Stereotactic radiotherapy in oligoprogressive and oligorecurrent urothelial cancer patients: A retrospective experience

Urothelial cancer is one of the most common malignancies; after relapse or disease progression available therapeutic options are limited. We analyze efficacy and toxicity of local treatment on metastases using stereotactic body radiation therapy (SBRT) in selected patients with oligometastatic disease from urothelial cancer. A significant percentage of treated lesions achieved local control, with a promising overall response rate.

OBJECTIVES

to analyze efficacy and toxicity of local treatment on metastases using stereotactic body radiation therapy (SBRT) in selected patients with oligometastatic disease from urothelial cancer.

MATERIALS AND METHODS

Data from clinical records of 19 patients treated in our institution since May 2011 to October 2017 with SBRT for oligometastatic/oligoprogressive urothelial carcinoma were retrospectively collected. Clinical outcomes in terms of local control (LC), response rate, symptoms control, progression free and overall survival (PFS and OS), and adverse events were analyzed and reported.

RESULTS

Nineteen patients were treated on 25 metastatic lesions; 5 of them received treatment on multiple sites. After an average follow up of 11.5 months, LC was achieved in 17 lesions (68%) and there was no local recurrence in lesions with complete or partial response. OS was 13.8 months. Adverse events were reported only in 3 patients (5 overall events). No late toxicity was reported.

CONCLUSIONS

An approach consisting in SBRT for local treatment of oligometastatic or persistent disease can be effective and safe in selected patients. Prospective studies are needed, to find correct selection criteria and optimal dose and fractionation.

Stereotactic body radiation therapy (SBRT) on renal cell carcinoma, an overview of technical aspects, biological rationale and current literature

BACKGROUND

Stereotactic body radiotherapy (SBRT) is characterized by the delivery of high doses of ionizing radiation in few fractions. It is highly effective in achieving local control, and, due to the high biological effective dose administered, it seems to overcome the radioresistance of renal cell carcinoma (RCC). Thus, SBRT could constitute a treatment option for the management of localized RCC in patients who are not surgical candidates. In this paper, we report an overview about data from the current evidence about SBRT in patients affected by localized RCC.

MATERIALS AND METHODS

A non-systematic review was performed, including data from both retrospective and prospective studies focusing on the use of SBRT for localized RCC and its biological rationale. Furthermore, ongoing trials on this issue are reported.

CONCLUSION

Currently, SBRT might be considered a treatment alternative in inoperable patients affected by primary RCC. Currently, dose-escalation to 48 Gy in 3-4 fractions are effective and well tolerated. Emerging role of immune therapies in RCC patients warrant further studies to explore interactions between SBRT and immune response.

[Essential fatty acids and lipid mediators. Endocannabinoids]

In 1929 Burr and Burr discovered the essential fatty acids omega-6 and omega-3. Since then, researchers have shown a growing interest in polyunsaturated fatty acids (PUFA) as precursors of "lipid mediator" molecules, often with opposing effects, prostaglandins, prostacyclins, thromboxanes, leukotrienes, lipossines, resolvines, protectines, maresins that regulate immunity, platelet aggregation, inflammation, etc. They showed that the balance between omega-3 and omega-6 acids has a profound influence on all the body's inflammatory responses and a raised level of PUFA omega-3 in tissue correlate with a reduced incidence of degenerative cardiovascular disease, some mental illnesses such as depression, and neuro-degenerative diseases such as Alzheimer's. The CYP-catalyzed epoxidation and hydroxylation of arachidonic acid (AA) were established recently as the so-called third branch of AGE cascade. Cytochrome P450 (CYP) epoxygenases convert AA to four epoxyeicosatrienoic acid (EET) regioisomers, that produce vascular relaxation anti-inflammatory effects on blood vessels and in the kidney, promote angiogenesis, and protect ischemic myocardium and brain. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are accessible to CYP enzymes in the same way as AA. Metabolites derived from EPA include epoxye-icosatetraenoic acids (EETR) and hydroxyeicosapentaenoic acids (19- and 20-HEPE), whereas DHA include epoxydocosapentaenoic acids (EDPs) hydroxydocosahexaenoic acids (21- and 22-HDoHE). For many of the CYP isoforms, the n-3 PUFAs are the preferred substrates and the available data suggest that some of the vasculo- and cardioprotective effects attributed to dietary n-3 PUFAs may be mediated by CYP-dependent metabolites of EPA and DHA. From AA derives also endocannabinoids like anandamide (N-arachidonoylethanolamine) and 2-arachidonoylglycerol, capable of mimicking the pharmacological actions of the active principle of Cannabis sativa preparations such as hashish and marijuana (-)-Delta9-tetrahydrocannabinol. They act as true 'endogenous cannabinoids' by binding and functionally activating one or both cannabinoid receptor present on nervous and peripheral cell membranes. Enzymes that carry out anandamide oxidation are the same fatty acid oxygenases that are known to act on endogenous arachidonic acid namely, the members of the COX, LOX, and P450 families of enzymes. Recent advances in the biochemistry and pharmacology of the endocannabinoid system, also for its central and peripheral roles in regulating food intake, will offer the development of novel therapeutic agents.

[Milk and butter. From the Neolithic to the current nutritional aspects]

The evolution in the history of nutrition knowledge towards dairy products, is strictly related to the socio-cultural development of humans. In fact, milk and butter have accompanied humans since ancient times, which traces of the consumption of such products are dated back about the earliest times after the last (glaciation) ice age, while the application for extra nutritional uses, such as cosmetics and ceremonial rites, are reported in the writings of the Old Testament. Even in Italy, before the Roman Empire, were known rudimentary techniques of production and storage of dairy products. But only with the advent of the Etruscans, and the Romans later, that the use of milk and dairy products reach a wide diffusion in several applications. Since the advent of Christ until today, milk and its derivatives have maintained a privileged place in the human diet, but it is only with the advent of modern medicine and new findings in lipidic chemistry that emerged multiple biological and nutritional properties, very important for human health. After a short summary of the ancient history of the milk and butter, the role of dairy products in cancer, in hypercholesterolemia, and cardiovascular disease are reported. Moreover, the current opinions on saturated fatty acids, the role of polyunsaturated fatty acids and their lipid mediators obtained by the action of cyclooxygenase, lipoxygenase and the cytochrome P450 enzymes, are treated. Even if sometimes mistreated, the milk, but most of all its high fat content derivatives such as butter, is a rich source of biologically active compounds that foster a controversial action against neolplastic and cardiovascular disease. These compounds, mainly contained in the lipid fraction, for the more obvious relationships that exist between nutrition and health status, have been the subject in the last decades of intense scientific investigation in which there were expressed lights and shadows, but recognizing that not all fats are harmful and further thorough studies are necessary, in particular, on the derived lipid mediators. This will allow a significant progress based on new scientific evidences, further orienting researchers and clinicians on evidence-based nutritional science.

