Gut mobilization improves behavioral symptoms and modulates urinary p-cresol in chronically constipated autistic children: A prospective study

Chronic constipation is common among children with ASD and is associated with more severe hyperactivity, anxiety, irritability, and repetitive behaviors. Young autistic children with chronic constipation display higher urinary, and foecal concentrations of p‐cresol, an aromatic compound produced by gut bacteria, known to negatively affect brain function. Acute p‐cresol administration to BTBR mice enhances anxiety, hyperactivity and stereotypic behaviors, while blunting social interaction. This study was undertaken to prospectively assess the behavioral effects of gut mobilization in young autistic children with chronic constipation, and to verify their possible correlation with urinary p‐cresol. To this aim, 21 chronically constipated autistic children 2–8 years old were evaluated before (T0), 1 month (T1), and 6 months (T2) after intestinal mobilization, recording Bristol stool scale scores, urinary p‐cresol concentrations, and behavioral scores for social interaction deficits, stereotypic behaviors, anxiety, and hyperactivity. Gut mobilization yielded a progressive and highly significant decrease in all behavioral symptoms over the 6‐month study period. Urinary p‐cresol levels displayed variable trends not significantly correlated with changes in behavioral parameters, mainly increasing at T1 and decreasing at T2. These results support gut mobilization as a simple strategy to ameliorate ASD symptoms, as well as comorbid anxiety and hyperactivity, in chronically constipated children. Variation in p‐cresol absorption seemingly provides limited contributions, if any, to these behavioral changes. Further research will be needed to address the relative role of reduced abdominal discomfort following mobilization, as compared to specific modifications in microbiome composition and in gut bacteria‐derived neuroactive compounds.

Many autistic children suffer from chronic constipation. Gut mobilization in 21 chronically constipated autistic children followed prospectively for 6 months, consistently reduced hyperactivity, anxiety, sociocommunication deficits, restricted interests, and stereotypic behaviors. Changes in urinary p‐cresol, a gut bacteria‐derived neuroactive compound able to negatively affect brain function in rodent models, was not correlated with behavioral parameters, except for a marginal association with changes in anxiety. Gut mobilization significantly improves behavioral symptoms in chronically constipated autistic children, through multiple mechanisms possibly including, but not limited to, reduction in p‐cresol absorption.

Safety culture in COVID-19 wards during 2020 SARS-COV-2 pandemic

Background

Safety of care is an essential aim of a healthcare system, even during a pandemic. Incident reporting (IR) is an important safety tool to identify system failures. This study evaluates the impact of SARS-COV-2 pandemic on IR trend in the COVID-19 wards of an Italian Academic Hospital (AH) in Italy.

Methods

The study analyzed the IR submitted by the wards of Infectious Diseases (ID), Intensive Care Unit (ICU), Pneumology (P) and Emergency Room (ER) of the AH of Udine from 2016 to 2020. For each ward, IR of 2020 were compared to IR of 2016-2019 period, expressed as the mean value. The IR's topics of ER unit, classified according to the International Standards of Patient Safety, were compared between 2019 and 2020. Variation in reporting was assessed using Chi-square tests.

Results

During 2020, 180 incidents were reported, 81.7% of which submitted by ER unit. Three wards showed a decrease in reporting compared to 2016-2019 period: -18% (7vs8,5) for ID unit, -26% (16v21,7) for ICU and -44% (10vs18) for P unit. ER unit, instead, showed a great IR increase (147vs49; +200%). Considering the reporting from 2016 to 2019, 196 out of 389 (50.4%) of IR came from ER unit. Analyzing the difference in reporting in ER unit between 2019 and 2020, the IR topics regarding “Delay in execution and reporting exams” increase from 2 to 21 (p < 0,05), “Lack of human and/or instrumental resources” from 4 to 29 (p < 0,05) and “Prevention and Control of Hospital Infectious” from 0 to 13 (p < 0,05).

