Nonvisualized sentinel node on preoperative lymphoscintigraphy in primary cutaneous melanoma: an 11-year retrospective survey

BACKGROUND

Sentinel lymph node (SLN) biopsy in cutaneous melanoma patients evaluates the regional draining basin for occult micrometastatic disease. Occasionally, nonidentification of SLN impairs the acquisition of this important prognostic factor.

OBJECTIVES

To investigate the outcomes of melanoma patients with negative lymphoscintigraphic findings and patients who underwent SLN biopsy from 2004 to 2015 ( n  = 1200) were retrospectively reviewed for tumor characteristics and clinical outcomes.

METHODS

Patients with nonvisualized lymph nodes (NV group) who underwent only preoperative lymphoscintigraphy were separated and compared with a cohort drawn from all melanoma patients who completed the surgical procedure within the same period (V group).

RESULTS

A negative lymphoscintigraphic scan was observed in 38 cases (3.2% of all patients). The NV group showed a significantly older age (median 66.0 vs. 48.3 years; P  < 0.0001). Head and neck melanomas were more frequent in the NV group compared to the control group (25.1 vs. 7.8%; P  = 0.009). Tumor characteristics such as ulceration and Breslow thickness do not influence the lymphoscintigraphy result. No differences were found in overall survival (OS) and disease-free survival (DFS) between the groups.

CONCLUSIONS

The nonvisualization of regional lymph nodes by lymphoscintigraphy is more frequent in older patients with head and neck melanomas. From the clinical point of view, no specific recommendation emerged for patients' management because the nonvisualization of the SLN did not show a significant influence on DFS and OS rates. However, lack of knowledge of lymph node status suggests performing a tighter follow-up eventually by ultrasound evaluation of all potential lymph node drainage basins.

Analysis of prognostic factors in COVID-19 hospitalized patients: an Italian single-center case-control study

OBJECTIVE

COVID-19 clinical presentation ranges from asymptomatic infection to an inflammatory cytokine storm with multi-organ failure and fatal outcomes. The identification of high-risk patients for severe disease is crucial to plan an early treatment and intensive follow-up. We aimed to investigate negative prognostic factors in a group of patients hospitalized for COVID-19.

PATIENTS AND METHODS

181 patients (90 men and 91 women, mean age 66.56 ± 13.53 years) were enrolled. Each patient received a work-up including medical history, clinical examination, arterial blood gas analysis, laboratory blood tests, feasible ventilatory support required during hospital stay, intensive care setting required, duration of illness and length of hospital stay (>or<25 days). For the assessment of the severity of COVID-19, three main indicators were considered: 1) the intensive care unit (ICU) admission 2) the hospitalization length >25 days; 3) the need of non-invasive ventilation (NIV).

RESULTS

The independent risk factor associated with the ICU admission were lactic dehydrogenase elevation (p=0.046), C reactive protein elevation (p=0.014) at hospital admission and direct oral anticoagulant home therapy (p=0.048); for hospital length >25 days: early corticosteroid therapy (p=0.035); for NIV treatment: ferritin elevation at hospital admission (p=0.006).

CONCLUSIONS

The presence of the above factors may be useful to identify patients at high risk of developing a severe COVID-19 that need an early treatment and intensive follow-up.

Efficacy of Anakinra on Multiple Coronary Arteries Aneurysms in an Infant with Recurrent Kawasaki Disease, Complicated by Macrophage Activation Syndrome

Kawasaki disease (KD) is rare in infants less than 3 months of age, and its recurrence is exceptional. Infants with KD are at higher risk of severe clinical presentation, therapy failure, complications and coronary aneurysms (CAAs), and this is the reason they deserve more aggressive therapy and a strict clinical follow-up. We report a 2-month-old male with KD, complicated by Macrophage Activation Syndrome (MAS). Despite timely and aggressive therapy with immunoglobulins, steroids and aspirin, multiple CAAs developed. Two-month therapy with anakinra completely reverted all the aneurysms. After six months, the infant experienced KD relapse and was successfully re-treated with immunoglobulins, steroids and aspirin. A strict echocardiographic follow-up did not show recurrence of aneurysms. Two years later, the child is healthy, without cardiac sequelae. In our experience, anakinra was effective in reverting multiple aneurysms and its effect proved to be long-lasting, even in front of KD recurrence. Based on this evidence, it seems reasonable to hypothesize not to limit the use of anakinra as rescue therapy for complicated or refractory KD, but to consider the possibility of adding it to first-line therapies for some subgroups of very-high-risk patients, in order to strengthen the prevention of CAAs.

Insulin resistance and potential modulators of ovarian reserve in young reproductive-aged women with obesity and type 1 diabetes

INTRODUCTION

Both obesity and diabetes play a significant role in reproductive disorders in women and insulin resistance (IR) is a confirmed trait d'union. We evaluated the relationship between IR and an established ovarian reserve biomarker such as anti-mullerian hormone (AMH) together with other potential modulators of ovarian physiology (adiponectin and kisspeptin) in young reproductive-aged group women with obesity and type 1 diabetes (T1D).

PATIENTS AND METHODS

We recruited 32 female youths: 14 of them presented with T1D (14.6 ± 2.6 years) and 18 with obesity (15.1 ± 2.6 years). The control group included 20 age-matched normal weight females. Each patient underwent physical examination and hormonal assessment. AMH, kisspeptin and adiponectin levels were also measured. IR was calculated as the homeostasis model assessment for insulin resistance (HOMA-IR) and the glucose disposal rate (eGDR) in patients with obesity and with T1D, respectively.

RESULTS

adiponectin and kisspeptin levels were significantly different into groups (p ≤ .001), whereas AMH levels were not. Adiponectin values were higher in controls compared to patients with obesity (p < .001) and T1D (p = .02). Kisspeptin levels were lower in controls compared to patients with obesity (p = .001), without reaching statistical significance when compared to T1D (p = .06). IR was associated with lower adiponectin and higher kisspeptin levels (p < .001 and p = .02, respectively), but not with AMH.

CONCLUSIONS

IR displays a relationship with adiponectin and kisspeptin in young reproductive-aged women with obesity and T1D. Interventions to correct IR in adolescents could be part of an early approach to prevent reproductive disorders and to promote factors associated with longevity in adult women.

