Social network characteristics and well-being in Italy: insights from the PHRASI Study

Background

Mental well-being should be prioritized in public health as it represents a valuable resource for individuals and communities, influencing behavior, social cohesion and social inclusion. The support individuals receive from their social networks can have a significant impact on mental well-being. This study used data from the Public Health Residents' Anonymous Survey in Italy, a nationwide cross-sectional survey. The objective was to assess the level of well-being among the Public Health Residents and investigate the association between the social network characteristics and the well-being in this population.

Study design

The current cross-sectional study targeted 1,600 public health residents enrolled in various Italian public health specialization schools between June 14 and July 26, 2022.

Methods

Participants self-reported both functional and structural characteristics of social network. Well-being was assessed using the WHO-5 well-being index. Linear regression models, adjusted for age and sex, were applied to examine the association between WHO-5 score and social network characteristics.

Results

Out of 379 participants, 51.5% reported bad well-being. Those with bad well-being are more likely women, experience lower peer-to-peer and supervisor support, face higher work-to-private life interference, and less frequently have a partner. Greater peer-to-peer support (β=1.13, 95% CI=0.68; 1.57), and increased supervisor support (β=1.26, 95% CI=0.86; 1.67), were associated with higher levels of well-being. Conversely, higher work-to-private life interference was associated with lower perceived well-being. Having a partner resulted in a better perceived well-being (β=1.96, 95% CI=0.94; 2.98). In logistic regression analysis, higher peer-to-peer support (OR=0.68, 95% CI = 0.55;0.85) greater supervisor support (OR=0.60, 95% CI=0.49;0.74) and having a partner (OR=0.51, 95% CI = 0.32;0.82) were associated with reduced odds of bad well-being. Conversely, increased WLI was associated with higher odds of bad well-being (OR=1.47, 95% CI = 1.19;1.82).

Conclusions

The characteristics of an individual's social network play a crucial role in her/his well-being and should be considered both in personal and professional contexts when aimed to enhance mental well-being in communities.

On Gait Consistency Quantification Through ARX Residual Modeling and Kernel Two-Sample Testing

OBJECTIVE

The quantification of the way an individual walks is key to the understanding of diseases affecting the neuromuscular system. More specifically, to improve diagnostics and treatment plans, there is a continuous interest in quantifying gait consistency, allowing clinicians to distinguish natural variability of the gait patterns from disease progression or treatment effects. To this end, the current article presents a novel objective method for assessing the consistency of an individual's gait, consisting of two major components.

METHODS

Firstly, inertial sensor accelerometer data from both shanks and the lower back is used to fit an AutoRegressive with eXogenous input model. The model residuals are then used as a key feature for gait consistency monitoring. Secondly, the non-parametric maximum mean discrepancy hypothesis test is introduced to measure differences in the distributions of the residuals as a measure of gait consistency. As a paradigmatic case, gait consistency was evaluated both in a single walking test and between tests at different time points in healthy individuals and those affected by multiple sclerosis (MS).

RESULTS

It was found that MS patients experienced difficulties maintaining a consistent gait, even when the retest was performed one-hour apart and all external factors were controlled. When the retest was performed one-week apart, both healthy and MS individuals displayed inconsistent gait patterns.

CONCLUSION

Gait consistency has been successfully quantified for both healthy and MS individuals.

SIGNIFICANCE

This newly proposed approach revealed the detrimental effects of varying assessment conditions on gait pattern consistency, indicating potential masking effects at follow-up assessments.

Work-Related Stress Questionnaire: confirmatory factor analysis for construct validation by the PHRASI study

OBJECTIVE

The purpose of this study is to validate the 13-item version of the Work-Related Stress Questionnaire (WRSQ) on a representative sample of Italian public health residents.

MATERIALS AND METHODS

The WRSQ was administered as part of the Public Health Residents' Anonymous Survey in Italy (PHRASI) from 14 June to 26 July 2022. Collinearity between each questionnaire item was assessed with Kendall's τ statistic. The latent factors identified associating similar items based on the authors' observations were workplace, job demand, support and unpleasant workplace. Goodness-of-fit was assessed with confirmatory factor analysis calculating: Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), Standardized Root-Mean-Residual (SRMR). Cronbach's alpha (α) and Omega McDonald (ω) were calculated to evaluate the reliability of the questionnaire. R 4.2.2 was used to perform the analyses.

RESULTS

379 Public Health residents (58% women) responded to the questionnaire. No significant collinearity was found between the items (τ range -0.31 to 0.49). Confirmatory Factor Analysis showed CFI = 0.975, TLI = 0.967, RMSEA = 0.041 and SRMR = 0.051. Internal consistency of the WRSQ Total Score was α = 0.80 and ω = 0.85.

CONCLUSIONS

Although validated in a sectorial subpopulation of healthcare workers, the WRSQ proved to be an excellent tool for assessing work-related stress. Unpleasant workplace latent factors showed lower factor loading and internal consistency than others. This could be due to the fact that topics investigated with unpleasant workplace items (e.g., abuse and discrimination) are experienced on a less regular basis than the ones assessed through the other items.

Social Network Characteristics and Depressive Symptoms of Italian Public Health Medical Residents: The Public Health Residents' Anonymous Survey in Italy (PHRASI)

Despite the high impact of the COVID-19 pandemic on social interactions and healthcare workers' (HWs') mental health, few studies have investigated the association between social network characteristics and HWs' mental health, particularly during the pandemic. Therefore, we aimed to assess the associations between public health residents' (PHRs') social network characteristics and depression. We used data from the Public Health Residents' Anonymous Survey in Italy (PHRASI), a nationwide cross-sectional study. Social network characteristics were self-reported. Depressive symptoms were assessed using the nine-item Patient Health Questionnaire. Linear and logistic models adjusted for age, sex, physical activity, and alcohol were used. A moderation analysis by sex was also performed. A total of 379 PHRs participated in the survey (58% females, median age of 30 years). More peer-to-peer (odds ratio OR = 0.62 (0.47-0.83)) and supervisor support (OR = 0.49 (0.36-0.68)), more social participation ((OR) = 0.36 95% CI (0.25-0.50)), and having a partner (OR = 0.49 (0.25-0.96)) were significantly associated with a lower risk of clinically relevant depressive symptoms. Work-to-private-life interference was significantly associated with a higher risk of clinically relevant depressive symptoms (OR = 1.77 (1.28-2.45)). Promoting a supportive work environment and social participation as well as reducing work-to-private life interference can contribute to reducing the high burden among PHRs.

