Longitudinal changes in bifidobacterial population during the first two years of life

Early life microbiota encompasses of a large percentage of Bifidobacterium, while it is not sufficiently understood how the Bifidobacterium population develops after infant's birth. Current study investigated the longitudinal changes in Bifidobacterium population during the first two years of life in 196 term born infants (1,654 samples) using 16S rRNA-23S rRNA internal transcribed spacer (ITS) sequence analysis. Throughout the first two years of life, Bifidobacterium breve, Bifidobacterium longum subsp. longum and Bifidobacterium adolescentis were most dominant and prevalent in the Bifidobacterium population, while B. breve had the highest relative abundance and prevalence during the first week of life and it was taken over by B. longum subsp. longum around two years after birth. Sampling time points, early antibiotic(s) exposure (effect only measurable within a month after birth), delivery mode (effect still detectable two-months after birth) and feeding mode (effect lasted until six months after birth), significantly contributed to the overall variation in the bifidobacterial population. From six months onwards, introducing of solid food and cessation of breastfeeding were accompanied with drastic changes in the composition in bifidobacterial population. Altogether, current study confirmed the effect of potential contributors to the longitudinal changes within the bifidobacterial population during the first two years of life. Registered at https://clinicaltrials.gov: NCT02536560.

Highly conserved bifidobacteria in the human gut: Bifidobacterium longum subsp. longum as a potential modulator of elderly innate immunity

Aging is a physiological and immunological process involving the deterioration of human health, characterised by the progressive alteration of organs and their functions. The speed and extent of such decline are dependent on lifestyle, environment, and genetic factors. Moreover, with advancing age, humans become progressively more fragile and prone to acute and chronic diseases. Although the intestinal microbiota is predisposed to perturbations that accompany aging and frailty, it is generally accepted that the gut microbiota engages in multiple interactions that affect host health throughout the host life span. In the current study, an exhaustive in silico investigation of gut-associated bifidobacteria in healthy individuals from birth to old age revealed that Bifidobacterium longum subsp. longum is the most prevalent member, especially during infancy and in centenarians. Moreover, B. longum subsp. longum genome reconstruction and strain tracing among human gut microbiomes allowed the identification of prototypes of this taxon in the human gut microbiota of healthy elderly individuals. Such analyses guided culturomics attempts to isolate B. longum subsp. longum strains that matched the genomic content of B. longum subsp. longum prototypes from healthy elderly individuals. The molecular effects of selected B. longum subsp. longum strains on the human host were further investigated using in vitro microbe-host interactions, revealing differences in the host immune system transcriptome, with a reduction in gene expression of inflammation-related cytokines. These intriguing findings support the potential anti-aging effects of elderly associated prototypes of B. longum subsp. longum.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Impact of Built Environment and Neighborhood on Promoting Mental Health, Well-being, and Social Participation in Older People: an Umbrella Review

Background

The built environment, especially in the context of the neighborhood, affects older people's health. This umbrella review aims to summarize the associations between factors and interventions in the built environment as regards modifying or improving mental health, well-being, social inclusion and participation in the elderly.

Methods

We searched articles in the following databases: PubMed, Embase, Cochrane Library, Scopus, Avery Index, Sage, Web of Science, Health Evidence, and Google Scholar, without any time limits. The factors and interventions examined have been classified into three categories (urban infrastructure, green infrastructure, built environment), and we have assessed their relationships with each of the health outcomes.

Results

Eight reviews have been included. The results show a positive association between factors and interventions and health outcomes, even though this tends to differ with respect to some of the elements (study design, sample size, built environment and health outcome measurements, and the quality of the primary studies included in the reviews) in the selected studies.

Conclusions

In conclusion, the present study suggests and confirms that acting on the built environment has a positive impact on mental health and social inclusion.

USCA service utilization in the city of Florence (Italy) during the COVID-19 pandemic

Background

In order to support primary care during the first pandemic wave (March 2020), the Italian Government instituted multiprofessional health teams called “USCA” (Special Continuity Care Units), which ensured continuity of care for COVID-19 patients who do not need hospitalization. The aim of our study was to compare the volumes of USCA service utilization in Florence (Tuscany, Italy) during the peak of home visits of three pandemic waves.

Methods

This single-center study followed a retrospective cross-sectional design. The USCA of the Heath District of Florence served a population of 366,190 people. The following data were collected: home medical visits, nursing home (NH) visits, visits in health-care hotels. The peak periods of three epidemic waves were considered in the analyses: the second wave (23 October - 20 November 2020), the third wave (25 March - 22 April 2021), and the Omicron period (27 December 2021 - 6 February 2022). The maximum 7-day moving averages of the daily number of visits during the three periods were calculated. Relative percent differences for visits comparing the considered periods were computed.

Results

Home visits during the third pandemic wave increased by 14% compared to the second wave (second wave: N = 1370, third wave: N = 1562), while a decrease was observed during the Omicron period (Omicron vs third wave: -21%; peak value: 41 vs 60). Visits in health-care hotels during the third wave doubled compared to the second wave. After the start of the COVID-19 vaccination campaign, NH visits steeply declined (third wave vs second wave: -95%; N = 323 vs 15; peak value= 14 vs 2 visits per day). During the Omicron period, NH visits increased by almost four times compared to the third wave period.