Conclusions

ER unit showed a higher attitude in reporting than the other considered wards, especially during the COVID-19 period, recognizing IR as an important tool to highlight critical issues. This aspect may reflect the stronger safety culture already present in this unit. SARS-COV-2 pandemic stressed in ER needs of human resources to cope with reorganization determined by COVID-19, rapid covid-test results for the patient's care path definition, implementation of infection control procedures.

Key messages

A solid safety culture may contribute to maintain high levels of IR even while during challenging times for healthcare systems. Difference in reporting among Covid wards could be explained by a different level of Safety Culture.

Impact of Covid-19 on incident reporting

Background

Incident reporting (IR) is a system of spontaneous and voluntary reporting of events, important for assessing safety risks and for improving safety and quality of care. Since Covid-19 pandemic led to a change on the hospital organization, related to an overload of work and an increase of pressure in the wards, this study aims to evaluate the impact of Covid-19 on IR and on safety culture.

Methods

This retrospective study analyzed the data of IR in 2019 and 2020 in the academic hospital of Udine. Number of IR, severity of the events (near miss, events with no harm and events with harm) and IR'S topic were compared. Inappropriate IR were excluded from severity analysis. The chi-square test was used for statistical significance.

Results

IR in 2020 showed a reduction of 17.7% compared to 2019 (1097 vs 1334, p < 0,05). Furthermore, we observed a reduction in near misses (276 vs 390, - 4,81%, p < 0,05) and an increase in events with harm (226 vs. 219, + 4,52%, p < 0,05). Events with no harm showed no significant increase. The analysis of topics revealed an increase in 2020 of problems concerning assessment of patient (+ 4.47%), especially swab's results delays, organizational aspects (+ 4.88%), due to staff reassignment and ward reorganization, and infection prevention and control (+ 4.65%). This increase is significantly associated with Covid-related IR (p < 0,05).

Conclusions

In 2020 were collected fewer IR than 2019 and with an higher level of severity. This change may be associated to the increased workload of the staff who had less time to report incidents. Nevertheless 2020 showed an increase in reporting Covid-19 related issues concerning delay of diagnostic test, new work condition and infection prevention and control measures. This analysis suggests that the decreased number of IRs and near miss during the first year of the pandemic could represent a reduction in safety culture. Additional data are needed.

Key messages

Covid-19 disease influenced the safety culture by reducing the number of IR and near misses reported.

New Covid-related issues emerged as critical during the pandemic.

The underestimated burden of aspiration event and pneumonia within hospitals: what happens after dysphagia

Study design

Prospective observational study.

Background

Despite dysphagia large prevalence and the growing ageing phenomenon occurring in European countries, aspiration events among inpatients are often underestimated, given their frequent spontaneous resolution or silent contribution to aspiration syndromes. Our main objective was to evaluate the incidence of aspiration events among medical inpatients and to identify risk factors influencing the outcome of the event.

Methods

Data about aspiration events - day, hour, type and outcome of the event occurred - along with underlying patient clinical conditions at the admission were collected. Between May 2015 and September 2016, data about aspiration event occurred among medical inpatients were collected in three large Italian hospitals.

Results

Patients affected by aspiration events were 135 on 102,619 cumulative days of hospitalization; they were mostly females (53%) with an average age of 82. The total incidence of aspiration events was of 1.4 every 1,000 days of hospitalization (C.I. 95%: 1.2-1.7) and the most frequent manifestation was cough (61.6%). The addition of drugs or an infection diagnosis during the 24 hours preceding the event acted as risk factors for those events that needed additional interventions during the hospitalization (OR 3.1 e OR 1.9 respectively), while the elimination of one or more prescribed drugs seemed to lead to aspiration events without impact on the hospitalization.

Conclusions

Results showed a large incidence of aspiration events within medical wards, many of them influencing patient outcomes. Healthcare professionals' attention concerning aspiration events should be fostered during the first hours and days of hospitalization.

