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Clarelli F, Barizzone N, Mangano E, Zuccalà M, Basagni C, Anand S, Sorosina M, Mascia E, Santoro S, Guerini FR, Virgilio E, Gallo A, Pizzino A, Comi C, Martinelli V, Comi G, De Bellis G, Leone M, Filippi M, Esposito F, Bordoni R, Martinelli Boneschi F, D'Alfonso S. Contribution of Rare and Low-Frequency Variants to Multiple Sclerosis Susceptibility in the Italian Continental Population. Front Genet 2022; 12:800262. [PMID: 35047017 PMCID: PMC8762330 DOI: 10.3389/fgene.2021.800262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022] Open
Abstract
Genome-wide association studies identified over 200 risk loci for multiple sclerosis (MS) focusing on common variants, which account for about 50% of disease heritability. The goal of this study was to investigate whether low-frequency and rare functional variants, located in MS-established associated loci, may contribute to disease risk in a relatively homogeneous population, testing their cumulative effect (burden) with gene-wise tests. We sequenced 98 genes in 588 Italian patients with MS and 408 matched healthy controls (HCs). Variants were selected using different filtering criteria based on allelic frequency and in silico functional impacts. Genes showing a significant burden (n = 17) were sequenced in an independent cohort of 504 MS and 504 HC. The highest signal in both cohorts was observed for the disruptive variants (stop-gain, stop-loss, or splicing variants) located in EFCAB13, a gene coding for a protein of an unknown function (p < 10-4). Among these variants, the minor allele of a stop-gain variant showed a significantly higher frequency in MS versus HC in both sequenced cohorts (p = 0.0093 and p = 0.025), confirmed by a meta-analysis on a third independent cohort of 1298 MS and 1430 HC (p = 0.001) assayed with an SNP array. Real-time PCR on 14 heterozygous individuals for this variant did not evidence the presence of the stop-gain allele, suggesting a transcript degradation by non-sense mediated decay, supported by the evidence that the carriers of the stop-gain variant had a lower expression of this gene (p = 0.0184). In conclusion, we identified a novel low-frequency functional variant associated with MS susceptibility, suggesting the possible role of rare/low-frequency variants in MS as reported for other complex diseases.
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Affiliation(s)
- Ferdinando Clarelli
- Laboratory of Human Genetics of Neurological Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nadia Barizzone
- Department of Health Sciences, UPO, University of Eastern Piedmont, and CAAD (Center for Translational Research on Autoimmune and Allergic Disease), Novara, Italy
| | - Eleonora Mangano
- Institute for Biomedical Technologies, National Research Council of Italy, Segrate, Italy
| | - Miriam Zuccalà
- Department of Health Sciences, UPO, University of Eastern Piedmont, and CAAD (Center for Translational Research on Autoimmune and Allergic Disease), Novara, Italy
| | - Chiara Basagni
- Department of Health Sciences, UPO, University of Eastern Piedmont, and CAAD (Center for Translational Research on Autoimmune and Allergic Disease), Novara, Italy
| | - Santosh Anand
- Department of Informatics, Systems and Communications (DISCo), University of Milano-Bicocca, Milan, Italy
| | - Melissa Sorosina
- Laboratory of Human Genetics of Neurological Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Mascia
- Laboratory of Human Genetics of Neurological Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Santoro
- Laboratory of Human Genetics of Neurological Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | - Eleonora Virgilio
- Department of Translational Medicine, Section of Neurology and IRCAD, UNIUPO, Novara, Italy
| | - Antonio Gallo
- MS Center, I Division of Neurology, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro Pizzino
- Department of Health Sciences, UPO, University of Eastern Piedmont, and CAAD (Center for Translational Research on Autoimmune and Allergic Disease), Novara, Italy
| | - Cristoforo Comi
- Department of Translational Medicine, Section of Neurology and IRCAD, UNIUPO, Novara, Italy
| | - Vittorio Martinelli
- Neurology Unit and Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Gianluca De Bellis
- Institute for Biomedical Technologies, National Research Council of Italy, Segrate, Italy
| | - Maurizio Leone
- Neurology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Massimo Filippi
- Neurology Unit and Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Esposito
- Laboratory of Human Genetics of Neurological Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit and Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Bordoni
- Institute for Biomedical Technologies, National Research Council of Italy, Segrate, Italy
| | - Filippo Martinelli Boneschi
