Early Results on the Efficacy of Demineralized Bone Matrix, Bone Morphogenic Protein, and Freeze-dried Bone Chips in Alveolar Cleft Repair

Background

Conventional treatment for alveolar cleft repair is done using autologous iliac crest alveolar bone graft (ABG). However, this method may not be ideal in all patients. Analysis of the efficacy of a mixture of demineralized bone matrix (DBX), bone morphogenic protein (rhBMP-2), and freeze-dried bone chips (FDBC) as an alternative for alveolar cleft repair was performed.

Methods

Consecutive patients from August 2019 to June 2022 undergoing early alveolar cleft repair, concomitant hard palate and alveolar cleft repair, secondary alveolar cleft repair, and regrafting from a previously failed ABG were analyzed. Computed tomography scans were performed to evaluate graft take at least 6 months postoperatively. Images were reviewed and scored. Alveolar graft height and graft thickness were recorded. A standardized scoring system was developed, with a score of 0 representing no graft take and 3 representing best possible graft take.

Results

Fifty-five consecutive alveolar clefts (43 patients) were identified as having undergone ABG and satisfied all the other inclusion criteria. Of these, 29 underwent first time ABG and 26 underwent redo ABG. The mean graft height and graft thickness recorded for all clefts was 2.2 and 2.0, respectively.

Conclusions

Early results evaluating the efficacy of ABG using DBX, rhBMP-2, and FDBC show feasibility in regard to both graft height and thickness when using a maxillary computed tomography scan to measure the bone graft take. These results suggest that DBX, rhBMP-2, and FDBC may act as a versatile bone graft material in cleft care, although further studies are needed to determine long-term outcomes.

Surgical Tips for Aesthetic Lower Lid Blepharoplasty: Prevention of Round Eye

In the present study, we highlight surgical tips based on our experience in lower eyelid blepharoplasty. These have been shown to be crucial in the prevention of several complications, specifically lateral lower-lid displacement.

Methods

A series of bilateral lower-lid blepharoplasties were performed on 280 patients at Humanitas-Research-Hospital (Milan, Italy) between January 2016 and January 2020. Patients with a history of lower-lid blepharoplasty and patients requiring canthopexy/canthoplasty were excluded. Needing to singularly evaluate and correct several lower-eyelid structures to obtain a harmonic result, we preoperatively assessed the amount of skin excess, the eyelid margin malposition relative to the globe, and the presence/absence of herniated fat-pads. Pre- and postoperative standard photographs were collected. Patients were evaluated by measuring scleral show, snap-back test, and distraction test. Blinded-fashioned photograph analysis was performed by independent plastic and oculoplastic surgeons who did not execute the procedures. A visual analogue scale was administered to all patients to assess satisfaction.

Results

In total, 280 patients underwent successful lower blepharoplasty, with satisfactory results of scleral show, snap-back test, and distraction test. Of the 280 patients, four presented postoperative complications. At 10-month follow-up visit, we achieved a mean patient visual analogue scale satisfaction score of 8.4. Postoperative surgeon's photographs mean score was 4.5.

Conclusions

Without the use of muscle flaps, our technique averts tarsal ligament misposition, preserves orbicularis-muscle innervation, and limits thermal spread, assuring excellent stability of results and high patient and surgeon satisfaction. Cosmetic outcome in terms of symmetry, appearance, and lower lid line definition revealed high satisfaction with the result over time, with a remarkably low complication rate.

Comment on "Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction"

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quantitative Analysis of the Histological Features of Tuberous Breast

INTRODUCTION

Tuberous breast deformity (TB) is a condition mostly characterized by breast stenosis, areolar widening and glandular asymmetry. The most accredited hypothesis describes an abnormal thickening of the fascia corporis that might influence an alteration in the glandular development, limiting the horizontal growth of breast parenchyma. Alterations in the extracellular matrix components (ECM) might be involved in the abnormal breast development.

PATIENTS

The aim of our case control study is to use histological specimens to analyze qualitative and quantitative differences in collagen fibers, elastic fibers and vessel densities in TB and normal breasts of 20 patients using a software for digital pathology.

RESULTS

The quantitative findings showed increasing concentrations of collagen fibers and decreasing elastic fibers in TB, compared to normal breasts. No difference was seen in vessel density among the two groups. The qualitative findings highlighted differences in the distribution of the ECM among the TB specimens. Collagen fibers showed a packed appearance rather a scattered distribution, while elastic fibers visibly presented a reduction and a focal distribution of their concentration.

CONCLUSIONS

The study proposes a correlation between abnormalities in ECM concentrations and TB, resulting in a higher degree of fibrosis and in the characteristic stenotic and less elastic morphology of the deformity.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Topical Hemostatic Agents in Burn Surgery: A Systematic Review

Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 nonduplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/ml. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.

801 Topical hemostatic agents in burn surgery: a systematic review

Introduction

Acute burn surgery (tangential excision and grafting) has long been associated with significant intra-operative bleeding over large surface areas, where in adults approximately 200-250 mL of blood loss would be expected per %TBSA excised and grafted using traditional methods. Several techniques were introduced to limit bleeding, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery.

Methods

A systematic review was performed by two independent reviewers using PubMed, Scopus, and Web of Science databases from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in acute burn surgery (excision and/or grafting). Animal studies and review articles were excluded. Data was extracted on the topical agent(s) used, their dosage, mode of delivery, hemostasis outcomes (if measured), and complications (if reported).

Results

The search identified 1982 non-duplicate citations, of which 134 underwent full text review, and 49 met inclusion criteria. Papers were grouped whether they compared (n=11, 22%), described (n=21, 43%) or secondarily described (n=17, 35%) topical hemostatic agents. Several authors (n=22, 45%) described topical hemostatics as part of a protocol that included other methods of blood conservation (tourniquet, tumescent infiltration, etc). In total, 31 studies incorporated a vasoconstrictor agent (epinephrine, phenylephrine, vasopressin), and 30 studies incorporated a procoagulant agent (thrombin, fibrin). Four studies incorporated other agents (hydrogen peroxide, tranexamic acid and collagen). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1,000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/mL. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III to V.

