Respiratory Syncytial Vaccination: Parents' Willingness to Vaccinate Their Children

BACKGROUND

This study was conducted to assess parents' willingness to vaccinate their children with the RSV vaccine and the key predictors of this intention among parents in Italy.

METHODS

Data were collected using an anonymous self-administered questionnaire from April to November 2023, targeting parents in public kindergartens and nursery schools in southern Italy. The survey assessed parents' socio-demographic characteristics, health-related details, their child's health status, attitudes toward RSV infection and its vaccine, and their source(s) of information.

RESULTS

A total of 404 parents agreed to participate in the study. Only 18.2% of participants were very concerned that their children could get infected by RSV, and this concern was more likely among parents whose child had been diagnosed with bronchiolitis, those who received information from HCWs, those who had heard of RSV, and those who needed additional information. Almost half (51.3%) were willing to vaccinate their child, and this inclination was more likely among fathers, employed parents, those with daughters, those who had heard of RSV, those who received information from HCWs, and those who needed additional information.

CONCLUSIONS

An educational campaign regarding a future RSV vaccine, especially about its safety and efficacy, is needed in order to improve parents' willingness.

Sudden Cardiac Death in the Young: State-of-the-Art Review in Molecular Autopsy

Sudden cardiac death (SCD) is defined as unexpected death due to a cardiac cause that occurs rapidly. Despite the identification of prevention strategies, SCD remains a serious public health problem worldwide, accounting for 15-20% of all deaths, and is therefore a challenge for modern medicine, especially when it affects young people. Sudden cardiac death in young people affects the population aged ≤ 35 years, including athletes and non-athletes, and it is due to various hereditary and non-hereditary causes. After an autopsy, if the cause remains unknown, it is called sudden unexplained death, often attributable to genetic causes. In these cases, molecular autopsy-post-mortem genetic testing-is essential to facilitate diagnostic and therapeutic pathways and/or the monitoring of family members of the cases. This review aims to elaborate on cardiac disorders marked by genetic mutations, necessitating the post-mortem genetic investigation of the deceased for an accurate diagnosis in order to facilitate informed genetic counseling and to implement preventive strategies for family members of the cases.

Nurse-to-Nurse Collaboration: A Scoping Review

OBJECTIVE

To map predictors and outcome of collaboration between nurses, outcomes of a good collaboration, and the tools developed to evaluate nurse-nurse collaboration.

BACKGROUND

Collaboration between nurses is an intraprofessional relationship between coworkers that is expressed through shared objectives, authority, and a decisional process. Studies on collaboration between nurses are very limited.

METHODS

A scoping review was conducted through 4 databases.

RESULTS

Eighteen studies were included. Nurses with higher levels of collaboration are more satisfied with their work and report less of an intention to leave their job. Greater collaboration among nurses resulted in a decrease of patient falling, hospital-acquired pressure ulcers, and a better care. Three tools have been developed to evaluate nurse-nurse collaboration: the Nurse-Nurse Collaboration Scale, the Nurse-Nurse Collaboration Behavior Scale, and the Nurse-Nurse Collaboration Between Sector.

CONCLUSIONS

Further studies should be conducted to fully understand the issue of collaboration between nurses and the factors connected to it.

Impact of the COVID-19 pandemic on behavioral changes in healthcare workers in Italy

Introduction

During the COVID-19 pandemic, adherence to wearing face mask and washing hands procedures and achieving high COVID-19 vaccine coverage among healthcare workers (HCWs) were essential to minimize morbidity and possible death and limit the transmission of the virus. The objectives of the cross-sectional survey were to explore the influence of COVID-19 on the use of preventive measures and vaccination willingness among HCWs in the southern part of Italy and the associated factors.

Methods

The survey was carried out from 15 June 2023 to 15 July 2023 among 521 HCWs who worked in three randomly selected public hospitals. All data were collected through a self-administered questionnaire.

Results

HCWs had a positive change in the use of preventive measures if they did not often/always use them before the pandemic, but they are using in the current epidemiologic context and they were willing to use in a future epidemic situation. A positive change in the adherence to face mask-wearing (24.6%) was more likely among those with at least 5 years of university degree, nurses/midwives, and who had worked in COVID-19 wards. A positive change in alcohol-based hand rubbing (3.1%) was more likely in HCWs in Emergency/Critical/Infectious Diseases wards compared with medical wards. HCWs who were more likely to believe that the COVID-19 vaccine should be mandatory for them (58.1%) had at least 5 years of university degree, in Emergency/Critical/Infectious Diseases wards compared with surgical and medical wards, had received more than three doses of this vaccine, were more concerned to get infected during their activity, and had received information from scientific journals. HCWs more willing to receive the COVID-19 vaccine every year (39.8%) were males, physicians, those in Emergency/Critical/Infectious Diseases wards compared with medical wards, who had received more than three doses of this vaccine, who believed that this vaccine should be mandatory for HCWs, and who needed additional information.

Discussion

The survey showed that the COVID-19 pandemic had an impact on the use of preventive measures among HCWs, not necessarily for the improvement or increase. Educational messages on the importance of these measures regarding the promotion and recommendation of the vaccine need to be investigated and applied among HCWs in order to reduce vaccination gaps and the spread of the infection.

The quality of sleep: evaluation among university students

Introduction

This study explored the quality of sleep among university students in the South of Italy during the Covid-19 pandemic.

Methods

A cross-sectional study was conducted between March 2022 and January 2023 and involved students over the age of 18, who were invited to complete a self-administered questionnaire using an online application.

