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This in vitro study was aimed to assess the efficacy of dry steam in inactivating Human Coronavirus OC43 (HCoV-OC43) as surrogate of SARS-CoV-2, Human Influenza Virus A/H1N1/WSN/33 and Echovirus 7 on stainless steel, polypropylene, and cotton. The virus models were chosen on the basis of their transmission route and environmental resistance. Tests were carried out under a laminar flow cabinet, where two panels of each material were contaminated with a viral suspension. The inocula were left to dry and then the virus on untreated panel (control) was collected by swabbing in order to determine the initial titer. The other panel was treated using a professional vacuum cleaner equipped with a dry steam generator. Dry steam is generated in a boiler where tap water is heated up to 155 °C at 5.5 bar pressure and then during the passage along the flexible hose the temperature decreases to a value between 100 °C and 110 °C at the output. The dry steam was applied for four sec with a window wiper on metal and plastic panels or a brush covered by a microfiber cap on cotton, simulating the steam application during routine cleaning. After the treatment, infectious virus possibly remained on the surface was collected following the same swabbing procedure applied for controls. HCoV-OC43 and Echovirus 7 were titrated by end-point method on HCT-8 line cells and Vero cells, respectively, while Human Influenza Virus was quantified by plaque reduction assay on MDCK cells. Dry steam resulted effective against the three viruses on all tested materials, achieving a mean Log10 reduction factor ≥4 in viral titer of treated samples compared with controls according to UNI EN 14476:2019. Thus, dry steam may be proposed as an ease to use, effective, fast, and nontoxic alternative to chemicals for surface disinfection without damaging materials. Therefore, this device could be employed not only in healthcare facilities but also in occupational, domestic, and community settings, with advantages for environment and human health.

BACKGROUND: Our objective was to measure hand bacterial contamination in a group of nursing and medical Italian students attending clinical wards for practical training, in order to verify the reliability of the information on hand hygiene (HH) adherence obtained by a self-reporting questionnaire. This questionnaire was administered with the aim to explore the effectiveness of basic education. METHODS: An anonymous questionnaire designed to investigate HH knowledge and practices was administered to a convenience sample of 100 nursing and 100 medical students. Data collected were combined with hand bacterial contamination measured both at the entry and the exit from the ward. RESULTS: HH practices and knowledge were significantly higher in nursing compared to medical students.. The most effective procedure in reducing bacterial contamination was the alternate use of handwashing and handrubbing compared to only one practice and the absence of hand hygiene (geom. mean: 180.3, 410.2 and 907.4 CFU/hand respectively, p Hand contamination was significantly higher in students who declared to hardly ever/never implement HH teaching during clinical practice compared to those who stated to have done it frequently/always (geom. mean: 716 vs 277.1 CFU/hand, p CONCLUSION: Our investigation adds something new to the topic of HH that is the measure of bacterial hand contamination to verify the reliability of the information obtained by questionnaire. The findings, pointing out some critical aspects in the HH teaching among healthcare students, highlight that solid knowledge results into correct behaviors, and consequently into a reduction of hand contamination.

Antenatal care (ANC) is considered a cornerstone of reproductive health programmes, but many women face difficulties in accessing these services, particularly in some sub-Saharan African countries, such as Tanzania. This study aimed to test ANC visit acceptability using mHealth system PANDA (Pregnancy And Newborn Diagnostic Assessment) in the Mufindi district (Tanzania). We investigated the ANC visit acceptability of pregnant women and healthcare workers (HCWs) in an intervention area using the PANDA system compared with a control area. An ad hoc questionnaire was administered to pregnant women in an implementation area (n = 52) and in a control area (n = 46). In the implementation area, group interviews with 50 pregnant women were conducted and five HCWs evaluated ANC visits through a questionnaire. The implementation group was significantly more satisfied with the ANC visit compared with the control group. All the 52 women and the HCWs declared that PANDA icons were useful in understanding and remembering the provided information and the PANDA app was able to improve the ANC quality and to positively influence the relationship of HCWs and pregnant women. HCWs reported that the PANDA app was “easy-to-use” and “able to improve the adherence to ANC WHO recommendations”. In underserved areas, many pregnant women could benefit from the PANDA system increasing their access to high-quality ANC and overcoming language and/or literacy barriers.

Over the last four decades, childhood overweight/obesity has dramatically increased, becoming a significant public health concern. The main aims of this study were to investigate the prevalence of overweight/obesity among first-year primary schools children in Modena and to identify the associated risk factors. Data were collected on the socio-demographic characteristics of family and weight, height, dietary habits and sedentary behaviours of the children, and on the parents' perception of their child's weight status, through an anonymous questionnaire administered to parents. The questionnaires were delivered by 660 out of 890 (74.2%) families, and after excluding those without anthropometric data, 588 children were included in the study. The prevalence of overweight/obesity among the children was 25.2%, significantly lower in children born to parents with a high education, and higher among children born to foreign parents and overweight/obese mothers. The multivariable analysis showed that the children most likely to become overweight/obese were those who skipped breakfast (OR 2.3, 95%CI 1.3-4.2) and/or mid-morning snacks (OR 3.2, 95%CI 1.5-6.5). Breakfast consumption was positively associated with higher parental education levels, whereas skipping mid-morning snacks is more frequent among children born to foreign parents and overweight/obese mothers. Moreover, 84.7% of the parents of overweight/obese children underestimated their child's weight status. One in four 6-7 year-old children is already overweight or obese. Childhood overweight/obesity is significantly associated with unhealthy lifestyles and family lifestyle. It is therefore essential to implement public health intervention programs aimed at both parents and children, in order to promote healthy lifestyles in early childhood.

The results of a voluntary screening campaign for the presence of anti-SARS-CoV-2 serum antibodies are presented, performed on workers in the highly industrialized province of Modena in northern Italy in the period 18 May–5 October 2020. The employment activities of the subjects that tested positive for anti-SARS-CoV-2 IgM and/or IgG antibodies were determined and classified using the International Standard Industrial Classification of All Economic Activities (ISIC). The distribution across different sectors was compared to the proportion of workers employed in the same sectors in the province of Modena as a whole. Workers with anti-SARS-CoV-2 serum antibodies were mainly employed in manufacturing (60%), trade (12%), transportation (9%), scientific and technical activities (5%), and arts, entertainment and recreation activities (4.5%). Within the manufacturing sector, a cluster of workers with positive serological tests was observed in the meat processing sector, confirming recent data showing a possible increased risk of SARS-CoV-2 infection in these workers.

