BACKGROUND: Despite the importance of hand hygiene in reducing infection, healthcare worker compliance with hand hygiene recommendations remains low. In a previous study, we found a generally low level of compliance at baseline, with substantial differences between doctors and nurses and between hospital units. We describe here the results of our multimodal intervention intended to improve levels of healthcare worker hand hygiene. METHODS: A 6-month, before-and-after, multimodal interventional study in five hospital units in Florence, Italy. We used direct observation to assess hand hygiene rates for doctors and nurses, focusing on hygiene before touching the patient. We explored reasons for unit variability via interviews of doctor and nurse leaders on the units. RESULTS: Overall healthcare worker hand hygiene increased from 31.5% to 47.4%(p<0.001). Hand hygiene adherence among nurses increased from 33.7% to 47.9%(p<0.001); adherence among doctors increased from 27.5% to 46.6%(p<0.001). Improvement was statistically significant in three out of five units, and units differed in the magnitude of their improvement. Based on the interviews, variability appeared related to the "champion" on each unit, as well as the level of motivation each physician leader exhibited when the preintervention results were provided. CONCLUSIONS: Although overall healthcare worker adherence with hand hygiene procedures before patient contact substantially increased after the multimodal intervention, considerable variability-for both nurses and doctors and across the 5 units-was seen. Although adherence substantially increased, overall hand hygiene in these units could still be greatly improved.

Objective:The mechanisms underlying the association of the increased albumin excretion rate (AER) with adiposity have yet to be clarified. We therefore investigated (1) the predictors of AER after 3 months of lifestyle intervention in a large cohort of nondiabetic obese women and (2) the relationships between AER and the adipose tissue gene expression of adipokines linked to inflammation and insulin resistance.Subjects:A total of 269 obese nondiabetic women (age 49.9+/-13.1 years, body mass index (BMI) 36.8+/-4.6 kg m(-2)) participated in this program. Measurements used were anthropometrics parameters, blood pressure, oral glucose tolerance test, lipids, creatinine, AER, homeostasis model assessment of insulin resistance (HOMA-IR) and glomerular filtration rate at baseline and after 3 months of lifestyle intervention. At baseline, in a subgroup of 34 women, subcutaneous adipose tissue biopsy was carried out for the analysis of mRNA expression levels of adiponectin, suppressor of cytokine signaling 3 (SOCS-3), tumor necrosis factor alpha (TNF-alpha), pentraxine 3 (PTX-3), angiotensinogen and angiotensin-converting enzyme, and a blood sample was also taken from this group for the measurement of circulating adiponectin, interleukin-6, TNF-alpha and PTX-3. Microalbuminuria was defined as albumin/creatinine ratio >/=3.5 mg mmol(-1). Real-time PCR was used to quantify mRNA.Results:Six percent of obese women had microalbuminuria. When dividing the whole cohort into three groups according to AER changes (decrease, stability and increase), we noted that 2 h glucose, insulin and HOMA-IR significantly decreased (P<0.05 for all) only in women who had a decrease in AER, whereas BMI and waist circumference significantly decreased in all the three groups (P<0.05). At baseline, higher AER was associated to significantly higher adipose tissue mRNA expression levels of SOCS-3 and PTX-3 (P<0.05) and to higher TNF-alpha and angiotensinogen expression.Conclusions:In obese women, weight loss alone is not sufficient to induce the AER decrease that occurs only with a concomitant improvement in glucose homeostasis. The adipose tissue gene expression profile seems to favor the early renal impairment often seen in obese subjects.International Journal of Obesity advance online publication, 27 October 2009; doi:10.1038/ijo.2009.227.

According to European Union Regulation EC 1531/2001, olive oil labelled as "extra-virgin" should be cold-pressed and contain no refined oil or oil from other oleaginous seeds or nuts. Adulteration of extra virgin olive oil (EVOO) with hazelnut oil (HAO) is a serious concern both for oil suppliers and consumers. The high degree of similarity between the two fats complicates the detection of low percentages of HAO in EVOO. Many analytical approaches have been developed in recent years to trace HAO in EVOO, principally based on chromatographic analyses, differential scanning calorimetry or nuclear magnetic resonance. In addition adulteration of EVOO with HAO may introduce hazelnut-derived allergens. The aim of this work was to analyse the protein and allergen content of EVOO intentionally spiked with raw cold-pressed HAO or solvent-extracted HAO. SDS-PAGE analysis confirmed the presence of hazelnut proteins in solvent-extracted HAO with molecular masses ranging 10-60 kDa. In contrast, cold-pressed HAO showed no traces of protein. In spiked EVOO, solvent-extracted HAO was still detectable at a 1% contamination level. Several bands on SDS-PAGE migrated at apparent molecular masses coinciding with known allergens, such as Cor a 1 ( approximately 17 kDa), Cor a 2 ( approximately 14 kDa), Cor a 8 ( approximately 12 kDa), oleosin ( approximately 17 kDa) and Cor a 9 ( approximately 60 kDa). MALDI-TOF MS analysis confirmed the presence of two oleosin isoforms and of Cor a 9. Immunoblotting demonstrated that an allergic patient with known reactivity to Cor a 1 and Cor a 2 recognized a 17-kDa band in solvent-extracted HAO. In conclusion, we have shown that adulteration of extra virgin olive oil with solvent-extracted hazelnut oil can be traced by simple SDS-PAGE analysis, and that adulteration introduces a potential risk for hazelnut allergic patients.

