High-Power Short-Duration Lesion Index-Guided Posterior Wall Isolation beyond Pulmonary Vein Isolation for Persistent Atrial Fibrillation

Background: High-power short-duration (HPSD) radiofrequency (RF) ablation has been adopted to improve atrial fibrillation (AF) ablation. Although the role of HPSD is well-established in pulmonary vein isolation (PVI), fewer data have assessed the impact of HPSD when addressing extra-pulmonary veins (PVs) targets. Therefore, this study aims to determine the safety, effectiveness, and acute outcomes of HPSD lesion index (LSI)-guided posterior wall isolation (PWI) in addition to PVI as an initial strategy in persistent atrial fibrillation (Pe-AF). Methods: Consecutive patients who underwent ablation of Pe-AF in our center between August 2021 and January 2022 were retrospectively enrolled. All patients' ablation strategy was PVI plus PWI using HPSD LSI-guided isolation. RF parameters included 50 W targeting LSI values of ≥5 on the anterior part of the PVs and anterior roofline and ≥4 for the posterior PVs aspect, bottom line, and within the posterior wall (PW). We compared the LSI values with and without acute conduction gaps after the initial first-pass PWI. Left atrial mapping was performed with the EnSite X mapping system and a high-density multipolar Grid-shaped mapping catheter. We compared the procedural characteristics using HPSD (n = 35) vs. a control group (n = 46). Results: Thirty-five consecutive patients were included in the study. PWI on top of PVI was achieved in all cases in the HPSD group. First-pass PVI was achieved in 93.3% of PVs (n = 126/135). First-pass roofline block was obtained in most patients (n = 31, 88.5%), while first-pass block of the bottom line was only achieved in 51.4% (n = 18). There were no significant differences compared to the control group; first-pass PVI was achieved in 94.9% of PVs (n = 169/178), first-pass roofline block in 89.1%, and bottom-line in 45.6% of patients. To achieve complete PWI with HPSD, scattered RF applications within the PW were necessary. No electrical reconnection of the PW was found after adenosine administration and the waiting period. The procedure and RF times were significantly shorter in the HPSD group compared to the control group, with values of 116.2 ± 10.9 vs. 144.5 ± 11.3 min, and 19.8 ± 3.6 vs. 26.3 ± 6.4 min, respectively, p < 0.001. Fluoroscopy time was comparable between both groups. No procedural complications were observed. At the 12-month follow-up, 71.4% of patients remained free from AF, with no differences between the groups. Conclusions: HPSD LSI-guided PWI on top of PVI seems effective and safe. Compared to a control group, HPSD is associated with similar rates of first-pass PWI and PVI but with a shorter procedural and RF time.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

BACKGROUND

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice.

METHODS

We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort.

RESULTS

In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor).

CONCLUSIONS

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

Background

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI).

Purpose

The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance and reliability in real-world clinical practice.

Methods

We analyzed ECG and angiographic data from 408 consecutive STEMI patients submitted to primary percutaneous coronary intervention, dividing the overall population into derivation (306 patients) and validation (102 patients) cohorts. In the derivation cohort, we tested &gt;60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance and reliability in the validation cohort.

Results

In the derivation cohort, the algorithm correctly predicted the IRA in 91% of cases and both the IRA and its occlusion level (proximal vs. mid-distal) in 73% of cases. When applied to the validation cohort, the algorithm resulted in 90% and 69% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (p=0.026 vs. best cardiologist and p&lt;0.001 vs.best emergency medicine doctor). The algorithm showed almost perfect reliability (Cohen's kappa 0.86) between a cardiologist and an ambulance paramedic.

Conclusions

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Funding Acknowledgement

Type of funding sources: None.

[Evaluation of a pulsed xenon ultraviolet light- emitting no-touch, portable device for disinfection of surfaces in operating rooms in the Policlinico University Hospital of Foggia, Italy, 2019. Preliminary results]

OBJECTIVES

To evaluate the effectiveness and the frequency of use of a pulsed xenon ultraviolet light-emitting no-touch portable device (PX-UV), applied after perform current cleaning, in reducing environmental bacterial burden and the presence of pathogens on surfaces in the operating rooms at the Policlinico University Hospital of Foggia.

DESIGN

Prospective before-and-after study with a follow up duration of four months, from May to August 2019.

SETTING AND PARTICIPANTS

Two operating rooms of an Orthopaedic and a Neurosurgical ward in a 780-bed university hospital in the District of Foggia, Italy (about 600,000 inhabitants).

MAIN OUTCOME MEASURES

According to the hygienic standards proposed by the Italian Workers Compensation Authority (ISPESL), the total and the average bacterial load and the presence of six pathogens were evaluated between pre- and post- PX-UV use combined with routine manual cleaning.

RESULTS

The PX-UV system was applied at five distinct time points: t1: start of the experiment, t2: after 28 days, t3: after 13 days, t4: after 7 days, and t5: after 8 days (t2-t5: 28 days in total). About 16-min of PX-UV cycle showed significant reduction in the level of environmental contamination by decreasing the mean colony count by 87.5%, compliant with the standard (5&lt; X ≤15 CFU per plat). Staphylococcus aureus and Acinetobacter baumannii that had been isolated in some of the samplings before PX-UV were no longer detected after t1, t2 and t5 treatments. Before PX-UV, the mean colony count was similar between t1 and t2 (p&gt;0.05); after t3 and t4 treatments, it was lower before t5 in both the Orthopaedic and Neurosurgical operating rooms (= -97% and -75%, respectively; p&lt;0,01).

CONCLUSIONS

Implication for practice: PX-UV could supplement the standard cleaning process in reducing the microbial burden in the operating rooms and potentially achieving lower healthcare-associated surgical site infections rates.

