A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation

Background

Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization.

Material and methods

This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors.

Results

More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss.

Conclusion

A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Low-cost simulation training program for endoscopic sinus surgery: optimizing the basic skills level

Background: The purpose of this study is to develop and validate a low-cost simulation model and training program for the acquisition of basic skills in endoscopic sinus surgery. Methodology: Experimental study. An eight-task low-cost simulation model was developed based on feeding bottles. Junior residents, general otolaryngologists, and fellowship-trained rhinologists (experts) were recorded performing each task. Operative time and number of errors were measured. Videos were evaluated by two blinded experts using a validated global rating scale (GRS) and a specific rating scale (SRS). A group of residents completed a six-session training program and then were recorded and evaluated using the same methodology. Results: Twenty-five participants were recruited. Statistically significant higher scores in the GRS and SRS and lower operative time and errors at higher levels of expertise were found. A significant correlation between SRS and GRS was found. Seven residents completed the training program. A significant improvement of SRS and GRS scores and reduction of operative time and errors were observed after training. Moreover, compared to experts, statistically significant fewer errors were made by residents after training, and no significant differences were found in terms of performance quality and operative time among these groups. Conclusions: Our low-cost simulation model can be accurately used as a validated objective assessment and training tool for basic endoscopic skills necessary for FESS, and can be potentially used in any otolaryngology surgical training program for residents.

Program Administrator Burnout in Graduate Medical Education: a Longitudinal Study

BACKGROUND

Little is known about the level of burnout among program administrators (PAs) in medical education and its impact on the trainee environment.

OBJECTIVE

To investigate variations in burnout levels over a 1-year period among a national cohort of PAs and examine any associations between perceived support and isolation.

DESIGN

A 1-year longitudinal study conducted to assess burnout levels among PAs across the USA. The Copenhagen Burnout Inventory (score range, 0-100) was used to measure burnout over one academic year (July 2017-June 2018). The generalized estimating equations model was used to measure changes in burnout levels from the start of the academic year. To explore the differences in burnout scores across question response levels, a one-way ANOVA test was utilized and reported as least squares means ± SD.

PARTICIPANTS

Individuals who self-identified as PAs in a graduate medical education training program. Among the 1084 persons nationwide who expressed interest, 904 (83%) completed the baseline survey; 29 of the 42 (69%) local administrators completed the survey. "Clients" defined as interns, residents/fellows, and medical students.

MAIN MEASURES

Change in burnout score using the validated tool. Hypothesis formulated prior to data collection.

KEY RESULTS

Among the 931 participants, the 3rd quarter (March 2018) marked the lowest average personal burnout score (change from the start of academic year, - 3.67; p < 0.001, 95% CI - 5.77 to - 1.58) and work-related burnout score (change, - 3.03; p < 0.001, 95% CI - 5.01 to - 1.06). Client-related burnout was the lowest in September 2017 (change, - 1.46; p = 0.491; 95% CI - 3.54 to 0.62). June 2018: those who strongly agreed to feeling isolated in their current position had an increased personal (69.1 ± 18.4 SD), work-related (72.5 ± 20.8 SD), and client-related (42.3 ± 23.7 SD) burnout score.

CONCLUSIONS

PA burnout levels fluctuate over the academic year and are shown to increase as feelings of isolation grow.

RHBDD2 overexpression promotes a chemoresistant and invasive phenotype to rectal cancer tumors via modulating UPR and focal adhesion genes

The current standard of care for locally advanced rectal cancer (RC) is neoadjuvant radio-chemotherapy (NRC) with 5-fluorouracil (5Fu) as the main drug, followed by surgery and adjuvant chemotherapy. While a group of patients will achieve a pathological complete response, a significant percentage will not respond to the treatment. The Unfolding Protein Response (UPR) pathway is generally activated in tumors and results in resistance to radio-chemotherapy. We previously showed that RHBDD2 gene is overexpressed in the advanced stages of colorectal cancer (CRC) and that it could modulate the UPR pathway. Moreover, RHBDD2 expression is induced by 5Fu. In this study, we demonstrate that the overexpression of RHBDD2 in CACO2 cell line confers resistance to 5Fu, favors cell migration, adhesion and proliferation and has a profound impact on the expression of both, the UPR genes BiP, PERK and CHOP, and on the cell adhesion genes FAK and PXN. We also determined that RHBDD2 binds to BiP protein, the master UPR regulator. Finally, we confirmed that a high expression of RHBDD2 in RC tumors after NRC treatment is associated with the development of local or distant metastases. The collected evidence positions RHBDD2 as a promising prognostic biomarker to predict the response to neoadjuvant therapy in patients with RC.

