The underexposed nature-based solutions: A critical state-of-art review on drought mitigation

Droughts are the most expensive climate disasters as they leave long-term and chronic impacts on the ecosystem, agriculture, and human society. The intensity, frequency, and duration of drought events have increased over the years and are expected to worsen in the future on a regional and planetary/global scale. Nature-based solutions (NBS) such as wetland and floodplain restorations, green infrastructures, rainwater harvesting, etc., are highlighted as effective solutions to cope with the future impacts of these events. While the role of NBS in coping with the impacts of other disasters, such as floods, has been extensively studied, there has been a lack of comprehensive review of NBS targeting drought. The following paper provides a unique critical state-of-the-art literature review of individual drought-related NBS around the world, in Europe, and particularly in Belgium, and assesses the critical differences between the NBS applied globally and in Flanders. An extensive literature review was conducted to systematically analyze NBS, listing the type, the location, the status of the implementation, and the possible recommendations proposed to optimize future NBS applications. Finally, a comparison is made between small- and large-scale applications of NBS. By analyzing all these aspects, especially the level of effectiveness and recommendations, insight was gained into the future potential of NBS and possible improvements. The research indicated a lack of scientific publications, especially in Belgium. Hence, grey literature was also included in the literature review. Only four papers included a quantitative assessment regarding the effectiveness of drought on a global level, all stating a positive impact on groundwater recharge. In contrast, at regional and country levels, the performance of NBS was not quantified. The number of large-scale implementations is low, where landscape- or watershed-scale holistic approaches to drought mitigation are still scarce. Some successfully implemented projects are only very local and have a long realization time, two aspects that limit achieving visible impact at a larger scale. Among the many NBS, wetlands are recognized as highly effective in coping with drought but are still degraded or lost despite their significant restoration potential. A common effectiveness evaluation framework shall be followed, which gives policymakers a clear view of the different NBS investment options. Furthermore, a more collaborative approach is recommended globally, including different stakeholder groups, with specific attention to the local communities. To conclude, future research should increase the evidence base and implementation of drought-mitigating NBS.

Vitamin D and interferon-γ co-operate to increase the ACE-2 receptor expression in primary cultures of human thyroid cells

BACKGROUND

A more severe course of COVID-19 was associated with low levels of Vitamin D (VitD). Moreover in vitro data showed that VitD up-regulates the mRNA of the Angiotensin Converting Enzyme 2 (ACE-2), the SARS-COV-2 receptor in different type of cells. ACE-2 is expressed in several type of tissues including thyroid cells, on which its mRNA was shown to be up-regulated by interferon-gamma (IFN-γ). The aim of the present study was to investigate if treatment with VitD alone or in combination with IFN-γ would increase ACE-2 both at mRNA and protein levels in primary cultures of human thyrocytes.

MATERIALS AND METHODS

Primary thyroid cell cultures were treated with VitD and IFN-γ alone or in combination for 24 h. ACE-2 mRNA levels were measured by Real-time Polymerase Chain Reaction (RT-PCR). The presence of ACE-2 on thyroid cell membrane was assessed by immunocytochemistry basally and after the previous mentioned treatments.

RESULTS

ACE-2 mRNA levels increased after treatment with VitD and IFN-γ alone. The combination treatment (VitD + IFN-γ) showed an additive increase of ACE-2-mRNA. Immunocytochemistry experiments showed ACE-2 protein on thyroid cells membrane. ACE-2 expression increased after treatment with VitD and IFN-γ alone and further increased by the combination treatment with VitD + IFN-γ.

CONCLUSIONS

VitD would defend the body by SARS-COV2 both by regulating the host immune defense and by up-regulating of the expression of the ACE-2 receptor. The existence of a co-operation between VitD and IFN-γ demonstrated in other systems is supported also for ACE-2 up-regulation. These observations lead to an increased interest for the potential therapeutic benefits of VitD supplementation in COVID-19.

National taxation on sugar-sweetened beverages: a scoping review and time series analysis

Background

The intake of Sugar-Sweetened Beverages (SSBs) has increased around the world, leading to a growing burden of disease due to these beverages, such as obesity, diabetes, and heart disease. Taxation is a major action for comprehensive programmes aimed at reducing consumption of sugars. For these reasons, the aims of our study were to systematically summarize national tax legislation on SSBs and to assess the impact of these laws on the prevalence of overweight, obesity, and diabetes.

Methods

We conducted a scoping review to summarize the landscape of national tax laws on SSBs implemented worldwide. We included any document reporting both currently into force and past national tax laws addressing SSBs. As to the time series analysis, data regarding the national prevalence of obesity, overweight, and diabetes were retrieved from WHO Global Health Observatory data repository.

Results

As of July 2020, 34 countries worldwide implemented SSB taxation (amount-specific and ad valorem tax design), of which 17 (50.0%) in high-income countries, 12 (35.3%) in upper-middle income countries, and 5 (14.7%) in low-income countries. As for overweight, Hungary was the only country showing a slower rate of change after the taxation. Regarding obesity, France, Guatemala, Hungary and Panama showed a deceleration of the rates of change after the intervention. Eventually, Hungary and Tonga exhibited a one-time decrease of diabetes prevalence at the intervention point. Decelerating rates of change in the post-intervention period was also found for Guatemala and Fiji.

Conclusions

Laws targeting SSBs showed, at least in part, to be an effective measure to reduce the prevalence of overweight, obesity, and diabetes. Less than one fifth of worldwide countries have implemented national taxation policies. Finally, while taxation might be effective to reduce SSB consumption, other types of Public Health interventions, such as educational initiatives, should not be neglected.

Key messages

• Sugar-Sweetened Beverages (SSBs) are associated with obesity, diabetes, and heart disease. Taxation can be an important tool to reduce the consumption of SSBs.

• Prevalence of obesity, overweight and diabetes decreased in countries that adopted taxation. However, other strategies such as educational programs should be implemented to reduce the intake of SSBs.

Impact of a multidisciplinary intervention on Mediterranean diet adherence and cardiovascular health

Background

Cardiovascular diseases represent a significant public health issue, and the promotion of healthy lifestyles plays a major role in their prevention. Good adherence to the Mediterranean diet has a protective effect on cardiovascular health and may reduce the risk of developing cardiovascular disease. Our prospective study aimed to evaluate the impact of educational lifestyle interventions on cardiovascular risk parameters and the improvement in adherence to the Mediterranean diet of the involved population.

Methods

Participants have been recruited by General Practitioners in Torresina neighborhood in Rome. From December 2018 to June 2020, 41 patients were involved in nutritional, psychological, and physical activity meetings by a multidisciplinary team of healthcare professionals. In particular, a nutritionist provided information to patients on balanced nutrition, considering the Mediterranean diet as a dietary model. Information on lifestyle, dietary habits and physical activity, anthropometric data and laboratory measurements were collected at baseline and after 12 months. The variations of the evaluated parameters were analyzed by paired t-test e Wilcoxon signed-rank test.

Results

The analysis showed statistically significant decreases in weight (p = 0.03) and BMI (p = 0.02), as well as in systolic (p < 0.001) and diastolic (p = 0.001) blood pressure and in total (p = 0.02) and LDL (p = 0.01) cholesterol level. Results also showed an improvement in the adherence to the Mediterranean diet (p = 0.001): the frequency of consumption of fruits and vegetables, legumes, cereals and fish has increased significantly, while the consumption of meat, milk and dairy products and alcohol decreased.

Conclusions

This study highlights that a multidisciplinary educational program can be effective in improving healthy habits and in reducing cardiovascular risk factors, supporting its implementation in primary prevention at the community level.

Key messages

• Promoting healthy lifestyle through primary prevention and health promotion actions is critical to reduce the onset of cardiovascular diseases.

• A population-based multidisciplinary educational intervention may be effective in improving adherence to a healthy, balanced diet and decreasing cardiovascular risk factors.

