The impact of the COVID-19 pandemic on the use of Emergency Departments in Italy

Background

During 2020, COVID-19 had a diversified distribution in Italy, the first nation in Europe to experience the outbreak of the epidemic. This was linked to geographical differences in population density and distribution of healthcare facilities, including Emergency Departments (EDs). This study aims to assess the impact of the pandemic on ED utilization in 2020 across different subpopulations and geographical locations in Italy.

Methods

We used anonymized data from a survey conducted by the Italian National Institute of Statistics on 25,000 families to analyze the yearly rate of people who used EDs from 2015 to 2020. The rate of persons who accessed ED services in 2020 per 1,000 population was compared with those of the previous non-pandemic years.

Results

The number of people accessing EDs in 2020 was 32.3% lower, although this reduction was not uniform across the 21 regions / autonomous provinces. People aged 0-14 years experienced the highest reduction in ED visits. In 2020, low educational level people exhibited a steeper reduction in the use of EDs.

Conclusions

This study shows a significant drop in EDs use especially by children; the population section mostly affected by the effects of the pandemic. This study also confirms that education and socio-economic status are important determinants of ED use. The heterogeneous reduction in ED use across the regions of Italy highlights the need to further investigate the impact of this pattern on the health of the population, as well as to define adequate preparedness strategies to face future emergencies.

Trust and its relations to vaccine beliefs: a latent class analysis on 140,000 individuals worldwide

Background

Research shows that vaccine-related beliefs (i.e., about efficacy, safety, purpose) may reflect a host of within-person and contextual factors yielding homogeneous subgroups of individuals. This study aims to characterize distinct subgroups of people and identify ideal targets for tailored public health interventions to increase vaccine adherence.

Methods

Latent class analysis was used to derive subgroups based on unique response profiles using the 2019 Gallup survey of 140 countries (>140,000 individuals). We modeled a composite of vaccine beliefs as a distal outcome examining differences for the obtained classes, with and without covariates in the model.

Results

A 5-class model fit best with classes distinguished primarily on whether individuals possessed or sought personal knowledge about science, medicine, and health, whether they trusted science, scientists and have confidence in the healthcare system. The lowest levels of vaccine beliefs were reported by a class not endorsing any of these indicators and the highest levels by a class endorsing all the indicators (p < 0.001). Age class showed a U-shaped relation with vaccine beliefs, while higher educational level (p = 0.025), higher subjective income (p = 0.006) and employment (p < 0.001) were related to higher vaccine beliefs. Country-level income was moderately related to class membership and vaccine beliefs were higher in lower-income countries (p < 0.001).

Conclusions

Our findings suggest that more work is needed to improve trust in science and medical providers. Tailored interventions grounded in a community-based and empowering approach with the collaboration of multiple stakeholders seems to be needed to improve vaccination rates. This can only be achieved when individuals trust science, scientists and healthcare providers and accrue the necessary wisdom to make good healthcare decisions that affect not only themselves but their fellow citizens.

Key messages

• Efforts to alter vaccine beliefs should touch on where people access information on science and health, the processes that build trust, and their belief whether science improves well-being.

• Public health interventions should focus on reassuring individuals that science and health workers are benevolent. An essential first step in the health worker-patient relations is building trust.

Innovative Health Technologies to Improve Emergency Department Performance

Background

Emergency Departments (EDs) are increasingly pivotal, with a constant increment in their use, despite stable or declining fundings. Crowding can lead to disruptions and the COVID-19 epidemic has further burdened ED services. However, the pandemic has seen an increased use of telemedicine and digital health tools, which may be notably beneficial for EDs. This study offers a review of the latest available digital health technologies and their effectiveness to improve ED performance.

Methods

We performed a narrative review to identify digital and technological innovations in EDs. The themes of interest were defined in 4 areas: Patient Assessment, Patient Experience, Resource Allocation, and Discharge. Data was analyzed by 5 independent reviewers who focused on different macro-areas. Disagreement on data was discussed with 2 independent tiebreakers.

Results

Our search yielded 25 articles addressing 4 topics: Patient Assessment, Resource Allocation, Patient Experience, Discharge. We found that digital tools and Artificial Intelligence are powerful tools to detect, collect, and process data from patients, to improve healthcare delivery in EDs. The Resource Allocation category showed to be key in optimizing services already in place. New technologies showed effective to improve Patient Experience by curbing pain and anxiety. Innovative technologies demonstrated efficacy after Discharge when patients need guidance from clinicians for follow-up care.

Conclusions

Our review shows evidence of increasing effectiveness of innovative tools in reducing wait time and improving performance and patient experience in EDs. Technology applied to resource allocation appeared to be the most effective category. Prediction algorithms could be used to improve workforce allocation and bed management. Critical care systems must meet the challenge of innovative technologies which can lead to a new era in healthcare delivery with improvements for patients and healthcare professionals.

Key messages

• Digital innovation will have a significant impact on several dimensions of healthcare in the near future.

• Healthcare systems and EDs must meet the challenge of innovative technologies which can lead to a new era in healthcare delivery with improvements for both patients and healthcare professionals.

The effect of active breaks on cognitive performance and classroom behaviour: the I-move study

Background

Active Breaks (ABs) intervention involves short bouts of moderate to vigorous physical activity (MVPA) conducted during or between curricular lessons by the appropriately trained teachers. The aim of the Imola Active Breaks Study (I-MOVE study) was to evaluate the effect of an ABs intervention on cognitive function and classroom behaviour in primary school children.

Methods

The study was quasi-experimental, and it involved two groups attending a primary school in Imola (Bologna, Italy). The Active Breaks group (ABsG) performed the I-MOVE protocol consisting in 10 minutes of ABs divided in warm up, tone-up with high intensity interval training and cool-down. This is repeated three times a day for one year and half. The control group (CG) continued with regular lessons. The baseline assessment was conducted in October 2019 and the follow-up in May 2021. Cognitive performance was assessed using working memory test and classroom behaviour was monitored using an “ad hoc questionnaire”.

Results

Working memory performance increased significantly more in the ABsG (change: 1.30±1.17) than in CG (0.96±1.20), p < 0.05. Almost the entire sample of the children wanted to continue with this intervention in the next following year. Children reported improvements in their school-life quality, including feeling better in class (75.40%) and in school (82.50%) when using ABs. Improvements were also reported in children time-on-task behaviours: 52.90% said they work easily in class, 52.90% that they could listen more clearly, 58.80% reported they can stay seated easily, and 59.60% that they learned better and were more focused after ABs.

Conclusions

In conclusion the program has proven to be very effective on the children's cognitive improvement and classroom behaviour. Since the ABs intervention demonstrates these positive effects, its implementation in schools can have a beneficial, sustainable and long-term impact on childhood health.

Key messages

• ABs intervention represents a cost-effective strategy to be implemented in the school settings regardless of the age and sex differences, to make the school a more dynamic environment.