Hearing loss in children with congenital cytomegalovirus infection: an 11-year retrospective study based on laboratory database of a tertiary paediatric hospital

Congenital cytomegalovirus infection is considered the main cause of infantile non-genetic neurosensory hearing loss. Although this correlation was described more than 50 years ago, the natural history of internal ear involvement has not yet been fully defined. Hearing loss is the most frequent sequela and is seen in a variable percentage up to 30%; the hearing threshold is characterised by fluctuations or progressive deterioration. The purpose of this study was to evaluate the prevalence of hearing loss in cases of congenital CMV infection from Modena county, starting from the database of the microbiology and virology reference laboratory. All children undergoing urine testing for suspected CMV infection or viral DNA testing on Guthrie Card in the period between January 2004 and December 2014 were enrolled in the study. Family paediatricians were contacted and asked about clinical information on the possible presence at birth or subsequent occurrence of hearing loss, excluding cases where this was not possible. The results showed an annual prevalence of congenital cytomegalovirus infection among suspected cases that was stable over time despite the progressive increase in subjects tested. The prevalence of hearing loss was in line with the literature, whereas in long-term follow-up cases of moderate, medium-to-severe hearing loss with late onset were not detected. The introduction of newborn hearing screening in the county has allowed early diagnosis of hearing loss at birth as non-TEOAE-born births underwent a urine virus test. Moreover, despite all the limitations of the study, we can conclude that European epidemiological studies are needed to better define the relationship between congenital CMV infection and internal ear disease as the impact of environmental and genetic factors is still not entirely clarified.

Residency and Fellowship Program Administrator Burnout: Measuring Its Magnitude

BACKGROUND

Little is known about the level of burnout among program administrators (PAs) working in graduate medical education.

OBJECTIVE

We created a national database with baseline burnout data for PAs from residency and fellowship programs, including intention to leave their current positions.

METHODS

A cross-sectional study was conducted in July 2017 to assess levels of burnout in a national cohort of PAs, who were largely members of online specialty forums. The Copenhagen Burnout Inventory (CBI) was used to measure burnout. Univariate analysis produced descriptive statistics for CBI. We performed a 2-sample t test to measure differences in average burnout scores for those who had thoughts of resigning from their positions and those who had not.

RESULTS

Of the approximately 10 205 national PAs, we sampled 1126 (11%). Of the 1126 individuals who received the study information, 931 (83%) completed the baseline survey. Total mean scores for all subscales were elevated (personal: 53.7, SD 21.4; work-related: 52.0, SD 22; and client-related: 30.6, SD 20.8; each scale ranged from 0, low, to 100, high). Burnout scores differed between those contemplating leaving their jobs and those who were not, across all subscales of CBI, including personal (64.2 versus 42.4, -24.18 to -19.44 confidence interval [CI]), work-related (63.5 versus 39.7, -26.12 to -21.35 CI), and client-related (36.6 versus 24.2, -14.95 to -9.84 CI; P < .0001 for all).

CONCLUSIONS

In this national survey of PAs, burnout scores measured by the CBI were higher among those who had considered leaving their positions.

In vitro model of postoncosphere development, and in vivo infection abilities of Taenia solium and Taenia saginata

Taenia solium is known to cause human cysticercosis while T. saginata does not. Comparative in vitro and in vivo studies on the oncosphere and the postoncospheral (PO) forms of T. solium and T. saginata may help to elucidate why cysticercosis can occur from one and not the other. The aim of this study was to use in vitro culture assays and in vivo models to study the differences in the development of the T. solium and T. saginata oncosphere. Furthermore, this study aimed to evaluate the expression of cytokines and metalloproteinases (MMPs) in human peripheral blood mononuclear cells (PBMCs), which were stimulated by these oncospheres and PO antigens. T. solium and T. saginata activated oncospheres (AO) were cultured in INT-407 and HCT-8 intestinal cells for 180 days. The T. solium began to die while the T. saginata grew for 180 days and developed to cysticerci in INT-407 cells. Rats were inoculated intracranially with AO and PO forms of either T. saginata or T. solium. Rats infected with T. solium AO and PO forms developed neurocysticercosis (NCC), while those infected with the T. saginata did not. Human PMBCs were stimulated with antigens of AO and PO forms of both species, and the production of cytokines and metalloproteinases (MMPs) was measured. The T. solium AO antigen stimulated a higher production of IL-4, IL-5, IL-13, IFN-γ, and IL-2 cytokines compared to T. saginata AO. In the PO form, the T. saginata PO antigen increased the production of IL-4, IL-5, IL-13, IFN-γ, IL-1β, IL-6, IL-10, TNF-α and IL-12 cytokines compared to T. solium, suggesting that this global immune response stimulated by different forms could permit survival or destruction of the parasite depending of their life-cycle stage. Regarding MMPs, T. solium AO antigen stimulated a higher production of MMP-9 compared to T. saginata AO antigen, which may be responsible for altering the permeability of intestinal cells and facilitating breakdown of the blood-brain barrier during the process of invasion of host tissue.

Taenia solium and Taenia saginata are two parasites that cause the tissue infection cysticercosis in their intermediate hosts, pigs and cows, respectively. One major difference between them is that T. solium can also cause neurocysticercosis in the human brain, while T. saginata cannot. Neurocysticercosis is thought to be the major cause of adult-onset seizures in developing countries. It is not well understood why only T. solium can survive in human tissue; however, the host inflammatory response likely plays an important role. The authors found that human immune cells stimulated with T. solium in the early stages of the parasite life cycle produced a more robust cytokine response than T. saginata. However, in the mature stage, which occurs once T. solium reaches the brain, T. solium antigens stimulated a lower inflammatory response compared to T. saginata, suggesting the parasite is able to manipulate the host immune response in some way to evade destruction. These findings may support the differences in growth observed by the authors when rat brains were inoculated with either parasite species. This study provides new insights into the different ways T. solium and T. saginata activate the immune response to survive and develop within the host.

