Is low-protein diet a possible risk factor of malnutrition in chronic kidney disease patients?

Chronic kidney disease (CKD) is becoming increasingly widespread in the world. Slowing its progression means to prevent uremic complications and improve quality of life of patients. Currently, a low-protein diet (LPD) is one of the tools most used in renal conservative therapy but a possible risk connected to LPD is protein-energy wasting. The aim of this study is evaluate the possible correlation between LPD and malnutrition onset. We enrolled 41 CKD patients, stages IIIb/IV according to K-DIGO guidelines, who followed for 6 weeks a diet with controlled protein intake (recommended dietary allowance 0.7 g per kilogram Ideal Body Weight per day of protein). Our patients showed a significant decrease of serum albumin values after 6 weeks of LDP (T2) compared with baseline values (T0) (P=0.039), whereas C-reactive protein increased significantly (T0 versus T2; P=0.131). From body composition analysis, a significant impairment of fat-free mass percentage at the end of the study was demonstrated (T0 versus T2; P=0.0489), probably related to total body water increase. The muscular mass, body cell mass and body cell mass index are significantly decreased after 6 weeks of LDP (T2). The phase angle is significantly reduced at the end of the study compared with basal values (T0 versus T2; P=0.0001, and T1 versus T2; P=0.0015). This study indicated that LPD slows down the progression of kidney disease but worsens patients' nutritional state.

Il follow up del bambino con ipoacusia permanente

I programmi di identificazione precoce delle ipoacusie infantili permette di intraprendere rapidamente l’iter riabilitativo e protesico appropriato; nonostante ciò appare ancora elevato il numero di pazienti che non aderiscono al programma terapeutico. L’obiettivo di questo articolo è presentare i risultati di un’analisi strategica che prende in considerazione i punti di forza, i punti di debolezza, le opportunità e i rischi del processo di follow up audiologico/protesico/linguistico di bambini affetti da ipoacusia bilaterale permanente. Il follow up in questione, coinvolgendo bambini piccoli, implica il coinvolgimento di professionisti specializzati e inseriti in un team multidisciplinare e una gestione plurisettoriale complessa e prolungata. Nell’ambito del progetto finanziato dal Ministero della Salute Italiano CCM 2013 denominato “Programma regionale di identificazione, intervento e presa in carico precoci per la prevenzione dei disturbi comunicativi nei bambini con deficit uditivo” lo scopo di quest’analisi è stata quella di offrire delle raccomandazioni per armonizzare i criteri di valutazione dei risultati terapeutici e trarre spunto da questi per successivamente fornire delle linee guida riguardanti le metodiche più adeguate nella valutazione del bambino con ipoacusia permanente.

Raccomandazioni per perfezionare i programmi regionali di screening uditivo neonatale universale in Italia

The Universal Newborn Hearing Screening (UNHS) programme aims at achieving early detection of hearing impairment. Subsequent diagnosis and intervention should follow promptly. Within the framework of the Ministry of Health project CCM 2013 "Preventing Communication Disorders: a Regional Program for early Identification, Intervention and Care of Hearing Impaired Children", the limitations and strengths of current UNHS programs in Italy have been analysed by a group of professionals working in tertiary centres involved in regional UNHS programmes, using SWOT analysis and a subsequent TOWS matrix. Coverage and lost-to-follow up rates are issues related to UNHS programmes. Recommendations to improve the effectiveness of the UNHS programme have been identified. The need for homogeneous policies, high-quality information and dissemination of knowledge for operators and families of hearing-impaired children emerged from the discussion.

