New insights into the therapeutic options to lower lipoprotein(a).

BACKGROUND: Elevated levels of lipoprotein(a) [Lp(a)] represent a risk factor for cardiovascular disease including aortic valve stenosis, myocardial infarction and stroke. While the patho-physiological mechanisms linking Lp(a) with atherosclerosis are not fully understood, from genetic studies that lower Lp(a) levels protect from CVD independently of other risk factors including lipids and lipoproteins. Hereby, Lp(a) has been considered an appealing pharmacological target. RESULTS: However, approved lipid lowering therapies such as statins, ezetimibe or PCSK9 inhibitors have a neutral to modest effect on Lp(a) levels, thus prompting the development of new strategies selectively targeting Lp(a). These include antisense oligonucleotides and small interfering RNAs (siRNAs) directed towards apolipoprotein(a) [Apo(a)], which are in advanced phase of clinical development. More recently, additional approaches including inhibitors of Apo(a) and gene editing approaches via CRISPR-Cas9 technology entered early clinical development. CONCLUSION: If the results from the cardiovascular outcome trials, designed to demonstrate whether the reduction of Lp(a) of more than 80% as observed with pelacarsen, olpasiran or lepodisiran translates into the decrease of cardiovascular mortality and major adverse cardiovascular events, will be positive, lowering Lp(a) will become a new additional target in the management of patients with elevated cardiovascular risk.

Evolution of echocardiographic and cardiac magnetic resonance imaging abnormalities during follow-up in patients with multisystem inflammatory syndrome in children.

AIMS: Multisystem inflammatory syndrome in children (MIS-C) with cardiovascular manifestations are frequent. However, there is lacking evidence regarding cardiological follow-up of this cohort of patients. The aim of our study was to describe the early and mid-term cardiac abnormalities assessed by standard and speckle-tracking echocardiography (STE), and cardiac MRI (CMR). METHODS AND RESULTS: We enrolled 32 patients (21 male, 11 female), mean age 8.25 ± 4years, with diagnosis of MIS-C. During admission, all children underwent TTE, STE with analysis of left ventricle global longitudinal strain (GLS) and CMR. Patients underwent cardiological evaluation at 2 (T1) and 6 months (T2) after discharge. Cardiac MRI was repeated at 6 months after discharge. Mean left ventricular ejection fraction (LVEF) at baseline was 58.8 ± 10% with 10 patients (31%) below 55%. Speckle-tracking echocardiography showed reduced mean LV GLS (-17.4 ± 4%). On CMR, late gadolinium enhancement (LGE) with non-ischaemic pattern was evident in 8 of 23 patients (35%). Follow-up data showed rapid improvement of LVEF at T1 (62.5 ± 7.5 vs. 58.8 ± 10.6%, P-value 0.044) with only three patients (10%) below ≤ 55% at T1. Left ventricular (LV) GLS remained impaired at T1 (-17.2 ± 2.7 vs.-17.4 ± 4, P-value 0.71) and significantly improved at T2 (-19 ± 2.6% vs. -17.4 ± 4%, P-value 0.009). LV GLS was impaired (>-18%) in 53% of patients at baseline and T1, whereas only 13% showed persistent LV GLS reduction at T2. Follow-up CMR showed LGE persistence in 33.4% of cases. CONCLUSION: Early cardiac involvement significantly improves during follow-up of MIS-C patients. However, subclinical myocardial dysfunction seems to be still detectable after 6 months of follow-up in a not negligible proportion of them.

Metabolic adaptations of cells at the vascular-immune interface during atherosclerosis.

Metabolic reprogramming is a physiological cellular adaptation to intracellular and extracellular stimuli that couples to cell polarization and function in multiple cellular subsets. Pathological conditions associated to nutrients overload, such as dyslipidaemia, may disturb cellular metabolic homeostasis and, in turn, affect cellular response and activation, thus contributing to disease progression. At the vascular/immune interface, the site of atherosclerotic plaque development, many of these changes occur. Here, an intimate interaction between endothelial cells (ECs), vascular smooth muscle cells (VSMCs) and immune cells, mainly monocytes/macrophages and lymphocytes, dictates physiological versus pathological response. Furthermore, atherogenic stimuli trigger metabolic adaptations both at systemic and cellular level that affect the EC layer barrier integrity, VSMC proliferation and migration, monocyte infiltration, macrophage polarization, lymphocyte T and B activation. Rewiring cellular metabolism by repurposing "metabolic drugs" might represent a pharmacological approach to modulate cell activation at the vascular immune interface thus contributing to control the immunometabolic response in the context of cardiovascular diseases.