Prevalence of Myopia in Open Angle Glaucoma

In this study concerning the prevalence of myopia in patients with open angle glaucoma, its distribution was analyzed within the sample tested in relation to the refraction defect size, compared with a control group of non-glaucomatous myopic subjects.

The overall myopic rate was 17.2% of the glaucomatous patients; high myopia was more frequent in the subjects with open angle glaucoma (p<0.001) than in the myopic patients, thus appearing as a possible risk factor for the development of glaucoma.

Emerging and re-emerging infectious disease in otorhinolaryngology

SUMMARY

Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

We Matter Too! Addressing the Wellness of Program Coordinators in Graduate Medical Education

INTRODUCTION

Burnout and stress in medical settings have been associated with despondent staff and decreased productivity. Although Program Coordinators (PCs) play an integral role in residency training programs, there exist few, if any, interventions aimed at addressing their burnout.

METHODS

A longitudinal study design was used to evaluate data from residency/fellowship training PCs who participated in a wellness retreat held at a single institution in August 2016. Subjects completed anonymous, pre- and post-retreat questionnaires in addition to a 3-month follow-up questionnaire, which included questions used to assess aspects of job demand, resiliency, and well-being. The seven-item Physician Well-Being Index and a logistic regression model were used to assess well-being. Mean values and SDs were reported to examine changes in mental health scores and participants' job satisfaction over the course of the intervention.

RESULTS

Nineteen of the 45 (43%) invited residency/fellowship training PCs completed data collection. Coordinators ranged in age from 25 to 64 years; all were female. Well-being, sleep, resiliency, and employee satisfaction scores improved over the assessment period. Well-being scores initially decreased by 0.37 at the postassessment, but increased at follow-up (mean: 2.0; SD 1.7). Stress scores increased from baseline to post, but decreased from baseline to follow-up: 0.2 and -0.2, respectively.

DISCUSSION

Residency PCs experienced improvements in mental quality of life, resiliency, stress, and sleep scores on attending the wellness program. Attention to such findings may have important implications, as we address the burnout crisis in the medical education community.

A mild phenotype of sensorineural hearing loss and palmoplantar keratoderma caused by a novel GJB2 dominant mutation

Dominant GJB2 mutations are known to cause a syndromic form of sensorineural hearing loss associated with palmo-plantar skin manifestations. We present the genotype/phenotype correlations of a new GJB2 mutation identified in three generations of an Italian family (proband, mother and grandfather) whose members are affected by sensorineural hearing impairment associated with adult-onset palmoplantar keratoderma. In all affected members we identified a new heterozygous GJB2 mutation (c.66G > T, p.Lys22Asn) whose segregation, population frequency and in silico prediction analysis have suggested a pathogenic role. The p.Lys22Asn GJB2 mutation causes a dominant form of hearing loss associated with variable expression of palmoplantar keratoderma, representing a model of full penetrance, with an age-dependent effect on the phenotype.

In Vitro Study of Taenia solium Postoncospheral Form

Background

The transitional period between the oncosphere and the cysticercus of Taenia solium is the postoncospheral (PO) form, which has not yet been completely characterized. The aim of this work was to standardize a method to obtain T. solium PO forms by in vitro cultivation. We studied the morphology of the PO form and compared the expression of antigenic proteins among the PO form, oncosphere, and cysticerci stages.

Methodology/Principal Findings

T. solium activated oncospheres were co-cultured with ten cell lines to obtain PO forms, which we studied at three stages of development–days 15, 30, and 60. A high percentage (32%) of PO forms was obtained using HCT-8 cells in comparison to the other cell lines. The morphology was observed by bright field, scanning, and transmission electron microscopy. Morphology of the PO form changed over time, with the six hooks commonly seen in the oncosphere stage disappearing in the PO forms, and vesicles and microtriches observed in the tegument. The PO forms grew as they aged, reaching a diameter of 2.5 mm at 60 days of culture. 15–30 day PO forms developed into mature cysticerci when inoculated into rats. Antigenic proteins expressed in the PO forms are also expressed by the oncosphere and cysticerci stages, with more cysticerci antigenic proteins expressed as the PO forms ages.

Conclusions/Significance

This is the first report of an in vitro production method of T. solium PO forms. The changes observed in protein expression may be useful in identifying new targets for vaccine development. In vitro culture of PO form will aid in understanding the host-parasite relationship, since the structural changes of the developing PO forms may reflect the parasite’s immunoprotective mechanisms. A wider application of this method could significantly reduce the use of animals, and thus the costs and time required for further experimental investigations.