Vaccination coverage trends in European Union from 1980 to 2020: A joinpoint Regression Analysis

 

Vaccinations are successful, cost-effective public health interventions; nevertheless, vaccine hesitancy represents a concern and several EU countries have implemented mandatory vaccinations to counteract it. The assessment of vaccination coverage data is helpful to clarify the reason behind this choice better and assess its impact. Data were extracted from the WUENIC database as of July 2021. All the 27 EU countries were included, considering the period from 1980 to 2020 (depending on data availability). Coverage indicators on seven vaccinations scheduled during the first year of life to prevent nine vaccine-preventable diseases were considered. Joinpoint regression was run using Joinpoint Trend Analysis Software 4.9.0.0. For each coverage indicator, the last two trends in time identified by the joinpoint regression were considered to identify countries with a positive vaccination coverage trend (having either the last trend significantly positive or the second last significantly negative but followed by a trend reversal) or a negative coverage trend (having either the last trend significantly negative or the second last significantly positive but followed by a trend reversal). To assess each country, we collated together information on each coverage indicator. A total of 180 jointpoint regressions were run. At least one joinpoint was observed in 144 cases: 39 (27.1%) showed a significant positive trend, and 49 (34%) had a significantly negative one. In 36 cases, there was a single trend lacking a joinpoint, either positive (21, 58.3%), negative (8, 22.2%), or not showing a change (7, 19.4%). Overall, 14 countries had mostly negative vaccination coverage trends, whereas 13 had mostly positive vaccination coverage trends. Systematised data collection and analysis of vaccination coverage trends are needed to support public health systems. EU countries differ broadly, but the overall situation shows that coverage trends are a key issue to be addressed.

Key messages

• Vaccination coverage in the EU shows a general negative trend. The assessment and comparison of coverage trends across EU countries could make policymakers able to respond to critical issues timely.

• Mandatory vaccinations have been issued in different countries to prevent vaccination coverages from decreasing. Some countries have not issued any mandate but show high vaccination coverages.

Leadership in public health crisis: a review to summarize lessons learned from COVID-19 pandemic

Background

During the COVID-19 pandemic, several public health challenges were faced, requiring worldwide leaders able to direct, guide, and establish appropriate strategies. The aim of this review was to summarize evidence on public health leadership during the COVID-19 era.

Methods

The systematic literature review was conducted according to the PRISMA 2020 checklist. A search of relevant articles was performed in the PubMed, Scopus, and Web of Science databases. Eligible articles were any type of publication, published between 2020 and 2022, that outlined one or more characteristics of effective public health leadership during the COVID-19 pandemic We excluded all articles that did not explicitly address the COVID-19 pandemic or had a different setting.

Results

A total of 2499 records were screened, and 45 articles were included. We identified 93 characteristics, clustered in six groups, that were reported as fundamental to be an effective leader in public health crises worldwide. Emotional intelligence and human traits (reported by 46.67% of the articles) were considered essential to build trust in the population and ensure cooperation with working groups. Communication skills (47%) are considered necessary to enable people to understand and accept measures. A supportive, multidisciplinary team and accountability mechanisms (33,33%) were highlighted as central elements, especially in the international field, to ensure reliability and consistency in action. Management skills (35,56%), adaptability (44,44%), and evidence-based approach (33,33%) were reported as key capabilities to ensure a prompt and rapid response to the challenges created by the pandemic.

Conclusions

The identification of the attributes of an effective public health leader conducted in this study is useful in choosing the key personalities who must lead public health today and in the training of tomorrow's European and worldwide leaders to be ready to face future threats.

Key messages

• Effective public health leaders in crisis are empathetic and trustworthy people, who have developed management and communication skills, and are able to make timely and evidence-based decisions.

• In order to create leaders capable of facing future threats, more emphasis in the training of public health workforce on soft skills and management competencies should be recommended.

Impact of COVID-19 on flu vaccination among pregnant women in a Teaching Hospital in Rome

Background

According to WHO, UNICEF, GAVI and the Sabin Vaccine Institute data, the COVID-19 pandemic caused the disruption of routine vaccinations in at least 68 countries. In March ‘20, the WHO published a guide to help countries continuing their provision safely to prevent unnecessary visits and hospitalizations: especially flu vaccination is paramount to reduce respiratory illnesses and their burden on healthcare systems. For the flu season 2021-22, the Italian Ministry of Health recommended prioritizing flu vaccination for pregnant women. This study aims at comparing flu vaccination rates between pre-pandemic and pandemic periods in pregnant women attending a birthing preparation course at the Fondazione Policlinico Universitario A.Gemelli IRCCS (FPG) in Rome.

Methods

A repeated cross-sectional study was carried out in FPG during two flu epidemic seasons (October ‘19-January ‘20 and September ‘20-January ‘21), when two different cycles of birthing preparation courses were held (face-to-face and online, respectively). Pregnant women and their partners attending them were offered flu vaccination at FPG. A χ2 test was performed to compare vaccination rates, with statistical significance set at p = 0.05.

Results

In 2019-20, 48 out of 119 women and 39 men out of 119 attending the course accepted flu vaccination, while in 2020-21 they were respectively 88 out of 317 and 89 out of 317. Overall vaccination compliance among pregnant women was significantly higher in 2019-20 than in 2020-21 (40.3% and 27.8% respectively, p = 0.012), while the difference was not significant among their partners (32.8% and 28.1% respectively, p = 0.337).

Conclusions

The COVID-19 pandemic negatively affected flu vaccination adherence among the pregnant women involved. Fear of contagion and access to facilities closer to their home could be potential key drivers. These results represent an important warning on flu vaccination attitudes during the pandemic: more actions are needed to improve compliance.

Key messages

• COVID-19 might have hindered access to immunization services for at-risk populations, such as that of pregnant women.

• From a Public Health point of view, more actions are needed to harmonize interactions between hospitals and local national health services to improve vaccination compliance.

Sand dams for sustainable water management: Challenges and future opportunities

Sand dams are impermeable water harvesting structures built to collect and store water within the volume of sediments transported by ephemeral rivers. The artificial sandy aquifer created by the sand dam reduces evaporation losses relative to surface water storage in traditional dams. Recent years have seen a renaissance of studies on sand dams as an effective water scarcity adaptation strategy for drylands. However, many aspects of their functioning and effectiveness are still unclear. Literature reviews have pointed to a range of research gaps that need further scientific attention, such as river corridors and network dynamics, watershed-scale impacts, and interaction with social dynamics. However, the scattered and partially incomplete information across the different reviews would benefit from an integrated framework for directing future research efforts. This paper is a collaborative effort of different research groups active on sand dams and stems from the need to channel future research efforts on this topic in a thorough and coherent way. We synthesize the pivotal research gaps of a) unclear definition of "functioning" sand dams, b) lack of methodologies for watershed-scale analysis, c) neglect of social aspects in sand dam research, and d) underreported impacts of sand dams. We then propose framing future research to better target the synthesized gaps, including using the social-ecological systems framework to better capture the interconnected social and biophysical research gaps on sand dams, fully utilizing the potential of remote sensing in large-scale studies and collecting sand dam cases across the world to create an extensive database to advance evidence-based research on sand dams.

Planetary health research: insights from The Lancet Planetary Health original articles

Background

In 2017, the Lancet group launched The Lancet Planetary Health to promote the dissemination of research conducted in this field. Planetary health was also extensively discussed during the World Congress on Public Health 2020, which underlines the strategic importance recognized to this topic by experts and researchers active in public health at an international level. The aim was to investigate the role of public health university departments in the field of planetary health.

Methods

The Lancet Planetary Health database was queried from the inception to February 2021, to retrieve original articles or reviews whose first and/or last author was affiliated to a University Department of Public Health worldwide. We used the twenty-six EUPHA operational sections to define the research areas of the identified articles. The following data were extracted: study design, EUPHA area, research question, topic, identified gaps in the literature, and key concepts.

Results

Out of 543 entries, 44 original articles and reviews were included. Thirty-two percent studies were conducted in Asia, 20% in America, 13% in Europe, 8% in Oceania, 4% in Africa while 23% in a multicentric global context. The area investigated was mainly environmental and health (68%) followed by infectious disease control (14%). Collaboration across different disciplines is highly present in the authorships. Regarding the study design, 30% of the included articles were cohort studies.

Conclusions

From 2017 till February 2021, the number of studies performed by public health researchers published on The Lancet Planetary Health is gradually increasing.

Since published articles take advantage of the typical research methods and topics of public health and environmental health research, public health university departments can contribute to planetary health science if they seek transdisciplinary collaboration and adopt a planetary health vision.

Impact of the COVID-19 pandemic on psychological well-being of students in an Italian university: a web-based cross-sectional survey

Background

Italy was the first European country to implement a national lockdown because of the COVID-19 pandemic. Worldwide, this pandemic had a huge impact on the mental health of people in many countries causing similar reaction in terms of emotions and concerns at the population level. Our study investigated the impact of the COVID-19 pandemic on psychological well-being in a cohort of Italian university students.

