The obligation of the physician to save the life of the detainee on a hunger strike: the opinion of the Italian National Bioethics Committee

Abstract

The Cospito case has highlighted a widely debated bioethical issue regarding the need to choose between safeguarding the life of a detainee and their right to self-determination through the practice of a hunger strike. Recently, the Italian National Bioethics Committee has been called upon to give an opinion on this matter. On the other hand, the media resonance of this case has shed light on the need to pose an ethical and social question regarding such situations: does the physician have an obligation to protect the detainee's health at the expense of their free choice? To be able to answer, it is necessary to understand whether law no. 219/17 is applicable to this context.

Secrets and lies of host-microbial interactions: MHC restriction and trans-regulation of T cell trafficking conceal the role of microbial agents on the edge between health and multifactorial/complex diseases

Here we critically discuss data supporting the view that microbial agents (pathogens, pathobionts or commensals alike) play a relevant role in the pathogenesis of multifactorial diseases, but their role is concealed by the rules presiding over T cell antigen recognition and trafficking. These rules make it difficult to associate univocally infectious agents to diseases' pathogenesis using the paradigm developed for canonical infectious diseases. (Cross-)recognition of a variable repertoire of epitopes leads to the possibility that distinct infectious agents can determine the same disease(s). There can be the need for sequential infection/colonization by two or more microorganisms to develop a given disease. Altered spreading of infectious agents can determine an unwanted activation of T cells towards a pro-inflammatory and trafficking phenotype, due to differences in the local microenvironment. Finally, trans-regulation of T cell trafficking allows infectious agents unrelated to the specificity of T cell to modify their homing to target organs, thereby driving flares of disease. The relevant role of microbial agents in largely prevalent diseases provides a conceptual basis for the evaluation of more specific therapeutic approaches, targeted to prevent (vaccine) or cure (antibiotics and/or Biologic Response Modifiers) multifactorial diseases.

Obstetric Violence in Italy: From Theoretical Premises to Court Judgments

Introduction

Historical mistreatment and violence directed toward women's bodies extend to the field of medicine, and obstetric and gynecological practices are not immune to such misconduct. Obstetric violence (OV) refers to actions involving disrespectful, abusive, or coercive treatment directed at pregnant and birthing women. This includes institutional and personal attitudes that lead to the violation of women's autonomy, human rights, and sexual and reproductive health. Despite various international legislative initiatives and recommendations from the World Health Organization (WHO) addressing disrespectful and abusive treatment, OV is still poorly known to Italian public opinion. This study aims to investigate whether the concept of OV has been conversely assimilated in judicial decisions.

Materials and methods

A retrospective analysis was conducted to scrutinize judgments in Italy until June 2023 related to OV. The Italian legal database 'De Jure Giuffrè', which collects sentences by various Courts, and the terms 'obstetric' and 'violence' as keywords were used for the research.

Results

The full-text revision of the results (n. 41 sentences) al-lowed the selection of 5 eligible contributions covering the following issues: Informed Consent, Kristeller maneuver, Vaginal Birth After Cesarean (VBAC), Acceleration of childbirth without indication, and Episiotomy. The analysis of individual judgments was complemented by an examination of the key issues involved.

Conclusions

The reviewed judgments frequently seemed to be grounded in technical aspects and inclined towards a predominant evaluation of childbirth outcomes. However, some encouraging aspects emerged, particularly in terms of attention to the female body, acknowledgment of consequences within the intimate-relational dimension, and a commitment to the principle of self-determination through the provision of free and informed consent. Ensuring the psychophysical well-being of women and unborn children, fostering positive interactions between pregnant women and medical staff, and actively working to reduce the grounds for litigation are among actual emerging priorities in healthcare. In this sense, fundamental elements include the implementation of continuous staff training and education as well as a focus on promoting the self-determination of women, leveraging new technologies for this purpose, and ensuring legal protection of their rights.

First Case of Medically Assisted Suicide in Italy Set New Legal Perspectives

Abstract

The first act of assisted suicide in Italy was recently carried out. This event is an absolute novelty for the country, affected by recent legislative changes aimed only at introducing the right to interrupt health treatments and, therefore, carry out exclusively omissive end-of-life acts. These normative provisions lay their foundations in a cultural context centered on the protection of the right to life and health; however, the cases that have occurred over time, including the famous story of DJ Fabo, have led the Constitutional Court to re-evaluate these dictates, introducing in 2019 the right to resort to assisted suicide procedures within well-defined areas, including incurability of the condition, the serious suffering of the individual and the retained ability to stand trial. The case addressed concerns a quadriplegic subject who was the victim of a road accident. Following consultation with a specialized institution, the subject made the decision to undergo an assisted sui-cide procedure in Italy. Having obtained the authorization from the competent authorities, he started a fundraiser to finance the devices and drugs required and, finally, he died. The opening by Italy towards the assisted suicide procedure represents a great step towards a broad context, as well as a decisive act for the purpose of protecting the right to self-determination of the individual. However, the current legislative framework presents significant criticalities and shortcomings. In first place, the dissonance between the laws in force and the judicial sentences is likely to generate problems of uneven application of the rules in a country dominated by the principle of Civil Law. Furthermore, the need for the applicant to fully self-finance the procedure clearly clashes with the constitutional principle of free access to care. Then emerges the need for a guideline document regarding the completion of the procedure itself, the times, methods and drugs implied, in order to significantly reduce the decision-making process by the ethics committees that still weighs on each individual case. Finally, conside-ring what has been observed on the subject of voluntary termination of pregnancy, it is necessary to ask what will be the general orientation of the doctors called to perform the act and whether they will be given the opportunity to express their refusal. The case analyzed could represent the beginning of a new era for Italian culture, but the large-scale application of assisted suicide procedures requires the introduction of legislative provisions that definitively eliminate the critical issues that have emerged so far.

COVID-19 Risk Management: a Survey among Italian physicians

Abstract

The COVID-19 pandemic had a significant global impact on public health. The increasing demand for intensive care and the closure of several health facilities has led to a reduction in the assistance of non-COVID patients. In our study, we investigated what changes health professionals have experienced in their professional activities and how they coped with them. A questionnaire was sent to 146 doctors, focused on three subjects: type of activity carried out during the pandemic; use of personal protective equipment (PPE) and recourse to vaccination; current medical liability profiles related to COVID-19. The questionnaire was completed by 111 doctors. The study showed no significant differences in the questionnaire response as regards the demographic and work variables of the participants (gender, age, area of specialties). Most of doctors assisted potentially positive patients, which also imposed derogations on their safety. Most of the complaints were about the low adequacy of PPE provision and about the compromission of specialist medical care. The interest in safety among participants was revealed by the high compliance to vaccination, with almost complete coverage. The questionnaires showed that most doctors (72,7%) believe that specialist medical care has been impaired during the COVID-19 pandemic. Secondly, a high percentage of participants (79.8%) expressed the need for both civil and criminal limitation of liability in connection with work in the management of SARS-Cov-2 patients. In conclusion, this survey tried to contribute to the identification of the main problems presented by healthcare professionals. Their versatility was a crucial element for the management of the pandemic, but also highlighted the need for health institutions to prepare pandemic plans in the future, with adequate and constant updating. Concerns were raised regarding financial deficits and legal protection. Political decisions must be entrusted to enhance medical assistance and to avoid the increasing phenomenon of defensive medicine.

