The armed conflict in Ukraine and the risks of inter-country surrogacy: the unsolved dilemma

Commercial surrogacy in Ukraine has been legal since 2002, and although no official figures are released, estimates point to several thousand births occurring yearly. The country has long been regarded as one of the surrogacy capitals of the world, due to relatively affordable costs and effective targeted legislation making the surrogacy contracts enforceable. Would-be parents come from countries where surrogacy is banned or heavily restricted to start a family despite their infertility, a practice known as inter-country surrogacy. When a child is born through surrogacy, the surrogate mother forfeits her rights over the child, thus allowing the so-called "intended" or "commissioning" parents to be recognized as such on the Ukrainian birth certificate. Inter-country surrogacy has long been a highly controversial practice from an ethical and legal perspective, but the brutally destructive armed conflict erupted in the country over three months ago has laid bare all the pitfalls and deep flaws of such a system. Children born through surrogacy cannot be handed over to their intended parents, and surrogates risk legal issues and see their rights jeopardized by their choices even in a war setting, for instance if they decide to seek refuge abroad. The horrors of war thus risk victimizing the most vulnerable to an irreparable degree. An international effort is now more urgent than ever to seek a tenable balance between the desires of couples to achieve parenthood and the rights and freedom of often vulnerable women who risk exploitation and abuse and their children.

New psychoactive substances and low-income countries: a burgeoning (and neglected) crisis

New psychoactive substances (NPS) are compounds intended to replicate the effects of legal and illegal drugs. The continuous detec-tion of new NPS via several forensic toxicology techniques attests to the considerable NPS popularity all over the world, although such determinations rely on still indecisive findings, given the elusiveness inherent in NPS and the the lack of standardized and uniformly applied detection and screening techniques. A worrisome and neglected issue is the proliferation of NPS and other drugs of abuse in developing countries. Demographics may partly explain such an emerging threat, which in a globalized world is likely to have an impact that goes well beyond national borders, especially in light of the criminal organiza-tions' ability to function and operate in the cyberspace, harnessing the potential of the "dark web" to overstep the boundaries and oversight mechanisms put in place by nations and international institutions.

The best interest of children born through medically assisted procreation procedures as construed in 2021 Italian Constitu- tional Court rulings 32 and 33

The authors have set out to briefly analyze the 2021 Constitutional Court rulings n.32 and 33, regarding the situation of children born in, or otherwise being raised by, same-sex couples. Such judgments address the problem by taking into account the fundamental principle of the child's best interests. This article is meant to highlight the issues that may arise if such interests were to be translated into specific law provisions or safeguards for the children's sake. Moreover, the authors aimed to focus on the valuable elements laid out in the Court rulings, while also highlighting the more critical and controversial elements therein.

COVID-19 vaccine mandates: what are the current European public perspectives?

The article aims to elaborate on European policy choices for the prevention of SARS‑CoV‑2 contagion, with a close focus on the rules and regulations enacted in Italy so far. European states have ruled out generalized vaccination mandates but have so far preferred to exert a form of "moral suasion", through the introduction of a digital certificate which can only be granted to those who are vaccinated, cured of COVID-19 or tested negative through an antigen test in the previous 48 hours. Italy has applied this tool, dubbed "Green Pass", very rigorously: many daily activities, including going to work, are only allowed for those who have the certificate. A one-year Green Pass is issued after vaccination, although data show that vaccine protection may subside gradually over about six months; the cost of the antigen tests every 48 hours is to be borne by the patient. Testing the unvaccinated is essential to contain the spread of the infection, but it would have been more logical to mandate that all the unvaccinated undergo regular testing (for example every ten days), instead of imposing a test every 48 hours only to be allowed to engage in some activities. The authors stress that in order to minimize the risk of future possible pandemics, prevention strategies are needed, and poor countries need to be enabled to vaccinate their populations in order to prevent new variants from developing. The pledges made by world leaders in that regard during the recent G20 summit must therefore be honored, for the sake of global health that never in our lifetime has been so threatened.

Substance abuse in times of COVID-19 pandemic: a "perfect storm" for substance use disorder and mental health?

