The intertwining of healthcare-associated infections and COVID-19 in Italian intensive care units: an analysis of the SPIN-UTI project from 2006 to 2021

BACKGROUND

Although healthcare-associated infections (HAIs) pose an extraordinary burden on public health, the impact of coronavirus disease 2019 (COVID-19) is still a matter of debate.

AIM

To describe trends of HAIs in Italian intensive care units (ICUs) from 2006 to 2021, and to compare characteristics and outcomes of patients with or without COVID-19.

METHODS

We evaluated patients participating in the 'Italian Nosocomial Infections Surveillance in Intensive Care Units' (SPIN-UTI) project, who were admitted to ICUs for more than 48 h. Data regarding diagnosis, clinical conditions, therapies, treatments and outcomes of COVID-19 patients were also collected.

FINDINGS

From a total of 21,523 patients from 2006 to 2021, 3485 (16.2%) presented at least one HAI. We observed an increasing trend for both the incidence of patients with HAI and the incidence density of HAIs (P-trend <0.001). Compared with the pre-pandemic period, the incidence density of HAIs increased by about 15% in 2020-2021, with pneumoniae being the greatest contributors to this increase (P-trend <0.001). Moreover, incidence of HAIs was higher in ICUs dedicated to COVID-19 patients (P<0.001), who showed a greater risk of HAIs and death than patients without COVID-19 (P-values <0.001). Accordingly, the mortality in ICUs increased over the years and doubled during the pandemic (P-trend <0.001). Notably, co-infected patients had higher mortality (75.2%) than those with COVID-19 (66.2%) or HAI (39.9%) alone, and those without any infection (23.2%).

CONCLUSIONS

Our analysis provides useful insight into whether and how the COVID-19 pandemic influenced HAI incidence and death in Italian ICUs, highlighting the need for evaluation of the long-term effects of the pandemic.

Altered collagen I and premature pulmonary embryonic differentiation in patients with OI type II

Pulmonary hypoplasia and respiratory failure are primary causes of death in patients with osteogenesis imperfecta (OI) type II. OI is a genetic skeletal disorder caused by pathogenic variants in genes encoding collagen type I. It is still unknown if the collagen defect also affects lung development and structure, causing lung hypoplasia in OI type II. The aim of this study was to investigate the intrinsic characteristics of OI embryonic lung parenchyma and to determine whether altered collagen type I may compromise airway development and lung structure. Lung tissue from nine fetuses with OI type II and six control fetuses, matched by gestational age, was analyzed for TTF-1 and collagen type I expression by immunohistochemistry, to evaluate the state of lung development and amount of collagen. The differentiation of epithelium into type 2 pneumocytes during embryonic development was premature in OI type II fetuses compared to controls (p < 0.05). Collagen type I showed no significant differences between the two groups. However, the amount of alpha2(I) chains was higher in fetuses with OI and the ratio of alpha1(I) to alpha2(I) lower in OI compared to controls. Cell differentiation during lung embryonic development in patients with OI type II is premature and impaired. This may be the underlying cause of pulmonary hypoplasia. Altered cell differentiation can be secondary to mechanical chest factors or a consequence of disrupted type I collagen synthesis. Our findings suggest that collagen type I is a biochemical regulator of pulmonary cell differentiation, influencing lung development.

Medical Care Use Among Patients with Monogenic Osteoporosis Due to Rare Variants in LRP5, PLS3, or WNT1

Pathogenic variants in the LRP5, PLS3, or WNT1 genes can significantly affect bone mineral density, causing monogenic osteoporosis. Much remains to be discovered about the phenotype and medical care needs of these patients. The purpose of this study was to examine the use of medical care among Dutch individuals identified between 2014 and 2021 with a pathogenic or suspicious rare variant in LRP5, PLS3, or WNT1. In addition, the aim was to compare their medical care utilization to both the overall Dutch population and the Dutch Osteogenesis Imperfecta (OI) population. The Amsterdam UMC Genome Database was used to match 92 patients with the Statistics Netherlands (CBS) cohort. Patients were categorized based on their harbored variants: LRP5, PLS3, or WNT1. Hospital admissions, outpatient visits, medication data, and diagnosis treatment combinations (DTCs) were compared between the variant groups and, when possible, to the total population and OI population. Compared to the total population, patients with an LRP5, PLS3, or WNT1 variant had 1.63 times more hospital admissions, 2.0 times more opened DTCs, and a greater proportion using medication. Compared to OI patients, they had 0.62 times fewer admissions. Dutch patients with an LRP5, PLS3, or WNT1 variant appear to require on average more medical care than the total population. As expected, they made higher use of care at the surgical and orthopedic departments. Additionally, they used more care at the audiological centers and the otorhinolaryngology (ENT) department, suggesting a higher risk of hearing-related problems.

Association of hospital/ICU characteristics with HAIs: findings from the SPIN-UTI project

Background

Preventing the spread of healthcare-associated infections (HAIs) in Intensive Care Units (ICUs) constitutes a priority for Public Health. In a country with decentralized healthcare system, the comparison between and within regions might represent a useful approach to identify what hospital and ICU indicators are associated with HAIs.

Methods

Using data from the SPIN-UTI (”Sorveglianza attiva Prospettica delle Infezioni Nosocomiali nelle Unità di Terapia Intensiva”) network, the present analyses aimed to identify the main hospital and ICU indicators associated with HAI incidence at national level, and to stratify the analyses between Italian regions.

Results

No associations between hospital/ICU characteristics and HAIs were evident at national level. However, ICUs in Southern Italy showed the highest incidence density of HAIs if compared with those in Central and Northern Italy (p &lt; 0.001). Stratified analyses found a positive association of incidence density of HAIs and total days in ICU in Northern Italy (β = 0.3; SE = 0.1; p = 0.002); a positive associations with ICU size (β = 1.8; SE = 0.7; p = 0.020), total days in hospital (β = 0.06; SE = 0.02; p = 0.037) and total days in ICU (β = 0.5; SE = 0.1; p = 0.006) in Center Italy; a positive association with hospital size in Southern Italy (β = 20.3; SE = 9.4; p = 0.033).

Conclusions

Although our study confirms that HAIs still represent an important issue in Italian ICUs, there is some variation between regions from Northern, Central and Southern Italy. In general, we found that HAI incidence increased with increasing number of beds in hospital and in ICU, as well as with the the increasing number of patient-days. However, further research is necessary to better understand if additional hospital and ICU characteristics could motivate the observed regional differences.

Key messages

• There is a large regional variation in the incidence of HAIs in Italian ICUs and hospitals.

• This difference that could be motivated by specific hospital and ICU characteristics.

Categorical principal component analysis to characterize patients at Intensive Care Unit admission

Background

Healthcare-associated infections (HAIs) are the most frequent complications in healthcare settings, with a major impact on adverse outcomes. Here, we aimed to identify the relationships between patients’ characteristics admitted to Intensive Care Units (ICUs).

Methods

We used data of patients included in the “Italian Nosocomial Infections Surveillance in Intensive Care Units” (SPIN-UTI) project, who stayed in ICU for more than 2 days. Using Categorical principal component analysis (CATPCA) two components of risk were assessed. Values of variance accounted for (VAF) >0.3 were accepted as the significant effect of a variable on each component. A Chronbach’s alpha >0.7 was accepted as a measure of the internal consistency of the model.