Neurocysticercosis is caused by T. solium, which is a neglected disease. The postoncospheral (PO) form is an intermediate form between the oncosphere, which is the larva, and the fully developed cysticercus, which is a cyst with a scolex. The morphology, development, and protein and antigen expression of the PO form have not previously been characterized. Here, we report the novel in vitro cultivation of T. solium PO forms and characterize the morphology, development, and expression of antigenic proteins. This new method will allow for better study of this transitional form, which is very difficult to study in the intermediate host. With the increased availability of secreted proteins and antigens, in vitro cultivation will help improve diagnostic assays and provide new targets for vaccine development to block transmission.

[Perception about the importance of feeding in a group of hematologic cancer patients]

INTRODUCTION

Oncohematologic patients usually present nutritional deficits associated with the disease, the treatments and side effects, etc. However, there are hardly any descriptive data about the dietary recommendations used and the patient's self-perception of its usefulness in their disease.

AIM

To assess the self-perception of the nutritional importance in a group of oncohematologic patients.

MATERIALS AND METHODS

111 oncohematologic patients self-reported a questionnaire containing items about socio-sanitary data and self-perception of the nutritional importance in their disease.

RESULTS

The mean age was 40.0 ± 12.8 years (64.86% women). The most frequent diagnosis and treatment was lymphoma (83.78%) and chemotheraphy (92.80%). 75% considered "very important" relationship between oncohematologic disease and nutritional status. Only 54.1% received dietary advice. And 53.2% and 50.5% considered that the use of nutritional supplements improve quality of life and/or disease respectively.

CONCLUSIONS

A significant percentage of patients had advanced stages of their disease. However, half the group had not received dietary advice despite high interest in receiving nutritional care. Therefore, the nutritional assessment and the personalized nutritional support implementation of the patient should be included in routine clinical practice.

Standardization of a fluorescent-based quantitative adhesion assay to study attachment of Taenia solium oncosphere to epithelial cells in vitro

To fully understand the preliminary stages of Taenia solium oncosphere attachment in the gut, adequate tools and assays are necessary to observe and quantify this event that leads to infection. A fluorescent-based quantitative adhesion assay, using biotinylated activated-oncospheres and monolayers of Chinese hamster ovary cells (CHO-K1) or human intestinal monolayer cells (INT-407, HCT-8 or HT-29), was developed to study initial events during the infection of target cells and to rapidly quantify the in vitro adhesion of T. solium oncospheres. Fluorescein streptavidin was used to identify biotinylated activated-oncospheres adhered to cells. This adherence was quantified using an automated fluorescence plate reader, and the results were expressed as fluorescence intensity values. A series of three assays were performed. The first was to identify the optimum number of biotinylated activated-oncospheres to be used in the adhesion assay. The goal of the second assay was to validate this novel method with the established oncosphere-binding system using the immunofluorescent-antibody assay (IFA) method to quantify oncosphere adhesion. A total of 10,000 biotinylated activated-oncospheres were utilized to assess the role of sera and laminin (LM) in oncosphere adherence to a CHO-K1 cell monolayer. The findings that sera and LM increase the adhesion of oncospheres to monolayer cells were similar to results that were previously obtained using the IFA method. The third assay compared the adherence of biotinylated activated-oncospheres to different types of human intestinal monolayer cells. In this case, the fluorescence intensity was greatest when using the INT-407 cell monolayer. We believe this new method of quantification offers the potential for rapid, large-scale screening to study and elucidate specific molecules and mechanisms involved in oncosphere-host cell attachment.

Proteomic study of activated Taenia solium oncospheres

Taenia solium cysticerci are a major cause of human seizures and epilepsy in the world. In the gastrointestinal tract of infected individuals, taeniid eggs release the oncospheres, which are then activated by intestinal stimuli, getting ready to penetrate the gut wall and reach distant locations where they transform in cysticerci. Information about oncospheral molecules is scarce, and elucidation of the oncosphere proteome could help understanding the host-parasite relationship during the first steps of infection. In this study, using liquid chromatography and tandem mass spectrometry (LC-MS/MS) analysis, we could identify a set of oncospheral proteins involved in adhesion, protein folding, detoxification and proteolysis, among others. In addition, we have characterized one of the identified molecules, the parasite 14-3-3, by immunoblot and immunolocalization. The identification of these oncospheral proteins represents the first step to elucidate their specific roles in the biology of the host-parasite relationship.

BALB/c Mice resist infection with Bartonella bacilliformis

BACKGROUND

Bartonellosis due to Bartonella bacilliformis is a highly lethal endemic and sometimes epidemic infectious disease in South America, and a serious public health concern in Perú. There is limited information on the immunologic response to B. bacilliformis infection. The objective of this research was to produce experimental infection of BALB/c mice to B. bacilliformis inoculation.

FINDINGS

BALB/c mice were inoculated with 1.5, 3.0 or 4.5 x 108 live B. bacilliformis using different routes: intraperitoneal, intradermal, intranasal, and subcutaneous. Cultures of spleen, liver, and lymph nodes from one to 145 days yielded no cultivable organisms. No organs showed lesions at any time. Previously inoculated mice showed no changes in the reinoculation site.

CONCLUSION

Parenteral inoculation of live B. bacilliformis via different infection routes produced no macroscopic or microscopic organ lesions in BALB/c mice. It was not possible to isolate B. bacilliformis using Columbia blood agar from 1 to 15 days after inoculation.