Conclusions

A multitude of topical hemostatic agents have been reported in the burn literature, with a wide range of dosages and modes of deliveries, as well as protocolization with other blood conservation techniques to limit blood loss during surgery. Determining the optimal topical hemostatic agent is limited by low quality data and challenges with consistent reporting of intra-operative blood loss and other clinically meaningful outcomes.

Algorithm-Assisted Decision Making in Otoplasty

INTRODUCTION

Ear congenital deformities represent an aesthetical concern in adult patients and a social matter in children. An accurate assessment of ear defects should be made preoperatively in order to plan surgery adequately.

MATERIALS AND METHODS

In order to correctly assess the ear preoperatively the authors have considered four different subunits: helical and scaphal region (A), antihelical region (B), conchal region (C) and lobule region (D). Surgical planning should start from sub-unit A evaluation, ending with sub-unit D, in a concentric fashion. When sub-unit A defects have to be corrected, an anterior approach is preferred.

DISCUSSION

A correct evaluation of ear defects prior to surgery is of dramatic importance. Sub-unit A ear defects are often disregarded, and surgical techniques for their correction are rarely considered. Correcting helical and scaphal defects requires an anterior approach, influencing the technique employed for the correction of subunits B and C defects. Sub-unit B defects should be evaluated and corrected before sub-unit C defects in order to avoid overcorrection of ear protrusion.

CONCLUSION

Several surgical techniques have been described in the literature for correcting ear defects. After many years of experience, we outlined a schematic flowchart that prevents from leaving areas of the ear untreated, providing the best possible result for the patient.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Upper eyelid blepharoplasty following hyaluronic acid injection with improved facial aesthetics and eye symptoms: a case report

BACKGROUND

Dermatochalasis of the upper eyelids (blepharochalasis) is a typical age-related change in the upper third of the face and a major concern for facial aesthetics. Nowadays both surgical and nonsurgical interventions are available for patients complaining of upper eyelid dermatochalasis. Although nonsurgical treatments are often easier to perform, if they are not performed correctly, complications may ensue and worsen the condition.

CASE PRESENTATION

We describe the case of a Caucasian patient presenting with bilateral upper eyelid dermatochalasis, previously treated with multiple injections of hyaluronic acid filler. Following these procedures, the patient reported nonspecific eye symptoms (such as a sense of heaviness and asthenopia) and cosmetic concerns. We decided to perform an upper eyelid blepharoplasty. During the procedure we found a ribbon of hard, fibrous material, which was carefully removed. The patient reported resolution of functional eye symptoms owing to the reduction of upper lid heaviness, which also resulted in subjective improvement of the visual field. Patient satisfaction was assessed preoperatively and 3 months postoperatively using the Blepharoplasty Outcomes Evaluation (BOE), which showed an overall satisfaction rate of 95.8 %.

CONCLUSIONS

Blepharoplasty not only treated the patient's blepharochalasis but also allowed us to correct the previous nonsurgical intervention by removing the excessive amount of injected hyaluronic acid. Both aesthetic and functional results were successfully achieved.

Evaluation of the ex vivo Effects of Tamoxifen on Adipose-Derived Stem Cells: A Pilot Study

Autologous fat grafting (AFG) is a safe and minimally invasive procedure to correct soft tissue defects. The benefit of AFG is attributed to adipose-derived stem cells (ASCs) in fat tissue graft. This technique is useful also in patients undergoing reconstructive surgery following quadrantectomy for breast cancer. However, these patients are frequently treated with tamoxifen. We evaluated the ex vivo effects of tamoxifen on ASCs to understand if cellular functions of ASCs are affected. We selected 24 female patients; 10 of which were breast cancer patients treated with quadrantectomy and tamoxifen. As control group, we selected 14 healthy female subjects (9 premenopausal and 5 menopausal). We found that tamoxifen has no effect on cellular proliferation, VEGF secretion or apoptosis of ASCs. The gene expression assessment demonstrated no impairment in differentiation capacity of ASCs. Our results showed that tamoxifen has no effect on cellular functions of ASCs for the first time in an ex vivo single-center study.

Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies

BACKGROUND

Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients.

MATERIALS AND METHODS

In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma.

RESULTS

The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009).

CONCLUSIONS

Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.

Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years' experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction.

METHODS

We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients' satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5).

RESULTS

The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients' satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon's photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr.

CONCLUSION

The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.

The evolution of autologous breast reconstruction

With breast cancer (BC) becoming more treatable, breast reconstruction has become an integral part of BC treatment. Nowadays, implant-based breast reconstruction is more common. However, there is a growing interest in autologous breast reconstruction due to the increasing awareness of implant-related complications. This work provides a comprehensive overview of the evolution of autologous reconstruction techniques of the breast and the nipple-areolar complex (NAC).

Breast Reconstruction in a Coronavirus Disease 2019 Hub

The coronavirus disease 2019 (COVID-19) pandemic presented a dramatic challenge to healthcare systems. Humanitas Clinical and Research Hospital (Rozzano, MI, Italy) was declared a regional hub for the treatment of COVID-19 patients. Our plastic surgery team, in consultation with our breast surgery colleagues, decided to perform immediate implant-based breast reconstruction for patients undergoing mastectomy for cancer. In this report, we present our experience performing breast reconstruction with a new protocol in the first month following the COVID-19 pandemic in the most affected region in Italy.

METHODS

We adopted a new protocol to treat patients with breast cancer during the COVID-19 pandemic. The main goals of our protocol were to reduce the risk of COVID-19 spread for both patients and clinicians, postpone nononcologic and more advanced surgery, develop rapid recovery for early patient discharge (within 24 hours from surgery) through pain management, and finally reduce postoperative consultations.

RESULTS

The protocol was applied to 51 patients between early March and early April 2020. After 1 month, we decided to retrospectively review our experience. We found no significant differences in terms of postoperative pain and complication rate compared with our data in the pre-COVID period.

CONCLUSION

Our new protocol is safe and effective, enabling tumor resection and immediate implant-based breast reconstruction, without increasing risks to the patient or staff.