COVID-19: Effects of lockdown on adenotonsillar hypertrophy and related diseases in children

BACKGROUND

In response to the coronavirus pandemic 2019 (COVID-19), Italy established the national school closings from March 5, 2020. It has been shown that during school closures, there are significant decreases in the diagnoses of the respiratory infections. This has brought as well to a reduction in all those symptoms related to adenotonsillar hypertrophy.

METHODS

The study included 162 children, aged between 3 and 13 years, waiting for adenoidectomy and/or tonsillectomy, eventually combined with tympanocentesis or tube insertion. Parents have been called to answer a telephone interview aimed at detecting how the symptoms related to adenotonsillar hypertrophy were changing during lockdown.

RESULTS

There was an improvement in the overall symptomatology of children during the lockdown period. The value attributed by parents to the children's general assessment during the lockdown period decreased significatively during the quarantine (p = 0,0000).

CONCLUSIONS

The present study demonstrates that lockdown can have a positive impact on those specific diseases derived from precocious socialization and that it results to be particularly effective for the most vulnerable children. Indeed, lockdown has resulted to be so efficient that it has caused a modification in a medical and surgical therapeutic indication.

Knowledge, attitude and practice on antibiotic use and resistance among the Italian population, 2019

Background

Public knowledge, awareness and behaviors related to antibiotic use and antimicrobial-resistance (AMR) are vital to ensure the prudent use of these drugs. In this work, we present the top-line results of the first national survey of AMR among the Italian general population aged ≥18 years.

Methods

From August to September 2019, we conducted a population-based cross-sectional random survey through mixed CATI/CAMI/CAWI methodologies among representative samples of the general population, parents of children aged 0-11 years, adults ≥65 years and pet's owners. Results were summarized using relative frequencies.

Results

Of 1,400 persons interviewed, 47% and 68% respectively correctly said that it is false that antibiotics kill viruses and are effective at treating colds and flu. More than 80% of respondents considered themselves to be well-informed about antibiotics but only one in two people knew what is meant by AMR. While the vast majority (96%) of respondents said that they obtained the last course of antibiotics that they used from a medical prescription, 11% incorrectly said that they stopped taking antibiotics when they felt better or that they used those left over from a previous course. In addition, 55% of pet's owners said they obtained antibiotics without a prescription from a pharmacy or elsewhere. Almost all respondents (97%) believed that it's everyone's responsibility to use antibiotics wisely, with the 80% who expressed concerns about the potential of AMR to affect themselves and their families; however, 40% did not think that action at an individual level is the most effective way of tackling resistance to antibiotics.

Conclusions

Our findings show some improvement in Italians' knowledge, awareness and behaviors related to antibiotic use and AMR but there are needs to be a greater sense of responsibility to take charge of the AMR problem. These results may be drivers of structured national awareness campaigns.

Key messages

In 2019, we conducted the first national survey of AMR among the Italian population: &gt;80% of respondents felt themselves well-informed about antibiotics but only 1/2 people knew what is meant by AMR. Almost all Italian sample believed that it's everyone's responsibility to use antibiotics wisely, but 40% did not think that action at an individual level is effective to tackle AMR.

Epidemiology and cost of cervical cancer care and prevention in Apulia (Italy), 2007/2016

BACKGROUND

According to recent estimates, cervical cancer is worldwide the second most common cancer in females and the fourth overall. The number of deaths for cervical cancer is around 7.5% of all female cancer deaths. Cervical cancer is the only tumour with a known necessary cause, the HPV infection and, globally, HPV is the most common sexually transmitted infection. Two major approaches for cervical cancer prevention have been designed: primary prevention by HPV vaccination and secondary prevention by screening. The aim of our study is to design an overview of epidemiology, cost of the therapies and cost of prevention measures (screening and vaccines) 9 years after the introduction of anti-HPV vaccination in the Apulia Regional Immunization Program.

STUDY DESIGN

Retrospective observational study.

METHODS

To describe the epidemiology of cervical cancer, we analysed data from the Apulia regional archive of hospital discharge forms (SDO). We considered all records referred to cervical cancer using the ICD 9 code 180.xxx both in primary and secondary diagnosis, for the years 2007-2016. Subjects living in Apulia have been considered. Costs of hospitalization were computed considering generated Diagnosis Related Groups (DRG). To describe the Apulian screening program, we analysed data from Regional Screening Data warehouse; the cost of the single test was established according to the Tariff List from the Ministry of Health. Finally, vaccination data were extracted by Regional Immunization Database and official ex-factory price has been used to calculate the costs of immunization program.

RESULTS

From 2007 to 2016, an important decrease in the incidence rate of cervical cancer in Apulia has been noted, ranging from 43.7 per 100,000 residents in 2007 to 21.0 per 100,000 residents in 2016. From an economic point of view, a clear reduction (39%) is observed in hospitalization costs over time. Total costs of prevention programs increased over time and globally exceed € 54,000,000, with a decreasing trend for vaccine prophylaxis and an increasing trend for screening.

CONCLUSIONS

The incidence and costs of cervical cancer in Apulia, although already significantly decreasing, likely will be further reduced since 2027-2032, when we can observe the effects of vaccine prophylaxis on the burden of disease; on this occasion it will be also possible to quantify the actual cost-effectiveness of the vaccine. In our opinion, in the future the Apulia healthcare executives should enhance and improve the active screening test offer, without underestimating the importance of sexual education in young people, especially in those who have not had sexual debut yet.

