Iron-catalyzed C-H Alkylation/Ring Opening with vinylbenzofurans Enabled by Triazoles

We report an unprecedented iron-catalyzed C-H annulation using readily available 2-vinylbenzofurans as the reaction pattern. The redox-neutral strategy, based on cheap, non-toxic and earth abundant iron catalysts, exploits triazole assistance to promote a cascade C-H alkylation, benzofuran ring-opening and insertion into a Fe-N bond, to form highly functionalized isoquinolones. Detailed mechanistic studies supported by DFT calculations fully disclosed the manifold of the iron catalysis.

Nickel-Catalyzed Atroposelective C-H Alkylation Enabled by Bimetallic Catalysis with Air-Stable Heteroatom-Substituted Secondary Phosphine Oxide Preligands

The catalytic asymmetric construction of axially chiral C-N atropisomers remains a formidable challenge due to their low rotational barriers and is largely reliant on toxic, cost-intensive, and precious metal catalysts. In sharp contrast, we herein describe the first nickel-catalyzed atroposelective C-H alkylation for the construction of C-N axially chiral compounds with the aid of a chiral heteroatom-substituted secondary phosphine oxide (HASPO)-ligated Ni-Al bimetallic catalyst. A wide range of alkenes, including terminal and internal alkenes, were well compatible with the reaction, providing a variety of benzimidazole derivatives in high yields and enantioselectivities (up to 97:3 e.r.). The key to success was the identification of novel HASPOs as highly effective chiral preligands. Mechanistic studies revealed the catalyst mode of action, and in-depth data science analysis elucidated the key features of the responsible chiral preligands in controlling the enantioselectivity.

Modern Organometallic C-H Functionalizations with Earth-Abundant Iron Catalysts: An Update

Iron-catalyzed C-H activation has recently emerged as an increasingly powerful synthetic method for the step- and atom- economical direct C-H functionalizations of otherwise inert C-H bonds. Iron's low-cost and toxicity along with its catalytic versatility have encouraged the scientific community to elect this metal for the development of new C-H activation methodologies. Within this review, we aim to present a collection of the most recent examples of iron-catalyzed C-H functionalizations with a particular emphasis on modern synthetic strategies and mechanistic aspects.

Triazole-enabled, iron-catalysed linear/branched selective C-H alkylations with alkenes

Iron-catalysed C-H alkylations with alkenes were achieved on benzamides by N-triazole assistance. A notable switch of the regioselectivity from linear to branched was observed depending on the nature of the olefin employed. The approach allowed for the synthesis of a family of decorated benzamides with ample scope and high levels of chemo-, regio- and site-selectivity.

Is Lactoferrin More Effective in Reducing Late-Onset Sepsis in Preterm Neonates Fed Formula Than in Those Receiving Mother's Own Milk? Secondary Analyses of Two Multicenter Randomized Controlled Trials

BACKGROUND

Lactoferrin is the major antimicrobial protein in human milk. In our randomized controlled trial (RCT) of bovine lactoferrin (BLF) supplementation in preterm neonates, BLF reduced late-onset sepsis (LOS). Mother's own milk (MM) contains higher concentrations of lactoferrin than donor milk or formula, but whether BLF is more effective in infants who receive formula or donor milk is uncertain.

AIM

To evaluate the incidence of LOS in preterm infants fed MM and in those fed formula and/or donor milk.

STUDY DESIGN

This is a (A) post hoc subgroup analysis, in our RCT of BLF, of its effects in preterm infants fed MM, with or without formula, versus those fed formula and/or donor milk (no-MM) and (B) post hoc meta-analysis, in our RCT of BLF and in the ELFIN (Enteral Lactoferrin in Neonates) RCT, of the effect of BLF in subgroups not exclusively fed MM.

RESULTS

(A) Of 472 infants in our RCT, 168 were randomized to placebo and 304 were randomized to BLF. Among MM infants, LOS occurred in 22/133 (16.5%) infants randomized to placebo and in 14/250 (5.6%) randomized to BLF (relative risk or risk ratio (RR): 0.34; relative risk reduction (RRR): 0.66; 95% confidence interval (95% CI) for RR: 0.18-0.64; p < 0.0008). Among no-MM infants, LOS occurred in 7/35 (20.0%) randomized to placebo and in 2/54 (3.7%) randomized to BLF (RR: 0.19; RRR: 0.81; 95% CI for RR: 0.16-0.96; p = 0.026). In multivariable logistic regression analysis, there was no interaction between BLF treatment effect and type of feeding (p = 0.628). (B) In 1,891 infants not exclusively fed MM in our RCT of BLF and in the ELFIN RCT, BLF reduced the RR of LOS by 18% (RR: 0.82; 95% CI: 0.71-0.96; p = 0.01).