Autologous fat grafting efficacy in treating PostMastectomy pain syndrome: A prospective multicenter trial of two Senonetwork Italia breast centers

Postmastectomy pain syndrome (PMPS) represents a common complication following breast surgery defined as a chronic neuropathic pain located in the front of the chest, in the axilla and in the upper arm that for more than 3 months after surgery. Several medications prove to be ineffective while autologous fat grafting revealed to be an innovative solution in the treatment of neuropathic pain syndromes based on retrospective studies. For this reason, we performed a prospective multicenter trial to reduce the memory bias and further increase the evidence of the results. From February 2018 to March 2019, 37 female patients aged between 18 and 80 years, underwent mastectomy or quadrantectomy with pathologic scarring and chronic persistent neuropathic pain, compatible with PMPS, are been included in the study and treated with autologous fat grafting. During the enrollment phase, patients were asked to estimate pain using the Visual Analogue Scale (VAS) and POSAS questionnaire in order to evaluate scar outcomes. The VAS scale, starting from 6.9 (1.3), decreased in the first month by 3.10 (1.59), continuing to fall by 0.83 (1.60) to 3 months and by 0.39 (2.09) at 6 months. Statistical analysis showed a significant reduction after 1 month (P < .0001) and 3 months (P < .005). All POSAS grades documented a statistically significant reduction (P < .0001) of the scores by both observers and patients. We observed that no significant association was found between age, BMI, menopausal status of patients, days from oncologic surgery to autologous fat grafting and reduction of VAS values over time while both smoking and axillary dissection were observed as the main factor significantly associated with a reduced clinical efficacy (respectively, P = .0227 and P = .0066). Our prospective multicenter trial confirms the efficacy of fat grafting in the treatment of PMPS based on the principle of regenerative medicine with a satisfactory response in terms of pain reduction and improvement of the quality of the treated tissues. Clinical questionnaires show that the cicatricial areas improve in terms of color, thickness, skin pliability, and surface irregularities. Regenerative effect is based also on the adoption of needles. The combined effect of fat grafting and needles determines a clinical full response.

Legionella control in a tertiary care hospital in Italy: adapting solutions to changing scenarios

Background

Legionella contamination of hospital water distribution system still remains a critical issue in healthcare settings, despite the disputed relationship between environmental legionella and hospital-acquired legionellosis. We report the experience of our 1200-beds hospital, where a new water safety plan (WSP) has been applied since 2017, and the results obtained with the application of different methods to control Legionella water contamination, especially in critical areas.

Methods

Policlinico San Martino is the referral tertiary acute-care university hospital in Liguria region, North-West Italy. It’s made of 21 buildings of different dimensions, 7 of which host high risk patients, according to Italian Guidelines for legionellosis prevention and control. A sampling plan for Legionella detection was implemented in 2017, focusing on the water network critical points. Different secondary disinfection procedures were used, including systemic (chlorine dioxide, monochloramine), focal (point-of-use filtration) and short-term methods (hyperchlorination), the last in case of contamination higher than 10^4 CFU/l.

Results

Respectively, during 2017 and 2018 a total of 201 and 119 hot water samples were collected, distributed among the 7 critical buildings of the hospital. Negative samples raised from 69.7% to 74.8%, while positive samples &gt;10^3 CFU/l (recommended cut-off for acute disinfection according to Italian guidelines) lowered from 21.9% to 9.2% of total samples. Out of 55 positive samples, Legionella sg 3 accounted for 98.2% of the total.

Conclusions

The new WSP determined a significant reduction of Legionella contamination of water distribution networks in our hospital critical buildings. The continuous surveillance of critical water system points provided evidence to elaborate an effective protocol for routine and extraordinary disinfection interventions, as result of a close collaboration between hospital hygiene unit and engineering and technical services.

Key messages

The implementation of an effective water safety plan and different disinfection procedures in hospital critical areas allow us to reduce and control the risk of hospital-acquired Legionella infection. Continuous surveillance cultures of drinking water to detect Legionella are necessary to adapt disinfection methods to local results.

Fat Graft in Composite Breast Augmentation with Round Implants: A New Concept for Breast Reshaping

BACKGROUND

Breast augmentation surgery with implants is one of the most common aesthetic surgical procedures. Round and anatomical textured implants are employed very often, and fat grafting has proven to be a very useful complementary procedure in breast augmentation. Many authors report a more natural result with anatomical compared to round implants. Nevertheless, anatomical implants can be associated with complications such as implant rotation with subsequent shape distortion. In this article, we propose a combination of high-profile round implants and fat grafting to obtain a natural result analyzing its impact on the aesthetic outcome and patient satisfaction.

METHODS

In this study, we report our personal approach on 31 consecutive patients undergoing primary aesthetic breast augmentation with high-profile round implants and fat grafting. We describe our personal technique of breast augmentation via the periareolar approach and fat grafting. We evaluated short- and medium-term aesthetic outcomes and patient satisfaction using a 10-point VAS scale.

RESULTS

We achieved in all cases high patient satisfaction and good aesthetic outcomes with a "natural" breast shape and a "smoothened" upper pole with low complication rates. The technique is safe, simple, fast, and it leads to high levels of patient satisfaction.

CONCLUSIONS

Our observations show that the combination of high-profile round implants and fat grafting in aesthetic breast augmentation can improve the aesthetic outcome and patient satisfaction as with anatomical implants eliminating the risk of implant rotation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Regional point prevalence study of healthcare-associated infections and antimicrobial use in acute care hospitals in Liguria, Italy

BACKGROUND

Given the importance of monitoring healthcare-associated infections (HCAIs) and the consumption of antibiotics, a regional point prevalence survey was conducted in Liguria between March and April 2016.

AIM

To measure the overall prevalence of HCAI and describe the use of antibiotics in all public hospitals.

METHODS

Data on risk factors and use of antibiotics were collected for each hospitalized patient. To define the variables significantly associated with HCAI, univariate and multivariate analyses were conducted. Standardized infection ratio and standardized antimicrobial use ratio were measured for each participating hospital.

FINDINGS

A total of 3647 patients were enrolled. In all, 429 HCAIs were diagnosed in 376 patients, giving a prevalence of HCAI of 10.3%. Respiratory tract (21.7%) and urinary tract (20%) were the most frequent sites of infection. High rates of meticillin-resistant Staphylococcus aureus (47.4%) and Enterobacteriaceae resistant to carbapenems (26.3%) were isolated. Forty-six percent of patients received at least one antibiotic. Combinations of penicillins including β-lactamase inhibitors (24.1%) were the most widely used; the main indication (46.7%) was the treatment of a community-acquired infection.