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Neuroscience Section, University of Milan, Milan, Italy.,Neurology Unit, MS Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sandra D'Alfonso
- Department of Health Sciences, UPO, University of Eastern Piedmont, and CAAD (Center for Translational Research on Autoimmune and Allergic Disease), Novara, Italy
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Mascia E, Clarelli F, Zauli A, Guaschino C, Sorosina M, Barizzone N, Basagni C, Santoro S, Ferrè L, Bonfiglio S, Biancolini D, Pozzato M, Guerini FR, Protti A, Liguori M, Moiola L, Vecchio D, Bresolin N, Comi G, Filippi M, Esposito F, D'Alfonso S, Martinelli-Boneschi F. Burden of rare coding variants in an Italian cohort of familial multiple sclerosis. J Neuroimmunol 2022; 362:577760. [PMID: 34922125 DOI: 10.1016/j.jneuroim.2021.577760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Multiple Sclerosis (MS) is a chronic inflammatory and neurodegenerative demyelinating disease of the central nervous system. It is a complex and heterogeneous disease caused by a combination of genetic and environmental factors, and it can cluster in families. OBJECTIVE to evaluate at gene-level the aggregate contribution of predicted damaging low-frequency and rare variants to MS risk in multiplex families. METHODS We performed whole exome sequencing (WES) in 28 multiplex MS families with at least 3 MS cases (81 affected and 42 unaffected relatives) and 38 unrelated healthy controls. A gene-based burden test was then performed, focusing on two sets of candidate genes: i) literature-driven selection and ii) data-driven selection. RESULTS We identified 11 genes enriched with predicted damaging low-frequency and rare variants in MS compared to healthy individuals. Among them, UBR2 and DST were the two genes with the strongest enrichment (p = 5 × 10-4 and 3 × 10-4, respectively); interestingly enough the association signal in UBR2 is driven by rs62414610, which was present in 25% of analysed families. CONCLUSION Despite limitations, this is one of the first studies evaluating the aggregate contribution of predicted damaging low-frequency and rare variants in MS families using WES data. A replication effort in independent cohorts is warranted to validate our findings and to evaluate the role of identified genes in MS pathogenesis.
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Affiliation(s)
- E Mascia
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - F Clarelli
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - A Zauli
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - C Guaschino
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy; Department of Neurology, Sant'Antonio Abate Hospital, Gallarate, Italy
| | - M Sorosina
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - N Barizzone
- Department of Health Sciences, Center on Autoimmune and Allergic Diseases (CAAD), UPO, University of Eastern Piedmont, A. Avogadro, 28100 Novara, Italy
| | - C Basagni
- Department of Health Sciences, Center on Autoimmune and Allergic Diseases (CAAD), UPO, University of Eastern Piedmont, A. Avogadro, 28100 Novara, Italy
| | - S Santoro
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - L Ferrè
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy; Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy
| | - S Bonfiglio
- Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - D Biancolini
- Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - M Pozzato
- Neurology Unit and MS Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - F R Guerini
- IRCCS Fondazione Don Carlo Gnocchi, ONLUS, Milan, Italy
| | - A Protti
- Ospedale Niguarda, Department of Neurology, Milan, Italy
| | - M Liguori
- National Research Council, Institute of Biomedical Technologies, Bari Unit, 70126 Bari, Italy
| | - L Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy
| | - D Vecchio
- SCDU Neurology, AOU Maggiore della Carità, 28100 Novara, Italy
| | - N Bresolin
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Neuroscience Section, University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy
| | - G Comi
- Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy
| | - M Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy; Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy; Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy
| | - F Esposito
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy; Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 48, 20132 Milan, Italy
| | - S D'Alfonso
- Department of Health Sciences, Center on Autoimmune and Allergic Diseases (CAAD), UPO, University of Eastern Piedmont, A. Avogadro, 28100 Novara, Italy
| | - F Martinelli-Boneschi
- Neurology Unit and MS Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy; Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Neuroscience Section, University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy.
