Are technology-based health education methods able to reduce oral health inequalities between the sexes in adolescents? A cluster randomized trial

PURPOSE

Determine if different technology-based health education interventions can reduce oral health inequalities between the sexes in a sample of adolescents.

METHODS

A cluster randomized clinical trial was conducted in three phases with an initial sample of 291 male and female adolescents 14-19 years of age. Phase I (n = 288) comprised a clinical examination performed by a calibrated examiner using the simplified oral hygiene index (OHI-S) and gingival bleeding index (GBI). Phase II involved two educational interventions: video (VD; n = 147) or oral counselling (OR; n = 141) with standardized content. In phase III, an App was made available to half of the clusters (OR + App; n = 66/OR without App; n = 71/VD + App; n = 63/VD without App; n = 63), and the clinical examination was performed a second time. Data were evaluated using descriptive analysis and nonparametric tests.

RESULTS

In phase I, boys had a lower standard of oral hygiene compared with girls, with higher mean OHI-S (p = 0.039) and GBI (p = 0.015). After VD and OR interventions, no significant difference between sexes was found regarding the mean OHI-S. However, males had a higher mean GBI compared with females in the OR group (p = 0.006). When the App was added to OR and VD groups, males in the 'OR without App' group had a higher mean GBI compared with females (p = 0.007).

CONCLUSION

This clinical trial demonstrated that educational interventions involving information technologies were effective at reducing oral health inequalities between the sexes among adolescents. However, oral counselling alone was not efficient in reducing GBI in male adolescents.

Migrant and ethnic minorities at higher risk of COVID-19 severe outcomes? A systematic review

Background

The Covid-19 pandemic has had a recognised impact in widening health inequalities, both between and within countries, with a major impact on socially disadvantaged population groups such as Migrants and Ethnic Minorities (MEMs). While there is growing evidence on the matter worldwide, data specific to the WHO European Region is scarce. The issue, however, is pressing, since it is estimated that almost 10% of the population living in the WHO European Region is made up of migrants. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes.

Methods

We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Fourteen researchers were involved in selection, study quality assessment, data extraction and analysis.

Results

Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. 82% of the studies were conducted in the UK.

Conclusions

These findings highlight the disproportionate impact of Covid-19 on MEMs population, with an increased risk of all the adverse outcomes taken into consideration. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policy-makers to consider the socio-economic barriers when designing health promotion plans.

Key messages

• The combination of disadvantage socioeconomic conditions with COVID-19 transmission characteristics put migrants and ethnic minorities at a higher risk of facing sever health outcomes.

• The amount of evidence on the inequal impact of COVID-19 on migrants and ethnic minorities produced by European countries is poor. This gap must be filled to develop effective health promotion plans.

Five-hub General Conceptual Framework to improve the vaccination coverage for newly arrived migrants

Background

Within the Project “Increased Access for Newly Arrived Migrants-AcToVax4NAM” (Grant n 101018349, 3rd EU Health Programme), a General Conceptual Framework (GCF) was developed for understanding how to improve vaccination coverage for Newly Arrived Migrants (NAM), by characterizing and critically analysing system barriers and possible solutions to increase vaccination

Methods

A logical pathway was hypothesized based on conceptual hubs in the immunization process. The identification of barriers and solutions was carried on by: a) non-systematic revision of scientific and grey literature, institutions and relevant websites, and documents suggested by Consortium Partners; b) qualitative research conducted in each Consortium Country. The GCF was used as a guide for the above mentioned activities and organize results into the GCF itself to enrich it with content

Results

5 conceptual hubs were identified: ENTITLEMENT to vaccination, REACHABILITY of people to be vaccinated, ADHERENCE to vaccination, ACHIEVEMENT of vaccination, EVALUATION of the intervention. All hubs are linked sequentially, starting with Entitlement without which the process cannot take place. Hubs are connected: if vaccination does not take place, it’s important to go back to the previous hubs to understand the barriers. Reachability-Adherence-Achievement are closely related because some approaches are cross-cutting, such as proximity interventions which, in addition to allowing the system to approach NAM, promote adherence and thus possibility of completing the process. Other strategies may be implemented with different purposes: training aims to foster a culturally competent approach to facilitate adherence and avoid vaccination hesitancy, but also to improve competence in the entire process and lead to vaccination completion

Conclusions

The proposed GCF facilitates identification of barriers and possible solutions to the effective achievement of immunization, at all stages of the process

Key messages

• The GCF can be the basis for the creation of country-specific flow-charts through which to test strategies aimed at increasing immunization coverage in NAM.

• The GCF will be useful at EU level, to facilitate both the harmonisation of approaches and interventions and the evaluation of comparable approaches.

Vaccinations for migrants during and beyond the COVID-19 pandemic

Issue

Migrants have suboptimal vaccination coverage compared to the general population in destination countries due to several factors

-administrative barriers or lack of legal entitlements to health -health system barriers (language, lack of cultural sensitivity and community engagement capacity, vaccination costs) -lack of trust in the health system and misconceptions about vaccines due to misinformation or beliefs

Problem

Countries should develop national policies and ensure an inclusive, free of charge and proactive vaccination offer to migrants, irrespective of their legal status; and to extend this approach beyond the current pandemic and the sole COVID-19 vaccine

Results

To achieve COVID-19 global herd immunity all population groups, including migrants, needs to access vaccination. Tailored vaccination strategies, once devised, shall be applied to routine national vaccination plan to tackle health inequalities

Lessons

The following actions shall be implemented at national level

Action 1. Develop tailored and equitable approaches for PH vaccination services targeting migrants through:

