Outpatient parenteral antimicrobial therapy (OPAT) from an emergency model applied during the COVID-19 pandemic to standard of care: Preliminary lessons from our experience

OBJECTIVES

We wish to report on our experience of OPAT during the first two years of the COVID19 outbreak.

PATIENTS AND METHODS

We recorded data on all patients treated in the OPAT regimen in 2020 and 2021 and compared overall trends, use of carbapenems and saved days of hospitalization.

RESULTS

The OPAT model enabled us to ensure the administration of first choice antibiotic therapy to 239 patients with an increase of 21.3% from 2020 to 2021 (108 vs 131). Applying this model, we also recorded a reduction in the use of carbapenems from 33% in 2020 to 26% in 2021 and a total of 3041 recovery days saved in 2021.The clinical cure rate reached 94%. Few adverse events occurred (35/239; 14.6%), and they did not require hospitalization.

CONCLUSION

OPAT is a safe, efficacious, and cost-effective model that functioned effectively during the COVID-19 crisis and could become the standard of care for the treatment of selected patients.

Unexpected macrophage activation syndrome in a healthy young woman: a case report

Macrophage activation syndrome (MAS) is a life-threatening condition and a medical emergency with a high-risk of mortality. It belongs to a group of diseases known as "hemophagocytic lymphohistiocytosis", characterized by a cytokine storm, with secretion of tumor necrosis factor, interleukins and interferon-gamma, and an inappropriate activation of macrophages and T-lymphocytes. Some inflammatory and systemic autoimmune diseases, such as systemic juvenile idiopathic arthritis, Still's disease and systemic lupus erythematosus, can develop into macrophage activation syndrome. This is the first episode of macrophage activation syndrome (MAS) in a young healthy woman. She arrived at the Emergency Department complaining of four days of weakness and fever not responsive to paracetamol. She had no significant past medical history, her mother suffered from rheumatoid arthritis. In the Emergency Department, we performed laboratory exams, autoimmune and infectious disease screening, bone marrow biopsy. The final diagnosis was of macrophage activation syndrome. Macrophage activation syndrome, in extremely rare cases, can arise independently years before the manifestation of an autoimmune disease. Persistent fever, high level of inflammatory markers and pancytopenia should raise suspicion in healthy people, especially when associated with a family history of autoimmune disease. Early diagnosis and consequent early treatment are fundamental to avoid progressive tissue damage that can lead to organ failure and death.

Beware of the dog - Capnocytophga Canimorsus septic shock: a case report

Capnocytophaga canimorsus is a Gram-negative rods frequently isolated as commensal in the saliva of pets that can be transmitted to humans. We report a case of septic shock caused by this pathogen. A 78-year-old man affected by diabetes and hypertension was admitted for fever in our Emergency Department. He reported fever (37.7°C) with normal values of blood pressure, heart rate and saturation of oxygen. Laboratory studies showed increased values of procalcitonin and normal white-cell level. Blood cultures were collected and an empirical antibiotic therapy was started. He reported six days earlier a bite of a dog at the right hand. During the following days the patient presented a deterioration of clinical conditions with fever, asthenia and comparison of petechial lesions. C. canimorsus was isolated from blood cultures. He was treated with fluids and appropriate antibiotic therapy with a full recovery. Dog wounds are frequent minor injuries with an underestimated worldwide incidence because only few patients develop complications. C. canimorsus could be an emerging cause of sepsis, also in immunocompetent patients. The current understanding of risk factors for C. canimorsus associated sepsis and a prompt approach to anamnesis and treatment of early stage injuries, could have a considerable medical outcome.

Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).

Latex Allergy and Sensitization in Cities: A Survey in a Population at Risk

The constant increase in allergic diseases in western countries is correlated with changes in lifestyle and with the deterioration of the air inhaled by the inhabitants because of the growing concentrations of pollutant substances present. Within a population at risk, i.e., the inhabitants of cities, a group of subjects at even higher risk was selected, whose job exposes them to automobile exhaust fumes for many hours a day. All the study subjects underwent allergological screening and spirometry. The results obtained show an overall increase of respiratory allergic diseases but no increased sensitisation to latex. It therefore seems plausible that, besides social and lifestyle changes, the deterioration of the quality of the air could be considered responsible, at least in part, for the growing numbers of allergic subjects. This study offers an opportunity to reconsider the validity of the “hygiene hypothesis” as an explanation for the increase of allergic disease in western countries, although recent reports have indicated that a sedentary lifestyle may also contribute, together with environmental degradation, to the notably increased prevalence of allergic diseases in large cities in industrialized nations.

Long-term exposure to black carbon, cognition and single nucleotide polymorphisms in microRNA processing genes in older men

INTRODUCTION

Air pollution exposure has been linked to impaired cognitive aging, but little is known about biomarkers modifying this association. MicroRNAs (miRNAs) control gene expression and neuronal programming. miRNA levels vary due to single nucleotide polymorphisms (SNPs) in genes processing miRNAs from precursor molecules.

OBJECTIVES

To investigate whether SNPs in miRNA-processing genes are associated with cognition and modify the relationship between black carbon (BC), marker of traffic-related pollution, and cognitive functions.

METHODS

533 Normative Aging Study men (mean±SD 72±7years) were tested ≤4 times (mean=1.7 times) using seven cognitive tests between 1995 and 2007. We tested interactions of 16 miRNA-related SNPs with 1-year average BC from a validated land-use-regression model. We used covariate-adjusted logistic regression for low (≤25) Mini-Mental tate Examination (MMSE) and mixed-effect regression for a global cognitive score combining six other tests.

RESULTS

Global cognition was negatively associated with the homozygous minor variant of rs595961 AGO1 (-0.42SD; 95%CI: (-0.71, -0.13)) relative to the major variant. BC-MMSE association was stronger in heterozygous carriers of rs11077 XPO5 (OR=1.99; 95%CI: (1.39, 2.85)) and minor variant carriers of GEMIN4 rs2740348 (OR=1.34; 95%CI: (1.05, 1.7)), compared to their major variant. The BC-global-cognition association was stronger in heterozygous carriers of GEMIN4 rs4968104 (-0.10SD; 95%CI: (-0.18, -0.02)), and GEMIN4 rs910924 (-0.09SD; 95%CI: (-0.17, -0.02)) relative to the major variant. Blood miRNA expression analyses showed associations only of XPO5 rs11077 with miR-9 and miR-96.

