[Quality of post-discharge growth in small for gestational age preterm infants: an explorative study]

OBJECTIVES

The Preterm newborns, especially if born small for gestational age (SGA), appear to be at risk for developing post-natal growth failure and an altered body composition. Nutrition-related growth during a critical window in infancy may affect the development of metabolic syndrome in adult life. Aim of the present study was to test the hypothesis that the post-discharge period is critical for programming the catch up growth and the later development of metabolic syndrome in small for gestational-age infants fed either standard or enriched formula.

METHODS

A clinic randomized explorative study was conducted. Twenty-seven preterm SGA infants (gestational age < or = 33 weeks; birth weight < or = 1500 g) underwent assessment of growth and body composition by means of an air displacement system at 36 weeks, 15 days and 1 months adjusted age. SGA infants were randomized to receive standard formula (Kcal: 67/100 ml, proteins: 1,4 g/100 ml) or enriched formula (Kcal: 75/100 ml, proteins: 2 g/100 ml) after discharge.

RESULTS

No differences in weight, fat mass, length and head circumference were found in SGA infants fed standard formula as compared to those fed enriched formula at 15 day or 1 months adjusted age.

CONCLUSIONS

This explorative study suggests that in SGA infants growth, both in terms of quantity and quality, is not influenced by different nutritional management during the early post-discharge period.

Emergency department syndromic surveillance system for early detection of 5 syndromes: a pilot project in a reference teaching hospital in Genoa, Italy

Early detection is fundamental for achieving effective control of infectious disease outbreaks. We described the development of a local chief complaint emergency department (ED)-based syndromic surveillance system to improve public health response in Genoa, Italy. The five syndromes under investigation by the syndromic surveillance system were influenza-like illness (ILI), low-respiratory tract illness (LRTI), not-haemorrhagic gastroenteritis, acute hepatitis, fever-with-rash (maculo-papular or vescicular) syndrome. Syndrome coding, data capture, transmission and processing, statistical analysis to assess indicators of disease activity and alert thresholds, and signal response were operatively described. Preliminary results on ILI syndromic surveillance showed that new system allowed the activation of the alert state with a specificity of 90.3% and a sensitivity of 72.9% in predicting epidemiological relevant events, such as > or = 10 accesses to ED for ILI in 3 days. The new syndromic surveillance system allowed to alert the public health institutions 2.5 days before than the local surveillance system based on sentinel physicians and paediatricians, permitting the early activation of the necessary measures for the containment and for burden reduction of the epidemic event. It is noteworthy that the syndromic surveillance epidemic cut-off was overcome once before and 4 times after influenza outbreak detected by sentinel-based surveillance system: all episodes were contemporary with Respiratory Syncytial Virus and Parainfluenza Virus circulation, as detected by regional reference laboratory.

[Body composition in small for gestational age newborns]

OBJECTIVES

Aim of the present study was to test the hypothesis that the body composition of small for gestational age preterm infants, assessed at term equivalent age, was different as compared to that of small for gestational age full-term newborns.

METHODS

Growth parameters and body composition, assessed by means of an air displacement pediatric plethysmography system, was measured in 120 newborns (67 preterm and 53 full-term).

RESULTS

Similar weight was found in preterm and full-term newborns at term equivalent age and at birth, respectively. On the contrary, percentage of total body fat mass was significantly higher in preterm newborns as compared to full-term newborns (14.3 +/- 4.7% vs. 5.7 +/- 3.8% respectively, P < 0.05). In the preterm group gestational age was negatively associated with total fat mass at term equivalent age. CONCLUSIONS. The preterm newborns, especially if born small for gestational age, appear to be at risk for developing an altered body composition, which is a risk factor for the development of the metabolic syndrome in adult life. Preterm infants, born small for gestational age, appear to develop a quantity of fat mass higher than the adipose tissue they would have accumulated if they had completed their intrauterine gestation. The gestational age and the nutritional management in the early postnatal life could play a key role in affecting the body composition in these vulnerable infants.

