[Determinant factors for the use of screening for cervical cancer in Friuli Venezia Giulia]

BACKGROUND

To describe the determinants of missed or irregular Pap-test.

METHODS

DESIGN

cross-sectional descriptive study.

SETTING

Trieste province (urban) and San Daniele district (mostly rural).

SUBJECTS

294 (89%) out of 332 (83%) women interviewed from a simple random sample of 400 women 25 to 64 years of age.

INTERVENTION

none.

DATA COLLECTION

planned telephone interview with a pre-tested questionnaire.

RESULTS

256 (87%) women had a Pap-test at least once in their life, 169 (57%) in the last two years. The 222 (76%) women with a Pap-test in the last five years know where and when, but not how often. The gynaecologist recommended the test in 63% of cases; only 23 women were informed by their general practitioner and only 8 decided the Pap-test based on this information. Fifty-three percent had the Pap-test always in the same health facility; the decision to change was related mainly with long waiting lists (18%) and distance (16%). In San Daniele district private health facilities were preferred to public ones more than in Trieste (48% vs 20%; p < 0.0005). Among women with regular Pap-test, 36% had higher education vs 23% among women with missed or irregular test (p = 0.05). The main reported reason for missed or irregular Pap test was inadequate information, followed by deficiencies in the quality of services.

CONCLUSIONS

The Pap-test rate was higher than expected. The small number of women with missed or irregular Pap-test (66/294; 22%) does not allow to draw firm conclusions about the reasons for non use, though these seem to be similar to those already reported in the literature, i.e. lack of adequate information. A regional programme, including standard methods of assessment of coverage, would lead to increased regular use of this screening.

Comparative studies of Ca2+-dependent proteases (CDP I and CDP II) from Allomyces arbuscula

Allomyces arbuscula, an aquatic fungus, contains two Ca2+-dependent neutral cysteine proteases (CDP I and CDP II), eluting respectively, at 0.07 and 0.2 M NaCl from DEAE cellulose columns. The purified CDP I has a Mr of 39 kDa whereas CDP II appears as a doublet of 43 and 40 kDa. Both enzymes require free thiol, the same concentration of Ca2+ for half maximal activation, and are inactivated by thiol protease inhibitors. Our results show that despite these similarities the two enzymes are different because affinity-purified CDP II antibodies do not cross-react with CDP I antigen in Western blots. In contrast, there is a strong cross-reaction between the two 43 and 40 kDa CDP II peptides and their respective antibodies. Both enzymes cleave preferentially the carboxy terminus of Arg and to a limited extent Lys on the cleavage site. This primary specificity is governed by the nature of the amino acids in the P2 and P3 positions. In general either Pro or Gly in P2 is required, with preference for Pro and in P3 position, Gly over Val. CDP II has higher catalytic activity than CDP I. The sulfhydryl reagent NEM is a more potent inhibitor of CDP I than CDP II. Although the function of the phosphorylable site(s) is not clear, both CDP I and CDP II contain phosphorylable serine residue(s).

Nipple care, sore nipples, and breastfeeding: a randomized trial

Sore and cracked nipples are common and may represent an obstacle to successful breastfeeding. In Italy, it is customary for health professionals to prescribe some type of ointment to prevent or treat sore and cracked nipples. The efficacy of these ointments is insufficiently documented. The incidence of sore and cracked nipples was compared between mothers given routine nipple care, including an ointment (control group), and mothers instructed to avoid the use of nipple creams and other products (intervention group). Breastfeeding duration was also compared between the two groups. Eligible mothers were randomly assigned, after informed consent, to one of the two groups. No difference was found between the control (n = 96) and the intervention group (n = 123) in the incidence of sore and cracked nipples and in breastfeeding duration. However, several factors were associated with sore nipples and with breastfeeding duration. The use of a pacifier and of a feeding bottle in the hospital were both associated with sore nipples at discharge (p = 0.02 and p = 0.03, respectively). Full breastfeeding up to 4 months postpartum was significantly associated with the following early practices: breastfeeding on demand, rooming-in at least 20 hours/day, non-use of formula and pacifier, no test-weighing at each breastfeed. The incidence of sore and cracked nipples and the duration of breastfeeding were not influenced by the use of a nipple ointment. Other interventions, such as providing the mother with guidance and support on positioning and latching, and modifications of hospital practices may be more effective in reducing nipple problems.

