Characterization of an influenza B virus isolated from a fatal case of myocarditis in a pediatric patient in Italy

Influenza B is one of the infective agents that can cause rapid and fatal myocarditis in children. Here, we describe a fatal case of myocarditis in a previously healthy child, after infection with an influenza B/Victoria-lineage virus during the 2022-23 epidemic season in Italy. Influenza B virus was isolated also in a second case, a younger family member showing only a mild influenza-like illness. Genotypic and phenotypic analyses have been performed on both virus samples and results showed that HA1 sequences were identical and genetically and antigenically related to other B viruses circulating in 2022-23 season in Italy. However, a D129N substitution was found in the receptor binding domain of the HA of the two viruses, not detected in other circulating viruses in Italy but only in a proportion of those circulating in other European countries. Phenotypic analyses assessed the susceptibility towards either neuraminidase inhibitors and baloxavir. Annual influenza vaccination remains one of the best interventions to prevent complications such as myocarditis, particularly in children.

Impact of different typologies of smoking on ovarian reserve and oocyte quality in women performing ICSI cycles: an observational prospective study

OBJECTIVE

Within the last few years smoking activities, as well as infertility, have increased in Italy, and so has the consumption of alternative cigarette devices among women of childbearing age. The aim of this observational study was to evaluate the impact of the consumption of cigarettes and alternatives devices, such as electronic cigarettes and heat-not-burn (HnB) products, on infertile women performing in vitro fertilization (IVF), in specific on the quality of oocytes retrieved in women performing intracytoplasmic sperm injection (ICSI) cycles.

PATIENTS AND METHODS

Prospective observational longitudinal study involving 410 women referring to the Reproductive Physiopathology and Andrology Unit, Sandro Pertini Hospital, Rome, from 2019-2022. All the women enrolled filled out an elaborate questionnaire investigating smoking consumption, before the beginning of ovarian stimulation by antagonist protocol, ovarian pick-up, and subsequent ICSI technique. The outcomes of the study were the evaluation of clinical and ICSI features between the groups of smokers and non-smokers: the number of retrieved oocytes, immature oocytes, and fertilization rate were confronted between the two groups and between cigarette smokers vs. e-cigarette and heat-not-burn (HnB) products smokers.

RESULTS

Clinical parameters were comparable between the group of smokers compared to one of the non-smokers, except for anti-Müllerian hormone (AMH), which was statistically lower in smokers (p<0.05). Regarding IVF hormonal stimulations it appears that the total dose of gonadotropin was statistically lower in the non-smoker's group, compared to smokers (1850±860 UI vs. 1,730±780 p<0.05). Regarding ICSI techniques interestingly the number of oocytes retrieved was lower in the smokers' group compared to non-smokers (5.21±0.9 vs. 6.55±3.5, p<0.001), and the number of empty zona pellucida oocytes was statistically higher in the smokers' group (0.51±0.1 vs. 0.2±0.1, p<0.05). On the other hand, the fertilization rate (FR) was statistically higher in non-smokers compared to the smokers' group (72.16±3.05 vs. 68.12±2.21, p=0.03). Out of the 203 smokers, overall, any statistically significant difference, regarding ICSI results, has been found between the group of cigarette smokers, compared to the group of e-cigarettes plus HnB products smokers.

CONCLUSIONS

Smoking negatively impacts human fertility, leading to a reduction of ovarian reserve and ovarian quality, which can negatively impact results in women performing ICSI cycles. Despite the limitation of the study, our results underline that consumption of cigarette alternative devices seems to have a similar negative impact on the quantity and quality of oocytes retrieved in ICSI cycles. Clinicians should emphasize the reduction of exposure to harmful substances derived from the combustion of tobacco smoking, as well as alternative devices, in women of childbearing age.

P-484 Oocytes quality assessment in breast cancer: implications for fertility preservation

Study question

Does the breast cancer (BC) influence the oocyte quality and ovarian response to controlled ovarian hyperstimulation (COH) for fertility preservation (FP) in female oncology patients?

Summary answer

The diagnosis of breast cancer does not seem to be associated with an impairment of ovarian reserve, but with a worsening of oocyte quality.

What is known already

Fertility preservation in female oncology patients should be integrated as part of management of cancer patient to improve their quality of life. Every day in Italy about 30 new cases of cancer are diagnosed in patients with age under 40 years and BC is the most common malignancy in women undergoing fertility preservation. Currently mature oocyte cryopreservation is a standard technique for fertility. The studies on the outcome of ovarian response after ovarian stimulation in specific cancer patients are limited. Only few reports have suggested a deleterious impact of the oncological disease on quality of follicular growth and ovarian function.

Study design, size, duration

This is a retrospective single-center case-control study carried out in the IVF (in vitro fertilization) Unit at the Sandro Pertini Hospital in Rome between 2016 and 2021. The aim of this study is to investigate the effect of BC on number, above all on quality of oocyte and on dysmorphic oocyte ratio, in oncology patients compared to women age- and date-matched controls undergoing COH for IVF for male or tubal factor infertility.

Participants/materials, setting, methods

A total of 294 women were enrolled in the study: 105 women affected by breast cancer in the case group and 189 healthy women in the control group. Boths groups were comparable in terms of age, body mass index (BMI) and antimulleran hormone (AMH) value, E2 level at triggering day, total FSH cumulative dose, stage, histotype, BRCA status and hormone receptors. The primary outcome was number and quality of retrievd oocyte from ovarian pick-up (OPU).