[Quality of growth in preterm infants assessed at term equivalent age: a pilot study]

BACKGROUND

The American Academy of Pediatrics (AAP) recommends that preterm infants' growth duplicates fetal growth rates and that body composition replicates in utero body composition. Aim ofthe study was to compare the total body fat mass between preterm infants assessed at term and full-term newborns.

METHODS

A prospective observational study was conducted. Forty-five preterm infants (mean (SD) gestational age: 30,1 (2.3) weeks; birth weight: 1125 (280) g), and 40 full term (mean (SD) 38.5 (1.2) weeks, 3203 (385) g, breast fed infants underwent assessment of growth and body composition by means of an air displacement system at term adjusted-age and on day 3 of life, respectively. A T test was used to compare % fat mass between preterm and term infants.

RESULTS

Weight, length and head circumference were smaller in the preterm group assessed at term adjusted-age as compared to the term group. Mean (SD) percentage of fat mass in preterm infants was significantly higher as compared to term infants [14.5 (4.3) vs 7,6 (3.6), P < 0.0001].

CONCLUSIONS

Our data demonstrate that preterm infants are at risk of developing an increased adiposity in addition to postnatal growth retardation.

Novel PTEN mutations in neurodevelopmental disorders and macrocephaly

Somatic mutations of the phosphatase and tensin (PTEN) gene have been frequently detected in many types of human cancer. However, germline mutations can determine multiple hamartoma syndromes and, as more recently ascertained, syndromes clinically characterized by autism associated with macrocephaly. To determine whether germline mutations of PTEN may lead to different phenotypes, we screened all the nine exons of the PTEN gene in 40 patients with neurodevelopmental disorders, with or without features of autism spectrum disorder, associated with macrocephaly. Three novel de novo missense mutations were found (p.H118P, p.Y176C, p.N276S) in two severely mentally retarded patients with autism and in a subject with neurodevelopmental disorders without autistic features. Our results provide evidence that PTEN germline mutations may sustain a more wide phenotypical spectrum than previously suggested.

Molecular epidemiology and case-control approaches for management of an outbreak of hepatitis A in Liguria, Italy

INTRODUCTION AND METHODS

Hepatitis A remains an important public health problem in low endemicity areas, because of the social and economic high burden of cyclical outbreaks. In this study we described an outbreak of HAV infection occurred in the city of Genoa and in its proximity and the viral circulation in the post-epidemic period. In order to identify risk factors associated to the illness and to determine the source of infection and the dynamics of virus evolution, we conducted an epidemiological and molecular investigation by a case-control study and by sequence analysis of high variable regions of the genome.

RESULTS

From May to October 2005, 58 HAV hepatitis cases were notified. The case-control study showed that beach establishment attending is strongly associated with HAV hepatitis (OR = 24.5, p-value < 0.01), at multivariate analysis. The profile of epidemic curve, the clinical onset of primary cases who occurred in few weeks and the geographic distribution of cases clearly indicated a common exposure to a point source: the outbreak can be probably associated with a contaminated food product dispensed in the affected area. The outbreak has been mainly caused by a single variant, confirming the common exposure to a point source; this variant previously circulated within homosexual man (MSM) network in Northern Europe. During the outbreak and in the following months, different variants originating from Southeast Asia, Southern America and Northern Africa, have co-circulated: all these cases were related to international travel and none of these had determined secondary cases.

DISCUSSION

The epidemiological picture of hepatitis A in Liguria is characterized by a wide heterogeneity of circulating HAV strains. This pattern could be associated with the increase of imported cases and transmission within network of persons with similar risk factors. Molecular approach coupled to descriptive and analytical epidemiological studies appeared un-replaceable tools for management and control of HAV outbreaks, because of their capacity to recognize infection origin, transmission patterns and dynamics of virus evolution.