Bariatric Surgery in Adolescents: To Do or Not to Do?

Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.

Sex-Specific Differences in the Relationship between Insulin Resistance and Adiposity Indexes in Children and Adolescents with Obesity

New indexes of adiposity have been introduced to evaluate body-fat distribution and cardiometabolic risk. However, data on the correlation between Insulin Resistance (IR) and these new indexes are limited. We therefore evaluated the relationship between IR and adiposity indexes in children and adolescents with obesity, focusing on gender differences. We retrospectively enrolled 586 patients with obesity (10.80 ± 2.63; 306F/279M). As adiposity indexes we considered body mass index (BMI), BMI-z score, WC, waist-to-height ratio (WHtR), a body shape index (ABSI), triponderal mass index (TMI), visceral adiposity index (VAI) and conicity index (ConI). The homeostasis model assessment for insulin resistance (HOMA-IR), HOMA of percentage β-cell function (HOMA-β), quantitative insulin sensitivity check index (QUICKI), and triglyceride and glucose index (TyG-index) were measured and recorded as IR surrogates. In both sexes, WC and VAI significantly correlated with all IR measurements (p < 0.001). BMI significantly correlated (p < 0.001) with all IR parameters except for the TyG-index in females. Fat mass and TMI correlated with IR parameters only in females, BMI-z score with IR markers except for HOMA-β in males, WHtR with HOMA-β in both sexes (p < 0.05), free fat mass with HOMA-IR and QUICKI only in females (p < 0.01), ConI correlated with the TyG index in females (p = 0.01). Tryglicerides and SBP were correlated with all IR measurements (p < 0.001), in both sexes. Correlations between different sex parameters were significantly more evident in middle puberty. The relationship between IR surrogates and obesity indexes is influenced by gender in pediatrics. Sex-specific differences in obesity-related complications should be considered in preventive intervention decision-making.

The Role of Fetal, Infant, and Childhood Nutrition in the Timing of Sexual Maturation

Puberty is a crucial developmental stage in the life span, necessary to achieve reproductive and somatic maturity. Timing of puberty is modulated by and responds to central neurotransmitters, hormones, and environmental factors leading to hypothalamic-pituitary-gonadal axis maturation. The connection between hormones and nutrition during critical periods of growth, like fetal life or infancy, is fundamental for metabolic adaptation response and pubertal development control and prediction. Since birth weight is an important indicator of growth estimation during fetal life, restricted prenatal growth, such as intrauterine growth restriction (IUGR) and small for gestational age (SGA), may impact endocrine system, affecting pubertal development. Successively, lactation along with early life optimal nutrition during infancy and childhood may be important in order to set up timing of sexual maturation and provide successful reproduction at a later time. Sexual maturation and healthy growth are also influenced by nutrition requirements and diet composition. Early nutritional surveillance and monitoring of pubertal development is recommended in all children, particularly in those at risk, such as the ones born SGA and/or IUGR, as well as in the case of sudden weight gain during infancy. Adequate macro and micronutrient intake is essential for healthy growth and sexual maturity.

Inflammation in Obesity-Related Complications in Children: The Protective Effect of Diet and Its Potential Role as a Therapeutic Agent

Obesity is a growing health problem in both children and adults, impairing physical and mental state and impacting health care system costs in both developed and developing countries. It is well-known that individuals with excessive weight gain frequently develop obesity-related complications, which are mainly known as Non-Communicable Diseases (NCDs), including cardiovascular disease, type 2 diabetes mellitus, metabolic syndrome, non-alcoholic fatty liver disease, hypertension, hyperlipidemia and many other risk factors proven to be associated with chronic inflammation, causing disability and reduced life expectancy. This review aims to present and discuss complications related to inflammation in pediatric obesity, the critical role of nutrition and diet in obesity-comorbidity prevention and treatment, and the impact of lifestyle. Appropriate early dietary intervention for the management of pediatric overweight and obesity is recommended for overall healthy growth and prevention of comorbidities in adulthood.

Timing, prevalence, and dynamics of thyroid disorders in children and adolescents affected with Down syndrome

Objectives Limited data on the evolution of thyroid disorders (TD) in Down syndrome (DS) are available. We characterized the timing, prevalence, and dynamics of TD in patients with DS during a long-term follow-up. Methods We retrospectively evaluated 91 children and adolescents with DS (12.5 ± 8.3; follow-up 7.5 ± 6.2). Children were monitored at birth, 6, and 12 months of age and twice a year thereafter. Thyroid status and autoimmunity were periodically investigated. Results TD were detected in 73.6% of patients, in particular congenital hypothyroidism (CH), autoimmune thyroid diseases (ATD) and subclinical hypothyroidism (SH) were recorded in 16.4, 31.8, and 25.3%, respectively. CH was diagnosed at newborn screening in 86.7% of cases and in the first 6 months of life in the remaining 13.3%; the condition was persistent in 61.5% of patients. In more than 30% of CH cases, glandular hypoplasia was also revealed. In the ATD group, 63.1% of patients with Hashimoto's disease (HD, 82.6%) were treated with levothyroxine and subjects with Graves' Disease (GD, 17.4%) started therapy with methimazole. DS with SH were treated in 42.1% of cases. A thyroid hypogenic echopattern, without autoantibody positivity was identified in 27.6% of SH patients. Conclusions The high prevalence and evolution of TD in SD requires frequent monitoring starting in the first months of life. CH can be misdiagnosed at screening. In DS subjects, there is a high prevalence of ATD and non-autoimmune diseases with early antibody-negative phases should not be excluded.