Main results and the role of chance

There were no significant differences in terms of basal fertility indices between the 2 groups: median AMH levels were 2.3 ng/mL in BC patients and 2.8 ng/mL in control group (p = 0.103). The median length of stimulation was 11 days in both groups. The median of total immature oocytes (oocytes MI + germinal vesicle) was 2 in cancer patients and 0 in control group (p &lt; 0.0001). Finally, the median of total dysmorphic oocytes were 1 in cancer group vs 0 (p &lt; 0.0001). The multivariable analysis identified the cancer as risk factors of presence of dysmorphic oocytes (OR (95%CI):3.92 (1.84-8.35). Moreover either in the case and control group age, BMI, AMH, duration of stimulation, E2 level at triggering day, total FSH cumulative dose and, only for BC patients, stage, histotype, BRCA status and hormone receptors were not statistical significantly associated with the presence of dysmophic oocytes. Finally, our data confirmed that the cancer is the only risk factors not only for the presence of dysmorphic oocytes, but also respect to the number of dysmorphic oocytes and to the percentage of dysmorphic oocytes respect to the total number of retrieved oocytes for patient. Two patients have had a spontaneous pregnancy.

Limitations, reasons for caution

The limitations concern the paucity of specific cancer group especially BRCA mutated BC patients and the different triggers for induction of final maturation. We still have not a follow up data to evaluate the competence of vitrified MII oocytes for oncology patients and we cannot report information on spontaneous births.

Wider implications of the findings

The BC diagnosis is a four times greater risk factor in retrieving dysmorphic oocytes, but the stage of BC does not influence the number of retrieved dysmorphic oocytes. Further studies are necessary to evaluate the etiopathogenetic mechanisms underlying oocyte abnormalities in specific group of female oncology patients.

Trial registration number

0104898/2020

AB1265 BIOTECHNOLOGICAL AGENTS IN PEDIATRIC-ONSET SCLERITIS

Background

the term scleritis refers to the inflammation of the sclera, the white outer type I collagen tunic of the eye (1). It may be rarely found in pediatric patients, with the incidence of pediatric scleritis accounting for about 1.2% of all scleritis cases (2). An early diagnosis and an adequate treatment are mandatory to avoid irreversible ocular sequelae (3). In this regard, the experience of biotechnological agents in patients with pediatric scleritis is quite limited at current.

Objectives

To assess the effectiveness of biotechnological agents in terms of scleritis control and glucocorticoid dosage tapering in patients with pediatric-onset scleritis; b) to assess the safety of the biotechnological agents employed and their ability in avoiding new ocular disease complications.

Methods

patients with pediatric-onset scleritis resistant to the conventional therapy and treated with biotechnological agents were retrospectively enrolled and prospectively followed-up. Demographic, clinical, ophthalmologic and therapeutic data were collected. The endpoints of the study consisted in the description of the therapeutic details gathered at the start of the biotechnological agents compared to what was observed at the 6-month, 12-month and last follow-up visits.

Results

5 patients (3 males; 2 females) treated with adalimumab, infliximab, abatacept secukinumab were consecutively enrolled. A remarkable clinical efficacy was observed in 5/5 cases during a 10-to-54 months follow-up period; complete and persistent suppression of ocular inflammation was pointed out in 2/2 patients with active disease at the start of the treatment, while a clinically relevant decrease of scleritis relapses was observed in 5/5 patients after the start of biotechnological treatment, compared to the past years of scleritis activity. In particular, the 5 patients suffered from a total number of 17 scleritis relapses during the 12 months preceding the start of the biologic treatment; the same patients suffered from 2 scleritis relapses within the first 12 months from the start of the treatment and 4 scleritis relapses during the entire follow-up period (median time of 28 months, interquartile range=118 months). These results were obtained despite the progressive and persistent glucocorticoid sparing effect, with a median daily dosage of prednisone or equivalent ranging from 15 (interquartile range =21.75) mg/day at the start of treatment to 2.5 (interquartile range =8.75) mg/day at the 3-month assessment, 2.5 (interquartile range=0) mg/day at 6 month visit, and 0.0 (interquartile range =2.5) mg/day at the last assessment. Regarding the safety profile, one out of five patients experienced an adverse event represented by oral candidiasis, presumably related to the concomitant use of glucocorticoids.

Conclusion

biotechnological agents have shown to be highly effective in controlling pediatric-onset scleritis, allowing a remarkable glucocorticoids sparing effect in patients previously resistant to conventional treatment and recalcitrant to a glucocorticoid-sparing approach. The safety profile was excellent.

References

[1]Yanoff M, Duker JS. Ophthalmology 5th ed. New York: Elsevier; 2019.

[2]Majumder PD, Ali S, George A, et al. Clinical Profile of Scleritis in Children. Ocul Immunol Inflamm 2019;27:535-539. doi: 10.1080/09273948.2017.

[3]Murthy SI, Sabhapandit S, Balamurugan S, et al. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. doi: 10.4103/ijo.IJO_2032_20.

Disclosure of Interests

None declared

POS1373 THE DIAGNOSTIC ROLE OF PATHERGY TEST IN PATIENTS WITH BEHÇET’S DISEASE FROM WESTERN EUROPE

Background

pathergy is the term used to describe the hyper-reactivity of the skin in response to a minimal trauma, as the consequence of an exacerbated response of the innate immune system [1]. Pathergy test has a central role for the diagnosis of Behçet’s disease (BD), especially in doubtful and atypical cases. However, while its incidence has been decreasing over the past few decades, there are significant variations in the frequency of pathergy among different geographic contexts [2]. These aspects affect the diagnostic role of pathergy test for patients with suspected BD.

Objectives

to evaluate the frequency and features of positive pathergy test (PPT) in Italy, its role in the diagnosis of BD, and any association with other BD-related manifestations.

Methods

29 BD patients, 15 patients with spondyloarthritis (SpA) and 19 healthy controls (HCs) underwent two types of pathergy test, which were performed on the hairless part of the volar forearm ipsilaterally: intradermal injection of 0.5 ml normal saline and intradermally needle soaked with fresh self-saliva. Both pricks were done with a monouse 25 gauge hypodermic needle inserted with a vertical approach at a depth of 5 mm into the skin. The needle was withdrawn with a twisting movement. Skin reactions were observed 48 hours after prick. The results of pathergy tests were statistically analysed in the light of demographic, clinical, and therapeutic features of subjects enrolled. The BD activity at the time of the pathergy test was assessed with the Behçet’s Disease Current Activity Form (BDCAF) [3].