Results

A total of 22402 admissions (62% female) were included. The average age was 65.7 years (SD = 16.6). Our model explains 35.3% of the total variability, with a Cronbach's alpha value of 0.847. The visual examination of component loading plot allows to evaluate the correlation between the quantified variables and each of the two components. In particular, the first component is explained by the presence of intubation (VAF=0.826), central venous catheter (VAF=0.749), and urinary catheter (VAF=0.727), patient’s origin (VAF=0.584), antibiotic treatment (VAF=0.479), non-surgical treatment for acute coronary disease (VAF=0.375), type of admission (VAF=0.509), surgical intervention (VAF=0.419). In the second component, the variables with the greatest contribution were the SAPS II (VAF=0.660), age (VAF=0.583), type of admission (VAF=0.531), surgical intervention (VAF=0.522). Thus, the first component would represent the exposure to invasive devices and medical procedures, and the second component the severity of patients.

Conclusions

Our results proposed the usefulness of CATPCA to identify factors involved in the development of adverse outcomes, highlighting the role of exposure to invasive devices and severity of patients.

Key messages

• There are several relationships between patients clinical and personal characteristics.

• CATPCA represents a useful approach for the analytical exploitation of healthcare data.

Citrus Flavonoids and Autoimmune Diseases: A Systematic Review of Clinical Studies

BACKGROUND

Autoimmune diseases are chronic disorders in which the immune system does not recognize and attacks one self's healthy components. In this context, although natural remedies might represent a promising therapeutic strategy, evidence regarding Citrus flavonoids is still controversial.

OBJECTIVE

To summarize and critically discuss the clinical evidence on the effects of Citrus flavonoids for the management of autoimmune diseases.

METHOD

A systematic review of articles has been carried out independently by two Authors using MEDLINE, Scopus and ISI Web of Science databases. Search terms comprised keywords related to Citrus flavonoids and autoimmune diseases. The last search was performed on March 16, 2021. No language restrictions were applied. Systematic review and study selection were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Before starting the review, Authors defined the types of articles to be included. Three reviewers independently carried out the extraction of papers.

RESULTS

Ten clinical studies fulfilled the eligibility criteria and were included in the final review.

CONCLUSION

The studies discussed in this review are heterogeneous. Indeed, some studies suggest the use of Citrus flavonoids in the frame of autoimmune disorders, whereas others discourage it. Hence, this systematic review highlights the need of further large-scale clinical studies to define the exact role of Citrus flavonoids in the management of autoimmune diseases (PROSPERO number CRD42021234903).

Gender-differences in outcomes of patients in Intensive Care Unit: findings from the SPINUTI network

Background

Achieving gender equality is one of the most important Sustainable Development Goals to guarantee health and wellbeing worldwide. Here, we aimed to assess gender-differences in risk factors and outcomes among patients admitted to Italian Intensive Care Units (ICUs).

Methods

Here, we included 12,534 patients from the “Italian Nosocomial Infections Surveillance in Intensive Care Units” (SPIN-UTI) project, who stayed in ICU for more than 48 hours. Firstly, characteristics at ICU admission were compared between males and females using the Mann-Whitney U or the Chi-Squared tests. Next, we compared the probability of death between genders by applying a logistic regression analysis. Results were adjusted for covariates (i.e., age, patient's origin, trauma, non-surgical treatment for acute coronary disease, surgical intervention and presence of intubation) and reported as Odds ratio (OR) and 95% Confidence Interval (CI). Finally, the Kaplan-Meier analysis was applied to assess gender difference in survival.

Results

Compared with male patients, females were older, more likely to come from other wards or healthcare facilities and to undergo a surgical intervention (p-values&lt;0.05). By contrast, they were less likely to be intubated or traumatized and to undergo non-surgical treatment for acute coronary disease (p-values&lt;0.05). Interestingly, a higher proportion of deaths was reported in female patients (p &lt; 0.001), so that their odds of dying was 13% higher than males (OR = 1.13; 95%CI=1.00-1.28; p = 0.046) after adjusting for covariates. Accordingly, females reported lower survival in ICU than males (median= 32.0 days vs. median= 34.0 days; p &lt; 0.001).

Conclusions

Our results pointed out gender-differences in patients' characteristics at ICU admission, which resulted into a higher risk of death and lower survival among females. In a Public Health point of view, these findings underline that is still important to sustain gender equality in ICUs and other hospital wards.

Key messages

There are several gender-differences in risk factors and outcomes among patients admitted to ICUs. Gender poses per se a higher risk for death in ICU, also considering other risk factors.

Healthy diet and lifestyles assessment using a mEMA approach: protocol of the HEALTHY-UNICT study

Background

Dietary intake, physical activity and other lifestyle factors, behaviors known to change in college students, may affect long-term health outcomes. The mobile Ecological Momentary Assessment (mEMA) methods represent an innovative, detailed and valid approach to capture the complexity of food intake and behaviors and to overcome limitations of traditional dietary assessment methods. The main aim of the HEALTHY-UNICT study is to characterize heating habits, including Mediterranean Diet adherence, and others lifestyle factors, and their relationship with anthropometrics and emotions in a sample of college students of the University of Catania, using real-time mEMA methods and an innovative custom mEMA application.

Methods

Data will be collected using a mEMA tool administered via a web-based application. mEMA data collection will be carried out in two waves during the second semester of the academic year. During each wave, participants will receive prompts via the text messages to complete the surveys during four selected days, eight times per day.

Results

This abstract describes the protocol of the study. The HEALTHY-UNICT study aims to follow university students from a large university. A total of 100 students will be enrolled in the pilot phase. Expected results are the characterization of dietary behaviors, including Mediterranean diet adherence, food choices and others lifestyle factors, including smoking habits and physical activity and their relationship with anthropometrics and emotions in the sample of college students of the University of Catania.

Conclusions

The project idea should be relevant since results of the study could be useful to identify targets for the improvement of health and the promotion of healthy lifestyles in young adults. The HEALTHY-UNICT project will contribute to Sustainable Development Goals (SDGs) in the area of food and nutrition, to improve nutrition and lifestyle, through actions that combine tradition and innovation.

Key messages

The study will provide a better understanding of the food choices that college students make and insights for individual and population level prevention interventions. Findings of this study could be used to develop targeted interventions that encourage healthy food choices and healthy habit and ultimately reduce the risk of overweight and others adverse outcomes.

Risk factors for severe and fatal COVID-19 among patients admitted to an Italian hospital

Background

The epidemic of COVID-19 has spread dramatically affecting more than 140 million people and leading to more than 3 million deaths. We aimed to investigate what factors pose a risk for disease severity and death.

Methods

We prospectively included patients with laboratory-confirmed COVID-19 from San Marco Hospital (Catania, Italy), who had been admitted by Dec 31, 2020. Demographic, clinical, treatment, and laboratory data, were collected and compared between severe and non-severe patients, as well as between survivors and non-survivors. We used univariable and multivariable methods to explore the risk factors associated with disease severity and death.

