Resident cardiac stem cells

The introduction of stem cells in cardiology provides new tools in understanding the regenerative processes of the normal and pathologic heart and opens new options for the treatment of cardiovascular diseases. The feasibility of adult bone marrow autologous and allogenic cell therapy of ischemic cardiomyopathies has been demonstrated in humans. However, many unresolved questions remain to link experimental with clinical observations. The demonstration that the heart is a self-renewing organ and that its cell turnover is regulated by myocardial progenitor cells offers novel pathogenetic mechanisms underlying cardiac diseases and raises the possibility to regenerate the damaged heart. Indeed, cardiac stem progenitor cells (CSPCs) have recently been isolated from the human heart by several laboratories although differences in methodology and phenotypic profile have been described. The present review points to the potential role of CSPCs in the onset and development of congestive heart failure and its reversal by regenerative approaches aimed at the preservation and expansion of the resident pool of progenitors.

[Strategies for prevention and control of healthcare related infections by Acinetobacter baumannii]

The frequent development of acquired antibiotics resistance in bacteria represents a challenge for Public Health in terms of healthcare associated infections control. Apart from the appropriate use of drugs, in particular the choice of proper antimicrobial therapy, increasing interest is, therefore, given to the non-pharmacological prevention of these infections. Acinetobacter (A.) baumannii is a micoorganism that commonly causes infections for patients hospitalized in critical hospital wards (intensive care units, burn centers, surgery, neonatology, etc) potentially severe and difficult to treat, because A. baumannii is resistant to many or sometimes all, available antibiotics (PDR - pan drug resistant). The aim of the present paper was to review the available measures for preventing and controlling the contamination and the spread of these types of bacterial infections in health care scenarios, with particular attention to two methods that stand out for efficiency and safety: hand hygiene and environmental disinfection.

Low 25(OH)D3 levels are associated with total adiposity, metabolic syndrome, and hypertension in Caucasian children and adolescents

OBJECTIVES

Evidence of the association between vitamin D and cardiovascular risk factors in the young is limited. We therefore assessed the relationships between circulating 25-hydroxyvitamin D(3) (25(OH)D(3)) and metabolic syndrome (MetS), its components, and early atherosclerotic changes in 452 (304 overweight/obese and 148 healthy, normal weight) Caucasian children.

METHODS

We determined serum 25(OH)D(3) concentrations in relation to MetS, its components (central obesity, hypertension, low high-density lipoprotein (HDL)-cholesterol, hypertriglyceridemia, glucose impairment, and/or insulin resistance (IR)), and impairment of flow-mediated vasodilatation (FMD) and increased carotid intima-media thickness (cIMT) - two markers of subclinical atherosclerosis.

RESULTS

Higher 25(OH)D(3) was significantly associated with a reduced presence of MetS. Obesity, central obesity, hypertension, hypertriglyceridemia, low HDL-cholesterol, IR, and MetS were all associated with increased odds of having low 25(OH)D(3) levels, after adjustment for age, sex, and Tanner stage. After additional adjustment for SDS-body mass index, elevated blood pressure (BP) and MetS remained significantly associated with low vitamin D status. The adjusted odds ratio (95% confidence interval) for those in the lowest (<17 ng/ml) compared with the highest tertile (>27 ng/ml) of 25(OH)D(3) for hypertension was 1.72 (1.02-2.92), and for MetS, it was 2.30 (1.20-4.40). A similar pattern of association between 25(OH)D(3), high BP, and MetS was observed when models were adjusted for waist circumference. No correlation was found between 25(OH)D(3) concentrations and either FMD or cIMT.

CONCLUSIONS

Low 25(OH)D(3) levels in Caucasian children are inversely related to total adiposity, MetS, and hypertension.

Duration of viral shedding in hospitalized patients infected with pandemic H1N1

Background

The first influenza pandemic of the 21th century was ignited by a new strain of influenza A virus (A/H1N1pdm). Specific patient groups, including those with comorbidities, pregnant women, young children, older and immunocompromised patients, are at increased risk for serious influenza-related disease. This study was aimed at investigating the influence of clinical presentation, antiviral treatment and possible drug resistance-associated mutations, on the extent and duration of viral shedding in patients infected with A/H1N1pdm.