Prioritization of high-cost new drugs for HCV: making sustainability ethical

Hepatitis C virus (HCV) infection is a major health problem worldwide. Chronic HCV infection may in the long run cause cirrhosis, hepatic decompensation and hepatocellular carcinoma, with an ultimate disease burden of at least 350,000 deaths per year worldwide. The new generation of highly effective direct acting antivirals (DAA) to treat HCV infection brings major promises to infected patients in terms of exceedingly high rates of sustained virological response (SVR) but also of tolerability, allowing even the sickest patients to be treated. Even in the face of the excellent safety and efficacy and wide theoretical applicability of these regimens, their introduction is currently facing cost and access issues denying their use to many patients in need. Health systems in all countries are facing a huge problem of distributive justice, since while they should guarantee individual rights, among which the right to health in its broader sense, therefore not limited to healing, but extended to quality of life, they must also grant equal access to the healthcare resources and keep the distribution system sustainable. In the face of a disease with a relatively unpredictable course, where many but not of all chronically infected will eventually die of liver disease, selective allocation of this costly resource is debatable. In most countries the favorite solution has been a stratification of patients for prioritization of treatment, which means allowing Interferon-free DAA treatment only in patients with advanced fibrosis or cirrhosis, while keeping on hold persons with lesser stages of liver disease. In this report, we will perform an ethical assessment addressing the issues linked to access to new therapies, prioritization and eligibility criteria, analyzing the meaning of the term "distributive justice" and the different approaches that can guide us (individualistic libertarianism, social utilitarianism and egalitarianism) on this specific matter. Even if over time the price of new DAA will be reduced through competition and eventual patent expiration, the phenomenon of high drug costs will go on in the next decades and we need adequate tools to face the problems of distributive justice that come with it.

Responses of peripheral blood mononuclear cells to moderate exercise and hypoxia

The purpose of this study was to analyze the physiological features of peripheral blood mononuclear cells (PBMCs) isolated from healthy female trekkers before and after physical activity carried out under both normoxia (low altitude, < 2000 m a.s.l.) and hypobaric hypoxia (high altitude, > 3700 m a.s.l.). The experimental design was to differentiate effects induced by exercise and those related to external environmental conditions. PBMCs were isolated from seven female subjects before and after each training period. The PBMCs were phenotypically and functionally characterized using fluorimetric and densitometric analyses, to determine cellular activation, and their intracellular Ca(2+) levels and oxidative status. After a period of normoxic physical exercise, the PBMCs showed an increase in fully activated T lymphocytes (CD3(+) CD69(+) ) and a reduction in intracellular Ca(2+) levels. On the other hand, with physical exercise performed under hypobaric hypoxia, there was a reduction in T lymphocytes and an increase in nonactivated B lymphocytes, accompanied by a reduction in O2 (-) levels in the mitochondria. These outcomes reveal that in women, low- to moderate-intensity aerobic trekking induces CD69 T cell activation and promotes anti-stress effects on the high-altitude-induced impairment of the immune responses and the oxidative balance.

Xenograft of microencapsulated Sertoli cells for the cell therapy of type 2 diabetes mellitus in spontaneously diabetic nonhuman primates: preliminary data

Insulin resistance in type 2 diabetes mellitus (T2DM) may be due to a chronic inflammation of the visceral adipose tissue (VAT) leading to local and systemic increases in proinflammatory cytokines. Microencapsulated porcine Sertoli cells (MC-pSC), by provision of immunomodulatory and trophic factors, have been successfully used to reduce such inflammation in rodent animal models of type 1 diabetes with no complications or deleterious side effects. Herein, we have begun to investigate this novel and safe therapeutic approach in the spontaneously obese nonhuman primate with spontaneous, insulin-dependent T2DM. After MC-pSC intraperitoneal injection we have evaluated, throughout a 6-month follow-up period, daily ad libitum fed glucose levels, daily exogenous insulin supplementation, biweekly body weight measurements, periodic fasting blood glucose concentrations, glycated hemoglobin (HbA1c) levels, glucose tolerance tests (GTT), and fluorescence-activated cell sorting cytometry (FACS) assessment of peripheral blood mononuclear cells. Very preliminarily, we have observed a slight reduction in fasting (FPG) and mean nonfasting (NF) plasma glucose levels. We found minimal changes, only in 1 animal, in daily exogenous insulin requirements and HbA1c levels. Flow cytometric analysis was associated with decrease in CD8(+) cells only in 1 recipient with a reduction in mean regulatory T Cells (Treg), whereas interestingly, decrease of B lymphocytes was observed in both animals. These results may suggest that this novel MC-SC-based transplantation protocol might possibly impact the metabolic status of T2DM in higher mammals that are close to humans.

