Unilateral segmental presentation and a novel EPHB4 gene variant in capillary malformation-arteriovenous malformation type 2

Capillary malformation-arteriovenous malformation is a rare autosomal dominant disorder associated with EPHB4 loss-of-function mutations. We report the unique presentation of a 6-year-old girl with multiple capillary malformations in a unilateral segmental distribution affecting the right hemiface, right upper chest, and right arm associated with overgrowth. Targeted next-generation sequencing on a tissue sample revealed a novel heterozygotic variant in the EPHB4 gene (NM_004444.5 (EPHB4): c.715T>A, p.[Cys239Ser]). This case highlights a distinct presentation of CM-AVM type 2 and showcases a new variant in EPHB4 not previously reported in the literature.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Efficacy and tolerability of the American Heartworm Society therapeutic protocol in dogs affected by heartworm disease without caval syndrome

OBJECTIVES

The American Heartworm Society medical protocol represents the current standard of therapy for canine heartworm disease without caval syndrome. However, data on the tolerability of this protocol are limited. This study aimed to describe efficacy and prevalence of possible treatment-related side effects in dogs with heartworm disease treated using the American Heartworm Society protocol.

MATERIALS AND METHODS

For this retrospective multi-centre cohort study, dogs diagnosed with classes 1 to 3 heartworm disease that completed the American Heartworm Society medical protocol were searched in four medical databases. Demographic, clinical, diagnostic, therapeutic and outcome data, including the number and type of possible treatment-related side effects, were retrieved.

RESULTS

Thirty-five dogs were included. The median age and bodyweight were 6 years (1 to 13 years) and 17.3 kg (4.9 to 50 kg), respectively. Heartworm disease was classified as classes 1, 2 and 3 in 20 of 35, 11 of 35 and four of 35 dogs, respectively. In addition to the therapeutic recommendations of the American Heartworm Society, eight of 35 dogs underwent sedation to favour melarsomine administration, and 30 of 35 received ice at the injection site. After adulticide therapy, all dogs were hospitalised with cage rest [median time 12 hours (6 to 48 hours)]. All dogs survived the treatment. All dogs with long-term follow-up (32/35) became negative. Furthermore, treatment-related side effects were rare, mild and rapidly recovered without the need for supporting therapies; these included depression/lethargy (4/35 dogs), cough (2/35 dogs) and lameness, pain and gastrointestinal signs (1/35 dog each).

CLINICAL SIGNIFICANCE

The American Heartworm Society medical protocol is efficient and safe in dogs with classes 1 to 3 heartworm disease.

Transient myocardial thickening: a retrospective analysis on etiological, clinical, laboratory, therapeutic, and outcome findings in 27 cats

INTRODUCTION/OBJECTIVE

Transient myocardial thickening (TMT) in cats is a poorly characterized clinical entity. Therefore, this study aimed to provide descriptions of additional cats diagnosed with this clinical phenomenon.

ANIMALS, MATERIALS, AND METHODS

For this multicenter observational retrospective study, cats diagnosed with TMT were searched in three medical databases. TMT was defined for cats with at least two echocardiograms showing an increased end-diastolic left ventricular wall thickness (LVWTd; i.e. ≥6 mm) at presentation and subsequent echocardiographic normalization (i.e. LVWTd <5.5 mm). Signalment, history, clinical, laboratory, therapeutic, and outcome data were retrieved.

RESULTS

Twenty seven cats were included. The median age was 3 years. In 9/27 cats, an antecedent event was documented. At admission, 27/27 cats had evidence of myocardial injury (median value of cardiac troponin I 5.5 ng/mL), 25/27 cats had congestive heart failure, 13/27 cats had hypothermia, 8/27 cats had systemic hypotension, 7/27 cats had bradycardia, and 7/27 cats had electrocardiographic evidence of an arrhythmia. The median LVWTd was 6.4 mm. A potential cause of myocardial injury was identified in 14/27 cats. The median time from diagnosis to a significant reduction in LVWTd was 43 days.

DISCUSSION

TMT can be diagnosed in a wide range of cats, including young subjects. An antecedent predisposing event and/or a possible causative trigger can be identified in some. The reduction in LVWTd that defines this phenomenon usually occurs over a variable time frame.

CONCLUSIONS

This study represents the largest investigation of TMT in cats and provides additional information on this uncommon clinical entity.

Structured handoff to improve communication from inpatient to outpatient dialysis units: A quality improvement project

BACKGROUND

Patients with end-stage kidney disease requiring dialysis encounter high hospital readmission rates. One contributor is poor communication between hospitals and outpatient dialysis facilities. We hypothesized that improved communication may reduce 30-day hospital readmissions for patients on dialysis at an urban, safety net hospital.

METHODS

We created a standardized discharge handoff tool that is easy to use and provides concise data for dialysis centers. The handoff tool is a novel, electronic MACRO template (called a "dot-phrase") to be included in discharge documentation. Instructions for the dot-phrase and electronic facsimile (e-faxing) were sent to Internal Medicine residents immediately prior to their rotation on an inpatient Renal service. We then measured the intervention implementation rate and its impact on hospital readmission metrics.