Neurocutaneous syndrome with mental delay, autism, blockage in intracellular vescicular trafficking and melanosome defects

We evaluated a 11-year-old male patient with mental delay, autism and brownish and whitish skin spots. The former resembled those of neurofibromatosis, the latter those of tuberous sclerosis. The patient received a complete clinical work-up to exclude neurofibromatosis, tuberous sclerosis, or any other known neurocutaneous disease, with biochemistry, chromosome analysis and analysis of skin specimens. Being all the other tests not significant, two main ultrastructural defects were observed. The first was a blockage in intracellular vescicular trafficking with sparing of the mitochondria; the second an aberrant presence of melanosomes in vacuoles of several cell lines and abnormal transfer of these organelles to keratinocytes. This patient presented with a unique clinical picture distinct from neurofibromatosis or tuberous sclerosis or any other known neurocutaneous disease. The ultrastructural abnormalities suggested a defect in cell trafficking involving several cell lines and compartments.

Epstein-Barr virus-associated post-transplant lymphoproliferative disease with central nervous system involvement after unrelated allogeneic hematopoietic stem cell transplantation

Post-transplant lymphoproliferative disorders (PTLD) represent an heterogeneous group of abnormal lymphoid proliferation related to Epstein-Barr virus (EBV) reactivation that arise early after allogeneic hematopoietic stem cell transplant (HSCT). PLTD with central nervous system (CNS) involvement has been reported in few cases. We describe the case of a 31-year-old-man who developed an EBV-related PTLD with CNS involvement 2 months after an allogeneic unrelated HSCT for acute myeloid leukemia in first complete remission who was successfully treated with rituximab, cidofovir and intrathecal infusion of methotrexate and methylprednisolone.

Role of individual disulfide bonds in the structural maturation of a low molecular weight glutenin subunit

Gliadins and glutenins are the major storage proteins that accumulate in wheat endosperm cells during seed development. Although gliadins are mainly monomeric, glutenins consist of very large disulfide-linked polymers made up of high molecular weight and low molecular weight subunits. These polymers are among the largest protein molecules known in nature and are the most important determinants of the viscoelastic properties of gluten. As a first step toward the elucidation of the folding and assembly pathways that lead to glutenin polymer formation, we have exploited an in vitro system composed of wheat germ extract and bean microsomes to examine the role of disulfide bonds in the structural maturation of a low molecular weight glutenin subunit. When conditions allowing the formation of disulfide bonds were established, the in vitro synthesized low molecular weight glutenin subunit was recovered in monomeric form containing intrachain disulfide bonds. Conversely, synthesis under conditions that did not favor the formation of disulfide bonds led to the production of large aggregates from which the polypeptides could not be rescued by the post-translational generation of a more oxidizing environment. These results indicate that disulfide bond formation is essential for the conformational maturation of the low molecular weight glutenin subunit and suggest that early folding steps may play an important role in this process, allowing the timely pairing of critical cysteine residues. To determine which cysteines were important to maintain the protein in monomeric form, we prepared a set of mutants containing selected cysteine to serine substitutions. Our results show that two conserved cysteine residues form a critical disulfide bond that is essential in preventing the exposure of adhesive domains and the consequent formation of aberrant aggregates.

Simvastatin-associated memory loss

The statins are widely used to treat dyslipidemias. They are generally associated with mild adverse effects, but rarely, more serious reactions may occur. A 51-year-old man experienced delayed-onset, progressive memory loss while receiving simvastatin for hypercholesterolemia. His therapy was switched to pravastatin, and memory loss resolved gradually over the next month, with no recurrence of the adverse effect.

Additional case of Marden-Walker syndrome: support for the autosomal-recessive inheritance adn refinement of phenotype in a surviving patient

In this report, we present a 14-year-old girl, born to consanguineous parents, who presented with severe mental retardation, hypotonia, short stature, and congenital joint contractures. The craniofacial features were scaphocephaly, thin/long and immobile face, marked hypoplasia of the midface, temporal narrowness, blepharophimosis, palpebral ptosis, and strabismus. The combination of such a distinctive craniofacial appearance and psychomotor retardation allows us to recognize a new case of the Marden-Walker syndrome. Our patient represents one of the rare cases in which consanguineous mating supports the autosomal-recessive pattern of inheritance of this condition. Furthermore, through refining the phenotype of a surviving patient, this report may contribute to a better recognition of this disorder in older affected children.

