Publications by authors named "Antonella Mattei"

45 Publications

Examining the Post-operative Well-Being of Women Who Underwent Mammoplasty: A Cross-Sectional Study.

Front Psychiatry 2021 29;12:645102. Epub 2021 Mar 29.

Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.

Mammoplasty is the most common surgery used for breast augmentation (aesthetic plastic) and breast reconstruction (disease-related plastic) in women who have been diagnosed with and surgically treated for regional breast cancer with modified radical mastectomy. This study aims to examine the long-term effects of mammoplasty on the psychological well-being of women. Participants were 44 women aged 30-50 years (mean = 40.4 ± 5.9). They were divided into two groups based on the purpose of the breast surgery they underwent [augmentation surgery (AS) vs. reconstruction surgery (RS)] and the time that had elapsed since their surgery (≤3 vs. >3 years). Our findings suggest that women who underwent AS reported a decline in their psychological well-being over time. The women who had undergone AS ≤3 and >3 years did not show any differences in emotional functioning, with the exception of the BREAST-Q scores on the satisfaction with breasts subscale. We examined the impact of mammoplasty on the satisfaction levels and well-being of women who had undergone RS (after MRM). They were less satisfied with their breasts than those who belonged to the AS group, confirming our hypothesis. However, this was true only among those who had undergone surgery ≤3 years earlier. In conclusion, our findings underscore the need to provide psychological support to those who have undergone breast AS and RS. Additionally, this study implies the need for personalized psychological interventions to improve the emotional adaptation process and enhance women's mental well-being.
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http://dx.doi.org/10.3389/fpsyt.2021.645102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039438PMC
March 2021

Associations between COVID-19 Incidence Rates and the Exposure to PM2.5 and NO: A Nationwide Observational Study in Italy.

Int J Environ Res Public Health 2020 12 13;17(24). Epub 2020 Dec 13.

Department of Life, Health & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy.

The COVID-19 outbreak disproportionately affected the elderly and areas with higher population density. Among the multiple factors possibly involved, a role for air pollution has also been hypothesized. This nationwide observational study demonstrated the significant positive relationship between COVID-19 incidence rates and PM2.5 and NO levels in Italy, both considering the period 2016-2020 and the months of the epidemic, through univariate regression models, after logarithmic transformation of the variables, as the data were not normally distributed. That relationship was confirmed by a multivariate analysis showing the combined effect of the two pollutants, adjusted for the old-age index and population density. An increase in PM2.5 and NO concentrations by one unit (1 µg/m) corresponded to an increase in incidence rates of 1.56 and 1.24 × 10 people, respectively, taking into account the average levels of air pollutants in the period 2016-2020, and 2.79 and 1.24 × 10 people during March-May 2020. Considering the entire epidemic period (March-October 2020), these increases were 1.05 and 1.01 × 10 people, respectively, and could explain 59% of the variance in COVID-19 incidence rates (R = 0.59). This evidence could support the implementation of targeted responses by focusing on areas with low air quality to mitigate the spread of the disease.
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http://dx.doi.org/10.3390/ijerph17249318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763344PMC
December 2020

Pertussis in Italy: how to protect the "unprotectable"?

Hum Vaccin Immunother 2021 Apr 29;17(4):1136-1141. Epub 2020 Oct 29.

Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.

Whooping cough continues to be an important public health issue despite high levels of vaccination coverage with acellular pertussis vaccine. Young unimmunized infants represent the most vulnerable group with the highest rates of complications and death. As infant-specific pertussis epidemiologic data, especially among neonates, in Italy were limited, a retrospective observational study of hospitalizations for whooping cough in Italian infants aged <12 months between 2007 and 2018 was conducted to address this knowledge gap. The temporal trend of rates, also stratified for age classes according to the expected age for the administration of vaccine doses, were analyzed by the slope of the regression line. The mean age at the time of admission was 92 d (±64). A clear seasonal pattern in the occurrence of pertussis hospitalizations with a summer peak was observed. Infants younger than 3 months old had the highest hospitalization rates (169 x 100000 infants on average), with a significant rising trend of 9 x 100000 infants on average per year. Limiting the analysis to -related hospitalizations such trend was even more evident. In the other age classes, hospitalization rates were considerably lower and gradually decreased with increasing age. This study demonstrated that pediatric populations, too young to be protected by vaccination, had a greater risk of contracting pertussis. Thus, it is necessary to promote additional immunization strategies besides one booster dose in adolescents, including vaccination during pregnancy.
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http://dx.doi.org/10.1080/21645515.2020.1806673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018419PMC
April 2021

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak.

J Minim Access Surg 2020 Sep 12. Epub 2020 Sep 12.

Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.

Setting: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives: This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients And Methods: This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results: GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions: Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.
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http://dx.doi.org/10.4103/jmas.JMAS_3_20DOI Listing
September 2020

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis.

Minerva Chir 2020 Dec 6;75(6):442-448. Epub 2020 Aug 6.

Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.

Background: Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA.

Methods: Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis.

Results: TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis.

Conclusions: TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.
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http://dx.doi.org/10.23736/S0026-4733.20.08274-7DOI Listing
December 2020

Analysis of Risk Factors Independently Associated with Cognitive Impairment in Patients with Permanent Atrial Fibrillation: A Cross-sectional Observational Study.

J Stroke Cerebrovasc Dis 2020 Aug 17;29(8):104895. Epub 2020 May 17.

Cardiology, Health and Environmental Science, University of L'Aquila, L'Aquila, Italy. Electronic address:

Background And Objective: Atrial Fibrillation (AF) is associated with an increased risk of stroke and development of cognitive impairment. Our cross-sectional study aims to identify risk factors for cognitive impairment in patients with permanent AF.

