Heparins and 2019-nCoV infection: a narrative review

OBJECTIVE

Patients with 2019-nCoV infection have a high risk to develop venous thrombotic events. Several guidelines recommend the use of either unfractionated heparin or low molecular weight heparins in preventing thrombotic events in these patients. However, results from clinical studies, so far published, reached controversial conclusions on heparin efficacy in this kind of patients since the incidence of venous thromboembolism remains high despite prophylaxis. This narrative review aims to provide an overview of the antiviral and anti-inflammatory properties of heparins and their efficacy and safety in SARS-CoV-2 medical ward-patients. Moreover, anatomical findings and ongoing trials are also reported. Finally, this narrative review tries to explain why heparins fail to prevent venous thrombosis.

MATERIALS AND METHODS

We searched for the most relevant published studies on heparins and 2019-nCoV infected patients using the MEDLINE electronic database in the period between January and December 2020. Articles were preliminarily defined as eligible if they: a) were in English language, b) enrolled 250 or more medical ward-patients and 100 or more ICU-patients, c) reported results on patients treated with heparins in a percentage of at least 70% and d) performed an objectively confirmed diagnosis of VTE.

RESULTS

Data from medium to large scientific studies show that the incidence of venous thrombotic events in medical ward-patients with SARS-CoV-2 vary between 0% and 8.3%, while this rate is higher, from 6.2% to 49%, in Intensive Care Unit-patients. However, heparins reduce the mortality rate in these patients of about 50%. Histological findings show that thrombosis could affect capillaries, main and small-mid-sized vessels, and it is associated with diffuse alveolar damage.

CONCLUSIONS

Heparins have anti-inflammatory and anti-viral properties, which may be of help in reducing mortality in SARS-CoV-2 patients. Failure of heparins at prophylactic dosages in preventing VTE, especially in ICU-patients, could be due to the severity of the disease. Data on the use of heparins in an early phase of the 2019-nCoV infection are still lacking.

Obstructive Sleep Apnea, oxidative stress, inflammation and endothelial dysfunction-An overview of predictive laboratory biomarkers

OBJECTIVE

Obstructive Sleep Apnea (OSA) represents an emerging public health concern with great impact on cardiovascular state. Oxidative stress (OS), inflammation and altered Nitric Oxide (NO) production are recognized as prominent mechanisms of many acute and chronic diseases and even of the normal aging process. They are investigated as major pathophysiological processes in OSA through the analysis and comparison of significative and validated biomarkers.

MATERIALS AND METHODS

The review is developed using as key terms "sleep apnea", "oxidative stress", "inflammation", and "endothelial dysfunction". Included studies must have followed the American Academy of Sleep Medicine guidelines according to the diagnosis and classification of OSA. Lipid, protein and DNA oxidation products, PCR, IL-6, IL-8, TNF-α, NO and nitrosative stress compounds, and endothelial functioning tests have been detected for their contribution in OSA along the last 3 decades.

RESULTS

Nocturnal intermittent hypoxia has emerged to be significantly associated to oxidative/nitrosative stress, increase in pro-inflammatory markers, imbalance in NO production, and endothelium impairment. Body Mass Index (BMI) contribution needs further clarifications. Continuous Positive Airway Pressure (CPAP) therapy has demonstrated beneficial effects on vascular function and pro-inflammatory milieu in OSA.

CONCLUSIONS

Oxidative stress and Inflammation significantly correlate with OSA; similarly, vascular functioning is impaired in accordance to unregulated levels of NO and derived compounds. Continuous Positive Airway Pressure markedly improves oxidative stress, inflammation and endothelial dysfunction in OSA.

Liver infection and COVID-19: the electron microscopy proof and revision of the literature

OBJECTIVE

COVID-19, the newly emerging infectious disease, has been associated with acute liver injury, often related to progression to severe pneumonia. The association between moderate-severe liver injury and more severe clinical course of COVID-19 has suggested that liver injury is prevalent in severe than in mild cases of COVID-19, while no difference in liver involvement has been reported between survivors and non-survivors. The spectrum of liver involvement during COVID-19 ranges from an asymptomatic elevation of liver enzymes to severe hepatitis. Only rarely, cases with acute hepatitis have been reported in the absence of respiratory symptoms. Both epithelial and biliary cells possess the angiotensin-converting enzyme-2 receptors that SARS-CoV-2 uses to be internalized. However, to our knowledge, no ultrastructural identification of the virus in liver cells has been reported to date. Here we provide evidence of SARS-CoV-2 in the liver of two patients, a 34-year-old woman and a 60-year-old man with COVID-19.