Methods

We conducted a cross-sectional survey in the period immediately after the first lockdown through the administration of a questionnaire on the personal websites of students attending their undergraduate courses at the Università Cattolica del Sacro Cuore. We used the Patient-Health-Engagement-Scale, Self-Rating-Anxiety-Scale, and Self-Rating-Depression-Scale to assess engagement, anxiety symptoms, and depression symptoms of our sample.

Results

The sample size was 501 subjects, of which 35.33% were classified as anxious and 72.93% as depressed. Over 90% of respondents had good understanding of the preventive measures despite over 70% suffered from the impossibility of physically seeing friends and partners. Around 55% of students would have been willing to contribute much more to face the pandemic. An increase in the occurrences of anxiety was associated with being female, being student of the Rome campus, suffering from the impossibility of attending university, being distant from colleagues, and being unable of physically seeing one's partner. Performing physical activity reduced this likelihood.

Conclusions

University students are at risk of psychological distress in the case of traumatic events. The evolution of the pandemic is uncertain and may have long-term effects on mental health. Therefore, it is crucial to study the most effective interventions to identify vulnerable subgroups and to plan for acute and long-term psychological services to control and reduce the burden of psychological problems.

Trends in vaccination coverage against influenza in the pediatric population: an Italian overview

Background

Influenza is a major public health issue for its epidemiological, clinical and economic impact. Children are a relevant age group for the diffusion of the infection in the community as they shed the virus in greater amounts and for longer periods of time than adults of any age. Vaccination is the best strategy to fight the disease. In Italy, until last year, influenza vaccination for the pediatric population was offered free only to children in specific risk categories, while in the last season its was extended also to all subjects from 6 months to 6 years old. The purpose of this work is to analyze the trend of vaccination coverage among children in the last decade in Italy.

Methods

We retrieved vaccination coverage data by the Italian Ministry of Health relating to influenza vaccination in the age groups 0-2, 2-4, 5-8 and 9-14 in the years 2010-2020 and analysed trends in and between regions.

Results

A preliminary analysis shows that vaccination coverage in the age groups considered ranged from a minimum of 1.1% to a maximum of 4.5%. The highest average percentage reached was recorded in the season 2010-11 (3.8%), while the lowest in the 2015-16 (1.5%). The highest average values (12,9%; 10,5%) were found in Puglia and Toscana, while the lowest (0.3%) in Friuli Venezia Giulia. From 2010 to 2015 there was a progressive decline in vaccination coverage, while in the following years there was a slight increase, up to the year 2019-2020, in which the average percentage value was 3%. Further results are expected for next summer, when 2020-21 data will be available.

Conclusions

Our analysis shows that in the Italian regions influenza vaccination coverage in children is variable but still extremely low. Childhood vaccination could provide an opportunity to decrease the burden of disease in this age group but may also help to protect the population at risk of serious complications, such as the elderly, due to the social role children play in the spread of this virus.

Key messages

Influenza vaccination in children is a major public health issue. Additional efforts are needed to make vaccination available for children and improve the stakeholders’ awareness on this topic.

Primary melanoma of the bladder: a case report and review of the literature

OBJECTIVE

Primary bladder melanomas are rare and aggressive neoplasms. We herein described a new case and performed a review of the literature.

PATIENTS AND METHODS

We present the case of a 81-year-old woman with a primary mucosal melanoma of the bladder after a history of acral melanoma (KRAS mutated) and lentigo maligna of the forehead. Using PubMed, we found that in literature 38 cases were described.

RESULTS

In our patients, during a transurethral resection (TURBT), two bladder lesions were detected. The histologic exam revealed a malignant melanoma, Mib1/ki67: 10-12%, PDL1 <1%. No BRAF, NRAS or KRAS mutations were detected. She subsequently underwent a transurethral revision of the trigone and a partial cystectomy of the dome with bilateral pelvic lymph node dissection. Microscopical findings showed a residual 5 mm non-muscle-invasive melanoma of the bladder, with negativity of the surgical margins and of the 17 pelvic lymph nodes. No adjuvant treatment was proposed. To date the patient is disease-free.

CONCLUSIONS

Primary bladder melanoma carries a poor prognosis and poses a therapeutic challenge to clinicians who manage patients with this rare condition. In our experience the multidisciplinary approach for the diagnosis and management of this rare cancer is mandatory.

Detection of SARS-COV-2 receptor ACE-2 mRNA in thyroid cells: a clue for COVID-19-related subacute thyroiditis

PURPOSE

SARS-COV-2 is a pathogenic agent belonging to the coronavirus family, responsible for the current global world pandemic. Angiotensin-converting enzyme 2 (ACE-2) is the receptor for cellular entry of SARS-CoV-2. ACE-2 is a type I transmembrane metallo-carboxypeptidase involved in the Renin-Angiotensin pathway. By analyzing two independent databases, ACE-2 was identified in several human tissues including the thyroid. Although some cases of COVID-19-related subacute thyroiditis were recently described, direct proof for the expression of the ACE-2 mRNA in thyroid cells is still lacking. Aim of the present study was to investigate by RT-PCR whether the mRNA encoding for ACE-2 is present in human thyroid cells.

METHODS

RT-PCR was performed on in vitro ex vivo study on thyroid tissue samples (15 patients undergoing thyroidectomy for benign thyroid nodules) and primary thyroid cell cultures.

RESULTS

The ACE-2 mRNA was detected in all surgical thyroid tissue samples (n = 15). Compared with two reporter genes (GAPDH: 0.052 ± 0.0026 Cycles^-1; β-actin: 0.044 ± 0.0025 Cycles^-1; ACE-2: 0.035 ± 0.0024 Cycles^-1), the mean level of transcript expression for ACE-2 mRNA was abundant. The expression of ACE-2 mRNA in follicular cells was confirmed by analyzing primary cultures of thyroid cells, which expressed the ACE-2 mRNA at levels similar to tissues.

CONCLUSIONS

The results of the present study demonstrate that the mRNA encoding for the ACE-2 receptor is expressed in thyroid follicular cells, making them a potential target for SARS-COV-2 entry. Future clinical studies in patients with COVID-19 will be required for increase our understanding of the thyroid repercussions of SARS-CoV-2 infection.

Global health challenges: Are future physicians prepared? The results of a 4 years training experience

Background

Current health challenges are highlighting as Global Health (GH) is a discipline of growing importance for future physicians. Although its training is globally recommended, it has not universally entered the curricula of degree courses in Medicine and Surgery. A cycle of 6 seminars in global health has been promoted by researchers and public health residents of the Center for Research and Studies in GH of the Università Cattolica del Sacro Cuore (UCSC) in Rome, and offered for 4 consecutive years to medical students attending the UCSC.

Objectives and Methods

Main goal was increasing students knowledge and awareness in global health issues exploring their needs and perceptions about the impact of the topic on their future career. Two-hours frontal lessons held by experts and practical sessions (PBL) facilitated by promoters were planned on topics as determinants and inequalities in health, UHC, fragile and vulnerable population as migrants and victims of violence, SDGs, AIDS and emerging infectious diseases,international cooperation, maternal-child health. A pre-course, single event and post-course questionnaire was administered to participants.

Results

A mean of 48 students (± 15.7SD), 66.7% females, attending mainly the second(40.4%) and the third year (39%), joined each event. The analysis of the pre-course questionnaire has highlighted students' interest in healthcare inequalities, pandemics, migration, health in developing countries, healthcare systems. At the end, 92% of participants has considered the course interesting, 87% stated that the topic should be part of the degree course and 78% that it will influence their career. The methodology was considered adequate in 94% of cases underlining its strong incentive to work in team.

Conclusions

The strong interest of medical students in acquiring skills in global health seems to firmly encourage its inclusion and strengthening in study plans to prepare them properly to face the future challenges in health.

Key messages

Medical students consider the global health training relevant for their career encouraging its inclusion in the Medicine and Surgery curriculum. Practical sessions and team work could be useful tools to adequately train the future health workforce.

Directive 2019/904/EU. The need to raise awareness on plastic misuse and consequences on health

The EU Directive 5 June 2019, n. 904, aims to promote sustainable reusable products and systems in a circular perspective, reducing the production of disposable products and waste.

