Are glucose and insulin levels at all time points during OGTT a reliable marker of diabetes mellitus risk in pediatric obesity?

PURPOSE

Childhood overweight and obesity associated with insulin resistance and metabolic syndrome represent the new global pandemic and the main causative factors for dysglycemia, prediabetes, and Type 2 Diabetes Mellitus (T2DM). Predictors, such as HOMA-IR, HOMA-β%, and QUICKI lack specific reference values in children. OGTT is a gold standard for glycometabolic assessment. Recently, a glycemic level higher than 155 mg/dl at + 60' after glucose ingestion has been defined as a risk factor for T2DM in obese adolescents. We aim to analyze and correlate fasting insulin-resistance markers with OGTT results in overweight/obese children and adolescents.

METHODS

We retrospectively evaluated glucose and insulin values during a 2-h OGTT every 30 min in 236 overweight/obese patients. Glucose values and insulin sum during OGTT were compared to glycometabolic indexes and different cut-off values for insulin sum.

RESULTS

A 1-h glucose > 155 mg/dl and insulin sum > 535 microU/ml at all times during OGTT are the best predictors of diabetes risk in obese youths. A1-h glucose > 155 mg/dl is significantly associated with HbA1c > 5.7%, while no association was observed between HbA1c > 5.7% and glucose levels at baseline and 2 h. The ability of the standardized HOMA-IR to predict the prediabetes status is clearly lower than the total insulin sum at OGTT.

CONCLUSION

Our study demonstrates that also 1-h post-OGTT glucose, together with HbA1c, is an effective diabetes predictor.

PerBrain: a multimodal approach to personalized tracking of evolving state-of-consciousness in brain-injured patients: protocol of an international, multicentric, observational study

BACKGROUND

Disorders of consciousness (DoC) are severe neurological conditions in which consciousness is impaired to various degrees. They are caused by injury or malfunction of neural systems regulating arousal and awareness. Over the last decades, major efforts in improving and individualizing diagnostic and prognostic accuracy for patients affected by DoC have been made, mainly focusing on introducing multimodal assessments to complement behavioral examination. The present EU-funded multicentric research project "PerBrain" is aimed at developing an individualized diagnostic hierarchical pathway guided by both behavior and multimodal neurodiagnostics for DoC patients.

METHODS

In this project, each enrolled patient undergoes repetitive behavioral, clinical, and neurodiagnostic assessments according to a patient-tailored multi-layer workflow. Multimodal diagnostic acquisitions using state-of-the-art techniques at different stages of the patients' clinical evolution are performed. The techniques applied comprise well-established behavioral scales, innovative neurophysiological techniques (such as quantitative electroencephalography and transcranial magnetic stimulation combined with electroencephalography), structural and resting-state functional magnetic resonance imaging, and measurements of physiological activity (i.e. nasal airflow respiration). In addition, the well-being and treatment decision attitudes of patients' informal caregivers (primarily family members) are investigated. Patient and caregiver assessments are performed at multiple time points within one year after acquired brain injury, starting at the acute disease phase.

DISCUSSION

Accurate classification and outcome prediction of DoC are of crucial importance for affected patients as well as their caregivers, as individual rehabilitation strategies and treatment decisions are critically dependent on the latter. The PerBrain project aims at optimizing individual DoC diagnosis and accuracy of outcome prediction by integrating data from the suggested multimodal examination methods into a personalized hierarchical diagnosis and prognosis procedure. Using the parallel tracking of both patients' neurological status and their caregivers' mental situation, well-being, and treatment decision attitudes from the acute to the chronic phase of the disease and across different countries, this project aims at significantly contributing to the current clinical routine of DoC patients and their family members.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04798456 . Registered 15 March 2021 - Retrospectively registered.

Deep venous thrombosis and abortion: an unusual clinical manifestation of severe form of pectus excavatum

Pectus excavatum is a chest wall malformation with a strong psychological and aesthetic impact. Rarely, pectus excavatum patients can show respiratory or cardiac symptoms occurring mainly during physical exertion. We report a case of a 34-year-old pregnant woman with a severe degree of pectus excavatum who developed serious cardiovascular disease resulting in spontaneous twin abortion at the twenty-first week of gestation. Cardiovascular disease was resolved after open surgical correction of pectus excavatum. This case shows how a tardive diagnosis and a delayed surgical approach for pectus excavatum can lead to severe consequences.

