Progress towards malaria elimination in the Greater Mekong Subregion: perspectives from the World Health Organization

Malaria remains a global health challenge, disproportionately affecting vulnerable communities. Despite substantial progress, the emergence of anti-malarial drug resistance poses a constant threat. The Greater Mekong Subregion (GMS), which includes Cambodia, China's Yunnan province, Lao People's Democratic Republic, Myanmar, Thailand, and Viet Nam has been the epicentre for the emergence of resistance to successive generations of anti-malarial therapies. From the perspective of the World Health Organization (WHO), this article considers the collaborative efforts in the GMS, to contain Plasmodium falciparum artemisinin partial resistance and multi-drug resistance and to advance malaria elimination. The emergence of artemisinin partial resistance in the GMS necessitated urgent action and regional collaboration resulting in the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030), advocating for accelerated malaria elimination interventions tailored to country needs, co-ordinated and supported by the WHO Mekong malaria elimination programme. The strategy has delivered substantial reductions in malaria across all GMS countries, with a 77% reduction in malaria cases and a 97% reduction in malaria deaths across the GMS between 2012 and 2022. Notably, China was certified malaria-free by WHO in 2021. Countries' ownership and accountability have been pivotal, with each GMS country outlining its priorities in strategic and annual work plans. The development of strong networks for anti-malarial drug resistance surveillance and epidemiological surveillance was essential. Harmonization of policies and guidelines enhanced collaboration, ensuring that activities were driven by evidence. Challenges persist, particularly in Myanmar, where security concerns have limited recent progress, though an intensification and acceleration plan aims to regain momentum. Barriers to implementation can slow progress and continuing innovation is needed. Accessing mobile and migrant populations is key to addressing remaining transmission foci, requiring effective cross-border collaboration. In conclusion, the GMS has made significant progress towards malaria elimination, particularly in the east where several countries are close to P. falciparum elimination. New and persisting challenges require sustained efforts and continued close collaboration. The GMS countries have repeatedly risen to every obstacle presented, and now is the time to re-double efforts and achieve the 2030 goal of malaria elimination for the region.

Surgical and functional outcomes of Dorsal Inlay Graft urethroplasty in revision vs primary hypospadias repair in the pediatric age

INTRODUCTION

Over the years, Dorsal Inlay Graft (DIG) urethroplasty has gained worldwide acceptance for primary hypospadias repair. However, its safety and effectiveness for revision surgery are yet to be proven.

OBJECTIVE

The aim of the study is to assess and compare complication rates and functional outcomes of DIG surgery in revision versus primary hypospadias repair.

MATERIAL AND METHODS

We carried out a retrospective analysis of data collected from 53 consecutive DIG urethroplasties performed by a single surgeon at our institution. Patients were stratified in two groups - primary repair and redo-urethroplasty. For each group, we recorded standard pre-operative characteristics, surgical technicalities, complication rates and uroflowmetry parameters.

RESULTS

Out of 53 DIG urethroplasties, 21 (39.6 %) where primary and 32 (60.4 %) were re-do. As expected, the two groups differed for median age at surgery: 20 months for primary and 68.5 months for revision surgery (p < 0.001). Additionally, all 21 (100 %) primary interventions were performed with a preputial graft, whereas among revision DIG urethroplasties only 2 (6.3 %) where preputial and 30 (93.8 %) were buccal (p < 0.001). Catheterization time (7 vs 8 days, p = 0.155) and postoperative complication rates (14.3 % vs 9.4 %, p = 0.581) were comparable between the primary and revision surgery group, respectively (all p > .05). Forty-two of the 53 patients underwent uroflowmetry during follow-up. Of these, 19 (63 %) patients presented with abnormal uroflowmetry and 11 (37 %) had equivocal parameters with no difference between the two groups.

DISCUSSION

Dorsal Inlay Graft urethroplasty has long been known to be safe and effective for primary hypospadias repair. On the other hand, data on dorsal inlay graft urethroplasty as a salvage surgery after primary hypospadias repair failure is scarce. Surprisingly, according to our findings, surgical outcomes and complication rates are comparable between primary and revision hypospadias cases. Additionally, our results in the redo group are absolutely encouraging if compared to those reported in the literature for the same subset of patients.

CONCLUSIONS

According to our findings, DIG urethroplasty is a safe and effective option to treat revision hypospadias repair.

Accelerating malaria elimination in Cambodia: an intensified approach for targeting at-risk populations

Background

Malaria in Cambodia has decreased by 90.8% between 2010 and 2020, driven by the commitment of the National Center for Parasitology, Entomology and Malaria (CNM) and the achievements of the roll-out of a village malaria worker programme. However, in the first seven months of 2018, CNM identified a 207% increase (11,969 to 36,778) in confirmed malaria cases compared to the same months in the previous year. To address this increase, CNM developed the “Intensification Plan” (IP), implemented between October 2018 and December 2020.

Methods

The structure of the IP was summarized, including the selection of sites, the interventions implemented in the selected health facility catchment areas (HFCAs) and the monitoring and evaluation process. Data on IP interventions were collected by CNM and civil society organisations. Data on malaria cases and tests from all HFCAs in Cambodia from January 2018 to December 2020 were sourced from the Cambodia Malaria Information System (MIS) and WHO Malaria Elimination Database. Malaria data from IP HFCAs and non-IP HFCAs was analysed and compared to present the changes in malaria testing and confirmed cases before and during implementation of the IP.

