Soluble CD30 and lymphocyte activation gene-3 (CD223), as potential serological markers of T helper-type cytokine response induced by acellular pertussis vaccine

T cell responses are involved in vaccine-induced immunity to pertussis but no easy-to-monitor, serological markers are available to assess these responses. The lymphocyte activation gene-3 (CD223) molecule is present on, and released by, activated T helper (Th) 1 cells, whereas CD30 molecules have been associated with Th2 immune responses. Starting from the recent knowledge of the cytokine profile induced by pertussis vaccination, we examined the levels of soluble (s)CD223 and sCD30 proteins in child recipients of acellular pertussis (aP) and diphtheria-tetanus (DT) vaccines and in children receiving DT vaccine only, as control. The correlation of the two proteins with specific antibody and T cell responses was assessed. The main findings are: i) sCD223 and sCD30 levels are inversely related, suggesting that the two markers are the expression of different and counter-regulated T-cell responses; ii) sCD30 level correlated with induction of T cell proliferation to pertussis vaccine antigens and antibody response to pertussis toxin. Overall, sCD30 and sCD223 levels seem to be promising candidate markers to assess the induction of Th-type responses in vaccine recipients.

How increased pertussis vaccination coverage is changing the epidemiology of pertussis in Italy

The epidemiology of pertussis in Italy is described by using data from the statutory notification system and from seroepidemiology studies. Starting from the 1990s, the incidence of pertussis in Italy has shown a sharp decline and is now at the lowest level ever reached. During this time period vaccination coverage has increased from 88% in 1998 to 95% in 2003. In 1996-97, the prevalence of subjects with levels of IgG antibodies against PT greater than 2EU/ml was 77.6%. The increase in vaccination coverage will probably change the pattern of disease transmission and increase the number of susceptible adults, unless administration of booster doses to adolescents and adults is considered.

Resurgence of pertussis in Europe

BACKGROUND

A resurgence of pertussis has been observed in Canada, the United States and Australia since the 1980s, but inconsistent data are currently available for Europe. The objective of this paper is to describe the epidemiology of pertussis in Western European countries to discuss future vaccination strategies.

METHODS

The European Community funded a network for the epidemiologic surveillance of measles and pertussis in 1998. Sixteen European countries provided national surveillance data for pertussis for the period 1998-2002 in a standard format. Data were pooled and analyzed to describe incidence rates by age group, seasonality, proportion of hospitalized patients and deaths among notified cases.

RESULTS

Children younger than 1 year had the highest incidence during the entire period. Rates in the older than 14 years age group increased by 115% during the study period. Northern countries showed the highest incidence figures in all age groups. Among children younger than 1 year, 70% were admitted into hospital. Children younger than 6 months of age and those not vaccinated were most likely to be hospitalized. Thirty-two deaths were reported, 87% of which were in children younger than 6 months of age.

CONCLUSIONS

Pertussis is far from being controlled in Europe. Whereas the incidence in children younger than 1 year was high but remained stable, rates in adults doubled in 5 years.

Incidence of vaccine preventable pneumococcal invasive infections and blood culture practices in Italy

In order to estimate the incidence of invasive pneumococcal diseases (IPD) and the amount of vaccine preventable serious infections, a 1-year population-based surveillance was undertaken in two comparable Italian regions (Piemonte and Puglia, representing 14% of the Italian population) prospectively collecting data and strains from all the hospital microbiological laboratories. A retrospective analysis of hospital discharge records, matched with the laboratory database, was also undertaken in nine hospitals in these two regions to determine the frequency of use of blood cultures and its impact on IPD incidence estimate. For children under 2 years of age, the incidence rates of IPD were 11.3 per 100,000 and 5.9 per 100,000 in Piemonte and in Puglia, respectively; for subjects 65 years of age and over the incidence rates were 5.7 per 100,000 and 0.2 per 100,000, in the two regions, respectively. The number of blood cultures performed was six times higher in Piemonte than that in Puglia. About 96% of isolates from IPD patients, aged 65 years and over, belonged to serogroups included in the 23-valent polysaccharide vaccine, whereas about 79% of strains isolated from patients under 5 years of age were related to serotypes included in the 7-valent conjugate vaccine. The estimate of the incidence of IPD is affected greatly by the different attitudes in performing blood cultures, especially in older patients. In Italy, bacteriological culture procedures should be undertaken more frequently to provide decision-makers with reliable estimates of serious vaccine preventable conditions.