Background In Tanzania, maternal and neonatal mortality is still high, mainly due to poor quality of Antenatal Care (ANC) and Post Natal Care (PNC) services. PANDA (Pregnancy And Newborn Diagnostic Assessment) is a telemedicine system that uses mobile technology to perform adequate ANC/PNC visits according to WHO recommendations. Two pilot studies showed that PANDA is efficient in providing high-quality ANC and facilitating the continuity of care for underserved communities. This project aims at testing the impact of PANDA in Tanzania for improving the adherence to both ANC and PNC WHO protocols. Methods This case-control study is conducted in two different areas of the Mufindi district, Tanzania. The PANDA system includes: - solar backpack containing instrumentation for communicable and non-communicable diseases screening; smartphone with an icon-based application, including 5 modules: socio-demographic information, medical history, clinical screening, health education and birth plan, postnatal care;hospital database with the data collected during the visits. Results At present, 405 women (1,066 ANC visits) were recruited in the implementation site and 200 in the control site. The preliminary results show that 60% of women attended ≥ 2 ANC visits in the implementation site. In this area, 52 women were found positive for HIV and 4 for syphilis. Data collection in both the sites is ongoing. Conclusions PANDA system allows the creation of electronic patient records and the identification of the high-risk pregnancies. The collection of population data is useful for health planning policies. The easy-to-use and easy-to-understand graphic interface overcomes language and literacy barriers and facilitates comprehension of women and compliance to visits. This can improve the quality of ANC/PNC services with an expected reduction in maternal and neonatal mortality. Key messages PANDA system increases access to high-quality ANC for pregnant women in low-income countries, improving the adherence to WHO recommendations. The telemedicine system PANDA is a useful tool for public health policy-makers, as it allows the collection of previously unavailable population data.

Background Childhood overweight/obesity can be influenced by food habits, but also by poor physical activity and excessive use of screens. The aim of this study was to investigate physical exercise and sedentary behaviours of children attending the first year of primary schools in Modena, and their association with weight status of children and characteristics of family. Methods We involved 890 children attending the first classes of 15 primary schools in Modena. The physical and sedentary activities of child were examined through an anonymous questionnaire administered to the parents. Sociodemographic characteristics of family, weight and height of child and parents were also collected. Univariate logistic regression models, eventually adjusted for parents' sociodemographic characteristics, were used to analyse data. Results Filled questionnaires were 660 out of 890 families (74.2%), of which 72 without anthropometric data were excluded. The prevalence of overweight/obesity was 25.2% without difference of gender. Less than 25% of children did physical activity per ≥7 hours per week; most children (about 40%) did 2 to 4 hours per week. There was no association between time spent in physical activity and overweight/obesity of children. From multivariate analysis, the habit significantly affecting children's overweight/obesity was spending time on tablets, PCs, mobile phones, videogames (OR = 2.2, CI 95%: 1.4-3.6). Children screen time ≥2 hours daily (63.9%) was associated with parents' low education level and father's weight status. Conclusions Our results suggest the need of educational interventions aimed to increase time spent in physical activity, and to promote a responsible use of digital media, by actively involving both children and parents. Key messages Children screen time ≥2 hours daily is strongly associated with childhood overweight/obesity. High education level of parents can positively affect lifestyles of their children.

Background Thermal mud therapy alone or in combination with thermal water baths is widely used in clinical practice for the management of rheumatic and dermatologic diseases in many countries. Despite its long history and tradition, its biological action and its clinical effectiveness are still not clear. The aim of this systematic review is to synthetize the current evidence on the mud therapy effects on pain, function and quality of life in patients with rheumatic and dermatologic diseases. Methods PubMed/Medline, Embase, and Cochrane Library were searched for articles about the comparative effectiveness of mud therapy alone or combined with other therapies on pain, function and quality of life in adults with rheumatic or dermatological diseases without any restrictions of severity. Studies were searched up to 15 October 2019. We included randomized and non-randomized trials and comparative cohort studies, as well as non-comparative case series and case reports only for safety outcomes. The following outcomes were considered: pain assessed by validated scales or through painkillers drugs consumption, function (i.e. muscle tone, joint motility and stiffness) assessed by validated scores, quality of life and autonomy assessed by validated scales and adverse events. Laboratory inflammation parameters were investigated as secondary outcomes. Results A total of 2,455 articles were retrieved through database search, remaining 1,914 records after duplicates removed. The selection by title and abstract led to include 140 studies for full-text evaluation. The screening of full-text is still being carried out. The majority of 140 records assess the effects of mud therapy in patients with osteoarthritis (51 articles), osteoarthrosis (12) and psoriasis (10). Conclusions Our results will provide a synthesis of the current evidence on the mud therapy effectiveness, useful to evaluate its inclusion within clinical protocols for the treatment of rheumatic and dermatologic diseases. Key messages The majority of studies report the treatment with mud for rheumatic diseases. The synthesis of the evidence is useful to evaluate the mud therapy as treatment for rheumatic and dermatologic diseases.

The formation of potentially carcinogenic N-nitrosamines, associated with monochloramine, requires further research due to the growing interest in using this biocide for the secondary disinfection of water in public and private buildings. The aim of our study was to evaluate the possible formation of N-nitrosamines and other toxic disinfection by-products (DBPs) in hospital hot water networks treated with monochloramine. The effectiveness of this biocide in controlling Legionella spp. contamination was also verified. For this purpose, four different monochloramine-treated networks, in terms of the duration of treatment and method of biocide injection, were investigated. Untreated hot water, municipal cold water and, limited to N-nitrosamines analysis, hot water treated with chlorine dioxide were analyzed for comparison. Legionella spp. contamination was successfully controlled without any formation of N-nitrosamines. No nitrification or formation of the regulated DBPs, such as chlorites and trihalomethanes, occurred in monochloramine-treated water networks. However, a stable formulation of hypochlorite, its frequent replacement with a fresh product, and the routine monitoring of free ammonia are recommended to ensure a proper disinfection. Our study confirms that monochloramine may be proposed as an effective and safe strategy for the continuous disinfection of building plumbing systems, preventing vulnerable individuals from being exposed to legionellae and dangerous DBPs.