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3
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Barizzone N, Cagliani R, Basagni C, Clarelli F, Mendozzi L, Agliardi C, Forni D, Tosi M, Mascia E, Favero F, Corà D, Corrado L, Sorosina M, Esposito F, Zuccalà M, Vecchio D, Liguori M, Comi C, Comi G, Martinelli V, Filippi M, Leone M, Martinelli-Boneschi F, Caputo D, Sironi M, Guerini FR, D’Alfonso S. An Investigation of the Role of Common and Rare Variants in a Large Italian Multiplex Family of Multiple Sclerosis Patients. Genes (Basel) 2021; 12:1607. [PMID: 34681001 PMCID: PMC8535321 DOI: 10.3390/genes12101607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 12/30/2022] Open
Abstract
Known multiple sclerosis (MS) susceptibility variants can only explain half of the disease's estimated heritability, whereas low-frequency and rare variants may partly account for the missing heritability. Thus, here we sought to determine the occurrence of rare functional variants in a large Italian MS multiplex family with five affected members. For this purpose, we combined linkage analysis and next-generation sequencing (NGS)-based whole exome and whole genome sequencing (WES and WGS, respectively). The genetic burden attributable to known common MS variants was also assessed by weighted genetic risk score (wGRS). We found a significantly higher burden of common variants in the affected family members compared to that observed among sporadic MS patients and healthy controls (HCs). We also identified 34 genes containing at least one low-frequency functional variant shared among all affected family members, showing a significant enrichment in genes involved in specific biological processes-particularly mRNA transport-or neurodegenerative diseases. Altogether, our findings point to a possible pathogenic role of different low-frequency functional MS variants belonging to shared pathways. We propose that these rare variants, together with other known common MS variants, may account for the high number of affected family members within this MS multiplex family.
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Affiliation(s)
- Nadia Barizzone
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
| | - Rachele Cagliani
- Bioinformatics, Scientific Institute IRCCS E.MEDEA, 23842 Bosisio Parini, Italy; (R.C.); (D.F.); (M.S.)
| | - Chiara Basagni
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
| | - Ferdinando Clarelli
- Laboratory of Genetics of Neurological Complex Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.C.); (E.M.); (M.S.); (F.E.)
| | - Laura Mendozzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy; (L.M.); (C.A.); (D.C.); (F.R.G.)
| | - Cristina Agliardi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy; (L.M.); (C.A.); (D.C.); (F.R.G.)
| | - Diego Forni
- Bioinformatics, Scientific Institute IRCCS E.MEDEA, 23842 Bosisio Parini, Italy; (R.C.); (D.F.); (M.S.)
| | - Martina Tosi
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
| | - Elisabetta Mascia
- Laboratory of Genetics of Neurological Complex Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.C.); (E.M.); (M.S.); (F.E.)
| | - Francesco Favero
- Department of Translational Medicine, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (F.F.); (D.C.)
| | - Davide Corà
- Department of Translational Medicine, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (F.F.); (D.C.)
| | - Lucia Corrado
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
| | - Melissa Sorosina
- Laboratory of Genetics of Neurological Complex Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.C.); (E.M.); (M.S.); (F.E.)
| | - Federica Esposito
- Laboratory of Genetics of Neurological Complex Disorders, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.C.); (E.M.); (M.S.); (F.E.)
| | - Miriam Zuccalà
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
| | - Domizia Vecchio
- Department of Translational Medicine, IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (D.V.); (C.C.)
| | - Maria Liguori
- Institute of Biomedical Technologies, Bari Unit, National Research Council, 70126 Bari, Italy;
| | - Cristoforo Comi
- Department of Translational Medicine, IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (D.V.); (C.C.)
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.C.); (M.F.)
| | - Vittorio Martinelli
- Neurology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Massimo Filippi
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.C.); (M.F.)
- Neurology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Maurizio Leone
- Dipartimento di Emergenza e Area Critica, UO Neurologia, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Filippo Martinelli-Boneschi
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Neuroscience Section, University of Milan, 20122 Milan, Italy;
- Neurology Unit and MS Centre, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Domenico Caputo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy; (L.M.); (C.A.); (D.C.); (F.R.G.)
| | - Manuela Sironi
- Bioinformatics, Scientific Institute IRCCS E.MEDEA, 23842 Bosisio Parini, Italy; (R.C.); (D.F.); (M.S.)
| | - Franca Rosa Guerini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy; (L.M.); (C.A.); (D.C.); (F.R.G.)
| | - Sandra D’Alfonso
- Department of Health Sciences, CAAD (Center for Translational Research on Autoimmune and Allergic Diseases), University of Eastern Piedmont, 28100 Novara, Italy; (C.B.); (M.T.); (L.C.); (M.Z.)