CONCLUSION

There was an increase in HCAI prevalence compared to a similar survey conducted in 2007; however, the performance of overlapping investigations will enable more reliable considerations. Nevertheless, data on antimicrobial resistance and use of antibiotics are consistent with the national trend. Despite methodological limitations, prevalence studies are useful to monitor HCAI over time and encourage greater awareness of the problem by all stakeholders.

[PALEODEMOGRAPHIC ANALYSIS]

Demography evaluates the traits of human populations mainly by measuring their sizes and fluctuations. Due to their features, the archeological population structures refer to the distribution of people based both on sex and age at death. These parameters have a direct impact on the risk of death because they vary significantly with age and sex and this is reflected in a proportional sharing of deaths in several groups at risk. This chapter deals with the demographic structure of several imperial communities scattered through the roman Suburbium. A whole sample of almost 3500 skeletons pertaining to 12 necropolis has been analyzed in order to determine the gender and the age at death. Each necropolis is contextualized according to information about people lifestyle and health, trying to deepen our knowledge on the death risk exposure for every population. Our results suggest to consider the imperial Suburbiumn population as a very complex landscape, where several communities were featured by their different way to face the socio-economic and biologic environments.

FMRI activation with an "affective speech" paradigm in vegetative and minimally conscious States: applicability and prognostic value

Vegetative state (VS) and minimally conscious state (MCS) are considered different clinical entities but their differential diagnosis remains challenging. Some VS patients can show an MCS-like activation in functional magnetic resonance imaging (fMRI) studies that seems to predict recovery from VS. We studied fMRI activation with an affective speech paradigm in a cohort of non-communicative brain-injured individuals consecutively admitted to a post-acute neurorehabilitation facility in five years. Among 93 eligible subjects, 65 met the clinical criteria for VS and 28 for MCS. Because of exclusion criteria, activation studies were performed in only 30 cases out of 93 and analysed in only 24 (about ¼ of the eligible cases): 19 VS and five MCS patients. The passive acoustic stimulus consisted in a familiar voice narrating a significant episode in the patient's life, administered by nonmagnetic earphones. All the MCS patients showed an activation spread to secondary associative cortices but also 52.7% of the VS patients displayed an "atypical" large-scale activation pattern. Regarding the clinical outcome, 80% of the patients with large-scale network activation (LSNA) had some recovery of consciousness. Our results confirm that the VS patients with LSNA at fMRI study have potential for further recovery of consciousness, whereas no patient without activation or only typical activation improved. fMRI study with an affective speech paradigm, when applicable, seems to have a valuable prognostic value in VS patients, even if there are major limitations in terms of applicability.

Genetic response to an environmental pathogenic agent: HLA-DQ and onchocerciasis in northwestern Ecuador

The aim of this study is to explore human leukocyte antigen (HLA)-DQ variability in two populations (Cayapas Amerindians and Afro-Ecuadorians) who live near one another along the Cayapa River and who are exposed to the same environmental stresses, such as infection by Onchocerca volvulus. HLA-DQA1 and HLA-DQB1 of 149 unrelated individuals (74 Cayapas and 75 Afro-Ecuadorians) have been analyzed. HLA high-resolution molecular typing was performed by sequence-based typing, sequence-specific oligonucleotides hybridization and sequence-specific primer (SSP) amplification. The comparison between affected (cases) and unaffected people (controls) in both populations shows the key role of several HLA-DQA1 alleles in susceptibility and protection against onchocerciasis. In both populations, there is strong evidence related to the protective role of DQA1*0401 against onchocerciasis. Alleles HLA-DQA1*0102 and *0103 seem to represent risk factors in Afro-Ecuadorians, while HLA-DQA1*0301 is only a suggestive susceptibility allele in Cayapas. These findings represent new positive/negative associations with onchocerciasis in South America, whereas previous findings pertained only to African populations.

Hospital-acquired infections and leading pathogens detected in a regional university adult acute-care hospital in Genoa, Liguria, Italy: results from a prevalence study

BACKGROUND

A prevalence study aimed to update the epidemiological scenario of Hospital-Acquired Infections (HAI) was performed at the San Martino University Hospital of Genoa, the Regional Reference Adult-care Center in Liguria, Italy, with more than 1300 beds.

MATERIALS AND METHODS

The investigation was performed in all the wards, except the Psychiatric Units, between 19th March and 6Ih April, 2007, using a one-day monitoring system for each ward. International standardized criteria and definitions for the surveillance of HAI were used for the collection of data, which were recorded in specific software for subsequent consolidation, analysis and quality control.

RESULTS

The hospital infection control staff actively monitored 912 inpatients: a total of 84 HAI among 72 patients were diagnosed, with an overall prevalence of infections and affected cases of 9.2% (95% CI: 7.3-11.1) and 7.9% (95% CI: 6.1-9.7), respectively. Urinary Tract Infections (UTI) (30.9%), Respiratory Tract Infections (RTI) (28.6%) and Blood Stream Infections (BSI) (21.4%) were found to be the most frequent infections. As expected, both specific prevalence and localization of HAI varied considerably between wards, with the highest values recorded in Intensive Care Units (ICU) and in Functional Rehabilitation wards. RTI (26.3%) and BSI (13.2%) were found primarily represented in ICU, while the highest values of UTI (13.3%) were registered in Functional Rehabilitation Units. Enterococcus spp. (16.8%), Candida spp. (14%), Pseudomonas spp. (12.2), Staphylococcus aureus (10.7%), Escherichia coli (10.3%) and Coagulase-negative staphylococci (CNS) (9.3%) were the most frequent pathogens isolated. The overall rate of administration of antibiotics was 55.3% and penicillin (26.7%), cephalosporins (22.8%) and fluoroquinolones (17.9%) were found to be the leading antibacterial administered.

CONCLUSION

Results of the present study have been, and are currently, used for orientating surveillance and control hospital policies, planning activities according to a rational and evidence-based approach.