Results

Between October 2018 and December 2020, through the IP 16,902 forest packs and 293,090 long-lasting insecticide treated nets were distributed. In the 45 HFCAs included in the IP, 431,143 malaria tests were performed and 29,819 malaria cases were diagnosed, 5364 (18%) of which were Plasmodium falciparum/mixed cases. During the intervention period, over all HFCAs included in IP, P. falciparum/mixed cases declined from 1029 to 39, a 96.2% decrease, and from 25.4 P. falciparum/mixed cases per HFCA to 0.9. HFCAs not included in IP declined from 468 to 43 cases, a 90.8% decrease, showing that routine malaria activities in Cambodia were also playing an important contribution to malaria control.

Conclusions

Over the course of IP implementation there was a substantial increase in malaria testing and both overall malaria cases and P. falciparum/mixed cases decreased month on month. The initiative yields lessons learned for Cambodia to reach the final stage of elimination as well as for other countries aiming to accelerate their malaria control programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04234-2.

Impact of diabetes on COVID-19-related in-hospital mortality: a retrospective study from Northern Italy

PURPOSE

The purpose of this study was to evaluate the impact of pre-existing diabetes on in-hospital mortality in patients admitted for Coronavirus Disease 2019 (COVID-19).

METHODS

This is a single center, retrospective study conducted at Policlinico di Monza hospital, located in the Lombardy region, Northern Italy. We reviewed medical records of 373 consecutive adult patients who were hospitalized with COVID-19 between February 22 and May 15, 2020. Data were collected on diabetes status, comorbid conditions and laboratory findings. Multivariable logistic regression was performed to evaluate the effect of diabetes on in-hospital mortality after adjustment for potential confounding variables.

RESULTS

Mean age of the patients was 72 ± 14 years (range 17-98), 244 (65.4%) were male and 69 (18.5%) had diabetes. The most common comorbid conditions were hypertension (237 [64.8%]), cardiovascular disease (140 [37.7%]) and malignant neoplasms (50 [13.6%]). In-hospital death occurred in 142 (38.0%) patients. In the multivariable model older age (Relative Risk [RR] 1.06 [1.04-1. 09] per year), diabetes (RR 1.56 [1.05-2.02]), chronic obstructive pulmonary disease (RR 1.82 [1.13-2.35]), higher values of lactic dehydrogenase and C-reactive protein were independently associated with in-hospital mortality.

CONCLUSION

In this retrospective single-center study, diabetes was independently associated with a higher in-hospital mortality. More intensive surveillance of patients with this condition is to be warranted.

Laparoscopic robotic-assisted "keel" bladder neck construction

INTRODUCTION

Robotic technology has gained popularity allowing performance of several complex and difficult reconstructive procedures. This video demonstrates the advantages of the robotic approach for a "keel" bladder neck construction in an obese patient.

MATERIAL AND METHODS

A 13 year-old-girl (BMI = 28) already treated elsewhere for a uro-genital sinus (Total Urogenital Mobilization) has been evaluated for disturbing persistent total urinary incontinence. Cisto-colposcopy revealed an extremely short and tortuous urethra. Bladder neck was wide open and incompetent. Video-Urodynamic evaluation showed a bladder with a capacity of 280 mL with low voiding pressures (14-16 cmH20) and continuous urinary leakage. MAG3 scan confirmed normal renal function. Thus, the girl underwent a laparoscopic robotic-assisted "keel" bladder neck construction.

RESULTS

The patient was discharged on 5th post-operative day without complications. After 4 years she is voiding spontaneously (300 cc) without post-void residuals. She has presented a persistent mild stress incontinence successfully treated with subsequent endoscopic bulking agent injection.

CONCLUSIONS

Robotic access to the bladder neck region is an excellent option with ideal anatomical exposure compared to conventional open surgery, especially in obese patients. The "keel" procedure allows to reconfigure and tubularize a wide and incompetent bladder neck creating a continent funnel without the absolute need of concomitant ureteric reimplantation.

Impact of using different biomarkers of liver fibrosis on hepatologic referral of individuals with severe obesity and NAFLD

PURPOSE

The purpose of this study was to estimate how many individuals with severe obesity and NAFLD should be referred to hepatologists according to the EASL-EASD-EASO guidelines and whether the choice of specific indicators of liver fibrosis would significantly impact the number of referrals.

METHODS

This was a single-center retrospective study of 495 individuals with severe obesity screened at our institution between 2012 and 2018 for a bariatric surgery intervention. The guidelines were applied using the NAFLD Liver Fat Score (NLFS) to assess the presence of steatosis and the NAFLD fibrosis score (NFS), Fibrosis-4 (FIB-4) and Hepamet Fibrosis Score (HFS) to assess the risk of advanced fibrosis.

RESULTS

Three hundred and seventy-nine patients (76.6%) had evidence of liver steatosis. The application of the guidelines would lead to referral of 66.3% of patients using NFS, 31.7% using FIB-4 and 34.2% using HFS. When referrals due to abnormal liver function tests were excluded, these percentages dropped to 55.8%, 7.3% and 12.1%, respectively. The strongest inter-biomarker agreement was found between FIB-4 and HFS (κ = 0.86, 95% CI 0.815-0.910).

