Autoimmune liver disease triggered by SARS-CoV-2: a case report and review of the literature

BACKGROUND

An increasing number of coronavirus disease 2019 (COVID-19) related autoimmune hepatitis (AIH) and autoimmune liver disease (AILD) has been already described so far in the last three years. This rise has set up some diagnostic and therapeutic concerns, although steroid therapy has mostly been efficient, avoiding main significant side effects.

CASE REPORT

We report the case of a 52-year-old subject displaying liver function impairment at the laboratory tests while positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab. Needle liver biopsy showed severe portal inflammation, interface hepatitis, lobular inflammation, abundant plasma cells, bridging necrosis, endothelialitis, bile duct vanishing disease, and ductular reaction. The diagnosis of autoimmune liver disease (AILD) was performed. After a month of steroid and ursodeoxycholic acid medications, liver function fully recovered. Azathioprine was introduced, and steroids were gradually reduced.

CONCLUSIONS

Probably triggered by the SARS-CoV-2-induced cytokine storm, the association between COVID-19 and autoimmune-related inflammatory injury may display a particular paradigm of AILD pathogenesis.

Direct-acting antivirals used in HCV-related liver disease do not affect thyroid function and autoimmunity

PURPOSE

It is well known that interferon-α (IFN-α), used for long time as the main therapy for HCV-related disease, induces thyroid alterations, but the impact of the new direct-acting antivirals (DAAs) on thyroid is not established. Aim of this prospective study was to evaluate if DAAs therapy may induce thyroid alterations.

METHODS

A total of 113 HCV patients, subdivided at the time of the enrollment in naïve group (n = 64) and in IFN-α group (n = 49) previously treated with pegylated interferon-α and ribavirin, were evaluated for thyroid function and autoimmunity before and after 20-32 weeks of DAAs.

RESULTS

Before starting DAAs, a total of 8/113 (7.1%) patients showed Hashimoto's thyroiditis (HT) all belonging to IFN-α group (8/49, 16.3%), while no HT cases were found in the naïve group. Overall, 7/113 (6.2%) patients were hypothyroid: 3/64 (4.7%) belonging to naïve group and 4/49 (8.2%) to IFN-α group. Furthermore, a total of 8/113 patients (7.1%) showed subclinical hyperthyroidism: 2/64 (3.1%) were from naïve group and 6/49 (12.2%) from IFN-α group. Interestingly, after DAAs therapy, no new cases of HT, hypothyroidism and hyperthyroidism was found in all series, while 6/11 (54.5%) patients with non-autoimmune subclinical thyroid dysfunction became euthyroid. Finally, the only association between viral genotypes and thyroid alterations was genotype 1 and hypothyroidism.

CONCLUSIONS

This study supports evidence that DAAs have a limited or missing influence on thyroid in patients with HCV-related diseases. Moreover, it provides preliminary evidence that subclinical non-autoimmune thyroid dysfunction may improve after HCV infection resolution obtained by DAAs.

Molecular characterization of epithelial-mesenchymal transition and medical treatment related-genes in non-functioning pituitary neuroendocrine tumors

INTRODUCTION

Different medical therapies have been developed for pituitary adenomas. However, Non-Functioning Pituitary Neuroendocrine Tumors (NF-PitNET) have shown little response to them. Furthermore, epithelial-mesenchymal transition (EMT) has been linked to resistance to medical treatment in a significant number of tumors, including pituitary adenomas.

METHODS

We aimed to evaluate the expression of EMT-related markers in 72 NF-PitNET and 16 non-tumoral pituitaries. To further explore the potential usefulness of medical treatment for NF-PitNET we assessed the expression of somatostatin receptors and dopamine-associated genes.

RESULTS

We found that SNAI1, SNAI2, Vimentin, KLK10, PEBP1, Ki-67 and SSTR2 were associated with invasive NF-PitNET. Furthermore, we found that the EMT phenomenon was more common in NF-PitNET than in GH-secreting pituitary tumors. Interestingly, PEBP1 was overexpressed in recurrent NF-PitNET, and could predict growth recurrence with 100% sensitivity but only 43% specificity. In parallel with previously reported studies, SSTR3 is highly expressed in our NF-PitNET cohort. However, SSTR3 expression is highly heterogeneous among the different histological variants of NF-PitNET with very low levels in silent corticotroph adenomas.

CONCLUSION

NF-PitNET showed an enhanced EMT phenomenon. SSTR3 targeting could be a good therapeutic candidate in NF-PitNET except for silent corticotroph adenomas, which express very low levels of this receptor. In addition, PEBP1 could be an informative biomarker of tumor regrowth, useful for predictive medicine in NF-PitNET.