Many disinfection treatments can be adopted for controlling opportunistic pathogens in hospital water networks in order to reduce infection risk for immunocompromised patients. Each method has limits and strengths and it could determine modifications on bacterial community. The aim of our investigation was to study under real-life conditions the microbial community associated with different chemical (monochloramine, hydrogen peroxide, chlorine dioxide) and non-chemical (hyperthermia) treatments, continuously applied since many years in four hot water networks of the same hospital. Municipal cold water, untreated secondary, and treated hot water were analysed for microbiome characterization by 16S amplicon sequencing. Cold waters had a common microbial profile at genera level. The hot water bacterial profiles differed according to treatment. Our results confirm the effectiveness of disinfection strategies in our hospital for controlling potential pathogens such as Legionella, as the investigated genera containing opportunistic pathogens were absent or had relative abundances &le, 1%, except for non-tuberculous mycobacteria, Sphingomonas, Ochrobactrum and Brevundimonas. Monitoring the microbial complexity of healthcare water networks through 16S amplicon sequencing is an innovative and effective approach useful for Public Health purpose in order to verify possible modifications of microbiota associated with disinfection treatments.

Innovative migrant-friendly tools are needed to assist health personnel manage the high number of pregnancies within reception centers. This study tests functionality and acceptability of a new mHealth system in providing antenatal care amongst migrants. The study, carried out between 2014 and 2016, involved 150 pregnant women residing in the largest European migrant reception center in Sicily. A ticket tracking system assessed the system's functionality and a questionnaire assessed women's acceptability. The system facilitated the collection of clinical data, enabling the creation of electronic patient records and identifying 10% of pregnancies as high-risk. The application's digital format increased health providers' adherence to antenatal-care recommendations, while the graphic interface facilitated women's engagement and retention of the health education modules. The study recorded a 91.9% patient satisfaction rate. The system was efficient in providing comprehensive and high-quality antenatal care amongst migrants, facilitating the continuity of care for a population undergoing frequent relocations.

Three cases of pneumonia caused by Legionella pneumophila serogroup 1 (Lp1) in immunosuppressed patients with repeated hospitalization were suspected as a healthcare-associated cluster. The environmental investigation did not reveal the presence of legionellae in the hospital patient rooms. Water samples collected from the homes of two patients were also negative for Legionella spp. In the absence of environmental strains potentially involved in the infections, we proceeded to genotype environmental Lp1 strains isolated in the hospital during routine water sampling during the decade 2009–2019 and recovered after long-term storage at −20 °C. These ‘historical’ strains exhibited a high grade of similarity and stability over time, regardless of the disinfection systems. The different molecular profiles shown among the clinical and environmental strains excluded a nosocomial outbreak. The study suggests that the application of molecular typing may be a useful tool to discriminate hospital vs community-acquired cases, mostly for severely immunosuppressed patients in whom the symptomatology could be insidious and the incubation period could be prolonged. Moreover, the genotyping allowed us to exclude any link between the cases. Keywords: Legionnaires’ disease, Immunosuppressed patients, Sequence-based typing, Cluster, Environmental strains, Clinical strains

In this study, the corrosion resistance of commonly used plumbing materials was evaluated when three disinfection treatments were applied in hot water distribution systems. In particular copper, br...

ObjectiveMedication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including abest possible medication history(BPMH) compared with a standard medication history in patients admitted to an internal medicine ward.DesignProspective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model.SettingInternal medicine ward in a secondary care hospital in Southern Switzerland.ParticipantsThe first 100 consecutive patients admitted in an internal medicine ward.Primary and secondary outcome measuresMedication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified.ResultsThe median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model.ConclusionEven in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.

In literature, the microbial diversity of hot spring waters has been the focus of extensive research, while there is a paucity of studies on thermal water distribution network of spa centres and, as yet, no studies have been carried out on the bacterial population of thermal muds. In this context, the aim of our study is to characterize the microbial community of sulphurous-bromine-iodine thermal water and mud within an Italian spa complex using Next Generation Sequencing (NGS) technologies. This is the first report of microbiome characterization along a water supply network from the spring to points of use within a spa. According to the 16S rRNA gene sequences analysis, our data highlight the presence of a typical microbial community, mainly composed of sulphur-cycling bacteria belonging to Desulfomonile, Thermodesulfovibrio, Geothermobacterium, Thermus, Thiofaba and Syntrophomonas genera. In addition, the characterization and evolution of the bacterial community in thermal muds during the maturation process is investigated for the first time. Interestingly, the microbiome of mature mud resulted dominated by bacteria capable of lipid biosynthesis, suggesting that these bacteria may play a role in the anti-rheumatic properties of thermal mud.

Selenium is a metalloid of considerable interest in the human from both a toxicological and a nutritional perspective, with a very narrow safe range of intake. Acute selenium intoxication is followed by adverse effects on the nervous system with special clinical relevance, while the neurotoxicity of long-term overexposure is less characterized and recognized. We aimed to address this issue from a public health perspective, focusing on both laboratory studies and the few epidemiologic human studies available, with emphasis on their methodological strengths and limitations. The frequently overlooked differences in toxicity and biological activity of selenium compounds are also outlined. In addition to lethargy, dizziness, motor weakness and paresthesias, an excess risk of amyotrophic lateral sclerosis is the effect on the nervous system which has been more consistently associated with chronic low-level selenium overexposure, particularly to its inorganic compounds. Additional research efforts are needed to better elucidate the neurotoxic effects exerted by selenium overexposure.

