Informing the pandemic response: the role of the WHO's COVID-19 Weekly Epidemiological Update

On 31 December 2019, the Municipal Health Commission of Wuhan, China, reported a cluster of atypical pneumonia cases. On 5 January 2020, the WHO publicly released a Disease Outbreak News (DON) report, providing information about the pneumonia cases, implemented response interventions, and WHO's risk assessment and advice on public health and social measures. Following 9 additional DON reports and 209 daily situation reports, on 17 August 2020, WHO published the first edition of the COVID-19 Weekly Epidemiological Update (WEU). On 1 September 2023, the 158th edition of the WEU was published on WHO's website, marking its final issue. Since then, the WEU has been replaced by comprehensive global epidemiological updates on COVID-19 released every 4 weeks. During the span of its publication, the webpage that hosts the WEU and the COVID-19 Operational Updates was accessed annually over 1.4 million times on average, with visits originating from more than 100 countries. This article provides an in-depth analysis of the WEU process, from data collection to publication, focusing on the scope, technical details, main features, underlying methods, impact and limitations. We also discuss WHO's experience in disseminating epidemiological information on the COVID-19 pandemic at the global level and provide recommendations for enhancing collaboration and information sharing to support future health emergency responses.

Disseminating information on acute public health events globally: experiences from the WHO's Disease Outbreak News

WHO works, on a daily basis, with countries globally to detect, prepare for and respond to acute public health events. A vital component of a health response is the dissemination of accurate, reliable and authoritative information. The Disease Outbreak News (DON) reports are a key mechanism through which WHO communicates on acute public health events to the public. The decision to produce a DON report is taken on a case-by-case basis after evaluating key criteria, and the subsequent process of producing a DON report is highly standardised to ensure the robustness of information. DON reports have been published since 1996, and up to 2022 over 3000 reports have been published. Between 2018 and 2022, the most frequently published DON reports relate to Ebola virus disease, Middle East respiratory syndrome, yellow fever, polio and cholera. The DON web page is highly visited with a readership of over 2.6 million visits per year, on average. The DON report structure has evolved over time, from a single paragraph in 1996 to a detailed report with seven sections currently. WHO regularly reviews the DON report process and structure for improvements. In the last 25 years, DON reports have played a unique role in rapidly disseminating information on acute public health events to health actors and the public globally. They have become a key information source for the global public health response to the benefit of individuals and communities.

Evaluating the effect of targeted strategies as control tools for hypervirulent meningococcal C outbreaks: a case study from Tuscany, Italy, 2015 to 2016

BackgroundMeningococcus (Neisseria meningitidis) is the causative bacteria of invasive meningococcal disease (IMD), a major cause of meningitis and sepsis. In 2015-16, an outbreak caused by serogroup C meningococci (MenC), belonging to the hyperinvasive strain ST-11(cc-11), resulted in 62 IMD cases in the region of Tuscany, Italy.AimWe aimed to estimate the key outbreak parameters and assess the impact of interventions used in the outbreak response.MethodsWe developed a susceptible-carrier-susceptible individual-based model of MenC transmission, accounting for transmission in households, schools, discos/clubs and the general community, which was informed by detailed data on the 2015-16 outbreak (derived from epidemiological investigations) and on the implemented control measures.ResultsThe outbreak reproduction number (Re) was 1.35 (95% prediction interval: 1.13-1.47) and the IMD probability was 4.6 for every 1,000 new MenC carriage episodes (95% confidence interval: 1.8-12.2). The interventions, i.e. chemoprophylaxis and vaccination of close contacts of IMD cases as well as age-targeted vaccination, were effective in reducing Re and ending the outbreak. Case-based interventions (including ring vaccination) alone would have been insufficient to achieve outbreak control. The definition of age groups to prioritise vaccination had a critical impact on the effectiveness and efficiency of control measures.ConclusionsOur findings suggest that there are no effective alternatives to widespread reactive vaccination during outbreaks of highly transmissible MenC strains. Age-targeted campaigns can increase the effectiveness of vaccination campaigns. These results can be instrumental to define effective guidelines for the control of future meningococcal outbreaks caused by hypervirulent strains.

COVID-19 Mortality and Progress Toward Vaccinating Older Adults - World Health Organization, Worldwide, 2020-2022

After the emergence of SARS-CoV-2 in late 2019, transmission expanded globally, and on January 30, 2020, COVID-19 was declared a public health emergency of international concern.* Analysis of the early Wuhan, China outbreak (1), subsequently confirmed by multiple other studies (2,3), found that 80% of deaths occurred among persons aged ≥60 years. In anticipation of the time needed for the global vaccine supply to meet all needs, the World Health Organization (WHO) published the Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework and a roadmap for prioritizing use of COVID-19 vaccines in late 2020 (4,5), followed by a strategy brief to outline urgent actions in October 2021.^† WHO described the general principles, objectives, and priorities needed to support country planning of vaccine rollout to minimize severe disease and death. A July 2022 update to the strategy brief^§ prioritized vaccination of populations at increased risk, including older adults,^¶ with the goal of 100% coverage with a complete COVID-19 vaccination series** for at-risk populations. Using available public data on COVID-19 mortality (reported deaths and model estimates) for 2020 and 2021 and the most recent reported COVID-19 vaccination coverage data from WHO, investigators performed descriptive analyses to examine age-specific mortality and global vaccination rollout among older adults (as defined by each country), stratified by country World Bank income status. Data quality and COVID-19 death reporting frequency varied by data source; however, persons aged ≥60 years accounted for >80% of the overall COVID-19 mortality across all income groups, with upper- and lower-middle-income countries accounting for 80% of the overall estimated excess mortality. Effective COVID-19 vaccines were authorized for use in December 2020, with global supply scaled up sufficiently to meet country needs by late 2021 (6). COVID-19 vaccines are safe and highly effective in reducing severe COVID-19, hospitalizations, and mortality (7,8); nevertheless, country-reported median completed primary series coverage among adults aged ≥60 years only reached 76% by the end of 2022, substantially below the WHO goal, especially in middle- and low-income countries. Increased efforts are needed to increase primary series and booster dose coverage among all older adults as recommended by WHO and national health authorities.

Evaluation of Meningococcal Serogroup C Bactericidal Antibodies after Primary Vaccination: A Multicentre Study, Italy

Here, we evaluated over time in different cohorts of children vaccinated against serogroup C Neisseria meningitidis, the presence of antibodies with neutralizing activity. A total of 348 sera samples of enrolled children by year since vaccination (<1 year- up to 5 years), starting from February 2016 to December 2017, were collected in three collaborating centers. Meningococcal serogroup C (MenC) antibody titers were measured with a serum bactericidal antibody (SBA) assay using rabbit complement (rSBA) following standard operating procedures. The cut-off of rSBA titer ≥ 8 is considered the correlate of protection. We observed a significantly declining of bactericidal rSBA titers by 23% every year, for every 1-year from vaccination (Adjusted PR = 0.77, 95% CI: 0.71−0.84). The proportions of children with bactericidal antibodies, immunized with the meningococcal serogroup C conjugate (MCC) vaccine, declined from 67.7% (95% CI: 48.6−83.3%) one year after vaccination, to 36.7% (95% CI: 19.9−56.1%) five years after vaccination (chi-square for linear trend, p < 0.001). Children vaccinated with the tetravalent meningococcal serogroup ACWY vaccine resulted in a high proportion of bactericidal rSBA MenC titer ≥ 1:8 (90.6%, 95% CI: 79.3−96.9%) after a mean time of seven months. Overall, the results provide some evidences on the evaluation of meningococcal serogroup C bactericidal antibodies after primary vaccination.

