Late-onset and long-lasting neutropenias in the young: A new entity anticipating immune-dysregulation disorders

This study identifies a new chronic form of immune neutropenia in the young with or without detectable indirect anti-neutrophil antibodies, characterized by mild/moderate neutropenia low risk of severe infection (14%), tendency to develop autoimmune phenomena over the course of the disease (cumulative incidence of 58.6% after 20 years of disease duration), leukopenia, progressive reduction of absolute lymphocyte count and a T- and B-cell profile similar to autoimmune disorders like Sjogren syndrome, rheumatoid arthritis, and systemic lupus erythematosus (increased HLADR+ and CD3 + TCRγδ cells, reduced T regulatory cells, increased double-negative B and a tendency to reduced B memory cells). In a minority of patients, P/LP variants related to primary immuno-regulatory disorders were found. This new form may fit the group of "Likely acquired neutropenia," a provisional category included in the recent International Guidelines on Diagnosis and Management of Neutropenia of EHA and EUNET INNOCHRON ACTION 18233. The early recognition of this form of neutropenia would help clinicians to delineate better specific monitoring plans, genetic counseling, and potentially targeted therapies.

Thyroiditis and COVID-19: focus on pediatric age. A narrative review

PURPOSE

In light of the growing concern over the possible link between SARS-CoV2 infection and autoimmune diseases, we conducted a review to investigate the impact of the pandemic outbreak on thyroid diseases.

METHODS

We carried out a narrative review of all pediatric cases described in the literature, mainly focusing on the possible association of COVID-19 with the incidence of autoimmune and post-infective thyroid diseases (namely Hashimoto's Thyroiditis (HT), Grave's Disease (GD) and Sub-Acute Thyroiditis (SAT)). We also felt it was necessary to provide a brief review of Non-thyroidal Illness Syndrome (NTIS) and Multisystem Inflammatory Syndrome in Children (MIS-C) because of their overlap with thyroiditis.

RESULTS

There is currently no conclusive evidence linking SARS-CoV-2 infection with an increased incidence of autoimmune thyroiditis (AT) in pediatric age. However, SAT may be a mild complication of SARS-CoV-2 infection, as is the case with other viral infections. SAT typically resolves on its own and does not require treatment. NTIS may be associated with inflammatory complications, such as MIS-C, and admission to intensive care. It may also be considered a prognostic risk factor for severe disease. The hypothesized pathogenetic mechanisms of thyroid damage in COVID-19 include direct damage due to the significant expression of angiotensin-converting enzyme 2 (ACE2) in the thyroid gland, which is a ligand for the virus, and indirect damage due to immune dysregulation, such as the overproduction of IL-6, which is thought to be part of the pathogenesis of thyroiditis.

CONCLUSION

However, due to the limited evidence available, further prospective longitudinal studies are required to clarify the relationship between COVID-19 and thyroid disease in children and adolescents, as well as to investigate any potential long-term consequences.

Transition from pediatric to adult care in patients with Turner syndrome in Italy: a consensus statement by the TRAMITI project

PURPOSE

Transition from pediatric to adult care is associated with significant challenges in patients with Turner syndrome (TS). The objective of the TRansition Age Management In Turner syndrome in Italy (TRAMITI) project was to improve the care provided to patients with TS by harnessing the knowledge and expertise of various Italian centers through a Delphi-like consensus process.

METHODS

A panel of 15 physicians and 1 psychologist discussed 4 key domains: transition and referral, sexual and bone health and oncological risks, social and psychological aspects and systemic and metabolic disorders.

RESULTS

A total of 41 consensus statements were drafted. The transition from pediatric to adult care is a critical period for patients with TS, necessitating tailored approaches and early disclosure of the diagnosis to promote self-reliance and healthcare autonomy. Fertility preservation and bone health strategies are recommended to mitigate long-term complications, and psychiatric evaluations are recommended to address the increased prevalence of anxiety and depression. The consensus also addresses the heightened risk of metabolic, cardiovascular and autoimmune disorders in patients with TS; regular screenings and interventions are advised to manage these conditions effectively. In addition, cardiac abnormalities, including aortic dissections, require regular monitoring and early surgical intervention if certain criteria are met.

CONCLUSIONS

The TRAMITI consensus statement provides valuable insights and evidence-based recommendations to guide healthcare practitioners in delivering comprehensive and patient-centered care for patients with TS. By addressing the complex medical and psychosocial aspects of the condition, this consensus aims to enhance TS management and improve the overall well-being and long-term outcomes of these individuals.

Whole genome sequencing in ROHHAD trios proved inconclusive: what's beyond?

Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation and Autonomic Dysregulation (ROHHAD) is a rare, life-threatening, pediatric disorder of unknown etiology, whose diagnosis is made difficult by poor knowledge of clinical manifestation, and lack of any confirmatory tests. Children with ROHHAD usually present with rapid onset weight gain which may be followed, over months or years, by hypothalamic dysfunction, hypoventilation, autonomic dysfunction, including impaired bowel motility, and tumors of neural crest origin. Despite the lack of evidence of inheritance in ROHHAD, several studies have been conducted in recent years that have explored possible genetic origins, with unsuccessful results. In order to broaden the search for possible genetic risk factors, an attempt was made to analyse the non-coding variants in two trios (proband with parents), recruited in the Gaslini Children's Hospital in Genoa (Italy). Both patients were females, with a typical history of ROHHAD. Gene variants (single nucleotide variants, short insertions/deletions, splice variants or in tandem expansion of homopolymeric tracts) or altered genomic regions (copy number variations or structural variants) shared between the two probands were searched. Currently, we have not found any potentially pathogenic changes, consistent with the ROHHAD clinical phenotype, and involving genes, regions or pathways shared between the two trios. To definitively rule out the genetic etiology, third-generation sequencing technologies (e.g., long-reads sequencing, optical mapping) should be applied, as well as other pathways, including those associated with immunological and autoimmune disorders, should be explored, making use not only of genomics but also of different -omic datasets.