CONCLUSIONS

Carriers of particular miRNA-processing SNPs had higher susceptibility to BC in BC-cognition associations, possibly due to influences on miRNA expression.

Tailoring groundwater quality monitoring to vulnerability: a GIS procedure for network design

Monitoring networks aiming to assess the state of groundwater quality and detect or predict changes could increase in efficiency when fitted to vulnerability and pollution risk assessment. The main purpose of this paper is to describe a methodology aiming at integrating aquifers vulnerability and actual levels of groundwater pollution in the monitoring network design. In this study carried out in a pilot area in central Italy, several factors such as hydrogeological setting, groundwater vulnerability, and natural and anthropogenic contamination levels were analyzed and used in designing a network tailored to the monitoring objectives, namely, surveying the evolution of groundwater quality relating to natural conditions as well as to polluting processes active in the area. Due to the absence of an aquifer vulnerability map for the whole area, a proxi evaluation of it was performed through a geographic information system (GIS) methodology, leading to the so called "susceptibility to groundwater quality degradation". The latter was used as a basis for the network density assessment, while water points were ranked by several factors including discharge, actual contamination levels, maintenance conditions, and accessibility for periodical sampling in order to select the most appropriate to the network. Two different GIS procedures were implemented which combine vulnerability conditions and water points suitability, producing two slightly different networks of 50 monitoring points selected out of the 121 candidate wells and springs. The results are compared with a "manual" selection of the points. The applied GIS procedures resulted capable to select the requested number of water points from the initial set, evaluating the most confident ones and an appropriate density. Moreover, it is worth underlining that the second procedure (point distance analysis [PDA]) is technically faster and simpler to be performed than the first one (GRID + PDA).

Local and systemic reactions occurring during immunotherapy: an epidemiological evaluation and a prospective safety-monitoring study

The efficacy of specific immunotherapy in allergic patients with IgE-mediated rhino-conjunctivitis, asthma and allergic reaction for stinging insects suggests the opportunity of improving technical procedures to minimize risk and optimise the safety of immunotherapy. This study investigated both local and systemic reactions, occurring in a population of 218 patients undergoing immunotherapy, in an attempt to correlate them with some parameters as well as age, sex and allergenic extracts. The epidemiological evaluation was based on the administration of a questionnaire to 218 patients in order to assess possible reactions to immunotherapy. The following data were evaluated: personal data, diagnosis, specific allergens, adverse reactions undergone during treatment, number of reactions and symptoms. The patients were followed-up by the medical staff of the Section of Allergological and Immunological Disease (SAID), University of Bari (Bari-Italy) for compilation of questionnaires. We found a correlation between female sex and adverse reactions. Among 107 patients referring reactions to the immunotherapy, 71 patients (66.3%) presented only local reactions; 11 patients (10.3%) systemic reactions and 25 patients (23.4%) systemic reactions associated with local reactions. Parietaria was mostly involved in patients with local reactions, instead, in patients with systemic reactions the prevalent allergens seem to be Dermatophagoides and grass-pollen. Rhinitis was the most frequent diagnosis for patients who have presented both local and systemic reactions. In our study, we had frequently mild systemic reactions and some cases of respiratory difficulties, while it is evident that in our group of patients no cases of anaphylaxis occurred. In addition, we considered some events before the administration of immunotherapy, such as assumption of drugs, meals, exposure to sun, stress or physical activity and the percentage of adverse reactions. On the light of a small number of fatality, immunotherapy represents a safer therapy for allergic diseases; nevertheless, our data suggest that safety is strictly correlated with prescriptions by specialists, administration by trained physicians and accurate follow-up of patients. In particular it is recommended to avoid some events before the administration of immunotherapy, above all the assumption of drugs and physical exercise.

Respiratory risks in tunnel construction workers

Respiratory diseases are frequent in tunnel construction workers. A group of 144 subjects randomly selected from the population of 2516 workers engaged in the construction of the railway tunnel under the Appennine Mountains, from Bologna to Firenze was investigated. A group of 69 males comparable for age, living area and habits was studied as a control group. Assessment of air pollutants (NO, NO2, SO2, total dust, silica %) was carried out by means of fixed monitoring stations as well as personal monitors. All the subjects included in the study were examined with a standardised protocol which included physical examination, lung function tests (before and after shift work) and a questionnaire to college respiratory symptoms. Low concentrations of environmental pollutants were evidenced. Significantly lower values of FEV1 and PEF were determined in the worker group pared to controls. A significant decrease in respiratory parameters was shown after shift work. Variables capable of influencing the decrease in parameters include smoking habits, work activity, presence of cough and expectoration, period of the year (spirometries resulted worse in the winter time). Significantly lower values of FEV1 and PEF were evidenced in the workers compared to controls. In spite of the present low work environmental exposure conditions, some physiologic parameters appear altered in tunnel construction workers. This may depend on a variety of noxious agents present in the working environment.

Fate of diuron and linuron in a field lysimeter experiment

The environmental fate of herbicides can be studied at different levels: in the lab with disturbed or undisturbed soil columns or in the field with suction cup lysimeters or soil enclosure lysimeters. A field lysimeter experiment with 10 soil enclosures was performed to evaluate the mass balance in different environmental compartments of the phenylurea herbicides diuron [3-(3,4-diclorophenyl)-1,1-dimethyl-urea] and linuron [3-(3,4-dichlorophenyl)-1-methoxy-1-methylurea]. After application on the agricultural soil, the herbicides were searched for in soil, pore water, and air samples. Soil and water samples were collected at different depths of the soil profile and analyzed to determine residual concentrations of both the parent compounds and of their main transformation products, to verify their persistence and their leaching capacity. Air volatilization was calculated using the theoretical profile shape method. The herbicides were detected only in the surface layer (0-10 cm) of soil. In this layer, diuron was reduced to 50% of its initial concentration at the end of the experiment, while linuron was still 70% present after 245 d. The main metabolites detected were DCPMU [3-(3,4-dichlorophenyl)-1-methylurea] and DCA (3,4-dichloroaniline). In soil pore water, diuron and linuron were detected at depths of 20 and 40 cm, although in very low concentrations. Therefore the leaching of these herbicides was quite low in this experiment. Moreover, volatilization losses were inconsequential. The calculated total mass balance showed a high persistence of linuron and diuron in the soil, a low mobility in soil pore water (less than 0.5% in leachate water), and a negligible volatilization effect. The application of the Pesticide Leaching Model (PELMO) showed similar low mobility of the chemicals in soil and water, but overestimated their volatilization and their degradation to the metabolite DCPMU. In conclusion, the use of soil enclosure lysimeters proved to be a good experimental design for studying mobility and transport processes of herbicides in field conditions.

