Effect of nutritional therapy in Emery-Dreifuss muscular dystrophy: a case report

Emery-Dreifuss muscular dystrophy (EDMD) is a rare, inherited human disease. Similar to other neuromuscular dystrophies, EDMD is clinically characterized by muscle atrophy and weakness, multi-joint contractures with spine rigidity, and cardiomyopathy. Over time, muscular weakness can lead to dysphagia and a severe lowering of body mass index (BMI), worsening the prognosis. We present the case of a young male patient affected by EDMD, admitted to the hospital for pneumothorax in a severe state of undernourishment. The patient was treated with total parenteral nutrition (TPN) with Smofkabiven®, supplemented with micronutrients (vitamins and trace elements), and with minimal enteral nutrition through food. Within a year, the patient gained 8.5 kg and kept his body weight stable for the 6 years of the follow-up. In this study, we show that TPN ensures the nutritional requirements of EDMD patients in a safe and well-tolerated manner, allowing a considerable and stable improvement in nutritional status, which has a positive impact on the disease itself and the patients' quality of life.

Weight loss trend after bariatric surgery in a population of obese patients

BACKGROUND AND AIMS

Bariatric Surgery (BS) is a therapeutic option in patients with severe obesity whose non-surgical techniques have failed. No work has previously explored trajectories of weight loss and how long this was maintained. Aim of study is to describe effect of BS and nutritional intervention on body weight trend in patients with obesity.

METHODS

792 patients who underwent BS from 1996 to 2021 were included. The Protocol provides Laparoscopic Sleeve Gastrectomy (LSG), Vertical Gastroplasty (VBG) and Roux-en-Y Gastric Bypass (GB). %Total Weight Loss (%TWL) and %Excess Weight Loss (%EWL) were evaluated in three cohort of patients. Cumulative incidence of clinical goal after surgery was calculated at two and five years after BS.

RESULTS

At two years of follow-up, average %TWL and %EWL were 31.2% (95% CI = 29.0-33.4%) and 71% (95% CI = 65.4-76.5%) for VBG, 34.7% (95% CI = 33.8-35.6%) and 78.0% (95% CI = 75.9-89.1%) for GB and 33.8% (95% CI = 32.5-35.1%) and 68.8% (95% CI = 66.1-71.6%) for LSG. At two years from surgery the cumulative incidence of clinical goal was 70.7% (95% CI = 59.1-79.1%) for VBG, 86.4% (95% CI = 82.4-89.6%) for GB and 83.4% (95% CI = 76.0-87.1%) for LSG. At five years from surgery, average % TWL and % EWL were 22.5% (95% CI = 10.2-34.8%) and 58.2% (95% CI = 28.4-88.1%) for VBG, 31.8% (95% CI = 30.2-33.3%) and 70.8% (95% CI = 67.5-74.1%) for GB and 29.5% (95% CI = 26.2-32.8%) and 62.0% (95% CI = 53.4-70.6%) for LSG respectively. At five years after having reached clinical goal the share of people who were able to maintain their weight was 49.5% (95% CI = 30.8-79.6%) for VBG, 69.5% (95% CI = 58.3-82.8%) for GB and 55.9% (95% CI = 42.1-74.3%) for LSG. The median time of clinical goal maintaining was 4.8 years for VBG (95% CI lower limit = 4.1), 6.6 years for GB (95% CI lower limit = 6.2) and 5.3 years for LSG (95% CI lower limit = 4.8).

CONCLUSIONS

Our work confirm effectiveness of BS in patients with obesity and show that who do not reach clinical goal within 2 years, hardly will reach it later and suggest necessity for a medium and long-term follow-up to prevent weight regain.

Impact of sarcopenia in SARS-CoV-2 patients during two different epidemic waves

Background

Sarcopenia was reported to be associated with poor clinical outcome, higher incidence of community-acquired pneumonia, increased risk of infections and reduced survival in different clinical settings. The aim of our work is to evaluate the prognostic role of sarcopenia in patients with the 2019 novel coronavirus disease (COVID-19).

Materials and methods

272 COVID-19 patients admitted to the University Hospital of Modena (Italy) from February 2020 to January 2021 were retrospectively studied. All included patients underwent a chest computed tomography (CT) scan to assess pneumonia during their hospitalization and showed a positive SARS-CoV-2 molecular test. Sarcopenia was defined by skeletal muscle area (SMA) evaluation at the 12th thoracic vertebra (T12). Clinical, laboratory data and adverse clinical outcome (admission to Intensive Care Unit and death) were collected for all patients.