Ukrainian refugee crisis: the experience of the Roman Local Health Authority “ASL Roma 1”

Problem

On February 24th, 2022, Ukraine was invaded by Russian forces, forcing many Ukrainians to flee from their homes as refugees. More than 55,000 Ukrainians have since arrived on Italian territory. In response to the humanitarian crisis, the Roman Local Health Authority “ASL Roma 1” provided socio-sanitary assistance through first reception centers to more than 7700 refugees, prioritizing people with high social vulnerability. Ukraine’s vaccine hesitancy and different epidemiological landscape represented a major hurdle to be overcome.

Practice

ASL Roma 1’s practice served to ensure infectious diseases prevention and control, as well as continuity of care for non-communicable diseases and mental health issues. It consisted of repurposing resources, such as COVID-19 Hubs and their personnel, stipulating Public-Private Partnerships and collaborations with the local Ukrainian community, massive training, creating a centralized multidisciplinary team (with Ukrainian members) and a dedicated database/IT system.

Results

ASL Roma 1 empowered local Ukrainian communities by providing equipment, medical and administrative staff and socio-sanitary assistance. Ukrainian volunteers helped bridge the cultural gap for essential service provision, such as COVID-19 screening, enrolment in the NHS, health and social orientation, vaccinations and a tailored care pathway. Thus, more than 7700 refugees were assisted, with 1830 COVID-19 vaccinations administered and 170 in critical conditions promptly receiving specialized care.

Lessons

The multidisciplinary and cross-cultural interaction between doctors, nurses, cultural mediators, social workers, and other key actors was essential in ensuring a holistic care pathway. Services catered to Ukrainian refugees need complete integration between primary and centralized care. Flexibility and resilience are fundamental to foster an ecosystem of innovation and optimization of healthcare provision on all levels, from local to supranational.

Key messages

• The multidisciplinary and cross-cultural interaction between all medical and non-medical key actors is essential in ensuring a holistic care pathway and complete social integration of asylum seekers.

• Health system flexibility, resilience and an ecosystem of innovation and optimization of healthcare provision on all levels are fundamental components of preparedness for future refugee crises.

Cluster of climatic and pollutant characteristics increases admissions for acute myocardial infarction: Analysis of 30,423 patients in the metropolitan area of Sao Paulo

BACKGROUND

The impact of simultaneous adverse climate conditions in the risk of myocardial infarction (MI) was not tested before. The aim of the present study was to investigate the impact of the combination of climate and air pollution features in the number of admissions and mortality due to acute myocardial infarction in 39 municipalities of São Paulo from 2012 to 2015.

METHODS

Data about MI admissions were obtained from the Brazilian public health system (DataSUS). Daily information on weather were accessed from the Meteorological Database for Teaching and Research. Additionally, daily information on air pollution were obtained from the Environmental Company of the State of São Paulo. A hierarchical cluster analysis was applied for temperature, rainfall patterns, relative air humidity, nitrogen dioxide, particulate matter 2.5 and particulate matter 10. MI admissions and in-hospital mortality were compared among the clusters.

RESULTS

Data analysis produced 3 clusters: High temperature variation-Low humidity-high pollution (n=218 days); Intermediate temperature variation/high humidity/intermediate pollution (n=751 days) and low temperature variation/intermediate humidity-low pollution (n=123 days). All environmental variables were significantly different among clusters. The combination of high temperature variation, dry weather and high pollution resulted in a significant 9% increase in hospital admissions for MI [30.5 (IQR 25.0-36.0)]; patients/day; P<0.01). The differences in weather and pollution did not have impact on in-hospital mortality (P=0.88).

CONCLUSION

The combination of atmospheric conditions with high temperature variation, lower temperature, dryer weather and increased inhalable particles was associated with a marked increase of hospital admissions due to MI.

Are vaccine shortages a relevant public health issue in Europe?

Background

National immunisation programmes depend on an adequate supply of vaccines but shortages have become more frequent globally in recent years. Vaccine shortages can lead to missed opportunities for vaccination and a greater risk of occurrence of vaccine-preventable diseases (VPD).

Methods

The EU-Joint Action on Vaccination is a European Commission-funded project* which aims to strengthen cooperation between European countries against VPDs, including improvement of vaccine supply and preparedness. In this context, from February to May 2019, we conducted a survey amongst persons in charge of national immunisation programmes or of vaccine supply/procurement in EU/EEA, to collect information on vaccine shortages in the previous three years.

Results

Twenty-one of 28 invited countries responded, of which 19 reported at least one shortage, for a total of 115 shortage events. The median number of shortages per country was 5 (range 0-15). At the time of survey completion, there were ongoing shortages in six countries. DT/dt-containing combination vaccines, hepatitis A, hepatitis B and BCG vaccines were the most frequently involved vaccines. Supply and production issues, and global shortage, were the most frequent causes. Median duration of shortages was five months; 34% caused a disruption in immunization services. Procurement and purchase methods varied by country. Only half of countries have recommendations or procedures in place to address shortages.

Conclusions

Vaccine shortages are a serious public health issue in the EU. Causes are complex and multifaceted and more research is needed to understand the economic and market-related causes. Improved communication between public health authorities, manufacturers and regulatory agencies is essential. Procurement and tender mechanisms should be improved. In case of vaccine shortages, all countries should have procedures or recommendation in place regarding the use of alternative vaccines or vaccination schedules.

Key messages

Vaccine shortages are a relevant public health issue in the EU. More research is needed on the complex and multifaceted causes of vaccine shortages. Timely communication between supply and demand is needed and procurement and tender mechanisms should be improved.

Body mass index at diagnosis and prognostic significance on head and neck carcinoma survival

Background

Previous findings suggest there might be an inverse association between body mass index (BMI) and overall (OS) and Head and Neck-specific survival. The aim of this study was to investigate the prognostic role of BMI in the largest available cohort of HNC patients.

Methods

We performed a pooled analysis of studies participating at the INHANCE consortium. Cases were adults with HNCs of the oral cavity, oropharynx, hypopharynx and larynx. We used cox's proportional hazards models to estimate the relationship between BMI and overall and HNC-specific mortality. Sensitivity analysis were performed according to tumour location, smoking status and length of follow-up.

