Generation of iPSC lines derived from skin fibroblasts of two healthy controls using non-transmissible form of Sendai Virus

We established two iPSC lines starting from skin fibroblasts of two healthy individuals using Sendai-virus-based technique. The obtained iPSCs were characterized showing same STR profile as starting fibroblasts, normal karyotype, loss of stemness vectors, expression of stemness markers, both through real-time PCR and immunofluorescence, (OCT4, SOX2, TRA-1-60, NANOG and SSEA4) and in vitro differentiation into three germ layers.

The impact of SARS-CoV-2 on emergency health care in a referral acute-care center in northern Italy

 

To assess how SARS-CoV-2 has changed the demand for in-person health care, we retrospectively analyzed data on access to the emergency department (ED) of San Martino Hospital, the referral acute-care center in the Liguria region (Northwest Italy). 181,699 records of patients diagnosed with an ICD-9 code between 2019 and 2021 were considered. In comparison to pre-pandemic levels, following the introduction of social distancing measures, the median number of ED visits declined by 41.4% in 2020 and by 28.1% in 2021. The period of maximum drop in access (-58.6%) corresponded to the 2020 11-12th calendar weeks and coincided with the highest rates of COVID-like illness - defined as either ILI or LRTI cases - identified through an operator-dependent syndromic surveillance system (+340%; 19.5% of total ED attendances). In terms of relative impact, in 2020 and 2021 non-urgent ED codes decreased (by 6.7% and 7.3%) and both urgent and emergency ED codes increased (by 4.8% and 3.8% the former; 5.5% and 8.8% the latter), even so, the absolute number of ED access fell drastically for all codes. Urgent codes, in particular, experienced the most severe decrease, shifting from a pre-pandemic value of 25,009 to 18,826 in 2020 and 19,528 in 2021. With regards to diagnosis, in 2020, respiratory infections saw the highest increase (+3.3%) while traumas and eye diseases saw the highest decrease (-1.1% and -3.8%, respectively). This trend reversed in 2021 during which respiratory infections decreased (-2.2%) and traumas increased (+2.2%). Despite the admissions of males and the elderly being routinely lower, these categories experienced the greatest increase in access for respiratory infections: +3.9% and +10.1% in 2020; +2.8% and +7.4% in 2021. While reduction of non-urgent ED visits indicates that the high pre-pandemic access levels may have been avoidable, the significant decline in non-COVID-19 urgent accesses potentially points to an increase in delayed and missed care.

Key messages

• During the COVID-19 pandemic – possibly due to fear and underestimation of symptoms – there was an overall reduction in ED accesses that potentially points to an increase in delayed or missed care.

• The reduction in non-urgent attendances indicates that high pre-pandemic accesses may have been avoidable and that a reduction in unnecessary ED visits is an attainable goal for healthcare systems.

Perceptions and experiences of medical student first responders: a mixed methods study

CONTEXT

Medical Student First Responders (MSFRs) are volunteers who respond to emergency calls, managing patients before ambulance staff attend. The MSFR role provides opportunities to manage acutely unwell patients in the prehospital environment, not usually offered as part of formal undergraduate medical education. There are few previous studies describing activities or experiences of MSFRs or exploring the potential educational benefits. We aimed to investigate the activity of MSFRs and explore their experiences, particularly from an educational perspective.

METHODS

We used a mixed methods design, combining quantitative analysis of ambulance dispatch data with qualitative semi-structured interviews of MSFRs. Dispatch data were from South Central and East Midlands Ambulance Service NHS Trusts from 1st January to 31st December 2019. Using propensity score matching, we compared incidents attended by MSFRs with those attended by other Community First Responders (CFRs) and ambulance staff. We interviewed MSFRs from five English (UK) medical schools in those regions about their experiences and perceptions and undertook thematic analysis supported by NVivo 12.

RESULTS

We included 1,939 patients (median age 58.0 years, 51% female) attended by MSFRs. Incidents attended were more urgent category calls (category 1 n = 299, 14.9% and category 2 n = 1,504, 77.6%), most commonly for chest pain (n = 275, 14.2%) and shortness of breath (n = 273, 14.1%). MSFRs were less likely to attend patients of white ethnicity compared to CFRs and ambulance staff, and more likely to attend incidents in areas of higher socioeconomic deprivation (IMD - index of multiple deprivation) (p < 0.05). Interviewees (n = 16) consistently described positive experiences which improved their clinical and communication skills.

CONCLUSION

MSFRs' attendance at serious medical emergencies provide a range of reported educational experiences and benefits. Further studies are needed to explore whether MSFR work confers demonstrable improvements in educational or clinical performance.

PP25 Activities and experiences of medical student first responders: a mixed methods study

Background

Medical Student First Responder (MSFR) schemes provide a Community First Responder (CFR) resource to their local ambulance Trust and experience for students. We aimed to investigate the contribution of these schemes and perceptions of students taking part in them.

Methods

In this convergent mixed methods study, we analysed dispatch data from two regional ambulance services and used propensity score matching to adjust for rurality and timing of attendance. MSFR attendances were compared with CFR and ambulance attendances. Multinomial logistic regression identified predictors of MSFR attendance compared with CFR and ambulance staff whilst accounting for confounders. We combined this with semistructured interviews of MSFRs from five schemes across the two regions. Interviews were transcribed verbatim and analysed using the Framework approach supported by NVivo. Final themes and categories were agreed through consensus.