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Cargnin S, Barizzone N, Basagni C, Pisani C, Ferrara E, Masini L, D’Alfonso S, Krengli M, Terrazzino S. Targeted Next-Generation Sequencing for the Identification of Genetic Predictors of Radiation-Induced Late Skin Toxicity in Breast Cancer Patients: A Preliminary Study. J Pers Med 2021; 11:jpm11100967. [PMID: 34683108 PMCID: PMC8540941 DOI: 10.3390/jpm11100967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 01/05/2023] Open
Abstract
Normal tissue radiosensitivity is thought to be influenced by an individual’s genetic background. However, the specific genetic variants underlying the risk of late skin reactions following radiotherapy for breast cancer remain elusive. To unravel the genetic basis for radiation-induced late skin toxicity, we carried out targeted next-generation sequencing of germline DNA samples from 48 breast cancer patients with extreme late skin toxicity phenotypes, consisting of 24 cases with grade 2–3 subcutaneous fibrosis and/or grade 2–3 telangiectasia (LENT-SOMA scales) and 24 controls with grade 0 fibrosis and grade 0 telangiectasia. In this exploratory study, a total of five single-nucleotide variants (SNVs) located in three genes (TP53, ERCC2, and LIG1) reached nominal levels of statistical significance (p < 0.05). In the replication study, which consisted of an additional 45 cases and 192 controls, none of the SNVs identified by targeted NGS achieved nominal replication. Nevertheless, TP53 rs1042522 (G > C, Pro72Arg) in the replication cohort had an effect (OR per C allele: 1.52, 95%CI: 0.82–2.83, p = 0.186) in the same direction as in the exploratory cohort (OR per C allele: 4.70, 95%CI: 1.51–14.6, p = 0.007) and was found be nominally associated to the risk of radiation-induced late skin toxicity in the overall combined cohort (OR per C allele: 1.79, 95%CI: 1.06–3.02, p = 0.028). These results raise the possibility of an association between TP53 rs1042522 and risk of radiation-induced late skin toxicity in breast cancer patients; however, large replication studies are warranted for conclusive evidence.
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Affiliation(s)
- Sarah Cargnin
- Department of Pharmaceutical Sciences, University of Piemonte Orientale, 28100 Novara, Italy;
| | - Nadia Barizzone
- Department of Health Sciences, University of Piemonte Orientale, 28100 Novara, Italy; (N.B.); (C.B.); (S.D.)
| | - Chiara Basagni
- Department of Health Sciences, University of Piemonte Orientale, 28100 Novara, Italy; (N.B.); (C.B.); (S.D.)
| | - Carla Pisani
- Radiation Oncology, University Hospital Maggiore della Carità, 28100 Novara, Italy; (C.P.); (E.F.); (L.M.); (M.K.)
| | - Eleonora Ferrara
- Radiation Oncology, University Hospital Maggiore della Carità, 28100 Novara, Italy; (C.P.); (E.F.); (L.M.); (M.K.)
| | - Laura Masini
- Radiation Oncology, University Hospital Maggiore della Carità, 28100 Novara, Italy; (C.P.); (E.F.); (L.M.); (M.K.)
| | - Sandra D’Alfonso
- Department of Health Sciences, University of Piemonte Orientale, 28100 Novara, Italy; (N.B.); (C.B.); (S.D.)
| | - Marco Krengli
- Radiation Oncology, University Hospital Maggiore della Carità, 28100 Novara, Italy; (C.P.); (E.F.); (L.M.); (M.K.)