CONCLUSION

Adequately powered studies should address the hypothesis that BLF is more effective in infants fed formula or donor milk than those fed MM. Such studies should evaluate whether a specific threshold of total lactoferrin intake can be identified to protect such patients from LOS.

Exposure to Gastric Acid Inhibitors Increases the Risk of Infection in Preterm Very Low Birth Weight Infants but Concomitant Administration of Lactoferrin Counteracts This Effect

OBJECTIVE

To investigate whether exposure to inhibitors of gastric acidity, such as H2 blockers or proton pump inhibitors, can independently increase the risk of infections in very low birth weight (VLBW) preterm infants in the neonatal intensive care unit.

STUDY DESIGN

This is a secondary analysis of prospectively collected data from a multicenter, randomized controlled trial of bovine lactoferrin (BLF) supplementation (with or without the probiotic Lactobacillus rhamnosus GG) vs placebo in prevention of late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) in preterm infants. Inhibitors of gastric acidity were used at the recommended dosages/schedules based on the clinical judgment of attending physicians. The distribution of days of inhibitors of gastric acidity exposure between infants with and without LOS/NEC was assessed. The mutually adjusted effects of birth weight, gestational age, duration of inhibitors of gastric acidity treatment, and exposure to BLF were controlled through multivariable logistic regression. Interaction between inhibitors of gastric acidity and BLF was tested; the effects of any day of inhibitors of gastric acidity exposure were then computed for BLF-treated vs -untreated infants.

RESULTS

Two hundred thirty-five of 743 infants underwent treatment with inhibitors of gastric acidity, and 86 LOS episodes occurred. After multivariate analysis, exposure to inhibitors of gastric acidity remained significantly and independently associated with LOS (OR, 1.03; 95% CI, 1.008-1.067; P = .01); each day of inhibitors of gastric acidity exposure conferred an additional 3.7% odds of developing LOS. Risk was significant for Gram-negative (P < .001) and fungal (P = .001) pathogens, but not for Gram-positive pathogens (P = .97). On the test for interaction, 1 additional day of exposure to inhibitors of gastric acidity conferred an additional 7.7% risk for LOS (P = .003) in BLF-untreated infants, compared with 1.2% (P = .58) in BLF-treated infants.

CONCLUSION

Exposure to inhibitors of gastric acidity is significantly associated with the occurrence of LOS in preterm VLBW infants. Concomitant administration of BLF counteracts this selective disadvantage.

TRIAL REGISTRATION

isrctn.org: ISRCTN53107700.

Zinc exposure for female workers in a galvanizing plant in Northern Italy

OBJECTIVES

Very little is known regarding the toxicokinetics of inhaled zinc, in particular in the case of female workers and for modern, low exposure settings. Our aim is to evaluate the relationship of external zinc levels to those of serum and urine for female workers.

MATERIAL AND METHODS

Eleven female workers (age: 41.7±8 years old, body mass index (BMI): 23.5±4.2 kg/m²) in a galvanizing plant were investigated. Exposure assessment consisted of personal/environmental air samples, and measurement of zinc in serum (collected at the end of first shift of the working week (T1)) and urine, collected before the first shift of the working week (T0), T1 and at the end of the last shift of the working week (T2).

RESULTS

Both environmental and personal air samplings for zinc and zinc compounds were below the recommended by the German Research Foundation (Deutsche Forschungsgemeinschaft - DFG) limit values of 2 mg/m³ (7.34±2.8 μg/m³ and 8.31±2.4 μg/ m³, respectively). Serum (118.6±20.9 μg /dl) and urine zinc levels were within reference values for female Italian subjects: the latter increased from 56.4±33.5 μg/dl at T0, to 59.8±37.0 μg/dl at T1, and ultimately 65.4±34.4 μg/dl at T2, but no significant trend was found. End of shift (Spearman's correlation coefficient p value = 0.027) and differential excretion of urinary zinc (both: T0 vs. T1 and T0 vs. T2) were correlated with airborne zinc concentration (p = 0.002 and 0.006, respectively).

CONCLUSIONS

In general, our data suggests that urine may be a useful medium also for female in order to assess zinc exposure. Further studies are required in order to evaluate whether differential excretion may be useful for the biomonitoring of zinc exposure in the workplaces also for male workers. Int J Occup Med Environ Health 2018;31(1):113-124.