-free of charge access -decentralization and outreach capacity of the health system -innovative service delivery models (mobile clinics, combined health services, mass vaccination) -health personnel and migrants participatory approach and engagement strategies

Action 2. Increase staff engagement through: -increasing health personnel's difference sensitivity -strengthening health personnel's communication capacities

Action 3. Increase migrants' health and vaccine literacy through:

-establishing vaccine literacy education programmes and strategies -offering health promotion educational interventions

Action 4. Monitor progress of inclusive vaccination offer by: -setting strategic goals, targets and indicators for national vaccination plans -expanding immunization information systems to monitor vaccination coverage, with appropriate disaggregation by migration status core variables

Key messages

Explicitly and proactively include migrants and displaced communities in vaccination plans and set up, test and implement new approaches in primary prevention and vaccination services. Extend this approach beyond the current pandemic and the sole COVID-19 vaccine in order to enhance preparedness to present and future health threats.

Dyslipidaemia after switch to tenofovir alafenamide (TAF)-based cART regimens in a cohort of HIV-positive patients: what clinical relevance?

OBJECTIVES

Switching from tenofovir (TDF) to tenofovir alafenamide (TAF) affects lipid profile. The aim of this study was to evaluate whether this results in an increased frequency of patients with low-density lipoprotein (LDL) above their cardiovascular-related target.

METHODS

All HIV patients switching from TDF to TAF, with no changes of the anchor drug, and with plasma lipids available within 6 months before and after the switch, were included. Demographic, HIV-related parameters, cardiovascular (CV) risk factors and lipid profile on both TDF and TAF were collected. The CV risk score and the relative target of LDL for each patient were calculated according to 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for the management of dyslipidaemias. Modifications in lipid profiles and in the prevalence of patients with LDL above their CV-related target were evaluated after switch to TAF.

RESULTS

Overall, 221 HIV patients were included, according to CV risk: 55% at low risk, 34% at moderate risk, and 11% at high/very high risk. By analysing lipid profiles according to CV risk, 38% of patients on TDF had LDL above their CV target; this prevalence increases to 60% after switching to TAF (P < 0.0001). The presence of cobicistat in the combination antiretroviral therapy (cART) regimen was associated with an increased risk of LDL above the CV-related target after switch to TAF [adjusted odds ratio (aOR) = 2.4, 95% confidence interval (CI): 1-5.1], P = 0.03) and with an increased prescription of lifestyle/therapeutic intervention (OR = 3.0, 95% CI: 1.7-5.3, P < 0.0001).

DISCUSSION

Switching from TDF to TAF affects lipid parameters, and data from real life suggest a clinical relevance of this worsening that often leads clinicians to implement lifestyle/therapeutic interventions.

Accessibility to health services in Italy and in the world

Background

The Universal Health Coverage (UHC) proposes that an ideal health system must be able to extend the health coverage to the whole population (universality), to guarantee all the necessary services (globality) and to do it without additional direct costs for the people (free of charge). The achievement of the UHC represents the target 3.8 of the Sustainable Developed Goals. The World Health Organization and the World Bank have developed an index to monitor the UHC (an algorithm that contains 16 indicators of essential health services), while for financial protection they rely on the incidence of catastrophic expenditure on health (percentage of families in which the living expenses for health without reimbursement exceed the10% of consumption).

Objectives

To strengthen the Italian operators' knowledge about the accessibility to health services in Italy and in countries around the world utilizing the UHC index and the incidence of catastrophic expenditure.

Results

The National Center for Global Health of the Italian National Institute of Health (ISS) collected the documents and the data already produced and validated by the international scientific community. ISS in collaboration with the Department of Public Health and Infectious Disease of Sapienza University of Rome developed a workshop training program to bring the UHC concepts at national level in a simplified manner. This was developed in order to encourage a reflection and to strengthen the understanding of the complexity of the UHC. The framework and the program of the workshop will be presented during the conference.

Conclusions

Studying the UHC means focusing on the inequalities in health care. To increase the sensibility of professionals may be a resource to promote the health coverage for all in the national territory.

Key messages

Encouraging the discussion between professionals is possible to understand the complexity of the UHC. The achievement of the UHC may happen only through the improving of the knowledge about it.

Turning constraints into resources: the experience of TRAIN4M&H training program on migrants’ health

Background

The tender TRAIN4M&H (Provision of training for first-line health professionals and law enforcement officers working at local level with migrants and refugees, and training of trainers- contract 20167204), funded by the EC-DG SANTE under the 3rd EU HP, intended to conduct training programme in all EU/EEA countries for health professionals, law enforcement officers an social workers in front-line countries and coach trainers in the others.

Objectives

Training was aimed at reinforcing skills, improving understanding and positive attitudes, and promoting a holistic approach in the work with migrants. The boundaries set by the tender included a short training duration; exclusive use of pre-existing and validated training materials; different professional targets. Italian National Health Institute and Sapienza University of Rome designed the training programme. Criteria for content selection and methodological choices were submitted for consultation to an inter-professional Expert Group in two steps.

Results

Given the limited training timeframe, the delivery of specialised content could not be the focus of this training. It was decided therefore to transform the target requirement into added value, by mixing the target groups into multi-professional classes. This bring a diversity of understandings into the classroom and enhance communication between sectors. The training included also topics such as “context of migration” and “intercultural competences” to create common ground for multi-professional exchange. Similarly, the need to adapt to different EU/EEA contexts argued for a modular structure where Units are selected by the Local Trainer based on a training needs assessment questionnaire sent to trainees beforehand. All materials are on EU Health Policy Platform's Agora (webgate.ec.europa.eu/hpf/).