Results

pathergy test performed with saline solution resulted always negative in all groups. Skin prick test using self-saliva resulted in the occurrence of a papule in 2 (6.9%) BD patients and in 1 (6.7%) patient with SpA. A ≥15 mm erythematous area surrounding the needle prick site was observed in 12 (41.4%) BD patients, in 4 (26.7%) patients with SpA (including the patient with the papule), and in 1 (5.6%) HCs (p=0.022). The frequency of skin erythema was significantly higher among BD patients compared to HCs (p=0.015); no statistically significant differences were observed between BD and SpA patients (p=0.53) as well as between SpA patients and HC (p=0.21). The occurrence of skin erythema was not associated with any of the BD-related clinical manifestations. No statistically significant differences were observed between BD patients with positive and negative pathergy test according to sex (p=0.873); HLA-B51 positivity (p-value=0.461); age at the pathergy test (p=0.929); and disease duration at the pathergy test (p=0.487). The mean BDCAF was 1.33±0.65 among patients with PPT and 0.82±0.72 among patients with negative pathergy test (p=0.092). Erythema at self-saliva prick test showed a sensitivity of 41.4% (C.I. 23.52%-61.06%) and a specificity of 85.3% (C.I. 68.94%-95.05%); the positive likelihood ratio was 2.81 (C.I. 1.12-7.05) and the negative likelihood ratio was 0.69 (C.I. 0.49-0.96).

Conclusion

this study confirms the lower frequency of PPT in Western European BD patients if considering the development of a papule or a pustule in the site of pathergy test. Conversely, the onset of a ≥15 mm erythematous area surrounding the prick site could be sufficient to unveil the hyper-reactivity of the innate immune system in BD patients from Western Europe. Pathergy test is not pathognomonic of BD, as its positivity can be also observed in other innate immune system disorders, as observed for SpA patients.

References

[1]Gül A, Esin S, Dilsen N, Koniçe M, Wigzell H, Biberfeld P. Immunohistology of skin pathergy reaction in Behçet’s disease. Br J Dermatol 1995;132:901-7. doi: 10.1111/j.1365-2133.1995.tb16946.x.

[2]Davatchi F, Chams-Davatchi C, Ghodsi Z, Shahram F, Nadji A, Shams H, et al. Diagnostic value of pathergy test in Behcet’s disease according to the change of incidence over the time. Clin Rheumatol. 2011;30:1151–1155. doi: 10.1007/s10067-011-1694-5.

[3]Lawton G, Bhakta BB, Chamberlain MA, Tennant A. The Behcet’s disease activity index. Rheumatology (Oxford) 2004;43:73-8. doi: 10.1093/rheumatology/keg453.

Disclosure of Interests

None declared

Anti-SARS-CoV-2 antibodies persistence after natural infection: a repeated serosurvey in Northern Italy

INTRODUCTION

To evaluate the decline of antibodies induced by SARS-CoV-2 infection, the individuals resident in 5 municipalities of the Autonomous Province of Trento, Northern Italy, who resulted IgG positive for anti-SARS-CoV-2 nucleocapsid (NC) in May 2020, were tested four months later.

METHODS

Anti-SARS-CoV-2 NC antibodies were detected using the Abbott SARS-CoV-2 IgG assay. Samples that gave a negative result were re-tested using the Liaison SARS-CoV-2 IgG assay to assess anti-spike (S) S1/S2 antibodies. The fifty-percent tissue culture infective dose (TCID50) neutralizing assay was performed on a subgroup of formerly positive sera. Statistical analysis was performed by STATA version 16.1 (STATA Corp., College Station, Texas, USA).

RESULTS

Overall, 480 out of 1159 participants became seronegative for anti-NC IgG antibodies. Age above 70 years and cough were associated with persistent anti-NC IgG levels. Most anti-NC IgG negative sera were positive for anti-S IgG (77.9%). The neutralization assay showed high concordance with anti-S antibodies positivity.

CONCLUSION

In conclusion, a decline of anti-NC IgG values was recorded four months after the first evaluation. A high proportion of anti-NC seronegative individuals were positive for anti-spike IgG antibodies, which appear to persist longer and to better correlate with neutralization activity.

Multiplex Real-Time Reverse-Transcription Polymerase Chain Reaction Assays for Diagnostic Testing of Severe Acute Respiratory Syndrome Coronavirus 2 and Seasonal Influenza Viruses: A Challenge of the Phase 3 Pandemic Setting

BACKGROUND

Pandemic coronavirus disease 2019 (COVID-19) disease represents a challenge for healthcare structures. The molecular confirmation of samples from infected individuals is crucial and therefore guides public health decision making. Clusters and possibly increased diffuse transmission could occur in the context of the next influenza season. For this reason, a diagnostic test able to discriminate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from influenza viruses is urgently needed.

METHODS

A multiplex real-time reverse-transcription polymerase chain reaction (PCR) assay was assessed using 1 laboratory protocol with different real-time PCR instruments. Overall, 1000 clinical samples (600 from samples SARS-CoV-2-infected patients, 200 samples from influenza-infected patients, and 200 negative samples) were analyzed.

RESULTS

The assay developed was able to detect and discriminate each virus target and to intercept coinfections. The limit of quantification of each assay ranged between 5 and 10 genomic copy numbers, with a cutoff value of 37.7 and 37.8 for influenza and SARS-CoV-2 viruses, respectively. Only 2 influenza coinfections were detected in COVID-19 samples.

CONCLUSIONS

This study suggests that multiplex assay is a rapid, valid, and accurate method for the detection of SARS-CoV-2 and influenza viruses in clinical samples. The test may be an important diagnostic tool for both diagnostic and surveillance purposes during the seasonal influenza activity period.