Voluntary interruption of pregnancy (VIP) in Italy: interpretation of the current situation according to the report 2019-2020 of the Italian Ministry of Health

Voluntary interruption of pregnancy (VIP) in Italy is regulated by Law no. 194/1978. Its monitoring is carried out by the VIP Epidemio-logical Surveillance System, which periodically analyses the results of questionnaires compiled by the territorial healthcare structures and sent by each Region. The latest report, covering the years 2019 and 2020, highlights the adequacy of preventive and proactive strategies, an improvement in the quality and effectiveness of the service offered. Furthermore, considering the COVID-19 pandemic, the reorganization of the IVG application guidelines showed a considerable adaptation to the emergency context through measures such as the increase in pharmacological procedures compared to surgical procedures. The interpretation of the data shows that in Italy there is one of the lowest VIP rates in Europe, reflecting the effectiveness of campaigns that promote responsible procreation. Further implementations should be extended to the foreign population, which still shows a medium-high VIP rate. The efficiency of the service offered resulted to be high. The latter was assessed considering the waiting period required for the performance of the VIP procedure. Furthermore, the high percentage of conscientious objectors does not harm the healthcare service. The estimates show an adequate territorial coverage by the authorized structures compared to the female population of fertile age. In conclusion, the central action of planning, organization, and monitoring finds a valid ally in the territorial management entrusted to the Regions. The analyzed report reflects even more margins of efficiency and adequacy when considered within the particular historical context of the pandemic by COVID-19.

Long-term incidence of cardiac device complications with intrathoracic versus extrathoracic venous access: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Funding Acknowledgements

Type of funding sources: None.

Introduction

Optimal venous access is crucial in successful cardiac device implantation. Most commonly used accesses are subclavian or axillary vein puncture and cephalic vein cutdown. The extrathoracic access has the advantage of reducing the risk of pneumothorax and lead disfunction; thus, this approach is recommended as the first choice approach.

Purpose

The aim of our retrospective registry was to evaluate the incidence of long-term device complications (pneumothorax, lead rupture or displacement, hematoma, infection or bleeding) with different venous approaches in four high-volume centers in Italy.

Methods

We collected data from implantation and device complications during follow up using available electronic records from each center.

Results

We included 4443 patients, mean age 73±11 years. Median follow up was 118 months (IC range 59-198 months). The incidence of any complication was 7.7 %, without difference between intrathoracic and extrathoracic access (7.8% vs 7.7% respectively, p=0.70). However, lead rupture was more frequent in the intrathoracic group (5.3% vs 1.4%, p=0.04).

Conclusion

In experienced, high-volume centers, the use of intrathoracic vein puncture in the case of unsuitable extrathoracic access may represent a safe alternative of venous access in patients undergoing cardiac device implantation, although associated with a higher occurrence of lead rupture.

P11 QUICK PREVENTION OF THE POTENTIALLY SERIOUS CONSEQUENCES OF ELECTROMAGNETIC INTERFERENCE ON A ICD PATIENT THANKS TO THE REMOTE MONITORING SYSTEM OF THE DEVICE

Clinical Case

We report the case of a 84–year–old female patient suffering from post–infarct heart disease with severe systolic dysfunction, wearing a dual–chamber defibrillator in secondary prevention because she had previously presented an episode of monomorphic ventricular tachycardia. After the implant, the patient was enrolled in the remote monitoring service of the device and constantly followed by our team. After a few months, at the remote control we found repeated episodes of very short duration of an alarm recognized by the device as ventricular arrhythmia in the VF window. Contrary to the arrhythmic interpretation of the device, the analysis of the EGM by the medical and nursing staff highlighted an electromagnetic interference defined by the type of signal, the presence of the same in all channels and by the lack of correlation with the underlying heart rhythm. The sensing of the ventricular lead was 5–6 mV, at the lower limits but stable over time, the other parameters were optimal. The patient was promptly contacted and questioned about the circumstances and symptoms: she was asymptomatic and we found that the interference came in conjunction with the use of a cordless telephone. The alarm was related to the electromagnetic field generated by the phone and the woman was asked to stop using the device with subsequent absence of device alarms. Electromagnetic interference in defibrillators can be a cause of potentially serious inappropriate therapies (ATP, pacing and shock), the analysis and correct interpretation of the EGM by the clinician is essential for the prevention of the same. Thanks to the efficiency of the remote monitoring service, the risk of serious consequences for our patient was avoided. Subsequently the lead was repositioned due to a worsening of the sensing, but even before the re–intervention there was no longer any false alarm thanks to the absence of the environmental source of interference. The remote monitoring service applied to implantable defibrillation systems is a valuable tool for identifying lead problems or, as in this case, environmental problems, and toprevent, thanks to rapid intervention, further potentially serious complications.

P380 THE REEL‘S SYNDROME : A RARE COMPLICATION AFTER PACEMAKER IMPLANTATION

We report the case of a 83–year–old male who underwent single chamber pacemaker implantation in another center for bradyarrhythmia (atrial fibrillation) symptomatic for syncope. A ventricular lead was implanted in the apical septum, the post–procedural posterior–anterior chest radiograph showed correct placement of the leads and generator. Approximately 4 months after the implant, the patient came to our observation for repeated electric pulsations in his left shoulder. The patient was affected by mild dementia and was asymptomatic except for the presenting symptomatology, in particular he denied a history of syncope. The ECG showed arrhythmia due to atrial fibrillation, ventricular undersensing, and lack of ventricular capture (Figure 1). The chest X–ray showed the complete dislodgement of the ventricular lead tip apparently into the vein secondary to the rotation of the pulse generator on its transverse axis with consecutive coiling of the lead (Fig. 2). These findings were consistent with Reel syndrome The patient was admitted to undergo a lead repositioning attempt in consideration of the recent first implant. During the surgery, however, it was shown that the lead was completely displaced from the venous system, near the pectoral muscle. This extreme dislocation of the lead has been related to the electric pulsations felt by the patient. We proceeded with a new re–implantation of the lead and removal of the previous one. The lead was firmly tied to the pectoral muscle with 2 silk points with slight traction control of optimal fixation. Reel‘s syndrome is a variant of the better known Twiddler syndrome, characterized by the coiling of catheters along the transverse axis of the pacemaker. It is often a complication due to the manipulation of the generator by the patient, unlike Twiddler syndrome it occurs early and the leads remain intact. This syndrome is one of the most serious complications of pacemaker or defibrillator implants, it can be potentially fatal due to lack of therapy in the case of defibrillators, or asystole in pacemaker–dependent patients.

P404 CAN THE BASELINE NT–PROBNP LEVEL BE USED AS A PROGNOSTIC MARKER IN PATIENTS HOSPITALIZED FOR COVID–19? A SINGLE CENTRE EXPERIENCE

Background

NT–proBNP is commonly used a reliable prognostic biomarker in heart failure. Although SARS–CoV–2 is primarily a respiratory virus, it can also cause a myocardial injury. Previous observations indicate that COVID–19 patients can show a pathological rise of NT–proBNP during the disease course.

Aim

To assess the in–hospital prognostic significance of baseline NT–proBNP levels in COVID–19 patients.