Abandoned plastics take decades to disintegrate, never disappearing completely from the environment, with serious consequences for human health. A study conducted by the European Food Safety Authority (EFSA) has found that pollutants such as polychlorinated biphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs) or bisphenol A (BPA) can accumulate in microplastics, which are swallowed by humans as well as inhaled or ingested reaching lungs. For instance, it has been estimated that every week we ingest the same amount of microplastics as a credit card. Furthermore, plastic kills and damages biodiversity. Aquatic animals are the most affected, as they are either trapped in man-made plastic waste or they swallow plastics with serious damage to their and the humans' health that eat them. Dangerous are also nanoplastics that can penetrate cell walls and are chemically more reactive.

However, Directive 2019/904/EU does not eliminate the use of plastic, setting the percentages of recycled plastics to be used in the manufacture of disposable plastic products. For instance, beverage PET bottles must contain at least 25% of recycled plastic from 2025 and 30% from 2030.

Despite the Directive has provided elements for states to legislate in favour of a society that makes less use of plastics, today no zero- plastic society has been created. In order to achieve this 'zero' it is necessary to start from the citizens, raising their awareness through awareness-raising campaigns and the distribution of leaflets and posters on the consequences of the mismanagement of plastic waste (and microplastics) on their health and on the environment.

Key messages

Raise citizens awareness on the consequences of the mismanagement of plastic waste (and microplastics) on their health and on the environment is fundamental. The importance of the creation of a zero plastic society thanks to the application of Directive 2019/904/EU at international level.

Air pollution health risk assessment: the role of benzene

Benzene is an aromatic polycyclic hydrocarbon (C6H6) ubiquitously present in the environment which results from the emissions of fires and volcanoes. However, the primary source is anthropogenic, mainly from industrial emissions and combustion. The aim of this study is to summarize the current evidence on benzene exposure in the Italian regions and the main health effects.

A retrospective observational study was conducted. Environmental data provided by ISPRA (Higher Institute for Environmental Protection and Research) relating to benzene pollution and the trend of national emissions of substance by region and sector of origin were analyzed.

Data available to date (1990-2016) show a significant decrease, over 91%, mainly due to the reduction in the transport sector. In 2016, the main share of substance relates to road transport (1,492 t), followed by use of solvents (1,100 t), and production processes (463 t). Much lower are the emissions due to the extraction and distribution of fossil fuels/geothermal (19 t) and combustion in the energy and transformation industries (5 t). The highest absolute values in 2015 were recorded in the Italian regions of Lombardia (751.4 t), Lazio (367.2 t), and Puglia (339.0 t). The lower values were in Valle d'Aosta (7.9 t), Molise (15,5 t) and Basilicata (25,3 t). The largest decrease in benzene exposure between 1990 and 2015 was recorded in Campania (-94.5%), Calabria (-93.9%) and Valle d'Aosta (-93.4%).

All Italian regions recorded a significant decrease in the absolute values of benzene emissions, mainly due to both the decrease of benzene in fuel composition during the 1990s and to the renewal of circulating cars equipped with energy saving systems (start and stop) and more optimized for low fuel consumption. The global reduction of energy sources based on fossil fuels, as well as a primary environmental objective to reduce Global Warming, would certainly constitute a way to decrease the impact of benzene on the environment.

Key messages

Additional efforts are needed to reduce energy sources based on fossil fuels. An information, training and health education policy through the environment aimed at implementing awareness and empowerment of the population would be desirable.

A shared battle against cancer: overcoming screening uptake differences within European countries

Cancer is the second leading cause of dead in Europe and it is responsible of more than 30% of all deaths. For this reason, European Union (EU) identified the battle against cancer as a priority for the European Research Program 2021-2027.About 40% of total deaths for cancers could be prevented with screening.Validated screening test are available for breast (BC), cervical (CC) and colorectal cancers (CRC).

In 2003 the Recommendation of the European Council indicated the right timing and the population target but, nowadays, the percentage of screening within EU is low and consistent differences persist among States.In 2020 there are still countries that don't have population-based screening programs. Last data available for all 28 EU countries are referred to 2014. Data were retrieved from “Osservasalute” reports and Global Burden of Disease database.Pearson test and a paired t test were used to describe correlation between mortality and screening coverage rates.

In 2014 the mean percentage of screening was 70.7% for CC, 68.7% for BC and 31.3% for CRC and the mean of mortality rate was of 2.1, 10.4 and 17.2 for 100,000, respectively.The rate of mortality did not change significantly in 2017 (2, 10 and 16 for 100,000 respectively).The median coverage is 67 for BC [IR: 43-91], 21.4 for CRC [IR: -3-46] and 70.6 for CC [IR: 54-87]. Pearson test resulted in a negative correlation for all three cancers equal to -0.045, -0.060 and -0.561, respectively.A higher adherence to screening programs is significantly associated to lower mortality rates in all the three types of cancer (p &lt; 0.01).

Even if many factors determine the rate of cancer mortality, screening represents the best method to early diagnosis and treatment.Up-to-date data are needed to correctly monitor progress towards the common goal of reaching the entire target population with screenings.A strong leadership at international level is necessary to improve screening programs all over EU and support screening campaigns.

Key messages

Screening is one of the most efficient and life-saving way to prevent cancer. It is needed to improve screening adherence through population-based programmes both at international and national level. Last data available for all EU countries are referred to 2014. It is necessary to update the data in order to enhance the understanding of screening efficiency.

Flu vaccination coverage among healthcare workers: the example of younger generations

Flu vaccination is highly recommended among Healthcare Workers (HCWs). The low coverage in Italy among HCWs (mean 15.6% for 2016/17 flu season, ECDC) calls for new approaches. The aim of this study was to evaluate in which measure the vaccination coverage among HCWs registered during the 2019-2020 flu vaccination campaign in a large Teaching Hospital in Rome was affected by age and education.

A retrospective observational quasi-experimental study was conducted. Descriptive and inferential statistical analysis (chi-square test, significance level of 0.05) were performed. The 2019-2020 flu vaccination campaign was aimed at more than 4000 employed HCWs (total coverage 24.2%). Vaccination was also extended to not-employed HCWs such as Medical Residents (MRs) and Medical Students (MSs) in clinical training. The coverage in this groups was higher (46.0% and 63.2% respectively) and the difference between them and the coverage among employed HCWs was statistically significant (p &lt; 0.05); Further analysis was performed comparing MRs / MSs in clinical training with their respective professional group of employed HCWs, with a percentage of vaccinated Medical Doctors (MD) of 36.6%. MRs / MSs in clinical training coverage was higher than MDs coverage and the difference still proved to be statistically significant (p &lt; 0.05).

The higher coverage among MRs / MSs in clinical training could be explained, in general, in light of the more open-mindedness to prevention and to healthy lifestyles that characterizes young people with an up-to-date education. It could also be explained considering the specific culture and sense of responsibility of Medical Students and Medical Residents towards their high-demanding educational path and clinical training as an incentive not to get ill.

Flu vaccination is highly recommended among HCWs. Younger generations, who represent the future of Healthcare, prove to be more open-minded and responsible towards good prevention practices such as this.

Key messages

Flu vaccination is highly recommended among HCWs. Younger generations, who represent the future of Healthcare, prove to be more open-minded and responsible towards good prevention practices.

1st European Academy for Healthcare Leaders: high training on leadership to manage health systems

Background

Nowadays having leadership skills is critical to manage healthcare systems. The World Health Organization Collaborating Centre on Health Policy, Governance and Leadership organized the 1st European Academy for Healthcare Leaders in Rome from 15th to 17th November 2018. Senior officials of the Ministries of Health of 16 Members Countries of the WHO European Region attended and actively participated to the event, led by experienced Italian and European experts. The Academy could be considered a moment of high training on leadership and governance of health systems.

Objectives

The event was aimed at creating effective networks among participants to share ideas and strategies to improve leadership skills, providing practical tools to be applied in healthcare systems and to develop a common and transferrable leadership framework in Europe. Frontal lectures and interactive workshops covered three main areas: leadership skills, current challenges of health systems and sustainability of health systems today.

Results

The 3-days event gave the opportunity to discuss the main issues in Public Health highlighting how to be an effective leader in healthcare. Leadership should enable the translation of knowledge into productive action pathways, providing health equity and improving population’s health. At the end of the event, participants filled a survey and the results showed high satisfaction about contents (100% out of 16 participants).

Conclusions

Health systems need to change in order to face the formidable challenges of our times. This event empowered the participants in order to support the creation of strategies and to develop leadership tools to apply at country level. The experiences, ideas and good practices shared during this event strengthened a collaborative network and have been useful to identify common goals and solutions.