Assessment of sexual and emotional distress in infertile couple: validation of a new specific psychometric tool

BACKGROUND

The diagnosis of infertility strongly impacts on psychological and sexological couple health. In this regard, some feelings and psychological states were demonstrated in association with reproductive problems. Depression and anxiety are the most common psychopathologies associated with infertility, although also sexuality is strongly involved in infertility conditions.

OBJECTIVES

The aim of this study is to develop a tool to probe and assess the emotional aspects, sexuality, and social relationships of the couple seeking medical care for infertility.

MATERIALS AND METHODS

A self-reported questionnaire that we will refer to as SEIq (Sexuality and Emotions in Infertility questionnaire) was constructed and developed and, consequently, administered to 162 heterosexual couples (324 subjects) seeking help for reproductive problems. Hence, we performed a specific statistical analysis to assess and validate this new psychometric tool.

RESULTS

About 60% of men and women (both partners in 43% of couples) declare that infertility has changed their life (Q10). Moreover, the incidence of sexual disorder declared by the subjects is quite rare in men (10%) but more frequent in women (29%) (p < 0.01).

CONCLUSION AND DISCUSSION

The results of this pilot test show that the diagnosis of infertility impacts on the couple relationship affecting the emotional area, interpersonal relationships, and sexual functions of the couples. Moreover, the SEIq appears a valuable tool to coherently probe and relate sexological, psychological, relational, and emotive aspects in partners and couples facing the infertility diagnosis. The explorative factor analysis of SEIq data allows to understand the women, men, and couples' behavior in our sample, individuating a reduced set of factors, prone to an easier evaluation. On the whole, the psychometric evaluation through SEIq might be suitable for the couples during Assisted Reproductive Technologies treatments.

Prevalence of SARS-CoV-2 IgG antibodies in an area of northeastern Italy with a high incidence of COVID-19 cases: a population-based study

Objectives

A seroprevalence study of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was conducted in a high-incidence area located in northeastern Italy.

Methods

All citizens above 10 years of age resident in five municipalities of the Autonomous Province of Trento, with the highest incidence of coronavirus disease 2019 (COVID-19) cases, were invited to participate in the study. Among 6098 participants, 6075 sera and a standardized questionnaire administered face-to-face were collected between 5 May and 15 May 2020 and examined. Symptomatic individuals and their family contacts were tested by RT-PCR. Anti-SARS-CoV-2 antibodies were detected using an Abbott SARS-CoV-2 IgG assay, which was performed on the Abbott Architect i2000SR automated analyser. Seroprevalence was calculated as the proportion of positive results among the total number tested. A multivariable logistic regression model was performed to assess the relationship between seropositive versus seronegative individuals for a set of explanatory variables.

Results

A total of 1402 participants were positive for IgG antibodies against SARS-CoV-2, with a prevalence of 23.1% (1402/6075). The highest prevalence was found in the age class 40–49 years. Overall, 34.4% (2096/6098) of the participants reported at least one symptom. The ratio between reported cases identified by molecular test and those with seropositive results was 1:3, with a maximum ratio of about 1:7 in the age group <20 years and a minimum around 1:1 in those >70 years old. The infection fatality rate was 2.5% (35/1402). Among the symptoms, anosmia and ageusia were strongly associated with seropositivity.

Conclusions

The estimated seroprevalence of 23% was three-fold higher than the number of cases reported in the COVID-19 Integrated Surveillance data in the study area. This may be explained in part by a relatively high number of individuals presenting mild or no illness, especially those of younger age, and people who did not seek medical care or testing, but who may contribute to virus transmission in the community.

Whole genome and phylogenetic analysis of two SARS-CoV-2 strains isolated in Italy in January and February 2020: additional clues on multiple introductions and further circulation in Europe

Whole genome sequences of SARS-CoV-2 obtained from two patients, a Chinese tourist visiting Rome and an Italian, were compared with sequences from Europe and elsewhere. In a phylogenetic tree, the Italian patient’s sequence clustered with sequences from Germany while the tourist’s sequence clustered with other European sequences. Some additional European sequences in the tree segregated outside the two clusters containing the patients’ sequences. This suggests multiple SARS-CoV-2 introductions in Europe or virus evolution during circulation.

Co-circulation of the two influenza B lineages during 13 consecutive influenza surveillance seasons in Italy, 2004-2017

BACKGROUND

Since 1985, two antigenically distinct lineages of influenza B viruses (Victoria-like and Yamagata-like) have circulated globally. Trivalent seasonal influenza vaccines contain two circulating influenza A strains but a single B strain and thus provide limited immunity against circulating B strains of the lineage not included in the vaccine. In this study, we describe the characteristics of influenza B viruses that caused respiratory illness in the population in Italy over 13 consecutive seasons of virological surveillance, and the match between the predominant influenza B lineage and the vaccine B lineage, in each season.

METHODS

From 2004 to 2017, 26,886 laboratory-confirmed influenza cases were registered in Italy, of which 18.7% were type B. Among them, the lineage of 2465 strains (49%) was retrieved or characterized in this study by a real-time RT-PCR assay and/or sequencing of the hemagglutinin (HA) gene.

RESULTS

Co-circulation of both B lineages was observed each season, although in different proportions every year. Overall, viruses of B/Victoria and B/Yamagata lineages caused 53.3 and 46.7% of influenza B infections, respectively. A higher proportion of infections with both lineages was detected in children, and there was a declining frequency of B/Victoria detections with age. A mismatch between the vaccine and the predominant influenza B lineage occurred in eight out of thirteen influenza seasons under study. Considering the seasons when B accounted for > 20% of all laboratory-confirmed influenza cases, a mismatch was observed in four out of six seasons. Phylogenetic analysis of the HA1 domain confirmed the co-circulation of both lineages and revealed a mixed circulation of distinct evolutionary viral variants, with different levels of match to the vaccine strains.

CONCLUSIONS

This study contributes to the understanding of the circulation of influenza B viruses in Italy. We found a continuous co-circulation of both B lineages in the period 2004-2017, and determined that children were particularly vulnerable to Victoria-lineage influenza B virus infections. An influenza B lineage mismatch with the trivalent vaccine occurred in about two-thirds of cases.

Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology

AIM

To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures.

METHODOLOGY

A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures.

RESULTS

A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered.

CONCLUSIONS

Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Changing Patterns of Ocular Manifestations in HIV Seropositive Patients Treated with HAART

Purpose

To report the changing patterns of ocular manifestations in human immunodeficiency virus (HIV) seropositive patients treated with highly active antiretroviral therapy (HAART).

Methods

The clinical charts of HIV seropositive patients, 735 examined from 1997 to 2003 and treated with HAART for at least 2 months (Group 1), and 838 untreated examined from 1988 to 1995 (Group 2), were reviewed to assess the frequency of ocular manifestations.

Results

HIV- related retinal microangiopathy and opportunistic retinal infections (cytomegalovirus retinitis and toxoplasmic retinochoroiditis) were significantly higher in Group 2 than 1 (p<0.0001), while in patients treated with HAART a statistically significant increase in the frequency of chalazion (p<0.0001), diabetic and hypertensive retinopathy (p<0.0001), lipid arc of the cornea (p<0.0001), cataract and glaucoma (p<0.0001), and uveitis (p=0.026) was observed.

Conclusions

HAART therapy has induced a dramatic decrease in the incidence of HIV-related microangiopathy and opportunistic retinal infection and the occurrence of new lesions related both to the metabolic alterations induced by HAART and to immune reconstitution, such as uveitis.

Controlled, prospective, observational study on the efficiency and tolerability of a combination of potential Nrf2-inducing antioxidants and micronutrients as pre-treatment for ICSI in dyspermic patients with previous failure

OBJECTIVE

To evaluate the efficiency of pre-treatment in dyspermic males in IVF couples with a combination of micronutrients, for the purpose of improving the fertilization rate, the implantation rate and the outcome of the pregnancy.

PATIENTS AND METHODS

This controlled prospective clinical study was performed in two medically assisted reproduction centers. 59 males with mild oligo-astheno-teratospermia (OAT) were admitted to the study. All of them had a history of previous in vitro fertilization (IVF) attempts with female partners aged < 40 diagnosed having tubal or idiopathic infertility. The subjects upon enrolment underwent a semen test and afterward were treated with alpha lipoic acid and glutathione (Fertiplus SOD®, Idi-Pharma, Catania, Italy) for 4 weeks (short-term). The primary endpoints that were evaluated are the following: fertilization rate (mean fertilization), implantation rate and pregnancy rate.

RESULTS

At the end of this study all the males (mean age 39.5 ± 5.1) reported in not having any side effects during the administration of Fertiplus. Their female partners (mean age 34.9 ± 4.5) underwent IVF using the ICSI technique. The number of oocytes retrieved and inseminated was not statistically different in comparison to previous attempts, but with the same number of oocytes treated, the fertilization rate per couple demonstrated statistically significant increase (p<0.001). We did not observe a percentage increase in evolutionary embryos, but we noticed an improvement in embryo quality per individual couple (p<0.001), associated with a net increase in the implantation rate per couple (p<0.001) in terms of clinical pregnancy. The estimated miscarriage risk after treatment was five times lower (p<0.001).

CONCLUSIONS

Short-term treatment with micronutrients in dyspermic subjects can improve the reproductive outcome of the IVF procedure.

Immunogenicity of modified vaccinia virus Ankara expressing the hemagglutinin stalk domain of pandemic (H1N1) 2009 influenza virus

BACKGROUND

Vaccination offers protection against influenza, although current vaccines need to be reformulated each year. The development of a broadly protective influenza vaccine would guarantee the induction of heterosubtypic immunity also against emerging influenza viruses of a novel subtype. Vaccine candidates based on the stalk region of the hemagglutinin (HA) have the potential to induce broad and persistent protection against diverse influenza A viruses.

METHODS

Modified vaccinia virus Ankara (MVA) expressing a headless HA (hlHA) of A/California/4/09 (CA/09) virus was used as a vaccine to immunize C57BL/6 mice. Specific antibody and cell-mediated immune responses were determined, and challenge experiments were performed by infecting vaccinated mice with CA/09 virus.

RESULTS

Immunization of mice with CA/09-derived hlHA, vectored by MVA, was able to elicit influenza-specific broad cross-reactive antibodies and cell-mediated immune responses, but failed to induce neutralizing antibodies and did not protect mice against virus challenge.

CONCLUSION

Although highly immunogenic, our vaccine was unable to induce a protective immunity against influenza. A misfolded and unstable conformation of the hlHA molecule may have affected its capacity of inducing neutralizing antiviral, conformational antibodies. Design of stable hlHA-based immunogens and their delivery by recombinant MVA-based vectors has the potential of improving this promising approach for a universal influenza vaccine.

Modified vaccinia virus Ankara expressing the hemagglutinin of pandemic (H1N1) 2009 virus induces cross-protective immunity against Eurasian 'avian-like' H1N1 swine viruses in mice

Objectives

To examine cross-reactivity between hemagglutinin (HA) derived from A/California/7/09 (CA/09) virus and that derived from representative Eurasian “avian-like” (EA) H1N1 swine viruses isolated in Italy between 1999 and 2008 during virological surveillance in pigs.

Design

Modified vaccinia virus Ankara (MVA) expressing the HA gene of CA/09 virus (MVA-HA-CA/09) was used as a vaccine to investigate cross-protective immunity against H1N1 swine viruses in mice.

Sample

Two classical swine H1N1 (CS) viruses and four representative EA-like H1N1 swine viruses previously isolated during outbreaks of respiratory disease in pigs on farms in Northern Italy were used in this study.

Setting

Female C57BL/6 mice were vaccinated with MVA/HA/CA/09 and then challenged intranasally with H1N1 swine viruses.

