PASSI d'Argento (Silver Steps): the main features of the new nationwide surveillance system for the ageing Italian population, Italy 2013-2014

BACKGROUND

Italy is particularly concerned by population ageing. The costs for society are substantial. In this context a national, representative surveillance system, Passi D'Argento (PDA), was implemented in 2009 to monitor "active aging" and health status in people aged over 64 and to develop preventive health programs to reduce frailty.

METHODS/DESIGN

PDA recruited a representative sample of 24 129 individuals (March 2012-January 2013) aged over 64 who were interviewed by trained staff using a standardized questionnaire. The PDA collects information about participation in society and employment, independent living, health conditions, safety and living environment. Indicator values are used to obtain population health profiles and to compare different LHUs' profiles within the same region or between different regions.

DISCUSSION

The PDA surveillance system proved to be feasible and to be a powerful and innovative local and national tool for monitoring health status, frailty in Italy's elderly population and the essential levels of care currently provided to the elderly.

Effect of Mirtazapine on Thyroid Hormones in Adult Patients with Major Depression

Hypothalamic pituitary thyroid (HPT) axis abnormalities and alterations in major depression are reported in literature. The aim of our study was to evaluate the effect of mirtazapine on thyroid hormones after 6 months of therapy in a sample of adult outpatients with Major Depression (MD). 17 adult outpatients (7 men, 10 women) with MD according to DSM-IV criteria, were included in the study. All participants had to have met criteria for a major depressive episode with a score of at least 15 on the Hamilton Depression Rating Scale (HAM-D). Fasting venous blood samples were obtained for determination of serum Thyroid Stimulating Hrmone (TSH), Free T3 (FT3) and Free T4 (FT4) concentrations both at baseline and after 6 months of therapy. HAM-D scores decreased significantly from the first day of treatment to the end of the treatment period (p<0.001) and twelve patients (70.6%) were classified as responders. A significant increase in FT3 concentrations was found between baseline and the end of treatment period (P=0.015) whereas FT4 concentrations decreased (P=0.046). No significant changes were found in TSH levels. Higher FT4 concentrations at baseline predicted higher HAM-D scorers both at baseline and at the end of the treatment period. Furthermore, higher FT3 concentrations at endpoint were found to be predictors of lower HAM-D scores. Long-term treatment with mirtazapine increases FT3 levels and decreases FT4 maybe involving the deiodination process of T4 into T3.

[E-cigarette use in university students and its relationship to cigarette smoking]

INTRODUCTION

There is concern that e-cigarette use could be a risk factor for subsequent cigarette smoking.

METHODS

This survey included a group of 1220 students at Aix-Marseille University who attended a check-up visit and volunteered to participate to the survey. They answered a standardized questionnaire relating to e-cigarette use, smoking habits and the relationship between both habits. Mean age of participants was 19.9 years and 56% of them were female.

RESULTS

All students invited to the check-up examination attended and agreed to participate in the survey. 13.3% of students answered they had already used e-cigarettes, a higher proportion of boys (17.5%) than girls (10.0%), starting at a mean age equal to 19.2 years. Forty-six percent of them had already smoked cigarettes, more girls (55.0%) than boys (45.0%). Among current cigarette smokers, e-cigarette use had induced giving up smoking in 12.6% and a decrease in the number of cigarettes smoked in 30.1%. Twenty percent said they begun to smoke cigarettes after using e-cigarettes.

DISCUSSION

E-cigarette use is much less prevalent than smoking conventional tobacco cigarettes. There is a strong link between both. E-cigarette use had allowed a cessation or reduction in tobacco smoking in half of users. E-cigarette users may go on to start tobacco smoking but prospective surveys are needed to know how this will evolve over time. E-cigarette use could also be a means to prevent or postpone cigarette smoking.

Heritability of arterial stiffness and carotid intima-media thickness: an Italian twin study

BACKGROUND AND AIMS

Carotid intima-media thickness (IMT) and arterial stiffness parameters, including aortic augmentation index (AIx) and pulse wave velocity (PWV), are independent predictors of stroke and cardiovascular disease. Genetic effects on these traits were never explored in a Mediterranean country. The present study aims to quantify the contribution of genes, environment and age to carotid IMT and aortic Aix and PWV.