Conclusions

Training on migrants' health is a complex process, requiring the engagement of learners from their previous experiences and an interdisciplinary approach.

Key messages

Inter-professional training programme can be used for the adult trainings especially in case of a cross-sectoral topic as migrants’ health is. Inter-professional training is a strategy that can guide coherently content design, outcome identification and the choice of evaluations tools.

National immunization policies and practices for migrants in EU/EEA countries

Background

Migrants represent a potential vulnerable group and adequate health protection, including vaccine preventable diseases prevention, should be ensured. The aim of this survey was to map national immunization policies and practices targeting asylum seekers, refugees and irregular migrants in EU/EEA countries.

Methods

A web-based cross-sectional survey was conducted in 28 EU and 2 EEA countries within the ECDC funded Vaccine European New Integrated Collaboration Effort (VENICE) Project in the period January-April 2018.

Results

All countries but one completed the survey and 28 countries offer vaccination to migrants. A national regulation/legal framework supporting migrant immunization is available in most countries. This is specifically established for migrants' health services for 5, part of the National Immunization Programme (NIP) for 15 and both for 3 countries. All the vaccinations included in the NIP appropriate for age are offered to children/adolescents in 27 countries and to adults in 13. In 15 countries offering only certain vaccinations to adults, priority is given to DT, MMR and polio. Vaccinations are mainly given at holding/community level and only 5 countries vaccinate at entry level. A vaccination card is delivered in 23/28 countries to children/adolescents and 24/28 to adults. Recording of individual data vary highly: for children/adolescents and adults, respectively, 15 and 12 countries use an electronic database, 5 and 4 use only paper registry, 2 and 3 use both electronic and paper registries, while 6 and 9 countries do not record information at all. Individual and aggregated data are not made available from the sites where vaccinations are delivered to other local or national institutions in 13 and 15 countries.

Conclusions

Although policies about immunization of migrants are available in most of EU/EEA countries, there are important differences as to their objectives and implementation, especially methods of recording and transmitting data.

Key messages

Given the survey results and the migrants’ mobility, it is important to share data within and across countries to better respond to migrants' immunization needs. Strengthening partnerships between countries of origin, transit and destination, and sharing documentation may ensure the completion of vaccination series and avoid unnecessary revaccinations.

Are Information Technologies Capable of Stimulating the Use of Dental Floss by Adolescents? A Cluster Randomised Clinical Trial

PURPOSE

To analyse the effect of information technologies on improving the frequency of the use of dental floss among adolescents.

MATERIALS AND METHODS

A randomised, controlled clinical trial was conducted with 291 adolescents (mean age: 16.1 years) in three phases. Phase I involved the application of a questionnaire and clinical examinations using the simplified Oral Hygiene Index and gingival bleeding index. In phase II, the adolescents were randomly allocated to four groups: oral counseling (OR) and the use of an application (App) for smartphones; OR without the app; video (VD) and app; and VD without app. Messages were set through the app for 30 days. Phase III involved the second administration of the questionnaire and clinical examination. The frequency of dental floss use was evaluated in phases I and III. The groups were categorised into the use of technology (VD and/or App) and non-use of technology (OR alone).

RESULTS

Statistically significant reductions in the clinical indices were found with all educational methods (p < 0.005) and improvements were found in the use of dental floss (p < 0.001). Moreover, information technologies were associated with an improvement in the frequency of dental floss use (p < 0.033).

CONCLUSION

All methods were effective at improving clinical indicators. The use of information technologies can be considered an effective tool for improving dental floss use among adolescents.

Predictors of incomplete viral response and virologic failure in patients with acute and early HIV infection. Results of Italian Network of ACuTe HIV InfectiON (INACTION) cohort

OBJECTIVES

The aim of this study was to evaluate the factors that can influence an incomplete viral response (IVR) after acute and early HIV infection (AEHI).

METHODS

This was a retrospective, observational study including patients with AEHI (Fiebig stages I-V) diagnosed between January 2008 and December 2014 at 20 Italian centres. IVR was defined by: (1) viral blip (51-1000 HIV-1 RNA copies/mL after achievement of < 50 HIV-1 RNA copies/mL); (2) virologic failure [> 1000 copies/mL after achievement of < 200 copies/mL, or ≥ 200 copies/mL after 24 weeks on an antiretroviral therapy (ART)]; (3) suboptimal viral response (> 50 copies/mL after 48 weeks on ART or two consecutive HIV-1 RNA levels with ascending trend during ART). Cox regression analysis was used to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) for IVR.

RESULTS

In all, 263 patients were studied, 227 (86%) males, with a median [interquartile range (IQR)] age of 38 (30-46) years. During a median follow-up of 13.0 (5.7-31.1) months, 38 (14.4%) had IVR. The presence of central nervous system (CNS) symptoms was linked to a higher risk of IVR (HR = 4.70, 95% CI: 1.56-14.17), while a higher CD4/CD8 cell count ratio (HR = 0.13, 95% CI: 0.03-0.51 for each point increase) and first-line ART with three-drug regimens recommended by current guidelines (HR = 0.40, 95% CI: 0.18-0.91 compared with other regimens including four or five drugs, older drugs or non-standard backbones) were protective against IVR.

CONCLUSIONS

Patients with lower CD4/CD8 ratio and CNS symptoms could be at a higher risk of IVR after AEHI. The use of recommended ART may be relevant for improving short-term viral efficacy in this group of patients.