Materials And Methods: 212 consecutive outpatients with history of permanent AF lasting more than 1 year were enrolled and the Short Portable Mental Status Questionnaire (SPMSQ) was used to assess cognitive impairment (number of errors ≥5). The type of antithrombotic therapy, the time in therapeutic range (TTR) in case of treatment with warfarin and the degree of heart rate (HR) control (upon Holter ECG monitoring) were also assessed.

Results: ROC curve analysis indicated that TTR was associated with cognitive impairment (AUC 0.85 ± 0.03; 95% CI 0.77-0.88; p < 0.0001). Multivariate logistic regression analysis showed an independent association of previous cerebrovascular or cardiovascular events (OR 7.24, 95% CI 1.37-38.25; p = 0.020), aspirin therapy instead of anticoagulant therapy (OR 24.74, 95% CI 1.27-482.12; p = 0.034), warfarin use with TTR ≤60% (OR 21.71 , 95%CI 4.35-108; p < 0.001) and an average daily HR either <60 bpm or >100 bpm (OR 6.04, 95% 1.09-33.29; p = 0.039) with cognitive impairment.

Conclusion: Among patients with permanent AF, cognitive impairment is more frequent in those with inadequate antithrombotic therapy (aspirin therapy instead of anticoagulant therapy) and with suboptimal oral anticoagulation (TTR ≤60%) or heart rate control. Efforts should be made to optimize therapies related to these parameters.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104895DOI Listing
August 2020

Evaluation of Lower Dental Arch Crowding and Dimension after Treatment with Lip Bumper versus Schwarz Appliance. A Prospective Pilot Study.

Dent J (Basel) 2020 Apr 10;8(2). Epub 2020 Apr 10.

Department of Health, Life and Environmental Science, University of L'Aquila, Piazza Salvatore Tommasi, 67100 L'Aquila, Italy.

The treatment of patients with mixed dentition, with inferior moderate dental crowding (the so-called borderline cases, between extraction and expansion) is not yet clear. Two examples of widely used appliances for increasing lower dental arch dimensions are the Schwarz's appliance and lip bumper. The aim of this prospective study was to compare dental crowding and arch dimensions from pre- to post-treatment with lip bumper versus Schwarz's appliance. Pre- and post-treatment orthodontic records of twenty subjects (10 males and 10 females) were analyzed in the present study. Inclusion criteria were: first/second molar class malocclusion; crowding of the mandibular arch, from mild to moderate (4-6 mm); mixed dentition; age ≤ 9 years at the beginning of the treatment; stage CS1 or CS2 of maturation of the cervical vertebrae analysis (CVM) at the beginning of the treatment. Ten subjects were treated with a lip bumper, and ten with the removable Schwarz appliance. The primary outcomes were the variations in dental crowding and arch dimensions from pre- to post-treatment. Both the two appliances caused a statistically significant mean improvement/reduction in crowding, of 3.5 mm and 2.9 mm, for the Schwarz appliance and lip bumper, respectively. The Schwarz appliance resulted more effective in increasing arch dimension at the intercanine level, and arch perimeter, while the lip bumper achieves a higher increase in arch length. A lip bumper and Schwarz appliance are both useful in reducing crowding in mixed dentition. This improvement is due to the increase in dental arch dimensions, although the distribution of space resulted slightly differently between the two appliances.
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http://dx.doi.org/10.3390/dj8020034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344829PMC
April 2020

The Effects of Low-Nickel Diet Combined with Oral Administration of Selected Probiotics on Patients with Systemic Nickel Allergy Syndrome (SNAS) and Gut Dysbiosis.

Nutrients 2020 Apr 9;12(4). Epub 2020 Apr 9.

PoliSmail, Specialistic Unit Allergic & Immunological Pathologies, Via Clemente Rebora, 1, 73100 Lecce, Italy.

Background: Nickel (Ni) oral consumption may elicit systemic reactions in patients affected by systemic nickel allergy syndrome (SNAS), including gastrointestinal symptoms, which in turn are associated with gut dysbiosis. We evaluated the effects of a low-Ni diet alone or in combination with the oral consumption of appropriate probiotics on Ni-sensitivity and urinary dysbiosis markers in SNAS patients.

Methods: = 51 patients with SNAS and concomitant intestinal dysbiosis were enrolled in the study. According to the urinary indican/skatole levels, quantified through a colorimetric and a high-performance liquid chromatographic method, respectively, patients were assigned to a dysbiosis type/grade and followed a low-Ni diet for three months. Along with the diet, 22 patients also consumed probiotics based on the dysbiosis type. In particular, a Lactobacilli- or Bifidobacteria-containing formulation was administered to patients with fermentative or putrefactive dysbiosis, respectively, while a broad-spectrum probiotic formulation containing both Lactobacilli and Bifidobacteria was administered to patients with mixed dysbiosis. After three months, patients were invited to repeat the Ni-stimulation and the dysbiosis tests.

Results: The fermentative dysbiosis group represented the largest group followed by the mixed dysbiosis group, while only two patients had putrefactive dysbiosis. Overall, at three months of treatment in general (diet alone with or without probiotics), the Ni-sensitivity and dysbiosis levels were strongly ameliorated. The association of a low-Ni diet with a specific probiotic oral supplementation was significantly more effective in decreasing dysbiosis levels or reaching eubiosis than with diet alone.

Conclusion: Our results, while confirming the benefits of a low-Ni diet in SNAS patients, strongly support that appropriate adjuvant treatment with probiotics significantly helps to improve intestinal dysbiosis or restore a healthy microbiota.
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http://dx.doi.org/10.3390/nu12041040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230804PMC
April 2020

Soluble Fraction from Lysates of Selected Probiotic Strains Differently Influences Re-Epithelialization of HaCaT Scratched Monolayer through a Mechanism Involving Nitric Oxide Synthase 2.