Implications of Heterogeneity of Epithelial-Mesenchymal States in Acromegaly Therapeutic Pharmacologic Response

Acromegaly is caused by excess growth hormone (GH) produced by a pituitary tumor. First-generation somatostatin receptor ligands (SRLs) are the first-line treatment. Several studies have linked E-cadherin loss and epithelial-mesenchymal transition (EMT) with resistance to SRLs. Our aim was to study EMT and its relationship with SRLs resistance in GH-producing tumors. We analyzed the expression of EMT-related genes by RT-qPCR in 57 tumors. The postsurgical response to SRLs was categorized as complete response, partial response, or nonresponse if IGF-1 was normal, had decreased more than 30% without normalization, or neither of those, respectively. Most tumors showed a hybrid and variable EMT expression profile not specifically associated with SRL response instead of a defined epithelial or mesenchymal phenotype. However, high SNAI1 expression was related to invasive and SRL-nonresponsive tumors. RORC was overexpressed in tumors treated with SRLs before surgery, and this increased expression was more prominent in those cases that normalized postsurgical IGF-1 levels under SRL treatment. In conclusion, GH-producing tumors showed a heterogeneous expression pattern of EMT-related genes that would partly explain the heterogeneous response to SRLs. SNAI1 and RORC may be useful to predict response to SRLs and help medical treatment decision making.

Molecular determinants of enhanced response to somatostatin receptor ligands after debulking in large GH-producing adenomas

OBJECTIVE

Large somatotrophic adenomas depict poor response to somatostatin receptor ligands (SRLs). Debulking has shown to enhance SRLs effect in some but not all cases and tumour volume reduction has been proposed as the main predictor of response. No biological studies have been performed so far in this matter. We aimed to identify molecular markers of response to SRLs after surgical debulking in GH-secreting adenomas.

DESIGN

We performed a multicenter retrospective study.

PATIENTS

24 patients bearing large GH-producing tumours.

MEASUREMENTS

Clinical data and SRLs response both before and after surgical debulking were collected, and 21 molecular biomarkers of SRLs response were studied in tumour samples by gene expression.

RESULTS

From the 21 molecular markers studied, only two of them predicted enhanced SRLs response after surgery. Tumours with improved response to SRLs after surgical debulking showed lower levels of Ki-67 (MKI67, FC = 0.17 and P = .008) and higher levels of RAR-related orphan receptor C (RORC) (FC = 3.1 and P ˂ .001). When a cut-off of no detectable expression was used for Ki-67, the model provided a sensitivity of 100% and a specificity of 52.6% with an area under the curve of 65.8%. Using a cut-off of 2 units of relative expression of RORC, the prediction model showed 100% of sensitivity and specificity.

CONCLUSIONS

High levels of RORC and low levels of Ki-67 identify improved SRLs response after surgical debulking in large somatotropic adenomas. To determine their expression would facilitate medical treatment decision-making after surgery.

Molecular profiling for acromegaly treatment: a validation study

Pharmacologic treatment of acromegaly is currently based upon assay-error strategy, the first-generation somatostatin receptor ligands (SRL) being the first-line treatment. However, about 50% of patients do not respond adequately to SRL. Our objective was to evaluate the potential usefulness of different molecular markers as predictors of response to SRL. We used somatotropinoma tissue obtained after surgery from a national cohort of 100 acromegalic patients. Seventy-one patients were treated with SRL during at least 6 months under maximal therapeutic doses according to IGF1 values. We analyzed the expression of SSTR2, SSTR5, AIP, CDH1 (E-cadherin), MKI67 (Ki-67), KLK10, DRD2, ARRB1, GHRL, In1-Ghrelin, PLAGL1 and PEBP1 (RKIP) by RT-qPCR and mutations in GNAS gene by Sanger sequencing. The response to SRL was categorized as complete response (CR), partial (PR) or non-response (NR) if IGF1 was normal, between >2<3 SDS or >3 SDS IGF1 at 6 months of follow-up, respectively. From the 71 patients treated, there were 27 CR (38%), 18 PR (25%) and 26 NR (37%). SSTR2, Ki-67 and E-cadherin were associated with SRL response (P < 0.03, P < 0.01 and P < 0.003, respectively). E-cadherin was the best discriminator for response prediction (AUC = 0.74, P < 0.02, PPV of 83.7%, NPV of 72.6%), which was validated at protein level. SSTR5 expression was higher in patients pre-treated with SRL before surgery. We conclude that somatotropinomas showed heterogeneity in the expression of genes associated with SRL response. E-cadherin was the best molecular predictor of response to SRL. Thus, the inclusion of E-cadherin in subsequent treatment-decision after surgical failure may be useful in acromegaly.

Early clinical predictors and correlates of long-term morbidity in bipolar disorder

Objectives:

Identifying factors predictive of long-term morbidity should improve clinical planning limiting disability and mortality associated with bipolar disorder (BD).