Methodologies to measure the coverage of vitamin A supplementation: a systematic review

Countries are increasingly transitioning from event-based vitamin A supplementation (VAS) distribution to delivery through routine health system contacts, shifting also to administrative, electronic-based monitoring tools, a process that brings certain limitations affecting the quality of administrative VAS coverage. At present, there is no standardised methodology for measuring the coverage of VAS delivered through routine health services. To address this gap, we conducted a systematic review of the literature to identify and recommend methods to measure VAS coverage, with the aim of providing guidance to countries on the collection of consistent data for planning, monitoring and evaluating VAS programmes integrated into routine health systems. We searched the PubMed®, Embase®, Scopus, Google Scholar and World Health Organization (WHO) Global Index Medicus databases for studies published from 1 January 2000 to 1 January 2021, reporting original data on VAS coverage and methodologies used for measurement. We screened 2371 original titles and abstracts, assessed twenty-seven full-text articles and ultimately included eighteen studies. All but two studies used a coverage cluster survey (CCS) design to measure VAS coverage, adapting the WHO Vaccination Coverage Cluster Surveys methodology, by modifying sample size and sampling parameters. Annual two-dose VAS coverage was reported from only four studies. Until electronic-based systems to collect and analyse VAS data are equipped to measure routine two-dose VAS coverage using administrative data, CCSs that comply with the 2018 WHO Vaccination Coverage Cluster Surveys Reference Manual represent the gold-standard method for effective VAS programme monitoring.

Lesson learned from an outbreak of invasive meningococcal disease: how HTA could have provided an evidence-based approach for public health response

During 2015-2016 an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11) occurred in Tuscany, a Region in Central Italy. Sixty-two cases with 13 deaths (13%) were recorded. Regional Authorities responded through a mass immunization campaign targeting all the age groups by offering free of charge a single dose of the tetravalent (ACWY) meningococcal conjugate vaccine or monovalent meningococcal C conjugate (MCC) vaccine. Nevertheless, the response was fragmented and the campaign did not reach the risk-population groups (i.e. men who have sex with men), that were identified only when a Regional outbreak investigation was implemented. Also linkage between cases (i.e. attending the same gay-venue) were identified at a second stage, not allowing prompt max-prophylaxis interventions. In such a situation, an evidence-based approach as Health Technology Assessment, could have informed public health emergency preparedness and response planning processes, i.e. by identifying through early warning alert systems similar ongoing clusters in Europe among specific population-groups and consequently better targeting the immunization campaign. The objective of this presentation is to explore through a practical example how HTA could provide an evidence-based approach for public health response during a real outbreak underlining lesson learned.

Addressing the challenge of bringing evidence in decision-making for public health emergencies: can HTA reach out to preparedness?

Background

Preparedness is one of the fundamental public health activities as it allows health systems to effectively manage threats. It can be considered a continuous quality improvement process, therefore requiring an assessment both in planning and checking phase. The assessment should consider several aspects spanning contextual factors but also health technologies being used. In order to manage threats, epidemics in particular, several health technologies are generally deployed. Among them, vaccines, antimicrobials, medical devices (i.e. masks), procedures (i.e. quarantine). Indeed, an early and as much as comprehensive evaluation of their value in the mitigation of epidemics' impact is needed. Health Technology Assessment (HTA) could help doing that. It could be also useful to predict the magnitude of the problem and to shed light on alternatives and needs for organizational reengineering. Anyway, what are the actions required to make HTA reaching out preparedness?

Results

In order to do it, several conditions should be brought about. The first one is the recognition of the importance of HTA in projecting health technologies impacts by health authorities and institutions. The second one is the timeliness of the assessment. In fact, HTA is generally a time and resource consuming approach as it is based on the collection of available evidence and data. Nevertheless, an early interaction with all stakeholders, the availability of flexible computer infrastructures for data collection and the preventive development of impact models might allow developing the assessment in a limited time. Furthermore, having dedicated working teams at supranational/national level could help keep down time and efforts to conduct the assessment.

Conclusions

Based on available experiences, advances and barriers in the use of HTA for preparedness might be highlighted and actions to strengthen the role of HTA in this field can be recognized.

The challenge of bringing evidence in decision-making for public health emergencies: can preparedness reach out to HTA?

Evidence-based decision-making is central to public health. Implementing evidence-informed actions is most challenging during a public health emergency as in an epidemic, when time is limited, scientific uncertainties and political pressures tend to be high, and reliable data is typically lacking.

The process of including data for preparedness and training for evidence-based decision making in public health emergencies is not systematic and is complicated by many barriers as the absence of common digital tools and approaches for resource planning and update of response plans. Health Technology Assessment (HTA) is used with the aim to improve the quality and efficiency of public health interventions and to make healthcare systems more sustainable. Many of today's public health crises are also cross-border, and countries need to collaborate in a systematic and standardized way in order to enhance interoperability to share data and to plan coordinated response. Digital health tools have an important role to play in this setting, facilitating use of knowledge about the population that can potentially affected by the crisis within and across regional and national borders. To strengthen the impact of scientific evidence on decision-making for public health emergency preparedness and response, it is necessary to better define and align mechanisms through which interdisciplinary evidence feeds into decision-making processes during public health emergencies and the context in which these mechanisms operate. Activities and policy development in the HTA network could inform this process. The objective of this presentation is to identify barriers for evidence-based decision making during public health emergencies and discuss how standardization in digital health and HTA processes may help overcome these barriers leading to more effective coordinated and evidence-based public health emergency response.

Coronavirus disease (COVID-19) outbreak: can HTA improve preparedness and response in emergencies with a high degree of uncertainty?

Evidence-based decision-making is central to public health. Implementing evidence-informed actions is most challenging during a public health emergency as in an epidemic, when time is limited, scientific uncertainties and political pressures tend to be high, and irrefutable evidence may be lacking. The Coronavirus disease (COVID-19) outbreak is determining a scenario of uncertainty for public health decision-making with fragmented and different responses also within countries (i.e. regional level), which are implemented quickly, sometimes not fully supported by the necessary body of scientific evidence. In such a situation, following a common line and having a shared tool that would allow to include evidence in public health decision-making, would be strategic to strengthen the impact of interventions, enabling stakeholders and decision makers taking actions based on the best available evidence through a process which is systematic and transparent. The objective of this presentation is to use the example of the COVID-19 outbreak, in order to explore how HTA can improve preparedness and response in emergencies with a high degree of uncertainty, representing the mechanisms through which interdisciplinary evidence feeds into decision-making processes during public health emergencies, addressing the link between scientific evidence and decision-making in public health emergencies, overcoming the key challenges faced by public health experts when advising decision makers, including strengthening and accelerating knowledge transfer through rapid HTA, improving networking between actors and disciplines.

