Migrant and ethnic minorities at higher risk of COVID-19 severe outcomes? A systematic review

Background

The Covid-19 pandemic has had a recognised impact in widening health inequalities, both between and within countries, with a major impact on socially disadvantaged population groups such as Migrants and Ethnic Minorities (MEMs). While there is growing evidence on the matter worldwide, data specific to the WHO European Region is scarce. The issue, however, is pressing, since it is estimated that almost 10% of the population living in the WHO European Region is made up of migrants. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes.

Methods

We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Fourteen researchers were involved in selection, study quality assessment, data extraction and analysis.

Results

Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. 82% of the studies were conducted in the UK.

Conclusions

These findings highlight the disproportionate impact of Covid-19 on MEMs population, with an increased risk of all the adverse outcomes taken into consideration. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policy-makers to consider the socio-economic barriers when designing health promotion plans.

Key messages

• The combination of disadvantage socioeconomic conditions with COVID-19 transmission characteristics put migrants and ethnic minorities at a higher risk of facing sever health outcomes.

• The amount of evidence on the inequal impact of COVID-19 on migrants and ethnic minorities produced by European countries is poor. This gap must be filled to develop effective health promotion plans.

POS1267 LONG-TERM SURVEY STUDY OF THE IMPACT OF COVID-19 ON SYSTEMIC AUTOIMMUNE DISEASES. LOW DEATH RATE DESPITE THE INCREASED PREVALENCE OF SYMPTOMATIC INFECTION. ROLE OF PRE-EXISTING INTERSTITIAL LUNG DISEASE AND ONGOING TREATMENTS

Background

Patients with autoimmune systemic diseases (ASDs) can be counted among frail populations as regards the predisposition to COVID-19 due to the frequent visceral organ involvement and comorbidities, as well as the ongoing immunomodulating treatments.

Objectives

Our long-term multicenter telephone survey prospectively investigated the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients during the first 3 pandemic waves.

Methods

A large series of 3,918 ASD patients (815 M, 3103 F; mean age 59±12SD years) was consecutively recruited at the 36 referral centers of COVID-19 & ASD Italian Study Group. In particular, ASD series encompassed the following conditions: rheumatoid arthritis (n: 981), psoriatic arthritis (n: 471), ankylosing spondylitis (n: 159), systemic sclerosis (n: 1,738), systemic lupus (172), systemic vasculitis (n: 219), and a miscellany of other ASDs (n: 178). The development of COVID-19 was recorded by means of telephone survey using standardized symptom-assessment questionnaire (1).

Results

A significantly increased prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) was observed in our ASD patients, while the cumulative death rate revealed statistically comparable to the Italian general population (3.65% vs 2.95%; p: ns). In particular, among the 328 ASD patients complicated by COVID-19, 57 (17%) needed hospitalization, while mild-moderate manifestations were observed in the large majority of individuals (83%). In addition, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular manifestations.

Interestingly, a significantly higher COVID-19-related death rate was observed in systemic sclerosis patients compared to the Italian general population (6.29% vs 2.95%; p=0.018). Other adverse prognostic factors to develop COVID-19 were the patients’ older age, male gender, pre-existing ASD-related interstitial lung involvement, and chronic steroid treatment. Conversely, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the chronic administration of low dose aspirin in a subgroup of SSc patients (with 5.57% vs without 27.84%; p=0.000).

Conclusion

The cumulative impact of COVID-19 on ASD patients after the first 3 pandemic waves revealed less severe than that observed during the first phase of pandemic (1), especially with regards to the death rate that was comparable to the Italian general population in spite of the increased prevalence of complicating COVID-19 in the same ASD series.

Ongoing long-term treatments, mainly csDMARDs, might usefully contribute to generally positive outcomes of in this frail patients’ population.

Of note, a significantly increased COVID-19-related mortality was recorded in only SSc patients’ subgroup, possibly favored by pre-existing lung fibrosis. Among different ASD, SSc deserves special attention, since it shares the main pathological alterations with COVID-19, namely the interstitial lung involvement and the endothelial injury responsible for diffuse microangiopathy.

Besides SSc, the patients’ subgroups characterized by older age, chronic steroid treatment, pre-existing interstitial lung disease, and/or impaired COVID-19 vaccine response (1-3), may deserve well-designed prevention and management strategies.

References

[1]Ferri C, et al. Ann Rheum Dis. 2020 Oct 14 doi: 10.1136/annrheumdis-2020-219113.

[2]Ferri C et al. J Autoimmun. 2021 Dec;125:102744. doi: 10.1016/j.jaut.2021.102744.

[3]Visentini M et al. Ann Rheum Dis. 2021 Nov 24. doi: 10.1136/annrheumdis-2021-221248

Disclosure of Interests

None declared

759 Platypnoea orthodeoxia syndrome following middle-lower bilobectomy: a case report

Aims

PlatypneaOrthodeoxiasyndrome (POS) is a rare clinical condition characterized by dyspnoea and arterial desaturation, typically occurring in orthostatism and vanishing in a supine position. The real pathophysiologic triggers are still not completely understood.

Methods and results

In January 2021, a 76-year-old female patient was admitted to our department for the management of a large mass in the right lung (69 × 54 × 76 cm). Pre-operative Computed Tomography (CT)-scan showed a lesion of the right lower lobe, with suspected infiltration of posterior costal pleura and bronchoscopy revealed distal occlusion of intermedious bronchus. Surgical treatment was planned: extrapleural lower bilobectomy with the removal of the VI rib to reduce intracavity space was performed, using postero-lateral thoracotomy approach. On the third post-operative day, an acute neurologic deficit with left-sided paralysis, associated with desaturation and hypotension, occurred during a new attempt to mobilize the patient. Nonetheless the patient showed complete resolution of symptoms in supine position. A new similar episode of severe desaturation (SO2 80%) was observed in the 7th post-operative day. Arterial blood gas test showed PO2 37 mmHg; PCO2 27 mmHg; SO2 80.3%, pH 7.61, tHb 12.4 g/dl; O2Hb 78.4%. CT pulmonary angiography excluded a suspicious of pulmonary embolism. A right to left atrial shunt was suspected. Contrast-enhanced transcranial Doppler ultrasound showed microembolic signals in the basal cerebral arteries. Transoesophageal echocardiography was performed, confirming an interatrial septum with an exuberant hyperdynamic movement and showing an abundant passage of contrast from the right atrium to the left, even without the Valsalva manoeuvre, compatible with an important patent foramen ovale (PFO). Patient was referred to the cardiac Catheterization Laboratory for percutaneous closure of PFO. The device was successfully placed via right femoral venous catheter access and on transesophageal echocardiogram guidance. The procedure was performed without any complications. The implanted device was noted to be in a stable position with trivial residual inter-atrial shunting immediately after the procedure. The day after implantation, positional discomfort improved remarkably and the patient was able to stand-up with no symptoms, maintaining normal saturation (SaO2 100%). The patient was discharged and sent home on the third post-implantation day. The 4 month follow-up examination showed a good andstable condition.

Conclusions

Platypnoea Orthodeoxia Syndrome after lobectomy is a rare cause of postoperative dyspnoea/hypoxia.It is the result of right-to-left shunt via interatrial communication. Mediastinal relocation, stretching of the atrial septum are among the functional elements necessary for the clinical manifestations. It is essential to have a high index of suspicion to detect POS in patient with dyspnoea given the subtle and positional nature of the symptoms. Physicians should always consider POS in patients with unexplained dyspnoea; hence the treatment modalities could alleviate symptoms and be potentially curative.

Molecular characterization of A. baumanni isolates causing co-infections in SARS-COV-2 patients

Background

Respiratory viral infections, such as COVID-19, predispose patients to co-infections leading to increased morbidity and mortality. A. baumannii poses as a serious threat to hospital facilities because of its ability to persist in the environment and acquire multi-drug resistance. The aim of this study was to quantify the extent of A. baumannii cross-infection and identify any gene clonality between isolates in SARS-CoV-2 patients.