Methods:

We analyzed factors associated with total, depressive and mania-related long-term morbidity and their ratio D/M, as %-time ill between a first-lifetime major affective episode and last follow-up of 207 BD subjects. Bivariate comparisons were followed by multivariable linear regression modeling.

Results:

Total % of months ill during follow-up was greater in 96 BD-II (40.2%) than 111 BD-I subjects (28.4%; P = 0.001). Time in depression averaged 26.1% in BD-II and 14.3% in BD-I, whereas mania-related morbidity was similar in both, averaging 13.9%. Their ratio D/M was 3.7-fold greater in BD-II than BD-I (5.74 vs. 1.96; P < 0.0001). Predictive factors independently associated with total %-time ill were: [a] BD-II diagnosis, [b] longer prodrome from antecedents to first affective episode, and [c] any psychiatric comorbidity. Associated with %-time depressed were: [a] BD-II diagnosis, [b] any antecedent psychiatric syndrome, [c] psychiatric comorbidity, and [d] agitated/psychotic depressive first affective episode. Associated with %-time in mania-like illness were: [a] fewer years ill and [b] (hypo)manic first affective episode. The long-term D/M morbidity ratio was associated with: [a] anxious temperament, [b] depressive first episode, and [c] BD-II diagnosis.

Conclusions:

Long-term depressive greatly exceeded mania-like morbidity in BD patients. BD-II subjects spent 42% more time ill overall, with a 3.7-times greater D/M morbidity ratio, than BD-I. More time depressed was predicted by agitated/psychotic initial depressive episodes, psychiatric comorbidity, and BD-II diagnosis. Longer prodrome and any antecedent psychiatric syndrome were respectively associated with total and depressive morbidity.

Acute study of dose-dependent effects of (-)-epicatechin on vascular function in healthy male volunteers: A randomized controlled trial

BACKGROUND & AIMS

There is convincing clinical evidence to suggest that flavanol-containing foods/beverages are capable of inducing improvements in human vascular function. However, whilst (-)-epicatechin has been tested for efficacy, a full dose-dependency has yet to be established, particularly at doses below 1 mg/kg BW. The current study examined the dose-dependent effects of (-)-epicatechin on human vascular function with concurrent measurement of plasma (-)-epicatechin metabolites and levels of circulating nitrite and nitrate species, NO_x.

METHODS

An acute, double-blind, placebo-controlled, crossover intervention trial was conducted in 20 healthy males with 4 treatment arms: water-based (-)-epicatechin (0.1, 0.5 and 1.0 mg/kg BW) and a water only as control. Vascular function was assessed by flow-mediated dilatation (FMD) measured at the brachial artery, laser Doppler imaging with iontophoresis (LDI) at the subcutaneous capillaries of the forearm (response to Ach and SNP) and peripheral blood pressure (BP) at baseline, 1, 2, 4 and 6 h post-intervention. Plasma analysis of epicatechin metabolites was conducted by LC-MS and circulating plasma of nitrite and nitrate species were performed using an HPLC-based system (ENO-30).

RESULTS

Significant increases in % FMD were found to occur at 1 and 2 h following intake of 1 mg/kg BW, and at 2 h for the 0.5 mg/kg BW intake. There were no significant changes in LDI or BP at any time-points or intake levels. Increases in FMD over the 6 h timeframe were closely paralleled by the appearance of total plasma (-)-epicatechin metabolites. Non-significant changes in circulating NOx was observed.

CONCLUSIONS

Our data add further evidence that (-)-epicatechin is a causal vasoactive molecule within flavanol-containing foods/beverages. In addition, we show for the first time that intake levels as low as 0.5 mg/kg BW are capable of inducing acute improvements in vascular function (FMD) in healthy volunteers.

Real-world GLP-1 RA therapy in type 2 diabetes: A long-term effectiveness observational study

AIMS

To evaluate in a real-world setting the effectiveness and tolerability of available GLP-1 RA drugs in patients with type 2 diabetes after a prolonged follow-up.

MATERIALS AND METHODS

Observational, retrospective, single-centre study in patients starting GLP-1 RA therapy. Change in HbA1c, fasting plasma glucose (FPG) and body mass index (BMI) along with gastrointestinal (GI) adverse events and withdrawal from GLP-1 RA therapy were evaluated. Lack of efficacy of GLP-1 RA therapy according to prespecified goals was also measured.

RESULTS

A total of 735 patients were included, mean age 59.7 years, duration of diabetes 9.01 years, HbA1c 8.18% and BMI 38.56 kg/m2. Average follow-up was 18.97 months (range 4.2-39.09). All HbA1c (0.93%; P < 0.01), FPG (24 mg/dL; P < 0.01) and BMI (1.55 kg/m2; P < 0.05) were significantly reduced from baseline and maintained throughout follow-up, regardless of prescribed GLP-1 RA. GI adverse events were present in 13.81% of patients at first follow-up visit, 37.07% of patients discontinued GLP-1 RA treatment, and 38.63% did not meet efficacy goals.