Results

Overall, 88% of men and 94.5% of women had Pittsburgh Sleep Quality Index (PSQI) scores of ≥5 and a mean PSQI score of 9.2 ± 3. Students with severe or extremely depression score, with sever or extremely stress score, male and who did not had Covid-19 infection were more likely to have a PSQI global score. Moreover, 62.6% of the students declared a reduction in social relations and 72.3% an increase in the use of social media during the pandemic period. The majority of respondents reported an extremely severe level of depression (68.1%), anxiety (84.4%) and stress (71.9%).

Conclusion

This finding indicate that a relevant percentage of students are poor sleepers with a higher overall PSQI score with depression and stress and underline the role the implementation of public health interventions to promote healthy life styles and in particular focus on the duration of long night sleep.

Respiratory Syncytial Virus: Willingness towards a Future Vaccine among Pregnant Women in Italy

BACKGROUND

This cross-sectional survey was designed to evaluate pregnant women's awareness regarding Respiratory Syncytial Virus (RSV) infection and willingness to receive the vaccine during pregnancy and to vaccinate their newborn against RSV.

METHODS

An anonymous survey was administered from 20 April to 30 June 2023, to pregnant women aged ≥ 18 years attending gynecology wards of randomly selected public hospitals in southern Italy. A minimum sample size of 427 participants was calculated. The survey assessed women's socio-demographic characteristics, health-related information, their source(s) of information, and attitudes regarding RSV.

RESULTS

A total of 490 women participated. Those who were married/cohabiting, with a high-school degree compared to those who had a university degree, and those who needed additional information were more concerned that the newborn could acquire the RSV infection. The perceived utility of a future RSV vaccine administered during pregnancy was higher among those who were married/cohabiting, with a university degree, those with very good perceived health status, those who received information from healthcare workers, and those who needed additional information. Only 45.9% were willing to be vaccinated during pregnancy, and this was more likely among those with a university degree, with a very good perceived health status, who had received information from healthcare workers, and who needed more information. Finally, almost two-thirds (61.1%) were willing to vaccinate their newborn, and this was more likely among women with a university degree, with a very good perceived health status, and who needed additional information.

CONCLUSIONS

An education campaign regarding RSV infection and its vaccine is needed in order to improve women's perception and to support healthcare workers in promoting it when it will be available.

The Impact of an Intensive Care Diary on the Psychological Well-Being of Patients and Their Family Members: Longitudinal Study Protocol

BACKGROUND

Thanks to medical and technological advancements, an increasing number of individuals survive admission to intensive care units. However, survivors often experience negative outcomes, including physical impairments and alterations in mental health. Anxiety, depression, cognitive impairments, post-traumatic stress disorders, and functional disorders are known collectively as post-intensive care syndrome (PICS). Among the key triggering factors of this syndrome, memory impairment appears to play a significant role.

AIMS

This study aims to evaluate the impact of an intensive care diary on the psychological well-being of patients and their relatives after discharge from the ICU.

DESIGN

Prospective observational study.

EXPECTED RESULTS

The results of this study evaluate the impact of an ICU diary on the quality of life of ICU survivors and their family members.

Staff perception of the implementation, enablers and barriers to pediatric intensive care unit diary writing: A qualitative study

OBJECTIVES

To explore how the multi-professional pediatric intensive care unit staff experienced the implementation of the diary.

RESEARCH METHODOLOGY/DESIGN

Qualitative study using the implementation research approach.

SETTING

a six-bed pediatric intensive care unit at a large Italian tertiary care pediatric hospital, treating patients with acute conditions from the Emergency Department or hospital wards.

MAIN OUTCOME MEASURES

Healthcare providers' experiences of the implementation of the diaries. Data was collected by focus groups and interviews and thematic analysis was performed.

FINDINGS

Three focus groups and four interviews with staff were conducted after the implementation of thediaries from August 2020 to June 2021. Staff describe an initial disbelief towards the effectiveness of diaries followed by an increasing perception of their relevance for parents' emotional expression through shared narration. Diaries are reported as a beneficial communication tool between the family, the child, and health care providers, increasing staff understanding of parents' experiences of their child's admission and parents' sense of the care received by their child. For staff, barriers for diary writing were logistics, lack of time, limited sense of ownership, fear of legal retaliation and fear of emotional labor.

CONCLUSION

Health care providers perceived diaries as beneficial for parents and the healthcare team, potentially supporting their partnership as recommended by Family Centered Care models. The enablers and barriers that emerged for diary writing can support the development of implementation strategies to prevent the reported challenges to diary writing in the healthcare team, enhancing their uptake in the pediatric intensive care unit setting.

Instruments to evaluate non-technical skills during high fidelity simulation: A systematic review

INTRODUCTION

High Fidelity Simulations (HFS) are increasingly used to develop Non-Technical Skills (NTS) in healthcare providers, medical and nursing students. Instruments to measure NTS are needed to evaluate the healthcare providers' (HCPs) performance during HFS. The aim of this systematic review is to describe the domains, items, characteristics and psychometric properties of instruments devised to evaluate the NTS of HCPs during HFS.