Mesenchymal cystic hamartoma presenting with pneumothorax: case report and review of the literature

Mesenchymal cystic hamartoma (MCH) of the lung is a rare disease, with an indolent course in the majority of cases. It can be single or multifocal and it is composed of primitive mesenchymal cells admixed with cystic spaces. Only few cases have been reported in the literature, with variable clinical presentation. We describe the case of a huge MCH, presenting with spontaneous pneumothorax in a 65-year-old man. Further, we provide a brief overview of the literature and discuss the differential diagnosis with other entities, and the possible diagnostic pitfalls.

Promoting the well-being of mothers with multidisciplinary psychosocial interventions in the perinatal period

BACKGROUND

Antenatal depressive and anxiety symptoms are common and may persist over time after delivery, with negative consequences on the mothers and their children. Evidence on the efficacy of psychological and pharmacological interventions during pregnancy aimed at preventing post-partum depression is controversial.

METHODS

A consecutive sample of 318 women presenting for scheduled obstetric visits during pregnancy was screened for risk factors and anxiety or depressive symptoms. Based on the screening results, women were classified into three groups at increasing risk of post-partum depression (PPD) and were offered different interventions.

RESULTS

Depressive or anxiety symptoms were found in 91 (28.6%) women, 89 (28.0%) had low risk of PPD and 138 (43.4%) had no risk of PPD. The multidisciplinary psychosocial interventions offered to women with clinical symptoms were well accepted, with an uptake of 76/91 (83.5%). Thirty-three women who did not improve with psychotherapy were offered sertraline or paroxetine as a second-line treatment: 7 accepted and 26 (78.8%) refused. Eleven women already on medication at baseline continued their treatment along with the MPI. The MPI interventions had some positive effects in terms of post-partum recovery, symptom reduction, and in preventing a new onset of depression. Among the 227 non-symptomatic during pregnancy, only 5 (2.2%) developed symptoms in the post-partum period. At 12 months post-partum, 84.6% of women who were symptomatic at 2 months post-partum recovered.

LIMITATIONS

Our results should be interpreted in light of important limitations, including the lack of a control group that was not offered the MPI, the lack of information on the reasons for refusal and discontinuation and on the number of psychotherapy sessions attended.

CONCLUSIONS

Our findings underscore the potential usefulness of MPI in recognizing early signs or symptoms during pregnancy and the advantage of building specific interventions for preventing post-natal depression. The MPI has positive effects on women with depressive or anxiety symptoms during pregnancy, that however did not exceed significantly those observed in women who refused the intervention. Thus, in the absence of a control group, our results are preliminary and warrant confirmation and testing in future randomized clinical trials.

Long-term facilitation of expiratory and sympathetic activities following acute intermittent hypoxia in rats

AIM

Acute intermittent hypoxia (AIH) promotes persistent increases in ventilation and sympathetic activity, referred as long-term facilitation (LTF). Augmented inspiratory activity is suggested as a major component of respiratory LTF. In this study, we hypothesized that AIH also elicits a sustained increase in expiratory motor activity. We also investigated whether the expiratory LTF contributes to the development of sympathetic LTF after AIH.

METHODS

Rats were exposed to AIH (10 × 6-7% O2 for 45 s, every 5 min), and the cardiorespiratory parameters were evaluated during 60 min using in vivo and in situ approaches.

RESULTS

In unanesthetized conditions (n = 9), AIH elicited a modest but sustained increase in baseline mean arterial pressure (MAP, 104 ± 2 vs. 111 ± 3 mmHg, P < 0.05) associated with enhanced sympathetic and respiratory-related variabilities. In the in situ preparations (n = 9), AIH evoked LTF in phrenic (33 ± 12%), thoracic sympathetic (75 ± 25%) and abdominal nerve activities (69 ± 14%). The sympathetic overactivity after AIH was phase-locked with the emergence of bursts in abdominal activity during the late-expiratory phase. In anesthetized vagus-intact animals, AIH increased baseline MAP (113 ± 3 vs. 122 ± 2 mmHg, P < 0.05) and abdominal muscle activity (535 ± 94%), which were eliminated after pharmacological inhibition of the retrotrapezoid nucleus/parafacial respiratory group (RTN/pFRG).

CONCLUSION

These findings indicate that increased expiratory activity is also an important component of AIH-elicited respiratory LTF. Moreover, the development of sympathetic LTF after AIH is linked to the emergence of active expiratory pattern and depends on the integrity of the neurones of the RTN/pFRG.