Key messages

These kinds of events are fundamental to improve knowledge about leadership in healthcare. Leadership should have a major role to play in healthcare worldwide.

Establishment and Morphological Characterization of Patient-Derived Organoids from Breast Cancer

Background

Patient-derived organoids (PDO) technology represents an emerging tool for the study of tumor biology and drug responsiveness, thus being useful to design personalized medicine approaches. Despite several studies and clinical trials are ongoing using PDO from colorectal and pancreatic cancer, only few research papers have been published exploiting PDO from breast cancer. Here, we have developed a new protocol to establish PDO from surgical and biopsy samples. Furthermore, we have set up also the methodologies adopted for culture and morphological evaluations.

Results

Surgical and core biopsy specimens collected from 33 patients with diagnosis of breast cancer have been processed using the protocols here described obtaining PDO from cancerous and healthy mammary tissue (when available) in a quick and easy way with good yields. The more critical aspects influencing the yield were the characteristic of the tissue of origin (healthy vs tumor tissue) and the amount of material obtained after enzymatic digestion process. Success rate from healthy samples was about 20,83%, while this percentage was higher in samples from cancer tissue (i.e. 87,5%). Also the morphological characterization of breast cancer PDO by brightfield and transmission electron microscopy has been reported.

Conclusions

Despite obtaining some organoids from a surgical or biopsy specimen is not a difficult procedure, the establishment of a stable organoid line able to grow and replicate, suitable for long-term biobank storage, is not so obvious. A novel, simple and quick procedure to obtain PDO from surgical and biopsy samples is here proposed to achieve high success rate .

Abstract P1-20-05: Raman imaging as a tool for the chemical and spatial characterization of breast microcalcifications to improve lesion assessment

Background: microcalcifications (MC) are common findings on screening mammography and are among the earliest signs of breast cancer. At the same time, from the use of well-known radiographic risk score systems, which include MC assessment, such as Breast Imaging-Reporting and Data System (BI-RADS), only 20% of screened patients are further associated with malignancy. This leads to repeated biopsies and to unnecessary surgeries with discomfort for patients and increased costs for the healthcare system. Furthermore, the definitive diagnosis by histological and immunohistological evaluations is still laborious and time-consuming.

Raman Spectroscopy (RS) is a photonic approach capable to provide detailed chemical information of analysed samples without complex tissue preparation or staining. RS has a proven ability to distinguish different crystal structures, including those commonly present in MC. In this context some studies based on RS suggested a correlation between MC chemical features and pathology. On the other hand, previous Raman-based studies mainly investigated the overall MC chemical composition (by single-point scans) while an extensive MC characterization by Raman imaging approaches (mapping) for diagnostic purposes is still lacking.

The aim of this study is to assess the usefulness of Raman imaging as a quick and accurate tool for a complete spatial characterization of MC detected on screening mammography and sampled by breast biopsy in order to better distinguish malignant vs. benign lesions.

Method: 30 patients with breast calcifications detected on mammography with radiological classification BI-RAD 3-5 where selected and evaluated by core biopsy. 10 μm formalin-fixed paraffin-embedded (FFPE) histological sections obtained from biopsies were dewaxed with a specifically developed protocol that allows the removal of paraffin in less than 15 minutes. All MC present in each tissue section (usually from 2 to &gt;10 per section) were then characterized by a Raman microscope thus obtaining Raman maps with lateral resolution between 5 and 10 μm. After pre-processing steps the Raman maps were analysed by both clustering and multivariate analysis approaches used to produce false-colour images and to perform automated features identification.

Results: Our results confirm that hydroxyapatite is the prevalent form of calcium phosphate in MC and that MC composition correlates with lesion malignancy. In addition, thanks to the Raman imaging approach used here, we report for the first time that hydroxyapatite is more homogeneously distributed in malignant lesions and that, on the contrary, benign lesions show a heterogeneous distribution of hydroxyapatite, whitlockite and calcium-carbonate, inside the lesion and in the surrounding tissue.

Conclusion: These evidences suggest that the characterization of MC by Raman imaging is a potential tool for the definition of new diagnostic signatures of breast cancer, especially if we consider that these evaluations can be performed by the simple and relative fast scanning of dewaxed slices, without altering the clinical workflow and without the need of staining or antibodies. Further studies with a larger cohort will be done to validate these results.

Citation Format: Vanna R, Morasso C, Piccotti F, Sorrentino L, Villani L, Torti E, Bonizzi A, Leporati F, Corsi F. Raman imaging as a tool for the chemical and spatial characterization of breast microcalcifications to improve lesion assessment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-20-05.

Coagulation Disorders in Patients with Tumors of the Uterus

Sixty-eight previously untreated female subjects were studied: 26 patients with cervical carcinoma, 22 with endometrial carcinoma, and 20 with benign uterine diseases. These patients, together with 25 healthy female control subjects, underwent several coagulation tests, including beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) plasma levels. Of all the parameters considered, the variations in beta-TG and PF4 were the most interesting. They were increased in patients with cervical and endometrial carcinoma. The sensitivity of the two tests reached 79% (15/19) for patients with invasive cervical carcinoma and 74% (16/22) for all patients with endometrial carcinoma. Our data demonstrate that among the investigated parameters beta-TG and PF4 are the earliest disorders of the hemostatic system and are more frequently increased in the gynecologic malignancies.

Pharmacological manipulation of the NMDA receptor differentially protects from systemic kainic acid neuropathology: evaluation through ornithine decarboxylase induction, morphology and GFAP immunohistochemistry

The excitotoxic brain damage caused by systemic administration of kainic acid requires the activation of N-methyl-D-aspartate (NMDA) receptors in order to fully express its neurotoxic potency. We have tested the relative efficacy of different manipulations of the NMDA receptor on morphological, immunohistochemical and neurochemical parameters in this experimental model. A competitive (CGP 39551) and a non-competitive (MK 801) antagonist of the NMDA receptor, granted full protection against neuronal degeneration and consequent glial proliferation in the hippocampus and olfactory cortex, two regions severely affected by systemic administration of kainic acid. In addition, CGP 39551 completely counteracted the dramatic induction of the enzyme ornithine decarboxylase which occurs shortly after kainic acid administration. Systemic administration of high amounts of MgSO4 concomitantly and after kainic acid injection, appeared to partially prevent neuronal degeneration but had no clear effects on glial reaction and ornithine decarboxylase induction. Finally administration of an antagonist of the polyamine site present in the NMDA receptor (SL 82.0715), did not appear to have any protective effect at the dose used here. The present results help to better understand the ways by which it could be possible to counteract excitotoxic brain injuries.

OEM-TACE: a new therapeutic approach in unresectable intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare life-threatening disease, whose only treatment with potential for cure is surgical resection. However, only 27% of patients at most are suitable for surgery when first diagnosed. For patients with unresectable disease, therapeutic options are chemotherapy or chemoradiation. We evaluated the feasibility and safety of oxaliplatin-eluting microspheres transarterial chemoembolization (OEM-TACE) associated with chemotherapy (ChT) in patients affected by unresectable ICC. Between December 2005 and May 2008 we treated nine patients (six female and three male) with unresectable ICC. All patients had undergone OEM-TACE associated with chemotherapy with oxaliplatin and gemcitabine. A retrospective comparison was carried out with a historical group of 11 patients treated with ChT only, estimating the prevalence of adverse effects and the median survival of the two groups. A total of 30 TACEs were performed during the observational time (ranging from one to seven procedures per patient). OEM-TACEs were followed by few adverse effects (AEs), without G4 AEs, according to CTACAE 3.0. According to RECIST criteria, 44% (4/9) of patients achieved partial responses and 56% (5/9) stabilization of disease. Overall survival analysis in the two groups showed a significantly increased survival in patients treated with ChT and OEM-TACE, with respect to those treated with ChT (30 vs. 12.7 months; p=0.004). In conclusion, in our experience OEM-TACE associated with ChT in the treatment of advanced unresectable ICC is a safe and feasible treatment causing no major adverse events. Although RECIST criteria can underestimate the rate of responses in patients treated with locoregional therapies, we achieved very encouraging results. A randomized multicentric trial is warranted to assess the actual superiority of OEM-TACE associated with ChT compared to conventional chemotherapy.