Results

Overall, 463 patients were included, of whom 33.7% had severe disease and 14.0% died in hospital. Patients with severe disease were older (p &lt; 0.001) and more likely to have had heart failure (p = 0.038). With respect to the risk of death, increasing age, hypertension, diabetes, ischemic heart disease, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, cancer, and chronic renal failure were more common among non-survivors than survivors (p-values&lt;0.05). In particular, a logistic regression model confirmed age (OR = 1.14; 95%CI=1.10-1.20; p &lt; 0.001) and heart failure (OR = 14.8; 95%CI=2.7-80.8; p = 0.002) as the main risk factors for death. The comparison between the first and the second waves of the epidemic did not reveal differences in demographic and clinical characteristics, however, the treatment approach has changed significantly.

Conclusions

The risk of severe and/or fatal COVID-19 was higher among older patients with comorbidities. These findings lay the foundation for prediction models that could inform shielding policies and vaccine prioritisation strategies.

Key messages

The risk of severe and fatal COVID-19 is substantially elevated among older patients with previous comorbidities. These findings are important to inform shielding policies and vaccine prioritisation strategies.

Design, protocol, and perspectives of the MADRE-REA study

Background

Unhealthy diet during pregnancy poses serious risks for both mothers and children, representing an important Public Health issue. Although Epigenetics offers a plausible explanation of the transgenerational pathway from mother to child, it is still necessary to understand if maternal epigenetic aging increases the risk for adverse outcomes in newborns. In this scenario, the “MAternal Diet, Risks and Epigenetic age during pregnancy: a Real-world Ecological momentary Assessment” (MADRE-REA) study aims to evaluate the relationship between maternal diet, epigenetic age and risk for adverse pregnancy outcomes in a mother-child cohort.

Methods

We will develop a smartphone-based ecological momentary assessment (EMA) of dietary, behavioral, physical, and sociopsychological information of 400 pregnant women recruited by the “Mamma & Bambino” cohort (Catania, Italy). Women will be asked to complete 6 waves of EMA during the 2nd and 3rd trimesters of pregnancy, and 3, 6, 9 and 12 months after delivery. Each wave consists of a 7-day assessment based on a signal-contingent approach, which prompts participants to record dietary consumption and other information. We will also examine maternal epigenetic age at recruitment and at delivery, using the DNAm PhenoAge.

Results

The novelty of the MADRE-REA study lies in the opportunity to apply a smartphone-based EMA to capture the complexity of dietary intake during and after pregnancy. Moreover, expected findings will help to understand if maternal behaviors and other exposures might affect epigenetic age, and hence if the eventual accelerated biological aging might be associated with health and disease in newborns.

Conclusions

This study could disentangle the relationship between maternal diet, epigenetic aging, and adverse outcomes, laying the foundation for future strategies to reduce the burden of disease in newborns throughout their life. The study is funded by the Italian Ministry of Health (Bando Ricerca Finalizzata 2019).

Key messages

The application of a smartphone-based tool could overcome limitations of traditional methods to assess dietary behaviors in the periconceptional period. Uncovering the relationship between maternal diet and epigenetic aging could provide the molecular basis for future strategies against adverse pregnancy outcomes.

A machine learning approach to predict healthcare-associated infections at intensive care unit admission: findings from the SPIN-UTI project

BACKGROUND

Identifying patients at higher risk of healthcare-associated infections (HAIs) in intensive care units (ICUs) represents a major challenge for public health. Machine learning could improve patient risk stratification and lead to targeted infection prevention and control interventions.

AIM

To evaluate the performance of the Simplified Acute Physiology Score (SAPS) II for HAI risk prediction in ICUs, using both traditional statistical and machine learning approaches.

METHODS

Data for 7827 patients from the 'Italian Nosocomial Infections Surveillance in Intensive Care Units' project were used in this study. The Support Vector Machines (SVM) algorithm was applied to classify patients according to sex, patient origin, non-surgical treatment for acute coronary disease, surgical intervention, SAPS II at admission, presence of invasive devices, trauma, impaired immunity, and antibiotic therapy in 48 h preceding ICU admission.

FINDINGS

The performance of SAPS II for predicting HAI risk provides a receiver operating characteristic curve with an area under the curve of 0.612 (P<0.001) and accuracy of 56%. Considering SAPS II along with other characteristics at ICU admission, the SVM classifier was found to have accuracy of 88% and an AUC of 0.90 (P<0.001) for the test set. The predictive ability was lower when considering the same SVM model but with the SAPS II variable removed (accuracy 78%, AUC 0.66).

CONCLUSIONS

This study suggested that the SVM model is a useful tool for early prediction of patients at higher risk of HAIs at ICU admission.

Carbapenem Consumption and Rate of carbapenemresistant gram-negative bacteria: results from the Sicilian Surveillance System

Conclusion

The results of the present study highlight the need for comprehensive strategies targeting the appropriate use of antibiotics and infection control measures.

Background

In the last decades, multidrug-resistant gram-negative bacteria have been increasing and they are involved in severe healthcare associated infections. In treating drug-resistant gram-negative bacterial infections, carbapenems are generally administered as a last choice. However, the rate of carbapenemresistant bacteria is constantly increasing the last years. The aim of the present study is to describe the relationship between the rate of carbapenem-resistant gram-negative bacteria and antibiotic consumption intensity.

Study design

In 2017, the Sicilian Region implemented a regional surveillance system to describe and analyze consumption of antibiotics in hospital settings, as well as prevalence of antibiotic resistant microorganisms.

Methods

Resistance data were retrospectively collected from routinary clinical antimicrobial susceptibility tests. Resistance rates (RRs) of carbapenems were calculated and Spearman's correlation analysis was performed to investigate the relationship between annual antibiotic consumption and rate of carbapenem resistance.

Results

In 2015, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 43.9 %, and was positively correlated with beta-lactam consumption (R=0.529, p<0.01), and with carbapenem consumption (R=0.364, p<0.05). In 2016, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 53.8 %, and was positively correlated with carbapenem antibiotic consumption (R=0.364, p<0.05). In 2017, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 58.7 %, and was significantly positively correlated with carbapenem antibiotic consumption (R=0.427, p<0.05). In 2015, the overall prevalence of carbapenem-resistant Escherichia coli isolates was 6.5 %, and was significantly positively correlated with antibiotic consumption for the ATC class J01 (i.e., antibacterial for systemic use) (R=0.402, p<0.05).

Cluster analysis identifies patients at risk of catheter-associated urinary tract infections in intensive care units: findings from the SPIN-UTI Network

BACKGROUND

Although preventive strategies have been proposed against catheter-associated urinary tract infections (CAUTIs) in intensive care units (ICUs), more efforts are needed to control the incidence rate.

AIM

To distinguish patients according to their characteristics at ICU admission, and to identify clusters of patients at higher risk for CAUTIs.

METHODS

A two-step cluster analysis was conducted on 9656 patients from the Italian Nosocomial Infections Surveillance in Intensive Care Units project.

FINDINGS

Three clusters of patients were identified. Type of admission, patient origin and administration of antibiotics had the greatest weight on the clustering model. Cluster 1 comprised more patients with a medical type of ICU admission who came from the community. Cluster 2 comprised patients who were more likely to come from other wards/hospitals, and to report administration of antibiotics 48 h before or after ICU admission. Cluster 3 was similar to Cluster 2 but was characterized by a lower percentage of patients with administration of antibiotics 48 h before or after ICU admission. Patients in Clusters 1 and 2 had a longer duration of urinary catheterization [median 7 days, interquartile range (IQR) 12 days for Cluster 1; median 7 days, IQR 11 days for Cluster 2] than patients in Cluster 3 (median 6 days, IQR 8 days; P<0.001). Interestingly, patients in Cluster 1 had a higher incidence of CAUTIs (3.5 per 100 patients) compared with patients in the other two clusters (2.5 per 100 patients in both clusters; P=0.033).