Methods

An observational study was performed, based on retrospective review of clinical and laboratory records of patients who were hospitalized for A/H1N1pdm infection at the National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy, between April 24 and December 31, 2009. Among 119 hospitalized patients, 39 were selected for a post hoc analysis, based on the availability of serial nasopharyngeal swabs samples and related information.

Results

Eleven out of the 39 study patients (28.2%) presented with pneumonia; 29 (74.4%) received antiviral treatment. Patients with pneumonia were significantly older than patients without pneumonia. The mean values of viral RNA concentration were not significantly increased in patients with pneumonia, but a significant increase in the duration of viral shedding was observed as compared to patients without pneumonia. In patients receiving antivirals, the viral RNA concentration was significantly reduced in comparison to untreated patients at days 4-5 after symptom onset, while the overall duration of viral shedding was only marginally affected. A significant correlation between duration of viral shedding and time elapsed between symptom onset and therapy start was observed, with a significant reduction of days of viral shedding when therapy was initiated within 2 days of symptoms appearance. No known drug resistance mutations were detected in patients with prolonged viral shedding.

Conclusions

Our results show that severe respiratory illness is associated with delayed virus clearance in patients with A/H1N1pdm infection. Antivirals caused an early reduction of viral load, but only marginally affected the overall duration of shedding. Prolonged shedding was not associated with the emergence of strains carrying known drug-resistance mutations.

[Pediatric non-alcoholic fatty liver disease: recent advances and challenges]

Non-alcoholic fatty liver disease (NAFLD) encompasses a range of liver histology severity and outcomes in the absence of chronic alcohol use. The mildest form is simple steatosis in which triglycerides accumulate within hepatocytes. A more advanced form of NAFLD, non-alcoholic steatohepatitis (NASH), includes inflammation and liver cell injury, progressive to cryptogenic cirrhosis. Although prevalence in children is very difficult to establish, NAFLD is probably the most common cause of liver disease in preadolescent and adolescent groups. Over the last two decades the rise in the prevalence rates of overweight and obesity likely explains the NAFLD epidemic worldwide. NAFLD is strongly associated with abdominal obesity, type 2 diabetes, and dyslipidemia, and most patients have evidence of insulin resistance. Thus, NAFLD shares many features of the metabolic syndrome, a highly atherogenic condition, and its presence could signify a substantial cardiovascular risk. Accurate diagnosis and staging of NAFLD requires liver biopsy. The development of non-invasive surrogate markers and the advancement in imaging technology will aid in the screening of large populations at risk for NAFLD. While the optimal treatment has yet to be determined, lifestyle modification through diet and exercise should be attempted in children diagnosed with NAFLD. This review outlines current understanding, recent advances and challenges on pediatric NAFLD for both clinicians and researchers. Key words: Fatty liver.

Association of profoundly impaired immune competence in H1N1v-infected patients with a severe or fatal clinical course

BACKGROUND

Pandemic A/H1N1v influenza is characterized by a mild clinical course. However, a small subset of patients develops a rapidly progressive course caused by primary viral pneumonia or secondary bacterial infections that, in many cases, lead to death due to respiratory failure. The aim of the present study was to analyze the involvement of the immune response in the clinical presentation of H1N1v influenza.

METHODS

The differentiation and functional capability of T cells from H1N1v-infected patients presenting with either mild disease (n=22) or severe or fatal disease (n=6) were compared. Moreover, plasma cytokines and chemokines were quantified.

RESULTS

T cells from H1N1v-infected patients presenting with a severe clinical course resulted in impaired effector cell differentiation and failed to respond to mitogenic stimulation. T cell anergy was strictly associated with a severe acute phase of infection, but T cells could be restored in patients able to recover. Of interest, massive expression of CD95 marker was found on anergic T cells, suggesting an apoptosis-related mechanism. Finally, lower plasma levels of interferon-alpha and monocyte chemoattractant protein-1 were found in patients with a worse clinical course of influenza, suggesting impaired production of these cytokines.