The impact of age on intravesical instillation of Bacille Calmette-Guerin treatment in patients with high-grade T1 bladder cancer

Intravesical instillation of Bacille Calmette-Guèrin (BCG) is the standard adjuvant treatment for high-risk non muscle invasive bladder cancer (NMIBC). Since its mechanism of action is supposed to be linked to the immune system efficiency and senescence could negatively affect this efficiency, BCG efficacy in the elderly has been questioned. This study aimed to assess the impact of age on BCG efficacy and safety in patients with high-grade T1 bladder cancer (BC).Among 123 patients with high-grade T1 BCG scheduled for BCG treatment, 82 were <75 year-old (group A) and 41 were ≥75 year-old (group B). Follow-up: urine cytology and cystoscopy every 3 months for the first 2 years, every 6 months for the third year, and then yearly. Tumor recurrence was defined as pathological evidence of disease at the bladder biopsy; tumor progression was defined as pathological shift to muscle invasive disease at the bladder biopsy or the imaging techniques showing recurrent BC and distant metastasis likely related to it.The median follow-up was 65 months (range 11-152). Recurrence occurred in 35 patients, 19 (23.2%) in the group A and 16 (39%) in the group B. Progression occurred in 18 patients, 12 (14.6%) in the group A and 6 (14.6%) in the group B. Recurrence free rate was similar in both groups up to 2 years. The 5 years progression rate was almost the same in both groups A and B (85.9% vs 84.7%), whereas the 5 years cancer-specific survival (CSS) was 92.6% in the group A and 85.4% in the group B. Of the 18 patients with progression, 11 underwent cystectomy; 12 patients died because of their BC. Kaplan-Meier plots pointed out no difference in recurrence-free, progression-free, and CSS between the 2 groups. Adverse events were similar in the 2 groups. Only 4 (3.3%) patients, 2 (2.4%) in the group A and 2 (4.8%) in the group B, experienced mild adverse reactions compatible with treatment.Elderly patients with high-grade T1 BC are not poorer candidates to BCG treatment, as they had similar benefit and adverse reactions than those aging ≥75 years.

Food-borne botulism in Apulia region, Italy: an expert witness testimony

We report the epidemiology of food-borne botulism in Puglia, Italy, between 1977-2017, using surveillance data and Experts' personal observations. As the disease is rare, the diagnosis is often missed or delayed, and cases are initially misdiagnosed. This was the case of a family outbreak of botulism in the 1970s.

The role of lipofilling in reconstructions with dermal regeneration template: clinical and histological assessment

Skin and soft tissue reconstruction represents one of the most debated issues of plastic surgery. The advent of regenerative medicine has shown new pathways with the use of lipofilling and dermal regeneration templates. The aim of this study was to investigate the histological and clinical modifications occurring after lipofilling in the areas previously reconstructed with Integra® and an autologous thin dermal-epidermal graft. Histological and immunohistochemical analysis were performed on nine patients to compare skin before and after lipofilling. Pre- and post-operative examinations (POSAS, VAS scale) were carried out as well as taking clinical photographs. The authors detected an overall clinical and histological improvement in all cases. Data obtained from POSAS and VAS scale showed a statistically significant (p less than 0.05) improvement concerning all variables investigated before surgery. The biopsies revealed qualitative modifications with hematoxylin-eosin and Masson trichrome stain. Immunohistochemistry with CD31 antibody also demonstrated quantitative changes with an increased number of vessels. The photographs enabled to compare the clinical situation before and after lipofilling with better aesthetic outcomes. Lipofilling gave good functional and aesthetic results in the areas treated with Integra® and autologous thin dermal-epidermal grafts.

Effects of short-to-long term enzyme replacement therapy (ERT) on skeletal muscle tissue in late onset Pompe disease (LOPD)

AIMS

Pompe disease is an autosomal recessive lysosomal storage disorder resulting from deficiency of acid α-glucosidase (GAA) enzyme. Histopathological hallmarks in skeletal muscle tissue are fibre vacuolization and autophagy. Since 2006, enzyme replacement therapy (ERT) is the only approved treatment with human recombinant GAA alglucosidase alfa. We designed a study to examine ERT-related skeletal muscle changes in 18 modestly to moderately affected late onset Pompe disease (LOPD) patients along with the relationship between morphological/biochemical changes and clinical outcomes. Treatment duration was short-to-long term.

METHODS

We examined muscle biopsies from 18 LOPD patients at both histopathological and biochemical level. All patients underwent two muscle biopsies, before and after ERT administration respectively. The study is partially retrospective because the first biopsies were taken before the study was designed, whereas the second biopsy was always performed after at least 6 months of ERT administration.

RESULTS

After ERT, 15 out of 18 patients showed improved 6-min walking test (6MWT; P = 0.0007) and most of them achieved respiratory stabilization. Pretreatment muscle biopsies disclosed marked histopathological variability, ranging from an almost normal pattern to a severe vacuolar myopathy. After treatment, we detected morphological improvement in 15 patients and worsening in three patients. Post-ERT GAA enzymatic activity was mildly increased compared with pretreatment levels in all patients. Protein levels of the mature enzyme increased in 14 of the 18 patients (mean increase = +35%; P < 0.05). Additional studies demonstrated an improved autophagic flux after ERT in some patients.

CONCLUSIONS

ERT positively modified skeletal muscle pathology as well as motor and respiratory outcomes in the majority of LOPD patients.

Incidence of Type 1 Diabetes among Children and Adolescents in Italy between 2009 and 2013: The Role of a Regional Childhood Diabetes Registry

BACKGROUND

Surveillance represents a key strategy to control type 1 diabetes mellitus (T1DM). In Italy, national data are missing. This study aimed at evaluating the incidence of T1DM in subjects <18 year olds in Apulia (a large southeastern region, about 4,000,000 inhabitants) and assessing the sensitivity of the regional Registry of Childhood-Onset Diabetes (RCOD) in the 2009-2013 period.