Results

The study included 9484 patients from 10 centres worldwide for a median follow-up of 48 months (IQR: 18-69). Overall 3623 patients (38.2%) died from all-causes and 1493 (15.7%) from HNC. Compared to patients with a normal weight, overweight or obese was associated with a longer HNC-specific survival (HR = 0.58, 95% CI: 0.35-0.95, HR = 0.37, 95% CI: 0.17-0.78, respectively), while underweight was associated to a shorter survival (HR = 1.73, 95% CI: 1.36-2.21). Results were heterogeneous according to tumour site, with the strongest effect among oropharynx and oral cavity cancer sites. When we restricted the analysis among patients with a follow-up longer than 5 years, underweight (HR = 5.17, 95% CI: 3.02-8.86) was associated with shorter HNC-specific survival.

Conclusions

Our findings suggest low BMI values are at diagnosis increase mortality in HNC patients. The protective effect of high BMI might be partially explained by residual confounding and reverse causality, so that further research is needed to clarify the potential role in tertiary prevention of BMI.

Key messages

BMI at diagnosis is a prognostic factor of HNC. Low BMI values predict unfavourable outcomes.

Increasing HPV vaccination uptake among adolescents: A Systematic Review

Background

Human Papillomavirus (HPV) is responsible for the development of several pathologies besides the cervical cancer and HPV vaccination is a key strategy for primary prevention. The aim of this research was to identify strategies adopted to increase HPV vaccination coverage among the adolescents.

Methods

A systematic review was carried-out by searching electronic databases (Pubmed, Scopus, and Web of Science) using selected keywords as “papillomavirus vaccine”, “vaccination strategy” and “efficacy”. Articles conducted in high-income countries and evaluating the impact of one or more strategies on vaccination coverage (initiation e/o completion) in adolescents were included.

Results

Out of 3571 single citations screened, 42 papers (2011-2018) were included. Study size ranged from 50 to 325229 individuals. The major part of the studies was from the United States (n = 35; 83,3%) and conducted with an experimental design (n = 17; 40,5%). The evaluated outcomes included first dose uptake, schedule completion, vaccination timeliness and the number of administered doses. Identified strategies included reminds (9), education activities (9), multicomponent strategies (22) and others (2) and were focused on adolescents/parents and/or healthcare providers. Significant positive results were reported in seven studies (77,8%) evaluating the impact of reminds, four studies (44,4%) on education strategies, and in 12 studies (54,5%) on multicomponent strategies. Offering vaccination in “bundle” or during any medical visit was also reported as significantly effective.

Conclusions

Increasing the vaccination coverage is essential to achieve HPV-related diseases control. Several types of strategies are available and showed a positive impact on vaccination uptake, in particular those relied on reminds. Nonetheless, the heterogeneity of interventions suggests the importance to adapt such initiatives to the specific context in order to maximize the improvement in vaccination uptake.

Key messages

Several types of strategies to increase vaccination uptake are available at international level and showed a positive impact among adolescents. These interventions are heterogeneous suggesting the importance of their adaptation to the specific context in order to gain the maximum improvement in vaccination uptake.

Measuring organizational performance. A review of the dimensions of hospital performance indicators

Key messages

Main dimensions of performance indicators: efficiency, effectiveness, patient centeredness, safety. More emphasis to sustainability and appropriateness to align with today’s healthcare challenges.

Hospital contextual factors affecting the use of health technologies: a systematic review

Background

Healthcare systems are facing great challenges due to increased share of aging population, growing health needs and economic restraints. To keep a high quality of assistance it is important to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though a lot of guidance does exist on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs, namely utilization in daily practice after formal adoption.

Methods

We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs at hospital level. PubMed, Scopus, Web of Science, Econlit and Ovid were searched to retrieve studies published in English from 1st January 2010 to 31st May 2018.

Results

A total of 33 studies were included mostly addressing information and communication technologies (ICTs). Findings suggest that contextual factors that impact on actual utilization of HTs at hospital level are ascribable to four main families: financial factors, leadership styles, human resource management and hospital infrastructure. It emerges also that involving professionals at all levels and planning people’s work and competencies are major determinants of HTs actual utilization.

Conclusions

The evidence suggests that several contextual factors play a major role in HTs actual utilization at hospital level even though data are mostly referred to ICTs being the other HTs unexplored. Indeed, findings from this study suggest that numerous items should be evaluated when considering to use a new HTs at hospital level. Nevertheless, evidence regarding actual utilization of medical and surgical HTs is still lacking and future research is needed.

Key messages

Financial factors, leadership styles, human resource management, hospital infrastructure are relevant determinants of actual utilization of new HTs at hospital level. The evidence on contextual factors that influence actual utilization of HTs is mostly referred to ICTs and further research is indeed deserved.

Strategies to achieve HPV-related disease control in Italy: results from an integrative approach

Background

Vaccination against Human Papilloma Virus (HPV) might allow controlling HPV-related diseases but coverage in Italy is far from the optimal goal. This project aimed at identifying strategies to promote HPV vaccination in Italy.

Methods

an integrative approach including a systematic review and a two-step panel consultation was used to identify strategies for improving coverage among adolescents who are already target of the national campaign and promote vaccination in further targets. The systematic review followed PRISMA recommendations and the panel consultation relied on the administration of questionnaires in the first step and on a televoting system during a consensus conference in the second one. Ten experts were involved belonging to Gynecology, Public Health, General Practice, Pediatrics and Consumers. Recommendations relied on a set of criteria drawn from the Evidence to Decision framework.

Results

The systematic review led the identification of three main strategies to improve coverage respectively based on reminds, education and multicomponent approaches. Following the evaluation of selected criteria, namely relevance of benefits, evidence strength, feasibility, equity, acceptability and costs, a strong recommendation was formulated on the use of reminds tailored to vaccine recipients or their parents whereas a moderate one was developed on the use of reminds directed to health professionals. A moderate recommendation was released on the implementation of multicomponent interventions. The panel consultation also supported the elaboration of a strong recommendation on the promotion of vaccination among women treated for HPV-related diseases, fertile women not yet vaccinated and 25 years old women. Catch-up initiatives, in particular among women and men 18 years old, were also identified as strongly recommendable.