Facilitation of breathing by leptin effects in the central nervous system

With the global epidemic of obesity, breathing disorders associated with excess body weight have markedly increased. Respiratory dysfunctions caused by obesity were originally attributed to mechanical factors; however, recent studies have suggested a pathophysiological component that involves the central nervous system (CNS) and hormones such as leptin produced by adipocytes as well as other cells. Leptin is suggested to stimulate breathing and leptin deficiency causes an impairment of the chemoreflex, which can be reverted by leptin therapy. This facilitation of the chemoreflex may depend on the action of leptin in the hindbrain areas involved in the respiratory control such as the nucleus of the solitary tract (NTS), a site that receives chemosensory afferents, and the ventral surface of the medulla that includes the retrotrapezoid nucleus (RTN), a central chemosensitive area, and the rostral ventrolateral medulla (RVLM). Although the mechanisms and pathways activated by leptin to facilitate breathing are still not completely clear, evidence suggests that the facilitatory effects of leptin on breathing require the brain melanocortin system, including the POMC-MC4R pathway, a mechanism also activated by leptin to modulate blood pressure. The results of all the studies that have investigated the effect of leptin on breathing suggest that disruption of leptin signalling as caused by obesity-induced reduction of central leptin function (leptin resistance) is a relevant mechanism that may contribute to respiratory dysfunctions associated with obesity.

Activation of the brain melanocortin system is required for leptin-induced modulation of chemorespiratory function

Melanocortin receptors (MC3/4R) mediate most of the metabolic and cardiovascular actions of leptin.

AIM

Here, we tested if MC4R also contributes to leptin's effects on respiratory function.

METHODS

After control measurements, male Holtzman rats received daily microinjections of leptin, SHU9119 (MC3/4R antagonist) or SHU9119 combined with leptin infused into the brain lateral ventricle for 7 days. On the 6th day of treatment, tidal volume (VT ), respiratory frequency (fR ) and pulmonary ventilation (VE ) were measured by whole-body plethysmography during normocapnia or hypercapnia (7% CO2 ). Baseline mean arterial pressure (MAP), heart rate (HR) and metabolic rate were also measured. VE , VT and fR were also measured in mice with leptin receptor deletion in the entire central nervous system (LepR/Nestin-cre) or only in proopiomelanocortin neurones (LepR/POMC-cre) and in MC4R knockout (MC4R(-/-) ) and wild-type mice.

RESULTS

Leptin (5 μg day(-1) ) reduced body weight (~17%) and increased ventilatory response to hypercapnia, whereas SHU9119 (0.6 nmol day(-1) ) increased body weight (~18%) and reduced ventilatory responses compared with control-PBS group (Lep: 2119 ± 90 mL min(-1)  kg(-1) and SHU9119: 997 ± 67 mL min(-1)  kg(-1) , vs. PBS: 1379 ± 91 mL min(-1)  kg(-1) ). MAP increased after leptin treatment (130 ± 2 mmHg) compared to PBS (106 ± 3 mmHg) or SHU9119 alone (109 ± 3 mmHg). SHU9119 prevented the effects of leptin on body weight, MAP (102 ± 3 mmHg) and ventilatory response to hypercapnia (1391 ± 137 mL min(-1)  kg(-1) ). The ventilatory response to hypercapnia was attenuated in the LepR/Nestin-cre, LepR/POMC-cre and MC4R(-/-) mice.

CONCLUSION

These results suggest that central MC4R mediate the effects of leptin on respiratory response to hypercapnia.

Control of respiratory and cardiovascular functions by leptin

Leptin, a peptide hormone produced by adipose tissue, acts in brain centers that control critical physiological functions such as metabolism, breathing and cardiovascular regulation. The importance of leptin for respiratory control is evident by the fact that leptin deficient mice exhibit impaired ventilatory responses to carbon dioxide (CO2), which can be corrected by intracerebroventricular leptin replacement therapy. Leptin is also recognized as an important link between obesity and hypertension. Humans and animal models lacking either leptin or functional leptin receptors exhibit many characteristics of the metabolic syndrome, including hyperinsulinemia, insulin resistance, hyperglycemia, dyslipidemia and visceral adiposity, but do not exhibit increased sympathetic nerve activity (SNA) and have normal to lower blood pressure (BP) compared to lean controls. Even though previous studies have extensively focused on the brain sites and intracellular signaling pathways involved in leptin effects on food intake and energy balance, the mechanisms that mediate the actions of leptin on breathing and cardiovascular function are only beginning to be elucidated. This mini-review summarizes recent advances on the effects of leptin on cardiovascular and respiratory control with emphasis on the neural control of respiratory function and autonomic activity.