METHODS

We performed a retrospective study matching records from regional Hospital Discharge Registry (HDR), User Fee Exempt Registry (UFER), and Drugs Prescription Registry (DPR) and calculated T1DM incidence; completeness of each data source was also estimated. In order to assess the RCOD sensitivity we compared cases from the registry to those extracted from HDR-UFER-DPR matching.

RESULTS

During 2009-2013, a total of 917 cases (about 184/year) in at least one of the three sources and an annual incidence of 25.2 per 100,000 were recorded, lower in infant, increasing with age and peaked in 5- to 9-year-olds. The completeness of DPR was 78.7%, higher than that of UFER (64.3%) and of HDR (59.6%). The RCOD's sensitivity was 39.05% (360/922; 95% CI: 34.01%-44.09%).

CONCLUSIONS

Apulia appeared as a high-incidence region. A full, active involvement of physicians working in paediatric diabetes clinics would be desirable to improve the RCOD performance.

Proceedings of the Consensus Day Meeting: Implications for Rotavirus Vaccination in the 2014 Apulian Lifetime Immunization Schedule. Foggia, 17 April 2015

Recommendations for vaccination against rotavirus (RV) were issued in Apulia in 2006; the vaccine was free of charge to children who entered day care or nursery school by 1 year of age or those affected by chronic diseases for which diarrhea caused by rotavirus can increase the risk of complications and hospitalization. In 2014, vaccination became available to all healthy children with only a copayment. However, there has not been a significant increase in vaccination coverage. On April 17, 2015, Apulian public health physicians and paediatricians met to share strategies to promote the RV vaccine indications provided in the regional immunization schedule. During the meeting, presentation of data reports were interspersed with discussions that were led with a "bottom-up" approach. The discussants responded to pre-planned questions raised by the participants and encouraged by the discussion.

Necro-inflammatory response of pancreatic acinar cells in the pathogenesis of acute alcoholic pancreatitis

The role of pancreatic acinar cells in initiating necro-inflammatory responses during the early onset of alcoholic acute pancreatitis (AP) has not been fully evaluated. We investigated the ability of acinar cells to generate pro- and anti-inflammatory mediators, including inflammasome-associated IL-18/caspase-1, and evaluated acinar cell necrosis in an animal model of AP and human samples. Rats were fed either an ethanol-containing or control diet for 14 weeks and killed 3 or 24 h after a single lipopolysaccharide (LPS) injection. Inflammasome components and necro-inflammation were evaluated in acinar cells by immunofluorescence (IF), histology, and biochemical approaches. Alcohol exposure enhanced acinar cell-specific production of TNFα, IL-6, MCP-1 and IL-10, as early as 3 h after LPS, whereas IL-18 and caspase-1 were evident 24 h later. Alcohol enhanced LPS-induced TNFα expression, whereas blockade of LPS signaling diminished TNFα production in vitro, indicating that the response of pancreatic acinar cells to LPS is similar to that of immune cells. Similar results were observed from acinar cells in samples from patients with acute/recurrent pancreatitis. Although morphologic examination of sub-clinical AP showed no visible signs of necrosis, early loss of pancreatic HMGB1 and increased systemic levels of HMGB1 and LDH were observed, indicating that this strong systemic inflammatory response is associated with little pancreatic necrosis. These results suggest that TLR-4-positive acinar cells respond to LPS by activating the inflammasome and producing pro- and anti-inflammatory mediators during the development of mild, sub-clinical AP, and that these effects are exacerbated by alcohol injury.

Safety and efficacy of incobotulinum toxin type A (NT 201-Xeomin) for the treatment of post-stroke lower limb spasticity: a prospective open-label study

BACKGROUND

In recent years, NT 201, a new botulinum toxin type A (BTX-A) free of complexing proteins, has been used for treating several movement disorders, showing safety and efficacy in upper limb spasticity.

AIM

To assess the safety and evaluate the effects of BTX-A NT 201 free from complexing proteins for the treatment of post-stroke lower limb spasticity evaluating spasticity grade, passive ankle dorsi-flexion motion, and muscle's spasms, as well as its efficacy and rate of satisfaction for patients and for the physicians.

DESIGN

Prospective open-label study.

POPULATION

Patients (71) with post-stroke lower limb spasticity at least 5 months by the event.

METHODS

Intramuscular injections of BTX-A NT 201 in soleus, medial, and lateral gastrocnemius with a maximum total dose of 180 U. Each patients was assessed at baseline, 30, and 90 days after treatment using Modified Ashworth Scale, Spasm Frequency Scale, evaluating passive ankle dorsi-flexion motion, and the rate of satisfaction for patients and investigators.

RESULTS

Patients treated with BTX-A NT 201 reported a statistically significant reduction in muscle tone and spasms daily increasing passive ankle dorsi-flexion at 30 days, persisting also at 90 days of follow-up.

CONCLUSION

BTX-A NT 201 for the treatment of post-stroke lower limb spasticity was safe and efficacious reducing muscle tone and spasms, and improving passive ankle dorsi-flexion movement.

CLINICAL REHABILITATION IMPACT

These results confirmed the safety and effectiveness of a new type of BTX-A, with low immunogenity, useful to improve rehabilitative treatment of post-stroke lower limb spasticity.

Assessment of activity of Crohn's disease of the ileum and large bowel: proposal for a new multiparameter MR enterography score

PURPOSE

We evaluated the diagnostic accuracy of magnetic resonance enterography (MR-E) in assessing Crohn's disease (CD) activity by differentiating acute, chronic and remission stages of disease through a quantitative MR-E assessment.