The development of rapid and sensitive methods for the detection and quantification of Legionella viable cells is essential for monitoring water quality and preventing legionellosis. The aim of this study was to verify the applicability of a quantitative PCR (qPCR) method used in combination with ethidium monoazide (EMA) to the quantification of Legionella spp. in samples collected from swimming pools, water recirculation systems and hot water systems in two fitness clubs. This molecular technique (EMA–qPCR) allows the amplification of target DNA from culturable and viable cells, but prevents the amplification of DNA from non-viable cells. The effectiveness of this new method able to detect alive legionellae was also compared with conventional qPCR and culture method. Our results confirm that EMA–qPCR allows to discriminate the non-viable cells from those viable and that it is particularly indicated for monitoring the effectiveness of thermal treatments for the Legionella contamination control in water environments, also providing information about the presence of Viable But Non-Culturable (VBNC) cells. Other Gram-negative bacteria typically associated with biofilm were identified in samples taken from swimming pools and balance tanks, suggesting that also the presence of biofilm should be monitored for a more general view of water contamination.

Legionella colonization in hospital hot water distribution networks was evaluated following 36 months of continuous treatment with monochloramine and compared with chlorine dioxide. Nitrite, nitrate, chlorite, chlorate, bromide, trihalomethanes and haloacetic acids as well as the biocide concentration at sampled points were measured. Only 8/84 samples treated with monochloramine were found contaminated and after the first 8 months of treatment no Legionella was isolated. Chlorine dioxide was associated with a strong reduction in Legionella contamination compared to pre-treatment, but differences according to the device were observed. Monochloramine between 2 and 3 mg l−1 and chlorine dioxide between 0.50 and 0.70 mg l−1 were needed to control Legionella colonization. Comparing no- and post-flush samples, a higher frequency of no-flush positive samples was noted using chlorine dioxide, suggesting an increased risk for patients when they open the tap. No increase in chlorite levels and no water nitrification occurred by using monochloramine. Chlorite at levels exceeding the limit requested for drinking water was measured when chlorine dioxide was applied. In conclusion, we highlight that continuous injection of monochloramine should be considered as an effective alternative to chlorine dioxide in controlling legionellae contamination inside hospital water distribution systems.

The aim of this study was to investigate the concentrations of five essential (Fe, Mn, Zn, Cu and Se) and four non-essential/toxic elements (Cr, Cd, Ni and Pb) in 35 different starter infant formulas (0-6 months) sold in Italy. In addition, a safety assessment of these trace elements was carried out, by comparing the estimated daily intake (EDI) with the adequate intake (AI) and the provisional tolerable daily intake (PTDI), with a view to provide information on the metal distribution patterns and health risk to infants arising from the consumption of these products. The concentrations were determined by using inductively coupled plasma mass spectrometry after microwave digestion. The concentrations expressed in geometric mean ± geometric standard deviation of Fe (6.17 ± 1.61 mg/L), Zn (6.21 ± 1.31 mg/L), Cu (416.4 ± 1.21 μg/L), Mn (121.5 ± 1.85 μg/L) and Se (13.27 ± 1.67 μg/L) were within legal limits. In spite of this, the mean EDIs of Fe (4.81 mg/day) and Mn (94.75 μg/day) were many times higher than the recommended AI, especially for Mn. Chromium, Ni, Cd and Pb concentrations were not detectable in 11, 37, 57 and 66% of the samples, respectively. Considering the overall sample, the GM ± GSD of these elements were 4.80 ± 5.35 μg/L for Cr, 1.02 ± 11.65 μg/L for Ni, 0.21 ± 14.83 μg/L for Cd and 0.14 ± 17.13 μg/L for Pb. The mean EDIs were far below the respective PTDI. When the safety assessment was based on the 75° percentile level of each elements, all EDIs remained well below the PTDI, with the exception of Cd, whose EDI approached (74.7%), albeit remaining below the PTDI. In conclusion, our results and the increased awareness on the potential risks of excessive Mn and Fe for infants support that an urgent scientific-based definition of the appropriated levels of fortification in formulas is required. Moreover, regular monitoring of all the stages of production of infant formulas is essential in order to limit toxic metal contamination.

Three Legionella pneumophila strains isolated from water samples and belonging to serogroups (sgs) 1, 6 and 9 were analysed for their capacity to colonise an experimental model simulating a domestic hot water distribution system. Ecological factors that could influence the persistence of the sgs such as intracellular life within protozoan hosts and bacterial interference by the production of antagonistic compounds were also studied. Viable counts of L. pneumophila increased both in the planktonic and in the sessile phases. Sg 6 showed a marked prevalence during the whole experiment and exhibited the highest host infection efficiency. Sg 1 was significantly less represented, but showed the highest capacity to reproduce in the protozoan hosts. Sg 9 was poorly represented and less adapted to intracellular life. Among the 14 bacteria constantly isolated in the system, five (35.7%) produced antagonistic substances against Legionella, with differences according to the bacterial strain and L. pneumophila sgs.

Aims: To compare the standard culture method with a new, rapid test (ScanVIT-Legionella™) using fluorescently labelled gene probes for the detection and enumeration of Legionella spp. The new technique was validated through experiments conducted on both artificially and naturally contaminated water and through an inter-laboratory comparison. Methods and Results: All samples were processed by the ScanVIT test according to the manufacturer’s instructions and by a culture method (ISO 11731). ScanVIT detected significantly more positive samples, although concentrations were similar and a strong positive correlation between the two methods was observed (r = 0·888, P

Extremely Low Frequency-Magnetic Fields (ELF-MF) are possible carcinogens to humans and some data suggest that they can act as promoters or progressors. Since NK cells play a major role in the control of cancer development, an adverse effect on ELF-MF on NK function has been hypothesized. We examined NK activity in 52 workers exposed to different levels of ELF-MF in various activities. Individual exposure was monitored during 3 complete work-shifts using personal dosimeters. Environmental exposure was also monitored. ELF-MF levels in the workers were expressed as Time-Weighted Average (TWA) values. NK activity was measured in peripheral blood lymphocytes (PBL). In the whole group the median occupational TWA was 0.21 microT. According to the TWA levels, workers were classified as low exposed (26 subjects, TWAor =0.2 microT) and higher exposed workers (26 subjects; TWA0.2 microT). In higher exposed workers, we observed a trend to reduce NK activity compared to low exposed, but the difference was not significant. Then we selected a subgroup of highest exposed workers (12 subjects; TWA1 microT); no difference was observed between low and highest exposed subjects in the main personal variables. Considering both E:T ratios from 12:1 to 50:1 and Lytic Units, a significant reduction in NK activity was observed in the highest exposed workers compared to the low exposed. Multivariate analysis showed a significant negative correlation between exposure and LU, while no correlation was evidenced with other personal characteristics. ELF-MF are considered possible carcinogens, and existing data suggest that they can act as promoters. Due to the role of NK activity in host defence against cancer, the results obtained in this study in workers exposed to ELF-MF levels exceeding 1 microT are in agreement with this hypothesis, and support the need for further investigation in this field.