CONCLUSION

Strict application of the guidelines in individuals with severe obesity would probably lead to over-referral, although a great variability exists among the different scores.

Plasmodium sporozoites can invade hepatocytic cells independently of the Ephrin receptor A2

Sporozoite forms of the malaria parasite Plasmodium are transmitted by mosquitoes and first infect the liver for an initial round of replication before parasite proliferation in the blood. The molecular mechanisms involved during sporozoite invasion of hepatocytes remain poorly understood. In previous studies, two receptors of the Hepatitis C virus (HCV), the tetraspanin CD81 and the Scavenger Receptor BI (SR-BI), were shown to play an important role during entry of Plasmodium sporozoites into hepatocytic cells. In contrast to HCV entry, which requires both CD81 and SR-BI together with additional host factors, CD81 and SR-BI operate independently during malaria liver infection, as sporozoites can use CD81 and/or SR-BI, depending on the Plasmodium species, to invade hepatocytes. However, the molecular function of CD81 and SR-BI during parasite entry remains unknown. Another HCV entry factor, the Ephrin receptor A2 (EphA2), was recently reported to play a key role as a host cell entry factor during malaria liver infection. Here, we investigated the contribution of EphA2 during CD81-dependent and SR-BI-dependent sporozoite infection. Using small interfering RNA (siRNA) and antibodies against EphA2, combined with direct detection of parasites by flow cytometry or microscopy, we show that blocking EphA2 has no significant impact on P. yoelii or P. berghei host cell infection, irrespective of the entry route. Thus, our findings argue against an important role of EphA2 during malaria liver infection.

NAFLD/NASH in patients with type 2 diabetes and related treatment options

Type 2 diabetes may reduce life expectancy and patients' quality of life due to its micro- and macro-vascular complications and to the higher risk of several types of cancer. An emerging important factor is represented by the hepatic involvement; it is recognized that excessive hepatic fat accumulation represents a typical feature of diabetic patients and that it also plays an important pathogenic role. It is now evident that non-alcoholic fatty liver disease (NAFLD), generally perceived as a benign condition, may have on the contrary an important deleterious impact for diabetic patients increasing the risk to develop cardiovascular complications but also serious hepatic diseases, in particular non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma. Lifestyle intervention, bariatric surgery and several drug therapies have now accumulated evidence of efficacy in treating NASH. On the other hand, their durability and safety in the long-term is yet to be proven and their use may be sometimes associated with side effects or higher risk of adverse events limiting the regular administration or contraindicating it. Professional health care providers, building awareness about the importance of these hepatic complications, should put more efforts in primary prevention using a behavioral therapy needing a multidisciplinary approach, in secondary prevention applying on a regular basis in the clinical setting available predictive algorithms to identify the patients at higher cardiovascular and hepatologic risk, and in tertiary prevention treating, when not contraindicated, the diabetic patients preferentially with drugs with proven benefit on NAFLD/NASH.

Serum Lipoprotein (a) and Coronary Artery Disease in Uremic Patients on Chronic Hemodialysis

There is convincing clinical and experimental evidence to support the notion that lipoprotein(a) [Lp(a)] is atherogenic. Patients undergoing chronic hemodialysis have an increased risk of atherosclerotic cardiovascular complications. In the present study, we investigated the possible relation between the alteration, if any, in serum Lp(a) and coronary artery disease in such patients. The mean serum concentration of Lp(a) tended to be higher in the 64 hemodialysis patients than in the 30 normal controls (15.1 ± 15.2 vs. 9.7 ± 10.4 mg/dl). However the difference did not reach statistical significance. The prevalence of levels above 30 mg/dl was 14% (9/64) and 10% (3/10), respectively, and the difference was also not statistically significant. Eleven hemodialysis patients with coronary artery disease had a significantly higher mean serum concentration of Lp(a) than the unaffected 53 (33.7 ± 18.4 vs. 11.1 ± 11.2 mg/dl, p < 0.001). Elevated levels were present in 63.6% (7/11) and 3.8% (2/53), respectively (p<0.01). Other parameters of lipid metabolism were not different between the two groups. We observed statistically significant positive correlations of Lp(a) to total cholesterol, LDL cholesterol and apolipoprotein B in controls, in hemodialysis patients as a whole and in those without coronary artery disease. No such correlations were obtained when hemodialysis patients with coronary artery disease were analysed separately. It is concluded that firstly, high serum levels of Lp(a) in hemodialysis patients are strongly associated with coronary artery disease, as well as in the general population; and secondly, abnormalities in the metabolism of Lp(a) may underlie atherogenesis in these patients, independently of alterations in other lipid constituents

Dynamics of correlation-frozen antinodal quasiparticles in superconducting cuprates