Our lives and communities have been besieged by COVID-19 for almost two years, and society and its functioning have been turned upside down and upset, through limitations and restrictions aimed at stemming the spread of the SARS-CoV-2 virus. Severe levels of anxiety, distress and uncertainty have taken a huge toll on our daily lives from the social, professional and emotional perspectives, but it is still rather unclear how serious an impact the emergency has had on a class of particularly vulnerable individuals: those with substance abuse issues. Particularly, we would like to draw attention to a uniquely troublesome development: forced isolation resulting from pandemic-related restrictions and how it has impacted drug users and their efforts to achieve recovery.

Impact of remdesivir according to the pre-admission symptom duration in patients with COVID-19

BACKGROUND

The use of remdesivir has demonstrated a significant reduction in the time to recovery in patients with COVID-19. However, the impact on mortality is still controversial. Therefore, it is necessary to evaluate whether there is a specific subgroup of patients in whom an active antiviral therapy also reduces the mortality.

METHODS

Patients admitted for >48 h in our hospital for a SARS-CoV-2 confirmed or suspected infection from February 2020 to February 2021 were retrospectively analysed. The primary outcome of the study was mortality at 30 days. Univariate and multivariate analyses were performed to identify predictors of mortality.

RESULTS

In total, 2607 patients (438 receiving remdesivir and 2169 not) were included with a median (IQR) age of 65 (54-77) years and 58% were male. Four hundred and seventy-six were admitted to the ICU (18.3%) and 264 required invasive mechanical ventilation (10.1%). The global 30 day mortality rate was 10.7%. Pre-admission symptom duration of 4-6 days and ≤3 days was associated with a 1.5- and 2.5-fold increase in the mortality rate, respectively, in comparison with >6 days and treatment with remdesivir was independently associated with a lower mortality rate (OR = 0.382, 95% CI = 0.218-0.671). The analysis showed that the major difference was among patients with shorter pre-admission symptom duration (<6 days).

CONCLUSIONS

Patients with ≤3 days and 4-6 days from symptom onset to admission are associated with a 2.5- and 1.5-fold higher risk of death, respectively. Remdesivir was associated with 62% reduced odds of death versus standard-of-care and its survival benefit increased with shorter duration of symptoms.

Increasing diversion of prescribed benzodiazepines and Z-drugs to new psychoactive substances

ABSTRACT

Over the last few years reports have indicated an increase in the number, type and availability of new psychoactive substances belonging to the benzodiazepine class. These molecules may pose high risks to users, since the majority have never undergone clinical trials or tests so their pharmacology and toxicology is largely unknown. However the new drug scenario emerging from the COVID-19 global pandemic seems to play a role in increasing the diversion of prescribed benzodiazepines and Z-drug. A brief presentation of this phenomenon is hereby presented. The awareness and response activities at national and international levels related to this issue should be enforced.

Commentary - Heroin purity and adulteration: an updated snapshot from the Italian Early Warning System

Not Available.

Management of GHB acute intoxications

Intoxications related to γ-Hydroxybutyric acid (GHB), arising from its success as recreational drug due to its psychotropic properties, are significantly and alarmingly jeopardizing public health, posing major challenges to medical staff. In recent years, GHB's prodrug γ-butyrolactone (GBL) has often supplanted GHB in recreational settings, owing to its lower cost and the ease with which it can be obtained, mainly due to its various legal industrial applications. The Authors intend to stress that symptoms should be assessed and confirmed by timely toxicological analyses by highly-trained, expert professionals. Such tests aimed at analytical confirmation are instrumental in providing physicians valuable indications in terms of the proper pharmacological treatments in order to revert the adverse, or even fatal, side effects, particularly when the overall intoxication picture looks ambiguous. At the time being, little is known about the pharmacological therapies effective in GHB intoxication cases; further comprehensive research is therefore essential, if we are to tackle such a burgeoning public health emergency before it is too late.

Fentanyl analogues potency: what should be known

Fentanyl is a full synthetic opioid acting as a strong µ-opioids receptor agonist. As other opioids, it exerts effects on central nervous systems like euphoria, sedation, anesthesia and respiratory depression at high dosage. It is the parent compound of the high potent opioids class, characterized by a potency up to 10,000 fold higher than mor- phine, currently prescribed as anesthetic and pain killers. Anyway, the diversion of fentanyl analogues has been reported since their appear- ance on the market, rising until alarming rate. Every year, new synthetic alternatives to the controlled fentanyl are proposed on the black market causing an increasing number of fatalities all over the World. Due to the high potency of this class of substances, it may be difficult to ana- lytically detect the molecules in biological matrices and find the actual cause of the deaths. Moreover, an additional analytical challenge is represented by the emergence of newly synthesized derivatives. In this concern, the harmonization of international guidelines, the adoption of common legal responses and the enforcement of international collaboration is desirable to face this alarming public health threat.