CONCLUSION

To the authors' knowledge, this is the first study to use cluster analysis to identify patients at higher risk of CAUTIs who could gain greater benefit from preventive strategies.

Klebsiella pneumoniae acquisition in ICUs: patient-based and laboratory-based surveillance

Klebsiella pneumoniae - and especially multidrug-resistant K. pneumoniae - represents a global threat for Public Health, due to its high dissemination in Intensive Care Units (ICUs) and its association with mortality. Here, we investigated the molecular epidemiology of multidrug-resistant K. pneumoniae strains in ICUs from Catania, Italy.

We used data and samples from the Italian Nosocomial Infections Surveillance in ICUs - SPIN-UTI project, which has been surveying the epidemiology and the risk of Healthcare-associated infections (HAIs) in Italian ICUs. The SPIN-UTI network adopted the ECDC protocols for patient-based HAI surveillance. In a sample of ICUs the patient-based surveillance was integrated with a laboratory-based surveillance of MDR K. pneumoniae isolates. K. pneumoniae isolates were genotyped by multilocus sequence typing (MLST), and patterns of K. pneumoniae acquisition (i.e. carriage, colonization and infection) were identified using standard definitions.

Our analysis included 155 patients who stayed in two ICUs for a total of 2254 days, from October 2016 to March 2017. Trauma patients were more likely to be infected with K. pneumoniae than other patients (OR = 5.9; 95%CI=2.4-14.8; p = 0.004). A total of 109 K. pneumoniae strains were isolated from different sites of 39 patients, which in turn were defined as 45.2% colonization, 25.8% infection, and 29% carriage. 79.3% K. pneumoniae isolates resistant to carbapenems and 100% resistant to penicillins and cephalosporins. The MLST identified two major clonal groups: the ST395 and the ST37, which represented respectively the 65.6% and the 21.3% of typed isolates.

Surveillance of colonization and infection by high-risk clones might help in implementing appropriate strategies, which are crucial to reduce the spread of K. pneumoniae in ICUs.

*Study Group AOU 'Policlinico-Vittorio Emanuele', Catania, Italy: Patrizia Bellocchi, Giacomo Castiglione, Alida Imbriani, Marinella Astuto, Giuseppa La Camera, Agata Sciacca

Key messages

Multidrug-resistant K. pneumoniae still represents a threat for Public Health in Italy and globally, due to its high dissemination in intensive care units. Surveillance of colonization and infection by high-risk clones might help in reducing the spread of Klebsiella pneumoniae.

The mediating effect of lifestyles on the association between social factors and DNA methylation

Background

Social disadvantage and unhealthy lifestyles may induce molecular changes associated with aging and age-related diseases. For instance, previous studies reported socioeconomic difference in DNA methylation, which in turn led to aberrant gene expression and genome instability. Socioeconomic status (SES) alone, however, does not completely explain this difference, and further studies are needed to unveil what factors contribute to it.

Methods

We conducted a cross-sectional study on 349 Italian women, aged 25-64 years, to assess SES differences in LINE-1 methylation level - a surrogate marker of global DNA methylation - and to examine the mediating effect of lifestyles (i.e. diet, smoking habits, physical activity, and weight status). Educational level was used as SES indicator. The adherence to Mediterranean diet (MD) was assessed by the Mediterranean Diet Score (MDS). Leukocyte LINE-1 methylation was assessed by pyrosequencing. Mediation analysis was conducted using the PROCESS macro for the SPSS software.

Results

We first observed that women with high educational level were more likely to be normal weight (p &lt; 0.001) and to adhere to MD (p = 0.018), and less likely to perform physical activity (p = 0.012) than their less educated counterpart. Moreover, age-adjusted linear regression demonstrated that LINE-1 methylation level increased with increasing educational level (β = 0.016; SE = 0.003; p &lt; 0.001). In line, mediation analysis demonstrated an indirect effect of high educational level on LINE-1 methylation through the adherence to MD (β = 0.003; 95%CI=0.001-0.006). Specifically, the mediator could account for 9.5% of the total effect. None of the other lifestyles, instead, exhibited a significant mediating effect.

Conclusions

To our knowledge, this is the first study demonstrating the mediation of diet in the relationship between SES and DNA methylation. Thus, our findings add even more value to the promotion of healthy dietary habits among social disadvantaged people.

Key messages

Social disadvantage is associated with epigenetic changes related to aging and age-related diseases. Adherence to the Mediterranean diet might mediate the association between socioeconomic status and DNA methylation.

The association of social and behavioral factors with dietary risks in adults: Evidence from the Kardiovize Brno 2030 study

BACKGROUND AND AIMS

Uncovering the main determinants of diet quality is one of the greatest challenges for Public Health, since it could guide future strategies and interventions against cardiovascular diseases (CVDs). The present cross-sectional analysis of the Kardiovize cohort evaluates the prevalence of dietary risk factors for CVDs and their association with social and behavioural characteristics in a random sample of 1536 adults (aged 25-64 years) from Brno, Czech Republic.

METHODS AND RESULTS

A face-to-face health interview guided by structured questionnaires was carried out on socio-demographic characteristics (age, sex, educational level, employment, marital status, income, and household size) and behaviours (smoking status, physical activity, and sleep habits). Twelve dietary risk factors covered by the Global Burden of Diseases comparative risk assessment framework were assessed using a Food Frequency Questionnaire. In general, we observed that the consumption of nearly all healthy foods and nutrients was suboptimal, and that it was also aggravated by high intake of foods and nutrients that constituted dietary risk factors. Moreover, we found several associations of social and behavioural characteristics with specific dietary risk factors. Particularly, being male (β = 0.466; SE = 0.079; p < 0.001), increasing household size (β = 0.130; SE = 0.047; p = 0.006), low income (β = 0.192; SE = 0.091; p = 0.035), and decreasing physical activity level (β = 0.172; SE = 0.054; p = 0.002) were associated with increasing number of dietary risk factors.

CONCLUSION

Thus, our study raises an urgent need for Public Health strategies promoting healthy eating in adulthood, which should be based on traditional and novel determinants of dietary risk.

Dietary patterns and school performance: evidence from a sample of adolescents in Sicily, Italy

BACKGROUND

Academic success in adolescence is a strong predictor of future wealth, productivity and health. While unhealthy dietary habits might be detrimental for academic outcomes, a positive association between healthy diet and school performance was found in adolescents worldwide.

STUDY DESIGN

A total of 213 adolescents (15 to 18 years old; 48% boys), attending three high schools in the urban area of Eastern Sicily, were enrolled in a cross-sectional study.

METHODS

Dietary data and informations about weekly consumption of main meals were collected administering a Food Frequency Questionnaire. The Mediterranean Diet Score and Principal Component Analysis were used to identify a priori and a posteriori dietary patterns, respectively. School performance was assessed through school marks, using the previous year as reference.

RESULTS

The Mediterranean Diet Score was weakly but positively correlated with performance in Italian, Science and Physical Education (p-values < 0.05). Similarly, the adherence to the prudent dietary pattern weakly positively correlated with marks in Mathematics. In contrast, we demonstrated a weak but significant negative correlation between adherence to the western dietary pattern and the performance in several subjects. The energy dense dietary pattern was instead negatively correlated with mark in Italian. We also showed that adolescents regularly eating all main meals have a better performance in several subjects, when compared to those who skipped at least one meal.