RESULTS

We compared 3 months of preintervention and 6 months of postintervention data, identifying 82 and 135 index discharges in each respective study period. Patients were predominantly male (56.2%) and receiving hemodialysis (89.8%); a minority (9.2%) were undomiciled at the time of discharge. Mean age was 60.5 years (SD 14.0). Renal discharges followed by 30-day Renal readmission were not statistically lower in the postintervention group for the index discharge alone (26.8% vs. 20.0%, p = 0.12), but were for overall discharges (51.2% vs. 25.7%, p < 0.0001). The dot-phrase was used in 95.4% of discharge summaries, and 74.7% of discharge summaries were e-faxed within 24 h of discharge.

CONCLUSION

There was high uptake of a standardized discharge handoff tool among Internal Medicine residents on a Renal inpatient service. Using a handoff tool and e-faxing may improve communication with outpatient dialysis centers and may reduce readmissions among some patients but is likely insufficient to fully address high readmission rates. Subsequent intervention iterations would benefit from further collaboration with outpatient dialysis units for customization of the handoff tool to meet local communication needs.

Allergy to lipid transfer proteins (LTP) in a pediatric population

Summary

Background. Lipid transfer proteins (LTP) are considered important plant food allergens in the Mediterranean area, but little is known about LTP allergy in pediatric age. Our aim was to characterize LTP allergy in children.Methods. We reviewed the clinical data from all children evaluated in our department with LTP allergy. From the 76 patients with LTP allergy, 26c hildren were included, 50% female, median age 10 years (1-17). Symptoms included urticaria in 58% (n = 15), anaphylaxis in 46% (n = 12) and OAS in 42% (n = 11). Results. Multiple reactions with different foods occurredin 69%. Cofactors were reported in 27% (n = 7). All patients had positive SPT to peach LTP extract and sIgE Pru p 3. No association between the occurrence of severe reactions and sIgE to Pru p 3 (p = 0.462), sIgE to Cor a 8(p = 0.896), SPT to peach LTP extract (p = 0.846) or the number of positive SPT to fruits/tree nuts (p = 0.972; p = 0.676) was found. Ninety-two percent of the patients tolerated fruits from Rosacea family without peel. Twelve percent reported reactions to new LTP containing foods during follow-up. LTP allergy can occur since early childhood. Conclusions. Since anaphylaxisis common and cofactors act as severity enhancers, it is fundamental to recognizeLTP allergy in children. Currently available diagnostic tests (SPT and sIgE) cannot accurately predict food tolerance or anticipate reaction severity.

Impact of Screening Mammography on Treatment in Young Women Diagnosed with Breast Cancer

BACKGROUND

There is little data exploring the impact of screening mammography on subsequent treatment in the 40-49-year age group with breast cancer. We sought to assess the association between frequency of mammography in young women and extent of surgery and chemotherapy required.

METHODS

An IRB-approved retrospective review was performed of patients diagnosed with breast cancer between ages 40 and 49 years from 1 January 2010 to 19 November 2018 within a single health system. Patients were grouped based on last screening 1-24 months prior to diagnosis (1-24 group), > 25 months prior to diagnosis (> 25 group), never screened, and > 25+ never screened (combination group). Multivariate logistic regression models were used to assess for associations between screening intervals and tumor and nodal stage, chemotherapy use, and extent of surgery.

RESULTS

Of 869 patients included for analysis, 20% were never screened, 60% screened 1-24 months, and 19% screened > 25 months prior to diagnosis. Compared with the 1-24 months group, the never-screened group, > 25 months group, and combined group were more likely to receive chemotherapy. The never-screened and combined groups were more likely to undergo mastectomy and/or axillary lymph node dissection. Of patients undergoing upfront surgery, the > 25 months and combined groups were more likely to receive adjuvant chemotherapy, while the never-screened and combined groups were more likely to have nodal disease.

CONCLUSION

Our findings support the initiation of screening mammography at age 40 years to reduce the risk of aggressive treatments for newly diagnosed breast cancers in this group.

External validation of a pediatric decision rule for blunt abdominal trauma

INTRODUCTION

Blunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast-enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.

METHODS

We conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non-pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.

RESULTS

A total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.

CONCLUSION

In a non-pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

AB0041 TO ESTIMATE THE PREVALENCE OF ACETABULAR OSSIFICATIONS IN THE ADULT POPULATION WITH ASYMPTOMATIC, MORPHOLOGICALLY NORMAL HIPS AT CT AND TO DETERMINE WHETHER THE PRESENCE OF LABRAL OSSIFICATIONS IS ASSOCIATED WITH PATIENT-RELATED OR HIP-RELATED PARAMETERS

Background:

In clinical practice, ossifications adjoining the acetabular rim are frequently seen in healthy-appearing hip joints, at all ages. The origin of these acetabular rim ossifications (ARO) is unclear. While ARO have been described by some authors as variants that may mimic marginal acetabular osteophytes, others have hypothesized that ARO may be the cause or the consequence of femoroacetabular impingement. Overall, the literature on ARO is limited, in particular in the healthy population, and their characteristics and origin not fully understood.

Objectives:

To estimate the prevalence of acetabular rim ossifications in the adult population with asymptomatic, morphologically normal hips at CT and to determine whether the presence of these ossifications is associated with patient-, or hip-related parameters.

Methods:

We prospectively included all patients undergoing thoracoabdominal CT over a 3-month period. After exclusion of patients with a clinical history of hip pathology and/or with signs of osteoarthritis on CT, we included a total of 150 hips from 75 patients. We analyzed the presence and the size of ossifications around the acetabular rim. The relationships between the size of acetabular rim ossifications and patient-related (sex, age, BMI), or hip-related parameters (joint space width, and cam- and pincer-type femoroacetabular impingement morphology) were tested using multiple regression analysis.