• Despite the pandemic difficulties, the ABs intervention proved to be sustainable, and to have a positive effect on classroom behaviour by improving children’s concentration and attention in class.

Camouflaged Fluorescent Silica Nanoparticles Target Aggregates and Condensates of the Amyloidogenic Protein Tau

Intrinsically disordered proteins (IDPs) are increasingly found to be associated with irreversible neurodegenerative disorders. The protein tau is a prototypical IDP whose abnormal aggregation into insoluble filaments is a major hallmark of Alzheimer's disease. The view has emerged that aggregation may proceed via alternative pathways involving oligomeric intermediates or phase-separated liquid droplets. Nanoparticles (NPs) offer significant potential for probing the mechanisms of protein fibrillation and may be capable of redirecting conformational transitions. Here, we camouflaged dye-doped silica NPs through functionalization with tau molecules to impart them the ability to associate with protein assemblies such as aggregates or condensates. The prepared NP-tau conjugates showed little influence on the aggregation kinetics and morphology of filamentous aggregates of tau but were found to associate with the filaments. Moreover, NP-tau conjugates were recruited and concentrated into polyanion-induced condensates of tau, driven by multivalent electrostatic interactions, thereby illuminating liquid droplets and their time-dependent transformation, as observed by fluorescence microscopy. NP-tau conjugates were capable of entering human neuroglioma cells and were not cytotoxic. Hence, we propose that NP-tau conjugates could serve as nanotracers for in vitro and in-cell studies to target and visualize tau assemblies and condensates, contributing to an explanation for the molecular mechanisms of abnormal protein aggregation.

Representativeness of women and racial/ethnic minorities in randomized clinical trials on bempedoic acid

Funding Acknowledgements

Type of funding sources: None.

Background

Women and racial minorities have continued for a long time to be underrepresented in randomized clinical trials testing lipid-lowering therapies (i.e. statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, ezetimibe, bile acid sequestrants, fibrates, niacin, and omega-3 polyunsaturated fatty acids).

Purpose

We sought to investigate presence of disparities in trials testing the new emergent lipid-lowering drug bempedoic acid (BA).

Methods

Several databases were searched with the use of a purposedly developed search strategy. To minimize the chances of missing data, the identified clinical trials were subsequently searched on http://www.clinicaltrials.gov. Original studies were included in the analysis if they met the following inclusion criteria: (i) being a clinical trial with either multicentre or single-centre design and (ii) having an appropriate controlled design for BA.

Results

Considering together, the overall participation rate and the mean participation rate across the clinical studies, men, whites and non-Hispanic/Latinos were sufficiently represented compared with their proportion in the disease population. Non-whites and Asians were underrepresented. Women, blacks and Hispanic/Latinos were from adequately to over-represented across clinical trials, though in the pooled population their portion was lower than their share of the disease population.

Conclusions

Further efforts are needed to enhance the representativeness of clinical trials according to race and sex and ensure complete information about efficacy and safety of treatment with BA.

COVID-19 Vaccine Hesitancy and Early Adverse Events Reported in a Cohort of 7,881 Italian Physicians

BACKGROUND

The COVID-19 vaccination campaign began in Italy at the end of December 2020, with the primary aim of immunizing healthcare professionals, using the EMA approved mRNA vaccines (Comirnaty® by Pfizer/BioNTech; mRNA-1273 by Moderna) and recombinant adenoviral vaccine (Vaxzevria® by AstraZeneca). The study aimed at evaluating the prevalence and motivations underlying Vaccine Hesitancy, as well as the incidence and type of adverse events associated with COVID-19 vaccination.

METHODS

Cross-sectional study. Data were collected January 1st to 28th 2021 using a purposely created online self-administered questionnaire from a selected cohort of Italian physicians.

RESULTS

Overall, 7,881 questionnaires were analyzed: 6,612 physicians had received one dose, and 1,670 two doses of Comirnaty®; 30 had received one dose of mRNA-1273. Vaccine Hesitancy rate was 3.6%; it correlated with prior SARS-CoV-2 infection, diabetes, Adverse Eventss at previous vaccinations and refusal of 2020 flu vaccine, and was mainly motivated by concerns about vaccine Adverse Events. Typical Adverse Events were pain/itching/paresthesia at the inoculation site, followed by headache, fever, fatigue and myalgia/arthralgia occurring more frequently after the second dose (77.8 vs 66.9%; p<0.001), and in subjects with a prior SARS-CoV-2 infection.

CONCLUSION

Adherence to COVID-19 vaccination is high among physicians. Adverse Events are typically mild and more frequent in people with a prior SARS-CoV-2 infection.

Parents’ perception of overweight-obese children Quality of Life in different settings

Background

Children's Health-Related Quality of Life (HRQoL) has been frequently investigated, in particular among individuals affected by chronic diseases. It is reported that agreement between child and parent ratings regarding the child's HRQoL is strongly influenced by the latter's health status. To our knowledge, there is no evidence of how this agreement is related to different healthcare settings. Thus, our study aims to examine the relationship between child's and parent-proxy reported HRQoL of similar overweight/obese children according to the recruitment setting.

Methods

A cross-sectional study was conducted among 68 overweight/obese children, aged 6-10, recruited in a primary school (Group1, G1) and in a hospital outpatient clinic (Group2, G2) of Imola (Italy) in 2019. HRQoL was assessed using Italian version 4.0 of the Pediatric Quality of Life (PedsQL) questionnaire. For each child, we obtained self-reported children's and parents' perceived children's HRQoL total score (5 questions investigating Physical Health domain and 10 questions investigating Psychosocial Health domain divided in Emotional, Social and School Functioning).

Results

In G1 there were n = 42 overweight/obese children and in G2 n = 26. The correlation between children's reported and parents' perceived HRQoL scores is lower in G1 (Physical Health: r=-0,17; Psychosocial Health: r = 0.38) compared to G2 (Physical Health: r = 0.80; Psychosocial Health: r = 0.66). Notably, in G1, parents tend to overestimate their children's HRQoL, specifically in the Physical Health domain.

Conclusions

Correlation between children's and parents' HRQoL scores is higher in the clinical setting compared to the school setting. Implementing this questionnaire on a large scale would allow us to identify settings which need awareness-raising initiatives to improve parents' knowledge about their children's health.

Key messages

Parents’ overestimate children’s HRQoL in the school setting, particularly in the Physical Health domain. Children’s HRQoL misinterpretation might determine less targeted actions to improve their wellbeing and highlights the need for raising parents’ awareness about obesity and its effects on children.

“Missed a vaccine?” Survey on vaccine hesitancy of high-risk categories in Bologna

Background

Vaccine Hesitancy (VH) is considered by the WHO to be one of the ten threats of the 21st century. The Italian National Plan for Vaccine Prevention, as well as the European Action Plan, have among their objectives that of increasing the adherence to vaccinations both in general population and in categories at higher risk. It is precisely to these latter groups that the action of the Bologna Local Health Authority (LHA) has addressed targeted vaccination campaigns in recent years (e.g., DTP, HepB, PCV/PPV, RZV). Aim of our study was to investigate adherence to the proposed vaccination campaigns.

