Integrating environmental, entomological, animal, and human data to model the Leishmania infantum transmission risk in a newly endemic area in Northern Italy

INTRODUCTION

Historically, leishmaniasis in Italy was constrained to areas with Mediterranean climate. In the last 20 years, sand fly vectors (Phlebotomus perniciosus), cases of canine leishmaniasis (CanL) and cases of human visceral leishmaniasis (VL) have been observed in Northern Italian regions, traditionally classified as cold areas unsuitable for sand fly survival.

AIM

We aim to evaluate through a One-Health approach the risk of endemic transmission of Leishmania infantum in the Piedmont Region, Northern Italy.

METHODS

We collected environmental, entomological, animal, and human data. We applied a geostatistical binomial model to map the probability of P. perniciosus presence in the study area, using selected environmental parameters as predictors. We evaluated the spatial relationship between the probability of P. perniciosus presence and the geographical distribution of CanL and VL cases observed between 1999 and 2013.

RESULTS

Between 1999 and 2003, 142 sampling sets (17%) out of 839 resulted positive for P. perniciosus. Elevation, degree of slope, normalized difference vegetation index (NDVI) and summer temperatures were associated with positive sampling sets. During the study period, 164 (13.6%) of Piedmont municipalities reported at least one autochthonous case of CanL, while 89 VL cases were observed in 54 municipalities (4.5%). We observed an association between municipalities affected by autochthonous CanL cases and the estimated probability of P. perniciosus presence (Odds Ratio for 10% increase of probability: 2.66; 95% confidence intervals (CI): 2.16-3.37). We found that human VL incident cases were positively associated with the probability of the municipality of residence of being endemic for CanL (Incidence Rate Ratio for 10% increase of probability: 1.49; 95% CI 1.02-2.16).

CONCLUSIONS

Using a One-Health approach, we quantified the spatial association between the distribution of P. perniciosus, municipalities endemic for CanL and incident cases of human VL, suggesting that the disease has become endemic in the Piedmont region.

Towards a smoke-free hospital: how the smoking status of health professionals influences their knowledge, attitude and clinical activity. Results from a hospital in central Italy

OBJECTIVES

In Italy, the prevalence of smoking among health professionals is higher than in the general population and this might hamper their role in the promotion of health. This study aimed to investigate how the smoking status of healthcare professionals might influence knowledge, attitudes and clinical practice in a hospital in central Italy in order to enforce effective tobacco control measures.

METHODS

Physicians and professionals of the hospital were asked to complete an anonymous questionnaire which yielded epidemiological and environmental information on knowledge, attitude, clinical practice and quality of the hospital environments, in relation to smoking.

RESULTS

Overall, among the employees of the hospital, the smoking prevalence was 47%, (42% among physicians and 43% among nurses); 30% admitted smoking in the hospital and three quarters of the smokers would like to quit. Some knowledge, opinions and attitudes differ statistically among the smoking categories. For example, only 35% of the smokers admitted that smoking is more dangerous to health than atmospheric and car pollution compared with 60% of the ex or never smokers (p=0.04). Fewer smokers realize that their behavior is seen as a role model by patients. A greater percentage of smokers state that patients (34%) and visitors (43%) often smoke in hospital and these percentages are significantly higher than those reported by ex or never smokers (p≤0.05). All smokers claim that they never smoke in patient rooms, infirmaries and clinics, whereas over 20% of ex or never smokers report that smoking sometimes occurs in these places (p=0.015). The mean concentration of PM 2.5 in the 25 rooms was 2.4 μg/m3 with a range from 1 to 7 μg/m3.

CONCLUSIONS

This study implies that the prevalence of smoking among health professionals may be very high, and might be twice the rate observed in the general population. Generally, smokers report less knowledge compared with ex and never-smokers and it seems that they systematically underestimate the dangers related to smoking both in their knowledge and in their behavior, and try to socially "normalize" smoking. All this and the evidence of cigarette butts in hospital rooms and clinics, notwithstanding the good quality of the air thanks to the modern ventilation system, imply that there is still a long way to go towards a smoke-free hospital.