Results:

The prevalence of acetabular rim ossifications in this population of asymptomatic, non-osteoarthritic hips was 96% (95%CI=[80.1;100.0]). The presence of ossifications and their size were correlated between right and left hips (Spearman coefficient=0.64 (95%CI=[0.46;0.79]),p<0.05)).The size of acetabular rim ossifications was significantly associated with age (p<0.0001) but not with BMI (p=0.35), gender (p=0.05), joint space width (p≥0.53 for all locations) or any of the qualitative or quantitative parameters associated with femoroacetabular morphology (p≥0.34).

Conclusion:

Acetabular rim ossifications are highly prevalent in asymptomatic, non-osteoarthritic adult hips at all ages. Their size is not correlated with any patient-, or hip-related parameters except for the age. These findings suggest that ossifications at the acetabular rim, when present in isolation, should not be considered as signs of osteoarthritis or femoroacetabular impingement morphology.

References:

[1]J. W. T. Byrd, K. S. Jones, C. R. Freema. Surgical Outcome of Pincer Femoroacetabular Impingement With and Without Labral Ossification. Arthroscopy 2016; 32: 1022–1029.

[2]P. D. Byers, C. A. Contepomi, and T. A. Farkas. A post mortem study of the hip joint. Including the prevalence of the features of the right side. Annals of Rheumatic Diseases 1970; 29: 15–31.

[3]S. Ninomiya, A. Shimabukuro, T. Tanabe, Y. T. Kim, Y. Tachibana. Ossification of the acetabular labrum. Journal of Orthopaedics Science 2001; 5: 511–514.

Table 1.

Association between the average severity size of ossifications and patient-related, and hip-related parameters

Regression coefficientp- valuePatient-related parametersBMI0.020.35Age0.04<0.001Gender-0.430.05Joint space widthApical0.170.53Supero-medial0.170.65Supero-lateral0.060.82Cam morphotype parametersAngle alpha 450.000.81Offset0.090.34Pincer morphotype parametersAcetabular version angle-0.010.83Lateral center-edge angle0.020.56Acetabular index0.030.53Crossover sign0.260.41Posterior wall sign-0.250.47Figure 1.

Coronal reformats of CT examinations showing different sizes of labral ossifications in the posterosuperior quadrant (arrows). (a) No labral ossification, (b-c-d-e) Increasingly large labral ossification from left to right. Two lines are visible at the location of the ossification, formed by the contour of the acetabular rim and of the ossification (double line-sign).

Disclosure of Interests:

None declared

The child with a syndrome: considerations for management in the emergency department

Children with syndromes often access emergency services and they may present unique challenges for emergency clinicians. This issue reviews 3 pediatric syndromes-spina bifida, Down syndrome, and Marfan syndrome-each of which are associated with unique emergent conditions. Patients with spina bifida have chronic colonization of bacteria in the urine, and antibiotics are not always needed. Children with Down syndrome are at risk for neurologic injury with minor trauma; advanced imaging such as magnetic resonance imaging may be needed in select cases. For children in whom a connective tissue disorder is suspected, aortic dissection and spontaneous pneumothorax must be considered. This issue reviews the pitfalls in interpreting routine testing and discusses the diagnostic and therapeutic approaches helpful in evaluating children with syndromes.

Response in breast vs axilla after neoadjuvant treatment and implications for nonoperative management of invasive breast cancer

Improved imaging and neoadjuvant chemotherapy (NAT) have led to higher pathologic complete response rates (pCR) in patients with invasive breast cancer. This has questioned the necessity of surgery and axillary lymph node (ALN) dissection in these patients. Prospective clinical trials are implementing extensive core biopsies of the tumor bed of patients with clinical complete response as a means to identify and spare them breast surgery. In addition, it is anticipated that patients with pCR are most likely going to have no or minimal disease in ALN as well. To verify the feasibility of these trials, we performed a pathologic analysis of all our patients who have undergone NAT from 2009 to present. Using pathology data base, we identified 362 patients treated with neoadjuvant chemotherapy followed by surgery. Clinical and pathologic information including gross and microscopic descriptions as well as biomarker status was collected. pCR was 50% for patients with negative ALN pretreatment but only 28% for patients with positive ALN at diagnosis. Despite achieving pCR in the breast, up to 10% of patients with positive ALN and 1% with negative ALN had persistent disease. Eight percent of patients that were presumed to have no ALN disease either clinically and or by imaging were found to have metastatic carcinoma in ALN. The metastases were predominantly (80%) <5 mm, and not palpable on physical examination and or due to biopsy sampling error. pCR in breast and ALN directly correlated with tumor size, ALN disease, and Her2 positive and triple negative receptor phenotype. In breast cancer patients who are node positive at time of diagnosis with pCR in the breast after neoadjuvant chemotherapy, residual lymph node disease was very uncommon. Further study is warranted to select patients who may avoid breast and axillary surgery post neoadjuvant chemotherapy.