["Butter, my love" joy, sorrow and rehabilitation: not simply cholesterol and saturated fatty acids]

The author refers to his "love" for butter and joy to eat and enjoy, during his childhood, bread, butter and jam at a time in which butter was still made with milk from cows that grazed and/or ate the hay. Subsequently the great bitterness occurred, due to the fact that many distinguished researchers have attributed to the the saturated fatty acids (SFA) and cholesterol, abundant in butter, the origin of atherosclerotic cardio vascular diseases (CVD) epidemic exploded in North America from the years 1920-1930. This happened in spite of the fact that various data did not overlap, and also that the most famous of cardiologists, worldwide known at the time, had written and pointed out that, if such a condition were caused by saturated fat animals, a corresponding increase in their consumption in the diet would be recorded, while it had actually dropped 20 percent. The prestige of some, alongside the desire to win their case, associated to the modest epidemiological skills of the time, have led them to fall into the error of "cherry picking", i.e. to choose only those data in support of their theory while ignoring others that contradicted that, for decades, the SFA were banned by encouraging the consumption of margarine and vegetable oils. Only in recent times it has emerged from indisputable surveys, that in the diet, if an excess of SFA is harmful, even an excess of simple carbohydrates or protein or polyunsaturated fatty acids omega-6 are responsible for atherosclerotic CD. The problem is not to eliminate from the SFA diet, as they look toxic while actually in some situations are indispensable, but to reach a correct balance of all the different nutrients in the diet, and not only of the SFA, plus physical activity. Butter, then, also in the light of new and important acquisitions, was rehabilitated. This brings to mind a claim issued by Hippocrates (460-377 BC), the pioneer of Western medicine, about 2400 years ago: "If you were to give each the right amount of nourishment and exercise, we found the road to health".

[The swimmer's otitis. An up to date and prevention options]

The swimmer's otitis or acute otitis externa, is a pathology that often occurs in those who practice swimming at a competitive level. The same problem often occurs in the summer with the attendance of swimming pools and bathing areas. A survey made in the United States in 2007 confirms the dynamics of the onset of this pathology, because the contamination of fungi and bacteria in the waters of the swimming pools and the sea cause the inflammation of the epithelium of the auditory canal. To face this issue, in addition to a correct diagnosis, and the necessary and appropriate therapies, it may follow the use of these medicinal preparations. The first one (A) is protective-acting, the second one (B) is characterized as a preventive, hygroscopic, moistening, antiseptic and antimycotic-acting solution. Swimmers who have been using the two (pre-and post) preparations daily for about a year have reported sporadic episodes of otitis. However, there is no doubt that these two compounds deserve a meticulous clinical trial in order to confirm their preventive and therapeutic potentials in external acute otitis.

[Adolescence yesterday and today: care issues]

In ancient Greece, the chronological boundaries of the stages of life hinged upon Solon's theory of human life as divided into ten seven year stages. At the peak of Latin civilization, the chronological limits of the infant, pueritia and adulescentia were respectively 0-8 years, 8-16 years and 16-17 years, when in a ceremony the adolescent (a term derived from adolescente (m) present participle of the Latin verb adolescere = to grow) wearing the "toga of manhood" is declared an adult (teenager adult) and up to 30 years later iuventus. Throughout the following centuries, the chronological boundaries of the various ages came to acquire only a theoretical worth, since the child, once introduced to the world of work, used to suddenly become an adult. Only in the wave of Humanism in the XVI-XVII century, people started to rediscover the Greek 'paideia' (education), the Latin Humanitas' (recognition and respect towards manhood in every man), and, through the Christian 'caritas' (to recognize and to love the son of God in every man) begins a moral vision of childhood, of his weakness and innocence, a reflection of the 'divine purity'. In this evolution, the twentieth century identifies itself with adolescence, so that history moves from an era devoiced of adolescence to an age in which adolescence appears to be the privileged age: the adolescent is the hero of the twentieth century. Several and many important institutions have proceeded to recognize the essential rights of adolescent care in pediatric departments, but many are still admitted to adult wards with suboptimal therapeutic results, particularly for blood-cancer. The pediatrician, both the family one and the one in the hospital, must be the referees for the health of the adolescent, especially in cases of chronic diseases or in those of psychosocial relevance, following her in the path of the disease especially if other specialists are involved with a view to further investigation, and establishing, since early childhood, communication, dialogue and compliance with her and the whole family. One of the greatest philosophers and sophists of Magna Graecia, Gorgia of Lentini, used to state that the word has tremendous power: it can instill the joy, eliminate pain, enhance compassion, put an end to fear: then be medicine for the suffering. The doctor is in fact, in certain situations of life, a drug for his patient. He is the most widely used drug because drugs are not the only thing that matters: the soul of medicine lies in the relationship, in the communication between the healer and the healed.

Dental enamel, fluorosis and amoxicillin

INTRODUCTION

Amoxicillin is one of the most used antibiotics among pediatric patients for the treatment of upper respiratory tract infections and specially for acute otitis media (AOM), a common diseases of infants and childhood. It has been speculated that the use of amoxicillin during early childhood could be associated with dental enamel fluorosis, also described in literature with the term Molar Incisor Hypomineralization (MIH), because they are generally situated in one or more 1st permanent molars and less frequently in the incisors. The effect ofAmoxicillin seems to be independent of other risk factors such as fluoride intake, prematurity, hypoxia, hypocalcaemia, exposure to dioxins, chikenpox, otitis media, high fever and could have a significant impact on oral health for the wide use of this drug in that period of life.

OBJECTIVE

The aim of this work was to review the current literature about the association between amoxicillin and fluorosis.

METHODS AND RESULTS

A literature survey was done by applying the Medline database (Entrez PubMed); the Cochrane Library database of the Cochrane Collaboration (CENTRAL). The databases were searched using the fol-lowing strategy and keywords: amoxicillin* AND (dental fluorosis* OR dental enamel*) and MIH*. After selecting the studies, only three relevant articles published between 1966 and 2011 were included in the review.

CONCLUSION

The presence of several methodological issues does not allow to draw any evidence-based conclusions. No evidence of association was detected, therefore, there is a need of further well-designed studies to assess the scientific evidence of the relationship between amoxicillin and fluorosis and to restrict the prescription of this drug for recurrent upper respiratory tract infections especially acute otitis media (AOM) during the first two years of life. When it is possible can be opportune to use an alternative antibiotic treatment.