CONCLUSION

The promotion of healthy diet in youth should be a priority for Public Health, in order to improve adolescents' quality of life and prevent negative health and social outcomes later in life.

The impact of social determinants and lifestyles on dietary patterns during pregnancy: evidence from the "Mamma & Bambino" study

BACKGROUND

During pregnancy, maternal dietary patterns play a critical role in determining maternal and new-born health. Recent evidence highlighted the influence of either social determinants and lifestyles on the adherence to different dietary patterns.

STUDY DESIGN

In this cross-sectional analysis, we evaluated the association of social determinants and lifestyles with maternal dietary patterns in the "Mother & Child" cohort, a prospective study that enrols mother-child pairs from Catania, Italy.

METHODS

Dietary patterns were derived using Food Frequency Questionnaire and Principal Component Analysis. Logistic regression models were used to evaluate the association between socio-demographic factors (i.e., age, educational level and employment status), lifestyles (i.e., smoking status, body mass index, use of folic acid, multivitamin and multi-mineral supplements) and dietary patterns.

RESULTS

Overall, 332 women were enrolled and the following dietary patterns were derived: the "western" dietary pattern, characterized by high intake of red meat, fries, dipping sauces, salty snacks and alcoholic drinks; the second one, named "prudent", characterized by high intake of potatoes, raw and cooked vegetables, legumes, rice and soup. Multivariable analysis showed that young age, low educational level and smoking were positively associated with the adherence to the western dietary pattern. In contrast, pre-gestational body mass index was negatively associated with the adherence to the prudent dietary pattern.

CONCLUSION

Our results raise the need of strategies for promoting healthy dietary habits among women in their reproductive age, which might also help control their body weight before and during pregnancy. These strategies should be prioritized to young women of low educational level, who generally share other unhealthy behaviours.

Overview of three-year trends of antimicrobial consumption and resistance in Sicilian hospitals

Background

Antimicrobial resistance (AMR) is one of the ten threats identified by the WHO in 2019. In order to face this issue and in the framework of the National Action Plan on Antimicrobial Resistance (PNCAR) 2017-2020, the Sicilian Health Authority has implemented a surveillance system of antibiotic consumption in the hospital sector and in the community and of antibiotic resistance in the Sicilian hospitals. The aim of the present work is to report the results of three-year surveillance.

Methods

From 2015 to 2017, data on antibiotic consumption have been collected from pharmacies of participating hospitals. AMR data on seven bacterial pathogens isolated in blood and cerebrospinal fluid have been collected from hospital laboratories, using routine clinical antimicrobial susceptibility tests. Antibiotic consumption was expressed as Defined Daily Dose (DDD) per 100 patient-days. Antibiotic resistance rates (RRs) were calculated as the number of non-susceptible isolates divided by the total number of isolates multiplied by 100.

Results

The most commonly consumed antibiotics in participating hospitals were fluoroquinolones in 2015, penicillins in 2016, and beta-lactams in 2017, respectively. RRs of Klebsiella pneumoniae significantly increased for all antimicrobial classes (p &lt; 0.001), but carbapenems. By contrast, RRs of Escherichia coli resistant to third-generation cephalosporins and carbapenems showed significant decreasing trends (p &lt; 0.001).

Conclusions

The implementation of the Sicilian surveillance system provides Sicilian reference data to monitor trends and target interventions and policies for reducing the threat of AMR. Recently, using toolkits of the ECDC-EAAD initiative adapted with regional surveillance data, an educational campaign “Obiettivo Antibiotico” - https://www.obiettivoantibiotico.it/ - was designed and launched to raise awareness of prudent use of antibiotics in the general public and in healthcare professionals in Sicily.

Key messages

Inappropriate antimicrobial consumption observed in Sicilian hospitals contributes to the emergence and selection of AMR. Surveillance system of antimicrobial consumption and AMR can help identify strategies for preventing spread of multi-drug resistant microorganisms.

Dietary patterns and gestational weight gain: evidence from the “Mamma & Bambino” cohort

Background

In 2009, the Institute of Medicine (IoM) revised the guidelines on recommended gestational weight gain (GWG), taking into account pre-pregnancy body mass index (BMI) independent of age and ethnicity. However, more than half of mothers does not meet these guidelines with adverse outcomes for themselves and for newborns. Here, we used data of 232 women from the “Mamma & Bambino” cohort (Catania, Italy) to investigate the association between maternal dietary patterns, pre-pregnancy BMI and GWG.

Methods

Pregnant women were enrolled during the prenatal genetic counselling, at 4-20 gestational week. Dietary patterns were derived by food frequency questionnaire and principal component analysis. Self-reported pre-pregnancy BMI and GWG was calculated according World Health Organization and IoM guidelines, respectively.

Results

Adherence to the “western” dietary pattern - characterized by high intake of red meat, fries, dipping sauces, salty snacks and alcoholic drinks - was associated with increased GWG (β = 1.217; SE = 0.487; p = 0.013), especially among obese women (β = 7.363; SE = 1.808; p = 0.005). In contrast, adherence to the “prudent” dietary pattern - characterized by high intake of potatoes, cooked vegetables, legumes, rice and soup - was associated with reduced pre-pregnancy BMI (β=-0.651; SE = 0.308; p-trend=0.035). Interestingly, the adherence to this pattern was positively associated with GWG among underweight (β = 4.127; SE = 1.722; p = 0.048), and negatively among overweight and obese (β=-4.209; SE = 1.635; p = 0.016 and β=-7.356; SE = 2.304; p = 0.031, respectively).

Conclusions

Our findings encourage further studies to evaluate potential preventive strategies against inadequate weight gain, including the promotion of healthy dietary habits even during the periconceptional period.

Key messages

Adherence to diet rich in red meat, fries, dipping sauces, salty snacks and alcoholic drinks increases GWG, especially among obese women. Adherence to diet rich in potatoes, vegetables, legumes, rice and soup was associated with lower pre-pregnancy BMI, increased GWG among underweight, and decreased GWG among overweight/obese women.

How does education affect diet in women? A comparison between Central and Southern Europe cohorts

Background

Comparisons among European populations is useful to identify opportunities for planning nutrition strategies to reduce social inequalities in health. Our study aims to identify dietary patterns in adult women and to evaluate their association with educational level in Czech Republic and Italy, which display different health inequalities.

Methods

We performed a cross-sectional analysis of women (aged 25-64 years) with no history of severe diseases, who have been recruited in Brno (Czech Republic; n = 957) and in Catania (Italy; n = 841). Dietary patterns were derived by Food Frequency Questionnaire and Principal Component Analysis. We tested the association between educational level (low vs. high) and adherence to dietary patterns. Logistic regression models were used to assess Odds ratio (OR) and 95% confidence interval (CI), after adjusting for age, employment status, marital status, smoking status, parity, BMI, and menopause.

Results

In both cohorts, we identified the healthy and the unhealthy dietary patterns. We observed that women with high adherence to the healthy dietary pattern were less educated in Czech Republic, and more educated in Italy. After adjusting for covariates, low educational level was positively associated with adherence to the healthy dietary pattern among Czech women (OR = 2.033; 95%CI=1.301-3.176; p = 0.002), and negatively associated among Italian women (OR = 0.166; 95%CI=0.029-0.952; p = 0.044). No association was identified between educational level and the unhealthy dietary pattern.