Methods

Bacterial isolates of A. baumannii found in patients with SARS-CoV-2 admitted to the main Intensive Care Unit (ICU) of the Umberto I Teaching Hospital of Rome were collected between March 2020 and February 2021. Isolates were typed by pulsed-field electrophoresis to analyse their homology relationships.

Results

Overall, 196 SARS-CoV-2 patients were admitted to the ICU. They were mainly male (N = 138) and aged 63 years on average. Of these, 122 died, and 74 were discharged. A total of 157 strains of A. baumannii were isolated from 74 patients (38%), who had a higher mean hospital stay than patients in whom the bacterial strain had not been isolated (24.6 vs. 12.2 days). The genotypic analysis of 120 isolates revealed two main patterns (A and F) and a few subtypes, especially A8 (43%), A4 (29%), and A11 (10%). Clone A8 was found mainly between October 2020 and February 2021, clone A4 in April-December 2020 and January-February 2021, and A11 in December 2020 and January 2021. The strains were susceptible to colistin only, were isolated mostly from tracheobronchial aspirates (41%) or rectal swabs (35%) and accounted for 56 healthcare-associated infections (33% of which sustained by A4, 38% by A8, and 9% by A11).

Conclusions

The isolation of A. baumannii from patients with COVID-19 highlighted the importance of monitoring co-infections caused by this pathogen, which frequently shows a multi-drug resistant profile that may lengthen the hospital stay. It is essential to implement preventive measures to contain these infections.

Key messages

A. baumanni is a pathogen that needs to be monitored because it may lengthen the hospital stay of SARS-CoV-2 patients. In critically ill patients, the continued growth of multidrug-resistant organisms shows the importance of preventing these infections.

Incidence rate of Healthcare Associated Infections in a COVID-19 Intensive Care Unit

Background

Intensive Care Units (ICU) faced a high pressure under the COVID-19 pandemic. It is recognized that patients admitted in these wards are more susceptible to Healthcare Associated Infections (HAIs). This study aims at comparing the incidence of HAIs in a COVID-19 ICU to a No-COVID ward.

Methods

A retrospective cohort study including patients admitted to the ICU of the Teaching Hospital Policlinico Umberto I in Rome from April 2020 to March 2021 was performed. Data on age, gender, hospitalization, different types of devices (ventilation, central venous and urinary catheter), number and type of device-related HAI were collected. Statistical analyses were performed with Episheet and STATA 13.

Results

Out of 347 patients admitted in the ICUs, 329 were included in the study (217 had COVID-19 and 112 had not). In the COVID-19 group, patients were mainly male (69.58%) with a mean age of 62.5±13.5 years, whereas the other group was slightly older (63.2±16.2 years) and more balanced between the two sexes (52.68% male). A total of 133 patients developed at least one HAI, 94 of which were SARS-CoV-2 positive. Globally, 246 HAIs were diagnosed: 163 occurred in the COVID group and 83 in the No-COVID one. The cumulative days of hospitalization were 3233 for the COVID group and 2134 for the No-COVID. The incidence of HAI considered for 1000 days of hospitalization among COVID patients was 50.42 (IC 95%: 42.97-58.78), compared to 38.89 (IC 95%: 30.98-48.22) for the No-COVID one, for an incidence rate ratio of 1.30 (IC 95%: 0.99-1.71).

Conclusions

Even though the confidence interval contains the value 1, the results point out that there is an increase in the incidence rate of HAI among COVID-19 patients. Further investigations are needed to better understand the reasons behind the present findings.

Key messages

Patients admitted to Intensive Care Units are more susceptible to Healthcare Associated Infections. Our study aims at describing the impact of COVID-19 on the risk of developing such conditions.

Being infected with COVID-19 leads to an increase in the incidence rate of Healthcare Associated Infections. Further studies are needed to understand the underlying reasons.

Perceived health and interaction with healthcare workers of a hard-to-reach group in a Roman suburb

 

Previous studies have showed that people living in Bastogi - a segregated and deprived peripheral area of Rome- have difficulties in accessing and relating to health services. Our aim was to analyze the health perception, health-related behaviors, and the interaction between healthcare professionals and the census population living in Bastogi, compared to the population living in the area of the same local health unit, ASL Roma 1 (hereafter ASL). The PASSI survey (from the Italian Surveillance System) was administered by phone and through door-to-door interviews to a sample of 210 residents of Bastogi. Data were analyzed and compared to the ones of the ASL collected in 2017-2018. Descriptive and univariate analysis were performed with STATA 13. P-values ≤ 0.05 were considered statistically significant. The socio-economic indicators, acknowledged determinants of health inequalities, showed a worse condition for the inhabitants of Bastogi. There was a significantly higher proportion of foreign and unemployed residents in Bastogi, with a lower educational level compared to the ASL. 58.1 % of the Bastogi group claimed their health to be good/very good (ASL: 71.6%; p = 0.000). 56.2% of the respondents from Bastogi were current smokers (ASL: 25.8%; p = 0.000). Risk factors for and prevalence of chronic diseases were significantly higher in Bastogi. The proportion of respondents who stated they had not had any recent contact with health professionals was significantly higher, and mammogram screening uptake was lower (75.3%; ASL: 90.4%; p = 0.001). Despite their lower help-seeking behavior, our study pointed out that the respondents from Bastogi who had had a contact with a health professional reported a higher perceived interest about their health than in the ASL. Further studies are needed to investigate whether this attention is attributable to the higher prevalence of chronic diseases or to the health professional's awareness of vulnerability of a hard-to-reach group.

Key messages

The population from Bastogi is marginalized and hard-to-reach: we found a worse overall self- reported health condition, a worse help-seeking behavior and a lack of reliance on health professionals. The PASSI survey administration has led to a greater involvement of the competent health institution, which resulted in the introduction of a community nurse and a Single Access Point.

The impact of the COVID-19 pandemic on healthcare-associated infections in intensive care unit patients: a retrospective cohort study

Background

During the intensive care units’ (ICUs) reorganization that was forced by the COVID-19 emergency, attention to traditional infection control measures may have been reduced. Nevertheless, evidence on the effect of the COVID-19 pandemic on healthcare-associated infections (HAIs) is still limited and mixed. In this study, we estimated the pandemic impact on HAI incidence and investigated the HAI type occurring in COVID-19 patients.

Methods

Patients admitted to the main ICU of the Umberto I teaching hospital of Rome from March 1st and April 4th 2020 were compared with patients hospitalized in 2019. We assessed the association of risk factors and time-to-first event through multivariable Fine and Grey’s regression models, that consider the competitive risk of death on the development of HAI (Model 1) or device related-HAI (dr-HAI, Model 2) and provide estimates of the sub-distribution hazard ratio (SHR) and its associated confidence interval (CI). A subgroup analysis was performed on the 2020 cohort.

Results

Data from 104 patients were retrieved. Overall, 59 HAIs were recorded, 32 of which occurred in the COVID-19 group. Patients admitted in 2020 were found to be positively associated with both HAI and dr-HAI onset (SHR: 2.66, 95% CI 1.31–5.38, and SHR: 10.0, 95% CI 1.84–54.41, respectively). Despite being not confirmed at the multivariable analysis, a greater proportion of dr-HAIs seemed to occur in COVID-19 patients, especially ventilator-associated pneumonia, and catheter-related urinary tract infections.

Conclusions

We observed an increase in the incidence of patients with HAIs, especially dr-HAIs, mainly sustained by COVID-19 patients. A greater susceptibility of these patients to device-related infections was hypothesized, but further studies are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00959-y.

Critical Limb Ischemia: A Practical Up-To-Date Review

Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.