[Proper antibiotic therapy. From penicillin to pharmacogenomic]

Antibiotics have always been considered one of the wonder discoveries of the 20th century. The use of penicillin by Flaming, opened up the golden era of antibiotics and now is hard to imagine the practice of medicine without antibiotics. Life-threatening infections, such as meningitis, endocarditis, bacteremic pneumonia sepsis, would again prove fatal. Also aggressive chemotherapy and transplant procedures would prove impossible. Another real wonder has been the rise of antibiotic resistance soon after the clinical use of penicillin in hospitals and communities. Several study demonstrated an excessive amount of antibiotic prescribing for communities patients and inpatients and in some hospital up to 50% of antibiotic usage is inappropriate: the benefits of antibiotic treatment come with the risk of antibiotic resistance development. In hospitals, infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. A variety of strategies has been proposed to reduce the cost and improve the quality of medication use. Education, guidelines and evidence based recommendations are considered to be essential elements of any program designed to influence prescribing behavior and can provide a foundation of knowledge that will enhance and increase the acceptance of stewardship strategies. Evidence-based recommendations, an approach to clinical practice helping to make decisions based on clinical expertise and on intimate knowledge of the individual patient's situations, beliefs, and priorities, enhance antimicrobial stewardship, that include appropriate selection, dosing, route, and duration of antimicrobial therapy can maximize clinical cure or prevention of infection while limiting the unintended consequences, such as the emergence of resistance, adverse drug events, and cost. These evidence-based guidelines are not a substitute for clinical judgment, and clinical discretion is always required in their application. Genome studies have identified hundreds of genetic polymorphism important determinants of the efficacy of therapy and several trial demonstrated the successful use of pharmacogenomic testing to reduce the incidence of hypersensitivity reactions in patients. Knowing the phenotype of a patient prior to therapy, optimal dose and type drugs can be prescribed to achieve better management of patients.

Gastroenteric pathology and probiotics: from myth to scientific evidence. Current aspects

Starting from Metchnikoff's theory of cell-mediated immunity and work on lactobacillus over 100 years ago, more and more applications for probiotics have been developed. Research into the health properties of probiotics has focused primarily on two areas: the interaction between intestinal microflora and enterocytes and the immune system and the use of probiotic products in the treatment of gastrointestinal diseases in adults and children. This review examines recent studies on the clinical use of monostrain and multistrain probiotic products in gastroenterology. The most widely studied strains are lactobacilli and yeasts, specifically, Lacto-bacillus rhamnosus GG and Saccharomices boulardii; the gastrointestinal disorders most commonly treated with probiotics are inflammatory bowel disease and dysbiosis, both of which clinically manifest as diarrhea.

Metchnikoff and the centenary of probiotics: an update of their use in gastroenteric pathology during the age of development

Acute gastroenteritis, antibiotic-associated diarrhea, diarrhea due to Clostridium difficile and traveller's diarrhea, Helicobacter pylori infection and intestinal inflammatory diseases are primitive and/or secondary pathological conditions that alter the intestinal mucosa and microbiota. For years researchers have searched for solutions to restore and rebalance normal transit and intestinal flora. Elia Metchnikoff was the first one to introduce oral bacteriotherapy, that uses very efficient microorganisms that prevent putrefaction and aging. Oral bacteriotherapy has now evolved in probiotics, whose helpful action to prevent and treat some gastroenteric pathologies is currently being studied.

[Omega-3: from cod-liver oil to nutrigenomics]

The leading role of cod-liver oil on rickets was a relevant factor in the knowledge of this disease. In 1922 the preventive and therapeutic value of cod-liver oil and sunlight against rickets in young infants was confirmed. The seasonal variation in the incidence of rickets, the role of skin pigmentation, of diet and the fact that breast milk was not an adequate source of vitamin D were understood. The discovery of essential fatty acids omega-6 and omega-3 have shown that deficiencies, mainly of omega-3 long chain polyunsaturated fatty acids, result in visual and cognitive impairment and disturbances in mental functions in infants and also in cognitive function in adults, as fatty acids are beneficial to vascular health and may forestall cerebrovascular disease and thus dementia. An adequate ratio of n-6 and n-3 fatty acids may promote a healthier balance of eicosanoids, which would protect membrane function with a nutraceutical function. Dietary lipids not only influence the biophysical state of the cell membranes but, via direct and indirect routes, they also act on multiple pathways including signalling, gene and protein activities, protein modifications and they probably play important role in modulating protein aggregation. Significant advances have been made in understanding the relation between dietary factors and inflammation, which is a central component of many chronic diseases, including coronary artery disease, rheumatoid arthritis, cancer prevention. However, the identification of those who will or will not benefit from dietary intervention strategies remains a major obstacle. Adequate knowledge about how the responses depend on an individual's genetic background (nutrigenetic effects), the cumulative effects of food components on genetic expression profiles through nutrigenomics mechanism, may assist in identifying responders and non-responders. Thus, fish and fish oil consumption might encourage brain development and gene expression to brain maintenance during aging through nutrigenomic mechanism.

[Childhood obesity: recent advances and an experimental contribution]

This work, in addition to the peculiar medical aspects of the children obesity, synthesize the experimental findings about the main plasmatic antioxidants (uric acid, ascorbic acid, retinol, coenzyme Q10, lycopene) and the platelet fatty acids profile in groups of children according to the following BMI criteria: 43 with a BMI ranging between 25 and 29; 43 with a BMI ranging between 21.7 e 22.9 and 20 with a BMI ranging between 18.5 e 20; average age 10.49 +/- 2.66. The antioxidants show a particular behaviour: in fact they decrease according to the BMI recorded within the groups. About this issue the international literature is not consistent. Probably different results can be found in more severe condition of obesity. Another important result is for the platelet fatty acid, independently from the BMI, weight etc. compared to the other subjects. The difference found is for the stearic acid, from 15 to 21 point of percentage, compared to all the other groups investigated. In agreement with the international literature, stearic acid seems to have an important role in the control of the platelet activation. This finding, could offer a better possibility to understand the progression of the atherosclerosis towards the ischemic condition, according to the age. The utilisation of particular mathematic models, the Artificial Neural Network, beyond the normal advanced statistic methods, has open to the understanding of phenomena, otherwise, inexplicable. With the Artificial Neural Network (ANN) it has been possible to classify the children using the ANN map built for the depressive condition (platelet fatty acids markers: palmitic acid, linoleic acid, arachidonic acid) and the ANN map built for the ischemic condition (platelet fatty acids markers: oleic acid, linoleic acid, arachidonic acid). Examining the maps, a certain percentage of children seems to be at high risk for several psychiatric conditions with respect to the major depression, while for the ischemic pathology the children are in the same position of the ischemic subjects. Because we know that the children are not ischemic, probably they have the same biochemical characteristics but are protected by the high level of stearic acid and by the high degree of saturation of the platelets. For this reason, children cannot belong to the map area of the major depression, which, in turn, is characterized by a very high degree of unsaturation of the fatty acids. Further studies are needed to better understand the complex situation of the children from the biochemical and psychiatric point of view.