Relative binding affinity of novel steroids to androgen receptors in hamster prostate

The in vivo and in vitro antiandrogenic activity of four aromatic esters 10a-10d, one aliphatic ester 10e based on the pregna-4,16-diene-6, 20-dione structure and two aromatic 17c, 17d and two aliphatic valeroyloxy esters 17a, 17b based on the more saturated 4-pregnene-6,20-dione skeleton was examined. The biological activity of steroids 9, 10a-10e and 17a-17d, was determined using prostate glands from gonadectomized adult male golden hamsters. In the in vitro studies, the relative binding affinity of these steroids to cytoplasmic androgen receptor (AR) of hamster prostate was determined from, the corresponding IC50 values obtained from the competitive binding plots. The standards dihydrotestosterone (DHT) and cyproterone (CA) acetate used have displaced [3H]DHT from the AR with an IC50 value of 3.2 and 4.4 nM respectively. All steroidal compounds synthesized in this study showed a binding affinity for the androgen receptor, present in the cytosol from prostate hamster; compounds 10a-10c showed the highest affinities for this receptor. The in vivo experiments showed that all steroidal derivatives were subcutaneously active, since they decreased the weight of the prostate gland in gonadectomized hamsters treated with DHT, and are antagonists for the androgen receptor since they block the DHT-induced prostate weight gain. The derivatives having the more conjugated 4,16-pregnadiene-6, 20-dione system (10a-10c) exhibited a higher antiandrogenic activity than the corresponding steroids (17a-17d) based on the more saturated 4-pregnene-6,20-dione system.

Iron but not folic acid supplementation reduces the risk of low birthweight in pregnant women without anaemia: a case-control study

OBJECTIVE

To assess whether iron and folic acid supplementation reduce the risk of low birthweight (LBW) in women without anaemia.

DESIGN

Case-control study.

SETTING

University Hospital of Cantabria.

STUDY POPULATION

Cases were 322 mothers without anaemia delivering a singleton infant of less than 2500 g. Controls were 934 mothers without anaemia delivering a term non-small-for-gestational-age infant.

DATA COLLECTION

Data on iron and folic acid supplementation were obtained from prenatal chart record and personal interview. Data on risk factors for LBW were also gathered.

RESULTS

Agreement between the two sources of information was good (82% for folic acid and 94% for iron). Odds ratios yielded from the two sources were very close. Folic acid only (15 mg/day) was unrelated to LBW, whereas iron supplementation (80 mg ferrous sulphate) was associated with a lower risk of LBW (odds ratio (OR) 0.58, 95% CI 0.34 to 0.98), adjusted for smoking, maternal education, body mass index, obstetric diseases during pregnancy, weight gain during pregnancy, and previous LBW. The results of iron plus folic acid were similar to those for iron (OR 0.56, 95% CI 0.33 to 0.96). There was a significant trend towards a lower risk of LBW (p<0.001) with the duration of iron supplementation. After stratifying by the type of LBW, the trend was also significant for any kind of LBW.

CONCLUSIONS

Iron supplementation is associated with a lower risk of LBW in pregnant women without anaemia.

Role of vegetables and fruits in Mediterranean diets to prevent hypertension

BACKGROUND/OBJECTIVES

Several studies support the effectiveness of increasing the consumption of fruits and vegetables (F&V) to prevent hypertension. However, none of them have been conducted in a Mediterranean setting. The aim of this study was to assess the association between F&V consumption and the risk of hypertension.

SUBJECTS/METHODS

A prospective Mediterranean study (the SUN cohort), including 8594 participants aged 20-95 years (mean, 41.1) with median follow-up of 49 months.

RESULTS

Analyses according to the joint classification by olive oil and F&V consumption showed a significant inverse relation between F&V consumption and the risk of hypertension only among participants with a low olive oil consumption (<15 g per day). Also, tests for trend were significant only in the low olive oil intake stratum.

CONCLUSIONS

We found a statistically significant interaction (P=0.01) between olive oil intake and F&V consumption. These data suggest a sub-additive effect of both food items.

Acute mastoiditis in children: the "Ferrara" experience

OBJECTIVE

This study aims to investigate the clinical features and outcomes of acute mastoiditis in children referred to the ENT/Audiology Department of the University of Ferrara from January 1994 to December 2005. It also aims to discuss risk factors and to find predictors for surgery.

METHODS

A retrospective study on case sheets of children with an acute mastoiditis diagnosis was carried out. Fifty-five cases fulfilled the inclusion criteria: they presented otoscopical evidence of acute otitis media and inflammatory findings of the mastoid area such as post-auricular swelling, redness or tenderness, protrusion of the auricle and/or radiological findings.

RESULTS

Twenty-six patients were only treated with antibiotic therapy, tympanocentesis alone was performed in 11 cases; in 5, a ventilation tube was positioned. Mastoidectomy was performed in 13 patients. The group who underwent mastoidectomy had a median hospital stay of 15 days (5-54), in this group were found the following complications: 1 meningitis, 1 meningo-encephalitis, 1 lateral and sigmoid sinus thrombosis, 1 facial palsy.