Main outcome measures

Cross-reactive antibody responses were determined by hemagglutination- inhibition (HI) and virus microneutralizing (MN) assays of sera from MVA-vaccinated mice. The extent of protective immunity against infection with H1N1 swine viruses was determined by measuring lung viral load on days 2 and 4 post-challenge.

Results and Conclusions

Systemic immunization of mice with CA/09-derived HA, vectored by MVA, elicited cross-protective immunity against recent EA-like swine viruses. This immune protection was related to the levels of cross-reactive HI antibodies in the sera of the immunized mice and was dependent on the similarity of the antigenic site Sa of H1 HAs. Our findings suggest that the herd immunity elicited in humans by the pandemic (H1N1) 2009 virus could limit the transmission of recent EA-like swine HA genes into the influenza A virus gene pool in humans.

Bovine lactoferrin inhibits influenza A virus induced programmed cell death in vitro

Influenza is one of the main plagues worldwide. The statistical likelihood of a new pandemic outbreak, together with the alarming emergence of influenza virus strains that are resistant to available antiviral medications, highlights the need for new antiviral drugs. Lactoferrin, a 80 kDa bi-globular iron-binding glycoprotein, is a pleiotropic factor with potent antimicrobial and immunomodulatory activities. Although the antiviral effect of lactoferrin is one of its major biological functions, the mechanism of action is still under debate. In this research, we have analyzed the effect of bovine lactoferrin (bLf) on Influenza A virus infection in vitro. Our results showed that (i) Influenza virus infected cells died as a result of apoptosis, (ii) bLf treatment inhibited programmed cell death by interfering with function of caspase 3, a major virus-induced apoptosis effector, and (iii) bLf efficiently blocked nuclear export of viral ribonucleoproteins so preventing viral assembly. These results provide further insights on the antiviral activity of bLf and suggest novel strategies for treatment of Influenza virus infection.

Effect of sodium hypochlorite with the addition of a proteolytic enzyme on postoperative discomfort: a multicenter randomized clinical trial

AIM

The purpose of this study was to compare the patient's postoperative discomfort when root canal irrigation was performed either with standard sodium hypochlorite or with sodium hypochlorite with the adjunct of a proteolytic enzyme.

METHODS

Two hundred patients were endodontically treated in two clinics. The type of irrigant to be used during root canal instrumentation was randomly assigned. Final irrigation was done using EDTA 17%. The canals were filled by warm vertical condensation with guttha-percha and the coronal seal was made using IRM. Patients were given a questionnaire to assess pain and swelling and the number of analgesics and other drugs taken during the first week after treatment.

RESULTS

A total of 166 questionnaires could have been evaluated. No significant difference was found between groups for pain, swelling and analgesics taken. Moderate pain and swelling was reported only in the first two days after treatment. No antibiotics use was reported. No guttha-percha excess beyond root apex was found by radiographic assessment.

CONCLUSIONS

The irrigating solution containing a proteolytic enzyme does not produce greater postoperative discomfort as compared to the conventional sodium hypochlorite in patients undergoing endodontic therapy.

An influenza A/H3 outbreak during the 2004/2005 winter in elderly vaccinated people living in a nursing home

This study examined the antibody response against the three vaccine antigens and the epidemic A/H3N2 drift variant (A/California) and the prevention of laboratory diagnosed influenza infections in a group of elderly institutionalized people vaccinated with the 2004/2005 influenza vaccine. Antibody titres were measured by hemagglutination inhibition (HI) in sera collected before and 1 month after vaccination. Laboratory diagnosis was done examining throat swabs (RT-PCR or MDCK cell culture) or by serology (seroconversion comparing HI titres in sera collected 1 and 5 months after vaccination). Results obtained showed that influenza vaccination induced an adequate immune response against the three vaccine antigens and the epidemic A/H3N2 variant, however it was not capable of preventing an influenza outbreak due to the new A/H3N2 (A/California) variant.

Respiratory viruses and influenza-like illness: a survey in the area of Rome, winter 2004-2005

Limited information is available on the viral aetiology of influenza-like illness (ILI) in Southern European countries. Hereby we report the main findings of a survey conducted in the area of Rome during the 2004-2005 winter season. ILI cases were defined as individuals with fever &gt;37.5°C and at least one constitutional symptom and one respiratory symptom, recruited during the survey period. Influenza and other respiratory viruses were identified using polymerase chain reaction (PCR) on throat swabs. Basic individual information was collected through a standard form. Of 173 ILI cases enrolled, 74 tested positive for one virus, and two tested positive for two viruses. Overall, 33.5% of the cases were positive for influenza viruses, 5.2% for adenoviruses, 3.5% for parainfluenza viruses, 1.7% for coronaviruses, and 1.2% for the respiratory syncitial virus. The proportion of influenza virus detection was higher in the 'high influenza activity' period. The distribution of viral agents varied across age groups, influenza viruses being more likely to be detected in younger patients. Viral pathogens were identified in less than 50% of ILI cases occurred during a high activity influenza season. The detection of other than influenza viruses was sporadic, without evidence of large outbreaks due to specific agents.

Respiratory viruses and influenza-like illness: a survey in the area of Rome, winter 2004-2005

Limited information is available on the viral aetiology of influenza-like illness (ILI) in Southern European countries. Hereby we report the main findings of a survey conducted in the area of Rome during the 2004-2005 winter season.ILI cases were defined as individuals with fever >37.5 degrees C and at least one constitutional symptom and one respiratory symptom, recruited during the survey period. Influenza and other respiratory viruses were identified using polymerase chain reaction (PCR) on throat swabs. Basic individual information was collected through a standard form. Of 173 ILI cases enrolled, 74 tested positive for one virus, and two tested positive for two viruses. Overall, 33.5% of the cases were positive for influenza viruses, 5.2% for adenoviruses, 3.5% for parainfluenza viruses, 1.7% for coronaviruses, and 1.2% for the respiratory syncitial virus. The proportion of influenza virus detection was higher in the 'high influenza activity' period. The distribution of viral agents varied across age groups, influenza viruses being more likely to be detected in younger patients. Viral pathogens were identified in less than 50% of ILI cases occurred during a high activity influenza season. The detection of other than influenza viruses was sporadic, without evidence of large outbreaks due to specific agents.