Incident reporting digitalization: the experience of an Italian academic hospital, 2019

Issue

Incident reporting (IR) is an important tool to assess potential or current problems within health care facilities. To increase the number of IR should be an important issue of the risk manager. In the academic hospital Santa Maria della Misericordia (SMM) of Udine, in North-east of Italy, IR were anonymous paper forms handwritten by health-care workers (HCW) and sent to Clinical Risk Management by internal mail. Digitalization was carried out aiming to increase IR, making it simpler, more direct and perceived as more anonymous by HCW.

Description of the problem

January 1st 2019 the digitized system was initialized, between January and March two training sessions for HCW were carried out and from the 1st April HCW began to send IR with the new application which was installed on every hospital's PC. The objectives were to push HCW to report more, mostly on their own wards' incidents, and to receive complete IR through the insertion of some mandatory information fields.

Results

Comparison between the period from 1st April to 31th December 2018 and from 1st April to 31th December 2019 showed an increase of 22,6% of IR (from 678 to 831), an increase of 11,2% (from 331 to 368) of IR regarding problems with other wards or services and an increase of 33,4% (from 347 to 463) of IR regarding their own wards' incidents.

Lessons

Digitalization seems to be appreciated by HCW despite they are forced to give more information due to the mandatory fields. This could be explained considering that a direct incident reporting system ensures privacy of the HCW which feels more warded also when he reports an internal problem of his own ward. Finally, mandatory fields facilitate risk management work giving all the relevant information about the incident.

Key messages

Digital reporting seems appreciated by HCW and could be a mean to increase the number of incident reporting. To guarantee the anonimity of incident reporting should be a priority and every way to make the HCW feel anonymous seems to be appreciated.

FARP-1 deletion is associated with lack of response to autism treatment by early start denver model in a multiplex family

Background

Children with autism spectrum disorder (ASD) display impressive clinical heterogeneity, also involving treatment response. Genetic variants can contribute to explain this large interindividual phenotypic variability.

Methods

Array‐CGH (a‐CGH) and whole genome sequencing (WGS) were performed on a multiplex family with two small children diagnosed with ASD at 17 and 18 months of age. Both brothers received the same naturalistic intervention for one year according to the Early Start Denver Model (ESDM), applied by the same therapists, yielding dramatically different treatment outcomes.

Results

The older sibling came out of the autism spectrum, while the younger sibling displayed very little, in any, improvement. This boy was subsequently treated applying a structured Early Intensive Behavioral Intervention paired with Augmentative Alternative Communication, which yielded a partial response within another year. The ESDM nonresponsive child carries a novel maternally inherited 65 Kb deletion at chr. 13q32.2 spanning FARP1. Farp1 is a synaptic scaffolding protein, which plays a significant role in neural plasticity.

Conclusion

These results represent a paradigmatic example of the heuristic potential of genetic markers in predicting treatment response and possibly in supporting the targeted prescription of specific early intervention approaches.

High-content drug screening for rare diseases

Per definition, rare diseases affect only a small number of subjects within a given population. Taken together however, they represent a considerable medical burden, which remains poorly addressed in terms of treatment. Compared to other diseases, obstacles to the development of therapies for rare diseases include less extensive physiopathology knowledge, limited number of patients to test treatments, and poor commercial interest from the industry. Recently, advances in high-throughput and high-content screening (HTS and HCS) have been fostered by the development of specific routines that use robot- and computer-assisted technologies to automatize tasks, allowing screening of a large number of compounds in a short period of time, using experimental model of diseases. These approaches are particularly relevant for drug repositioning in rare disease, which restricts the search to compounds that have already been tested in humans, thereby reducing the need for extensive preclinical tests. In the future, these same tools, combined with computational modeling and artificial neural network analyses, may also be used to predict individual clinical responses to drugs in a personalized medicine approach.