Knowledge, attitudes, beliefs and practices of occupational physicians towards vaccinations of health care workers: A cross sectional pilot study in North-Eastern Italy

OBJECTIVES

This study aims to characterize personal attitudes and knowledge of a sample of Italian occupational physicians (OPhs) towards immunization practice in the case of healthcare workers (HCWs).

MATERIAL AND METHODS

A total of 90 OPhs (42.2% of males, 57.8% of females, mean age of 50.1±8.3 years old) compiled a structured questionnaire through a telephonic interview. They were asked about the official Italian recommendations for HCWs, their general knowledge of vaccine practice, their propensity towards vaccines (both in general and about specific immunizations), their risk perception about the vaccine-preventable infectious diseases. Eventually, a regression analysis was performed in order to identify factors predictive for vaccine propensity.

RESULTS

Only 12 out of 90 subjects correctly identified all the 7 recommended immunizations. The hepatitis B virus (HBV) vaccine was correctly identified by 95.6% of the sample, and was also associated with the more positive attitude and the more accurate risk perception. Influenza vaccine had the lowest acceptance (75.9%). Eventually, pertussis, measles, parotitis and varicella vaccines were insufficiently recognized as recommended ones (all cases < 50% of the sample). General knowledge of vaccine and knowledge of official recommendations were significantly correlated with the attitude towards immunization practice (r = 0.259, p = 0.014 and r = 0.438, p < 0.0001). In the regression analysis general knowledge (unstandardized coefficient (B) = 0.300, 95% confidence interval (CI): 0.090-0.510, p = 0.006) and risk perception (B = 0.579, 95% CI: 0.155-1.003, p = 0.008) were significant predictors of the propensity to vaccinate.

CONCLUSIONS

Vaccinations gaps in HCWs may found their roots in OPhs incomplete knowledge of evidence-based recommendations. Specific training programs and formations courses should then be planned. Int J Occup Med Environ Health 2017;30(5):775-790.

Knowledge, attitudes, beliefs and practices of Occupational Physicians towards seasonal influenza vaccination: a cross-sectional study from North-Eastern Italy

INTRODUCTION

The present study aims to characterize personal attitudes and knowledge of a sample of Italian Occupational Physicians (OPh) towards Seasonal Influenza Vaccine (SIV) in healthcare workers (HCWs).

METHODS

In total, 92 OPh (42.4% males, 57.6% females, mean age of 47.3 ± 10.4 years, 50 specialists in Occupational Medicine, 42 specialists in Hygiene and Public Health) were asked about their attitudes towards influenza vaccine, their general knowledge of vaccine practice, their propensity towards vaccines and, eventually, their risk perception about the influenza and influenza vaccine was investigated. A regression analysis was then performed in order to better characterize predictive factors for vaccine propensity.

RESULTS

Influenza was recognized as a vaccination recommended for HCWs in 89/92 of the sampled OPh (96.7%). However, prevalence of misconceptions about vaccines was relatively high, with 26/92 (28.3%) and 24/92 (26.1%) referring vaccinations as eliciting allergic and autoimmune diseases, respectively and identifying lethargic encephalitis (18/92, 19.6%), autism (17/92, 18.5%), diabetes mellitus (15/92, 16.3%) and multiple sclerosis (13/92, 14.1%) as causatively vaccine-related. Propensity towards influenza vaccination found a significant predictor in the general knowledge (beta coefficient 0.213, p value = 0.043), risk perception (beta coefficient 0.252, p value = 0.018) and general propensity towards vaccinations (beta coefficient 0.384, p value = 0.002).

DISCUSSION

In spite of a diffuse propensity towards SIV, adherence of OPh was still < 50% of the sample. Moreover, sharing of misbeliefs and misconceptions was significant. As knowledge and risk perceptions were identified as significant predictors of vaccine propensity, our results suggest that information and training programs for OPh should be appropriately designed.

Quantitative olfactory disorders and occupational exposure to phenolic resins

BACKGROUND

To investigate whether exposure to phenolic resins (PR) is associated with quantitative olfactory disorders (QOD), a cross-sectional study of self-reported olfactory impairment (SROI) was performed in occupationally exposed subjects.

MATERIAL AND METHODS

Sixty-six workers (45 males, 21 females) at the age (mean ± standard deviation) of 39.8±10.15 years old were divided into 3 exposure groups on the basis of biological exposure indices (BEI) for urinary phenols. It was asked whether the sense of smell has been normal or abnormal during the recent 2 months: the participants were eventually divided into self-reported normosmic, hyposmic, hyperosmic groups.