The Effects of Acute Passive Smoke Exposure on Endothelium-Dependent Brachial Artery Dilation in Healthy Individuals

Passive smoking has both short-term and long-term vascular effects. It is not clear whether impairment of endothelial function reflects the acute effects of passive smoke exposure or the chronic effects. The purpose of this study was to assess the hypothesis that short-term exposure to passive smoke impairs endothelium-dependent vasodilation in healthy nonsmokers. Eighteen healthy young never smokers (12 men, 6 women) 21 to 55 years old (mean ± SD: 34 ±9 years) underwent ultrasonography measuring baseline brachial-artery diameter and brachial-artery diameter during hyperemia and after sublingual administration of nitroglycerin, twice: in a smoke-free environment, and then in the same environment polluted by 30 to 35 ppm carbon monoxide. Each subject served as his/her control. Carboxyhemoglobin was measured in blood samples of subjects tested. Mean value of carboxyhemoglobin was 0.6 ±0.5% in a smoke-free environment and 1.4 ± 0.5% in a smoking environment (p <0.02). Mean values of flow-mediated dilation (FMD) were 12.6% ± 7.8% in a smoke-free environment versus 6.8 ± 7.8% in a smoking environment (p <0.01). On the contrary, nitroglycerin-induced vasodilation did not show any statistical difference (21 ± 9.8% versus 23 ±1.4%). Finally, the increase of carboxyhemoglobin was related statistically to the impairment of flow-mediated dilation (r = 0.51; p <0.002). Passive smoking impaired flow-mediated vasodilation in healthy never smokers in a smoking environment. The impairment was strongly related to carboxyhemoglobin level.

Treatment of extreme maxillary atrophy with Zygoma implants

The implant-prosthetic rehabilitation of severe maxillary atrophy often requires difficult bone grafting techniques or microvascularized flaps with long healing time and severe discomfort for the patients. An alternative is represented by the use of particular thick bone areas like "zygomatic buttresses" that are away from the alveolar ridge but they are good for anchoring implants. From 2008, 31 patients, aged between 52 and 82 years, with severe maxillary atrophy, have been rehabilitated using zygomatic implant (Zygoma Brånemark System®) and conventional implants (4 mm of diameter and a length of 13 to 15 mm); a total of 152 implants were inserted, 78 Zygoma implants and 74 conventional implants in the premaxilla. As dictated by our protocol, all of them were followed by immediate prosthetic loading. Follow-up ranges from 20 months to 5 years. Two Zygoma implants failed out of 78 fixtures inserted with a success rate of around 98%. No failure of conventional implants. Two patients developed a postoperative sinusitis; one case healed only after endoscopically guided medium meatal antrostomy. In one case the removal and reinsertion of one Zygoma implant was necessary. We observed two cases of temporary zygomatic hypoesthesia, two cases of persistent oedema for three weeks and one case of facial postoperative haematoma; all of them spontaneously solved after a few weeks. Our results are in agreement with the Literature and lead to the conclusion that the use of Zygoma implants is a reproducible and predictable alternative to bone grafts, with the advantage of a considerable saving of time.

Bilateral posterior maxillary segmental osteotomy to rehabilitate edentulous mandibular area: case report

The purpose of this work was to describe a clinical case with reduced vertical height in both the posterior sectors, due to maxillary dento-alveolar extrusion in mandibular edentulous space, as a result of some extractions which have not been promptly replaced by a prosthetic rehabilitation, eventually resolved with a bilateral posterior segmental maxillary osteotomy (PMSO). Our surgical technique was practised under general anesthesia according to Kufner's version of Schuchardt's original description. In the light of the present outcomes, in severe clinical cases of dento-alveolar extrusion, the PMSO can be considered the optimal solution, because of the quality and the stability of the final result, the short therapeutic times, the limited morbidity and the modest compliance asked to the patient.

Carotid Intima-Media Thickness in Asymptomatic Patients With Arterial Hypertension Without Clinical Cardiovascular Disease: Relation With Left Ventricular Geometry and Mass and Coexisting Risk Factors

We analyzed in NYHA I hypertensives the interactions between Carotid Intima-Media Thickness (IMT), Hypertension and Cardiovascular (CV) risk factors and relationships between IMT, CV risk factors and left ventricular (LV) geometric remodelling. 198 asymptomatic, never treated, essential hypertensives (age: 58.2 ± 13) and 67 (age-gender matched) healthy subjects, were studied. Complete clinical examination, 2D Doppler echocardiography and vascular echography were performed in all study subjects. Major values of IMT are present in concentric LVH. Distribution of IMT among risk factors groups shows an higher IMT respect to increasing number of risk factors (P < 0.001). Significant correlation are present between pulse pressure and IMT (P < 0.006; r = 0.19) and IMT and LVM (P < 0.0001; r = 0.35). Altered patterns of LV geometry and carotid structural changes occur in many patients with essential hypertension. LVH or carotid remodeling are greater in elderly, in patients with higher systolic BP and with associated CV risk factors.

Relation of carotid intima-media thickness and aortic valve sclerosis (from the ISMIR study ["Ispessimento Medio Intimale e Rischio Cardiovascolare"] of the Italian Society of Cardiovascular Echography)

Carotid intima-media thickness (IMT) and aortic valve sclerosis (AVS) have recently emerged as important predictive factors for cardiovascular (CV) events. However, few data are available on their association and the respective roles of major CV risk factors in determining either condition. In this study, 479 asymptomatic subjects (mean age 58 +/- 13 years, 62% men) were assessed, without histories of CV disease, consecutively referred for comprehensive evaluations by echocardiography and carotid ultrasonography because of the presence of > or = 1 risk factor. Common carotid artery IMT and aortic valve morphology and function were analyzed. The mean IMT was 0.82 +/- 0.19 mm. The prevalence of increased carotid IMT (>0.80 mm) and AVS was 60.8% and 18.4%, respectively. The prevalence of increased IMT was 79.6% in subjects with AVS and 56.5% in those without AVS (relative risk 2.99, 95% confidence interval 1.72 to 5.21, p <0.001). On multivariate analysis, increased IMT was significantly and independently associated with hypertension, dyslipidemia, obesity, family history of CV disease, and age. Only age emerged as an independent predictor of AVS. The presence of both markers was independently associated only with hypertension and age. In conclusion, increased carotid IMT was strongly associated with AVS in a population of asymptomatic patients. IMT and AVS were differently related to individual CV risk factors, and their association seems to be correlated mainly with age and hypertension.

Congenital hypoplasia of the inferior vena cava and inherited thrombophilia: rare associated risk factors for idiopathic deep vein thrombosis. A case report

In young patients, acquired and genetic causes of deep vein thrombosis frequently interact. The association of congenital hypoplasia of the inferior vena cava with antithrombin III deficiency has never been described in the literature as a causal factor of proximal deep vein thrombosis in young patients. We report the case of an 18-year-old patient affected by deep vein thrombosis due to this rare association without other common risk factors.

Measles outbreak in Grosseto, central Italy, 2006

From 2003 to 2007, Italy is implementing a national plan to eliminate measles and congenital rubella

Dental caries and bone mineral density: a cross sectional study

AIM

The relationship between bone mineral density (BMD), age and dental caries has been studied. Quantitative ultrasonography (QUS) is an economic, non invasive, and reproducible method for measuring both bone mineral density and bone elasticity in growing subjects in large populations.

METHODS

This study evaluated the relationship between BMD and prevalence of dental caries (Decayed Missing Filled Tooth - DMFT) in 540 healthy adolescent with mean age 12.3 years, age range 10 to 15 years, resident in two provinces in south Italy. BMD was measured using QUS by calculating the speed of sound (m/s) on the last four fingers of the non dominant hand, with the estimate thus obtained being defined as the AD-SoS (Amplitude-Dependent Speed of Sound and categorised as AD-SoS < or = 1900 m/s and AD-SoS > 1900 m/s). Occurrence of dental caries was defined using the DMFT index (DMFT=0 and DMFT > 0).