METHODS

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Studies were retrieved from PubMed, Cinahl, Web of Science, Cochrane Library, ProQuest and PubPsych. Studies evaluating the measurement properties of instruments used to assess NTS during HFS training were included. Pairs of independent reviewers determined the eligibility, extracted and evaluated the data. Risk of bias and appraisal of the methodological quality of the studies was assessed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist, and the quality of the evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 3,953 articles were screened. A total of 110 reports were assessed for eligibility and 26 studies were included. Studies were conducted in Europe/United Kingdom (n = 13; 50%), North America/Australia (n = 12; 46%) and Thailand (n = 1; 4%). The NTS instruments reported in this review included from 1 to 14 domains (median of 4, Q1 = 3.75, Q3 = 5) and from 3 to 63 items (median of 15, Q1 = 10, Q3 = 19.75). Out of 19 NTS assessment instruments for HFS, the Team Emergency Assessment Measure (TEAM) can be recommended for use to assess NTS. All the other instruments require further research to assess their quality in order to be recommended for use during HFS training. Eight NTS instruments had a positive overall rating of their content validity with at least a moderate quality of evidence.

CONCLUSION

Among a large variety of published instruments, TEAM can be recommended for use to assess NTS during HFS. Evidence is still limited on essential aspects of validity and reliability of all the other NTS instruments included in this review. Further research is warranted to establish their performance in order to be reliably used for HFS.

Implementation of paediatric intensive care unit diaries: Feasibility and opinions of parents and healthcare providers

BACKGROUND

The implementation of paediatric intensive care unit (PICU) diaries has been reported as feasible in routine care. To date no feasibility study has compared PICU healthcare providers' (HCPs) and parents' opinions on this tool.

OBJECTIVES

The aim of this study is to describe the feasibility and perception of PICU diaries in an Italian PICU from the point of view of parents and HCPs.

METHODS

This is a single-centre, prospective, observational study conducted in a tertiary care paediatric hospital from August 2020 to May 2021. Children admitted to the emergency department PICU, intubated, and sedated for ≥48 h were enrolled. To explore their perceptions and attitudes with the PICU diary, parents were interviewed at 30 days from their child's discharge from the PICU, whereas PICU HCPs were surveyed at the end of the study. Data were analysed as proportions for categorical variables and means and medians for continuous variables according to the distribution, whereas qualitative data were summarised in categories by two independent researchers.

RESULTS

Twenty families were enrolled in this study. A total of 275 daily PICU diary entries were collected. Children's median age was 9 years (interquartile range = 2-13.25), and the length of stay ranged from 6 to 39 days. PICU diary applicability was rated high by parents and HCPs (>8 on a 1-10 Likert scale). Parents and HCPs perceived PICU diaries as beneficial for communication between staff and families, for parents by expressing their emotions and for staff by becoming aware of how parents experienced their child's admission. Reported barriers were the lack of a private environment, the risk of exposure to public reading, and PICU workload.

CONCLUSIONS

PICU diaries were feasible and perceived as beneficial both by parents and HCPs. Future research is warranted to understand the effect of PICU diaries on post-PICU outcomes.

Narrative diaries in the paediatric intensive care unit: A thematic analysis

BACKGROUND

The paediatric intensive care unit (PICU) diary is a shared tool, kept at the patient bedside, written by relatives and health care providers. There is little evidence about its feasibility and how it supports the families of children admitted to the PICU. Currently, there is no evidence about how the PICU diary is used and what we can learn from it.

AIM

To explore the contents of narrative PICU diaries in an Italian PICU.

STUDY DESIGN

Qualitative study of PICU diaries conducted with a narrative research approach.

METHODS

Children sedated and mechanically ventilated for >48 hours were enrolled in a six-bed Italian PICU of a tertiary care paediatric hospital. During the child's PICU admission, caregivers, relatives, friends, and health care providers were invited to report events, thoughts, and messages, and attach drawings/pictures for the child in the PICU diary. A thematic analysis of the PICU diary contents was performed.

RESULTS

Thirteen PICU diaries were completed between August and December 2020, mainly by parents (n = 95; 45%) and health care providers (n = 52; 25%). Three main themes emerged: "Social and spiritual support," "Caregiver's emotions, feelings and distress," and "PICU life." Diaries offer insight into caregivers' emotions, social support, clinical activities, and interactions with health care providers, and on progression towards recovery.

CONCLUSION

PICU diaries are valuable in facilitating family-centred care by providing a space for the written account of the child's admission by parents, other visitors, and health care providers.

RELEVANCE TO CLINICAL PRACTICE

PICU diaries support the relationship and the communication between the family and the team; they provide an informal account of the emotions and needs of parents that has the potential to improve mutual understanding and family-centred care. Social support and spiritual support are key elements reported by parents for coping with their child's PICU admission.

Narrative Diaries in Pediatrics: A Scoping Review

PROBLEM

Health diaries with both clinical and narrative elements have been widely used in pediatrics to study children's and families' experiences of illness and coping strategies. The objective of this study is to obtain a synthesis of the literature about narrative health diaries using the PRISMA extension for scoping reviews.

ELIGIBILITY CRITERIA

Sources were limited to: English language; narrative diaries; children/adolescents and/or parents/caregivers.

SAMPLE

The following databases were searched: PubMed, Embase and CINAHL with no time limits.

RESULTS

Among 36 articles included the most common context where a diary was implemented was the home (61%), the hospital (17%) and the school (14%). The most common diarist is the child or adolescent (50%). Paper diary was the most common type (53%), followed by the video diary (19%), the e-diary (8%) or the audio diary (8%). None of the studies explored the impact of the use of diaries on patient outcomes.

CONCLUSIONS

The narrative health diary is used to report patient experiences of illness or common life from the point of view of the child, adolescent or other family members. The diversity of the diaries found shows how the narrative diary may be 'adapted' to different settings and pediatric populations.