[The essential fatty acids omega-6 and omega-3: from their discovery to their use in therapy]

In 1929 Burr and Burr discovered the essential fatty acids omega-6 and omega-3. Since then, researchers have shown a growing interest in unsaturated essential fatty acids as they form the framework for the organism's cell membranes, particularly the neurones in the brain, are involved in the energy-transformation process, regulate the information flows between cells. Polyunsaturated fatty acids are also precursors of ''hormonal'' molecules, often with opposing effects, prostaglandins, prostacyclins, thromboxanes, leukotrienes, lipossines, resolvines, protectines that regulate immunity, platelet aggregation, inflammation, etc. They showed that raised levels of polyunsaturated fatty acids omega-3 in tissue correlate with a reduced incidence of degenerative cardiovascular disease, some mental illnesses such as depression, and neuro-degenerative diseases such as Alzheimer's. The balance between omega-3 and omega-6 acids allows the cell membranes to develop with exactly the right flexibility and fluidity, to carry messages between neurones, that is a determining factor in physical and mental well-being and has a profound influence on all the body's inflammatory responses. The results of a number of scientific studies suggest that omega-3 acids contribute to measuring and restricting inflammatory symptoms, whereas omega-6 acids (and saturated fats) give free range to inflammatory responses and amplify allergic reactions. Today in the Western countries, the ratio of omega-3 acids to omega-6 in the diet is weighted 1:10 in favour of omega-6 to up to 1:25 in some areas, while for proper functioning a 4:1 ratio of omega-6 acids to omega-3 acids is generally considered the optimum. In addition, the type of diet followed in the Western countries is very rich in saturated fats like butter and animal fats, but because of an excessive supply of these less noble fats, the cell membranes lose flexibility and this can affect the way they work. An appropriate supplement can be an efficient, effective and often necessary way to meet the body's needs, enhance its daily functions and promote health and longevity.

[Membrane platelet fatty acids: biochemical characterisation of the ischemic cardiovascular disease, characteristics of the paediatric age, through an artificial neural network interpretation]

During the last 30 years, a huge research has been performed about the markers involved in the atherogenetic process and in the fatty acid thrombogenetic effect. More recently many studies have been made on the biochemical aspects of the saturated fatty acids with respect to the cardiovascular risk, in particular, the Stearic Acid (SA). Because of the peculiar characteristic of the platelets in the control of the thrombogenetic risk, we have investigated the platelet fatty acid profile in three groups of subjects: supposed healthy (n = 60), ischemic (n = 50), young children (n = 118). The aim of the study was to understand wich of the fatty acids could be evaluated as markers of the ischemic cardiovascular pathology and to have the possibility to classifie the subjects using the artificial neural network (ANN) system. The results highlight the peculiar position of the Oleic Acid, Linoleic Acid and Arachidonic Acid. According to the ANN results of the ischemic subjects, the young children were in the same position. Because this result is not commonly accepted, as children are healty, we have looked for a reason. There are well strong reasons to believe that all this is due to the stearic acid wich is extremely higher than the stearic acid of all the other subjects investigated. Particularly it has been underlined the possibility to modify the platelet stearic and oleic acid to obtain a better saturation index (Stearic/Oleic ratio). This could bring to a better control of the cardiovascular risk. It is possible, according with the results obtained, to open a new field of research on the lipid metabolism of the young children in relation to the atherogenesis. It is the first time that an observation on the platelet membrane phospholipid stearic acid is made in comparison to other adult subjects and a plausible explanation is given about the protection of the young children against the cardiovascular disease.

[Childhood feeding, chronic-degenerative disease in adults, and nutrigenomics]

Significant advances have been made in understanding the relation between dietary factors and disease prevention. However, the identification of those who will or will not benefit from dietary intervention strategies remains a major obstacle. The execution of the Human Genome Project has brought forth a wealth of information about the structure of the genome and the spectacular development of broad genomics technologies have catalyzed a new era in both medicine and nutrition. Each person is genetically unique and phenotypically distinct, and the genetic makeup that individuals inherit from their ancestors is responsible for variation in responses to food. Evidence continues to implicate dietary components and genetic susceptibilities as important determinants of chronic diseases, cancer risk and tumor behavior. Variation in incidence among and within populations with similar dietary patterns suggests that an individual's response may reflect interactions with genetic factors, which may modify gene, protein, and metabolite expression patterns. Nutrigenetics studies the genetic basis of the different individual responses to the same nutritional stimulus and Nutrigenomics is defined as the interaction between nutrition and an individual's genome. With the application of "omic" technologies, proteomic, metabolomic, transcriptomic, will increase our fundamental knowledge of the interaction between life processes and diet. The identification of diet-gene interactions will offers an opportunity to develop dietary interventions that will lead to evidence-based dietary strategies for restoring health and fitness, obviate the effects of genetic factors for preventing diet-related diseases and provide important clues about gene expression and gene modulation by environmental factors.

ESWL Prediction of Outcome and Failure Prevention

Based on our own experiences and a review of the recent literature, this article evaluates recent developments in predicting outcomes and failures of shockwave lithotripsy when treating patients with urinary tract stones. After a detailed MEDLINE research, the authors identified several variables that influence and predict extracorporeal shockwave lithotripsy (ESWL) success. These variables may be categorized as stone variables, patient variables and operator variables. Only multivariate analysis on a large number of homogenous patients may offer an objective evaluation of the factors conditioning ESWL outcome.

[Virgin olive oil. From legend to scientific knowledge of the nutraceutical aspects]

Proper nutrition has been considered the basis of good health since ancient times. Hippocrates (460-377 BC), father of modern medicine in the western world, claimed that "good health implies an awareness of the powers of natural or processed foods", the Salernitan School (eleventh-twelfth centuries) maintained that "the doctor must observe what food consists of, how much, and when it must be eaten", while Leonardo da Vinci (1452-1519) believed that "a man's life depends on what he eats". We know that lipids are important in nutrition and extra-virgin olive oil plays a predominant role in this field, recognised for its high levels of monounsaturated fatty acids. An example of a "nutraceutic" or "functional" food right from infancy, it is one of the best medicaments for delaying aging, and is also a good source of phytochemicals including polyphenolic compounds, squalene, alpha-tocopherol, carotenoid that may contribute to its overall therapeutic characteristics. An integral ingredient of the Mediterranean diet, extra-virgin olive oil has always been considered a middle road between food and medicine and there is growing evidence that its health benefits include reduction of coronary heart disease risk factor, prevention of several types of cancer, and the modification of immune and inflammatory responses. The origins of the olive tree date back to the Eneolithical era, or Copper Age, in the sixth millennium BC. Having first appeared in Italy during the Bronze Age, the fruit and oil of the olive tree were widely used in nutrition, medicine, art, literature, and daily life during the Etruscan and Roman civilisations, and throughout the Middle Ages and Renaissance. Mysteriously entwined with our own history, the olive tree has a human shape, strong, resilient, tenacious, filled with fruit, but also wounded, suffering and moving. Well-grounded reasons exist for considering olive oil the best nutritional gift we can offer ourselves as it preserves good health, improves the quality of our life and also makes it more enjoyable.

