities, but a continuation and a completion of that activity into the total means by which one seeks goals in a world so conceived.Mia Di Tota is associated with the Ethnographic Museum at the University of Oslo.

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Prevalence of Primary Fluoroquinolone Resistance Among Clinical Isolates of Helicobacter pylori at a University Hospital in Southern Taiwan

Background:  Fluoroquinolone-containing therapy is effective in eradicating Helicobacter pylori . However, the resistance rate of H. pylori to fluoroquinolones in Taiwan has not yet been reported. In this study, we aimed to investigate the susceptibility to antibiotics commonly used in eradication schedules and fluoroquinolones in H. pylori .
Methods:  A total of 210 clinical isolates of H. pylori were collected from April 1998 to September 2007 from patients in southern Taiwan. The in vitro activities of six antimicrobial agents were determined by the agar dilution method and Etest. The mutations in quinolone resistance-determining regions of gyrA and gyrB were investigated by direct sequencing.
Results:  Overall, 5.7% of the isolates were resistant to ciprofloxacin and levofloxacin. The resistance rate to amoxicillin, clarithromycin, metronidazole, and tetracycline was 1.0% (two of 210), 9.5% (20 of 210), 27.6% (58 of 210), and 0.5% (one of 210), respectively. The resistance rate to either ciprofloxacin or to levofloxacin increased from 2.8% (1998–2003) to 11.8% (2004–2007). The mutations in gyrA at N87 or D91 had an impact on primary fluoroquinolone resistance in H. pylori . Garenoxacin, but not moxifloxacin, had a good in vitro inhibitory effect against ciprofloxacin/levofloxacin-resistant strains compared with objective minimal inhibitory concentration values.
Conclusions:  Drug resistance to ciprofloxacin and levofloxacin in H. pylori collected from 2004 to 2007 increased significantly compared with resistance level observed during 1998–2003. The continuous surveillance of quinolone resistance among H. pylori is important in this area.     

Retrospective Analysis of 15 Cases of Penicilliosis marneffei in a Southern China Hospital

We retrospectively analyzed the medical records and clinical characteristics of 15 patients diagnosed with Penicilliosis marneffei (PSM) between January 1, 1993, and December 31, 2012, at the Third Affiliated Hospital of Sun Yat-sen University. The most common symptoms of PSM were fever (14/15, 93 %), cough (13/15, 87 %), and sputum production (6/15, 40 %), weight loss (14/15, 60 %), lymph node enlargement (9/15, 60 %), hepatosplenomegaly (7/15, 47 %), anemia (7/15, 47 %), and hemoptysis (4/15, 26 %). The most common underlying diseases in patients diagnosed with PSM were AIDS (9/15, 60 %), post-organ transplantation (3/15, 20 %), rheumatic autoimmune disease (2/15, 13 %), and hematological malignancy (1/15, 7 %). All patients, except those with AIDS, were treated with immunosuppressant drugs. White blood cell counts were increased in 10/15 (67 %) patients, while hemoglobin concentrations were decreased in 8/15 (53 %) patients. The ratios of CD4⁺/total T lymphocytes and CD4⁺/CD8⁺ T lymphocytes declined in all the 11 test cases. Nodular lesions or masses were the most common anomalies detected during computed tomography scans, but disseminated inflammation and interstitial changes were also seen. Clinical samples with positive culture results were obtained from sputum or secretions obtained by bronchoscopy, venous blood, percutaneous pulmonary puncture, bone marrow, or skin lesions. Between 1993 and 2003, only four cases of PSM, all connected with AIDS, were diagnosed, while 11 cases of PSM, with or without concurrent AIDS, were diagnosed between 2003 and 2012. Amphotericin B was used to control the disease in some cases. In conclusion, the occurrence of PSM, especially in patients without concurrent AIDS, has increased. The early culture of Penicillium marneffei from clinical samples is critical for correct diagnosis of PSM, and amphotericin B is recommended as the first choice for treatment.     

瘢痕子宫再次住院妊娠不同分娩方式的研究

目的:探讨瘢痕子宫妇女再次妊娠后采用不同分娩方式的临床效果,为今后瘢痕子宫产妇分娩提供可靠经验和指导.方法:选择从2011年5月至2012年10月在我院门诊检查并收住入院的120例瘢痕子宫再次妊娠孕妇,将120例再次妊娠产妇平均分为两组,分别是剖宫产组和阴道分娩组,对比两组孕妇产后新生儿窒息情况、产后出血及产后发热等情况.结果:通过统计后发现采用剖宫产组产妇在平均产后出血量、新生儿窒息等方面与阴道分娩组差异不大,但和初产妇剖宫产之间差距较多.结论:瘢痕子宫妇女再次妊娠后可以采用阴道分娩方式分娩,在分娩前后做好准备工作和产妇心理疏导,值得临床使用.     

Aflatoxin M1 in milk,in Southern Italy

A survey on the occurrence of aflatoxin M1 was carried out in the province of Bari (Italy) on a total of 106 samples of raw milk from local farms, commercially heattreated milk, and dried milk. About 72% of the samples were contaminated with aflatoxin M1 within the concentration range 4–280ng/Kg. The incidence of aflatoxin M1 was much higher in commercial milk (91%) than in farm milk (26%), and all the dried milk samples contained aflatoxin Ml (10 to 280ng per Kg of powder milk).     