IMPLICATIONS

The narrative diary is a relevant tool for the exploration of children's and adolescents' experiences of illness and common life. Studies are still needed to describe the impact of narrative diaries keeping on children's health outcomes.

An update on atezolizumab for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a worldwide problem, with a high prevalence in nonindustrialized countries and a rising incidence in industrialized countries. Its close association with chronic liver diseases and liver cirrhosis represents a significant challenge in its treatment. Sorafenib, the first front-line systemic treatment for unresectable HCC cases, was approved only in 2007. The role of sorafenib remained largely unchallenged until very recently, with the sole exception of a trial demonstrating the noninferiority of lenvatinib, another tyrosine kinase inhibitor. The therapeutic scenario changed dramatically in 2020, when the combination of atezolizumab and bevacizumab proved to be significantly superior to sorafenib and, thus, establishing a new standard of care. In this monograph we provide an update about the safety and efficacy of atezolizumab reported in the clinical trials of HCC, as monotherapy or in combination with other agents.

Novel insights on Andersen-Tawil syndrome type 1

Background

Andersen-Tawil Syndrome type 1 (ATS1) in a rare arrhythmogenic disease caused by loss-of-function mutations in the KCNJ2 gene and characterized by ventricular arrhythmias, dysmorphic features and episodes of periodic paralysis. Although the prognosis of ATS1 patients is typically considered benign, definitive outcome data are lacking.

Purpose

We aimed to: 1) define the risk of life-threatening arrhythmic events (LAEs); 2) identify risk factors for such events; 3) assess the efficacy of anti-arrhythmic drugs in preventing LAEs.

Methods

We included 118 ATS1 patients from 57 families with confirmed pathogenic or likely pathogenic KCNJ2 mutations. Clinical and genetical data were acquired by investigators from 23 centers in 9 countries.

Results

Baseline characteristics of the population are presented in the Table. Over a follow-up of 6.2 years, 17/118 (14%) patients experienced a first LAE, with a 5-year cumulative probability of 7.9% (Figure). Cox multivariable analysis demonstrated that a previous history of syncope (HR 4.5, p=0.02), the documentation of sustained VT (HR 9.3, p=0.001) and the administration of amiodarone (HR 268, p<0.001) were associated with an increased risk of LAE. The baseline rate of LAE was not reduced by beta-blockers alone (1.37 per 100 py; p=1), or in combination with class Ic antiarrhythmic drugs (1.46 per 100 py, p=1).

Conclusions

Our data demonstrate that the clinical course of patients with ATS1 is characterized by a high rate of LAE. A history of unexplained syncope, and documentation of sustained ventricular tachycardia are independently associated with a higher risk of LAE. Amiodarone is proarrhythmic and should be avoided in ATS1 patients.

ATS1: Diagnosis, Outcome, Risk Factors

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): ERN Guard-Heart European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart

Pre-operative pediatric cardiac surgery: enema Versus not enema

Background and aim of the work:

There is evidence in adult literature that the enema in the preoperative of thoracic surgery can be dismissed without disadvantage. However, there is a gap of articles about enema in childhood for thoracic surgeries. The aim of the work is to investigate whether the administration of enema in the preparation for cardiac surgery, the use of different analgosedation drugs and the Extracorporeal Circulation influence the children’s intestinal motility in the post-operative period.

Methods:

A retrospective study was carried out comparing the data between users subjected to saline solution enema, originating from the U.O.C. of Pediatric Cardiology and Pediatric Cardiac Surgery and Congenital Heart Disease and users not subjected to such procedure, coming from the U.O.S.D. Pediatric Intensive Care. The data collected will evaluate the intestinal motility in the post-operative cardiac surgery.

Results:

The following three variables were analyzed: interval of post-operative evacuation days (mean 2.14, median 2.00, standard deviation 1.525 in non-enema children; mean 2.76, median 2.00, standard deviation 1.318 in enema children), administered analgosedation drugs and use of Extracorporeal Circulation - for which the Pearson Test was used. A sampling bias is also reported from the analysis of the data. The study did not show a statistical significance correlates the variables analyzed to intestinal motility in post-operative period.

Conclusion:

The sampling bias emerged could reflect the diversity of the catchment area in the two Wards. The study - in agreement with the literature concerning the adult user - proves that the practice of enema evacuation pre-operative cardiac surgery in the pediatric user is unnecessary and does not influence intestinal transit in the post-operative period. (www.actabiomedica.it)

An update of treatments of hepatocellular carcinoma in patients refractory to sorafenib

Hepatocellular carcinoma (HCC) remains among the neoplastic diseases with the most unfavorable prognosis. Historically, systemic treatments for HCC have been scarce. In particular, sorafenib was the only registered drug for the treatment of unresectable HCC until 2017. Last year, regorafenib was approved by the global regulatory agencies as second-line therapy. Since then, further randomized, controlled trials have been successful in this patient population. This paper deals with the most recent data concerning cabozantinib and ramucirumab, the two drugs that have recently demonstrated efficacy in phase III, randomized, controlled trials in HCC patients who failed previous treatment with sorafenib.

Narrative Based Medicine as a tool for needs assessment of patients undergoing hematopoietic stem cell transplantation

BACKGROUND AND AIM

In the last years we have seen an ever increasing number of patients with haematologic disorders who need hematopoietic stem cell transplantation (HSCT). The whole sector of HSCT results, infact to be in a continous scientific and technological clinical progress, offering a very advanced care. Despite this, some aspects are underconsidered, some of which could be fundamental to determine the success of the care pathway, such as the experience of the illness by the patient. Using a Narrative Based Medicine approach we wanted to investigate clinical, psychosocial and organizational aspects of the patient's journey whilst undergoing HSCT.