Co-expression of TrkB and the N-methyl-D-aspartate receptor subunits NR1-C1, NR2A and NR2B in the rat visual cortex

In the visual cortex, brain-derived neurotrophic factor expression is modulated through glutamate receptors, including the N-methyl-D-aspartate glutamate receptor. It has been proposed that the N-methyl-D-aspartate glutamate receptor subunit composition itself might be regulated by brain-derived neurotrophic factor. Here, we investigated the co-expression of the neurotrophin-4/brain-derived neurotrophic factor receptor TrkB with the N-methyl-D-aspartate glutamate receptor subunits NR1-C1, NR2A and NR2B, on postnatal days 10 and 22 and in the adult rat primary visual cortex. At both postnatal days 10 and 22, TrkB is co-expressed in all cortical layers with the studied N-methyl-D-aspartate glutamate receptor subunits. In the adult, in layers IV-V, co-expression is restricted to a subpopulation of neurons, while in layers II-III, VI nearly all neurons co-express TrkB with NR1-C1, NR2A and NR2B. We conclude that in layers IV-V, the co-expression of TrkB with subunits NR2B and NR2A is developmentally regulated.

The selection of intracellular antibodies

The intracellular expression of antibodies in mammalian cells is a strategy to inhibit the in vivo function of selected molecules but is limited by the unpredictable behaviour of antibodies when intracellularly expressed. Recent advances in the field of antibody expression in Escherichia coli show that the introduction of mutations can improve the properties of some antibody domains, but the general applicability of this approach to intracellular antibodies remains to be proved. As a complement to rational approaches, we describe selection schemes in which antibodies are selected on the basis of their performance in vivo as intracellular antibodies.

Signs of severe bacterial infection in neonates

The objective of this study was to identify a short list of valid signs for the development of standard case management guidelines for severe bacterial infection (SBI) in newborn infants, an important cause of neonatal deaths in low-income countries. The reported and observed signs of 83 sick neonates admitted during 12 consecutive months were recorded. At discharge, 50 cases were classified, using predefined criteria, as SBI, mostly pneumonia, and 33 as other disease. The neonates with other diseases were significantly younger than those with SBI. None of the reported and observed signs, when used alone, had a high sensitivity, an important feature for a severe disease amenable to effective treatment. The best sensitivity (74 per cent) was obtained when a doctor observed severe chest indrawing or fast breathing or 'not looking well'; the specificity was 67 per cent and the positive predictive value 77 per cent. The sensitivity of reported difficult breathing and of observed severe chest indrawing, when measured only for the diagnosis of pneumonia, improved to 77 per cent, with a specificity of 84 per cent and 66 per cent, respectively. Reported fever and the observation that the neonate was 'not looking well' were the best independent predictors of SBI on logistic regression analysis. Simple standard case management (SCM) guidelines based only on reported and observed clinical signs would not identify the majority of neonates with SBI at primary health care level.

Single-chain variable fragments selected on the 57-76 p21Ras neutralising epitope from phage antibody libraries recognise the parental protein

Phage antibodies have been widely prospected as an alternative to the use of monoclonal antibodies prepared by traditional means. Many monoclonal antibodies prepared against peptides are able to recognise the native proteins from which they were derived. Here we show that the same is also true for phage antibodies. We have selected a number of single-chain variable fragments (scFv) from a large phage scFv library against a peptide from the switch region II of p21Ras. This peptide is known to reside in a mobile area of the native protein and is the epitope of a well characterised monoclonal antibody. Selected scFvs were able to recognise native p21Ras in both ELISA and Western blots, indicating that peptides are also likely to be very useful in selecting from phage antibody libraries.