Investigation of Fungal Contamination in Sheep and Goat Cheeses in Southern Italy

One hundred and twenty-two samples of cheeses made from goat and sheep milk and a mixture of the two types, produced in Southern Italy by industrial establishments or artisans, were analysed for the detection of fungal contamination and the presence of potentially toxigenic moulds. Only organoleptically acceptable cheeses without evident fungal contamination were studied. Among these, 40 were unripened, 30 medium and 52 long ripened cheeses. Moulds were found in 54 of the 122 analysed samples (44.3%). The most contaminated cheeses were the medium and long ripened ones (46.3% and 35.2%), and the industrial cheeses (59.1%). The artisan cheeses were the least contaminated (26.8%). Among the cheeses that tested positive, Penicillium species were the most frequently isolated (72.9%), followed by Geotrichum spp. (7.3%), Aspergillus spp. (4.2%) and Mucor spp. (4.2%). The potentially toxigenic species within the genera Penicillium, Aspergillus and Fusarium were mainly detected in sheep cheeses.     

Presence of Plant Viruses in some Rivers of Southern Italy

Water samples were collected from some rivers of Southern Italy whose water is normally used for irrigation and checked for the presence of plant viruses. The assayes were carried out by centrifuging at 5000x g one liter of water, resuspending the sediments in phosphate buffer and testing their infectivities on Chenopodium quinoa Willd. It was possible to isolate tobacco mosaic virus, cucumber mosaic virus and two more viruses not identified yet.     

Soil-Atmosphere Methane Exchange in Undisturbed and Burned Mediterranean Shrubland of Southern Italy

Soils represent the primary biotic sink for atmospheric methane (CH₄). Uncertainty is associated, however, with global soil CH₄ consumption because of the few data available from many areas and, in particular, from Mediterranean-type ecosystems. In this study, soil-atmosphere CH₄ exchange was measured for one year in a coastal Italian shrubland (maquis), from both undisturbed areas and areas treated with experimental fire. Although fire represents one of the most frequent disturbance factors in seasonally dry environments, very few studies in these ecosystems have focused on its effect on soil CH₄ fluxes. Significant differences in soil ammonium content, water content, and temperature were measured between burned and unburned plots, however, no statistical differences were observed for CH₄ fluxes. CH₄ fluxes varied between −0.39 and −16.1 mg CH₄ m⁻² day⁻¹ and temporal variations were mainly driven by variations in soil water content and temperature. The highest CH₄ oxidation rates were measured during the driest and warmest period. Low gravimetric soil water content in the top 10 cm, as well as high NH₄⁺ concentration, did not seem to reduce methanotrophic activity, suggesting that maximal CH₄ oxidation activity might take place deeper in the soil profile, at least during part of the year.     

Biology and monitoring of Dryocosmus kuriphilus on Castanea sativa in Southern Italy

• 1 The cynipid gall wasp Dryocosmus kuriphilus Yasumatsu (Hymenoptera: Cynipidae) is an invasive wasp in Europe and is one of the major pests of chestnuts worldwide. An investigation of this cynipid was started in Campania, Southern Italy, in 2008, with the aim of providing guidelines for its sustainable control.
• 2 The number of larvae/gall increased in the second year of colonization relative to the first one but thereafter decreased in the third year of colonization, whereas the volume of the galls after the initial increase in the second year of colonization became stable. Adult emergence generally peaked between the middle of June and July.
• 3 The only reliable method for assessing the presence of the pest at its earliest stage was through dissecting the buds because oviposition scars on the buds tended to disappear during the winter.
• 4 Yellow traps were shown to be an effective method for assessing the emergence of cynipid adults and could potentially be used to time chemical applications in those cases in which this control method is feasible.
• 5 No correlation was recorded between the relative durations of the final stages (pupae, pharate adults and emergence).
• 6 Possible control strategies for this invasive pest are discussed.

     

Dientamoeba fragilis in the North-East of Italy: Prevalence study and treatment

Dientamoeba fragilis is an intestinal protozoan, an inhabitant of the human gastrointestinal tract, with a worldwide distribution. The reported prevalence of D. fragilis varies worldwide in different populations between 0.3% and 82.9%, and its role as a pathogen is still unclear. The parasite has been identified in the faeces of asymptomatic patients and with different acute and chronic symptoms, like abdominal pain, diarrhoea, flatulence, nausea and vomiting.The aims of this study were to evaluate the prevalence of D. fragilis in the North-East of Italy, and the clinical improvement of symptoms after recommended treatment with paromomycin or metronidazole. Furthermore, a literature review of D. fragilis prevalence studies in Italy was carried out to show the Italian situation.Of 575 enrolled people, 85 (14.8%) were positive for D. fragilis. The most prevalent symptoms were abdominal pain 28.2%, anal itching 27.1%, watery diarrhoea 18.8%, meteorism 16.5% and nausea/lack of appetite 14.1%. The high rate of anal itching was unexpected, because it wasn't a common symptom. 32 patients were co-infected with B. hominis (37.7%) and three with G. lamblia (3.5%).Our study showed paromomycin had a high efficacy for treatment of D. fragilis infections 100.0% (45/45), while caution must be used when using metronidazole 53.3% (24/40). We recommend paromomycin for empirical treatment, given its great effectiveness in our population.     

Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis

While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.     

Cryptococcus gattii Infection in an Immunocompetent Patient from Southern Italy

Cryptococcus gattii has becoming more prevalent in temperate climate zones, during the past decades. We describe a C. gattii serotype B infection in an immunocompetent Italian patient with sclerosing cholangitis. The patient traveled once to Eastern Canada and otherwise no other countries than Italy were visited. Molecular analysis revealed that the C. gattii isolate belong to genotype AFLP4/VGI and has mating-type α which is the most common genotype in the Mediterranean environment. The C. gattii strain was found to be closely related, but not identical, to other C. gattii strains from the Mediterranean area.