Beginning of life ethics at the dawn of a new era of genome editing: are bioethical precepts and fast-evolving biotechnologies irreconcilable?

The amazing and almost unimaginable advances that have unfolded over the past decades in biotechnologies (heritable germline editing in particular) have brought bioethical issues to the forefront, sparking public debate and increasing attention worldwide. Such mind-blowing progress has already resulted in major improvement and enhancements for humans, and holds the potential for even more. Technology and bioengineering have begun to take over in the life sciences industry. Man's capacity to genetically engineer the biological world is nothing short of mind-boggling in its current magnitude, and may even evolve, in a not too distant future, into attempts to fuse man and machine into a cohesive bioengineered entity; a "super human being", endowed with enhanced cognitive and physical capabilities and impervious to disease, may be not too far down the road. That will not come without caveats, however. In fact, scientific advancements at such an accelerated pace have already negatively affected our cultural, ethical, and legal values and our ability to harness the opportunities and face the dangers posed by such developments. As a matter of fact, science seems to consistently outpace public morals, ethics and policymaking, which calls for a high degree of caution and common answers.

Childbirth Injuries: an issue fraught with risks from the health care and medicolegal perspectives

Birth injuries caused by medical negligence are a real threat for mothers and their children, which can entail catastrophic, life-changing consequences, permanent disability, or even death. Families almost always seek redress from doctors and/or facilities, but in order for a birth injury malpractice claim to be successful, it needs to be proven that the medical care providers owed a duty to the child and that they were derelict in that duty and did not meet the proper standard of care; Furthermore, a causal relationship needs to be established between injury sustained by the child and the physician's or provider's breach of duty to the child. Relevant scientific articles have been collected by drawing upon medical search engines and archives such as Medline, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar, through December 2019, using keywords such as "birth injuries", "malpractice", "claims". Moreover, the Authors have delved into legal databases (Justia, Lexis, De Jure, Leagle), identifying 6 meaningful instances of court cases centered around birth injuries with severe consequences, all stemming from malpractice and negligence. Ultimately, it can be concluded that demonstrable and adequately documented compliance with well-established guidelines and/or best practices are a determining factor in the legal defence of health care operators; that in turn can go a long way towards discouraging meritless claims and frivolous lawsuits, which constitute a challenging issue raising health care costs in many countries.

Advances in Medically-assisted procreation technologies: can malpractice claims and "reproductive damage" be identified

Medically assisted procreation and assisted reproductive techniques have made giant strides over the past decades, enabling countless couples to achieve parenthood. Still, the ethical and moral concerns that have come to the fore as a result of ART's rise pose a multi-faceted issue that lawmakers have struggled to keep up with; procedures such as heterologous fertilization are strictly regulated, and even banned, in several nations around the globe, among which Italy, where a controversial piece of legislation was passed in 2004; such a reform has been partly nullified by court decisions, among which the Italian Constitutional Court and even the European Court of Human Rights. Relevant scientific articles were identified from Medline, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar, through February 2020, by using the following keywords: "assisted reproductive techniques", "heterologous fertilization", "European rulings on ART", "reproductive damages". The rise of ART has laid bare a shortage of adequate legal tools for the purpose of guaranteeing the exercise of reproductive rights for all. Hence, the harmonization of regulations, at least at the European level, is greatly needed in order to ensure equality of parental opportunities for all.

Nootropics use in the workplace: psychiatric and ethical aftermath towards the new frontier of bioengineering

OBJECTIVE

The authors have sought to expound upon and shed a light on the rise of nootropics, which have gradually taken on a more and more relevant role in workplaces and academic settings.

MATERIALS AND METHODS

Multidisciplinary databases have been delved into by entering the following keys: "nootropics", "cognitive enhancement", "workplace", "productivity", "ethics", "bioengineering". In addition, a broad-ranging search has been undertaken on institutional websites in order to identify relevant analysis and recommendations issued by international institutions and agencies. Papers and reports have been independently pored over by each author. This search strategy has led to the identification of 988 sources but only 64 were considered appropriate for the purposes of the paper after being selected by at least 3 of the authors, independently.