[Multidimensional evaluation: an example to be applied in dialysis]

Between June and July 2005 we submitted the IPPE survey (Pluridimensional Record for Hemodialysis Patient) to 61 chronic hemodialysis patients of our Centre. The aim of the survey was to estimate the six most important components in the life of patients undergoing chronic dialysis: familiar relationships, relationship with their own body, need of drinking, daily life, general needs, disease perception. The most critical factor is the need of drinking, followed by the problems about body feelings and daily life. Disease perception and familiar relationships seem to be less important problems. Regarding patients needs of medical and nursing care and about the condition of in-hospital patient, there is a strong lack of information about diagnosis (72%), a high request of better discussion with doctors (69%) and the need of a greater involvement in the therapeutic choices (57%), related to the difficult communication between doctor and patient. 30% of the interviewed patients would like to have more attention by the nurses: this aspect is not due to the absence of the nurse but rather to a lack of empathy between nurse and patient. These data should be seen as a reason for improving medical and nursing care, because being aware of problems is the first step to their solution.

Degradation and leaching of the herbicides metolachlor and diuron: a case study in an area of Northern Italy

In this work the degradation of the herbicides metolachlor, diuron, monuron and of the metabolites 2-ethyl-6-methylaniline (EMA), and 3,4-dichloroaniline (DCA) was assessed in laboratory experiments on microbiologically active and sterilized soils. Their leaching potentials were calculated, using Gustafson's equation, by determining their mobility (as Koc) and persistence (expressed as DT50). Lysimeter experiments were also conducted to assess the actual leaching of the studied herbicides in a cereal crop tillage area vulnerable to groundwater contamination. The data obtained from the field were compared to the laboratory results. Moreover, some compounds of particular concern were searched for in the groundwater located near the experimental area in order to evaluate actual contamination and to test the reliability of the leaching potential. The GUS index, computed on data from microbiologically active soil, shows monuron as a leacher compound, EMA and DCA as non-leachers, metolachlor and diuron as transient ones. The presence of metolachlor in the groundwater monitored, even at concentrations up to 0.1 mug/l, confirms the possibility that transient compounds can be leached if microbial activity has not completely occurred in active surface soil.

Studies on mobility and degradation pathways of terbuthylazine using lysimeters on a field scale

Terbuthylazine [N2-tert-butyl-6-chloro-N4-ethyl-1,3,5-triazine-2,4-diamine] degradation pathways in agricultural soils were evaluated by following the appearance and mobility of its main transformation products: dealkylated and hydroxylated derivatives. Three experimental degradation studies in open field were performed in different hydraulic conditions: constant hydraulic head on topsoil, achieved to simulate the highest-risk situation for the aquifer, intermittent artificial precipitation to simulate a medium-risk situation; and natural precipitation to reproduce the lowest-risk condition. Concentrations of terbuthylazine transformation products derived from dealkylation and hydroxylation reactions were measured in leachates and soil samples collected during the three experiments. Desethylterbuthylazine (DET) and deethylterbuthylazine-2-hydroxide [DETH; 4-amino-6-terbutylamino-(1,3,5)-triazine-2-OH] were found to be the highest-leaching compounds and therefore can be considered as potential pollutants for aquifer contamination.

A probabilistic methodology to assess the risk of groundwater quality degradation

An approach to assess the risk of groundwater quality degradation with regard to fixed standards. based on Disjunctive Kriging (DK) is presented. The DK allows one to evaluate the Conditional Probability (CP) of overriding a given threshold of concentration of a pollutant at a given time, and at a generic point in a considered groundwater system. The result of such investigation over the considered area can be plotted in form of maps of spatial risk. By repeating this analysis at different times, several spatial risk maps will be produced, one for each considered time. By means of non-parametric statistics, the temporal trend of the CPs can be evaluated at every point of the considered area. The trend index, assessed by means of a sort of classification of the trend values obtained as described above, can be superimposed on the most recent values of the spatial risk (i.e.: the most recent values of probability). Consequently a classification of the risk of groundwater quality degradation results with which to weigh both the spatial distribution and the temporal behaviour of the probability to exceed a given standard threshold. The methodology has been applied to values of nitrate concentration sampled in the monitoring well network of the Modena plain, northern Italy. This area is characterised by intensive agricultural exploitation and hog breeding along with industrial and civil developments. The influence of agriculture on groundwater results in a high nitrate pollution that limits its use for potable purposes.

[Phenomenon of occupational accidents of workers of IRCCS of Neurosciences]

On the basis of information collected from ten IRCCS, it has emerged altogether that the accident are not much frequent. Accident statistics indices from 1994 to 1998 were respectively: frequency rate 21.36, incidence rate 3.32, severity rate 0.24. In the "Neurology" Institutes we have above all needlestick injuries and cufs to the arms and hands. The workers most exposed are doctors, trained nurses, technicians. In the "Psychic" Institutes we have falling, impact, lifting and physical contact accidents. The injuries are contusions to legs and head. The most exposed workers are therapists and rehabilitation educators.