Anomalous Left Coronary Artery From The Pulmonary Artery (ALCAPA) as a Cause of Heart Failure

BACKGROUND Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare anomaly. When present it can result in failure to thrive and congestive heart failure. CASE REPORT We present the case of a 6-month old female whose presentation was one of failure to thrive. Point of care ultrasound and electrocardiogram (ECG) were used to diagnose heart failure with consideration of ALCAPA. These tools helped to expedite transfer to a tertiary care center for definitive therapy. CONCLUSIONS Although a rare anomaly, ALCAPA induced heart failure can be quickly identified on bedside ultrasound. Together with ECG findings, the Emergency Physician can expedite the diagnosis and proper disposition.

Portuguese consensus document for the management of alpha-1-antitrypsin deficiency

Alpha-1-antitrypsin deficiency (AATD) is a genetic autosomal codominant disorder caused by mutations in SERPINA1 gene. It is one of the most prevalent genetic disorders, although it remains underdiagnosed. Whereas at international level there are several areas of consensus on this disorder, in Portugal, inter-hospital heterogeneity in clinical practice and resources available have been adding difficulties in reaching a diagnosis and in making therapeutic decisions in this group of patients. This raised a need to draft a document expressing a national consensus for AATD. To this end, a group of experts in this field was created within the Portuguese Pulmonology Society - Study group on AATD, in order to elaborate the current manuscript. The authors reviewed the existing literature and provide here general guidance and extensive recommendations for the diagnosis and management of AATD that can be adopted by Portuguese clinicians from different areas of Medicine. This article is part of a supplement entitled "Portuguese consensus document for the management of alpha-1-antitrypsin deficiency" which is sponsored by Sociedade Portuguesa de Pneumologia.

Cytomegalic hepatitis in a patient receiving omalizumab

Cytomegalovirus is a double stranded DNA virus that can be present in nearly all organs and body fluids. The primary infection is usually asymptomatic in the immunocompetent host and it is common among adolescents and young adults. The symptomatic form appears, in the majority of cases, as a mononucleosis syndrome with full recovery without specific treatment. We report a case of a 25 years old woman who presented with hepatitis due to CMV infection and history of omalizumab administration one month earlier. This recombinant monoclonal antibody is used to control refractory asthma and chronic spontaneous urticarial as it inhibits human IgE. Despite that, the long course of the disease lead us to initiate treatment with valganciclovir. The improvement after that was rapid and complete.

Clinical, serological and molecular investigations of EHV-1 and EHV-4 in 15 unweaned thoroughbred foals

Fifteen unweaned thoroughbred foals, born on a stud farm to vaccinated mares, were clinically monitored during their first six months of life and repeatedly tested for equine herpesvirus type 1 (EHV-1) and equine herpesvirus type 4 (EHV-4). Nasopharyngeal swabs and blood samples were collected and screened respectively by PCR and seroneutralisation to detect the presence of the virus, explore its role as a possible cause of respiratory disease, and to assess the efficiency of the pcr for the diagnosis of this disease. The foals were divided into three groups on the basis of their clinical signs and whether they had seroconverted to EHV-1 and/or EHV-4: first, foals with no clinical signs of disease that had not seroconverted; secondly, foals with clinical signs that had seroconverted, and thirdly, foals with clinical signs that had not seroconverted. The results indicated that the viruses circulated on the stud farm despite stringent vaccination regimens against them, and confirmed their association with respiratory disease. The absence of significantly different pcr results among the three groups of foals showed that the pcr was effective in confirming the circulation of the viruses on the premises without being particularly helpful as a diagnostic tool.

Seroepidemiological survey of Rhodoccocus equi infection in asymptomatic horses from Bursa, Izmir and Istanbul provinces, Turkey

In order to assess the Rhodococcus equi infection in three provinces of Turkey (Bursa, Izmir and Istanbul), 696 sera from healthy foals and adult horses were tested by indirect ELISA using a R. equi reference strain (ATCC 6939) as antigen. 103 sera (14.80%) with titres >0.646 resulted positive. Seroprevalence was significantly higher (P=0.0053) in male than in female horses of Istanbul province, although higher antibody titres (mean value) were observed in the female group of Bursa and Izmir provinces with differences estimated between provinces (P=0.0002). Seroprevalence was correlated with age: foals aged less than 1 year (P<10(-4)) and horses from 5 to 10 years old (P=0.018) resulted more infected in Bursa and Izmir provinces. Our findings indicate that R. equi infection actually occurs in all investigated provinces, suggesting the importance of serological survey to diagnose the infection and to prevent the zoonotic risk.

[Intra-articular treatment with Hylan G-F 20 under ultrasound guidance in hip osteoarthritis. Clinical results after 12 months follow-up]

Hip is a site very commonly affected by osteoarthritis (OA), yet few data exist in literature regarding intra-articular use of hyaluronic acid in this pathology. We evaluated the efficacy of Hylan G-F 20 hip viscosupplementation performed under ultrasound guidance. We enrolled 26 patients affected by symptomatic hip OA and treated them with a single intraarticular injection of Hylan G-F 20, which could be repeated every two months. The injection was performed under ultrasound guidance with an antero-superior approach. Treatment efficacy was assessed through Lequesne index, visual analogue scale (VAS) pain quantification, and NSAID intake at the timepoint zero (baseline), and after 2, 6 and 12 months. We observed a statistically significant reduction of all considered parameters at the timepoints 2 and 6 months, when compared to baseline. At 12 months the changes were still statistically significant for all parameters for about 50% of the patients. No side effect was observed, nor systemic complication. Viscosupplementation is a promising approach for hip OA, although further and wider studies are wanted to determine how long the beneficial effect lasts, and what is the optimal number of injections to administer.