Conclusions

In the Italian cohort, findings were consistent with the notion that healthy dietary choices are less common among low-educated groups. By contrast, in newly developed countries such as the Czech Republic, the “nutrition transition” from traditional staples to western foods might be more common in highly-educated groups, probably due to the advocacy of Western culture through mass media and commercial marketing.

Key messages

Low educational level has an opposite effect on healthy diet, exhibiting a positive association in Czech women, and a negative association in Italian women. From a broader perspective, the observed effect of education on diet quality helps explain social health inequalities in Central and Southern Europe.

P6497Loeys-Dietz syndrome-5: phenotypic spectrum of TGFB3 mutations in an international cohort and first report of a homozygous patient

Background

Mutations in TGFB3 cause Loeys-Dietz syndrome-5 (LDS5), an autosomal dominantly inherited connective tissue disorder. LDS5 is characterized by aortic aneurysms and dissections associated with systemic features mainly involving the ocular and skeletal systems. Precise delineation of LDS5 phenotype is difficult because of the small number of identified cases.

Purpose

The purpose of this study was to further define LDS5 with an emphasis on cardiologic features by describing the genotype and phenotype in an international cohort of patients.

Methods

We performed a retrospective cross-sectional multicentre study. Genetic testing was performed as a part of standard medical care. Clinical data were collected by means of an anonymized questionnaire, which was sent to the referent physicians.

Results

Ten (7 novel) TGFB3 mutations were identified in 31 patients (16 index patients). The mean age at last evaluation was 32 years (range 4–60 years). Aortic root dilatation, varices, and mitral valve insufficiency were the most common cardiovascular findings, reported in 28%, 22%, and 21% of patients, respectively. Higher incidences (40%, 29%, and 25%) of these findings were observed in the index patients. Four patients (8%) underwent aortic surgery, all after age 40. Abdominal aortic aneurysms were reported in 2/26 (8%) patients. Extra aortic artery disease included iliac artery aneurysm (one index patient) and tortuosity of the internal carotid and vertebral arteries (one index patient and one relative). The most frequently reported systemic features were high-arched palate, arachnodactyly, pes planus, pectus deformity, and joint hypermobility. Interestingly, we identified an homozygous TGFB3 mutation in a patient who presented with aortic dilatation at age 17, splenic torsion, severe myopia, cleft palate, and other skeletal features. Her heterozygous parents, brother, and sister displayed signs of the disease, but to a milder degree. To the best of our knowledge, this is the first identification of homozygous TGFB3 mutation.

Conclusions

Our data are in line with previous research, showing that aortic root dilatation is the main cardiovascular feature of LDS5. No deaths related to cardiovascular events were reported in any of the presented families. The cardiovascular phenotype of LDS5 appears to be milder compared to other vascular connective tissue disorder, such as Marfan syndrome, although our findings suggest that homozygosity is associated with a more severe and early-onset phenotype.

Association between eating time interval and frequency with ideal cardiovascular health: Results from a random sample Czech urban population

BACKGROUND AND AIMS

The frequency and timing of meals may affect cardiovascular health (CVH) outcomes, but large-scale epidemiological studies are lacking. The aim of this study was to understand the relationship between eating time interval and frequency, and measures of ideal CVH in the Kardiovize Brno cohort study, a random urban sample population in Central Europe.

METHODS AND RESULTS

1659 members of the Kardiovize Brno 2030 cohort were included in a cross-sectional study (mean age = 46.86 years; 44.6% male). Exposure variables were eating time interval and frequency, and skipping meals. Primary outcomes were indices of CVH, including body mass index, diet, physical activity, smoking, blood pressure, glucose and cholesterol, and the composite CVH score. Cluster analysis and binary logistic regression analysis were used to evaluate eating habits and the association between variables. After adjustment for well-known risk factors, subjects who skipped breakfast or the afternoon snack had a higher risk of poor CVH (OR = 1.613; 95%CI = 1.121-2.320; p = 0.010; OR = 1.409; 95%CI = 1.110-1.788; p = 0.005, respectively). Moreover, we identified three clusters of individuals based on eating habits; from cluster 1 to cluster 3, eating time interval and frequency increased and this was associated with increases in CVH score from 8.70 (SEM = 0.10) in cluster 1, and 9.06 (SEM = 0.08) in cluster 2 to 9.42 (SEM = 0.09) in cluster 3 (p-trend = 0.019).

CONCLUSIONS

Our findings suggest that skipping breakfast or the afternoon snack are risk factors for poor CVH, while higher eating time interval and frequency may promote ideal CVH.

NGS panel analysis in 24 ectopia lentis patients; a clinically relevant test with a high diagnostic yield

BACKGROUND

Several genetic causes of ectopia lentis (EL), with or without systemic features, are known. The differentiation between syndromic and isolated EL is crucial for further treatment, surveillance and counseling of patients and their relatives. Next generation sequencing (NGS) is a powerful tool enabling the simultaneous, highly-sensitive analysis of multiple target genes.

OBJECTIVE

The aim of this study was to evaluate the diagnostic yield of our NGS panel in EL patients. Furthermore, we provide an overview of currently described mutations in ADAMTSL4, the main gene involved in isolated EL.

METHODS

A NGS gene panel was analysed in 24 patients with EL.

RESULTS

A genetic diagnosis was confirmed in 16 patients (67%). Of these, four (25%) had a heterozygous FBN1 mutation, 12 (75%) were homozygous or compound heterozygous for ADAMTSL4 mutations. The known European ADAMTSL4 founder mutation c.767_786del was most frequently detected.

CONCLUSION

The diagnostic yield of our NGS panel was high. Causative mutations were exclusively identified in ADAMTSL4 and FBN1. With this approach the risk of misdiagnosis or delayed diagnosis can be reduced. The value and clinical implications of establishing a genetic diagnosis in patients with EL is corroborated by the description of two patients with an unexpected underlying genetic condition.

Recognizing the tenascin-X deficient type of Ehlers-Danlos syndrome: a cross-sectional study in 17 patients

The tenascin-X (TNX) deficient type Ehlers-Danlos syndrome (EDS) is similar to the classical type of EDS. Because of the limited awareness among geneticists and the challenge of the molecular analysis of the TNXB gene, the TNX-deficient type EDS is probably to be under diagnosed. We therefore performed an observational, cross-sectional study. History and physical examination were performed. Results of serum TNX measurements were collected and mutation analysis was performed by a combination of next-generation sequencing (NGS), Sanger sequencing and multiplex ligation-dependent probe amplification (MLPA). Included were 17 patients of 11 families with autosomal recessive inheritance and childhood onset. All patients had hyperextensible skin without atrophic scarring. Hypermobility of the joints was observed in 16 of 17 patients. Deformities of the hands and feet were observed frequently. TNX serum level was tested and absent in 11 patients (seven families). Genetic testing was performed in all families; 12 different mutations were detected, most of which are suspected to lead to non-sense mRNA mediated decay. In short, patients with the TNX-deficient type EDS typically have generalized joint hypermobility, skin hyperextensibility and easy bruising. In contrast to the classical type, the inheritance pattern is autosomal recessive and atrophic scarring is absent. Molecular analysis of TNXB in a diagnostic setting is challenging.