METHOD

Various narrative interviews were conducted using non-structured approach. Results were analysed by thematic contents.

RESULTS

Psycological dimension is the most compromised: above all emerged sentiments of oppression linked to the isolation period in the Low Bacterial Load (LBL) room. To note are also the different dynamics with which the patients perceive the organisation and hospital structures, and how much these factors can influence their care experience.

CONCLUSIONS

Results suggest the need in clinical practice of an integration between qualitative and clinical approach, so as to permit the psychosocial and relational necessities to emerge, often unexpressed by patients undergoing HSCT.

A new surgical technique for the treatment of scaphotrapezial arthritis associated with trapeziometacarpal arthritis: the narrow pseudoarthrosis

We describe a technique for treating Eaton stage IV osteoarthritis of the first ray, which is a development of our previously published technique for treating trapeziometacarpal arthritis. This simple technique is based on a limited resection arthroplasty of the first trapeziometacarpal and the scaphotrapezial joints, with the aim of inducing the formation of a narrow pseudoarthrosis at both sites. A total of 26 consecutive patients were treated for Eaton stage IV arthritis at a mean follow-up of 4.7 years (range 3.2-6.6). There were statistically significant improvements in all clinical parameters: mean appositional and oppositional pinch strength, mean DASH score (65 points pre-operatively to 8.7 points at final follow-up), and in mean visual analogue scale score (8.6 to 0.2 points). Although a larger cohort and a longer follow-up will be necessary to evaluate this new technique fully, these results encourage us to believe that the limited excision arthroplasty of the trapeziometacarpal and scaphotrapezial joints is a viable alternative to the existing surgical treatments for stage IV thumb arthritis.

LEVEL OF EVIDENCE

4.

In vitro functional response of human tendon cells to different dosages of low-frequency pulsed electromagnetic field

PURPOSE

Chronic tendinopathy is a degenerative process causing pain and disability. Current treatments include biophysical therapies, such as pulsed electromagnetic fields (PEMF). The aim of this study was to compare, for the first time, the functional in vitro response of human tendon cells to different dosages of PEMF, varying in field intensity and duration and number of exposures.

METHODS

Tendon cells, isolated from human semitendinosus and gracilis tendons (hTCs; n = 6), were exposed to different PEMF treatments (1.5 or 3 mT for 8 or 12 h, single or repeated treatments). Scleraxis (SCX), COL1A1, COL3A1 and vascular endothelial growth factor-A (VEGF-A) expression and cytokine production were assessed.

RESULTS

None of the different dosages provoked apoptotic events. Proliferation of hTCs was enhanced by all treatments, whereas only 3 mT-PEMF treatment increased cell viability. However, the single 1.5 mT-PEMF treatment elicited the highest up-regulation of SCX, VEGF-A and COL1A1 expression, and it significantly reduced COL3A1 expression with respect to untreated cells. The treated hTCs showed a significantly higher release of IL-1β, IL-6, IL-10 and TGF-β. Interestingly, the repeated 1.5 mT-PEMF significantly further increased IL-10 production.

CONCLUSIONS

1.5 mT-PEMF treatment was able to give the best results in in vitro healthy human tendon cell culture. Although the clinical relevance is not direct, this investigation should be considered an attempt to clarify the effect of different PEMF protocols on tendon cells, in particular focusing on the potential applicability of this cell source for regenerative medicine purpose, both in surgical and in conservative treatment for tendon disorders.

Variations of cervical lordosis and head alignment after pedicle subtraction osteotomy surgery for sagittal imbalance

INTRODUCTION

The variations of the cervical lordosis after correction of sagittal imbalance have been poorly studied. The aim of our study is to verify whether the cervical lordosis changes after surgery for sagittal imbalance.

MATERIALS AND METHODS

Thirty-nine patients were included in the study. Cervical, thoracic and lumbar spine, pelvic and lower-limb sagittal parameters were recorded. The cranial alignment was measured by the newly described Cranial Slope.

RESULTS

The global cervical kyphosis (preop -43°, postop -31.5°) and the upper (preop -24.1°, postop -20.2°) and lower cervical kyphosis (preop -18.1°, postop -9.2°) were significantly reduced after surgical realignment of the trunk. A positive linear correlation was observed between the changes in T1 slope and the lower cervical lordosis, and between T1 slope and the global cervical alignment.

CONCLUSIONS

The cervical lordosis is reduced by surgical correction of malalignment of the trunk, suggesting an adaptive role to maintain the head's neutral position.