The first T cell response to transmitted/founder virus contributes to the control of acute viremia in HIV-1 infection

Identification of the transmitted/founder virus makes possible, for the first time, a genome-wide analysis of host immune responses against the infecting HIV-1 proteome. A complete dissection was made of the primary HIV-1–specific T cell response induced in three acutely infected patients. Cellular assays, together with new algorithms which identify sites of positive selection in the virus genome, showed that primary HIV-1–specific T cells rapidly select escape mutations concurrent with falling virus load in acute infection. Kinetic analysis and mathematical modeling of virus immune escape showed that the contribution of CD8 T cell–mediated killing of productively infected cells was earlier and much greater than previously recognized and that it contributed to the initial decline of plasma virus in acute infection. After virus escape, these first T cell responses often rapidly waned, leaving or being succeeded by T cell responses to epitopes which escaped more slowly or were invariant. These latter responses are likely to be important in maintaining the already established virus set point. In addition to mutations selected by T cells, there were other selected regions that accrued mutations more gradually but were not associated with a T cell response. These included clusters of mutations in envelope that were targeted by NAbs, a few isolated sites that reverted to the consensus sequence, and bystander mutations in linkage with T cell–driven escape.

HIV evolution in early infection: selection pressures, patterns of insertion and deletion, and the impact of APOBEC

The pattern of viral diversification in newly infected individuals provides information about the host environment and immune responses typically experienced by the newly transmitted virus. For example, sites that tend to evolve rapidly across multiple early-infection patients could be involved in enabling escape from common early immune responses, could represent adaptation for rapid growth in a newly infected host, or could represent reversion from less fit forms of the virus that were selected for immune escape in previous hosts. Here we investigated the diversification of HIV-1 env coding sequences in 81 very early B subtype infections previously shown to have resulted from transmission or expansion of single viruses (n = 78) or two closely related viruses (n = 3). In these cases, the sequence of the infecting virus can be estimated accurately, enabling inference of both the direction of substitutions as well as distinction between insertion and deletion events. By integrating information across multiple acutely infected hosts, we find evidence of adaptive evolution of HIV-1 env and identify a subset of codon sites that diversified more rapidly than can be explained by a model of neutral evolution. Of 24 such rapidly diversifying sites, 14 were either i) clustered and embedded in CTL epitopes that were verified experimentally or predicted based on the individual's HLA or ii) in a nucleotide context indicative of APOBEC-mediated G-to-A substitutions, despite having excluded heavily hypermutated sequences prior to the analysis. In several cases, a rapidly evolving site was embedded both in an APOBEC motif and in a CTL epitope, suggesting that APOBEC may facilitate early immune escape. Ten rapidly diversifying sites could not be explained by CTL escape or APOBEC hypermutation, including the most frequently mutated site, in the fusion peptide of gp41. We also examined the distribution, extent, and sequence context of insertions and deletions, and we provide evidence that the length variation seen in hypervariable loop regions of the envelope glycoprotein is a consequence of selection and not of mutational hotspots. Our results provide a detailed view of the process of diversification of HIV-1 following transmission, highlighting the role of CTL escape and hypermutation in shaping viral evolution during the establishment of new infections.

HIV is a rapidly evolving virus, displaying enormous genetic diversity between and even within infected individuals, with implications for vaccine design and drug treatment. Yet, recent research has shown that most new infections result from transmission of a single virus resulting in a homogeneous viral population in early infection. The process of diversification from the transmitted virus provides information about the selection pressures experienced by the virus during the establishment of a new infection. In this paper, we studied early diversification of the envelope gene in a cohort of 81 subjects acutely infected with HIV-1 subtype B and found evidence of adaptive evolution, with a proportion of sites that tended to diversify more rapidly than expected under a model of neutral evolution. Several of these rapidly diversifying sites facilitate escape from early cytotoxic immune responses. Interestingly, hypermutation of the virus, brought about by host proteins as a strategy to restrict infection, appeared to be associated with early immune escape. In addition to single base substitutions, insertions and deletions are an important aspect of HIV evolution. We show that insertion and deletion mutations occur evenly across the gene, but are preferentially fixed in the variable loop regions.

Variations in adiponectin receptor genes and susceptibility to type 2 diabetes in women: a tagging-single nucleotide polymorphism haplotype analysis