Biomolecules 2019 11 21;9(12). Epub 2019 Nov 21.

Department of Life, Health & Environmental Sciences, University of L'Aquila, Building Delta 6, Coppito, 67100 L'Aquila, Italy.

A growing body of evidence supports the use of probiotics in the treatment of several skin conditions, including wounds. Even if in vitro and in vivo studies have highlighted the pro-healing effects of some probiotic bacteria, the underlying mechanisms are still not fully defined. The current investigation aimed to determine the re-epithelialization potential of the soluble fraction from lysate of seven different probiotic strains belonging to different genera (i.e., , , and ) on in vitro physically wounded HaCaT monolayer model. The results suggested that the soluble fraction of , and promoted the re-epithelialization of scratched HaCaT monolayers, whereas those from , and significantly inhibited the process. On the other hand, showed no significant effect on in vitro wound repair. The mechanisms underlying the pro- or anti-healing properties of selected bacterial strains strictly and positively correlated with their ability to modulate nitric oxide synthase 2 (NOS2) expression and activity. Accordingly, the pre-treatment with aminoguanidine (AG), a specific inhibitor of NOS2 activity, abrogated the pro-healing effects of , and .
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http://dx.doi.org/10.3390/biom9120756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995614PMC
November 2019

Trends in Hospital Admissions for Pertussis Infection: A Nationwide Retrospective Observational Study in Italy, 2002-2016.

Int J Environ Res Public Health 2019 11 15;16(22). Epub 2019 Nov 15.

Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila AQ 67100, Italy.

: Pertussis is a highly contagious infectious disease which continues to be an important public-health issue despite the high immunization coverage rates achieved. However, evidence of increased circulation of pertussis among adolescents and adults due to waning immunity and atypical clinical manifestations seem to be the main reasons for its resurgence. The aim of this study was the analysis of the epidemiological trend for pertussis-related hospitalizations in Italy, in relation with vaccination coverage and information from laboratory confirmed cases of pertussis: A retrospective observational study investigating hospitalizations for pertussis from 2002 to 2016 in Italy was conducted. Frequencies and rates of hospitalization were analyzed and hospitalization data were compared with a series of already published laboratory confirmed data. : This study highlighted a rising trend for pertussis hospitalizations in Italy since 2008. Infants aged <1 year showed the highest frequencies (63.39%) and average rates (74.60 × 100000 infants) of hospitalization despite an extremely high vaccination coverage (95.89%). An increasing trend of hospitalization frequency emerged for the age group with levels of IgG antibodies to pertussis toxin compatible with pertussis infection within the last year (20-29 years old age group). : The rising trend for pertussis hospitalizations and the greater involvement of infants aged <1 year require an integrated approach, including the implementation of booster doses administration in adolescence and adulthood, the vaccination of pregnant women and the strategy.
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http://dx.doi.org/10.3390/ijerph16224531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6888113PMC
November 2019

Lifestyle, body mass index and wellness in youth: Strengthens and weakness in Italian youth.

Health Psychol Res 2019 Mar 18;7(1):8035. Epub 2019 Sep 18.

Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy.

This study investigated the psychological wellbeing and body perception among young Italian people. Drinking, eating, and sexual behaviors have been examined in relation to body mass index (BMI) and psychological well-being by EPOCH framework. This was a cross-sectional observational study conducted on Italian adolescent and young adult population through an online survey. Qualitative and quantitative data on lifestyle, BMI classes, and psychological characteristics of wellness in youth were obtained from a sample of 1221 Italian participants using a self-report questionnaire on body perception and habits, a socio-demographics inventory, and the EPOCH measure. Findings suggest that being underweight or overweight is associated with various factors, including gender, self-control regarding food, perception of one's body, and the happiness domain. EPOCH framework revealed the psychological wellness of girls and young women did not seem strongly affected by BMI, though Perseverance and Happiness seemed reduced with increasing BMI. The Engagement, Optimism, and Connectedness domains were not significantly affected by the BMI variable. On the contrary, Perseverance and Happiness seemed reduced with increasing BMI and were related to physical shape. Our study offers a new perspective: promoting the development of positive psychological characteristics since adolescence to boost quality of life by improving wellness, by EPOCH approach could be functional reinforcing specific psychological aspects in young generations regarding future wellness, improving the positive perception and management of their own health.
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http://dx.doi.org/10.4081/hpr.2019.8035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763709PMC
March 2019

Temperature-Neutrophils-Multiple Organ Failure Grading for Complicated Intra-Abdominal Infections.

Surg Infect (Larchmt) 2020 Feb 28;21(1):69-74. Epub 2019 Aug 28.

Department of Surgery, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy.

The grading systems for intra-abdominal sepsis (IAS) are not employed commonly in clinical practice because they are too complicated or too specific. We propose to grade IAS with a simple grading system: the TNM system, which is an acronym borrowed from cancer staging, where T indicates Temperature, N indicates Neutrophils, and M indicates Multiple organ failure (MOF). The aim of this prospective observational study is to assess the predictive value of the TNM score on deaths of patients with complicated IAS. We considered 147 patients with complicated IAS. Three classes of attribute were chosen: Temperature (T), Neutrophil count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3), and M (M0-M2), they were grouped in stages (0-IV). We analyzed specific variables for their possible relation to death: Age, gender, blood transfusion, causes of IAS, T, N, pre-operative organ failure, immunocompromised status, stage 0, I, II, III, and IV. Odds ratios were calculated in a uni-variable and multi-variable analysis. This was the distribution in classes, based on TNM stages: One patient was in stage 0; 15 patients in stage I; 47 patients in stage II; 56 patients in stage III; 28 patients in stage IV. Death occurred in 45 (30.6%) patients. The N, pre-operative organ failure, immunocompromised status, stage III-IV were potential predictors of post-operative death in uni-variable analysis. Only pre-operative organ failure and stage IV were significant independent predictors of post-operative death in multi-variable analysis. The TNM classification is an easy system that could be considered to define the death risk of patients with IAS and to compare patients with sepsis.
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http://dx.doi.org/10.1089/sur.2019.092DOI Listing
February 2020

Measles-Related Hospitalizations in Italy, 2004-2016: The Importance of High Vaccination Coverage.