METHODS AND RESULTS

The twin design was used. A total of 348 adult twins from the Italian Twin Register underwent measurements of carotid IMT and aortic PWV and AIx in three university hospitals located in Rome, Padua and Perugia. Carotid IMT was measured by B-mode ultrasound, aortic PWV and AIx by Arteriograph. Genetic modelling was performed to decompose total variance of traits into genetic, shared and unshared environmental and age components. For each phenotype, the best-fitting model included additive genetic, unshared environmental and age effects. For IMT, heritability was 0.32 (95% confidence interval (CI): 0.25-0.38), unshared environmental component was 0.25 (0.18-0.32) and age contribution was 0.44 (0.39-0.49). For AIx and PWV, heritabilities were 0.42 (0.29-0.55) and 0.49 (0.35-0.62), unshared environmental components were 0.31 (0.22-0.44) and 0.37 (0.26-0.51) and age contributions were 0.27 (0.16-0.39) and 0.14 (0.06-0.24), respectively.

CONCLUSION

This study shows substantial genetic and unshared environmental influences on carotid intima-media thickness and arterial stiffness and confirms the relevant role of age in the aetiology of these traits. Further support is provided for prevention and health promotion strategies based on modifiable factors.

Piccolipiù, a multicenter birth cohort in Italy: protocol of the study

Background

The fetal and infant life are periods of rapid development, characterized by high susceptibility to exposures. Birth cohorts provide unique opportunities to study early-life exposures in association with child development and health, as well as, with longer follow-up, the early life origin of adult diseases. Piccolipiù is an Italian birth cohort recently set up to investigate the effects of environmental exposures, parental conditions and social factors acting during pre-natal and early post-natal life on infant and child health and development. We describe here its main characteristics.

Methods/design

Piccolipiù is a prospective cohort of expected 3000 newborns, who will be recruiting in six maternity units of five Italian cities (Florence, Rome, Trieste, Turin and Viareggio) since October 2011. Mothers are contacted during pregnancy or at delivery and are offered to participate in the study. Upon acceptance, their newborns are recruited at birth and followed up until at least 18 years of age. At recruitment, the mothers donate a blood sample and complete a baseline questionnaire. Umbilical cord blood, pieces of umbilical cord and heel blood spots are also collected. Postnatal follow-up currently occurs at 6, 12, and 24 months of age using on-line or postal self administered questionnaire; further questionnaires and medical examinations are envisaged. Questionnaires collect information on several factors, including mother’s and/or child’s environmental exposures, anthropometric measures, reproductive factors, diet, supplements, medical history, cognitive development, mental health and socioeconomic factors. Health promotion materials are also offered to parents.

Discussion

Piccolipiù will broaden our understanding of the contribution of early-life factors to infant and child health and development. Several hypotheses on the developmental origins of health can be tested or piloted using the data collected from the Piccolipiù cohort. By pooling these data with those collected by other existing birth cohorts it will be possible to validate previous findings and to study rare exposures and outcomes.

Genetic influence on the relation between exhaled nitric oxide and pulse wave reflection

Nitric oxide has an important role in the development of the structure and function of the airways and vessel walls. Fractional exhaled nitric oxide (FE(NO)) is inversely related to the markers and risk factors of atherosclerosis. We aimed to estimate the relative contribution of genes and shared and non-shared environmental influences to variations and covariation of FE(NO) levels and the marker of elasticity function of arteries. Adult Caucasian twin pairs (n = 117) were recruited in Hungary, Italy and in the United States (83 monozygotic and 34 dizygotic pairs; age: 48 ± 16 SD years). FE(NO) was measured by an electrochemical sensor-based device. Pulse wave reflection (aortic augmentation index, Aix(ao)) was determined by an oscillometric method (Arteriograph). A bivariate Cholesky decomposition model was applied to investigate whether the heritabilities of FE(NO) and Aix(ao) were linked. Genetic effects accounted for 58% (95% confidence interval (CI): 42%, 71%) of the variation in FE(NO) with the remaining 42% (95%CI: 29%, 58%) due to non-shared environmental influences. A modest negative correlation was observed between FE(NO) and Aix(ao) (r = -0.17; 95%CI:-0.32,-0.02). FE(NO) showed a significant negative genetic correlation with Aix(ao) (r(g) = -0.25; 95%CI:-0.46,-0.02). Thus in humans, variations in FE(NO) are explained both by genetic and non-shared environmental effects. Covariance between FE(NO) and Aix(ao) is explained entirely by shared genetic factors. This is consistent with an overlap among the sets of genes involved in the expression of these phenotypes and provides a basis for further genetic studies on cardiovascular and respiratory diseases.

Development and evaluation of tuberculosis screening scores in Brazilian prisons

BACKGROUND

Tuberculosis (TB) is highly endemic in Rio de Janeiro State prisons. In addition to TB screening at entry and passive case detection, active case identification may be warranted.