[Antipneumococcal vaccine: up date and prospective]

The authors, after a brief survey of the historical evolution of the antipneumococcal vaccines, concentrate on the most recent acquisitions concerning epidemiologic infections of pneumococcus in Italy and abroad. What emerged is the importance of prevention through an efficacious vaccination of the invasive forms particularly frequent in infants. Among there, and above all, meningitis; when not fatal, is very often the cause of serious illness. For this motive with the availability today of efficacious conjugated vaccine in infancy, a period with more frequent and invasive forms, it was first proposed to offer an antipneumococcal vaccination to children under 5 years of age that present particular clinical pathological conditions and later reconsidered the opportunity to extend the vaccination. Discussed and underlined are the differences between antipneumococcal vaccines available today, the importance of vaccinal coverage with conjugated vaccine from the first months of birth, and the fact that on extended vaccination campaign with such a vaccine can reduce the state of nasopharyngeal carriage of serotypes contained in the vaccine ever though penicillin resistant with an increase, however, of the state of carriage for serotypes not contained in the vaccine giving place to a phenomenon some call ''replacement'' of pathogens with non-pathogen germs. An ulterior benefit over the pneumococcal pathology is represented by the significative effect of ''herd immunity'' on subjects not vaccinated, factor that underscores the opportunity to extend the vaccination as much as possible. The importance of a precocious and rapid diagnosis with the tests available today and the necessity to vaccinate ever subjects that have overcome a serious pneumococcal infection in order to protect the subject from other types of pneumococcal particularly aggressive. Even though the vaccines actually available do not represent a final solution in the prevention of pneumococcus disease and the struggle against such pathology is destined to continue, the success obtained merits a certain satisfaction.

The vinification of partially dried grapes: a comparative fermentation study of Saccharomyces cerevisiae strains under high sugar stress

AIMS

The study of the fermentation performance of Saccharomyces cerevisiae strains under high sugar stress during the vinification of partially dried grapes.

METHODS AND RESULTS

Microvinification of partially dried grape must with sugar concentration of 35 degrees Brix was performed using four commercial strains to carry out alcoholic fermentation. A traditional red vinification without nutrients addition was applied. Yeasts displayed different efficiency to convert sugar in ethanol and varied in glycerol yield. Sugar consumption and ethanol level were attested at 80-87% and 143.5-158.0 g l(-1) respectively. High correlation between sugar and assimilable nitrogen consumption rate was observed. Statistical treatment of data by principal component analysis highlighted the different behaviours that strains exhibited in regard to the production of higher alcohols and other compounds important to wine quality.

CONCLUSIONS

Saccharomyces cerevisiae strains displayed appreciable capability to overcome osmotic stress and to yield ethanol fermenting high sugar concentration grape must in winemaking condition.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results provided insights on the strain contribution to wine quality subordinate to stress condition. This investigation is of applicative interest for winemaking and processing industry that use high sugar concentration musts.

[Rhinosinusitis in childhood]

Rhinosinusitis is a pathology having a multifactorial genesis, in which predisposing factors can help the transition from simple rhinitis, that is a very frequent disease in pediatric patient, to a more severe acute bacterial infection of nasal and paranasal cavities. Usually rhinosinusitis, at least at the beginning, has viral origin. Symptomatology of rhinosinusitis is aspecific and clinical data are modest. The course can be acute, subacute or chronic and sometimes recourrent. Diagnosis is given by clinical data, and nasal endoscopy with optics fibers, if necessary. Radiological examination, computed axial tomography and nuclear magnetic resonance, are required in complex and recourrent forms. In 70-80% of cases it recuperates spontaneously, without followings, otherwise it needs a support therapy to relieve symptoms, and to prevent complications. This can be made using hypertonic solutions (Iperclean), in order to remove nasal secretion, to decongest mucosa and improve ciliary clearance. Some researcers demonstrated the effectiveness of this approach, also preventig otitis. Nasal decongestants and antinflammatories are useful, too. Antihistaminic, overall those of 2nd generation, like levocetirizina, are used in allergic forms. Antibiotic therapy is required when rhinosinusitis lasts over 15-20 days, to prevent complications and to avoid the illness to become chronic. Endoscopic nasal surgery allows to reopen natural ways of drainage of paranasal cavities, and it is anyway suggested in more complicated cases.

[Transfusions in paediatric emergencies]

The interest in pathological emergencies and their therapeutical options has underscored the need for immediate, precise and evidence based criteria in the administration of blood products. In fact these often are an extremely important therapeutical option, above all for children less than 3 years old. Therefore our work pointed out a precise and easy to follow diagnostic and therapeutic alghoritm as already done for other clinical emergencies. We tried to supply all the indications for the correct use of whole blood, red packed cells, platelets, granulocytes, plasma and albumin. This alghoritm includes the history, the ethiological and clinical aspects, the domiciliary interventions, the indications to the admission, the diagnostic investigations, the therapeutical aspects and the indications to the discharge. Starting from our assigned aims and following the above mentioned alghoritm, we also try to give some practical updated and evidence based hints to face the difficult situations arisen by the anxious attentions of the relatives. In fact these can sometimes be cause of mistakes. Medicine is, however, a ever changing science. The new knowledges and technologies and the changes according to the new acquisitions are at the basis of the continuous development of new diagnostic and therapeutical approaches. Our aim was therefore to provide a state of art in this field using the data published in the most recent and authoritative literature.

Uric Acid, Phosphate and Oxalate Stones: Treatment and Prophylaxis

Medical treatment for the most commonly encountered types of renal stones is described. Nowadays treatment for uric acid stones is well-defined: alkalinizing urine is easy with drugs that are sufficiently active and well enough managed. Relapse is avoided in a high percentage of patients. Medical treatment of phosphate or calcium stones is a more open question as results are far from satisfactory compared with intra- and extra-corporeal approaches which are often minimally invasive and well accepted by both patient and urologist. Relapses are not easy to control because prophylactic measures such as changes in lifestyle and diet are never activated or because they are adopted for a brief period of time. Water therapy is examined, with the choice of water depending on the type of stone, together with drug therapy. Drugs such as citrate, with or without magnesium, and thiazides are considered excellent for curing renal stones and relapses. Although medical therapy has a limited role in many types of stones, its use is decisive in some others.