RESULTS

Prevalence of the SROI was 45.5%, with 21 (31.8%) workers complaining about the hyposmia, 12 (18.2%) - anosmia and 9 (13.6%) - hyperosmia. In univariate analyses, female sex was associated with the SROI and the hyperosmia. Highly exposed workers showed the SROI more frequently (odds ratio (OR) = 4.714; 95% confidence interval (CI): 1.077-20.626) than those not exposed (reference) or low exposed (OR = 1.333; 95% CI: 0.416-4.274). In multivariate analyses, female sex was the main risk factor for the SROI (adjusted odds ratio (ORa) = 5.622; 95% CI: 1.525-20.722) and the hyperosmia (ORa = 25.143; 95% CI: 2.379-265.7) but a high exposure to phenol (ORa = 11.133; 95% CI: 1.060-116.9) was the main risk factor for the anosmia.

CONCLUSIONS

This study has found slight evidence among the cross-section of chemical industry workers that the exposure to phenol may be associated with the SROI. On the other hand, self-reporting of the QOD may be biased by personal factors and further research with objective measurement is therefore required. Med Pr 2016;67(2):173-186.

Bovine lactoferrin supplementation for prevention of necrotizing enterocolitis in very-low-birth-weight neonates: a randomized clinical trial

IMPORTANCE

NEC is a common and severe complication in premature neonates, particularly those with very-low-birth-weight (VLBW, <1500 g at birth). Probiotics including lactobacillus rhamnosus GG (LGG) proved effective in preventing NEC in preterm infants in several RCTs.

OBJECTIVE

Lactoferrin, a mammalian milk glycoprotein involved in innate immune host defences, can reduce the incidence of NEC in animal models, and its action is enhanced by LGG. We tried to assess whether bovine lactoferrin (BLF), alone or with the probiotic LGG, has a similar effect in human infants, something that has not yet been studied.

DESIGN

An international, multicenter, randomized, double-blind, placebo-controlled trial conducted from October 1st, 2007 through July 31st, 2010.

SETTING

Thirteen Italian and New Zealand tertiary neonatal intensive care units.

PARTICIPANTS

743 VLBW neonates were assessed until discharge for development of NEC.

INTERVENTION

Infants were randomly assigned to receive orally either BLF (100 mg/day) alone (group LF; n = 247) or with LGG (at 6×10(9) CFU/day; group BLF + LGG; n = 238), or placebo (Control group; n = 258) from birth until day 30 of life (45 for neonates <1000 g at birth).

MAIN OUTCOME MEASURES

≥ stage 2 NEC; death-and/or-≥ stage 2 NEC prior to discharge.

RESULTS

Demographics, clinical and management characteristics of the 3 groups were similar, including type of feeding and maternal milk intakes. NEC incidence was significantly lower in groups BLF and BLF + LGG [5/247 (2.0%)] and 0/238 (0%), respectively] than in controls [14/258 (5.4%)] (RR = 0.37; 95% CI: 0.136-1.005; p = 0.055 for BLF vs. control; RR = 0.00; p < 0.001 for BLF + LGG vs. control). The incidence of death-and/or-NEC was significantly lower in both treatment groups (4.0% and 3.8% in BLF and BLF + LGG vs. 10.1% in control; RR = 0.39; 95% CI: 0.19-0.80; p = 0.008. RR = 0.37; 95% CI: 0.18-0.77; p = 0.006, respectively). No adverse effects or intolerances to treatment occurred.

CONCLUSIONS AND RELEVANCE

Compared with placebo, BLF supplementation alone or in combination with LGG reduced the incidence of ≥ stage 2 NEC and of death-and/or ≥ stage 2 NEC in VLBW neonates. BLF might be a promising strategy to prevent NEC in NICU settings. Further data on larger sample sizes are warranted before BLF can be widespreadly used in clinical settings.

TRIAL REGISTRATION

ISRCTN53107700-http://www.controlled-_trials.com/ISRCTN53107700.

Serratia marcescens in a neonatal intensive care unit: two long-term multiclone outbreaks in a 10-year observational study

We investigated two consecutive Serratia marcescens (S. marcescens) outbreaks which occurred in a neonatal intensive care unit (NICU) of a tertiary level hospital in North Italy in a period of 10 years (January 2003-December 2012). Risk factors associated with S. marcescens acquisition were evaluated by a retrospective case-control study. A total of 21,011 clinical samples was examined: S. marcescens occurred in 127 neonates: 43 developed infection and 3 died. Seven clusters were recorded due to 12 unrelated clones which persisted for years in the ward, although no environmental source was found. The main epidemic clone A sustaining the first cluster in 2003 reappeared in 2010 as an extended spectrum ?-lactamase (ESBL)-producing strain and supporting the second epidemic. Birth weight, gestational age, use of invasive devices and length of stay in the ward were significantly related to S. marcescens acquisition. The opening of a new ward for non-intensive care-requiring neonates, strict adherence to alcoholic hand disinfection, the timely identification and isolation of infected and colonized neonates assisted in containing the epidemics. Genotyping was effective in tracing the evolution and dynamics of the clones demonstrating their long-term persistence in the ward.