An index to measure the association between dietary patterns and coronary heart disease risk factors: findings from two Italian studies

BACKGROUND

To examine the association between established coronary heart disease (CHD) risk factors and eating patterns by creating a dietary index utilizing a limited amount of food frequency questionnaire data on specified indicator foods.

METHODS

Selected data from the Italian Risk Factors and Life Expectancy (RIFLE) project collected between 1978-1979 and 1983-1984 on 7665 men and women, aged 20-59 years, were used to compute a dietary index summarizing the relative proportion of fatty to non-fatty foods. The association between this index and systolic and diastolic blood pressure (SBP, DBP), body mass index, total serum cholesterol (TC), and blood glucose, controlling for potential confounders was then tested using multiple linear regression.

RESULTS

Among men, a positive association was found between the index and all five CHD risk factors (P < 0.01). Among women, the associations were weaker, becoming statistically significant only for TC and glucose.

CONCLUSIONS

Our food index was able to detect relationships between diet and traditional CHD risk factors. A tool such as this, which requires only a limited number of key indicator food items, might enhance the use of existing food frequency questionnaires and also streamline the process of collecting new dietary information.

European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease: the Italian experience

In Italy, 35 clusters of travel associated Legionnaires' disease were identified from July 2002, when the European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease have been adopted by the EWGLINET network, to October 2003. Eight per cent (28.6%) would not have been identified without the network. The clusters detected were small, ranging from 2 cases to a maximum of 6. All clusters involved 5 camping sites and 30 hotels/residences, and an overall of 87 patients. The diagnosis was confirmed in 92.0% of the cases and mainly performed by urinary antigen detection (84.7%). A clinical isolate was available only in one case. Following environmental investigations, samples were collected for all the 35 clusters from the water system, and Legionella pneumophila was found in 23 occasions (65.7%). In 15 resorts out of 35, investigations were already in progress at the time of EWGLI cluster notification, since in Italy full environmental investigation is performed even after notification of a single case. Control measures were implemented in all accommodation sites at risk and one hotel only was closed. In all the 35 clusters, reports were completed and sent on time, highlighting that it is possible to comply with the procedures requested by the European Guidelines.

Virus-specific CD8+ lymphocytes share the same effector-memory phenotype but exhibit functional differences in acute hepatitis B and C

Hepatitis B and hepatitis C viruses (HBV and HCV) are both noncytopathic and can cause acute and chronic infections of the liver. Although they share tropism for the same organ, development of chronic hepatitis is much more frequent following HCV infection, suggesting different mechanisms of viral persistence. In this study, we show that circulating HBV- and HCV-specific tetramer-positive CD8 cells during the acute phase of hepatitis B and C belong almost entirely to an effector-memory subset (CCR7(-) CD45RA(-)). Despite this phenotypic similarity, HBV- and HCV-specific CD8 cells show striking functional differences. HBV-specific tetramer-positive CD8 cells express high perforin content ex vivo, expand vigorously, and display efficient cytotoxic activity and gamma interferon (IFN-gamma) production upon peptide stimulation. A comparable degree of functional efficiency is maintained after the resolution of hepatitis B. In contrast, HCV-specific CD8 cells in the acute phase of hepatitis C express significantly lower levels of perforin molecules ex vivo and show depressed CD8 function in terms of proliferation, lytic activity, and IFN-gamma production, irrespective of the final outcome of the disease. This defect is transient, because HCV-specific CD8 cells can progressively improve their function in patients with self-limited hepatitis C, while the CD8 function remains persistently depressed in subjects with a chronic evolution.