Conclusions

This project led to identify several valuable strategies to strengthen HPV vaccination at national level.

Key messages

Using reminds tailored to vaccine recipients or their parents is strongly recommended while using reminds directed to health professionals and multicomponent interventions are moderately recommended. It is strongly recommended to promote HPV vaccination among women treated for HPV-related diseases, fertile women not yet vaccinated and 25 years old women.

1st European Academy for Healthcare Leaders: high training on leadership to manage health systems

Background

Nowadays having leadership skills is critical to manage healthcare systems. The World Health Organization Collaborating Centre on Health Policy, Governance and Leadership organized the 1st European Academy for Healthcare Leaders in Rome from 15th to 17th November 2018. Senior officials of the Ministries of Health of 16 Members Countries of the WHO European Region attended and actively participated to the event, led by experienced Italian and European experts. The Academy could be considered a moment of high training on leadership and governance of health systems.

Objectives

The event was aimed at creating effective networks among participants to share ideas and strategies to improve leadership skills, providing practical tools to be applied in healthcare systems and to develop a common and transferrable leadership framework in Europe. Frontal lectures and interactive workshops covered three main areas: leadership skills, current challenges of health systems and sustainability of health systems today.

Results

The 3-days event gave the opportunity to discuss the main issues in Public Health highlighting how to be an effective leader in healthcare. Leadership should enable the translation of knowledge into productive action pathways, providing health equity and improving population’s health. At the end of the event, participants filled a survey and the results showed high satisfaction about contents (100% out of 16 participants).

Conclusions

Health systems need to change in order to face the formidable challenges of our times. This event empowered the participants in order to support the creation of strategies and to develop leadership tools to apply at country level. The experiences, ideas and good practices shared during this event strengthened a collaborative network and have been useful to identify common goals and solutions.

Key messages

These kinds of events are fundamental to improve knowledge about leadership in healthcare. Leadership should have a major role to play in healthcare worldwide.

Whole exome sequencing approach to childhood onset familial erythrodermic psoriasis unravels a novel mutation of CARD14 requiring unusual high doses of ustekinumab

BACKGROUND

Autosomal dominant gain of function mutations in caspase recruitment domain family member 14 (CARD14) is a rare condition associated with plaque-type psoriasis, generalized pustular psoriasis, palmoplantar pustular psoriasis and pityriasis rubra pilaris. Recently, a new CARD14 -associated phenotype defined as CAPE (CARD14-associated papulosquamous eruption) with clinical features of both psoriasis and pityriasis rubra pilaris was reported. We describe a family carrying a novel heterozygous mutation in CARD14 gene, with childhood-onset erythrodermic psoriasis requiring an unusual extremely high dose (up to 2 mg/kg every 8 weeks) of ustekinumab to achieve disease remission.

CASE PRESENTATION

We describe a large family with three pairs of twins presenting a clinical phenotype characterized by childhood-onset erythrodermic psoriasis; in some family members is also reported psoriatic arthritis. The two probands presented poor clinical response to topic and systemic therapy with antihistamine, steroid, retinoids, cyclosporine and etanercept. After exclusion of the most common genes associated to autoinflammatory diseases (IL36RN, IL1RN, MVK, TNFRSF1A, NLRP3, NLRP12, MEFV, NOD2, PSMB8, PSTPIP1, LPIN2) we approached a new gene search by subjecting to Whole Exome Sequencing (WES) analysis five members of the family. A novel heterozygous mutation (c.446 T > G, leading to the missense amino acid substitution p.L149R) in the exon 4 of the CARD14 gene was identified in all affected members. Increasing dosages (up to 2 mg/kg every 8 weeks) of ustekinumab, a human monoclonal antibody targeting interleukin-12 (IL-12) and interleukin-23 (IL-23), allowed the complete control of the clinical manifestations, with an evident reduction of circulating Th17 and Th22 CD4+ T cell subsets.

CONCLUSIONS

We describe the association of mutations of the CARD14 gene with an erythrodermic psoriasis pedigree, underlying the necessity to investigate CARD14 mutations in childhood-onset psoriasis cases and confirming the presence of CARD14 causative mutations also in erythrodermic psoriasis form, as recently reported. Also in pediatric age, ustekinumab represents a powerful therapeutic option for this rare condition, that is usually refractory to other treatments. In young children, high and frequent dosages allowed a complete control of the clinical manifestations without any severe side effects, with a long-term follow-up.

Impact of preoperative infection on outcome after liver transplantation

BACKGROUND

Bacterial infection in patients with liver failure can lead to a dramatic clinical deterioration. The indications for liver transplantation and outcome in these patients is still controversial.

METHODS

All adult patients who underwent liver transplantation between 1 January 2010 and 31 December 2015 were selected from an institutional database. Characteristics of the donors and recipients, and clinical, biochemical and surgical parameters were retrieved from the database. Post-transplant survival rates and complications, including grade III-IV complications according to the Dindo-Clavien classification, were compared between patients with an infection 1 month before transplantation and patients without an infection.

RESULTS

Eighty-four patients with an infection had statistically significant higher Model for End-stage Liver Disease (MELD), D-MELD and Balance of Risk (BAR) scores and a higher rate of acute-on-chronic liver failure compared with findings in 343 patients with no infection. The rate of infection after liver transplantation was higher in patients who had an infection before the operation: 48 per cent versus 30·6 per cent in those with no infection before transplantation (P = 0·003). The percentage of patients with a postoperative complication (42 versus 40·5 per cent respectively; P = 0·849) and the 90-day mortality rate (8 versus 6·4 per cent; P = 0·531) was no different between the groups. Multivariable analysis showed that a BAR score greater than 18 and acute-on-chronic liver failure were independent predictors of 90-day mortality.

CONCLUSION

Bacterial infection 1 month before liver transplantation is related to a higher rate of infection after transplantation, but does not lead to a worse outcome.