Results

Prevalence of sarcopenia was high (41.5%) but significantly different in each pandemic wave (57.9% vs 21.6% p < 0.0000). At the multivariate analysis, sarcopenia during the first wave (Hazard Ratio 2.29, 95% confidence intervals 1.17 to 4.49 p = 0.0162) was the only independent prognostic factor for adverse clinical outcome. There were no significant differences in comorbidities and COVID19 severity in terms of pulmonary involvement at lung CT comparing during the first and second wave. Mixed pattern with peripheral and central involvement was found to be dominant in both groups.

Conclusion

We highlight the prognostic impact of sarcopenia in COVID-19 patients hospitalized during the first wave. T12 SMA could represent a potential tool to identify sarcopenic patients in particular settings. Further studies are needed to better understand the association between sarcopenia and COVID-19.

The conceptual framework of ontogenetic trajectories: parallel transport allows the recognition and visualization of pure deformation patterns

Ontogeny is usually studied by analyzing a deformation series spanning over juvenile to adult shapes. In geometric morphometrics, this approach implies applying generalized Procrustes analysis coupled with principal component analysis on multiple individuals or multiple species datasets. The trouble with such a procedure is that it mixes intra- and inter-group variation. While MANCOVA models are relevant statistical/mathematical tools to draw inferences about the similarities of trajectories, if one wants to observe and interpret the morphological deformation alone by filtering inter-group variability, a particular tool, namely parallel transport, is necessary. In the context of ontogenetic trajectories, one should firstly perform separate multivariate regressions between shape and size, using regression predictions to estimate within-group deformations relative to the smallest individuals. These deformations are then applied to a common reference (the mean of per-group smallest individuals). The estimation of deformations can be performed on the Riemannian manifold by using sophisticated connection metrics. Nevertheless, parallel transport can be effectively achieved by estimating deformations in the Euclidean space via ordinary Procrustes analysis. This approach proved very useful in comparing ontogenetic trajectories of species presenting large morphological differences at early developmental stages.

Evaluation of the strain-line patterns in a human left ventricle: a simulation study

The aim of this paper is to emphasise the role of the primary strain-line patterns in a human left ventricle (LV) within the complex system that is the heart. In particular, a protocol is proposed for the measurement of the principal strain lines (PSL) in the walls of the LV; this protocol is tested by means of a computational model which resembles a human LV. When the analysis is focused on the epicardial surface, PSL can be used to derive information on the directions of muscle fibres during the entire cardiac cycle, not only the systolic phase.

Passive circulating cell sorting by deformability using a microfluidic gradual filter

The deformability of circulating leukocytes plays an important role in the physiopathology of several diseases like sepsis or acute respiratory distress syndrome (ARDS). We present here a microfluidic method for the passive testing, sorting and separating of non-adherent cell populations by deformability. It consists of microfluidic sieves in series with pore sizes decreasing from the upstream to the downstream. The method capabilities are demonstrated with monocytic cell lines (THP-1) treated by Jasplakinolide (a stabilizer of polymerized actin), LatrunculinA (an inhibitor of actin polymerization), and with the plasma of patients suffering from ARDS. Simple sample injection with standard syringes and pumps makes the method readily adapted for experimentation in hospitals.

[How to implement a unique triage system in the emergency departments of Latium, Italy]

Triage is an efficient system that emergency departments (EDs) use to sort out presenting patients on the basis of the speed with which they need treatment. Because triage is not used consistently in the EDs of Latium, a region in central Italy, the regional Public Health Agency (PHA) planned and implemented a regional model of triage in all EDs. This manuscript describe the regional implementation strategy. The PHA activated the "Regional Triage Program--RTP" including: development and testing of a "triage section" in the computerized EDs clinical chart; production of an operational handbook for the RTP for triage health professionals (HPs); implementation of an continuum educational program on the "RTP" in all EDs of Latium. The computerized triage section was tested and implemented in all EDs in the region. The handbook for triage HPs was produced. The educational program, has been ongoing since 2008 in all regional EDs. Selected HPs, identified as "facilitators", were trained on how to implement the RTP. They will organize, in their own EDs, small groups of nurses to conduct on-site training of the RTP. The RTP was received with enthusiasm by most HPs, however its introduction into current practice could be hampered by organizational/structural problems and conflicts between nurses and doctors. Next actions of the regional program will be to overcome the possible above mentioned troubles.