A new ethical and medico-legal issue: vascular surgery and the postoperative cognitive dysfunction

Patients undergoing major surgery are at risk for postoperative cognitive dysfunction (POCD). The consciousness of the POCD arises new ethical and medico-legal issues that should be identified, managed and, if possible, prevented. Elderly patients still represent a real challenge for physicians and medical science. This challenge can be surmounted not only through technical progress but also by safeguarding the correct ethical behavior at the base of each relationship between a patient and his physician. Effective communication with the elderly patient is a prerequisite for clear and complete information, involving family members and caregivers when necessary. In every case, the identification of patients with pre-existing risk factors of POCD, shortening the period of time preceding the surgery and a proper technique of the procedure as well as physical and intellectual exercises, nutrition and medication play an important role in decreasing the incidence of neurocognitive deficits in the elderly.

[Literature review and state of the art of the Italian law on medically assisted reproduction]

This article analyzes the current situation of medically assisted reproduction in Italy after the promulgation of Law 40 in 2004. This law is actually completely different from the origin version. The controversial points like reproduction for couples who bear genetic diseases, prohibition of heterologous fertilization, cryoconservation of the embryos, obligation to perform just one and contemporaneous implant of all the embryos produced, are today definitively erased. This new situation is due to the jurisprudence of the Italian Courts but especially to the changes introduced by the European Court of Human Rights and by the questions of constitutionality raised by some Italian Courts. After analysis of the legislation, the views of various authors are compared, and the weaknesses and strong points of the law are considered from the point of view of legal medicine, science and bioethics. After ten years of operation of this law Italy has returned to a situation that existed before the law. In fact the old law was only full of prohibitions. Now is possible to do heterologous fertilization and this article photographs the current situation of hospitals for assisted procreation in Italy. The work also comments on procreative tourism, a direct consequence of this law, and on the status of women, who must be the subject and not the object of the legislation.

ClC-1 mutations in myotonia congenita patients: insights into molecular gating mechanisms and genotype-phenotype correlation

KEY POINTS

Loss-of-function mutations of the skeletal muscle ClC-1 channel cause myotonia congenita with variable phenotypes. Using patch clamp we show that F484L, located in the conducting pore, probably induces mild dominant myotonia by right-shifting the slow gating of ClC-1 channel, without exerting a dominant-negative effect on the wild-type (WT) subunit. Molecular dynamics simulations suggest that F484L affects the slow gate by increasing the frequency and the stability of H-bond formation between E232 in helix F and Y578 in helix R. Three other myotonic ClC-1 mutations are shown to produce distinct effects on channel function: L198P shifts the slow gate to positive potentials, V640G reduces channel activity, while L628P displays a WT-like behaviour (electrophysiology data only). Our results provide novel insight into the molecular mechanisms underlying normal and altered ClC-1 function.

ABSTRACT

Myotonia congenita is an inherited disease caused by loss-of-function mutations of the skeletal muscle ClC-1 chloride channel, characterized by impaired muscle relaxation after contraction and stiffness. In the present study, we provided an in-depth characterization of F484L, a mutation previously identified in dominant myotonia, in order to define the genotype-phenotype correlation, and to elucidate the contribution of this pore residue to the mechanisms of ClC-1 gating. Patch-clamp recordings showed that F484L reduced chloride currents at every tested potential and dramatically right-shifted the voltage dependence of slow gating, thus contributing to the mild clinical phenotype of affected heterozygote carriers. Unlike dominant mutations located at the dimer interface, no dominant-negative effect was observed when F484L mutant subunits were co-expressed with wild type. Molecular dynamics simulations further revealed that F484L affected the slow gate by increasing the frequency and stability of the H-bond formation between the pore residue E232 and the R helix residue Y578. In addition, using patch-clamp electrophysiology, we characterized three other myotonic ClC-1 mutations. We proved that the dominant L198P mutation in the channel pore also right-shifted the voltage dependence of slow gating, recapitulating mild myotonia. The recessive V640G mutant drastically reduced channel function, which probably accounts for myotonia. In contrast, the recessive L628P mutant produced currents very similar to wild type, suggesting that the occurrence of the compound truncating mutation (Q812X) or other muscle-specific mechanisms accounted for the severe symptoms observed in this family. Our results provide novel insight into the molecular mechanisms underlying normal and altered ClC-1 function.