Results

We included MSFR attendances from 2019 (n = 5817). MSFRs were more likely to attend urgent category 1 and 2 calls (vs ambulance category 3: RRR 4.67, 95%CI 3.08 - 7.07 or category 4: RRR 8.85, 95%CI 1.09 - 71.75) and cardiorespiratory (vs ambulance RRR 0.44, 95%CI 0.35 - 0.56) or neurological/endocrine calls (vs ambulance RRR 0.55, 95%CI 0.41 - 0.74). MSFRs were more likely, compared to CFRs and ambulance staff, to be dispatched to younger patients, those from ethnic minorities and deprived areas.

We interviewed 16 MSFRs from 5 medical schools. Participants described routes, requirements and challenges to recruitment. Training, mentorship, shadowing and debriefing were helpful to the role. Despite the risks and stress, most MSFRs enjoyed and valued their experience for enhancing clinical knowledge and skills in emergency care and understanding the wider context of care delivery. MSFRs’ experience also helped prepare for a future career involving emergency care.

Conclusions

MSFR schemes provide a valuable contribution to prehospital care and beneficial experiences for medical students.

EP.TU.200Improving variable rate insulin infusion compliance in general surgery

Aims

1. Audit the current variable rate insulin infusion (VRII) practice per local guidelines.

2. Understand barriers to good VRII practice to create an intervention.

3. Re-Audit the VRII practice following intervention.

Methods

Junior doctors were surveyed using Likert scales (1 to 5: not at all confident to very confident) as well as closed and open questions. Chain action reaction (CAR) theory was used. Six domains were identified against a local proforma. Initial audit and questionnaire were collected from November 2019 to January 2020 and analysed using Microsoft Excel. Intervention consisted of a condensed one-page algorithm with group teaching. Re-audit data was collected between June 2020 to August 2020 for comparison.

Results

Questionnaire – 53.6% (15/28) of juniors responded. Challenges included conversion oral hypoglycaemics and complexity of the guidance. Group teaching and a condensed portable format were the most popular modalities for delivery of further education.

Initial Audit – 12 VRII charts were audited. 33.3% (4/12) were completed correctly. Areas of significant need for improvement were as follows: ensuring long-acting insulin is prescribed, transferring from a VRII back to oral medications and appropriate fluid prescribing.

Re-Audit – 18 charts were audited following intervention. Of these, 66.7% (12/18) were completed correctly. There was a significant improvement in appropriate fluid prescribing and long-acting insulin prescriptions.

Conclusions

Understanding the factors involved throughout the chain of how VRIIs are prescribed has helped to implement a positive intervention in our department. The improvement has been significant (100% better) however there is still further work required to improve compliance.

Risk assessment in hematology ward renovation, a FMEA example in a tertiary hospital in Italy

Background

Hospital construction and renovation works cause derangement, increasing mistake rate in healthcare workers and resulting in dust contamination and dispersal of fungal spores that could improve morbidity and mortality in severely immune suppressed patients. The necessary renovation of hematology ward at IRCCS Policlinico San Martino in Genoa, scheduled for February 2020 required a risk assessment to avoid logistical, organizational and clinical problems. Two possible scenarios were proposed: (1) displacement of patients in another building previously used as hematological unit or (2) department split in 2 sections to carry out renovation works in different periods. Risk management of the choice relies on failure mode and effects analysis (FMEA) method, a proactive tool based on risk priority number (RPN) that ranks failure modes in terms of occurrence, severity and detection. Aim of this work is to analyze and compare the two scenarios; a team of experts in Public health with specific skills in risk management and hospital governance used FMEA to single out failure modes and to compute RPN.

Methods

Thirteen failure modes were combined together in four major possible risks: (a) lengthening waiting times and delay haematopoietic stem cell transplant procedures, (b) exposure to airborne contamination, (c) cross contamination and water contamination, (d) wrong behaviors. RPN was computed for each failure mode.

Results

Relevant failure modes were: reduction of bedsides in both scenarios (7 bedsides lost in first scenario RPN1 540 vs 9 bedsides lost in second scenario RPN2 630), less air exchange/hour in the first scenario (4/h RPN1 500 vs 6/h RPN2 400) balanced by closeness to the work site in the second scenario(RPN2 500). First scenario total RPN was 2430, second scenario was 3250.

Conclusions

Using FMEA, we assessed the different risks profile of two scenarios. Although some residual risks persisted, the first scenario shows a lower risk profile for all major risks.

Key messages

Risk assessment is a key element to better understand hospital problems and improve environmental health in healthcare setting FMEA represents a useful tool to guide hospital manager in difficult choices concerning severely immune suppressed patients.

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.

RSV burden among hospitalized patients: 6-years surveillance of Liguria regional reference lab

Background

Respiratory syncytial virus (RSV) represents one of the most common agent causing respiratory infections in infants and adults. It causes seasonal epidemics, with a peak prevalence in winter. RSV epidemiology and burden are still under-recognized, although it leads to complications and increased mortality in patients at risk, such as infants, pregnant women, the elderly and patients with chronic diseases.

Materials/Methods

Data analyzed in this study were collected during the virological surveillance system activities at the Policlinico San Martino university hospital in Genoa, Italy. The regional reference laboratory receive swabs from all Liguria region, and detects the main circulating respiratory viruses by using molecular methods. The proportion rate of RSV (subtypes A and B) positive samples was determined in the period January 2013 - December 2018, stratifying data by gender, age and hospital units.