- Department of Translational Medicine, University of Piemonte Orientale, 28100 Novara, Italy
| | - Salvatore Terrazzino
- Department of Pharmaceutical Sciences, University of Piemonte Orientale, 28100 Novara, Italy;
- Correspondence:
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5
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Savastio S, Cadario F, D'Alfonso S, Stracuzzi M, Pozzi E, Raviolo S, Rizzollo S, Gigliotti L, Boggio E, Bellomo G, Basagni C, Bona G, Rabbone I, Dianzani U, Prodam F. Vitamin D Supplementation Modulates ICOS+ and ICOS- Regulatory T Cell in Siblings of Children With Type 1 Diabetes. J Clin Endocrinol Metab 2020; 105:5897243. [PMID: 32844222 DOI: 10.1210/clinem/dgaa588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Vitamin D plays an immunoregulatory activity. The aim of this study was to assess the correlation between blood serum 25(OH)D levels and Th17 and Treg circulating subsets, mainly Treg/inducible costimulatory-positive (ICOS+), which seems to have a protective role in autoimmunity, in children with type 1 diabetes mellitus (T1D) and their healthy siblings (S). The secondary aim was to evaluate the impact of vitamin D supplementation on these subsets. PATIENTS AND METHODS 22 T1D and 33 S were enrolled. Glucose, hemoglobin A1c, 25 OH vitamin D (25[OH]D), T helper type 17 (Th17; CD4+CCR6+), regulatory T cells (Treg; CD4+CD25+Foxp3+), and Treg/ICOS+ cells were evaluated. According to human leukocyte antigen (HLA) haplotypes, subjects were classified as "at risk" (HLA+), "protective haplotypes" (HLA-; "nested controls"), and "undetermined" (HLAUND). T1D and S subjects were supplemented with cholecalciferol 1000 IU/die and evaluated after 6 months. RESULTS Vitamin D insufficiency (74.4%) and deficiency (43%) were frequent. S subjects with 25(OH)D levels <25 nmol/L had Th17, Treg (p < 0.01), and Treg/ICOS+ (P < 0.05) percentages higher than subjects with 25(OH)D >75 nmol/L. Treg/ICOS+ percentages (P < 0.05) were higher in HLA- S subjects compared to percentages observed in S with T1D. At baseline, in S subjects, a decreasing trend in Th17 and Treg/ICOS+ values (P < 0.05) from vitamin D deficiency to sufficiency was observed; 25(OH)D levels were negative predictors of Treg/ICOS+ (R2 = 0.301) and Th17 percentages (R2 = 0.138). After 6 months, supplemented S subjects showed higher 25(OH)D levels (P < 0.0001), and lower Th17 (P < 0.0001) and Treg/ICOS+ (P < 0.05) percentages than at baseline; supplemented T1D patients only had a decrease in Th17 levels (P < 0.05). CONCLUSION Serum 25(OH)D levels seem to affect Th17 and Treg cell subsets in S subjects, consistent with its immunomodulating role. HLA role should be investigated in a larger population.
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Affiliation(s)
- Silvia Savastio
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
| | - Francesco Cadario
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
- Interdisciplinary Research Center of Autoimmune Diseases, Università del Piemonte Orientale, Novara, Italy
| | - Sandra D'Alfonso
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Marta Stracuzzi
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
| | - Erica Pozzi
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
| | - Silvia Raviolo
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
| | - Stefano Rizzollo
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
| | - Luca Gigliotti
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Elena Boggio
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Giorgio Bellomo
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Basagni
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Gianni Bona
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Ivana Rabbone
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Umberto Dianzani
- Interdisciplinary Research Center of Autoimmune Diseases, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
- SCDU of Clinical Biochemistry, University Hospital Maggiore della Carità, Novara, Italy
| | - Flavia Prodam
- SCDU of Pediatrics, University Hospital Maggiore della Carità, Novara, Italy
- Interdisciplinary Research Center of Autoimmune Diseases, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
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Cuccaro C, Tarroni M, Tinturini A, Cresti S, Basagni C, Nante N, Messina G, De Marco FM. Carbapenem-resistant enterobacteriaceae: don’t trust your neighbour. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The spread of carbapenem-resistant enterobacteriaceae (CRE) outbreaks consists not only of germs producing KPC and OXA-48, endemic already, but also metallo-beta-lactamase such as NDM or VIM. In Tuscany, Italy, a multidisciplinary regional task force has extended, since NDM alert spread out, from 1st Oct 2019 the CRE screening programme, via molecular testing, to newly admitted patients in high risk settings (medical, intensive care, oncology, transplant, infectious diseases, cardiac surgery units) to fight cross-contamination. The aim of the study is to assess levels and types of CRE in an italian teaching hospital (615 beds) after the programme became effective.