Methods

We retrospectively analysed the data of one–hundred and ninety–two consecutive patients (mean age 70±15, 54.6 % males), hospitalized in our institution for COVID–19 disease. Demographic parameters, clinical history, pharmacological treatments and laboratory data at the admission were analysed. According to the baseline NT–proBNP levels, the whole population was divided into normal (Group A) and elevated (Group B) NT–proBNP, considering ≥ 125 pg/mL level as the pathological cut off. The length–of–stay, the orotracheal intubation rate, non–invasive ventilation and in–hospital mortality were taken into account as prognostic parameters.

Results

Forty–seven patients and one–hundred and forty–five patients belonged to Group A and Group B, respectively. Group A patients were significantly younger (57±13 vs 74±13 yrs, p < 0.001), with a lower rate of previous cardiac disease (6.4% vs 39.3%, p < 0.001) and atrial fibrillation (4.3% vs 16.7%, p < 0.033) and a better eGFR (94±20 vs 71±29 ml/m’, p < 0.001). No differences were noted between the two groups in the prevalence of diabetes, hypertension, ACE/ARBs treatment. The length–of–stay was similar (20±13 days in Group A vs 22±19 days in Group B, respectively, p=ns). Although patients of Group B showed a higher rate for orotracheal intubation (4.3% vs 13.8%) and non–invasive ventilation (13.8% vs 32.4%,), these differences were not significantly different. The in–hospital mortality was considerably lower in patients with normal baseline NT–proBNP level, as compared to Group B patients (2.1% vs 23.4% p < 0.001). When stratified by quartiles of NT–proBNP, the subgroups showed a prognosis clearly related to the expression of the biomarker.

Conclusion

In patients hospitalized for COVID–19, normal baseline NT–proBNP level identifies a population with a short–term better outcome. This widely diffuse biomarker could be used in the initial phase of admission as a prognostic tool to characterize the in–hospital prognosis.

P177 A SHOT TO THE HEART

We report the case of a 50–year–old man who, during a wild bird hunt, was accidentally fired with a shotgun loaded with pellets which hit the chest, the neck and the face of the hunter. The patient was taken to the emergency room, tachypnoic and suffering from chest pain, systolic blood pressure was 150/70 mmHg, SpO2 88%, analgesic therapy, liquids administration and O2 therapy were performed with moderate response. On physical examination there was a reduced vesicular murmur in middle field on the right, no heart murmurs; noticeable edema of face and neck soft tissues and absence of evident jugular turgor. The ECG showed sinus rhythm, HR 100/min, morphology at the limit for ST slightly rigid in the inferior site. He underwent a total body CT in which a shotgun pellet was found located at the heart base near the right atrium, with associated pericardial fluid, with a maximum thickness of about 10 mm, with blood density. A shotgun pellet was also found in the apical segment of the right upper lung lobe with associated parenchymal ground glass (the pellet site of passage) without pneumothorax and pleural effusion. CT also showed multiple hunting pellets in the soft tissues of the face and of the neck without significant lesions. The echocardiogram confirmed the presence of circumferential pericardial effusion of mild degree, but progressively worsening, mainly represented along the cardiac apex and the inferolateral wall, but without signs of cardiac tamponade (right atrium within limits, absence of significant Doppler variation in blood flow across cardiac valves). The hospital where the patient arrived was at a distance of 30 minutes from the cardiac surgery, therefore the patient was urgently transferred to the cardiac surgery room of the hub (distance of 30 minutes). Fortunately, the patient maintained hemodynamic stability and arrived in the operating room with good blood pressure, but with a pre–tamponade effusion. The man quickly underwentcardiac surgery, the pericardial effusion was drained and the responsible breach was found in at the atrio–caval junction and successfully sutured. The patient was discharged in the 6th day and currently is in good clinical condition.

C87 THE SHORT–TERM PROGNOSTIC SIGNIFICANCE OF BASELINE TROPONIN LEVELS IN PATIENTS HOSPITALIZED FOR COVID–19

Background

Troponin (TN) is the biomarker of choice for the detection of cardiomyocite injury. Elevation of TN has been noted in COVID–19 patients (pts), implicating myocardial injury as a possible pathogenic mechanism contributing to disease severity.

Aim

To assess the in–hospital prognostic significance of baseline TN levels in COVID–19 pts. Methods. The data of 192 consecutive COVID–19 individuals (mean age 70±15 yrs, 54.6% males) hospitalized in a single institution were retrospectively analysed. According to the baseline TN–I levels (normal value up to 34 pg/ml), the whole population was divided into normal (Group A) and elevated (Group B) TN–I. Demographic parameters, clinical history, pharmacological treatments and laboratory data at the admission were evaluated. The length–of–stay, rate of orotracheal intubation, non–invasive ventilation and in–hospital mortality were considered as prognostic parameters.

Results

One–hundred–fifty–seven pts belonged to Group A, while thirty–five pts to Group B. Group A pts were significantly younger (67±14 vs 79 ±12 yrs, p < 0.001). As expected, a better renal profile was observed in pts with normal TN–I levels (eGFR 82±25 ml/m’ in Group A vs 48±30 ml/m’ in Group B, p < 0.001). No differences were noted between the two groups in the prevalence of diabetes, previous CAD, hypertension, ACE/ARBs treatment. The length–of–stay was similar (21±11days in Group A vs 19±17 days in Group B, respectively, p=ns). Also, the need for orotracheal intubation (11.4% vs 11.5% p=ns) and non–invasive ventilation (26.8% vs 28.6%, p=ns), were not significantly different between Group A and Group B. However, the in–hospital mortality was considerably lower in pts with normal baseline TN–I, as compared to those with a definite level of cardiomyocyte damage (20/157 Group A pts, 12.7%, vs 15/35 Group B pts, 42.9%, p < 0.001).

Conclusion

Our data demonstrate that high TN–I baseline level upon admission should be considered as a strong prognostic parameter in pts hospitalized for COVID–19. In our population, this observation seems not to be related to the different comorbidities, except for the renal function profile.

Italian law no. 1/2021 on the subject of vaccination against Covid-19 in people with mental disabilities within the nursing homes

Abstract

The Coronavirus Disease-19 (Covid-19) pandemic, in the last year, has resulted in a significant number of infections and deaths among nursing homes' residents. This phenomenon has set up the necessity to subject these patients, often suffering from mental disabilities to a vaccination against Covid-19. However, vaccination has long been the subject of public atten-tion, being regulated differently in many European countries. In Italy, the Ministry of Health has given priority, vaccination-wise, to health facilities' patients. The government has regulated through-law no. 1 of January 5, 2021, art. 5, the manifestation of consent to be Covid-19 vac-cinated in incapacitated subjects admitted to assisted health facilities. This rule arose from the need to protect fragile individuals as well as providing real dispositions for the involved health professionals. Nursing homes' elderly guests could be divided into four catego-ries: a) subjects capable to express their will (affected by physical problems); b) subjects who, due to varying degrees of incapacitation, have their own legal guardian, curator or support administrator, ap-pointed in accordance with the law; c) incapacitated subjects without legal representatives d) subjects who, pursuant to law no. 219/2017, have appointed their own trustee. This paper provides for a clear exemplification of all the possible scenarios identified by the Italian law no.1/2021.