Screening for celiac disease among children with overweight and obesity: toward exploring celiac iceberg

Background The coexistence of celiac disease (CD) and obesity/overweight is not unusual. Objective We investigate the prevalence and clinical presentation of CD, detected by screening, among children with excessive weight gain. Methods We enrolled 200 children referred for overweight/obesity to our outpatient clinic. Medical history during pregnancy and childhood and lifestyle variables were recorded. Patients were screened for CD with total immunoglobulin A (IgA), IgA anti-transglutaminase (tTG-IgA) and IgA anti-endomysial antibodies (EMA-IgA). In subjects with positive autoantibodies, esophagogastroduodenoscopy (EGDS) was performed and genetic testing for HLA DQ2 and/or DQ8 haplotypes was tested. Results CD positive antibodies (tTg-IgA and EMA-IgA) were detected in eight patients (4%); in all subjects CD diagnosis was confirmed by HLA-DQ2 and/or DQ8 compatibility and EGDS. No association between CD and medical history during pregnancy and childhood or lifestyle variables was noted; however, a dietary difference was identified with those testing positive for CD also reporting a lower weekly consumption of fruits and vegetables (p=0.04). Headache was reported more frequently in patients with than without CD (p=0.04). Familiar positivity for autoimmune diseases was revealed in CD patients (p=0.01). Conclusion CD should be considered in children with excessive weight gain. Familial predisposition to other autoimmune diseases may represent a risk factor for development of CD. Even though the relationship between headache and CD is not well defined, the patients with headache of unknown origin should be screened for CD.

Rapid progressive central precocious puberty: diagnostic and predictive value of basal sex hormone levels and pelvic ultrasound

Objectives Data on the predictive values of parameters included in the diagnostic work-up for precocious puberty (PP) remain limited. We detected the diagnostic value of basal sex hormone levels, pelvic ultrasound parameters and bone age assessment for activation of the hypothalamic-pituitary-gonadal axis in girls with PP, in order to help in the decision to perform GnRH testing. Patients and methods We retrospectively considered 177 girls with PP. According to puberty evolution, the girls were divided into two groups: rapid progressive central precocious puberty (RP-CPP) and non/slowly progressive/transient forms (SP-PP). In all patients we considered Tanner stage, basal luteinizing hormone (LH) and estradiol (E2) values, bone age, and pelvis examination. We assessed the diagnostic value of each variable and identified the number of pathological parameters that best identify patients with RP-CPP. Results Basal LH ≥ 0.2IU/L, E2 level ≥ 50 pmol/L, uterine longitudinal diameter ≥ 3.5 cm, transverse uterine diameter ≥ 1.5 cm, endometrial echo and ovarian volume ≥ 2 cm3 were significantly associated with RP-CPP (p ≤ 0.01). The ability to diagnose RP-CPP was enhanced with increasing number of pathological hormonal and instrumental parameters (p < 0.001). With more than three parameters detected, sensitivity and specificity reached 58% (95%CI 48-67) and 85% (95%CI 74-92), respectively, with a PPV = 86% (95%CI 76-93) and PPN = 54% (95%CI 43-54); the area under the ROC curve was 0.71 (95%CI 0.65-0.78). Conclusion Despite the availability of different tests, diagnosing RP-CPP remains difficult. A diagnosis model including at least three hormonal and/or ultrasound parameters may serve as a useful preliminary step in selecting patients who require GnRH testing for early detection of RC-PP.

Autoimmune Thyroid Diseases in Children and Adolescents with Maturity Onset Diabetes of the Young Type 2

BACKGROUND/AIM

The relationship between type 1 diabetes mellitus (T1DM) and autoimmune thyropathies is well known and has been described in the literature. Based on present knowledge, the relationship between thyropathies and other forms of diabetes, such as monogenic diabetes, has not been investigated. The aim of our study was to assess the prevalence of autoimmune thyroid diseases (ATD) in children and adolescents with maturity onset diabetes of the young type 2 (MODY2) in comparison with patients with T1DM and a control group.

PATIENTS AND METHODS

We examined 23 children and adolescents with MODY2 (11 F/12 M; 13.5 ± 5.3 years) and 166 patients with T1DM (80 F/86 M; 14.0 ± 4.7 years). The control group consisted of 62 age-matched healthy subjects (34 F/28 M). ATD diagnosis was based on the finding of one or more positive thyroid autoantibodies and characteristic thyroid ultrasound lacking homogeneity, with a hypogenic or mixed echo pattern.

RESULTS

ATD was diagnosed in 15 (10.5%; 9 F/6 M) patients with T1DM, in 4 with MODY2 (17.4%; 4 F), and in 1 (1.6%) control. A significantly higher ATD prevalence was detected in T1DM and MODY2 compared to the control subjects (p = 0.02), without differences between T1DM and MODY2 (p = 0.26). There were no gender differences noted in T1DM (p = 0.42); on the contrary, in MODY2 a higher prevalence was noted in females (p = 0.04). Celiac disease and a positive family history of ATD were not detected in subjects with MODY2.

CONCLUSION

Our study showed an increased prevalence of ATD in patients with MODY2. Therefore, a careful follow-up of all children with MODY2 is recommended in order to assess the presence of thyroid disorders.

Gender-based differences in the clustering of metabolic syndrome factors in children and adolescents

Background We depicted gender-differences in metabolic syndrome (MS) clustering before and after puberty in pediatrics, in order to develop gender specific preventive strategies for childhood obesity. Methods We considered 1079 children and adolescents (529 females and 550 males; mean age 11.5 ± 2.8 year). According to body mass index (BMI) percentiles the subjects were classified as normal weight BMI <75th, overweight BMI 75-95th and with obesity BMI >95th. MS was diagnosed when three of the following criteria for age and sex percentiles were met: BMI >95th, triglycerides (TGs) level >95th, high-density lipoprotein-cholesterol (HDL-c) level <5th, blood pressure (blood pressure) >95th percentile, fasting blood glucose (FBG) >100 mg/dL and/or homeostatic model assessment- insulin resistance (HOMA-IR) >97.5th percentile. Results The prevalence of dismetabolic factors was similar in both genders, except for pathological BP, which was higher in males (p = 0.02). MS was detected only in patients with obesity, with a higher prevalence in pubertal than late/post-pubertal subjects (p < 0.001), without any significant difference between gender. In pre-puberty, the most common MS combination was obesity (HBMI) + hypertension (HBP) + hyperglycemia/insulin resistance (HGLY/IR) followed by HBMI + low HDL-levels (LHDL) + HGLY/IR versus HBMI + HBP + HGLY/IR followed by HBMI + HBP + LHDL, respectively, in females and males. In the early and late/post-pubertal periods, the most prevalent combination remained similar to pre-puberty, additionally in both sexes other combinations, such as HBMI + HTG + HBP + HGLY/IR, HBMI +  HBP + LHDL + HGLY/IR, HBMI + HTG + LHDL + HGLY/IR and HBMI + HTG + LHDL + HBP + HGLY/IR were also detected, differently distributed in males and females. Conclusions We confirm that MS is an important consequence related to obesity, particularly in the post-puberty stage. Some gender-based differences should be considered early in order to identify specific preventive and treatment strategies.