Results

From January 2013 to December 2018, 14911 swabs were analyzed, 585 patients reported at least once RSV positive respiratory sample. The median age of RSV positive patients was 56 years (IQR 27-71), with a males: females ratio of 0.93: 1. The peak RSV infection period occurred mainly during first quarter, confirming the seasonal trend of the virus. Greatest proportion of RSV positive samples were received from hematology-oncology wards (45.2% of isolations) and medicine units (31.9%). From 2013 to 2018 an increase of swabs collection of 207% was observed. Neonatology and pediatrics resulted in the highest rate of positive swabs (above 30%), hemato-oncology departments collected 7932 swabs with 3,3 % resulted positive.

Conclusions

A virological surveillance system able to detect the principal respiratory viruses circulating in adult population is a key element to better understand the RSV epidemiology and evaluate therapeutical strategies, in view of the availability of effective vaccines able to prevent RSV infection in the next future.

Key messages

RSV represents a leading cause of respiratory disease in hospitalized patients, especially in hematology-oncology, medicine and intensive care unit wards. Virological surveillance is a key element to better understand RSV epidemiology in all ages, in view of the availability of new effective vaccines.

How should vaccination services be planned, organized, and managed? Results from a survey on the Italian vaccination services

BACKGROUND

Quality improvement is an increasingly recognized approach to maximize service effectiveness and minimize costs in public health. However, the Italian law never provided for the institutional accreditation of vaccination services. Furthermore, a recently approved law added six more compulsory vaccinations to the original four, which has led to a considerable increase in vaccination efforts, without any previous resources evaluation. The aim of the study was to investigate structural, organizational and managerial characteristics of the Italian vaccination services, in order to suggest the adoption of adequate quality standards.

STUDY DESIGN

A survey involving the representatives of the Italian Regions and Autonomous Provinces was performed between September 2017 and September 2018.

METHODS

An online questionnaire, including 26 items, designed to evaluate the structural, organizational and managerial characteristics of vaccination services was administered. The correlation between the number of vaccination centres and the coverage for each region was used to evaluate the performance of the vaccination services.

RESULTS

Respondents from seven Regions, totaling >15,000,000 inhabitants, answered the questionnaire. Overall, each vaccination service was potentially accessed by an average of 519 children aged zero to 24 months, with a β-coefficient of -0.87 (p = 0.01) for infant vaccination coverage in 2016. Eighty-five percent of vaccination services were provided with architectural features to accommodate the disabled but only 49% provided reserved parking lots. An average of 0.4 physicians and 0.6 other healthcare workers per 10,000 inhabitants were employed in vaccination services, with complete computerization in 74% of them.

CONCLUSION

The inverse relation between vaccination services' spatial accessibility and vaccination coverage suggests that distance and accessibility of vaccination services should be considered in planning. This survey constitutes a baseline data for Italian vaccination services that could be useful for decision makers in establishing minimum requirements to provide high-quality preventive healthcare service.

Hexavalent vaccines: characteristics of available products and practical considerations from a panel of Italian experts

Combination vaccines represent a valuable technological innovation in the field of infectious disease prevention and public health, because of their great health and economic value from the individual, societal, and healthcare system perspectives. In order to increase parents' and healthcare professionals' confidence in the vaccination programs and maintain their benefits to society, more information about the benefits of innovative vaccination tools such as combination vaccines is needed. Purpose of this work is an examination of available hexavalent vaccines, that protect against Diphtheria, Tetanus, Pertussis, Poliomyelitis, Hepatitis B and Haemophilus influenzae type b infections. From the epidemiological updates of vaccine preventable diseases to the vaccine development cycle, from the immunogenicity of antigenic components to the safety and co-administration with other vaccines, several aspects of available hexavalent vaccines are discussed and deepened. Also a number of practical considerations on schedules, age of employment, strategies for vaccination recovery, vaccination in at-risk births are issued, based on the recommendations of Italian Ministry of Health, Italian Society of Pharmacology (SIF), Italian Society for Pediatrics (SIP), Italian Federation of Family Paediatricians (FIMP) and Italian Society of Hygiene, Preventive Medicine and Public Health (SItI).

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.

Determinants of adherence to seasonal influenza vaccination among healthcare workers from an Italian region: results from a cross-sectional study

OBJECTIVES

Notwithstanding decades of efforts to increase the uptake of seasonal influenza (flu) vaccination among European healthcare workers (HCWs), the immunisation rates are still unsatisfactory. In order to understand the reasons for the low adherence to flu vaccination, a study was carried out among HCWs of two healthcare organisations in Liguria, a region in northwest Italy.

METHODS

A cross-sectional study based on anonymous self-administered web questionnaires was carried out between October 2013 and February 2014. Through univariate and multivariate regression analysis, the study investigated the association between demographic and professional characteristics, knowledge, beliefs and attitudes of the study participants and (i) the seasonal flu vaccination uptake in the 2013/2014 season and (ii) the self-reported number of flu vaccination uptakes in the six consecutive seasons from 2008/2009 to 2013/2014.

RESULTS

A total of 830 HCWs completed the survey. Factors statistically associated with flu vaccination uptake in the 2013/2014 season were: being a medical doctor and agreeing with the statements 'flu vaccine is safe', 'HCWs have a higher risk of getting flu' and 'HCWs should receive flu vaccination every year'. A barrier to vaccination was the belief that pharmaceutical companies influence decisions about vaccination strategies.

DISCUSSION

All the above-mentioned factors, except the last one, were (significantly) associated with the number of flu vaccination uptakes self-reported by the respondents between season 2008/2009 and season 2013/2014. Other significantly associated factors appeared to be level of education, being affected by at least one chronic disease, and agreeing with mandatory flu vaccination in healthcare settings.

CONCLUSIONS

This survey allows us to better understand the determinants of adherence to vaccination as a fundamental preventive strategy against flu among Italian HCWs. These findings should be used to improve and customise any future promotion campaigns to overcome identified barriers to immunisation.