RESULTS

The notion of an artificially enhanced work performance - carried out by the 'superworker' - is particularly noteworthy and resonates with the conception of contemporary work on so many different levels: the rising need and demands for higher degrees of flexibility and productivity on the job, the implications of a '24/7' society, where more and more services are available at any time, the ever greater emphasis on entrepreneurial spirit, individual self-reliance and self-improvement, and last but not least, the impact of an ageing society on economic standards and performance.

CONCLUSIONS

Moreover, it is worth mentioning that human enhancement technologies will predictably and increasingly go hand in hand with gene editing, bioengineering, cybernetics and nanotechnology. Applications are virtually boundless, and may ultimately affect all human traits (physical strength, endurance, vision, intelligence and even personality and mood).

Reproductive medicine between advancement and ethics

Over the past five decades, sweeping changes have occurred in the realm of childbirth. Thanks to medically assisted procreation, child- birth as an event has come to be characterized by the interweaving of biological as well as social elements. Research has been forging ahead, the first uterus transplant has been carried out and the experimental cloning of apes has taken place in China. All such innovations entail a wide array of ethical and medical issues, involving different parties in the process of generating new life: parents, children and gamete donors.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Law on advance health care directives: a medical perspective

The paper's authors aim to elaborate on law 22 dicembre 2017, n. 219 , designed to regulate informed consent practices and advance health care directives", which has sparked a passionate debate centered on the substantial innovation achieved over the past decades in bio-medical science and at the same time, the noteworthy accomplishments made in enforcing human and personal rights. Within the paper, article three is delved into, which covers the creation of the so-called DAT ("Disposizioni anticipate di trattamento", advance health care directives), by which patients, in light of possible future incapacity to choose, can express their convictions and decisions on how to be treated and their consent or dissent to undergo treatments and procedures, including artificial nutrition and hydration. The authors peruse the new law's provisions through a medical perspective, and observe how they are heavily tilted towards patient choice, thus making doctors little more than mere tools of such decisions.

Effectiveness of combination therapy versus monotherapy with a third-generation cephalosporin in bacteraemic pneumococcal pneumonia: A propensity score analysis

OBJECTIVE

Combining a macrolide or a fluoroquinolone to beta-lactam regimens in the treatment of patients with moderate to severe community-acquired pneumonia is recommended by the international guidelines. However, the information in patients with bacteraemic pneumococcal pneumonia is limited.

METHODS

A propensity score technique was used to analyze prospectively collected data from all patients with bacteraemic pneumococcal pneumonia admitted from 2000 to 2015 in our institution, who had received empirical treatment with third-generation cephalosporin in monotherapy or plus macrolide or fluoroquinolone.

RESULTS

We included 69 patients in the monotherapy group and 314 in the combination group. After adjustment by PS for receiving monotherapy, 30-day mortality (OR 2.89; 95% CI 1.07-7.84) was significantly higher in monotherapy group. A higher 30-day mortality was observed in monotherapy group in both 1:1 and 1:2 matched samples although it was statistically significant only in 1:2 sample (OR: 3.50 (95% CI 1.03-11.96), P = 0.046).

CONCLUSIONS

Our study suggests that in bacteraemic pneumococcal pneumonia, empirical therapy with a third-generation cephalosporin plus a macrolide or a fluoroquinolone is associated with a lower mortality rate than beta-lactams in monotherapy. These results support the recommendation of combination therapy in patients requiring admission with moderate to severe disease.

Cosmetic surgery for children and adolescents. Deontological and bioethical remarks

The only interventions deemed ethically acceptable are those that serve the "objective interest" of the minors involved from the standpoint of and conducive to sound mental health and balance in a patient's teenage years; by the same token, disproportionate interventions (e.g. overly invasive or pointlessly risky), or all those deemed unsuitable with regards to a poor cost-benefit ratio are viewed as unacceptable. In the process of considering the best interest of the minors involved, a wide array of factors come into play, such as: age, maturity, psychological and emotional conditions, motivations put forth by the underage patient, the opportunity to procrastinate the operation: parents, who are naturally entitled to give consent to the surgical procedures, and physicians are primarily liable to safeguard and act in the minor's best interest. The authors attempt to lay out how medical science has evolved over the past century, and aim to set forth an array of considerations centered on cosmetic surgery for adolescents.