Detection of gunshot residues on cadaveric skin using sodium rhodizonate and a counterstain

We report a staining method for cadaveric tissue using sodium rhodizonate as a skin marker for gunshot residues and a counterstain for the surrounding connective tissue. We studied six well preserved subjects who had died of close range gunshot injury. Skin fragments were removed from the bullet entrance hole including both the disrupted area and adjacent macroscopically intact tissue. Because microscopic examination of postmortem material is difficult after histomorphologic alterations already have occurred as a consequence of postmortem tissue changes, it is necessary to use a staining method that, while detecting gunshot residues, can also make skin cell constituents recognizable from both qualitative and quantitative perspectives. Triphenylmethane dyes (acid fuchsin, aniline blue WS, light green SF yellowish, brilliant green and ethyl green) have proven appropriate for the purpose.

Three-dimensional quantitative assessment of lung parenchyma in cystic fibrosis: preliminary results

PURPOSE

The aim of this study was to assess the feasibility of three-dimensional (3D) reconstructions and quantitative analysis of the volume of each component of the lung with cystic fibrosis (CF).

MATERIALS AND METHODS

Twenty-two patients with CF (mean age 17+/-8 years) were included in the study. The patients underwent an unenhanced single-slice spiral computed tomography (CT) chest scan with the following parameters: collimation 3 mm, table feed 6 mm x rot(-1), reconstruction interval 1 mm, soft tissue reconstruction kernel. Four image data sets were obtained: native axial slices, cine-mode display, virtual bronchographic volume-rendered images with algorithm for tissue transition display and virtual endoluminal views. The lungs were segmented manually from the hilum to the visceral pleura on the axial images, and the entire lung volume was calculated. A histogram was generated representing the fractional volume of tissues, the density of which was within a preset range. A curve was then obtained from the histogram.

RESULTS

Native axial images and cine-mode display allowed complete evaluation of lung volumes. Virtual bronchography allowed a better assessment of the distribution of bronchiectasis. Virtual bronchoscopy was limited by the fact that it visualised only the surface, without differentiating mucus from the bronchial wall. Manual segmentation and generation of density-volume curves required 41+/-7 min for each lung. Three curve patterns were identified depending on disease severity.

CONCLUSIONS

Volume-density analysis of lungs with CF is feasible. Its main advantage is that image analysis is not analogical, as the assessment is not performed using scoring systems or similar ordinal scales. This technique cannot differentiate acute from chronic findings, and the predictive value of the curve should be assessed.

IRF-1 deficiency skews the differentiation of dendritic cells toward plasmacytoid and tolerogenic features

Members of the IFN regulatory factors (IRFs) family are transcriptional regulators that play essential roles in the homeostasis and function of the immune system. Recent studies indicate a direct involvement of some members of the family in the development of different subsets of dendritic cells (DC). Here, we report that IRF-1 is a potent modulator of the development and functional maturation of DC. IRF-1-deficient mice (IRF-1(-/-)) exhibited a predominance of plasmacytoid DC and a selective reduction of conventional DC, especially the CD8alpha(+) subset. IRF-1(-/-) splenic DC were markedly impaired in their ability to produce proinflammatory cytokines such as IL-12. By contrast, they expressed high levels of IL-10, TGF-beta, and the tolerogenic enzyme indoleamine 2,3 dioxygenase. As a consequence, IRF-1(-/-) DC were unable to undergo full maturation and retained plasmacytoid and tolerogenic characteristics following virus infection ex vivo and in vivo. Accordingly, DC from IRF-1(-/-) mice were less efficient in stimulating the proliferation of allogeneic T cells and instead, induced an IL-10-mediated, suppressive activity in allogeneic CD4(+)CD25(+) regulatory T cells. Together, these results indicate that IRF-1 is a key regulator of DC differentiation and maturation, exerting a variety of effects on the functional activation and tolerogenic potential of these cells.

Impaired myelopoiesis in mice devoid of interferon regulatory factor 1

Interferon regulatory factor (IRF)-1 is a transcription factor controlling the expression of several genes, which are differentially induced depending on the cell type and signal. IRF-1 modulates multiple functions, including regulation of immune responses and host defence, cell growth, cytokine signalling and hematopoietic development. Here, we investigated the role of IRF-1 in granulocytic differentiation in mice with a null mutation in the IRF-1 gene. We show that IRF-1(-/-) bone marrow cells exhibit an increased number of immature granulocytic precursors, associated with a decreased number of mature granulocytic elements as compared to normal mice, suggestive of a defective maturation process. Clonogenetic analyses revealed a reduced number of CFU-G, CFU-M and CFU-GM colonies in IRF-1(-/-) mice, while the number of BFU-E/CFU-E colonies was unchanged. At the molecular level, the expression of CAAT-enhancer-binding protein (C/EBP)-epsilon, -alpha and PU.1 was substantially lower in the CD11b(+) cells from the bone marrow of IRF-1(-/-) mice as compared to cells from wild-type mice. These results, together with the fact that IRF-1 is markedly induced early during granulo-monocytic differentiation of CD34+ cells, highlight the pivotal role of IRF-1 in the early phases of myelopoiesis.

[Family pediatricians and obstructive sleep disorders]

BREATHING: Problems related to the Obstructive Sleep Disordered Breathing (OSDB) are so many: 1) a noso- graphic setting has still to be defined and this leads to contrasting results concerning the prevalence of the OSDB; 2) the absence of a single pathogenetic trigger which can explain the sudden increase of the number of cases of the OSDB since the 1980's; 3) a poor integration between clinical and diagnostic tests; 4) a not well defined role of the family pediatrician in approaching the OSDB.

OBJECTIVES

From the above introduction we can deduce four objectives of the study: 1) verifying the prevalence of the OSDB; 2) studying if an early development of the adenotonsillar tissues can influence the on-set of the OSDB; 3) a better definition of the clinical diagnosis; 4) knowing what decisions the family pediatrician do take as concerns the diagnostic tests and therapy.

MATERIAL AND METHOD

This study was carried out on questionnaires completed by 8 family pediatricians which consisted of two parts: the first section regarded the whole population interviewed (2.271 children) and the second more specific was reserved only to the 42 children classified as affected by the OSDB. These 42 children presented at least 3 of the following 4 features during sleep: (1) the parents are worried about the way their child breaths (2) snoring (3) apnea (4) paradoxical rib cage movement in inspiration.