[Knowledge of occupational risk in IRCCS of Neurosciences]

A Professional Multicentric Audit, concerning Staff knowledge level about security on workplaces, was conducted by way of a standardized questionnaire given to 1022 (26.4%) IRCCS professional staff pertaining to Neurobiology. Four were the principal tasks of the questionnaire investigating the "sensibility" and "consciousness" concerning risk prevention on workplaces. It came out that there is a great variability in the knowledge level on this field, even if the "medium value" is "pretty good".

Lichen myxedematosus with systemic involvement: clinical and autopsy findings

Lichen myxedematosus is a rare disease that is characterized by the formation of lichenoid papules and plaques. Histologic examination shows deposition of mucinous material in the dermis. We report the case of a patient with cutaneous and systemic involvement and examine the clinical and postmortem data.

The site of production of superoxide radical in mitochondrial Complex I is not a bound ubisemiquinone but presumably iron-sulfur cluster N2

The mitochondrial respiratory chain is a powerful source of reactive oxygen species, considered as the pathogenic agent of many diseases and of aging. We have investigated the role of Complex I in superoxide radical production in bovine heart submitochondrial particles and found, by combined use of specific inhibitors of Complex I and by Coenzyme Q (CoQ) extraction from the particles, that the one-electron donor in the Complex to oxygen is a redox center located prior to the binding sites of three different types of CoQ antagonists, to be identified with a Fe-S cluster, most probably N2 on the basis of several known properties of this cluster. Short chain CoQ analogs enhance superoxide formation, presumably by mediating electron transfer from N2 to oxygen. The clinically used CoQ analog, idebenone, is particularly effective in promoting superoxide formation.

alpha1(I) collagen gene expression in quail epiphyseal chondrocytes

We examined alpha1(I) collagen expression by using primary cultures of quail epiphyseal chondrocytes which exhibit high levels of synthesis of cartilage-specific collagens and do not undergo phenotypic modulation when replated onto collagens I and II or fibronectin. These cells also synthesize proalpha1(I) collagen chain, however, alpha1(I) mRNA fails to be detected by Northern blot and RNase protection analysis. Nuclear transcription rate with a 5-end specific probe is detected in suspension quail chondrocytes and RT-PCR analysis shows the presence of low levels of alpha1(I) mRNA in these cells. The lack of correspondence between procollagen mRNA levels and the rate of collagen synthesis is consistent with previous reports describing the regulation of this transcript in chondrocytes and in collagen I-producing cells.

[Role of radioisotopic lymphoscintigraphy in postphlebitic syndrome of the legs]

Post-phlebitis syndrome of the lower limbs is a set of symptoms that follow a state of phlebostasis and phlebolymphostasis with consequent oedema and tissue distress. We submitted 36 patients with post-phlebitis syndrome of the lower limbs to radioisotopic lymphoscintigraphy for the purposes of evaluating the vicariant function of the lymphatic system and the possible role of the lymphatic system in the genesis of dermo-epidermal abnormalities. The average age of the patients was 53.2 years (range: 43-69 years; M:F ratio: 0.50). The control group consisted of 6 healthy subjects. The average duration of the post-phlebitis syndrome in the patients studied was 8.5 years. We excluded from the study patients in whom a central cause was identified as being responsible for the pathogenisis of the oedema of the lower limbs. In addition, patients with obliterant arteriopathy were also excluded. Venous pathology was evaluated first clinically and then investigated by continuous-wave Doppler. As a first step, venous pressure was measured by Doppler phlebomanometry in clino- and orthostatism. All patients underwent radioisotopic lymphoscintigraphy with microcolloids using the Rijke technique. Radioactivity was monitored by means of a computerized gamma-camera. We classified the pathological findings of radioisotopic lymphoscintigraphy as follows: 1) delayed transit; 2) obstacles; 3) star-shaped superficial collateral lymphatic circulations; 4) lymphocoele or cutaneous lakes. A significant difference was detected (p < 0.05) between the pressure values in the post- phlebitis lower limbs and the pressure values in normal subjects. Combining the results of our measurements we recorded delayed transit in 5 patients (69.5%). This latter group included the cases with the severest forms of post-phlebitis syndrome. Therefore, better knowledge of the pathophysiology of the lymphatic system would appear to be useful in order to understand the origin and evolution of oedema of the lower limbs of patients with post-phlebitis syndrome. To this end, radioisotopic lymphoscintigraphy may be useful as a first-level examination in order to evaluate the capacity and efficiency of the lymphatic system.

Effects of silica on human lung fibroblast in culture

Silica has been reported to directly stimulate cellular proliferation of human lung fibroblasts, and silica-treated macrophage supernatants induce fibroblast proliferation and some of their biosynthetic activities. Alveolar macrophages produce increased amount of tumour necrosis factor alpha (TNF-alpha) and transforming growth factor beta (TGF-beta). Lung fibroblasts are producers of interleukin-6 (IL-6). We investigated the capacity of lung fibroblasts obtained from normal and silicosis subjects to elaborate IL-6 in response to TNF-alpha and to TGF-beta. Our data show that TNF-alpha and TGF-beta are able to stimulate the proliferation of human lung fibroblasts in culture, to increase the collagen production of the cells and are both able to increase IL-6 production by lung fibroblasts of patients with silicosis. We hypothesise that silica is able to stimulate lung fibroblast both directly, increasing the cell proliferation, and indirectly stimulating the release of factors (as TNF-alpha and TGF-beta) from activated alveolar macrophages, that are able to increase proliferative and biosynthetic activities of fibroblast.

Contact dermatitis in students practicing sports: incidence of rubber sensitisation

BACKGROUND

Over the last few years, changes in cutaneous homoeostasis resulting from sports activities have been reported. In particular, alterations in sweating mechanisms, the hydrolipid barrier, and surface bacterial flora, together with exposure to atmospheric conditions and the need to use medicaments, detergents, and other topical substances, predispose subjects to allergic contact dermatitis.

OBJECTIVE

To evaluate the incidence of allergic contact dermatitis in a group of young people practising sports activities.

METHODS

Patch tests were performed to confirm the diagnosis of irritant or allergic dermatitis; in addition, the radioallergoabsorbent test (RAST) to latex was evaluated in the group studied.