Ann Glob Health 2019 03 19;85(1). Epub 2019 Mar 19.

Department of Life, Health and Environmental Sciences, University of L'Aquila.

Background: Measles is a highly contagious human infectious disease. It can lead to serious complications and often requires hospitalization. In Italy, as in other European countries, the goal of measles elimination in 2015 failed. To reach this target, identifying susceptible individuals, closing any immunity gaps and reaching adequate vaccination coverage is necessary.

Objective: To contribute to these purposes, a retrospective observational study on measles-related hospitalization between 2004 and 2016 in Italy was conducted, using the national hospital discharge database as informational flow.

Methods: Admission frequencies and hospitalization rates were compared between regions with low (<90%) and high (≥90%) vaccination coverage for measles at age 24 months. Categorical variables were analyzed using the χ2 test or the χ2 test for trend for ordinal variables; t test was performed to verify the significance when annual average hospitalization rates were compared. Trends of vaccination coverage and hospitalization rates were analyzed using the slope of the regression line.

Findings: During the study period, 9,546 measles-related hospitalizations were collected in Italy, with an average annual number equal to 734. The overall measles hospitalization rates increased from 0.21 × 100,000 persons in 2004 to 0.82 × 100,000 in 2016 (β = 0.04; p = 0.689). A shift of mean age (from 1-17 years to 18-44 years) of measles-related hospitalizations was shown. A number of admissions for the low vaccination coverage group about twice as much as recorded for the other regional group was shown (6,344 vs 3,202). The involvement of 18-44 age class in the high vaccination coverage group was 14% higher compared with the low vaccination coverage group, in which, however, the 1-17 age class presented a 16% higher frequency.

Conclusions: These findings confirmed that large measles epidemics continue to occur in Italy, although with regional differences related to different rates of measles immunization. Vaccination coverage >90% led to a halving of measles hospitalizations, but it is insufficient for the elimination: ≥95% coverage continues to be the target to be reached.
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http://dx.doi.org/10.5334/aogh.2455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6634350PMC
March 2019

Influence of the Menstrual Cycle Phase on Pain Perception and Analgesic Requirements in Young Women Undergoing Gynecological Laparoscopy.

Pain Pract 2019 02 15;19(2):140-148. Epub 2018 Nov 15.

Department of MESVA, University of L'Aquila, L'Aquila, Italy.

Context: The influence of the gonadal hormones on some aspects of the human physiology has been studied with uncertain results. Still a confusion exists in relation to the real effects of the female hormones on the perception of pain. The existing data refer mainly to experimental studies and have provided results not always useful in the clinical practice.

Data Source: This study was designed to detect whether there are differences in the perception of the postoperative pain in women, during two clearly defined phases of hormonal asset: luteal and follicular phases.

Conclusion: The results of this study have demonstrated that in postoperative female patients pain is perceived significantly more in the luteal phase of the menstrual period, than in the follicular phase. This could suggest that female in child-bearing age should be scheduled for elective surgery preferentially during the follicular phase, unless differently necessary. It would guarantee a more comfortable postoperative period, with reduced necessity of analgesics.
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http://dx.doi.org/10.1111/papr.12727DOI Listing
February 2019

Sporotrichosis in Southern Brazil, towards an epidemic?

Zoonoses Public Health 2018 11 15;65(7):815-821. Epub 2018 Jul 15.

Mycology Lab, Faculty of Medicine, Federal University of Rio Grande (FaMed-FURG), Rio Grande, Brazil.

Rio Grande do Sul (RS) is the second highest state with respect to sporotrichosis incidence in Brazil, with most cases occurring in the southern region. Given the importance of epidemiologic monitoring in hyperendemic areas, this study evaluated the spatial, geographical and annual sporotrichosis incidence over a period of 7 years in the southern region of RS, as well as the disease evolution over the last two decades. Data were collected from the Mycology Laboratory of the Federal University of Rio Grande (FAMED-FURG) and from the Centre for Zoonosis Control (CZC) of the Prefeitura Municipal of Pelotas city. All feline cases of sporotrichosis diagnosed between 2010 and 2016 were included and analysed. In addition, cases of human and canine sporotrichosis were accounted for. Over the 7-year period (2010-2016), 372 feline, 34 canine and 83 human cases of sporotrichosis were diagnosed, being the mean number of cases/year 18.33 in the first 3 years of the study and 116.33 in the last 3 years. Cases were distributed among 34 and 28 neighbourhoods in Rio Grande and Pelotas city, respectively. Socioeconomic features reinforced the result that the disease is already spreading across a major part of the southern region. In addition, the study demonstrated the intensification and expansion of the high endemicity areas. Therefore, given that the number of feline sporotrichosis cases in southern RS reached alarming proportions, we suggested that this region will promptly face an epidemic of sporotrichosis if no preventive or control measures are undertaken.
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http://dx.doi.org/10.1111/zph.12504DOI Listing
November 2018

Antifungal activity of diphenyl diselenide alone and in combination with itraconazole against Sporothrix brasiliensis.

Med Mycol 2019 Apr;57(3):328-331

Mycology Lab, Faculty of Medicine, Federal University of Rio Grande (FaMed-FURG), Rio Grande do Sul, Brazil.