Increased density of M1 receptors in the hippocampus of juvenile rats chronically deprived of NGF

Binding studies were used to assess the changes in affinity and/or number of M1 muscarinic receptors in hippocampi from juvenile rats chronically deprived of NGF. NGF deprivation was obtained by implanting into right ventricle at postnatal day 2 (P2) hybrydoma cells secreting high levels of monoclonal antibodies against NGF (alphaD11). Parenteral myeloma cells (P3U) were used as controls. Competition experiments were used to characterise the [3H]-PNZ binding sites in membrane preparations of hippocampi from rats sacrificed at P15. [3H]-PNZ bound M1 receptors both in P3U and alphaD11 group as shown by displacing potency order of antagonists: TLZ=4-DAMP>PNZ>p-F-HHSiD>MTC. The deprivation of NGF for two weeks significantly increased the number of M1 receptors without changing the Ki values of antagonists with exception of methoctramine which showed an increase in affinity in alphaD11 group. Similar changes in binding parameters were already observed after the first week of anti-NGF treatment. In contrast, a treatment for a week with implant at postnatal day 15 failed to produce any changes in M1 binding parameters. These results provide further physiological evidence for developmentally regulated modulatory role of NGF in the cholinergic function in the hippocampus.

Dark rearing blocks the developmental down-regulation of brain-derived neurotrophic factor messenger RNA expression in layers IV and V of the rat visual cortex

In this study, we describe the distribution of brain-derived neurotrophic factor messenger RNA in the binocular primary visual cortex of the rat during postnatal development, starting at postnatal day (P) 13. High-resolution non-isotopic in situ hybridization combined with Nissl staining were used to quantify the number of cells expressing brain-derived neurotrophic factor messenger RNA. At P13, most of the cells express brain-derived neurotrophic factor messenger RNA. After eye opening (P14-P15), the relative number of brain-derived neurotrophic factor messenger RNA-positive cells decreases by a factor of two in layer IV, i.e. that receiving the visual input, and in layer V. To verify the hypothesis that light could trigger this decrease, pups were kept in complete darkness from birth. At P22, pups reared in the dark were killed and the visual cortex processed for in situ hybridization and northern blotting. The results obtained in dark-reared animals prove that light deprivation can: (i) decrease the general levels of brain-derived neurotrophic factor messenger RNA, and (ii) increase the relative number of brain-derived neurotrophic factor messenger RNA-positive cells in layers IV and V with respect to control rats. Exposure to light for five days after the period of darkness restored the number of brain-derived neurotrophic factor messenger RNA-positive cells. We conclude that the expression of brain-derived neurotrophic factor messenger RNA in the rat primary visual cortex is regulated during development and that this process is under the control of visual input.

A non-radioactive in situ hybridization method that does not require RNAse-free conditions

This report describes a quick and versatile method to perform non-radioactive in situ hybridization in which none of the hybridization steps are performed under RNAse-free conditions. This study demonstrates that in situ hybridization can be performed without an RNAse-free environment provided that the concentration of RNAse introduced during the experiment does not reach 0.1 microg/ml, a concentration that is unlikely to be achieved through an accidental contamination. Moreover, evidence is provided that the only step sensitive to RNAse degradation is the pretreatment since degradation during the hybridization step can not occur due to a very efficient protective effect exerted by formamide. Finally, our data suggest that endogenous RNAse activity might be readily neutralized through paraformaldehyde fixation. A feature of this method is the strong fixation that ensures a perfect tissue preservation, even at level of the fine structure of the cell processes. The method allows a uniform tissue penetration by sodium periodate and sodium borohydride treatment and can be easily used in combination with diaminobenzidine immunohistochemistry for double labeling experiments.