PATIENTS AND METHODS

We investigated two patients with COVID-19 showing several virions within cytoplasmic vacuoles of cholangiocytes and in endothelial cells of hepatic sinusoids. In both patients, we performed histological and ultrastructural examinations by liver biopsy. After two months, both patients were free of symptoms, and the SARS-CoV-2 infection had resolved.

RESULTS

Liver biopsy histological and ultrastructural examination showed liver injury and several virions within cytoplasmic vacuoles of cholangiocytes and in endothelial cells of hepatic sinusoids.

CONCLUSIONS

Although most studies in COVID-19 have been focused on the lungs, recently, cholestatic liver pathology has been introduced in the spectrum of pathological changes related to COVID-19. To the best of our knowledge, those presented in this paper are the first images of hepatic SARS-CoV-2 infected liver cells. Our findings suggest a role for cholangiocytes and biliary structures in the COVID-19.

Oral human papilloma virus infection: an overview of clinical-laboratory diagnosis and treatment

OBJECTIVE

The aim of this review is to describe the "hot points" of current clinical governance for oral HPV comprising the use of new diagnostic molecular procedures, namely, Pyrosequencing and Next Generation Sequencing.

MATERIALS AND METHODS

The data on oral HPV was collected through two levels of research. First for all, we used the canonical medical search engines, PubMed, and Medline, followed by the study of current commercial tools for HPV diagnosis, particularly within commercial companies involved in the molecular procedures for HPV detecting and genotyping.

RESULTS

Different medical procedures are now described and used throughout the world in HPV diagnosis and treatment. However, the laboratory methods are often validated and used for genital infections, and, in these cases, data are missing in the literature as regards the clinical approach for oral lesions.

CONCLUSIONS

Dental care units are often the front line for a clinical evaluation of a possible HPV lesion in the oral cavity, which means that correct clinical governance could avoid a viral neoplastic progression of this disease with great advantages for the patient. In this case, the problem is due to the difficulty in lesion recognition but also and more especially the absence of correct laboratory diagnosis and subsequent treatment in the clinical course.

Association between the spread of COVID-19 and weather-climatic parameters

OBJECTIVE

To explore whether the climate has played a role in the COVID-19 outbreak, we compared virus lethality in countries closer to the Equator with others. Lethality in European territories and in territories of some nations with a non-temperate climate was also compared.

MATERIALS AND METHODS

Lethality was calculated as the rate of deaths in a determinate moment from the outbreak of the pandemic out of the total of identified positives for COVID-19 in a given area/nation, based on the COVID-John Hopkins University website. Lethality of countries located within the 5th parallels North/South on 6 April and 6 May 2020, was compared with that of all the other countries. Lethality in the European areas of The Netherlands, France and the United Kingdom was also compared to the territories of the same nations in areas with a non-temperate climate.

RESULTS

A lower lethality rate of COVID-19 was found in Equatorial countries both on April 6 (OR=0.72 CI 95% 0.66-0.80) and on May 6 (OR=0.48, CI 95% 0.47-0.51), with a strengthening over time of the protective effect. A trend of higher risk in European vs. non-temperate areas was found on April 6, but a clear difference was evident one month later: France (OR=0.13, CI 95% 0.10-0.18), The Netherlands (OR=0.5, CI 95% 0.3-0.9) and the UK (OR=0.2, CI 95% 0.01-0.51). This result does not seem to be totally related to the differences in age distribution of different sites.

CONCLUSIONS

The study does not seem to exclude that the lethality of COVID-19 may be climate sensitive. Future studies will have to confirm these clues, due to potential confounding factors, such as pollution, population age, and exposure to malaria.

The effect of single and repeated tDCS sessions on motor symptoms in Parkinson's disease: a systematic review

OBJECTIVES

to update understanding of the effectiveness of transcranial direct current stimulation (tDCS) on motor dysfunction in Parkinson's disease, since the last review was published in 2016.