Impact of VEGF and CgA as new predictive tools in management of elderly hormone-refractory prostate cancer (HRPC) patients

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Background: Prostate cancer is one of the most frequent malignancy in men of the Western countries. The identification of new predictive factors of drug activity is crucial for elderly cancer patients, who need a particular selection according to prediction of efficacy and safety by pre-treatment parameters. Several prostate cancers show focal neuroendocrine (NE) spots and CgA seems to be associated to NE phenotype both in tissue and in circulation. VEGF expression in NE cells is corelated with clinical characteristics and disease-specific survival. Somatostatin analogues induce a decrease in plasma CgA and could have also anti-angiogenic activity by inhibition of VEGF, bFGF and GH/IGF-I axis. Methods: elderly patients, median age 75 (range: 65–83), were selected for hormone-refractory disease, previously treated with CAB. Serum PSA and plasmatic CgA and VEGF were evaluated in all pts at baseline (T0) and at 4 months (T4) and 8 months (T8) after therapy. Pts were treated with docetaxel 75 mg/m2 every 3 weeks for 6 cycles and octreotide acetate 20 mg administered intramuscularly every 4 weeks until progression. Clinical and biochemical response, progression- free survival and toxicity were also evaluated. A correlation of basal CgA and VEGF with biochemical response, clinical response and clinical benefit was also investigated. Results: Median duration of follow-up was 18 months (range: 8–32). Patients evaluable for response were 22. PSA response rate (RR) was observed in 10/22 (45%); clinical objective RR was 33% (7/22). Clinical benefit was observed in 19/22 pts (86%). Only mild toxicities was observed in both groups. CgA and VEGF were both strongly reduced after therapy. Lower CgA values correlated with clinical benefit, lower VEGF values also correlated with biochemical and clinical response. Conclusions: This combination treatment showed a good toxicity profile. The most relevant data in this study refer to the role of serum CgA and VEGF levels, for prediction of tumour response. If these findings were confirmed, it could be sufficient to measure these markers levels for identification of those HRPC patients who have more probability of obtaining clinical benefit from a docetaxel-based treatment in combination with a somatostatin analogue.

No significant financial relationships to disclose.

Differential effects of all-trans retinoic acid on the growth of human keratinocytes and mouth carcinoma epidermoid cultures. Involvement of GRIM-19 and complex I of the respiratory chain

Squamous cell carcinoma (SSC) is the most frequent malignant tumor of the oral cavity. A study on the effect of all-trans retinoic acid (RA) on cell growth, expression of GRIM-19 and content and activity of complex I of the mitochondrial respiratory chain in normal human keratinocytes (NHEK) and mouth carcinoma cells with low (HN) and high (KB) transformation grade was carried out. In NHEK cells, RA treatment resulted in growth suppression, significant overexpression of GRIM-19 protein, enhanced content of complex I but depressed activity of NADH-UQ oxidoreductase activity of the complex. In HN cells, RA treatment depressed cell growth, inhibited the enzymatic activity of complex I but had no significant effect on the levels of GRIM-19 and complex I. In KB cells RA had no effect on cell growth, GRIM-19 expression, content and activity of complex I.

Comparison between gemcitabine-based combination (G) and single-agent chemotherapy (S) for elderly patients (EP) with advanced non-small cell lung cancer (NSCLC): A literature-based meta-analysis