Depressive Symptoms of Public Health Medical Residents during the COVID-19 Pandemic, a Nation-Wide Survey: The PHRASI Study

Depression is a widespread condition, which increased during the COVID-19 pandemic among healthcare workers as well. The large workload of the pandemic response also affected Public Health Residents (PHRs) who played an important role in infection prevention and control activities. This work aims to assess depression in Italian PHRs, based on data collected through the PHRASI (Public Health Residents' Anonymous Survey in Italy) study. In 2022, 379 PHRs completed the self-administered questionnaire containing Patient Health Questionnaire-9 to evaluate clinically relevant depressive symptoms (PHQ-9 ≥ 10). Multivariate logistic regression shows that the intention (aOR = 3.925, 95% CI = (2.067-7.452)) and the uncertainty (aOR = 4.949, 95% CI = (1.872-13.086)) of repeating the test to enter another postgraduate school/general practitioner course and the simultaneous attendance of two traineeships (aOR = 1.832, 95% CI = (1.010-3.324)) are positively related with depressive symptoms. Conversely, the willingness to work in the current traineeship place (aOR = 0.456, 95% CI = (0.283-0.734)) emerged as a protective factor. Similar results were obtained considering mild-to-severe (PHQ-9 ≥ 5) depressive symptoms and/or stratifying by sex. The findings, suggesting the protective role of job satisfaction toward depression, might entail future interventions to improve the learning experience and promote work-life balance.

Public Health Residents' Anonymous Survey in Italy (PHRASI): Study Protocol for a Cross-Sectional Study for a Multidimensional Assessment of Mental Health and Its Determinants

The COVID-19 pandemic has evolved into a severe psychosocial crisis affecting patients, their relatives, friends, and healthcare professionals. In Italy, public health residents (PHRs) remain essential to the national response to the pandemic. To assess their mental sphere, the "Public Mental Health" working group of the medical residents' Assembly of the Italian Society of Hygiene and Preventive Medicine has designed the Public Health Residents' Anonymous Survey in Italy (PHRASI). This is a nation-wide cross-sectional study based on an 88-item self-administered voluntary survey that evaluates how sociodemographic variables are associated with mental issues, including wellness, eating disorders, sleeplessness, alcohol misuse, depression, and anxiety. Data will be gathered by disseminating a Google Forms link across the Assembly network of medical residents. All PHRs enrolled in a four-year program in one of the Italian postgraduate schools of public health will be qualified as participants. PHRASI aims to draw a comprehensive and detailed picture of the mental health state of Italian PHRs. PHRs are a significant group of healthcare professionals that may serve as a future benchmark for developing and enacting regulations intended to support the mental health of healthcare professionals.

The Role of Gender in the Association between Mental Health and Potentially Preventable Hospitalizations: A Single-Center Retrospective Observational Study

Psychiatric disorders and substance abuse are barriers that limit access to timely treatment and can lead to Potentially Preventable Hospitalizations (PPH). The aim of this study is to identify the role played by gender in the association between mental health and PPH. Hospital discharge records (HDRs) from the Local Health Authority of Pescara (Italy) from 2015 to 2021 were examined and PPH were measured according to Prevention Quality Indicators (PQIs) provided by the Agency for Healthcare Research and Quality. In total, 119,730 HDRs were eligible for the study and 21,217 patients fell into the PQI categories. Mental health disorders and addictions were extracted from the HDRs through the Elixhauser Enhanced ICD-9-CM algorithm. The association between PQI hospitalization and some predictors considered was evaluated with multivariate logistic regression models. In males and females, alcohol abuse showed a protective role towards preventable admissions for PQI-90 (all types of conditions) and PQI-92 (chronic conditions). In contrast, there is a gender gap in accessibility to primary health care, especially for acute conditions leading to PPH. Indeed, in males, PQI-91 admissions for acute conditions were found to be positively associated with drug abuse, psychosis, and depression, whereas this was not the case for females.

The role of gender in the association between mental health and avoidable hospitalization

Background

Hospital discharge records (HDR) can indirectly assess the quality of primary care through algorithms proposed by the Agency for Health Research and Quality (AHRQ). Mental illnesses or substance addictions represent barriers to accessibility to medical care which, can lead to hospitalizations deemed potentially preventable. The aim of this study is to evaluate the gender differences in the association between potentially preventable acute hospitalizations whether mental health or addiction.

Methods

The study examined HDRs of the Local Health Authority of Pescara, Abruzzo, period 2015-2021. The aggregate Prevention Quality Acute Composite 91 (PQI-91) has been coded according to the indications of the AHRQ. Were selected HDRs with a diagnosis of depression, psychosis, alcohol or substance abuse according to Enhanced ICD-9-CM Elixhauser algorithm. Four univariate logistic regression models were implemented correcting for age.

Results

In the study period 252,775 HDRs of which 3,459 PQI-91 were analyzed. A diagnosis of depression is positively associated with a PQI-91 hospitalization only in the male gender (aOR 3.16; 95%CI 2.18-4.58) and not in the female one (aOR 1.13; 95%CI 0.75-1.72). The same is true for a diagnosis of psychosis, males (aOR 2.41; 95%CI 1.66-3.48) and females (aOR 1.19; 95%CI 0.67-2.12). In both genders there was an association with substance abuse, males (aOR 3.92; 95%CI 2.65-5.81) and females (aOR 2.68; 95%CI 1.19-6.07), while for the alcohol abuse the female gender is positively associated (aOR 2.52; 95%CI 1.11-5.73) and not the male one (aOR 1.24; 95%CI 0.80-1.92).

Conclusions

Gender is an innovative approach to health inequalities: women and men respond to a different diagnostic-prescriptive appropriateness, which depends both on biology and on social, cultural, psychological and economic distances. Research efforts must be made to observe the effect healthcare access disparities have on patients who experience mental illness or addiction.

Key messages

• Mental health can limit access to primary care for other comorbidities or acute diseases; poor-quality primary care can result in preventable hospitalizations that increase the cost of health care.

• The gender differences for the same diagnosis of mental illness/addiction that cause potentially preventable acute hospitalizations impose gender-specific strategies aimed at modifying care pathways.