Human milk feeding prevents retinopathy of prematurity (ROP) in preterm VLBW neonates

BACKGROUND

Retinopathy of prematurity (ROP) is a multifactorial disease, but little is known about its relationships with neonatal nutritional policies. Human, maternal milk is the best possible nutritional option for all premature infants, including those at high risk for severe complications of prematurity, such as ROP.

OBJECTIVE

This is a secondary analysis of data collected during two multicenter RCTs performed consecutively (years 2004 through 2008) by a network of eleven tertiary NICUs in Italy. The two trials aimed at assessing effectiveness of fluconazole prophylaxis (Manzoni et al., N Engl J Med 2007 Jun 14;356(24):2483-95), and of bovine lactoferrin supplementation (Manzoni et al., JAMA 2009 Oct 7;302(13):1421-8), in prevention of invasive fungal infection, and of late-onset sepsis in VLBW infants, respectively. We tested the hypothesis that exclusive feeding with fresh maternal milk may prevent ROP of any stage - as defined by the ETROP study - in VLBW neonates, compared to formula feeding.

METHODS

We analyzed the database from both trials. Systematic screening for detection of ROP was part of the protocol of both studies. The definition of threshold ROP was as defined by the ETROP study. Univariate analysis was performed to look for significant associations between ROP and several possible associated factors, and among them, the type of milk feeding (maternal milk or formula for preterms). When an association was indicated by p < 0.05, multiple logistic regression was used to determine the factors significantly associated with ROP.

RESULTS

In both trials combined, 314 infants received exclusively human maternal milk (group A), and 184 a preterm formula because their mothers were not expected to breastfeed. The clinical, demographical and management characteristics of the neonates did not differ between the two groups, particularly related to the presence of the known risk factors for ROP. Overall, ROP incidence (any stage) was significantly lower in infants fed maternal milk (11 of 314; 3.5%) as compared to formula-fed neonates (29 of 184; 15.8%) (RR 0.14; 95% CI 0.12-0.62; p = 0.004). The same occurred for threshold ROP (1.3% vs. 12.3%, respectively; RR 0.19; 95% CI 0.05-0.69; p = 0.009). At multivariate logistic regression controlling for potentially confounding factors that were significantly associated to ROP (any stage) at univariate analysis (birth weight, gestational age, days on supplemental oxygen, systemic fungal infection, outborn, hyperglycaemia), type of milk feeding retained significance, human maternal milk being protective with p = 0.01.

CONCLUSIONS

Exclusive human, maternal milk feeding since birth may prevent ROP of any stage in VLBW infants in the NICU.

Bovine lactoferrin prevents invasive fungal infections in very low birth weight infants: a randomized controlled trial

BACKGROUND

Lactoferrin is a mammalian milk glycoprotein involved in innate immunity. Recent data show that bovine lactoferrin (bLF) prevents late-onset sepsis in preterm very low birth weight (VLBW) neonates.

METHODS

This is a secondary analysis of data from a multicenter randomized controlled trial where preterm VLBW neonates randomly received bLF (100 mg/day; group A1), bLF + Lactobacillus rhamnosus GG (10(6) colony-forming units per day; group A2), or placebo (group B) for 6 weeks. Here we analyze the incidence rates of fungal colonization, invasive fungal infection (IFI), and rate of progression from colonization to infection in all groups.

RESULTS

This study included 472 neonates whose clinical, nutritional, and demographical characteristics were similar. Overall, the incidence of fungal colonization was comparable (17.6%, 16.6%, and 18.5% in A1, A2, and B, respectively; P = .89 [A1] and .77 [A2]). In contrast, IFIs were significantly decreased in A1 and A2 (0.7% and 2.0%, respectively) compared with B (7.7%; P = .002 [A1] and .02 [A2]), and this was significantly true both in <1000 g (0.9% [A1] and 5.6% [A2], vs 15.0%) and in 1001 to 1500 g infants (0% and 0% vs 3.7%). The progression rate colonization-infection was significantly lower in the bLF groups: 3.7% (A1) and 12% (A2), vs 41.9%; P < .001 (A1) and P = .02 (A2). No IFI-attributable deaths occurred in the treatment groups, versus 2 in placebo. No adverse effects or intolerances occurred.