Serological analysis of serum samples from humans exposed to avian H7 influenza viruses in Italy between 1999 and 2003

We evaluated the potential for avian-to-human transmission of low pathogenic avian influenza (LPAI) and highly pathogenic avian influenza (HPAI) H7N1 and LPAI H7N3 viruses that were responsible for several outbreaks of influenza in poultry in Italy between 1999 and 2003. A serological survey of poultry workers was conducted by use of a combination of methods. Evidence of anti-H7 antibodies was observed in 3.8% of serum samples collected from poultry workers during the period in 2003 when LPAI H7N3 virus was circulating. These findings highlight the need for surveillance in people occupationally exposed to avian influenza viruses, so that they can be monitored for the risk of avian-to-human transmission during outbreaks of avian influenza caused by both LPAI and HPAI viruses.

Changes in the hemagglutinins and neuraminidases of human influenza B viruses isolated in Italy during the 2001-02, 2002-03, and 2003-04 seasons

Throughout most of the last decade, B/Yamagata/16/88-lineage influenza viruses were predominant among the B isolates circulating worldwide, whereas B/Victoria/2/87-lineage viruses were isolated infrequently and restricted geographically to eastern Asia. During the 2001-02 influenza season, B/Victoria/2/87-lineage viruses re-emerged in North America and Europe and spread worldwide. Virological surveillance in Italy during that season showed wide circulation of influenza B viruses, of which most were antigenically related to the B/Sichuan/379/99 (Yamagata-lineage) vaccine strain, together with a smaller number of B viruses antigenically similar to B/HongKong/330/01, a recent B/Victoria/2/87-lineage antigenic variant. In the subsequent 2002-03 epidemic season, B viruses with a Victoria-lineage hemagglutinin (HA), more closely related to that of B/Shandong/7/97, were isolated exclusively. Similar strains have continued to predominate among the few B viruses isolated in Italy during last season (2003-04), although most influenza B viruses, isolated sporadically elsewhere in Europe, again belong to the Yamagata-lineage. In the present study, phylogenetic analyses of the HA and neuraminidase (NA) genes of representative B strains, isolated throughout Italy during 2001-04, showed that during the first influenza season the NA genes, as well as the HA genes, separated into the two distinct clades, the Yamagata- and Victoria-lineages, and showed no evidence of genetic reassortment. On the contrary, all the B viruses isolated in the 2002-03 and most of those isolated in the 2003-04 epidemic season were "Victoria HA-Yamagata NA" reassortants similar to those isolated in other parts of the world, showing that these reassortants became established in the human population. The frequency of reassortment between HA and NA of distinct lineages and sublineages highlights again the importance of detailed molecular analyses of both surface glycoproteins in understanding the evolution of influenza B viruses.

[Prenatal diagnosis of congenital diaphragmatic hernia: an update]

Congenital diaphragmatic hernia (CDH) has an incidence of approximately 1:4000 live births. Most frequently the diaphragmatic defect is a left and posterolateral (Bochdalek) one. Prenatal diagnosis is made at ultrasonography; the relevant sonographic features will be described in the paper. Cystic adenomatoid malformation of the lung (CAML), pulmonary sequestration, bronchogenic cysts, pulmonary hypoplasia/agenesia need to be considered in differential diagnosis. In some cases, diagnosis of CDH is not possible "in utero": in such cases, herniation of abdominal viscera into the thorax takes place presumably just at delivery through a small diaphragmatic defect. CDH may be associated with intrauterine growth retardation (IUGR), chromosomal abnormalities (3%) and/or other malformations (10-50%): such as Central Nervous System, digestive, cardiac and urogenital anomalies. Therefore, search of associated malformations and amniocentesis with analysis of fetal karyotype are mandatory, whenever a CDH is diagnosed. CDH is still at present characterised by a high mortality (reportedly, about 45%). Many prognostic factors have been correlated to postnatal outcome of CDH: some of them are valuable prenatally by ultrasonography. However, the role of sonography in the prediction of neonatal outcome is still controversial: in particular, although many ultrasonographic parameters have been proposed, prenatal evaluation of pulmonary hypoplasia (a crucial factor related to postnatal survival) has not proved to be very accurate so far. Nevertheless, it is undisputable that prenatal diagnosis itself represents a crucial prognostic factor for CDH, since it allows birth of the affected fetuses in 3d level Perinatologic Centres provided with a Neonatal Intensive Care Unit and Neonatal Surgery.

Preoperative evaluation of ovarian masses: ultrasound and biochemical screening

OBJECTIVE

The preoperative study of an ovarian mass, with a negative dosage of plasmatic BhCG, mainly has the purpose of discriminating between a benign neoplastic mass and a malignant mass. The aim of our work was to evaluate the validity of preoperative screening including a pelvic ultrasound examination and the dosage of some plasmatic tumor markers.

METHODS

This is a retrospective study conducted on 78 patients who were referred to the III Division of the Department of Gynaecological Sciences, Perinatology and Puericulture of Rome University "La Sapienza" from January 1st 2001 to December 31st 2001 with a diagnosis of ovarian tumefaction whose origin was still to be determined. These patients underwent both a transabdominal and transvaginal ultrasound scan and biochemical examination of serum levels of Ca-125, Ca 19-9 and CEA. Subsequently these patients underwent surgery or medical therapy according to the suspected diagnosis. We then compared our suspected diagnosis with the precise histological diagnosis. Finally, following this comparison, we judged the validity of the proposed screening.

RESULTS

Ultrasound examination is on its own an excellent method for preoperative screening in cases of adnexal tumefactions. However, its association with plasmatic dosages of Ca 125, Ca 19-9 and CEA improves the validity of the screening.