CONCLUSION

the incidence of otomastoiditis does not seem to be decreasing, on the contrary, in some countries, it seems to be on the increase. Our experience cannot confirm a real increase of the incidence but we noted periodic variations during the time of observation. It is important, that careful attention is paid to the clinical assessment of children who are 2-years old or under, as they seem to be more exposed to the risk of clinical complications; therefore, it is highly recommended that the otologist and the paediatrician collaborate closely.

Measuring the psychosocial consequences of hearing loss in a working adult population: focus on validity and reliability of the Italian translation of the hearing handicap inventory

Despite increasing demand for questionnaires for assessing hearing handicap and the effectiveness of some tools across different languages, empirical studies to evaluate the reliability and the validity of translations of original English questionnaires into an Italian version have not been reported in the literature, thus making comparisons of Italian experimental and clinical data across cultures and countries impossible. This study tested the global assumption that the Hearing Handicap Inventory for Adults (HHIA), that is one of the most widely used instruments in English-speaking countries, can be adapted to the Italian language maintaining the reliability and clinical validity of the original version. The English version of this 25-item, self-assessment questionnaire was developed by Newman et al. in 1990 and special emphasis was placed on emotional reaction and social limitations perceived by hearing-impaired subjects and scored separately. This tool was translated into the Italian language by a forward and backward technique, as established by the IQOLA (International Quality of Life Assessment) project. Overall, 94 subjects, aged 18-65 years, with acquired hearing impairment and 104 individuals with no hearing problems, well-matched for socio-demographic variables, were enrolled in the study in a case-control design. Reliability of the Italian version of HHIA was tested by measuring internal consistency and test-retest reproducibility. Validity was assessed by using construct, convergent and discriminant methods. A Cronbach's alpha coefficient near 0.90 confirmed a more than acceptable internal consistency and a highly statistically significant Spearman's correlation coefficient (< 0.005) between scores of the two administrations at an interval of one month documented an excellent stability of the questionnaire over time. Construct validity was demonstrated by a correlation between the severity of hearing loss and the score of questionnaire (< 0.005) and convergent validity was supported by a significant correlation between the scores of the emotional and socio/situational subscales of the HHIA to the analogous subscales of a health-related quality of life questionnaire (MOS 36-Item Short Form Health Survey) (< 0.005). Finally, since hearing-impaired subjects scored significantly higher than controls on HHIA (< 0.005), it clearly emerged that also the Italian version of HHIA differentiates the two populations (those with and those without hearing problems) demonstrating a robust discriminant validity. Given the lack of appropriate measures to assess hearing handicap in Italy, the results achieved in this study, confirm that the HHIA, Italian version, is suitable for both experimental and clinical use.

Early hyponatraemia after pituitary surgery: cerebral salt-wasting syndrome

Hyponatraemia is a common complication in patients undergoing neurosurgery. It can be caused either by the syndrome of inappropriate secretion of antidiuretic hormone or by the cerebral salt-wasting syndrome (CSWS). CSWS frequently occurs in patients suffering from subarachnoid haemorrhage and brain injury, but it is rare after pituitary tumour surgery. However, this diagnostic possibility should be considered as these disorders require specific treatment and have different prognoses. In this article, we present a case of acute and early hyponatraemia caused by CSWS after pituitary tumour surgery. We also revise the aetiology, mechanisms, differential diagnosis and treatment of hyponatraemia after pituitary surgery.

Dietary fat intake and the risk of osteoporotic fractures in the elderly

OBJECTIVE

To explore the association between fat intake, serum lipids and the risk of osteoporotic fractures in the elderly.

DESIGN

A hospital-based case-control study.

SETTING

The study was conducted at a tertiary centre and referral hospital for the province of Jaén (Spain).

SUBJECTS

Cases (n=167) were patients aged 65 years or more with a low-energy fracture selected from the population attended at the hospital. Controls (patients without antecedents of any fracture) were 1:1 matched to cases by sex and age (n=167).

METHODS

Diet was assessed by a semiquantitative food frequency questionnaire. Serum total cholesterol and high-density lipoprotein (HDL) cholesterol were also measured.

RESULTS

Participants in the two upper quartiles of polyunsaturated fat (PUFA) intake showed an increased risk of fracture, with statistically significant differences with respect to the first quartile in the adjusted model (odds ratio (OR)=3.59; 95% confidence interval (CI)=1.06-12.1 and OR=5.88; 95% CI=1.38-25.02); P=0.01 for the trend test). A higher ratio of monounsaturated fat (MUFA) to PUFA was associated with a reduced risk of fracture (OR=0.20; 95% CI=0.07-0.60 for the fourth quartile; P=0.002 for the trend test). The intake of omega-6 fatty acids was associated with an elevated risk of fracture (OR=3.41; 95% CI=1.05-11.15 for the fourth quartile; P=0.01 for the trend test). HDL-cholesterol levels were inversely associated with the risk of fracture (test for trend P=0.03 across quartiles).

CONCLUSIONS

PUFA intake was associated with an increased risk of osteoporotic fractures in the elderly, whereas a high ratio of MUFA:PUFA was associated with decreased risk.