Conclusions

The USCA service utilization was significant in all the analyzed periods. In a pandemic context, it is necessary to strengthen primary care services such as USCA, which have proved to respond to rapidly changing health needs.

Key messages

• The USCA service is an innovative model of integrated home care that has proved to respond to rapidly changing health needs during all phases of the COVID-19 pandemic.

• The USCA service utilization was significant during all phases of the pandemic. The USCA service has introduced new ways of working and new relationships between services in primary care.

Serum concentration of mineralocorticoids, glucocorticoids, and sex steroids in peripartum bitches

The aim of the work was to describe the profile of steroid hormones in the peripartum period of the bitch. Twenty-five healthy pregnant bitches presented for pregnancy monitoring and parturition assistance were included in the study. A blood sample was collected for routine progesterone assay, and serum was stored at -20°C. The day of parturition and the number of delivered puppies were registered. Concentrations of corticosteroids, androgens, progestogens, estrogens, for a total number of 17 different hormones, were measured using ultra-performance supercritical fluid chromatography-tandem mass spectrometry. Data were analyzed using a repeated measure, mixed-model approach, taking into account day (from day -4 to day +2 from parturition), age, parity (primiparous vs pluriparous), number of delivered puppies (<4 vs 4-8 vs > 8), and interactions between factors. Day related to parturition significantly affected the concentration of progesterone (P < 0.001), testosterone (P < 0.001), 17α-hydroxyprogesterone (P = 0.0002), and cortisone (P = 0.006). Estrogen concentration did not show any significant variation over time. Testosterone and androstenedione showed an abrupt decline on the day of parturition. The concentration of all glucocorticoids increased the day before parturition. Age or parity was not significantly associated with any of the steroids. Litter size significantly affected concentrations of aldosterone (P = 0.02) and etiocholanolone (P = 0.01). Aldosterone concentrations were higher in litters with 4 to 8 pups than in litters with more than 8 pups (P = 0.02). None of the steroids measured in our study, with the already known exception of progesterone, shows potential to be clinically useful in predicting the onset of parturition in the bitch.

Health needs, community and network in primary care: an action research program

Issue

According to the Alma Ata Declaration, Comprehensive Primary Health Care (C-PHC) addresses the main health problems in the community, promotes participation and involves all health related sectors. In Italy the so called Case della Salute model aims at realizing these principles. The purpose of the project is to understand how this model should be implemented in order to better answer the community needs. In the outskirts of Florence there is an area mostly made of public housing, devoted to people with housing and economic problems. There it is Casa della Salute (a health center where a PHC multidisciplinary team works), which could represent the key to cope with health inequalities and to create a network with the multiple associations rooted in the community. The implementation of an experimental model of C-PHC needs to involve local population, community actors, health professionals and researchers in a process of action-research.

Results

• An epidemiological study described a heavily deprived population compared with the rest of the city, with a burden of mortality especially affecting those most deprived and women. Mental health and addictions showed a deep need of care. A map of the neighbourhood was created in order to analyse formal and informal resources.The health needs of the community were deepened using social and ethnographic methodologies (semi-structured interviews, participant observation and focus groups with health workers, associations' representatives and individuals).Standing multi professional briefings were launched in order to facilitate the process of taking care of complex situations as a team.

Lessons

Preliminary results show the need for stronger collaborations with the actors in the community; further exploration of health related topics; community participation in the process of informing and transforming health practices; involvement of health workers in interprofessional practices to create a shared knowledge.

Key messages

Local health networks need a methodology to expand knowledge of peoples’ needs. Complexity in health and inequalities require a paradigm based on social determinants of health such as PHC.

Renewing primary care: the bottom-up experience of an Italian health professional movement

Sustainability of the National Health Systems (NHS) has been facing different challenges. A community-oriented Comprehensive Primary Health Care (CommOr C-PHC) could help its survival. Such a framework, focused on health promotion, primary prevention, not communicable disease management, requires new capabilities among health professionals. Considering teamwork and interprofessional collaboration (IPC) as PHC core elements, there is growing recognition of the need of interprofessional education (IPE). Nevertheless, italian medical education is distant from other disciplines and mainly based on hospital care settings. Since this situation represents an obstacle to implement a CommOr C-PHC model of health service, new ways of training students and retraining actual health workers should be developed.

The aim of the project is to design IPE programs and to improve IPC within the C-PHC framework, shared learning environments placed in the community were developed.

At the end of 2017 a group of young italian health professionals (public health resident, young general practitioner, social assistant, nurse, medical anthropologist, etc) founded the Campaign “2018 Primary Health care: Now or never”, a cultural movement of public health advocacy. Its goals are: The creation of a common cultural background through the study of PHC evidence and best italian and international practices. Organization of workshops all over Italy: peer education training session, site-visits, lectures with Italian and foreigner health professionals, based on need assessment methods.

Individuation of learning environments placed in the community and in a primary care setting where students can apprehend social determinants of health, exercise critical thinking and develop transprofessional knowledge.

Key messages

Young health professionals from Italy, starting from the need for a different educational framework, based on IPE, created a movement to defend the NHS and promote PHC principles. The success and large participation of a national campaign sustaining PHC and aimed at promoting interprofessional education shows the need for a change in the medical education field.