Constitutive and Stimulated Production of Vegf by Human Megakaryoblastic Cell Lines: Effect on Proliferation and Signaling Pathway

Release of vascular endothelial growth factor (VEGF) and other candidate angiogenic factors such as basic fibroblast growth factor and transforming growth factor β, may play a role in sustaining neoplastic cell proliferation and tumor growth. We evaluated VEGF expression and synthesis in the two erythro-megakaryocytic cell lines B1647, HEL and one megakaryocyte cell line MO7 expressing erythroid markers. In this study RT-PCR was performed to evaluate VEGF expression and that of its receptor KDR; VEGF production was assayed by Elisa test and western blot analysis; sensitivity to VEGF was tested by thymidine incorporation. VEGF and its receptor KDR were expressed in B1647 and HEL, both as mRNAs and as proteins, while only KDR transcript was found in MO7 cells. Only B1647 and HEL cells showed a strong spontaneous proliferating activity. In fact, measurable amounts of VEGF were present in the unstimulated cell medium, thus suggesting an autocrine production of VEGF by B1647 and HEL cells, but not by MO7, which was inhibited in mRNA-silencing conditions. This production could not be further boosted by other growth factors, whereas it was inhibited by TGF-β1. Finally, analysis of She signal transduction proteins following stimulation with VEGF indicated that only p46 was tyrosine phosphorylated. These data indicate that leukemic cells may be capable of autocrine production of VEGF which, in turn, maintains cell proliferation, possibly mediated by She p46 phosphorylation.

Life span history of non-fatal suicidal behaviours in a large sample of general practitioners' patients: data from Rovigo, Northern Italy

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners' practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

A new active thermal neutron detector

This communication presents the main results about the design and in-house fabrication of a new solid-state neutron detector, which produces a DC output signal proportional to the thermal neutron fluence rate. The detector has been developed within the framework of the 3-y project NESCOFI@BTF of INFN (CSN V). Due to its sensitivity, photon rejection, low cost and minimum size, this device is suited to be used in moderator-based spectrometers.

Management of Cancer Anemia

Anemia complicates the course of disease in about 50% of patients with cancer, and negatively affects their quality of life. A correct approach to therapy should consider all the possible causes and patients need to be treated accordingly. The observation that erythropoietin production is often blunted offers new treatment possibilities. Fifty to 70% of anemic patients respond to rHuEpo, given in a three times or once-a-week schedule. The novel hyperglycosylated protein darbepoetin permits longer intervals between administrations, thanks to its longer half-life, and a once per cycle or once-a-month schedule is a reasonable target. Correction of anemia improves the quality of life, and it has been hypothesized that improvement of cognitive function may derive from a direct effect of Epo on CNS cells. Although anemia is an adverse prognostic factor in cancer, results of recent clinical trials have raised the question whether rHuEpo may favor neoplastic cell proliferation. Results are conflicting at the moment, and further studies are required before arriving at a conclusion. Data available so far do not indicate any negative effect of darbepoetin on the outcome of cancer disease, nor has the production of anti-darbepoetin antibodies or PRCA been reported, a complication observed in less than 200 patients with anemia due to renal insufficiency and treated with rHuEpo alpha.

Alpha-actinin interactions with syndecan-4 are integral to fibroblast-matrix adhesion and regulate cytoskeletal architecture

All cells of the musculoskeletal system possess transmembrane syndecan proteoglycans, notably syndecan-4. In fibroblasts it regulates integrin-mediated adhesion to the extracellular matrix. Syndecan-4 null mice have a complex wound repair phenotype while their fibroblasts have reduced focal adhesions and matrix contraction abilities. Signalling through syndecan-4 core protein to the actin cytoskeleton involves protein kinase Cα and Rho family G proteins but also direct interactions with α-actinin. The contribution of the latter interaction to cell-matrix adhesion is not defined but investigated here since manipulation of Rho GTPase and its downstream targets could not restore a wild type microfilament organisation to syndecan-4 null cells. Microarray and protein analysis revealed no significant alterations in mRNA or protein levels for actin- or α-actinin associated proteins when wild type and syndecan-4 knockout fibroblasts were compared. The binding site for syndecan-4 cytoplasmic domain was identified as spectrin repeat 4 of α-actinin while further experiments confirmed the importance of this interaction in stabilising cell-matrix junctions. However, α-actinin is also present in adherens junctions, these organelles not being disrupted in the absence of syndecan-4. Indeed, co-culture of wild type and knockout cells led to adherens junction-associated stress fibre formation in cells lacking syndecan-4, supporting the hypothesis that the proteoglycan regulates cell-matrix adhesion and its associated microfilament bundles at a post-translational level. These data provide an additional dimension to syndecan function related to tension at the cell-matrix interface, wound healing and potentially fibrosis.

Gender differences in bone mineral density in obese children during pubertal development

OBJECTIVE

To investigate whether body mass index (BMI) and body composition can affect peak bone mass in a population of obese (OB) (BMI SDS>2.0) and normal weight (NORM) (BMI-SD score <2.0) pubertal subjects (Tanner stage T3 to T5).

PATIENTS AND METHODS

151 subjects (81 OB, age 14.5±2.4 yr) were analyzed using dual-X-ray absorbiometry technique to study Lumbar and whole body bone mineral density (BMD) (areal, normalized for height) and Z-score, lean mass (LM) and lean/fat ratio.

RESULTS

As a whole group, OB males did not show any significant difference in bone parameters vs NORM, while OB females showed higher bone density parameters (p<0.05). When grouped according to T, while OB males showed higher bone density at T3-4 stage (p<0.01), and lower at T5 (p<0.01) compared to NORM, OB females showed a tendency through increased BMD at T3-4 and T5 although statistically different only at T5. BMD was independently correlated to LM, lean/fat ratio, and testosterone in NORM males and, at lower level, in OB males, while to LM in NORM females and only to age in OB females.

CONCLUSION

Our data seem to confirm the possible negative influence of obesity on bone density in boys, a possible explanation could be an unfavorable body composition during sexual maturation that seems not to affect bone development in adolescents girls.