Physical and chemical disinfection methods have been proposed with the aim of controlling Legionella water contamination. To date, the most effective procedures for reducing bacterial contamination have not yet been defined. The aim of this study was to assess the long-term effectiveness of various disinfection procedures in order to reduce both culturable and nonculturable (NC) legionellae in different hospital water networks treated with heat, chlorine dioxide, monochloramine, and hydrogen peroxide. The temperature levels and biocide concentrations that proved to give reliable results were analyzed. In order to study the possible effects on the water pipes, we verified the extent of corrosion on experimental coupons after applying each method for 6 months. The percentage of positive points was at its lowest after treatment with monochloramine, followed by chlorine dioxide, hydrogen peroxide, and hyperthermia. Different selections of Legionella spp. were observed, as networks treated with chlorine-based disinfectants were contaminated mainly by Legionella pneumophila serogroup 1, hyperthermia was associated with serogroups 2 to 14, and hydrogen peroxide treatment was associated mainly with non- pneumophila species. NC cells were detected only in heat-treated waters, and also when the temperature was approximately 60°C. The corrosion rates of the coupons were within a satisfactory limit for water networks, but the morphologies differed. We confirm here that chemical disinfection controls Legionella colonization more effectively than hyperthermia does. Monochloramine was the most effective treatment, while hydrogen peroxide may be a promising alternative to chlorine-based disinfectants due to its ability to select for other, less virulent or nonpathogenic species.

Few issues involving nutritional and environmental epidemiology have received as much interest as the relation between selenium (Se) intake and human health, as reflected by the large body of evidence from observational and experimental studies with reference to cancer and other clinical endpoints. Se deficiency may play a major role in favoring the onset of a human cardiomyopathy, Keshan disease. Se overexposure has been linked to skin and advanced prostate cancers in recent randomized controlled trials, in contrast with earlier hypotheses of protective effects of Se intake against cancer generally, and prostate cancer in particular. Overexposure has also been linked to higher risk for diabetes and amyotrophic lateral sclerosis. For cardiovascular disease risk, such as ischemic heart disease and stroke, little evidence of any modifying effect of Se exposure has been provided by epidemiologic studies. The results of these studies should be used in public health to set better standards for intake of organic and inorganic Se species, focusing on experimental studies with individual Se compounds more than overall exposure to the element, in order to improve reliability and reduce bias in the studies.

This study was designed to standardize dust collection in recently built operating theatres equipped with a continuous monitoring system. The objectives were to establish the relationship between microbiological and dust contamination, and then to compare those parameters with the main indicators of surgical activity in order to better define risk factors affecting air quality. The air quality during 23 surgical operations was studied in three conventionally ventilated operating theatres. Microbiological air counts were taken using both passive and active sampling methods. Air dust particles, > or =0.5 and > or =5 microm in size, were measured using a light-scattering particle analyser. The overall dust load was mainly (98%) composed of fine particulate matter, most probably due to its longer suspension time before settlement. These particles positively correlated with operation length, but not with surgical technique, suggesting that fine particles may be a good tracer of operation complexity. In contrast, the surgical technique was the main predictor for the concentration of particles > or =5 microm, with a higher risk from general conventional surgery compared with scope surgery. The frequency of door-opening, taken as an index of staff and visitor movement, was the main negative predictor of over-threshold values of both fine and larger dust particles but, conversely, was a positive predictor of raised bacterial counts.

We report a case of Legionella pneumonia in a patient with psoriasis. The clinical strain had an identical PFGE pattern of 1 subtype of L. pneumophila serogroup 1 isolated at low concentration in a sporting club bath. Diagnostic, clinical and epidemiological aspects are discussed for their relevant public health implications.

L atrial (LA) stunning after cardioversion of atrial fibrillation (AF) has been reported during spontaneous conversion to sinus rhythm.1 This observation suggest that atrial stunning is a function of underlying arrhythmia and not of the mode of cardioversion. It is known that AF causes atrial dilation, and progressive LA enlargement occurs when AF becomes chronic.2 Recently, it has been shown that multiple factors contribute to LA enlargement, including the presence and persistence of arrhythmia.3 Many reports suggest that if sinus rhythm is restored then dilation may regress.4 The Framingham Study showed a relation between LA size and the risk of stroke in men and the risk of death in both genders.5–7 Previous studies have suggested that N-terminal atrial natriuretic peptide (NANP) levels are elevated in patients with AF.8,9 It is unclear whether AF rather than LA dilation,10 hemodynamic impairment,11 or another hormonal alteration, can result in the elevation of N-ANP levels.8 The present report evaluates the changes in LA size and function after spontaneous cardioversion of AF and their relation to N-ANP. • • • Hemodynamically stable patients referred for cardioversion for nonrheumatic AF between September 1997 and March 2000 were considered for inclusion in this investigation. The initial study group included 202 consecutive patients; 98 patients spontaneously recovered sinus rhythm within 48 hours from the onset of arrhythmia and were selected for the study (Group A). The study population included 57 men and 41 women of mean age 60 16 years; patients were compared with 98 ageand gender-matched control subjects (mean age 61 16 years) who underwent pharmacologic cardioversion within 48 hours from the onset of arrhythmia (Group B). Patients received intravenous propafenone 2 mg/kg of body weight; the drug was dissolved in 100 ml of 5% glucose and infused over 30 minutes. Exclusion criteria were: atrial flutter, valvular stenosis, valvular prosthesis, significant valvular insufficiency, atrial and/or left ventricular thrombosis, spontaneous echo contrast, patent foramen ovale or an atrial septal aneurysm, or decreased LV function (ejection fraction 45%). No patients received long-term therapy with antiarrhythmic drugs. Demographic and clinical characteristics of the patients are listed in Table 1. Clinical records included age, gender, time and circumstances of the onset of symptoms related to AF, and the duration of AF estimated from the initial onset of symptoms until the time of the in-hospital conversion. The protocol was approved by the Ethical Committee of our university and all patients signed an informed consent form. The initial Doppler echocardiographic study was performed during AF and after cardioversion (mean 3 1.5 hours). A complete monoand 2-dimensional color Doppler echocardiogram was performed in each patient using a commercial Hewlett-Packard echocardiograph (Andover, Massachusetts) with a 2.5-MHz probe. LA function was assessed using these parameters: (1) transmitral pulsed Doppler recorded from the apical 4-chamber view with the sample volume positioned between the tips of the mitral leaflets; peak early filling (E) and atrial filling (A) velocities; and From the Departments of Cardiology and Biomedics, University of Modena and Reggio Emilia, Modena, Italy. Dr. Mattioli’s address is: Department of Cardiology, University of Modena, Via del pozzo, 71, 41100 Modena, Italy. E-mail: mattioli.annavittoria@ unimo.it. Manuscript received December 17, 2002; revised manuscript received and accepted March 3, 2003. TABLE 1 Demographics and Clinical Characteristics