Continuous exposure to high concentrations of nitric oxide leads to persistent inhibition of oxygen consumption by J774 cells as well as extraction of oxygen by the extracellular medium

Nitric oxide (NO) plays a key role in many physiological and pathophysiological events, including the control of cell respiration. Both reversible and irreversible inhibition of mitochondrial respiration have been reported following the generation of NO by cells. We have exposed the murine macrophage cell line J774 to high concentrations of NO, such as are generated in some pathological conditions, and determined their effect on oxygen consumption. We observed a persistent inhibition of respiration which was due to a redox-dependent, progressive inhibition of complex I activity. No other enzyme of the respiratory chain was inhibited in this way. At the same time, we detected a paradoxical removal of oxygen by the extracellular medium. This removal was due to a chemical interaction between dissolved oxygen and NO-related species released from cells exposed to NO. A similar removal of oxygen by the cell supernatant also occurred following activation of cells with cytokines and bacterial products. Thus, the amounts of NO generated during pathological conditions may contribute to tissue hypoxia both by inhibiting cell respiration and by promoting removal of oxygen from the extracellular medium.

Strongyloides stercoralis: ultrastructural study of newly hatched larvae within human duodenal mucosa

AIM

To investigate the ultrastructural features of the newly hatched larvae of Strongyloides stercoralis in human duodenal mucosa.

METHODS

Duodenal biopsies from an AIDS patient were studied by transmission electron microscopy to investigate morphology, location, and host-worm relations of newly hatched larvae.

RESULTS

Newly hatched larvae were found in the Lieberkuhn crypts within the tunnels formed by migration of parthenogenic females. Delimiting enterocytes were compressed. Release of larvae into the gut lumen was also documented. It was shown that both a thin and a thick membrane surrounded the eggs and larvae, as a tegument derived respectively from parasite and host. Segmentary spike-like waves, caused by contractures of worm body musculature, were observed on the surface of newly hatched larvae, and their intestinal lumen was closed and empty, with no budding microvilli. Immaturity of the cuticle and some degree immaturity of amphidial neurones were found, but there was no evidence of either immaturity or signs of damage to other structures.

CONCLUSIONS

Newly hatched larvae of S stercoralis appear to be a non-feeding immature stage capable of active movement through the epithelium, causing mechanical damage. The tegument resulting from the thin and the thick membrane may protect the parasite and reduce any disadvantage caused by immaturity.

Persistent damage to Enterocytozoon bieneusi, with persistent symptomatic relief, after combined furazolidone and albendazole in AIDS patients

AIM

To investigate morphological changes in Enterocytozoon bieneusi and the duration of symptomatic relief after combination treatment with furazolidone and albendazole in AIDS patients.

METHODS

Four severely immunocompromised AIDS patients with symptomatic E bieneusi infection of the gut received an 18 day course of combined furazolidone and albendazole (500 + 800 mg daily). All patients were monitored for parasite shedding in stool by light microscopy at the end of treatment and monthly during follow up. At the end of treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists blind to the patients' treatment or clinical outcome. Duodenal biopsy specimens obtained from one of the patients two months after completion of treatment were also studied electronmicroscopically.

RESULTS

All patients had long lasting symptomatic relief, with a major decrease--or transient absence--of spore shedding in stools from completion of treatment. After treatment, changes in faecal spores were persistently found by light microscopy in all cases, and there was evidence of both a substantial decrease in the parasite load and ultrastructural damage in the parasite in all biopsy specimens. The treatment was well tolerated, and no patient had clinical or parasitological relapse during follow up (up to 15 months).

CONCLUSIONS

The long lasting symptomatic relief observed in all four treated patients correlated with the persistent decrease in parasite load both in tissue and in stool, and with the morphological changes observed in the life cycle of the protozoan. These data suggest that combined treatment with furazolidone and albendazole is active against E bieneusi and may result in lasting remission even in severely immunocompromised patients.