Occurrence of medullary thyroid carcinoma, bronchial carcinoid tumor, and papillary thyroid carcinoma in a family bearing the RET G691S polymorphism

RET mutations play an important role in the development of human neuroendocrine tumors. The prevalence of the RET polymorphism G691S of exon 11 is higher in patients with medullary thyroid carcinoma (MTC) as compared to the general population. A weak association between RET polymorphisms and sporadic papillary thyroid carcinoma (PTC) has also been described. We hereby describe the association of MTC, bronchial carcinoid tumor, and PTC in a familial setting. A 75-yr-old woman developed MTC 7 yr after successful treatment of a bronchial carcinoid. Serum calcitonin was 12.9 pg/ml with a peak response to pentagastrin (151.0 pg/ml). The patient underwent total thyroidectomy and a genetic mutational analysis of the RET gene. Histological evaluation confirmed MTC with no evidence of lymph nodes involvement. After thyroidectomy serum calcitonin was <2.0 pg/ml. A germline missense mutation at codon 691 in exon 11 of the RET gene was found. The mutational analysis was extended to the patient's offspring, and her daughter was found to bear the G691S polymorphism of RET. Wild type RET gene was found in the son. The daughter, who showed a nodular goiter, autoimmune thyroiditis and normal serum calcitonin, also underwent thyroidectomy. Histologic examination of the thyroid revealed an incidental PTC. This is the first description of a bronchial carcinoid tumor occurring in association with MTC. The occurrence of apparently unrelated NET in the same subject, or within a family, should be regarded as a challenge for deeper investigations into the possible oncogenic role of this genetic alteration.

Proton pump inhibitors, enterochromaffin-like cell growth and Helicobacter pylori gastritis

In both rodents and humans the development of gastrin-promoted gastric argyrophil enterochromaffin-like cell carcinoids requires the involvement of a genetic factor inherent to multiple endocrine neoplasia syndrome or of type A autoimmune chronic atrophic gastritis. Prolonged severe hypergastrinaemia acting on non-gastritic mucosa, as in Zollinger-Ellison syndrome patients, results in diffuse argyrophil enterochromaffin-like cell hyperplasia but, as a rule, does not produce tumours. Combination of chronic atrophic gastritis (mostly related to Helicobacter pylori infection) with hypergastrinaemia frequently causes linear and micronodular hyperplasia of argyrophil cells, whereas carcinoids are exceptional. No tumours or pre-neoplastic lesions have been observed in patients treated long-term with proton pump inhibitors, apart from rare cases in patients with combined Zollinger-Ellison and multiple endocrine neoplasia syndromes. A moderate increase in the incidence of argyrophil cell clustering, with or without hyperplasia, probably results from the parallel evolution of ulcer-associated Helicobacter gastritis into chronic atrophic gastritis. Eradication of H. pylori with a combination of proton pump inhibitors and antibiotics suppresses gastritis and prevents ulcer recurrence.

Cytopathologic examination of epidural catheter for postoperative analgesia. Pathophysiology and clinical management

AIM

The authors performed a prospective study in a series of patients undergoing combined general and epidural anaesthesia for major abdominal surgery in order to define if the epidural catheter inserted for postoperative analgesia induced in the short-term (7-8 postoperative days) any cytopathologically appreciable inflammatory response.

METHODS

From April to September 2001, 20 consecutive patients undergoing combined general and epidural anaesthesia for major abdominal surgery at the National Cancer Research Institute and Villa Scassi Hospital (Genoa), were recruited after obtaining Institutional Ethics Committee approval and written consent from the patients. The standard technique for epidural anaesthesia was adopted. Preoperatively, all patients received peridurally a dose test of 3 ml of 2% lidocaine (60 mg) followed by 5 ml of ropivacaine 0.75%, and a continuous infusion of ropivacaine 0.375% (5-10 ml/h; maximal dose=20 ml) intraoperatively. As regards the therapeutic management of postoperative analgesia, patients received a continuous infusion of ropivacaine 0.2% for at least 48 hours and supplemental bolus (2 mg/die) of morphine hydrochloride. The epidural catheter was always removed between the 7th and 8th postoperative day, and it was examined by the pathologist according to the Thin Prep 2000 procedure.

RESULTS

The cytopathologic examination of the tip of the epidural catheter gave the following findings: amorphous material without cells (n=10); rare granulocytes and histiocytes (n=6); stromal cells (n=3), and rare lymphocytes (n=1).

CONCLUSION

We were unable to detect any cytopathologically appreciable inflammatory response at the tip of the epidural catheter which could have suggested the occurrence of inflammation in the epidural tissues. Given the positive results of prophylactic epidural administration of small doses of corticosteroids in the reduction of postepidural anaesthesia back pain and their direct membrane action on nociceptive C-fibers, this kind of backache seems to be related to the stimulations of such nociceptors more than to a catheter-related inflammatory response of epidural tissues with possible evolution in peridural fibrosis, as reported following surgical intervention for lumbosacral disease.

Distribution and expression of A1 adenosine receptors, adenosine deaminase and adenosine deaminase-binding protein (CD26) in goldfish brain

The expression patterns of adenosine A(1) receptors (A(1)Rs), adenosine deaminase (ADA) and ADA binding protein (CD26) were studied in goldfish brain using mammalian monoclonal antibody against A(1)R and polyclonal antibodies against ADA and CD26. Western blot analysis revealed the presence of a band of 35 kDa for A(1)R in membrane preparations and a band of 43 kDa for ADA in both cytosol and membranes. Immunohistochemistry on goldfish brain slices showed that A(1) receptors were present in several neuronal cell bodies diffused in the telencephalon, cerebellum, optic tectum. In the rhombencephalon, large and medium sized neurons of the raphe nucleus showed a strong immunopositivity. A(1)R immunoreactivity was also present in the glial cells of the rhombencephalon and optic tectum. An analogous distribution was observed for ADA immunoreactivity. Tests for the presence of CD26 gave positive labelling in several populations of neurons in the rhombencephalon as well as in the radial glia of optic tectum, where immunostaining for ADA and A(1)R was observed. In goldfish astrocyte cultures the immunohistochemical staining of A(1)R, ADA and CD26, performed on the same cell population, displayed a complete overlapping distribution of the three antibodies. The parallel immunopositivity, at least in some discrete neuronal areas, for A(1)Rs, ADA and CD26 led us to hypothesize that a co-localization among A(1)R, ecto-ADA and CD26 also exists in the neurons of goldfish since it has been established to exist in the neurons of mammals. Moreover, we have demonstrated for the first time, that A(1)R, ecto-ADA and CD26 co-localization is present on the astroglial component of the goldfish brain. This raises the possibility that a similar situation is also shown in the glia of the mammalian brain.

Loss of heterozygosity at 18q21 region in gastric cancer involves a number of cancer-related genes and correlates with stage and histology, but lacks independent prognostic value

Several studies support a role of 18q21 LOH, involving the DCC locus, in colorectal cancer progression; however, its contribution to the natural history of gastric cancer is less clear. Recently, a number of cancer-related genes have been mapped in the 18q21 region, either centromeric or telomeric to DCC. This study searched for 18q21 LOH in 161 gastric cancers representative of all tumour stages and main histological types. To this purpose, seven highly polymorphic markers were used flanking the 18q21 band and spanning the entire region. Thirty-four out of 147 (23.1%) informative cases showed LOH. In 27 of 34 cases (79%), LOH involved all the informative loci. The remaining seven cases showed LOH at more telomeric sites and retained heterozygosity at more centromeric markers, mostly those proximal to the DCC gene. A strong correlation between 18q21 LOH and level of gastric wall invasion, lymph node metastases, or stage was found in cohesive (glandular+solid) and mixed tumours, but not in diffuse cancers. Cox univariate and multivariate analysis showed that invasion level, lymph node metastases, distant metastases, TNM stage, and histology were effective predictors of survival, whereas 18q21 LOH did not show predictive power. The simultaneous deletion of a variety of cancer-related genes with different and even opposite roles might explain why, apparently, 18q21 LOH does not per se contribute significantly to the natural history of gastric cancer, despite strong correlation with stage.

Nasal paraganglioma. A case report

Nasal paraganglioma. A case report. Nonchromaffin paragangliomas or chemodectomas arise in paraganglia distributed in various parts of the body. The jugular bulb, the vagal body and the bifurcation of the carotid artery are the most common sites of origin of paraganglioma in the head and neck region. Paragangliomas in the nose and paranasal sinuses are extremely rare and very few cases of definite paraganglioma arising primarily in the nose or paranasal sinuses have been reported. The paraganglioma is a slow-growing tumour that produces nasal obstruction, profuse epistaxis and facial swelling. Complete excision of the glomus tumour is normally curative. We report a case of nasal paraganglioma and discuss the diagnosis and therapy.