A 200 km-long mercury contamination of the Paglia and Tiber floodplain: Monitoring results and implications for environmental management

This paper reports the results of a joint project carried out by three regional environmental agencies of Italy to evaluate long-range mercury (Hg) transport from the abandoned Mt. Amiata Hg district in southern Tuscany (the third largest worldwide site for Hg production) to the fluvial ecosystems of the Paglia and Tiber rivers. Most of the work focused on stream sediments, surface waters and soils. A preliminary survey of Hg⁰ content in air was also conducted. Data obtained by public health authorities on Hg in vegetables and fish were also included. The highest Hg concentrations (up to thousands of μg/g Hg) were observed in stream sediments and soils directly impacted by Hg mine runoff. Although progressive Hg dilution was observed from north to south along the river, sediments and soils show anomalous Hg levels for over 200 km downstream of Mt. Amiata, testifying to an extreme case of long-range Hg contamination. A pervasive redistribution of Hg is observed in all sediment compartments. Presumably, the width of the impacted fluvial corridor corresponds to the entire alluvial plains of the rivers. The floodplains can be considered new sources for downstream Hg redistribution, especially during large flood events. On the other hand, results from water, air, and vegetable sampling indicate low potential for human exposure to Hg. The extent and distribution of the contamination make remediation not viable. Therefore, people and human activities must coexist with such an anomaly. On the technical side, the most urgent action to be taken is a better definition of the exact extent of the contaminated area. On the management side, it is necessary to identify which public institution(s) can best deal with such a widespread phenomenon. According to the precautionary principle, the impact of the contamination on human activities in the affected areas should be considered.

Plasma levels of protein C pathway proteins and brain magnetic resonance imaging volumes in multiple sclerosis

BACKGROUND AND PURPOSE

The involvement of protein C (PC) pathway components in multiple sclerosis (MS) has scarcely been explored. The aim was to investigate their levels in relation to clinical and neurodegenerative magnetic resonance imaging (MRI) outcomes in patients.

METHODS

In all, 138 MS patients and 42 healthy individuals were studied. PC, protein S (PS) and soluble endothelial protein C receptor (sEPCR) were evaluated by multiplex assays and enzyme-linked immunosorbent assay. Regression analyses between 3 T MRI outcomes and PC pathway components were performed. ancova was used to compare MRI volumes based on protein level quartiles. Partial correlation was assessed amongst levels of PC pathway components and hemostasis protein levels, including soluble thrombomodulin (sTM), heparin cofactor II (HCII), plasminogen activator inhibitor 1 (PAI-1) and factor XII (FXII). The variation of PC concentration across four time points was evaluated in 32 additional MS patients.

RESULTS

There was an association between PC concentration, mainly reflecting the zymogen PC, and MRI measures for volumes of total gray matter (GM) (P = 0.003), thalamus (P = 0.007), cortex (P = 0.008), deep GM (P = 0.009) and whole brain (P = 0.026). Patients in the highest PC level quartile were characterized by the lowest GM volumes. Correlations of PC-HCII, PC-FXII and sEPCR-sTM values were detectable in MS patients, whilst PC-PS and PS-PAI-1 correlations were present in healthy individuals only.

CONCLUSIONS

Protein C plasma concentrations might be associated with neurodegenerative MRI outcomes in MS. Several differences in correlation amongst protein plasma levels suggest dysregulation of PC pathway components in MS patients. The stability of PC concentration over time supports a PC investigation in relation to GM atrophy in MS.

Protein S mRNA in Patients with Protein S Deficiency

A protein S gene polymorphism, detectable by restriction analysis (BstXI) of amplified exonic sequences (exon 15), was studied in seven Italian families with protein S deficiency. In the 17 individuals heterozygous for the polymorphism the study was extended to platelet mRNA through reverse transcription, amplification and densitometric analysis. mRNA produced by the putative defective protein S genes was absent in three families and reduced to a different extent (as expressed by altered allelic ratios) in four families. The allelic ratios helped to distinguish total protein S deficiency (type I) from free protein S deficiency (type IIa) in families with equivocal phenotypes. This study indicates that the study of platelet mRNA, in association with phenotypic analysis based upon protein S assays in plasma, helps to classify patients with protein S deficiency.

New Coagulation Factor V Gene Polymorphisms Define a Single and Infrequent Haplotype Underlying the Factor V Leiden Mutation in Mediterranean Populations and Indians

Two novel polymorphisms were identified in the factor V gene by direct sequencing of intronic areas. One of them, located in intron 9, is the marker closest to the Leiden mutation ever described, whereas the other, in intron 16, displays a rare allele invariantly associated to the mutation. Allele-specific amplification protocols were designed to perform extensive screenings for both polymorphic sites. The new markers were used in combination with six previously described polymorphisms to define specific factor V gene haplotypes. Haplotype investigations in 506Q homozygous thrombotic patients and normal controls showed the presence of a single haplotype underlying the factor V Leiden mutation in Mediterranean populations (among which Greek Cypriots, where the R506Q mutation is particularly frequent) and Indians. When traced in the absence of the Leiden mutation, the background haplotype was found to be present and roughly as frequent as the mutation itself in these populations. These findings indicate a single mutational event, that probably occurred outside Europe, as the cause of the Leiden mutation and provide a powerful tool to investigate its evolutionary history.