Available influenza vaccines: immunization strategies, history and new tools for fighting the disease

The main public health strategy for containing influenza-related disease is annual vaccination, which is recommended for the elderly and others belonging to risk-factor categories, who present the highest morbidity and mortality, as reported by the World Health Organization (WHO) Recommendations. The availability of different influenza vaccine formulations makes the choice of the best immunization strategy a challenge for stakeholders and public health experts. Heterogeneity in at-risk categories included in national influenza vaccine recommendations still exists, in particular among European countries. Broader consensus is expected, which should positively impact on influenza vaccination coverage. The availability of quadrivalent vaccines, containing both influenza B lineages, offers the potential to improve protection by overcoming the drawbacks of wrongly predicting which B lineage will predominate in a given year.

Pneumococcal vaccination strategies in adult population: perspectives with the pneumococcal 13 - valent polysaccharide conjugate vaccine

Streptococcus pneumoniae (Sp) is a leading cause of infection in people of all ages worldwide, determining a significant impact because of its relatively high incidence rate, the associated economic costs, and the high case-fatality rates. More attention has to be paid for elderly and people with one or more risk factors, in order to reduce health costs and pneumococcal hospital admissions. Moreover, the increasing incidence of antibiotic-resistant Sp strains is a source of concern for its relevant clinical importance in health-care settings. At present, the 23-valent polysaccharide (PPV23) vaccine has shown some limits in terms of protection in the elderly population and against invasive diseases, among adults affected with chronic diseases, non-bacteriemic pneumonias and with immune suppression, in particular in adults with HIV. In December 2011, FDA licensed the 13-valent pneumococcal conjugate vaccine (PCV13) for prevention of pneumonia and invasive diseases (IPDs) in adults aged ≥50 years. The same decision was concomitantly assumed in Europe by EMA. PCV13 has shown superior results both in terms of immunogenicity and of adequate stimulation of a stable and long-lasting immunological memory. European recommendations for PCV13 vaccination in adults are still heterogeneous between Countries. The availability of PCV13 for adults offer a new and promising tool against Sp IPDs and non-IPDs, especially in elderly and at risk populations.

HPV related diseases in males: a heavy vaccine-preventable burden

Human Papillomavirus (HPV) has a significant impact in male's health, as cause of clinical manifestations ranging from genital warts to several cancers of the anogenital and aero-digestive tract. HPV types which most frequently affect men are 6, 11, 16 and 18, included in the HPV quadrivalent vaccine, recently approved for use in males by Food and Drug Administration (FDA) and European Medicines Agency (EMA). Although several data about the safety and efficacy of quadrivalent vaccine are available, the implementation of proper immunization plans dedicate to male's population cannot ignore the knowledge of the characteristics of the disease in men, which in some aspects should be clarify, in particular clearance of type-specific HPV infections and transmission dynamics. Purpose of this review is to summarise the main information about the burden and the natural history of the HPV related disease in males.

Dynamic and transient interactions of Atg9 with autophagosomes, but not membrane integration, are required for autophagy

Autophagy is a catabolic process essential for cell homeostasis, at the core of which is the formation of double-membrane organelles called autophagosomes. Atg9 is the only known transmembrane protein required for autophagy and is proposed to deliver membrane to the preautophagosome structures and autophagosomes. We show here that mammalian Atg9 (mAtg9) is required for the formation of DFCP1-positive autophagosome precursors called phagophores. mAtg9 is recruited to phagophores independent of early autophagy proteins, such as ULK1 and WIPI2, but does not become a stable component of the autophagosome membrane. In fact, mAtg9-positive structures interact dynamically with phagophores and autophagosomes without being incorporated into them. The membrane compartment enriched in mAtg9 displays a unique sedimentation profile, which is unaltered upon starvation-induced autophagy. Correlative light electron microscopy reveals that mAtg9 is present on tubular-vesicular membranes emanating from vacuolar structures. We show that mAtg9 resides in a unique endosomal-like compartment and on endosomes, including recycling endosomes, where it interacts with the transferrin receptor. We propose that mAtg9 trafficking through multiple organelles, including recycling endosomes, is essential for the initiation and progression of autophagy; however, rather than acting as a structural component of the autophagosome, it is required for the expansion of the autophagosome precursor.

Impact of influenza during the post-pandemic season: epidemiological picture from syndromic and virological surveillance

INTRODUCTION

Following the observation that 1 or 2 pandemic peak due to the circulation ofAHINlv had occurred in most countries and in most World Health Organization (WHO) Regions, WHO declared on August 10"h, 2010 that the world was moving into the post-pandemic period, whose surveillance presents considerable interest both from epidemiological and clinical point of view. We described the epidemiological picture emerged from syndromic and virological surveillance during the post-pandemic season in Liguria, Italy.

MATERIALS AND METHODS

An Emergency Department Syndrome surveillance system, based on data collected at "San Martino" and IRCCS "G. Gaslini" Liguria Regional Reference University Hospitals for adults and children is active since July 2007. Monitored syndromes include "Influenza-Like Illness" (ILl) and "Low Respiratory Tract Infections" (LRTI). The Ligurian Regional Reference laboratory for Influenza virological surveillance and diagnosis offers rapid detection of influenza viruses by real-time and block RT-PCR, viral culture and genetic characterization by entire sequence analysis of haemagglutinin- and neuraminidase-coding regions in accordance with the international standards established by the global laboratory network.