Angiogenic potential of human dental pulp stromal (stem) cells

Dental pulp is a heterogeneous microenviroment where unipotent progenitor and pluripotent mesenchymal stem cells cohabit. In this study we investigated whether human dental pulp stromal (stem) cells (DP-SCs) committed to the angiogenic fate. DP-SCs showed the specific mesenchymal immunophenotypical profile positive for CD29, CD44, CD73, CD105, CD166 and negative for CD14, CD34, CD45, in accordance with that reported for bone marrow-derived SCs. The Oct-4 expression in DP-SCs, evaluated through RT-PCR analysis, increased in relation with the number of the passages in cell culture and decreased after angiogenic induction. In agreement with their multipotency, DP-SCs differentiated toward osteogenic and adipogenic commitments. In angiogenic experiments, differentiation of DP-SCs, through vascular endothelial growth factor (VEGF) induction, was evaluated by in vitro matrigel assay and by cytometric analysis. Accordingly, endothelial-specific markers like Flt-1 and KDR were basally expressed and they increased after exposure to VEGF together with the occurrence of ICAM-1 and von Willebrand factor positive cells. In addition, VEGF-induced DP-SCs maintained endothelial cell-like features when cultured in a 3-D fibrin mesh, displaying focal organization into capillary-like structures. The DP-SC angiogenic potential may prove a remarkable tool for novel approaches to developing tissue-engineered vascular grafts which are useful when vascularization of ischemic tissues is required.

Bone mineral density and body composition in male children with hypogonadism

Estrogen deficiency in females and androgen deficiency in males may harm periosteal and endosteal apposition, reduce bone size and both cortical and trabecular thickness, modifying in this way the bone structure later in life. To date, few systematic studies on bone mineral density (BMD) and hypogonadism in adolescents are available. Therefore we aimed to determine if sexual hormone deficiency during pubertal age might have an impact on peak bone mass and body composition. We compared areal BMD (L-aBMD), volumetric lumbar spine BMD (L-vBMD), lumbar spine Z-score (L-Z-score), lumbar spine bone mineral content (L-BMC), whole body (wbBMD), normalized whole body (n-wbBMD) BMD, and whole body BMC (wb-BMC) of 25 male children with hypogonadism (HYPO) with 37 sex-, age-, and body mass index-matched healthy subjects (CNT) using dual-energy X-ray absorptiometry. Furthermore we analyzed whether a difference in lean (lean%) and fat (fat%) mass as percentage of body weight and as a lean/fat ratio is present in the two groups of children. HYPO demonstrated a statistically lower L-aBMD, LvBMD, L-BMC, Z score, wbBMD, n-wbBMD, and wb-BMC compared to CNT. CNT showed a higher lean% and lower fat% and a higher lean/fat ratio when compared with HYPO group. Lean mass correlated positively with L-aBMD, L-BMC, and wb-BMC. Our study seems to confirm previous observations that sex hormone deficiency during puberty reduces bone mass accrual. Body composition alterations may play a role in bone parameters during development in healthy as such as in hypogonadal children during developmental age.

Young elite athletes of different sport disciplines present with an increase in pulsatile secretion of growth hormone compared with non-elite athletes and sedentary subjects

Acute exercise is a well-known stimulus for GH secretion but the effect of chronic training on GH secretion still remains equivocal. The aim of our study was to analyse spontaneous pulsatile GH secretion (during a period of 2 hours in the morning) in a group of young elite athletes (EA) compared with non-elite athletes (NEA), and sedentary subjects (SS). Mean and peak GH levels proved significantly higher in EA than in NEA and SS (p=0.0004 and p<0.0001, respectively). The same differences in mean and peak GH levels were also demonstrated in males and females when considered separately (males: p=0.0062 and p=0.0025; females: p=0.0056 and p=0.0032). In addition, GH levels (mean and peak) were higher in females than in males in SS while no differences were demonstrated between the 2 sexes in the EA and NEA groups. IGF-I levels were within the normal range for age in all the subjects with no difference between the 3 groups. Body mass index (BMI) exhibited no difference between groups, while EA showed higher lean mass (p=0.0063) and lower fat mass (p=0.0139) than NEA and SS measured by dual-energy x-ray absorptiometry. A strong positive correlation between GH levels (mean and peak) and hours of training a week was demonstrated (p=0.0101; r2=0.1184; p=0.0022; r2=0.1640, respectively). In conclusion, GH levels were higher in EA than NEA and SS without any modification of IGF-I levels; a strong positive correlation was present between GH levels and intensity of training. An increase in the knowledge of the effect of chronic training on GH secretion could improve the training programme to elicit the greatest exercise- induced GH response.

Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy

AIM

The aim of the study was to evaluate the long-term efficacy of night-only splint wear therapy for carpal tunnel syndrome (CTS).

METHODS

We conducted a randomized case-control trial with evaluation after three and six months of follow-up of outpatients with mild, recent onset symptoms of CTS recruited from the department clinic. Fifty patients (50 hands) were enrolled, of which 36 completed the study at 6 months. The case group utilized a thermoplastic neutral wrist splint for night-only wear. Outcome measures were instrumental parameters (sensory and motor nerve conduction velocity), symptom and function alterations (as measured by Levine's self-administered questionnaire), clinical parameters (pressure-provocative and Phalen tests).

RESULTS

Improvements were observed in Levine's symptom status score at the three-month (P=0.001) and the six-month (P=0.001) follow-up visits, in functional score (P=0.0001) and (P=0.0004), in median distal sensory latency (P=0.01) and (P=0.02), in pressure-provocative test outcome (P=0.01) and (P=0.003), in Phalen test outcome (P=0.04) and (P=0.05) respectively.

CONCLUSION

Symptom relief and neurophysiological improvement after night-only splint wear therapy lasted up to the six-month follow-up visit.

VEGF inhibition and cytotoxic effect of aplidin in leukemia cell lines and cells from acute myeloid leukemia

BACKGROUND

Aplidine (APL) is a marine depsipeptide isolated from the Mediterranean tunicate Aplidium albicans that is under clinical phase II development. In contrast to the lack of bone marrow toxicity reported in phase I/II studies, it has been shown to induce cytotoxicity at very low concentration against lymphoblastic leukemia blast, as well as having an impact in the vascular endothelial growth factor (VEGF)/VEGF receptor 1 loop.

PATIENTS AND METHODS

To confirm these findings we investigated APL-related VEGF inhibition and its cytotoxic effect on myeloid leukemic cells lines (K-562, HEL and HL60) and fresh leukemia blasts derived from 30 patients with acute myeloid leukemia (AML). The conventional active 4-demetoxi-daunorubicin (idarubicin; IDA) was included as a positive control.