Detection of New Polymorphic Markers in the Factor V Gene: Association with Factor V Levels in Plasma

Three novel polymorphisms were found in the repeated region of the large exon 13 of factor V gene, one giving rise to a codon dimorphism (Serl240) and two causing aminoacid substitutions (Hisl299Arg, Leul257Ile). An increasing frequency of the Argl299 (R2 allele) correlated with a decreasing mean plasma factor V activity in the groups of subjects under study, which included 26 unrelated subjects with partial factor V deficiency. Family studies supported the co-inheritance both of low factor V activity and of R2 allele. The reduction of factor V activity associated with the R2 allele was not clinically symptomatic even in the homozygous condition and was characterized by a parallel reduction of antigen in plasma, in which abnormal molecules were not detected. Data suggest that the R2 allele represents a marker in linkage with an unknown defect rather than a functional polymorphism.

These studies provide the first evidence of a genetic component in determining factor V levels in plasma and of a genetic linkage between the factor V gene and factor V deficiency. They also define specific haplotypes which are associated with factor V deficiency or with APC resistance (Arg506Gln) and are valuable fools for the study of factor V defects.

Improving adolescents' periodontal health: evaluation of a mobile oral health App associated with conventional educational methods: a cluster randomized trial

BACKGROUND

Adolescence is a decisive period in the construction of new conduits.

OBJECTIVE

The influence of an App associated with conventional educational methods in adolescents' oral health.

STUDY DESIGN

Randomized controlled trial including 291 participants (mean age = 16.1 years) in baseline. The study consisted of four phases. Interventions were evaluated through the knowledge score (KS) and oral indexes (OHI-S/GBI). KS was obtained through five affirmations about periodontal diseases applied in different moments (pre-test, post-test, and follow-up test). Phase I included pre-test and oral clinical examination. Sample was randomly divided into two groups: oral (OG) and video orientation (VG) and post-test (phase II). Phase III characterized the formation of groups: OG + App/OG without App/VG + App/VG without App. App consisted of reinforcement messages which was sent during 30 days. Phase IV comprised follow-up test and clinical evaluation.

RESULTS

There was no significant difference in KS between OG/VG. Overall, App improved KS (P < 0.001). VG + App showed a significant increase in KS in the follow-up test compared to the post-test (P = 0.046). There was a significant reduction in oral indexes for all methods.

CONCLUSION

App was effective in increasing knowledge, especially associated with video. The different methods were equally effective for a better standard in oral hygiene.

Hemostasis biomarkers in multiple sclerosis

BACKGROUND AND PURPOSE

The aim was to investigate the plasma levels of hemostasis components in multiple sclerosis (MS) and their association with clinical and magnetic resonance imaging (MRI) outcomes.

METHODS

In all, 138 MS patients [85 with relapsing-remitting MS (RR-MS) and 53 with progressive MS (P-MS) with a mean age of 54 years; 72.5% female; median Expanded Disability Status Scale 3.5; mean disease duration 21 years] and 42 age- and sex-matched healthy individuals (HI) were studied. All subjects were examined with 3 T MRI and clinical examinations. Plasma levels of hemostasis factors [procoagulant, factor XII (FXII)] and inhibitors [tissue factor pathway inhibitor (TFPI), thrombomodulin, heparin cofactor II, a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13) and plasminogen activator inhibitor 1 (PAI-1)] were evaluated by magnetic Luminex assays and enzyme-linked immunosorbent assay. Associations between hemostasis plasma levels and clinical and MRI outcomes were assessed.

RESULTS

Lower ADAMTS13 levels were found in MS patients compared to HI (P = 0.008) and in MS patients presenting with cerebral microbleeds compared to those without (P = 0.034). Higher PAI-1 levels were found in MS patients compared to HI (P = 0.02). TFPI levels were higher in the P-MS subgroup compared to RR-MS patients (P = 0.011) and compared to HI (P = 0.002). No significant associations between hemostasis plasma levels and clinical or MRI outcomes were found.

CONCLUSIONS

Decreased ADAMTS13, particularly in MS patients with cerebral microbleeds, which deserves further investigation, and increased PAI-1 and TFPI levels were observed in MS patients, which deserves further investigation. No relationship between hemostasis plasma levels and measures of disease severity was detected.

Unconventional T cells in chronic hepatitis B patients on long-term suppressive therapy with tenofovir followed by a Peg-IFN add-on strategy: A randomized study

HBV eradication in chronic hepatitis B (CHB) subjects is rarely achieved with either nucleos(t)ide analogues (NA) or pegylated interferon (Peg-IFN), which both have a limited effect in restoring immune responses. Thirty CHB subjects on long-term treatment with tenofovir (TDF) and HBV suppression were enrolled and randomized 1:2 to either receive Peg-IFN-α-2a add-on therapy or continue TDF alone. We studied γδ T and iNKT frequency and function (by flow cytometry) at baseline, at 12 weeks and 12 weeks after the end of treatment. A higher reduction in qHBsAg occurred in the add-on group compared with the NA group at W12 (P = .016) and at W24 (P = .012). A decline of qHBsAg ≥0.5 log₁₀ at week 24 occurred in 4 of 10 patients in the add-on arm and 1 of 20 in the NA arm, respectively (P = .03). HBsAg loss was seen in 20% of subjects in the add-on group and in none of the NA group. Compared to HBV negative, CHB on TDF showed lower frequency of iNKT (P = .03) and γδ T cells (P = .03) as well as fewer γδ T cells expressing Vδ2 T-cell receptors (P = .005). No changes in unconventional T-cell frequency and function were shown in both add-on and NA patients nor were differences detected between the two treatment groups. We report persistent impairment of unconventional T cells in CHB. Despite a greater qHBsAg decline of add-on patients, our data failed to detect any effect of Peg-IFN treatment on unconventional T cells.