METHODS

in order to identify suitable publications for inclusion, an online search of the Pubmed, Scopus and Cochrane databases was carried out. Searches of relevant full-text articles were performed through specific keywords. The final database check was performed in July 2019. Papers were restricted to studies investigating motor rehabilitative effects of tDCS in adult patients with Parkinson's disease. Studies involving either single or repeated tDCS sessions with a sham or controlled trial type design (which incorporated outcomes on motor performance measures) were considered. As studies varied widely in terms of methodology, a qualitative analysis of the selected studies was performed using the Newcastle-Ottawa Quality Assessment Scale or the Delphi list (depending on the study design).

RESULTS

twenty-nine studies were retained in this systematic review. Of the studies included, fifteen involved single tDCS session (patients = 256) and fourteen involved repeated tDCS sessions (patients = 294). Eight investigations of single tDCS and ten investigations of repeated tDCS demonstrated significant results. Studies involving multi- target stimulation demonstrated significant improvements on mobility (p=0.006), balance (by 50.9%), gait velocity (by 29%), fall reduction (p0.05) compared to mono-target stimulations.

CONCLUSIONS

despite increasing evidence that tDCS may improve motor symptoms, the results showed that fully optimized tDCS protocols are not yet established.

Porphyromonas gingivalis in the tongue biofilm is associated with clinical outcome in rheumatoid arthritis patients

Several studies have suggested a link between human microbiome and rheumatoid arthritis (RA) development. Porphyromonas gingivalis seems involved in RA initiation and progression, as supported by the high occurrence of periodontitis. In this case-control study, we analysed tongue P. gingivalis presence and quantification in a large healthy and RA cohort. We enrolled 143 RA patients [male/female (M/F) 32/111, mean ± standard deviation (s.d.), age 57·5 ± 19·8 years, mean ± s.d. disease duration 155·9 ± 114·7 months); 36 periodontitis patients (M/F 11/25, mean ± s.d., age 56 ± 9·9 years, mean ± s.d. disease duration 25·5 ± 20·9 months); and 57 patients (M/F 12/45, mean ± s.d., age 61·4 ± 10·9 years, mean ± s.d. disease duration 62·3 ± 66·9 months) with knee osteoarthritis or fibromyalgia. All subjects underwent a standard cytological swab to identify the rate of P. gingivalis/total bacteria by using quantitative real-time polymerase chain reaction. The prevalence of P. gingivalis resulted similarly in RA and periodontitis patients (48·9 versus 52·7%, P = not significant). Moreover, the prevalence of this pathogen was significantly higher in RA and periodontitis patients in comparison with control subjects (P = 0·01 and P = 0·003, respectively). We found a significant correlation between P. gingivalis rate in total bacteria genomes and disease activity score in 28 joints (DAS28) (erythrocyte sedimentation rate) (r = 0·4, P = 0·01). RA patients in remission showed a significantly lower prevalence of P. gingivalis in comparison with non-remission (P = 0·02). We demonstrated a significant association between the percentage of P. gingivalis on the total tongue biofilm and RA disease activity (DAS28), suggesting that the oral cavity microbiological status could play a role in the pathogenic mechanisms of inflammation, leading to more active disease.

Oral Signs and HLA-DQB1∗02 Haplotypes in the Celiac Paediatric Patient: A Preliminary Study

Celiac disease (CD) diagnosis can be extremely challenging in the case of atypical patterns. In this context, oral signs seem to play a decisive role in arousing suspicion of these forms of the disease. At the same time, the different expressions of the HLA-DQB1∗02 allele apparently seem to facilitate the interpretation of signs and highlighted symptoms. The aim of this work was to verify whether it is possible to identify a correlation between the development of oral signs and different DQ2 haplotypes in celiac pediatric patients. 44 celiac patients with a medium age of 9.9 were studied. Oral examinations were performed in order to identify recurrent aphthous stomatitis (RAS) and dental enamel defects (DED). The diagnosis of DED resulted as being related to allele expression (P value = 0.042) while it was impossible to find a similar correlation with RAS. When both oral signs were considered, there was an increase in correlation with HLA-DQB1∗02 expression (P value = 0.018). The obtained results identified both the fundamental role that dentists can play in early diagnosis of CD, as well as the possible role of HLA haplotype analysis in arousing suspicion of atypical forms of the disease.

Is target opioid therapy within sight?