Sporothrix brasiliensis is the main agent of feline and zoonotic sporotrichosis. Given the scarcity of options for sporotrichosis treatment and the promising activity of diphenyl diselenide (PhSe)2 against a diversity of fungal pathogens, this study aimed to evaluate the in vitro susceptibility of Sporothrix brasiliensis to (PhSe)2 alone and in combination with itraconazole (ITC). Forty clinical isolates of S. brasiliensis were subjected to broth microdilution method to evaluate their susceptibility to (PhSe)2 in concentrations ranging between 0.25 and 128 μg/ml, and to ITC (0.0313-16 μg/ml) following the protocol of the Clinical and Laboratory Standards Institute (CLSI, 2008). All of these isolates were also used to evaluate the interaction between these drugs by checkerboard technique. Geometric mean of (PhSe)2 MIC values was 12.12 μg/ml, ranging from 4 to 32 μg/ml, and for ITC was 0.37 μg/ml (0.125 to 1 μg/ml). Benefic effect (additive or synergistic) in the interaction test between (PhSe)2 and ITC occurs in 73% (29/40) of the isolates. The promising (PhSe)2in vitro activity against S. brasiliensis suggests that it may not only be a potential alternative therapy but also be used as a combination with ITC, which is the first choice of therapy to sporotrichosis.
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http://dx.doi.org/10.1093/mmy/myy044DOI Listing
April 2019

Can sleep quality and burnout affect the job performance of shift-work nurses? A hospital cross-sectional study.

J Adv Nurs 2018 Mar 22;74(3):698-708. Epub 2017 Nov 22.

Department of Health, Life and Environmental Sciences, University of L'Aquila, Italy.

Aim: The aim of this study was to investigate any possible relationship between sleep disorders, burnout and job performance in a shift-work population of nurses.

Background: Sleep disorders and burnout can affect the job performance of nurses in terms of efficiency, productivity, task execution speed and supervision, which can be compromised when work shifts are organized on a 24-hour schedule and when the shift itself is irregular.

Design: A cross-sectional observational study was conducted from August 2014 - January 2015 on a sample of 315 shift-work nurses across 39 wards in seven central Italian hospitals.

Methods: The Pittsburgh Sleep Quality Index was used to detect the presence of sleep disorders, the Copenhagen Burnout Inventory was used to detect the presence of any possible type of burnout and the Job Performance Scale was used to measure job performance. Data analysis was mainly based on a multivariate logistic regression to identify variables significantly associated with investigated outcomes.

Results: On shift-work nurses' sleep quality and burnout correlated positively. The female gender and personal burnout were significantly associated with impaired sleep quality, while working in the psychiatric setting, working a long cycle shift pattern and experiencing daytime dysfunction were significantly associated with burnout. A significant negative association between patient-related burnout and job performance was observed.

Conclusion: Specific characteristics of shift-work nurses can directly affect sleep quality and burnout and indirectly job performance. This evidence offers healthcare administrators opportunities to intervene with measures to promote nurse's health, well-being and safety.
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http://dx.doi.org/10.1111/jan.13484DOI Listing
March 2018

Stress and Burnout in Health-Care Workers after the 2009 L'Aquila Earthquake: A Cross-Sectional Observational Study.

Front Psychiatry 2017 12;8:98. Epub 2017 Jun 12.

Department of Mental Health-Residences for the Execution of Security Measures, Subiaco, Rome, Italy.

Burnout is a work-related mental health impairment, which is now recognized as a real problem in the context of the helping professions due to its adverse health outcomes on efficiency. To our knowledge, the literature on the postdisaster scenario in Italy is limited by a focus on mental health professionals rather than other health-care workers. Our cross-sectional study aims to evaluate the prevalence of burnout and psychopathological distress in different categories of health-care workers, i.e., physicians, nurses, and health-care assistants, working in different departments of L'Aquila St. Salvatore General Hospital 6 years after the 2009 earthquake in order to prevent and reduce work-related burnout. With a two-stage cluster sampling, a total of 8 departments out of a total of 28 departments were selected and the total sample included 300 health-care workers. All the participants completed the following self-reporting questionnaires: a sociodemographic data form, a Maslach Burnout Inventory and a General Health Questionnaire 12 Items (GHQ-12). Statistically significant differences emerged between the total scores of the GHQ-12: analysis showed that the total average scores of the GHQ-12 were significantly higher in doctors than in health-care assistants. A high prevalence of burnout among doctors (25.97%) emerged. Using multivariate analysis, we identified a hostile relationship with colleagues, direct exposure to the L'Aquila earthquake and moderate to high levels of distress as being burnout predictors. Investigating the prevalence of burnout and distress in health-care staff in a postdisaster setting and identifying predictors of burnout development such as stress levels, time-management skills and work-life balance will contribute to the development of preventative strategies and better organization at work with a view to improving public health efficacy and reducing public health costs, given that these workers live in the disaster-affected community as survivors and serve as disaster relief workers at the same time.
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http://dx.doi.org/10.3389/fpsyt.2017.00098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466955PMC
June 2017

Burnout among healthcare workers at L'Aquila: its prevalence and associated factors.

Psychol Health Med 2017 12 15;22(10):1262-1270. Epub 2017 May 15.

c Department of Mental Health - Residences for Execution of Security Measures , ASL , Rome 5, Subiaco , Italy.