OBJECTIVES

To develop and evaluate performances of scores aimed at identifying "tuberculosis suspects" in order to target TB screening among inmates.

METHODS

Systematic chest X-ray screening was carried out in two prisons (n=1910). TB was diagnosed among individuals with X-ray abnormalities by sputum microscopic examination and culture or, if bacteriological results were negative, by response to TB treatment. Using this strategy as a reference, the clinical score proposed in WHO guidelines "TB Control in Prisons" was evaluated. Using the same variables in a logistic regression comparing TB and non-TB cases, another score was developed and evaluated. Finally, a 'new score', based on socio-demographic and clinical variables was developed and evaluated.

RESULTS

When applied to our study population (prevalence of active TB: 4.6%), these scores missed many TB cases (sensitivities: 56%, 72%, 74%, respectively). Among the "TB suspects", the probability of finding TB cases was low (positive predictive value: 10%). The scores had high negative predictive values (>97%); specificities (75%, 60%, 67%) were low. Performances were similarly poor for smear-negative and smear-positive cases.

CONCLUSION

The scores investigated performed poorly and would be unhelpful to target TB screening. Therefore, systematic X-ray screening may be considered, at least during the initial stages of the reinforced TB programme, in order to reduce the impressive burden of TB.

Local neural block at the wrist for treatment of palmar hyperhidrosis with botulinum toxin: Technical improvements

BACKGROUND

Wrist blockage of median and ulnar nerves before treatment of palmar hyperhidrosis with botulinum toxin (BTX-A) reduces discomfort and improves accuracy of BTX-A injections, but can be associated with mechanical/chemical injury.

OBJECTIVES

We sought to compare locoregional anesthesia of median and ulnar nerves using conventional 25-G x 0.50 x 13 mm gauge needle with short 30-G x 0.40 x 6 mm gauge needle.

METHODS

In all, 37 patients with idiopathic, recalcitrant palmar hyperhidrosis were treated with BTX-A after median and ulnar nerve blockage. In 18 patients, a conventional needle was used to achieve nerve blockage and in 19 the short needle was used. The 2 groups of patients were compared for analgesic effects and lag phase.

RESULTS

No differences were found between groups for lag phase (P=.26) and discomfort of subsequent BTX-A treatment (P=1.0).

CONCLUSION

The use of a short-gauge needle to block median and ulnar nerves is a suitable method to anesthetize the palm before treatment with BTX-A.

Effect of parity on second-trimester uterine artery Doppler flow velocity and waveforms

OBJECTIVES

To investigate the relationship between second-trimester uterine artery Doppler findings and parity in a large pregnant population.

METHODS

Uterine artery Doppler studies were performed in all singleton pregnancies at 18-23 weeks of gestation. The mean uterine artery resistance index and the presence or absence of protodiastolic notches were recorded. Two groups were identified: pregnancies not complicated by pre-eclampsia, and pregnancies with pre-eclampsia severe enough to require delivery at or before 32 weeks of gestation.

RESULTS

In the 4132 pregnancies uncomplicated by pre-eclampsia, parity was shown to be an independent predictor for both mean uterine artery resistance index (beta = 0.073, P < 0.001) and the presence of bilateral protodiastolic notches (odds ratio = 0.67; 95% CI, 0.45-0.98). In the 17 pregnancies complicated with severe pre-eclampsia, uterine artery Doppler indices showed a trend towards being better predictors of disease in nulliparous compared with parous women.

CONCLUSION

Parity has a significant effect on the resistance index and the prevalence of protodiastolic notching in the uterine artery flow waveforms. This difference is clinically noticeable in its effect on notching. These findings suggest that some permanent modification may persist in the maternal vessels after a successful pregnancy, altering their impedance in subsequent pregnancies.

Cesarean section for non-medical reasons

Cesarean section without medical indication is cited as a factor in the increase in the rate of cesarean delivery in modern obstetric practice. Individual obstetricians often express strong views supporting or refuting the right of women to request operative delivery and their rights to decline or fulfill this request. Such strong opinions may be misplaced as the available evidence does not conclusively support either view-point.