CONCLUSIONS

In a real-world setting, GLP-1 RA therapy is largely prescribed in severely obese patients with a long-standing and poorly controlled diabetes. All prescribed GLP-1 RAs significantly decreased HbA1c, FPG and BMI. GI adverse events affected a low proportion of patients. Inversely, a high proportion of patients did not meet efficacy goals and/or discontinued GLP-1 RA treatment. Baseline characteristics of patients and lack of adherence may represent important issues underlying differences in effectiveness in real-world studies versus randomized trials.

Hypocalcemia due to 22q11.2 deletion syndrome diagnosed in adulthood

Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a genetic syndrome that may present with hypocalcemia due to primary hypoparathyroidism (PH) at any age. We report a new diagnosis of 22q11.2DS in a 57-year-old man who presented with symptomatic hypocalcemia. It is important to consider genetic causes of hypocalcemia due to PH regardless of age.

Learning points

It is important to discard genetic cause of primary hypoparathyroidism in a patient without autoimmune disease or prior neck surgery.A new diagnosis of a hereditary disease has familial implications and needs genetic counselling.It is also important to discard other syndrome's comorbidities.

Factors Associated with Depression Severity in Adolescence

Introduction

Severe depression is greatly impairing during adolescence and involves a high risk for suicidal behaviors.

Objectives and aims

Identify clinical and demographic factors associated with severity of depression in adolescents diagnosed with a major mood disorder so as to improve clinical treatment and prevent suicidal behaviors.

Methods

We analyzed factors associated with depression severity in 145 severely ill adolescents diagnosed with a major affective disorder using the K-SADS (Kiddie-Schedule for Affective Disorders and Schizophrenia) at the Mood Disorder Outpatient Program of Bambino Gesù Children's Hospital (Rome). Depressive and manic symptoms were rated with the CDRS-R (Children's Depression Rating Scale-Revised) and K-SADS-MRS (Mania Rating Scale), respectively. Bivariate comparisons were followed by multivariable linear regression modeling.

Results

Depression severity was greater among females than males (mean CDRS scores: 53.0 vs. 42.8; P < 0.0001) and with major depressive versus bipolar disorder diagnosis (50.4 vs. 45.4; P = 0.001). Manic symptoms, including irritability, mood lability, crowded thoughts, delusions, and insomnia, were more likely with more severe depression; their number and severity correlated with CDRS-R total score (respectively, β = 1.53 and 5.44;both P < 0.0001). Factors independently and significantly associated with CDRS-R depression score in multivariate modeling were:

– presence of suicidal ideation;

– absence of ADHD;

– female sex;

– greater number of manic symptoms.

Conclusions

Severe depression was associated with manic symptoms and with suicidal ideation among adolescents diagnosed with either bipolar or major depressive disorders. This relationship should be considered in treatment planning and suicide prevention, including consideration of mood-stabilizing and antimanic agents in the treatment of severe adolescent depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Risk Factors for Suicide Attempt: A Retrospective Study

Introduction

Suicide is a leading cause of death among adolescents.

Objectives

To investigate suicidal behaviors among Italian adolescents.

Aims

To assess the rates of suicidal ideation (SI) and suicide attempts (SA) and the associated risk factors in patients admitted to emergency department (ED) of the Bambino Gesù Children's Hospital.

Methods

Retrospective study based on data of patients admitted to the ED from 1 January 2011 to 30 May 2016 who required a neuropsychiatric (NPI) consultation. We analyzed:

– outcome of the NPI consultation (hospitalization or discharge);

– risk factors for SA and SI;

– methods employed for SA.

Results

The number of NPI consultations for SI and SA increased from 6.45% in 2011 to 13.3% in 2015. More than 90% of consultations recommended hospitalization in the psychiatric unit (137 patient [66% female]; mean age of 15.5 ± 1.6 years) with average length of stay of 13.64 ± 10.63 days. Risk factors for SI and SA were non-suicidal self-injury, family conflicts and previous suicide attempts. Subjects evaluated for a SA reported a significantly higher frequency of family history of mood disorder (χ2 = 5.94; P = 0.02) and a comorbid substance abuse (χ2 = 4.49; P = 0.03) when compared with SI group. The method most frequently used to attempt suicide was ingestion of medications (52.83%).

Conclusions

There was an increasing demand of NPI consultation of SA and SI in the last years. A family history of mood disorder and a history of substance abuse are risk factors able to differentiate between SI and SA.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Age at menarche predicts age at onset of major affective and anxiety disorders

BACKGROUND

Menarche age has been associated inconsistently with the occurrence, timing or severity of major depressive disorder (MDD), but rarely studied in women with bipolar (BDs) or anxiety disorders.