Burnout, which is now recognized as a real problem in terms of its negative outcome on healthcare efficiency, is a stress condition that can be increased by exposure to natural disasters, such as the 2009 L'Aquila earthquake. This study aims to evaluate burnout syndrome, its associated risk factors and stress levels, and the individual coping strategies among healthcare professionals at L'Aquila General Hospital. A cross-sectional study of 190 healthcare workers was conducted. There was a questionnaire for the collection of the socio-demographic, occupational and anamnestic data, and the Maslach Burnout Inventory, the General Health Questionnaire-12 items (GHQ-12) and the Brief COPE were used. The burnout dimensions showed high scores in Emotional Exhaustion (38.95%), in Depersonalization (23.68%) and in lack of Personal Accomplishment (23.16%), along with the presence of moderate to high levels of distress (54.21%). In addition to factors already known to be associated with burnout (job perception and high levels of distress) exposure to an earthquake emerged as a factor independently associated with the syndrome. Adaptive coping strategies such as religiosity showed a significant and negative relationship with burnout. Our research highlights the need for interventions directed at a reduction in workload and work-stressors and an improvement of adaptive coping strategies, especially in a post-disaster workplace.
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http://dx.doi.org/10.1080/13548506.2017.1327667DOI Listing
December 2017

Alcohol-free essential oils containing mouthrinse efficacy on three-day supragingival plaque regrowth: a randomized crossover clinical trial.

Trials 2017 03 31;18(1):154. Epub 2017 Mar 31.

Department of Life, Health and Environmental Sciences, University of L'Aquila, P. le G. Liberatore, Ed. Delta 6, 67100, L'Aquila, Italy.

Background: To evaluate the antiplaque effects of an alcohol-free mouthrinse containing essential oils-Listerine Zero (LZ)-and an alcohol-based essential oils mouthrinse (EO+) compared with a positive control of 0.20% chlorhexidine mouthrinse (CHX) and a negative control of a placebo solution (saline), using an in vivo plaque regrowth model of three days.

Methods: The study was designed as a double-masked, randomized, crossover clinical trial, involving 21 volunteers to compare four different mouthrinses, using a three-day plaque regrowth model. After receiving thorough professional prophylaxis at baseline, over the next three days each volunteer refrained from all oral hygiene measures and performed two daily rinses with 15 mL of the test mouthrinses. EO+ was compared with LZ. CHX rinse served as a positive control and a placebo solution as a negative control. At the end of each experimental period, the Plaque Index (PI) was assessed and a panelist completed through a visual analogue scale (VAS) questionnaire evaluating the organoleptic properties of each product. Each participant underwent a 14-day washout period and then there was another allocation.

Results: LZ showed the same inhibitory activity on plaque regrowth compared with EO+ in the whole mouth (PI = 1.72 versus 1.65, respectively), but there was less of an effect compared to the CHX (overall PI of 1.07) and a more efficient activity than the saline solution negative control (PI = 2.31). The difference of 0.07 between LZ and EO+ was not statistically significant.

Conclusions: LZ seems to have the same inhibiting effect on plaque regrowth as EO+ and a less inhibiting effect than the CHX control. Both LZ and EO+, as well as the CHX control, show a better inhibiting effect on plaque regrowth than the placebo solution.

Trial Registration: ClinicalTrials.gov, NCT02894593 . Registered on 4 September 2016.
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http://dx.doi.org/10.1186/s13063-017-1901-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374648PMC
March 2017

Improving the outcome of fractional CO2 laser resurfacing using a probiotic skin cream: Preliminary clinical evaluation.

Lasers Med Sci 2016 Nov 13;31(8):1607-1611. Epub 2016 Jul 13.

Department of Life, Health & Enviromental Sciences, Plastic and Reconstructive Surgery Section, University of L'Aquila, 67100, L'Aquila, Italy.

As known, fractional CO resurfacing treatments are more effective than non-ablative ones against aging signs, but post-operative redness and swelling prolong the overall downtime requiring up to steroid administration in order to reduce these local systems. In the last years, an increasing interest has been focused on the possible use of probiotics for treating inflammatory and allergic conditions suggesting that they can exert profound beneficial effects on skin homeostasis. In this work, the Authors report their experience on fractional CO laser resurfacing and provide the results of a new post-operative topical treatment with an experimental cream containing probiotic-derived active principles potentially able to modulate the inflammatory reaction associated to laser-treatment. The cream containing DermaACB (CERABEST™) was administered post-operatively to 42 consecutive patients who were treated with fractional CO laser. All patients adopted the cream twice a day for 2 weeks. Grades were given according to outcome scale. The efficacy of the cream containing DermaACB was evaluated comparing the rate of post-operative signs vanishing with a control group of 20 patients topically treated with an antibiotic cream and a hyaluronic acid based cream. Results registered with the experimental treatment were good in 22 patients, moderate in 17, and poor in 3 cases. Patients using the study cream took an average time of 14.3 days for erythema resolution and 9.3 days for swelling vanishing. The post-operative administration of the cream containing DermaACB induces a quicker reduction of post-operative erythema and swelling when compared to a standard treatment.
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http://dx.doi.org/10.1007/s10103-016-2024-6DOI Listing
November 2016

Steroid-Eluting Ethmoidal Stent Versus Antero-Posterior Ethmoidectomy: Comparison Of Efficacy And Safety In Allergic Patients.

Otolaryngol Pol 2016 Apr;70(2):6-12

Paediatric Allergology Unit, S. Pertini Hospital, Rome Italy.

Background: Allergic and chronic rhinosinusitis is a disabling pathological condition with an 8% prevalence in the European population and 5% in the Italian one. The ethmoidal sinus is the first one involved in the inflammation. The typical surgical procedure to manage ethmoidal sinusitis is an endoscopic antero-posterior ethmoidectomy. Recently introduced on the European market balloon called Relieva Stratus MicroFlow Spacer can be inserted within the ethmoid, with a local slow release of a steroid drug. This study had the aim to evaluate the efficacy and safety of the steroid-eluting ethmoidal stent in the management of allergic chronic rhinosinusitis in comparison with the traditional endoscopic ethmoidectomy. Methodos: 70 allergic patients who presented chronic rhinosinusitis were randomly divided into 2 groups and receive respectively the steroid-eluting ethmoidal stent or endoscopic ethmoidectomy.