CONCLUSIONS

Prophylactic oral administration of bLF reduces the incidence of IFI in preterm VLBW neonates. No effect is seen on colonization. The protective effect on IFI is likely due to limitation of ability of fungal colonies to progress toward invasion and systemic disease in colonized infants.

Lactoferrin and prevention of late-onset sepsis in the pre-term neonates

Late-onset sepsis (LOS) affects a large proportion of pre-term neonates in neonatal intensive care units (NICUs) worldwide, with high morbidity and related mortality, and frequent occurrence of severe late neurodevelopmental impairment. Due to the frequency, severity and difficulties in early diagnosis and prompt therapy, prevention is crucial for decreasing the burden of infection-related complications in NICUs. It is well known that feeding with fresh maternal milk, hygiene measures and the cautious use of H2-blockers are related with a decreased risk of developing sepsis. However, evidence from randomised clinical trials exists only for fluconazole in the prevention of fungal infections in the NICU. Lactoferrin is the main whey protein in mammalian milk, and is involved in innate immune host defences. Notably, human lactoferrin can be found at increased concentrations in colostrum and in milk from mothers of premature neonates. Human (hLF) and bovine lactoferrin (bLF) share a high (77%) amino-acid homology, and the same N-terminal peptide responsible for antimicrobial activity, called lactoferricin. In vitro, bLF shows potent direct antimicrobial activity against all types of pathogens, which occurs via anti-cell wall actions and leads to disintegration of the micro-organism's membranes. bLF is also synergistic with many antimicrobials and antifungals, and promotes growth and differentiation of the immature gut. Based on this background data, a randomised clinical trial was recently conducted in very low birth weight pre-term neonates given bLF alone or with the probiotic Lactobacillus GG. The aim of the trial was to assess the ability of bLF to prevent late-onset sepsis of any origin in the studied infants during their stay in the NICU. This article discusses the preliminary data from this study, along with the proposed mechanisms of action of bLF in pre-term infants.

Bovine lactoferrin supplementation for prevention of late-onset sepsis in very low-birth-weight neonates: a randomized trial

CONTEXT

Sepsis is a common and severe complication in premature neonates, particularly those with very low birth weight (VLBW) (<1500 g). Whether lactoferrin, a mammalian milk glycoprotein involved in innate immune host defenses, can reduce the incidence of sepsis is unknown. In animal models, the probiotic Lactobacillus rhamnosus GG (LGG) enhances the activity of lactoferrin but has not been studied in human infants.

OBJECTIVE

To establish whether bovine lactoferrin (BLF), alone or in combination with LGG, reduces the incidence of late-onset sepsis in VLBW neonates.

DESIGN, SETTING, AND PATIENTS

Prospective, multicenter, double-blind, placebo-controlled, randomized trial conducted in 11 Italian tertiary neonatal intensive care units. Patients were 472 VLBW infants enrolled from October 1, 2007, through July 31, 2008, and assessed until discharge for development of sepsis.

INTERVENTION

Infants were randomly assigned to receive orally administered BLF (100 mg/d) alone (n = 153), BLF plus LGG (6 x 10(9) colony-forming units/d) (n = 151), or placebo (n = 168) from birth until day 30 of life (day 45 for neonates <1000 g at birth).

MAIN OUTCOME MEASURE

First episode of late-onset sepsis, ie, sepsis occurring more than 72 hours after birth with isolation of any pathogen from blood or from peritoneal or cerebrospinal fluid.

RESULTS

Demographic, clinical, and management characteristics of the 3 groups were similar, including type of feeding and intake of maternal milk. Incidence of late-onset sepsis was significantly lower in the BLF and BLF plus LGG groups (9/153 [5.9%] and 7/151 [4.6%], respectively) than in the control group receiving placebo (29/168 [17.3%]) (risk ratio, 0.34; 95% confidence interval, 0.17-0.70; P = .002 for BLF vs control and risk ratio, 0.27; 95% confidence interval, 0.12-0.60; P < .001 for BLF plus LGG vs control). The decrease occurred for both bacterial and fungal sepsis. No adverse effects or intolerances to treatment occurred.

CONCLUSION

Compared with placebo, BLF supplementation alone or in combination with LGG reduced the incidence of a first episode of late-onset sepsis in VLBW neonates.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN53107700.