RESULTS AND DISCUSSION

The integration of syndromic surveillance system and laboratory surveillance for rapid detection and characterization of the disease responsible agent represented a specific and sensitive tool for influenza surveillance. The post-pandemic season was characterized by early onset and by the heaviest impacts for ILI and LRTI among the recent epidemic seasons. In contrast to the picture observed during the pandemic season, the 2010/11 winter was characterized by the intensive circulation of pandemic AH1N1v coupled with sustained activity due to influenza B and Respiratory Syncytial Virus (RSV). Antigenic and molecular characterization of influenza strains confirmed the good matching between circulating and 2010/11 vaccine viruses.

Epidemiological and molecular approaches for management of a measles outbreak in Liguria, Italy

Since March 2010 a measles outbreak has been occurred in Genoa, Liguria, an administrative Region in Northern Italy. Epidemiological and molecular data on the outbreak, obtained from the passive mandatory notification system, the laboratory surveillance and an innovative syndrome surveillance system, were investigated. Overall 39 cases were reported in the urban area. Information about demography, vaccination status, hospitalization and geographic distribution of measles cases are available. 19 cases (48.7%) were laboratory-confirmed and were characterized by sequence analysis: 18 strains belonged to genotype D8, so identifying a new measles variant within the Liguria population. Adopted control measures seem to have limited viral circulation. The outbreak allowed to test the efficacy of the 3 surveillance systems active in Liguria, highlighting their advantages and some important limitations. More efforts are needed to collect and integrate any epidemiological and virological available data in order to better describe the local measles transmission dynamics.

[A cross-sectional survey on childhood immunization coverage and reasons of non-compliance in Lazio Region, Italy (2007)]

During 2007, Laziosanità conducted a cross-sectional survey on childhood immunization coverage in Lazio Region. The survey, implemented in collaboration with the 12 LHUs of the Region, aimed at assessing immunization coverage among children, with 24 months of age or older, at regional and district level. In addition, the survey assessed reliability of the routine surveillance system and immunization records at peripheral level. Finally, delay in immunization schedule, and major reasons for non-compliance, as reported by the mothers, were analyzed. The survey results allowed to identify weakness in the routine surveillance system, low coverage levels for specific LHUs, and strategies for improvement of immunization coverage.

[Quality of post-discharge growth in small for gestational age preterm infants: an explorative study]

OBJECTIVES

The Preterm newborns, especially if born small for gestational age (SGA), appear to be at risk for developing post-natal growth failure and an altered body composition. Nutrition-related growth during a critical window in infancy may affect the development of metabolic syndrome in adult life. Aim of the present study was to test the hypothesis that the post-discharge period is critical for programming the catch up growth and the later development of metabolic syndrome in small for gestational-age infants fed either standard or enriched formula.

METHODS

A clinic randomized explorative study was conducted. Twenty-seven preterm SGA infants (gestational age < or = 33 weeks; birth weight < or = 1500 g) underwent assessment of growth and body composition by means of an air displacement system at 36 weeks, 15 days and 1 months adjusted age. SGA infants were randomized to receive standard formula (Kcal: 67/100 ml, proteins: 1,4 g/100 ml) or enriched formula (Kcal: 75/100 ml, proteins: 2 g/100 ml) after discharge.

RESULTS

No differences in weight, fat mass, length and head circumference were found in SGA infants fed standard formula as compared to those fed enriched formula at 15 day or 1 months adjusted age.

CONCLUSIONS

This explorative study suggests that in SGA infants growth, both in terms of quantity and quality, is not influenced by different nutritional management during the early post-discharge period.

Emergency department syndromic surveillance system for early detection of 5 syndromes: a pilot project in a reference teaching hospital in Genoa, Italy

Early detection is fundamental for achieving effective control of infectious disease outbreaks. We described the development of a local chief complaint emergency department (ED)-based syndromic surveillance system to improve public health response in Genoa, Italy. The five syndromes under investigation by the syndromic surveillance system were influenza-like illness (ILI), low-respiratory tract illness (LRTI), not-haemorrhagic gastroenteritis, acute hepatitis, fever-with-rash (maculo-papular or vescicular) syndrome. Syndrome coding, data capture, transmission and processing, statistical analysis to assess indicators of disease activity and alert thresholds, and signal response were operatively described. Preliminary results on ILI syndromic surveillance showed that new system allowed the activation of the alert state with a specificity of 90.3% and a sensitivity of 72.9% in predicting epidemiological relevant events, such as > or = 10 accesses to ED for ILI in 3 days. The new syndromic surveillance system allowed to alert the public health institutions 2.5 days before than the local surveillance system based on sentinel physicians and paediatricians, permitting the early activation of the necessary measures for the containment and for burden reduction of the epidemic event. It is noteworthy that the syndromic surveillance epidemic cut-off was overcome once before and 4 times after influenza outbreak detected by sentinel-based surveillance system: all episodes were contemporary with Respiratory Syncytial Virus and Parainfluenza Virus circulation, as detected by regional reference laboratory.

[Body composition in small for gestational age newborns]

OBJECTIVES

Aim of the present study was to test the hypothesis that the body composition of small for gestational age preterm infants, assessed at term equivalent age, was different as compared to that of small for gestational age full-term newborns.

METHODS

Growth parameters and body composition, assessed by means of an air displacement pediatric plethysmography system, was measured in 120 newborns (67 preterm and 53 full-term).