Documented early circulation of Coronavirus Disease 2019 (COVID-19) in Florida, USA, since February 2020

In this Update, we document the circulation of Coronavirus Disease 2019 (COVID-19) in Florida, USA, since February 2020. On 8th March 2020, a confirmed case of COVID-19 was notified to the Health Authority of Central Tuscany, Florence, Italy. The patient developed symptoms on 3rd March while staying in Miami where he arrived on 12th February. The case returned to Italy on 6th March and was admitted to a local hospital of Florence on 7th March with fever (38.2°C/100.4°F), cough and breathing difficulties. First COVID-19 cases in Florida where confirmed by the Centers for Disease Control and Prevention on 2nd March as imported cases. Therefore, this event documents COVID-19 circulation in Florida at least since mid-February 2020.

Interconnected clusters of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11), involving bisexuals and men who have sex with men, with discos and gay-venues hotspots of transmission, Tuscany, Italy, 2015 to 2016

In 2015 an increased incidence of invasive meningococcal disease due to serogroup-C (MenC) occurred in Tuscany, Italy. This led the Regional Health Authority of Tuscany to implement a reactive immunisation campaign and to launch an epidemiological field investigation aiming to address targeted immunisation interventions. In 2011–14, 10 MenC cases had been reported compared with 62 cases in 2015–16. The case fatality rate was 21% (n = 13) and 51 cases (82.3%) were confirmed as C:P1.5–1,10–8:F3–6:ST-11(cc11). Overall, 17 clusters were recognised. Six discos and four gay-venues were found to have a role as transmission-hotspots, having been attended by 20 and 14 cases in the 10 days before symptoms onset. Ten and three cases occurred, respectively, among men who have sex with men (MSM) and bisexual individuals, who were involved in 11 clusters. In addition, heterosexual cases (n = 5) attending gay-venues were also found. Secondary cases were not identified. Molecular typing indicated close relationship with MenC clusters recently described among gay, bisexual and other MSM in Europe and the United States, suggesting a possible international spread of the serogroup-C-variant P1.5–1,10–8:F3–6:ST-11(cc11) in this population-group; however, epidemiological links were not identified. In December 2016, a targeted vaccination campaign involving discos and lesbian, gay, bisexual, and transgender (LGBT) associations was implemented. During 2017, 10 cases of MenC occurred, compared with 32 and 30 cases reported in 2015 and 2016 respectively, suggesting the effectiveness of the reactive and targeted immunisation programmes.

Genomic analysis of Neisseria meningitidis carriage isolates during an outbreak of serogroup C clonal complex 11, Tuscany, Italy

Background

In 2015–2016, a cross-sectional carriage survey was performed in Tuscany Region, Italy, during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C clonal complex 11 (MenC:cc11). This study aims to evaluate the genomic profile of meningococcal carriage isolates collected during the survey.

Methods

Whole-genome sequencing (WGS) was performed using Illumina MiSeq on 85 cultivated meningococcal carriage isolates received at the Dept. of Infectious Disease, National Institute of Health (Istituto Superiore di Sanità, ISS), as National Reference Laboratory (NRL) for Invasive Meningococcal Disease (IMD). De novo assembled genomes were scanned by the BIGSdb platform to assign: the genotypic profiles, the cgMLST, the vaccine antigen variants and allele types of antimicrobial resistance associated genes, together with denitrification pathway loci.

Results

Capsule null and non-groupable meningococci accounted for 52.9% and 10.6%, respectively. Among the remaining carriage isolates, serogroup B was the predominant (71.0%). Serogroup C meningococci were culture negative and unavailable for WGS. Overall, 64 genotypic profiles were identified and, based on cgMLST, isolates clustered according to clonal complexes. Eight isolates (9.4%) harbored at least one gene encoding a 4CMenB vaccine antigen. Mutated penA alleles were found in more than 82%. Finally, complete aniA and norB coding sequences were detected among 71.8% of carriage isolates.

Conclusions

Meningococcal carriage isolates collected during the MenC:cc11 outbreak were characterized by an extensive genetic diversity. The lack of outbreak-related isolates among carriage might be attributable to the high transmissibility with low duration of colonization of MenC:cc11 meningococci.

Impact of hepatitis B vaccination on acute hepatitis B epidemiology in European Union/European Economic Area countries, 2006 to 2014

Hepatitis B prevention in European Union/European Economic Area (EU/EEA) countries relies on vaccination programmes. We describe the epidemiology of acute hepatitis B virus (HBV) at country and EU/EEA level during 2006–2014. Using a multi-level mixed-effects Poisson regression model we assessed differences in the acute HBV infection notification rates between groups of countries that started universal HBV vaccination before/in vs after 1995; implemented or not a catch-up strategy; reached a vaccine coverage ≥ 95% vs < 95% and had a hepatitis B surface antigen prevalence ≥ 1% vs < 1%. Joinpoint regression analysis was used to assess trends by groups of countries, and additional Poisson regression models to evaluate the association between three-dose HBV vaccine coverage and acute HBV infection notification rates at country and EU/EEA level. The EU/EEA acute HBV infection notification rate decreased from 1.6 per 100,000 population in 2006 to 0.7 in 2014. No differences (p > 0.05) were found in the acute HBV infection notification rates between groups of countries, while as vaccine coverage increased, such rates decreased (p < 0.01). Countries with universal HBV vaccination before 1995, a catch-up strategy, and a vaccine coverage ≥ 95% had significant decreasing trends (p < 0.01). Ending HBV transmission in Europe by 2030 will require high vaccine coverage delivered through universal programmes, supported, where appropriate, by catch-up vaccination campaigns.

Carriage rates and risk factors during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11) in Tuscany, Italy: a cross-sectional study

Background

During 2015–2016 an outbreak of invasive meningococcal disease due to N. meningitidis serogroup C ST-11 (cc11) occurred in Tuscany, Italy. The outbreak affected mainly the age group 20–30 years, men who have sex with men, and the area located between the cities of Firenze, Prato and Empoli, with discos and gay-venues associated-clusters. A cross-sectional-survey was conducted to assess the prevalence and risk factors for meningococcal-carriage, in order to address public health interventions.

Methods

A convenience sample of people aged 11–45 years provided oropharyngeal swab specimens and completed questionnaires on risk factors for meningococcal carriage during a 3 months study-period, conducted either in the outbreak-area and in a control-area not affected by the outbreak (cities of Grosseto and Siena). Isolates were tested by culture plus polymerase chain reaction. Serogroup C meningococcal isolates were further characterized using multilocus sequence typing. Univariate and multivariate analyses were performed to estimate adjusted odds ratios (AORs) for meningococcal carriage.