Methods
The surveillance team began recording daily all the CRE positive cases, defined as laboratory confirmed colonizations/infections with CRE. Our retrospective, descriptive study covers the time span between 30th Sep - 16th Dec 2019. Cases were classified by infected apparatus and by resistance phenotype, and we calculated descriptive statistics.
Results
In total we identified 97 cases (male 60.82%, mean (+/-SD) age 71.58+/-17.34 years, 74.23% in medical wards); 5 patients had two body districts infected and 9 carried two different phenotypes. Out of 102 positive samples, 92.16% were bowel colonization, 1.96% BSI, 3.92% urinary and 1.96% respiratory. Among these, 21 were NDM (19.81%), 29 KPC (27.36%), 4 OXA-48 (3.77%), 52 VIM (49.06%). The most detected germ was Klebsiella pneumoniae (30.19%), followed by Escherichia coli (2.83%), Enterobacter cloacae (2.83%), Citrobacter freundii and braakii (2.83%), Klebsiella oxytoca (1.89%). 61 agents were unspecified (57.55%). Among the 21 NDM, 76.19% were K. pneumoniae, only one was a BSI.
Conclusions
CREs continue to be present despite constant surveillance. Although high levels of KPC-producing agents persist, the new spread of VIM phenotype is significant, highlighting, however, that the pathogen wasn't detected in over 50% of the samples.
Key messages
Despite increased surveillance, there is still a consistent portion of patients colonized with unidentified CRE. A surveillance mainly focused on NDM-producing CREs had incidentally highlighted an unexpected spread of VIM phenotype.
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Affiliation(s)
- C Cuccaro
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - M Tarroni
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - A Tinturini
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - S Cresti
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - C Basagni
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - N Nante
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - G Messina
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - F M De Marco
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
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7
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Cuccaro C, Tarroni M, Tinturini A, Cresti S, Basagni C, Nante N, Messina G, De Marco FM. Know your enemy, fight the outbreak: an Italian experience. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Issue
The New Delhi-Enterobateriaceae producing metallo-beta-lactamase NDM, resistant to carbapenems, are responsible of hospital outbreaks. The European Centre for disease prevention and control has published a report about the NDM outbreaks in Italy. Knowledge and application of all types of precautions is necessary to obtain adequate control.
Description
Between June and August 2019 an outbreak of Klebsiella pneumoniae producing NDM-1 occurred in an acute cardiac surgery setting from medium to high intensity, in a third level-hospital in Italy. Every patient with at least one positive typing test for NDM in clinical specimens was defined as a case. The infection control team sought patient 0, reviewed patients' daily records and created a timeline to control movements, verifying risk factors and time to positivity. The correct application of isolation and standard precautions was assessed. Auditing and training sessions were carried out. Our aim is to verify if these actions sufficed to control and halt the outbreak.
Results
Fourteen cases were identified, mean age=66.28 (SD = 13.55), 71.43% of them had a previous negative test. Positivity was found in samples from 13 rectal swabs (prevalence 12.38%), 7 lung aspirates, 3 urine cultures, 2 blood cultures and 2 wound swabs. Eight patients were positive in multiple body districts, 5 have been admitted to the same hospital within the year before, 3 came from other hospitals. The patient 0 has been moved in from a medical ward. After auditing, a training class was given to healthcare staff. The class concerned NDM phenotype, hand hygiene, isolation and personal protective equipment, with further observation in wards. In the following three months no new cases were registered.
Lessons
A continuous high-level adherence to standard precautions and hand hygiene by healthcare staff should be supported by adequate training. This is confirmed to be a strong action to prevent or stop cross-contamination.
Key messages
Colonization of multiresistant germs in healthcare due to cross-contamination has to be tackled promptly. Auditing and training actions should be taken into serious account in order to ensure an effective reaction from healthcare staff.