RESULTS

The results of the multifactorial analysis, carried out with logistic model, confirms the expected statistically significant association between response (DMFT) and explicative variables -- AD-SoS (P < 0.006) and Age (P < 0.004).

CONCLUSION

Greater bone mineralisation (AD-SoS1900 m/s) and younger age (Age < or =12 years) are dental caries prevention factors: the probability to have caries for the subjects in such conditions is 0.34, about the half of that recorded in the subjects with lower bone mineralisation and older age (0.62).

Minimal tolerance to the bronchoprotective effect of inhaled salmeterol/fluticasone combination on allergene challenge

In order to assess whether the administration of salmeterol/fluticasone propionate combination (50/250 mcg by Diskus) for 1 week induces tolerance to the bronchoprotective effect of salmeterol on allergen challenge, a single-blind, cross-over study was carried out. We studied nine subjects (eight men and one woman; mean age+/-SD: 31.3+/-11.0 yr) with mild intermittent allergic asthma, never treated with regular beta2-agonists or inhaled corticosteroids. In a previous allergen challenge all subjects had shown a positive early airway response (EAR) to allergen. They underwent allergen challenge after 1-week treatment with placebo and a single dose of placebo immediately before allergen challenge (T1), or 1-week treatment with placebo and a single dose of salmeterol/fluticasone immediately before allergen challenge (T2), or 1-week treatment with salmeterol/fluticasone combination bid and a single dose of salmeterol/fluticasone immediately before allergen challenge (T3). EAR was evaluated both as maximum decrease in FEV1 (MaxDeltaFEV1 %) after allergen challenge and as area under FEV1 -time curve. MaxDeltaFEV1 % during allergen challenge protected by placebo (T1) was significantly greater than MaxDeltaFEV1 % during allergen challenges protected by single dose of salmeterol/fluticasone (T2) and by salmeterol/fluticasone 1-week treatment (T3). No difference was found in MaxDeltaFEV1 % between T2 and T3. The same results were observed also after computing the area under the curve for each challenge. When individually considered, all subjects were protected against EAR (protection index > or = 80%) at T2, while at 3 seven out of nine subjects were still protected against EAR. In conclusion, the simultaneous administration of salmeterol and fluticasone in the same device prevents in almost 80% of examined subjects the development of tolerance to the protective effect of salmeterol on allergen challenge. This observation may contribute to explain the positive interaction between inhaled beta2-agonists and corticosteroids in the long-term treatment of asthma.

Thrombolytic therapy in peripheral arterial disease

The two main causes of peripheral arterial occlusion (PAO) are embolism and thrombosis. Surgical treatment of acute limb ischemia, because of related complications, has a 30-day mortality rate of 15% to 25%. Intra-arterial thrombolysis for lower extremity ischemia is a well-accepted and frequently used technique. It may offer definitive treatment without the need for major surgery in a significant series of patients with acute occlusion of a native leg artery or a by-pass graft. Thrombolysis can offer several potential advantages when compared with surgical therapy. Thrombolytic agents include streptokinase (SK), urokinase (UK), pro-UK and recombinant tissue plasminogen activators (rt-PA-Alteplase and r-PA-Reteplase). All these agents induce a systemic fibrinolytic state. Three prospective randomized trials, ROCHESTER, STILE, and TOPAS, which compared thrombolytic therapy with traditional surgical revascularization for lower limb ischemia, have recently been published. They suggest that thrombolysis, as an initial therapy, reduces the risk of subsequent surgery and improves limb salvage for patients with PAO. Using this approach, the underlying lesions can be identified and treated by transluminal balloon angioplasty or stenting, or by elective surgical revascularization. However, severe bleeding is still a non rare complication of intra-arterial thrombolysis and the risk of intracranial hemorrhage is 1-2%.

Passive smoking and coronary heart disease

A large series of clinico-epidemiological studies, meta-analyses and experimental findings have concluded that there is a relationship between coronary heart disease (CHD) and passive smoking either after acute or chronic exposure. Cigarette smoking is the most important cause of premature death in industrialized countries because it is associated with an increased risk of developing several types of cancer and arterial disease. In family homes as well as in workplaces, environmental tobacco smoke (ETS) exposure is associated with an increased risk of CHD in exposed non-smokers when compared to un-exposed non-smokers. Different anatomical structures are damaged by ETS. The endothelium, artery wall and heart are target organs for passive smoking. Therefore, smoking cessation will benefit both smokers and those exposed to ETS.

One week treatment with salmeterol does not prevent early and late asthmatic responses and sputum eosinophilia induced by allergen challenge in asthmatics

Salmeterol is an effective long-acting beta(2)-agonist bronchodilator, able to inhibit, as a single dose, asthmatic responses induced by several stimuli including allergen, and the subsequent increase in sputum eosinophilia. Aim of the present study was to investigate whether these effects of salmeterol persisted after 1 week of continuous treatment, or whether a loss of the bronchoprotective effects of salmeterol can occur over time. We investigated in a cross-over double blind placebo-controlled study, the protective effect of 1 week treatment with salmeterol on allergen-induced early and late responses and the associated airway inflammation in 15 atopic asthmatic subjects. Eosinophil percentage and Eosinophil Cationic Protein (ECP) concentration in peripheral blood and in hypertonic saline induced sputum were measured at baseline and 24 h after allergen inhalation. Salmeterol partially inhibited early asthmatic response, but it did not inhibit late asthmatic response in comparison with placebo. Salmeterol did not inhibit also the increase in sputum eosinophils percentage 24 h after allergen inhalation (E%, median: 22.7 and 15%, after placebo and after salmeterol respectively, p=n.s. between two post-allergen sputum samples). Also, the increase in blood eosinophils and both sputum and serum ECP at 24 h after allergen challenge was not affected by salmeterol pre-treatment. In conclusion, 1 week treatment with salmeterol causes a loss of its protective effect on allergen-induced airway bronchoconstriction, and does not prevent the subsequent increase in sputum and serum eosinophilic markers.

Clinical assessment of asthma severity partially corresponds to sputum eosinophilic airway inflammation

In the aim to evaluate the relationship between sputum eosinophil percentages and eosinophil cationic protein (ECP) concentrations, as markers of airway inflammation, and different Levels of asthma severity, we examined 223 patients consecutively observed in our asthma clinic. Diagnosis of asthma was made according to internationally accepted criteria. Asthma severity was evaluated according to frequency of symptoms, FEV1, peak expiratory flow variability and level of asthma treatment needed to control asthma. Spontaneous or induced sputum was collected. Adequate sputum samples were obtained in 68 untreated subjects and in 117 subjects regularly treated with ICS. A control group of 14 normal subjects was also examined. In untreated subjects, mild intermittent asthmatics showed a lower sputum eosinophil percentage in comparison with other groups of asthma severity, while no difference in ECP levels was detected. In treated subjects, severe asthmatics showed higher levels of sputum eosinophils and ECP in comparison with other groups of asthma severity. Mild persistent and moderate persistent patients did not differ for sputum eosinophils or ECP in both untreated and treated subjects. Controls were significantly different from all groups of untreated and treated asthmatics. In conclusion, the assessment of asthma severity according to clinical and functional findings only partially corresponds to the severity of eosinophilic airway inflammation as assessed by induced sputum analysis.