The mode of action of Y13-259 scFv fragment intracellularly expressed in mammalian cells

The anti-p21ras Y13-259 single-chain Fv fragment (scFv) neutralizes the activity of p21-ras when intracellularly expressed in different systems. We have studied the mode of action of this inhibition in 3T3 K-ras fibroblasts and demonstrated that (i) this antibody fragment is highly aggregating when cytoplasmically expressed and (ii) the p21-ras antigen is sequestered in these aggregates in an antibody-dependent manner. This co-segregation leads to an efficient inhibition of DNA synthesis. These results suggest that an antigen can be diverted from its normal location inside the cells in an antibody mediated way, prospecting a new mode of action for intracellular antibodies in vivo.

The effects of anti-nerve growth factor monoclonal antibodies on developing basal forebrain neurons are transient and reversible

In order to reassess the role of nerve growth factor (NGF) on rat basal forebrain cholinergic neurons (BFCNs) survival and/or phenotype maturation during the early postnatal life, we immunoneutralized NGF in vivo. Hybridoma cells producing the neutralizing anti-NGF monoclonal antibody alphaD11 were implanted in the lateral ventricle of the rat at different postnatal ages (P2, P8 and P15) and the effects on the number and the soma size of cholinacetyltransferase (ChAT) positive neurons were analysed 1, 2 or 3 weeks after the injection. A marked decrease in the number and in the soma size of BFCNs was observed implanting hybridoma cells at P2 and performing the analysis 1 week later. These effects are reversed 3 weeks after the implant of hybridoma cells at P2. At this time point, the levels of alphaD11 antibodies in the brain parenchyma are still in a vast molar excess over endogenous NGF. No effects on BFCNs were observed implanting alphaD11 cells at P15 while LGN neurons showed marked shrinkage. Our results demonstrate that the reduction in the number of ChAT-positive neurons during the first two postnatal weeks of anti-NGF treatment is not due to cell death. We conclude that NGF is not a survival factor for BFCNs, and that the influence of NGF on BFCNs cell maturation during the first 2 postnatal weeks is transient and reversible. Our results on tyrosine kinase (Trk) coexpression, suggest that NGF may cooperate with other factors in the cholinergic phenotype differentiation and maintenance after the second postnatal week.

Tau cleavage and dephosphorylation in cerebellar granule neurons undergoing apoptosis

Cerebellar granule cells undergo apoptosis in culture after deprivation of potassium and serum. During this process we found that tau, a neuronal microtubule-associated protein that plays a key role in the maintenance of neuronal architecture, and the pathology of which correlates with intellectual decline in Alzheimer's disease, is cleaved. The final product of this cleavage is a soluble dephosphorylated tau fragment of 17 kDa that is unable to associate with microtubules and accumulates in the perikarya of dying cells. The appearance of this 17 kDa fragment is inhibited by both caspase and calpain inhibitors, suggesting that tau is an in vivo substrate for both of these proteases during apoptosis. Tau cleavage is correlated with disruption of the microtubule network, and experiments with colchicine and taxol show that this is likely to be a cause and not a consequence of tau cleavage. These data indicate that tau cleavage and change in phosphorylation are important early factors in the failure of the microtubule network that occurs during neuronal apoptosis. Furthermore, this study introduces new insights into the mechanism(s) that generate the truncated forms of tau present in Alzheimer's disease.

Predicting outcome in the intensive care unit using scoring systems: is new better? A comparison of SAPS and SAPS II in a cohort of 1,393 patients. GiViTi Investigators (Gruppo Italiano per la Valutazione degli interventi in Terapia Intensiva). Simplified Acute Physiology Score

OBJECTIVES

This study sought to compare the performance of the old and new versions of the Simplified Acute Physiology Score, SAPS and SAPS II, in classifying patients according to the risk of hospital mortality.

METHODS

To compare the performance of the two systems, measures of association between the scores and observed mortality were adopted, together with discrimination (area under the Receiver Operating Characteristics curve) and calibration (goodness-of-fit statistics) estimates. Subjects were 1,393 eligible patients recruited during 1 month in 1994. The outcome measure was vital status at hospital discharge.