MATERIALS AND METHODS

One hundred patients with a histological diagnosis of CD were studied with MR-E. Intestinal distension was obtained by oral administration of approximately 2 L of a polyethylene glycol solution (PEG). In all cases, the ileum and large bowel were imaged with morphological sequences (heavily T2-weighted single-shot, dual fast-field echo, balanced fast-field echo) and a postcontrast dynamic sequence (T1-weighted high-resolution isotropic volume excitation). Disease activity was assessed according to a multiparameter score (0-8) based on lesion morphology, signal intensity and contrast enhancement. MR-E findings were compared with clinical-laboratory data and disease activity indices [Crohn's Disease Activity Index (CDAI); Inflammatory Bowel Disease Questionnaire (IBDQ)]. Multiple regression analysis was performed by correlating MR-E score, CDAI and IBDQ. Frequencies were then compared using the χ (2) test.

RESULTS

MR-E identified inactive disease in 9% of cases, chronic disease in 57% and active disease in the remaining 34%. The most frequently involved bowel segment was the terminal ileum (52%). A statistically significant correlation was found between MR-E score and CDAI (R=0.86; p<0.001) and between MR-E score and IBDQ (R=-0.83; p<0.001). The most suggestive parameter for disease activity was layered bowel-wall enhancement, a finding predominantly present in patients with increased CDAI (≥ 150) and/or local complications (χ (2)=7.13; p<0.01).

CONCLUSIONS

MR-E is a noninvasive and diagnostic imaging modality for CD study and follow-up. The MR-E score proposed in this study proved to be useful in assessing disease severity and monitoring response to treatment.

[Centralized immunization schedules and regional equity of access: an audit among Apulian healthcare workers]

The reform of the Vth Title of the Italian Constitution has given the Regions autonomous power over planning of their immunization programme and immunization calendar. This amendment has federalized Italy's vaccination system and, is justified by epidemiological evidence however casts doubt on its provision of equal rights to health care. The objective of this current study is to gain insight into the opinion of vaccine services officers in the Apulia region on federal immunization and the regional immunization programme. Research was conducted using an anonymous standardized questionnaire to which 302 vaccines services staff responded. 67.4% of respondents believe that the current federal vaccination programme should be maintained, whilst 20.2% believe that the current system should be eradicated and 12.4% believe it should be phased out gradually. The current apulian vaccination calendar provides free and active immunizations for all newborns for the pneumococcal, meningitis C, chickenpox and hepatitis A vaccines. The interviewees believe that the vaccinations provided in the regional immunization programme are very important (average importance out of 10 = 6.1/7). The positive response to the regional vaccination plan given by the health officers explains, at least in part, the conservative attitude tewards federal vaccination plans. It cannot be excluded that sacrificing regional autonomy over vaccination programmes might be considered by the vaccination officers as being responsible for the abandonment of the Region's long established immunization practices. The success of these practices is evident in the case of the Region's Hepatitis A immunization programme where the active provision of this vaccine has drastically reduced the endemicity of the illness in Apulia. These experiences of good practice should be adequately considered in before opting to phase out the current immunisation programme.

[Epidemiology of femoral neck fractures in Puglia (Italy): an analysis of existing data]

The aim of this study was to describe the epidemiology of femoral neck fractures in Puglia (Italy) by analysing hospital discharge records from 1998 to 2005 and mortality data from 1998 to 2003. In total, 41,354 admissions for femoral neck fractures were recorded, 75% of which in females. The mean age of patients was 78 years (73 in males, 79 in females). Approximately 70% of patients below 50 years of age were male, while above age 50, only 23% of patients were male. Yearly admission rates increased from 1998 to 2005. Mortality records recorded 1,031 deaths due to femoral neck fracture with a decreasing trend in mortality rates in the years considered. Fractures in males were most commonly associated with work related accidents and motor vehicle accidents. In females most fractures were related to home accidents. These results may be used to guide prevention strategies.

A selective COX-2 inhibitor suppresses chronic pancreatitis in an animal model (WBN/Kob rats): significant reduction of macrophage infiltration and fibrosis

INTRODUCTION

Therapeutic strategies to treat chronic pancreatitis (CP) are very limited. Other chronic inflammatory diseases can be successfully suppressed by selective cyclooxygenase 2 (COX-2) inhibitors. As COX-2 is elevated in CP, we attempted to inhibit COX-2 activity in an animal model of CP (WBN/Kob rat). We then analysed the effect of COX-2 inhibition on macrophages, important mediators of chronic inflammation.

METHODS

Male WBN/Kob rats were continuously fed the COX-2 inhibitor rofecoxib, starting at the age of seven weeks. Animals were sacrificed 2, 5, 9, 17, 29, 41, and 47 weeks later. In some animals, treatment was discontinued after 17 weeks, and animals were observed for another 24 weeks.

RESULTS

Compared with the spontaneous development of inflammatory injury and fibrosis in WBN/Kob control rats, animals treated with rofecoxib exhibited a significant reduction and delay (p<0.0001) in inflammation. Collagen and transforming growth factor beta synthesis were significantly reduced. Similarly, prostaglandin E(2) levels were markedly lower, indicating strong inhibition of COX-2 activity (p<0.003). If treatment was discontinued at 24 weeks of age, all parameters of inflammation strongly increased comparable with that in untreated rats. The correlation of initial infiltration with subsequent fibrosis led us to determine the effect of rofecoxib on macrophage migration. In chemotaxis experiments, macrophages became insensitive to the chemoattractant fMLP in the presence of rofecoxib.

CONCLUSION

In the WBN/Kob rat, chronic inflammatory changes and subsequent fibrosis can be inhibited by rofecoxib. Initial events include infiltration of macrophages. Cell culture experiments indicate that migration of macrophages is COX-2 dependent.