Peroxisome proliferator-activated receptor gamma inhibits follicular and anaplastic thyroid carcinoma cells growth by upregulating p21Cip1/WAF1 gene in a Sp1-dependent manner

Peroxisome proliferator-activated receptor gamma (PPARgamma) has been demonstrated to be anti-neoplastic against various human tumors. The aim of this study was to delineate the molecular mechanism underlying PPARgamma ligand rosiglitazone (BRL) antiproliferative effects in follicular WRO and anaplastic FRO human thyroid carcinoma cells. BRL upregulated the p21Cip1/WAF1 levels in the two thyroid cancer cells, while did not modify the p53 protein content. Different evidences indicate that the p21Cip1/WAF1 upregulation by BRL requires a functional PPARgamma, since it was reversed by silencing PPARgamma and pretreatment with GW9662, an irreversible PPARgamma antagonist. Transient transfection assays showed that BRL triggered the transcriptional activity of p21Cip1/WAF1 promoter gene in a p53-independent way, being a p21Cip1/WAF1 promoter construct deleted in the p53 sites still activated by BRL. The Sp1 inhibitor mithramycin silenced the p21Cip1/WAF1 promoter activity suggesting an important role of Sp1 in mediating BRL activation. The electrophoretic mobility shift and chromatin immunoprecipitation (ChIP) assays evidenced a functional interaction between PPARgamma and Sp1 in regulating p21Cip1/WAF1. Intriguingly, ChIP analysis revealed in the p21Cip1/WAF1 gene promoter an increased recruitment of the RNA Pol II associated with an increased histone H3 acetylation and a reduced H3 methylation. The biological event, consistent with PPARgamma-induced WRO and FRO cell growth inhibition, was reversed by p21Cip1/WAF1 antisense oligonucleotides and was confirmed by increasing the PPARgamma expression, suggesting a crucial role exerted by p21Cip1/WAF1 in PPARgamma action. Our results further candidate BRL as a potential agent able to inhibit tumor progression of follicular and anaplastic thyroid carcinoma.

Impact de la remédiation cognitive dans la schizophrénie sur les stratégies de résolution de problèmes et l’autonomie sociale : utilisation du logiciel REHACOM®

INTRODUCTION

Despite recent developments, the impact of pharmacotherapy on social autonomy and interpersonal problem solving skills in patients with schizophrenia remains limited, with consequences in terms of socio-professional functioning. Indeed, independently of the positive, negative and/or disorganization symptoms, functional deficits in patients with schizophrenia rely mainly on various cognitive impairments.

OBJECTIVES

To determine the impact of a new Cognitive Remediation Strategy on interpersonal problem solving skills, social autonomy and symptoms in patients with schizophrenia.

METHODS

Thirty patients with schizophrenia were enrolled in a program consisting of 14 training sessions of 4 cognitive functions (attention/concentration, topological memory, logical reasoning, executive functions) using the REHACOM software. Measurements of attention (Continuous Performance Test, CPT), memory (Rivermead Behavioural Memory Test, RBMT) and executive functions (Wisconsin Card Sorting Test, WCST) as well as interpersonal problem solving skills (Assessment of Interpersonal Problem-Solving Skills, AIPSS) and social autonomy (Social Autonomy Scale, EAS) and finally schizophrenia symptoms (Positive And Negative Syndrom Scale, PANSS) were undertaken at the beginning and the end of the 14 remediation meetings.

RESULTS

Cognitive functions, interpersonal problems solving skills, social autonomy and symptoms were significantly improved by the Cognitive Remediation Strategy.

CONCLUSION

Our results confirm the therapeutic impact of a Cognitive Remediation Strategy among 30 schizophrenic patients stabilised on clinical, therapeutic and functional levels. The question of the long-term maintenance of such improvements still requires further investigation.

[The prevalence survey of nosocomial infections: a very informative tool in a big hospital setting]

In November 2001 a one-day prevalence survey of nosocomial infections (NI) was conducted in surgical and intensive care units at two hospitals in Rome. The main goal was to quantify the occurrence of NI and of some patient-care practices, such as antibiotic use. The following NI were studied: pneumonia, bloodstream infections, urinary tract infections, surgical site infections (SSI), central line-related local infections. A total of 517 patients were included. The prevalence of the above mentioned NI was 6.6%. SSI were the most frequent NI (50%), with a prevalence of 6.5% in patients who underwent surgery; the SSI prevalence was 4.7% in clean surgical procedures (SP) and 5.6% in clean-contaminated SP. In 29 NI, 33 micro-organisms were isolated; the most frequent (24.3%) was Staphylococcus aureus, which was methicillin-resistant (MRSA) in 75% of the strains. On the day of the study, 41.8% of the patients were treated with antimicrobials, mainly aminopenicillins and third generation cephalosporins. In 31.8% of cases antibiotics were given for surgical prophylaxis; patients received prophylactic antibiotics more than 2 hours prior the initial incision in almost 40% of clean SP and 60% of clean-contaminated SP. In our hospitals prevalence survey was a very useful tool to identify the following priorities: SSI prospective surveillance in clean and clean-contaminated SP, control of MRSA selection and transmission, guidelines for antimicrobial prophylaxis in surgery.