The conserved amphipatic alpha-helical core motif of RARgamma and RARalpha activating domains is indispensable for RA-induced differentiation of F9 cells

In monolayers cultures, retinoic acid (RA) induces the differentiation of F9 embryonal carcinomal (EC) cells into primitive endoderm-like cells, while a combination of RA and dibutyryl cAMP leads to parietal endoderm-like differentiation. Knock out of all RARgamma isoforms (RARgamma(-/-) line) drastically impairs primitive and subsequent parietal endodermal differentiation and affects the induction of many endogenous RA-responsive genes. Using lines that reexpress RARgamma2 or overexpress RARalpha1 lacking their AF-2AD core (RARgammadeltaAF2 and RARalphadeltaAF2, respectively), we show that this conserved amphipatic alpha-helical motif (helix 12) of the ligand binding domain, and therefore the activation function AF-2 of both receptors, is required for the induction of differentiation and target gene expression upon RA treatment of F9 EC cells. We also show that these deletion mutants behave as dominant negatives.

Hyperphosphorylation of the retinoid X receptor alpha by activated c-Jun NH2-terminal kinases

The nuclear receptor mouse retinoid X receptor alpha (mRXRalpha) was shown to be constitutively phosphorylated in its NH2-terminal A/B region, which contains potential phosphorylation sites for proline-directed Ser/Thr kinases. Mutants for each putative site were generated and overexpressed in transfected COS-1 cells. Constitutively phosphorylated residues identified by tryptic phosphopeptide mapping included serine 22 located in the A1 region that is specific to the RXRalpha1 isoform. Overexpression and UV activation of the stress-activated kinases, c-Jun NH2-terminal kinases 1 and 2 (JNK1 and JNK2), hyperphosphorylated RXRalpha, resulting in a marked decrease in its electrophoretic mobility. This inducible hyperphosphorylation involved three residues (serines 61 and 75 and threonine 87) in the B region of RXRalpha and one residue (serine 265) in the ligand binding domain (E region). Binding assays performed in vitro with purified recombinant proteins demonstrated that JNKs did not interact with RXRalpha but bound to its heterodimeric partners, retinoic acid receptors alpha and gamma (RARalpha and RARgamma). Hyperphosphorylation by JNKs did not affect the transactivation properties of either RXRalpha homodimers or RXRalpha/RARalpha heterodimers in transfected cultured cells.

Prenatal diagnosis of a large fetal arachnoid cyst

A case of prenatal diagnosis and management of a giant fetal arachnoid cyst is presented. The importance of an accurate diagnosis is highlighted and the use of three-dimensional ultrasound is discussed. The recent literature is reviewed.

Phosphorylation of activation functions AF-1 and AF-2 of RAR alpha and RAR gamma is indispensable for differentiation of F9 cells upon retinoic acid and cAMP treatment

The role of RAR alpha 1 and RAR gamma 2 AF-1 and AF-2 activation functions and of their phosphorylation was investigated during RA-induced primitive and parietal differentiation of F9 cells. We found that: (i) primitive endodermal differentiation requires RAR gamma 2, whereas parietal endodermal differentiation requires both RAR gamma 2 and RAR alpha 1, and in all cases AF-1 and AF-2 must synergize; (ii) primitive endodermal differentiation requires the proline-directed kinase site of RAR gamma 2-AF-1, whereas parietal endodermal differentiation additionally requires that of RAR alpha 1-AF-1; (iii) the cAMP-induced parietal endodermal differentiation also requires the protein kinase A site of RAR alpha-AF-2, but not that of RAR gamma; and (iv) the AF-1-AF-2 synergism and AF-1 phosphorylation site requirements for RA-responsive gene induction are promoter context-dependent. Thus, AF-1 and AF-2 of distinct RARs exert specific cellular and molecular functions in a cell-autonomous system mimicking physiological situations, and their phosphorylation by kinases belonging to two main signalling pathways is required to enable RARs to transduce the RA signal during F9 cell differentiation.

Cyclic AMP signalling pathway and cellular proliferation: induction of CREM during liver regeneration

The CREM gene encodes both activators and repressors of cAMP-induced gene expression. An isoform of CREM encodes the powerful transcriptional repressor ICER (Inducible cAMP Early Repressor), which has been shown to be inducible by virtue of an alternative, intronic promoter. The CREM gene belongs to the early response class and displays a characteristic neuroendocrine cell- and tissue-specific expression. To date ICER inducibility has been described in non-replicating, terminally differentiated tissues. In this paper we document a robust induction of CREM expression in the regenerating rat liver after partial hepatectomy. This represents the first link of inducible CREM expression to the phenomenon of cellular proliferation. Furthermore, it represents the first example of transcriptional activation of a cAMP-responsive factor in the regenerating liver. This has significant physiological relevance since the adenylate cyclase signalling pathway is strongly implicated in liver regeneration. Finally, we show that the repressor ICER is inducible in the hepatoma cell line H35 upon activation of the adenylate cyclase and phosphorylation of the activator CREB.