Relationship between postpartum uterine involution and biomarkers of inflammation and oxidative stress in clinically healthy mares (Equus caballus).

To test the hypothesis that delayed/impaired uterine involution could be associated with oxinflammation, we studied the progression of the uterine involution in association with some biomarkers of inflammation and oxidative stress in clinically healthy mares (N = 26) during early postpartum. The examination of the reproductive tract was performed on Days 7 and 21 after foaling. Uterine involution was assessed considering: a) the increase of the gravid uterine horn diameter (GUHD) compared with diameter recorded before pregnancy during the previous breeding season; b) the level of endometrial edema (EE); c) the degree of accumulation of intrauterine fluid (IUFA); d) the status of the cervix (CS). Inflammation and oxidative stress were studied by measuring serum amyloid A (SAA), cortisol, DHEA, AOPP, protein carbonyl groups, malondialdheyde (MDA) and thiols in plasma on Days 7 and 21. By Day 21 after parturition, a significant improvement (P < 0.01) was observed for GUHD and EE; while IUFA increased in six animals. Plasma SAA and DHEA concentrations were higher when the clinical parameters indicated a lower degree of uterine involution. On Day 7, the cortisol/DHEA ratio was lower in animals with higher degree of EE. Plasma AOPP and MDA concentrations were significantly lower (P < 0.05) in animals with the lower GUHD. On Day 21, plasma MDA concentrations were significantly lower (P < 0.05) in animals with the lower IUFA. Our data suggest that a mild condition of inflammation and oxidative stress occur in mares with delayed/impaired uterine involution.

Expression of 8-OHdG in Zosterisessor ophiocephalus from the Venetian lagoon, Italy.

The aim of the present work was to evaluate the expression of 8-OHdG (8-hydroxydeoxyguanosine) in the benthic fish Zosterisessor ophiocephalus collected in two differently polluted sites of the Venetian lagoon (Porto Marghera and Caroman). We compared our data on 8-OHdG with those of CYP1A (Cytochrome P450, family 1, subfamily A, polypeptide 1), which is a well known biomarker for detoxification of contaminants. Immunohistochemistry with an antibody to 8-OHdG showed immunopositivity in nuclei of hepatocytes as well as in melanomacrophage centres of spleen and kidney, whereas an anti-CYP1A antibody exhibited positive immunostaining in the liver, kidney and ovary. The liver of males showed higher expression of both proteins than females. In animals from Porto Marghera site, the enzymatic assay for 8-OHdG exhibited higher levels in liver of males than in females. Western Blot analysis using the antibody anti-CYP1A recognized the presence of a band of about 60 kDa in the liver of males and females. Males exhibited a strong band, whereas in females the band showed a lower intensity. By using Real-Time PCR, the mRNA expression of CYP1A did not show any differences between males and females from each site, but it was at borderline significance level. Comparing the two sites, mRNA expression of CYP1A was significantly higher in the liver of both males and females from Porto Marghera than that of Caroman. The present data suggest that pollutants are bio-available as demonstrated by our biomarker analyses and may have a harmful effect on aquatic organisms such as Z. ophiocephalus. We report that the highest levels of hepatic 8-OHdG and CYP1A expression were detected in males, showing clear gender specificity.

Paediatric community-acquired septic shock: results from the REPEM network study.

UNLABELLED: INTRODUCTION AND PURPOSE OF THE STUDY: With this study we aimed to describe a "true world" picture of severe paediatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included. RESULTS: A 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). 'Severe' outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept). CONCLUSION: The outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

DNA bacterial load in children with bacteremic pneumococcal community-acquired pneumonia.