Public health effectiveness of digital contact tracing in the COVID-19 pandemic: A systematic review of available data

Background and aim Contact tracing is a key element of epidemiologic investigation and active surveillance during infectious diseases outbreaks. Digital contact tracing (DCT) are new technologies that have been increasingly adopted in different countries to support conventional contact tracing efforts to control the COVID-19 pandemic. However, scant evidence is available on its public health effectiveness. We applied the Indicator Framework issued in 2021 jointly by the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) to assess the available evidence on DCT adoption and impact in the context of the COVID-19 pandemic. Methods We carried out a systematic review following the PRISMA guidelines (Prospero registration number: CRD42021253662) to retrieve, pool, and critically appraise studies published in English from November 2019 to April 2021. We excluded mathematical models of effectiveness. Only studies representative of the general population or specific populations were included . In line with the WHO-ECDC indicator framework, outcomes of interest were grouped in indicators of: i) DCT use, ii) DCT success, and iii) DCT performance. Results We identified 1.201 citations searching the PubMed, Embase, Web of Science and The Cochrane Library. After screening, 10 studies were included. All included studies reported measures of DCT use, varying widely by study population and setting (percentage of DCT apps download from 0.01% to 58.3% in included studies). Almost no data quantified an association between DCT adoption rate and infection transmission at the community level.  Only one reported measures of DCT success (ratio of exposure notifications received to positive test results entered), while no studies were retrieved reporting measures of DCT performance. Conclusions DCT has large potential to control epidemics. Its adoption is hindered by several normative, technical and acceptance barriers in different regions and countries. Our review shows that while some evidence is available on its adoption and use in selected settings, very scant data is available on its effectiveness in the fight against COVID-19. As digitalization provides new tools for infection control at the population level, solid research is needed to quantify the public health effects of their application.

A wearable multi-sensor system for real world gait analysis

Gait analysis is commonly performed in standardized environments, but there is a growing interest in assessing gait also in ecological conditions. In this regard, an important limitation is the lack of an accurate mobile gold standard for validating any wearable system, such as continuous monitoring devices mounted on the trunk or wrist. This study therefore deals with the development and validation of a new wearable multi-sensor-based system for digital gait assessment in free-living conditions. In particular, results obtained from five healthy subjects during lab-based and real-world experiments were presented and discussed. The in-lab validation, which assessed the accuracy and reliability of the proposed system, shows median percentage errors smaller than 2% in the estimation of spatio-temporal parameters. The system also proved to be easy to use, comfortable to wear and robust during the out-of-lab acquisitions, showing its feasibility for free-living applications.

Use and effectiveness of Digital Contact Tracing during COVID-19 pandemic: a systematic review

Background

Contact tracing (CT) is a pillar of infection control during outbreaks and its implementation has been great ally in the context of the COVID-19 pandemic that pressured national health systems. Digital CT (DCT) aids manual CT by logging proximity contacts and timely notifying contacts of positive cases, contributing to greater epidemic. We aim to systematically review and critically appraise the available evidence on adoption, effectiveness, acceptance and barriers to access of available CT apps.

Methods

We conducted a systematic literature review by means of Pubmed, Embase, Cochrane and Web of Science and applying the PRISMA guidelines. We classified studies according to selected characteristics (eg, original data, mathematical models, policy papers, overview of the experience with national CT apps) in order to better outline our results.

Results

Our queries yielded 1201 articles, of which 790 remained after duplicates' removal. After applying a priori selected inclusion criteria, 428 (54.17%) were eliminated after screening by title and abstract. 362 records were included in our study: of them 33.7% were original studies, 54.1% were opinion papers not reporting quantitative data, 14.91% were mathematical models, 6% were systematic reviews on DCT-related topics. Among original studies, 11.47% described national experiences and 25.40% discussed adoption dynamics.

Conclusions

DCT adoption still faces several cultural, normative and technical barriers, ranging from adoption mandates to privacy issues, to device compatibility. Overall, scant evidence is available on the impact of DCT in controlling infection spread and wide heterogeneity persists within studies in term of design and assessed outcomes Future research is needed based on shared evaluation frameworks.

Key messages

Digital contact tracing apps are a powerful but underestimated tool to counter epidemiological emergencies. Future epidemiological challenges will require a shared implementation and evaluation protocol for digital contact tracing apps.

Algorithms for Walking Speed Estimation Using a Lower-Back-Worn Inertial Sensor: A Cross-Validation on Speed Ranges

Walking/gait speed is a key measure for daily mobility characterization. To date, various studies have attempted to design algorithms to estimate walking speed using an inertial sensor worn on the lower back, which is considered as a proper location for activity monitoring in daily life. However, these algorithms were rarely compared and validated on the same datasets, including people with different preferred walking speed. This study implemented several original, improved, and new algorithms for estimating cadence, step length and eventually speed. We designed comprehensive cross-validation to compare the algorithms for walking slow, normal, fast, and using walking aids. We used two datasets, including reference data for algorithm validation from an instrumented mat (40 subjects) and shanks-worn inertial sensors (88 subjects), with normal and impaired walking patterns. The results showed up to 50% performance improvements. Training of algorithms on data from people with different preferred speeds led to better performance. For the slow walkers, an average RMSE of 2.5 steps/min, 0.04 m, and 0.10 m/s were respectively achieved for cadence, step length, and speed estimation. For normal walkers, the errors were 3.5 steps/min, 0.08 m, and 0.12 m/s. An average RMSE of 1.3 steps/min, 0.05 m, and 0.10 m/s were also observed on fast walkers. For people using walking aids, the error significantly increased up to an RMSE of 14 steps/min, 0.18 m, and 0.27 m/s. The results demonstrated the robustness of the proposed combined speed estimation approach for different speed ranges. It achieved an RMSE of 0.10, 0.18, 0.15, and 0.32 m/s for slow, normal, fast, and using walking aids, respectively.

Inter-leg Distance Measurement as a Tool for Accurate Step Counting in Patients with Multiple Sclerosis

Step detection is commonly performed using wearable inertial devices. However, methods based on the extraction of signals features may deteriorate their accuracy when applied to very slow walkers with abnormal gait patterns. The aim of this study is to test and validate an innovative step counter method (DiSC) based on the direct measurement of inter-leg distance. Data were recorded using an innovative wearable system which integrates a magneto-inertial unit and multiple distance sensors (DSs) attached to the shank. The method allowed for the detection of both left and right steps using a single device and was validated on thirteen people affected by multiple sclerosis (0 <; EDSS <; 6.5) while performing a six-minute walking test. Two different measurement ranges for the distance sensor were tested (DS₂₀₀: 0-200 mm; DS₄₀₀: 0-400 mm). Accuracy was evaluated by comparing the estimates of the DiSC method against video recordings used as gold standard. Preliminary results showed a good accuracy in detecting steps with half the errors in detecting the step of the instrumented side compared to the non-instrumented (mean absolute percentage error 2.4% vs 4.8% for DS₂₀₀; mean absolute percentage error 2% vs 5.4% for DS₄₀₀). When averaging errors across patients, over and under estimation errors were compensated, and very high accuracy was achieved (E_%<; 1.2% for DS₂₀₀; E_%<; 0.7% for DS₄₀₀). DS₄₀₀ is the suggested configuration for patients walking with a large base of support.

Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer

BACKGROUND

It is still unclear whether D2 lymphadenectomy improves the survival of patients with gastric cancer and should therefore be performed routinely or selectively. The aim of this multicentre randomized trial was to compare D2 and D1 lymphadenectomy in the treatment of gastric cancer.

METHODS

Between June 1998 and December 2006, patients with gastric adenocarcinoma were assigned randomly to either D1 or D2 gastrectomy. Intraoperative randomization was implemented centrally by telephone. Primary outcome was overall survival; secondary endpoints were disease-specific survival, morbidity and postoperative mortality.

RESULTS

A total of 267 eligible patients were allocated to either D1 (133 patients) or D2 (134) resection. Morbidity (12.0 versus 17.9 per cent respectively; P = 0.183) and operative mortality (3.0 versus 2.2 per cent; P = 0.725) rates did not differ significantly between the groups. Median follow-up was 8.8 (range 4.5-13.1) years for surviving patients and 2.4 (0.2-11.9) years for those who died, and was not different in the two treatment arms. There was no difference in the overall 5-year survival rate (66.5 versus 64.2 per cent for D1 and D2 lymphadenectomy respectively; P = 0.695). Subgroup analyses showed a 5-year disease-specific survival benefit for patients with pathological tumour (pT) 1 disease in the D1 group (98 per cent versus 83 per cent for the D2 group; P = 0.015), and for patients with pT2-4 status and positive lymph nodes in the D2 group (59 per cent versus 38 per cent for the D1 group; P = 0.055).

CONCLUSION

No difference was found in overall 5-year survival between D1 and D2 resection. Subgroup analyses suggest that D2 lymphadenectomy may be a better choice in patients with advanced disease and lymph node metastases.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

Pattern formation in auxin flux

The plant hormone auxin is fundamental for plant growth, and its spatial distribution in plant tissues is critical for plant morphogenesis. We consider a leading model of the polar auxin flux, and study in full detail the stability of the possible equilibrium configurations. We show that the critical states of the auxin transport process are composed of basic building blocks, which are isolated in a background of auxin depleted cells, and are not geometrically regular in general. The same model was considered recently through a continuous limit and a coupling to the von Karman equations, to model the interplay of biochemistry and mechanics during plant growth. Our conclusions might be of interest in this setting, since, for example, we establish the existence of Lyapunov functions for the auxin flux, proving in this way the convergence of pure transport processes toward the set of equilibrium points.

Molecular background and genotype-phenotype correlation in autoimmune-polyendocrinopathy-candidiasis-ectodermal-distrophy patients from Campania and in their relatives

BACKGROUND

Autoimmune-polyendocrinopathy-candidiasis- ectodermal-distrophy (APECED) is a recessive disease, caused by mutations in the AutoImmune REgulator (AIRE) gene. Different mutations are peculiar of particular populations. In Italy, 3 hot spots areas where APECED shows an increased prevalence, have been identified in Sardinia, Apulia, and in the Venetian region.

AIM

In this study, we analyzed AIRE mutations and genotype-phenotype correlation in APECED patients originating from Campania and in their relatives.

PATIENTS AND METHODS

In 6 patients affected with APECED clinical findings, genetic analysis of AIRE, and APECED-related autoantibodies were performed.

RESULTS

All patients carried at least 1 mutation on exon 1 or on splice-site flanking exon 1. Two siblings carried a complex homozygous mutation [IVS1 + 1G>C; IVS1 + 5delG] on intron 1; 2 patients were compound heterozygous for [T16M]+[W78R] (exons 1+2); 1 patient was compound heterozygous for [A21V]+[C322fs] (exons 1+8) and another was homozygous for [T16M]+[T16M] on exon 1. Expression of the disease showed wide variability while circulating autoantibodies paralleled to phenotype in each patient. Analysis of relatives allowed the identification of 8 heterozygotes. None of heterozygous subjects presented major findings of APECED.

CONCLUSIONS

Mutations localized on exon 1 and the region flanking exon 1 are common in APECED patients originating from Campania. Genotype-phenotype correlation failed to reveal a relationship between detected mutations and clinical expression. Mutations in heterozygosis in AIRE gene are not associated to major findings of APECED.

Effects of toluidine blue-mediated photodynamic therapy on periopathogens and periodontal biofilm: in vitro evaluation

Photodynamic therapy (PDT) is a selective modality of killing targeted cells, mostly known for its application in neoplasms. PDT can be considered to be an alternative method for the elimination of periodontal bacteria from the pocket without harms for the resident tissues. Therefore, PDT may replace systemic antibiotics and enhance the effect of mechanical treatments of periodontal defects. This effort focused on the in vitro sensitization of periopathogens (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum and Prevotella intermedia ) Toluidine Blue mediated and on the use of a Diode laser emitting source. The objective of this research was to evaluate the bactericidal in vitro effect of laser diodes 830 nm (as the light source) after photosensitization with Toluidine Blue (TBO) on the following periopathogenic bacteria: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum and Prevotella intermedia. After evaluating the effect on the single bacterial strain, the ability of Diode Laser to disrupt the structure of biofilms produced by A. actinomycetemcomitans after photosensitization with TBO was also analyzed. The study suggests that the association of TBO and diode laser light 830 nm is effective for the killing of bacteria strains and determines the photoinactivation of Aggregatibacter biofilms. In summary, photodynamic therapy has effectively shown its capabilities and, therefore, it can be considered a valid alternative approach to antimicrobial therapy of periodontitis.

No Evidence of Association of CTLA-4 -318 C/T, 159 C/T, 3′ STR and SUMO4 163 AG Polymorphism with Autoimmune Diabetes

Autoimmune diabetes is an organ specific and multifactorial disorder including insulin dependent diabetes mellitus (Type 1 Diabetes) and latent autoimmune diabetes in adults (LADA), which progresses to insulin dependency because of the beta cells destruction. Several polymorphisms in different genes have been associated with diabetes. The CTLA4 gene is considered a down regulator of T cell function, and the SUMO4 gene encodes a small ubiquitin-like modifier implicated in the intensity and duration of the immune response. We selected 62 LADA patients, 123 patients with Type 1 diabetes patients and 136 unrelated volunteers to study CTLA4 -318 C/T, 159 C/T, 3' STR and SUMO4 163 A/G polymorphisms by PCR. There was a statistical difference significant in the frequency of the allele 209pb for the 3'STR between LADA and Type 1 diabetes patients but not with respect the normal group, the frequencies were found to be 6.9%, 1.0% and 1.9%, respectively. However, no association with either of the polymorphisms has been found in the studied population. The knowledge of the several susceptibility loci in autoimmune diabetes will enhanced the prediction of individuals at high risk of developing the disease in order to establish the best treatment and the prevention of autoimmune diabetes.