Short-term effect of the addition of leukotriene receptor antagonists to the current therapy in severe asthmatics

In a single blind study, the short-term efficacy of the addition of leukotriene receptor antagonists (LTRA: montelukast 10 mg o.d. in 15 subjects, zafirlukast 20 mg b.i.d. in 11 subjects) to the current therapy was evaluated in severe asthmatics, unstable under regular treatment with high dose inhaled corticosteroids, bronchodilators and, in seven of them, oral corticosteroids. Each subject monitored symptoms, PEF and rescue medication during two weeks with the addition of placebo, and during two following weeks with the addition of LTRA; clinic FEV1 was measured at the beginning and at the end of each 2 weeks period. There was no significant difference in the mean FEV1, PEF, symptom score and rescue medication use between two periods of placebo and LTRA treatments. When two subjects with asthma exacerbation during treatment with LTRA were excluded, FEV1 was higher after LTRA than after placebo treatment (p=0.055). An increase in FEV1>12% pred. at the end of LTRA treatment was observed in five out of 26 subjects (19%). We suggest that LTRA have no overall significant efficacy in severe asthmatics not controlled by high dose inhaled corticosteroids and bronchodilators, but that a minority of these patients could be particularly sensitive to the positive effects of these drugs. The detection of these 'responders' could be relevant in the treatment of severe asthma.

[Anterior iliac bone grafts: techniques and sequelae. Report on 107 cases and review of the literature]

The anterior iliac crest is the harvest site preferred by many authors because of the quantity and quality of bone obtainable and the simplicity of harvesting techniques. The purpose of the present paper is to present a review of anterior iliac crest harvesting techniques and to illustrate the most serious sequelae reported in the literature. A clinical series is also presented in order to evaluate what is, in our experience, the degree of morbility connected with this donor site. We have controlled 107 patients who underwent bone harvesting from the anterior iliac crest between 1980 and 2000, investigating minor complications such as walking deficiency (immediate and long-term) the formation of seromas, haematomas, adynamic ileus and more serious complications such as retroperitoneal haemorrhages, abdominal hernias, ileus fractures, nervous lesions (immediate and long-term). From our survey it emerged that, among the major complications, incidentally rarely reported in the international literature, we found only a small percentage of cases involving damage to nervous structures. Minor complications were also limited and the only problem remains difficulty in walking after the operation which resolves fully in almost all cases. We can therefore state that the anterior iliac crest remains, to date, an excellent site for harvesting and there is no significant morbility and the surgeon has numerous techniques available for reducing the incidence of complications to the minimum.

Fifty microg b.i.d. of inhaled fluticasone propionate (FP) are effective in stable asthmatics previously treated with a higher dose of FP

Twenty-seven subjects with moderate asthma at the time of diagnosis, well controlled under regular fluticasone propionate (FP) (250 microg b.i.d.) for 6 months at least, were randomized to receive in double-blind fashion: FP 125 microg b.i.d. (Group 1) or FP 50 microg b.i.d. (Group 2) or placebo (Group 3) for 3 months or until symptom recurrence. Daily symptom score and peak expiratory flow were monitored. At the beginning and at the end of the study subjects underwent methacholine challenge and sputum induction. Recurrence of symptoms occurred shortly after randomization in all subjects receiving placebo. None from Group 1 or 2 experienced symptom recurrence during the study. No significant difference in clinical and functional data, and in sputum eosinophil percentages was observed between the beginning and the end of the study in both Groups 1 and 2. Subjects from Group 3 showed a significant increase of sputum eosinophils (P<0.05) and a significant decrease in provocative dose of methacholine (P<0.05) when asthma symptoms recurred. Therefore, very low doses of FP (50 microg b.i.d.) are effective in maintaining for 3 months a good control of the disease in asthmatics already stable under high-dose fluticasone, considering both clinical and functional outcomes and markers of airway inflammation.

Questionnaires, spirometry and PEF monitoring in epidemiological studies on elderly respiratory patients

Questionnaires are the most used subjective instrument of measurement in respiratory epidemiology. The standardisation of the questionnaires aims to limit bias by maximising validity and reliability, and comparability. Within the European Union project BIOMED1, a compendium of respiratory standard questionnaires (CORSQ) was developed for adults covering 18 topics from general information to early life events, through environmental risk factors and respiratory symptoms and diseases. Reliable spirometry data needs a rigorous quality control programme, as in the "Salute Respiratoria nell'Anziano" (Sa.R.A.) project, Italian for "Respiratory Health in the Elderly". Reproducibility rates were 95.8% for forced expiratory volume in one second (FEV1). Male sex and age were independent risk factors for a poorer reproducibility, as well as cognitive and physical impairment (shorter 6-min walking distance) and lower educational level for a poorer acceptability. Reference values for people aged 65-85 yrs have been produced; these results suggest that the effect of aging should be corrected for physical and mental disability. A revision of interpretative strategies included in current guidelines is needed. Peak expiratory flow monitoring has several methodological problems: reliability and sensitivity of the measurement in order to detect changes in airway calibre; compliance with long-term monitoring; choice of the best variability index; difference between asthmatic and nonasthmatic subjects; age-related differences. Despite these methodological problems, peak expiratory flow monitoring has been successfully used in the evaluation of the effects of air pollution in normal and asthmatic subjects, and in the elderly.

Quality evaluation of samples obtained by spontaneous or induced sputum: comparison between two methods of processing and relationship with clinical and functional findings

The aim of the study was to assess, on a large group of spontaneous or induced sputum samples, the difference in quality between slides processed by two different methods, and the relationship between quality assessment and some clinical and functional characteristics of the examined subjects. We examined 631 sputum samples obtained from 337 subjects with proven (n = 291) or suspected bronchial asthma. Of these, 467 samples were processed using the whole-sample method (Group I), while 164 samples were processed using the plug method (Group II). Salivary contamination, cell distribution on the slide, and cell borders were evaluated, and samples were classified as inadequate, adequate, or good. Inadequate samples were equally represented in both groups, while good samples were represented more in Group II. No significant difference in most clinical and functional findings was observed between the different quality categories of both groups. A higher proportion of inadequate samples was observed in Group I samples spontaneously collected. Mild intermittent asthmatics produced a better quality of slides in comparison with other groups of asthma severity. In conclusion, sputum quality partially depends on the different methods of sputum collection and/or processing, although the percentage of inadequate samples is similar for the two methods of processing. Sputum quality is only marginally affected by clinical and functional characteristics of asthma, or by asthma severity.

Comparison of anti-inflammatory and clinical effects of beclomethasone dipropionate and salmeterol in moderate asthma

Inhaled corticosteroids and long-acting beta2-agonists effectively control asthma symptoms and improve airway function. The effects of beclomethasone were compared with those of salmeterol on markers of eosinophilic inflammation in induced sputum in steroid-naive asthmatic subjects with moderate asthma. Fifteen moderate asthmatics were treated with either beclomethasone dipropionate (500 microg b.i.d.) or salmeterol (50 microg b.i.d.) for 4 weeks, according to a randomised, double-blind, parallel-group study design. All patients underwent spirometry, methacholine test, sputum induction, and blood sampling before and after 2 and 4 weeks of treatment. They also recorded daily symptoms and peak expiratory flow (PEF). Sputum eosinophils, eosinophil cationic protein (ECP) and eosinophil protein X (EPX), and blood eosinophils, as well as the forced expiratory volume in one second (FEV1) and morning PEF, significantly improved after beclomethasone but not after salmeterol. PEF variability, the symptom score and rescue beta2-agonist use significantly improved after both treatments, although the improvement in the symptom score tended to be greater after beclomethasone. After 2 and 4 weeks of beclomethasone treatment, both serum ECP and EPX decreased. With salmeterol, only serum EPX decreased, after 4 weeks. Bronchial hyperresponsiveness to methacholine did not change after either treatment. The authors conclude that beclomethasone, but not salmeterol, substantially improves airway inflammation in asthma. Beclomethasone also had an overall greater clinical effect, although the improvement in symptoms and peak expiratory flow variability was similar after both treatments.