RESULTS

Similar weight was found in preterm and full-term newborns at term equivalent age and at birth, respectively. On the contrary, percentage of total body fat mass was significantly higher in preterm newborns as compared to full-term newborns (14.3 +/- 4.7% vs. 5.7 +/- 3.8% respectively, P < 0.05). In the preterm group gestational age was negatively associated with total fat mass at term equivalent age. CONCLUSIONS. The preterm newborns, especially if born small for gestational age, appear to be at risk for developing an altered body composition, which is a risk factor for the development of the metabolic syndrome in adult life. Preterm infants, born small for gestational age, appear to develop a quantity of fat mass higher than the adipose tissue they would have accumulated if they had completed their intrauterine gestation. The gestational age and the nutritional management in the early postnatal life could play a key role in affecting the body composition in these vulnerable infants.

[Quality of growth in preterm infants assessed at term equivalent age: a pilot study]

BACKGROUND

The American Academy of Pediatrics (AAP) recommends that preterm infants' growth duplicates fetal growth rates and that body composition replicates in utero body composition. Aim ofthe study was to compare the total body fat mass between preterm infants assessed at term and full-term newborns.

METHODS

A prospective observational study was conducted. Forty-five preterm infants (mean (SD) gestational age: 30,1 (2.3) weeks; birth weight: 1125 (280) g), and 40 full term (mean (SD) 38.5 (1.2) weeks, 3203 (385) g, breast fed infants underwent assessment of growth and body composition by means of an air displacement system at term adjusted-age and on day 3 of life, respectively. A T test was used to compare % fat mass between preterm and term infants.

RESULTS

Weight, length and head circumference were smaller in the preterm group assessed at term adjusted-age as compared to the term group. Mean (SD) percentage of fat mass in preterm infants was significantly higher as compared to term infants [14.5 (4.3) vs 7,6 (3.6), P < 0.0001].

CONCLUSIONS

Our data demonstrate that preterm infants are at risk of developing an increased adiposity in addition to postnatal growth retardation.

Novel PTEN mutations in neurodevelopmental disorders and macrocephaly

Somatic mutations of the phosphatase and tensin (PTEN) gene have been frequently detected in many types of human cancer. However, germline mutations can determine multiple hamartoma syndromes and, as more recently ascertained, syndromes clinically characterized by autism associated with macrocephaly. To determine whether germline mutations of PTEN may lead to different phenotypes, we screened all the nine exons of the PTEN gene in 40 patients with neurodevelopmental disorders, with or without features of autism spectrum disorder, associated with macrocephaly. Three novel de novo missense mutations were found (p.H118P, p.Y176C, p.N276S) in two severely mentally retarded patients with autism and in a subject with neurodevelopmental disorders without autistic features. Our results provide evidence that PTEN germline mutations may sustain a more wide phenotypical spectrum than previously suggested.

Molecular epidemiology and case-control approaches for management of an outbreak of hepatitis A in Liguria, Italy

INTRODUCTION AND METHODS

Hepatitis A remains an important public health problem in low endemicity areas, because of the social and economic high burden of cyclical outbreaks. In this study we described an outbreak of HAV infection occurred in the city of Genoa and in its proximity and the viral circulation in the post-epidemic period. In order to identify risk factors associated to the illness and to determine the source of infection and the dynamics of virus evolution, we conducted an epidemiological and molecular investigation by a case-control study and by sequence analysis of high variable regions of the genome.

RESULTS

From May to October 2005, 58 HAV hepatitis cases were notified. The case-control study showed that beach establishment attending is strongly associated with HAV hepatitis (OR = 24.5, p-value < 0.01), at multivariate analysis. The profile of epidemic curve, the clinical onset of primary cases who occurred in few weeks and the geographic distribution of cases clearly indicated a common exposure to a point source: the outbreak can be probably associated with a contaminated food product dispensed in the affected area. The outbreak has been mainly caused by a single variant, confirming the common exposure to a point source; this variant previously circulated within homosexual man (MSM) network in Northern Europe. During the outbreak and in the following months, different variants originating from Southeast Asia, Southern America and Northern Africa, have co-circulated: all these cases were related to international travel and none of these had determined secondary cases.

DISCUSSION

The epidemiological picture of hepatitis A in Liguria is characterized by a wide heterogeneity of circulating HAV strains. This pattern could be associated with the increase of imported cases and transmission within network of persons with similar risk factors. Molecular approach coupled to descriptive and analytical epidemiological studies appeared un-replaceable tools for management and control of HAV outbreaks, because of their capacity to recognize infection origin, transmission patterns and dynamics of virus evolution.

Neurocutaneous syndrome with mental delay, autism, blockage in intracellular vescicular trafficking and melanosome defects

We evaluated a 11-year-old male patient with mental delay, autism and brownish and whitish skin spots. The former resembled those of neurofibromatosis, the latter those of tuberous sclerosis. The patient received a complete clinical work-up to exclude neurofibromatosis, tuberous sclerosis, or any other known neurocutaneous disease, with biochemistry, chromosome analysis and analysis of skin specimens. Being all the other tests not significant, two main ultrastructural defects were observed. The first was a blockage in intracellular vescicular trafficking with sparing of the mitochondria; the second an aberrant presence of melanosomes in vacuoles of several cell lines and abnormal transfer of these organelles to keratinocytes. This patient presented with a unique clinical picture distinct from neurofibromatosis or tuberous sclerosis or any other known neurocutaneous disease. The ultrastructural abnormalities suggested a defect in cell trafficking involving several cell lines and compartments.