Methods

An anonymous QR-code scanned survey was administered to adults during the COVID-19 vaccine campaign in February in Bologna, a city in Northern Italy.

Results

A total of 2,321 participants were enrolled, 59% of whom were female. Among healthcare workers (n = 1,417), VH was 45.6% for Hib in 2020, 60.3% in 2019, and 68.3% in 2018; and 14.9% for HepB. Among people with chronic conditions (n = 149), 36.6% did not get the PCV/PPV vaccine. Among RZV vaccine recipients (n = 406), only 11.1% reported having been vaccinated. Women who were at least once pregnant in the last 5 years (n = 124), did not get the anti-pertussis vaccine in 41.9% of cases, and 71.8% of them refused the Hib vaccine. In general, the reasons most often given for missed vaccinations were ‘I did not inform myself enough about this specific vaccine' (ranging from 16.0% for Hib for healthcare workers to 44.8% for RZV), ‘I am not informed about the vaccinations I am entitled to' (27.3% for RZV, 31.8% for PCV/PPV), and ‘I do not find it useful' (46.2% for Hib in healthcare workers).

Conclusions

Our findings show that even in those who accept the COVID-19 vaccine, VH is high for other vaccinations campaigns run by the Bologna LHA. Targeted awareness and designed catch-up actions are needed, especially regarding this group that does not totally stand in the ranks of the so-called ‘no vax'.

Key messages

Vaccine Hesitancy toward other vaccines remains high among those who accept the anti-COVID-19 vaccination. A large number of hesitant respondents report either not being aware of the possibility of vaccination or not being adequately informed about the specific vaccine.

Preliminary data on physical well-being of children and adolescents during the SARS-CoV-2 pandemic

Background

The COVID-19 outbreak has forcibly overshadowed the physical well-being of children and adolescents, of which we will see the consequences in near future. The programs to contain the spread of Sars-CoV-2 resulted in prolonged lockdown periods, discontinuity of educational services and a possible decrease in physical activities (PA) among the youngest. In the local reality of the Metropolitan City of Bologna children and adolescents underwent a radical change in habits and lifestyle, overall predisposing sedentariness and unhealthy behaviors. Our project, “Come te la passi?”, aims to acknowledge lifestyle variations (concerning diet, PA, sleep behavior/quality) to design, in second-phase interventions, individualized school-based educational programs.

Methods

This ongoing study is being conducted using an on-line anonymous questionnaire targeting parents/guardian of children and adolescents aged 6-17 recruited from 26th to 28th of April in Bologna, a city in Northern Italy.

Results

Preliminary data suggested that among adolescents (n = 124) 91.2% used to do PA 2 or more times a week before lockdown, while during lockdown this percentage decreased, reaching 41.1%. In children (n = 38) we observed an even more pronounced difference, with PA decreasing from 89.5% to 26.3%. In children 29% of the participants also reported a weight gain, while 65.8% did not report any variation and only 5.2% reported a weight loss. For the majority of both children's and adolescents' parents (n = 162), the strategies to address the reduction in PA were predominantly having school time dedicated only to PA (53.1%) and being more educated about simple physical exercises (14.5%).

Conclusions

Our preliminary findings suggest that the current pandemic had a strong impact on the well-being of children and adolescents; “Come te la passi?” second-phase interventions could be crucial in addressing the youngest' needs, to educate and promote healthier lifestyles through school-based programs.

Key messages

Children’s and adolescents’ lifestyle behaviors were strongly affected by the current pandemic, with physical activity frequency more than halved.

“Come te la passi?” objectives are to frame the major critical issues detected and to shape educational school programs based on identified needs.

MR Brain Screening in ADPKD Patients : To Screen or not to Screen?

BACKGROUND

Adult polycystic kidney disease (ADPKD) still represents a major cause of renal failure and intracranial aneurisms (IA) have a higher prevalence in ADPKD than in the general population. Current guidelines suggest performing brain MRI only in the subjects with a positive familiar history of IAs or subarachnoid hemorrhage (SAH). This is a retrospective case-control analysis to evaluate the usefulness of a MR screening program in ADPKD patients.

METHODS

We retrospectively analyzed all ADPKD patients followed in our outpatient clinic between 2016 and 2019 who underwent a brain MRI screening. We evaluated the presence of IAs and others brain abnormalities and compared our results with a non-ADPKD population (n = 300). We performed univariate and multivariate regression analysis to evaluate if general and demographic features, laboratory findings, clinical parameters and genetic test results correlated with IAs or other brain abnormalities presence.

RESULTS

Among the patients evaluated 17 out of 156 (13.6%) ADPKD patients had IAs, compared to 16 out of 300 (5.3%) non-ADPKD controls (p < 0.005). Considering ADPKD patients presenting IAs, 12 (70.6%) had no family history for IAs or SAH. Genetic analysis was available for 97 patients: in the sub-population with IAs, 13 (76.5%) presented a PKD1 mutation and none a PKD2 mutation. We found that arachnoid cysts (AC) (p < 0.001) and arterial anatomical variants (p < 0.04) were significantly more frequent in ADPKD patients.

CONCLUSION

In our population ADPKD patients showed a higher prevalence of IAs, AC and arterial variants compared to non-ADPKD. Most of the IAs were found in patients presenting a PKD1 mutation. We found a significant number of alterations even in those patients without a family history of IAs or SAH. The practice of submitting only patients with familial IAs or kidney transplantation candidates to MRI scan should be re-evaluated.

Trust of Italian healthcare professionals in covid-19 (anti-sars-cov-2) vaccination

Abstract

Background. Vaccination is one of the most effective tools available to Public Health. Its potential usefulness is threatened by the rise of vaccine hesitancy among the general population, which has grown as much as to prompt the World Health Organization to express its concerns on the matter. The risk posed by vaccine hesitancy is even more concerning in the light of the efforts to curb the ongoing COVID-19 pandemic, which focus mainly on mass vaccination campaigns. This holds especially true when applied to healthcare professionals, among whom vaccine hesitancy can be particularly detrimental. For these reasons, our study focuses on potential determinants of vaccine hesitancy among healthcare professionals. Study design. The study is a cross-sectional study. Methods. Data were collected from January 1st to February 16th, by means of a self-administered online questionnaire in a cohort of Italian healthcare professionals. Results. Overall, 10,898 questionnaires were collected. Among the respondents, 1.1% expressed vaccine hesitancy. Hesitancy was less frequent in professionals involved in Primary Care and in the Clinical Sciences/ Public Health group. Among clinicians, paediatricians, oncologists, and geriatrists showed especially accepting attitudes towards vaccination. Lower hesitancy rates were also registered among the respondents who already had received influenza vaccination and who never had any adverse effects following vaccination. Higher hesitancy rates were observed among individuals who had family members aged >65 years and with a history of severe adverse reactions to vaccination. Conclusion. Vaccine hesitancy rates were extremely low among participants in our study. Some medical specialties shown were particularly accepting towards vaccination. The potential predictors and protective factors pointed out by our analysis might allow more refined targets.