Large diameter fully covered self-expanding metal stent placement for palliation of proximal malignant esophageal strictures

In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self-expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large-diameter WallFlex(®) fully covered self-expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4-6 cm from the upper esophageal sphincter) and six with very proximal strictures (<4 cm from the upper esophageal sphincter) were palliated with this fully covered self-expanding metal stent and included in the study. Technical success was 100% and clinical success was 94%. The mean baseline dysphagia score was 3.2, and 1 week after stenting it improved significantly to 1.3 (P < 0.001). Early complications occurred in four patients, more frequently in patients with very proximal strictures as compared with patients with proximal strictures (P = 0.02). Late complications occurred in five patients, and there were no differences between patients with very proximal strictures or proximal strictures (P = 0.245). The mean survival after stent placement was 119 days, and no differences between patients with very proximal strictures versus proximal strictures were found (P = 0.851). There was no stent-related mortality or 30-day mortality. Our results suggested that a large-diameter fully covered self-expanding metal stent is an effective and secure device for palliation of patients with proximal malignant esophageal strictures.

Leptin into the ventrolateral medulla facilitates chemorespiratory response in leptin-deficient (ob/ob) mice

AIM

Leptin, an adipocyte-derived hormone, is suggested to participate in the central control of breathing. We hypothesized that leptin may facilitate ventilatory responses to chemoreflex activation by acting on respiratory nuclei of the ventrolateral medulla. The baseline ventilation and the ventilatory responses to CO2 were evaluated before and after daily injections of leptin into the retrotrapezoid nucleus/parafacial respiratory group (RTN/pFRG) for 3 days in obese leptin-deficient (ob/ob) mice.

METHODS

Male ob/ob mice (40-45 g, n = 7 per group) received daily microinjections of vehicle or leptin (1 μg per 100 nL) for 3 days into the RTN/pFRG. Respiratory responses to CO2 were measured by whole-body plethysmography.

RESULTS

Unilateral microinjection of leptin into the RTN/pFRG in ob/ob mice increased baseline ventilation (VE ) from 1447 ± 96 to 2405 ± 174 mL min(-1) kg(-1) by increasing tidal volume (VT ) from 6.4 ± 0.4 to 9.1 ± 0.8 mL kg(-1) (P < 0.05). Leptin also enhanced ventilatory responses to 7% CO2 (Δ = 2172 ± 218 mL min(-1) kg(-1) , vs. control: Δ = 1255 ± 105 mL min(-1) kg(-1) ), which was also due to increased VT (Δ = 4.71 ± 0.51 mL kg(-1) , vs. control: Δ = 2.27 ± 0.20 mL kg(-1) ), without changes in respiratory frequency. Leptin treatment into the RTN/pFRG or into the surrounding areas decreased food intake (83 and 70%, respectively), without significantly changing body weight.

CONCLUSION

The present results suggest that leptin acting in the respiratory nuclei of the ventrolateral medulla improves baseline VE and VT and facilitates respiratory responses to hypercapnia in ob/ob mice.

EPA Guidance Mental Health Care of Migrants

Migration is an increasingly commonplace phenomenon for a number of reasons. People migrate from rural to urban areas or across borders for reasons including economic, educational or political. There is increasing recent research evidence from many countries in Europe that indicates that migrants are more prone to certain psychiatric disorders. Because of their experiences of migration and settling down in the new countries, they may also have special needs such as lack of linguistic abilities which must be taken into account using a number of strategies at individual, local and national policy levels. In this guidance document, we briefly present the evidence and propose that specific measures must be taken to improve and manage psychiatric disorders experienced by migrants and their descendants. This improvement requires involvement at the highest level in governments. This is a guidance document and not a systematic review.

Short- and long-term outcomes of self-expanding metal stent placement as a bridge to surgery for acute left-sided colorectal cancer obstruction

AIM

The aim of this study was to evaluate the short- and long-term outcomes of self-expanding metal stent (SEMS) insertion as a bridge to surgery (BTS) in patients presenting with acute left-sided colorectal cancer obstruction (LCCO).

METHODS

All patients with acute LCCO who underwent endoscopic SEMS placement as a BTS between January 2005 and December 2010 were reviewed and included in the study.