Donor-matched mesenchymal stem cells from knee infrapatellar and subcutaneous adipose tissue of osteoarthritic donors display differential chondrogenic and osteogenic commitment

Cell-based therapies have recently been proposed for the treatment of degenerative articular pathologies, such as early osteoarthritis, with an emphasis on autologous mesenchymal stem cells (MSCs), as an alternative to terminally differentiated cells. In this study, we performed a donor-matched comparison between infrapatellar fat pad MSCs (IFP-MSCs) and knee subcutaneous adipose tissue stem cells (ASCs), as appealing candidates for cell-based therapies that are easily accessible during surgery. IFP-MSCs and ASCs were obtained from 25 osteoarthritic patients undergoing total knee replacement and compared for their immunophenotype and differentiative potential. Undifferentiated IFP-MSCs and ASCs displayed the same immunophenotype, typical of MSCs (CD13+/CD29+/CD44+/CD73+/CD90+/CD105+/CD166+/CD31-/CD45-). IFP-MSCs and ASCs showed similar adipogenic potential, though undifferentiated ASCs had higher LEP expression compared to IFP-MSCs (p<0.01). Higher levels of calcified matrix (p<0.05) and alkaline phosphatase (p<0.05) in ASCs highlighted their superior osteogenic commitment compared to IFP-MSCs. Conversely, IFP-MSCs pellets showed greater amounts of glycosaminoglycans (p<0.01) and superior expression of ACAN (p<0.001), SOX9, COMP (p<0.001) and COL2A1 (p<0.05) compared to ASCs pellets, revealing a superior chondrogenic potential. This was also supported by lower COL10A1 (p<0.05) and COL1A1 (p<0.01) expression and lower alkaline phosphatase release (p<0.05) by IFP-MSCs compared to ASCs. The observed dissimilarities between IFP-MSCs and ASCs show that, despite expressing similar surface markers, MSCs deriving from different fat depots in the same surgical site possess specific features. Furthermore, the in vitro peculiar commitment of IFP-MSCs and ASCs from osteoarthritic donors towards the chondrogenic or osteogenic lineage may suggest a preferential use for cartilage and bone cell-based treatments, respectively.

Trapeziometacarpal narrow pseudarthrosis: a new surgical technique to treat thumb carpometacarpal joint arthritis

We describe a technique that arose from the observation of the clinical outcome of failed arthrodeses of the thumb carpometacarpal joint. In these cases a pseudoarthrosis developed which, surprisingly, rarely lead to a poor clinical outcome. Thus we developed a simple technique which deliberately caused the formation of a narrow pseudoarthrosis in the carpometacarpal joint. We present a retrospective review of 248 consecutive patients treated for Eaton stages II and III osteoarthritis. We observed a statistically significant improvement in mean appositional and oppositional pinch strength, mean DASH score (63.8 pre-operatively to 10.5 at final follow-up), and the mean pain score (8.3 to 0.2). We conclude that trapeziometacarpal limited excision arthroplasty is a simple and reliable alternative to existing surgical techniques for treating Stage II or III thumb carpometacarpal joint arthritis.

Preoperative calculation of the necessary correction in sagittal imbalance surgery: validation of three predictive methods

INTRODUCTION

Surgery for correction of sagittal imbalance has frequent adverse events and complications. The most frequent cause of failure is inadequate correction of imbalance. The aim of this study is to verify the accuracy of three published methods (exact method by Ondra, FBI method by Le Huec and spinofemoral angle method by Lamartina) to preoperatively calculate the needed correction.

DESIGN

This is a retrospective cohort study.

METHODS

Fifteen patients treated for correction of sagittal imbalance, with preoperative and postoperative lateral standing whole spine radiographs, were identified. Preoperative calculation of the amount of needed correction has been done using these methods. In postoperative X-rays, the amount of correction obtained with and the degree of correction of sagittal imbalance have been measured.

RESULTS AND DISCUSSION

The FBI and SFA methods obtain equivalent calculations of the amount of needed correction. The estimated correction angle with both methods is higher than that calculated with the exact trigonometric method. The difference between the latter and the former methods is equivalent to the observed excess of pelvic tilt.

Early angiogenic response to shock waves in a three-dimensional model of human microvascular endothelial cell culture (HMEC-1)

The exact nature of shock wave (SW) action is not, as yet, fully understood, although a possible hypothesis may be that shock waves induce neoangiogenesis. To test this hypothesis, a three-dimensional (3D) culture model on Matrigel was developed employing a human microvascular endothelial cell line (HMEC-1) which was stimulated with low energy soft- focused SW generated by an SW lithotripter. After 12 hours we observed a statistically significant increase in capillary connections subsequent to shock-wave treatment in respect to the control group and a marked 3-hour down-regulation in genes involved in the apoptotic processes (BAX, BCL2LI, GADD45A, PRKCA), in cell cycle (CDKN2C, CEBPB, HK2, IRF1, PRKCA), oncogenes (JUN, WNT1), cell adhesion (ICAM-1), and proteolytic systems (CTSD, KLK2, MMP10). Our preliminary results indicate that microvascular endothelial cells in vitro quickly respond to SW, proliferating and forming vessel-like structures, depending on the energy level employed and the number of shocks released. The early decreased expression in the analysed genes could be interpreted as the first reactive response of the endothelial cells to the external stimuli and the prelude to the events characterizing the neo-angiogenic sequence.

Treatment of late-stage Freiburg's disease using a temporary metal interpositional device

There are few reports of the surgical treatment for late stage Freiburg's disease with flattening of the metatarsal head and osteoarthritis. We describe the results of the surgical treatment of ten consecutive patients with advanced stage Freiburg's disease (Smillie's stage V), using a technique that has not been published previously.

Ribonuclear inclusions as biomarker of myotonic dystrophy type 2, even in improperly frozen or defrozen skeletal muscle biopsies

Myotonic dystrophy type 2 (DM2) is a dominantly inherited disorder caused by a CCTG repeat expansion in intron 1 of ZNF9 gene. The size and the somatic instability of DM2 expansion complicate the molecular diagnosis of DM2. In situ hybridization represents a rapid and sensitive method to obtain a definitive diagnosis in few hours, since it allows the direct visualization of the mutant mRNA foci on skeletal muscle sections. This approach makes the muscle biopsy an important tool for definitive diagnosis of DM2. Consequently, a rapid freezing at ultra cold temperature and a good storage of muscle specimens are essential to avoid morphologic alterations and nucleic acids degradation. However incorrect freezing or thawing may accidentally occur. In this work we report that fluorescence in situ hybridization may be applied on improperly frozen or inappropriately stored muscle biopsies since foci of mutant mRNA are well preserved and can still be detected in muscle sections no more useful for histopathological evaluation.