Many puzzling properties of high-critical temperature (Tc) superconducting (HTSC) copper oxides have deep roots in the nature of the antinodal quasiparticles, the elementary excitations with wave vector parallel to the Cu-O bonds. These electronic states are most affected by the onset of antiferromagnetic correlations and charge instabilities, and they host the maximum of the anisotropic superconducting gap and pseudogap. We use time-resolved extreme-ultraviolet photoemission with proper photon energy (18 eV) and time resolution (50 fs) to disclose the ultrafast dynamics of the antinodal states in a prototypical HTSC cuprate. After photoinducing a nonthermal charge redistribution within the Cu and O orbitals, we reveal a dramatic momentum-space differentiation of the transient electron dynamics. Whereas the nodal quasiparticle distribution is heated up as in a conventional metal, new quasiparticle states transiently emerge at the antinodes, similarly to what is expected for a photoexcited Mott insulator, where the frozen charges can be released by an impulsive excitation. This transient antinodal metallicity is mapped into the dynamics of the O-2p bands, thus directly demonstrating the intertwining between the low- and high-energy scales that is typical of correlated materials. Our results suggest that the correlation-driven freezing of the electrons moving along the Cu-O bonds, analogous to the Mott localization mechanism, constitutes the starting point for any model of high-Tc superconductivity and other exotic phases of HTSC cuprates.

New minimally invasive technique for cystoscopic laser treatment of fetal ureterocele

Prenatal ultrasound detection of fetal ureterocele with bilateral hydroureteronephrosis, obstruction of the bladder outlet and progressive amniotic fluid reduction have been associated with a significant risk of end-stage chronic renal disease after birth. Fetal cystoscopic laser incision of the ureterocele, using standard 3.5-mm fetoscopic access to the amniotic cavity and the fetal bladder with the aim of relieving the bladder outflow obstruction to preserve renal function, has been reported previously in a case with a favorable outcome. We report on two additional cases of fetal ureterocele treated by cystoscopic laser decompression. In the first case, a standard 3.3-mm uterine entry was used. In the second case, a new approach was adopted using an 'all-seeing needle' 1.6-mm endoscope. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Plasmodium P36 determines host cell receptor usage during sporozoite invasion

Plasmodium sporozoites, the mosquito-transmitted forms of the malaria parasite, first infect the liver for an initial round of replication before the emergence of pathogenic blood stages. Sporozoites represent attractive targets for antimalarial preventive strategies, yet the mechanisms of parasite entry into hepatocytes remain poorly understood. Here we show that the two main species causing malaria in humans, Plasmodium falciparum and Plasmodium vivax, rely on two distinct host cell surface proteins, CD81 and the Scavenger Receptor BI (SR-BI), respectively, to infect hepatocytes. By contrast, CD81 and SR-BI fulfil redundant functions during infection by the rodent parasite P. berghei. Genetic analysis of sporozoite factors reveals the 6-cysteine domain protein P36 as a major parasite determinant of host cell receptor usage. Our data provide molecular insights into the invasion pathways used by different malaria parasites to infect hepatocytes, and establish a functional link between a sporozoite putative ligand and host cell receptors.

Total hip prosthesis complication, periprosthetic infection with external fistulizing due to Enterobacter cloacae complex multiple drugs resistance: A clinical case report

•

The incidence of periprosthetic hip infections his just below 2%, and the Enterobacteriaceae are fairly rare, being the cause of infection in 3–6% of cases.

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A 76 year old woman with multiple comorbidities underwent surgical implantation of endoprosthesis of the left hip.

•

Multidisciplinary diagnosis of a rare periprosthetic infection.

Introduction

The Enterobacter cloacae is a microorganism found in the intestinal flora of the majority of animals, including humans. Primary infections caused by E. cloacae are rare in immunocompetent patients, but are very common in hospital settings in newborns and immunocompromised patients, and can be aggravated by the insurgence of antibiotic resistance. The incidence of periprosthetic hip infections is just below 2%.

Case presentation

A 76 year old woman with multiple comorbidities underwent surgical implantation of intermediary total hip prosthesis of the left hip, in a different health facility, in February 2014, after the basicervical fracture of the upper femur extremity due to trauma. After an episode of dislocation of the prosthetic implant, in September 2014, she underwent a surgical operation to implant the acetabular component. A month later not in our facility, following a re-hospitalization for the dislocation of the arthroprosthesis, an infection from E. cloacae complex was discovered. After 2 years of chronic infection she came to our attention; the clinical picture featured coxalgia and secreting fistula in the surgical wound. Following a specific antibiotic therapy, carried out intravenously over the course of a month, we decided to intervene removing the left hip arthroprosthesis and placing an antibiotic spacer following the direction deduced from the antibiogram study of August 2016.

Conclusion

The patient was hospitalized in our facility and 2 months later she underwent another operation to remove the antibiotic spacer and to place a new total hip arthroprosthesis. Multiple swabs showed the complete healing from the infection, which was confirmed a couple of months later.

Evidence for a Strong Topological Insulator Phase in ZrTe_{5}

The complex electronic properties of ZrTe_{5} have recently stimulated in-depth investigations that assigned this material to either a topological insulator or a 3D Dirac semimetal phase. Here we report a comprehensive experimental and theoretical study of both electronic and structural properties of ZrTe_{5}, revealing that the bulk material is a strong topological insulator (STI). By means of angle-resolved photoelectron spectroscopy, we identify at the top of the valence band both a surface and a bulk state. The dispersion of these bands is well captured by ab initio calculations for the STI case, for the specific interlayer distance measured in our x-ray diffraction study. Furthermore, these findings are supported by scanning tunneling spectroscopy revealing the metallic character of the sample surface, thus confirming the strong topological nature of ZrTe_{5}.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party

INTRODUCTION

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).