The purpose of this review is to discuss the scientific literature on waterborne healthcare-associated infections (HCAIs) published from 1990 to 2012. The review focuses on aquatic bacteria and describes both outbreaks and single cases in relation to patient characteristics, the settings and contaminated sources. An overview of diagnostic methods and environmental investigations is summarized in order to provide guidance for future case investigations. Lastly, on the basis of the prevention and control measures adopted, information and recommendations are given. A total of 125 reports were included, 41 describing hospitalized children. All cases were sustained by opportunistic pathogens, mainlyLegionellaceae,PseudomonadaceaeandBurkholderiaceae. Hot-water distribution systems were the primary source of legionnaires’ disease, bottled water was mainly colonized byPseudomonaceae, andBurkholderiaceaewere the leading cause of distilled and sterile water contamination. The intensive care unit was the most frequently involved setting, but patient characteristics were the main risk factor, independent of the ward. As it is difficult to avoid water contamination by microbes and disinfection treatments may be insufficient to control the risk of infection, a proactive preventive plan should be put in place. Nursing staff should pay special attention to children and immunosuppressed patients in terms of tap-water exposure and also their personal hygiene, and should regularly use sterile water for rinsing/cleaning devices.

The degree of Legionella pneumophila contamination in hospital water supplies has been shown to correlate with the incidence of nosocomial Legionnaires’ disease (LD). Within the context of the Italian Multicentric Study of Legionellosis, the authors carried out a 4-year active prospective LD surveillance program in a large university hospital in Rome. They assessed the usefulness of the hospital water monitoring program to predict the risk of nosocomial LD. A monthly decontamination procedure of the intermediate tanks is carried out, which consists of mechanically cleaning out the tanks to remove the formed organics, followed by washing out the tanks with sodium hypochlorite. Once the nosocomial LD case had occurred, epidemiological and environmental investigations were performed in the hospital ward involved. The low incidence of nosocomial LD cases in the hospital during the study period seems to be correlated to the low contamination level of L. pneumophila (20% of positive samples in 4 years) in hospital wards and to a low percentage of positive water samples per semester of surveillance. An infection control system for nosocomial LD should therefore be based on both environmental and clinical surveillance, together with the appropriate maintenance of the hospital water distribution system.

This study was performed to evaluate the relation between a stable personality trait, a mood state and immune response to an examination stress. A self-reported measure of emotional stability (BFQ-ES scale) was obtained in a sample (n = 39) randomly selected from 277 cadets; this personality trait was also investigated by completing a neuroticism scale (Eysenck personality inventory) and a trait-anxiety scale (STAI). Natural killer (NK) cell activity was measured at baseline, long before the examination time and the examination day. The state-anxiety scale evaluated the response to the stressful stimulus. Taking subjects all together, the academic task did not result in significant modification over baseline in NK cell activity. Subjects were then divided into three groups based on emotional stability and state-anxiety scores: high emotional stability/low anxiety, medium, and low emotional stability/high anxiety. Examination stress induced significant increases in NK cell activity in the high emotional stability/low anxiety group, no effect in the medium group, and significant decreases in the low emotional stability/high anxiety group. The repeated-measure ANOVA revealed a significant interaction of group x period (baseline vs. examination) for both lytic units and percent cytolysis. The results did not change after introducing coffee and smoking habits as covariates. Our findings suggest that the state-anxiety acts in concert with a stable personality trait to modulate NK response in healthy subjects exposed to a psychological naturalistic stress. The relation between anxiety and poor immune control has been already described, whereas the ability of emotional stability to associate with an immunoenhancement has not yet reported. The peculiarity of our population, a very homogeneous and healthy group for life style and habits, can have highlighted the role of emotional stability, and may account for the difference with other studies.

One hundred and nine unselected patients with Acute Renal Failure (ARF) of medical aetiology were hospitalized at the Nephrological Unit of Policlinico University Hospital (Modena) during a 30-month period. ARF was considered as a rapid increase of serum creatinine > 2mg/dl over the baseline level or the doubling of pre-existing value in chronic renal failure. Mean age of patients was 67+/-17 years and median age was 72; 64.2% needing dialytic treatment. Four main causes of ARF were identified: 33 patients had reduced renal perfusion by dehydration, hypotension etc.; 20 multifactorial aetiology; 14 biopsy-investigated renal parenchymal diseases and 39 had drug-related acute renal failure (D-ARF). The clinical outcome was significantly worse in elderly patients as regard mortality (P < 0.02), chronic dialytic treatment (P < 0.04) and complete recovery (P < 0.004). The mean age of D-ARF patients was significantly greater than remaining ARF patients (72.6+/-12.8 vs 63.2+/-18.5: P < 0.004. Nonsteroidal antiinflammatory drugs (NSAIDs) and ACE-inhibitors (Ace-i) caused ARF in 24 and 8 patients respectively. Elderly age, vascular disease and monoclonal gammopathy represented the main risk factors and were significantly more frequent in D-ARF patients (P