Early combination treatment with existing HIV antivirals: an effective treatment for COVID-19?

OBJECTIVE

Since no effective therapy exists, we aimed to test existing HIV antivirals for combination treatment of Coronavirus disease 19 (COVID-19).

MATERIALS AND METHODS

The crystal structures of SARS-CoV-2 main protein (Mpro) (PDB ID: 6Y2F) and SARS-CoV-2 RNA-dependent RNA polymerase (RdRp) (PDB ID: 7BV2) both available from Protein Data Bank were used in the study. Automated Docking by using blind and standard method both on Mpro and RdRp bound to the modified template-primer RNA was performed with AutoDock 4.2.6 program suite. Lamarckian genetic algorithm (LGA) was used for structures docking. All inhibitors were docked with all bonds completely free to rotate.

RESULTS

Our molecular docking findings suggest that lopinavir, ritonavir, darunavir, and atazanavir activated interactions with the key binding sites of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) protease with a better inhibition constant (Ki) for lopinavir, ritonavir, and darunavir. Furthermore, we evidenced the ability of remdesivir, tenofovir, emtricitabine, and lamivudine to be incorporated in SARS-CoV-2 RdRp in the same protein pocket where poses the corresponding natural nucleoside substrates with comparable Ki and activating similar interactions. In principle, the four antiviral nucleotides might be used effectively against SARS-CoV-2.

CONCLUSIONS

The combination of a protease inhibitor and two nucleoside analogues, drugs widely used to treat HIV infection, could be evaluated in clinical trials for the treatment of COVID-19.

Antifungal activity of oils macerates of North Sardinia plants against Candida species isolated from clinical patients with candidiasis

Antibiotic resistance is one of the bigger problem of public health: the rise of multi-drug resistant organisms causes a challenge in the treatment of infective diseases. Anti-Candida resistance to conventional antifungal agents has increased in the last period. Our research was intended to evaluate antimicrobial activity of oil macerate (OM) of Helichrysum microphyllum Cambess. subsp. tyrrhenicum Bacch., Brullo & Giusso and OM of Hypericum perforatum subsp. angustifolium against several clinical strains. The study included 30 patients with candidiasis who had not received any antifungal treatment before they were enrolled. A collection of 30 clinical isolates belonging to 5 different species of Candida spp. was selected for this study. The data obtained showed an interesting activity of both Oil Macerate especially against C. krusei and C. parapsilosis. On the contrary, H. microphyllum Oil Macerate has had a better activity than the H.perforatum especially in relation to C. glabrata and C. krusei.

Transglutaminase type 2 plays a key role in the pathogenesis of Mycobacterium tuberculosis infection

BACKGROUND

Mycobacterium tuberculosis (MTB), the aetiological agent of tuberculosis (TB), is capable of interfering with the phagosome maturation pathway, by inhibiting phagosome-lysosome fusion and the autophagic process to ensure survival and replication in macrophages. Thus, it has been proposed that the modulation of autophagy may represent a therapeutic approach to reduce MTB viability by enhancing its clearance.

OBJECTIVE

The aim of this study was to investigate whether transglutaminase type 2 (TG2) is involved in the pathogenesis of MTB.

RESULTS

We have shown that either genetic or pharmacological inhibition of TG2 leads to a marked reduction in MTB replicative capacity. Infection of TG2 knockout mice demonstrated that TG2 is required for MTB intracellular survival in macrophages and host tissues. The same inhibitory effect can be reproduced in vitro using Z-DON, a specific inhibitor of the transamidating activity of TG2. Massive cell death observed in macrophages that properly express TG2 is hampered by the absence of the enzyme and can be largely reduced by the treatment of wild-type macrophages with the TG2 inhibitor. Our data suggest that reduced MTB replication in cells lacking TG2 is due to the impairment of LC3/autophagy homeostasis. Finally, we have shown that treatment of MTB-infected murine and human primary macrophages with cystamine, a TG2 inhibitor already tested in clinical studies, causes a reduction in intracellular colony-forming units in human macrophages similar to that achieved by the anti-TB drug capreomycin.

CONCLUSION

These results suggest that inhibition of TG2 activity is a potential novel approach for the treatment of TB.

Lack of Response to HBHA in HIV-Infected Patients with Latent Tuberculosis Infection

Heparin-binding haemagglutinin (HBHA) has been proposed as an immunological biomarker for discriminating active tuberculosis (TB) from latent TB infection (LTBI) and to identify those at higher risk of progressing to active disease. Few data are available in immune-compromised patients, which are those with increased risk of TB reactivation. The aim of this stusy was to evaluate the immune response to HBHA in HIV-infected subjects with LTBI (HIV-LTBI) or active TB (HIV-TB) in comparison with the immune response to additional Mycobacterium tuberculosis (Mtb) or HIV and CMV antigens. The responses are evaluated in relation to TB status and in the LTBI subjects with the progression to active TB within 2 years. Forty-one HIV-infected antiretroviral-naïve subjects were prospectively enrolled: 18 were HIV-TB and 23 HIV-LTBI. Whole blood was in vitro stimulated overnight with several antigens and mitogen. Interferon-γ response in the harvested plasma was evaluated by ELISA. Despite that CD4 cell count was significantly different between HIV-LTBI and HIV-TB, no differences were observed in response to Mtb- or HIV-specific antigens. Differently, low responses to HBHA were observed in both HIV-LTBI and HIV-TB subjects. Importantly, none of the six HIV-LTBI responding to HBHA developed TB, while two of 17 non-HBHA responders developed active disease. HIV-TB-coinfected subjects, regardless of their TB status, showed low responses to HBHA despite maintaining detectable responses to other antigens; moreover, among the HIV-LTBI, the lack of HBHA responses indicated an increased risk to develop active TB. These results, although preliminary, suggest that a positive response to HBHA in HIV-LTBI correlates with Mtb containment.

Progress in the development of small molecules as new human A3 adenosine receptor ligands based on the 3-thiophenylcoumarin core

3-Thiophenylcoumarins are described as adenosine receptor ligands. Synthesis, in vitro pharmacological assays and docking studies were performed.

PREPARATION OF B-CYCLODEXTRIN-THIABENDAZOLE-PIPERONYL BUTOXIDE SUPRAMOLECULAR COMPLEX AND ITS ACTIVITY AGAINST BLUE AND GREEN MOULD DECAY ON INOCULATED SATSUMA FRUIT

The supramolecular complex of β-cyclodextrin-thiabendazole-piperony butoxide (βCD-TBZ/PBO) was prepared and its structure was characterized by 1H NMR. Additionally, the antifungal activity of βCD-TBZ/PBO was investigated in comparison with the commercially available thiabendazole (TBZ) fungicide by in vitro tests and on artificially inoculated 'Okitsu' satsuma fruit dipped in water at 20 degrees C or at 50 degrees C to control postharvest blue (Penicillium italicum) and green mould (P. digitatum). β-CD-TBZ/PBO is stable for several months when stored as powder in a dark bottle. At pH 7.0 the water solubility of the βCD-TBZ/PBO complex was consistently higher than free TBZ. Water dip at 20 degrees C did not affect decay incidence caused by blue mould but favoured the development of green mould during 4-8 days of storage at 20 degrees C with respect to untreated (control) fruit. Water at 50 degrees C effectively reduced the incidence of blue mould and totally suppressed green mould during the first 4 days but lost its efficacy afterwards. By contrast, both TBZ and βCD-TBZ/PBO had a lasting effect and were equally effective in controlling green and blue mould decay when applied at 20 degrees C and 60 mg L(-1) active ingredient (a.i.). When applied at 50 degrees C and 20 mg L(-1) a.i. the activity of the complex against blue mould was inferior than the corresponding treatment with TBZ. In vitro assays revealed a significant effectiveness of βCD-TBZ/PBO complex at low concentration compared to commercial formulation of TBZ.