CONCLUSION

The use of pelvic scanning, both transabdominal and transvaginal, associated with plasmatic dosages of Ca 125, Ca 19-9 and CEA, represents an excellent method of preoperative screening for the evaluation of benign or malignant ovarian tumefactions and for directing the surgeon towards the best therapy.

H3N2 influenza viruses from domestic chickens in Italy: an increasing role for chickens in the ecology of influenza?

In Italy, multiple H3N2 influenza viruses were isolated from chickens with mild respiratory disease and were shown to replicate in the respiratory tracts of experimentally infected chickens; this finding is the first to show that H3N2 influenza viruses can replicate and cause disease in chickens. H3N2 influenza viruses in pigs on nearby farms seemed a likely source of the virus; however, antigenic and molecular analyses revealed that the gene segments of the viruses in chickens were mainly of Eurasian avian origin and were distinguishable from those isolated from pigs and wild aquatic birds in Italy. Thus, several different H3 influenza viruses were circulating in Italy, but we failed to identify the source of the chicken H3N2 influenza viruses that have disappeared subsequently from Italian poultry. Until recently, the transmission of influenza viruses (other than the H5 and H7 subtypes) from their reservoir in aquatic birds to chickens was rarely detected and highly pathogenic and non-pathogenic viruses were considered to be restricted to poultry species. However, the recent reports of the transmission of H9N2 and H5N1 influenza viruses to chickens in Hong Kong and, subsequently, to humans and our findings of the transmission of H3N2 influenza viruses to domestic chickens in Italy suggest an increased role for chickens as an intermediate host in the ecology of influenza.

[The creation of a neovagina with laparoscopic technique]

Vaginal agenesis is sometimes found isolated but more frequently as a part of a malformative syndrome, such as the Rokitansky-Küster-Hauser or the Morris syndrome. In our department the technique of choice for surgical creation of a neovagina is that described by Vecchietti. A pelviscopic approach for this technique has recently been described. Two cases of vaginal atresia are described; one with Rokitansky-Küster-Hauser and the other with Morris syndrome, in which the laparoscopic technique was attempted. Due to the aetiopathogenetic and anatomical differences of the two syndromes, the laparoscopic technique resulted easy in the first case but very difficult in the Morris syndrome case, needing laparotomic conversion. We therefore believe that in choosing the surgical approach, a decisive issue is the type of malformation. Indeed in the Morris syndrome, the contiguity between rectum and bladder makes the laparoscopic technique more difficult.

[A case of intestinal occlusion caused by endometriosis of the cecum]

The purpose of this study is to heighten awareness of intestinal endometriosis, a disease that may mimic other abdominal pathologies (bowel carcinoma, intestinal inflammatory disease, diverticulitis), sometimes found in the emergency setting. The Authors report a case of acute bowel obstruction due to coecal endometriosis with appendix mucocele, peritoneal pseudomyxoma and ovarian endometrioma. The patient was operated on in the emergency setting, a right colectomy was performed and she then received pharmacological suppressive treatment with Gn-RH analogues and danatrol. We remark that preoperative diagnosis is very difficult in those cases that do not have a past history of pelvic endometriosis. An accurate anamnesis regarding the chronology of pain onset (typically only during the menstruation at first), but especially intraoperative histopathologic examination are useful for diagnosis. An increased awareness of intestinal endometriosis in reproductive age women with acute bowel obstruction, associated with an accurate anamnesis of menstrual history may allow pre- or intraoperative diagnosis, which is the clue to a less aggressive operation. Postoperative follow up and hormonal therapy are mandatory.

Continued evolution of H1N1 and H3N2 influenza viruses in pigs in Italy

Swine influenza viruses possessing avian genes were first detected in Europe in 1979 (Scholtissek et al., 1983, Virology, 129, 521-523) and continue to circulate in pigs in that region of the world. To characterize the molecular epidemiology of swine influenza viruses currently circulating in Europe, we used dot-blot hybridization and sequence analysis to determine the origin of the genes encoding the nonsurface proteins ("internal" genes) of 10 H1N1 and 11 H3N2 swine influenza viruses isolated in Italy between 1992 and 1995. All of the 126 genes examined were of avian origin; thus the currently circulating H3N2 strains which possess A/Port Chalmers/1/73-like surface glycoproteins appear to be descendants of the reassortant human-avian viruses that emerged between 1983 and 1985 in Italy. Sequence analysis of matrix (M), nonstructural, and nucleoprotein genes, as well as phylogenetic analysis of M gene showed that the H1N1 and H3N2 viruses from the pigs were closely related to recent isolates of the avian-like swine H1N1 influenza strain currently circulating in northern Europe and were distinguishable from the genes of viruses isolated from European swine in 1979. To evaluate the frequency of transmission of swine H1N1 and H3N2 viruses to man, we tested 123 human sera for hemagglutination-inhibiting antibodies against avian and mammalian H1N1 and H3N2 virus strains. Our findings indicate that swine influenza viruses possessing A/Port Chalmers/1/73-like hemagglutinin may have transmitted to approximately 20% of young persons under 20 years of age who had contact with pigs. Thus, H3N2 swine viruses, possibly possessing avian-derived internal genes, may be entering humans more often than was previously thought. We strongly recommend that pigs be regularly monitored as a potential early warning system for detection of future pandemic strains.

Costs and Benefits of Office Diagnostic Hysteroscopy

In Italy, the main location for performing diagnostic hysteroscopy is the office. The success of office hysteroscopy is related to savings of time and money and the convenience for the physician and patient. We evaluated 4000 diagnostic hysteroscopies performed between January 2, 1989, and March 1, 1996. In 17.8% of these patients we subsequently performed operative hysteroscopies (metroplasty, synechiolysis, myomectomy, polypectomy for polyps >2 cm), and in 5.2% a total abdominal hysterectomy for abnormal uterine bleeding or endometrial cancer. The low percentage of operations underlines the efficacy of office diagnostic hysteroscopy, especially if we evaluate costs and accuracy of this procedure in detecting uterine pathologies.