Reduced Activation of the Gla19Ala FX Variant via the Extrinsic Coagulation Pathway Results in Symptomatic CRMred FX Deficiency

We characterized a symptomatic CRMred factor X (FX) deficiency produced by the Glu19Ala mutation in the γ-carboxyglutamic-rich domain. FX activity levels in plasma were markedly reduced in prothrombin time assays (< 1-5%), whereas in activated partial thromboplastin assays (16%) and in RVV assays (17%) the reduction in activity mirrored that in antigen levels (17%). Activation of recombinant 19Ala-FX by factor IXa/factor VIIIa or RVV, and the activity in thrombin generation assays, were comparable to those of wild-type FX. Differently, complete activation of recombinant 19AlaFX required a factor VIIa/TF concentration 30-fold higher than that of wild-type FX. The recombinant FVIIa significantly reduced PT values in 19Ala-FX reconstituted plasma, thus suggesting an alternative approach for treatment of FX deficiencies characterized by defective FX activation.

The study of this FX deficiency provides an “in vivo” and “in vitro” model for the investigation of Gla domain interactions.

Implementation of GOLD consensus report in real life: results from the Velletri-Lariano (VELA) cohort

Background

COPD is one of the leading causes of morbidity and mortality. Pharmacotherapy improves quality of life and reduces exacerbations although low adherence with prescribed treatments may represent a barrier to optimal disease management.

The first objective of this paper is to report the distribution of COPD patients according to GOLD categories, in a sample of patients from a cohort study in an area of the Latium region in Italy. The second objective is to evaluate the agreement between the distributions of severity obtained from the HCPs and the experts included in the study board (Board).

Methods

COPD patients were given a card to collect demographic and clinical data at baseline. Information in those cards was independently evaluated by HCPs and Board to include each patient into one of the four GOLD categories.

Results

In a sample of 187 stable COPD patients, 59% male, mean age 70 year, the distribution of GOLD categories according to the Board was: 6% A, 34% B, 2% C, and 58% D. A discrepancy in GOLD classification was observed between the study board and field-based HCPs, regarding more than 50% of the patients, with a clear trend to underestimate the frequency of patients in D level (21%) and to overestimate the frequency in C level (21%).

Conclusions

These results describe for the first time the distribution of COPD patients in an Italian cohort according to the GOLD categories, with the highest frequencies in levels B and D. The misclassification from HCPs may impact the therapeutic approach and the clinical outcomes.

Implementation of GOLD consensus report in real life: results from the Velletri-Lariano (VELA) cohort

Background: COPD is one of the leading causes of morbidity and mortality. Pharmacotherapy improves quality of life and reduces exacerbations although low adherence with prescribed treatments may represent a barrier to optimal disease management. The first objective of this paper is to report the distribution of COPD patients according to GOLD categories, in a sample of patients from a cohort study in an area of the Latium region in Italy. The second objective is to evaluate the agreement between the distributions of severity obtained from the HCPs and the experts included in the study board (Board). Methods: COPD patients were given a card to collect demographic and clinical data at baseline. Information in those cards was independently evaluated by HCPs and Board to include each patient into one of the four GOLD categories. Results: In a sample of 187 stable COPD patients, 59% male, mean age 70 year, the distribution of GOLD categories according to the Board was: 6% A, 34% B, 2% C, and 58% D. A discrepancy in GOLD classification was observed between the study board and field-based HCPs, regarding more than 50% of the patients, with a clear trend to underestimate the frequency of patients in D level (21%) and to overestimate the frequency in C level (21%). Conclusions: These results describe for the first time the distribution of COPD patients in an Italian cohort according to the GOLD categories, with the highest frequencies in levels B and D. The misclassification from HCPs may impact the therapeutic approach and the clinical outcomes.

Prevalence of pain in the departments of surgery and oncohematology of a paediatric hospital that has joined the project "Towards pain free hospital"

BACKGROUND

Among hospitalized adults and children pain is undertreated. This study wants to assess the effectiveness of pain therapy in two departments of a large children's hospital.

MATERIALS AND METHODS

During a single day work three committees, administering a questionnaire to patients or parents, have evaluated the adherence to international recommendations (JCI and WHO) in the management of analgesic therapy. Patient demographics, prevalence and intensity (moderate and/or severe) of pain (during hospitalization, 24 hours before and at the time of the interview), analgesia (type, route, duration and frequency of administration) and Pain Management Index (=analgesic score-pain score) were recorded.

RESULTS

75 patients participated in the study (age: 2 months up to 24 years, mean 7.8 ± 6). During hospitalization 43 children (57%) had no pain while 32 (43%) have experienced pain. 22 children (29 %) had pain 24 hours before and 12 (16%) at the time of the interview. The average value of the PMI was -0.8±1.3 with a minimum of -3 and a maximum of +2: 60% (19) of the children had a PMI less than 0 (undertreated pain) while 40% (13) had a value=or>0. Out of 32 patients who needed an analgesic therapy 14 (44%) received an around-the-clock dosing, 8 (25%) an intermittent therapy and 10 (31%) no treatment.17 (77 %) were the single drug therapy and 5 (23%) the multimodal ones.

CONCLUSIONS

The prevalence of pain in the two departments is high. The main cause is that knowledge is not still well translated into clinical practice.

Assessment of radiological vertebral fractures in HIV-infected patients: clinical implications and predictive factors

OBJECTIVES

The aim of this study was to evaluate the clinical impact of including lateral spine X-ray in the screening of bone diseases in HIV-positive patients.