A public health Italian ethical movement to sustain the beveridge model: health promotion and equity

Worldwide sustainability of the National Health Systems (NHS) has been facing different challenges, such as population ageing, epidemiologic transition and deep social transformations. All these changes are struggling Italian welfare state and its public NHS. Following the principle of the Right to Health of the Declaration of Human Right and the Italian Constitution, a group of young health professionals from all over Italy founded a campaign called “2018 Primary Health care: Now or Never”(PHC Campaign) reminding WHO report of 2008 “primary Health Care: Now more than never”. This movement promotes a reform of the NHS focusing on comprehensive-PHC (C-PHC) and health promotion to guarantee sustainability of the Beveridge model italian system, fight health inequalities and answer the complexity of population needs in a period of spending cuts.

Since the beginning, the movement started an educational program through the study of the literature and the research of the Italian and international best practices of C-PHC and community health promotion. As a result, to achieve the goal of this project, PHC campaign organized peer education training sessions, educational site-visit of some Italian best practices, lectures and workshops with Italian and foreigner health professionals experts on the field. Several national and regional events had been organized all over Italy. Members of “PHC” Campaign have been invited to write books, news on web-based newspapers on this topic and participate in congresses. To date, PHC campaign might be considered one of the strongest not-institutional voices in Italy in supporting the public beveridge-model NHS

Moved from a strong ethical health policy view underlined the importance of the Right-to-Health and of a C-PHC based NHS, since the beginning, “2018 Primary Health care: Now or Never” Movement identified three asset of action: advocacy, education/knowledge and diffusion.

Key messages

The experience showed the importance of health professionals engagement in public health topics such as sustainability of public NHS in order to promote a reform towards health promotion and equity. PHC Campaign is an example of how a bottom-up ethical movement on public health from different Health professionals could actively contribute to promoting cultural and health policy change.

Migrants and access to healthcare: the Italian public health residents action plan

Background

Fighting health inequalities have been included in the WHO Sustainable Development Goals as a priority. Migrants are between the most vulnerable individuals and healthcare interventions, also during the post-migration period, should be oriented, context-specific and aimed at identifying reasons underlying inequalities, as suggested by the recent WHO report ’No public health without migrant health’. The “Inequality Working Group” of the Italian network of public health (PH) residents of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) aims at identifying an interdisciplinary approach suitable to detect barriers to healthcare access for migrants in different Italian regions. Secondly, we aspire to develop some strategies to overcome unequal healthcare access.

Methods

Focus group methodology was applied to set working group educational needs, priorities of action and working plan. Moreover, we implemented a network between various professionals involved in migrant healthcare, particularly with the Regional Groups of the Italian Society of Migration Medicine (SIMM).

Results

After a period of peer-to-peer education about social determinants of health and migration, we reviewed Italian policies about migrants’ healthcare and considered potential discrepancies from WHO recommendations. Furthermore, we mapped practices regarding access to care for migrant population and we focused on causes underlying unequal healthcare access.

Conclusions

Although with regional differences, migrants have limited access to healthcare services and therefore represent a vulnerable subpopulation.

Key messages

Fighting against the barriers that limit access to care for migrants is a priority for health systems. PH residents have a relevant role in identifying and defining critical issues, designing enforcement measures and implementing advocacy actions.

Asylum seekers’ healthcare in Italy: policies and practices among different regions

Background

The Italian law provides for international protection and universal health-care coverage for asylum seekers (AS). Indeed, they are entitled to be regularly registered at the National Healthcare Service. Before submitting the application for refugee status, medical assistance to migrants is up to local administration. Our aim was to describe and compare policies and protocols regulating AS healthcare from their arrival to their application for refugee status, at national and regional level. Moreover, we investigated the daily healthcare practice addressing potential gaps between policies and practice.

Methods

The research team is a subgroup of the Inequality working group of the Italian hygiene society and it is composed of public health residents. The research involved also local health workers and other professionals belonging to regional groups of Italian migrant medicine society (SIMM). We collected national, regional and local policies and protocols and we compared them using a specific framework. Furthermore, we achieved a mapping of daily practice implementation at local health organization (LHO) level using a checklist.

Results

The most relevant findings were that regional policies themselves vary notably from each other and, as regard practices, LHO implement differently the same regional legislation. Furthermore, we found some critical issues: the delayed inclusion in primary care assistance and lack of continuity of care and of a computerized system of recording information.

Conclusions

The lack of uniformity concerning policies and practices of AS healthcare might also result in unawareness and uncertainty about how to access to healthcare services by migrants. An enhanced cooperation between groups dealing with migrants’ issues may lead to avoid variability at the implementation. Finally, a computerized system for data collection might facilitate the continuity of care and the assessment of the real health needs of the AS population.

Key messages

It is a priority challenge for health systems to strengthen the interventions aimed at overcoming the linguistic, economic, cultural and administrative barriers to the health services access. It is crucial to improve the recording information system to detect the real health needs of AS, their change and the inequalities in access and to improve collaboration between groups and university.