Budesonide reduces neutrophilic but not functional airway response to ozone in mild asthmatics

Ambient ozone concentration is related to asthma exacerbation, but few findings are available regarding the effects of pharmacologic asthma treatment on this relationship. The purpose of this study was to investigate whether inhaled corticosteroids inhibit ozone-induced airway neutrophilic inflammation, as detected in induced sputum, and reduce functional response to ozone exposure. Eleven subjects with mild persistent asthma were exposed for 2 h, on separate days, to 0.27 ppm ozone and to air in random order, before and after 4 wk of treatment with budesonide (400 microg twice daily). Before exposure, 1 and 2 h after the beginning of exposure, and 6 h after the end of exposure, pulmonary function was measured, and a total symptom score questionnaire was completed; 6 h after exposure, sputum was induced with hypertonic saline. Budesonide treatment did not inhibit the functional response to ozone exposure, as determined by reduction in FEV(1) and increase in total symptom score, but it significantly blunted the increase in the percentage of sputum neutrophils and interleukin-8 concentrations in the supernatant (p < 0.05). Therefore, 4 wk of inhaled budesonide blunted the airway neutrophilic inflammatory response but did not prevent the functional impairment of the airways after ozone exposure.

Activity of the new antifungal triazole, posaconazole, against Cryptococcus neoformans

The new antifungal derivative posaconazole was tested against three clinical isolates of Cryptococcus neoformans var. neoformans using a broth microdilution procedure performed according to the guidelines established by the NCCLS. Posaconazole MICs were 0.125, 0.25 and 1.0 mg/L for isolates 491, 2337 and 486, respectively. To investigate the in vivo activity of this new compound, we established an experimental model of systemic cryptococcosis in CD1 mice by iv injection of cells of each strain of C. neoformans. Low (3 mg/kg/day) and high (10 mg/kg/day) doses of posaconazole were compared with amphotericin B given at 0.3 mg/kg/day for 10 consecutive days. Survival studies showed that all treatment regimens were effective in prolonging the survival of mice infected with C. neoformans 486 (P < 0.001). Only posaconazole at 10 mg/kg and amphotericin B were effective in prolonging the survival in mice infected with C. neoformans 2337 (P from <0.01 to <0.001), while neither agent was effective in mice infected with C. neoformans 491. Tissue burden experiments performed 24 h after the end of therapy revealed that posaconazole at 10 mg/kg was effective at reducing the fungal burden in both lung and brain tissues of all three strains of C. neoformans. In particular, for C. neoformans 491 and 2337 posaconazole was superior to amphotericin B at reducing the fungal burden in the brain (P < 0.05). The efficacy of posaconazole was also confirmed by determining the capsular antigen serum levels of treated mice versus untreated mice. Our study underlines the excellent activity of posaconazole against this pathogenic yeast.

Tolerance to the protective effect of salmeterol on allergen challenge can be partially restored by the withdrawal of salmeterol regular treatment

STUDY OBJECTIVE

To assess whether the withdrawal of salmeterol treatment for 3 days (72 h) can restore its bronchoprotective ability on specific bronchial provocative test (sBPT) with allergen, which was completely lost after 1 week of regular treatment with salmeterol.

STUDY DESIGN

Single-blind design.

PATIENTS AND METHODS

We investigated 10 nonsmoking subjects (8 men and 2 women; mean +/- SD age, 24 +/- 8 years) with mild intermittent allergic asthma in the stable phase of the disease, who were never previously treated with regular beta(2)-agonists. Subjects with a previous positive early airway response (EAR) to a screening allergen challenge were considered. They underwent sBPT with allergen after a single dose of inhaled salmeterol, 50 microg (T(1)), and then underwent sBPT after 1 week of regular treatment with inhaled salmeterol, 50 microg bid (T(2)); after that, they continued inhaled salmeterol treatment for 4 days, and then changed to inhaled salmeterol with placebo (two puffs bid) for 3 days (72 h) and underwent sBPT with allergen after a single dose of salmeterol, 50 microg (T(3)).

RESULTS

EAR to allergen (DeltaFEV(1) > or = 20% with respect to postdiluent value) was completely abolished by a single dose of salmeterol (T(1); protection index [PI] > or = 50% in all subjects), but it was still present after 1 week of regular treatment with salmeterol (T(2); PI < 50% in all subjects). The maximum FEV(1) percentage fall during sBPT with allergen was significantly lower after withdrawal of regular inhaled salmeterol (T(3)) than after regular treatment with salmeterol (T(2)) (mean, 23% vs 29.5%; range, 4 to 41% vs 18 to 49%, respectively; p < 0.05); a similar result was obtained considering the PI of salmeterol on sBPT with allergen (mean, 44% vs 20%; range, 2 to 86% vs - 11 to 49%, respectively; p < 0.05). However, the maximum FEV(1) percentage fall and PI were significantly different in T(3) than after T(1), and only 4 of 10 patients showed in T(3) a PI > or = 50%.

CONCLUSIONS

The bronchoprotective effect of salmeterol on allergen-induced EAR, completely lost after 1 week of regular treatment with salmeterol, may be partially restored by the withdrawal of salmeterol therapy for 3 days (72 h). However, this withdrawal time period is not sufficient to recover the baseline bronchoprotective efficacy of the first dose of salmeterol.

Interactions of posaconazole and flucytosine against Cryptococcus neoformans

A checkerboard methodology, based on standardized methods proposed by the National Committee for Clinical Laboratory Standards for broth microdilution antifungal susceptibility testing, was applied to study the in vitro interactions of flucytosine (FC) and posaconazole (SCH 56592) (FC-SCH) against 15 isolates of Cryptococcus neoformans. Synergy, defined as a fractional inhibitory concentration (FIC) index of <0.50, was observed for 33% of the isolates tested. When synergy was not achieved, there was still a decrease in the MIC of one or both drugs when they were used in combination. Antagonism, defined as a FIC of >4.0, was not observed. The in vitro efficacy of combined therapy was confirmed by quantitative determination of the CFU of C. neoformans 486, an isolate against which the FC-SCH association yielded a synergistic interaction. To investigate the potential beneficial effects of this combination therapy in vivo, we established two experimental murine models of cryptococcosis by intracranial or intravenous injection of cells of C. neoformans 486. At 1 day postinfection, the mice were randomized into different treatment groups. One group each received each drug alone, and one group received the drugs in combination. While combination therapy was not found to be significantly more effective than each single drug in terms of survival, tissue burden experiments confirmed the potentiation of antifungal activity with the combination. Our study demonstrates that SCH and FC combined are significantly more active than either drug alone against C. neoformans in vitro as well in vivo. These findings suggest that this therapeutic approach could be useful in the treatment of cryptococcal infections.

Effects of inhaled corticosteroids on cough threshold in patients with bronchial asthma

In asthmatic subjects cough can be related to the degree of airway inflammation. The aim of this study was to evaluate the effect of treatment with high dose inhaled beclomethasone dipropionate (BDP) on cough threshold in asthmatic subjects. Cough threshold to inhaled capsaicin (one breath of 10(-8)-10(-4)M solution) and to citric acid (one breath of 10(-4)-1 M), expressed as provocative concentration of two (PC2) and four coughs (PC4), was measured in 16 normal and 36 asthmatic subjects. After baseline evaluation, asthmatic subjects were randomized in two groups: (a) Group A, n=20: treated with salbutamol (200 microg t.i.d.) plus BDP (500 microg t.i.d.); (b) Group B, n=16: treated with salbutamol plus placebo in the same doses. After 1 month, cough threshold and clinical and functional evaluation were repeated. After treatment, asthmatics of group A showed a significant improvement in PC4 citric acid, in total symptom and cough scores, and in PD20FEV1 methacholine. In asthmatics of group B, treatment caused no improvement in symptoms, PD20FEV1 methacoline and cough threshold. In addition, cough threshold was not different between normal and asthmatic subjects and, in asthmatics, cough threshold did not correlate with PD20FEV1 methacholine. These data confirm that cough in asthma can be partially related to airway inflammation.