METHODS

We investigated women patients at a Sardinian mood disorder center for associations of age at menarche with age at illness onset for major affective or anxiety disorders, year of birth, and other selected factors, using bivariate comparisons and multivariate regression modeling.

RESULTS

Among women (n=1139) with DSM-IV MDD (n=557), BD-I (n=223), BD-II (n=178), or anxiety disorders (n=181), born in 1904-1998, of mean age 42.9 years, menarche age averaged 12.8 [CI: 12.7-12.9] years. Illness onset age averaged 30.9 [30.1-31.8] years, ranking: BD-I, 25.8; anxiety disorders, 28.0; BD-II, 30.3; MDD, 34.1 years. Menarche age declined secularly over birth years, and was associated with younger illness-onset, having no or fewer siblings, more psychiatrically ill first-degree relatives, living in rural environments, being suicidal, substance abuse, and being unemployed. Earlier menarche and earlier illness-onset were significantly associated for onset age groups of ≤ 20, 20-39, and > 40 years. Menarche age versus diagnosis ranked: BD-II<BD-I<anxiety disorders<MDD.

CONCLUSIONS

Age at menarche in Sardinia, as elsewhere, has declined over the past decades. It was strongly associated with age at onset of bipolar and anxiety, as well as major depressive disorders across the age range, suggesting sustained effects of biological maturational factors.

Evaluation of antimicrobial activity of Italian honey for wound healing application in veterinary medicine

INTRODUCTION

Honey as a topical treatment for infected wounds dates back to ancient times. However, few studies have been reported concerning the medical properties of Italian honey. In this study, the microbial contamination, the antimicrobial activity and the antibiotic residues of 6 different varieties of Piedmont honeys were evaluated. The antimicrobial activity of honeys was tested by agar well diffusion method and 1 honey for each variety has been selected and tested by broth micro-dilution test to determine Minimum Inhibitory Concentrations (MICs) and evaluated by Minimum Bactericidal Concentrations (MBCs). The honeys with a high level of antibacterial activity were analyzed for the presence of tetracyclines, sulfonamides and macrolide residues. The agar well diffusion method showed the greatest antimicrobial activity for honeydew, chestnut and lime tree honeys. The MICs and MBCs identified the close similarity to the medical manuka honey of honeydew, polyfloral and chestnut honey. The levels of antibiotic residues on these honeys were below the limit of quantification. Based on our results the Italian variety of honeydew showed the best antimicrobial activity and can be considered for the treatment of infected wounds in animals.

A GIS based method for soil mapping in Sardinia, Italy: a geomatic approach

A new project was recently initiated for the realization of the "Land Unit and Soil Capability Map of Sardinia" at a scale of 1:50,000 to support land use planning. In this study, we outline the general structure of the project and the methods used in the activities that have been thus far conducted. A GIS approach was used. We used the soil-landscape paradigm for the prediction of soil classes and their spatial distribution or the prediction of soil properties based on landscape features. The work is divided into two main phases. In the first phase, the available digital data on land cover, geology and topography were processed and classified according to their influence on weathering processes and soil properties. The methods used in the interpretation are based on consolidated and generalized knowledge about the influence of geology, topography and land cover on soil properties. The existing soil data (areal and point data) were collected, reviewed, validated and standardized according to international and national guidelines. Point data considered to be usable were input into a specific database created for the project. Using expert interpretation, all digital data were merged to produce a first draft of the Land Unit Map. During the second phase, this map will be implemented with the existing soil data and verified in the field if also needed with new soil data collection, and the final Land Unit Map will be produced. The Land Unit and Soil Capability Map will be produced by classifying the land units using a reference matching table of land capability classes created for this project.

Synthesis of cyclohexapeptides as antimalarial and anti-trypanosomal agents

Azolic and non-azolic cyclohexapeptides were obtained and/or evaluated as promising antimalarial and/or anti-trypanosomal agents.

Whole-tumour CT-perfusion of unresectable lung cancer for the monitoring of anti-angiogenetic chemotherapy effects

OBJECTIVE

To determine whether CT-perfusion (CT-p) can be used to evaluate the effects of chemotherapy and anti-angiogenic treatment in patients with non-small-cell lung carcinoma (NSCLC) and whether CT-p and standard therapeutic response assessment (RECIST) data obtained before and after therapy correlate.

METHODS

55 patients with unresectable NSCLC underwent CT-p before the beginning of therapy and 50 of them repeated CT-p 90 days after it. Therapeutic protocol included platinum-based doublets plus bevacizumab for non-squamous carcinoma and platinum-based doublets for squamous carcinoma. RECIST measurements and calculations of blood flow (BF), blood volume (BV), time to peak (TTP) and permeability surface (PS) were performed, and baseline and post-treatment measurements were tested for statistically significant differences. Baseline and follow-up perfusion parameters were also compared based on histopathological subclassification (2004 World Health Organization Classification of Tumours) and therapy response assessed by RECIST.