A simultaneous outbreak of Serratia marcescens and Klebsiella pneumoniae in a neonatal intensive care unit

We describe two concurrent outbreaks of Serratia marcescens and Klebsiella pneumoniae in a neonatal intensive care unit (NICU). Over a 16-month period, a total of 27 infants were either colonized (N=14) or infected (N=13). There were 15 cases of S. marcescens and 11 cases of K. pneumoniae. Both micro-organisms were involved in one fatal case. Seven preterm babies developed septicaemia, two had bacteraemia, three had respiratory infections and one had purulent conjunctivitis. The S. marcescens and K. pneumoniae isolates were investigated by three molecular methods: enterobacterial repetitive intergenic consensus polymerase chain reaction (PCR), arbitrary primed PCR with M13 primer, and random amplification of polymorphic DNA. Different patterns were found in the 16 S. marcescens epidemic isolates from 16 newborn infants. The major epidemic-involved genotype was linked to the first nine cases and this was subsequently replaced by different patterns. Eight different typing profiles were also determined for the 13 K. pneumoniae isolates from 12 newborn infants. Four K. pneumoniae bacteraemic strains proved to be identical. In conclusion, the typing results revealed that two different micro-organisms (S. marcescens and K. pneumoniae) were simultaneously involved in invasive nosocomial infections in preterm newborns. Two simultaneous clusters of cases were documented. Heterogeneous genotypes among both species were also demonstrated to be present in the NICU at the same time. A focal source for both micro-organisms was not identified but cross-transmission through handling was probably an important route in this outbreak. Strict adherence to handwashing policies, cohorting, isolation of colonized and infected patients, and rigorous environmental hygiene were crucial measures in the containment of the epidemic.

[Sepsis caused by Corynebacterium xerosis in neonatology: report of a clinical case]

The pathogenicity of the nondiphtheria corynebacteria, most commonly known as coryneform bacteria in humans has been recognized in the last two decades. Corynebacterium xerosis is part of the normal flora of the skin, nasopharynx, conjunctives and it has recently been isolated from vaginal swabs. During the last few years, there has been an increased number of case reports claiming an association of C. xerosis with diseases, like septicemia, endocarditis, pleuropneumonia, peritonitis, osteomyelitis, septic arthritis, mediastinitis, meningitis, ventriculitis specially in immunocompromised patients or surgical patients. Infections due to C. xerosis have been reported rarely in newborn. We report a case of sepsis due to C. xerosis in a newborn without evident immunodeficiency. Our case further support the recognition of C. xerosis as a human pathogen and reinforces the fact that it should not be routinely considered as a contaminant.

[Model of integrated hospital project for the management of patients at risk of sudden death syndrome]

Home cardiorespiratory monitoring (HM) is an accepted practice in infants at high risk for Sudden Infant Death Syndrome (SIDS) as those with the following conditions: 1) Siblings of SIDS; 2) Apparent Life Threatening Events (ALTE); 3) Apneas of prematurity. From 1998 the Division of Neanotology of the Policlinico of Modena has followed prospectively infants at high risk for SIDS, in collaboration with the General Health Service. To support the clinical trial 10 apnea monitors were provided by the General Health Service and managed from the Department of Neonatology. During 18 months 24 infants have been followed by HM, and among then 20 were at risk of SIDS (11 female and 9 male): 7 were siblings of SIDS (35%); 10 had previous episodes of ALTE (50%); 3 were born prematurely and had persistent apneas before discharge (15%). The mean period of HM was 5.85 months. None of the infants died for SIDS or had episodes of ALTE that required resuscitation measures. In only one case parents stopped earlier than recommended, but personal interview to parents showed that all the others families gained benefits and reassurance from HM.

[Database of air pollution and air quality indicators for the principal Italian cities: the ITARIA-WHO project]

This paper presents air quality data collected in eight Italian cities (Turin, Genoa, Milan, Bologna, Florence, Rome, Naples, Palermo) during the period 1994-98. Storage and analysis of data have been performed by the ITARIA collaborative group in the framework of a national study promoted by ECEH-WHO, aimed at evaluating the health impact of urban air pollution. Methods used to compare data from different networks are described. A slight reduction in the annual mean concentrations of NO2, SO2 and CO over the period under study was observed. However, for most of the cities, national and European air quality standards are frequently exceeded also in 1998, particularly for ozone pollution.