Curcumin and curcumin-like molecules: from spice to drugs

Curcumin is the major yellow pigment extracted from turmeric, a commonly used spice in Asian cuisine and extensively employed in ayurvedic herbal remedies. A number of studies have shown that curcumin can be a prevention and a chemotherapeutic agent for colon, skin, oral and intestinal cancers. Curcumin is also well known for its antiinflammatory and antioxidant properties, showing high reactivity towards peroxyl radicals, and thus acting as a free radical scavenger. Recently, experimental studies have demonstrated that curcumin might be used in the prevention and the cure of Alzheimer's disease. Indeed, curcumin injected peripherally in vivo into aged Tg mice crossed the blood-brain barrier and bound to amyloid plaques, reducing amyloid levels and plaque formation decisively. The present review will resume the most recent developments in the medicinal chemistry of curcumin and curcumin-like molecules.

Critical research concepts in tuberculosis vaccine development

A new and improved vaccine against tuberculosis (TB) would provide a powerful tool to conquer one of the most insidious infectious diseases of mankind. Protection afforded by bacillus Calmette-Guérin (BCG) has been shown to be limited and inconsistent, especially in adults that are known to transmit TB disease. In the last two decades, several new vaccines have been developed and tested with the aim to elicit robust and long-lived T-cell responses against Mycobacterium tuberculosis antigens. Although much progress has been made in the TB vaccine field, there is an urgent need to address critical research questions about TB immunity with a special focus on designing vaccines aimed at preventing infection and transmission of TB. Here, we discuss the rationale behind the current immunization strategies being implemented for TB vaccines and provide some suggestions for hypothesis driven research to encourage the development of novel TB vaccines.

Microbiological and immunological diagnosis of tuberculous spondylodiscitis

BACKGROUND

Tuberculous spondylodiscitis is one the many manifestations of active tuberculosis (TB) and can result following primary infection or, more frequently, from reactivation of active TB in subjects with latent TB. Definitive diagnosis of tuberculous spondylodiscitis requires the identification of Mycobacterium tuberculosis in the biological sample following microbiological analysis.

AIM

To summarize the recent advancement in the diagnosis of TB, focusing on classical and molecular microbiological procedures, providing an overview on the recent advancements in the understanding of TB pathogenesis and their implications for the immunological diagnosis

MATERIALS AND METHODS

Isolation in culture of the bacilli and detection using molecular tools are the gold standards, though sensitivity of these assays is significantly lower compared to what observed for pulmonary TB, making diagnosis of spinal TB challenging.

RESULTS

The use of the interferon-gamma release assays (IGRAs) for the immunological diagnosis of TB infection could be of help and shall precede the invasive techniques, such as biopsy or surgery, required to obtain the biological sample. IGRAs measure the presence of effector T cells in the blood that can readily respond to an antigenic stimuli by secreting cytokines, and that are an indication of the presence of the bacilli in vivo. IGRAs are more sensitive and specific than the intradermic reaction of Mantoux, though both these immunological tests cannot distinguish between latent TB infection and active TB.

CONCLUSIONS

A modern diagnosis of TB spondylodiscitis should rely on the use of microbiological and immunological assays and the latter could potentially be of great help in monitoring therapy effectiveness.

Suspected transmission of tuberculosis in a maternity ward from a smear-positive nurse: preliminary results of clinical evaluations and testing of neonates potentially exposed, Rome, Italy, 1 January to 28 July 2011

We report preventive measures adopted after tuberculosis(TB) transmission from a nurse to a newborn assessed in late July 2011. All exposed neonates born between January and July 2011 were clinically evaluated and tested by QuantiFERON TB gold in-tube; newborns testing positive were referred for prophylaxis.Of 1,340 newborns, 118 (9%) tested positive and no other active cases of TB were found. Active surveillance for TB will be continued over the next three years for all those exposed.

Clinical applicability of Quantiferon-TB-Gold testing in psoriasis patients during long-term anti-TNF-alpha treatment: a prospective, observational study

BACKGROUND

Psoriasis patients who are treated with tumour necrosis factor (TNF)-alpha antagonists are at increased risk of reactivation of latent tuberculosis infection (LTBI) and should be adequately screened and monitored during active treatment.

OBJECTIVES

To evaluate in a prospective study, the performance of Quantiferon-TB-Gold in tube (QFT) in vitro assay compared to the conventional tuberculin skin test (TST) in detecting LTBI among a cohort of non-BCG-vaccinated patients with moderate-to-severe psoriasis during long-term treatment (12 months) with TNF-alpha antagonists.

METHODS

A total of 50 patients underwent QFT and TST testing at baseline and after 6 and 12 months of continuous anti-TNF-alpha treatment. Diagnosis of LTBI was made on the basis of a positive QFT result and negative chest-radiographic and microbiological assays. Patients with LTBI were subjected to standard isoniazid chemoprophylaxis and after 1 month, they resumed anti-TNF-alpha treatment with subsequent QFT and TST testing after 6 months. In all the cases, a follow-up period of 12 months was observed.

RESULTS

During the 12-month-study period, 14% of patients presented a QFT conversion. During active anti-TNF-alpha treatment, a QFT conversion was observed in 10% of patients (five cases). Agreement between QFT and TST was moderate (κ=0.408) at screening, good (κ=0.734) after 6 months and fair (κ=0.328) after 12 months of treatment. A total of 18% of patients presented a positive, discordant TST during the study period.

CONCLUSIONS

A single-test QFT-based screening strategy for LTBI in psoriasis patients receiving long-term anti-TNF-alpha treatment could reduce the incidence of false-positive LTBI cases, preventing unnecessary TB chemoprophylaxis.

Effect of L-carnitine on oxidative stress and platelet activation after major surgery

BACKGROUND

The surgical/anesthesia trauma is associated with an increased production of reactive oxygen species (ROS). This enhanced oxidative stress leads to cell damage resulting in various complications such as sepsis, myocardial injury and increased mortality. The aim of this study was to investigate the role of antioxidant treatment with l-carnitine in oxidative stress and platelet activation in patients undergoing major abdominal surgery.

METHODS

Forty patients scheduled for abdominal surgery were randomly allocated to l-carnitine, administered with a rapid infusion (0.05 g/kg) diluted in 250 ml of saline solution, vs. placebo treatment just before the surgical intervention. At baseline and after treatment, oxidative stress was evaluated by detection of circulating levels of soluble NOX2-derived peptide (sNOX2-dp), a marker of NADPH oxidase activation, and by analyzing platelet ROS formation. Platelet activation was studied by dosing sCD40L.