RESULTS

Tumour histology was consistent with large cell carcinoma in 14/50 (28%) cases, adenocarcinoma in 22/50 (44%) cases and squamous cell carcinoma in the remaining 14/50 (28%) cases. BF and PS differences for all tumours between baseline and post-therapy measurements were significant (p=0.001); no significant changes were found for BV (p=0.3) and TTP (p=0.1). The highest increase of BV was demonstrated in adenocarcinoma (5.2±34.1%), whereas the highest increase of TTP was shown in large cell carcinoma (6.9±22.4%), and the highest decrease of PS was shown in squamous cell carcinoma (-21.5±18.5%). A significant difference between the three histological subtypes was demonstrated only for BV (p<0.007). On the basis of RECIST criteria, 8 (16%) patients were classified as partial response (PR), 2 (4%) as progressive disease (PD) and the remaining 40 (80%) as stable disease (SD). Among PR, a decrease of both BF (18±9.6%) and BV (12.6±9.2%) were observed; TTP increased in 3 (37.5%) cases, and PS decreased in 6 (75%) cases. SD patients showed an increase of BF, BV, TTP and PS in 6 (15%), 21 (52.5%), 23 (57.5%) and 2 (5%) cases, respectively. PD patients demonstrated an increase of BF (26±0.2%), BV (2.7±0.1%) and TTP (3.1±0.8%) while only PS decreased (23±0.2%).

CONCLUSION

CT-p can adequately evaluate therapy-induced alterations in NSCLC, and perfusion parameters correlate with therapy response assessment performed with RECIST criteria.

ADVANCES IN KNOWLEDGE

Evaluating perfusional parameters, CT-p can demonstrate therapy-induced changes in patients with different types of lung cancer and identify response to treatment with excellent agreement to RECIST measurements.

A new mutation in EDA gene in X-linked hypohidrotic ectodermal dysplasia associated with keratoconus

Hypohidrotic ectodermal dysplasia (HED) was first described in 1848 by Thurnam. HED belongs to ectodermal dysplasias (EDs), which are developmental impairments of ectodermal-derived tissues. X-linked hypohidrotic ectodermal dysplasia (XLHED) is the most common form of the EDs and consists in abnormal development of teeth, hair, and eccrine sweat glands. XLHED is determined by mutations in the ED1 gene, which is responsible for the coding of ectodysplasin-A(EDA-A), a protein that regulates ectodermal appendage formation. In the present study we found both in our proband and in the mother the same missense mutation in exon 9 (c.957 C>A), which resulted in an aminoacid change at position 319 (Ser319Arg). This latter anomaly might alter the charges in the TNF domain of EDA-A, affecting the stability of the protein and therefore the interaction with its receptor. The male propositus presented classical manifestations of HED except for keratoconus (KC) and, to the best of our knowledge, this association has not been previously described. The identification of this new mutation may contribute to evaluating the genotype/phenotype correlations. Finally, this report can give useful information about the genetic basis of KC and HED. Future studies will allow us to understand if a genetic bond exists between them.

CAD (computed-aided detection) and CADx (computer aided diagnosis) systems in identifying and characterising lung nodules on chest CT: overview of research, developments and new prospects

Computer-aided detection (CAD) systems allow the automatic identification of lung nodules on chest computed tomography (CT), providing a second opinion to the radiologist's judgement and a volumetric evaluation of lesions - a very important aspect in oncological patients. The natural evolution of these systems has led to the introduction of computer-aided diagnosis (CADx) systems, which are able not only to identify nodules but also to characterise them by determining a likelihood of malignancy or benignity. The aim of this article is to describe the main technical principles of CAD and CADx systems, their applicability and influence in clinical practice and new prospects for their future development.

White matter hyperintensities, suicide risk and late-onset affective disorders: an overview of the current literature

White matter hyperintensities (WMHs) refer to areas of hyperintense signal on T2- or proton density-weighted brain magnetic resonance imaging. Although WMHs are a common finding in patients with bipolar disorder (BD), particularly with a later disease onset, some studies report a higher frequency of WMHs only in unipolar affective disorders. We reviewed the literature examining examining both the severity and presence of WMHs in late life and particularly in individuals with late-onset BD (LOBD). Studies investigating white matter lesions in LOBD were systematically retrieved and the reference lists of these studies were scanned for additional relevant studies of neuroimaging in LOBD. The majority of neuroimaging studies reported an association between older age and LOBD and the presence of WMHs in LOBD. Also, we found in a small sample of patients preliminary evidence of a significant relationship between older age with late-onset BD and WMHs having a higher prevalence of cardiovascular and cerebrovascular risk factors. In conclusion over 60 years older individuals with LOBD and WMHs might have a type of illness characterized by more neuropathological changes and biologically different compared to non LOBD. This is consistent with the hypothesis of vascular mania. WMHs could be a reliable biological risk marker for late onset mood disorders.