Expression of Heterochromatin Protein 1 in the Primary Tumor of Breast Cancer Patients in the Presence or Absence of Occult Metastatic Cells in the Bone Marrow

Gene silencing may occur in breast cancer samples from patients presenting with occult metastatic cells in the bone marrow and one mechanism regulating gene suppression is heterochromatin formation. We have studied whether members of the heterochromatin protein 1 family (HP1Hsα, HP1Hsβ and HP1Hsγ), which take part in chromatin packaging and gene expression regulation, were differentially expressed in tumors from patients with and without occult metastatic cells in their bone marrow. Tumor samples and bone marrow aspirates were obtained from 37 breast cancer patients. Median age was 63 years and 68% of the patients presented with clinical stage I/II disease. Presence of occult metastatic cells in bone marrow was detected through keratin-19 expression by nested RT-PCR in samples from 20 patients (54.1%). The presence of occult metastatic cells in bone marrow was not associated with node involvement, histological grade, estrogen receptor and ERBB2 immunoexpression. Relative gene expression of HP1Hsα, HP1Hsβ and HP1Hsγ was determined by real-time RT-PCR and did not vary according to the presence of occult metastatic cells in bone marrow. In addition, the combined expression of these three transcripts could not be used to classify samples according to the presence of bone marrow micrometastasis. Our work indicates that regulation of heterochromatin formation through HP1 family members may not be the sole mechanism implicated in the metastatic process to the bone marrow.

Estimation of fetal lung development using quantitative analysis of ultrasonographic images in normal canine pregnancy

We investigated the quantitative analysis of sonographic images to predict fetal lung maturity of the canine foetus in normal pregnancy. Twelve bitches were recruited in the present study. Serial ultrasonographic exams were performed at three pre-determined time periods corresponding to the pseudoglandular (40-48 days of pregnancy), canalicular (49-56 days of pregnancy) and saccular phase (57-63 days of pregnancy) of lung development. Mean grey level (MGL) and the standard deviation of the histogram (SDH) of fetal lung and liver sonographic images were measured with dedicated software. The lung-to-liver ratio (LLR) for both parameters was also calculated. Measurements were taken on the two caudal-most foetuses and then averaged. SDH did not show any statistically significant difference between the three time periods in the lungs or in the liver. MGL measured in the lungs significantly increased in the first period and reached a plateau during the last two periods. Liver echogenicity was constant during the first two periods and significantly increased during the last week of gestation. The LLR of MGL significantly decreased during the last week of pregnancy. The LLR was a very good test to detect fetal lung maturity (area under the receiver operator curve (AUROC) = 0.875); using a cut-off value of LLR < 1.541, sensitivity was 83.33% and specificity was 83.33%, positive likelihood ratio = 5. LLR of MGL is an accurate test to estimate lung development in normal canine pregnancies.

Use of the gonadotropin-releasing hormone (GnRH) stimulation test to monitor gonadal function in intact adult male cats

The gonadotropin-releasing hormone (GnRH) stimulation test is a common procedure used to investigate normality of the pituitary-gonadal axis in mammals. There is very little information on the technique, its efficacy and side effects in small animals and in particular no information for male cats. In dogs, such test is performed by intravenous (IV) administration. With cats, the number of times the animal needs to be restrained for blood sampling should be the least possible. The purpose of this study was to assess efficacy and side effects of the GnRH stimulation test in tomcats comparing the IV with the intramuscular (IM) route of administration. A GnRH stimulation test was performed in eight adult tomcats through IM or IV administration of 50 μg gonadorelin. The response of the pituitary-gonadal axis was assessed by measuring serum testosterone on blood samples collected prior to and 1 hr following treatment. When considering each single group of cats, the post-stimulation serum testosterone values were significantly higher than the pre-treatment ones (p < .05). When comparing the two groups of cats, basal testosterone concentrations did not differ, and also post-GnRH testosterone concentrations did not differ. In conclusion, in the cats of our study, the GnRH stimulation test produced the same results following the IM or the IV route of administration. Therefore, in tomcats, the IM route can be considered as effective as the IV one and should be preferred when doing a GnRH test.

The human gut microbiota and its interactive connections to diet

The microbiota of the gastrointestinal tract plays an important role in human health. In addition to their metabolic interactions with dietary constituents, gut bacteria may also be involved in more complex host interactions, such as modulation of the immune system. Furthermore, the composition of the gut microbiota may be important in reducing the risk of contracting particular gut infections. Changes in the microbiota during an individual's lifespan are accompanied by modifications in multiple health parameters, and such observations have prompted intense scientific efforts aiming to understand the complex interactions between the microbiota and its human host, as well as how this may be influenced by diet.