RESULTS

The prevalence of the OSDB was 1.8%. However considering how suggested by some authors even those children who snored and also presented oral respiration, the prevalence increased to 10.3%. These values are similar to the international results with a prevalence of 2-3% for the more severe forms defined as Obstructive Sleep Apnea Syndromes (OSAS) and of 8-11% considering all the forms of the OSDB. Grouping these patients according to their ages, it resulted that the highest incidence of the OSDB was in children between 3-5 years. This observation supports the hypothesis that at the base of the OSDB is an early development of the adenotonsillar tissues, thus in constrast which the classical course which identifies the peak of adenotonsillar hypertrophy between 4 and 6 years of age. The frequency of the single signs and symptoms in the various ages permits the improvement of the clinical diagnosis: in particular snoring, oral respiration and tonsillar hypertrophy are less frequent in the first three years of life, while in the older children the percentage of growth inhibition decreased and it becomes more difficult observing paradoxical rib cage movement in inspiration. Concerning the diagnostic tests, the family pediatrician asks only exceptionally specific test during sleep (5% of the patients). Concerning therapy, many were the indications for adenotonsillectomy even during the first three years of age (82% of the patients) proving that the family paediatrician has overcome the old attitude of not indicating operation in the first 4-5 years of age.

CONCLUSION

The confirmed high prevalence of the OSDB, the possibility of further improving the clinical diagnosis, the good capacity of the family pediatrician concerns diagnosis and therapy are all factors which favour the direct management of most of the children with adenotonsillar hypertrophy by the family pediatrician. The diagnosis and therapeutic choice can find support in sleep tests when necessary. These tests have to be carried out in a specialized laboratory and the results be interpreted together with the clinical signs and symptoms. Patients who have to be managed by Pediatric sleep laboratory are: 1) children with OSDB due to organic and functional alterations on genetic basis; 2) children in whom adenotonsillectomy presents a high risk such as a severe respiratory insufficiency and the young age of the patient (less 12-18 months of life).

IRF regulation of HIV-1 long terminal repeat activity

Interferon (IFN) regulatory factors (IRF) constitute a family of transcriptional activators and repressors implicated in multiple biologic processes, including regulation of immune responses and host defense, cytokine signalling, cell growth regulation, and hematopoietic development. All members are characterized by well-conserved DNA binding domains at the N-terminal region that recognize similar DNA sequences termed IRF-binding element/IFN-stimulated response element (IRF-E/ISRE) present on the promoter of the IFN-alpha/beta genes and of some IFN-stimulated genes (ISG). Recently, a sequence homologous to the ISRE has been identified downstream of the 5' human immunodeficiency virus type 1 (HIV-1) long terminal repeat (LTR). This sequence is a binding site for IRF-1 and IRF-2. Deletion of the LTR-ISRE results in impaired LTR promoter activity and decreased synthesis of viral RNA and proteins. Here, we briefly summarize characteristics of IRF-1 and IRF-2 binding to the HIV-1 LTR-ISRE and the data obtained to date on the functionality of this cis-element and on the role of IRF in the regulation of HIV-1 LTR transcriptional activity.

Interferon-gamma receptor 2 expression as the deciding factor in human T, B, and myeloid cell proliferation or death

The heterodimeric interferon (IFN)-gamma receptor (IFN-gammaR) is formed of two chains. Here we show that the binding chain (IFN-gammaR1) was highly expressed on the membranes of T, B, and myeloid cells. Conversely, the transducing chain (IFN-gammaR2) was highly expressed on the surfaces of myeloid cells, moderately expressed on B cells, and poorly expressed on the surfaces of T cells. Differential cell membrane expression of IFN-gammaR2 determined the number of receptor complexes that transduced the IFN-gamma signal and resulted in a different response to IFN-gamma. After IFN-gamma stimulation, high IFN-gammaR2 membrane expression induced rapid activation of signal transducer and activator of transcription-1 (STAT-1) and high levels of interferon regulatory factor-1 (IRF-1), which then triggered the apoptotic program. By contrast, low cell membrane expression resulted in slow activation of STAT-1, lower levels of IRF-1, and induction of proliferation. Because the forced expression of IFN-gammaR2 on T cells switched their response to IFN-gamma from proliferative to apoptotic, we concluded that the surface expression of IFN-gammaR2 determines whether a cell stimulated by IFN-gamma undergoes proliferation or apoptosis.

Ectopic expression of interferon regulatory factor-1 potentiates granulocytic differentiation

Numerous transcription factors allow haematopoietic cells to respond to lineage- and stage-specific cytokines and to act as their effectors. It is increasingly evident that the interferon regulatory factor-1 (IRF-1) transcription factor can selectively regulate different sets of genes depending on the cell type and/or the nature of cellular stimuli, evoking distinct responses in each. In the present study, we investigated mechanisms underlying the differentiation-inducing properties of granulocytic colony-stimulating factor (G-CSF) and whether IRF transcription factors are functionally relevant in myeloid differentiation. Both normal human progenitors and murine 32Dcl3 myeloblasts induced to differentiate along the granulocytic pathway showed an up-regulation of IRF-1 expression. Ectopic expression of IRF-1 did not abrogate the growth factor requirement of 32Dcl3 cells, although a small percentage of cells that survived cytokine deprivation differentiated fully to neutrophils. Moreover, in the presence of G-CSF, granulocytic differentiation of IRF-1-expressing cells was accelerated, as assessed by morphology and expression of specific differentiation markers. Down-modulation of c-Myb protein and direct stimulation of lysozyme promoter activity by IRF-1 were also observed. Conversely, constitutive expression of IRF-2, a repressor of IRF-1 transcriptional activity, completely abrogated the G-CSF-induced neutrophilic maturation. We conclude that IRF-1 exerts a pivotal role in granulocytic differentiation and that its induction by G-CSF represents a limiting step in the early events of differentiation.