RESULTS

Thirty-six patients (19M and 17F; mean age 68.5) were included. The most frequent location was the sigmoid colon (47.2%). Technical success was achieved in 91.6% and clinical success in 88.9%. Technical failure was related to the location of the stricture at the rectosigmoid junction (P=0.03). There were four SEMS-related complications: one fecal obstruction, one haemorrhage treated with APC and two silent perforations which were noted during surgical resection. The mean time between SEMS insertion and surgical treatment was 19 days (range 6-80 days) and the most frequent intervention was a left hemicolectomy (46.9%). No intraoperative mortality and morbidity, or postoperative mortality were observed. The postoperative morbidity rate was 18.8% (two wound infections, one deep venous thrombosis, one case of pneumonia and one anastomotic dehiscence). Finally, after discharge from hospital, a total of 29 patients (90%) were stoma free. At the end of the follow-up period, 24 patients are still alive and the mean survival rate was 37.3±18 months (range 9-72).

CONCLUSION

In our experience, SEMS placement as a BTS is a safe and effective strategy for the treatment of patients with acute LCCO.

Carbon dioxide insufflation versus air insufflation during endoscopic retrograde cholangiopancreatography under general anesthesia

AIM

The aim of this paper was to evaluate the effect of carbon dioxide (CO2) vs. air insufflation on post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain and distension. In addition, we investigated the changes in the partial pressure of end-tidal CO2 (PetCO2) and the partial pressure of arterial CO2 (PaCO2).

METHODS

From October 2009 to January 2010, all patients admitted to our centre for ERCP were screened for enrollment; the patients recruited were randomised to CO2 or air insufflation. The patients were asked to rate their abdominal pain intensity and distension using a 100-mm Visual Analogue Scale (VAS) before, in the recovery room and at 1, 3, 6 and 24 hours after the ERCP. All anesthesiological and endoscopic details and complications were evaluated.

RESULTS

We included 76 patients, 39 in the Air group and 37 in the CO2 group. The groups were similar for age, gender, indications and duration of the procedure. Post-procedure mean values of pain (in the recovery room and at 1, 3 and 6 hours) and distension (at recovery room, and at 1 and 3 hours) according to the VAS were significantly reduced in the CO2 group as compared to the Air group. At baseline, the PetCO2 values were similar between the two groups while, during the ERCP, they increased significantly in CO2 group as compared to the Air group; these values were reduced by simply increasing the ventilation.

CONCLUSION

CO2 insufflation during ERCP significantly reduces post-procedural abdominal pain and distension. Increased PetCO2 and PaCO2 values remained within acceptable or readily controllable ranges.

EUS-guided biliary drainage with placement of a new partially covered biliary stent for palliation of malignant biliary obstruction: a case series

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage technique in patients with obstructive jaundice where endoscopic retrograde cholangiopancreatography (ERCP) has failed. Between July 2008 and December 2009, 16 patients (9 men; median age 79 years) with biliopancreatic malignancy, who were candidates for alternative techniques of biliary decompression because ERCP had been unsuccessful, underwent EUS-BD with placement of a transmural or transpapillary partially covered nitinol self-expandable metal stent (SEMS). EUS-assisted cholangiography was successful in all patients, with definition of the relevant anatomy, but biliary drainage was successfully performed in only 12 (75 %) of the 16 patients (9 choledochoduodenostomies with SEMS placement and 3 biliary rendezvous procedures with papillary SEMS placement), with regression of the cholestasis. No major complications and no procedure-related deaths occurred. There was one case of pneumoperitoneum which was managed conservatively. The median follow-up was 170 days. During the follow-up, eight patients of the 12 patients in whom biliary draining was successful died; four are currently alive. None of the patients required endoscopic reintervention. This series demonstrated that EUS-BD with a partially covered SEMS has a high rate of clinical success and low complication rates, and could represent an alternative choice for biliary decompression.

Socio-demographic characteristics of the neighborhoods and depression

Over the 50% of the world's population now is living in the cities and particularly in the large metropolitan areas. Empirical evidence again and again confirms that some features of the context of a large city can influence the mental health of citizens. Faris and Dunham in 1939 were the first to show that the environmental and social disorganization in neighborhoods of Chicago was one of the most important factors to undermine the mental health of residents. This evidence was confirmed by a study carried out in midtown Manhattan, New York City. It suggests that the urban characteristics, such as social and environmental disorganization, could affect the mental health of the residents. Substantial evidence links structural inequalities to health and mental health and the researchers suggest that the disproportionate concentration of recent immigrants in urban neighborhoods contributes to racial and ethnic health disparities. While most part of the studies has examined the relationships between neighbourhood characteristics (e.g. socio-demographic characteristics, stability and mobility of the residents, ethnic composition, public transport, availability of green areas and parks, meeting places for social and cultural events, sport and leisure facilities, shopping centres, health and social services, etc.) and mental health, few studies have examined the factors that contribute to increase the incidence and the prevalence of the depressive disorders. Our research in Milan, Italy, is carrying out at the neighborhoods level, in analysis of intercity comparison, typically focused on the evaluation between environmental characteristics, neighbourhood-specific, and the incidence and prevalence of depression in residents.