Misuse of antimicrobials and selection of methicillin-resistant Staphylococcus pseudintermedius strains in breeding kennels: genetic characterization of bacteria after a two-year interval

Methicillin-resistant Staphylococcus pseudintermedius (MRSP) strains have been isolated from dogs with increasing frequency; prolonged or excessive use of antimicrobials is associated with the selection of MRSP, and misuse of antimicrobials is frequent in breeding kennels. This study was carried out in two breeding kennels (A and B) in which we had isolated MRSP in 2008: the aim was to assess colonization of previously positive bitches and of other bitches sharing the same environment and to assess the genetic profile of both the old and the new strains [spa typing, staphylococcal cassette chromosome mec (SCCmec) typing and Pulsed-field Gel Electrophoresis (PFGE)]. Six animals from Kennel A (two from 2008) and eight from Kennel B (one from 2008) were tested: 16 MRSP strains were isolated only from bitches housed in Kennel B. Old and new isolates were mecA positive, resulted spa type t02 and carried SSCmec II-III. PGFE showed that all isolates were related and belonged to the main clone lineage dominating in Europe, ST71-J-t02-II-III. Kennels A and B differ in the use of antimicrobials, which has been reduced over time in Kennel A, while has remained excessive in Kennel B, where many agents belonging to different classes (third-generation cephalosporins, fluoroquinolones, macrolids) are administered to dogs, without veterinary supervision, especially around parturition. Misuse of antimicrobials is the key factor for the selection of MRSP strains in healthy dogs and for their persistence over time. Dog breeders should be aware that infections caused by multiresistant bacteria have very limited therapeutical options and represent a huge challenge for animal health.

Gastrointestinal and hepatic complications of hematopoietic stem cell transplantation

Recognition and management of gastrointestinal and hepatic complications of hematopoietic stem cell transplantation has gained increasing importance as indications and techniques of transplantation have expanded in the last few years. The transplant recipient is at risk for several complications including conditioning chemotherapy related toxicities, infections, bleeding, sinusoidal obstruction syndrome, acute and chronic graft-versus-host disease (GVHD) as well as other long-term problems. The severity and the incidence of many complications have improved in the past several years as the intensity of conditioning regimens has diminished and better supportive care and GVHD prevention strategies have been implemented. Transplant clinicians, however, continue to be challenged with problems arising from human leukocyte antigen-mismatched and unrelated donor transplants, expanding transplant indications and age-limit. This review describes the most commonly seen transplant related complications, focusing on their pathogenesis, differential diagnosis and management.

Early onset of primary hypogonadism revealed by serum anti-Müllerian hormone determination during infancy and childhood in trisomy 21

Male patients with an extra sex chromosome or autosome are expected to present primary hypogonadism at puberty owing to meiotic germ-cell failure. Scarce information is available on trisomy 21, a frequent autosomal aneuploidy. Our objective was to assess whether trisomy 21 presents with pubertal-onset, germ-cell specific, primary hypogonadism in males, or whether the hypogonadism is established earlier and affects other testicular cell populations. We assessed the functional status of the pituitary-testicular axis, especially Sertoli cell function, in 117 boys with trisomy 21 (ages: 2months-20year). To compare with an adequate control population, we established reference levels for serum anti-Müllerian hormone (AMH) in 421 normal males, from birth to adulthood, using a recently developed ultrasensitive assay. In trisomy 21, AMH was lower than normal, indicating Sertoli cell dysfunction, from early infancy, independently of the existence of cryptorchidism. The overall prevalence rate of AMH below the 3rd percentile was 64.3% in infants with trisomy 21. Follicle-stimulating hormone was elevated in patients <6months and after pubertal onset. Testosterone was within the normal range, but luteinizing hormone was elevated in most patients <6months and after pubertal onset, indicating a mild Leydig cell dysfunction. We conclude that in trisomy 21, primary hypogonadism involves a combined dysfunction of Sertoli and Leydig cells, which can be observed independently of cryptorchidism soon after birth, thus prompting the search for new hypotheses to explain the pathophysiology of gonadal dysfunction in autosomal trisomy.

HIV-negative plasmablastic lymphoma: not in the mouth

Plasmablastic lymphoma (PBL) is an aggressive variant of non-Hodgkin lymphoma initially reported in the oral cavity of HIV-positive individuals. Since its original description, several cases have been reported in patients who do not have HIV infection. However, despite its recognition as a distinct subtype of diffuse large B-cell lymphoma several years ago, comprehensive reviews of this entity are lacking. A MEDLINE search through June 2010 was performed to identify cases with a pathologic diagnosis of HIV-negative PBL based on morphology and minimal immunohistochemical criteria. Our study included a total of 76 cases. The median age was 57 years (range, 1 to 90 years) with a male-to-female ratio of 1.7. Seventy-four percent of cases did not have an apparent association with immunosuppression, 18% had a concurrent lymphoproliferative or autoimmune disorder and 9% developed PBL after solid organ transplantation. Oral involvement was observed in 21%, advanced stage in 60%, Epstein-Barr virus-encoded RNA expression was positive in 45% and Ki-67 expression of greater than or equal to 80% in 61% of the cases. Chemotherapy was documented in 43 patients, from which 43% received the cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP)-like regimens. The median and the 2-year overall survival for the whole group were 9 months and 10%, respectively. Patients who had HIV-negative PBL have distinct clinicopathological characteristics, such as short overall survival and lower rates of oral involvement and Epstein-Barr virus-encoded RNA expression than the previously reported in HIV-positive patients.