Control of pain has a central role in patients treatment either in advanced cancer or other terminal illnesses and in acute postsurgical or chronic non-malignant diseases. Hospitals should promote programs of research on genetic mechanism, and also biochemical and physiological aspects of pain through highly specialized labs. Opioids are the first choice drugs for moderate to severe chronic pain, especially at the end of life, and among them oral morphine is worldwide recognized by the World Health Organization and by the European Association for Palliative Care as the conventional therapy. Although this general agreement, administration of this class of drugs may be a major medical challenge due to the high effects' variability related to pharmacokinetic and pharmacodynamic parameters, such as absorption, distribution and metabolism, as well as intrinsic efficacy at the receptors involved. For such a reason, optimization of the management regime is not always reached in all the patients. Up to now no one can easily predict which patient will experience side effects or an inadequate pain control. The growing body of evidence concerning a sound genetic background of this human intervariability has prompted research on the field of a personalized therapy, focusing on single nucleotide polymorphisms (SNPs), being the most common and diffuse form of genetic variation. This review has the main goal to report the most promising human genetic polymorphisms involved in opioid treatment, and address the relationship between these polymorphisms and the clinical outcome.

A rapid sample method for HLA haplotype typization. A preliminary study on celiac patients

AIM

The aim of the present work was to determine the human leukocyte (HLA) haplotype in 64 Sardinian patients affected with celiac disease, using a rapid and easy to apply sampling method that permits samples from blood drawing to be stored more easily. Numerous studies have demonstrated how the HLA system plays a very important role in immune system regulation, determining a link between this gene and a high number of pathologies including celiac disease. In fact a genetic susceptibility exists in celiac sprue, linked to HLA-DQB1*0201 and -DQB1*0302 genes which represent sierologic groups -DQ2 and -DQ8 whose early identification could be fundamental in obtaining a diagnosis of celiac disease.

METHODS

To realize this study a collecting method of samples was developed through the brushing of oral mucosa, which is extremely less traumatic than the classic sampling method using blood drawing, and which also allows a long conservation period before sample analysis. Samples were later analyzed with Van Embden's DNA extraction method to extract the patient's DNA, on which we executed the Polymerase Chain Reaction (PCR). To obtain the HLA haplotype from each patient we used 8 specific primers that amplified the HLA-DQB1 allele in low-resolution.

RESULTS

Out of the 64 patients we found 26 HLA-DQB1*02 homozygotes, 28 HLA-DQB1*02 heterozygotes and 10 negative samples for the HLA-DQB1*02 allele, thus confirming what had emerged from previous blood draws.

CONCLUSION

These results show how the method we developed using oral brushing is a sure method to obtain samples for determining the HLA haplotype in extra-hospital areas. This could allow the use of this method to obtain early diagnosis for chronic pathologies linked to the HLA groups and for recognizing this genotype in extensive population studies.

A sensitive FRET probe assay for the selective detection of Mycobacterium marinum in fish

Mycobacterium marinum is the causative agent of mycobacteriosis in wild and cultured fish and of atypical infection in humans. For the diagnosis of M. marinum, cultural and traditional polymerase chain reaction (PCR) methods are currently used. However, these protocols, although able to discriminate within Mycobacterium spp., have proved to be time-consuming or difficult to carry out. For this reason, the aim of this study was to obtain a rapid and specific diagnostic tool to quantify fish Mycobacterium spp. or to discriminate M. marinum from other mycobacteria. A primary PCR amplification with SYBR Green had a detection limit (dl) of 10(2)Mycobacterium DNA copies with a log-linear quantification range up to 10(4) (R(2) = 0.99). The second PCR using FRET probes, flanking a region containing species specific nucleotide variations, was designed and validated with synthetic erp gene fragments corresponding to different mycobacterial species, different whole mycobacteria suspensions, experimentally infected fish tissues, tissues from experimentally infected fish, and samples of cultured fish. The results show that the FRET probes demonstrate a high specificity as the melting curve analysis allowed efficient discrimination of M. marinum from Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium pseudoshottsii, Mycobacterium shottsii and Mycobacterium ulcerans. The kidney is the organ with the strongest detection signal and using fish tissues the method has a mean sensitivity of 50 DNA copies/PCR.

Evidence of hepatitis E virus (HEV) infection in human and pigs in Sardinia, Italy

INTRODUCTION

The aim of this study was to determine the seroprevalence of anti-HEV antibodies in humans sera and to study HEV prevalence in swine from different Sardinian farms, testing viral HEV-RNA in bile samples.