Measures of walkability in the pediatric population: a qualitative review of the literature

CONTEXT

Sedentary lifestyle is spreading among children living in urban settings. Recent studies in urban health investigated the effects of built environment on children's physical activity, focusing on the concept of "walkability", an index of how much an area is conducive to walking and active transportation. We decided to browse the literature in order to review all possible tools and methods by which walkability has been evaluated and measured.

METHODS

We conducted a qualitative review of the literature in agreement with PRISMA guidelines, searching three medical databases for papers published between January 1994 and July 2017. Inclusion criteria were: primary studies, population ≤18 years and exposure variable as an assessment of walkability or built environment.

RESULTS

We retrieved 1,702 articles and included 195 of them in the final review. Most of the studies were cross-sectional (n=188, 96.4%). We identified two possible approaches and four main tools to address walkability measurement. A subjective method approach was used in 71 studies (36.4%), an objective method in 87 (44.6%). Only 37 studies (19.0%) used both. Main tools were survey (n=70, 35.9%), Geographic Information System (GIS) (n=64, 32.8%), street audits (n=11, 5.6%) and Walk-score™ (n=3, 1.5%). Forty-six studies (23.4%) used mixed methods. Environmental variables' assessment and definition was found to vary greatly by method of choice.

CONCLUSIONS

We found a high degree of heterogeneity regarding methods and measurements of walkability. A standard approach regarding tools and environmental variables' choice and definition will be advisable in order to allow comparisons among studies. Also, more longitudinal studies are needed.

Results and predictors of outcome of endoscopic endonasal surgery in Cushing's disease: 20-year experience of an Italian referral Pituitary Center

PURPOSE

To assess outcomes and predictors of early and long-term remission in patients with Cushing's disease (CD) due to ACTH-secreting adenomas treated via endoscopic endonasal approach (EEA).

METHODS

This is a retrospective study. Consecutive patients operated for CD from 1998 to 2017 in an Italian referral Pituitary Center were enrolled. Clinical, radiological, and histological data at enrollment and follow-up were collected.

RESULTS

151 patients (107 F) were included; 88.7% were naïve for treatment, 11.3% had been treated surgically and 11.2% medically. At pre-operative magnetic resonance imaging (MRI), 35 had a macroadenoma and 80 a microadenoma, while tumor was undetectable in 36 patients. Mean age at surgery was 41.1 ± 16.6 years. Diagnosis was confirmed histologically in 82.4% of the cases. Patients with disease persistence underwent second surgery and/or medical and/or radiation therapy. Mean follow-up was 92.3 ± 12.0 (range 12-237.4) and median 88.2 months. Remission rate was 88.1% after the first surgery and 90.7% at last follow-up. One patient died of pituitary carcinoma. Post-surgical cortisol drop (p = 0.004), tumor detection at MRI (p = 0.03) and size < 1 cm (p = 0.045) increased the chance of disease remission; cavernous sinus invasion was a negative predictor of outcome (p = 0.002). Twenty-seven patients developed diabetes insipidus and 18 hypopituitarism. Surgery repetition increased the risk of hypopituitarism (p = 0.03), but not of other complications, which included epistaxis (N = 2), cerebrospinal fluid leakage (1), pneumonia (3), myocardial infarction (1), and pulmonary embolisms (2).

CONCLUSIONS

Selective adenomectomy via EEA performed by experienced surgeons, supported by a multidisciplinary dedicated team, allows long-term remission in the vast majority of CD patients with low complication rate.

Concordance between child’s and parents’- reported Health-related quality of life and overweight

Background

Health-related quality of life (HRQoL) of children is an important health outcome which has frequently been investigated regarding children's chronicle illnesses using parents proxy-reported HRQoL. Obesity is an increasingly frequent condition in children, for which the evidence about perceived quality of life is lacking. The aim of our study is to examine the concordance between child's and parents'- reported HRQoL according to children's weight status.

Methods

A cross-sectional study was conducted in 2019 among 128 children, aged 6-10, recruited in a primary school of Imola (Italy). Children were divided in Group1 (G1: normal-underweight) and Group2 (G2: overweight-obese) using the International Obesity Task Force cut points. HRQoL was assessed using the Italian version 4.0 of Paediatric Quality of Life (PedsQL) questionnaire. We obtained self-reported children's HRQoL total score and the parents' perceived children's HRQoL total score. Each score had two subscales: one for physical health and one for emotional, social and school functioning.

Results

In G1 there were 86 children and in G2 42. The correlation between the children's and parents' HRQoL scores is low in G1 (physical health: 0.24; emotional, social and school functioning: 0.15). Children in G2 and their and parents' perception of physical health are poorly correlated (r=-0.09) and those of emotional, social and school functioning are well correlated (r = 0.43).We observed that in case of discordant HRQoL results, parents usually overestimate their children's HRQoL.

Conclusions

Correlation between the children's and parents' HRQoL scores is low in G1. In G2 children's and parents' perception are concordant for emotional, social and school functioning and unrelated for physical health. It would be useful to investigate whether these results depend from lack of communication between parents and children or lack of parents' awareness of health-related problems with obesity.

Key messages

Parents and children have a discordant perception of physical health quality of life. Further studies should investigate the reasons why these results are discordant.

Measles and young adults: the case of the Local Health Authority of Bologna over the last decade

Background

Measles is increasing globally, with a 300% increase in the first three months of 2019 in the WHO European Region. Measles cases recorded annually over the last decade in Italy have been cyclical with the last peak in 2017 with 84 cases per million inhabitants. In the same year, national coercive vaccination measures were introduced for access to educational services. Although the country is again achieving adequate vaccination coverage (VC) for the second dose of MRR (93.2% in 2018), outbreaks can still occur in communities with low VCs.

Methods

The aim of this study was to analyze measles epidemiology in Bologna Local Health Authority (LHA) from 2010 to 2018, focusing on age groups at higher risk of spread. Aggregate data on measles incidence were provided by Bologna HLA and VCs in residents were provided by the Emilia-Romagna Region (RER).

Results

The number of cases in the period of reference was 261 cases, 240 of which were laboratory confirmed (92%). The overall average age was 28.5 years (standard deviation, ds: ±14.73 years). The age group with the highest average incidence rate was 20-24 years (93 per 1.000.000 inhabitants), followed by 25-29 years (88) and 30-34 years (75). With regard to occupation at highest risk of prevalence, students represented the largest group with 22.6% of cases. VC data in residents in RER showed that in the age group 19-35 the fraction of the population not vaccinated with two doses of vaccine decreased significantly in the birth cohorts of the 1990s with a coverage of 6.9% for the 1984 birth cohort. None of the cohorts taken into consideration achieved a VC of 95% for the second dose.