CONCLUSIONS

Our results show a strict association between host immune competence and the severity of the clinical course of H1N1v infection. By monitoring host functional response, patients with an enhanced risk of developing influenza-associated severe complications could be identified in a timely manner.

Radiological findings of pneumonia in patients with swine-origin influenza A virus (H1N1)

Purpose

During spring 2009, a pandemic swine-origin influenza A (H1N1) virus (S-OIV) emerged and spread globally. We describe the chest X-ray and computed tomography (CT) findings of 40 patients with pneumonia due to S-OIV observed in our institution.

Material and methods

Among 534 patients with S-OIV, according to the US Centers for Disease Control and Prevention case definition, seen between June and November 2009, 121 underwent chest X-ray and 40 (median age 44 years, range 16–79) had pneumonia. The initial chest radiographs were evaluated for pattern, distribution and extent of lung abnormalities. Unenhanced chest CT scans were performed in two patients and were reviewed for the same findings. Underlying medical conditions were present in 42% of patients (17/40).

Results

Our patients had predominantly mild illness, and pneumonia was observed in 40 individuals (40/121 patients who had chest X-rays, 33%; and 40/534 patients with S-OIV, 7.5%). However, S-OIV can cause severe illness requiring admission to the intensive care unit for advanced mechanical ventilation and extracorporeal life support, including adult respiratory distress syndrome (ARDS) and death. The major radiological abnormalities observed were interstitial changes (60.0%), with (22.0%) or without patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones (7.5%). Extensive disease was seen in 37.5% (15/40), and ARDS was observed in three individuals (0.30%)with underlying medical conditions. Subtle pleural effusion was noted in four patients.

Conclusions

In our series, the most frequent pneumonia patterns observed during S-OIV (H1N1) virus were interstitial changes and patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones. CT, performed in severely ill patients, confirmed the ARDS identified with chest X-rays, better depicting the features and extent of lung abnormalities.

Influenza A (H1N1) in Rome, Italy in family: three case reports

Introduction

A new Influenza A virus H1N1 appeared in March-April 2009, and thousands of cases are being reported worldwide. In the initial months, several imported cases were reported in many European countries, while some countries reported local chains of transmission. We describe the first cluster of in-country transmission of the new Influenza A H1N1 which occurred in Italy, involving 3 patients.

Case presentation

Patient 1, a 11-year-old male child developed fever, cough, and general malaise 4 days after returning from a travel to Mexico. Some days later, the 69-year-old grandfather (patient 2), who did not travel to Mexico, and the 33-month-old brother (patient 3) of patient 1 developed mild influenza symptoms. PCR tests resulted positive for Influenza A, and sequence analysis confirmed infection with the Influenza A (H1N1) strain for all three patients. Some problems were experienced in the administration of chemoprophylaxis and therapy in the patient 3. The chemoprophylaxis policies in other family members are described, too.

Conclusion

Some interesting facts emerge from the analysis of this cluster. The transmission of Influenza A H1N1 virus seems to be dependent on strict contacts. Patient 2 and patient 3 did not take the chemoprophylaxis properly. The problems in the administration of chemoprophylaxis and therapy to patient 3 suggest that in infants specific individual-based strategies for assuring the correct administration are advisable.

[Specific antisepsis and environmental disinfection in preventing "Clostridium difficile associated diarrhea"]

In the last years, Clostridium difficile acquired great interest for public health because of constant increase of Clostridium difficile associated diarrhea (CDAD), especially in nosocomial field and as a consequences of its pathogenicity and virulence. Oro-faecal transmission and great environmental persistence of Clostridium difficile indicate hand hygiene of health care workers and environmental disinfection practices as key interventions for prevention and control of nosocomial CDAD. The current indications relative to the hand hygiene suggest the use of soap and water for hand washing and, to achieve a better compliance of health care workers to this treatment, the alternative use of sodium dichloroisocyanurate or alcohol-based solution or gel waterless. Regard to environmental disinfection, to avoid high concentrations of sodium hypochlorite (in the magnitude of 5.000-6.000 ppm), necessary to reduce microbic load of dirty environment, the most appropriate treatment should consist of 2 phases: preliminary cleaning with water and detergents or polyphenol, followed by treatment with solution containing 1.000 ppm available chlorine, obtained from sodium hypochlorite or sodium dichloroisocyanurate.