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Affiliation(s)
- C Cuccaro
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - M Tarroni
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - A Tinturini
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - S Cresti
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - C Basagni
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
| | - N Nante
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - G Messina
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - F M De Marco
- Infection control Unit, “Santa Maria alle Scotte” Teaching Hospital, Siena, Italy
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Gori F, Vonci N, Tinturini A, Basagni C, Messina G, De Marco F. Antibiotic consumption and healthcare associated infection in a third level Italian hospital. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The extended length of stay (LoS) is one of the main causes of hospital infections (HAI), followed by an increase in antibiotics consumption. The final step is the development of multiresistant microorganisms, with a consequent increase in costs for the national healthcare system. Aim of this study is to evaluate the prevalence of HAI and to analyze ATB consumption in a teaching hospital
Methods
Between 17-21 June 2019 the infection control team collected the clinical records of 425 patients to perform a point of prevalence analysis (PPA). Eligible patients were hospitalized in surgical and medical wards of the teaching Hospital (615 beds) in Siena, Italy. For each patients according to guidelines of European Centers for Disease Control and Prevention (ECDC 4.2) we searched for evidence of HAI and for all indication of ATB consumption. Data were processed using Stata12
Results
Overall 425 patients have been analyzed (48.24% female), mean age was 60.88 (SD 26.11) years, mean LoS 8.37 (min 1 max 86) days. Patients were admitted mostly in General Medicine wards (48.94%); 34% underwent surgery. 63.8% of patients had Peripheral Venous Catheter, 20% Central Venous Catheter and 31.06% Urinary Catheter. Twenty-nine HAI were discovered (PPA 6.82%); the higher prevalence (19.23%) was in Intensive Care Unit. LoS (OR:1.07;IC95%1.04-1.1) and devices (OR:2.17;IC95%1.39-3.37) were the two variables that significantly influenced the infection risk. Forty-six percent of all patients received ATB, the most used were third generation Cephalosporines (26,18%), followed by Penicillines (24,73%). The main use was to treat community infections (62.12%), followed by medical prophylaxis (30.81%)
Conclusions
PPA of HAI was 6.82%, comparable to 2017 national PPA (6.5%); prolonged LoS is probably the main cause of this result. Our analysis showed that ATB consumption was quite high, in agreement with the Italian prevalence (44.9%), but the percentage of medical prophylaxis was still high.
Key messages
The way to achieve the health care infection control is still long, the length of the hospitalization could be a field to be improved. High consumption of antibiotics for prophylaxis is still the main point to fight in the battle against the multiresistant microorganisms.
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Affiliation(s)
- F Gori
- Post-Graduate School of Public Health, University of Siena, Siena, Italy
| | - N Vonci
- Post-Graduate School of Public Health, University of Siena, Siena, Italy
| | - A Tinturini
- Infection Control Unit, Santa Maria Delle Scotte Teaching Hospital, Siena, Italy
| | - C Basagni
- Infection Control Unit, Santa Maria Delle Scotte Teaching Hospital, Siena, Italy
| | - G Messina
- Post-Graduate School of Public Health, University of Siena, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - F De Marco
- Infection Control Unit, Santa Maria Delle Scotte Teaching Hospital, Siena, Italy
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Fattorini M, Rosadini D, Cresti S, De Luca A, Cubattoli L, Messina G, Basagni C, Tinturini A, De Marco MF. An educational programme for prevention and control of multidrug resistant organism outbreaks. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky218.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Fattorini
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - D Rosadini
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - S Cresti
- Department of Medical Biotechnologies, University of Siena - Laboratory of Clinical Microbiology and Virology, Siena University Hospital, Siena, Italy
| | - A De Luca
- Department of Medical Biotechnologies, University of Siena - Department of Infectious Diseases, Siena University Hospital, Siena, Italy
| | - L Cubattoli
- Department of Medical Biotechnologies, University of Siena - Unit of Intensive Care Medicine, Siena University Hospital, Siena, Italy
| | - G Messina
- Post Graduate School of Public Health, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - C Basagni
- Medical Management, Siena University Hospital, Siena, Italy
| | - A Tinturini
- Medical Management, Siena University Hospital, Siena, Italy
| | - MF De Marco
- Medical Management, Siena University Hospital, Siena, Italy
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Fattorini M, Rosadini D, Messina G, Basagni C, Tinturini A, De Marco MF. A multi-disciplinary educational programme for the management of a carbapenem-resistant Klebsiella pneumoniae outbreak: an Italian experience. J Hosp Infect 2018; 99:427-428. [PMID: 29630913 DOI: 10.1016/j.jhin.2018.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 01/28/2023]
Affiliation(s)
- M Fattorini
- Post Graduate School of Public Health, University of Siena, Siena, Italy
| | - D Rosadini
- Post Graduate School of Public Health, University of Siena, Siena, Italy
| | - G Messina
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy.