MATERIALS AND METHODS

The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.

RESULTS

A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.

DISCUSSION

This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.

CONCLUSIONS

Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Ultrafast dynamics in unaligned MWCNTs decorated with metal nanoparticles

The relaxation dynamics of unaligned multi-walled carbon nanotubes decorated with metallic nanoparticles have been studied by using transient optical measurements. The fast dynamics due to the short-lived free-charge carriers excited by the pump are not affected by the presence of nanoparticles. Conversely, a second long dynamics, absent in bare carbon nanotubes, appears only in the decorated samples. A combination of experiment and theory allows us to ascribe this long dynamics to relaxation channels involving electronic states localized at the tube-nanoparticle interface.

Ultrafast Optical Control of the Electronic Properties of ZrTe₅

We report on the temperature dependence of the ZrTe(5) electronic properties, studied at equilibrium and out of equilibrium, by means of time and angle resolved photoelectron spectroscopy. Our results unveil the dependence of the electronic band structure across the Fermi energy on the sample temperature. This finding is regarded as the dominant mechanism responsible for the anomalous resistivity observed at T*∼160  K along with the change of the charge carrier character from holelike to electronlike. Having addressed these long-lasting questions, we prove the possibility to control, at the ultrashort time scale, both the binding energy and the quasiparticle lifetime of the valence band. These experimental evidences pave the way for optically controlling the thermoelectric and magnetoelectric transport properties of ZrTe(5).

Effects of short-term manipulation of serum FFA concentrations on left ventricular energy metabolism and function in patients with heart failure: no association with circulating bio-markers of inflammation

BACKGROUND AND AIMS

We wanted to assess the effects of short-term changes in serum free fatty acids (FFAs) on left ventricular (LV) energy metabolism and function in patients with heart failure and whether they correlated with circulating markers of inflammation.

METHODS AND RESULTS

LV function and phosphocreatine (PCr)/ATP ratio were assessed using MR imaging (MRI) and 31P magnetic resonance spectroscopy (MRS) in 11 men with chronic heart failure in two experimental conditions 7 days apart. Study 1: MRI and 31P-MRS were performed before and 3-4 h after i.v. bolus + continuous heparin infusion titrated to achieve a serum FFA concentration of 1.20 mM. Study 2: The same protocol was performed before and after the oral administration of acipimox titrated to achieve a serum FFA concentration of 0.20 mM. Serum concentrations of IL6, TNF-α, PAI-1, resistin, visfatin and leptin were simultaneously assessed. Serum glucose and insulin concentrations were not different between studies. The PCr/ATP ratio (percent change from baseline: +6.0 ± 16.9 and -16.6 ± 16.1 % in Study 1 and Study 2, respectively; p = 0.005) and the LV ejection fraction (-1.5 ± 4.0 and -6.9 ± 6.3 % in Study 1 and Study 2, respectively; p = 0.044) were reduced during low FFA when compared to high FFA. Serum resistin was higher during Study 1 than in Study 2 (p < 0.05 repeated measures ANOVA); meanwhile, the other adipocytokines were not different.

CONCLUSION

FFA deprivation, but not excess, impaired LV energy metabolism and function within hours. Cautions should be used when sudden iatrogenic modulation of energy substrates may take place in vulnerable patients.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers

INTRODUCTION

Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable.

OBJECTIVE

To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN.

STUDY DESIGN

We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC).

RESULTS

The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression.

DISCUSSION

UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation.

CONCLUSION

UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

CD81 is required for rhoptry discharge during host cell invasion by Plasmodium yoelii sporozoites

Plasmodium sporozoites are transmitted by Anopheles mosquitoes and first infect the liver of their mammalian host, where they develop as liver stages before the onset of erythrocytic infection and malaria symptoms. Sporozoite entry into hepatocytes is an attractive target for anti-malarial prophylactic strategies but remains poorly understood at the molecular level. Apicomplexan parasites invade host cells by forming a parasitophorous vacuole that is essential for parasite development, a process that involves secretion of apical organelles called rhoptries. We previously reported that the host membrane protein CD81 is required for infection by Plasmodium falciparum and Plasmodium yoelii sporozoites. CD81 acts at an early stage of infection, possibly at the entry step, but the mechanisms involved are still unknown. To investigate the role of CD81 during sporozoite entry, we generated transgenic P. yoelii parasites expressing fluorescent versions of three known rhoptry proteins, RON2, RON4 and RAP2/3. We observed that RON2 and RON4 are lost following rhoptry discharge during merozoite and sporozoite entry. In contrast, our data indicate that RAP2/3 is secreted into the parasitophorous vacuole during infection. We further show that sporozoite rhoptry discharge occurs only in the presence of CD81, providing the first direct evidence for a role of CD81 during sporozoite productive invasion.