Human breast tumor slices: a model for identification of vitamin D regulated genes in the tumor microenvironment

While many studies have addressed the direct effects of 1alpha,25(OH)2D3 on breast cancer (BC) cells, stromal-epithelial interactions, which are important for the tumor development, have been largely ignored. In addition, high concentrations of the hormone, which cannot be attained in vivo, have been used. Our aim was to establish a more physiological breast cancer model, represented by BC tissue slices, which maintain epithelial-mesenchymal interactions, cultured with a relatively low 1alpha,25(OH)2D3 concentration, in order to evaluate the vitamin D pathway. Freshly excised human BC samples were sliced and cultured in complete culture media containing vehicle, 0.5 nM or 100 nM 1alpha,25(OH)2D3 for 24 h. BC slices remained viable for at least 24 h, as evaluated by preserved tissue morphology in hematoxylin and eosin (HE) stained sections and bromodeoxyuridine (BrdU) incorporation by 10% of tumor cells. VDR mRNA expression was detected in all samples and CYP24A1 mRNA expression was induced by 1alpha,25(OH)2D3 in both concentrations (but mainly with 100 nM). Our results indicate that the vitamin D signaling pathway is functional in BC slices, a model which preserves stromal-epithelial interactions and mimics in vivo conditions.

Effect of an injectable cabergoline formulation on serum prolactin (PRL) and milk secretion in early postpartum Beagle bitches

This study was conducted in order to evaluate effects on prolactin (PRL) concentration and mammary milk secretion of an injectable cabergoline formulation administered to five lactating Beagle bitches during early postpartum (PP). Bitches were bled twice daily (from PP day 3 to PP day 12) and then daily (from PP day 13 to PP day 16) to assay serum PRL. On PP day 6, a subcutaneous (SC) injection of 0.1 ml/kg of placebo was administered. On PP day 9, a SC 0.1 ml/kg dose of injectable cabergoline was administered. All bitches were checked for milk production, using a clinical scoring in order to quantify milk expression from each teat. A circadian variation of serum PRL was evident during the 6 days of pre-treatment monitoring. The day after cabergoline injection, an 80% decrease of PRL serum concentration was observed (p < 0.05). The circadian oscillatory pattern of PRL secretion disappeared after administration of cabergoline, and PRL values remained significantly lower than in the previous days for the first 60 h following treatment (p < 0.001). Milk production was drastically reduced when comparing pre-treatment to post-treatment scores (p < 0.001). A single dose of injectable cabergoline caused a significant reduction in serum PRL concentration and a significant reduction in milk flow. The injectable formulation of cabergoline appeared to be safe and well tolerated.

Prognostic factors in chemotherapy-treated patients with HIV-associated Plasmablastic lymphoma

BACKGROUND

Plasmablastic lymphoma (PBL) is a variant of diffuse large B-cell lymphoma commonly seen in the oral cavity of HIV-infected individuals. PBL has a poor prognosis, but prognostic factors in patients who have received chemotherapy have not been adequately evaluated.

METHODS

An extensive literature search rendered 248 cases of PBL, from which 157 were HIV(+). Seventy cases with HIV-associated PBL that received chemotherapy were identified. Whenever possible, authors of the original reports were contacted to complete clinicopathological data. Univariate analyses were performed calculating Kaplan-Meier estimates and compared using the log-rank test.

RESULTS

The mean age was 39 years, with a male predominance. The mean CD4(+) count was 165 cells/mm(3). Advanced clinical stage was seen in 51% and extraoral involvement was seen in 43% of the cases. The expression levels of CD20 and Epstein-Barr virus-encoded RNA were 13% and 86%, respectively. The overall survival duration was 14 months. In a univariate analysis, early clinical stage and a complete response to chemotherapy were associated with longer survival. There was no apparent difference in survival with regimens more intensive than cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP).

CONCLUSIONS

Patients with HIV-associated PBL have a poor prognosis. Prognosis is strongly associated with achieving a complete clinical response to CHOP or CHOP-like chemotherapy. The role of more intensive regimens is currently unclear. Further research is needed to improve responses using novel therapeutic agents and strategies.

Breast Cancer Gene Expression Profile in Post-Menopausal Patients Supplemented with Vitamin D