RESULTS

Allergic contact dermatitis caused by thiourams (23.3%) and mercaptobenzothiazole (20.9%) was prevalent. Other haptens, such as benzocaine and nickel, which are contained in clothing, equipment, topical medicaments, and creams used for massage, were also allergenic. In two cases, RAST positivity to latex was registered.

CONCLUSIONS

-The results suggest that close contact with sports equipment may increase the incidence of allergic contact dermatitis. Students practising certain sports may have "professional" allergic contact dermatitis to additives used in the production of rubber.

Typhlitis (neutropenic enterocolitis) after a single dose of vinorelbine

We report a case of a 50-year-old man with pretreated adenocarcinoma of the lung, who developed fatal neutropenic enterocolitis (typhlitis) after a standard dose of the cytotoxic drug vinorelbine. Blood cultures were negative for all microorganisms tested for. Stool cultures were negative for enteric rods but direct examination of fresh stool revealed the presence of Giardia lamblia. Abdominal pain and diarrhoea developed very rapidly while the patient was only moderately neutropenic. Metronidazole was prescribed without clinical benefit: the abdominal pain remained stable. The duration of neutropenia was very short (4 days). The abdominal catastrophe ending in shock occurred after complete recovery of the neutrophil count. Neutropenic colitis has been reported with increasing frequency in solid tumours after the introduction of taxanes. This complication has been observed mainly in phase I studies, near the maximally tolerated doses (MTD). The combined use of vinorelbine has recently been reported to exacerbate the toxic effects of taxane on the colon. The case presented here demonstrates that typhlitis can occur even with vinorelbine alone, used at a standard recommended dose (30 mg/m2).

Genetic dissection of blue-light sensing in tomato using mutants deficient in cryptochrome 1 and phytochromes A, B1 and B2

Several novel allelic groups of tomato (Solanum lycopersicum L.) mutants with impaired photomorphogenesis have been identified after gamma-ray mutagenesis of phyA phyB1 double-mutant seed. Recessive mutants in one allelic group are characterized by retarded hook opening, increased hypocotyl elongation and reduced hypocotyl chlorophyll content under white light (WL). These mutants showed a specific impairment in response to blue light (BL) resulting from lesions in the gene encoding the BL receptor cryptochrome 1 (cry1). Phytochrome A and cry1 are identified as the major photoreceptors mediating BL-induced de-etiolation in tomato, and act under low and high irradiances, respectively. Phytochromes B1 and B2 also contribute to BL sensing, and the relative contribution of each of these four photoreceptors differs according to the light conditions and the specific process examined. Development of the phyA phyB1 phyB2 cry1 quadruple mutant under WL is severely impaired, and seedlings die before flowering. The quadruple mutant is essentially blind to BL, but experiments employing simultaneous irradiation with BL and red light suggest that an additional non-phytochrome photoreceptor may be active under short daily BL exposures. In addition to effects on de-etiolation, cry1 is active in older, WL-grown plants, and influences stem elongation, apical dominance, and the chlorophyll content of leaves and fruit. These results provide the first mutant-based characterization of cry1 in a plant species other than Arabidopsis.

Retrospective study on fluticasone propionate aqueous nasal spray efficacy in patients with allergic rhinitis: evaluation of clinical and laboratory parameters

BACKGROUND

In allergic rhinitis, allergenic stimulation causes the release of various mediators that induce symptoms and the development of chronic inflammation, which, in turn, is caused by cells involved in the late phase of inflammation, such as eosinophils. The eosinophils also cause damage at the mucosal level through the secretion of eosinophil cationic protein and other preformed factors contained in their granules. The objective was to verify the efficacy of fluticasone propionate aqueous nasal spray in patients with allergic rhinitis; in a retrospective study, we have evaluated mediators of inflammation, making correlations with the clinical symptoms score during and outside the pollen season.

METHODS

Forty patients with allergic rhinitis and 15 normal controls were included in our study. Eosinophil cationic protein, eosinophil chemotactic activity, and blood and nasal lavage eosinophil count were evaluated as laboratory parameters.

RESULTS

We found a significant increase in nasal lavage levels of eosinophil cationic protein in allergic patients, and this was strictly correlated with the clinical symptoms score. No differences were found in the eosinophil count of allergic patients and in the serum eosinophil cationic protein of patients sensitized to seasonal allergens in comparison with normal subjects. By contrast, an increase in serum eosinophil cationic protein level was found in patients sensitized to perennial allergens. After topical administration of fluticasone propionate aqueous nasal spray, a reduction in nasal lavage eosinophil cationic protein secretion was obtained with a reduction of eosinophil chemotactic activity at the local level. This reduction correlated with an improvement of clinical symptoms.

CONCLUSIONS

The clinical improvement and reduction in nasal lavage eosinophil cationic protein and eosinophil chemotactic activity after administration of fluticasone propionate aqueous nasal spray further confirms the role of this treatment in allergic rhinitis.

[General criteria of working ability in subjects with color vision defects]

A correct evaluation of the colour vision is important to make decisions concerning the recruitment in numerous occupations that require colour discrimination. In order to identify valid pre-employment colour vision testing methods, tests actually used and in particular the Ishihara test are considered. After a careful examination we conclude that candidates who pass the Ishihara test have sufficient colour perception to meet ordinary needs and further trade test are not necessary. Nevertheless we do not consider sufficient to rely on the Ishihara test alone to reject a candidate. The diagnostic algorihm proposed is recommended in pre-employment medical examinations for distinguishing people with normal colour vision, slight or sever colour deficiency.

Metabolic engineering of beta-carotene and lycopene content in tomato fruit

Ripe tomato fruits accumulate large amounts of the red linear carotene, lycopene (a dietary antioxidant) and small amounts of its orange cyclisation product, beta-carotene (pro-vitamin A). Lycopene is transformed into beta-carotene by the action of lycopene beta-cyclase (beta-Lcy). We introduced, via Agrobacterium-mediated transformation, DNA constructs aimed at up-regulating (OE construct) or down-regulating (AS construct) the expression of the beta-Lcy gene in a fruit-specific fashion. Three transformants containing the OE construct show a significant increase in fruit beta-carotene content. The fruits from these plants display different colour phenotypes, from orange to orange-red, depending on the lycopene/beta-carotene ratio. Fruits from AS transformants show up to 50% inhibition of beta-Lcy expression, accompanied by a slight increase in lycopene content. Leaf carotenoid composition is unaltered in all transformants. In most transformants, an increase in total carotenoid content is observed with respect to the parental line. This increase occurs in the absence of major variations in the expression of endogenous carotenoid genes.