Iron reduction and sustained response to interferon-alpha therapy in patients with chronic hepatitis C: results of an Italian multicenter randomized study

OBJECTIVES

It has been suggested that iron depletion improves the response to interferon in patients with chronic hepatitis C. We aimed to evaluate whether iron reduction by phlebotomy before interferon improves the rate of virological sustained response in previously untreated noncirrhotic patients.

METHODS

One hundred fourteen hepatitis C virus (HCV) RNA positive patients with hepatic iron concentrations of > or =700 microg/g dry wt (men) and > or =500 microg/g dry wt (women), stratified according to HCV genotype and gamma-glutamyltransferase values, were randomly allocated to interferon alone (6 MU three times a week) (group A) or to phlebotomy until iron depletion followed by interferon (6 MU three times a week) (group B). After 4 months dosage was reduced to 3 MU three times a week for another 8 months.

RESULTS

Virological sustained response was observed in 25 patients (22%), nine (15.8%, 95% CI = 7.5-27.9) of group A and 16 (28.1%, 95% CI = 17.0-41.6) of group B. At univariate analysis the variables associated with the response were HCV genotypes 2-3, normal gamma-glutamyltransferase, higher levels of baseline ALT, normal ALT values, and negativity for HCV-RNA at the 3rd month of therapy. At multivariate analysis, genotype and ALT levels at enrollment maintained their association with the response. A trend toward a better response to interferon was observed in patients who received phlebotomy (odds ratio = 2.32, 95% CI = 0.96-6.24, p = 0.082). Patients with hepatic iron concentration of < or = 1100 microg/g dry wt had a trend toward a higher rate of virological sustained response (p = 0.059) when submitted to treatment B.

CONCLUSION

Iron removal by phlebotomy is able to improve the rate of response to interferon, especially in patients with lower hepatic iron deposits; it could be useful as adjuvant therapy to new therapeutic modalities.

African sleeping sickness in tourists returning from Tanzania: the first 2 Italian cases from a small outbreak among European travelers

A recent cluster of cases of African trypanosomiasis in humans (HAT) has been reported in tourists (most of whom were European) returning from Tanzania; we describe the first 2 patients (both of whom were Italian travelers) with HAT, who have been treated successfully. Because neither vaccine nor drug prophylaxis is currently recommended and/or available for persons traveling to areas of endemicity, physicians should be alerted about this uncommon but potentially life-threatening disease.

Hepatitis C virus (HCV) RNA determination after two weeks of induction interferon treatment is an accurate predictor of nonresponse: comparison of two treatment schedules

The aim of this study was to analyze of HCV kinetics during interferon treatment administered daily or three times weekly. Seventy-seven naive patients were randomized to two treatment courses starting with four weeks of high-dose interferon administered daily or three times weekly. Twenty-two patients (28.6%) achieved end-of-treatment response and nine (11.7%, four of whom received daily induction) sustained response. The initial decline of viral load was sharper in patients receiving daily induction, but the rates of early RNA clearance were independent of treatment schedule, being higher in patients with genotype non-1. Detectable HCV RNA during treatment predicted nonresponse more significantly than high pretreatment viral load or genotype 1. HCV RNA at week 2 was the best predictor (100% sensitivity in patients receiving daily induction). In conclusion, daily induction increased the HCV decline slope, but not the rate of virological response. HCV RNA at week 2 reliably identified nonresponders.