Osteogenesis Imperfecta: A Review with Clinical Examples

Osteogenesis imperfecta (OI) is characterized by susceptibility to bone fractures, with a severity ranging from subtle increase in fracture frequency to prenatal fractures. The first scientific description of OI dates from 1788. Since then, important milestones in OI research and treatment have, among others, been the classification of OI into 4 types (the 'Sillence classification'), the discovery of defects in collagen type I biosynthesis as a cause of most cases of OI and the use of bisphosphonate therapy. Furthermore, in the past 5 years, it has become clear that OI comprises a group of heterogeneous disorders, with an estimated 90% of cases due to a causative variant in the COL1A1 or COL1A2 genes and with the remaining 10% due to causative recessive variants in the 8 genes known so far, or in other currently unknown genes. This review aims to highlight the current knowledge around the history, epidemiology, pathogenesis, clinical/radiological features, management, and future prospects of OI. The text will be illustrated with clinical descriptions, including radiographs and, where possible, photographs of patients with OI.

Genotyping microarray (gene chip) for the ABCR (ABCA4) gene

Genetic variation in the ABCR (ABCA4) gene has been associated with five distinct retinal phenotypes, including Stargardt disease/fundus flavimaculatus (STGD/FFM), cone-rod dystrophy (CRD), and age-related macular degeneration (AMD). Comparative genetic analyses of ABCR variation and diagnostics have been complicated by substantial allelic heterogeneity and by differences in screening methods. To overcome these limitations, we designed a genotyping microarray (gene chip) for ABCR that includes all approximately 400 disease-associated and other variants currently described, enabling simultaneous detection of all known ABCR variants. The ABCR genotyping microarray (the ABCR400 chip) was constructed by the arrayed primer extension (APEX) technology. Each sequence change in ABCR was included on the chip by synthesis and application of sequence-specific oligonucleotides. We validated the chip by screening 136 confirmed STGD patients and 96 healthy controls, each of whom we had analyzed previously by single strand conformation polymorphism (SSCP) technology and/or heteroduplex analysis. The microarray was >98% effective in determining the existing genetic variation and was comparable to direct sequencing in that it yielded many sequence changes undetected by SSCP. In STGD patient cohorts, the efficiency of the array to detect disease-associated alleles was between 54% and 78%, depending on the ethnic composition and degree of clinical and molecular characterization of a cohort. In addition, chip analysis suggested a high carrier frequency (up to 1:10) of ABCR variants in the general population. The ABCR genotyping microarray is a robust, cost-effective, and comprehensive screening tool for variation in one gene in which mutations are responsible for a substantial fraction of retinal disease. The ABCR chip is a prototype for the next generation of screening and diagnostic tools in ophthalmic genetics, bridging clinical and scientific research.

The expanding roles of ABCA4 and CRB1 in inherited blindness

Mutations in the ABCA4 gene cause Stargardt disease (STGD), most cases with autosomal recessive (ar) cone-rod dystrophy (CRD), and some cases with atypical ar retinitis pigmentosa (arRP). We found compound heterozygous ABCA4 mutations in two unrelated patients with STGD and homozygous splice site mutations in their 2nd and 4th degree cousins with RP. Some ABCA4 mutations display strong founder effects. In Dutch and German STGD patients, the 768G > T mutation is present in 8% and 0.6% of ABCA4 alleles respectively. Vice versa, the complex L541P;A1038V allele is found in 70% of ABCA4 alleles in German STGD patients but absent in Dutch patients. As approximately 70% of ABCA4 mutations are known, a microarray-based analysis of known ABCA4 gene variants allows routine DNA diagnostics in Caucasian patients. Mutations in the CRB1 gene underlie RP12, some cases with classic arRP, 55% of cases with RP and Coats-like exudative vasculopathy, and 13% of patients with Leber congenital amaurosis (LCA), rendering CRB1 a significant cause of autosomal recessive retinal dystrophy. Different combinations of mutations in ABCA4 or CRB1 can be correlated with disease severity, suggesting that small increments of protein activities in patients might have significant therapeutic effects. Mouse and Drosophila studies strongly suggest that both patient groups might benefit from reduced light exposure and therefore should be detected as early as possible using molecular techniques.

[From gene to disease: from the ABCA4 gene to Stargardt disease, cone-rod dystrophy and retinitis pigmentosa]

Autosomal recessive Stargardt disease is caused by mutations in the ABCA4 gene. Mutations in ABCA4 are also found in two-thirds of cases with autosomal recessive cone-rod dystrophy, and a small fraction of patients with autosomal recessive retinitis pigmentosa. Patients with autosomal recessive retinitis pigmentosa, the most severe of these three phenotypes, invariably carry ABCA4 inactivating mutations; patients with autosomal recessive cone-rod dystrophy and Stargardt disease carry combinations of mutations that do not completely inactivate the retina specific 'ATP-binding cassette transporter' (ABCR) protein. DNA diagnostics is complicated by the high allelic heterogeneity and the uncertainty as to whether some ABCA4 variants are pathological. Nevertheless, ABCA4 mutation analysis is particularly important for patients with cone-rod dystrophy to confirm the autosomal recessive mode of inheritance.

Mutations in the ABCA4 (ABCR) gene are the major cause of autosomal recessive cone-rod dystrophy

The photoreceptor cell-specific ATP-binding cassette transporter gene (ABCA4; previously denoted "ABCR") is mutated, in most patients, with autosomal recessive (AR) Stargardt disease (STGD1) or fundus flavimaculatus (FFM). In addition, a few cases with AR retinitis pigmentosa (RP) and AR cone-rod dystrophy (CRD) have been found to have ABCA4 mutations. To evaluate the importance of the ABCA4 gene as a cause of AR CRD, we selected 5 patients with AR CRD and 15 patients from Germany and The Netherlands with isolated CRD. Single-strand conformation-polymorphism analysis and sequencing revealed 19 ABCA4 mutations in 13 (65%) of 20 patients. In six patients, mutations were identified in both ABCA4 alleles; in seven patients, mutations were detected in one allele. One complex ABCA4 allele (L541P;A1038V) was found exclusively in German patients with CRD; one patient carried this complex allele homozygously, and five others were compound heterozygous. These findings suggest that mutations in the ABCA4 gene are the major cause of AR CRD. A primary role of the ABCA4 gene in STGD1/FFM and AR CRD, together with the gene's involvement in an as-yet-unknown proportion of cases with AR RP, strengthens the idea that mutations in the ABCA4 gene could be the most frequent cause of inherited retinal dystrophy in humans.