Endoscopic resection as a safe and effective technique for treatment of pedunculated and non-pedunculated benign-appearing colorectal neoplasms measuring 40 mm or more in size

AIM

The aim of this paper was to evaluate the outcome of endoscopic resection (ER) for pedunculated and non-pedunculated colorectal neoplasms exceeding 4 cm in size.

METHODS

All patients with a colorectal neoplasms measuring 4 cm or more, who underwent ER at our institution between January 1996 and December 2008 were included in the study.

RESULTS

In the study period, 67 ERs were carried out in 67 patients with a mean (±SD) age of 72±11 years. The mean neoplasms size was 48.2±12.5 mm. There were 32 sessile, 26 flat and 9 pedunculated neoplasms. The most frequent location (49.3%) was rectum. No perforation occurred, there were 4 procedural and 2 delayed bleeding, treated endoscopically, and 3 cases of transmural burn syndrome, managed conservatively. Pathologic examination showed 18 low-grade dysplasia, 43 high-grade dysplasia, 3 intramucosal and 3 invasive cancer. The most frequent type of neoplasm was villous adenoma (76.1%). The presence of malignancy was related to villous histology (P=0.005) and to age ≥ 80 of patients (P=0.04).

RESULTS

During endoscopic follow-up (49.4± 26.3 months) recurrence was found in 25.8% of lesions (11 sessile and 4 flat), always treated endoscopically. Recurrence was more likely in patients with lesions larger than 60 mm (P=0.04). The three patients with invasive cancer did not undergo surgery, because of advanced age and/or severe extracolonic diseases. During follow-up no local recurrence or metastasis was found.

CONCLUSION

ER is a safe and effective procedure for removing benign appearing very large colorectal neoplasms.

Alcoholic pancreatitis: new pathogenetic insights

Though amply described, alcoholic pancreatitis continues to stir controversy. One of the most debated points is whether it is a chronic disease since onset or progresses to a chronic form after repeated episodes of acute pancreatitis. Histologic studies on patients with pancreatitis have clearly shown that it is chronic since onset and that if necrotic acute pancreatitis develops in an alcoholic, it occurs in a pancreas damaged by chronic lesions. While the possibility cannot be wholly excluded that alcohol-related acute pancreatitis may develop in the absence of chronic lesions, such an occurrence would be rare. In addition to alcoholism, genetic factors play a determinant role in the pathogenesis of the disease. Genetic studies have suggested that in hereditary pancreatitis mutation of the cationic trypsinogen gene and serine peptidase inhibitor, Kazal type 1 (SPINK1) genes mutations of the may have pathogenetic importance; however, studies on alcoholic pancreatitis have produced disappointing results so far.

Economic evaluation of sublingual immunotherapy: an analysis of literature

Allergic rhinitis and asthma constitute a global health problem because of their very high prevalence and the consequent burden of disease, concerning medical and economical issues. Among the treatments of allergy, specific immunotherapy has the capacity to favourably alter the natural history of the disease both during and after its performance and thus to reduce the direct and indirect costs of allergic rhinitis and asthma. A number of studies reported such cost reduction for traditional, subcutaneous immunotherapy and recent data demonstrate that also sublingual immunotherapy (SLIT) is associated to economic advantages and/or monetary savings, specifically in terms of reduction of disease economic burden. Only few formal economic assessments of SLIT have been carried out so far, this article will present and discuss the published studies addressed to this issue. The data obtained, although the number of studies is still limited, provide preliminary evidence supporting a SLIT effect on sparing costs for respiratory allergy.