Xenoestrogens and the induction of proliferative effects in breast cancer cells via direct activation of oestrogen receptor alpha

Environmental contamination with a variety of industrial products has been associated with developmental and reproductive abnormalities in wildlife species. Increasing evidence has suggested that bisphenol A (BPA) and 4-nonylphenol (NPH), two major endocrine-disrupting chemicals, might be responsible for adverse effects on humans as a consequence of ubiquitous use together with potential oestrogen-like activity. To provide insight into the oestrogen-like nature of BPA and NPH, their ability to activate a reporter gene construct via an oestrogen response element in the hormone-dependent breast cancer cell lines MCF7 and T47D was ascertained. Both compounds transactivated the endogenous oestrogen receptor (ER) alpha in a direct fashion since the anti-oestrogen 4-hydroxytamoxifen abolished the response. In addition, using steroid-receptor-negative HeLa cells engineered to express ERalpha and ERbeta and the hormone-binding domains of both ERalpha and ERbeta, BPA and NPH confirmed the direct transcriptional activity. Interestingly these properties were supported in MCF7 cells by the ability to autoregulate ERalpha expression as well as to induce its nuclear compartmentalization. We therefore evaluated by reverse transcriptase polymerase chain reaction the expression of oestrogen-controlled genes such as cathepsin D and TFF1 (formerly pS2), which were increased by both chemicals tested. The agonistic effects exhibited in all assays performed prompted the evaluation of a more complex biological response such as the proliferation of MCF7 and T47D cells. The same concentration of xenoestrogens eliciting substantial transcriptional activity significantly stimulated the proliferation of both breast cancer cell lines, although with a reduced effectiveness with respect to the natural hormone 17beta-oestradiol. The results indicate that the biological action of environmental oestrogen such as BPA and NPH should be taken into account for the potential impact on human disease-like hormone-dependent breast cancer. However, further studies are needed to clarify their bioavailability and metabolism as well as whether compound mixtures could produce noticeable effects by synergistic activity.

[Activities at the Rome Anti-Rabies Center in 2000: analysis and proposals]

The Authors analyzed data from the 1,817 patients (mean age 35.3 +/- 20.6, median 32) treated at the Antirabies Centre of Rome in the year 2000; of these 8.9% were immigrants. Dogs (84.1%) and cats (9.8%) were responsible for most bites. Stray animals were 39.9%, with an owner 58.3% and those without data 1.8%. Over 1/3 of patients could not refer the cause of bite. Most patients (93.0%) went first to hospital, where tetanus prophylaxis was administered preferably by immunoglobulins (25.0%) instead of vaccine (6.6%). Antirabies vaccine (HDCV and/or DEV) was prescribed to 777 patients (42.8%) and administered to 642 (35.3%), but only 296 (16.3%) of them received at least 5 doses. Veterinary observation always confirmed the absence of rabies in central Italy. Immunoglobulins were prescribed only to 14 patients. The data shown in this study emphasize the opportunity to differentiate the Italian antirabies protocol according to the geographic area.

Emerging potentials for an antioxidant therapy as a new approach to the treatment of systemic sclerosis

Oxidative stress, favoring disease progression by a rapid degeneration of endothelial cell function is deeply involved in Systemic Sclerosis (SSc) pathogenesis. Raynaud's phenomenon (RP), present in 90% of patients with SSc, provoking frequent daily episodes of hypoxia-reperfusion injury, produces several episodes of free radicals-mediated endothelial derangement. These events results in a positive feedback effect of luminal narrowing and ischemia and therefore to the birth of a vicious cycle of oxygen free radicals (OFR) generation, leading to endothelial damage, intimal thickening and fibrosis. Thus ischemia and reperfusion are two criticals events that may induce oxidative stress and inactivation of antioxidant enzymes. In RP and SSc, a reduced concentration of ascorbic acid, alpha-tocopherol and beta-carotene as well as low values of Selenium have been reported. This antioxidative potential deficiency increases the propensity to oxidative stress. favoring the development of injury mediated by OFR. We reviewed several antioxidant compounds, aiming at their capacity of reverting endothelial dysfunction and damage, scavenging lipid peroxidation and reducing multiple episodes of hypoxia-reperfusion injury. In order to interrupt SSc vicious cycle, we propose a main strategy for SSc treatment by a supplementation of antioxidants and different kind of drugs with antioxidant property, such as Lazaroids, Resveratrol, Melatonin and Probucol.