Molecular mechanisms involved in the pathogenesis of gastric carcinoma: interactions between genetic alterations, cellular phenotype and cancer histotype

Gastric cancer develops through the accumulation of multiple genetic lesions that involve oncogenes, tumor suppressor genes and DNA mismatch repair genes. Lauren's classification of gastric carcinoma does not correlate with cellular phenotypes expressed by neoplastic cells and gastric and intestinal cell differentiation markers are widely expressed in both types (intestinal and diffuse) of gastric carcinoma. In contrast, the study of the correlation between morphologic events and genetic alterations, which come about in the cancerogenetic process, seems to indicate the existence of distinct cancerogenetic pathways for the intestinal (or glandular) and diffuse type carcinoma, both originating from a HP-positive gastritis. In particular there seem to be three different profiles of cancerogenesis: 1) p53 mutations which accompany the onset of dysplasia and intestinal-type carcinoma; 2) DNA repair mechanism alterations conditioning microsatellite instability, seem mutually exclusive with regards to p53 mutations. Microsatellite instability correlates with antrally located intestinal-type carcinoma, with little metastatic tendency and a better prognosis; microsatellite instability frequently involves the TGF beta RII, IGF II R genes or the BAX proapoptotic gene, in as much as these contain microsatellite sequences; 3) alterations of E-cadherin, both with regards to mutations and abnormal expression. These lead to junctional and cell polarity loss and are primarily associated with diffuse type carcinoma, which is characterized by poorly cohesive neoplastic cells. Some tumors, initially arising as intestinal-type (glandular structure), acquire a mixed histotype during neoplastic progression, in which both the typical alterations of the intestinal cancerogenesis (p53, microsatellite instability) and those of the diffuse carcinoma (E-cadherin) coexist. The identification of a mixed histotype could have importance both in epidemiologic, pathogenetic and prognostic terms.

MPTP-induced apoptosis in the retina of goldfish

Neuronal degeneration observed in the goldfish retina after MPTP administration, displays features of apoptosis, a physiological mechanism of cell death that occurs during development. The ultrastructural features of degenerating retinal neurons, that are seen in the inner nuclear layer two days after intravitreal MPTP administration, are consistent with classic changes observed in the programmed cell death. The DNA strand breaks that characterize apoptotic death are in situ detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling.

Regional distribution of nitric oxide synthase and NADPH-diaphorase activities in the central nervous system of teleosts

Neuronal nitric oxide synthase (nNOS) and NADPH-diaphorase activities were investigated in discrete areas of the central nervous system of goldfish and brown trout. Both species showed a similar distribution pattern of nNOS activity with regional differences in all examined areas. Telencephalon and hypothalamus showed the highest nNOS values, while in the goldfish cerebellum and its valvula nNOS was not detectable. In both species, NADPH-diaphorase activity showed a lower regional variability, compared to nNOS. The highest activity was measured in the olfactory bulbs where, conversely, low levels of nNOS activity were present. The non close correspondence between NOS and NADPH-diaphorase activities confirms the discrepancies indicated by morphological data. Western blot analysis revealed the presence of a nNOS isoform of about 150 kDa mol. wt. corresponding to that of mammals. The pattern of nNOS expression in the considered brain regions of the goldfish and trout was comparable to the levels of the nNOS activity.

The development of NADPH-diaphorase and nitric oxide synthase in the visual system of the cichlid fish, Tilapia mariae

The pattern of NADPH-diaphorase expression was studied in the retina and optic tectum of the cichlid fish Tilapia mariae during the first developmental stages. NADPH-diaphorase activity was seen early, at hatching. In the retina a few cell bodies of the retinal inner nuclear layer showed a faint labeling. Scattered labeled cells were found in the stratum periventriculare of the optic tectum, while the optic nerve was unlabeled. Two days after hatching, the number of labeled neurons increased in the inner nuclear layer and a few stained cell bodies were also scattered in the ganglion cell layer. Both the inner and outer plexiform layers showed a diffuse staining and the optic nerve was devoid of labeling. In the optic tectum several positive cells in the periventricular layer, with their dendritic trees extending in the superficial fibrous layer, were found. In 1-month-old Tilapia, NADPH-diaphorase staining and nitric oxide synthase immunoreactivity were found to overlap in both the retina and optic tectum. The density of NADPH-diaphorase labeled neurons in the inner nuclear layer of the retina and in the stratum periventriculare of the optic tectum was largely reduced in comparison with 2 days posthatching embryos. These findings indicated an early and transient production of nitric oxide in the retina and optic tectum of Tilapia, suggesting a functional role for nitric oxide in the development of visual structures in aquatic vertebrates.

The calcium-dependent [3H]acetylcholine release from synaptosomes of brown trout (Salmo trutta) optic tectum is inhibited by adenosine A1 receptors: effects of enucleation on A1 receptor density and cholinergic markers

Presynaptic inhibition is one of the major control mechanisms in the CNS. Previously we reported that A1 adenosine receptors are highly concentrated in the brain, including optic tectum, of trout and that they inhibited the release of glutamate. The optic tectum is heavily innervated by cholinergic nerve terminals. We have investigated whether A1 receptors inhibit the presynaptic release of acetylcholine and whether the inhibition is triggered by calcium. The release of [3H]ACh evoked by 30 mM KCl was Ca2+ dependent and it was dose-dependently inhibited by the A1 adenosine receptor agonist 2-chloro-N(6)-cyclopentyladenosine (CCPA) ranging between 10 nM to 100 microM. The maximum of inhibition was reached at 10 microM. The A1 receptor antagonist 8-cyclopentyltheopylline (CPT, 10 microM), reversed almost completely the inhibition induced by CCPA 10 microM. In Fura-2/AM loaded synaptosomes, K(+) depolarization raised [Ca2+](i) by about 64%. CCPA (10 microM) reduced the K(+)-evoked Ca2+ influx increase by about 48% and this effect was completely antagonised by CPT 10 microM. Synaptosome pretreatment with different Ca2+ channel blockers differently affected K(+)-evoked Ca2+ influx. This was not significantly modified by nifedipine (1 microM, L-type blocker) nor by omega-agatoxin IVA (0.3 microM, P/Q-type blocker), whereas about 50% reduction was shown by 0.5 microMomega-conotoxin GVIA (N-type blocker). Neurochemical parameters associated with cholinergic transmission and the density of A(1) adenosine receptors were measured in the trout optic tectum 12 days after unilateral eye ablation. A significant drop of both acetylcholinesterase (AChE) activity (24%) and choline acetyltransferase (CAT) activity (32%) was observed in deafferentated optic tectum, whereas the high affinity choline uptake did not parallel the decrease in enzyme activity. Eye ablation caused a marked decrease (43%) of A1 receptor density without changing the affinity. The K(+)-evoked release of [3H]ACh from synaptosomes of deafferentated was not modify as well as the efficacy of 10 microMCCPA in decreasing [3H]ACh release was not apparently modified.

Analysis of gastroduodenitis and oesophagitis in relation to dyspeptic/reflux symptoms

BACKGROUND/AIMS

The pathogenesis of dyspeptic/reflux symptoms and the clinico-pathologic profile of affected patients are still poorly understood. To improve our knowledge in this field we carried out a systematic, comparative analysis of symptom profiles and histopathologic patterns of oesophagogastroduodenal mucosa in a series of 221 subjects, 140 with and 81 without endoscopic evidence of hiatal hernia. Of these, 190 showed reflux and/or dyspeptic symptoms.

METHODS

Before endoscopy, all the subjects were questioned about the presence and severity of 12 individual symptoms. Biopsies were taken from the distal oesophagus, cardia, corpus, angulus, antrum and duodenal bulb, and were scored in accordance with the Sydney system.

RESULTS

Patient groups with a distinct clinico-pathologic profile were better identified when symptoms of adequate severity were compared with histopathologic parameters. A correlation between gastroesophageal reflux disease (GORD) symptoms and histologic signs of oesophagitis was mostly restricted to patients endoscopically positive for oesophagitis. Retroxiphoid pyrosis correlated with cardial gastritis but not with oesophagitis, either endoscopic or histologic, while ulcer-like epigastric pain correlated with active duodenitis and distal gastritis. No definite histopathologic background was detected in patients with putative dysmotility-like symptoms, endoscopy-negative GORD and low score or mixed symptoms.