RESULTS

SAPS II was associated more strongly with hospital mortality than the earlier version. SAPS II also had better discrimination ability than SAPS (area under Receiver Operating Characteristics curve 0.80 versus 0.74) and predicted an overall number of deaths (416.5) closer to the observed figure (475) than SAPS (267.7). Conversely, neither SAPS nor SAPS II fitted our data. Both P values derived from goodness-of-fit statistics were lower than 0.05.

CONCLUSIONS

SAPS II offers a real improvement compared with SAPS in its ability to explain hospital mortality, but its standard parameters do not fit our data from Italy. The role and impact of potential determinants of this lack of fit, such as random errors and confounders related to casemix and/or quality of care should be clarified before this scoring system be used outside formal research projects. Special caution is suggested when SAPS II is adopted to predict mortality to compare intensive care unit performance across different countries and systems of care.

Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings

A randomized controlled trial was carried out for 1 y in three tertiary and teaching hospitals, in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), to study the effectiveness, feasibility, acceptability and cost of kangaroo mother care (KMC) when compared to conventional methods of care (CMC). About 29% of 649 low birthweight infants (LBWI; 1000-1999 g) died before eligibility. Of the survivors, 38% were excluded for various reasons, 149 were randomly assigned to KMC (almost exclusive skin-to-skin care after stabilization), and 136 to CMC (warm room or incubator care). There were three deaths in each group and no difference in the incidence of severe disease. Hypothermia was significantly less common in KMC infants in Merida (13.5 vs 31.5 episodes/100 infants/d) and overall (10.8 vs 14.6). Exclusive breastfeeding at discharge was more common in KMC infants in Merida (80% vs 16%) and overall (88% vs 70%). KMC infants had a higher mean daily weight gain (21.3 g vs 17.7 g) and were discharged earlier (13.4 vs 16.3 d after enrolment). KMC was considered feasible and presented advantages over CMC in terms of maintenance of equipment. Mothers expressed a clear preference for KMC and health workers found it safe and convenient. KMC was cheaper than CMC in terms of salaries (US$ 11,788 vs US$ 29,888) and other running costs (US$ 7501 vs US$ 9876). This study confirms that hospital KMC for stabilized LBWI 1000-1999 g is at least as effective and safe as CMC, and shows that it is feasible in different settings, acceptable to mothers of different cultures, and less expensive. Where exclusive breastfeeding is uncommon among LBWI, KMC may bring about an increase in its prevalence and duration, with consequent benefits for health and growth. For hospitals in low-income countries KMC may represent an appropriate use of scarce resources.

Cholinergic function in the hippocampus of juvenile rats chronically deprived of NGF

Intracellular and extracellular recordings were used to assess the cholinergic function in hippocampal slices from juvenile rats chronically deprived of NGF. NGF was neutralised by implanting into the lateral ventricle of postnatal (P) day 2 rats, alphaD11 hybridoma cells (secreting monoclonal antibodies specific for NGF). Parental myeloma cells (P3U) were used as controls. At P15-P18, slow cholinergic EPSPs could be elicited in cells from both alphaD11- and P3U-treated rats. However, slices from alphaD11-implanted rats exhibited a 50% reduction in acetylcholine release following stimulation of cholinergic fibres. This effect was associated to a significant increase in the sensitivity of pyramidal cells to carbachol, as suggested by the shift to the left of the dose/response curve. This may reflect a compensatory mechanism for the reduced efficacy of cholinergic innervation in NGF-deprived rats. In both alphaD11- and P3U-treated rats, carbachol was able to induce a similar concentration-dependent depression of the field EPSPs, evoked by Schaffer collateral stimulation, suggesting that presynaptic muscarinic receptors were not altered. In rats implanted with alphaD11 cells at P15 and sacrificed at P21-P24, no changes in the sensitivity to carbachol were found. At this developmental stage, no differences in acetylcholine release were observed between P3U- and alphaD11-treated animals. These results provide physiological evidence for a regulatory role of NGF in the cholinergic function of the hippocampus during postnatal development.