Low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol and apolipoprotein B: relationships among the different measurements

Serum low-density lipoprotein cholesterol (LDLC) value is a recognized target for atherosclerotic risk management, and is generally calculated using the "Friedewald formula". Alternative risk markers include directly measured LDLC, non-high-density lipoprotein cholesterol (non-HDLC) and apolipoprotein B (ApoB). The relationships among such various measured or calculated quantities in medium-sized sets of patient results were investigated. Results from two sets of patients were retrieved from our laboratory information systems. One group (n=8436) included results of cholesterol, HDLC, triglyceride (TG) and glucose measurements. A second group (n = 902) included, in addition, results of ApoB measurement. The results confirmed the unreliability of the Friedewald formula at TG >350 mg/dL (3.96 mmol/L), but also indicated TG-linked underestimation of LDLC below such a TG level. By contrast, non-HDLC values were shown to be independent of TG, and better correlated to ApoB than LDLC values. Mathematically, the difference between non-HDLC and LDLC is TG x 0.458 (values in mmol/L): therefore, the latter cannot be compared to (or converted into) the former by simply adding a constant amount. The ratio LDLC/ApoB was shown continuously to decrease with increasing TG concentrations, while the ratio non-HDLC/ApoB did not. The TG-dependent underestimation of LDLC may be the reason for the reported better cardiovascular risk predictivity of non-HDLC in diseases associated with TG increase, such as in diabetes. Non-HDLC values are not influenced by TG levels, and are better correlated with ApoB.

[Safety profile of 185 ultrasound-guided intra-articular injections for treatment of rheumatic diseases of the hip]

OBJECTIVE

We have developed a standardized technique for intra-articular injection of the hip joint with the purpose of extending routine intra-articular injection of hyaluronans and steroids to the hip, as commonly used in the knee. The purpose of this study was to examine the safety of this technique in an extended series of patients.

METHODS

A 7 MHz linear or 3.5 MHz convex transducer was used with a sterilized biopsy guide attached. Intra-articular (IA) injection was performed by inserting into the biopsy guide a 20 gauge needle with the anterosuperior approach. Then, using biopsy real-time guidance software, the needle was advanced into the anterior capsular recess, at the level of the femoral head.

RESULTS

The standardised technique was used to inject 97 patients (114 hips) with 185 injections of either steroid/local anaesthetic (10) or hyaluronan (175) over a three-year period. The treatment was well tolerated with few, and exclusively local, side effects. No systemic side effects or joint infections were observed in our study. The colour Doppler vision allowed us to avoid injecting blood vessels. In all cases direct visualization of needle introduction and progression into the articular space was shown by on-screen guidance. Ultrasound guidance is more economic and faster in comparison to the TC or fluoroscopic guidance. Contrary to TC or fluoroscopic techniques ultrasound does not require use of radiations or iodized contrast.

CONCLUSION

Our data suggest that the administration of hyaluronans or steroids with ultrasound-guided intra-articular injection is a safe technique for treatment of rheumatic diseases of the hip.

Staphylococcus aureus: study of genomic similarity of strains isolated in veterinary pathology using amplified fragment length polymorphism (AFLP)

Staphylococcus aureus is a widespread pathogen causing infections in different animal species. The extensive use of antibiotics, particularly methicillin, causes the rise of antibiotic-resistant strains (MRSA). In order to verify the epidemiology and genetic relatedness among MRSA and sensible strains (MSSA), an accurate fingerprinting technique, the amplified fragment length polymorphism (AFLP), was carried out. The isolates were cultured, subdivided on MRSA and MSSA and submitted for the genomic DNA extraction that was utilized for AFLP. The data were analysed for genetic similarity using the Dice coefficient. The results of genomic analysis among MRSA and MSSA and within them revealed that the major component of variation was due to variation within strains (82.12%), while variance among strains was lower (17.88%). The low level of genomic similarity found among S. aureus strains implies high level of genetic diversity. Different similarity was found as well in all strains independently of the source.

Master Amino acid Pattern as sole and total substitute for dietary proteins during a weight-loss diet to achieve the body's nitrogen balance equilibrium

Results of this multicentric study have shown that by giving Master Amino acid Pattern (MAP) as a sole and total substitute of dietary proteins to 500 overweight participants undergoing the American Nutrition Clinics/Overweight Management Program (ANC/OMP), the participants' body nitrogen balance could be maintained in equilibrium with essentially no calories (MAP 1 g=0.04 kcal), thereby preserving the body's structural and functional proteins, eliminating excessive water retention from the interstitial compartment, and preventing the sudden weight increase after study conclusion commonly known as the yo-yo effect. Study results have shown that the use of MAP, in conjunction with the ANC/OMP regimen, has proven to be safe and effective by preventing those adverse effects associated with a negative nitrogen balance, such as oversized or flabby tissue, stretch marks, the sagging of breast tissue, increased hair loss, faded hair color, and fragile or brittle nails. Also prevented were those anomalies commonly associated with weight-loss diets, such as hunger, weakness, headache caused by ketosis, constipation, and decreased libido. The use of MAP in conjunction with the ANC/OMP also allowed for mean weight loss of 2.5 kg (5.5 lb) per week, achieved through reduction of excessive fat tissue and elimination of excessive water retention from the interstitial compartment.