The proper tidal volume target using volume guarantee ventilation in the course of neonatal respiratory distress syndrome: a crucial endpoint

Volume guarantee ventilation (VGV) is an optional ventilation mode which has become the most widely and extensively studied in the last 10 years in premature infants. Nonetheless, theoretical expected endpoints are intriguing and even though VGV has not yet become 'the' standard ventilation mode, a great deal of information has been acquired and stored. In our experience, VGV during the course of respiratory distress syndrome is useful and can be considered a standard ventilation mode. Weaning occurs in real time as described earlier, and synchronized intermittent positive pressure ventilation and pressure support ventilation (PSV) seem to be the preferred combined modes. Management during the acute phase requires more care since several sudden changes take place in both the lung mechanics and clinical behavior. The software is designed to protect the lung, and subsequently, sudden changes in lung compliance following iatrogenic procedures such as surfactant administration are powerfully counteracted. VGV has been extensively studied and the proposed algorithm has been found to function as planned. Although the 'superiority' of one method over another cannot be demonstrated, the use of new technologies require 'a staff learning curve' and homogeneity of treatment, while at the same time other factors, such as patient heterogeneity or illness phase, should be taken into due account.

Neonatal hearing screening model: An Italian regional experience

OBJECTIVE

To produce a model for routine centralized hearing screening including all aspects of the screening, from diagnosis to psychological counseling and early rehabilitation.

METHODS

A prospective observational study on a geographically defined pediatric population (Liguria region, northwestern Italy) and data collection in a data bank. The model proposed was created for the audiological screening of all newborns of the Liguria region. The model includes four phases: (1) preliminary identification of contractual, administrative, legal aspects; (2) screening for identification of congenital hearing impairment; (3) therapy and rehabilitation of identified subjects and genetic analysis; (4) epidemiology, data management, and workload management. To test the feasibility of the model proposed and to establish the workload required according to the resources available in the regional health plan, we performed a pilot study on all infants born in four of the 13 regional birth centers of Liguria region from 1 April 2001 to 30 September 2001.

RESULTS

Out of the 3268 newborns enrolled during the 6-month pilot study, 3238 (99.1%) were screened with otoacoustic emissions (OAE), while screening was refused in 30 newborns (0.9%). OAE resulted in a 'pass' for 3180 newborns (98.2%) and a 'refer' in 58 (1.8%). The standard auditory brainstem response (ABR) test was performed in 156 newborns, 58 of them as a result of the 'refer' at the second OAE and 98 others at audiological risk. Results were positive or uncertain at first ABR in 45 patients. Workload was calculated on the basis of the data obtained in the pilot study to allocate financial and organizational resources.

CONCLUSIONS

The results of the pilot study allowed project planning. We think that the screening model proposed is an example of how a regional organization can deliver improved quality care through a rationalization and optimization process.

Breastfeeding in Northern Italy

AIM

To describe the duration and type, as classified by World Health Organization (WHO) criteria, of breastfeeding in Ligurian newborns up to 1 year of age, and to identify possible related factors.

METHODS

A prospective, observational study on a cohort of 757 women recruited in 10 hospitals in Northern Italy. Women were followed up by means of a questionnaire at discharge and by telephone interviews in the 4th, 12th, 24th and 48th weeks postpartum using the 'recall period' method.

RESULTS

At discharge, 97.3% of mothers had started breastfeeding; regional breastfeeding rates at the 4th, 12th, 24th and 48th weeks were respectively 84.4%, 71.2%, 54.4% and 26.3%. Socio-demographic factors did not significantly influence these percentages. Median duration of breastfeeding was 6.5 months. No statistically significant differences were observed in duration of breastfeeding between women who started exclusive breastfeeding (EBF) and those who did predominant breastfeeding (PBF), while the difference was statistically significant when comparing complementary breastfeeding (CBF) with EBF and with PBF.

CONCLUSIONS

Our study is the first regional experience in the Liguria region and represents a starting point for the diffusion of the culture of breastfeeding. Our results are satisfactory with regards to the overall duration of breastfeeding until the first year of life (26.3%), while duration of EBF (9.5% at the 24th week) is still unsatisfactory according to WHO objectives that include EBF for all children up to the sixth month of life.

Ligurian experience on neonatal hearing screening: clinical and epidemiological aspects

AIM

Early identification and rehabilitation of newborns with congenital hearing impairment (HI) by Universal Neonatal Hearing Screening (UNHS).