Steady-state expression of self-regulated genes

MOTIVATION

Regulatory gene networks contain generic modules such as feedback loops that are essential for the regulation of many biological functions. The study of the stochastic mechanisms of gene regulation is instrumental for the understanding of how cells maintain their expression at levels commensurate with their biological role, as well as to engineer gene expression switches of appropriate behavior. The lack of precise knowledge on the steady-state distribution of gene expression requires the use of Gillespie algorithms and Monte-Carlo approximations.

METHODOLOGY

In this study, we provide new exact formulas and efficient numerical algorithms for computing/modeling the steady-state of a class of self-regulated genes, and we use it to model/compute the stochastic expression of a gene of interest in an engineered network introduced in mammalian cells. The behavior of the genetic network is then analyzed experimentally in living cells.

RESULTS

Stochastic models often reveal counter-intuitive experimental behaviors, and we find that this genetic architecture displays a unimodal behavior in mammalian cells, which was unexpected given its known bimodal response in unicellular organisms. We provide a molecular rationale for this behavior, and we implement it in the mathematical picture to explain the experimental results obtained from this network.

Association between threatened pre-term labour and periodontal disease: does a relationship exist? A matched case-control study

AIM

The relationship between periodontal disease and preterm labour has been target of several studies with contrasting findings. The aim of this study is to verify the association between periodontal diseases in pregnant women and threatened preterm labour (TPL).

METHODS

Two hundred and twenty pregnant women were enrolled in a matched prospective case-control study. Matching factors were age, parity and date of admission. Cases were defined as women admitted with a diagnosis of TPL before the 37th week; controls were defined as women with term labour (= or > 37 weeks) in the same ward. Primary exposure was defined as the presence of at least one tooth with probing depth (PD) >6 mm and BOP+. Average pocket depth, full-mouth bleeding on probing (FMBS) and the presence of plaque (FMPS) were also investigated. Matched univariate (McNemar's test and Wilcoxon signed rank test) and multivariate (conditional logistic regression model) analyses were performed.

RESULTS

At least one PD >6 mm BOP+ was found in 30 TPL cases (27.3%) and 37 controls (33.6%), without significant difference (P=0.27). There was also no difference was found in shallow pockets. The average pocket depth was similar in TPL cases (2.67 mm) and controls (2.78 mm) (P=0.29). The average FMPS was 56.4% in the cases and 50.7% in the controls, while FMPS was 36.5% and 39.6%, respectively, though these differences are not statistically significant (P=0.26 and P=0.42, respectively).

CONCLUSION

From our study, there seems to be no association between threatened pre-term labour and periodontal disease.

Stem cell transplantation for the Wiskott-Aldrich syndrome: a single-center experience confirms efficacy of matched unrelated donor transplantation

The treatment of Wiskott-Aldrich syndrome (WAS), a once uniformly fatal disorder, has evolved considerably as the use of hematopoietic stem cell transplant has become more widespread. For the majority of patients who lack an human leukocyte antigen-identical sibling, closely matched unrelated donor bone marrow transplant (MUD BMT) at an early age is an excellent option that nevertheless is not uniformly chosen. We retrospectively analyzed our experience with transplantation in 23 patients with WAS from 1990 to 2005 at the University of Brescia, Italy, of whom 16 received MUD BMT. Myeloablative chemotherapy was well tolerated with median neutrophil engraftment at day 18, and no cases of grade III or IV graft-vs-host disease. Overall survival was very good with 78.2% (18/23) of the whole cohort and 81.2% (13/16) of MUD BMT recipients surviving. Among 18 survivors, full donor engraftment was detected in 12 patients, and stable mixed chimerism in all blood lineages in four patients. Deaths were limited to patients who had received mismatched related BMT or who had severe clinical symptomatology at the time of transplantation, further emphasizing the safety and efficacy of MUD BMT when performed early in the clinical course of WAS.

Lack of interaction between a polymorphism in the dopamine D2 receptor gene and the clinical features of migraine

The purpose of this study was to evaluate whether a particular genotype of the dopamine D2 receptor (DRD2) gene would affect the clinical features of migraine. In a group of 118 migraineurs (55 migraine with aura and 63 migraine without aura patients), we tested the association of the biallelic C/T NcoI DRD2 polymorphism with several characteristics of the disease. Genotype and allele frequencies resulted similarly distributed in migraine with aura and migraine without aura patients (chi2 = 1.58, P = 0.45 and chi2 = 0.09, P = 0.77, respectively). The different DRD2 genotypes (C/C, C/T and T/T) had no significant effects on age at onset of migraine, presence of premonitory phenomena, frequency of headache attacks, associated symptoms, psychological features and quality of life of our migraine patients. The results of our study do not support a role for the DRD2 gene in modifying the clinical features of migraine.

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome: time to review diagnostic criteria?

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is an autosomal-recessive syndrome defined by two of the following conditions: chronic mucocutaneous candidiasis, hypoparathyroidism, or Addison's disease. Other autoimmune conditions may be associated, such as hypothyroidism, hypogonadism, insulin-dependent diabetes mellitus, chronic active hepatitis, pernicious anemia, vitiligo, alopecia, biliary cirrhosis, and ectodermal dysplasia. APECED is caused by mutations in the autoimmune regulator gene, mapping to 21q22.3. We report on three patients whose clinical and molecular features challenge the currently used diagnostic criteria for APECED. AR presented at 15 yr of age with a history of recurrent infections and mucocutaneous candidiasis. He is now 21 yr old, and no other signs or symptoms of APECED have appeared to date. DR presented at 7 yr of age with hypocalcemia and a prolonged Q-T interval on the electrocardiogram. He also had minor facial dysmorphisms and mild mental retardation. Serum calcium levels were low, PTH levels were undetectable, and hypoparathyroidism was therefore diagnosed. All other biochemical, immunological, and endocrinological tests were normal. DR is now 8 yr old with no other signs or symptoms of APECED. ST presented at 14 yr of age for alopecia aerata and pitted nail dystrophy and goiter. Thyroid function was normal in the presence of thyroid-specific antibodies. No other signs or symptoms of APECED have appeared to date. Genetic analysis revealed a typical mutation (R257X) on a single allele in both AP and DR; in ST, heterozygosity for a novel mutation (V484M) involving one of the zinc fingers of the plant homeodomain of the protein was found. The finding of a typical APECED mutation in two patients presenting with one isolated major clinical APECED feature and of a novel mutation in a patient presenting with atypical features of APECED onset suggests that the time might have come for updating the diagnostic criteria of this syndrome.