Lymphocyte subpopulations, cytokines and trace elements in asymptomatic atopic women exposed to an urban environment

This study evaluates the immune response to exposure to an urban environment from 30 non-atopic and 30 non-symptomatic women with history of respiratory and/or cutaneous allergies. Blood lymphocyte subsets and serum interleukin (IL) 4 and interferon gamma (INF-gamma) of the two groups were similar, while serum IgE and "in vitro" production of IL-4 and INF-gamma by mononuclear blood cells of the atopic women were higher spontaneously or in the presence of PHA, respectively. Blood lead of the nonatopic women (mean 55 microg/l) was positively correlated with CD4+-CD45RO-, CD3+-CD8+ and CD3--HLA-DR+ lymphocyte subsets, while urinary trans-trans muconic acid (a metabolite of benzene) of both groups of women (mean about 50 microg/l) was significantly correlated with NK CD16+CD56+ lymphocytes. Urine chromium of the non-atopic subjects was significantly correlated with activated T, B and NK HLA-DR+ cells. Urine nickel of both groups of women was correlated with CD4+-CD45RO+ "memory" lymphocytes and their ratio with CD4+-CD45RO- "virgin" lymphocytes suggesting that the metal enhances maturation of "virgin" into "memory" lymphocytes. On the whole, this study demonstrates that exposure to low levels of toxic agents, produced by vehicular traffic in an urban environment, exerts effects on immune functions of women.

Combined effects of traffic and electromagnetic fields on the immune system of fertile atopic women

Object of this preliminary study was the immune response to high or low frequency electromagnetic fields (ELMF) of non-atopic and atopic fertile women with uniform exposure to toxic compounds produced by traffic. Women were divided in group A (non-atopic, non-exposed to ELMF); B (atopic, non-exposed to ELMF); C (non-atopic, exposed to ELMF); D (atopic, exposed to ELMF). "In vitro" cell proliferation of peripheral blood mononuclear cells (PBMC) of atopic women (groups B and D) stimulated by phytohaemoglutinin (PHA) was reduced. The ELMF exposed women (groups C and D) showed lower levels of blood NK CD16(+)-CD56+ lymphocyte subpopulations and of "in vitro" production of interferon-gamma (both spontaneously and in presence of PHA) by PBMC, suggesting that ELMF reduces blood cytotoxic activity. Serum IgE of the atopic women exposed to ELMF (group D) was higher than that of the other groups. Linear discriminant analysis including serum zinc and copper (essential enzymes for immune functions), blood lead and urinary transtrans muconic acid, a metabolite of benzene (markers of exposure to traffic) and key parameters of immune functions (CD16(+)-CD56+ lymphocyte subset, serum IgE, interferon-gamma produced by PBMC in presence of PHA, stimulation index of blastogenesis) showed absence of significant difference between groups A and C and a marked separation of groups B and D. This datum suggests that ELMF have a greater influence on atopic women exposed to traffic than on non-atopic ones.

Tomato contains homologues of Arabidopsis cryptochromes 1 and 2

Cryptochromes are blue light photoreceptors found in both plants and animals. They probably evolved from photolyases, which are blue/UV-light-absorbing photoreceptors involved in DNA repair. In seed plants, two different cryptochrome (CRY) genes have been found in Arabidopsis and one in Sinapis, while three genes have been found in the fern Adiantum. We report the characterisation of tomato CRY genes CRY1 and CRY2. They map to chromosomes 4 and 9, respectively, show relatively constitutive expression and encode proteins of 679 and 635 amino acids, respectively. These proteins show higher similarity to their Arabidopsis counterparts than to each other, suggesting that duplication between CRY1 and CRY2 is an ancient event in the evolution of seed plants. The seed plant cryptochromes form a group distinct from the fern cryptochromes, implying that only one gene was present in the common ancestor between these two groups of plants. Most intron positions in CRY genes from plants and ferns are highly conserved. Tomato cryl and cry2 proteins carry C-terminal domains 210 and 160 amino acids long, respectively. Several conserved motifs are found in these domains, some of which are common to both types of cryptochromes, while others are cryptochrome-type-specific.

Evaluation of monocyte chemotactic responsiveness in uraemic patients undergoing haemodialysis with different dialytic membranes

Recent data show that monocyte chemotactic peptide-1 (MCP-1), a chemotactic factor specific for monocytes, may play a central role in regulating the activation of these cells. For this reason, the production of MCP-1 in peripheral blood mononuclear cell (PBMC) cultures of eight healthy subjects, six chronic uraemic subjects under conservative treatment and six chronic uraemic patients undergoing haemodialysis (HD), was assessed. In the latter group of individuals, complement-activating membranes such as cuprophan (CU) were used for 1 month followed by biocompatible non-complement-activating membranes, like polymethylmetacrylate (PMMA) for the next 30 days. The chemotactic index (CI) elicited by PBMC supernatants from patients undergoing dialysis was found to be significantly higher than that obtained by supernatants recovered from normal subjects or uraemic patients on conservative therapy. Furthermore, the CI from PBMC supernatants having had contact with CU membranes was higher than that obtained from PBMC activated by PMMA. Finally, the increased chemotactic ability in the supernatants was closely correlated with the augmented MCP-1 gene expression and production, as assessed by in vitro hybridization studies.