METHODS

A total of 194 HIV-positive patients underwent dual-energy X-ray absorptiometry (DEXA), lateral spine X-ray and bone biochemical analysis. Vertebral fractures were identified using a morphometric analysis of X-rays and classified using the semiquantitative scoring system of Genant et al. For each patient, a spine deformity index (SDI) score was calculated by summing the grades of vertebral deformities. Reductions in vertebral body height of > 25% were considered vertebral fractures, and those < 25% were considered vertebral deformities. Risk factors associated with vertebral fractures were evaluated by univariate and multivariate analysis.

RESULTS

Vertebral fractures were detected in 24 patients (12.4%) and vertebral deformities in 17 patients (8.7%); 153 patients (78.9%) did not show any vertebral deformity. Among patients with fractures, only two with SDI > 10 reported lumbar pain; the remaining were asymptomatic. Patients over 50 years old showed a higher prevalence of vertebral fracture [24.4% versus 11.8% in patients 41-50 years old (P = 0.05) and 1.9% in patients ≤ 40 years old (P = 0.04)]. No significant increase in the prevalence according to bone mineral density (BMD) reduction was observed, and 70% of fractures were diagnosed in nonosteoporotic patients. Older age [adjusted odds ratio 1.09; 95% confidence interval (CI) 1.03-1.13; P = 0.001] and steroid use (adjusted odds ratio 3.64; 95% CI 1.29-10.3; P = 0.01) were independently associated with vertebral fracture; no association was found with HIV- or highly active antiretroviral therapy (HAART)-related variables.

CONCLUSIONS

A prevalence of vertebral fractures of 12.4% was observed in our HIV-positive cohort. Given that two-thirds of fractures occurred in nonosteoporotic patients, spine X-ray may be considered in patients at increased risk, irrespective of BMD; that is, in elderly patients and/or patients using steroids.

Plasma renin concentration as a predictor of outcome in a medical intensive care setting: a retrospective pilot study

BACKGROUND

Renin and aldosterone are involved in an organ perfusion pathway that may be an estimate of disease severity. The primary objective was to explore the relationship between outcome and aldosterone and renin levels at medical intensive care unit (MICU) admissions in comparison to SAPS II scores.

METHODS

This retrospective study was conducted on patients admitted to the adult MICU during 12 months. Exclusion: subjects with creatinine >176 mmol/l, chronic arrhythmia and ACE-inhibitor therapy. Admission aldosterone and renin plasma levels were measured and SAPS II scores were calculated.

RESULTS

Eighty-two patients were included. Only the plasma renin median concentration difference between survivors and non-survivors was significant (P=0.0168). The area under the ROC curve for mortality and plasma renin concentration was similar to that of SAPS II. The correlation between mortality and renin >84 pg/mL showed an odds ratio of 5.78±3.45, P=0.003.

CONCLUSION

Renin was correlated to outcome in critically ill medical patients.

Quantitative risk assessment of verocytotoxin-producing Escherichia coli O157 and Campylobacter jejuni related to consumption of raw milk in a province in Northern Italy

A quantitative risk assessment was developed to describe the risk of campylobacteriosis and hemolytic uremic syndrome (HUS) linked to consumption of raw milk sold in vending machines in Northern Italy. Exposure assessment considered the microbiological status of dairy farms, expected milk contamination, storage conditions from bulk tank to home storage, microbial growth during storage, destruction experiments, consumption frequency of raw milk, age of consumers, serving size, and consumption preference. The differential risk between milk handled under regulation conditions (4°C throughout all phases) and the worst field handling conditions was considered. The probability of Campylobacter jejuni infection was modeled with a single-hit dose-response beta-Poisson model, whereas for HUS an exponential dose-response model was chosen and two probabilities were used to model the higher susceptibility of children younger than 5 years old. For every 10,000 to 20,000 consumers each year, the models predicted for the best and worst storage conditions, respectively, 2.12 and 1.14 campylobacteriosis cases and 0.02 and 0.09 HUS cases in the 0- to 5-year age group and 0.1 and 0.5 HUS cases in the >5-year age group. The expected pediatric HUS cases do not differ considerably from those reported in Italy by the Minister of Health. The model developed may be a useful tool for extending the assessment of the risk of campylobacteriosis and HUS due to raw milk consumption at the national level in Italy. Considering the epidemiological implications of this study, the risk of illness linked to raw milk consumption should not be ignored and could be reduced by the use of simple measures. Boiling milk before consumption and strict control of temperatures by farmers during raw milk distribution have significant effects on campylobacteriosis and HUS and are essential measures for risk management.

Stillbirth and fetal growth restriction

OBJECTIVE

To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths.

METHODS

Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence.

RESULTS

Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05).

CONCLUSIONS

Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Immunological mechanisms of interleukin-2 (IL-2) treatment in HIV/AIDS disease

HIV establishes a chronic infection that is marked by the progressive depletion of CD4+ T-cells, yet the mechanisms by which this depletion arises are a matter of controversy. Evidence is accumulating that T CD4+ depletion is not effected solely by virus-mediated killing and that mechanisms involving T-cell dynamics play a major role in the pathogenesis of HIV infection. Hence antiretroviral therapy, by controlling viral replication alone, invariably fails to achieve the broadest immune reconstitution. This issue has strengthened the rationale to widely explore new adjuvant immunotherapy. Most work has been performed on IL-2, given its potential to correct HIV-driven immune defects, possibly translating in a more effective immune competency. Important insights stem from the IL-2-mediated immune reconstitution pattern, with a rise in peripheral turnover and thymopoiesis, IL-7 synthesis and functional markers, resulting in the correction of the skewed T-cell immunophenotype and cytokine milieu. Combined, these findings suggest that IL-2 has a beneficial effect in correcting the severe disruption in T-cell homeostasis induced by HIV, through the interaction with T-cells and cytokine microenvironment. However, whether or not these immunologic effects translate in an actual immunologic competency and therefore clinical benefit, still awaits demonstration from ongoing large, controlled clinical studies.