Fine-tuning of Th17 Cytokines in Periodontal Disease by IL-10

Periodontitis (PD) is a chronic disease caused by the host inflammatory response to bacteria colonizing the oral cavity. In addition to tolerance to oral microbiome, a fine-tuned balance of IL-10 levels is critical to efficiently mount antimicrobial resistance without causing immunopathology. Clinical and animal studies support that adaptive T-helper (Th) cytokines are involved in the pathogenesis of alveolar bone destruction in PD. However, it remains unclear what type of Th response is related to human PD progression and what role IL-10 has on this process. We addressed the contribution of IL-10 in limiting Th1 and Th17 inflammatory response in murine and human PD. Through a combination of basic and translational approaches involving selected cytokine-deficient mice as well as human genetic epidemiology, our results demonstrate the requirement for IL-10 in fine-tuning the levels of Th17 (IL-17A and IL-17F) cytokines in experimental and human PD. Of novelty, we found that IL-17F correlated with protection in murine and human PD and was positively regulated by IL-10. To our knowledge, this is the first demonstration of the protective role for IL-17F in PD, its positive regulation by IL-10, and the potential differential role for IL-17A and IL-17F in periodontal disease.

Management and treatment of anaphylaxis in children: still too low the rate of prescription and administration of intramuscular epinephrine

Despite it being well known that anaphylaxis is a severe life-threatening reaction requiring prompt management and treatment, this entity is still under-recognized and not correctly managed, above all in children. The aim of this study was to analyze the most frequent features of anaphylaxis in a pediatric population (n=65 patients) and to identify factors predicting more severe reactions. Among the 70 recorded episodes, food was the main culprit of anaphylaxis, and patients with a positive history for allergic asthma had more severe episodes (P=0.008). A self-injectable adrenaline was used only in 2 of the 70 episodes and none of the 50 episodes managed in the Emergency Department was treated with intramuscular adrenaline. Only 10/65 patients (15&#x0025;) had a prescription for an auto-injector prior to the first episode of anaphylaxis. The retrospective analysis of the risk factors potentially requiring an epinephrine auto-injector prescription before the first anaphylactic episode, showed that of the 55 patients without prescription, at least 10 (18&#x0025;) should have been provided with a device, according to the most recent guidelines. In conclusion, notwithstanding intramuscular adrenaline being the first-line treatment of anaphylaxis, many episodes are still undertreated and the risk of anaphylaxis is still under-estimated. More efforts should be made to promote the correct management of anaphylaxis among both healthcare-providers and patients.

Cow's milk allergy (CMA) in children: identification of allergologic tests predictive of food allergy