In this study, we discuss some relevant aspects concerning the determination of selenium in biological materials with special reference to fluorometry and hydride generation atomic absorption spectroscopy (HG-AAS) techniques. The two methods may be applied without modifications to the analysis of Se in a wide spectrum of specimen types, and we describe their reliability in serum and hair analyses. Thirty-six independent control serum samples, the concentrations of which were unknown to the analyst, were analyzed in duplicate using both techniques in the Italian External Quality Assessment Scheme (EQAS). Accuracy was assessed by comparing Se values with those previously assigned by the organizers of the scheme using graphite furnace atomic absorption spectrometry (GF-AAS), which is the most frequently used technique for selenium determination in serum among the participants in the Italian EQAS. The results confirmed that fluorometry has a higher degree of accuracy than HG-AAS: the mean differences between observed and expected values were 1.5 μg/liter (95% confidence interval, -1.06 to 3.97) for fluorometry and -1.1 μg/liter (95% confidence interval, -5.05 to 2.76) for Hg-AAS. We also report some results obtained for the determination of Se in hair. Since a critical step in hair preparation is the pretreatment for removal of external contamination, we compared six different washing procedures. In general, Se is poorly leached from hair, but the efficiency of removal differed with the substance used, ranging from 0 to 13% of the original content. A nonionic detergent like Triton X-100 offers the advantage of safe working conditions and a substantial reduction in costs compared with organic solvents. Lastly, in a consistent group (n = 131) of women, Se in hair was found to be strongly reduced by the use of dye (389.9 ng/g vs 498.7 ng/g, P < 0.001). We recommend recording information on cosmetic treatments when hair is collected to evaluate Se reference values in epidemiological studies.

Since zinc is an important factor in membrane stability, we assayed the levels of zinc in several brain areas during the development of hepatic encephalopathy due to d -galactosamine-HCl in rat. We now report that zinc is significantly reduced in all tested brain areas. This finding seems to indicate an involvement of zinc in the changes of membrane properties that lead to alteration of GABA receptors in hepatic encephalopathy.

Genetic heterogeneity in tubular hypomagnesemia-hypokalemia with hypocalciuria (Gitelman's syndrome). To better clarify the genetic inheritance of primary tubular hypomagnesemia-hypokalemia with hypocalciuria, or Gitelman's syndrome (GS), we studied eight families (10 patients aged 11 to 22 years; 16 parents; 9 siblings) in which at least one offspring had GS (plasma magnesium < 0.65 mmol/liter; plasma potassium < 3.6 mmol/liter; high magnesium and potassium fractional excretions; molar urinary calcium/creatinine < 0.10). Two families each had two offspring of different sex with GS, who all had tetanic episodes and/or marked weakness during childhood or adolescence, whereas in three other families two mothers and three offspring presented GS and one father and two other offspring had hypomagnesemia and hypocalciuria but normal plasma potassium. The mean plasma magnesium and potassium levels of the patients of the first two families were significantly lower (P < 0.05) than those of the other three families. Intralymphocytic but not intraerythrocytic magnesium and potassium were significantly lower (P < 0.05) in patients compared to controls. We hypothesize that there are two different types of genetic transmission of GS, one autosomal recessive and one autosomal dominant with high phenotypic variability. It seems that this genetic heterogeneity is associated with a different clinical expression with frequent tetanic episodes and lower plasma potassium and magnesium levels in the autosomal recessive form.

Hand hygiene in nursing and medical students during training: a pilot study on knowledge, practices and impact on bacterial contamination.Despite exhaustive guidelines on hand hygiene (HH), compliance in health care professionals is reported to be low. In order to improve adherence with HH, interventions on students' education should be effective.To describe the knowledge, behavior and hand hygiene (HH) practices in nursing and medical students. The results of the pilot study are presented.A questionnaire designed to investigate knowledge on HH and its practical implementation was administered to a sample of 50 nursing and 50 medical students. Data collected were associated with hand contamination measured at the beginning and at the end of the training shift.All nursing students performed HH with a significantly higher frequency compared to medical students. At the end of training, total bacterial counts were significantly reduced in both groups, but more in nursing students. Total bacterial count increased in absence of hygienic practices and the most effective procedure was the alternate use of conventional hand washing and alcohol-based hands rubs. The knowledge of both groups was adequate, although some differences were observed.At the beginning of their course, nursing students are educated to correct practices that implement during practical training. Medical students receive information on HH later in their education and pay less attention to these aspects, also due to the limited number of physical contacts with patients. Thus, the contents on HH should be anticipated before the start of the training activity.

The issue of Legionnaires’ disease has emerged as a major public health problem, interesting not only researchers, but also managers of public and private organisations, those responsible for public health, the general population and occasionally magistrates.The cases of legionellosis are increasing as a result of improved etiological diagnostic methods, population lifestyles and characteristics which favour the presence of the responsible organism in the environment which leads to the frequent exposure and transmission of the disease to at-risk groups whose relative numbers are growing.Legionella spp is an opportunistic waterborne pathogen that finds its ideal habitat in warm-humid environments, it is able to survive in conditions unfavourable to other germs (elevated temperatures, presence of biocides, etc.) and multiply in particular ecological niches (amoebas and other protozoa, biofilm).Because of this, it frequently colonises the hot water systems of houses, hotels, campsites, sports centres, hospitals, tertiary care centres, etc., as well as air-conditioning cooling towers, evaporative condensers and places where water stagnates at temperatures of at least 20°C. From our experience,the disease is frequently contracted by inhaling aerosols from the contaminated water systems of houses or work places, but it has also been contracted during stays in holiday accommodation, from using baths/showers in sports and recreation centres and finally during hospital stays.