Cholesterol and serum albumin as risk factors for death in patients undergoing general surgery

Background

Serum levels of total cholesterol, its fractions (high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol) and albumin are related to a poor outcome during hospital stay. It has been not assessed whether they are related to death in the long term after general surgery.

Methods

This prospective cohort study included 2848 general surgical patients with a median follow-up of 6 years after discharge from hospital. Sampling for biochemical measurements was done at the time of admission. The outcome investigated was all-cause mortality and multivariable Cox regression was used for statistical analysis.

Results

Three hundred and seventy-eight patients (13·3 per cent) died during follow-up. Serum albumin (adjusted hazard ratio (HR) 2·2 (95 per cent confidence interval (c.i.) 1·5 to 3·4) for lowest versus highest quintile), total cholesterol (HR 1·6 (95 per cent c.i. 1·1 to 2·3) for lowest versus highest quintile) and HDL-C (HR 1·6 (95 per cent c.i. 1·1 to 2·4) for lowest versus highest quintile) showed a significant inverse relationship with all-cause mortality in both crude and multivariable analyses. Serum albumin and HDL-C were associated with death for up to 2 years after surgery, whereas total cholesterol had the strongest association more than 2 years after discharge.

Conclusion

Low levels of serum albumin, total cholesterol and HDL-C are associated with death after discharge from hospital in patients having general surgery.

Effect of ascorbic acid based amphiphiles on human erythrocytes membrane

6-O-alkyl ascorbic acid esters (ASCn) are amphiphilic molecules that behave as surfactants in aqueous solution. These compounds show physico-chemical and aggregation properties that depend on the alkyl chain length, pH and temperature. It must consider that ASCn have shown some physical and rheological properties that suggest a potential utility as drug carriers. The present paper aims to evaluate the effects of these surfactants on human erythrocyte membranes. The membrane properties studied were: osmotic resistance in hypotonic media, shape transformation, and vesicle release at lytic concentration. According to our results, all properties depended on the length of the hydrophobic chain and they did not evolve monotonically. Finally, the study of ASCn interaction with erythrocyte membrane allowed us to postulate the crucial influence that the molecular structure exerts upon the manner in which amphiphiles interact with biological membranes and the effects involved in them.

Effect of p53 haploinsufficiency on melphalan-induced genotoxic effects in mouse bone marrow and peripheral blood

Mice heterozygous for a p53 null mutation develop tumours induced by genotoxic carcinogens with a shorter latency than wild type mice and have been proposed as an alternate animal model for carcinogenicity testing. Some literature data suggest that p53+/- mice might also be more sensitive to the short-term effects of genotoxic agents and manifest a haploinsufficiency phenotype that could contribute to the higher tumour susceptibility. We have compared the induction of micronuclei in bone marrow and blood of p53+/- and p53+/+ isogenic mice after treatment with a single or multiple doses of melphalan (MLP), a crosslinking genotoxic carcinogen. We have also characterized the mechanism of micronucleus induction with CREST staining of kinetochore proteins to distinguish between chromosome break- and chromosome loss-induced micronuclei. Significant increases of micronucleated bone marrow polychromatic erythrocytes and blood reticulocytes were induced under all MLP exposure conditions. The frequency of micronucleated blood erythrocytes increased linearly with duration of exposure. Micronuclei were essentially a consequence of chromosome break events. After a single MLP dose, a significant reduction of the frequency of polychromatic erythrocytes in bone marrow of p53+/+ animals suggested the induction of cytotoxicity/cell cycle delay. This effect was not observed in p53+/- mice. We believe this finding to provide some evidence of a haploinsufficiency phenotype in the modulation of cell cycle/apoptotic pathways mediated by the p53 protein. In bone marrow of wild type mice, an increased effect of multiple MLP doses was detected over that of a single administration, whereas, in p53+/- mice, no differential effect was found of different exposure durations. Possibly, the probability of micronucleus formation increased under chronic exposure because of increased cell division in response to peripheral anemia and a reduction of p53 protein level had a small effect on cell cycle modulation and on such indirect mechanism of micronucleus induction. However, pairwise comparisons between the frequencies of cells with micronuclei in wild type and p53+/- mice under all exposure conditions did not show statistically significant differences, suggesting that the observed effects of p53 haploinsufficiency were weak and temporary and a higher/faster induction of irreversible chromosome damage could not account for the increased susceptibility of p53+/- mice to MLP-induced tumours.

Determinants of the interval between diagnosis and treatment in patients with digestive tract cancer

The main objective was to analyze the influence of social factors on the interval from diagnosis to treatment in a cohort of 217 patients with digestive tract cancer. From the clinical charts data were obtained for: date of the beginning of illness, dates of medical attendance, type and date of diagnostic tests, characteristics of the disease (symptoms, stage), and date of treatment. From the personal interview we gathered information lacking in the clinical charts such as socio-demographic factors, other underlying diseases, and variables related to life style. The information on hospital admission, diagnosis, and treatment was prospectively gathered, whereas data before hospitalization were retrospectively assessed. In statistical analysis the Kruskal-Wallis test and Cox regression were used. The predictors associated with a shorter diagnosis-treatment period were: low social class, lymphatic involvement at diagnosis, first visit at secondary/tertiary level of health care, no car availability, two or more symptoms at the beginning of disease, sex (male), age (less than 74 years), and diagnosis out of vacation periods. In conclusion, several socio-demographic variables (age, gender, social class, and car availability) influence the interval diagnosis-treatment.