Adiponectin has been associated with low diabetes risk. The metabolic effects of adiponectin are mediated by adiponectin receptors 1 (ADIPOR1) and 2 (ADIPOR2). We conducted a prospective, nested case-control study of 714 cases of type 2 diabetes and 1,120 control subjects. Six polymorphisms in ADIPOR1 and 16 polymorphisms in ADIPOR2 were determined. Haplotypes inferred from ADIPOR1 polymorphisms were significantly associated with diabetes risk (overall test, -2log-likelihood = 15.1 on 5 df; P = 0.0098). A single copy of haplotype 001100 (0, common allele; and 1, minor allele) was associated with 24% decreased risk (odds ratio [OR] 0.76 [95% CI 0.61-0.96], P = 0.02) compared with the most common haplotype, 110000, adjusting for age, BMI, and other covariates. A 3' untranslated region (UTR) polymorphism, rs1139646, showed the strongest and nominally significant association with greater diabetes risk (unadjusted OR 1.26 [1.03-1.53] and adjusted OR 1.36 [1.10-1.70]). However, such an association became marginal after controlling for multiple comparisons by permutation test (P = 0.08 on the basis of 10,000 permutations). There were not significant associations between ADIPOR2 polymorphisms, individually or in haplotypes, and the risk of type 2 diabetes. In conclusion, our data indicate significant associations between ADIPOR1 haplotypes and diabetes risk but do not support a relation between ADIPOR2 variability and the disease.

A systematic assessment of common genetic variation in CYP11A and risk of breast cancer

CYP11A catalyzes the rate-limiting step in the biosynthesis of sex-steroid hormones. In this study, we employed a systematic approach that involved gene resequencing and a haplotype-based analysis to investigate the relationship between common variation in CYP11A and breast cancer risk among African-Americans, Latinas, Japanese-Americans, Native Hawaiians, and Whites in the Multiethnic Cohort Study. Resequencing in a multiethnic panel of 95 advanced breast cancer cases revealed no common missense variant (> or =5% frequency). Common haplotype patterns were assessed by genotyping 36 densely spaced single nucleotide polymorphisms (SNPs) spanning 67 kb of the CYP11A locus in a multiethnic panel of subjects (n = 349; 1 SNP/1.86 kb on average). We identified one to two regions of strong linkage disequilibrium in these populations. Twelve tagging SNPs were selected to predict the common haplotypes (> or =5% frequency) in these regions with high probability (average R(h)(2) = 0.94) and were examined in a breast cancer case-control study in the Multiethnic Cohort Study (1,615 cases and 1,962 controls). A global test for differences in risk according to common haplotypes over the locus was statistically significant (P = 0.006), as were associations with haplotypes in each block (block 1 global test, P = 0.008; haplotype 1D, effect per haplotype copy, odds ratios, 1.23; 95% confidence interval, 1.03-1.48) and block 2 (global test, P = 0.016; haplotype 2F odds ratios, 1.52; 95% confidence interval, 1.15-2.01). These haplotypes were most common in Japanese-Americans and Native Hawaiians, followed by Whites then Latinas, and were rare in African-Americans (<5% frequency); the haplotype effects on risk across each group were homogeneous. Based on these findings, CYP11A deserves further consideration as a candidate breast cancer susceptibility gene.

Haplotype-Based Association Studies of IGFBP1 and IGFBP3 with Prostate and Breast Cancer Risk: The Multiethnic Cohort

Collective evidence suggests that the insulin-like growth factor (IGF) system plays a role in prostate and breast cancer risk. IGF-binding proteins (IGFBP) are the principal regulatory molecules that modulate IGF-I bioavailability in the circulation and tissues. To examine whether inherited differences in the IGFBP1 and IGFBP3 genes influence prostate and breast cancer susceptibility, we conducted two large population-based association studies of African Americans, Native Hawaiians, Japanese Americans, Latinos, and Whites. To thoroughly assess the genetic variation across the two loci, we (a) sequenced the IGFBP1 and IGFBP3 exons in 95 aggressive prostate and 95 advanced breast cancer cases to ensure that we had identified all common missense variants and (b) characterized the linkage disequilibrium patterns and common haplotypes by genotyping 36 single nucleotide polymorphisms (SNP) spanning 71 kb across the loci ( approximately 20 kb upstream and approximately 40 kb downstream, respectively) in a panel of 349 control subjects of the five racial/ethnic groups. No new missense SNPs were found. We identified three regions of strong linkage disequilibrium and selected a subset of 23 tagging SNPs that could accurately predict both the common IGFBP1 and IGFBP3 haplotypes and the remaining 13 SNPs. We tested the association between IGFBP1 and IGFBP3 genotypes and haplotypes for their associations with prostate and breast cancer risk in two large case-control studies nested within the Multiethnic Cohort [prostate cases/controls = 2,320/2,290; breast cases (largely postmenopausal)/controls = 1,615/1,962]. We observed no strong associations between IGFBP1 and IGFBP3 genotypes or haplotypes with either prostate or breast cancer risk. Our results suggest that common genetic variation in the IGFBP1 and IGFBP3 genes do not substantially influence prostate and breast cancer susceptibility.