Selection of intracellular antibodies

The intracellular expression of antibodies in mammalian cells is a strategy to inhibit in vivo the function of selected molecules. One limitation of this technology is represented by the unpredictable behaviour of antibodies, under conditions of intracellular expression. Recent advances in the field of antibody expression in E. coli show that the introduction of mutations inspired by sequence comparisons or by educated guesses can improve the properties of some antibody domains, but the general applicability of this approach to intracellular antibodies remains to be proven. As a complement to rational approaches, selection schemes whereby antibodies are selected on the basis of their performance in vivo as intracellular antibodies can be exploited. (Fig. 3, Ref. 44.)

Pediatric risk of mortality: an assessment of its performance in a sample of 26 Italian intensive care units

OBJECTIVE

To assess the validity of the Pediatric Risk of Mortality (PRISM) scoring system in accurately predicting the probability of mortality in an Italian intensive care unit (ICU) sample.

DESIGN

Prospective, observational, multicenter study.

SETTING

Twenty-six Italian ICUs classified into two groups: a) ICUs specifically dedicated to treating pediatric patients; and b) adult ICUs treating children on a regular basis.

PATIENTS

Consecutive patients (n = 1,533) <15 yrs of age admitted during 1 yr.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

To assess the performance of the PRISM scoring system, the discrimination and calibration measures were adopted both in the whole population and in 12 preselected subgroups. A good discrimination capability of the scoring system was observed for both the whole population and subgroups (areas under the receiver operating characteristic curves were never <0.82). On the other hand, we documented an unsatisfactory calibration capability in the whole population and in most subgroups (p values of the Hosmer-Lemeshow goodness-of-fit test were <.001 in all but two subgroups).

CONCLUSIONS

The analyses suggest that the unsatisfactory calibration of PRISM can be attributed to various reasons. Among those reasons, a poor performance of the system, as well as its sensitivity to factors not connected to clinical ICU performance, seem particularly important. A special caution is needed in adopting a severity of illness scoring system to assess quality of care, particularly in contexts different from the one in which the instrument was originally developed.

Assembled IgG molecules are exported from the endoplasmic reticulum in myeloma cells despite the retention signal SEKDEL

The KDEL retention signal, when added at the C-terminal of the constant region of light and heavy chains of immunoglobulins is able to efficiently retain assembled immunoglobulins only in cells of nonlymphoid origin. In transfected myeloma cells the wild type and the KDEL-Ig mutants are secreted with the same efficiency. This phenomenon is not due to a proteolytic cleavage of the KDEL signal nor to a lack of intermolecular disulfide bond formation and is not due to an impaired recognition of the KDEL signal in myeloma cells. Thus, the constitutive secretion of assembled immunoglobulins, currently considered to follow a default process, appears to be regulated by a mechanism that is able to overcome an efficient ER retention system.

Recommendations for the implementation of Kangaroo Mother Care for low birthweight infants. International Network on Kangaroo Mother Care

Good quality care of low birthweight infants could reduce neonatal mortality in low-income countries, but the technologies used in rich countries are inappropriate. Kangaroo Mother Care does not need expensive and sophisticated equipment, and for its simplicity it can be applied almost everywhere, including peripheral maternity units of very low-income countries. Kangaroo Mother Care (KMC) can also contribute to the humanization of neonatal care and to better bonding between mother and baby in both poor and rich countries. A group of health professionals with experience in KMC met in a workshop to discuss its effectiveness, safety, applicability and acceptability in different settings: from first and second level maternity units in settings with very limited resources, to second and third level units in settings with limited resources, to second and third level maternity and neonatal care units in settings with ample resources and infant mortality rates <15/1000. The paper summarizes the recommendations of this group of health professionals for the implementation of KMC in these various settings, together with suggested research priorities.