Results

A total of 2285 oropharyngeal samples were collected. Overall, meningococcal carriage prevalence was 4.8% (n = 110), with nonencapsulated meningococci most prevalent (2.3%; n = 52). Among encapsulated meningococci, serogroup B was the most prevalent (1.8%; n = 41), followed by serogroup Y (0.5%; n = 11) and serogroup C (0.2%; n = 4); one carrier of serogroup E and one of serogroup Z, were also found (0.04%). Three individuals from the city of Empoli were found to carry the outbreak strain, C:ST-11 (cc11); this city also had the highest serogroup C carriage prevalence (0.5%). At the multivariate analyses, risk factors for meningococcal carriage were: illicit-drugs consumption (AOR 6.30; p < 0.01), active smoking (AOR 2.78; p = 0.01), disco/clubs/parties attendance (AOR 2.06; p = 0.04), being aged 20–30 years (AOR 3.08; p < 0.01), and have had same-sex intercourses (AOR 6.69; p < 0.01).

Conclusions

A low prevalence of meningococcal serogroup C carriage in an area affected by an outbreak due to the hypervirulent N. meningitidis serogroup C ST-11 (cc11) strain was found. The city of Empoli had the highest attack-rate during the outbreak and also the highest meningococcal serogroup C carriage-prevalence due to the outbreak-strain. Multivariate analyses underlined a convergence of risk factors, which partially confirmed those observed among meningococcal outbreak-cases, and that should be considered in targeted immunization campaigns.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3598-3) contains supplementary material, which is available to authorized users.

The Ebola virus disease outbreak in Tonkolili district, Sierra Leone: a retrospective analysis of the Viral Haemorrhagic Fever surveillance system, July 2014-June 2015

In Sierra Leone, the Ebola virus disease (EVD) outbreak occurred with substantial differences between districts with someone even not affected. To monitor the epidemic, a community event-based surveillance system was set up, collecting data into the Viral Haemorrhagic Fever (VHF) database. We analysed the VHF database of Tonkolili district to describe the epidemiology of the EVD outbreak during July 2014-June 2015 (data availability). Multivariable analysis was used to identify risk factors for EVD, fatal EVD and barriers to healthcare access, by comparing EVD-positive vs. EVD-negative cases. Key-performance indicators for EVD response were also measured. Overall, 454 EVD-positive cases were reported. At multivariable analysis, the odds of EVD was higher among those reporting contacts with an EVD-positive/suspected case (odds ratio (OR) 2.47; 95% confidence interval (CI) 2.44-2.50; P < 0.01) and those attending funeral (OR 1.02; 95% CI 1.01-1.04; P < 0.01). EVD cases from Kunike chiefdom had a lower odds of death (OR 0.22; 95% CI 0.08-0.44; P < 0.01) and were also more likely to be hospitalised (OR 2.34; 95% CI 1.23-4.57; P < 0.05). Only 25.1% of alerts were generated within 1 day from symptom onset. EVD preparedness and response plans for Tonkolili should include social-mobilisation activities targeting Ebola/knowledge-attitudes-practice during funeral attendance, to avoid contact with suspected cases and to increase awareness on EVD symptoms, in order to reduce delays between symptom onset to alert generation and consequently improve the outbreak-response promptness.

Meningococcal C conjugate vaccine effectiveness before and during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C/cc11, Tuscany, Italy

INTRODUCTION

In Tuscany, Italy, where a universal immunization program with monovalent meningococcal C conjugate vaccine (MCC) was introduced in 2005, an outbreak of invasive meningococcal disease (IMD) due to the hypervirulent strain of Neisseria meningitidis C/cc11 occurred in 2015-2016, leading to an immunization reactive campaign using either the tetravalent (ACWY) meningococcal conjugate or the MCC vaccine. During the outbreak, IMD serogroup C (MenC) cases were also reported among vaccinated individuals. This study aimed to characterize meningococcal C conjugate vaccines (MenC-vaccines) failures and to estimate their effectiveness since the introduction (2005-2016) and during the outbreak (2015-2016).

METHODS

MenC cases and related vaccine-failures were drawn from the National Surveillance System of Invasive Bacterial Disease (IBD) for the period 2006-2016. A retrospective cohort-study, including the Tuscany' population of the birth-cohorts 1994-2014, was carried out. Based on annual reports of vaccination, person-years of MenC-vaccines exposed and unexposed individuals were calculated by calendar-year, birth-cohort, and local health unit. Adjusted (by birth-cohort, local health unit, and calendar-year) risk-ratios (ARR) of MenC invasive disease for vaccinated vs unvaccinated were estimated by the Poisson model. Vaccine-effectiveness (VE) was estimated as: VE = 1-ARR.

RESULTS

In the period 2006-2016, 85 MenC-invasive disease cases were reported; 61 (71.8%) from 2015 to 2016. Twelve vaccine failures occurred, all of them during the outbreak. The time-interval from immunization to IMD onset was 20 days in one case, from 9 months to 3 years in six cases, and ≥7 years in five cases. VE was, 100% (95%CI not estimable, p = 0.03) before the outbreak (2006-2014) and 77% (95%CI 36-92, p < 0.01) during the outbreak; VE was 80% (95%CI 54-92, p < 0.01) during the overall period.

CONCLUSIONS

In Tuscany, MenC-vaccine failures occurred exclusively during the 2015-2016 outbreak. Most of them occurred several years after vaccination. VE during the outbreak-period was rather high supporting an effective protection induced by MenC-vaccines.

Macrophages in Skin Cancer: Quantitative and Functional Studies

The number of tumor-infiltrating macrophages was estimated in 43 patients with skin cancer, including 18 cases of squamous cell and 25 cases of basal cell carcinoma. Macrophages were identified in cell cultures by 2 assays, namely phagocytosis and resistance to detachment by trypsin. The average percentage of adherent cells for the 2 groups of skin tumors was 4.5 ± 2.6 and 10.2 ± 5.2, respectively, and the difference was statistically significant. Follow-up studies after surgical excision of the primary neoplasm showed a relatively low macrophage content in 2 of the 4 cases in which local recurrences occurred. Preliminary functional studies suggested that soluble factors may be released by neoplastic cells, accounting for the inhibitory effect of tumor cell supernatants on macrophage Chemotaxis in vitro.

Effect of BCG Immunotherapy on Cell-Mediated Cytotoxicity in Bladder Cancer Patients following Surgical Treatment

Peripheral blood lymphocytes from bladder cancer patients display in vitro cytotoxicity against established bladder tumor target cells. Following surgery and after separation of lymphocytes in non-T and T with high affinity and low affinity for sheep erythrocytes fractions, the cytotoxic activity was significantly decreased in all subsets. After BCG therapy the cytotoxic capacity was restored and the effect was equally distributed in the different subpopulations. The monocyte-enriched fraction did not show any change in the cytotoxic activity after treatment.