Analysis of induced sputum before and after withdrawal of treatment with inhaled corticosteroids in asthmatic patients

To assess whether sputum eosinophilia predicts the recurrence of asthma symptoms after withdrawal of therapy in moderate stable asthmatics on low-dose inhaled corticosteroids. Randomized, double-blind, placebo-controlled study involving 30 subjects with stable asthma, asymptomatic, with low PEF variability measured over two run-in weeks, on treatment with low-dose inhaled beclomethasone dipropionate (BDP, 250 microgram b.i.d. in the last 3 months). At the end of the run-in, all patients underwent a methacholine challenge test and sputum induction (T1). They then stopped therapy and received either placebo (20 subjects, study group) or BDP at the same dose as in the previous 3 months (10 subjects, control group). They continued to monitor PEF and symptom score for 3 months, or until asthma symptoms recurred (diurnal and nocturnal symptom score >/=2 on two consecutive days). At the end of the study (T2), i.e., either within 5 days from the beginning of asthma symptoms or after 3 months in subjects without recurrence of asthma symptoms, all subjects repeated the methacholine challenge test and sputum induction. In the placebo-treated group, sputum eosinophils at T1 were significantly higher in subjects who subsequently developed recurrence of asthma symptoms (n = 7) after cessation of treatment than in subjects who remained asymptomatic for 3 months (8.2% [0-56.6] vs 0.9% [0-11], P < 0.05). At the time of recurrence of asthma symptoms, sputum eosinophil percentages significantly increased (from 8.2% [0-56.6] to 16.6% [5.8-73.6], P < 0.05). The positive predictive value of sputum eosinophils for the recurrence of asthma symptoms was 71%, while the negative predicting value was 84%. In the BDP-treated control group, none of the subjects experienced recurrence of asthma symptoms, and sputum eosinophil percentages measured at the beginning (T1) and at the end (T2) of the study were similar. Sputum eosinophil percentages may vary over a wide range in asthmatic subjects, although regularly treated and apparently well controlled. However, high sputum eosinophil percentages are related to early recurrence of asthma symptoms after cessation of inhaled corticosteroids.

Dissociation between microalbuminuria and common carotid thickness in essential hypertensive men

BACKGROUND

The reasons why microalbuminuria (albuminuria > or = 15 microg/min), an expression of a renal microcirculatory abnormality, predicts cardiovascular disease in essential hypertension are unsettled. To test the hypothesis that microalbuminuria represents a marker of subclinical atherosclerosis, we evaluated its association with common carotid artery (CCA) intima media thickness (IMT), a measure of preclinical atherosclerosis and an independent predictor of cardiac and cerebrovascular events, in uncomplicated essential hypertensive individuals.

MATERIALS AND METHODS

Albuminuria, ultrasonographic CCA IMT (the mean of six bilateral far wall measurements within 1.5 cm proximally to the flow divider), brachial blood pressure (BP), smoking habits and lipids were evaluated in 136 stage 1-3 untreated essential hypertensive men free of cardiovascular disease.

RESULTS

CCA IMT did not differ between normo- (n = 99) and microalbuminuric (n = 37) patients. The correlation between CCA IMT and albuminuria was not significant, and the prevalence of microalbuminuria across IMT quartiles was not different. Microalbuminuric patients showed higher systolic BP and that parameter was the only independent correlate in a multivariate logistic regression model including also age, CCA IMT, diastolic BP, lipids and smoking habits as independent variables and microalbuminuria as the dependent one.

CONCLUSION

This cross-sectional study in hypertensive subjects free of cardiovascular disease has shown a dissociation between microalbuminuria and CCA IMT, a surrogate measure of subclinical atherosclerosis, and a parameter linearly related to cardiovascular events. The data do not support the theory of microalbuminuria as a surrogate measure of subclinical atherosclerosis, while confirming the importance of systolic BP levels as an independent correlate of increased albuminuria in essential hypertension. Journal of Human Hypertension (2000) 14, 831-835

Natural exposure to pollen reduces the threshold but does not change the pattern of response to the allergen in allergic subjects

It is known that exposure to seasonal allergen in sensitized asthmatics increases non-specific bronchial responsiveness, but it is controversial if exposure to seasonal allergen influences the presence and the severity of the late asthmatic response (LAR) to allergen. Fifteen asthmatic subjects sensitized to grass pollen performed a specific bronchial provocative test (sBPT) with Phleum pratensis extract before and during the pollen season. Changes of methacholine were also assessed. Allergen PD20FEV1 significantly decreased during the pollen season with respect to outside (allergen PD20FEV1, geometric mean: 0.10 vs. 0.23 biological units; P < 0.05), but the pattern of specific airway response did not change. Particularly, a consistent LAR was observed in three subjects outside the pollen season and in two subjects during the pollen season. Seven subjects with isolated early asthmatic response (EAR) outside the season did not show LAR after allergen inhalation during the pollen season. However, four of five subjects with slight LAR outside the pollen season (deltaFEV1% between 15 and 20%) lost LAR during season. Methacholine sensitivity increased slightly but significantly from outside to during the pollen season. This increase was greater in subjects with LAR outside the pollen season. The natural exposure to pollen induces an increase in bronchial sensitivity to allergen in sensitized subjects, but it does not induce LAR in subjects without LAR outside the pollen season.

Interactions between triazoles and amphotericin B against Cryptococcus neoformans

The interaction of amphotericin B (AmB) and azole antifungal agents in the treatment of fungal infections is still a controversial issue. A checkerboard titration broth microdilution-based method that adhered to the recommendations of the National Committee for Clinical Laboratory Standards was applied to study the in vitro interactions of AmB with fluconazole (FLC), itraconazole (ITC), and the new investigational triazole SCH 56592 (SCH) against 15 clinical isolates of Cryptococcus neoformans. Synergy, defined as a fractional inhibitory concentration (FIC) index of < or =0.50, was observed for 7% of the isolates in studies of the interactions of both FLC-AmB and ITC-AmB and for 33% of the isolates in studies of the SCH-AmB interactions; additivism (FICs, >0.50 to 1.0) was observed for 67, 73, and 53% of the isolates in studies of the FLC-AmB, ITC-AmB, and SCH-AmB interactions, respectively; indifference (FICs, >1.0 to < or =2.0) was observed for 26, 20, and 14% of the isolates in studies of the FLC-AmB, ITC-AmB, and SCH-AmB interactions, respectively. Antagonism (FIC >2.0) was not observed. When synergy was not achieved, there was still a decrease, although not as dramatic, in the MIC of one or both drugs when they were used in combination. To investigate the effects of FLC-AmB combination therapy in vivo, we established an experimental model of systemic cryptococcosis in BALB/c mice by intravenous injection of cells of C. neoformans 2337, a clinical isolate belonging to serotype D against which the combination of FLC and AmB yielded an additive interaction in vitro. Both survival and tissue burden studies showed that combination therapy was more effective than FLC alone and that combination therapy was at least as effective as AmB given as a single drug. On the other hand, when cells of C. neoformans 2337 were grown in FLC-containing medium, a pronounced increase in resistance to subsequent exposures to AmB was observed. In particular, killing experiments conducted with nonreplicating cells showed that preexposure to FLC abolished the fungicidal activity of the polyene. However, this apparent antagonism was not observed in vivo. Rather, when the two drugs were used sequentially for the treatment of systemic murine cryptococcosis, a reciprocal potentiation was often observed. Our study shows that (i) the combination of triazoles and AmB is significantly more active than either drug alone against C. neoformans in vitro and (ii) the concomitant or sequential use of FLC and AmB for the treatment of systemic murine cryptococcosis results in a positive interaction.