Background We report the results of 1-year application of monochloramine to control Legionella pneumophila contamination in a hospital hot water distribution system. Methods In the main building of the hospital, a device continuously distributing monochloramine was installed. Legionella pneumophila and Pseudomonas spp contamination was followed in comparison with 2 other water networks in the same building using chlorine dioxide. Results Monochloramine significantly reduced the number of contaminated sites compared with baseline (from 97.0% to 13.3%, respectively), chlorine dioxide device I (from 100% to 56.7%, respectively), and device II (from 100% to 60.8%, respectively). No positive sample exceeded 104 colony-forming units/L versus 59.4% at baseline. Conclusion Monochloramine could represent a good alternative to chlorine dioxide in controlling legionellae contamination in public and private buildings.

The results of a study on Zn, Cu, Ca and Mg content in whole saliva and supernatant of young adults in relation to caries prevalence are reported. A total of 225 university students were selected for the study on the basis of voluntary participation. The salivary electrolytes showed a high intersubjective variability and females had significantly lower levels than males. In whole saliva, the trace elements were highly correlated, whereas the correlations were weaker in the supernatant. The ratio supernatant/whole saliva varied between subjects and according to the examined electrolytes. No association could be found between the measured trace elements and DMFT. When we analysed the relation with recent caries experience in the subgroup of subjects undergoing oral examinations for at least 1 year, we found evidence that the Zn/Cu molar ratios in whole saliva were significantly decreased in subjects with more than three decayed teeth compared with those with no caries (1.54 vs. 1.11, P < 0.05). No significant association was found when supernatant was analysed. We conclude that the electrolytes' levels in whole saliva might be more adequate than the levels in supernatant to evaluate the relationship with caries.

We report our ten-year experience of hyperchlorination, thermal shock, chlorine dioxide, monochloramine, boilers and point-of-use filters for controlling legionella contamination in a hospital hot water distribution system. Shock disinfections were associated with a return to pre-treatment contamination levels within one or two months. We found that chlorine dioxide successfully maintained levels at100 cfu/L, whilst preliminary experiments gave satisfactory results with monochloramine. No contamination was observed applying point-of-use filters and electric boilers at temperatures of58°C and no cases of nosocomial legionellosis were detected in the ten-year observation period. Our performance ranking in reducing legionella contamination was filter, boiler, chlorine dioxide, hyperchlorination and thermal shock. Chlorine dioxide was the least expensive procedure followed by thermal shock, hyperchlorination, boiler and filter. We suggest adopting chlorine dioxide and electric boilers in parallel.

The contamination of hot water samples with Legionella spp. was studied in relation to temperature, total hardness, trace element concentrations (iron, zinc, manganese, and copper) and heterotrophic plate counts (HPC) at both 22 and 37 °C. Factor analysis and receiver operating characteristic (ROC) curves were used to establish the cut-off of water parameters as predictors for Legionella contamination. Legionella spp. was isolated in 194 out of 408 samples (47.5%), with Legionella pneumophila being the most common (92.8%). After multiple logistic regression analysis, the risk for legionellae colonisation was positively associated with Mn levels >6 μg l−1, HPC at 22 °C >27 CFU l−1, and negatively with temperature >55 °C and Cu levels >50 μg l−1. Multiple regression analysis revealed that Legionella spp. counts were positively associated with Mn, HPC at 37 °C and Zn and negatively associated with temperature. Only 1 out of the 97 samples (1%) having a Mn concentration, an HPC at 22 °C and an HPC at 37 °C below the respective median values exhibited a Legionella spp. concentration exceeding 104 CFU l−1 vs. 41 out of the 89 samples (46.1%) with the three parameters above the medians. Our results show a qualitative and quantitative relationship between Legionella spp., the Mn concentration and heterotrophic plate counts in hot water samples from different buildings, suggesting that these parameters should be included in a water safety plan. The role of manganese in biofilm formation and its possible involvement in the mechanisms favouring Legionella survival and growth in water niches should be investigated further.

In a preliminary study a reduction in natural killer (NK) cell activity in peripheral blood lymphocytes (PBL) was observed in a group of workers exposed to levels of extremely low frequency-magnetic fields (ELF-MF) exceeding 1 microT. This study was performed to confirm the results. In 121 workers engaged in various occupational activities, individual ELF-MF exposure was monitored for 2 work shifts. Exposure levels were calculated as time-weighted average (TWA). Subjects were classified as Low exposure (TWAor = 0.2 microT), Medium exposure (TWA 0.21-0.99 microT), or Higher exposure (TWAor = 1 microT). In higher exposure workers NK activity proved significantly reduced compared to low exposure,(p0.01). In medium exposure a reduction was also observed, but the difference was not significant. Multivariate analysis also confirmed the relation between exposure and NK activity. It has been suggested that ELF might affect tumour progression by inducing changes in the immune system: due to the role played by NK activity in host defence against cancer, the interference with the NK cell activity observed in this study is in agreement with this hypothesis. Furthermore, an increased risk for some neurodegenerative disorders has been reported in some epidemiological studies in ELF-MF-exposed workers: changes in NK function were also described in these diseases. Our results, showing the effect on NK activity of exposure exceeding 1 microT, suggest a possible mechanism for ELF-MF effects. This could open new horizons regarding the adverse long-term effects of these fields.

We investigated in solid medium, in water microcosm co-cultures and by light and transmission electron microscopy the influence of Legionella pneumophila Lp-1, Pseudomonas aeruginosa ATCC 27853, Burkholderia cepacia ATCC 25416 and Pseudomonas fluorescens SSD35 on the growth and survival of Acanthamoeba polyphaga. The infection with L. pneumophila was microscopically characterized by the presence of few bacteria inside protozoa at 4th h, and by the beginning of disruptive effects in late phase of trial. In water microcosm studies, performed at different temperature, the more significant interactions were observed at 30°C. In these conditions, L. pneumophila caused a marked reduction in trophozoite and cyst counts from the 4th day until the end of incubation (11 days). B. cepacia showed, by microscopic observation, few and generally single rods within protozoan phagosomes and caused a light reduction of trophozoite viability and cyst formation in co-cultures. A more invasive type of endocytosis, characterized by an early invasion with the presence of a high bacteria number inside amoebae, was observed for Pseudomonas strains. P. fluorescens produced a violent lysis of the host, whereas P. aeruginosa did not cause lysis or suffering. These results underline that water bacteria other than legionella are capable of intracellular survival in Acanthamoeba, influencing the protozoa viable cycle.