Detection of antibodies against Rhodococcus equi in Alpaca (Lama pacos) in Italy

After isolating the two virulent strains of Rhodococcus equi from Alpaca, a serological survey of Rhodococcus equi infection was carried out on 57 blood samples of Alpaca collected in Central Italy. The survey was performed with an ELISA test using a reference R. equi strain as antigen (ATCC 33701). Four (7.0%) sera (OD greater or equal to 0.3) tested positive, while five (8.77%) were considered doubtful (OD between 0.2 and 0.3). This is the first serological survey of R. equi infection in Alpaca in Italy. The results indicate that besides the horse R. equi infection could also affect some ruminant species. The ELISA test was recently introduced as a reliable diagnostic method in horses and was adapted to alpaca.

A serological survey of Rhodococcus equi infection in foals in central Italy: comparison of two antigens using an ELISA test

A serological survey of Rhodococcus equi infection was carried out on 602 blood samples collected from foals in central Italy. The assay was performed with an ELISA test using two different antigens prepared with reference strains of R. equi, ATCC 33071 and ATCC 6939. A positive reaction was obtained on 81 serum samples (13.45%) (OD > or = 0.3) using antigen ATCC 33071, and on 73 serum samples (12.12%) using antigen ATCC 6939. Although the frequency of the disease was not high, the serological positivity was about 13%. There was no statistically significant difference between males and females. The ELISA test using either Antigen 33071 or Antigen 6939 is a rapid and reliable tool for detecting antibodies against R. equi in foals.

Evaluation of the Abbott LCx Mycobacterium tuberculosis assay for direct detection of Mycobacterium bovis in bovine tissue samples

The commercial LCx amplification assay, usually employed to detect the Mycobacterium tuberculosis complex in respiratory specimens, was evaluated by comparing the results it gave with those obtained using Lowenstein-Jensen solid medium and pathological findings in 55 lymph nodes from cattle with positive and 10 lymph nodes from cattle with negative skin tests for tuberculosis. Fifty-three cultures (51 and 2, respectively) were positive for M. bovis, while the results for the LCx assay and the histological method were positive in 48 (45, 3) and 24 (20, 4) samples, respectively. None of the samples from cattle from certified tuberculosis-free herds were positive by any of the procedures. The results obtained with the LCx assay, compared with the culture procedure, regarded as the gold standard among the diagnostic techniques, gave a specificity of 91.6% and sensitivity of 90.5%. Although the sensitivity of LCx was suboptimal, DNA of M. bovis was detected in 81.8% of the skin test-positive animals. Amplification techniques could provide a rapid and reasonably reliable tool for detecting bovine tuberculosis.

[Human leptospirosis. A short review concerning a caseload]

Leptospirosis, a zoonosis with worldwide distribution, may have a broad spectrum of clinical manifestations that can delay the diagnosis, especially in wet climates where other conditions may dissimulate the main aspects. The authors describe 42 cases of patients with leptospirosis admitted to the Infectious Diseases Unit of a general hospital since 1990. The goal was to analyse epidemiological features, clinical manifestations, laboratory findings, treatment and evolution. There were 23 males (54.7%) and 19 females (45.2%), with ages ranging from 17 to 82 years. Most cases occurred in occupational settings, especially in those in contact with animals or stagnant water. All the cases had serological confirmation (by MAT or ELISA methods). Anicteric forms represented 42.9% of the total, which implies that in many cases a diagnosis is not immediately evident. The main symptoms, other than fever (97.6%) and jaundice (57.1%), were myalgia (71.4%), headache (42.8%) and nausea (33.3%). Renal involvement was common (52%), but the most severe forms occurred in 3 patients who required hemodialysis; followed by D.I.C. in 9.5%; meningitis in 4.7% and pulmonary involvement in 2.3% of the cases. The serovars most commonly identified were L. icterohaemorraghiae (28.5%), L. australis (14.3%), L. grippothyphosa (11.9%) and L. canicola (9.5%). The patients were treated with penicillin G (83.3%) or doxycyclin (9.5%). Two of them deceased (4.7%) and the remainder had a good evolution. The diagnosis of leptospirosis may be delayed if physicians fail to include this infection in the initial differential diagnosis. In view of this, the authors emphasize that when nonspecific clinical manifestations occur, a good epidemiological history is useful in proposing this diagnosis.

Serological survey for antibodies against selected infectious agents among fallow deer (Dama dama) in central Italy

Sera were collected from 224 fallow deer (Dama dama) in reserves in central Italy. Samples were tested for antibodies against Chlamydia spp., Brucella spp. and Coxiella spp. with the complement fixation (CF) test. Indirect immunofluorescence was used to test for antibodies against Borrelia spp. and agglutination tests were conducted for Leptospira interrogans antibodies. Enzyme-linked immunosorbent assay (ELISA) tests were used to detect antibodies against bovine herpesvirus-1 (BHV-1) and bovine viral diarrhoea virus (BVDV). All samples were negative for antibodies against Brucella spp., L. interrogans, Coxiella spp. and BHV-1. Four samples (1.8%) had antibodies against Chlamydia spp., nine (4%) against Borrelia spp. and 10 (4.5%) against BVDV. These results indicate that fallow deer in central Italy have a low rate of exposure to pathogens typical of domestic livestock.