CREM: a master-switch in the transcriptional response to cAMP

The CREM gene encodes both repressors and activators of cAMP-dependent transcription in a tissue and developmentally regulated manner. In addition, multiple and cooperative phosphorylation events regulate the function of the CREM proteins. CREM plays a key physiological and developmental role within the hypothalamic-pituitary axis. There is a functional switch in CREM expression during the development of male germ cells which is directed by the pituitary hormone FSH. The CREM protein in germ cells is a powerful activator which appears to function as a master-switch in the regulation of postmeiotic genes. CREM is inducible by activation of the cAMP signalling pathway with the kinetics of an early response gene. The induction is transient, cell-specific, does not involve increased transcript stability and does not require protein synthesis. The subsequent decline in CREM expression requires de novo protein synthesis. The induced transcript encodes ICER and is generated from an alternative, intronic promoter. ICER functions as a powerful repressor of cAMP-induced transcription, and represses the activity of its own promoter, thus constituting a negative autoregulatory loop.

The nuclear response to cAMP: role of transcription factor CREM

In eukaryotes, transcriptional regulation upon stimulation of the adenylate cyclase signalling pathway is mediated by a family of cAMP-responsive nuclear factors. This family consists of a large number of members which may act as activators or repressors. These factors contain the basic domain/leucine zipper motifs and bind as dimers to cAMP-response elements (CRE). The function of CRE-binding proteins is modulated by phosphorylation by several kinases. The ICER (inducible cAMP early repressor) protein is the only inducible member of this family. The induction of this powerful repressor is likely to be important for the transient nature of cAMP-induced gene expression. CRE-binding proteins have been found to play an important role in the physiology of the pituitary gland, in regulating spermatogenesis, in the response to circadian rhythms and in the molecular basis of memory.

First trimester amnifiltration: technical, cytogenetic and pregnancy outcome of 104 consecutive procedures

OBJECTIVE

To investigate the technical, cytogenetic and pregnancy complications of first trimester amnifiltration for the diagnosis of fetal karyotype.

DESIGN

Observational study.

SETTING

The fetal medicine unit, UMDS St Thomas' Campus, London.

SUBJECTS

One hundred and four women seeking prenatal diagnosis of fetal karyotype.

MAIN OUTCOME MEASURES

Sampling success, culture rate, harvest time and karyotype, pregnancy outcome and complications.

RESULTS

Sampling was successful in all 104 cases, but equipment failure forced the procedure to be changed to early amniocentesis in eight (7%) cases. The karyotype was normal in 101 (97%) cases, abnormal in three. The mean harvest time was 14 days (range 9-26 days; SD = 3.4), and three cultures failed (2.8%). Pregnancies resulted in 99 (95%) live births, with a mean gestation of 277 days (range 182-300 days; SD = 16). There was one termination for trisomy 21 and four spontaneous miscarriages (3.8%). Amniotic fluid leakage occurred in six cases (5%), all resulted in live births, five at term and one at 35 weeks.

CONCLUSIONS

This study demonstrates that amnifiltration is technically possible in the first trimester of pregnancy, and that samples can be successfully karyotyped. The harvest time for culture is similar to early amniocentesis and chorion villus sampling. The rate of fetal loss, adjusted by the estimated natural loss, is 1.7%, which compares favourably with both chorionic villus sampling and early amniocentesis.

Taking cervical smears in departments of genitourinary medicine

The smear taking practices of departments of genitourinary medicine were investigated by telephone inquiry. Departments seem to be broadly and equally divided into those where the smear is taken before the cervix is wiped or endocervical specimens are taken for microbiology, and those where the smear is taken afterwards. In the unit at Guy's Hospital we compared cervical smears taken in both of these sequences and concluded that, to diagnose more cases of premalignant cervical disease, smears should be taken before any other cervical samples.

[Effect of veralipride on LH, FSH, and PRL levels and on the climacteric syndrome]

21 women with menopausal disorders were given veralipride, which is a benzamide derivative having a central anti-dopaminergic action. The LH, FSH and PRL plasma levels were controlled before and after treatment. Treatment, using veralipride at a daily dose of 100 mg for 20 days, improved the climacteric syndrome, and, in particular, the sudden hot flushes. The FSH plasma levels remained unchanged, the LH levels were reduced, although they remained high, and the PRL levels increased during the course of the treatment.