Gender Differences at the Onset of Autoimmune Thyroid Diseases in Children and Adolescents

Background: The incidence of autoimmune thyroid diseases (ATD) may vary with the beginning of reproductive function, although few reports differentiate the incidence before and during the onset of puberty, examining gender bias. We analyzed onset of ATD in a pediatric population to assess gender differences in onset age, disease subtype, pubertal status, autoimmune co-morbidity, family history and treatment, focusing on the interaction between gender and pubertal stage. Patients and methods: We retrospectively recorded 382 children and adolescents with ATD. In each patient physical examination was considered. The presence of other associated autoimmune diseases (AAD) and familial predisposition was also recorded. Results: Predominant prevalence was noted in females compared to males (p < 0.001), both in Hashimoto's diseases (HD or HT) and Graves' disease (GD) (p < 0.001). Mean age at diagnosis showed no significant difference between sexes (p > 0.05). A higher prevalence in pubertal subjects was noted compared to prepubertal (p < 0.001, particularly HT in early and GD in late pubertal stage), without sexes difference intra-(prepubertal vs. pubertal) and inter-puberty groups (prepubertal vs. early pubertal vs. late pubertal). Both in HT and in GD, the prevalence of autoimmune associated diseases (AAD) was higher in males compared to females (p = 0.04), with similar distribution according to the pubertal maturation. The familial predisposition was similarly distributed in both genders (p > 0.05) and into pubertal stages (p > 0.05). Conclusions: Females are more prone to develop ATD during puberty, earlier in HT than in GD. The effect of puberty is not different between genders, suggesting the role of additional factors other than hormones. The screening for detection of ATD is recommended in all patients with positive family history and other autoimmune diseases, mostly in males. Considerations of gender in pediatrics could be important to define pathogenic mechanisms of ATD and to help in early diagnosis and clinical management.

Anti-gastric parietal cell antibodies for autoimmune gastritis screening in juvenile autoimmune thyroid disease

OBJECTIVE

Patients with autoimmune thyroid disease (ATD) have a higher prevalence of autoimmune gastritis (AIG) compared with the general population. The association between ATD and AIG is poorly characterized in the pediatric age. We reviewed the prevalence of anti-gastric parietal cell antibodies (PCA) in young patients with ATD to evaluate its usefulness as a marker for AIG screening.

METHODS

We evaluated 220 children and adolescents (11.28 ± 6.37 years) with ATD (186 with autoimmune thyroiditis (AT) and 34 with Graves' disease (GD). At ATD diagnosis and annually thereafter, blood counts and PCA levels were measured. In patients positive for PCA, plasma gastrin, chromogranin A, vitamin B₁₂, iron and ferritin levels and H. pylori antigen were measured. PCA-positive patients > 18 years were invited to undergo a gastroscopic exam.

RESULTS

PCA positivity was detected in ten (4.5%) subjects (5F/5M; 12.6 ± 3.4 years). The prevalence of PCA positivity was not significantly different in the comparison of GD and AT patients (p = 0.9). PCA positivity was detected after 2.7 ± 2.7 years of follow-up in AT and 4.4 ± 4.0 years in GD (p = 0.4). Autoantibody positivity was more prevalent in female patients, in both AT and GD (p = 0.02 and p = 0.03, respectively). At detection of PCA positivity, five out of ten PCA-positive patients had iron deficiency, four vitamin B₁₂ deficiency, two anemia, three hypergastrinemia and two elevated chromogranin values. Two patients had H. pylori infection. Gastroscopy was performed in the five ATD patients and in all patients, AIG was confirmed.

CONCLUSION

In the juvenile population, ATD and AIG may also be associated. PCA screening is useful to detect subjects at risk for this condition. Due to the longer life expectancy of the pediatric population and considering the relatively high risk of malignant transformation, early surveillance monitoring is mandatory for children and adolescents with ATD.

Th17 and Treg Balance in Children With Obesity and Metabolically Altered Status

Background: Chronic low-grade inflammation and activation of the immune system are hallmark pathogenic mechanisms involved in metabolic dysfunction and are related to obesity. In particular, the involvement of regulatory and pro-inflammatory lymphocyte subpopulations has been reported in adults. We evaluated the Th17/Treg lymphocyte balance in obese and normal weight children, in relation with their metabolic status. Methods: We enrolled 50 pediatric patients. According to metabolic status, subjects were classified into: metabolically healthy (MH) and metabolically unhealthy (MU) groups. MU phenotype was defined as the presence of at least one of the following risk factors: blood pressure >90th percentile, glycemia>100 mg/dl, HDL cholesterol <40 mg/dl, triglycerides>100 mg/dl (<10 years) or >130 mg/dl (>10 years), impaired insulin sensitivity with HOMA-IR>97.5th percentile. Patient Treg and Th17 profiles were also evaluated. Results: Based on the presence of metabolic and/or cardiovascular pathological parameters, we classified 15 MU (30%) and 35 MH (70%) children; all MU children were obese. Analyzing the correlations between lymphocyte subpopulations and metabolic data, we noted a correlation between Th17 percentage and systolic hypertension (p = 0.01, r = -0.37); Treg/Th17 ratio and HOMA-IR (p = 0.02, r = 0.32) and systolic hypertension (p = 0.05, r = 0.30). Conclusion: Children with obesity have a high risk of developing metabolic and cardiovascular complications. The Th17/Treg lymphocyte balance appears to be involved in glycemic homeostasis and blood pressure control. Careful and early monitoring of the immune system would facilitate new early preventive strategies in pediatric metabolic diseases.