Six-minute walking test in cystic fibrosis adults with mild to moderate lung disease: comparison to healthy subjects

The six-minute walking test (6MWT) has been widely utilized to evaluate global exercise capacity in patients with cystic fibrosis. The aim of this study was to assess the exercise capacity by 6MWT, measuring four outcome measures: walk distance, oxygensaturation and pulse rate during the walk, and breathlessness perception after the walk, in a group of cystic fibrosis adults with mild to moderate lung disease, and in healthy volunteers, as the control group. Moreover, the study examined the relationship between 6MWT outcome measures and pulmonary function in patients. Twenty-five adults (15 females, age range 18-39 years) with cystic fibrosis and 22 healthy volunteers (14 females, age range 20-45 years) performed a 6MWT following a standard protocol. Walk distance, oxygen saturation (SpO2) and pulse rate at rest and during walk, and breathlessness perception after walk assessed by visual analogue scale (VAS) were measured. Cystic fibrosis patients did notdiffer from healthy volunteers in walk distance (626 +/- 49 m vs. 652 +/- 46 m) and pulse rate. Patients significantly differed from healthy volunteers in SPO2 during the walk (mean SpO2) (P < 0.0001) and VAS (P < 0.0001). In patients, SPO2 during the walk significantly correlated with forced expiratory volume in 1 sec (FEV1) (P < 0.0001), residual volume (RV) (P < 0.001), resting SPO2 (base SpO2) (P < 0.001), and inspiratory capacity (IC) (P < 0.01). In addition, VAS significantly correlated with resting SPO2 (P < 0.01) and IC (P < 0.01). On the basis of regression equations by stepwise multiple regression analysis, SpO2 during walk was predicted by FEV1 (r2 = 0.60) and VAS by IC (r2 = 0.31), whereas walk distance was not reliably predicted by any assessed variables. This study showed that cystic fibrosis adults with mild to moderate lung disease covered a normal walk distance with unimpaired cardiac adaptation, but experienced a significant fall in oxygen saturation and an increased breathlessness perception during exercise. Resting pulmonary function was related to oxygen saturation and breathlessness perception during walk, but contributed significantly only tothe prediction of oxygen saturation. We suggest that 6MWT could be valuable for identifying patients who might experience oxygen desaturation and dyspnoea during demanding daily activities.

[Thirty years of activity at the center for cystic fibrosis in Parma]

One hundred fourteen patients (52 males, age range 1 to 40 yr, median age 16 yr) affected by Cystic Fibrosis (CF) are currently followed by the CF Centre of Parma. Forty two percent of them are adults. Most patients live in Emilia Romagna (59%) and Lombardia (19%). With respect to CF genotype, delta F508 mutation has been found in 54% of patients. Despite of the improvement in knowledge of CF, its diagnosis is still based on the clinical features and sweat test is usually used to confirm the diagnosis. Recent diagnostic tools, such as the genetic analysis and the potential difference measurement, could also be helpful in ambiguous situations. In the CF Centre of Parma, in agreement with the literature, the disease is now diagnosed earlier than in the past. Particularly, in the last year the median age of diagnosis was seven months, while it was 20 months in the 1980s. The early diagnosis and the improvement in the treatment of lung disease has significantly increased the median survival age of our patients, changing from 7.5 years in 1975 to 20 years in 1999. A significant improvement in CF prognosis could be further achieved by potential investigational agents, such as "protein-repair" addressed to CFTR activation. However, the gold standard for CF therapy is represented by gene therapy, although it is not yet available.

[The pediatrician facing the problem of polluted air]

The enormous amount of data concerning outdoor pollution has allowed quantifying the damage caused by single pollutants. On the basis of these data, and knowing the concentration of a pollutant in a given area, to date it is possible to foresee the expected risk for a given disease in our community. For instance, in an average size town like Parma, it can be calculated that in the middle of the winter, suspended particulate pollution (PM10), one day/three, will increase by 30% the number of symptomatic asthmatic children. In the long term, in a town like Parma, PM10 and NO2 pollution increases the number of children with more than 4 episodes of bronchitis or persistent cough by 30-50%. With regard to the typical summer pollution by O3, extremely harmful as it expands outside towns, in Parma and surroundings in August one should expect in 1/3 days double the number of symptomatic asthmatic patients, and every other day a 25% reduction of the respiratory function in asthmatic children exercising. With regard to indoor pollution besides the well known and severe problem of passive smoking, and that of volatile organic compounds still under investigation, one must consider NO2 pollution originating from the burning processes for heating and cooking. As this latter is extremely important in Italy, as gas is used in practically every house, the Author has done a specific research in which it is shown that if this kind of pollution was eliminated one could reduce the incidence of asthma in childhood from 7 to 5%, and noticeably the severity of the disease in affected subjects. Thus, paediatricians have two new aims. The first is to identify in pollution one of the possible causes of respiratory problems in each single patient, giving recommendations (ex. advise asthmatic children to avoid physical activity in the open and in the sunny hours during the summer, or avoid having children in the kitchen while cooking, or have boilers, heaters, etc. checked). Second, paediatricians should make aware, using the local actual data on pollution, not only the local administrators, but also and may be more important the parents of children with respiratory problems. These are in fact the ones who can and must become the most active in facing the big problem of pollution.

HHV-8 encoded vIRF-1 represses the interferon antiviral response by blocking IRF-3 recruitment of the CBP/p300 coactivators

Human herpes virus 8 (HHV-8) has developed unique mechanisms for altering cellular proliferative and apoptotic control pathways by incorporating viral homologs to several cellular regulatory genes into its genome. One of the important pirated genes encoded by the ORF K9 reading frame is a viral homolog of the interferon regulatory factors (IRF), a family of cellular transcription proteins that regulates expression of genes involved in pathogen response, immune modulation and cell proliferation. vIRF-1 has been shown to downregulate the interferon- and IRF-mediated transcriptional activation of ISG and murine IFNA4 gene promoters. In this study we demonstrate that vIRF-1 efficiently inhibited virus-induced expression of endogenous interferon B, CC chemokine RANTES and CXC chemokine IP-10 genes. Co-expression analysis revealed that vIRF-1 selectively blocked IRF-3 but not IRF-7-mediated transactivation. vIRF-1 was able to bind to both IRF-3 and IRF-7 in vivo as detected by coimmunoprecipitation analysis, but did not affect IRF-3 dimerization, nuclear translocation and DNA binding activity. Rather, vIRF-1 interacted with the CBP/p300 coactivators and efficiently inhibited the formation of transcriptionally competent IRF-3-CBP/p300 complexes. These results illustrate that vIRF-1 is able to block the early stages of the IFN response to virus infection by interfering with the activation of IRF-3 responsive, immediate early IFN genes.