Transmission of hepatitis C virus in a gynecological surgery setting

A cluster of hepatitis C virus (HCV) infections among gynecological patients who underwent surgical intervention in the same setting is described. An epidemiological investigation was conducted to identify the cases, the likely source of infection, and the route of transmission. Four recent HCV infections were identified. Based on molecular fingerprinting analysis and epidemiological investigation, transmission between the putative source patient (an HCV-positive woman who was the first patient of the surgical session) and outbreak patients was highly suggestive. All patients, including the source patient, were infected with HCV type 1b. Molecular characterization of HCV clones by sequence analysis of both structural envelope regions (20 clones from the source patient and 58 from the outbreak patients) and the nonstructural NS5 region of the viral genome (12 clones from the source patient and 32 from the outbreak patients) showed close homology between the viral isolates from the source and those from the outbreak patients that was higher than that observed between the viral isolates from the source and those from four unrelated, HCV type 1b-infected patients from the same geographical area (in the latter case, 33 clones were sequenced for the envelope regions and 30 were sequenced for the NS5 region). The mean percent divergence between clones was 4.69 for the envelope and 3.71 for the NS5 region in the source patient and the outbreak patients compared with 6.76 (P = 0.001) and 5.22 (P = 0.01) in the source patient and control patients, respectively. Among the risk factors investigated, only that of having undergone surgery in the morning session of the same day reached statistical significance (P = 0.003). The investigation showed that the source patient and outbreak patients shared only the administration of propofol in multidose vials. The study documents the risk of nosocomial transmission of HCV and the importance of infection control procedures in the operating room and highlights the crucial role of molecular strategies, especially sequence-based phylogenetic analysis of cloned viral isolates, in the investigation of HCV outbreaks.

Short-term adverse effects from and discontinuation of antiretroviral post-exposure prophylaxis

OBJECTIVE

To evaluate short-term toxicity from and discontinuation of antiretroviral combination prophylaxis in HIV-exposed individuals in Italy.

DESIGN

Longitudinal, open study conducted by prospective collection of data in the National Registry of PEP.

SETTING

All the Italian centres dedicated to HIV related care and licensed by the Ministry of Health to dispense antiretroviral drugs.

STUDY POPULATION

Health care workers and other persons consenting to be treated with post exposure prophylaxis (PEP) after exposures to HIV.

RESULTS

Until October, 2000, 207 individuals receiving two nucleoside reverse transcriptase inhibitors (NRTIs), and 354 receiving two NRTIs plus a protease inhibitor (PI) were enrolled. More individuals experienced side-effects in the 3-drug group (53% and 62%, respectively; OR 0.68, (95% CI 0.48-0.98), p < 0.03). However, the proportion of individuals discontinuing prophylaxis because of side-effects did not differ significantly between the 2 groups (21% and 25% respectively; OR 0.82 (95% CI 0.53-1.26); p=0.4). The 43 individuals in the 2 NRTI group discontinued PEP after a mean of 10.4 days of treatment (median 8, range 1-27), similarly to the 88 discontinuations observed in the 3-drug group (mean duration 10.5 days, median 7.5, range 1-26). Type and incidence of specific adverse effects were similar to those reported in the literature.

CONCLUSION

Our study indicates that the difference in the proportion of individuals developing side effects and discontinuing PEP is not significant. The rate of discontinuation because of protease inhibitor side-effects does not justify per se the initial use of a less potent PEP regimen. We suggest initiating PEP with a three-drug regimen and discontinuing the protease inhibitor in the case of adverse effects.

Conserved hepatitis C virus sequences are highly immunogenic for CD4(+) T cells: implications for vaccine development

The HLA class II-restricted T-cell response to hepatitis C virus (HCV) antigens is believed to influence the final outcome of hepatitis C, because it is vigorous in patients who recover from acute hepatitis C, but it is weak in those who develop a chronic infection. For this reason, exogenous stimulation of T-cell responses in chronic HCV infection may represent a strategy to cure patients with chronic hepatitis C by approximating the vigor of their T-cell reactivity to that of patients who succeed in recovering from hepatitis. It may also be a preventive approach to avoid spread of the virus by facilitating the development of a vigorous protective response at the very early stages of infection. T-cell-based vaccines composed of immunodominant, promiscuous, and conserved T-cell epitopes may represent a powerful tool to achieve optimal stimulation of the T-cell reactivity. To identify HLA class II-restricted T-cell epitopes useful for this purpose, 22 subjects with acute HCV infection were studied and followed for an average time of 29 months. Eight of them recovered from hepatitis, and 14 developed a chronic infection. Overlapping 20-mer peptides covering the entire core and NS4 antigens and a panel of peptides representing highly conserved regions of core, NS3, NS4, and NS5 were used. By direct peripheral blood T-cell stimulation and by fine-specificity analysis of HCV-specific T-cell lines and clones, highly immunogenic T-cell epitopes were identified within core, NS3, and NS4. All these epitopes are immunodominant and highly conserved among the known HCV isolates. Moreover, they are promiscuous, because they can be presented to T cells by different HLA class II molecules. Immunodominance, sequence conservation, and promiscuity make these epitopes ideal components of preventive or therapeutic T-cell-based vaccines against HCV.