Evaluation of Allostatic Load as a Marker of Chronic Stress in Children and the Importance of Excess Weight

Introduction: Allostatic load (AL) refers to the physiological response associated with the burden of chronic stress. Excessive weight is an important source of physiological stress that promotes a detrimental chronic low-inflammation state. In order to define a correlation between cumulative biological dysregulation and excess weight, we measured AL scores in a pediatric population. Patients and Methods: We enrolled 164 children and adolescents (11.89 ± 3.89). According to their body mass index (BMI) threshold, subjects were classified as normal in the BMI < 75th percentile, overweight in the BMI 75-95th percentile or obese in the BMI >95th percentile. Data based on 16 biomarkers were used to create the AL score. A dichotomous outcome for high AL was defined in those who had more than four dysregulated components. Results: High AL was noted in 88/164 subjects (53.65%), without significant differences between genders (p = 0.07) or pubertal status (p = 0.10). Subjects with a high AL, in addition to a higher BMI (p < 0.001), showed higher WC and WC/HtR (p < 0.001), triglycerides (p = 0.002), fasting blood glucose (p = 0.03), insulin resistance (p < 0.001), systolic (p < 0.001) and diastolic blood pressure (p = 0.001), GGT (p = 0.01), PCR (p = 0.01), and calprotectin (p < 0.01) as well as lower HDL cholesterol (p = 0.002) than subjects with a low AL. The rate of the cumulative biological dysregulation increased progressively with increases in BMI (p < 0.001). Conclusions: A high AL was associated with excess weight. AL may be considered a significant factor correlated with increased morbidity in children who are overweight/obese.

[Effect of treatment with selective serotonin reuptake inhibitors on lipid profile: state of the art]

Selective Serotonin Reuptake Inhibitors (SSRI) are an effective treatment for depressive disorder. Nevertheless, there is evidence suggesting a negative effect of these drugs on the lipid profile of the patients. We carried out a systematic review of the literature evaluating the influence of therapy with SSRI on lipid profile. Data source was MEDLINE. Clinical trials, prospective studies, retrospective studies and reviews published until November 2011 were considered. We identified twelve studies published from 1994 to 2011, of which four were randomized clinical trials, six were prospective studies and two were retrospective studies. Sertraline and Paroxetine seemed to have negative effects on the serum levels of Total and LDL Cholesterol. Citalopram did not demonstrate any influence on Total and LDL Cholesterol blood levels, being conversely associated with a slight increase of the HDL Cholesterol levels. Few data were found about the effects of Fluoxetina e Fluvoxamina on lipid profile and no data were found about Escitalopram. Sertaline and Paroxetine, two effective and widely used drugs for the treatment of major depression, seem to have a negative effect on the lipid profile; Citalopram, with its neutral or positive effect on lipid profile, should be considered the treatment of choice for depressive patients affected by dyslipidemia.

[Health surveillance in health care workers]

In a complex reality as the hospital, occupational physician plays a key role in risk prevention through health surveillance. The medical examination is intended to highlight any possible deterioration of workers' health and to detect workers' hypersusceptibility to occupational hazards. We report biostatistic data resulted from health surveillance conducted on health care workers in 2005 and 2006 in a universitary hospital, with particular regard to the judgement of the fitness to work and the reasons that has determined it. Our report, in agreement with data available in literature, shows that manual patient lifting is one of the most common professional hazards within the hospital and occupational physician must pay a special attention to it, promoting an integrated answer.

[Role of the occupational health physician in the evaluation of biological risk and cancer in a hospital setting]

OBJECTIVE

Elaborating and proposing a model of behaviour which is useful for any occupational doctor of a hospital in the management of the people exposed to biological risk, with the aim of preventing or early diagnosing neoplasias caused by cancerogenic infective agents.

MATERIALS AND METHODS

This study was conducted analyzing the literature data regarding biohazard work accidents which happened in health environment and the scientific evidence of the causal relationship between infective agents and development of neoplasias.

RESULTS

Data in literature show that the biohazard work accidents are very numerous and there is high percentage of sub-communication of them; many infective agents that the health workers can get in contact with, after biohazard biological accidents, are cancerogenic: HBV, HCV, HIV, HP belong to group 1 of IARC classification.

CONCLUSION

Health workers exposed to biological risk and in particular those who got in contact with infective biological liquids can be considered at risk of neoplasia development; for this reason, we propose a three phases behaviour model: 1. Biological risk accidents prevention; 2. Prevention of infective disease after an accident; 3. Neoplasia prevention and/or early diagnosis after the development of the infective disease.

[Evaluation and risk management of the risk of robbery]

The carried out work have permitted to make a technical evaluation of the risk robbery in a big Company of services and to formulate a strategy in order to prevent the criminal event and its effects on the workers' health. At this point an algorithm of prevision of risk has been formulated, taking account the elements of probability of criminal act and those ones referring to the relating damage according to the following formula: RISK(R) = PROBABILITY(P) x DAMAGE(D). The use of this method has proved useful to obtain the right evaluation risk robbery and it has permitted to elaborate a document of Health Protection to use towards the workers who are involved in the event with the active participation of the Company doctor.

[Biomechanical risk assessment of manual material handling in vegetables and fruit departments of supermarkets]

There is little in the literature about the risks of manual handling of material in supermarkets and what there is refers solely to storehouse work. This contrasts with the substantial number of studies of the risk of repeated arm movements among supermarket cash-desk staff. The scarcity of information is partly due to the difficulties of applying widely employed, standardized evaluation methods in this sector. One of the conditions limiting the application of the NIOSH protocol in this retail sector is that lifting tasks are so often closely tied to transport. The biomechanical analysis method we used brought to light considerable risks in many of the steps investigated: unpacking the pallet, unloading the crates from the pallet to the ground, lifting them from the floor onto display stands, and filling the boxes on the stands with goods before the shop opens. Images acquired on site were analyzed in the laboratory. We selected the most indicative images, which were then studied as regards posture and biomechanics using Apalys 3.0 software (ILMCAD GmbH, Ilmenau, Germany). Biomechemical analysis was done on the following movements: unloading crates from the pallet, positioning them on fruit and vegetable department display stands, and filling the boxes on the stands. We obtained a prediction of 2720 to 5472 N for the load at the lumbosacral junction (L5-S1). Simulation of the NIOSH index gave a value of 2.69 in the only case where the Waters protocol could be applied.