IFN-gamma and IL-4 differently regulate inducible NO synthase gene expression through IRF-1 modulation

NO is a labile radical involved in several immunological, antimicrobial and inflammatory processes. In macrophages, NO formation is catalyzed by the cytokine-inducible enzyme inducible NO synthase (iNOS). The importance of IFN regulatory factor (IRF)-1 and of the signal transducers and activators of transcription (STAT)-1 for the induction of iNOS gene expression in response to IFN-gamma has been well defined. Here, we investigated the molecular events responsible for the inhibition of iNOS gene expression by IL-4 in the murine macrophage cell line RAW264.7. Unidirectional deletion analysis on iNOS promoter demonstrated that an IFN-stimulated responsive element (ISRE), contained in the -980 to -765 bp region of the iNOS promoter, may be involved in the IL-4-mediated inhibition of IFN-gamma-inducible iNOS transcription. Accordingly, the IFN-gamma-induced binding activity of IRF-1 to the ISRE sequence was reduced in cells pre-treated with IL-4, while the binding activity of STAT-1 to the STAT-binding element (SBE) within the same region of the iNOS promoter remained unaffected. Moreover, IL-4 even down-regulated IFN-gamma-inducible expression of IRF-1 mRNA. This could be related to a transcriptional mechanism by which IL-4 and IFN-gamma differentially influence the trans-acting activity of the STAT factors binding to SBE within the IRF-1 promoter. SBE is targeted by IFN-gamma-inducible STAT-1 and by IL-4-inducible STAT-6. Although STAT-6 has no trans-acting function on iNOS gene expression, it is able to inhibit the IFN-gamma-induced expression of IRF-1. Thus, IL-4 may down-regulate IFN-gamma-inducible iNOS transcription by activation of STAT-6 which in turn inhibits IRF-1 expression.

[Medical treatment of respiratory emergencies]

Of the four treatments that can be used to treat respiratory insufficiency due to laryngitis, two, nebulized adrenaline and O2 therapy, are undoubtedly effective. The inhalation of water vapour appears to be increasingly useless and may be also harmful. The use of steroids is still under debate. In recent literature, however, the utility of steroids seems to be confirmed, especially if administered per Os, and even at a relatively low single oral dose (1-2 mg/kg of prednisone). According to the official organs (see Red Book) and according to the Evidence Based Medicine (see Cochrane Library) the treatment of bronchiolitis should be limited to an eventual support therapy, i.e. O2 therapy and rehydration. However, the approach adopted by North American Hospitals and European specialists in infectious diseases is in contrast and consists in the use of beta 2 agonists and steroids in 90-100% and 40-80% of patients, respectively. This contrast could be due to a deficiency in the researches of the Evidenced Based Medicine which is obliged to retrieve studies done over 10-15 years in order to obtain a sufficient number of data for a statistically valid investigation. These studies unfortunately are not updated with regard to the dose of individual drugs and the immediate association of drugs. In particular, with regard to nebulized beta 2 agonists, the absence of a positive effect could be due to an excessively low dose in relation to the age of the patient. According to the most recent knowledge, in fact, reduced doses are no longer required for babies in consideration of age and weight. In reality an equal and even higher dose than that used in adults would be best. The other reason for a lack of response could be the absence of the association of a steroid with a beta 2 agonists at the right moment. The lack of timing in associating these two drugs could also account for the absent response to the steroid. On the basis of these considerations it would be a mistake to give up the use of beta 2 agonists and steroids. Considering also the severity and frequency of a disease as bronchiolitis. To follow the "fashion" of the Evidence Based Medicine. Recently, magnesium sulphate, ketamine and the association elium-O2 have been suggested as marginal and not revolutionary medical interventions for the treatment of asthma. Among bronchodilators, the subordinate role of anticholinergics (for ex. ipratropium bromide), and of adrenaline has been defined with respect to beta 2 agonists, in particular salbutamol. The optimisation of the administration by nebulizers of the latter has been fundamental as it has a key role in the treatment of acute severe asthma. In detail, traditional nebulizers tend to be substituted by Metered Dose Inhaler + spacer with a ratio in the dose of 5/1. The venous route is used only in very severe cases and is used late and in intensive care although a single initial intravenous administration could determine a more rapid reduction of bronchoconstriction and reduce the number of nebulized bronchodilatators that can become extremely frequent in most severe cases. For steroids, instead, the only safe therapeutic route is by PO, i.v., i.m.: nebulized steroids although used with a definitely higher dose than that used for chronic asthma, can be used only in the milder forms.

Comparison of two enteric coated microsphere preparations in the treatment of pancreatic exocrine insufficiency caused by cystic fibrosis

BACKGROUND

Pancreatic exocrine insufficiency is a common condition in patients with cystic fibrosis. Large amounts of pancreatic enzyme supplements are required to reduce malabsorption but patient compliance is not always optimal.

AIMS

To compare patients' preference and the efficacy of two enteric coated microsphere preparations in patients with cystic fibrosis.

PATIENTS

Patients with pancreatic exocrine insufficiency due to cystic fibrosis.

METHODS

Patients were assigned to the crossover treatment with Creon or Pancrease for 1 week and then to the alternative treatment. Patients had to follow a fixed diet (at least 2 g fat/kg) and had to assume 1000 units lipase/g fat. The evaluation parameters were: patients' preference, acceptance of therapy, stool fat excretion, stool weight, gastrointestinal symptoms, and tolerance.

RESULTS AND CONCLUSIONS

Of the 33/60 patients who expressed a preference for one of the two treatments, 30 preferred Creon while only 3 patients preferred Pancrease (p<0.001). No difference between the two treatments was observed regarding stool characteristics, gastrointestinal symptoms and tolerance. The mean number of capsules taken daily was reduced by 35% with Creon. The results of this study showed a preference in favour of Creon probably due to the reduction of daily capsule intake of 35%, supporting digestion as well as Pancrease.