Cocoa beans are rich source of polyphenols, contributing about 10% of the dry weight of the whole bean and its derivative chocolate, particularly dark chocolate, is considered one of major contributors of antioxidants to the American diet after fruits and vegetables. At present the wide variation in cocoa processing and in the content and profile of polyphenols make it difficult to determine to what extent the findings about positive effects expressed in different studies, translate into tangible clinical benefits. Moreover, before claiming any healthy properties to a plant, natural product or food item on human subject, a basic research project approved by scientific and ethical commissions has to be performed. Until now the definition, composition, manufacturing specifications, packaging and labelling of cocoa and chocolate products in Europe, are regulated by "Directive 2000/36/EC of the European parliament and of the council". The definitions take changes in consumer tastes, chocolate composition and labelling into account, but don't consider the real potential of healthy, beneficial and nutraceutical effects. In fact, they fail to establish an official analytical methodology for the quantification of phenolic compounds in cocoa and chocolate. Moreover quantification of these compounds is not used in product classification. This article reviews many qualitative differences of cocoa and chocolate, in particular dark chocolate, aiming to establish the different implications for public health through the use of the analyzed concentration of polyphenols in cocoa products.

A 81-year-old man was referred to our department for the acute onset of dyspnea. Chest radiograph suggested a bowel shadow containing gases in the right chest. Computed tomography (CT) scan revealed the dislocation of the liver and the transverse colon in the right pleural cavity. Although the patient had no history of a blunt trauma, he had undergone the right nephrectomy for the renal cancer 3 years before. An emergency operation revealed the right lobe of the liver and the transverse colon profoundly entering into the right pleural cavity. The dislodged organs were gently restored through a dual approach, and the defect of the diaphragm was repaired with a prosthesis. The postoperative course was satisfactory. A diaphragmatic hernia sometimes occurs acutely and often shows life-threatening symptoms. The occurrence of the diaphragmatic hernia associated with previous surgery must be taken into account, when the procedure involved the diaphragm.

Congenital diaphragmatic hernia (CDH) is a rare anomaly (1 of 2-4000 live births) where abdominal organs can enter the thoracic cavity. It is usually diagnosed shortly after birth, often associated with pulmonary hypoplasia and pulmonary hypertension causing life threatening condition. In approximately one out of four patients CDH is diagnosed later in life, usually within several weeks or months from birth. CDH diagnosed in adulthood is very uncommon. Here we describe a 45 year old previously healthy woman that was diagnosed with a large tumor in her right hemithorax, after having symptoms of chronic cough and chest pain for several months. At thoracotomy the tumor was found to be omentum covered with a hernial sac that had penetrated the chest through a small diaphragmatic hernia. Six months postoperatively she was doing well with no respiratory or abdominal symptoms.

We herein present a case of intrathoracic omental herniation through the esophageal hiatus in a young patient. A 21-year-old obese man was asymptomatic, and his chest X-ray demonstrated a large, sharply defined mass. A computed tomography scan of the thorax indicated a large retrocardial mediastinal mass in which the density indicated the presence of fatty tissue judging from the Hounsfield unit range. A thoracotomy was performed under a diagnosis of either mediastinal lipoma or liposarcoma with an encapsulated fatty mass, measuring 17 x 12 x 8 cm in size. The mass, however, proved to be an omental herniation through the esophageal hiatus. It is generally assumed that the major contributing factors leading an individual to develop an omental herniation through the esophageal hiatus include aging and obesity. This is the first report of omental herniation through the esophageal hiatus in a patient still in his twenties.