Pharmacoeconomics of subcutaneous allergen immunotherapy

The current burden of allergic diseases, estimated by both direct and indirect costs, is very relevant. In fact the cost estimation for rhinitis amount globally to 4-10 billion dollars/year in the U.S. and to an average annual cost of 1089 euros per child/adolescent and 1543 euros per adult in Europe. The estimated annual costs in Northern America for asthma amounted to 14 billion dollars. Consequently, preventive strategies aimed at reducing the clinical severity of allergy are potentially able to reduce its costs. Among them, specific immunotherapy (SIT) joins to the preventive capacity the carryover effect once treatment is discontinued. A number of studies, mainly conducted in the US and Germany demonstrated a favourable cost-benefit balance. In the nineties, most surveys on patients with allergic rhinitis and asthma reported significant reductions of the direct and indirect costs in subjects treated with SIT compared to those treated with symptomatic drugs. This is fully confirmed in recent studies conducted in European countries: in Denmark the direct cost per patient/year of the standard care was more than halved following SIT; in Italy a study on Parietaria allergic patients demonstrated a significant difference in favor of SIT plus drug treatment for three years versus drug treatment alone, with a cost reduction starting from the 2nd year and increasing to 48% at the 3rd year, with a highly statistical significance which was maintained up to the 6th year, i.e. 3 years after stopping immunotherapy, corresponding to a net saving for each patient at the final evaluation of 623 euros per year; in France a cost/efficacy analysis comparing SIT and current symptomatic treatment in adults and children with dust mite and pollen allergy showed remarkable savings with SIT for both allergies in adults and children.

Practice parameters for sublingual immunotherapy

The efficacy and safety of sublingual immunotherapy (SLIT) are currently supported by clinical trials, meta-analysis and post-marketing surveys. Practice parameters for clinical use of SLIT are proposed here by a panel of Italian specialists, with reference to evidence based criteria. Indications to SLIT include allergic rhinoconjunctivitis, asthma, and isolated conjunctivitis (strength of recommendation: grade A). As to severity of the disease, SLIT is indicated in moderate/severe intermittent rhinitis, persistent rhinitis and mild to moderate asthma (grade D). SLIT may be safely prescribed also in children aged three to five years (grade B), and its use in subjects aged more than 60 years is not prevented when the indications and contraindication are ascertained (grade D). The choice of the allergen to be employed for SLIT should be made in accordance with the combination of clinical history and results of skin prick tests (grade D). Polysensitisation, i.e. the occurrence of multiple positive response does not exclude SLIT, which may be done with the clinically most important allergens (grade D). As to practical administration, co-seasonal, pre co-seasonal, and continuous schedules are available, being the latter recommended for perennial allergens or for pollens with particularly prolonged pollination, such as Parietaria (grade D). For pollens with relatively short pollination, such as grasses and trees (cypress, birch, alder, hazelnut, olive) the pre co-seasonal and perennial schedules are preferred (grade C). The build-up phases suggested by manufacturers can be safely used (grade A), but they can be modified according to the patient's tolerance (grade C). A duration of SLIT of 3-5 years is recommended to ensure a long-lasting clinical effect after the treatment has been terminated (grade C).

Acid‐Base Regulation in the South American LungfishLepidosiren paradoxa: Effects of Prolonged Hypercarbia on Blood Gases and Pulmonary Ventilation

The South American lungfish (Lepidosiren paradoxa) has well-developed lungs and highly reduced gills. To evaluate acid-base regulation, we applied hypercarbia while blood gases and pulmonary ventilation were measured for up to 48 h. Dorsal aortic blood was analyzed, and pulmonary ventilation was measured by pneumotachography. Two protocols were used: (1) normocarbia (control) followed by aquatic hypercarbia (7% CO2 approximately 49 mmHg), gas phase normocarbic; and (2) normocarbia (control) followed by combined aquatic/gas phase hypercarbia (7% CO2). Normocarbic values were pHa~7.5, Paco2 approximately 17 mmHg, and [HCO-3]pl approximately 22 mM. For protocol 1, the first hour of exposure increased Paco2 from 17.0 to 37.4 mmHg, and pHa fell to 7.21 and remained there for the rest of the experiment. At 3 h, pulmonary ventilation reached sixfold the normocarbic value but then decreased. For protocol 2, combined gas phase/water hypercarbia had a large effect on acid-base status. Thus, Paco2 increased gradually to 74 mmHg (pHa=7.15) at 48 h. At 3 h, ventilation reached a sixfold increase relative to normocarbic control but then rose further to a 60-fold peak at 6 h, followed by a gradual decline. As in some salamanders and air-breathing teleosts, there was no evidence of active extracellular modulation bicarbonate.