A rapid and robust selection procedure for generating drug-selectable marker-free recombinant malaria parasites

Experimental genetics have been widely used to explore the biology of the malaria parasites. The rodent parasites Plasmodium berghei and less frequently P. yoelii are commonly utilised, as their complete life cycle can be reproduced in the laboratory and because they are genetically tractable via homologous recombination. However, due to the limited number of drug-selectable markers, multiple modifications of the parasite genome are difficult to achieve and require large numbers of mice. Here we describe a novel strategy that combines positive-negative drug selection and flow cytometry-assisted sorting of fluorescent parasites for the rapid generation of drug-selectable marker-free P. berghei and P. yoelii mutant parasites expressing a GFP or a GFP-luciferase cassette, using minimal numbers of mice. We further illustrate how this new strategy facilitates phenotypic analysis of genetically modified parasites by fluorescence and bioluminescence imaging of P. berghei mutants arrested during liver stage development.

Post-transcriptional silencing of UIS4 in Plasmodium berghei sporozoites is important for host switch

Plasmodium sporozoites are transmitted by mosquitoes and first infect hepatocytes of their mammalian host, wherein they develop as liver stages, surrounded by the parasitophorous vacuole membrane (PVM). The parasite must rapidly adapt to its changing environment after switching host. Shortly after invasion, the PVM is remodelled by insertion of essential parasite proteins of the early transcribed membrane protein family such as UIS4. Here, using the rodent malaria model Plasmodium berghei, we show that transcripts encoding UIS4 are stored in a translationally repressed state in sporozoites, allowing UIS4 protein synthesis only after host cell invasion. Using a series of reporter transgenic parasite lines we could demonstrate that the open reading frame of UIS4 mRNA is critical for gene silencing, whereas the 5' and 3' untranslated regions are dispensable. Our data further indicate that the UIS4 translational repression machinery is present only in mature sporozoites in the mosquito salivary glands, and that premature expression of UIS4 protein results in a loss of parasite infectivity. Our findings reveal the importance of specific post-transcriptional control in sporozoites, and establish that host switch requires high levels of translationally silent UIS4 RNA, which permits stage conversion, yet avoids premature expression of this liver stage-specific protein.

Observational retrospective study on acquired megalourethra after primary proximal hypospadias repair and its recurrence after tapering

INTRODUCTION

Acquired megalourethra (AMU) after repair of proximal hypospadias can be a serious complication. An observational retrospective study of its incidence among different types of repair was performed.

MATERIALS AND METHODS

Clinical charts of patients operated on for proximal hypospadias were reviewed.

INCLUSION CRITERIA

all primary hypospadias operated in 1991-2004, with the meatus positioned in proximal penile, scrotal or perineal position.

RESULTS

Of 770 hypospadias cases treated, 130 (16%) were proximal. Seventy-two patients (55%) were treated using preputial flaps: 36 with a tubularized preputial island flap (TIF) and 36 an onlay island flap (OIF). Fifty-eight patients (45%) underwent staged repairs: Belt-Fuquà (BF) in 18 and Bracka procedure in 40 cases. After a mean follow up of 16 years (range 6-19) the overall incidence of complications for each technique was: TIF 36%; OIF 33%; BF 25%; two-stage Bracka 7.5%. The most common complication encountered was neo-urethral fistula. AMU occurred in only 5 cases, none with associated distal urethral stenosis, all in the TIF and OIF groups, and all successfully treated by reduction re-do urethroplasty.

CONCLUSION

A very small number of the patients operated using preputial island flaps techniques developed AMU. None of the staged repairs developed AMU, and this is the preferred choice in proximal hypospadias when the urethral plate requires division and/or substitution. All cases of AMU resolved after urethral tapering.

IL-6 and IL-1α together, but not alone, are key modulators of regulatory T cell suppressive function: insights from computational and in vitro studies. (49.11)

Modulation of the susceptibility of effector T cells to suppression by naturally-arising regulatory T cells (Treg) influences the development of autoimmune diseases, cancer, and transplant outcome. However, our understanding of the factors that underlie this modulation is limited. We aimed to identify the inflammatory mediators that are released by innate immune cells following their exposure to danger signals, and that reduce T cell susceptibility to suppression. A CFSE-based, in vitro mouse T cell activation system was employed to quantify Treg function and to measure the influence of the supernatant of dendritic cells sampled at multiple times after stimulation with the TLR4 ligand LPS. In parallel, 24 cytokines were quantified using Luminex™ in each sample tested. ‘Principal Component Analysis’ was utilized to assess the likely role of these cytokines with the extent of Treg suppression. This analysis suggested that IL-6, IL-1α, and TNFα were possible inhibitory mediators working in synergy. Using the CFSE dilution assay, we found that no single cytokine was capable of reducing Treg suppression. However, combinations of cytokines, in particular IL-6 and IL-1α, resulted in pronounced modulation of suppression. Our results suggest that combining computation with experimentation may help to dissect the complex milieu that determines T cell susceptibility to suppression, and specifically to identify the synergy between IL-6 and IL-1α as target for immunomodulatory therapies.

Functional living skills assessment: a standardized measure of high-order activities of daily living in patients with dementia

AIM

Performance measures are tools aimed to directly evaluate social function in older adults. The authors present the standardization of a new direct performance measure for patients with dementia, the functional living skills assessment (FLSA).