Ribonuclear inclusions as biomarker of myotonic dystrophy type 2, even in improperly frozen or defrozen skeletal muscle biopsies

Myotonic dystrophy type 2 (DM2) is a dominantly inherited disorder caused by a CCTG repeat expansion in intron 1 of ZNF9 gene. The size and the somatic instability of DM2 expansion complicate the molecular diagnosis of DM2. In situ hybridization represents a rapid and sensitive method to obtain a definitive diagnosis in few hours, since it allows the direct visualization of the mutant mRNA foci on skeletal muscle sections. This approach makes the muscle biopsy an important tool for definitive diagnosis of DM2. Consequently, a rapid freezing at ultra cold temperature and a good storage of muscle specimens are essential to avoid morphologic alterations and nucleic acids degradation. However incorrect freezing or thawing may accidentally occur. In this work we report that fluorescence in situ hybridization may be applied on improperly frozen or inappropriately stored muscle biopsies since foci of mutant mRNA are well preserved and can still be detected in muscle sections no more useful for histopathological evaluation.

Biomolecular identification of (CCTG)n mutation in myotonic dystrophy type 2 (DM2) by FISH on muscle biopsy

Myotonic dystrophy type 2 (DM2) is a dominantly inherited disorder with multisystemic clinical features, caused by a CCTG repeat expansion in intron 1 of the zinc finger protein 9 (ZNF9) gene. The mutant transcripts are retained in the nucleus forming multiple discrete foci also called ribonuclear inclusions. The size and the somatic instability of DM2 expansion complicate the molecular diagnosis of DM2. In our study fluorescence-labeled CAGG-repeat oligonucleotides were hybridized to muscle biopsies to investigate if fluorescence in situ hybridization (FISH), a relatively quick and simple procedure, could be used as a method to diagnose DM2. When FISH was performed with (CAGG)5 probe, nuclear foci of mutant RNA were present in all genetically confirmed DM2 patients (n=17) and absent in all patients with myotonic dystrophy type 1 (DM1; n=5) or with other muscular disease (n=17) used as controls. In contrast, foci were observed both in DM1 and DM2 myonuclei when muscle tissue were hybridized with (CAG)6CA probe indicating that this probe is not specific for DM2 identification. The consistent detection of ribonuclear inclusions in DM2 muscles and their absence in DM1, in agreement with the clinical diagnosis and with leukocyte (CCTG)n expansion, suggests that fluorescence in situ hybridization using (CAGG)5 probes, may be a specific method to distinguish between DM1 and DM2. Moreover, the procedure is simple, and readily applicable in any pathology laboratory.

Colocalization of ribonuclear inclusions with muscle blind like-proteins in a family with myotonic dystrophy type 2 associated with a short CCTG expansion

Myotonic dystrophy type 2 (DM2) is an autosomal dominant multisystemic disorder caused by a CCTG repeat expansion in intron 1 of the zinc finger protein 9 (ZNF9) gene. We present a three first-degree relative Italian family (proband, his mother and his sister) with a mild DM2 phenotype associated with a short (CCTG)(100) expansion as far as regards the proband and his mother, while his sister shows larger expansion correlated to a more severe phenotype. FISH analysis with (CAGG)(5) probe demonstrated that nuclear foci of mutant RNA were present in the proband muscle and co-localized with muscleblind-like proteins, determining their sequestration in the nucleus. This is one of the smallest expansion reported and the shortest with the evidence of nuclear foci. These data contribute to the clinical and molecular correlation of ZNF9 gene short expansion.

The hypocretin neurotransmission system in myotonic dystrophy type 1

BACKGROUND

Patients with myotonic dystrophy type 1 (DM1) frequently have symptoms of excessive daytime sleepiness (EDS). Some patients with DM1 show sleep-onset REM, similar to that observed in narcolepsy. Narcolepsy is characterized by impaired hypocretin (Hcrt) neurotransmission.

OBJECTIVE

To test for dysregulation of Hcrt neurotransmission in a prospective cohort of patients with DM1.

METHODS

Hcrt levels in CSF were measured by radioimmunoassay. Sleep physiology was assessed by overnight polysomnography (PSG) and a multiple sleep latency test (MSLT). Splicing of Hcrt receptor 1 and 2 (HcrtR1 and HcrtR2) mRNA was examined in postmortem samples of temporal cortex.

RESULTS

Seventeen of 38 patients with DM1 reported symptoms of EDS. Among patients with DM1 with EDS who underwent PSG/MSLT, 7 of 13 showed reduced sleep latency, sleep-onset REM, or both. However, CSF Hcrt levels in DM1 (mean 277 pg/mL, n = 38) were not different from controls (mean 277 pg/mL, n = 33). Also, splicing of HcrtR1 and HcrtR2 mRNA in patients with DM1 was similar to controls.

CONCLUSIONS

Excessive daytime sleepiness and dysregulation of REM sleep occur frequently in patients with myotonic dystrophy type 1 (DM1). However, the pathophysiologic basis is distinct from narcolepsy, as patients with DM1 do not have a consistent defect of Hcrt release or receptor splicing.