Epstein-Barr virus-associated post-transplant lymphoproliferative disease with central nervous system involvement after unrelated allogeneic hematopoietic stem cell transplantation

Post-transplant lymphoproliferative disorders (PTLD) represent an heterogeneous group of abnormal lymphoid proliferation related to Epstein-Barr virus (EBV) reactivation that arise early after allogeneic hematopoietic stem cell transplant (HSCT). PLTD with central nervous system (CNS) involvement has been reported in few cases. We describe the case of a 31-year-old-man who developed an EBV-related PTLD with CNS involvement 2 months after an allogeneic unrelated HSCT for acute myeloid leukemia in first complete remission who was successfully treated with rituximab, cidofovir and intrathecal infusion of methotrexate and methylprednisolone.

Role of individual disulfide bonds in the structural maturation of a low molecular weight glutenin subunit

Gliadins and glutenins are the major storage proteins that accumulate in wheat endosperm cells during seed development. Although gliadins are mainly monomeric, glutenins consist of very large disulfide-linked polymers made up of high molecular weight and low molecular weight subunits. These polymers are among the largest protein molecules known in nature and are the most important determinants of the viscoelastic properties of gluten. As a first step toward the elucidation of the folding and assembly pathways that lead to glutenin polymer formation, we have exploited an in vitro system composed of wheat germ extract and bean microsomes to examine the role of disulfide bonds in the structural maturation of a low molecular weight glutenin subunit. When conditions allowing the formation of disulfide bonds were established, the in vitro synthesized low molecular weight glutenin subunit was recovered in monomeric form containing intrachain disulfide bonds. Conversely, synthesis under conditions that did not favor the formation of disulfide bonds led to the production of large aggregates from which the polypeptides could not be rescued by the post-translational generation of a more oxidizing environment. These results indicate that disulfide bond formation is essential for the conformational maturation of the low molecular weight glutenin subunit and suggest that early folding steps may play an important role in this process, allowing the timely pairing of critical cysteine residues. To determine which cysteines were important to maintain the protein in monomeric form, we prepared a set of mutants containing selected cysteine to serine substitutions. Our results show that two conserved cysteine residues form a critical disulfide bond that is essential in preventing the exposure of adhesive domains and the consequent formation of aberrant aggregates.

Simvastatin-associated memory loss

The statins are widely used to treat dyslipidemias. They are generally associated with mild adverse effects, but rarely, more serious reactions may occur. A 51-year-old man experienced delayed-onset, progressive memory loss while receiving simvastatin for hypercholesterolemia. His therapy was switched to pravastatin, and memory loss resolved gradually over the next month, with no recurrence of the adverse effect.

Additional case of Marden-Walker syndrome: support for the autosomal-recessive inheritance adn refinement of phenotype in a surviving patient

In this report, we present a 14-year-old girl, born to consanguineous parents, who presented with severe mental retardation, hypotonia, short stature, and congenital joint contractures. The craniofacial features were scaphocephaly, thin/long and immobile face, marked hypoplasia of the midface, temporal narrowness, blepharophimosis, palpebral ptosis, and strabismus. The combination of such a distinctive craniofacial appearance and psychomotor retardation allows us to recognize a new case of the Marden-Walker syndrome. Our patient represents one of the rare cases in which consanguineous mating supports the autosomal-recessive pattern of inheritance of this condition. Furthermore, through refining the phenotype of a surviving patient, this report may contribute to a better recognition of this disorder in older affected children.

Continuous exposure to high concentrations of nitric oxide leads to persistent inhibition of oxygen consumption by J774 cells as well as extraction of oxygen by the extracellular medium

Nitric oxide (NO) plays a key role in many physiological and pathophysiological events, including the control of cell respiration. Both reversible and irreversible inhibition of mitochondrial respiration have been reported following the generation of NO by cells. We have exposed the murine macrophage cell line J774 to high concentrations of NO, such as are generated in some pathological conditions, and determined their effect on oxygen consumption. We observed a persistent inhibition of respiration which was due to a redox-dependent, progressive inhibition of complex I activity. No other enzyme of the respiratory chain was inhibited in this way. At the same time, we detected a paradoxical removal of oxygen by the extracellular medium. This removal was due to a chemical interaction between dissolved oxygen and NO-related species released from cells exposed to NO. A similar removal of oxygen by the cell supernatant also occurred following activation of cells with cytokines and bacterial products. Thus, the amounts of NO generated during pathological conditions may contribute to tissue hypoxia both by inhibiting cell respiration and by promoting removal of oxygen from the extracellular medium.

Strongyloides stercoralis: ultrastructural study of newly hatched larvae within human duodenal mucosa

AIM

To investigate the ultrastructural features of the newly hatched larvae of Strongyloides stercoralis in human duodenal mucosa.

METHODS

Duodenal biopsies from an AIDS patient were studied by transmission electron microscopy to investigate morphology, location, and host-worm relations of newly hatched larvae.

RESULTS

Newly hatched larvae were found in the Lieberkuhn crypts within the tunnels formed by migration of parthenogenic females. Delimiting enterocytes were compressed. Release of larvae into the gut lumen was also documented. It was shown that both a thin and a thick membrane surrounded the eggs and larvae, as a tegument derived respectively from parasite and host. Segmentary spike-like waves, caused by contractures of worm body musculature, were observed on the surface of newly hatched larvae, and their intestinal lumen was closed and empty, with no budding microvilli. Immaturity of the cuticle and some degree immaturity of amphidial neurones were found, but there was no evidence of either immaturity or signs of damage to other structures.

CONCLUSIONS

Newly hatched larvae of S stercoralis appear to be a non-feeding immature stage capable of active movement through the epithelium, causing mechanical damage. The tegument resulting from the thin and the thick membrane may protect the parasite and reduce any disadvantage caused by immaturity.