METHODS

The neonatal population was divided into two groups: babies with No Audiological Risk (NAR), and babies With Audiological Risk (WAR). NAR neonates underwent OAE testing, and in case of a doubtful (Refer) result, ABR testing was carried out. All WAR newborns underwent ABR testing within the third month of life.

RESULTS

Between February 1, 2002 and December 31, 2004, UNHS was carried out on 32 502 newborns at the 13 regional birth centres, representing 98.7% of the whole regional neonatal population. The prevalence of HI in the population we tested was estimated at about 1 per thousand, while Bilateral Hearing Impairment (BHI) was estimated at 0.65 per thousand. A 3.7% prevalence of HI and a 2.8% prevalence of BHI was observed among the WAR population. Median age at the end of the diagnostic procedures was 6.7 months in the WAR population and 6.9 months in the NAR population.

CONCLUSIONS

Our project is based on two levels of testing, which resulted in a 0.28% false-positive rate with 100% sensitivity and 99% specificity. Our screening is the first Italian experience that has been extended to a whole region and the results prove that regional neonatal hearing screening is feasible.

Treatment of chronic hepatitis D

Despite recent advances in the treatment of chronic viral hepatitis, therapy of chronic hepatitis D is not yet satisfactory. The only option currently available is interferon-alpha (IFN), whose efficacy is related to the dose and duration of treatment. However, the rate of sustained hepatitis D virus (HDV) clearance after a 1-year course with high doses of standard IFN is low. Better results have recently been reported with pegylated IFN both in IFN-naïve and in previous nonresponders to standard IFN, suggesting the use of pegylated IFN as a first-line therapy in chronic hepatitis D. Nucleoside analogues that inhibit hepatitis B virus (HBV) are ineffective against HDV and combination therapy with lamivudine or ribavirin has not shown significant advantages over monotherapy with either standard or pegylated IFN. Because the ultimate goal of treatment is eradication of both HDV and HBV, in responders IFN therapy should be continued as long as possible until the loss of hepatitis B surface antigen, adjusting the dose to patient tolerance. However, because side-effects are common, continuous monitoring is mandatory. Although the first results obtained with pegylated IFN have been encouraging, the rate of sustained virological response is still low and the rate of relapse high, emphasizing the need for developing novel classes of antivirals specifically interfering with the life cycle of this unique virus.

Volume targeted ventilation (volume guarantee) in the weaning phase of premature newborn infants

OBJECTIVE

Several options are currently available in neonatal mechanical ventilation: complete breathing synchronization (patient triggered ventilation, synchronized intermittent positive pressure ventilation--SIPPV); positive pressure flow-cycled ventilation (pressure support ventilation, PSV); and volume targeted positive pressure ventilation (volume guarantee, VG). The software algorithm for the guarantee volume attempts to deliver a tidal volume (Vt) as close as possible to what has been selected by the clinician as the target volume. Main objectives of the present study were to compare patient-ventilator interactions and Vt variability in premature infants recovering from respiratory distress syndrome (RDS) who were weaned by various ventilator modes (SIMV/PSV + VG/SIPPV + VG and SIMV + VG).

METHODS

This was a short-term crossover trial in which each infant served as his/her own control. Ten premature infants born before the 32nd week of gestation in the recovery phase of RDS were enrolled in the study. All recruited infants started ventilation with SIPPV and in the weaning phase were switched to synchronized intermittent mandatory ventilation (SIMV). Baseline data were collected during an initial 20-min period of monitoring with the infant receiving SIMV alone, then they were switched to SIPPV + VG for a 20-min period and then switched back to SIMV for 15 min. Next, they were switched to PSV + VG for the study period and switched back to SIMV for a further 15 min. Finally, they were switched to SIMV + VG and, at the end of monitoring, they were again switched back to SIMV alone.

RESULTS

Each mode combined with VG discharged comparable Vts, which were very close to the target volume. Among the VG-combined modes, mean variability of Vt from preset Vt was significantly different. Variability from the target value was significantly lower in SIPPV and PSV modes than in SIMV (P < 0.0001 and P < 0.04 respectively). SIPPV + VG showed greater stability of Vt, fewer large breaths, lower respiratory rate, and allowed for lower peak inspiratory pressure than what was delivered by the ventilator during other modes. No significant changes in blood gases were observed after each of the study periods.

CONCLUSIONS

With regards to the weaning phase, among combined modes, both of the ones in which every breath is supported (SIPPV/PSV) are likely to be the most effective in the delivery of stable Vt using a low working pressure, thus, at least in the short term, likely more gentle for the neonatal lung. In summary, we can suggest that the VG option, when combined with traditional, patient triggered ventilation, adheres very closely to the proposed theoretical algorithm, achieving highly effective ventilation.