This study was conducted to evaluate the association between pneumococcal DNA load and parapneumonic pleural effusion (PPE) in children with community-acquired pneumonia. Bacterial load was quantified and related to the presence of PPE with or without empyema in 72 otherwise healthy children aged ≤5 years who were hospitalised because of radiographically confirmed CAP and showed a real-time polymerase chain reaction that was positive for Streptococcus pneumoniae. The proportion of children with a high bacterial load (i.e. ≥265 DNA copies/mL) was larger among the subjects with PPE than those without it. Multivariate analysis showed that a high bacterial load was significantly associated with PPE (OR 8.65; 95% CI 1.10-67.8 vs a bacterial load of <125 copies/mL). Children with infection due to pneumococcal serotype 19A were at highest risk of developing PPE (OR 7.44; 95% CI 1.10-50.4 vs all other typeable serotypes). The patients with CAP due to pneumococcal serotypes that are not included in the 13-valent conjugate vaccine (PCV13) were more frequently affected by PPE than those with infections associated with serotypes included in the vaccine, except for serotype 19A. Bacterial loads of ≥265 DNA copies/mL are significantly associated with PPE, and serotype 19A is significantly associated with a high bacterial load and the development of PPE. The mean bacterial load of the patients with empyema was higher than that of patients with simple PPE. Although further studies are required, it seems that serotypes not included in PCV13 can play a major role in causing a higher bacterial load and PPE.

Measuring fecal progestogens as a tool to monitor reproductive activity in captive female bottlenose dolphins (Tursiops truncatus).

The objective was to develop and test radioimmunoassays (RIAs) to measure fecal progestogens (P) and estrogens (E) to monitor ovarian activity in the bottlenose dolphin (Tursiops truncatus). Fecal samples were collected at least once a week for 20 mo from three peripubertal female bottlenose dolphins. Blood samples were collected at least once a month to compare serum and fecal steroid concentrations. Moreover, random fecal samples from three pregnant females, one lactating female, and one sexually mature female receiving oral altrenogest treatment were also collected. Fecal samples were collected behaviorally with a probe to avoid water contamination and extracted with petroleum ether (for P analysis) or diethyl ether (for E analysis). When possible, vaginal cytology and ovarian ultrasonography were used to monitor the estrous cycle. The RIA for fecal P had good reproducibility and negligible matrix effect. In addition, when fecal samples (N=25) were extracted with ethanol, the results with the two methods of extraction were highly correlated (r=0.923). Therefore, extraction of fecal samples with petroleum ether represented a valid alternative to other, more time-consuming methods of determining fecal P concentrations. In the absence of luteal activity, fecal P concentrations were consistently < 10 pmol/g feces, although they never decreased below 10 pmol/g during pregnancy. Thus, the threshold to confirm the presence of an active corpus luteum was provisionally set at 10 pmol/g. Around the onset of puberty, luteal phases appeared shorter and irregular in the bottlenose dolphin, as in other mammalian species. Additional HPLC-MS studies should be performed to identify predominant P metabolites to be used as fecal indicators of luteal activity in this species.

Severe clinical course of systemic lupus erythematosus in the first year of life.

Systemic lupus erythematosus (SLE) very rarely occurs before the age of 5. Herein we describe the clinical features of infantile SLE (iSLE) with onset during the first year of life. The clinical and laboratory characteristics of iSLE patients followed at the Department of Pediatrics of Padua were analyzed. They were combined with those collected from the literature by performing a systematic literature search on PubMed using the following keywords: SLE, infant, laboratory, therapy, and outcome. A total of 13 patients with iSLE, 2 from our Institution and 11 from the literature, are included in this review. Seven (53.8%) were females and 6 were males (46.2%). The age at disease onset ranged from 6 weeks to 11 months. In comparison with juvenile systemic lupus erythematosus (jSLE), iSLE showed a higher prevalence of positive family history for autoimmune diseases, systemic symptoms at presentation, internal organs involvement, and shorter time between symptoms onset and diagnosis. Anemia and thrombocytopenia were present in the majority of the patients at diagnosis, whereas leukopenia was rarely observed. The overall prognosis in iSLE was very poor: 5/13 infants died between 2 and 31 months after the onset, and 5/13 had severe disease course with residual organ damage. SLE can start as early as during the first year of life and is more severe than in the later age groups.

Prospective study of the burden of acute gastroenteritis and rotavirus gastroenteritis in children less than 5 years of age, in Padova, Italy.