[Probiotics: from Metchnikoff to the current preventive and therapeutic possibilities]

About a century ago, Metchnikoff first hypothesised that some intestinal bacteria "produce compounds useful against a premature ageing". Since then, studies progressed over last century, leading to a remarkable improvement of the knowledge about the role of intestinal micro-organisms. Nowadays a number of different micro-organisms satisfying certain requisites are named probiotics and are produced on a large scale. At present, a rational use of probiotics with preventive and therapeutic purposes has been proposed not only for some gastrointestinal pathologies, such as the infective diarrhea (as recommended by the Italian Society of Pediatric, the Italian Society of Gastroenterology and Hepatology, the Italian Society of Pediatric Infectious Disease, and by International Societies), but also for other pathologic conditions, such as the atopic dermatitis and related affections (as suggested by the American Academy of Dermatology Association guide lines). Moreover, the use of probiotics is going to be extended to other pathologies, such as the inflammatory intestinal and respiratory diseases, and even to the prevention of tooth decay, although the actual preventive and therapeutic effects of probiotics onto these pathologies have to be carefully investigated. It is unknown if the genius Leonardo Da Vinci (1452-1519), stating that "man's life is built up by food" imagined how nutrients can influence human health, besides being essential for life, as it is today increasingly evident. Avoiding an excessive optimism and the thought that an efficacious panacea for all troubles has been found, there are sound reasons to believe that probiotics, and prebiotics as well, can influence human health, through the prevention and therapy of many diseases, although further studies are still requested to fully clarify the mechanisms of action of these micro-organisms on each pathology.

[Head trauma: clinical and diagnostic factors in pediatric emergency]

The Authors describe the clinical spectrum of head trauma. The importance of history (the way the trauma occurred) and of the intrinsic dynamics of the lesions are emphasized, as is their role for the outcome. They delineate the major intervention the pediatrician should perform in emergency, and the diagnostic and therapeutical approach. In particular, recommendations are made about the best neuroradiological test which should be done.

Fatty acids composition of plasma phospholipids and triglycerides in children with cystic fibrosis. The effect of dietary supplementation with an olive and soybean oils mixture

Cystic fibrosis (CF) is characterized by abnormal levels of essential fatty acids (EFA) in plasma phospholipids. The reduced availability of EFA has been reported to alter patterns of circulating and tissue esterified acids and may determine profound changes in membrane fluidity and cell signaling mechanisms. In the current study, the results of a new strategy aimed at the realization of a practical, low cost integrator, for daily use in the dietary management of FC subjects, are reported. We investigated the plasma phospholipids and triglycerides fatty acids composition of CF patients subjected to a dietary supplement constituted of a mixture of 50% extra virgin olive oil and 50% soybean oil and studied the clinical effects of this supplementation. The study included fourteen young subjects, aged between 6 and 15 years, affected by cystic fibrosis, with pancreatic insufficiency and heterozygotes or homozygotes for the delta F508 mutation. The subjects were matched by age and randomly assigned to either an oil mixture supplemented (OM) group (n = 7), or to a control (C) group (n = 7). In contrast to the control group, the patients with supplemented diet achieved significant increases of the relative amount of C18:1 in the triglycerides as well as a significant decrease in saturated fatty acids (C 16:0, C 17:0, C 18:0, C 22:0). Moreover, the ratio between LA acid and AA significantly increased in the triglycerides of the OM group. In the phospholipids of the OM group, the relative amount of C 18:1 and of palmitic acid increased significantly whereas the relative amount of the most important polyunsaturated fatty acids (PUFA) decreased. These results show that oleic acid can be absorbed and incorporated into the plasma triglycerides of CF patients receiving pancreatic enzymes, whereas poor incorporation of LA occurs. Despite the reduction in the relative amounts of phospholipid PUFA, the supplemented subjects did not reported adverse effects There were no significant differences between groups in the clinical indexes recorded (height, weight, BMI, Schwachman-Kulczycki score and FEV 1s). The results of this study showed that the supplementation with a mixture of extravirgin olive and soybean oil was safe in seven CF patients treated during a 2-months period and no negative clinical effects were evident. However, further clinical trials will be necessary in order to better evaluate the consequence of the observed changes in plasma fatty acids composition in a longer testing period.

[Polyunsaturated fatty acids: omega-3 in child development]

The understanding of the role of lipids has made major advances following the identification, by George and Mildred Burr, of so-called "essential fatty acids", i.e. linoleic acid (LA) and alpha-linolenic acid (ALA). LA is supplied by animal and vegetal fats, while ALA reaches higher levels in breastmilk, fish, and olive oil. For both LA and ALA, the human body depends exclusively on the dietary supply. These lipids play a major role as structural components of cell membranes, in particular of neurons, nerves, myelinated sheath, retina, vessels, heart, and blood cells; moreover, they act as precursors of several short-life compounds with hormone-like action: prostaglandins, prostacylins, thromboxanes, leukotriens, all with a regulatory effect on several cell functions, and on cholesterol pathway. It has been suggested a "health programming" role for food, due to the impact of the type of feeding on the subsequent neuromotor development, learning abilities, behavior, metabolism, blood pressure, bone mineralization, and degenrative diseases. This is the consequence of changes of the genomic expression, with a guided clone selection. This is in line with the "imprinting hypothesis" proposed by K. Lorenz (1973 Nobel Prize for Physiology and Medicine), who suggested that stimulations at a particular age may drive animal behavior for the rest of their life.

[Compliance with nebulized therapy in childhood]

While in the past diagnostic and therapeutic means were rather limited, nowadays doctors have a vast and valid selection of both at their disposal which, if used correctly, are able to successfully treat various pathologies. It is for this reason that the paediatrician undertakes to give patients--and above all their parents--all the correct information regarding their treatment and/or lifestyle in order to obtain the best possible therapeutic results as well as optimum health conditions. However, despite efforts on the part of the paediatrician, the parents and even the patients themselves, much of what is advised is often partly ignored, forgotten or incorrectly implemented, whether intentionally or by mistake. In essence, the compliance to advice given is often inadequate especially in more serious conditions such as asthma. All of these problems are mainly due to the fact that communication is more than often poor, despite the primary role it plays in the compliance to treatment and its correct implementation. Such impaired communication is usually caused by a sense of wanting to do things quickly on the part of the doctor, the patient and/or the family. Moreover, it must also be said that nowadays patients above all are impatient and the desire to recover is rarely equal to the commitment shown towards treatment. All of this obviously has negative affects on our patients' health conditions as well as on health care costs. Frequently failures and no significant reduction in mortality due to asthma, especially during adolescence when interpersonal relationships are more difficult, are a reality. Moreover, this reality strongly suggests that, despite doctors' competence and progress in both therapy and technology which permit the administration of simple to use medicines such as aerosols, greater commitment is required in order to obtain better results which are consistent with the current availability of such technological and therapeutic measures.