Reduction in Neisseria meningitidis infection in Italy after Meningococcal C conjugate vaccine introduction: A time trend analysis of 1994-2012 series

The incidence of invasive meningococcal disease (IMD) in Italy is among the lowest in Europe. Meningococcal C conjugate vaccine (MCC) was introduced in 2005 for 12 months old infants. The aim of this study was to describe the epidemiology of IMD in Italy from 1994 to 2012 and to evaluate the impact of MCC introduction. Data about Neisseria meningitidis (N. meningitidis) cases were drawn from the National Surveillance of Invasive Bacterial Diseases. The average incidence of IMD during 1994-2012 in Italy was 0.36 per 100,000 (95%CI 0.30; 0.40). N. meningitidis B was the most frequent serogroup and infants less than 12 months old were the most affected. Joinpoint analysis showed a statistically significant reduction in the incidence of N. meningitidis C related IMD after MCC introduction: the Annual Percentage Change declined from 21.8 (95%CI 15.1; 28.9) in 1994-2005 to -19.9 (95%CI -28.2; -10.7) afterwards. No changes were observed with respect to N. meningitidis B related IMD. Poisson regression showed a statistically significant reduction in the incidence of IMD both associated to N. meningitidis C (Incidence Rate Ratio 0.33; 95%CI 0.29; 0.37) and due to all serogroups (Incidence Rate Ratio 0.70; 95%CI 0.65; 0.75) in the post-vaccination period compared to the pre-vaccination one. On the other hand, the incidence of N. meningitidis B related IMD did not decrease. Our results suggest that MCC had an impact in decreasing the incidence of N. meningitidis C related IMD. However, data on typing are incomplete and efforts are needed to make them available for studying the need and the impact of other meningococcal vaccines.

Increased incidence of invasive meningococcal disease of serogroup C / clonal complex 11, Tuscany, Italy, 2015 to 2016

We report an increase of serogroup C Neisseria meningitidis invasive meningococcal disease in Tuscany. From January 2015 to end February 2016, 43 cases were reported, among which 10 were fatal, compared to two cases caused by serogroup C recorded in 2014 and three in 2013. No secondary cases occurred. Thirty-five strains belonged to C:P1.5-1,10-8:F3-6:ST-11(cc11). Control measures have been adopted and immunisation campaigns implemented. Studies on risk factors and carriage are ongoing.

Vaccine coverage and determinants of incomplete vaccination in children aged 12-23 months in Dschang, West Region, Cameroon: a cross-sectional survey during a polio outbreak

BACKGROUND

Inadequate immunization coverage with increased risk of vaccine preventable diseases outbreaks remains a problem in Africa. Moreover, different factors contribute to incomplete vaccination status. This study was performed in Dschang (West Region, Cameroon), during the polio outbreak occurred in October 2013, in order to estimate the immunization coverage among children aged 12-23 months, to identify determinants for incomplete vaccination status and to assess the risk of poliovirus spread in the study population.

METHODS

A cross-sectional household survey was conducted in November-December 2013, using the WHO two-stage sampling design. An interviewer-administered questionnaire was used to obtain information from consenting parents of children aged 12-23 months. Vaccination coverage was assessed by vaccination card and parents' recall. Chi-square test and multilevel logistic regression model were used to identify the determinants of incomplete immunization status. Statistical significance was set at p < 0.05.

RESULTS

Overall, 3248 households were visited and 502 children were enrolled. Complete immunization coverage was 85.9% and 84.5%, according to card plus parents' recall and card only, respectively. All children had received at least one routine vaccination, the OPV-3 (Oral Polio Vaccine) coverage was >90%, and 73.4% children completed the recommended vaccinations before 1-year of age. In the final multilevel logistic regression model, factors significantly associated with incomplete immunization status were: retention of immunization card (AOR: 7.89; 95% CI: 1.08-57.37), lower mothers' utilization of antenatal care (ANC) services (AOR:1.25; 95% CI: 1.07-63.75), being the ≥ 3(rd) born child in the family (AOR: 425.4; 95% CI: 9.6-18,808), younger mothers' age (AOR: 49.55; 95% CI: 1.59-1544), parents' negative attitude towards immunization (AOR: 20.2; 95% CI: 1.46-278.9), and poorer parents' exposure to information on vaccination (AOR: 28.07; 95 % CI: 2.26-348.1). Longer distance from the vaccination centers was marginally significant (p = 0.05).

CONCLUSION

Vaccination coverage was high; however, 1 out of 7 children was partially vaccinated, and 1 out of 4 did not complete timely the recommended vaccinations. In order to improve the immunization coverage, it is necessary to strengthen ANC services, and to improve parents' information and attitude towards immunization, targeting younger parents and families living far away from vaccination centers, using appropriate communication strategies. Finally, the estimated OPV-3 coverage is reassuring in relation to the ongoing polio outbreak.

Health profile and disease determinants among asylum seekers: a cross-sectional retrospective study from an Italian reception centre

BACKGROUND

Data on diseases' determinants and health status of asylum seekers (ASs) are limited.

METHODS

We performed a cross-sectional retrospective study in a large ASs centre in Italy. Data were collected during a 1-year period. Descriptive statistics were calculated. A χ(2) test was used to assess the association between socio-demographics characteristics of ASs and screening test results. A multiple logistic regression analysis was performed to identify diseases' predictors by using ICD-10 diagnoses classification as outcome variable, socio-demographic characteristics as independent variable and visits' number as confounding variable.

RESULTS

Overall, data on 792 ASs (mean age 27 years, 80% males, 58% from Africa) were assessed, 43% underwent voluntary infectious diseases screening and 2843 diagnoses were recorded. The most frequent diagnoses were: respiratory diseases, symptoms/signs not elsewhere classified, digestive diseases and infectious diseases. Gender was the most frequent predictor of ICD-10 diagnoses, while African origin, civil status and education were, respectively, predictive of cardiovascular and infectious diseases, genitourinary diseases and pregnancy-related disorders. Higher mean age was associated with syphilis, HIV and HCV infection and African origin with HIV infection.

CONCLUSIONS

Communicable diseases were not prevalent in the ASs population we analysed. A stronger cultural mediation support is needed to facilitate prevention, access and continuity of care for ASs.

Is EU/EEA population protected from polio?

The WHO European Region has been declared polio-free since 2002. By 2010, inactivated polio vaccine (IPV) was the only polio vaccine in use in the EU/EEA for the primary vaccination of children. A systematic review of the literature on polio seroprevalence studies, complemented by the analysis of available vaccine coverage data, has been carried out with the aim of assessing the level of protection against polio in the European population. A total of 52 studies, with data from 14 out of the 31 EU/EEA countries, were included in the analysis. This systematic review shows that, overall, seroprevalence for PV1 and PV3 is high in most countries, although seroimmunity gaps have been detected in several birth cohorts. In particular, relatively low immunity status was found in some countries for individuals born in the 60's and 70's. Discrepancies between reported vaccination coverage and immunity levels have been also highlighted. Countries should make sure that their population is being vaccinated for polio to reduce the risk of local poliovirus transmission in case of importation. Moreover, assessing immunity status should be priority for those traveling to areas where wild polioviruses are still circulating.