BACKGROUND: Data on the burden of rotavirus gastroenteritis in Europe are needed to help understand the potential impact of introducing new rotavirus vaccines. MATERIALS AND METHODS: As part of prospective observational study (Rotavirus gastroenteritis Epidemiology and Viral types in Europe Accounting for Losses in Public Health and Society Study, REVEAL) conducted in 2004--2005 in seven European countries, we studied, the characteristics of acute gastroenteritis and rotavirus gastroenteritis in children less than 5 years in primary care, emergency room and hospital settings (Padova, Italy). RESULTS: A total of 757 children with acute gastroenteritis were included and enzyme-linked immunoabsorbent assay (ELISA) results were available for 725 cases. The overall estimated annual incidence for rotavirus gastroenteritis was 4.7%. Overall, rotavirus gastroenteritis was estimated to account for 43.6% of acute gastroenteritis cases. Among children with acute gastroenteritis (AGE) aged 6-23 months, 61.2% were rotavirus positive. Rotavirus gastroenteritis (RVGE) was responsible for 68.8% of hospitalizations, 61% of emergency consultations, and 33% of primary care consultations. The most prevalent serotype was G9 (84.4%) followed by G1 (11.8%). The relative risk for rotavirus gastroenteritis of being referred to hospital after an initial consultation in primary care was 3.37 (95% CI: 1.77-6.43) and 3.38 (95% CI: 2.28-5.01) for emergency room referral. Children with rotavirus gastroenteritis generally had more severe disease than children with rotavirus-negative gastroenteritis. CONCLUSION: Rotavirus accounts for a significant proportion of acute gastroenteritis cases in children less than 5 years in Italy, many of whom require frequent primary care consultations, or care in emergency room or hospital settings.

Procoagulant activity in children with community acquired pneumonia, pleural effusion and empyema.

UNLABELLED: In patients with community-acquired pneumonia (CAP), bacterial-cell-wall-derived fragments may induce the coagulation cascade. To contribute to the knowledge of underlying mechanisms, we have studied the fibrinolytic activity in children with CAP and parapneumonic effusions. PATIENTS AND METHODS: Twenty previously healthy children admitted to our Department with CAP were studied; with (n = 11) or without (n = 9) pleural effusion (PPE). We also investigated 10 children with empyema. In all children we analyzed coagulation and fibrinolytic parameters and compared the results to nine controls. RESULTS: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were not significantly modified in the three groups as compared to controls (P = 0.975, P = 0.535, respectively). The fibrinogen levels were significantly increased in respect to the control group (P < 0.0001). The median values of D-dimer showed an increasing trend that was statistically significant: children with pneumonia 244 microg/L, with pneumonia and PPE 751 microg/L and with empyema 2003 microg/L, in respect to values (48 microg/L) of our control group (P < 0.0001). CONCLUSION: The results suggest that plasma level of D-dimer can give an additional contribution for the evaluation of the severity of CAP and its complications in children.

A case if infant botulism due to neurotoxigenic Clostridium butyricum type E associated with Clostridium difficile colitis.

Reported here is the sixth case of intestinal toxemia botulism caused by Clostridium butyricum type E in Italy since 1984. In this case, the patient was concomitantly affected with colitis due to Clostridium difficile toxin. A review of previously reported cases revealed that some of these patients may also have had intestinal toxemia botulism associated with Clostridium difficile colitis, based on the reported symptoms. Given that this association has been shown to exist not only in Italy but also in the USA, it is recommended that individuals with intestinal botulism and symptoms of colitis undergo testing for Clostridium difficile and its toxins in fecal samples.

Biochemical and molecular characterization of hereditary myeloperoxidase deficiency.