Neuronal differentiation of murine bone marrow Thy-1- and Sca-1-positive cells

Recent evidence suggests that cells from bone marrow can acquire neuroectodermal phenotypes in cell culture or after transplantation in animal models and in the human brain. However, isolation of the bone marrow cell subpopulation with neuronal differentiation potential remains a challenge. To isolate and expand neural progenitors from whole murine bone marrow, bone marrow was obtained from hind limb bone of C57BL6 mice and plated in culture with neuronal medium with basic fibroblast growth factor and epidermal growth factor. After 5-7 days in culture, cellular spheres similar to brain neurospheres appeared either floating or attached to culture dishes. These spheres were collected, dissociated, and expanded. The bone marrow-derived spheres were positive for nestin as assessed by immunocytochemistry and by reverse transcriptase polymerase chain reaction. Thy-1- and Sca-1-positive bone marrow cells selected by magnetic cell sorting resulted in a higher yield of nestin-positive spheres. After exposure to neuronal differentiative medium retinoic acid with and without Sonic hedgehog, cells positive for neuronal markers tubulin III (TuJ-1) and neurofilament (NF) were detected. The mRNA profile of these cells included the expression of TuJ-1, neuronal-specific enolase (NSE), and NF-light chain. To evaluate the in vivo behavior of these cells, spheres derived from bone marrow-derived cells of transgenic green fluorescent protein (GFP) mice were transplanted into newborn mouse brain. Two months later, the mouse neural cortex contained a minor proportion of GFP(+) cells co-expressing neuronal markers (TuJ-1, NF, MAP-2, NeuN). Although cell fusion phenomena with the host cells could not be ruled out, bone marrow-derived neurosphere transplantation could be a strategy for cellular mediated gene therapy.

A CAV3 microdeletion differentially affects skeletal muscle and myocardium

BACKGROUND

Caveolin-3 is the muscle-specific protein product of the caveolin gene family and an integral membrane component of caveolae. Mutations in the gene encoding caveolin-3 (CAV3) underlie four distinct disorders of skeletal muscle: the autosomal dominant form of limb-girdle muscular dystrophy type 1C (LGMD-1C), rippling muscle disease (RMD), sporadic and familial forms of hyperCKemia, and distal myopathy.

OBJECTIVE

To characterize a multigenerational Italian family affected by an autosomal dominant myopathic disorder and to assess the expression of caveolin-3, dystrophin, dystrophin-associated glycoproteins, and neuronal nitric oxide synthase in the myocardium of an affected patient.

METHODS

Clinical analysis involved 15 family members. Skeletal muscle expression of sarcolemmal proteins was evaluated by immunohistochemistry and western blot analysis in three affected individuals. Caveolar structures were analyzed through electron microscopy in muscle biopsies and in one heart biopsy.

RESULTS

CAV3 genetic analysis showed a heterozygous 3-bp microdeletion (328-330del) in affected individuals, resulting in the loss of a phenylalanine (Phe97del) in the transmembrane domain. In the skeletal muscle, the mutation was associated with severe caveolin-3 deficiency and caveolar disorganization, whereas the expression of the other analyzed muscle proteins was unaltered. Remarkably, caveolin-3 was expressed in myocardium at a level corresponding to about 60% of that of control individuals and was correctly localized at the myocardial cell membranes, with preservation of cardiac myofiber caveolar structures. Clinical analysis revealed the concomitant presence in this family of the following phenotypes: RMD, LGMD, and hyperCKemia.

CONCLUSIONS

Intrafamilial phenotypic heterogeneity is associated with caveolin-3 Phe97 microdeletion. The molecular network interacting with caveolin-3 in skeletal muscle and heart may differ.

Molecular analysis of LGMD-2B and MM patients: identification of novel DYSF mutations and possible founder effect in the Italian population

Dysferlin, the protein product of the dysferlin gene (DYSF), has been shown to have a role in calcium-induced membrane fusion and repair. Dysferlin is absent or drastically reduced in patients with the following autosomal recessive disorders: limb-girdle muscular dystrophy type 2B (LGMD-2B), Miyoshi myopathy (MM) and distal anterior compartment myopathy. To date, less than 45 mutations have been described in DYSF and a wide inter- and intra-familial variation in clinical phenotype has been associated with the same mutation. This observation underlines the relevance of any new report describing genotype/phenotype correlations in dysferlinopathic patient and families. Here we present the results of clinical, biochemical and genetic analysis performed on one MM and three LGMD Italian families. By screening the entire coding region of DYSF, we identified three novel mutations (two missense substitutions and one frame shift microdeletion). The possible existence of a founder effect for the Arg959Trp mutation in the Italian population is discussed.

Clinical, morphological and immunological evaluation of six patients with dysferlin deficiency

Limb girdle muscular dystrophy (LGMD) type 2B and distal Miyoshi myopathy (MM) are caused by mutations in a recently discovered mammalian gene coding for a skeletal muscle protein called dysferlin. The protein is normally expressed at the skeletal muscle level and absent or reduced in affected patients. We selected a clinically heterogeneous population of Italian myopathic patients with clinical evidence of myopathy and/or hyperCKemia, EMG myopathic pattern, and no alterations of the dystrophin-sarcoglycan complex. Calpain, merosin, emerin and caveolin were also tested and found normal in all patients. Dysferlin immunohistochemical and Western blot analyses allowed us to identify six patients with dysferlin deficiency: one with distal myopathy, four with limb girdle myopathy and one with hyperCKemia. No apoptosis was found in any of the six muscle specimens, although expression of the pro-apoptotic Fas antigen was mildly increased in two cases. Inflammatory reactions were present in two of the six cases, but we found no evidence of immune-mediated processes.