Treatment for periodic paralysis

BACKGROUND

Primary periodic paralyses are rare inherited muscle diseases characterised by episodes of flaccid weakness affecting one or more limbs, lasting several hours to several days, caused by mutations in skeletal muscle channel genes.

OBJECTIVES

The objective of this review was to systematically review treatment of periodic paralyses.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), and EMBASE (from January 1980 to July 2007) and any other available international medical library sources from the University of Milan for randomised trials.

SELECTION CRITERIA

We included randomised (including cross-over studies) and quasi-randomised trials in participants with primary periodic paralyses, in which any form of treatment, including physical therapy and alternative therapies, was compared to placebo or another treatment.

DATA COLLECTION AND ANALYSIS

Our primary outcome measure was the change in attack severity or frequency by eight weeks from the start of treatment. Our secondary outcome measures were: change in muscle strength and mass; change in Quality of Life, using Short Form 36 (SF36) or similar; preference of treatment strategy; adverse effects at eight weeks.

MAIN RESULTS

Three studies met our inclusion criteria. In one study dichlorphenamide (DCP) vs placebo was tested in two groups of participants: 42 with hypokalemic periodic paralysis (HypoPP) and 31 with hyperkalemic periodic paralysis (HyperPP), based on clinical criteria. Thirty-four of 42 participants with hypokalemic periodic paralysis completed both treatment phases. For the 34 participants having attack rate data for both treatment phases, the mean improvement in attack rate (P = 0.02) and severity-weighted attack rate (P = 0.01) on DCP relative to placebo were statistically significant. Fifteen preferred DCP, three placebo and six their baseline medication. Twenty-four of 31 participants with hyperkalemic periodic paralysis completed both treatment phases: for the 16 participants who had attack rate data for both treatment phases, the mean improvement in attack rate (P = 0.006) and in severity-weighted attack rate (P = 0.02) on DCP relative to placebo were significant. Fifteen preferred DCP, one placebo and five their baseline medication. Acetazolamide proved to improve muscle strength in eight participants with HypoPP in one other study and pinacidil, a potassium channel opener, also improved muscle strength in 2/4 participants with HypoPP in a third study.

AUTHORS' CONCLUSIONS

The largest included study that met our inclusion criteria suggested that DCP was effective in the prevention of episodic weakness in both hypokalemic and hyperkalemic periodic paralyses. The other two studies provide some evidence that either acetazolamide or pinacidil may improve muscle strength. However we still lack sufficient evidence to provide full guidelines for the treatment of people with periodic paralysis.

[Early infantile and late infantile form of Krabbe disease: CT and MRI findings]

The Authors present the CT and MR findings in three patients with Krabbe disease: early infantile, late infantile and juvenile. Three children, 5 and 9 months old respectively with Krabbe disease, were studied with CT and MR. the children presented with spasticity and signs of peripheral neuropathy, blindness and no interaction with the environment. In all patient CT revealed nonenhancing discrete dense lesions, simmetrically distribuited in the posterior limb of the internal capsule and posterior thalami and focal hypodensities of the midcerebellar peduncles and dentate nuclei, with mild cerebral atrophy. In one patients CT demonstrated bilateral calcifications of paraventricular white matter. Mr, in all, showed a generalized increase in T2 values of the periventricular white matter. The thalami and adjacents regions had markedly shortened T1 and slightly shortenede T2. The cerebellum and the brainstem appeared mottled with scattered areas of increased T2. MR confirmed the cerebral atrophy. In conclusion CT and MR findings in Krabbe disease (early infantile and late infantile) are usually not specific. However when they are both performed at the onset of neurological symptoms they can alert clinicians to the possibility of Krabbe disease.

Hypokalemic periodic paralysis in a patient with acquired growth hormone deficiency

CONTEXT

Hypokalemic periodic paralysis (HypoPP) is a rare disorder consisting of sudden episodes of muscle weakness with areflexia involving all four limbs, which spontaneously resolve within several hours or days. Primary HypoPP is genetically determined, while secondary acquired HypoPP has been described in association with thyreotoxycosis, hyperaldosteronism, kidney diseases, diuretics and liquorice abuse, gastrointestinal potassium loss, or cysplatinum therapy.

OBJECTIVE

To report a case of HypoPP associated with GH deficiency.

PATIENT

A 33 yr-old man with hypopituitarism and diabetes insipidus secondary to pituitary stalk-localized sarcoidosis, and documented HypoPP episodes.

CLINICAL PRESENTATION

Neurologic exam outside HypoPP episodes was normal. Needle electromyography was normal without myotonia or other spontaneous electric activity. Muscle biopsy documented a vacuolar myopathy with tubular aggregates. However, genetic analysis ruled out common mutations of the voltage-gated calcium channel observed in primary HypoPP. Common causes of secondary HypoPP were also ruled out. The patient was diagnosed with severe GH deficiency with modest fasting hyperinsulinemia and insulin resistance and started on GH replacement therapy, an alpha-glucosidase inhibitor (acarbose) and a diet low in simple carbohydrates.

CONCLUSIONS

GH replacement therapy, acarbose and a diet low in simple carbohydrates resulted in the complete long-term (>2 yr) remission of HypoPP episodes. This is consistent with the hypothesis that the hyperinsulinemia associated to GH deficiency may trigger HypoPP episodes by increasing Na+/K+ ATPase activity and K+ transport into the intracellular compartment with subsequent hypokalemia.