Conclusions

Our results confirm the high proportion of measles cases among young adults. This highlights the need to consider catch-up actions and awareness campaign. For example, by focusing on students without previous documented vaccinations, considering that Bologna is home to tens of thousands of University students every year.

Key messages

The measles epidemiology analysis in the Local Health Authority of Bologna (Italy) over the last decade showed that the young adults (aged 20-35) have the highest average incidence rate of measles. Considering the need to focus on young adults in order to contain new cases of measles; checks on previous vaccinations, catch-up actions and improved awareness campaign are essential.

Scientific literature response in Pubmed for the novel Coronavirus outbreak: a literature analysis

Background

Recent events highlight how emerging and re-emerging pathogens are actually becoming global challenges for public health. In December 2019, a novel coronavirus (SARS-CoV-2) has emerged. This has suddenly turned out into a global health concern which has led to a very high number of papers published in the scientific literature. Aim of this research is to focus on the bibliometric aspects in order to give researchers a glimpse on what is published in the first 30-days of a global epidemic outbreak.

Methods

We searched MEDLINE (PubMed) electronic database in order to find all relevant studies in the first 30-days from the first publication (which appeared on Pubmed at 14/01/2020), meaning the period 15/01/2020-13/02/2020. We used the following search string: coronavirus* OR Pneumonia of Unknown Etiology OR Covid-19 OR nCoV. We placed a language restriction for English, but no publication status or study design limit was put in place for our search.

Results

From the initial 462 identified articles, 234 articles were found as pertinent and read in extenso in order to classify them. The vast majority of papers come from China, UK and USA. 66.2% of the papers were Editorials, comments, letters or other kind of mainly reported data. 10.7% of papers were secondary literature papers (mainly narrative reviews). The remaining 23.1% were original primary studies. Only 17.5% of the sources used data which were directly collected on the field.

Conclusions

Almost all of data came from China. Even if some preferential channels were guaranteed for publishing those results in the most important journals, it appears that the vast majority of publication in scientific literature in the first 30-days of an epidemic outbreak is based more on reported data and comments, and only a small fraction of the papers have primary data collected in the field. Nevertheless the whole international literature depends on that type of data sources in the early days of the epidemic.

Key messages

This is the first bibliometric research in Pubmed Database on the first 30 days of publications regarding the novel Coronavirus (2019-nCoV) outbreak of 2019.

The vast majority of publication in the first 30-days of an epidemic outbreak are reported data or comments, and only a small fraction of the papers has directly collected data.

Comparison between health-related quality of life in normal-weight and overweight-obese children

Background

In Italy 32% of 6-10 aged children were overweight in 2017-2018. Measures of Health-Related Quality of Life (HRQoL) assess important aspects of health daily activities, physical symptoms, social interactions and emotional well-being. It is suggested that HRQoL is influenced by children's weight status. The aim of the study is to compare HRQoL among normal-underweight and overweight-obese children in an Italian sample.

Methods

A cross-sectional study was conducted in 2019 among 144 children, aged 6-10, recruited in a primary school in Bologna (Italy). Children were divided in Group1 (G1: normal-underweight) and Group2 (G2: overweight-obese) using the International Obesity Task Force cut points. HRQoL was assessed using 4.0 Italian version of PedsQL questionnaire. We obtained summary scores for children's total HRQoL and two subscales: one for physical health and one for emotional, social and school functioning.

Results

Of 144 children, 98 (68%) and 46 (32%) were respectively in G1 and G2. HRQoL total scores were 73.10±1.30 in G1 and 69.28±1.96 in G2 (p = 0.051). We analysed separately children in Grade 1 and Grade 3-4. In Grade 1, there were 68 children: 48 (71%) in G1 and 20 (29%) in G2. In grade 3-4 there were 76 children: 50 (66%) in G1 and 26 (34%) in G2. HRQoL total scores in grade 3-4 were: 73.28±1.63 in G1 and 72.66±2.32 in G2 (p = 0.41). In Grade 1, HRQoL total scores were 72.92±2.05 in G1 and 64.89±3.15 in G2 (p = 0.02); at subscale levels, means for physical health were 77.73±1.92 in G1 and 72.5±3.58 in G2 (p = 0.08) and means for emotional, social and school functioning were 70.35±2.48 in G1 and 60.83±4.04 in G2 (p = 0.02).

Conclusions

The effects of child overweight and obesity on health-related QOL was more evident in children aged 6-7, especially regarding emotional, social and school functioning. Prevention of childhood overweight and obesity is important not only to avoid health consequences of weight but also to improve children' quality of life.

Key messages

Overweight is a public health problem in Italy not only among adults, but even among children. Overweight has a negative impact on quality of life, therefore a healthy lifestyle should be promoted.

The Imola Active Breaks study: a new strategy in child public health to reduce sedentary

Background

Physical inactivity is worldwide considered one of the biggest public health problems of the 21st century. WHO recommended in children, at least 60 minute of Moderate Vigorous Physical activity (MVPA) per day, but low percentages comply with guidelines. Considering that children spend many hours at school, classroom is the ideal setting to increase their PA. Active Breaks (AB) are a 5-15-minute bouts of PA led by the teachers during academic lessons. The aim of the Imola AB study is to implement a 1-year intervention based on AB (10min/3per-day) in primary school as a new strategy to reduce inactivity. We present the baseline results.

Methods

Quasi-experimental pre-post study in 6-10aged primary school children, in Imola(Italy).We evaluated PA level with Actigraph accelerometers: time (in minutes) spent in MVPA Weekly and Daily (W-MVPA; D-MVPA) and Weekly Sedentary behaviours (W-SB).

Results

We recruited 152 children: N = 110 in Active Breaks experimental group (AB) and N = 42 in control group (CG). Actigraph's analysis showed that 42,5% of children in the ABG vs 31.0% in the CG reach the WHO recommendation (p=ns). We investigated baseline differences between groups using ANOVA dividing children by grade. In 3-4 grades: W-MVPA (AB = 318.3±15.5 vs CG = 310.4±98.0 p = 0.78); D-MVPA (AB = 53.0±20.3 vs CG = 51.8±16.3 p = 0.79);W-SB (AB = 6,687.5±375.3 vs CG = 6,754.7±281.0 p = 0.45). In 1grade: W-MVPA (AB = 376.1±127.9 vs CG = 300.3±120.0 p = 0.02); D-MVPA (AB = 62.7±21.3 vs CG = 50.0±20.0 p = 0.02); W-SB (AB = 6,436.0±496.0 vs CG = 6,373.3 ±1,532.0 p = 0.7).

Conclusions

Only the 39.2% of the total sample met the 60-minute/day of MVPA recommended. We found no significant baseline differences in PA level measured by Actigraph between CG and AB, excepted in 1 grade. The intervention implemented in the Imola AB study could be a good strategy to reduce sedentary in children and reach the WHO recommendation, thus contributing to the aims of the new Global Action Plan on PA 2018-2030.