CLA reduces breast cancer cell growth and invasion through ERalpha and PI3K/Akt pathways

We previously reported that conjugated linoleic acid (CLA), a naturally occurring fatty acid, inhibits the growth of ERalpha(+) MCF-7 and ERalpha(-) MDA-MB-231 human breast cancer cells by negative modulation of the ERK/MAPK pathway and apoptosis induction. Here we show that in these cell lines CLA also down-regulates the PI3K/Akt cascade. In MCF-7 cells CLA also triggers ERalpha/PP2A complex formation reducing the phosphorylation state and transcriptional activity of Eralpha whereas in MDA-MB-231 cells CLA does not induce PP2A activation. Moreover, CLA induces the expression of proteins involved in cell adhesion and inhibits cell migration and MMP-2 activity. These findings suggest that CLA may induce the down-regulation of ERalpha signalling and the reduction of cell invasion through the modulation of balancing between phosphatases and kinases.

Estradiol increases IRS-1 gene expression and insulin signaling in breast cancer cells

This study demonstrates how the potentiating effects of E2 on insulin signaling in ER-positive breast cancer cells are consequent to an enhanced IRS-1 expression [corrected]. It induces an increase of both PI-3K/AKT and ERK1/2 activities. A direct action of E2 in the regulating mouse IRS-1 gene is also investigated in both Chinese hamster ovary and MCF-7 cells that are transfected with mouse IRS-1 regulatory sequences. The authors have reported, for the first time, how E2 induction of IRS-1 mRNA was correlated with a direct positive regulatory role of E2 on the IRS-1 promoter. This effect seems to be not strictly related to the cell type.

Cytoskeleton-interacting activity of geiparvarin, diethylstilbestrol and conjugates

Geiparvarin, a natural compound isolated from the leaves of Geijera parviflora, inhibits the growth of various tumor cell lines with a mode of action which may be attributed to its anti-microtubular activity. Our previous findings indicated that geiparvarin is able to inhibit the in vitro polymerization of tubulin and to derange the microtubular network in fibroblasts more effectively in the presence of paclitaxel. To further explore its biological activity here we have studied the effects exerted on the other components of the cytoskeleton by geiparvarin and two derivatives obtained by conjugating the 3(2H)-furanone ring of geiparvarin with diethylstilbestrol (DES). Firstly, observations by electron microscopy confirmed anti-microtubular properties, a near-total absence of microtubules is detected when tubulin is incubated with drugs in the presence of paclitaxel, whereas microtubule formation is not inhibited by drugs when assembly is induced by guanosine 5'-triphosphate (GTP). Immunofluorescence assays demonstrated that geiparvarin and DES act in a vinblastine-like fashion, causing a marked depletion of intermediate filaments while the network of microfilaments is not affected. Both the conjugates alter the 'stress fibers' organization of actin and disrupt the vimentin pattern; generally they derange cytoskeleton more markedly than the parent compounds. The cell growth inhibiting effects of geiparvarin and derivatives are dose-dependent; they vary according to the cell line used, when compounds were administered either alone or simultaneously with paclitaxel. Unlike other anti-microtubule agents, they do not exhibit cell-cycle compartment specificity and do not influence thymidine uptake in the cell.

Lumbar disc excision in children and adolescents

STUDY DESIGN

The authors examined a case series of patients under the age of 18 years treated for lumbar intervertebral disc herniation.

OBJECTIVES

To evaluate postoperative and long-term results of surgery in patients younger than 18 years.

SUMMARY OF BACKGROUND DATA

There are only a few series, with controversial results, available on the surgical treatment of disc herniation in growing patients.

METHODS

Between 1975 and 1991, a consecutive series of 129 patients 9-18 years of age (average age, 16.2 years) underwent surgery for lumbar intervertebral disc herniation. Low back pain associated with leg pain was the main clinical symptom in 106 subjects (82%), back pain in 17 (13%), and leg pain in 6 (5%).

RESULTS

Short-term results were excellent or good for 123 cases (95%), with complete pain relief in 97 (75%) and moderate but incomplete relief in 26 (20%). A total of 98 (76%) long-term responses obtained at a mean follow-up of 12.4 years revealed excellent outcomes in 40% of the cases, good in 47%, and poor in 13%. Ten patients (10%) underwent reintervention after 9 years on average (2 fusions and 8 re-explorations for herniated disc).

CONCLUSIONS

Results have confirmed a tendency for outcomes to deteriorate between the short-term and long-term follow-up in young patients treated by discectomy: this tendency and the rate of reintervention (10%) confirmed the need for long-term follow-up of children and adolescents treated for disc herniation.

Antimicrotubular and cytotoxic activity of geiparvarin analogues, alone and in combination with paclitaxel

Geiparvarin is an antiproliferative compound isolated from the leaves of Geijera parviflora, and may represent a new drug which targets tubulin. To better explore the potential use of this agent, we investigated the antimicrotubular and cytotoxic effects of new synthetic aromatic derivatives of geiparvarin. These drugs inhibited polymerization of microtubular protein, particularly when the assembly was induced by paclitaxel. The microtubular network organization of fibroblasts was altered more effectively by some drugs. Normal microtubule architecture completely disappeared when the cells were treated simultaneously with drugs and paclitaxel: microtubules depolymerized or were reorganized into bundles, in a similar but more disarrayed fashion than that observed after treatment with paclitaxel alone. Cytotoxicity studies showed a dose-dependent effect, whereas combined administration of drugs and paclitaxel increased cytotoxicity, more effectively in paclitaxel versus derivatives administration alone.

[Scombroid syndrome with severe and prolonged cardiovascular involvement]

Scombroid poisoning is a form of ichthyosarcotoxism caused by eating spoiled fish, mainly of the scombroid family. Inappropriate storage of these fish can lead to the decarboxylation of histidine in the flesh to histamine by enterobacteria. The symptoms of histamine poisoning mimic those of an IgE-mediated food allergy, as well as flushing, headache, diarrhea and palpitations. However, in some cases, the scombroid poisoning can be characterized by very serious symptoms, as well as cardiovascular compromission. We describe two cases of scombroid poisoning with severe hypotension requiring continuous intravenous dopamine with resolution of symptoms only several hours later.