Chronic cryptosporidiosis in patients with AIDS: stable remission and possible eradication after long-term, low dose azithromycin

AIMS

To investigate the effectiveness of long term, low dose azithromycin treatment for chronic cryptosporidiosis in patients with AIDS.

METHODS

Azithromycin was administered as initial daily treatment to 13 patients with AIDS: 6 patients received 500 mg for 30 to 40 days (mean 35); 3 patients received 1000 mg for 21 to 50 days (mean 37); and 4 patients received 1500 mg for 20 days. Nine of the 13 patients were also given low dose maintenance treatment with different schedules of azithromycin for 30 to 360 days (mean 129). Patients were monitored, during and after treatment, for parasite shedding in stool and for daily stool frequency and body weight. All but one patient had severe immunodeficiency.

RESULTS

Long term, low dose maintenance treatment was associated with major clinical and parasitological benefits: there was probable eradication of infection in 2 patients, and 7 patients showed a complete response with persistent high decrease (5 patients) or clearance (2 patients) of parasite in stool. The drug was well tolerated, and there was no relapse either during treatment or during follow up (up to 21 months). These results were more impressive than those observed after the short term initial course of azithromycin, which was unable at any tested dose to achieve parasite clearance in stool (except in the patient with less advanced immunodeficiency) or to prevent relapse in 3 patients who discontinued treatment. Reversible side effects occurred with the 1500 mg daily dose.

CONCLUSIONS

Long term, low dose azithromycin is well tolerated and may induce stable remission of chronic cryptosporidiosis in patients with AIDS. It may lead to probable eradication of the infection in some patients, even those with severe immunodeficiency.

Enterocytozoon bieneusi in AIDS: symptomatic relief and parasite changes after furazolidone

AIMS

To investigate changes in morphology of the developmental stages of Enterocytozoon bieneusi and symptomatic relief observed in AIDS patients after treatment with furazolidone.

METHODS

Six AIDS patients with symptomatic E bieneusi infection of the small intestine were treated with a course of furazolidone. All patients had a weekly monitoring of parasite shedding in stool by light microscopy during and after treatment. At the end of the treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists who were unaware of the patients' treatment.

RESULTS

All patients showed both clinical and parasitological response with transient clearance or decrease of spore shedding in stool. After treatment, alterations in faecal spores were observed in all patients by light microscopy, and ultrastructural changes in E bieneusi at all stages of the life cycle were demonstrated in biopsy specimens of the three patients who underwent post-treatment endoscopy.

CONCLUSIONS

The clinical benefit seen after treatment with furazolidone in six AIDS patients with E bieneusi intestinal infection may be due to damage to the developmental stages causing a partial inhibition to reproduction of the parasite.

Microflora persistence on duodenojejunal flat or normal mucosa in time after a meal in children

A pathogenic role for high numbers of bacteria in the small intestine had been suggested previously by bacterial counts on luminal aspirates, but these investigations were flawed by the sampling device "contamination" in the mouth and the changing nature of fluent intestinal content. A procedure was developed to sterilize the Watson biopsy capsule with HCl in the upper portion of the duodenum. Bacteria were counted in the mucosal homogenate of the first (diagnostic) duodenojejunal biopsy in 80 untreated celiac children, and in 46 children with irritable bowel syndrome (IBS) in a four-cell, controlled, randomized investigation. Persistence of bacteria on the mucosa for 20 h after the last meal was investigated in 62 subjects, and for 26 h after the last meal in 64 subjects. Bacteria, mainly streptococci and staphylococci, persisted at a concentration of 10(6) per gram of mucosa 20 h after the last meal. The number of bacteria per gram of mucosa was 24 times higher in all 62 children of the 20-h fast groups than in all 64 children of the 26-h fast groups (p < 0.001). The bacteria count in celiac children was 39 times higher in the 20-h fast group than in the 26-h one. This difference was significantly higher than the 11 times difference that was found on the normal mucosa between the 20- and 26-h fast IBS groups (p < 0.001), which was still significant. The number of bacteria on duodenojejunal mucosa depends on nutrient absorption and persists longer than the intermeal interval in these subjects.