[Results of a health surveillance program for health care workers exposed to a patient affected by tuberculosis]

A health surveillance program was implemented in 71 health care workers (HCW) exposed to a patient with active TB infection. A two-step tuberculin skin test (TST) was performed in all the exposed, and a QuantiFERON-TB Gold (QTF) test was scheduled for positive TST subjects. Clinical-radiological surveillance (CRS) was scheduled for subjects positive to TST and QTF or symptomatic. Thirty eight percent HCW were TST positive; 19% of them were also QTF positive and were referred to CRS. No clinical TB was observed among the exposed HCW. Comprehensive health surveillance allows to increase risk perception, compliance to HS and to reduce cost in respect to less cost-effective practices.

Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United States

BACKGROUND

Proton pump inhibitors (PPIs) are the preferred agents for the prevention of aspirin-associated upper gastrointestinal bleeding (UGIB). Data are limited to determine whether PPIs are being used to reduce UGIB risk.

AIM

To evaluate the implementation of PPI treatment to reduce the GI risk in two cardiology centres from Europe and the United States.

METHODS

A retrospective cross-sectional study was carried out at the University of Michigan and University Hospital-Zaragoza in 429 consecutive patients hospitalized for percutaneous coronary intervention (PCI) on dual antiplatelet therapy.

RESULTS

Admission for PPI co-therapy was similar (34% vs. 30%) in both centres. At discharge, the proportion of high-risk patients receiving PPI therapy in the Spanish centre (75.4%) was higher than their American peers (55.6%) (OR: 2.5; 95% CI; 1.3-4.7). No differences in PPI prescription rates were found among Spanish patients with/without GI risk factors. The opportunity to initiate PPI co-therapy in high-risk patients was missed in 81.8% (36/44) of those not on PPI at admission in US patients vs. 24.1% (19/79) (P < 0.0001) in Spanish patients.

CONCLUSIONS

There are important differences concerning PPI prescription and risk stratification in the two centres when managing PCI patients. Efforts to stratify risks and utilize appropriate strategies for UGIB prophylaxis in high-risk patients are warranted.

[Electrocardiogram changes in shift workers]

BACKGROUND

Besides a significant deterioration in their family and personal life, shift workers also suffer health problems ranging from chronic fatigue to gastro-intestinal disorders, changes in sleep rhythm and cardiovascular disease, including arrhythmia and ischaemic heart disease.

OBJECTIVES

The aim of the study was to assess the prevalence of electrocardiographic changes, such as conduction disorders, alterations in the repolarization phase and frequency-adjusted QT interval (QTc) in relation to shift work.

METHODS

We conducted a cross sectional survey of 125 male subjects, 60 of whom worked fixed hours, and 65 were shift workers on two different schedules: 32 were on duty for 24 hours followed by 96 hours rest, and 33 worked 8-hour shifts (3 x 8). During periodical health assessment we examined their electrocardiograms (ECG), classified the morphology and measured the QTc interval.

RESULTS

The QTc interval did not differ by type of work shift or by the presence of morphological changes in the ECG, including concurrent conduction disorders, or alterations in the repolarization phase. However, unlike day workers and 24-h shift workers, the QTc interval tended to increase with age among 8-h shift workers (r = 0.338; p = 0.05). Also, risk of conduction disorders was moderately, but not significantly, elevated among 8-h shift workers compared with subjects working fixed hours (OR = 1.9; I.E 95% 0.6, 5.7).

CONCLUSIONS

Our study did not reveal significant changes in the ECG morphology in relation to the type of work shift.

Multiband negative refraction in one-dimensional photonic crystals

We simulate a lossless one-dimensional photonic crystals (1DPC) structure and show that negative refraction could be present near the low frequency edge of at least the second, fourth and sixth bandgaps. We experimentally demonstrate for the first time negative refraction in strongly modulated porous silicon 1D-PC in the visible and near infrared regions. This 1D-PC structure may allow the realization of short-focus Veselago lenses in different optical bands. An advantage of our structure is its simplicity allowing for cheap and rapid fabrication of samples.