Primary adenocarcinoma of the rectovaginal septum arising in pregnancy in the absence of endometriosis

A case of primary adenocarcinoma of the rectovaginal septum (PARVS) is reported with clinical and pathological findings. A 37-year-old Caucasian woman with a history of sterility and small posterior leiomyoma, a few months after a cesarean section, was admitted because of vaginal spotting, abdominal pain and constipation. Her previous history did not reveal exposure to diethylstil bestrol (DES). Pelvic computed tomography showed a heterogeneous pelvic mass in the Douglas pouch, measuring 9 cm in diameter, located in the rectovaginal septum, involving the rectal and vaginal wall. Histological examination of neoplastic tissue revealed solid sheet structures, occasional tubular lumen, extensive necrotic areas and clear cells. The neoplastic elements showed immunoreactivity for Mullerian markers (cytokeratin 7, CA-125 and vimentin). Because, the present case of PARVS cannot be due to DES exposure, the clear appearance of the neoplastic elements could represent only one differentiation of Mullerian rests. Moreover, because no foci of endometriosis were identified in several sections of the neoplasm, uterine and cervical wall, and tissues nearby the neoplasm could represent a rare subtype of PARVS arising in the absence of endometriosis.

Does fluvastatin favour HCV replication in vivo? A pilot study on HIV-HCV coinfected patients

Fluvastatin showed anti-hepatitis C virus (HCV) activity in vitro, through the inhibition of geranylgeranylation of cellular proteins, and a synergistic effect with interferon (IFN)-alpha. Nevertheless statins up-regulate low-density lipoprotein (LDL) receptor, required for HCV cell entry, and the closely related scavenger receptors SRBI and CD36; moreover they reduce class II major histocompatibility complex expression on antigen presenting cell, modulating T-cell activation. In vivo LDL levels have been identified as prognostic indicator of sustained viral response to IFN in patients with HCV infection, suggesting that lipid-lowering agents might conversely favour HCV entry into the hepatocytes and translate into higher viral replication. We evaluated the effect of fluvastatin on HCV-RNA levels, CD36 expression and T-cell homeostasis in HCV-RNA positive patients. HCV-RNA was measured at baseline and after 4 weeks in 42 HCV/HIV-1 co-infected patients, randomized to receive either fluvastatin 80 mg qd or no treatment. CD36 expression and markers of T-cell activation were evaluated by means of flow cytometry. Plasma interleukin (IL)-10, IFN-gamma and IL-7 were measured by ELISA. Serum cholesterol and LDL decreased significantly in the treatment group (P = 0.0001 and 0.01, respectively). Surprisingly a significant increase of HCV-RNA levels was seen after 4 weeks of fluvastatin (P = 0.03). The percentages of naive/activated/apoptotic cells and CD36 expression remained unchanged. Fluvastatin did not inhibit HCV-RNA replication in vivo; conversely we observed a significant increase of HCV-RNA levels. CD36 expression on monocytes were not up-regulated by statins as previously reported in vitro. The correlation between HCV infectivity, oxidized-LDL receptor and statins in HCV infection need further evaluation.

Does fluvastatin favour HCV replication in vivo? A pilot study on HIV-HCV coinfected patients

Fluvastatin showed anti-hepatitis C virus (HCV) activity in vitro, through the inhibition of geranylgeranylation of cellular proteins, and a synergistic effect with interferon (IFN)-alpha. Nevertheless statins up-regulate low-density lipoprotein (LDL) receptor, required for HCV cell entry, and the closely related scavenger receptors SRBI and CD36; moreover they reduce class II major histocompatibility complex expression on antigen presenting cell, modulating T-cell activation. In vivo LDL levels have been identified as prognostic indicator of sustained viral response to IFN in patients with HCV infection, suggesting that lipid-lowering agents might conversely favour HCV entry into the hepatocytes and translate into higher viral replication. We evaluated the effect of fluvastatin on HCV-RNA levels, CD36 expression and T-cell homeostasis in HCV-RNA positive patients. HCV-RNA was measured at baseline and after 4 weeks in 42 HCV/HIV-1 co-infected patients, randomized to receive either fluvastatin 80 mg qd or no treatment. CD36 expression and markers of T-cell activation were evaluated by means of flow cytometry. Plasma interleukin (IL)-10, IFN-gamma and IL-7 were measured by ELISA. Serum cholesterol and LDL decreased significantly in the treatment group (P = 0.0001 and 0.01, respectively). Surprisingly a significant increase of HCV-RNA levels was seen after 4 weeks of fluvastatin (P = 0.03). The percentages of naive/activated/apoptotic cells and CD36 expression remained unchanged. Fluvastatin did not inhibit HCV-RNA replication in vivo; conversely we observed a significant increase of HCV-RNA levels. CD36 expression on monocytes were not up-regulated by statins as previously reported in vitro. The correlation between HCV infectivity, oxidized-LDL receptor and statins in HCV infection need further evaluation.