Hypercalcaemia secondary to hepatocellular carcinoma

Many syndromes reflecting impaired metabolism have been described in association with primary neoplastic diseases. Hypercalcaemia secondary to malignancy without bone metastases and with normal parathyroid glands has been described as "pseudohyperparathyroidism". Differentiation from primary hyperparathyroidism is difficult and care should be taken to exclude an occult malignancy prior to surgical exploration for a parathyroid adenoma. Hypercalcaemia associated with hepatocellular carcinoma is not uncommon. Nevertheless, we describe a rare case of coma with persistent hypercalcaemia in a cirrhotic patient not previously known to have hepatocellular carcinoma.

[Emergency surgical management of lesions from ingestion of caustics. Role of primary endoscopic classification]

Management of caustic ingestion in adults improved in the last decade due to the new diagnostic developments, the better predictability of injuries from signs and symptoms, the intensive care improvements and the more aggressive surgical approach for the most severe lesions. In fact, the early surgical treatment of severe lesions for ingestion of caustic and corrosive substances may reduce mortality, morbidity and hospitalization. The role of early endoscopic examination is today worldwide accepted: is herein proposed a new endoscopic classification of caustic lesions adjusted after a retrospective analysis of a twenty years experience in this field, and applied in twelve patients affected by severe esophageal and gastric injuries then submitted to emergency surgical treatment and survived. It showed a great usefulness in selection of patients to submit immediately to surgery and may play a fundamental role in indications and timing of surgical management of severe injuries by caustic ingestion.

[Duodenal gangliocytic paraganglioma: intraoperative ultrasound evaluation]

Case report. A case of obstructive jaundice due to a preoperative unrecognized rare periampullary tumor, histologically demonstrated to be a gangliocytic paraganglioma of duodenum associated with Von Recklinghausen's disease, is herein reported. Intraoperative ultrasonography guided identification and evaluation of the obstructing lesion, suggesting in Whipple's procedure the most suitable treatment. The clinical case and ultrasonographic and Color Doppler findings are in detail described.

Distribution and localization of immunoreactive FMRFamide-like peptides in the lancelet

Immunofluorescence was used to study the distribution of FMRFamide (Phe-Met-Arg-Phe-NH2) in premetamorphic larvae and adults of the lancelet, Branchiostoma lanceolatum. In the larvae, FMR-Famide-containing presumably neuronal perikarya and fibers were limited to the anterior third of the dorsal nerve cord. Throughout this region, most of the immunoreactive perikarya and fibers were located ventrolaterally and ventrally within the nerve cord; in addition, in the caudal part of the cerebral vesicle, some of the immunofluorescent cells projected cytoplasmic extensions across the slot-like neural canal. In adult lancelets, immunofluorescence was detected in cells of the Hatschek's pit (a probable homologue of the anterior hypophysis of vertebrates); however, no immunofluorescence was detected in the larval preoral pit, which is the ontogenetic precursor of Hatschek's pit. Moreover, the FMR-Famide-containing elements do not show immunoreactivity to other peptides of the FaRPs family such as pancreatic polypeptide (PP). The results suggest that FMRF-amide may be involved in neuroendocrine functions of lancelets.