Experimental induction of fluconazole resistance in Candida tropicalis ATCC 750

Candida tropicalis is less commonly isolated from clinical specimens than Candida albicans. Unlike C. albicans, which can be occasionally found as a commensal, C. tropicalis is almost always associated with the development of fungal infections. In addition, C. tropicalis has been reported to be resistant to fluconazole (FLC). To analyze the development of FLC resistance in C. tropicalis, an FLC-susceptible strain (ATCC 750) (MIC = 1.0 microg/ml) was cultured in liquid medium containing increasing FLC concentrations from 8.0 to 128 microg/ml. The strain developed variable degrees of FLC resistance which paralleled the concentrations of FLC used in the medium. The highest MICs of FLC were 16, 256, and 512 microg/ml for strains grown in medium with 8.0, 32, and 128 microg of FLC per ml, respectively. Development of resistance was rapid and could be observed already after a single subculture in azole-containing medium. The resistant strains were cross-resistant to itraconazole (MIC > 1.0 microg/ml) and terbinafine (MIC > 512 microg/ml) but not to amphotericin B. Isolates grown in FLC at concentrations of 8.0 and 32 microg/ml reverted to low MICs (1.0 microg/ml) after 12 and 11 passages in FLC-free medium, respectively. The MIC for one isolate grown in FLC (128 microg/ml) (128 R) reverted to 16 microg/ml but remained stable over 60 passages in FLC-free medium. Azole-resistant isolates revealed upregulation of two different multidrug efflux transporter genes: the major facilitators gene MDR1 and the ATP-binding cassette transporter CDR1. The development of FLC resistance in vitro correlated well with the results obtained in an experimental model of disseminated candidiasis. While FLC given at 10 mg/kg of body weight/day was effective in reducing the fungal burden of mice infected with the parent strain, the same dosing regimen was ineffective in mice infected with strain 128 R. Finally, the acquisition of in vitro FLC resistance in strain 128 R was related to a loss of virulence. The results of our study elucidate important characteristics and potential mechanisms of FLC resistance in C. tropicalis.

Basal metabolic rate in anorexia nervosa: relation to body composition and leptin concentrations

BACKGROUND

Leptin is thought to represent a peripheral signal involved in the regulation of energy balance. Its action has been studied in animals and obese subjects. Little is known about leptin's role during negative energy balance.

OBJECTIVE

The objective was to evaluate the relation between energy turnover, body composition, and plasma leptin concentrations in anorexia nervosa (AN).

DESIGN

Sixteen weight-stable women with AN were compared with 22 control subjects and 14 rehabilitated AN patients (R-AN). Basal metabolic rate (BMR) was measured by indirect calorimetry; fat-free mass (FFM) and fat mass (FM) were calculated according to a 4-compartment model. Plasma leptin was determined by radioimmunoassay.

RESULTS

The BMR of AN patients (2.73 +/- 0.37 kJ/min) was significantly lower than that of control subjects (3.45 +/- 0.34 kJ/min) (P < 0.001), even after adjustment for FFM (2.92 +/- 0.33 kJ/min in AN patients and 3.30 +/- 0.26 kJ/min in control subjects; P < 0.004). Plasma leptin concentrations in AN patients were 76% lower than in control subjects, even after body fat was controlled for. In R-AN patients, BMR was not significantly different from that of control subjects and leptin concentrations were generally close to normal. Plasma leptin concentrations correlated significantly with FM (r(2) = 0.53, P < 0.0000) and BMR, even after adjustment for FFM (r(2) = 0.21, P < 0.0003).

CONCLUSIONS

BMR and plasma leptin concentrations are depressed in patients with AN; this is not explained by body-composition changes. The relation between leptin and BMR suggests that leptin plays a role in the energy sparing response to exposure to chronic energy deficiency. The return of BMR to normal and the significant increase in leptin concentrations in R-AN patients suggests a full reversibility of this adaptation mechanism.

Reproducibility of early and late asthmatic responses to allergen challenge in a large group of asthmatics

The specific bronchial provocative test (sBPT) coupled with allergen is used to investigate asthma. Very few studies have examined the reproducibility of responses to allergen challenge. The aim of this study was to measure the reproducibility of PD20FEV1 allergen and late asthmatic response (LAR) in 53 asthmatics and to relate the reproducibility to the time interval between two allergen challenges. Fifty-three atopic asthmatics performed two allergen challenges not less than 2 and not more than 26 weeks apart. Randomly, 19 subjects were assigned to a short-interval group (14-35 days between the two tests) and 34 to a long-interval group (40-180 days). In each challenge, the PD20FEV1 was sought for and the maximum % fall in FEV1 from 3 to 7 h after the allergen challenge was evaluated as a measurement of magnitude of the LAR. High intraclass correlation coefficients (R(I)) were found for both PD20FEV1 (R(I) = 0.78) and LAR (R(I) = 0.77) in all subjects. PD20FEV1 allergen showed a high R(I) in the long-interval group (R(I) = 0.80), but a low R(I) in the short-interval group (R(I) = 0.63). In contrast LAR showed a lower R(I) in the long-interval group (R(I) = 0.68) than in the short-interval group (R(I) = 0.77). Moreover, the R(I) for PD20FEV1 was particularly low in subjects with a dual pattern to the allergen challenge and a short interval between the two allergen challenges. Our study confirmed that asthmatic responses induced by allergen challenge have a good reproducibility. Moreover, we have demonstrated that the interval between two allergen challenges can determine a change in reproducibility in asthmatic responses induced by allergen challenge.

The protective effect of salbutamol inhaled using different devices on methacholine bronchoconstriction

STUDY OBJECTIVE

To determine the protective effect of salbutamol, 100 microg, inhaled by different devices (pressurized metered-dose inhaler [pMDI; Ventolin; GlaxoWellcome; Greenford, UK], pMDI + spacer [Volumatic; GlaxoWellcome], or breath-activated pMDI [Autohaler; 3M Pharmaceuticals; St. Paul, MN]) on bronchoconstriction induced by methacholine.

DESIGN

Randomized, double-blind, cross-over, placebo-controlled study.

PATIENTS

Eighteen subjects with stable, moderate asthma, asymptomatic, receiving regular treatment with salmeterol, 50 microg bid, and inhaled beclomethasone dipropionate, 250 microg bid, in the last 6 months, with high hyperreactivity to methacholine (baseline provocative dose of methacholine causing a 20% fall in FEV(1) [PD(20)] geometric mean [GM], 0.071 mg). Subjects were classified into two groups: subjects with incorrect (n = 5) pMDI inhalation technique, and subjects with correct (n = 13) inhalation technique.

METHODS AND MEASUREMENTS

After cessation of therapy for 3 days, all subjects underwent four methacholine challenge tests, each test 1 week apart, each time 15 min after inhalation of salbutamol, 100 microg (via pMDI, pMDI + spacer, or Autohaler), or placebo. The protective effect on methacholine challenge test was evaluated as the change in the PD(20), and expressed in terms of doubling doses of methacholine in comparison with placebo treatment.

RESULTS

The PD(20) was significantly higher after salbutamol inhalation than after placebo inhalation, but no significant difference was observed among the three different inhalation techniques. Only when salbutamol was inhaled via pMDI + spacer, PD(20) was slightly but not significantly higher (pMDI GM, 0.454 mg; pMDI + spacer GM, 0.559 mg; and Autohaler GM, 0.372 mg; not significant [NS]) than other inhalation techniques. Similar results (mean +/-SEM) were obtained with doubling doses of methacholine (pMDI, 2 +/- 0.47; pMDI + spacer, 3 +/- 0.35; and Autohaler, 2.4 +/- 0.40; NS). No significant difference was found among techniques when subjects with correct or incorrect inhalation technique were separately considered.

CONCLUSIONS

Our data show that the protective effect of salbutamol, 100 microg, on methacholine-induced bronchoconstriction is not affected by the different inhalation techniques, although inhalation via pMDI + spacer tends to improve the bronchoprotective ability of salbutamol. These data confirm the clinical efficacy of salbutamol, whatever the device, and the patient's inhalation technique.