Cellular uptake and cytotoxicity of solid lipid nanospheres (SLN) incorporating doxorubicin or paclitaxel

Solid Lipid Nanospheres (SLN) are colloidal therapeutic systems proposed for several administration routes and obtained by dispersing warm microemulsions in cold water. SLN as carriers of doxorubicin and paclitaxel have been previously studied. In this study, the cellular uptake of SLN and the cytotoxicity of doxorubicin and paclitaxel incorporated into SLN were investigated on two cell-lines, human promyelocytic leukemia (HL60) and human breast carcinoma (MCF-7). Cellular uptake of SLN was determined by incorporating 6-coumarin as fluorescent marker. The cellular uptake of fluorescent SLN was clearly evidenced by fluorescence microscopy. The cytotoxicity of doxorubicin incorporated in SLN was higher compared to the conventional doxorubicin solution, even at the lower concentrations. Paclitaxel in SLN was about 100-fold more effective than free paclitaxel on MCF-7 cells, while on HL60 cells a lower sensitivity was achieved with paclitaxel in SLN. Unloaded SLN had no cytotoxic effect on HL60 and MCF-7 cells.

[Pancytopenia caused by ticlopidine treated with filgrastim. Description of a case]

Ticlopidine is an antiplatelet agent that is used to reduce the occurrence of atherothrombotic arterial events, but it can sometime cause severe haematological side-effects. We describe the case of a 79-year old woman suffering from ischaemic cardiopathy and chronic cerebral vasculopathy treated with ticlopidine, who developed a rare pancytopenia on the 26th day of ticlopidine treatment. The patient was successful treated with intravenous antibiotics and with filgrastim, with complete reversion of the pancytopenia.

Long-term follow-up of patients with anti-HBe/HBV DNA-positive chronic hepatitis B treated for 12 months with lamivudine

BACKGROUND/AIMS

Interferon alpha provides benefit in only a limited number of patients with chronic anti-HBe-positive hepatitis B. The aim of this study was to verify the long-term efficacy of lamivudine treatment of these patients and the incidence of lamivudine-resistant hepatitis B virus mutants.

METHODS

Fifteen consecutive patients with chronic anti-HBe-positive hepatitis B were treated with lamivudine 100 mg once daily for 52 weeks. Levels of alanine aminotransferase, HBV DNA, hepatitis B surface antigen, and IgM antibodies to hepatitis B core antigen were monitored during therapy and 12-month follow up. The polymerase gene was amplified by polymerase chain reaction and the region coding for YMDD amino acid motif was directly sequenced.

RESULTS

Only 2/15 patients (13%) had a sustained virological and biochemical response and improved histologically. Eleven out of 15 (74%) showed inhibition of viral replication and normalization of alanine aminotransferase levels during lamivudine treatment but relapsed 1-12 months after terminating therapy. In the two remaining patients (13%), HBV DNA initially became negative but reappeared in the serum after 24 weeks, and in both patients the emergence of YMDD mutants was demonstrated.

CONCLUSIONS

Our data confirm the antiviral efficacy of lamivudine in anti-HBe-positive patients, but response to a 1-year course was only transient as the majority of patients relapsed after therapy withdrawal. The lack of a sustained effect and the emergence of lamivudine-resistant mutants suggest that therapy for chronic hepatitis B should be based on a combination of several therapeutic agents.

Posterior surgery for the treatment of thoracolumbar pathologic fractures in metastatic patients

A total of 25 pathologic fractures in patients affected with thoracolumbar vertebral metastases associated with neurologic deficit are reported. None of the pathologic fractures were stable, while 14 were unstable and 11 were very unstable. Decompression with intralesional excision of the neoplastic mass compressing the dural sac was performed in all of the cases. Posterior stabilization was performed in the first cases using systems of sublaminar segmental fixation, and thereafter using systems of pedicle fixation. Removal of the vertebral body followed by anterior fusion after preventive posterior stabilization was performed in 2 cases. Pain symptoms regressed in 85% of the cases and in more than 50% of the patients there was improvement in the neurologic findings and in vertebral deformity consequent to fracture. Mean survival rate was 12 months. Despite the limited number of cases posterior stabilization of pathological fractures is a good choice of treatment in patients with severe neurologic deficit.

Geiparvarin and derivatives in combination with taxol: effect on microtubular organization in 3T3 fibroblasts

Geiparvarin, a natural product that exhibits antiproliferative activity, inhibits the growth of various tumour cell lines with a mechanism of action so far unknown. Our preliminary findings showed that geiparvarin and some derivatives obtained from its conjugation with diethylstilboestrol and meso-hexestrol significantly inhibit taxol-induced in vitro polymerization of both tubulin and microtubular protein. In this study we investigated the effect of geiparvarin and of the oestrogen-combined derivatives on the cellular microtubular network of fibroblasts. Geiparvarin altered the microtubular organization of fibroblasts and strengthened the derangement of the microtubular pattern in cells exposed simultaneously to taxol. However, the microtubular network remained quite well organized in fibroblasts exposed to geiparvarin and preincubated with taxol, which in this case prevented the deranging effect of the former. The antimicrotubular activity of the oestrogen-combined derivatives was more similar to that of geiparvarin than to that of the oestrogens, and often this activity was stronger than that of each reference drug alone; the cytotoxic activity examined in the same experimental conditions generally confirmed the microscopic analysis.

Von Willebrand factor abnormalities in IgA nephropathy

BACKGROUND

Plasma concentration of von Willebrand factor (vWF) has been used as an index of endothelial dysfunction. Increased release of vWF from endothelial cells has been reported in several conditions, and there is also evidence that dysfunctioning endothelial cells synthesize defective molecules. In fact, unusually large vWF multimers have been described and related to the pathogenesis of some microangiopathic diseases. Abnormal levels of vWF have been reported in primary glomerulitis, but this was no referred to histological diagnosis. Furthermore, no qualitative vWF analysis was performed in these glomerulopathies. Therefore the aim of our study was to analyse quantitatively and qualitatively vWF in patients with IgA (IgAN) and non-IgA mesangial proliferative glomerulonephritis (PGN).

METHODS

Fourteen IgAN patients, eight PGN patients, seven subjects with different glomerulonephritides, and 10 healthy controls formed the basis of this study. On peripheral venous blood collected in the presence of protease inhibitors, vWF parameters were investigated. vWF antigenic activity (vWF:Ag) was measured by electroimmunodiffusion. vWF subunits mobility was studied by crossed immunoelectrophoresis (CIE) and in some patients vWF multimeric analysis was performed by SDS-agarose gel electrophoresis.

RESULTS

Mean vWF:Ag was significantly higher in PGN patients as compared to controls, while there was no significant difference between PGN and IgAN patients and between IgAN and controls. CIE revealed a pre-peak in 12 of 14 IgAN patients and a migration index which did not differ between controls, IgAN, and PGN subjects. No pre-peak was observed in PGN and in other glomerulonephritides. Analysis of plasma vWF multimeric pattern by SDS-agarose gel electrophoresis disclosed in four IgAN patients abnormally large vWF multimers that were not documented in PGN subjects.

CONCLUSIONS

This study, by showing the presence of a pre-peak and of large vWF multimers in IgAN patients, suggests an altered postsecretory handling of the vWF in IgAN and possibly a different role of the vWF in IgAN in respect to PGN.