Two dystrophin proteins and transcripts in a mild dystrophinopathic patient

Two muscle dystrophin transcripts and proteins were detected in a 17-year-old boy with a persistently elevated serum creatine kinase level. A decreased amount of full-length dystrophin and a 360 kDa polypeptide lacking the COOH-terminus were detectable in the patient's muscle biopsy; accordingly, transcript analysis revealed the expression of a wild type messenger RNA together with a shorter frameshifted one. No genomic DNA mutation was found and the presence of a somatic mosaicism was excluded. This dystrophinopathy may be caused by a novel dystrophin gene transcriptional defect, namely aberrant intraexonic splicing.

A subpopulation of murine bone marrow cells fully differentiates along the myogenic pathway and participates in muscle repair in the mdx dystrophic mouse

Bone marrow (BM) transplantation in mice suggests the existence of pluripotent cells able to differentiate into skeletal muscle tissue, although sustained myofiber reconstitution has not yet been achieved. We investigated the myogenic potential of mouse BM cells and evaluated whether a BM fraction enriched for cells expressing skeletal muscle markers would ameliorate muscle repair, when compared to whole BM, into the dystrophic mdx mouse. We demonstrate that cells expressing striated-muscle-specific proteins are already present in the BM independently from experimentally forced myogenic conversion. We observed the presence of both markers of early myogenic program such as Pax3, Myf5, MyoD, desmin, and late myogenesis such as myosin heavy chain and alpha-sarcomeric actin. These myogenic cells are more represented in the early nonadherent BM fraction, which generates clones able to fully differentiate into myotubes. Transplantation in mdx mice by intravenous injection of whole BM and a tenfold BM myogenic enriched fraction resulted in BM reconstitution and limited dystrophin restoration. Taken together, these data show that a fraction of BM cells have a definite potential for differentiation along the skeletal muscle pathway and can be recruited by muscle repair mechanisms. They also indicate that factors limiting the degree of muscle recruitment and the host stem cell competition should be assessed in order to evaluate the usefulness of BM-derived myogenic cells into the context of cell-mediated gene therapy of inherited muscle diseases.

Retrospective study of a large population of patients affected with mitochondrial disorders: clinical, morphological and molecular genetic evaluation

Mitochondrial disorders are human genetic diseases with extremely variable clinical and genetic features. To better define them, we made a genotype-phenotype correlation in a series of 207 affected patients, and we examined most of them with six laboratory examinations (serum CK and basal lactate levels, EMG, cardiac and EEG studies, neuroradiology). We found that, depending on the genetic abnormality, hyperckemia occurs most often with either chronic progressive external ophthalmoplegia (CPEO) and ptosis or with limb weakness. Myopathic EMGs are more common than limb weakness, except in patients with A8344G mutations. Peripheral neuropathy, when present, is always axonal. About 80% of patients with A3243G and A8344G mutations have high basal lactate levels, whereas pure CPEO is never associated with increased lactate levels. Cardiac abnormalities mostly consist of conduction defects. Abnormalities on CT or MRI of the brain are relatively common in A3243G mutations independently of the clinical phenotype. Patients with multiple mtDNA deletions are somehow "protected" against the development of abnormalities with any of the tests. We conclude that, despite the phenotypic heterogeneity of mitochondrial disorders, correlation of clinical features and laboratory findings may give the clinician important clues to the genetic defect, allowing earlier diagnosis and counselling.

Beta-enolase deficiency, a new metabolic myopathy of distal glycolysis

A severe muscle enolase deficiency, with 5% of residual activity, was detected in a 47-year-old man affected with exercise intolerance and myalgias. No rise of serum lactate was observed with the ischemic forearm exercise. Ultrastructural analysis showed focal sarcoplasmic accumulation of glycogen beta particles. The enzyme enolase catalyzes the interconversion of 2-phosphoglycerate and phosphoenolpyruvate. In adult human muscle, over 90% of enolase activity is accounted for by the beta-enolase subunit, the protein product of the ENO3 gene. The beta-enolase protein was dramatically reduced in the muscle of our patient, by both immunohistochemistry and immunoblotting, while alpha-enolase was normally represented. The ENO3 gene of our patient carries two heterozygous missense mutations affecting highly conserved amino acid residues; a G467A transition changing a glycine residue at position 156 to aspartate, in close proximity to the catalytic site, and a G1121A transition changing a glycine to glutamate at position 374. These mutations were probably inherited as autosomal recessive traits since the mother was heterozygous for the G467A and a sister was heterozygous for the G1121A transition. Our data suggest that ENO3 mutations result in decreased stability of mutant beta-enolase. Muscle beta-enolase deficiency should be considered in the differential diagnosis of metabolic myopathies due to inherited defects of distal glycolysis.

Primary beta-sarcoglycanopathy manifesting as recurrent exercise-induced myoglobinuria

We report an unusual presentation of a primary beta-sarcoglycanopathy (LGMD type 2E). A 12- year-old boy came to our attention after six episodes of exercise-induced myoglobinuria. Electromyogram showed mild myopathic features of the proximal lower limb muscles. Electrocardiogram was normal. Neurological examination revealed normal muscle strength and reduced deep tendon reflexes. A muscle biopsy showed rare regenerating fibers; the immunohistochemistry was normal for dystrophin, while all the sarcoglycans were diffusely decreased. Western blot analysis showed a relevant decrease of all sarcoglycan proteins and a mild dystrophin reduction. beta-Sarcoglycan gene analysis demonstrated a compound heterozygous status for these mutations: a novel A-T base pair substitution at nucleotide 85 in exon 2, changing the codon Arg to a stop codon; a C-T base pair substitution at nucleotide 272 in exon 3 changing a Arg to a Cys residue. We consider that exercise-induced myoglobinuria may be the presenting sign of primary beta-sarcoglycanopathy.