[Oral antibiotic therapy: problems and perspectives]

As all therapies, oral antibiotic therapy has its own scientific rationale. Infact, for an optimal oral therapy the drug must be absorbed completely, reach the infection site and diffuse in the tissues. It should also remain active for as long as possible at the minimal bactericidal level of concentration. It is therefore necessary to use drugs with a specific bactericidal action for the pathogens in question and that these drugs be administered at right doses for the necessary duration so that the infection is eliminated. It is an inappropriate therapy that which not only fails to eliminate the infection, but leads to the development of resistance, which is an increasingly serious and diffused problem. In hospital and at home it is possible to switch from an injected antibiotic form to the more practical and less expensive oral form, therefore creating a sequential therapy which is better accepted by patients and their families. The acceptance of prescribed therapies is an aspect that should never be underestimated, especially during the development age. Infact, despite the general understanding that unsatisfactory clinical results are a consequence of unadequate compliance with therapy, the desire to recover is rarely the same as the will to follow such plans, even if the patient expects a quick and full recovery. It is therefore necessary to use those therapies which are best accepted but always effective in order to avoid legal implications.

Post-operative monitoring of cortical taurine in patients with subarachnoid hemorrhage: a microdialysis study

Intracerebral MD enables the retrieval of endogenous substances from the extracellular fluid (ECF) of the brain and has been demonstrated to be a sensitive technique for early detection of subtle vasospasm-induced neurometabolic abnormalities in patients with subarachnoid hemorrhage (SAH). The aim of this study was to monitor cortical extracellular concentrations of energy metabolism markers, such as glucose and lactate, neurotransmitter amino acids, such as glutamate, aspartate, GABA and taurine to identify any neurochemical patterns of cerebral ischemia. A prospective clinical study was conducted on a group of 16 patients with non-severe SAH operated on within 72 hours after initial bleeding. Following aneurysm clipping, an MD catheter was inserted in the cortical region where vasospasm could be expected to develop, and perfused with artificial CSF at 0.3 microl/min flow rate. Dialysate was collected every 6 hours and then analyzed on High Performance Liquid Cromatography (HPLC) for glucose, lactate, pyruvate, glutamate, aspartate, GABA and taurine. Mean ECF taurine concentrations ranged from 1.4 + 0.7 to 12.3 + 7.8 micromol/l in single patients: global mean value was 5.8 + 3.8 micromol/l. In this series, the highest absolute taurine value was 25.7 micromol/l, observed in a patient who developed clinical and radiological signs of cerebral ischemia. Nine patients presented clinical disturbances related to cerebral vasospasm. In this setting, representing a mild-to-moderate hypoxic condition, MD data demonstrated that lactate is the most sensitive marker of cellular energy imbalance. Increased lactate levels positively correlated with glutamate (P<0.0001), aspartate (P<0.0001), GABA (P<0.0001) and taurine (P<0.0001) concentrations. These results suggest that also in humans increased taurine levels reflect a condition of cellular stress. This study confirms that MD is a sensitive technique to reveal subtle metabolic abnormalities possibly resulting in cell damage.

Epidemiology and treatment of otitis media with effusion in children in the first year of primary school

In this multicentre study we evaluated the prevalence and risk factors of otitis media with effusion (OME) in Italian school-children and the effectiveness of medical treatment of chronic OME with a new cephalosporin, ceftibuten. During two winter periods, 3413 children, aged 5 to 7 years, were examined for the presence of OME by means of pneumotoscopy and a portable, hand-held tympanometer. The prevalence of asymptomatic OME was 14.2%, with no difference as regards sex, age, month of examination or geographic area. Younger children had significantly more bilateral than unilateral effusion. A recent episode of acute otitis media and previous tonsillectomy or adenoidectomy were associated with an increased risk of OME in multivariate logistic regression models. The presence of OME was unrelated to such factors as birthweight, prematurity, sibling or parental history of allergy, duration of daycare attendance, family history of ear infections. After 12 weeks, 26.6% of children with OME still had middle-ear fluid: 52 were randomized to ceftibuten (9 mg/kg q.d. for 14 days) and 59 to no treatment (nasal saline drops allowed). Children treated with ceftibuten had a significantly better resolution of middle-ear effusion after 4 and 8 weeks. As mass screening programmes for OME in the year of school entry are questioned, a focus only on children with known risk factors seems advisable. Ceftibuten can be useful in reducing the duration of middle-ear effusion.

Spondylo-mesomelic-acrodysplasia with joint dislocations and severe combined immunodeficiency: a newly recognised immuno-osseous dysplasia

A newborn girl is described with an association of spondylo-acrodysplasia, mild short limbed dwarfism without significant metaphyseal changes, joint dislocations, and severe immune system dysfunction. This association is distinct from other known immuno-osseous dysplasias, including Schimke dysplasia, ADA deficiency with osseous changes, and Omenn phenotype with short limbed dwarfism.

Genetic history of cystic fibrosis mutations in Italy. I. Regional distribution

Earlier analysis of the Italian population showed patterns of genetic differentiation that were interpreted as being the result of population settlements going back to pre-Roman times. DNA disease mutations may be a powerful tool in further testing this hypothesis since the analysis of diseased individuals can detect variants too rare to be resolved in normal individuals. We present data on the relative frequencies of 60 cystic fibrosis (CF) mutations in Italy and the geographical distribution of the 12 most frequent CF mutations screened in 3492 CF chromosomes originating in 13 Italian regions. The 12 most frequent mutations characterize about 73% of the Italian CF chromosomes. The most common mutation, delta F508, has an average frequency of 51%, followed by N1303K and G542X, both with average frequencies around 5%. Multivariate analyses show that the relative frequencies of CF mutations are heterogeneous among Italian regions, and that this heterogeneity is weakly correlated with the geographical pattern of non-DNA 'classical' genetic markers. The northern regions are well differentiated from the central-southern regions and within the former group the western and eastern regions are remarkably distinct. Moreover, Sardinia shows the presence of mutation T338I, which seems absent in any other European CF chromosome. The north-western regions of Italy, characterized by the mutation 1717-1G-->A, were under Celtic influence, while the north-east regions, characterized by the mutations R1162X, 2183AA-->G and 711 + 5G-->A, were under the influence of the Venetic culture.

Chickenpox complications among immunocompetent hospitalized children in Italy. Acyclovir-Chickenpox Italian Study Group

OBJECTIVE

To evaluate the frequency and clinical spectrum of chickenpox complications among immunocompetent hospitalized children.

PATIENTS AND METHODS

Multicentre retrospective study of clinical records of all patients consecutively hospitalized for varicella during the last decade, in ten tertiary care clinical centres of Pediatrics and Infectious Diseases, throughout Italy.