It is estimated that 10% of intra-cranial tumours are localized in the cerebellopontine angle and internal auditory canal and early symptoms of the different histological forms are almost identical. Acoustic neuroma account for 90% and meningioma for 5-10% of these tumours, while a small percentage of rare tumours exist, the most frequent being epidermoid cyst, also known as congenital cholesteatoma or keratoma. The case is reported here of a large epidermoid cyst of the right cerebellopontine angle, and the clinical-radiological course is reviewed. The patient, a 35-year-old, male, initially presented an episode of objective rotatory vertigo, and a history of right ear fullness, of a few months' duration, with normal otoscopy. Audiometric test was normal in left ear, while slight pantonal sensori-neural hypoacusia was observed in the right ear. The impedenzometric findings were normal as was the vestibular test. Auditory brainstem evoked response showed an increased latency of fifth wave. Gadolinium-enhanced magnetic resonance imaging of brain revealed the presence of a voluminous epidermoid cyst occupying the extra-axial side of the right cerebellopontine cistern with superior extension into the cistern. Due to the low-grade of symptoms, we had chosen to wait and not perform surgery immediately, with otologic and vestibular test-controls every 6 months, with cerebral magnetic resonance imaging to control extension of the mass, without radiation exposure for the patient. One year after diagnosis, at the last control, otofunctional findings were not modified and repeat magnetic resonance imaging did not demonstrate important variations compared to the first. Thus, the choice not to proceed with surgery was justified since surgery is burdened by the risk of important complications. At magnetic resonance imaging, the epidermoid cyst, unlike the majority of intra-cranial tumours, such as acoustic neuroma and meningioma, does not show gadolinium-enhancement; this again supporting the important role of magnetic resonance imaging in the differential diagnosis of intra-cranial neoformations. It is, therefore, worthwhile stressing the validity of the approach, step by step, in the diagnosis of patients with otologic symptoms, together with the importance of magnetic resonance imaging that, in comparison with computed tomography, allowed us to exactly assess the growth rate of the mass and to "wait and see" without risks and without radiations for the patient.

We report a rare case of massive left atrial lipoma occupying pericardial space. A 52-year-old male was admitted because of cardiomegaly of unknown etiology. Computed tomography showed a large epicardial mass located along the anterior surface of the heart, from the diaphragm level through the aortic arch level. The mass showed an attenuation value identical with that of subcutaneous adipose tissue and contained some areas with high density. The mass was not enhanced by contrast media. Histologic examination of the specimen obtained by percutaneous biopsy demonstrated mature adipose tissue. An encapsulated adipose mass weighing 620 g, which originated from the left atrium without any invasion to the pericardium, was completely excised. Microscopic examination revealed mature adipose tissue with partial necrosis, confirming the diagnosis of lipoma.

The painting Mona Lisa in the Louvre, Paris, by Leonardo da Vinci (1503-1506), shows skin alterations at the inner end of the left upper eyelid similar to xanthelasma, and a swelling of the dorsum of the right hand suggestive of a subcutaneous lipoma. These findings in a 25-30 year old woman, who died at the age of 37, may be indicative of essential hyperlipidemia, a strong risk factor for ischemic heart disease in middle age. As far as is known, this portrait of Mona Lisa painted in 1506 is the first evidence that xanthelasma and lipoma were prevalent in the sixteenth century, long before the first description by Addison and Gall in 1851.

A 72-years woman presented with a 4-weeks history of abdominal pain and sickness. Physical examination was normal except for a large, smooth, non-tender solid mass in the right upper quadrant. US demonstrated a 12 x 9 x 4-cm solid, homogeneous, hyperechogenic mass between the posterior abdominal wall and the right kidney and the right lobe of the liver. The primary diagnosis was established as Tumor hepatis. The CT showed a great mass of measurements between - 80 and - 100 Hounsfield units; it filled right half of the abdominal cavity, with focal intratumoral calcifications. The right lobe of the liver, gallbladder, the right kidney, and loops of the small intestine were dislocated and pressured to anterior abdominal wall. The lower pole of the tumor was located in right iliac fosse. It was easily dissected from the adjacent tissues and removed completely. The histopathological diagnosis was lipomas. The next case was a 60-years woman with a 2-months history of pain and gastrointestinal symptoms. US demonstrated a 13 x 12-cm solid, homogeneous, hyperechogenic mass in right epigastria, below the liver. The primary diagnosis was established as abdominal tumor. The CT showed lipomas with numerous septa and calcifications of measurements between -20 and -61 Hounsfield units filling the right half of the abdominal cavity. The right kidney and loops of the small intestine were dislocated to the left side. The root of the tumor seems to be connected with the mesentery of the small intestine. The patient was treated surgically and remains well under regular follow-up.