Vitamin D supplementation is indicated for post-menopausal women to prevent osteoporosis and lower 25(OH)2D3 or 1,25(OH)2D3 serum levels have been associated with breast cancer incidence or prognosis (metastasis). The antiproliferative effects of vitamin D are observed in breast cancer cell lines exposed to phamacological doses of calcitriol (1,25(OH)2D3, 100nM) but whether physiological doses are sufficient to produce growth inhibition in vivo is not known. The aim of our study was to investigate gene expression profile changes of breast cancer samples from patients supplemented with calcitriol, presenting an anti-proliferative effect on the tumor. Post-menopausal women diagnosed with breast cancer were instructed to take one (0.25ug/day, n=8) or two (0.50ug/day, n=8) tablets of calcitriol after tumor biopsy. Median time of supplementation was 30 days. Sixteen tumor samples were collected during biopsy (before supplementation) and breast surgery (after supplementation). Proliferation index was evaluated by tumor Ki-67 immunohistochemistry (IHC) expression in breast cancer samples before and after calcitirol supplementation and 1000 cells were counted by three observers (p &lt; 0,001, Pearson's correlation). After establishing a counting error between observers, the cut-off value was fixed in 26.53% (percentile 60%) to define response. Patients were then categorized as responsive (a reduction of more than 26.53% on positive Ki-67 positive cells) and non-responsive (difference between samples before and after supplementation not exceeding 26.53%). Among our sixteen patients, all were categorized as responsive to calcitriol supplementation except for two. So far, gene expression profile of two patients (both categorized as responsive) has been analyzed using the U133 Plus 2.0 Affymetrix Gene Chips from 100ng of total RNA. To verify signalling pathways possibly involved in response to vitamin D exposure, additional five samples from a parallel study, in which breast cancer samples from post menopausal patients were collected at surgery and treated in vitro with a low concentration of calcitriol, 0.5nM (that can be attained with subcutaneous administration of doses of 8ug calcitriol, without hypercalcemia) for 24h, were included in the analysis. All samples had RNA hybridized to the same gene chips. Results were normalized and analyzed using RMA and Mev.TM4 softwares. CYP24A1, a target gene of vitamin D, presented a positive regulation after calcitriol supplementation in all samples analyzed. Differentially expressed genes were involved in the regulation of cell cycle [SMAD2, cyclin E, YWHAQ (14-3-3 family] and calcium signalling (HTR7, PTGER1 and PTGER2). Our results indicate that the tumor proliferation index is reduced upon calcitriol supplementation. Moreover, potentially regulated pathways in breast cancer specimens after administration of low doses of calcitriol are regulation of cell cycle and calcium signaling.Supported by FAPESP 2007/01111-0 – 2007/04799-2

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6128.

Thromboembolic complications of intravenous immunoglobulin (IVIG) in an immunocompromised patient with Chronic Lymphocytic Leukemia: a case report

Introduction

Infectious complications represent a major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (CLL). The etiology is postulated to be secondary to aberrations in cell-mediated immunity, as well as to therapy-related immunosuppression. Hypogammaglobulinemia, which occurs in virtually all patients with CLL, may be profound and correlates with disease duration and stage. Intravenous immunoglobulin (IVIG) therapy has been used successfully to prevent and treat infections in this cohort of patients. However IVIG administration and treatment is not benign and should be used with caution given the potential manifestations of thromboembolic complications. High concentration and rapid infusion rate of the IVIG, as well as increased dose and osmolarity of the solution are thought to predispose to thrombotic events. Serum viscosity is the implicated mechanism for compromised blood flow and predisposition of high-risk patients to cardiovascular or cerebrovascular infarction. We report a case of IVIG related thromboembolic manifestations in a CLL patient, to highlight the importance of risk stratifying patients prior to treatment administration.

Case presentation

We present a 55-year-old Caucasian man with CLL who presented to our clinic with neutropenic fevers following a cycle of chemotherapy. Laboratory parameters revealed hypogammaglobulinemia prompting IVIG administration. Shortly thereafter, he developed a massive cascade of thromboembolic phenomena precipitating his demise.

Conclusion

The current consensus surrounding IVIG is that of a relatively safe treatment, with minor adverse effects such as hypertension, fever and chills, nausea, myalgias, or headache. However our report highlights the importance of proceeding with caution in the application of this therapy, as it's proclivity for thrombotic complications has not been fully elucidated in patients with underlying malignancies. Pre-existing thrombogenic risk factors should be carefully evaluated in patients undergoing treatment with IVIG. Clinical evaluation, with careful attention to vascular history and underlying co-morbidities can potentially unmask the high-risk patient where IVIG could be lethal.

HIV-associated anaplastic large cell lymphoma

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Background: Anaplastic large cell lymphoma (ALCL) is a CD30+ T-cell lymphoma that is generally unrelated to EBV in the non-HIV setting. Based upon anaplastic lymphoma kinase (ALK) expression, the new WHO classification provisionally distinguishes between ALK+ (favorable) and ALK- (unfavorable) ALCL. The characteristics of ALCL, such as ALK expression and EBV coinfection, in individuals with HIV infection have not been adequately evaluated. The aim of this study was to investigate these features in HIV-associated ALCL cases. Methods: A MEDLINE search for all cases of HIV-associated non-cutaneous ALCL was undertaken. Data regarding patient age, gender, HIV status (CD4 count, viral load, opportunistic infections), HAART, lymphoma features (B symptoms, stage, sites of involvement, immunophenotype, ALK expression, molecular studies), EBV coinfection, therapy and outcome (survival, cause of death) were extracted and analyzed. Results: A total of 23 cases were included. Patients were of median age 39 years with a male:female ratio of 7:1. Median CD4+ count was 76 cells/mm3 and HIV viral load 416,500 copies/ml. Most (67%) patients had an opportunistic infection, although only 3 (17%) were on HAART. ALCL was extranodal in 22 cases (96%) affecting most commonly lung, soft tissue and liver. Many (78%) patients had stage IV disease and B symptoms were reported in 9 cases (50%). T-cell receptor gene rearrangement was present in all cases, CD30 was positive in 22 (96%), and the vast majority (90%) were ALK-negative. EBV was identified in 8 (35%) cases. Therapy for ALCL was documented in 15 (67%) cases; 64% received CHOP. In 2 of the 3 patients who were on HAART, long-term survival was achieved. Many (68%) patients died, with a median survival of 9 months. Death was caused by either lymphoma progression (42%) or infection (58%). Conclusions: HIV-associated non-cutaneous ALCL appears to affect younger individuals and is associated with EBV infection in a subset of cases. Apart from marked immunosuppression, the poor prognosis of HIV-associated ALCL appears to be related to the absence of ALK expression, advanced stage at presentation with prominent extranodal disease, inadequate therapy including HAART, and poor response to CHOP. Further research is needed to better understand and treat this unique HIV-associated lymphoma.