RESULTS

Two hundred and nineteen out of 991 patients (22.1%) hospitalized for varicella suffered from a complicated disease (247 complicating events on the whole). Central nervous system (CNS) involvement was prevalent (104 episodes), followed by skin/soft tissue infections, lower respiratory tract involvement, and thrombocytopenia. A complicated disease was significantly associated with the male gender and an elevated incidence of varicella-zoster (VZ) virus infection acquired by household contacts. The involvement of lower respiratory airways and skin/soft tissues seemed to occur at an earlier age, compared with CNS and thrombocytopenia. Moreover, lower respiratory tract and skin/soft tissue infections occurred earlier during disease course than complications interesting the CNS and coagulation system. All subjects with complicated chickenpox showed a favourable outcome within 5-40 days, except two patients developing a lethal cardiomyopathy and Reye syndrome, respectively. Anyway, chickenpox complications led to a prolonged hospitalization, and needed further pharmacologic treatment in all evaluated cases. The administration of anti-VZ virus treatments (i.v. acyclovir or VZ immunoglobulins) did not modify significantly the course of disease in treated patients, when compared with untreated ones.

CONCLUSIONS

Although chickenpox is considered a self-limiting, uncomplicated disease in immunocompetent children, when assessing hospitalized patients a considerable incidence and a broad spectrum of complications are observed, requiring prolonged admission and pharmacologic and supportive care. Even though a lethal outcome remains a rare occurrence, it may be of relevant concern when considering the overall incidence of chickenpox in the general population. The role of an early antiviral treatment in reducing the incidence and severity of varicella complications deserves further evaluation.

The efficacy of E.P.D., a new immunotherapy, in the treatment of allergic diseases in children

A double blind study was made on a group of 35 children, 8 of whom were allergic to Grass and 27 allergic to Pteronyssinus and Farinae Dermatophagoides. We verified the efficacy and tolerability of a new immunotherapy called E.P.D. (Enzyme Potentiated Desensitization). This particular immunotherapy consists in an intradermal injection of a mix made up of an allergic solution at extremely low doses and an enzyme, beta-glucuronidase. The vaccine is administered once a year, two weeks before pollen peaks for children with seasonal allergies and two times a year, in February and November, for children with non-seasonal allergies (Dermatophagoides). The results, statistically analyzed on the basis of a symptoms score, showed good clinical efficacy in patients affected by both seasonal and non-seasonal allergies. Due to the clinical effectiveness, easy administration and excellent tolerability of the immunotherapy, E.P.D. is particularly suited for treating or reducing allergic symptoms in allergic children.

The management of cystic fibrosis with carbocysteine lysine salt: single-blind comparative study with ambroxol hydrochloride

The effectiveness of carbocysteine lysine salt monohydrate (SCMC-Lys) and ambroxol hydrochloride (ABX) in the management of respiratory impairment was compared in a single-blind, randomized study of 26 cystic fibrosis patients with similar baseline characteristics. Adults received either SCMC-Lys 900 mg or ABX 33 mg three times a day and children under 14 years of age either SCMC-Lys 270 mg three times a day or ABX 10 mg four times a day. All treatments were given orally for 80 days and at the end of this control period both groups showed significant improvement in chest sound score but improvement in cough score was observed only in those receiving SCMC-Lys. Expectorate viscosity and elasticity decreased significantly in both groups. In SCMC-Lys-treated patients paCO2 decreased and paO2 and Hb O2 saturation increased while only paO2 increased significantly in those treated with ABX. An increase in tidal volume, peak expiratory flow values and forced expiratory volume were evident in those receiving SCMC-Lys while significant increases in forced expiratory flow were recorded in those receiving ABX. SCMC-Lys patient's Shwachmann index improved significantly and conversely to the ABX patients. No adverse events were recorded in either treatment group. The study concluded that SCMC-Lys is at least as effective as ABX in improving respiratory function in patients with cystic fibrosis.

Role of the low zinc bioavailability on cellular immune effectiveness in cystic fibrosis

An altered cellular immune response as a secondary phenomenon has been suggested to be probably involved in the bronchopulmonary infections by Pseudomonas aeruginosa in cystic fibrosis (CF). The difficulty to eradicate with modern anti-pseudomonal antibiotics the bronchopulmonary infections has led us to further investigate the possible existence of other cellular immune defects and their cause. Alterations in zinc turnover are present in CF. Zinc is relevant for good immune functioning. In particular, zinc is required to confer biological activity to thymulin (ZnFTS), a biochemically defined thymic hormone with a modulating action on cell-mediated immunity. The zinc-unbound form (FTS) is inactive and it can be unmasked by in vitro zinc addition to the plasma samples revealing the total amount of circulating thymulin (active + inactive). Marginal zinc deficiencies may prevent peripheral biological activation of active thymulin. Total zinc-saturable thymulin fractions in CF are similar to those observed in normal subjects, whereas the active quota is strongly reduced associated with concomitant high plasma levels of inactive thymulin compared to the values of healthy children (P < 0.01). A strict correlation exists between zinc and thymic hormone-saturable fraction (r = 0.87, P < 0.01) in CF. These findings suggest that the defect is not due to a thymic failure but to a reduced peripheral saturation of thymulin by zinc ions. This defect might depend on augmented plasma concentration of alpha 2-macroglobulin, which has a higher binding affinity for zinc than thymulin. T cell subsets are normal in CF. Reduced NK cell number and activity are present. Also, plasma IL-2 levels are reduced. The existence of positive correlations between zinc and IL-2 (r = 0.79, P < 0.01) and between zinc or active thymulin and NK activity (r = 0.70, P < 0.01 and r = 0.88, P < 0.01, respectively) suggest a close link among zinc failure, impaired IL-2 activity, low thymulin level, and reduced NK activity in CF patients with both normal and growth retardation. Although the role of NK cells is unknown in CF, a zinc supplementation, in order to induce a complete saturation of thymulin molecules, to correct some cellular immune defects and to improve the growth, may be suggested.

Varicella in immunocompetent children in the first two years of life: role of treatment with oral acyclovir. Italian Acyclovir-Chickenpox Study Group

An open multicenter study has been carried out to evaluate efficacy and tolerability of oral acyclovir in the treatment of varicella in immunocompetent patients in the first two years of life. Fifty-three children aged 3-24 months received acyclovir at 80 mg/Kg/day in four divided doses for 4 to 6 days; 24 of them were treated in the first 24 hours following disease onset, while the remaining 29 patients were enrolled within 48 hours. The assessment of evolution of disease signs and symptoms showed a rapid resolution of fever, itching and other constitutional symptoms, with interruption of vesicle formation and acceleration of cutaneous healing processes. No statistically significant differences have been demonstrated as to disease progression between patients treated in the first 24 hours, when compared with subjects receiving acyclovir in the following 24 hours. Acyclovir confirmed its excellent clinical and laboratory safety profile. By acting favorably on both the duration and severity of disease signs and symptoms, acyclovir treatment should be recommended in young children and infants with varicella, since a higher incidence of severe and complicated disease has been observed in these patient groups.