RESULTS

We observed an increase of soluble sNOX2-dp, sCD40L and ROS production in the placebo group compared with the baseline after the surgical intervention. Conversely, in the l-carnitine-treated group, sNOX2-dp, sCD40L and ROS production did not significantly differ from the baseline. A linear correlation analysis showed that Δ of ROS correlated with Δ of sNOX2 (R(s) =0.817; P<0.001) and Δ of sCD40L (R(s) =0.780; P<0.001). Multiple linear regression analysis showed that the only independent predictive variable associated with Δ of ROS was Δ of serum NOX2 levels (SE=0.05; standardized coefficient β=1.075; P<0.001).

CONCLUSION

Our findings suggest that l-carnitine could be helpful in modulating oxidative stress and platelet activation during major abdominal surgery-dependent oxidative damage.

TLR2: A Crossroads between Infections and Autoimmunity?

Environment has both pathogenic and protective roles in the determination of autoimmune disease development, possibly through infectious agents. TLR2 has the capability to recognize the widest range of PAMPs, and it is important for the recognition of mycobacteria and gram-positive bacteria. Here we review recent information showing that TLR2 ligands, its signaling machinery and the effects of its engagement on T cell polarization and differentiation, all play a decisive role in experimental models of autoimmunity. Thus, we propose that engagement of TLR2 is an important crossroads between encounter with bacteria and development of self-reactive diseases.

Exploiting immunotherapy in Mycobacterium tuberculosis-infected mice: sphingosine 1-phosphate treatment results in a protective or detrimental effect depending on the stage of infection

Sphingosine 1-phosphate (S1P) is a natural lysophospholipid able to enhance antimycobacterial innate immune response. In the present study, we address the possible therapeutic role of S1P administered during primary or acute infection in mice aerogenically infected with Mycobacterium tuberculosis (MTB). Results show that the administration of S1P during primary infection significantly reduces the presence of MTB-infected cells within pulmonary granulomas and mycobacterial burden in the lung and in the spleen. However, if S1P treatment was started during acute infection, a detrimental effect was observed in terms of pulmonary histopathology and mycobacterial burden in the lung and in the spleen. Taken together, these results show that S1P can exert a therapeutic effect as a treatment of primary infection only.

Perioperative management in patients undergoing pancreatic surgery: the anesthesiologist's point of view

BACKGROUND

A high rate of mortality and morbidity has been associated with pancreaticoduodenectomy; the 5-year survival rate is 15% to 25% compared with 1% to 5% among those who did not have any cancer-directed treatment. Systemic rather than surgical complications cause the majority of perioperative deaths, so the anesthesiologist has a crucial role in the management of these patients. This work sought to evaluate an improved approach to perioperative pain management, postsurgical complications as well as outcomes.

PATIENTS

From 2002 to 2007, 40 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The anesthesia protocol was standardized for postoperative pain control. Patients were randomly divided into two groups: 16 patients received an epidural analgesia with local anesthetics combined with opioids (T(9)-T(10); group A) and 24 had IV analgesia with morphine (group B).

RESULTS

Postoperative mortality was 2.5%. With regard to complications we observed 4 biliary fistulas, 2 pancreatic fistulas with spontaneous healing in one patient and death in the other as well as wound infections. Patients treated with epidural analgesia experienced better pain relief, compared with subjects receiving IV analgesia, which demonstrated a higher incidence of opioid-related adverse effects such as sedation and respiratory depression.

CONCLUSION

Adequate perioperative treatment included suitable nutritional support and pain management using loco-regional techniques, which seem to improve the surgical outcomes among pancreatic cancer patients.

Acanthamoeba castellanii promotion of in vitro survival and transmission of coxsackie b3 viruses

This work was undertaken to determine whether Acanthamoeba could play a role in the survival and transmission of coxsackieviruses and focused on in vitro interactions between Acanthamoeba castellanii and coxsackie B3 viruses (CVB-3). Residual virus titer evaluations and immunofluorescence experiments revealed a remarkable CVB-3 adsorption on amoeba surfaces and accumulation inside cells. The survival of viruses was independent of the dynamics of amoeba replication and encystment. In addition, our results indicated that virus-infected amoebas can release infectious viruses during interaction with human macrophages. On the basis of these data, Acanthamoeba appears to be a potential promoter of the survival of coxsackieviruses and their transmission to human hosts.

Plasma levels of IL-10 and nitric oxide under two different anaesthesia regimens

BACKGROUND AND OBJECTIVE

An alteration in production of both interleukin-10 (IL-10) and nitric oxide (NO) has been found following surgical/anaesthesia trauma. It is also suggested that IL-10 could be an important factor in regulating NO metabolism during the postoperative period. Furthermore, NO seems to play a crucial role in the anaesthetic state. The purpose of this study was to investigate plasma levels of IL-10 and NO following surgery, any possible correlation between these two variables and whether anaesthesia technique could influence NO and IL-10 circulating concentrations.

METHODS

Thirty-two patients scheduled to undergo elective major surgery were enrolled in the study and allocated into two groups to receive two different techniques of anaesthesia, total intravenous (i.v.) anaesthesia (Group I) and inhalational anaesthesia (Group II). Blood samples were drawn before (t0), at the end (t1) of operation and after 24 h (t2). Plasma IL-10 and NO levels were measured by using an enzyme-linked-immunosorbent assay (ELISA) and a total NO assay kit, respectively.

RESULTS

In both patient groups there was a significant decrease of plasma NO levels at the end of surgery (30.35 +/- 2.70 mmol L(-1) at t0 to 13.76 +/- 1.51 mmol L(-1) at t1 in Group I, P < 0.0001; 28.23 +/- 2.50 mmol L(-1) at t0 to 11.38 +/- 0.95 mmol L(-1) at t1 in Group II, P < 0.0001). This reduction remained at 24 h postoperatively (14.33 +/- 1.52 mmol L(-1) in Group I, P < 0.0001; 12.52 +/- 1.11 mmol L(-1) in Group II, P < 0.0001, both vs. t0). There was an increase in IL-10 concentrations (26.35 +/- 3.42 pg mL(-1) and 75.39 +/- 8.33 pg mL(-1) at t1 and t2, respectively, vs. 4.93 +/- 0.31 pg mL(-1) at t0, P = 0.03 and P < 0.0001, respectively, in Group I; 26.18 +/- 3.22 pg mL(-1) and 69.91 +/- 7.33 pg mL(-1) at t1 and t2, respectively, vs. 5.50 +/- 0.33 pg mL(-1) at t0, P = 0.02 and P < 0.0001, respectively, in Group II). No relationship was found between circulating IL-10 and NO.

CONCLUSIONS

During the postoperative period, IL-10 overproduction does not correlate with the decrease in systemic NO concentration.

Subarachnoid sufentanil as sole agent vs standard spinal bupivacaine in transurethral resection of the bladder

AIM

The aim of the study was to determine whether intrathecal sufentanil alone provides an adequate analgesia for patients undergoing transurethral resection of the bladder (TURB) and to compare it to standard spinal bupivacaine anesthesia in terms of motor and sensory blockade, discharge time and side effects.