Impact of high saline wastewaters on anaerobic granular sludge functionalities

Three UASB reactors were operated at different salinity levels in order to assess the effects on the granular sludge properties. High levels of activity inhibition were observed at sodium concentrations over 7 g Na(+)/L, which resulted in low applicable organic loading rates and VFA accumulation in reactor effluents. However, either sludge adaptation or selection for saline resistant microorganisms occurred, which could be concluded from the observed increase in the 50% activity inhibitory concentrations of sodium during continuous flow experiments. Changes in Na(+) susceptibility in time are likely to be expected when treating saline wastewaters. The latter was evidenced by the high sodium tolerance of granular methanogenic sludge coming from a full-scale industrial reactor treating such wastewater. High salinity conditions resulted in a reduced granule strength, predicting process instabilities during long term reactor operation. Batch tests showed that high sodium concentrations seemed to displace the calcium from the granular sludge, a factor known to affect anaerobic granules formation.

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer

The Piver classification of radical hysterectomy for the treatment of cervical cancer is outdated and misused. The Surgery Committee of the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer (EORTC) produced, approved, and adopted a revised classification. It is hoped that at least within the EORTC participating centers, a standardization of procedures is achieved. The clinical indications of the new classification are discussed.

Leucodysplasia, microcephaly, cerebral malformation (LMC): a novel recessive disorder linked to 2p16

We report three related and one unrelated child with an apparently novel neurodevelopmental disorder. The clinical course was very similar in all the four patients: congenital microcephaly with severe failure of post-natal brain growth, neonatal onset of intractable seizures associated with lack of developmental progression and death within the first 3 years of life. The appearance on cerebral neuroimaging was almost identical, with simplified gyration associated with a non-thickened cortex, severe hypoplasia of the corpus callosum, a small flattened brain stem, and specific cystic lesions in the white matter around the temporal and occipital horns. To our knowledge these patients represent a previously unreported, autosomal recessive syndrome. Homozygosity mapping in the consanguineous family has identified a candidate region on the chromosome 2p16.

Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature

OBJECTIVES

To add to the limited information on infective endocarditis (IE) not related to intravenous drug abuse (IVDA) in HIV-1-infected patients.

METHODS

We have reviewed the characteristics of eight cases of IE in non-IVDA HIV-1 infected patients diagnosed in our institution between 1979 and 1999 as well as cases in the literature.

RESULTS

All our patients were male, and the mean age was 44 years (range 29-64). HIV-1 risk factors were: homosexuality in five, heterosexuality in two, and the use of blood products in one. HIV stage C was found in six cases, and the median (range) CD4 cell count was 22/microL (4-274 cells/microL). IE was caused by Enterococcus faecalis in three cases, staphylococci in two cases, and Salmonella enteritidis, viridans group streptococci and Coxiella burnetii in one case each. Three patients acquired IE while in the hospital. All IE cases involved a native valve, and underlying valve disease was found in three patients. The aortic valve was the most frequently affected (five cases). Two patients underwent surgery, with a good outcome, and one patient died. Fourteen cases of IE not related to IVDA in HIV-1-infected patients were found in the literature review. The most common causative agents were Salmonella spp. and fungi (four cases each). Two patients had prosthetic valve IE, and the mitral valve was the most frequently affected (10 cases). The remaining clinical characteristics and the outcome were similar to those in the present series.

CONCLUSIONS

IE not related to IVDA is rare in HIV-1-infected patients. In more than half of the cases, IE develops in patients with advanced HIV-1 disease. A wide etiologic range is found, reflecting different clinical and environmental conditions. None of the patients who underwent surgery died, and the overall mortality rate was not higher than in non-HIV-1-infected patients with IE.

Reduction of species in the wild potato Solanum section Petota series Longipedicellata: AFLP, RAPD and chloroplast SSR data

Species boundaries were assessed with three molecular markers [AFLPs, RAPDs and chloroplast simple sequence repeats (cpSSRs)] for all six species of wild potatoes ( Solanum section Petota) assigned to ser. Longipedicellata: Solanum fendleri, S. hjertingii, S. matehualae, S. papita, S. polytrichon and S. stoloniferum. These tetraploid (2n = 4 x = 48) species grow in the southeastern United States ( S. fendleri) and Mexico (all six species), and a recent morphological analysis supported only three species: (1) S. polytrichon, (2) S. hjertingii (including S. matehualae) and (3) S. stoloniferum (including S. fendleri and S. papita). We analyzed all six species of ser. Longipedicellata (tetraploid) and also analyzed diploids in ser. Bulbocastana, ser. Pinnatisecta, ser. Polyadenia and ser. Tuberosa; tetraploids in ser. Acaulia and hexaploids in ser. Demissa. Concordant with morphological data, AFLP and RAPD results support the synonymy of S. hjertingii and S. matehualae, and completely intermix S. papita and S. fendleri. However, accessions of S. stoloniferum have a tendency to cluster but with exceptions, and S. polytrichon is completely intermixed with S. fendleri and S. papita. The cpSSRs fail to distinguish any of the species in ser. Longipedicellata. Combined morphological and molecular data support only two species in ser. Longipedicellata: S. hjertingii and S. stoloniferum.

Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998

We describe 30 cases (1.7%) of community-acquired penicillin-susceptible Streptococcus agalactiae endocarditis among 1771 episodes of endocarditis diagnosed in 4 Spanish hospitals from 1975 through 1998. Endocarditis affected a native valve (most often the mitral valve) in 25 cases (83%). Surgical valve replacement was performed for 12 patients (40%). Fourteen patients (47%) died. Mortality rates for patients with native and prosthetic valve endocarditis were 36% and 100%, respectively (P=.01). The mortality rate for native valve endocarditis decreased during the last 6 years of the study (from 61% in 1975-1992 to 8% in 1993-1998; P<.05). Additionally, 115 cases in the literature from 1962-1998 were reviewed. During 1980-1998, the percentage of patients who underwent cardiac surgery increased from 24% (in the previous period, 1962-1979) to 43% (P=.05) and the mortality rate decreased from 45% to 34% (P=NS). S. agalactiae is an uncommon cause of endocarditis with a high mortality rate, although the prognosis of native valve endocarditis has improved in recent years, probably because of an increased use of cardiac surgery.

Effects of selenium and zinc supplementation on nutritional status in patients with cancer of digestive tract

OBJECTIVE

To evaluate the effect of oral administration of selenium and zinc tablets in patients with cancer of the digestive tract during chemotherapy.

DESIGN

A case-control, randomized study.

SETTING

Medical Oncology, II University of Naples, Naples, Italy.

SUBJECTS

A total of 60 patients (median age 55 y, range 46-61 y) with diagnosis of gut cancer were randomized in 1999. Patients were treated for 60 days with chemotherapy.

INTERVENTIONS

Trace elements were measured by atomic absorption spectroscopy. The nutritional status of the patients was assessed by biochemical and bio-impedance analysis (BIA) parameters in basal condition and after 60 days of treatment. Oral administration of selenium and zinc in oral tablet form for 50 days was Se 200 microg/day (50 microg/tablet) and Zn 21 mg/day (7 mg/tablet).

RESULTS

Both in the basal condition and at 60 days all patients were malnourished. Selenium and zinc concentrations were significantly lower (P < 0.01) whereas copper concentration was significantly higher (P < 0.01) in cancer patients than in control subjects. However, 21/30 (70%) of those treated with Se and Zn did not showed a further worsening of nutritional status and experienced a significant decrease of asthenia with an increase of appetite. On the other hand, 24/30 (80%) untreated patients had a significant decline of all parameters studied after 60 days (prealbumin, cholesterol, transferrin, P < 0.05 vs 0 time; total proteins, albumin/globulin ratio, P < 0.01 vs 0 time; fat-free mass, fat mass, Na+/K+ ratio, body mass index P < 0.05 vs 0 time; fat free mass/fat mass, total body water, extra cellular/intra cellular water, basal metabolic rate: P < 0.01 vs 0 time).

CONCLUSIONS

Data indicate that Se and Zn supplementation may improve the clinical course of general conditions in patients with gut cancer. These effects of Se and Zn require confirmation in an independent trial of appropriate design before new public health recommendations regarding Se and Zn supplementation can be made.

Coexisting preexcitation syndrome and intermittent heart block presenting as neonatal seizures

An infant presented with neonatal syncope and seizures. An ECG showed a preexcitation pattern, most compatible with Wolff-Parkinson-White (WPW) syndrome. Rhythm monitoring during an event demonstrated prolonged periods of complete AV block with no ventricular escape mechanism. We postulated that ventricular asystole was initiated by mechanical or autonomic influences on the accessory pathway and sustained by electrophysiologic interactions between the accessory pathway and the junctional escape focus. This is the first case report of a newborn having coexisting congenital AV block and WPW syndrome.