[Evaluation of the working load in subjects using equipment fitted with VDU]

In Italy the health and safety of VDU workers is regulated by section VI of Legislative Decree 626/94 (with later modifications). In compliance with this law, employers shall be obliged to analyse workstations, assess and reduce risks; they shall also identify any worker who habitually uses display screen equipment as significant part of his normal work (20 hours per week). Our study presents a new method, named WODSE (Workers of Display Set Equipment), for the objective evaluation of VDU workers effort. It is a software created for measurement of VDT usage time, able to calculate weekly use for each worker. We applied this method to tellers of a great national services agency, obtaining an improvement of VDU risk assessment and, consequently, management.

[Presentation forms of occupational psychologic disorders: experience at a national-level call center]

Often in Occupational Medicine doctors misunderstand or underestimate the occupational psychologic discomfort forms deriving from "transverse risks" of organizational kind. In this communication is shortly described a our study with in a "call center". We explain the several kinds of psychologic discomfort which we have here recognized and studied. We show, at last, some of job's organization modifications rose from the first outcome of our study.

Occupational risk factors for the sporadic form of Creutzfeldt-Jakob disease

Some case reports among European farmers and a few case-control studies suggested the hypothesis of an increased risk of the sporadic form of CJD (sCJD) associated with livestock farming or work as a butcher. Also, the discovery of the possibility of transmission of the disease via blood or by contact following corneal or dura madre transplant suggested that health occupations might also run higher sCJD risks. However, a meta-analysis of three case-control studies and a multicentre European study did not find any positive association between sCJD and health-related jobs or occupational contact with livestock, such as cattle and sheep, or animal products. To explore possible occupational risk factors for Creutzfeldt-Jakob disease (CJD), we used a publicly available US database including about 6 million deaths in 24 states during 1984-95. Cases were 636 deaths (300 men and 336 women) with CJD (ICD-9 code 046.1) as the underlying cause of death. Controls were 3,180 deaths randomly selected from among those who died from all other diseases except those affecting the central nervous system. CJD cases represented a wide variety of occupations (159) and industries (147). Among occupations and industries, for which previous reports suggested potential exposure to a transmissible spongiform encephalopathy (TSE) agent, the OR for CJD was significantly increased among butchers (OR = 6.8, 95% C.I. 1.5, 30.1, based on 4 cases and 3 controls), and persons working in offices of physicians (OR = 4.6, 95% C.I. 1.2, 17.6 based on 5 cases and 4 controls). Nine other occupations and seven other industries, for which no previous suggestion existed in the literature, also showed significant associations. Overall, our results suggest that occupational exposures are not an important source of sCJD infection. However, as the excess among butchers and some workers in health occupations was consistent with previous reports, more indepth research is warranted to address the hypothesis.

Pro-sequence assisted folding and disulfide bond formation of human nerve growth factor

Nerve growth factor (NGF) is a member of the neurotrophin family. These growth factors support neuronal survival and differentiation. Neurotrophins are synthesized as pre-pro-proteins. Whereas the pre-sequences mediate secretion, the function of the pro-peptides is largely unknown. To test the role of the pro-sequence as a folding enhancer, recombinant human pro-NGF (rh-pro-NGF) was produced in Escherichia coli. The oxidative refolding of rh-pro-NGF and rh-NGF was studied using electrospray mass spectrometry (ESIMS) time-course analysis. This analysis permitted both the identification and quantification of intermediates present during the process. The disulfide bonds formed at different times of the refolding processes were characterized by proteolytic digestion followed by matrix assisted laser desorption ionization mass spectrometry (MALDIMS) analysis. Folding yields and kinetics of rh-pro-NGF were significantly enhanced when compared to the in vitro refolding of mature rh-NGF. These results suggest that the pro-sequence of NGF promotes folding of the mature part.

[Health promotion in the occupational setting: what are the prospects in the Italian situation?]

Over the past decades advances in sciences and medicine have improved living and health conditions and lengthened life expectancy. These benefits are associated with an increase in prevalence of chronic degenerative diseases. With their multi-factorial aetiology these diseases are influenced by life styles and personal habits and require prolonged medical care and high social costs. Now days health is no longer considered as the absence of disease but a state of mental, physical and social well-being. The World Health Organization has defined health promotion as "the process of enabling people to increase control over and to improve health". Since the 70s in the USA many health promotion programmes have been proposed, especially by large corporations, in order to ensure a more efficient, productive and motivated work-force, to reduce health insurance costs and to provide a better company image. Workplaces,--particularly when the working population is relatively stable--are excellent areas for health promotion programmes because workers can be monitored over a long period of time. The most successful programmes are aimed at modifying behaviour in risk patterns (smoking, alcohol abuse, eating disorders, etc.) through information, active participation, screening, follow-up, personalized programmes, changes in the working environment, physical exercise programmes. These health promotion programmes are extremely hard to develop for Italian workers. Most firms are small or very small and much still remains to be done to eliminate well-known occupational risk factors. The current flexibility of modern work patterns could constitute a further obstacle.

Contribution of individual disulfide bonds to the oxidative folding of ribonuclease A

The eight cysteine residues of ribonuclease A form four disulfide bonds in the native protein. We have analyzed the folding of three double RNase A mutants (C65A/C72A, C58A/C110A, and C26A/C84A, lacking the C65-C72, C58-C110, and C26-C84 disulfide bonds, respectively) and two single mutants (C110A and C26A), in which a single cysteine is replaced with an alanine and the paired cysteine is present in the reduced form. The folding of these mutants was carried out in the presence of oxidized and reduced glutathione, which constitute the main redox agents present within the ER. The use of mass spectrometry in the analysis of the folding processes allowed us (i) to follow the formation of intermediates and thus the pathway of folding of the RNase A mutants, (ii) to quantitate the intermediates that formed, and (iii) to compare the rates of formation of intermediates. By comparison of the folding kinetics of the mutants with that of wild-type RNase A, the contribution of each disulfide bond to the folding process has been evaluated. In particular, we have found that the folding of the C65A/C72A mutant occurs on the same time scale as that of the wild-type protein, thus suggesting that the removal of the C65-C72 disulfide bond has no effect on the kinetics of RNase A folding. Conversely, the C58A/C110A and C26A/C84A mutants fold much more slowly than the wild-type protein. The removal of the C58-C110 and C26-C84 disulfide bonds has a dramatic effect on the kinetics of RNase A folding. Results described in this paper provide specific information about conformational folding events in the regions involving the mutated cysteine residues, thus contributing to a better understanding of the complex mechanism of oxidative folding.