METHODS

FLSA was conceived to detect functional impairment in very mild to moderate patients and to pick up functional modification due to intervention. The patient is asked to perform an activity, and the performance is scored according to completeness and level of assistance required. Eight areas of interest are evaluated (Resources, Consumer Skills, Public Transportation, Time Management, Money management, Leisure, Telephone Skills, Self-Care and Health). Subjects included 54 patients with dementia and 36 normal controls.

RESULTS

Total and partial FLSA scores significantly differed for the two groups (P<0.0001). Performance on FLSA could divide clinical dementia rating (CDR) 0 from CDR 1, CDR 2 e CDR 3 groups. Both sensitivity and specificity were 94%; inter-rater and test-retest reliability was good (P>0.9). Correction scores for education were calculated, while age influence was only marginally significant. Mini Mental State Examination (MMSE) and CDR highly influenced FLSA score (P< 0.0001); FLSA was highly correlated with another performance measure (the Direct Assessment of Functional Status; P=0.821), and with the Instrumental Activity of Daily Living (IADL) scale (P=-0.612), while no significant correlation was present with the Geriatric Depression Scale.

CONCLUSION

FLSA evidences construct, concurrent and discriminative validity. We suggest that this tool could be possibly useful when a high sensibility to different levels of functional impairment is needed, as evaluation of treatment efficacy (both non-pharmacological and pharmacological) identification of relatively intact functional areas to plan cognitive rehabilitation, and confirmation of dementia in the initial phase when there are doubts about functional decline.

Laparoscopic approach to postoperative adhesive obstruction

BACKGROUND

Some authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.

METHODS

From January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.

RESULTS

The procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.

CONCLUSIONS

Laparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

Laparoscopically assisted ureterocystoplasty

OBJECTIVE

To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children.

PATIENTS AND METHODS

From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed.

RESULTS

The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision.

CONCLUSION

LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.

Alpha-dihydroergocryptine in the prophylaxis of migraine: a multicenter double-blind study versus flunarizine

This multicenter, double-blind, clinical study was designed to compare the efficacy and safety of alpha-dihydroergocryptine and flunarizine in the prophylaxis of migraine without aura. One hundred thirty-five patients fulfilling the diagnostic criteria of the International Headache Society were enrolled at five neurologic centers. The study design included a 1-month pretreatment phase with placebo; a 6-month, double-blind, double-dummy treatment phase with alpha-dihydroergocryptine (10 mg twice daily) or flunarizine (5 mg once daily); a further 3-month follow-up phase without treatment. Efficacy was assessed using the patient's diary. Laboratory tests, vital signs, and adverse events were monitored. Analysis of covariance for repeated measures was performed on the intent-to-treat sample. Both treatments led to a significant reduction in the frequency of migraine, days with headache, and use of relief medication. Overall, 51% of those treated with alpha-dihydroergocryptine and 49% of those treated with flunarizine were responders (50% or greater reduction in attack frequency), the average percentage of reduction being 64% with alpha-dihydroergocryptine and 51% with flunarizine. There was no significant difference between the two groups in terms of incidence of adverse events; dizziness and weight gain were the most frequent observed adverse events with alpha-dihydroergocryptine and flunarizine, respectively. Based on the overall improvement in migraine parameters, alpha-dihydroergocryptine can be recommended for use in migraine prophylaxis.

Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches

A multicenter study was carried out in 10 Italian Headache Centers to investigate the prevalence of psychosocial stress and psychiatric disorders listed by the IHS classification as the "most likely causative factors" of tension-type headache (TTH). Two hundred and seventeen TTH adult outpatients consecutively recruited underwent a structured psychiatric interview (CIDI-c). The assessment of psychosocial stress events was carried out using an ad hoc questionnaire. The psychiatric disorders that we included in the three psychiatric items of the fourth digit of the IHS classification were depressive disorders for the item depression, anxiety disorders for the item anxiety, and somatoform disorders for the item headache as a delusion or an idea. Diagnoses were made according to DSM-III-R criteria. At least one psychosocial stress event or a psychiatric disorder was detected in 84.8% of the patients. Prevalence of psychiatric comorbidity was 52.5% for anxiety, 36.4% for depression, and 21.7% for headache as a delusion or an idea. Psychosocial stress was found in 29.5% of the patients and did not differ between patients with and without psychiatric comorbidity. Generalized anxiety disorder (83.3%) and dysthymia (45.6%) were the most frequent disorders within their respective psychiatric group. The high prevalence of psychiatric disorders observed in this wide sample of patients emphasizes the need for a systematic investigation of psychiatric comorbidity aimed at a more comprehensive and appropriate clinical management of TTH patients.

Congenital reflux nephropathy: a follow-up of 108 cases diagnosed perinatally

OBJECTIVE

To determine: (i) the proportion of vesicoureteric reflux (VUR) associated with congenital renal damage and whether it can be severe enough to cause renal impairment from birth: (ii) to evaluate the distribution of males and females affected; and (iii) to describe the course of congenital damage in the first years of life.

PATIENTS AND METHODS

A total of 108 children (76 male and 32 female, M:F 2.3:1), whose VUR was diagnosed before any infection, were followed from birth for a mean (range) of 4.3 (1-10) years. Renal damage was defined by serum creatinine concentration, creatinine clearance and renal imaging (ultrasonography and renal scintigraphy) performed within the first month of life and periodically thereafter.