Detection of equine arteritis virus in semen by reverse transcriptase polymerase chain reaction-ELISA

The reverse transcriptase polymerase chain reaction (RT-PCR) assay was used to detect Equine Arteritis Virus (EAV) in the semen of 88 horses and 2 donkeys, with neutralising antibodies against EAV, on the basis of the amplification of a 279 bp long fragment located in the viral polymerase gene. The RT-PCR assay revealed the virus at 4 TCID50/ml in cell culture and showed a greater sensitivity (54.4%) than cell culture isolation (33.3%). Moreover, the two samples of donkey semen were found positive. The cDNAs obtained from 14 samples of horse and 2 of donkey semen were sequenced. Comparing the sequence of reference strain Bucyrus, the analysed samples were 78-100% identical and showed a 84-97% nucleotide identity with Bucyrus isolate. The results demonstrate high levels of genomic heterogeneity among the extracted RNAs, but inside the fragment amplified a well-preserved region of 24 bp was found with only three mismatches in some samples, suggesting that this could be ideal as a probe for RT-PCR-ELISA. The RT-PCR-ELISA assay using the EAV 7 and 8 primer set, has proved to be sensitive, specific and above all directly applicable to semen. Additionally, the short time needed for the overall procedure makes this method suitable for diagnostic purposes.

Molecular cloning and functional characterization of brefeldin A-ADP-ribosylated substrate. A novel protein involved in the maintenance of the Golgi structure

Brefeldin A (BFA) is a fungal metabolite that disassembles the Golgi apparatus into tubular networks and causes the dissociation of coatomer proteins from Golgi membranes. We have previously shown that an additional effect of BFA is to stimulate the ADP-ribosylation of two cytosolic proteins of 38 and 50 kDa (brefeldin A-ADP-riboslyated substrate (BARS)) and that this effect greatly facilitates the Golgi-disassembling activity of the toxin. In this study, BARS has been purified from rat brain cytosol and microsequenced, and the BARS cDNA has been cloned. BARS shares high homology with two known proteins, C-terminal-binding protein 1 (CtBP1) and CtBP2. It is therefore a third member of the CtBP family. The role of BARS in Golgi disassembly by BFA was verified in permeabilized cells. In the presence of dialyzed cytosol that had been previously depleted of BARS or treated with an anti-BARS antibody, BFA potently disassembled the Golgi. However, in cytosol complemented with purified BARS, or even in control cytosols containing physiological levels of BARS, the action of BFA on Golgi disassembly was strongly inhibited. These results suggest that BARS exerts a negative control on Golgi tubulation, with important consequences for the structure and function of the Golgi complex.

Use of the stable isotope 65Cu test for the screening of Wilson's disease in a family with two affected members

BACKGROUND/AIMS

An improved method for the study of copper metabolism in Wilson's disease, using a stable, rather than radioactive, copper isotope (65Cu) has recently been described. We report on the use of this method for the study of a family with two members affected by Wilson's disease.

SUBJECTS

The family comprised parents and four siblings: one 20-year-old male and three females, aged 22, 17 and 5 years, respectively. The boy and the 17-year-old girl both presented with liver cirrhosis. Diagnosis of Wilson's disease was suggested by elevated liver copper content and/or low caeruloplasmin levels and Kayser-Fleischer ring.

METHODS

All family members were given an oral dose of 3 mg of 65Cu. Blood samples were taken at 0, 1, 2, 6, 24, 48, and 72 hours. In 4 subjects, additional blood samples were drawn at 7, 14 and 21 days after dosage. The ratio 65Cu:63Cu in serum was determined in all samples by means of Inductively Coupled Plasma Mass Spectrometry.

RESULTS

The diagnosis of Wilson's disease was confirmed in the two symptomatic members by the unequivocal decrease observed in the 65Cu percent enrichment, which approached zero by 72 hours. In contrast, Wilson's disease could be definitely excluded in both siblings, one of whom only 5 years old, on the evidence of net secondary peaks, showing normal incorporation of 65Cu into caeruloplasmin. These findings were later confirmed by genetic analysis. Parents, who carried defective genes with different mutations, also showed different abnormalities of copper metabolism.

CONCLUSIONS

The oral test with the stable copper isotope 65Cu is a safe, non invasive option able to exclude Wilson's disease in patients with a difficult diagnosis or in a presymptomatic stage. However, positive tests must still be confirmed by copper dosage in liver biopsies, as heterozygotes can present with severe alterations of copper metabolism, without developing symptoms of the disease. The use of this test in conjunction with genetic analysis on a larger number of heterozygous subjects may add to the understanding of the Wilson's disease defect.

The management of failed dual or triple therapy for Helicobacter pylori eradication

BACKGROUND

After each treatment for Helicobacter pylori infection there is an eradication failure rate ranging from 5 to 50%. Thus, the best therapy schedule and treatment regimen sequence have still to be identified.

METHODS

Patients with H. pylori infection were randomized to receive either a 1-week triple therapy of omeprazole 20 mg b.d., clarithromycin 250 mg b.d. and tetracycline 500 mg b.d. (OCT; 78 patients) or a 2-week dual therapy of omeprazole 20 mg b.d. and amoxycillin 1 g b.d. (OA; 75 patients). H. pylori infection at entry and eradication 4-6 weeks after therapy had ended were assessed by rapid urease test and histology on biopsies from the antrum and the corpus. When eradication did not occur with either the OCT or OA regimens, patients were switched over to the OA or OCT therapy, respectively. Eradication in these patients was assessed 4-6 weeks after conclusion of treatment by a further endoscopy.