Results: The most significant observation coming from the comparative analysis of the results is the substantial equivalence of the treatment with the steroid-eluting ethmoidal stent (SEES) compared with endoscopic ethmoidectomy in the management of ethmoid chronic rhinosinusitis with the exception of a reduction of overall discomfort and nasal secretion and better functional results at rhinomanometry in the steroid-eluting ethmoidal stent group.

Conclusion: in our experience, the SEES was efficacious in the treatment of allergic patients with ethmoidal CRS when conventional medical treatment had failed, or when wishing to avoid the classic endoscopic ethmoidectomy (EE). However, further long-term studies will be performed in order to confirm the safety and stability, over time, of the results obtained.
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http://dx.doi.org/10.5604/00306657.1199343DOI Listing
April 2016

[Health status perception among the elderly of L'Aquila after the 2009 earthquake].

Epidemiol Prev 2016 Mar-Apr;40(2 Suppl 1):59-64

Dipartimento di medicina clinica, sanità pubblica, scienze della vita e dell'ambiente, Università degli Studi dell'Aquila.

Objectives: to evaluate the health status' perception in relation to the displacement in the over-65-year population of L'Aquila, about three years after the earthquake of April 6th, 2009.

Design: a cross-sectional observational study was performed using a structured interview with a questionnaire divided into 36 closed and multiple questions.

Setting And Participants: interviews were conducted in the offices of general practitioners and at the Department of prevention - vaccinations service. The respondents were 569 elderly, equally represented by gender; 57% was 65-74 years old, 25% was 75-79 years old, and 18% was more than 80 years old.

Results: the study showed that the negative perception of health status is significantly associated with delocalization, female gender, more advanced age, low education, and living with a person not belonging to the family unit. Among people who perceive health in a negative way and live in temporary housing, the inability to perform daily activities, and therefore a lower degree of self-sufficiency, was detected more frequently. Even the presence of certain chronic degenerative diseases (even if self-reported) contributes to the negative perception. This is associated with a decrease in the ability to perform daily activities.

Conclusions: the living conditions and the traditional determinants of old age negatively affect the perception of health status. Relocation and the absence of infrastructure change everyday life and affect judgment on one's health.
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http://dx.doi.org/10.19191/EP16.2S1.P059.050DOI Listing
December 2017

Temporal trends in hospitalization for rotavirus gastroenteritis: A nationwide study in Italy, 2005-2012.

Hum Vaccin Immunother 2016 ;12(2):534-9

f General and Applied Hygiene; Section of Public Health ; Department of Life, Health and Environmental Sciences; University of L'Aquila ; L'Aquila , Italy.

AGE severity is linked to etiology, and Rotavirus (RV) accounts for most of severe cases. In 2009 the World Health Organization recommended RV vaccination for all children. Worldwide a number of Countries implemented RV vaccination in their pediatric immunisation programmes, but only a limited number in Europe. This study was designed to estimate the proportion of RVGE among children aged <6 y who were diagnosed with AGE and admitted to hospitals in Italy during the years 2005-2012. A total of 334,982 hospital discharge forms were collected, being 79,344 hospitalizations associated with RV. The average hospitalization rate (HR) was 146/100,000 children for RVGE in primary diagnosis (PD) and 150/100,000 children for RVGE in secondary diagnosis (SD). Since 2008 the RVGE hospitalization figures and rates (HRs) in SD exceed those in PD. The majority of RVGE hospitalizations (33.67%) were reported among children aged ≤ 2 years. Despite some limitations due to the hospital discharge database (HDD) synthetic contents and low potential for clinical interpretation, the analysis of national HDD, including PD and SD, documents that RV still represents a consistent cause of pediatric hospitalizations in Italy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049727PMC
http://dx.doi.org/10.1080/21645515.2015.1081726DOI Listing
December 2016

Use of Mueller-Hinton broth and agar in the germ tube test.

Rev Inst Med Trop Sao Paulo 2014 Nov-Dec;56(6):483-5

Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil.

Candida albicans is often isolated from clinical samples, thus its presumptive differentiation from other species of the same genus can be based on its ability to form the germ tube in human serum. Nevertheless, there are two other species that share this characteristic: C. dubliniensis and C. africana. The aim of this study was to compare four different substrates to perform the germ tube (GT) test. The Candida spp. isolates were identified using a manual system (135 C. albicans, 24 C. tropicalis and one C. dubliniensis). The germ tube test was performed with fresh, previously frozen serum and Mueller-Hinton (MH) broth and agar. GT was observed in 96% (130/136) of the isolates through the fresh serum technique, 94% (128/136) through previously frozen serum, 92% (125/136) in MH agar, and 90% (122/136) in MH broth. The sensitivity of each test was higher than 90%, with 100% specificity. Both the MH agar and broth were able to identify the true positives, and false positives were not found. However, some C. albicans isolates were not identified. MH agar and broth may be used in laboratory for the rapid presumptive identification of C. albicans, as an alternative method for germ tube test.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296867PMC
http://dx.doi.org/10.1590/s0036-46652014000600005DOI Listing
April 2015

Influenza vaccination coverage among medical residents: an Italian multicenter survey.

Hum Vaccin Immunother 2014 6;10(5):1204-10. Epub 2014 Mar 6.

Department of Public Health, Neuroscience, Experimental and Legal Medicine; University of Pavia; Pavia, Lombardi, Italy.