RESULTS

Of the 108 children, 58 had bilateral and 50 unilateral reflux (total number of refluxing units, 166). High-grade VUR (grade > or = 4) was found in 96 (58%) refluxing renal units (RRUs). Males had a prevalence of bilateral severe (> or = grade 4) reflux (M:F 5.2:1), while in those wit unilateral VUR, the M:F ration was 1.5:1. At birth, mild to moderate damage was present in 56 (36%) RRUs and only associated with VUR of grade > or = 3. Bilateral reflux of grade > or = 4 was associated with congenital moderate/severe renal failure in nine neonates (seven males). In infants with grade > or = 4 VUR who underwent surgical correction, VUR resolved in 92% of cases. In infants with VUR of grade > or = 4 followed medically, the reflux spontaneously resolved in 42% and ameliorated in 16% after 18 months. Serial renal scans during the follow-up showed no progression of renal damage.

CONCLUSIONS

VUR diagnosed at birth on prenatal ultrasonography is associated with congenital damage, with males affected more often than females. The damage involves both kidneys in a consistent proportion and is an important cause of chronic renal impairment from birth. It does not progress in the first years of life if infections are prevented. It is suggested that males with this condition may constitute a major group at risk of developing chronic renal failure in later life.

Tubularized incised plate hypospadias repair for proximal hypospadias

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty for proximal hypospadias.

MATERIALS AND METHODS

From August 1993 to December 1996 tubularized incised plate urethroplasty was performed in 27 boys 6 months to 3 years old with mid shaft and penoscrotal hypospadias. In 7 other boys complex reconstruction combined the tubularized incised plate technique for the glanular urethra with other repairs for the proximal urethra.

RESULTS

Tubularized incised plate surgery created a functional neourethra even in penoscrotal hypospadias. Complications of the primary repair developed in only 3 of 27 patients (11%). No complications were attributed to use of the technique for the glanular urethra in complex repairs.

CONCLUSIONS

Tubularized incised plate urethroplasty is a versatile operation that corrects proximal hypospadias defects with few complications and superior cosmetic results.

Tubularized incised plate hypospadias repair for proximal hypospadias

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty for proximal hypospadias.

MATERIALS AND METHODS

From August 1993 to December 1996 tubularized incised plate urethroplasty was performed in 27 boys 6 months to 3 years old with mid shaft and penoscrotal hypospadias. In 7 other boys complex reconstruction combined the tubularized incised plate technique for the glanular urethra with other repairs for the proximal urethra.

RESULTS

Tubularized incised plate surgery created a functional neourethra even in penoscrotal hypospadias. Complications of the primary repair developed in only 3 of 27 patients (11%). No complications were attributed to use of the technique for the glanular urethra in complex repairs.

CONCLUSIONS

Tubularized incised plate urethroplasty is a versatile operation that corrects proximal hypospadias defects with few complications and superior cosmetic results.

Tubularized incised plate hypospadias repair: results of a multicenter experience

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty to correct distal hypospadias.

MATERIALS AND METHODS

A total of 148 patients underwent repair by 6 pediatric urologists at different institutions in the United States and Europe.

RESULTS

Tubularized incised plate repair created a functional neourethra with a vertically oriented meatus. Complications, including meatal stenoses and fistulas, occurred in 10 patients (7%).

CONCLUSIONS

Tubularized incised plate urethroplasty can be performed in most cases of distal hypospadias. Cosmetic results are superior to those of other popular techniques.

Serum lipoprotein(a) and coronary artery disease in uremic patients on chronic hemodialysis

There is convincing clinical and experimental evidence to support the notion that lipoprotein(a) [Lp(a)] is atherogenic. Patients undergoing chronic hemodialysis have an increased risk of atherosclerotic cardiovascular complications. In the present study, we investigated the possible relation between the alteration, if any, in serum Lp(a) and coronary artery disease in such patients. The mean serum concentration of Lp(a) tended to be higher in the 64 hemodialysis patients than in the 30 normal controls (15.1 +/- 15.2 vs. 9.7 +/- 10.4 mg/dl). However the difference did not reach statistical significance. The prevalence of levels above 30 mg/dl was 14% (9/64) and 10% (3/10), respectively, and the difference was also not statistically significant. Eleven hemodialysis patients with coronary artery disease had a significantly higher mean serum concentration of Lp(a) than the unaffected 53 (33.7 +/- 18.4 vs. 11.1 +/- 11.2 mg/dl, p < 0.001). Elevated levels were present in 63.6% (7/11) and 3.8% (2/53), respectively (p < 0.01). Other parameters of lipid metabolism were not different between the two groups. We observed statistically significant positive correlations of Lp(a) to total cholesterol, LDL cholesterol and apolipoprotein B in controls, in hemodialysis patients as a whole and in those without coronary artery disease. No such correlations were obtained when hemodialysis patients with coronary artery disease were analysed separately. It is concluded that firstly, high serum levels of Lp(a) in hemodialysis patients are strongly associated with coronary artery disease, as well as in the general population; and secondly, abnormalities in the metabolism of Lp(a) may underlie atherogenesis in these patients, independently of alterations in other lipid constituents.