[Tuberculosis risk assessment in Italian healthcare centres]

BACKGROUND

Tuberculosis transmission is a significant hazard in healthcare settings.

METHODS

Risk factors suggested by CDC guidelines in 1994, which were adopted by the Italian Ministry of Health, were assessed in 29 centres via questionnaires in 2005.

RESULTS

Few centers were equipped with negative pressure, respiratory isolation rooms. Half of the centres had high or ongoing risk.

CONCLUSIONS

The hazard is underestimated mostly because of a high number of initially undiagnosed TB patients.

[Low colonization with MRSA among health-care workers in an Italian hospital]

The Authors carried out a study on MRSA colonization rate among health-care workers (HCW) in a large roman hospital. Samples were obtained from staff members at the beginning of each work shift. Two-hundred HCW were included (78 physicians and 122 nurses), mean age 36.6 +/- 10.9 years. We identified 38 (19.0%) S. aureus carriers, prevalently nurses (21.3%) vs. physicians (15.4%). Results showed a RR 2,7; IC95% 1.47-4.86; p < 0.01 among men vs. women. Overall three (1.5%) MRSA strains were isolated among HCW (two nurses and one physician). None of them was a CA-MRSA. The study suggests that HCW act principally as cross transmission vectors and not as main sources of MRSA.

Multidrug-resistant Acinetobacter baumannii outbreak in an intensive care unit

Carbapenem-resistant Acinetobacter baumannii was isolated from 15 colonized or infected patients (carriers) between April and July 2004, in a teaching hospital ICU in Rome, Italy. All isolated strains were susceptible only to gentamicin, ampicillin-sulbactam and colistin and displayed the same Random Amplified Polymorphic DNA (RAPD) 1 pattern. Twelve out of 15 strains were susceptible to tigecycline, whereas the remaining three showed intermediate susceptibility. Although infection control measures were reinforced and carriers isolated in separate rooms, A. baumannii transmission continued. Therefore, finally A. baumannii carriers were moved to another available subintensive unit, which was re-equipped, and cared for by dedicated personnel, whereas only the non infected/colonized patients remained in the ICU. This study shows that during an outbreak by multiresistant A. baumannii it may be indispensable to geographically isolate not only patients but also dedicated staff.

[Preoperative hair removal review]

Surgical site infection (SSI) frequency is influenced by several risk factors, among which perioperative hair removal. Traditionally it is part of the procedures carried out on skin before surgery. Although preoperative shaving is widely used in many hospitals, its use should be re-evaluated. Therefore the AA. carried out a systematic literature review about the opportunity, the modality and the risks associated to preoperative hair removal. We found first of all that preoperative shaving (razor) is associated with a significantly higher surgical site infection (SSI) risk. Second, when hair removal is considered necessary by the surgeon, it should be carried out by means of a clipper or depilatory cream. Furthermore hair removal should be performed immediately before surgery and not in advance, to avoid an increased risk of SSI.

Vicissitudes of bisexuality. Crucial points and clinical implications

The author begins by noting that the heuristic value of the concept of bisexuality can be explored in two directions, involving respectively its role in psychopathology and in the development of creativity and thought. The author concentrates on the first of these aspects, which entails a reconsideration of the 'phallic question'. The status of femininity is investigated on the basis of Freud's and Winnicott's theories of bisexuality and the author here finds an explanation for the repudiation of femininity and for the 'phallic question' thereby implied, which represents the underlying bedrock resulting in interminable analyses. An important element in this rejection is stated to be the maternal aspect of femininity. Particular reference is made to the somatic roots of phallic defences and to their effects on thought and symbolisation. Some brief clinical examples are presented to suggest that the bedrock may be due to the distorted use of sensoriality and of the erotogenic zones. The author contends that the anal zone plays a crucial part in the manifestations of bisexuality and contrasts phallic logic with the logic of triangulation. Numerous literature references and clinical examples support and illustrate her arguments throughout. The author ends with a discussion of the implications of bisexuality for thought and knowledge.