Retrospective study of adverse reactions to non steroid anti-inflammatory drugs (NSAIDs): predictive value of controlled challenge with alternative drugs

Acetylsalicylic acid (ASA) and NSAIDs, which inhibit the cyclo-oxygenase enzyme (C-O), are responsible, when administered at therapeutic doses, for adverse reactions mainly involving the skin and respiratory tract. The prevalence of intolerance to ASA and NSAIDs, assessed by the Section of Allergic and Immunological Diseases at the University of Bari on a population of 15,800 patients referred for allergic diseases over a period of 7 years, was found to be 11.4%. The adverse reactions to NSAIDs observed were in most cases skin complaints (88.9%), followed by respiratory symptoms (asthma +/- rhinitis, rhinitis) and general symptoms (shock, hypotension, lipothymia). The most common types of NSAIDs taken were pyrazolones, salicylics, arylpropionics, paracetamol. Controlled oral challenges with alternative NSAIDs (especially nimesulide) confirm the predictive power of this test: in fact, among patients who showed tolerance to the challenge drug, only 10.6% manifested unexpected reactions during the course of one year's follow-up.

Cryptochrome 1 controls tomato development in response to blue light

Cryptochrome genes (CRY) are a novel class of plant genes encoding proteins that bear a strong resemblance to photolyases, a rare class of flavoproteins that absorb light in the blue (B) and UV-A regions of the spectrum and utilise it for photorepair of UV-damaged DNA. In Arabidopsis, both CRY1 and CRY2 are implicated in numerous blue light-dependent responses, including inhibition of hypocotyl elongation, leaf and cotyledon expansion, pigment biosynthesis, stem growth and internode elongation, control of flowering time and phototropism. No information about the in vivo function of CRY genes is available in other plant species. The tomato CRY1 gene (TCRY1) encodes a protein of 679 amino acids, which shows 78% identity and 88% similarity to Arabidopsis CRY1. In order to verify the in vivo function of TCRY1, we constructed antisense tomato plants using the C-terminal portion of the gene. Partial repression of both mRNA and protein levels was observed in one of the transformants. The progeny from this transformant showed an elongated hypocotyl under blue but not under red light. This character co-segregated with the transgene and was dependent on transgene dosage. An additional, partially elongated phenotype was observed in adult plants grown in the greenhouse under dim light and short days with no artificial illumination. This phenotype was suppressed by artificial illumination of both short and long photoperiods. The synthesis of anthocyanins under blue light was reduced in antisense seedlings. In contrast, carotenoid and chlorophyll levels and second positive phototropic curvature were essentially unaltered.

Expression of lymphocyte subpopulations, cytokine serum levels, and blood and urinary trace elements in asymptomatic atopic men exposed to an urban environment

The objective of this study was to analyze the role of some trace metals in the immune system of nonallergic or atopic men. One of these elements (Zn) is essential for immune function, whereas others, present in the urban environment, are known to be allergenic (Ni and Cr) or toxic (Pb). Serum levels of interleukin (IL) 2, 4, 5, and 13 and of interferon-y and immunoglobulins, blood lymphocyte subsets, blood concentrations of Pb and Zn, serum levels of Zn, and urinary Cr and Ni concentrations were determined in 17 nonallergic men (mean age 34 years) and 17 healthy nonsymptomatic atopic men living in urban areas. The mean blood concentration of Pb (a marker of exposure to toxic agents) was 11 microg/dl in both groups, which showed similar levels of blood Zn and of urinary Ni and Cr, whereas the serum Zn concentration was lower in the atopic group. Serum IgE levels were much higher in atopic men than in nonallergics, whereas serum IL-2, IL-5, and IL-13 concentrations were lower, possibly due to binding to tissue receptors and cells. Moreover, in atopic subjects, numbers of blood CD4+-CD45RO-"virgin" lymphocytes were significantly lower and the CD4+ -CD45RO+/CD4+ -CD45RO- ratio was more elevated, indicating an activation of the immune system. Serum IgE levels of atopic men, in contrast to those of nonallergic subjects, were correlated with CD19+ and CD5--CD19+ B lymphocytes. Blood Pb levels of both groups of men were correlated with CD4+, CD4+-CD45RO+, and HLA-DR+ [activated T-, B-, CO4+ -C. and natural killer (NK) cells] lymphocytes; in particular, blood Pb levels of the nonallergic men were also significantly correlated with CD25+ cells activated by IL-2, whereas those of the atopic men were also correlated with CD3--HLA-DR+ (B- and NK-cells) and CD5--CD19+ lymphocytes. Besides serum Zn levels, urinary Ni and Cr of nonallergic men were correlated with several immune parameters; in particular, urinary Cr was correlated with serum IL-5 and IgE and urinary Ni was correlated with CD4+ -CD45RO+ and CD3+ -CD25+ lymphocytes. This correlation of Ni and Cr, also found in previous studies in nonallergic subjects, confirms the hypothesis that these metals are involved in mechanisms of immune response regulation and that allergy to Ni or Cr represents an alteration of physiological mechanisms. Previous experimental studies have demonstrated that Pb exerts immunomodulatory effects on CD4+ and B- lymphocytes, enhancing the production of Th2-like cytokines and IgE. These experimental results confirm those of this study, showing in atopic men the correlation of B-lymphocytes with both blood Pb and serum IgE levels. This suggests that Pb may enhance the incidence of atopy in populations exposed to an urban environment.

Modulation of eosinophilic chemotaxis with azelastine and budesonide in allergic patients

In this paper, the effect of azelastine hydrochloride, a potent inhibitor of leukotrienes (LTs) and H1 receptors for histamine, was assessed as regards modulation of in vitro eosinophilic chemotaxis. In this respect, chemotaxis of eosinophils (EOS), isolated from the peripheral blood of untreated allergic subjects in the acute phase, was significantly diminished after in vitro treatment with azelastine in comparison to values before treatment. When EOS were pre-incubated with serial dilutions of the drug, it was observed that azelastine inhibited chemotaxis in a dose-dependent fashion. Since azelastine acts in vitro as a regulator of the calcium pump, EOS were pre-incubated with different concentrations (0.6 and 3.0 mM) of Ca++. In these experimental conditions azelastine was able to reduce EOS chemotactic activity only in the presence of 0.6 mM Ca++, whereas with higher Ca++ concentrations (3.0 mM) the inhibitory effect of the drug was abrogated. On the other hand, particular attention was paid to inhaled budesonide, a non halogenated glucocorticosteroid derivative, structurally related to 16 alpha-hydroxy prednisolone, which represents a helpful for treatment mild to moderate asthma. Data obtained after in vitro treatment with budesonide of a group of allergic patients demonstrated that EOS chemotactic activity was significantly reduced in these subjects. Conclusively our data show that 1) azelastine acts as a dose-dependent antagonist of chemotaxis; 2) it may exert this action by inhibiting Ca++ flow into cells; 3) inhaled budesonide may induce inhibition of bronchial inflammation by downregulating EOS chemotactic capacity.