The minimum effective dose of 0.5% hyperbaric spinal bupivacaine for cesarean section

BACKGROUND

The aim of this prospective, blind study was to determine the minimum effective dose of hyperbaric bupivacaine required for cesarean section.

METHODS

With Ethical Committee approval and written consent, 24 healthy women undergoing elective cesarean section received a combined spinal epidural anesthesia. We sought to determine the minimum effective dose of spinal bupivacaine using a staircase method. In each patient an arbitrary dose of 0.5% hyperbaric bupivacaine in relation to patient height was used. The initial dose was 0.075 mg/cm height, while the outcome of each patient's response determined the dose for the subsequent patient. When successful spinal block (sensory level = or < T4 with complete motor blockade) was achieved within 20 min from spinal injection, the dose of spinal bupivacaine for the next patient was decreased by 0.01 mg/cm height. Conversely, when successful spinal block was not observed, the dose of spinal bupivacaine for the next patient was increased by 0.01 mg/cm height. Sensory and motor blocks were evaluated every 5 min by an independent, blinded observer. If successful spinal block was not achieved within the designed period, a 5-8 ml epidural bolus of 2% lidocaine was given to achieve adequate surgical anesthesia.

RESULTS

No complications were reported during the study, and all women delivered their baby uneventfully (APGAR scores 5 min after delivery ranged from 9 to 10) within 5 min from uterus incision. The duration of surgical procedure ranged from 30 to 48 minutes. The dose of hyperbaric bupivacaine providing adequate surgical anesthesia within 20 min from spinal injection in 50% of subjects was 0.036 mg/cm height (95% confidence intervals: 0.031-0.041 mg/cm height). The ED95 calculated from the probit transformation to provide effective spinal anesthesia for cesarean section was 0.06 mg/cm height.

CONCLUSIONS

This prospective, blind study demonstrated that a dose as low as 0.06 mg/cm height represents the dose of intrathecal bupivacaine providing effective spinal block in 95% of women undergoing elective cesarean section.

Combined spinal-epidural anaesthesia for Caesarean section in a paraplegic woman: difficulty in obtaining the expected level of block

We describe the satisfactory use of combined spinal epidural (CSE) anaesthesia in the management of a 29-year-old paraplegic woman, with a spinal cord lesion at the T7 level, suffering from episodes of autonomic hyper-reflexia, during elective Caesarean section.

Rapid turnover proteins in critically ill ICU patients. Negative acute phase proteins or nutritional indicators?

BACKGROUND

Rapid turnover proteins are often used as metabolic indicators in patients receiving nutritional therapy. However, their plasmatic concentration can be influenced by activation of acute phase reaction due to stress. The aim of this prospective, observational study was to evaluate changes of positive and negative acute phase proteins in mechanically ventilated ICU patients with acute stress.

METHODS

Plasmatic concentrations of prealbumin (PRA), retinol-binding protein (RBP), c-reactive protein (CRP) as well as resting energy expenditure (REE) and nitrogen balance were measured in thirty ICU patients before starting nutritional support (Baseline) and then after 3 and 8 days of parenteral nutrition (TPN).

RESULTS

Plasmatic concentrations of CRP were high at baseline and did not change (p = 0.47), while RBP and PRA were low and progressively increased during the study (p = 0.0001 and p = 0.004). Percentage changes from baseline of both PRA and RBP were significantly correlated with nitrogen balance (p = 0.01 and p = 0.009); while no significant correlation was observed between changes of rapid turnover proteins and CRP (p = 0.72 and p = 0.10).

CONCLUSIONS

All the variables involved in the study are known to be influenced by both metabolic state and resolution of inflammation. However, the observed changes of rapid turnover proteins significantly correlate with nitrogen balance in the face of a persistent inflammation, as documented by CRP plasmatic concentrations. This suggests that RBP and PRA monitoring may be used as complement clinical evaluation of nutritional therapy also in ICU patients with ongoing inflammation.

[Complications during preoperative embolization in intracranial meningioma]

We report a rare case of meningioma of the parieto-occipital convexity accompanied by hemorrhage in the tumor and in the subdural space that occurred while pre-operative embolization was being applied. The patient, a 48 year old woman, presented sudden headache and, in a few minutes, comatose status and decerebrate rigidity. A quick diagnosis with CT-scan of acute intratumoral and subdural hemorrhage and a rapid intervention on the patient led to complete recovery. The possible reason for the hemorrhage is the sudden change in blood pressure of pathologic small vessels triggered by embolization.