Key messages

Less than 50% reach the WHO recommendations of PA. AB implemented in the Imola Study could be a public health school-based strategy to reduce sedentary and increase healthy behavior in children. Active breaks (AB) are emerging as a good strategy to increase the PA level, reducing the time in sedentary habits.

Tackling Sustainable Development Goals in Italian Regional Legislation: a Health in All Policies comparative analysis

Background

The Health in All Policies approach has been increasingly used to assess public health impact of rules and regulations. In 2015, all UN member States adopted 17 Sustainable Development Goals (SGDs) to achieve the 2030 Global Agenda. SDGs can be conceived in a practical way, as analytic tools to classify existing legislation. In the context of the ASPHER-ASPPH sponsored “This is Public Health in Italy” campaign, the Public Health Schools of University San Raffaele, University of Bologna, University of Pavia and University of Parma decided to monitor their own local governments' level of SDG compliance. The study aims at identifying a procotol for a Health in All Policies, SDG-driven analysis in two Northern Italy Regions: Lombardy and Emilia-Romagna. These two regions 4.45 millions and 10.04 million accounting for over 24% of national population.

Methods

Between November and December 2019, two teams were established for separate analyses of the 2 Regions. All laws were retrieved from the two Regional Council's offical websites. Exclusion criteria were set by ruling all healthcare-related laws out of the analysis. An agreement was reached to label each law with the most representatives SDG tackled. As a proxy for internal validity, results were double-blinded. Each Regional Group met collectively and double-checked the other group's anlysis. To minimise detection bias, results were sent anonymously to the Scientific Committee, who supervised the analytic process and solved disagreements.

Results

A total of 57 laws were examined, 26 issued by Lombardy Region and 31 by Emilia-Romagna Region. SDG-related laws number was: 11 (42%) in Lombardy Region, whereas in Emilia-Romagna Region the proportion was much higher (n = 22, 71%). The most addressed SGD in Lombardy Region was number 15 (Life on Land), while in Emilia-Romagna number 8 (Decent Work & Economic Growth).

Conclusions

SDGs can be considered an innovative indicator to measure governement's activities and monitor the progress towards achieving the 2030 Global Agenda.

Key messages

Sustainable Development Goals are useful tools for policy analysis. The “This is Public Health in Italy” campaign allowed for a survey of public health legislative initiatives.

Comparative assessment of hypothalamic-pituitary-adrenal axis suppression secondary to intrabursal injection of different glucocorticoids: a pilot study

BACKGROUND

Hypothalamic-pituitary-adrenal axis (HPAA) suppression is the most common and dangerous, although often unrecognized and untreated, side effect of glucocorticoid administration. The risk and duration depend both on patient and treatment characteristics. High-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) currently represents the gold standard method to evaluate the metabolism of endogenous and exogenous steroids.

OBJECTIVE

To assess prevalence, severity, and duration of HPAA suppression subsequent to the injection of two steroids with equivalent potency but different pharmacokinetics.

SUBJECTS AND METHODS

Single-blind randomized case-control pilot study. Forty patients (22 F; age 48.7 ± 7.2 years) with shoulder calcific tendinopathy received an intrabursal injection of 40 mg of 6α-methylprednisolone acetate (MA) or triamcinolone acetonide (TA). Just before (T0) and after 1 (T1), 7 (T2), 15 (T3), 30 (T4) and 45 (T5) days, we assessed morning blood cortisol and ACTH by RIA, and 24-h urinary levels of MA, TA and free cortisol by HPLC-MS/MS.

RESULTS

HPAA function was normal at baseline. At T1, all patients presented HPAA suppression reaching the lowest cortisol, ACTH and UFC levels, that were similar between groups. At T2, mean cortisol remained lower than at baseline (p < 0.0001) in the TA group. In both groups, mean cortisol and ACTH levels progressively normalized, suggesting HPA recovery, except for three patients in the MA and two in the TA group. UFC levels remained lower than normal (p < 0.0001) up to T5, despite the disappearance of exogenous GCs. No patient developed manifestations of hypocortisolism.

CONCLUSIONS

A single 40-mg intrabursal injection of MA or TA is sufficient to suppresses HPAA up to 45 days. Although typically asymptomatic, patients should be instructed to recognize and report symptoms suggestive for hypocortisolism, to provide prompt diagnosis, and eventually, treatment, thus avoiding severe complications.

Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta-analysis of European, North American and Australian cohorts

OBJECTIVE

To assess the separate and combined associations of maternal pre-pregnancy body mass index (BMI) and gestational weight gain with the risks of pregnancy complications and their population impact.

DESIGN

Individual participant data meta-analysis of 39 cohorts.

SETTING

Europe, North America, and Oceania.

POPULATION

265 270 births.

METHODS

Information on maternal pre-pregnancy BMI, gestational weight gain, and pregnancy complications was obtained. Multilevel binary logistic regression models were used.

MAIN OUTCOME MEASURES

Gestational hypertension, pre-eclampsia, gestational diabetes, preterm birth, small and large for gestational age at birth.

RESULTS

Higher maternal pre-pregnancy BMI and gestational weight gain were, across their full ranges, associated with higher risks of gestational hypertensive disorders, gestational diabetes, and large for gestational age at birth. Preterm birth risk was higher at lower and higher BMI and weight gain. Compared with normal weight mothers with medium gestational weight gain, obese mothers with high gestational weight gain had the highest risk of any pregnancy complication (odds ratio 2.51, 95% CI 2.31- 2.74). We estimated that 23.9% of any pregnancy complication was attributable to maternal overweight/obesity and 31.6% of large for gestational age infants was attributable to excessive gestational weight gain.

CONCLUSIONS

Maternal pre-pregnancy BMI and gestational weight gain are, across their full ranges, associated with risks of pregnancy complications. Obese mothers with high gestational weight gain are at the highest risk of pregnancy complications. Promoting a healthy pre-pregnancy BMI and gestational weight gain may reduce the burden of pregnancy complications and ultimately the risk of maternal and neonatal morbidity.

TWEETABLE ABSTRACT

Promoting a healthy body mass index and gestational weight gain might reduce the population burden of pregnancy complications.

Characterization and implications of thyroid dysfunction induced by immune checkpoint inhibitors in real-life clinical practice: a long-term prospective study from a referral institution

PURPOSE

Autoimmune diseases are typically associated with immune checkpoints blockade. This study aims at assessing, in real-life clinical practice, the prevalence and impact of thyroid disorders induced by immune checkpoint inhibitors.

METHODS

52 patients (30 F; age 61 ± 13 years) with advanced melanoma treated with ipilimumab (3 mg/kg i.v./3 weeks; 4 doses) were included. For disease progression, 29 (16 F) of them received nivolumab (3 mg/kg i.v./2 weeks) or pembrolizumab (2 mg/kg i.v./3 weeks). Thyroid function and autoimmunity were assessed before, after 6 weeks, at the end of ipilimumab, as well as before and every 3 months during nivolumab/pembrolizumab treatment.