Retinoic acid stimulates plasminogen activator inhibitor 2 production by blood mononuclear cells and inhibits urokinase-induced extracellular proteolysis

Retinoids have been shown to modulate several functions of mononuclear phagocytes. We investigated the in vitro effect of all-trans-retinoic acid (ATRA) on the production of two major fibrinolytic components, urokinase-type plasminogen activator (u-PA) and PA inhibitor 2 (PAI-2), by human blood mononuclear cells (MNC). ATRA caused a dose-dependent (range 0.01-10 microM) accumulation of PAI-2 antigen and activity into the cell culture medium, with a maximal increase (about 5-fold over control) at a concentration of 1-10 microM. Similarly, a dose-dependent increase in PAI-2 antigen was observed in cell extracts upon ATRA stimulation. Northern blot analysis showed a parallel increase in the amount of PAI-2 mRNA in ATRA-treated cells. Time-course experiments with 1 microM ATRA showed enhanced PAI-2 mRNA expression as early as 2 h, reaching a maximum at 4-6 h and then declining at 18-24 h, and a time-dependent increase in PAI-2 antigen in the cell culture medium. At variance with PAI-2, u-PA was not influenced by the drug. To establish whether ATRA-induced changes influenced the fibrinolytic process, we evaluated the effect of MNC stimulated with ATRA on u-PA-induced degradation of diluted plasma clots. ATRA-treated cells markedly inhibited clot lysis induced by low concentrations of u-PA. The effect was due to enhanced extracellular PAI-2 accumulation since it was observed with conditioned medium from ATRA-treated cells; it was abolished by the addition of neutralizing anti-PAI-2 antibodies and was negligible when single-chain t-PA was used instead of u-PA. Since monocyte/macrophage-mediated, plasminogen-dependent extracellular proteolysis has been proposed as an important mechanism of tissue damage in several inflammatory states, our findings might contribute to better explain the anti-inflammatory properties of retinoids.

The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance

Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables.

IMPLICATIONS

Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.

Endoscopic treatment of vesicoureteral reflux prior to renal transplantation

Endoscopic subureteral injection of Teflon was done in 34 potential renal transplant recipients to correct vesicoureteral reflux. Follow-up ranged from 6 to 24 months. After one injection reflux was corrected in 53.7% of the patients; this increased to 64.8% after a second injection. The procedure is simple, effective, without major morbidity, and avoids the risk of nephroureterectomy. However, efforts must be made to find an ideal substance with a higher biocompatibility and without risk of migration.

[Long term results of endoscopic treatment of reflux in hemodialysis patients waiting for transplantation]

Between January 1986 and April 1988, 13 patients (mean age: 35 years) waiting for renal transplantation (mean duration of haemodialysis: 46 months) were treated by means of O'Donnell's technique. Vesico-ureteric reflux was unilateral in 6 patients and bilateral in 7 patients (20 refluxing ureteric units). Reflux was classified as Grade II for 7 ureters, Grade III for 8 ureters and Grade IV for 5 ureters. The volume of Teflon injected ranged from 1 to 4 cm3 and 6 patients received repeated injections. No complications were observed. Complete resolution of reflux was obtained in 9 patients (69%), i.e. 15 ureteric units (75%). Reflux persisted in 4 patients (31%), i.e. 5 ureteric units (25%). Three nephro-ureterectomies were performed in 2 patients with persistent high grade reflux, but 2 patients with Grade I reflux after endoscopic treatment were not operated. All patients were transplanted after endoscopic treatment (mean interval between correction of reflux and transplantation: 13 months) and a follow-up cystography was systematically performed after transplantation (mean follow-up after transplantation: 27 months): no recurrence of the reflux was detected (mean follow-up after endoscopic treatment: 40 months). Endoscopic treatment of reflux avoids the need for nephro-ureterectomy in 80% of haemodialysis patients waiting for renal transplantation and presenting with vesico-ureteric reflux.

[Ulcer of the gastric fundus after abdominal fundoplication. A peculiar entity?]

Ulcers of the greater gastric curve after Nissen's abdominal fundoplication are rare. They pose a difficult pathogenic and therapeutic problem. In cases of failure of medical treatment, the question of total gastrectomy should be considered.