Monocytes from Wiskott-Aldrich patients differentiate in functional mature dendritic cells with a defect in CD83 expression

Wiskott-Aldrich syndrome (WAS) is an X-linked disorder characterized by congenital thrombocytopenia and progressive deterioration of the immune function. Dendritic cells (DC) are key effectors in the induction of specific immunity and are highly specialized in antigen uptake and subsequent migration to draining lymph nodes. DC were generated in vitro from circulating monocytes from ten WAS patients characterized by a different disease score. Immature DC showed similar morphology and membrane phenotype, as compared to normal DC. In chemotaxis assay, immature DC had a reduced migration in response to MIP-1alpha/CCL3, but efficiently endocytosed the macromolecules FITC-dextran and FITC-albumin. Upon terminal differentiation with LPS or CD40 ligand, the acquisition of a mature surface phenotype was variably achieved among WAS patients, with increased expression of CD80, CD86 and DC-LAMP. In contrast, the expression of CD83 was usually low. A defective up-regulation of CD83 was also observed in the lymph node from one WAS patient, whose DC stained positively for DC-LAMP. Mature DC from all the patients tested, but one, significantly migrated in vitro in response to MIP-3beta, a finding confirmed in vivo by the detection of HLA-DR/DC LAMP-positive cells in secondary lymphoid organs. When tested in MLR assays, both immature and mature WAS DC induced allogenic T cell proliferation in a manner comparable to control DC. Collectively these results suggest that, although many functional activities of WAS DC are essentially similar to normal DC, subtle and selective alterations of DC differentiation were also observed, with reduced migratory activity of immature DC and defective CD83 expression upon maturation.

Crystal structure of the human nuclear cap binding complex

The heterodimeric nuclear cap binding complex (CBC) binds to 5'-capped polymerase II transcripts. It enhances the efficiency of several mRNA maturation steps and is essential for U snRNA nuclear export in multicellular eukaryotes. The 2A crystal structure of human CBC shows that the large subunit, CBP80, comprises three domains, each containing consecutive helical hairpins and resembling the so-called MIF4G domain found in several other proteins involved in RNA metabolism. The small subunit, CPB20, has an RNP fold and associates with the second and third domains of CBP80. Site-directed mutagenesis revealed 4 residues of CBP20 which are critical for cap binding. A model for cap binding is proposed based on these results and the known mode of binding of RNA to RNP domains.

Henoch-Schönlein purpura in Wiskott-Aldrich syndrome

Wiskott-Aldrich syndrome (WAS) is a rare immune deficiency disease. Sialophorin glycosylation is defective in WAS. Although it is not very common, renal involvement including IgA nephropathy (IgAN) was reported. Abnormal glycosylation plays a key role in the pathogenesis of IgAN. We present an 8-year-old boy with WAS who had recurrent episodes of Henoch-Schönlein purpura with renal involvement following upper respiratory tract infections. His renal function did not deteriorate. Both IgAN and WAS have glycosylation defects, but there must be some other factors (genetic and environmental) to explain their rare association.

Obesity prevalence and trends in Latin-American countries

The prevalence of obesity in some lower-income and transitional countries is as high as, or even higher than, the prevalence reported in developed nations, and it seems to be increasing rapidly. In most countries, the prevalence of obesity is higher in women than in men, and higher in urban than in rural areas. Preobesity prevalence is very high in most Latin-American countries. Sixty per cent of the population in Venado Tuerto (Argentina) has a body mass index (BMI) of > or = 25 kg m-2, as do 35% of the population in Brazil, 60% in Mexico, 68% in Paraguay and 53% in Peru. Trends are available from Brazil, where marked increases in the prevalence of obesity have occurred, except in women from higher-income groups. Women from the higher-income quartiles in urban regions experienced a marked reduction in obesity prevalence from 1989 to 1997 (12.8 to 9.2%). Although data in children is scant, the prevalence of undernutrition is decreasing and the prevalence of obesity is high also in Latin-American children. The prevalence of obesity is high even in minority Indian groups. Rapid changes in dietary structure (in particular associated with urbanization) and major changes in the levels of physical activity, both occupationally and during leisure time, may explain these changes.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects

OBJECTIVE

The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse.

MATERIALS AND METHODS

Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination.

RESULTS

Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding.

CONCLUSION

Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

Of genes and phenotypes: the immunological and molecular spectrum of combined immune deficiency. Defects of the gamma(c)-JAK3 signaling pathway as a model

Cytokines play a major role in lymphoid development. Defects of the common gamma chain (gamma(c)) or of the JAK3 protein in humans have been shown to result in a severe combined immune deficiency (SCID), with a profound defect in T and natural killer (NK)-cell development, whereas B-cell generation is apparently unaffected (T-B+NK-SCID). While extensive molecular and biochemical analysis of these patients has been instrumental in understanding better the biological properties of the gamma(c) and JAK3 protein, an unexpected phenotypic heterogeneity of gamma(c) and JAK3 deficiency has emerged, indicating the need for appropriate and extensive investigations even in patients with atypical presentations. At the same time, characterization of the defects has been instrumental in the development of novel therapeutic approaches, from in utero hematopoietic stem cell transplantation to gene therapy.

Combined immunodeficiencies due to defects in signal transduction: defects of the gammac-JAK3 signaling pathway as a model

Combined immune deficiencies comprise a spectrum of genetic disorders characterized by developmental or functional defects of both T and B lymphocytes. Recent progress in cell biology and molecular genetics has unraveled the pathophysiology of most of these defects. In particular, the most common form of severe combined immune deficiency in humans, with lack of circulating T cells, a normal or increased number of B lymphocytes, and an X-linked pattern of inheritance (SCIDXI) has been shown to be due to defects of the IL2RG gene, encoding for the common gamma chain (gammac), shared by several cytokine receptors. Furthermore, defects of the JAK3 gene, encoding for an intracellular tyrosine kinase required for signal transduction through gammac-containing cytokine receptors, have been identified in patients with autosomal recessive T-B+ SCID. Characterization of the functional properties of cytokines that signal through the gammac-JAK3 signaling pathway has been favored by the detailed analysis of SCID patients. Specifically, the key role of IL-7 in promoting T cell development has been substantiated by the identification of rare patients with T-B+ SCID who have a defect in the alpha subunit of the IL-7 receptor (IL7Ralpha). The heterogeneity of genetic defects along the same signaling pathway that may lead to combined immune deficiency is paralleled by the heterogeneity of immunological phenotypes that may associate with defects in the same gene, thus creating a need for detailed immunological and molecular investigations in order to dissect the spectrum of combined immune deficiencies in humans.