RESULTS

APL was found to be significantly (P<0.001) more active than IDA in obtaining 50% growth-inhibition in K-562, HEL and HL60 cell lines. Results obtained with AML blast cells were super imposible. ID(50) ranged from 0.024 to 0.610 microM for IDA (0.200+/-0.176) and from 0.001 to 0.108 microM for APL (0.020+/-0.031). Annexin V tests and cell cycle analysis performed on cell lines confirmed the stronger citotoxic capability of APL as apoptotic inducer and as a G(1) blocker. The inhibitory effects of APL on VEGF release and secretion have been confirmed by ELISA tests performed on HEL: the VEGF concentration in cell surnatant was reduced from 169 to 36 pg/ml after 24 h of exposure to a pharmacological concentration of APL.

CONCLUSIONS

APL harbors a strong in vitro antileukemic activity at a concentration achievable in patients at non-myelotoxic doses. Our data also support the notion of an impact on VEGF secretion. Clinical studies with this new marine-derived compound in relapsed/resistant leukemia are underway.

Impact of a new dosing regimen of epoetin alfa on quality of life and anemia in patients with low-risk myelodysplastic syndrome

This study evaluated the impact of a new epoetin alfa dosing regimen on quality of life (QOL), transfusion requirements, and hemoglobin (Hb) levels in 133 patients with low-risk myelodysplastic syndrome (MDS) and Hb < or =10 g/dl. Epoetin alfa 40,000 IU was given subcutaneously twice weekly; after 4 weeks, the dose could be reduced to 40,000 IU weekly in patients achieving erythroid response. QOL was assessed using the functional assessment of cancer therapy-anemia (FACT-An) questionnaire. FACT-An scores increased on average by 7.5 after 4 weeks and by 8.8 after 8 weeks compared with baseline. FACT-An scores were positively associated with Hb values (r=0.53, P<0.01). The mean FACT-An score increase at week 8 was 10.2 in responders and 5.6 in nonresponders. The overall erythroid response rate at week 8 was 68%: 74% in transfusion-independent patients and 59% in transfusion-dependent patients. Of all responders at week 8, response was maintained in 86% at week 12, 71% at week 16, 65% at week 20, and 54% at week 24. Treatment was generally well tolerated. Our data provide new and encouraging results regarding the benefits of 40,000 IU biweekly induction doses followed by 40,000 IU weekly in improving QOL, correcting anemia, and reducing transfusion requirements in low-risk MDS patients.

Prevalence and drug susceptibility of pathogens causing bloodstream infections in northern Italy: a two-year study in 16 hospitals

The epidemiology of bacterial pathogens causing bloodstream infection was studied in 16 hospitals in Lombardy (northern Italy) over a 2-year period (1999 and 2000). Overall, 2924 microorganisms causing significant bacteremia were collected. The most frequent isolates were Escherichia coli ( n=663; 22.7%), Staphylococcus aureus ( n=534; 18.3%), Staphylococcus epidermidis ( n=242; 8.2%), and Pseudomonas aeruginosa ( n=176; 6.0%). Unlike Escherichia coli, which was usually acquired from the community, Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa were usually acquired in hospitals. Rates of resistance to oxacillin and its associated traits were significantly higher among hospital-acquired staphylococci as compared to those of isolates from the community. Escherichia coli was highly susceptible to extended-spectrum cephalosporins, with a very low percentage of strains producing extended-spectrum ss-lactamases (ESBLs). On the contrary, production of ESBL appeared to be an important mechanism of resistance among nosocomial isolates of Klebsiella pneumoniae. Resistance to ciprofloxacin was widespread in several members of the family Enterobacteriaceae, with rates often exceeding 10%. Moreover, with regard to ciprofloxacin, there were no significant differences between rates of resistance among Enterobacteriaceae causing hospital-acquired infections versus those causing community-acquired infections. Multidrug resistance was commonly observed in Pseudomonas aeruginosa, indicating the need for new antimicrobial agents that are more active against nonfermentative gram-negative bacteria. In conclusion, epidemiological studies of the prevalence and antimicrobial susceptibility patterns of blood isolates in northern Italy appear to provide useful information for both empirical treatment of suspected infections and better management of patients.

European Confederation of Medical Mycology (ECMM) prospective survey of candidaemia: report from one Italian region

An ECMM epidemiological prospective survey of candidaemia was performed in one Italian region (Lombardy; population: 8 924 870) by the National Society of Medical Mycology (FIMUA) from September 1997 to December 1999. In total, 569 episodes were reported with an overall rate of 0.38/1000 admissions, 4.4/100000 patient days. Predisposing factors included presence of an intravascular catheter (89%), antibiotic treatment (88%), surgery (56%), intensive care (45%), solid tumour (28%), steroid treatment (15%), haematological malignancy (7%), HIV infection (6%), fetal immaturity (4%). Mucous membrane colonization preceded candidaemia in 83% of patients. Candida albicans was identified in 58% of cases, followed by Candida parapsilosis (15%), Candida glabrata (13%), Candida tropicalis (6%). Septic shock occurred in 95 patients. Crude mortality was 35%, the highest in C. tropicalis fungaemia (44%), the elderly (64%) and solid tumour cancer patients (43%). Intravascular catheter removal was associated with higher survival rate (71 vs. 47%). This survey underscores the importance of candidaemia in hospital settings.

Long-term intrathecal Baclofen infusion in supraspinal spasticity of adulthood

OBJECTIVE

To evaluate long-term results of chronic intrathecal Baclofen infusion on the spasticity, on the spasms and to evaluate the side-effects of the intrathecal Baclofen in patients with supraspinal spasticity.

CLINICAL MATERIALS AND METHODS

Fourteen patients with severe progressive refractory to medical therapy spasticity were evaluated after chronic intrathecal Baclofen infusion performed by implantation of subcutaneous pump. The patients had suffered traumatic or anoxic acquired brain injuries. The clinical evaluation was made using Ashworth Scale (AS) and the Spasm Frequency Scale (SFS).