Interaction of geiparvarin and related compounds with purified microtubular protein

Geiparvarin is an antiproliferative compound whose mechanism of action has not yet been identified. We have investigated the biochemical action on purified microtubular protein, as well as on tubulin, of geiparvarin and of some derivatives resulting from its conjugation with two synthetic oestrogens, diethylstilboestrol and meso-hexoestrol, in comparison with the antimicrotubular action of the reference oestrogens. Geiparvarin and derivatives did not inhibit colchicine binding to tubulin nor did they significantly influence GTP-induced polymerization. On the contrary, they effectively counteracted the stimulating effect of taxol on microtubule formation, both in the presence and in the absence of microtubule-associated proteins. A competitive inhibition mechanism at the taxol binding site of tubulin may thus be proposed to explain the antimicrotubular action of geiparvarin.

Antimicrotubular effect of calvatic acid and of some related compounds

A structure-activity relationship has been established between calvatic acid and some related synthetic compounds, and their ability to inhibit GTP-induced microtubular protein polymerization in vitro. These compounds were effective in a dose- and a time-dependent manner. The most active drug was the p-chloro substituted compound, which showed its inhibitory activity without any preincubation period, which the others needed. Since if cysteine was present, polymerization was no longer affected, an involvement of titratable -SH groups of tubulin could be suggested. In contrast, taxol-induced polymerization was only slightly inhibited by these compounds, and colchicine-binding activity was not generally impaired.

Interactions between calvatic acid and related compounds with rat liver microsomes

In this study we examined the interactions of liver microsomes with the antibiotic calvatic acid and with structural analogues, some of which had shown antimicrotubular properties. These drugs decreased cytochrome P-450 content differently according to the substitutions on the azoxy function and the ethoxycarbonyl derivatives were found to be the most effective ones. The decrease in cytochrome P-450 could be prevented by addition of cysteine or GSH, suggesting an involvement of sulphydryl groups. Furthermore, chromatographic analyses showed that ethoxycarbonyl derivatives were completely metabolized, and this would explain the different behaviour of these compounds towards microtubular protein when they were incubated with purified bovine brain protein or with liver or hepatoma extracts.

Mild balanoposthitis

AIM

To identify and study cases of mild balanoposthitis (MBP) with penile pathology among patients observed at a dermatology clinic over an 18-month period.

MATERIALS

The study included 321 patients with penile pathology. The term MBP was used to describe balanoposthitis of a localised, inflammatory nature with few, non-specific symptoms and a tendency to become chronic or recur. Two hundred and seventy had diseases clearly identifiable by clinical examination or laboratory tests; 51 cases were diagnosed as MBP and these patients had blood tests (to evaluate immune status) and microbiological examination; when these proved negative, a series of patch tests was also used.

RESULTS

Of the 51 patients diagnosed as having MBP, the cause was ascertained in 34 cases (infection, mechanical trauma, contact irritation, contact allergy, etc.), whereas no specific aetiological factor was detected to explain the symptoms in the remaining 17 cases.

Lumbosacral fusion with pedicular osteosynthesis

A total of 40 patients affected with lumbosacral degenerative pathology and submitted to pedicular synthesis and laminectomy were followed-up. There was an 86% success rate after an average of 2 years. The authors conclude by recognizing the effectiveness of pedicular fixation, and the need to associate laminectomy with fusion because of the frequent association of instability and stenosis in degenerative low back pain.

Familial idiopathic hyperphosphatasia (FIH): response to long-term treatment with pamidronate (APD)

A 5-year-old child suffering from familial idiopathic hyperphosphatasia (FIH) was treated by: (1) intravenous infusion of pamidronate (APD) (3 h) (0.75 mg/kg/day) for 5 days; and (2) oral administration of APD (8 mg/kg/day) for 1 year, in association with calcium (1 g/day) as calcium gluconate. A decrease of both serum calcium and phosphate, and a slight PTH increase were observed immediately after the IV treatment; serum alkaline phosphatase did not change, but a marked and rapid decline in the hydroxyprolinuria was observed: basal 659 +/- 207 during IV treatment 169 +/- 59 (mean +/- SD mg/24 h, P < 0.005). At the end of one year of oral APD treatment clinical and radiological findings showed a remarkable improvement. Serum calcium, phosphate and PTH returned to the initial values. Plasma alkaline phosphatase levels showed a 70% decrease: basal 1370 IU/l, 1 year 410 IU/l whereas the hydroxyprolinuria values were similar to those determined at the end of the intravenous treatment (212 +/- 13 mg/24 h), but still significantly lower than the basal levels (P < 0.01). No side-effects were observed. APD appears to be a promising treatment for patients with FIH.

The in vitro metabolic inversion of R(-) to S(+) indoprofen

The paper reports a study on the metabolic inversion of indoprofen (2-[4-(2-isoindolinyl-1-one)-phenyl]-propionic acid) following incubation of the drug with liver microsomes from non-induced and phenobarbital-induced rats. The enantiomeric composition of the drug was determined after different incubation times of the racemate and the individual isomers. The S(+)/R(-) ratio was evaluated by densitometry following HPTLC separation of the R(+)-1-phenylethylamides. After incubation of the racemate and the individual isomers, no detectable amounts of indoprofen catabolites were extracted from the acidified incubation mixture. An appreciable enrichment in the S(+) enantiomer was observed after incubation of both racemate and R(-)-indoprofen; the S(+)/R(-) ratio reached a maximum after 1 h. Values were higher in the case of induction. After incubation of S(+)-indoprofen, a small but statistically significant decrease of the S(+)/R(-) ratio was observed. The increase of the S(+)-isomer concentration observed following incubation of R(-)-indoprofen can be ascribed to metabolic inversion by phenobarbital-inducible liver enzymes.

Intraoperative ultrasonography imaging in spinal surgery (technique and indications)

Intraoperative ultrasonography was conducted in 20 patients; the technique of intraoperative ultrasonography for use in spinal surgery is described. The authors emphasize that this non-invasive method obtains real time images of considerable diagnostic importance, allowing for a significantly minor use of image intensifier, with a consequent reduction in doses for both the patient and the staff.

Aldehyde-induced modifications of the microtubular system in 3T3 fibroblasts

The molecular structure of aldehydes is closely related to their antimicrotubular effect. Morphological modifications of the microtubular system in living cells after incubation with certain aldehydes are consistent with biochemical alterations detected in previous research. The microtubular arrangement was visualized by an immunofluorescence technique with antitubulin antibodies, while the content of tubulin in the cells was evaluated by a colchicine binding assay. 2-Nonenal behaved similarly to 4-hydroxynonenal, a lipid peroxidation product, disorganizing microtubular network in 3T3 fibroblasts and decreasing the amounts of tubulin able to bind labelled colchicine. Nonanal did not significantly impair the tubulin characteristics in the cells, despite the fact that it has been shown to be active on the purified microtubular system; benzaldehyde was ineffective. This would appear to explain the mechanisms of interaction of aliphatic aldehydes which might be suitable for use as antimicrotubular drugs.