Oral food challenge (OFC) is still considered the gold standard for diagnosis of food allergy (FA). Skin prick test (SPT) and specific IgE (sIgE) tests are very useful but limited in their predictive accuracy. End point test (EPT) has been recently considered to determine the starting dose to induce oral desensitization. Allergometric tests combined may discriminate children at higher risk of reactions during OFC. We considered 94 children referred to our Allergy and Immunology Pediatric Department between January 2009 and December 2011 with CMA. Cutaneous allergometric skin tests (SPT and EPT) were periodically performed on all 94 children with CMA; sIgE levels against cow's milk proteins (CMP) α-lactalbumin, β-lactoglobulin and casein were periodically evaluated through blood samples every 6-12 months. During the period of the study, 26/94 (27.6%) children underwent more than once OFC. We collected 135 OFC compared with clinical presentation: 49/135 (36.2%) OFC were performed shortly after the onset of symptoms directly related to spontaneous intake of milk, to confirm suspicion of FA; 86/135 (63.7%) OFC were performed to evaluate the acquisition of tolerance. Of these, 52/86 (60.4%) OFC resulted positive, 34/86 (39.5%) were negative. The 3D EPT has the best ratio sensitivity (SE) / positive predictive value (PPV), SE 83%, specificity (SP) 58.3%, PPV 89.3%, negative predictive value (NPV) 45.1%. EPT 6D and 7D have the best PPV (100%) with a low NPV (respectively 22.2% and 21.2%). We obtained that a mean fresh milk wheal diameter ≥ 12 mm was predictive of 97% OFC, but only 32/101 (31.6%) allergic children presented this value. The tests with a wheal diameter ≤ 5 were performed on younger children, all of which were less than 9 months old; only 5 other tests performed on less than 9 months olds resulted in the others subgroups (1 in ≥ 12 mm wheal and 4 in the group between 6-11 mm). We also found that 95% of children with 4D EPT wheal diameter < 6 mm resulted tolerant. This cut off could be useful to decide which children have a lower risk of reactions during the OFC. EPT is more useful than SPT especially for children < 1 year of age being a less operator dependent test, and it could be helpful to discriminate between children with the highest risk to develop anaphylaxis following an OFC (≥ 5D positive EPT) and children with lowest risk (> 2D positive EPT), but it can't replace OFC, that currently remains the gold standard in the diagnosis of FA. We also underline that in allergic children younger than 9 months old, the values of SPT with fresh milk is much lower than in older children, so that it's better to separate this group of age when we try to predict the evolution of OFC through the evaluation with EPT. A validation of such results in a prospective study could maybe be useful to confirm the outcome of our data in the predictivity of OFC.

The ethical and legal implications of nanotechnologies: a preliminary survey to picture the perceptions of law students and medical students

PURPOSE

The aim of this preliminary survey was to picture the current knowledge and opinions of law students and medical students about nanotechnologies.

MATERIALS AND METHODS

Data were collected in June 2012 by interviews with 60 students of the University of Camerino (Macerata, Italy) defined as "jurist population" and 159 medical students of the Università Cattolica del Sacro Cuore (Rome, Italy) defined as "medical population".

RESULTS

The Authors found that both law and medical students have some knowledge on what nanotechnologies are; with regards to the ethical issues and risks perception, both categories indicated that nanotechnologies generate bioethical issues. Nevertheless, a high percentage of respondents believed that neither existing technologies nor nanotechnologies pose risks for human health. Opinions on regulation of nanotechnologies are instead different.

CONCLUSIONS

These preliminary findings underlined the ambiguity surrounding nanotechnologies both concerning the bioethical dimension and risks perception and their regulation. These early data therefore showed a need of additional reflection on these technologies that should be investigated more in detail; moving from students, future scientists and regulators, these data could contribute to clarify the debate on them.

Benign paroxysmal positional vertigo and migraine: analysis of 186 cases

OBJECTIVE

This retrospective study assessed several clinical, case history and functional parameters to investigate benign paroxysmal positional vertigo (BPPV) in patients with migraine.

METHODS

Two groups of patients were compared: those affected by BPPV and migraine (group A), as defined by International Headache Society criteria, and those with BPPV without migraine or with another form of headache (group B). The following parameters were investigated: onset of BPPV, recovery time, residual dizziness, recurrence of BPPV, atypical eye movement patterns and Meniere-like vertigo in the inter-critical BPPV period.