Although influenza vaccination is recognized to be safe and effective, recent studies have confirmed that immunization coverage among health care workers remain generally low, especially among medical residents (MRs). Aim of the present multicenter study was to investigate attitudes and determinants associated with acceptance of influenza vaccination among Italian MRs. A survey was performed in 2012 on MRs attending post-graduate schools of 18 Italian Universities. Each participant was interviewed via an anonymous, self-administered, web-based questionnaire including questions on attitudes regarding influenza vaccination. A total of 2506 MRs were recruited in the survey and 299 (11.9%) of these stated they had accepted influenza vaccination in 2011-2012 season. Vaccinated MRs were older (P = 0.006), working in clinical settings (P = 0.048), and vaccinated in the 2 previous seasons (P<0.001 in both seasons). Moreover, MRs who had recommended influenza vaccination to their patients were significantly more compliant with influenza vaccination uptake in 2011-2012 season (P<0.001). "To avoid spreading influenza among patients" was recognized as the main reason for accepting vaccination by less than 15% of vaccinated MRs. Italian MRs seem to have a very low compliance with influenza vaccination and they seem to accept influenza vaccination as a habit that is unrelated to professional and ethical responsibility. Otherwise, residents who refuse vaccination in the previous seasons usually maintain their behaviors. Promoting correct attitudes and good practice in order to improve the influenza immunization rates of MRs could represent a decisive goal for increasing immunization coverage among health care workers of the future.
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http://dx.doi.org/10.4161/hv.28081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896598PMC
June 2015

Cutaneous infection by Diaporthe phaseolorum in Brazil.

Med Mycol Case Rep 2013 Apr 8;2:85-7. Epub 2013 Apr 8.

Mycology Laboratory, Santa Casa-Complexo Hospitalar, Annes Dias, 285, 96000-020, Porto Alegre, RS, Brazil.

Diaporthe phaseolorum is a frequent fungal parasite of plants, rarely involved in human diseases. We describe a case of cutaneous infection caused by this fungus diagnosed by morphology and molecular biology, on the hands and on a foot of a renal transplanted Brazilian farmer. The infection was resolved with oral itraconazole.
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http://dx.doi.org/10.1016/j.mmcr.2013.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885928PMC
April 2013

Well-being and perceived quality of life in elderly people displaced after the earthquake in L'Aquila, Italy.

J Community Health 2014 Jun;39(3):531-7

Department of Medicine, Health and Environment Sciences, University of L'Aquila, Viale S. Salvatore Edificio 6, 67100, L'Aquila, Italy,

On 6 April 2009, the city of L'Aquila was hit by a violent earthquake that destroyed almost all of its medieval centre, and the surviving inhabitants were evacuated and relocated in temporary quarters or undamaged homes. The aim of this study was to investigate the perceived quality of life of the elderly population 3 years after the earthquake in relation to the social and logistic issues of new housing. The study was carried out between October 2011 and March 2012, and involved 571 subjects aged over 65 years living in the municipality of L'Aquila. The interviews took place in the surgeries of general practitioners and the city's Department of Prevention and Vaccination in the anti-influenza immunisation period. The instrument used was a 36-item questionnaire with closed, multiple choice answers divided into the following sections: demographics, everyday activities, health and perceived health, and the quality of life in the city. The results show that, 3 years after the earthquake, the elderly population living in the new towns and temporary housing of L'Aquila have a worse perception of their quality of life than the others. They feel a certain social isolation and wish to live elsewhere. Governments faced with the problems arising from a natural calamity should take into account all of the elements making up a good quality of life and, before making choices whose impact cannot be changed, consider both their immediate and long-term social consequences.
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http://dx.doi.org/10.1007/s10900-013-9793-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000418PMC
June 2014

Isolation of dermatophytes in wild felids from screening centers.

Braz J Microbiol 2013 31;44(1):171-4. Epub 2013 May 31.

Programa de Pós-Graduação em Veterinária, Departamento de Veterinária Preventiva, Faculdade de Veterinária, Universidade Federal de Pelotas, Pelotas, RS, Brazil.

The aim of this study was detect the presence of dermatophyte fungi on wild felids from screening centers. Samples were taken from 30 animals, assembled in two groups: "free-ranging" and "transitory captivity". The dermatophytes (Trichophyton genus), isolated from two felids (6.6%), both of the group "free-ranging".
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http://dx.doi.org/10.1590/S1517-83822013000100025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804195PMC
October 2013

Clinical and mycological analysis of dog's oral cavity.

Braz J Microbiol 2013 9;44(1):139-43. Epub 2013 Apr 9.

Centro de Diagnóstico e Pesquisa em Micologia Veterinária, Departamento de Veterinária Preventiva, Universidade Federal de Pelotas, Pelotas, RS, Brazil.

The oral microbiota of humans and animals is made up of a wide variety of yeasts and bacteria, but microbiota of dogs is not totally described. Although such identification is an important step to establish the etiopathogenesis and adequate therapy for the periodontal disease The aim of this study was to evaluate and correlate oral alterations with the presence of yeasts in oral cavity of female dogs. After clinical evaluation samples from healthy and from dogs with oral diseases were obtained from three different oral sites by swabs, curettes, millimeter periodontal probes and HA membrane tip in cellulose ester. Yeast identification was performed through macroscopic and microscopic colony features and biochemical tests. Dental calculus was the most prevalent occurrence in the oral cavity of 59 females. However, the isolation of yeasts was significantly higher (p < 0.05) in animals suffering from halitosis. Eleven yeast species were identified, namely: Malassezia pachydermatis, Rhodotorula spp., Candida albicans, C. catenulata, C. famata, C. guilliermondii, C. parapsilosis, C. intermedia, Trichosporon asahii, T. mucoides and Cryptococcus albidus. It could be concluded that the yeasts are part of the microbiota from the different sites of the oral cavity of the female canines studied without causing any significant alterations except halitosis.
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http://dx.doi.org/10.1590/S1517-83822013005000018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804190PMC
October 2013