RESULTS

During ipilimumab, 7 (4 F) patients developed thyroid dysfunction (4 thyroiditis, 1 associated with hypothyroidism; 2 thyrotoxicosis in a previously euthyroid multinodular goiter; 1 hypothyroidism worsened). During PD1 inhibitors, 7 patients (3 F) developed hypothyroidism with severe manifestations in 6 of them; 3 patients suffered from euthyroid autoimmune thyroiditis from baseline, one after ipilimumab; 2 patients developed after transient thyrotoxicosis. Mean follow-up after anti-CTLA4 inhibitors treatment was 36 ± 28 months. Thyroid disorders occurred 45.1 ± 20.8 and 151 ± 67 days after the initiation of CTLA4 and PD1 inhibitors, respectively. Autoimmune disorders and BRAF mutation were associated with a better clinical response to CTLA4 followed by PD1 treatment.

CONCLUSIONS

Immune checkpoint blockade is burdened by a high incidence of autoimmune thyroid dysfunction, which is often severe. Therefore, early and careful monitoring and, eventually, treatment are crucial to prevent the negative impact of thyroid dysfunction on the clinical outcome.

Effectiveness of educational and lifestyle interventions to prevent paediatric obesity: systematic review and meta-analyses of randomized and non-randomized controlled trials

OBJECTIVE

This review and meta-analysis aim at updating a previous meta-analysis carried out by Waters et al. on the efficacy of interventions aimed at preventing childhood obesity and at identifying predictors of outcome.

METHODS

Using an ad-hoc search string, PubMed database was searched for studies assessing body mass index reduction associated with programmes lasting ≥12 weeks in overweight and obese children aged 2-18 years. Studies designed for children with eating disorders or relevant comorbidities were excluded. Studies meeting inclusion criteria were classified according to patient age (<6, 6-12 and 13-18 years), and intervention type (physical activity, diet or both), setting (educational, family or both) and duration (≤1 or >1 year). The search was also extended to other databases. Hand-searching techniques were also applied. The Cochrane 'risk of bias' was applied for quality assessment.

RESULTS

Seventy-two studies were meta-analysed. Overall, the best results were achieved by programmes combining diet and physical activity (n = 39). With regard to the setting, programmes involving both school and family and lasting ≤1 year were the most efficacious for 6- to 12-year-old children (n = 26); family-based-only interventions were also effective in children <6 years old (n = 2), although results have to be interpreted cautiously because of the small number of patients enrolled and the high study heterogeneity. In 13- to 18-year-old patients, interventions delivered at school (n = 8) were substantially unsuccessful.

CONCLUSIONS

Interventions for childhood obesity prevention should include both diet and physical activity, be preferentially targeted towards school age children and involve both the school and family setting. However, because of the important methodological limitations associated with currently available literature, additional studies are needed to draw definite conclusions.

1H NMR and PCA-based analysis revealed variety dependent changes in phenolic contents of apple fruit after drying

Dry and fresh apples have been studied monitoring their polyphenolic profiles through ¹H NMR, antioxidant capacity and total polyphenol content. Six ancient and underutilized apple varieties (Mantovana, Mora, Nesta, Cipolla, Ruggina, Sassola) and a commercial one (Golden Delicious) were dried with an air-drying system at 45°C for 19h. Although some of their polyphenol constituents were lost during drying, the antioxidant capacity of some apple varieties remained higher compared to Golden Delicious. This result is very important for ancient and underutilized varieties that are not consumed on large scale as fresh product since they have low attractiveness, due to their ugly appearance. Combining quantitative NMR spectroscopy with principal component analysis we have identified and quantified several polyphenols (such as catechin, epicathechin, and chlorogenic acid) that are important to establish the nutraceutical value of the different investigated apple varieties.

Usefulness of an ad hoc questionnaire (Acro-CQ) for the systematic assessment of acromegaly comorbidities at diagnosis and their management at follow-up

PURPOSE

To determine the validity of a self-administered questionnaire (Acro-CQ) developed to systematically assess the presence, type and time of onset of acromegaly comorbidities.

METHODS

This is a cross-sectional study; 105 acromegaly patients and 147 controls with other types of pituitary adenoma, referred to a specialized Italian Center, autonomously compiled Acro-CQ in an outpatient clinical setting. To test its reliability in a different setting, Acro-CQ was administered via mail to 78 patients with acromegaly and 100 with other pituitary adenomas, referred to a specialized US Center. Data obtained from questionnaires in both settings were compared with medical records (gold standard).

RESULTS

Demographics of patients and controls from both countries were similar. In both settings, >95 % of the questionnaires were completely filled; only one item was missed in the others. Concordance with medical record was excellent (k > 0.85) for most of the items, independently from the way of administration, patient age, gender and nationality, pituitary adenoma type and disease activity.

CONCLUSIONS

Acro-CQ is an inexpensive, highly accepted from patients and reliable tool recommended to expedite systematic collection of relevant clinical data in acromegaly at diagnosis, to be replicated at follow-ups. This tool may guide a targeted, cost-effective management of complications. Moreover, it could be applied to retrieve data for survey studies in both acromegaly and other pituitary adenomas, as information is easily and rapidly accessible for statistical analysis.

The independent role of prenatal and postnatal exposure to active and passive smoking on the development of early wheeze in children

Maternal smoking during pregnancy increases childhood asthma risk, but health effects in children of nonsmoking mothers passively exposed to tobacco smoke during pregnancy are unclear. We examined the association of maternal passive smoking during pregnancy and wheeze in children aged ≤2 years.Individual data of 27 993 mother-child pairs from 15 European birth cohorts were combined in pooled analyses taking into consideration potential confounders.Children with maternal exposure to passive smoking during pregnancy and no other smoking exposure were more likely to develop wheeze up to the age of 2 years (OR 1.11, 95% CI 1.03-1.20) compared with unexposed children. Risk of wheeze was further increased by children's postnatal passive smoke exposure in addition to their mothers' passive exposure during pregnancy (OR 1.29, 95% CI 1.19-1.40) and highest in children with both sources of passive exposure and mothers who smoked actively during pregnancy (OR 1.73, 95% CI 1.59-1.88). Risk of wheeze associated with tobacco smoke exposure was higher in children with an allergic versus nonallergic family history.Maternal passive smoking exposure during pregnancy is an independent risk factor for wheeze in children up to the age of 2 years. Pregnant females should avoid active and passive exposure to tobacco smoke for the benefit of their children's health.