RESULTS

The intrathecal therapy showed a statistically significant improvement of the tone and of the spasms.

CONCLUSIONS

The intrathecal infusion of Baclofen seems to be an effective treatment in patients with supraspinal spasticity.

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up

BACKGROUND

Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience.

METHODS

Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included.

RESULTS

There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively.

CONCLUSIONS

Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.

Patency of anastomoses after bilio-intestinal bypass: radioisotope demonstration

BACKGROUND

Bilio-intestinal bypass (BIB) is effective for the treatment of refractory obesity. BIB permits bile flow into the non-functional jejunum, whereas food transit occurs via the remaining intestine. We used the radioisotope method of 99mTc-Hida cholescintigraphy (HC) in the follow-up of patients.

METHODS

21 patients were studied 3 months to 3 years after BIB with HC. After 3 hours acquisition, images were reviewed by two independent observers. Regions of interest (ROIs) were drawn on images: liver parenchyma, cholecysto-jejunal anastomosis (CC), choledochus (COL). Radioactivity taken up by liver was compared with radioactivity of CC and COL. % radioactivity passing through CC (%CC) and through COL (%COL) were determined. The final parameter, -COL, indicates the radioactive bile which does not pass through the choledochus.

RESULTS

Anastomoses were found patent a few months to 3 years after operation. -COL showed linear correlation with the decrease in cholesterolemia and in body weight in the 1st year after BIB.

CONCLUSIONS

HC shows passage of radioactive bile through anastomoses and provides semiquantitative evaluation of bile flux diversion. Bile flux towards the gallbladder and non-functional jejunal limb far exceeds flux directed towards the duodenum via the choledochus.

Searching for the magic bullet against cancer: the butyrate saga

n-Butyric acid and its "polymorphic" derivatives have been largely but somehow "blindly" studied in oncology and in red cell diseases with consistent results through decades indicating a strong maturative effect determined by enhancement of gene transcription. Although these effects have been observed mainly in vitro, the relative absence of systemic toxicity of butyrates render these compounds appealing as specific therapeutic agents. More interestingly, their specific mechanism of action, i.e. inhibition of histone deacetylase and de-repression of transcription represents at present an unique tool for diseases such as acute leukemias which are characterised by a disregulation of co-repressors and co-activators of gene transcription. More insight into specificity and modalities of action of different butyrate derivatives may be a guarantee for excellent tailored antileukemic therapy in the future.

Safety and efficacy of thalidomide in patients with myelofibrosis with myeloid metaplasia

We administered the anti-angiogenic drug thalidomide to 21 patients (12 men) with myelofibrosis with myeloid metaplasia (MMM), who were not responsive to standard treatment. Patients received thalidomide at an escalating dose from 100 to 400 mg/d. Administration of the drug was discontinued before the planned 6 months of treatment in 19 patients (90.5%), mainly because of somnolence and/or fatigue, neurological symptoms or neutropenia. Of the 13 evaluable patients (who received more than 30 d of therapy), anaemia improved in three out of seven (43%) who were treated because of anaemia; thrombocytopenia improved in two out of three (66.6%) who were treated because of thrombocytopenia; splenomegaly was reduced in four (30.8%). Undesired increases in white blood cell and platelet counts were observed in three (23.1%) and five (38.5%) patients respectively. A severity score, indexed on haematological and clinical parameters, improved in two patients (15.4%), but worsened in five (38.5%). In conclusion, standard-dose thalidomide in MMM patients is burdened with a high rate of side-effects, which prevent prolonged treatment. Because the drug is effective in improving anaemia and thrombocytopenia and in reducing splenomegaly, low-dose therapy warrants evaluation. The unexpected observation of leucocytosis and thrombocytosis suggests biological studies and better criteria for selection of patients for treatment.

Hashimoto's disease during interferon-alpha therapy in a patient with pre-treatment negative anti-thyroid autoantibodies and with the specific genetic susceptibility to the thyroid disease

OBJECTIVES

The authors described a case of Hashimoto's disease during interferon-alpha (IFN-alpha) treatment for chronic viral C hepatitis in a patient with the specific genetic susceptibility associated with the thyroid disease.

RESULTS

A 60-year-old woman with chronic active viral C hepatitis (HCV genotype = 3a) started IFN-alpha therapy in November '96. Before treatment thyroid function tests were normal and anti-thyroid (anti-thyroglobulin and anti-thyroid peroxidase) Abs were negative. During IFN therapy, serum aminotransferases fell within the normal range and viremia (serum HCV-RNA) became negative after one year. After 20 months, the patient presented clinical features of primary hypothyroidism. Anti-thyroid Abs were found positive. Hormonal, ultrasonographic, radioiodine scanning and fine needle aspiration findings were consistent with the diagnosis of Hashimoto's thyroiditis. The tissutal typing of the patient showed the presence of Human Leukocyte Antigen (HLA) DRB1*11 gene (corresponding to DR5 antigen). IFN-alpha therapy was suspended and a treatment with l-T4 started. Chronic viral infection relapsed after the suspension of the IFN-alpha therapy.

CONCLUSIONS

This case report showed that the clinical appearance of Hashimoto's disease after IFN-alpha therapy for chronic C hepatitis in our patient was associated with a specific genetic predisposition (DR5) for this pathology. Further studies are necessary to evaluate whether the study of HLA antigens may be a very useful tool to detect the patients with a predisposition to develop autoimmune thyroiditis, in order to make a early diagnosis of thyroid disorders during the IFN-alpha treatment.

[Repair of anterior mitral leaflet prolapse: state of the art]

Surgical repair of anterior leaflet prolapse has evolved and widely expanded over the past decade. A number of surgical techniques have been developed. In this study a review of all reparative techniques has been provided. A classification has been proposed according to the involvement of valve components and, eventually, to graft employment. For each technique the following points have been detailed: a) advantages and drawbacks; b) likelihood of effective valve repair based on morpho-pathologic variability of degenerative mitral disease; c) long-term outcome as freedom from reoperation. The authors provide indications for early surgical anterior leaflet prolapse repair and recommend that surgeons should be familiar with many reparative procedures to select the right option and improve their operative results.