[A case of female pseudohermaphroditism caused by maternal androluteoma]

Female pseudohermaphroditism is a condition characterized by various degree of external genitalia virilization in a patient with female internal genitalia and karyotype (XX). External genitalia is masculinized congenitally when female fetus is exposed to excess androgenic environment. Fetal metabolic abnormalities, like congenital adrenal hyperplasia, are the most common causes of female pseudohermaphroditism, however there is a low incidence of gestational hyperandrogenism caused by maternal pathology. We report a case of female pseudohermaphroditism secondary to a maternal ovarian luteoma of pregnancy producing androgenic hormones. The newborn presented a severe degree of external genitalia virilization with high urogenital sinus (stage Prader V). Moreover we describe the main steps of diagnostic iter that are necessary both to exclude other causes of virilization and to study all anatomical aspects in view of the surgical correction. The operation consists in two phases of action: an early clitorisvulvoplasty according to Passerini-Glazel and a late vaginal pull-through with anterior saggital transanorectal approach (ASTRA).

[Neonatal cystic fibrosis: report of 2 cases]

Cystic fibrosis is the most common life-limiting recessive genetic disorder in Caucasian. It is caused by mutations of CFTR gene (cystic fibrosis transmembrane conductance regulator); at present over 500 mutations are known. Cystic fibrosis as a cause of respiratory distress in the neonate is quite rare. In neonatal period the most important clinical manifestations are meconium ileum and much rarely cholestatic jaundice. We present two cases of cystic fibrosis in newborns. In the first one, we point out the strict association between meconium ileum and cystic fibrosis. The patient underwent a surgical treatment for meconium ileum and the diagnosis was rapidly confirmed by genetic analysis and sweat test. The second one had intestinal obstruction from birth caused by meconium ileum associated with ileal atresia; besides, he developed cholestatic jaundice, severe and rapidly progressive respiratory disease. He died at 102 degrees day of age for cardiac failure. The diagnosis of cystic fibrosis, supported by typical clinical features and high level of serum trypsin, unfortunately wasn't confirmed by genetic analysis (lambda F508/neg), in addition, the sweat test wasn't reliable because an inadequate quantity of sweat was collected.

[Continuous intraesophageal pH monitoring in the study of gastroesophageal reflux (GER) in children. Influence of age on the considered parameters]

Gastroesophageal reflux is a very common event in children; it is studied using 24-hour intraesophageal pH-monitoring, which has a large sensitivity and specificity, but in the literature is not clear if the age of the children could have influence on the parameters considered in the pH-monitoring. The aim of our study is to assess if the age of our small patients could modify the results of pH-monitoring. During 3-year period from 1991-1993 continuous intraesophageal pH-monitoring of 45 children (29 males and 16 females), divided in three groups on the bases of age, homogeneous for number, sex and clinical symptoms, with pathologic reflux time (> 4% of 24 hours) has been evaluated. In our cases the pathologic total reflux time in 24 hours doesn't seem change with age. It has been noted that under two years of age the pH-monitoring measures are homogeneous with a tendency of reflux longer than children over two years. This older group has more after lunch refluxes; that is the number of total refluxes is larger in older children but the number of refluxes with length higher than five minutes is more in younger. These data are discussed in relation to the anatomical and functional gastroesophageal characteristics of the different age of the child.

Comparative investigations among meteorological conditions, air chemical-physical pollutants and airborne particulate mutagenicity: a long-term study (1990-1994) from a northern Italian town

The findings of a continuos monitoring (Apr90-Mar94) on urban air quality of a Po Valley town are reported. Chemical-physical and genotoxicity data were detected. The results show the presence of mutagenic agents during the whole investigated period. Short term mutagenesis tests together with chemical-physical parameters analysis are able to better assess air quality and genotoxic risk for the population.

Urban air pollution: use of different mutagenicity assays to evaluate environmental genetic hazard

The genotoxic activities associated with airborne particulate matter collected in Parma (northern Italy) have been determined. The airborne particle extracts were tested for mutagenicity using Salmonella frameshift (TA98) and base-substitution (TA100) tester strains with and without S9 microsomal activation and Saccharomyces cerevisiae strain D7 in order to determine the frequency of mitotic gene conversion and ilv1-92 mutant reversion in cells harvested at stationary and logarithmic growth phase. The relationship between mitochondrial DNA mutations and ageing, degenerative diseases and cancer prompted us to take into account the mitochondrial informational target, i.e., the respiratory-deficient (RD) mutants. The results obtained show a variability in the response for the different test systems during different months. The Salmonella mutagenicity trend was directly correlated with carbon monoxide, nitrogen oxides (NOx) and Pb concentration in airborne particulates and inversely correlated with temperature, whereas the mitochondrial genotoxic effect was higher during spring and late summer. These data suggest that the genotoxic risk assessment is a time-dependent value strictly correlated with the evaluation system being tested.