Hereditary myeloperoxidase (MPO) deficiency is a neutrophil disorder characterized by the lack of peroxidase activity. Cytochemical, biochemical, spectroscopic, immunocytochemical, and genetic studies were carried out on a 5-year-old MPO-deficient subject and on her parents. The father was also MPO-deficient, whereas the mother had 24% of normal MPO activity. Although the typical absorption spectrum of MPO was absent in both the father and daughter, the father's neutrophils, and not those of the daughter, contained material antigenically related to MPO. In the MPO gene of the father, two mutations were found, each located in a different allele: a T --> C transition, causing the nonconservative replacement M251T and a 14-base deletion within exon 9. The M251T substitution occurred in the carboxy-terminal region of the light chain that is included in the heme pocket. The daughter inherited the 14-base deletion from her father. The study of the MPO mRNAs present in liquid cultures of granulocyte precursors surprisingly showed that the same genetic defect, ie, the 14-base deletion, seemed to exhibit different mRNA phenotypes in the father and the daughter. In fact, mRNA derived from the 14-base-deleted allele was not found in the father and an aberrantly spliced MPO mRNA with a 77-base deletion of exon 9, which includes the 14-base deletion and leads to the generation of a premature stop codon, was found in the daughter. The possibility that Delta77 mRNA could derive from other mutations linked to the Delta14 allele was dismissed because no sequence differences were found in the region (exons and exon-intron junctions). Our data indicate that the alteration of the mRNA context caused by the 14-base deletion provide a basis for the 77-base deletion in the mRNA processing. Since the granulocyte precursors from the liquid cultures of the father were more differentiated than those from the daughter, the observed different behavior of the 14-base-deleted allele in the father and daughter may be the result of a differentiation-stage dependent control of altered spliced mRNA, which may be tolerated during the early stages of differentiation but degraded at later stages. In the liquid cultures of the daughter's cells, in addition to the mRNA with the 77-base deletion, a mRNA with the wild type sequence was also found. This mRNA was inherited from the mother, since no mutations were found in her MPO cDNA and MPO gene. The MPO defect might be caused by a regulatory mutation that induces the MPO gene switch off at an early stage of granulocyte differentiation.

[The evolution of care for the critical child: pediatric intensive care]. / L'evoluzione dell'assistenza al bambino critico: la terapia intensiva pediatrica.

Pediatric intensive care units (PICUs) have been developed to provide intensive care for children between post-neonatal age and adolescence. These units have largely been developed in North America, mainly in tertiary hospitals. In Italy, critically ill children are still often nursed on adult ICU's, where medical and nursing staff often lack pediatric training. Here we report the first 5-year experience of the multidisciplinary PICU developed at the Department of Pediatrics, University of Padua, focusing on PICU and patients characteristics, as well as on the evaluation of outcome by means of the Pediatric Risk of Mortality (PRISM) score.

Severity grading of childhood poisoning: the Multicentre Study of Poisoning in Children (MSPC) score.

Scores for severity grading of childhood poisoning may be useful in comparing different causes of poisoning, in order to identify the main risks and their changes over time. The Multicentre Study of Poisoning in Children score is based on four levels of severity (1-mild, 2-moderate, 3-severe, 4-very severe) involving nine target groups: seven relating to organ systems (gastrointestinal, nervous, respiratory, circulatory, renal, hepatic, skin), one to metabolic abnormalities and one to injuries from corrosive substances. Each patient is classified by the highest level attributed to any one of the nine groups. The score has been prospectively tested in 644 symptomatic children, aged 0-13 years, admitted to six pediatric hospitals of Northern Italy from January 1, 1991 to December 31, 1993. Poisoning was categorized as mild (1) in 357 children (53.8%), moderate (2) in 285 (42.9%), severe (3) in 18 (2.7%) and very severe (4) in 4 (0.6%). No deaths occurred. Severity grading according to The Multicentre Study of Poisoning in Children score confirms the prevalence of mild and moderate poisonings in children; the score seems to be an objective method suitable for epidemiological studies in different countries. Its clinical usefulness deserves more investigation.

Pupillary reactivity in children with recurrent abdominal pain.

Electronic pupillometry before and after phenylephrine instillation in the right eye was carried out in 18 children aged 10 to 16 years suffering from recurrent abdominal pain (RAP) and 15 age-matched controls. Before stimulation the pupillary diameter was almost equal in the two groups. After phenylephrine eye drops iris dilatation was greater in RAP patients than in controls, even though the difference was not statistically significant. These results seem to suggest children with RAP have a chronically disturbed receptor sensitivity in their iris neuromuscular junction caused by a sympathetic hypofunction, similar to that already reported in migrainous patients.