Probiotics for prevention of atopic diseases in infants: systematic review and meta-analysis

Growing evidence underlines the pivotal role of infant gut colonization in the development of the immune system. The possibility to modify gut colonization through probiotic supplementation in childhood might prevent atopic diseases. The aim of the present systematic review and meta-analysis was to evaluate the effect of probiotic supplementation during pregnancy and early infancy in preventing atopic diseases. PubMed, Embase and Cochrane Library were searched for randomized controlled trials evaluating the use of probiotics during pregnancy or early infancy for prevention of allergic diseases. Fixed-effect models were used, and random-effects models where significant heterogeneity was present. Results were expressed as risk ratio (RR) with 95% confidence interval (CI). Seventeen studies, reporting data from 4755 children (2381 in the probiotic group and 2374 in the control group), were included in the meta-analysis. Infants treated with probiotics had a significantly lower RR for eczema compared to controls (RR 0.78 [95% CI: 0.69-0.89], P = 0.0003), especially those supplemented with a mixture of probiotics (RR 0.54 [95% CI: 0.43-0.68], P < 0.00001). No significant difference in terms of prevention of asthma (RR 0.99 [95% CI: 0.77-1.27], P = 0.95), wheezing (RR 1.02 [95% CI: 0.89-1.17], P = 0.76) or rhinoconjunctivitis (RR 0.91 [95% CI: 0.67-1.23], P = 0.53) was documented. The results of the present meta-analysis show that probiotic supplementation prevents infantile eczema, thus suggesting a new potential indication for probiotic use in pregnancy and infancy.

Interictal abnormalities of regional cerebral blood flow in migraine with and without aura

Some controversial issues exist whether regional cerebral blood flow (rCBF) changes are present both in migraine with and without aura during the interictal period. For this reason we have studied rCBF characteristics in migraine patients when headache-free. rCBF examinations were performed by the 133Xe inhalation method on 39 normal subjects (24 aged 45 or less and 15 older than 45), on 10 migraine patients with (A+) and on 10 without (A-) aura. The values of each patient were compared with the age-matched control population mean by a computer-assisted mapping system that allows statistical analysis in real time. To compare inter-individual variability 10 subjects, out of 39 normals, constituted an age-, sex- and CO2-matched control group (C). 8 A+ patients and 7 A- showed significant alterations of CBF in comparison with the age-matched control population. The analysis between the age-, sex- and CO2 matched groups showed significant differences of the inter-hemispheric (F = 6.669, p = 0.004) and of the frontal (F = 7.480 p = 0.0008) asymmetries. These data show that in the headache-free period a derangement of the cerebral perfusion is present in both migraine with and without aura, suggesting they are due to the same disease process. Furthermore they show the usefulness of a computer-assisted mapping system, suitable for clinical use, in discovering small alterations in cerebral perfusion.

[Metastasis from one tumor to another]

Tumour in tumour metastasis. The occurrence of more than one primary tumour in the same person is uncommon, nevertheless metastasis of one tumour to another is an extraordinary event. The malignant tumour usually metastasizes in a benign tumour, however a metastatic deposit within a malignant tumour is described. In the present study the literature is briefly reviewed and 43 new cases are described: in 38 the host neoplasm is a benign one, and in 4 is a malignant tumour. In the last case the metastases are present both in a malignant and in a benign tumor.

[Endomyocardial biopsy: experience with 156 patients]

Transcatheter endomyocardial biopsy (EMB) is a well known technique but its clinical value is still controversial. Our experience in the first 156 patients studied, in whom 182 EMB were performed, is reported and particular attention is given to the clinical value of the biopsy. Complications were observed in 7 patients and left ventricular EMB appeared to be more complicated (2/23) than right ventricular EMB (5/159). The clinical value of EMB was well documented (63.5%) in patients with congestive heart failure and a dilated heart (group 1) in whom a fairly high presence of myocarditis (17.5%), in different stages, was observed (13/74 patients). In patients with congestive failure and a restrictive/constrictive physiology (group 2), with angina and normal coronary arteries (group 3) and with acute advanced atrio-ventricular block and young age (group 5) the clinical value of EMB was good (85.7%, 58.3% and 60.6% respectively). The clinical value of EMB was on the contrary poor in patients with idiopathic ventricular arrhythmias (group 4) and in an heterogeneous group of patients (group 7), where EMB was mainly performed to exclude myocarditis. EMB had no clinical value in patients with aortic or mitral incompetence (group 6) studied according to a research protocol. EMB is a safe procedure which provides useful clinical informations in more than 50% of patients studied. The fairly high incidence of myocarditis (25 out of 156 patients studied) and the protean clinical presentations of the disease are stressed.

Giant-Cell Pneumonia and Lung Tumorlets in a Leukemic Four-Year-Old Child

The authors report a case of a 4-year-old child whose death resulted from acute lymphoblastic leukemia (ALL) and giant-cell pneumonia. Typical lung tumorlets were occasionally observed. On electron microscopy study it was possible to demonstrate a large number of neurosecretory granules in the tumorlet's cells, identical to those present in Kulchitsky's cells. These studies suggest the occurrence of an abnormal immunitary process.

A renal abnormality as a possible cause of "essential" hypertension

The renal abnormality which causes hypertension in the Milan hypertensive strain of rats disappears as hypertension develops. Because of the many analogies between the condition in these rats and "essential" hypertension in man, the same pattern of change may occur if a renal abnormality is the cause of essential hypertension in man. This hypothesis was tested in two groups of young normotensive subjects matched for age, sex, and body-surface area; in the first group both parents were hypertensive, and in the second group both parents were normotensive. Renal plasma-flow, glomerular filtration-rate, plasma-volume, plasma-renin activity, plasma-concentrations of Na+, K+, and catecholamines, 24 h urinary excretion of Na+, K+, and aldosterone, and the cardiac index were measured so that renal function and the role of factors affecting blood-pressure regulation could be assessed. Renal plasma-flow was significantly higher (p less than 0.01) in the first group, whereas results of tests for all the other factors were almost the same in both groups. The hypothesis that a primary kidney abnormality causes hypertension in a proportion of patients with essential hypertension is proposed.

Familial hypertension and hormonal profile, renal haemodynamics and body fluids of young normotensive subjects

1. Almost all the factors that may cause a rise in blood pressure are, in turn, influenced by the increase in blood pressure per se. Thus any primary involvement of one or more of these factors in the pathogenesis of essential hypertension must be evaluated before or during the development of hypertension.

2. Young normotensive subjects both of whose parents are hypertensive have a much higher probability of developing hypertension than those whose parents are both normotensive.

3. The following measurements were made in 56 subjects of the first group (both parents hypertensive) and 35 of the second group (both parents normotensive), matched for age, sex and body surface area: renal plasma flow and glomerular filtration rate, using p-aminohippurate and inulin clearance; 24 h urinary excretion of aldosterone, protein and electrolytes; plasma renin activity; plasma volume. Plasma catecholamines and cardiac index were also measured in 26 subjects of the first group and 25 subjects of the second group using a radioenzymic method and echocardiography.

4. All these factors were similar in the two groups except that renal plasma flow was higher in the first group (767·2 ± 30 versus 650·7 ± 17 ml/min, P < 0·01). Plasma renin activity tended to be lower in subjects with a higher renal plasma flow, but there was no significant negative correlation between the two factors.

5. The possibility that the higher renal plasma flow in subjects with a high probability of developing hypertension is a compensatory mechanism for a primary intrarenal defect is discussed.