Iliac arteriovenous fistula as a complication of lumbar disc surgery. Report of two cases and review of literature

Vascular lesions following surgery of the lumbar disc are very infrequent, and exceptionally an arteriovenous fistula can developed. An important proportion of the reported cases were previously diagnosed as deep venous thrombosis, because this kind of pathology was not suspected. Postsurgical arteriovenous fistula produces severe haemodynamic disturbances, and congestive heart failure will develop if they are left to their natural course without intervention. Arteriovenous fistula should be suspected in the post-operative period of the lumbar disc surgery if congestive heart failure appears, accompanied by swelling of one or both lower limbs. Early surgery is the treatment of choice in order to prevent the congestive heart failure, and to preserve the normal function of the lower extremities. The technical choice seems to be the closure of the orifice of the fistula through the arterial lumen, together with appropriate arterial reconstruction.

Abdominal aortic aneurysms. Results of surgical treatment

One hundred and twenty-one aneurysms of the abdominal aorta were operated on during a ten year period (1971-1981). Elective surgery was carried out in 89 patients (73.5%). Thirty-two patients were operated on for impending or frank rupture. Most of the patients treated electively had no symptoms on admission. The mortality of this group of patients was 6.7% (6 patients). All the patients treated as emergencies had acute abdominal or back pain. Six cases presented with shock and acute renal failure. The hospital mortality was high in this group of 11 patients (34.3%). Nine of them were operated on because of suspected rupture but this was not confirmed at operation. Only one patient in this group died after the operation (11.1%). The hospital mortality of the 23 patients with ruptured aneurysms was 43.4% (10 patients). Six of them died in the operating room. While elective surgery carries an acceptable mortality, the emergency procedure involves a high risk. All the aneurysms must be resected electively in spite of the absence of symptoms.

Neural control of gene expression in the skeletal muscle fibre: the nature of the lesion in the muscular protein-synthesizing machinery following denervation

Experiments are reported showing that following 8 days of denervation the function of the protein-synthesizing machinery, operating in the rat gastrocnemius fibres, is altered, probably as a consequence of decreased amounts of ribosomes and actively translated mRNA. In addition, the data obtained show that the amount per muscle and the availability per ribosome of the soluble factors involved in the process of protein synthesis are markedly decreased, thus suggesting that the amounts of ribosomes, mRNA and soluble factors are regulated in a concerted fashion when muscular protein synthesis is decreased after denervation.

Neural control of gene expression in the skeletal muscle fibre: changes in the muscular mRNA population following denervation

The mRNA populations of control and 8-days-denervated adult rat gastrocnemius have been analysed by the translation assay and the cDNA-mRNA molecular hybridization technique. This analysis demonstrates the appearance of marked changes in many of the mRNA sequences present in muscle fibres following denervation and thus gives strong support to the hypothesis that the motoneurons are able to control the gene expression of muscle fibres.

The role of growth hormone in the pathogenesis of postmenopausal osteoporosis

The secretory response of somatotropic hormone (STH) to arginine hydrochloride stimulation (0.5 g/kg) was studied in 13 postmenopausal women. Eight showed evidence of osteoporosis, based on clinical and morphoradiological data and on metacarpal cortical thickness measurement, and five had normal bone mass. In addition, the response to levodopa (500 mg) was determined in four of the osteoporotic patients. Baseline STH concentrations in the osteoporotic subjects did not differ from those in the nonosteoporotic group, but the latter showed a significant increase over the former at 45, 60, 90, and 120 minutes after stimulation. Similar findings were obtained with levodopa stimulation. Without necessarily implying a cause-effect relationship, our data appear to support the hypothesis that the poor secretory response of STH may be to some degree responsible for the osteopenia observed during the climateric.

Metacarpal cortical thickness in uremic patients on regular hemodialysis

Metacarpal cortical thickness was measured in 83 patients with chronic renal failure undergoing periodic hemodialysis. Patients were dialyzed twice weekly, 8--9h per session, with a calcium concentration in dialysate of 6.5 mg/dl. Supplements of calcium, vitamin D (5,000 I.U. a day), steroid anabolic hormones, and aluminium hydroxyde were administered to all patients. They were on a normal protein intake and unrestricted physical activity. The results show that the young males have a reduction in cortical thickness as compared to age-matched controls, and that there is a progressive loss in cortical width as the length of dialysis increases. This bone loss is statistically significant in males during their first 18 months of dialysis.