Mammalian FKBP-25 and its associated proteins

Soluble proteins from porcine brain were divided into two packs: (1) proteins which pass freely through CM52-cellulose, and (2) proteins retained on CM52. Each of these two packs of proteins was fractionated on preparative flat-bed isoelectrofocusing gel in the range of pH 2-12. Native FKBP-25 and its truncated forms were found among other proteins retained on CM52-cellulose. Immunoblotting with anti-FKBP-25 showed two bands in the range 27-30 kDa, one due to unmodified FKBP-25 and other due to FKBP-25 mixed with high-mobility group II protein (HMG-II). Selective immunostaining with anti-FKBP-25 antibodies of proteins which were not retained on CM52-cellulose showed several bands within the range of pI 7-5 and mass of 23 +/- 2 kDa. These fractions of proteins were next resolved on two-dimensional gels and immunostained with anti-FKBP-25 antibodies. Six proteins in the pI range 7-5 were detected. Edman degradation of alpha-chymotrypsin digests of the major spot suggests that it contains the GTP-binding protein Rab5 co-migrating with guanylyl kinase, whereas MALDI-TOF showed that a residual content of FKBP-25 may be also associated with these two proteins. A residual quantity of FKBP-25 was also associated with the phosphatidylethanolamine-binding protein which is abundant in the brain.

Investigation of the DsbA mechanism through the synthesis and analysis of an irreversible enzyme-ligand complex

Approaching the molecular mechanism of some enzymes is hindered by the difficulty of obtaining suitable protein-ligand complexes for structural characterization. DsbA, the major disulfide oxidase in the bacterial periplasm, is such an enzyme. Its structure has been well characterized in both its oxidized and its reduced states, but structural data about DsbA-peptide complexes are still missing. We report herein an original, straightforward, and versatile strategy for making a stable covalent complex with a cysteine-homoalanine thioether bond instead of the labile cystine disulfide bond which normally forms between the enzyme and polypeptides during the catalytic cycle of DsbA. We substituted a bromohomoalanine for the cysteine in a model 14-mer peptide derived from DsbB (PID-Br), the membrane partner of DsbA. When incubated in the presence of the enzyme, a selective nucleophilic substitution of the bromine by the thiolate of the DsbA Cys(30) occurred. The major advantage of this strategy is that it enables the direct use of the wild-type form of the enzyme, which is the most relevant to obtain unbiased information on the enzymatic mechanism. Numerous intermolecular NOEs between DsbA and PID could be observed by NMR, indicating the presence of preferential noncovalent interactions between the two partners. The thermodynamic properties of the DsbA-PID complex were measured by differential scanning calorimetry. In the complex, the values for both denaturation temperature and variation in enthalpy associated with thermal unfolding were between those of oxidized and reduced forms of DsbA. This progressive increase in stability along the DsbA catalytic pathway strongly supports the model of a thermodynamically driven mechanism.

Aspartate aminotransferase from the Antarctic bacterium Pseudoalteromonas haloplanktis TAC 125. Cloning, expression, properties, and molecular modelling

The gene encoding aspartate aminotransferase from the psychrophilic bacterium Pseudoalteromonas haloplanktis TAC 125 was cloned, sequenced and overexpressed in Escherichia coli. The recombinant protein (PhAspAT) was characterized both at the structural and functional level in comparison with the E. coli enzyme (EcAspAT), which is the most closely related (52% sequence identity) bacterial counterpart. PhAspAT is rapidly inactivated at 50 degrees C (half-life = 6.8 min), whereas at this temperature EcAspAT is stable for at least 3 h. The optimal temperature for PhAspAT activity is approximately 64 degrees C, which is some 11 degrees C below that of EcAspAT. The protein thermal stability was investigated by following changes in both tryptophan fluorescence and amide ellipticity; this clearly suggested that a first structural transition occurs at approximately 50 degrees C for PhAspAT. These results agree with the expected thermolability of a psychrophilic enzyme, although the observed stability is much higher than generally found for enzymes isolated from cold-loving organisms. Furthermore, in contrast with the higher efficiency exhibited by several extracellular psychrophilic enzymes, both kcat and kcat/Km of PhAspAT are significantly lower than those of EcAspAT over the whole temperature range. This behaviour possibly suggests that the adaptation of this class of endocellular enzymes to a cold environment may have only made them less stable and not more efficient. The affinity of PhAspAT for both amino-acid and 2-oxo-acid substrates decreases with increasing temperature. However, binding of maleate and 2-methyl-L-aspartate, which both inhibit the initial steps of catalysis, does not change over the temperature range tested. Therefore, the observed temperature effect may occur at any of the steps of the catalytic mechanism after the formation of the external aldimine. A molecular model of PhAspAT was constructed on the basis of sequence homology with other AspATs. Interestingly, it shows no insertion or extension of loops, but some cavities and a decrease in side chain packing can be observed.

Early intermediates in the PDI-assisted folding of ribonuclease A

The oxidative refolding of ribonuclease A has been investigated in several experimental conditions using a variety of redox systems. All these studies agree that the formation of disulfide bonds during the process occurs through a nonrandom mechanism with a preferential coupling of certain cysteine residues. We have previously demonstrated that in the presence of glutathione the refolding process occurs through the reiteration of two sequential reactions: a mixed disulfide with glutathione is produced first which evolves to form an intramolecular S-S bond. In the same experimental conditions, protein disulfide isomerase (PDI) was shown to catalyze formation and reduction of mixed disulfides with glutathione as well as formation of intramolecular S-S bonds. This paper reports the structural characterization of the one-disulfide intermediate population during the oxidative refolding of Ribonuclease A under the presence of PDI and glutathione with the aim of defining the role of the enzyme at the early stages of the reaction. The one-disulfide intermediate population occurring at the early stages of both the uncatalyzed and the PDI-catalyzed refolding was purified and structurally characterized by proteolytic digestion followed by MALDI-MS and LC/ESIMS analyses. In the uncatalyzed refolding, a total of 12 disulfide bonds out of the 28 theoretical possible cysteine couplings was observed, confirming a nonrandom distribution of native and nonnative disulfide bonds. Under the presence of PDI, only two additional nonnative disulfides were detected. Semiquantitative LC/ESIMS analysis of the distribution of the S-S bridged peptides showed that the most abundant species were equally populated in both the uncatalyzed and the catalyzed process. This paper shows the first structural characterization of the one-disulfide intermediate population formed transiently during the refolding of ribonuclease A in quasi-physiological conditions that mimic those present in the ER lumen. At the early stages of the process, three of the four native disulfides are detected, whereas the Cys26-Cys84 pairing is absent. Most of the nonnative disulfide bonds identified are formed by nearest-neighboring cysteines. The presence of PDI does not significantly alter the distribution of S-S bonds, suggesting that the ensemble of single-disulfide species is formed under thermodynamic control.