Persistent damage to Enterocytozoon bieneusi, with persistent symptomatic relief, after combined furazolidone and albendazole in AIDS patients

AIM

To investigate morphological changes in Enterocytozoon bieneusi and the duration of symptomatic relief after combination treatment with furazolidone and albendazole in AIDS patients.

METHODS

Four severely immunocompromised AIDS patients with symptomatic E bieneusi infection of the gut received an 18 day course of combined furazolidone and albendazole (500 + 800 mg daily). All patients were monitored for parasite shedding in stool by light microscopy at the end of treatment and monthly during follow up. At the end of treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists blind to the patients' treatment or clinical outcome. Duodenal biopsy specimens obtained from one of the patients two months after completion of treatment were also studied electronmicroscopically.

RESULTS

All patients had long lasting symptomatic relief, with a major decrease--or transient absence--of spore shedding in stools from completion of treatment. After treatment, changes in faecal spores were persistently found by light microscopy in all cases, and there was evidence of both a substantial decrease in the parasite load and ultrastructural damage in the parasite in all biopsy specimens. The treatment was well tolerated, and no patient had clinical or parasitological relapse during follow up (up to 15 months).

CONCLUSIONS

The long lasting symptomatic relief observed in all four treated patients correlated with the persistent decrease in parasite load both in tissue and in stool, and with the morphological changes observed in the life cycle of the protozoan. These data suggest that combined treatment with furazolidone and albendazole is active against E bieneusi and may result in lasting remission even in severely immunocompromised patients.

Chronic cryptosporidiosis in patients with AIDS: stable remission and possible eradication after long-term, low dose azithromycin

AIMS

To investigate the effectiveness of long term, low dose azithromycin treatment for chronic cryptosporidiosis in patients with AIDS.

METHODS

Azithromycin was administered as initial daily treatment to 13 patients with AIDS: 6 patients received 500 mg for 30 to 40 days (mean 35); 3 patients received 1000 mg for 21 to 50 days (mean 37); and 4 patients received 1500 mg for 20 days. Nine of the 13 patients were also given low dose maintenance treatment with different schedules of azithromycin for 30 to 360 days (mean 129). Patients were monitored, during and after treatment, for parasite shedding in stool and for daily stool frequency and body weight. All but one patient had severe immunodeficiency.

RESULTS

Long term, low dose maintenance treatment was associated with major clinical and parasitological benefits: there was probable eradication of infection in 2 patients, and 7 patients showed a complete response with persistent high decrease (5 patients) or clearance (2 patients) of parasite in stool. The drug was well tolerated, and there was no relapse either during treatment or during follow up (up to 21 months). These results were more impressive than those observed after the short term initial course of azithromycin, which was unable at any tested dose to achieve parasite clearance in stool (except in the patient with less advanced immunodeficiency) or to prevent relapse in 3 patients who discontinued treatment. Reversible side effects occurred with the 1500 mg daily dose.

CONCLUSIONS

Long term, low dose azithromycin is well tolerated and may induce stable remission of chronic cryptosporidiosis in patients with AIDS. It may lead to probable eradication of the infection in some patients, even those with severe immunodeficiency.

Enterocytozoon bieneusi in AIDS: symptomatic relief and parasite changes after furazolidone

AIMS

To investigate changes in morphology of the developmental stages of Enterocytozoon bieneusi and symptomatic relief observed in AIDS patients after treatment with furazolidone.

METHODS

Six AIDS patients with symptomatic E bieneusi infection of the small intestine were treated with a course of furazolidone. All patients had a weekly monitoring of parasite shedding in stool by light microscopy during and after treatment. At the end of the treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists who were unaware of the patients' treatment.

RESULTS

All patients showed both clinical and parasitological response with transient clearance or decrease of spore shedding in stool. After treatment, alterations in faecal spores were observed in all patients by light microscopy, and ultrastructural changes in E bieneusi at all stages of the life cycle were demonstrated in biopsy specimens of the three patients who underwent post-treatment endoscopy.

CONCLUSIONS

The clinical benefit seen after treatment with furazolidone in six AIDS patients with E bieneusi intestinal infection may be due to damage to the developmental stages causing a partial inhibition to reproduction of the parasite.

Microflora persistence on duodenojejunal flat or normal mucosa in time after a meal in children

A pathogenic role for high numbers of bacteria in the small intestine had been suggested previously by bacterial counts on luminal aspirates, but these investigations were flawed by the sampling device "contamination" in the mouth and the changing nature of fluent intestinal content. A procedure was developed to sterilize the Watson biopsy capsule with HCl in the upper portion of the duodenum. Bacteria were counted in the mucosal homogenate of the first (diagnostic) duodenojejunal biopsy in 80 untreated celiac children, and in 46 children with irritable bowel syndrome (IBS) in a four-cell, controlled, randomized investigation. Persistence of bacteria on the mucosa for 20 h after the last meal was investigated in 62 subjects, and for 26 h after the last meal in 64 subjects. Bacteria, mainly streptococci and staphylococci, persisted at a concentration of 10(6) per gram of mucosa 20 h after the last meal. The number of bacteria per gram of mucosa was 24 times higher in all 62 children of the 20-h fast groups than in all 64 children of the 26-h fast groups (p < 0.001). The bacteria count in celiac children was 39 times higher in the 20-h fast group than in the 26-h one. This difference was significantly higher than the 11 times difference that was found on the normal mucosa between the 20- and 26-h fast IBS groups (p < 0.001), which was still significant. The number of bacteria on duodenojejunal mucosa depends on nutrient absorption and persists longer than the intermeal interval in these subjects.