RESULTS

H. pylori eradication was achieved in 67.9% (95% CI = 57.6-78.3%) of patients treated with the OCT regimen and in 75.7% (95% CI = 65.9-85.5%) of patients treated with the OA therapy (chi 2 = 1.11; P = 0.29). Moreover, H. pylori eradication was achieved in 39.1% (95% CI = 19.2-59.1%) of patients re-treated with the OA regimen and in 88.9% (95% CI = 74.4-100%) of patients re-treated with the OCT therapy (chi 2 = 8.52; P = 0.003). Thus, the overall success rate 'per protocol' analysis in our study was 81.6% (95% CI = 72.9-90.3%) for the triple and dual therapy sequence and 97.3% (95% CI = 93.6-100%) for dual followed by triple therapy (chi 2 = 8.14; P = 0.004).

CONCLUSIONS

Our data found that H. pylori eradication with OA therapy after OCT therapy failure was poor, while that obtained with OCT after OA therapy was good.

The polymerase chain reaction for the identification of different species of Mycobacterium

The polymerase chain reaction (PCR) was performed to identify reference and field strains of mycobacteria. PCR was able to identify all the reference strains of the Mycobacterium genus and sub-divide them into no Tuberculosis-no Avium complex, Tuberculosis complex and, partially, Avium complex. The primers used for the last recognised only some strains of the different types of M. avium and M. intracellulare. A number of field strains were identified as belonging to the Mycobacterium genus, but further research is required for a complete sub-division into Tuberculosis complex and Avium complex.

Formal education as an effect modifier of the relationship between Mini-Mental State Examination score and IADLs disability in the older population

The objective of this retrospective, case-series study was to examine the relationship between disability in Instrumental Activities of Daily Living (IADLs) and cognitive impairment measured by the Mini-Mental State Examination (MMSE), and how this relationship was influenced by different levels of formal education. The setting of the study was the Cognitive Disorders Center of the Local Sanitary Unit (USL) No. 4 in Prato (Italy). Independence in IADL was strongly related to MMSE scores. A score of less than 24 at the MMSE was predictive of disability in at least one IADL with 0.82 sensitivity and 0.73 specificity. However, when only people with a very low level of formal education were considered, the best threshold predicting IADL disability was 17 (sensitivity 0.76, specificity 0.75). Thus, scholastic achievement is an effect modifier of the relationship between cognitive status, as measured by the MMSE, and IADL disability. Subjects with low education level and poor performance at the MMSE are often independent in activities making demand on cognitive function, such as IADLs. These results suggest that a lower MMSE cut-off score should be considered when screening for cognitive impairment in these persons.

Use of an experimental chicks model for paratuberculosis enteritis (Johne's disease)

Developments in the diagnosis and treatment of paratuberculosis is constrained by the lack of an experimental animal model. To investigate this problem conventional chicks immunodepressed by a Cyclophosphamide injection and concurrent inoculation of Infectious Bursal Disease Virus (IBDV) were infected with Mycobacterium paratuberculosis and kept for 4 months. The immunodepressed chicks eliminated mycobacteria with their faces from the first month until the third month and developed typical intestinal lesions of mycobacterial infection characterized by aggregation of macrophages with monocytes and lymphocytes. Diarrhoea was absent. The number of lymphocytes decreased by about 80%. The serological tests carried out with Complement Fixation test were negative. For the positive bacteriology and typical granulomatous lesions, the conventionally reared chicks proved to be a useful laboratory model for reproduction of Johne's disease.

Ultrastructural features of danazol-induced cholestasis: a case study

A case study of a severe cholestatic syndrome induced by danazol, with ultrastructural description of liver morphology, is reported. Cholestasis appeared after 3 months treatment with danazol (300 mg/daily) and completely resolved 2 months after withdrawal. In spite of the severe increase in serum bilirubin and total serum bile salts, transaminases were only slightly elevated and GGT and alkaline phosphatases were almost normal. Light microscopy shows a pattern of predominantly centrolobular cholestasis without necrosis, with minimal inflammatory infiltrate and with no sign of bile ductule involvement. At the ultrastructural level very dilated bile canaliculus predominate with stunted or loss of microvilli and dense bile material in the lumen. Nonspecific alterations were seen in hepatocyte intracellular organelles. It is suggested that danazol may cause a rare but severe hepatocanalicular cholestasis, differing from the "bland" cholestasis frequently described during therapy with other anabolic steroids.

[Evaluation of the therapeutic activity of and gastric lesions due to new NSAID versus placebo in patients with osteoarticular diseases]

Oral amtolmetineguacyl 600 mg/day in a single blind comparative trial with placebo carried out in 24 patients suffering from rheumatic disorders of varying severity, reduced statistically all the symptomatology correlated to inflammation. Moreover our results indicate a lack of any gastric problem even in patient with a previous history of intolerance to other NSAIDs.

[Serologic diagnosis of several infectious diseases]

Serological tests are, in some situations, the only method of diagnosis of some infectious diseases. The authors make a review of the literature about the most important tests used in the most common infectious diseases and also their interpretation. It is important to point out that serology should not be considered alone but compared to clinical manifestations presented by the patient. It is also necessary, in some cases, to obtain two samples of serum, to confirm if there is an increase in the antibodies' titles. The results sent from the laboratory should be interpreted based on references given by it.