METHODS

Sixty-two patients were blindly and randomly assigned to receive either intrathecal bupivacaine (10 mg of 0.5% hyperbaric bupivacaine) or intrathecal sufentanil (15 microg). Motor and sensory blockade was evaluated using a modified Bromage scale as well as cold and pinprick tests. Severity of pain was assessed by means of a 10-point verbal analog scale.

RESULTS

We found that the mean duration of sensory blockade was similar for both sufentanil and bupivacaine patients but the quality of analgesia induced by sufentanil alone was poor as compared with spinal bupivacaine anesthesia.

CONCLUSION

The subarachnoid administration of sufentanil 15 mg seems to be inadequate for TURB surgery. In addition, the advantage of a faster recovery we observed in sufentanil patients is minimized by the occurrence of a troublesome symptom such as pruritus. On the other hand, spinal bupivacaine produces an undesirable motor blockade exceeding, in our opinion, the requirement for TURB procedure.

In vitro evaluation of the effectiveness of the macrolide rokitamycin and chlorpromazine against Acanthamoeba castellanii

The present study demonstrates the in vitro effectiveness of the macrolide rokitamycin and the phenothiazine compound chlorpromazine against Acanthamoeba castellanii. Growth curve evaluations revealed that both drugs inhibit trophozoite growth in dose- and time-dependent ways. The effects of both drugs when they were used at the MICs at which 100% of isolates are inhibited were amoebistatic, but at higher doses they were amoebicidal as well as cysticidal. Experiments showed that when rokitamycin was associated with chlorpromazine or amphotericin B, rokitamycin enhanced their activities. Furthermore, low doses of rokitamycin and chlorpromazine, alone or in combination, blocked the cytopathic effect of A. castellanii against WKD cells derived from the human cornea. These results may have important significance in the development of new anti-Acanthamoeba compounds.

Chromosome instability in T-cells cultured in the presence of pancuronium or fentanyl

BACKGROUND

Genomic instability is recognized as a cause of cellular apoptosis and certain drugs that exhibit a proapoptotic effect are also able to induce chromosome damage. Since we found in recent experiments that drugs such as pancuronium and fentanyl exerted an apoptogenic effect on T cells, we studied the capacity of those agents to promote chromosome instability, i.e. chromosome aberrations (CA) and telomeric associations (tas) in peripheral blood lymphocytes.

METHODS

Lymphocytes from healthy donors were cultured with pancuronium or fentanyl, using two different concentrations for each drug: 20 and 200 ng/ml for pancuronium and 10 and 30 ng/ml for fentanyl, respectively. Cells were exposed to each concentration of these drugs either for 24 or 48 h. The higher concentration chosen was the same at which we detected the proapoptotic effect in our previous works. Cytogenetic analysis was performed by means of a standard technique and chromosome aberrations or telomeric associations were blindly evaluated by two independent observers.

RESULTS

The chromosome aberrations we observed in treated cells were not significantly different from control lymphocytes. However, an unusual rate of telomeric associations (P < 0.001) was detected in cells exposed to both pancuronium and fentanyl, at each concentration tested and at each exposure time of the study.

CONCLUSIONS

Fentanyl and pancuronium do not have a direct clastogenic effect on T cultures, but at the same concentrations at which we demonstrated their apoptogenic power, these drugs are able to increase genomic instability through inducing an elevated rate of telomeric associations. Such a capacity could exploit in peripheral T cells the same mitochondrion-mediated signal pathway of apoptosis death.

Pancuronium bromide, a non-depolarizing muscle relaxant which promotes apoptosis of blood lymphocytes in vitro

BACKGROUND

Several compounds used in anesthesia practice have demonstrated to impair immune function and to influence the process of apoptotic death in T cell population following surgical trauma. We designed this study to test in vitro the impact of neuromuscular blocker, such as pancuronium, at clinically relevant concentration on lymphocyte apoptosis, death factor expression and mitochondrial function.

METHODS

Following isolation, lymphocytes were incubated with pancuronium bromide at a clinically relevant concentration (0.136 micro mol l-1) for 3 h at 37 C in a 5% carbon-dioxide-humidified atmosphere and the frequency of apoptotic lymphocytes was then measured. We also investigated crucial steps in the apoptotic process, including Fas/Fas ligand (FasL) phenotype, intracellular expression of the interleukin-1beta-converting enzyme (ICE) p20, mitochondrial membrane potential (DeltaPsim), generation of mitochondrial reactive oxygen species, and glutathione (GSH) levels. Control experiments were performed incubating cells in the complete culture medium added with the dilution medium of the drug without addition of the drug.

RESULTS

Expression of Fas, FasL and ICEp20 was six-fold, four-fold, and five-fold increased, respectively, among pancuronium-treated lymphocytes with respect to control cultures (P = 0.0001). The percentage of cells exhibiting either dissipation of mitochondrial membrane potential or increased production of reactive oxygen species was seven-fold increased following exposure to pancuronium compared with untreated lymphocytes (P = 0.0001). These findings were associated with a decrease in GSH level. In addition, the frequency of apoptotic cells was 10-fold greater among lymphocytes cultured in the presence of the drug with respect to control cultures. (P = 0.0001).

CONCLUSION

Our data suggest an apoptogenic effect of pancuronium in vitro at clinically relevant concentration on peripheral blood lymphocytes. This could be implicated in the transient immune suppression following a surgical operation.

Induction of a preferred sense of twist in flexible diphenyls by carbohydrate scaffolds. Synthesis of two "naked" ellagitannin analogous

The synthesis of "naked" ellagitannin analogues 1 and 2, having a preferred sense of twist of the diphenyl moiety, with a rhamnose and a glucose template, is reported. A clear induction in the chirality of the diphenyl moiety, mediated through a 10-membered ring via ester linkages, was observed. The chiral scaffold of glucose (diequatorial 2,3-hydroxyl groups) exerts a remarkable stronger atropdiastereoselective effect onto the diphenoyl group than the rhamnose ring (axial-equatorial 2,3-hydroxyl groups), according to the Schmidt-Haslam hypothesis.

Evidence that mycobacterial PE_PGRS proteins are cell surface constituents that influence interactions with other cells

The elucidation of the genomic sequence of Mycobacterium tuberculosis revealed the presence of a novel multigene family designated PE/PE_PGRS that encodes numerous, highly related proteins of unknown function. In this study, we demonstrate that a transposon insertion in a PE_PGRS gene (1818(PE_PGRS)) found in Mycobacterium bovis BCG Pasteur, which is the BCG homologue of the M. tuberculosis H37Rv gene Rv1818c, introduces new phenotypic properties to this BCG strain. These properties include dispersed growth in liquid medium and reduced infection of macrophages. Complementation of the 1818(PE_PGRS)::Tn5367 mutant with the wild-type gene restores both aggregative growth (clumping) in liquid medium and reestablishes infectivity of macrophages to levels equivalent to those for the parent BCG strain. Western blot analysis using antisera raised against the 1818(PE_PGRS) protein shows that PE_PGRS proteins are found in cell lysates of BCG and M. tuberculosis H37Ra and in the cell wall fraction of M. tuberculosis H37Rv. Moreover, immunofluorescent labeling of mycobacteria indicates that certain PE_PGRS proteins are localized at the cell surface of BCG and M. tuberculosis. Together these results suggest that certain PE_PGRS proteins may be found at the surface of mycobacteria and influence both cell surface interactions among mycobacteria as well as the interactions of mycobacteria with macrophages.