[Selective parathyroidectomy with unilateral cervical exploration for primary hyperparathyroidism]

Primary hyperparathyroidism (pHPT), is caused in over 90% of the cases by a single parathyroid adenoma. Preoperative diagnostic imaging techniques, in particular dual phase scintigraphy with SestaMIBI/TC99 and high frequency probe ecography, are able to pinpoint it 90% of the time. These are the two cornerstones of modern pHPT surgery, which has witnessed the passage from cervical exploration of all the most common parathyroid glandular sites to a more carefully targeted, restricted approach in the side of the neck where the adenoma is suspected to be. This is how selective parathyroidectomy with unilateral cervical exploration and, recently, mini-invasive parathyroidectomy, came into being. Between 1996 and 2001, in the Otolaryngology Department of S. Maria della Misericordia Hospital in Udine, 39 patients affected by pHPT, half of whom (49%) were asymptomatic, underwent selective parathyroidectomy with unilateral cervical exploration. The object of this paper was to evaluate the efficacy of this surgical technique by comparing the pre- and post-operative calcaemia and parathormone levels. The normalization of these parameters, and particularly of the latter, was considered indicative of successful treatment. All the postoperative calcaemia levels were normal, while elevated parathormone levels persisted in only 2 cases (5%). Our statistics showed a 95% efficacy for selective parathyroidectomy, a result that is comparable to the percentages described in the literature. There were, furthermore, no significant peri- or postoperative complications in any of the cases. These observations, together with the brief operating times required for the procedure (20-25 minutes on average) and the low cost of the material employed, enable us to conclude that selective parathyroidectomy with unilateral cervical exploration continues to hold its own as a valid option in the present scenario of surgical pHPT treatment, also in consideration of the fact that it does not present the rigid inclusion criteria characteristics of mini-invasive techniques.

Relationship between hospital infection and long-term mortality in general surgery: a prospective follow-up study

A prospective study of 1431 patients admitted to a general surgery department were followed up for a median of 6.2 years after discharge (7679 person-years of follow-up). We collected information on underlying conditions, including severity of illness, and healthcare-related variables. Relative rates of death and their 95% confidence interval (CI) were estimated using person-years as the denominator. Multiple-risk factors adjusted for relative rates (RR) were obtained using Poisson regression analysis. There were 172 deaths during the follow-up period after hospital discharge (2/100 person-years). Follow-up was complete in 91% of the cohort. There were no important differences in demographic characteristics or risk factors between patients followed up and those lost to follow-up. The death rate in patients with any hospital-acquired infection was 5.3/100 person-years, and the relative rate was 3.07 (95% CI: 2.20-4.24). After adjusting for the main predictors of mortality, we found an effect modification by the presence of chronic disease (P = 0.01 for the product-term between hospital infection and the diagnosis of chronic diseases). Among patients without any underlying chronic disease, hospital-acquired infection was related to a significantly higher long-term mortality (RR = 2.47, 95% CI: 1.24-4.91). In these patients, surgical wound infection yielded a RR of mortality of 3.44 (95% CI: 1.63-7.27). Among patients with underlying chronic disease no association between hospital infection and long-term mortality was found. No evidence of an important modification of the relative rate along the follow-up period was observed. In conclusion surgical patients without chronic disease developing hospital-acquired infection have an increased risk of long-term mortality.

Validation of the Victorian Perinatal Morbidity Statistics form: new items, pre-coded text and free text

This study assessed the quality of information on the form used by the Victorian Perinatal Data Collection Unit. Information relating to four new and one modified data items, and to pre-coded and free text regions relating to maternal morbidity, was compared with that in the medical record. The new data items were documented correctly on 95.5% of forms, as were 67% of pre-coded conditions. Between 53% and 75% of free text items were correctly recorded. The results highlight the need for information and education sessions for midwives and other staff in order to collect and maintain high quality data.

Antenatal exercise and birthweight

Does strenuous antenatal exercise reduce birthweight? Does reducing maternal exercise increase birthweight? What to advise about exercise during pregnancy? We recruited 117 women who intended to exercise 5 or more times weekly during pregnancy to a study of whether reducing the amount of maternal exercise during pregnancy is associated with an increase in birthweight. Only 61/117 (52%) of women agreed to be randomised to either continue or to reduce (to 3 or fewer sessions of exercise weekly) their intended pregnancy exercise program. Most women who refused randomisation did not want to risk being asked to reduce their exercise during pregnancy. Within the randomised trial, there was no statistically significant difference between the mean birthweight of babies born to women who continued and those who reduced their intended exercise program. The high rate of refusal of randomisation limits the power of the study to find a difference in birthweight, limits the generalisability of the results and shows that many women intending to exercise at this level during pregnancy have an uncompromising attitude to exercise.