Estimation of lead intake from crystalware under conditions of consumer use

The purpose of this study was to estimate the lead intake from crystalware resulting from short-term contacts with beverages, under conditions that are likely to occur to a consumer. The extraction ability of different kinds of beverages was estimated by comparison with 4% acetic acid under conditions of continuous contact for 3 h. It was found that lead release increased in the following order: cola drink > HAc > whisky > white wine. Under conditions of repeated use under different scenarios, lead release showed a steep decrease with increasing number of contacts, for both wine and cola drink. The maximum lead intake resulted from the cola drink, corresponding to an ingestion of 14.5 micrograms Pb for consumption of 350 ml beverage. Assuming a fixed contribution from the diet of 71 micrograms/day, in the six scenarios taken into consideration, total daily lead intake levels ranged from a minimum of about 76 micrograms up to a maximum of 86 micrograms lead. As these values, converted on a weekly basis, would correspond to 35% and 40% PTWI respectively, significant health risks resulting from the ingestion of beverages in contact with crystalware can be excluded. Finally it was found that the use of a dishwater did not affect significantly the release of lead into wine, while release into cola drink was slightly but significantly increased after the third cycle.

Blood lead concentration and biological effects in workers exposed to very low lead levels

A longitudinal study was carried out on two groups of workers engaged in tin/lead alloy welding in the telecommunication sector. The risk of exposure was evaluated by measuring levels of airborne lead (PbA) and the amount of lead absorbed (PbB). The-correlated effects were assessed by determining zinc protoporphyrin (ZPP) and hemoglobin levels (Hb) and red blood cell (RBC) count. We also recorded subjective symptoms reported by workers. One group of welders composed of 365 subjects underwent two monitoring sessions performed in 1991 and 1995, respectively (Group A). A second group of welders (whose number fluctuated between 148 and 247 subjects) underwent yearly testing for 7 consecutive years (1988-1994; Group B). Results indicated a very low risk of lead exposure during microwelding operations (PbA range, 1.5-24 micrograms/m3). In fact, blood concentrations of Pb (range, 5-55, micrograms/dL) among both groups of welders were significantly higher than those in the general population in Rome (PbB range, 5-16 micrograms/dL); nevertheless, they were significantly lower than the Occupational Safety and Health Administration's permissible exposure limits ZPP determined only in Group B of welders ranged from 5 to 16 micrograms/dL (median, 22 micrograms/dL). No variation was found in the other biological parameters investigated, and no health effects were observed. During the study period, the introduction of some technological innovations led to a further reduction in Pb exposure and, subsequently, to its total elimination. PbB concentrations gradually declined to lower values (6-36 micrograms/dL), and it was interesting to note that ZPP concentrations also decreased to normal levels (range, 2-47 micrograms/dL; median, 11 micrograms/dL), demonstrating that the effect of lead on heme synthesis may occur even at very low levels of Pb exposure.

Occupational exposure to chromium--an assessment of environmental pollution levels and biological monitoring of exposed workers

In an aircraft construction factory where adhesives containing Cr(VI) compounds were used, the risk of chromium exposure was studied by assessing airborne chromium levels and urinary levels of chromium excretion. Chromium exposure was evaluated by personal sampling over a period of 4 hr in a group of 16 occupational workers selected from a group of 55. Chromium absorption was determined by collecting urine samples from all subjects (n = 55) at 3 different times: prior to the work-shift at the beginning of the working week and prior to and after the workshift at the end of the working week. Each urine sample was tested for chromium and creatinine concentration. Results showed very low exposure to airborne chromium, since values obtained (0.02-1.5 micrograms/m3, GM: 0.17, GSD: 5.34 micrograms/m3) were significantly lower than the ACGIH Hygiene Standard (50 micrograms/m3). Likewise, urinary chromium excretion (0.16-7.74 micrograms/g creat.) was higher than excretion in the general population (0.07-0.17 microgram/g creat.) but lower than BEI-ACGIH (30 micrograms/g creat.). The greatest difference between excretion levels measured before and after the workshift was 2.44 micrograms/g creat, i.e. 4 times lower than the difference proposed by ACGIH (10 micrograms/g creat.).

Fatigue in MS is associated with specific clinical features

INTRODUCTION

fatigue is a common and disabling symptom in multiple sclerosis (MS). In this study we evaluated if fatigue is associated with different demographic and clinical features of MS.

MATERIAL

A survey was performed on 507 consecutive patients affected by clinically definite MS referred to our centre between January 1 and December 31, 1993. During the examination patients were asked to answer a brief fatigue questionnaire. To evaluate the probability of the occurrence of fatigue in association with several covariant factors (age, sex, duration, disease form, disease severity, month of examination, functional sub-systems on the expanded disability status scale (EDSS), a logistic regression analysis was performed.

RESULTS

we confirmed that fatigue is common in MS, recorded in 53% of patients. Patients affected by a more severe disability, by progressive MS, both primary and secondary, with an older age at examination, and assessed during spring, had a significantly higher risk of fatigue. Sex was not associated with the occurrence of fatigue. When the single items of EDSS were considered, we found that fatigue is also associated with the occurrence of cerebellar, sphincteric, pyramidal and sensitive signs, but not with brain stem, visual and cognitive impairment.

CONCLUSION

fatigue in MS is more frequent in association with specific clinical features.