[Proapoptotic effect of propofol on T cells]

BACKGROUND

Surgery and general anesthesia induce excessive apoptosis on peripheral lymphocytes and this phenomenon significantly contributes to the postoperative lymphocytopenia. However, the role played by anesthetic agents on this event remains to be elucidated. In this study we examined whether an anesthetic compound such as propofol is able to exert, in vitro, a proapoptotic effect on T cells.

METHODS

Lymphocytes were isolated from heparinized venous blood in healthy volunteers and were incubated with propofol at clinically relevant concentration (5 mg/ml) and at 10 times this concentration (50 mg/ml). The counts of cells either bearing the Fas/FasL phenotype or expressing the intracellular Bcl2 protein were determined by means of flow cytometry. Assessment of lymphocytes undergoing apoptosis was made both by staining of apoptotic nuclei with propidium iodide (PI) and by phenotypic analysis of apoptotic cells with 7-amino-actinomycin D (7-AAD).

RESULTS

Treated lymphocytes exhibit a significantly enhanced expression of Fas/FssL system associated with a decrease of Bcl2 expression at both 5 and 50 mg/ml propofol concentrations (p<0.05). On the other hand, the rate of apoptotic cells was not significantly different as compared to control in the absence of propofol.

CONCLUSIONS

Propofol impairs, in vitro, both Fas/FasL and Bcl2 expressions on lymphocytes at clinically relevant concentrations but fails to induce apoptotic cell death. It is suggested that the antioxidative properties of the drug could inhibit some way the mechanisms by which mitochondrial free-radicals mediating apoptosis ultimately lead to cell death execution.

Bacillus cereus keratitis associated with contact lens wear

OBJECTIVE

We report the first case of contact lens-related Bacillus cereus keratitis and ulcer associated with B. cereus contamination of the contact lens case. This is also the first study to investigate and establish the genetic identity of an organism isolated from the cornea and contact lens case in a patient with contact lens-associated keratitis.

DESIGN

Case report.

INTERVENTION AND TESTING

Conjunctival swabs and corneal scrapings from the left eye were inoculated for culture. The contact lens case was also cultured. Antibiotic susceptibility testing was determined by agar disk diffusion method. Initial treatment with topical ciprofloxacin and fortified tobramycin was given. Genetic analysis of the bacterial isolates was performed using polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus primers (ERIC; ERIC-PCR). Susceptibility of B. cereus to heat and contact lens disinfecting solutions containing hydrogen peroxide, hydrogen peroxide-catalase, polyquaternium-1, and polyaminopropyl biguanide (PAPB) was tested.

MAIN OUTCOME MEASURES

Clinical features, culture results, and antibiotic susceptibility testing were analyzed. The ERIC-PCR amplification products were visualized in ethidium bromide-stained agarose gel. Bacterial growth after exposure to heat and contact lens disinfecting solutions was assessed on blood agar plates.

RESULTS

B. cereus was grown from the conjunctiva, corneal ulcer, and contact lens case. All isolates were sensitive to gentamicin, tobramycin, ciprofloxacin, clindamycin, and vancomycin. The corneal ulcer gradually healed over the next 6 days. Results of ERIC-PCR showed that the isolates from the cornea and contact lens case were indistinguishable, thus demonstrating the source of infecting organism to be the contaminated contact lens case. Exposure to a temperature of 80 degrees C for 20 minutes and incubation with hydrogen peroxide-catalase, polyquaternium-1, and PAPB for the minimum recommended time failed to kill B. cereus. Only exposure to hydrogen peroxide for 4 hours eradicated the organism.

CONCLUSIONS

B. cereus should be considered a possible etiologic agent of contact lens-associated keratitis. Heat and many types of contact lens disinfecting solutions may be ineffective in eradicating B. cereus from contaminated contact lens cases. Only prolonged exposure to hydrogen peroxide appeared to be sporicidal to B. cereus in this study.

Mitochondrial perturbations and oxidant stress in lymphocytes from patients undergoing surgery and general anesthesia

BACKGROUND

Previous studies have shown that a profound suppression of immune function transiently occurs in patients who undergo surgery under general anesthesia. The decline in the absolute counts of peripheral blood lymphocytes constitutes a major factor accounting for this immune defect, and recent evidence indicates that apoptosis plays a crucial role in determining postsurgical lymphocytopenia.

HYPOTHESIS

An altered oxidation-reduction status of mitochondria may contribute through apoptosis to the loss of lymphocytes following surgical trauma and general anesthesia.

DESIGN

We studied 16 patients with American Society of Anesthesiologists' physical status I or II who underwent elective surgery under general anesthesia. The data were collected prospectively.

SETTING

University hospital.

MAIN OUTCOME MEASURES

Samples of peripheral blood were drawn on the day before surgery and at 24 and 96 hours after the operation. Following lymphocyte isolation, the mitochondrial transmembrane potential was assessed by flow cytometry using 3,3'-dihexylocarbo-cyanine iodide, and stains with hydroethidine and 2'-7'-dichlorofluorescein diacetate were used to determine the generation of reactive oxygen species. The labeling of lymphocytes with monobromobimane was used to assess the presence of reduced glutathione.

RESULTS

At 24 hours after surgery, we detected a significantly elevated frequency of peripheral blood lymphocytes (P =.002), which incorporated low levels of 3,3'-dihexylocarbo-cyanine iodide, compared with the preoperative period. At this same time point, the frequency of lymphocytes with the hydroethidine- and 2'-7'-dichlorofluorescein diacetate-positive phenotype was elevated compared with baseline levels. Conversely, at 24 hours after surgery, the frequency of cells that stained positive for glutathione was strongly decreased compared with preoperative values. Overall measurements returned to the baseline levels at 96 hours after surgery.

CONCLUSION

The strict association we observed between the overproduction of reactive oxygen species and the disruption of the mitochondrial transmembrane potential supports the view that alterations in mitochondrial energy metabolism, paralleled by the presence of a pro-oxidant oxidation-reduction status, could be involved in the accelerated apoptotic loss of lymphocytes following surgical trauma and general anesthesia.

Molecular basis of rifampin and isoniazid resistance in Mycobacterium bovis strains isolated in Sardinia, Italy

Fourteen of 22 (68%) Mycobacterium bovis strains isolated from cattle in Sardinia were found to be resistant to rifampin and isoniazid. Analysis of the rpoB and the katG, oxyR-ahpC, and inhA gene regions of these strains was performed in order to investigate the molecular basis of rifampin and isoniazid resistance, respectively. The most frequent mutation, encountered in 6 of 10 strains (60%), was in the rpoB gene; it occurred, at codon position 521 and resulted in leucine changed to proline. This suggests that codon 521 may be important for the development of rifampin resistance in M. bovis. Resistance to isoniazid is associated in Mycobacterium tuberculosis with a variety of mutations affecting one or more genes. Our results confirm the difficulty of interpreting the sequence variations observed in clinical strains of M. bovis. M. bovis strains isolated from the same geographic area showed similar mutations within the genes responsible for rifampin and isoniazid resistance. Our results represent the first study to elucidate the molecular genetic basis of drug resistance in M. bovis isolated from cattle.