CONCLUSION

A contribution of Helicobacter pylori gastroduodenitis to the pathogenesis of some dyspeptic symptoms seems likely. However, the identification of specific histologic changes causing individual symptoms remains rather elusive, with the exception of active antroduodenitis in patients with ulcer-like pain and of active proximal gastritis in patients with severe retroxiphoid pyrosis.

Altered intercellular glycoconjugates and dilated intercellular spaces of esophageal epithelium in reflux disease

BACKGROUND AND AIMS

The usefulness of histological diagnosis of gastroesophageal reflux disease (GERD) is limited by poor specificity or sensitivity of available diagnostic tools. Recently, ultrastructural morphometry showed interstitial space dilation (ISD) to be a reliable sign of reflux disease. Aims of this study were to (a) search for a light microscopy equivalent of ISD, (b) test its diagnostic value, and (c) look for a possible role of intercellular glycoconjugates in its genesis.

METHODS

Esophageal grasp biopsies were taken during endoscopy, 2-3 cm and 6-7 cm above the squamocolumnar junction, from patients under investigation for GERD symptoms. The biopsies were fixed in aldehyde solutions and embedded in resin for electron microscopy or in paraffin for routine histology, and the glycoconjugates underwent immunohistochemistry using 3-fucosyl-N-acetylactosamine antibodies.

RESULTS

Irregular intercellular space dilation was detected in the basal and prickle layers using both light and electron microscopy. Hematoxylin-eosin preparations showed ISD in 20 of 22 (90%) erosive esophagitis cases, 30 of 44 (68%) endoscopy negative GERD cases, and 1 of 12 (8%) controls, with good interobserver (K = 0.75) and bioptic site reproducibility. ISD correlated with loss or rearrangement of intercellular glycoconjugates of the overlying layers and with granulocyte (eosinophil and/or neutrophil) infiltration.

CONCLUSIONS

Light microscopy ISD is a suitable index of GERD. Alterations of intercellular glycoconjugates are likely to have a role in the genesis of ISD and GERD.

Developmental pattern of NADPH-diaphorase activity in the peripheral nervous system of the cichlid fish Tilapia mariae

The distribution of NADPH-diaphorase activity was studied in the cichlid fish Tilapia mariae, during the first developmental stages by means of the tetrazolium salt technique. The reaction product was first found, 48 hours after fertilization (stage 10), in the cells of the olfactory placodes and in the superficial neuromasts. A faint positivity was seen in some hair cells of the otic vesicles. The epithelial cells of the most caudal part of the intestinal tract showed a strong labeling. At stage 12 (hatch), the reaction product was in addition detected in scattered enteric neurons surrounding the digestive tract. At stage 13 (4.5 days after spawning), the reaction product was also found in the putative sympathetic trunk, which supplies the gill arches and digestive tract. The epithelial cells of the gastrointestinal canal showed a more strong positive labeling and two large clusters of cells near the pronephritic tubules (the putative adrenomedullar tissue) were also labeled. The present results indicate an early activity of NADPH-diaphorase during the development of the peripheral nervous system of Tilapia and reveal a gradual maturation of NADPH-diaphorase positive structures.

Development of NADPH-diaphorase activity in the central nervous system of the cichlid fish, Tilapia mariae

The distribution of nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase activity was studied in the cichlid fish Tilapia mariae during ontogenesis by the histochemical reaction of NADPH-diaphorase that indicates, in aldehyde-fixed tissue, the presence of nitric oxide synthase, which is the enzyme responsible for nitric oxide production. The first appearance of NADPH-diaphorase-positive neurons has a striking bilateral symmetry and occurs 20 h after fertilization (stage 8) in the olfactory placodes and in the neural tube where two clusters of positive neurons were seen in the diencephalon and in the rhombomere r4 of the hindbrain. Two days after fertilization (stage 10), the clusters of positive neurons showed labeled axons. The two longitudinal fiber bundles that arose from the diencephalic positive neurons ran caudally in the tract of the postoptic commissure. At stage 12 (3.5 days after fertilization), new populations of NADPH-diaphorase-positive neurons appeared in the telencephalon, in some diencephalic nuclei, and in the hypothalamus. Several trigeminal motor neurons showed strong NADPH-diaphorase activity, whereas the optic tectum and cerebellum were completely free of enzymatic activity. In the hindbrain, clusters of positive neurons were seen in the octavolateral region and in the region defined by the exit of the vagus nerve. In the cervical spinal cord, some ventral putative motor neurons were labeled. At stage 14 (5.5 days after fertilization), several periventricular neurons of the optic tectum and some neurons of the cerebellar lamina were labeled. Dorsal neurons, including a few large superficial neurons were also labeled in the cervical spinal cord. NADPH-diaphorase activity was seen in the neuropil area of the telencephalon, the target of olfactory inputs, and in the sensory dorso-lateral area of the spinal cord.

Genetic pattern, histological structure, and cellular phenotype in early and advanced gastric cancers: evidence for structure-related genetic subsets and for loss of glandular structure during progression of some tumors

Gastric cancer shows remarkable heterogeneity in histological pattern, cellular phenotype, and genotype. Tumor subsets identified by varying procedures have shown limited reciprocal correlation and have failed to provide a sound rationale for the characterization and classification of all tumors. Based on a case series of 130 gastric cancers that covered both early (70 cases) and advanced (60 cases) stages and that represented most histological types and structural patterns, this study investigated (1) microsatellite instability and p53 gene mutation by means of PCR-based molecular techniques and (2) p53 protein accumulation or tumor cell immunophenotype by means of immunoperoxidase procedures. It was found that microsatellite instability and p53 gene mutation involve two distinct subsets of both early and advanced-stage glandular (intestinal) cancer, and that, contrastingly, they leave purely diffuse cancers unaffected. Mixed cancers, namely, those in which glandular admixed with diffuse growths, showed scarce microsatellite instability at all stages, whereas prominent p53 gene mutation and p53 protein accumulation was limited to the advanced stage alone. No significant correlation was found between tumor cell immunophenotype and either genotype or histotype, although some correlation with particular structural patterns was detected. Comparison of intramucosal with invasive growths within any given tumor suggested that invasive cancers with diffuse-type growth arise in part from mucosal cancers of glandular or mixed structure through progressive loss of intercellular junctional systems. It is concluded that at least two genetically distinct subsets of glandular cancer, one with microsatellite instability and the other with p53 lesions, should be separated both from purely diffuse cancer and, at least in the advanced stage, from mixed cancer. Available evidence suggests distinct clinicopathologic profiles for such tumor entities.

Changes in NADPH-diaphorase expression induced by excitotoxicity in the goldfish retina: relation with some morphological and biochemical aspects

We report alterations in the pattern of NADPH-diaphorase staining, a marker of nitric oxide, in the goldfish retina after kainic acid administration. The heavily stained ellipsoids of the photoreceptors, the heavily stained neurons of the inner plexiform layer and the labeled neurons of the ganglion cell layer are spared by excitotoxic insult, while the faintly medium sized neurons of the inner plexiform layer disappear after kainic acid administration. Furthermore, in the bipolar and in the horizontal retinal neurons we observe an induction of NADPH-diaphorase expression. The kainic acid-induced neurotoxicity evaluated by morphological observations and by measuring the levels of choline acetyltranferase in retinal homogenates, is not prevented by the administration of a nitric oxide synthase inhibitor.

Apoptosis is induced by excitotoxicity in goldfish retina

Apoptosis is an important mechanism of cell death that occurs physiologically during development. Recently, it has been shown that the selective pattern of neuronal degeneration in some brain disorders or in excitotoxic animal models, can reveal signs of apoptosis. This work produces evidence that kainic acid, a non-NMDA receptor agonist, induces apoptotic cell death in the goldfish retina. DNA breaks are in situ detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL). This reaction shows a large number of positive cells in the inner nuclear layer 48 hours after intravitreal kainic acid administration. TUNEL staining of apoptotic death was prevented by the non-NMDA glutamate receptor antagonist 6,7-dinitroquinoxaline-2,3-dione (DNQX) but not by the NMDA receptor antagonist MK-801 administration. Ultrastructural changes that occur in kainic acid affected retinal neurons (hypercondensation and clumping of the chromatin and shrinkage of the cytoplasm) are consistent with those described in programmed cell death. Our results indicate that the excitotoxicity of intravitreally injected kainic acid causes the degeneration of those neurons in the goldfish retina, that underwent apoptotic death.