Cost effectiveness of sublingual immunotherapy in children with allergic rhinitis and asthma

BACKGROUND

Economic evaluations are increasingly relevant in order to provide support for decision makers when judging about alternative ways to allocate public funds. Aim of this study was to evaluate the economic effect of treatment with high dose sublingual immunotherapy (SLIT) in children.

METHODS

The study involved one allergy center, located in the north of Milan, Italy. From the existing records of patients seen for allergic disease, we extracted all children and adolescents with allergic disease, who had 1-year data prior to receiving SLIT and 3-year data on SLIT. Outcome measures (number of exacerbations, visits, absence from nursery or school), direct costs (euros spent on drugs, specialist visits, SLIT) and indirect costs (costs resulting from children school and parental work loss) were analysed. A second analysis compared a sub-group of allergic asthmatic children with a control group for costs, based on records of patients not SLIT-treated, extracted from a network-database of paediatricians.

RESULTS

135 patients were extracted, of which 46 had perennial, and 89 had seasonal allergy with comparable gender and age distribution. A substantial reduction was found in all outcome measures during SLIT compared with the before period. The average annual cost/patient was 2672 before SLIT initiation and _629/year during SLIT. Similar results were found for allergen subgroups. The asthma sub-analysis involved 41 children with SLIT and 35 controls. Again, SLIT patients showed a substantial reduction in outcome measures; the direct cost/patient over the whole follow-up (4 years) was _1182 for SLIT patients and _1100 for controls.

CONCLUSION

High dose SLIT may be effective in reducing the cost of allergic rhinitis and asthma and comparably expensive to conventional treatment in children with allergic asthma over a 4 years follow-up.

Pulmonary Oxygen Diffusing Capacity of the South American LungfishLepidosiren paradoxa: Physiological Values by the Bohr Method

Lungfish (Dipnoi) may represent the sister group to all land vertebrates and are therefore important for reconstructing the conquest of land by tetrapods. We determined venous and arterial blood gases, pulmonary O(2) uptake, and the form of the hemoglobin-O(2) dissociation curves in the South American lungfish Lepidosiren paradoxa. Measurements were performed at 25 degrees and 35 degrees C. Based on this information, we calculated its pulmonary O(2) diffusing capacity (D(L)O(2)), using the Bohr integration procedure. D(L)O(2) increased with temperature to reach about 0.04 mL stpd kg(-1) min(-1) mmHg(-1) at 35 degrees C. This value represents about 40% of the morphometric diffusing capacity and is similar to physiological values in some amphibians and reptiles.

Light intensity influences chromium bioaccumulation and toxicity in Scenedesmus acutus (Chlorophyceae)

The influence of light intensity on chromium uptake was studied in two strains of the freshwater unicellular alga Scenedesmus acutus (Chlorophyceae) having different sensitivity to Cr poisoning and light intensity. The two strains were subjected to different Cr treatments at 3000 and 80 lux. Cr toxicity was assessed by algal growth rate, recovery test, methylene blue staining, and determination of photosynthetic activity. After 2 and 4 days of treatment, bioaccumulated chromium, cell dry mass, and protein and carbohydrate contents were also assessed. When the algae were treated at 3000 lux, different bioaccumulation patterns were obtained when Cr content was related to dry mass, cell number, or protein content. A direct relationship between Cr content and cell mortality was observed only when the amount of Cr was related to protein content. In both strains Cr uptake was slower in subdued light, suggesting that it is linked to energy-dependent processes. The difference between the strains in sensitivity to Cr poisoning was also evident in subdued light.

The quality of experience in adolescents' daily lives: developmental perspectives

The authors analyzed the pattern of experience fluctuation in adolescents' daily activities. Italian high school students (N = 120; 16-20 years of age) were tested with the experience sampling method, a technique based on on-line sampling of daily life and experience. A total of 4,794 forms were gathered and analyzed by means of a model for the study of experience fluctuations. Among daily activities, studying at home, doing classwork, watching television, and having structured leisure were selected as the focus of analysis on the basis of their frequency and meaning in the adolescents' lives. Results showed that (a) daily activities have unique experiential profiles, (b) engagement may be used as an index of long-term commitment to a given activity, (c) studying at home and doing classwork share this basic component and can foster behavioral development, (d) structured leisure can play an edifying role at the short-term level for a socially integrated transition to adulthood, and (e) watching television is associated with lack of goals and engagement and is a source of apathy. The results (a) shed light on the role of daily life experience in shaping individual development and (b) provide suggestions for educational and psychosocial intervention in adolescence.