Brain tumors in children under 3 years of age. Recent experience (1987-1997) in 39 patients

Brain tumors in children under 3 years of age differ in clinical presentation and pathological behavior from those in older patients. In this study, we reviewed data from 39 children (24 males and 15 females) under 3 years of age who were treated for intracranial brain tumors since the introduction of magnetic resonance imaging. The purpose was to assess correlations between clinicoradiological and treatment-related factors, and their impact on prognosis. The following factors were analyzed: sex, age, duration of symptoms, intracranial hypertension on admission, tumor location, surgical removal and histology. Associations between these factors and correlations with prognosis were determined using bivariate analyses (chi(2) test) and Kaplan-Meier survival curves. Collins' concept of a period of risk recurrence was tested. Mean follow-up was 41 months (range 0-136). In March 1998, 20 children were still alive (51.2%) with a mean survival time of 65 months (range 2-136). The incidence of supratentorial tumors was significantly higher in children less than 1 year old (p = 0.027). Lateral tumors were 9/10 (90%) supratentorial versus only 7/26 (27%) midline tumors (p = 0.001). Outcome (dead or alive) was significantly better (p = 0.037) for low-grade astrocytomas (9/12 = 75% survival) when compared to ependymomas (2/6 = 33%) and primitive neuroectodermal tumors (3/12 = 25%). Total tumor removal was achieved in 20 cases and was associated with a better outcome (65 vs. 33% survival; p = 0.049). Survival analysis confirmed a worse prognosis for children with ependymomas and primitive neuroectodermal tumors (p = 0.011) and revealed a worse survival for children with intracranial hypertension on admission (p = 0.047). Total tumor removal was associated with a longer survival, although not significantly (p = 0. 077). Finally, we found no exceptions to Collins' law.

Influence of maternal CD4 levels on the predictive value of virus load over mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1). Study Group for Vertical Transmission

Forty-four anti-HIV seropositive pregnant women were enrolled in a study of maternal factors related to mother-to-infant human immunodeficiency virus type 1 (HIV-1) transmission. HIV-1 infection was documented in 11 of 45 infants (24.4%). Obstetric factors, maternal CD4 counts, and disease stage were not related to the risk of transmission. HIV-1 RNA levels at delivery were significantly higher in mothers who transmitted the infection (P = .024). A strong relationship between viral load and risk of transmission was observed in women with stage A1 (P= .006), but not in those with stages A2-A3. These results suggest that vertical transmission of HIV-1 is multifactorial and that viral load plays a major role in mothers with early-stage HIV-1 infection.

Successful reconstruction of refractory posttraumatic skull base defects with free radial forearm flap

After our experience with two patients who had persistent posttraumatic defects of the anterior skull base, we recommend using a deepithelialized free radial forearm flap for one-stage reconstruction. The flap provides a thin, water-tight barrier between the cranial cavity and the subcranial spaces for effective prevention of cerebrospinal fluid leakage and ascending infection. It is particularly useful when local flap options are not available.

Nonoperative treatment of cerebellar abscesses. A case report and review of the literature

A case of a 5-year-old child presenting with a cerebellar abscess occupying the ponto-cerebellar region, who was treated with antibiotic therapy alone, is reported. Symptomatology, radiological findings, and antibiotic regimens are presented, and the literature is reviewed from the viewpoint of therapeutic management.

Unusual charge stabilization of NADP+ in 17beta-hydroxysteroid dehydrogenase

Type 1 17beta-hydroxysteroid dehydrogenase (17beta-HSD1), a member of the short chain dehydrogenase reductase (SDR) family, is responsible for the synthesis of 17beta-estradiol, the biologically active estrogen involved in the genesis and development of human breast cancers. Here, we report the crystal structures of the H221L 17beta-HSD1 mutant complexed to NADP+ and estradiol and the H221L mutant/NAD+ and a H221Q mutant/estradiol complexes. These structures provide a complete picture of the NADP+-enzyme interactions involving the flexible 191-199 loop (well ordered in the H221L mutant) and suggest that the hydrophobic residues Phe192-Met193 could facilitate hydride transfer. 17beta-HSD1 appears to be unique among the members of the SDR protein family in that one of the two basic residues involved in the charge compensation of the 2'-phosphate does not belong to the Rossmann-fold motif. The remarkable stabilization of the NADP+ 2'-phosphate by the enzyme also clearly establishes its preference for this cofactor relative to NAD+. Analysis of the catalytic properties of, and estradiol binding to, the two mutants suggests that the His221-steroid O3 hydrogen bond plays an important role in substrate specificity.

[Deglutition in patients treated with reconstructive laryngectomy]

INTRODUCTION

We stress the importance of dynamic radiologic studies of swallowing in the patients submitted to reconstructive laryngectomy.

MATERIAL AND METHODS

January, 1989, to December, 1996, we examined 36 patients submitted to reconstructive laryngectomy, namely cricohyoidoepiglottopexy in 34 cases, cricohyoidopexy in 1 case and Guerrier's cricohyoidoepiglottopexy in 1 case. Dynamic radiologic studies were performed with fluoroscopic videorecording (Sony U-Matic RM 580) from an X-ray unit. The study was performed with the patients standing or sitting, initially acquiring AP and LL fluoroscopic images of the oropharyngeal region at rest and during swallowing. The patients then swallowed 2 boluses of 5 ml liquid (60%) and semiliquid (250%) barium. When aspiration was suspected, we began with a 2-ml bolus.

RESULTS

The patients were grouped by symptoms: group A patients had no symptoms, group B patients had dysphagia and group C patients presented aspiration. The functional changes were: reduced pharyngeal contraction, reduced epiglottis deflection, reduced hyoid bone elevation, aspiration, altered upper esophageal sphincter function. The organic alterations were: parapharyngeal diverticulum, pharyngeal stenosis, posterior pharyngeal wall introflexion. Three group A patients had severe posterior pharyngeal wall introflexion, 4 had marked retention and 2 of them presented postswallowing aspiration. Two group B patients had major retention, 1 cricopharyngeal incoordination, 3 posterior pharyngeal wall introflexion, 2 a pseudodiverticulum and 2 a luminal stenosis. Seven group C patients had intraswallowing and 3 postswallowing aspiration.

CONCLUSION

The videofluorographic identification of organic and functional complications, sometimes unknown in asymptomatic patients, is useful for therapy and suggests the speech specialist the best compensatory mechanism to improve the patients' swallowing and consequently their quality of life. Moreover, videofluorography of swallowing is a very useful tool in the follow-up, to monitor treatment outcome after rehabilitation.