No significant financial relationships to disclose.

HIV-associated peripheral T-cell lymphoma

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Background: T-cell lymphomas (TCL) constitute 3% of all AIDS-related lymphomas. Over the past 2 decades numerous case reports have documented the emergence of TCL among HIV-infected individuals. These lymphomas comprise a diverse group of disease entities, including peripheral T-cell lymphomas (PTCL), which represent the most common subtype. The aim of this study was to investigate the clinical and pathological features of HIV-associated PTCL. Methods: A MEDLINE search for cases of HIV-associated PTCL was conducted through December 2008. Data regarding patient age, gender, HIV status (CD4 count, viral load, opportunistic infections), use of HAART, lymphoma features (B symptoms, stage, sites of involvement, immunophenotype, molecular studies), EBV coinfection, therapy, and outcome (survival, cause of death) were analyzed and reported descriptively. Results: A total of 34 cases were included. Patients had a median age of 36 years with a male:female ratio of 4:1. Median CD4+ count was 126 cells/mm3. Seventeen patients (50%) had an opportunistic infection, but only 7 patients (26%) were on HAART treatment; 4 patients on HAART (57%) were alive at time of publication. PTCL was extranodal in 75% of cases, affecting predominantly the oral cavity, lung, and GI tract. B symptoms were present in 60% of cases. Stage III and IV disease was found in 17 and 5 cases, respectively, accounting for 76% of the total cases. T-cell receptor gene rearrangement was positive in 10 out of 10 (100%) analyzed cases. EBV was identified in 6 of 12 cases (50%). Median LDH level was 269 IU/L. Therapy for PTCL was administered in 23 cases (68%), while 10 cases (30%) did not receive therapy; 9 of the treated patients (39%) received CHOP with a 33% remission rate. Twenty-two patients (69%) died complicated by infections in 57% and lymphoma progression in 36% of cases. The reported median survival was 12 months. Conclusions: HIV-associated PTCL tends to affect young male individuals with low CD4 counts. Apart from marked immunosuppression, the poor prognosis of HIV-associated PTCL appears to be related to advanced stage at presentation, presence of B symptoms, elevated LDH levels, prominent extranodal disease, and poor response to CHOP chemotherapy. The role of HAART and EBV in the development of PTCL needs further clarification.

No significant financial relationships to disclose.

Veltuzumab, an anti-CD20 mAb for the treatment of non-Hodgkin's lymphoma, chronic lymphocytic leukemia and immune thrombocytopenic purpura

Veltuzumab is a humanized, second-generation anti-CD20 mAb currently under development by Immunomedics Inc for the potential treatment of B-cell non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia (CLL). Licensee Nycomed is developing veltuzumab for the potential treatment of rheumatoid arthritis and immune thrombocytopenic purpura (ITP). Veltuzumab contains 90 to 95% human antibody sequences with identical antigen framework regions to epratuzumab (a humanized anti-CD22 mAb) and similar antigen-binding determinants to rituximab (chimeric, anti-CD20 mAb and the first-line treatment of aggressive and indolent NHL). In vitro studies have demonstrated that veltuzumab has enhanced binding avidities and a stronger effect on complement-dependent cytotoxicity compared with rituximab in selected cell lines. In dose-finding phase I/II clinical trials in patients with low-grade NHL, intravenous veltuzumab demonstrated a substantial rate of complete responses in concurrence with shorter and more tolerable infusions compared with rituximab. Currently there has been no evidence of an immune response to repeated administrations, and no serious adverse events related to veltuzumab treatment in patients with NHL. Veltuzumab is undergoing clinical trials using a low-dose subcutaneous formulation in patients with NHL, CLL and ITP. Prospective, randomized clinical trials are needed to clarify the role veltuzumab will play in a market where the therapy of B-cell lymphoproliferative disorders is dominated by rituximab.

Left sided inferior vena cava duplication and venous thromboembolism: case report and review of literature

The etiology of venous thromboembolism in young patients is frequently associated with hereditary coagulation abnormalities, immunologic diseases, and neoplasia. The advent of radiological advances, namely Computed Tomography (CT) scans and venography has identified vena cava malformations as a new etiologic factor worthy of consideration. In this case report, we describe the unusual occurrence of venous thromboembolism in association with a duplicated inferior vena cava. Duplications of the inferior vena cava (IVC) are seen with an incidence of 0.2% to 3.0% in the general population. Embryogenesis of the IVC is a complex process involving the intricate formation and regression of numerous anastomoses, potentially leading to various anomalies. We present a 23-year-old Caucasian woman with IVC duplication who developed a deep venous thrombosis and multiple pulmonary emboli. Anomaly of the IVC is a rare example of a congenital condition that predisposes to thromboembolism, presumably by favoring venous stasis. This diagnosis should be considered in patients under the age of 30 with spontaneous occurrence of blood clots.