Chronic alcohol exposure of rats exacerbates apoptosis in hepatocytes and sinusoidal endothelial cells

Background/aims: The liver apoptotic response to chronic alcohol consumption remains poorly characterized. The purpose of this study was to determine in rats the effects of chronic alcohol consumption on the relative magnitude of apoptosis in two major targets of alcohol-induced liver injury: the hepatocyte (Hep) and sinusoidal endothelial cell (SEC). Methods: Rats were fed a liquid diet containing either alcohol or isocaloric amounts of maltose-dextrin for 14 weeks. Hep and SEC were isolated by liver perfusion with collagenase followed by centrifugal elutriation. The state of the liver was assessed on the basis of light microscopic appearance, plasma liver enzymes (alanine and aspartate:2-oxoglutarate amino transferases), and the content of malondialdehyde in Hep. Apoptosis was assessed on the basis of DNA fragmentation in the whole organ (TUNEL), and caspase-3 and -8 activity in isolated cells. A mechanistic approach was also undertaken by measuring mRNA expression and the amount of protein for Fas/CD95, Fas ligand, caspase-3, Bax, Bcl-X(L), and Bcl-2 in the isolated Hep and SEC. Results: The livers of alcohol-fed rats displayed prominent steatosis. Oxidative stress was also present as reflected by an increase in the malondialdehyde content of Hep. Alcohol consumption increased apoptosis in the whole liver assessed on the basis of TUNEL procedure and in Hep and SEC as reflected by significant increase in caspase-3 activity. Of the multiple pro- and anti-apoptotic factors determined in this study, significant changes as assessed by both mRNA expression and the amount of proteins, were observed only in the SEC compartment. Conclusions: The data presented in this study indicate that: (1) chronic alcohol consumption in rats leads to a moderate augmentation of apoptosis in the whole liver and in two liver cell types which are targets for injury in alcoholic liver disease: Hep and SEC; (2) the mechanisms recruited/activated by these two types of liver cells to initiate and execute apoptosis in response to alcohol vary with the cell type.

Apoptosis and dysregulated ceramide metabolism in a murine model of alcohol-enhanced lipopolysaccharide hepatotoxicity

BACKGROUND

The role of apoptosis in EtOH-induced liver injury has not been investigated much. Therefore, the question whether apoptosis is a contributory factor to alcoholic liver disease remains to be answered. The purpose of this study was to characterize the liver apoptotic response in a murine model of alcohol-enhanced lipopolysaccharide (LPS) hepatotoxicity.

METHODS

Mice were fed an alcohol-containing liquid diet for 49 days followed by an acute LPS challenge. The liver state was judged on the basis of histological appearance, plasma liver enzyme activity (alanine:2-oxoglutarate and aspartate:2-oxoglutarate aminotransferases, as markers of hepatocytolysis), and plasma hyaluronan levels (as a marker of the sinusoidal endothelial cell scavenging function). The liver apoptotic response was assessed by DNA fragmentation (TUNEL procedure), and caspases-3 and -8 activity. To determine if ceramide played a role in the liver apoptotic response, the activity of acidic sphingomyelinase and tissue content of ceramide were also quantified.

RESULTS

Alcohol exposure induced fat accumulation and sensitized the liver to LPS injurious effects. Plasma liver enzyme activity was elevated by alcohol and this effect was potentiated by LPS. Liver apoptosis was augmented by both alcohol and LPS treatment as reflected by high frequency of positive TUNEL staining nuclei and by an increased activity of caspase-3 and -8. Acidic sphingomyelinase activity was also increased and it was associated with an elevated tissue content of ceramide. In addition, LPS also increased plasma TNF-alpha levels. These changes were accompanied by elevated plasma hyaluronan, reflecting an impaired sinusoidal endothelial cell scavenging function.

CONCLUSIONS

These results provide a more complete description of the liver apoptotic response to both alcohol and LPS and may constitute the basis for further mechanistic studies on a possible role apoptosis may play in alcoholic liver injury.

Alcohol feeding and lipopolysaccharide injection modulate apoptotic effectors in the rat pancreas in vivo

The purpose of this study was to determine if alcohol consumption and endotoxin injection change the rate of apoptosis in the pancreas. Rats were fed a Lieber-DeCarli diet for 14 weeks. At 14 weeks, the animals were injected with lipopolysaccharide (LPS) or saline and killed. The pancreata were resected and snap frozen. Apoptosis was detected by TUNEL assay. Caspase-3 activity, Bcl-2 (protein), and Fas ligand (mRNA) were assayed in pancreas extracts and alpha-amylase in plasma. Alcohol feeding significantly decreased alpha-amylase and caspase-3 activity, and significantly increased Bcl-2. LPS injection increased caspase-3 activity and decreased Bcl-2. Fas ligand mRNA was increased only in alcohol-fed, LPS-injected rats. TUNEL labeling was significantly increased only in alcohol-fed, LPS-injected rats. These data show that (a) long-term alcohol feeding suppresses apoptosis in the pancreas; (b) LPS increases the rate of apoptosis in the pancreas; (c) caspase-3 activity and Bcl-2 expression change in opposite directions; (d) TUNEL positivity and Fas ligand expression are increased, and Bcl-2 is decreased in ethanol-fed + LPS-injected rats. These results suggest that prolonged alcohol consumption may sensitize acinar cells to endotoxin-induced injury and raise the possibility that a similar mechanism may cause pancreatitis in human alcoholics.