Prognostic factors in childhood intracranial ependymomas: the role of age and tumor location

Despite several clinical reports on intracranial ependymomas in children, the factors which affect prognosis, and the possibility that certain combinations of factors might limit survival, are still a matter of debate. Between 1976 and 1996 we operated on 35 children with intracranial ependymomas. Postoperative irradiation was given to 27 patients, with associated chemotherapy in 6 cases. Mean follow-up was 62 months. In 12 patients a 5-year follow-up was possible. In October 1996, 18 patients (51.4%) were still alive, the longest disease-free follow-up being 20 years, and the shortest 8 months. We analyzed the prognostic relevance of eight factors. For each factor, different subgroups were distinguished and compared as follows: age at diagnosis (<4 vs. >/=4 years), sex, tumor location (supratentorial vs. infratentorial), tumor size (<4 vs. 4-7 vs. >7 cm), surgical removal (total vs. subtotal), histology (low-grade vs. anaplastic), morphology (solid vs. cystic), adjuvant therapies (treatment vs. no treatment). Two-way contingency tables were made to identify associations between variables. The only significant association was between age and tumor location (p = 0.022): in children under 4, tumors were almost invariably located in the posterior fossa (9 out of 10 cases) with a clear preference for the lateral recess (8 cases). Other correlations were not significant. Kaplan-Meier survival curves were compared to assess the prognostic relevance of each factor. Survival was significantly lower for children under 4, for those with posterior fossa tumors, and for patients with residual tumor (p < 0.05). A multivariate analysis compared variables which significantly affected survival, revealing that age is the most important factor affecting prognosis (p < 0.05), while tumor location and surgical removal do not add any significance to the effect of age on survival. We conclude that age has the strongest prognostic relevance in childhood intracranial ependymomas, while the effect of tumor location on survival may be related to the high incidence of lateral recess ependymomas in younger children.

Prospective study of mother-to-infant transmission of hepatitis C virus (HCV) infection. Study Group for Vertical Transmission

Seventy-five women with anti-hepatitis C virus (HCV) antibody were enrolled prospectively during pregnancy or at delivery for study of mother-to-child transmission of HCV. Twenty-three women were coinfected with the human immunodeficiency virus (HIV). Seventy babies were monitored for at least 6 months. HCV infection was diagnosed in six infants (8.6%), four of whom were born to anti-HIV-positive mothers. HCV RNA was first detected between 2 and 6 months, and the genotypes of infected babies matched those of their mothers (type 1: n = 4; type 3: n = 2). Identical master sequences of the hypervariable region (HVR1) were detected in a mother-infant pair. In three babies coinfected with HCV and HIV, anti-HCV disappeared between 2 and 7 months, being persistently negative in two cases monitored for 11 and 26 months. Transmitting mothers did not differ significantly from those who did not transmit the infection with anti-HIV, HCV genotypes, and viral load at delivery, but had lower rate of reactivity to C100 by the recombinant immunoblot assay (RIBA) (P < .01). This prospective study confirms transmission of HCV from anti-HIV-negative mothers (4.4% in this series). Absence of anti-C100 antibodies at delivery is apparently related to increased risk of vertical transmission. Seronegative HCV infection can be observed in children coinfected with HIV.

Endovascular treatment of pial AVMs: technical options, indications and limits in pediatric age patients

Our study group consisted of 29 patients who underwent endovascular treatment for the presence of pial AVMs. The patients were treated with various embolization methods including "-free flow" embolization (2 cases); embolization with suture threads (2 mm long micro-emboli: 17 cases) and embolization with acrylic glue (10 cases). There were significant angio-architectural and AVM location differences between the pediatric and the adult patient groups. In pediatric patients, the more frequent AVMs were of the mono or few-pedunculated type, then simple direct fistulas and high-flow fistulous-plexiform AVMs and giant infra-tentorial or deep-seated malformations. In mono or few-pedunculated AVMs, the elected treatment was acrylic glue followed by radio-surgery achieving definitive cure in 3 cases. In direct AVFs and elevated flow AVMs, embolization with suture and acrylic glue offered definitive results. Treatment for infra-tentorial and deep-seated AVMs presented the greatest difficulty in pediatric patients. In two of them, embolization with glue enabled radiosurgery (giant cerebellar AVMs). Our experience did not confirm that current endovascular techniques provide definitive treatment in extensive, deep-seated AVMs. Each treatment, in children more so than in adults, requires a risk/benefit evaluation of the method taking into account the natural history data.

Stereotactic radiosurgery for the treatment of arteriovenous malformations in childhood

BACKGROUND

The main techniques and results in stereotactic radiosurgical treatment of endocranial AVM's are described and compared. The authors also report their preliminary experience in the treatment of 6 consecutive pediatric patients with intracerebral vascular malformations using gamma knife (GK) radiosurgery.

METHODS

The various stereotactic radiosurgery methods currently used (charged-particle beam, modified linear accelerator, and GK) are described. At the Department of Neurosurgery in Verona, from February 1993 to February 1996, stereotactic GK radiosurgery was performed on 721 patients, including 20 of pediatric age (3%). Of the 78 AVMs, 7 (9%) were diagnosed in children. One patient was lost at follow-up. Among the remaining 6 children, there were 3 males and 3 females with a mean age of 12.3 years (range, 5-16 years). Treatment general anesthesia was needed only in 1 case. The AVM volume was always less than 10 cc. After completion of the procedure, children were discharged from the hospital the following day.

RESULTS

The follow-up period ranged from 4 months to 29 months (median 18.8 months). The angiographic confirmed total obliteration is used as the end point of an AVM treated radiosurgically, and usually requires 2 to 3 years. All the patients are alive; four of the treated children are neurologically normal and one patient has clinically improved to a normal neurological status. The sixth patient has fixed neurological deficits that existed prior to treatment. Among the three cases with a follow-up period of over 2 years, complete obliteration has been angiographically confirmed in 2 patients and subtotal in 1 patient. In the three remaining patients with follow-up periods less than 2 years, serial MR images suggest subtotal obliteration in 2 cases and no significant change in one patient who had undergone treatment within the current year. To date, neither persistent GK radiosurgery-related complications nor bleeding following stereotactic radiosurgery has been described.

CONCLUSIONS

The review of literature and our preliminary results suggest that also in children, as in adults, the use of stereotactically delivered irradiation represents a safe and effective technique obtaining complete obliteration of AVMs previously considered surgically inaccessible due to their location and poor response to resection and/or embolization.