| | - C Basagni
- Medical Management, 'Le Scotte' Teaching Hospital, Siena, Italy
| | - A Tinturini
- Medical Management, 'Le Scotte' Teaching Hospital, Siena, Italy
| | - M F De Marco
- Medical Management, 'Le Scotte' Teaching Hospital, Siena, Italy
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Ceriale E, Fattorini M, Lenzi D, Manzi P, Basagni C, Nante N, Messina G. Use of a fluorescent marker for assessing hospital cleanliness. Eur J Public Health 2015. [DOI: 10.1093/eurpub/ckv172.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Martino A, Monaco L, Golia R, Miletto P, Capasso P, Lombardi C, De Chiara G, Iannace C, Basagni C, Caracciolo F. A new radioguided procedure for localization and surgical treatment of neck node metastasis of papillary thyroid cancer. J Endocrinol Invest 2010; 33:339-42. [PMID: 20061783 DOI: 10.1007/bf03346596] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AIM OF THE STUDY We intended to use a radioguided technique for pre-operative localization of neck node recurrences in patients with papillary thyroid cancer (PTC) already submitted to thyroidectomy and radioiodine treatment. PATIENTS AND METHODS We selected 20 patients affected by PTC with evidence of neck nodes recurrences at ultrasound examination. Our method has been derived from the Radioguided Occult Lesion Localization technique used for pre-operative localization of occult breast lesions. The technique involves the inoculation of human albumin macroaggregates labeled with radioactive technetium (0.4 mCi in a volume of 0.05 ml) directly in the suspicious lesion, under ultrasound guidance. The persistence of the radioactive tracer in the nodes is confirmed by a scintigraphy performed 2 h after injection. During surgery, a gamma detecting probe is used to locate the suspicious lesions as "hot spots". RESULTS Fifty lymph-nodes were injected with the tracer. All radiolabeled lymph-nodes were located and removed during surgery. At histology, metastasis of PTC was confirmed in 38/50 (76%) lymph-nodes. At least one metastatic lymph-node per patient was removed. In 8/20 (40%) patients, reactive lymphoid hyperplasia was found in 12/50 (24%) lymph-nodes. CONCLUSIONS This radioguided technique has been highly effective for localization and surgical treatment of suspicious lymph-node detected at neck ultrasound and may play a valuable role in case of node metastases of thyroid cancer that show no radioiodine uptake.
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Affiliation(s)
- A Martino
- Department of Radiology, AORN "Giuseppe Moscati", Avellino, Italy.
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Tozzi A, Blancasio AC, Basagni C, Ricci C, Burzynska J, Battaglia MA. Prevention and cure of rhinogenous deafness at the Thermal Baths "Bagni delle Galleraie". J Prev Med Hyg 2006; 47:146-50. [PMID: 17263161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Hearing is foundamental for human social life. Secretory Otitis Media (SOM) is the most important cause of trasmissive hypoacusis in early childhood. METHODS The Department of Physiopathology, Experimental Medicine and Public Health of Siena University in collaboration with the Thermal Baths "Bagni delle Galleraie" proposed a prevention and cure campaign of rhinogenous deafness in June 2002 in some primary schools in the Colle val D'Elsa district. A sample of 87 children was involved in the study (average age of 5,64 +/- 1,41 years). On entering the thermal baths a questionnaire was administered to the parents, to point out possible risk factors. RESULTS Among the 87 children, 28 cases of SOM and 21 cases of severe tubal disorder were found. Only 19 cases out of 49 were already known to the parents and only 28 joined the study and were examined for three years consecutively. DISCUSSION Out of the 35 children examined in 2002, 28 returned to "The Galleraie" for the two following years. They repeated the thermal cure for two years as a preventive measure. At present they are not affected by SOM and during the winters suffered a lower number of infections in the primary airways and took less antibiotics. CONCLUSIONS Our study focuses on infant school children because of their critical age for linguistic and social development. Early diagnosis and therapy prevent any negative social development.
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Affiliation(s)
- A Tozzi
- Department of Physiopathology, Experimental Medicine and Public Health of Siena University, Italy
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