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Background: It was estimated that a quarter of all patients who have a diagnosis of NSCLC worldwide are more than 70 years old. This meta-analysis tries to shed light on the controversial results of phase III trials evaluating in NSCLC EP doublets against third generation S. Methods: We performed a literature search using MEDLINE and Cochrane Library. We selected only clinical trials responding to the question of our meta-analysis. Outcomes recorded were 1-year survival rate (1-y SR), overall response rate (ORR) and haematological toxicity (HT). Fixed-effects and random-effects models were used to calculate pooled odds ratios (OR). An OR greater than 1 indicates that doublet is more effective for 1-y SR and ORR and more toxic for HT. Results: Three published randomized controlled phase III trials (SICOG 9909; MILES; AISCAP-SICOG) were selected yielding a total of 1082 patients (G: 426; S: 655) clustered in seven comparisons. Drugs delivered to randomized patients included gemcitabine, vinorelbine and paclitaxel. EP treated with doublets showed respect to control patients a pooled estimate for 1-y SR advantage of 36%, not statistically significant (OR=1.356; 95% CI=0.925–1.990; p>0.05). The pooled estimate for ORR advantage was 57% and statistically significant (OR=1.559; 95% CI=1.220–2.015; p<0.05). However G showed not significant difference for HT (OR=1.168; 95% CI=0.685–1.992; p>0.05). Conclusions: These data confirm in EP superior efficacy and equal tolerability of G in comparison with S previously demonstrated for adult patients. Anyway G seems to not change prognosis of NSCLC EP. It is worthy to note that all the trials analysed showed some biases: early closure of the study, second-line therapy or crossover, lower dosage of drugs in combination regimen, inclusion of unfit or strongly comorbid patients. This meta-analysis doesn’t solve troubles in decision-making of treatment for EP, but suggest to design a better phase III trial including more patients and improving accrual criteria for reducing biases. An indication of a potentially active combination regimen (gemcitabine + paclitaxel) is suggested in SICOG 9909 trial.

No significant financial relationships to disclose.

Regulation by the cAMP cascade of oxygen free radical balance in mammalian cells

A study is presented of the effect of the cAMP cascade on oxygen metabolism in mammalian cell cultures. Serum-starvation of the cell cultures resulted in depression of the forward NADH-ubiquinone oxidoreductase activity of complex I, decreased content of glutathione, and enhancement of the cellular level of H2O2. Depressed transcription of cytosolic Cu/Zn-SOD 1, mitochondrial glutathione peroxidase and catalase was also observed. Activation of the cAMP cascade reversed the depression of the activity of complex I and the accumulation of H2O2. The effect of cAMP involved the cAMP-dependent protein kinase.

Milking tests on Murgese mares and the design of adapted stalls

The results of research into the milking of mares of the Murgese breed are described. A comparison was made between hand and mechanical milking with two pulsation rates (120 and 140 cycles/min) with the objective of defining mechanical and operational solutions for the design or standardisation of machine milking of mares with special reference to the Murgese breed. The study was performed on four multiparous mares, after a suitable adaptation period. The trial lasted 45 days, during which the animals were milked twice a day. Research showed considerable advantages, both from productive and technical manipulation viewpoints, of milking this species by mechanical means, rather than by hand. Moreover, mechanical milking at 140 cycles/min provided better results than other techniques examined, as it is possible to obtain the best milk production, the smallest specific power consumption and, in addition, the highest working capacity and labour productivity. The adaptation of the animals to mechanical milking and the resultant production can be considered adequate. Mechanical and operating solutions are proposed for new plants, together with adaptations to ensure security in existing plants.

Psychoacoustical performance in children

In order to contribute to knowledge of the elementary auditory functions in infancy, a group of normally hearing children below the age of four years was examined using advanced tests for cochlear (remote masking, brief-tone audiometry, critical ratio) and central auditory functions (masking-level difference). The results showed that both cochlear and central auditory functions were almost the same in three-year-olds as they were in adults, if not better. This behavior is similar to that recorded with electrophysiological methods and leads to the conclusion that at age three years the auditory system has completed its neurofunctional maturation and it is therefore completely efficient in its elementary psychosensorial functions.

The use of collagenase-clostridiopeptidase combined with chloramphenicol in orthopaedics and traumatology

The authors report a consecutive group of 95 patients suffering from chronic ulceration treated by a mixture of Collagenase Clostridiopeptidase A and 1% Chloramphenicol. Some cases involved skin only, some affected skin and muscle, and some also affected bone. The treatment was successful in all cases. The mixture acts by inducing debridement and cleansing of the necrotic areas and stimulating granulation tissue formation. This is followed by epithelialisation. At the same time the vitality of the deep tissues is maintained, even when it involves bone.