METHODS

In the first six months of 2008, 532 subjects of whom 402 blood donors and 130 workers at zoonotic risk, were enrolled. Anti-HEV were determined with an enzyme linked immunosorbent assay (ELISA). In positive subjects, RNA was extracted and tested by RT-Nested-PCR. From July 2006 to March 2007, 95 bile samples were collected from randomly selected pigs. RNA was extracted from 250 microl of bile and tested by RT-Nested-PCR.

RESULTS

The overall prevalence of anti-HEV antibodies was 4.3%; 5.0% among blood donors and 2.3% among workers at zoonotic risk, with no statistically significant differences between sex, age classes and occupation. The search for HEV-RNA in the subjects positive for antibodies, gave negative results. HEV genome was detected in 6 of the 95 swine bile samples tested. Sequences were clustered within the genotype 3 and are edited on GenBank under accession number: from FJ850960 to FJ850962 and from FJ883000 to FJ883002.

DISCUSSION

The overall prevalence of anti-HEV shows that the virus circulates without giving origin to cases of acute hepatitis. The low prevalence value found in workers at zoonotic risk do not apparently support the hypothesis of professional risk. In this study, HEV-RNA was isolated from pigs in Sardinia for the first time confirming the role of swine as HEV reservoir and the possibility of virus transmission to humans.

Combined scanning electron microscopy and image analysis to investigate airborne submicron particles: a comparison between personal samplers

The main objectives of this study were: (i) to compare commonly used personal samplers and verify their collection efficiency with regards to submicron particles; (ii) to investigate how the submicron particles deposit onto the filter surface in order to assess the homogeneity of the deposition; (iii) to estimate the biases which could affect results when number concentration values have to be determined by particle counting. A method based on image analysis (IA) and scanning electron microscopy (SEM) is developed and adopted to investigate a large numbers of particles. Four different personal samplers were tested: the IOM sampler, the Button sampler and the German GSP for the inhalable aerosol fraction; the PEM sampler for the thoracic aerosol fraction. In order to investigate how particles distribute on the filters surface, the area of each filter was virtually divided into circular concentric areas or deposition zones (DZ). Results from different DZ of the same filter were compared. Uniformity of deposition was mostly observed for three of the four tested samplers. A significant radial distribution was observed only for the GSP sampler. The major homogeneity was found for the Button sampler. In order to estimate the relative collection efficiency between samplers, particles number concentrations determined by particle counting were compared. The GSP sampler provided the greatest concentrations but also the greatest variability. The PEM sampler provided the lowest concentrations. The homogeneity of particle deposition on the filter surface mostly affected results when counting is performed on localized areas of the filter.

Molecular differentiation of field and vaccine strains of bluetongue virus serotype 2 using the real-time polymerase chain reaction and fluorescene resonance energy transfer hybridisation probes

As a consequence of the recent outbreaks of bluetongue (BT) disease amongst sheep in the Mediterranean Basin, and following the subsequent vaccination campaign to control further spread of the disease and its long-term maintenance, it has become most important to develop rapid and sensitive methods that can reliably differentiate between field and vaccine strains of the causative virus. The authors describe a new method to differentiate bluetongue virus serotype 2 (BTV-2) field and vaccine strains, using the VP2 gene sequence differences between the South African vaccine and the Italian field wild-type strains. The method is based on the principle that the melting temperature of a DNA duplex gives information on the sequence, which enables the identification of even single-base alterations in the amplicon. The real-time polymerase chain reaction the generation of melting curves and fluorescence detection were all performed using the light cycler system (Roche). Primers and probes were designed using VP2 gene sequences. After RT-PCR, the melting curves analysis, derived by the fluorescence resonance energy transfer (FRET) real-time PCR, was performed using the light cycler data analysis program (Roche). To assess the diagnostic value of the method, a BTV-2 vaccine strain (Onderstepoort Biological Products, South Africa) was first compared against a field strain of BTV-2 (isolated during an outbreak in 2000 in Sardinia). The ability of the method to reliably identify all the BTV-2 strains was tested using an array of eleven BTV-2 field strains isolated during outbreaks in various Italian regions between 2000 and 2002 and other serotypes (BTV-1, BTV-4, BTV-9 and BTV-16) that had been isolated during recent outbreaks of BT in the Mediterranean Basin. The method was clearly able to differentiate BTV-2 strains of vaccine virus from all wild-type strains of the same serotype tested. The resultant melting curves distinctly reveal the two strains to have differing peak values of 47.8 degrees C-/+0.6 degrees C and 60.5 degrees C-/+0.6 degrees C, respectively.