[The role of echo-endoscopy in the staging of squamous-cell carcinoma of the esophagus. The correlation between the surgical and anatomicopathological findings]

BACKGROUND

Endoscopic ultrasonography (EUS) is a relatively new diagnostic method to assess the extent and the depth of infiltration of esophageal carcinoma.

METHODS

From October 1990, 100 patients affected by esophageal squamous cell carcinoma underwent preoperative evaluation with endoscopic ultrasonography, 85 of whom were operated on. The first 23 patients underwent endosonography with an Olympus GF-EUM2 with a 7.5 MHz echo-probe; the remaining 77 patients underwent EUS with an Olympus GF-EUM3 with a 7.5-12 MHz echo-probe.

RESULTS

In 33 cases (33%), the procedure was not completed because of the impossibility of passing through the neoplastic stenosis. The depth of infiltration was correctly defined by EUS in 73 of 85 patients (86%) compared with 47% of Computed Tomography (CT) (p < 0.05). Overestimation occurred in 6 patients (7%), whereas underestimation occurred in 6 cases (7%). Lymph-node involvement was correctly classified by EUS in 50 of 57 patients (88%) compared with 39% of CT.

CONCLUSIONS

EUS provides a high degree of accuracy in assessing both T and N parameters in staging esophageal cancer. The major problem of the method is still the frequent impossibility of passing through a neoplastic stenosis.

Value and limits of endorectal ultrasonography for preoperative staging of rectal carcinoma

In rectal cancer, the depth of tumor infiltration and metastatic involvement of lymph nodes are important prognostic factors. Endosonography of the rectum, combining the advantages of both endoscopy and sonography, provides information not available from other imaging diagnostic techniques. From January 1989 to December 1997, 85 patients affected by rectal carcinoma were submitted to preoperative evaluation with endorectal ultrasonography. In 75 cases the results obtained with the endosonography were compared to the histology of the resected specimens. Overall accuracy in staging depth of infiltration was 90.7%. Overstaging occurred in 4% of patients, whereas understaging occurred in 5.3%. In staging lymph nodal involvement, overall accuracy was 76%, sensitivity was 69.8%, specificity was 84.4%, positive predictive value was 85.7%, and negative predictive value was 67.5%. Endorectal ultrasound is a safe and accurate diagnostic method for staging both tumor invasion and lymph node metastatic involvement, and for selecting an appropriate surgical strategy in patients affected by rectal cancer.

Endoscopic ultrasonography in the evaluation of leiomyoma and extramucosal cysts of the esophagus

BACKGROUND/AIMS

Leiomyoma is the most common type of benign esophageal tumor, whereas extramucosal cysts of the esophagus are congenital anomalies frequently asymptomatic in the adult and in most cases detected incidentally on chest x-ray. It is worthwhile considering these conditions together, because they present similar diagnostic and surgical problems. Conventional imaging tests do not lead to a precise diagnosis. The purpose of this study was to evaluate the use of endoscopic ultrasonography in the diagnosis of, and planning of treatment modalities for, these conditions.

METHODOLOGY

Fifteen patients with esophageal leiomyoma and seven patients with extramucosal esophageal cysts were studied with endoscopic ultrasonography using an Olympus GF- EU-M3 instrument with a 7.5-12 MHz echoprobe. In all patients, the results of endoscopic ultrasonography were compared with the histology of the resected specimens.

RESULTS

The histology of the resected specimens confirmed the endosonographic diagnosis in all patients. No malignancy was found in any specimen.

CONCLUSIONS

Endoscopic ultrasonography is very accurate in visualizing these lesions and differentiating cystic from solid submucosal esophageal masses; in addition, the test can establish the exact location of the mass in relation to the esophageal wall and mediastinum. Therefore, endoscopic ultrasonography has a great impact in confirming the diagnosis of leiomyoma and extramucosal cysts of the esophagus and facilitates therapeutic decision-making because of its capacity to clearly define the size, layer of the origin, and pattern of the mass.