Light-dependent regulation of carotenoid biosynthesis occurs at the level of phytoene synthase expression and is mediated by phytochrome in Sinapis alba and Arabidopsis thaliana seedlings

In chloroplasts, carotenoids are essential pigments involved in photosynthesis. During-photomorphogenesis, a coordinated increase in the amounts of chlorophylls and carotenoids, in conjugation with other components, leads to the formation of a functional photosynthetic apparatus. To investigate the regulation of carotenoid biosynthesis during this process at the molecular level, GGPS, PSY and PDS cDNAs have been cloned from white mustard (Sinapis alba L). GGPS encodes a key enzyme in plastid isoprenoid metabolism, while the products of PSY and PDS catalyse the subsequent steps in carotenoid biosynthesis. Due to the low mRNA levels of the genes involved, the use of a RT-PCR protocol was necessary to measure gene expression during photomorphogenesis. With light, there is an up-regulation of PSY expression, the first gene within the carotenoid biosynthetic pathway, while PDS and GGPS expression levels remain constant. Treatment with different light qualities reveals a phytochrome-mediated regulation of PSY expression in developing white mustard seedlings. To obtain more detailed information on the light-regulation, Arabidopsis thaliana wild-type and phytochrome mutants were utilized. Continuous far-red and red light both increase the expression of PSY in wild-type seedlings, demonstrating that both light-labile and light-stable phytochromes are involved in PSY regulation. The response to far-red light is completely abolished in the phyA mutant, showing that PHYA mediates the increase in PSY transcript levels under these light conditions. In the phyB mutant, the red light response is normal, indicating that PSY expression is not controlled by PHYB but by other light-stable phytochromes. Measurement of chlorophylls and carotenoids under the same light regimes shows that the up-regulation of PSY expression does not necessarily result in an increase of the carotenoid content. Only those light conditions which allow chlorophyll biosynthesis lead to a significant increase of the carotenoid content. Therefore, it is proposed that up-regulation of PSY mRNA levels leads to an increased capacity for the formation of carotenoids. However, this only takes place under light conditions leading to protochlorophyllide photoconversion.

[Classification of congenital heart diseases and surgical interventions in pediatric cardiology for the standardization of hospitalization records]

The utilization of DRGs for the evaluation of hospital activity requires the availability, on a current basis, of coded in-patient records (Hospital Discharge Form, SDO) with information concerning nosology of the patient and procedures performed. Consequently, the promotion of a standardized use of ICD.9 and ICD.9.CM code systems (International Classification of Diseases, 9th Revision, and International Classification of Diseases, 9th Revision, Clinical Modification) among clinicians is necessary. The National Research Council, Council Research Hospital for Cardiology and Cardiac Surgery (CREAS-IFC-CNR) has promoted the establishment of a permanent work group for the evaluation of the activity in the field of pediatric cardiology and cardiosurgery at a national level. In co-operation with two leading institution (AO "Bambino Gesù", Rome; AO "G. Gaslini", Genoa) an in-patient survey has been promoted including an overall revision of the ICD.9.CM code systems both for diagnosis and procedures in order to improve the standardization of data. Besides, the fitness of DRGs allocation by different codes has been judged. Some general and specific suggestions upon codes adequacy and DRGs identification have emerged from this study. The aim of this paper is to spread this preliminary standardization activity of the group as a contribution to the improvement of in-patient coded records quality.

[Allergic contact dermatitis to nickel: modification of receptor expression on peripheral lymphocytes of women after oral provocation tests (preliminary data)]

Blood lymphocyte subset evaluation was performed before after oral challenge with 10 mg of Ni, in 9 healthy women and in 15 allergic to Ni. Following challenge, 7 allergic showed a flare up of eczema and/or urticaria. In the controls, CD4+ lymphocytes were modified 24 hours after Ni challenge: CD4+/CD44RO- "virgin" cells were reduced while CD4+/CD45RO+ "memory" cells increased. The allergic women, not sensitive to oral Ni, showed an increase of B lymphocytes after the test. On the contrary, the oral Ni reacting patients presented a reduction of monocytes 4 hours after Ni ingestion and marked reduction (ranging from 20 to 50%) of T and B lymphocytes after 24 hours. These significant T and B lymphocytes changes suggest a migration of the cells in peripheral tissues, likely skin and GUT mucosa.

[Trace elements in biological samples and immunologic parameters in environmentally exposed populations (preliminary study)]

In non-smoking policemen from a town of Central Italy, blood CD4+ lymphocytes were reduced and CD8+ were increased as compared with a control group. This immunological alteration was not evident in the smoking policemen. Urine lead (marker of exposure to toxic agents produced by traffic) and blood natural killer (NK) CD16+ lymphocytes as well as serum copper and HLA-DR+ cells (B, T, NK activated lymphocytes and monocytes) were significantly correlated in the whole group of 42 examined subjects. Another study was performed on 15 healthy men, occupationally not exposed to toxic agents and living in a suburban area. Their urine lead, was positively correlated with the serum IgA immunoglobulins and negatively correlated with blood CD5(+)-CD19+ (a B subset bearing the T CD5 antigen) lymphocytes. On the contrary, urine chromium was negatively correlated with serum IgA and positively correlated with CD16(+)-56+ NK and CD5(+)-CD19+ B lymphocytes as well as with HLA-DR+cells. Serum zinc was also correlated with total HLA-DR+and CD3-HLA+DR+ (activated B and NK lymphocytes and monocytes) cells. These later data suggest that only zinc and copper but also trivalent chromium (to which normal population is mainly exposed in ordinary environmental conditions) may play a role in the mechanisms regulating the immune response.