The retinitis pigmentosa GTPase regulator (RPGR) interacts with novel transport-like proteins in the outer segments of rod photoreceptors

Mutations in the retinitis pigmentosa GTPase regulator (RPGR) gene cause X-linked retinitis pigmentosa type 3 (RP3), a severe, progressive and degenerative retinal dystrophy eventually leading to complete blindness. RPGR is ubiquitously expressed, yet mutations in the RPGR gene lead to a retina-restricted phenotype. To date, all RP3 associated missense mutations that have been identified are located in the RCC1-homologous domain (RHD) of RPGR. To investigate the molecular pathogenesis of RP3, we screened retinal yeast two-hybrid libraries with the RHD of RPGR. We identified several alternatively spliced gene products, some with retina-restricted expression, that interact specifically with RPGR in vivo and in vitro. Thus, these proteins were named RPGR-interacting protein 1 (RPGRIP1) isoforms. They contain a C-terminal RPGR-interacting domain and stretches of variable coiled-coil domains homologous to proteins involved in vesicular trafficking. The interaction between RPGR and RPGRIP1 isoforms was impaired in vivo by RP3-associated mutations in RPGR. Moreover, RPGR and RPGRIP1 co-localize in the outer segment of rod photoreceptors, which is in full agreement with the retinitis pigmentosa phenotype observed in RP3 patients. The localization of RPGRIP1 at 14q11 makes it a strong candidate gene for RP16. These results provide a clue for the retina-specific pathogenesis in RP3, and hint towards the involvement of RPGR and RPGRIP1 in mediating vesicular transport-associated processes.

The 2588G-->C mutation in the ABCR gene is a mild frequent founder mutation in the Western European population and allows the classification of ABCR mutations in patients with Stargardt disease

In 40 western European patients with Stargardt disease (STGD), we found 19 novel mutations in the retina-specific ATP-binding cassette transporter (ABCR) gene, illustrating STGD's high allelic heterogeneity. One mutation, 2588G-->C, identified in 15 (37.5%) patients, shows linkage disequilibrium with a rare polymorphism (2828G-->A) in exon 19, suggesting a founder effect. The guanine at position 2588 is part of the 3' splice site of exon 17. Analysis of the lymphoblastoid cell mRNA of two STGD patients with the 2588G-->C mutation shows that the resulting mutant ABCR proteins either lack Gly863 or contain the missense mutation Gly863Ala. We hypothesize that the 2588G-->C alteration is a mild mutation that causes STGD only in combination with a severe ABCR mutation. This is supported in that the accompanying ABCR mutations in at least five of eight STGD patients are null (severe) and that a combination of two mild mutations has not been observed among 68 STGD patients. The 2588G-->C mutation is present in 1 of every 35 western Europeans, a rate higher than that of the most frequent severe autosomal recessive mutation, the cystic fibrosis conductance regulator gene mutation DeltaPhe508. Given an STGD incidence of 1/10,000, homozygosity for the 2588G-->C mutation or compound heterozygosity for this and other mild ABCR mutations probably does not result in an STGD phenotype.

ABCR unites what ophthalmologists divide(s)

Over the last years, the molecular causes of monogenic chorioretinal diseases have been elucidated at an increasing pace. In contrast, only recently have genetic factors been found that contribute to multifactorial eye disorders such as age-related macular degeneration (AMD). Mutations in the retina-specific ATP-binding cassette transporter gene (ABCR) cause recessive Stargardt's disease (STGD) and fundus flavimaculatus (FFM), and were also found in 16% of patients with AMD. In addition, ABCR mutations were identified in families with recessive retinitis pigmentosa (RP), cone dystrophy (COD), and cone-rod dystrophy (CRD). In this review, we summarize these findings and propose a model which provides a framework to explain the observed genotypes and phenotypes. We hypothesize that most ABCR mutations can be classified in different classes of severity, and that, depending on the remaining total activity of ABCR, the phenotype can range from AMD at the mild end to RP at the severe end of the spectrum. This model allows us to make several predictions on the type and/or severity of ABCR mutations that are present in patients with AMD, STGD/FFM, COD, CRD, and RP.

Helicobacter pylori and cell proliferation of the gastric mucosa: possible implications for gastric carcinogenesis

OBJECTIVES

Helicobacter pylori infection is recognized as a risk factor for gastric adenocarcinoma. "Mitogenesis increases mutagenesis," so the effects of H. pylori infection on the gastric mucosal proliferative compartment have been investigated.

METHODS

In 25 H. pylori-positive and 19 H. pylori-negative subjects, epithelial cell proliferative activity and the pattern of the proliferative compartment were separately evaluated in relation to both the different type of mucosa (antrum and corpus) and the H. pylori positivity/negativity after 3H-thymidine labeling.

RESULTS

Both mucosal cell kinetics and the pattern of the proliferative compartment in the antrum appeared different from those of the corpus. Comparing H. pylori-positive and H. pylori-negative subjects, differences were detected only in the total number of cells in the antrum, whereas all of the cell kinetics parameters, except the labeling index, were greater in the corpus of the former group. A superficialization of the proliferative compartment was shown in H. pylori-positive subjects. Changes were more evident in subjects with more severe gastritis but were also present in H. pylori-positive subjects without corpus gastritis.

CONCLUSIONS

These results show that H. pylori infection is associated with modifications in the proliferative compartment of the gastric mucosa. Both infection per se and chronic gastritis seem to be relevant for such changes.

Cell kinetics in breast cancer

In breast cancer the study of prognostic factors has been well developed during last years and many biologic and biochemical parameters have been analyzed. Cell kinetics parameters demonstrated the capability to select patients with different risk of evolution of the neoplasia and in some cases treatment protocols are established by means of proliferation rate. The present study deals with the determination of Thymidine Labelling Index in breast tumors mostly T1-T2 with negative lymph nodes. Results demonstrated that the proliferative activity is higher in younger patients, in T2 cancers compared to T1, and in ductal infiltrating forms compared to the other more frequent histotypes. A significant correlation has been observed between TLI and nuclear grade. The preliminary analysis of the prognostic value of TLI has been two performed using an experimental cut off that is able to discriminate groups of patients with overall survival rate of 67% and 88%, depending on the different proliferative activity of the tumor.

Steady-state pharmacokinetics of idebenone in healthy volunteers

An open study was conducted with 12 healthy male Caucasian volunteers to determine the single dose and steady-state pharmacokinetics in plasma after a total daily dose of 90 mg of idebenone administered as 45 mg twice daily for 10 consecutive days. In the dose regimen investigated, multiple daily doses of 90 mg of idebenone were well tolerated by healthy male volunteers and were not associated with any clinically relevant changes in ECG or clinical laboratory parameters. The results of the physical examinations after study termination revealed normal findings in all volunteers. To evaluate the single dose and steady-state pharmacokinetic profile, blood samples were collected at predetermined time points during the study. In those subjects examined, generally good systemic exposure with rapid absorption of idebenone was obtained throughout the entire dosing period. Exposures to idebenone and its metabolites after both single and repeated oral doses of idebenone were comparable in magnitude. Further, the exposures attained were generally consistent with those observed in a previous study after 30 mg three times daily. All pharmacokinetic assessments were associated with a low to moderate degree of inter-subject variability.

Afferent vagal fibres and central cholinergic mechanisms are involved in the TRH-induced reversal of haemorrhagic shock

In a model of haemorrhagic shock causing the death of all saline-treated rats within 25.8 +/- 2.7 min after treatment, the intravenous injection of thyrotropin-releasing hormone tartrate (TRH-T) at the dose of 4 mg/kg induces a prompt and sustained increase of arterial pressure and pulse amplitude, with survival of all rats. Bilateral vagotomy, atropine sulphate (2 mg/kg intraperitoneally) and hemicholinium-3 (20 micrograms/rat intracerebroventricularly) partially prevent the TRH-T-induced shock reversal, whereas atropine methylbromide has no effect. These data indicate that afferent vagal fibres, brain cholinergic neurons and central muscarinic receptors play a role in the mechanism of the anti-shock effect of TRH-T.