RESULTS

Mean age at BPPV onset was 39 years +/- 9.2 in Group A and 53 years +/- 7.3 in Group B (p = 0.00). No significant difference emerged in the number of manoeuvres needed to achieve recovery (Group A: 1.7 +/- 0.94; Group B: 1.9 +/- 0.89; p > 0.05). Highly recurrent BPPV (at least 4 documented episodes) was observed in 15 patients from group A (19.4%) and in 8 patients from group B (7.3%). Atypical eyes movements and Meniere-like vertigo were more frequent in migraineurs with highly recurrent BPPV (Chi square = 5.76; p < 0.016).

CONCLUSIONS

A high prevalence of BPPV and earlier onset in migraine are the main findings of this study. There is a higher incidence of a range of neurotological patterns in the intervals between BPPV episodes in migraineurs with recurrent vertigo. No direct pathophysiological link between migraine and BPPV has yet been established; comorbidity seems to affect clinical features in a sub-population of patients and make BPPV more debilitating.

Skin prick test: the only predictive tool of anaphylaxis? A case report

Currently, in the literature there is a lack of definite predictive values parameters to identify patients with the risk to develop anaphylaxis. The controlled oral food challenge remains the gold standard for food allergy diagnosis. We report a case of a girl allergic to cow's milk with low levels of specific IgE and large skin prick test wheal sizes for cow's milk. In some cases the high diameter of skin prick test wheal may be more reliable than specific IgE levels in predicting an anaphylactic reaction.

Successful rescue hysteroscopic resection of a cervical ectopic pregnancy previously treated with methotrexate with no combined safety precautions

BACKGROUND

Cervical pregnancy (CP) is a life-threatening condition that represents less than one percent of all ectopic pregnancies. Transvaginal sonography (TVS) is the gold standard for an accurate diagnosis. For hemodinamically stable women the available treatments involve a medical therapy, alone or in combination with interventional measures (hysteroscopy, angiographic embolization or laparoscopic ligation of uterine arteries).

MATERIALS AND METHODS

The authors describe a CP unsuccessfully treated with methotrexate (MTX), but resolved with hysteroscopy.

CASE REPORT

A nulliparous woman arrived with low abdominal pain without vaginal bleeding at six weeks of amenorrhea. TVS revealed a gestational sac implanted in the isthmic cervical region, with a serum beta-hCG of 1,100 mUI/ml, that raised to 4,274 mUI/ml in a week, despite one intrasaccular-MTX injections and two systemic doses. The authors arranged for a hysteroscopic resection with no previous dilatation of the cervix. They did not adopt any safety precautions to their procedure.

CONCLUSION

It is difficult to define the exact role of hysteroscopy regarding CP. Despite some authors dispute on its complementary function to MTX, the authors believe that it could be used as a rescue method in case of MTX failure. The final aims of a proper management are to minimize the risk of haemorrhage and preserve women's fertility.

Additional indications for the low allergenic properties of the apple cultivars Santana and Elise

Patients with Oral Allergy Syndrome (OAS) to fresh apple may tolerate low allergenic apple cultivars. We aimed to investigate if the low allergenic properties of Elise and Santana, as previously identified in a Dutch population, could be generalised within North West Europe within the birch pollen region with regard to both the prevalence and degree of sensitization. Prick-to-prick tests (PTP) were performed in eighty-five adult patients with OAS to fresh apple in Great Britain, Switzerland and Northern Italy, before the birch pollen season, using the putatively low allergenic apple cultivars Elise, Santana, Granny Smith, Modi and Mcintosh, as well as the putatively high allergenic apple cultivars Golden Delicious and Kanzi. No significant differences in percentages of negative responses of PTPs were found between the three countries. Negative responses did not differ from negative responses to the different apple cultivars we previously found in 2006/2007 in the Netherlands. The size of the PTPs of all apple cultivars tested were correlated to the size of the skin prick tests with birch pollen. These results add to the indications for the low allergenic properties of the low allergenic apple cultivars Santana and Elise, as the number of negative responses were reproducible in three countries within the birch pollen region and were similar to previous results in the Netherlands. These results justify oral challenge studies with Elise and Santana within the birch pollen region, to establish the low allergenic properties for the benefit for apple allergic consumers for definite conclusions.