[Ethics in clinical practice and in health care]. / L'etica nella pratica clinica e nell'assistenza sanitaria.

The clinical ethics is the identification, analysis and solution of moral problems that can arise during the care of a patient. Given that when dealing with ethical issues in health care some risks will be encountered (talking about ethics in general, or as a problem overlapped with others in this area, or by delegation to legislative determinations) in the text certain important aspects of the topic are examined. First of all ethics as human quality of the relationship between people for the common good, especially in health services where there are serious problems like the life and the health. It is also necessary a "humanizing relationship" between those who work in these services in order to achieve quality and efficiency in this business. It is important a proper training of health professionals, especially doctors, so that they can identify the real needs and means of intervention. It is also important that scientific research must respect fundamental ethical assumptions. In conclusion, ethics in health care is not a simple matter of "cookbook" rules, but involves the responsibility and consciousness of individual operators.

Evaluating diagnostic accuracy of anti-tissue Transglutaminase IgA antibodies as first screening for Celiac Disease in very young children.

BACKGROUND: Small bowel biopsy is the gold standard for Celiac Disease (CD) diagnosis, nevertheless serum assays are the first step in ascertaining a diagnosis of CD. New ESPGHAN Criteria 2012 (European Society of Pediatric Gastroenterology Hepatology and Nutrition) suggest using exclusively anti-tissue Transglutaminase IgA antibodies (anti-tTGA) as initial approach to symptomatic subjects. The aim of our study was to evaluate the diagnostic accuracy of anti-tTGA as initial screening assay for CD in a large cohort of pediatric patients. METHODS: We selected 730 subjects aged between 6 months and 4 years ("Group A") and 348 subjects younger than 2 years (which are part of the 730 subjects) ("Group B"). We performed anti-Deamidated Gliadin Peptides IgA and IgG antibodies (a-DGP IgA/IgG) and anti-tTGA assays by ELISA test. We evaluated the agreement between anti-tTGA and a-DGP IgA/IgG assays and compared the diagnostic accuracy of a-DGP IgA/IgG with that of anti-tTGA in both groups of patients. RESULTS: There was a substantial agreement between anti-tTGA and a-DGP IgA in "Group A" and an almost perfect agreement in "Group B"; the strength of agreement between anti-tTGA and a-DGP IgG was moderate in "Group A" and substantial in "Group B". anti-tTGA were more sensitive and specific than a-DGP IgA/IgG in both groups. CONCLUSIONS: anti-tTGA could be used as initial screening assay for CD in all subjects from 6 months of age according to ESPGHAN Criteria 2012.

A 5' regulatory sequence containing two Ets motifs controls the expression of the Wiskott-Aldrich syndrome protein (WASP) gene in human hematopoietic cells.

The recently-identified Wiskott-Aldrich syndrome protein gene (WASP) is responsible for the Wiskott-Aldrich X-linked immunodeficiency as well as for isolated X-linked thrombocytopenia (XLT). To characterize the regulatory sequences of the WASP gene, we have isolated, sequenced and functionally analyzed a 1.6-Kb DNA fragment upstream of the WASP coding sequence. Transfection experiments showed that this fragment is capable of directing efficient expression of the reporter chloramphenicol acetyltransferase (CAT) gene in all human hematopoietic cell lines tested. Progressive 5' deletions showed that the minimal sequence required for hematopoietic-specific expression consists of 137 bp upstream of the transcription start site. This contains potential binding sites for several hematopoietic transcription factors and, in particular, two Ets-1 consensus that proved able to specifically bind to proteins present in nuclear extracts of Jurkat cells. Overexpression of Ets-1 in HeLa resulted in transactivation of the CAT reporter gene under the control of WASP regulatory sequences. Disruption of the Ets-binding sequences by side-directed mutagenesis abolished CAT expression in Jurkat cells, indicating that transcription factors of the Ets family play a key role in the control of WASP transcription.

Defect of interleukin-2 production and T cell proliferation in atopic patients: restoring ability of the CD28-mediated activation pathway.

We previously reported that T lymphocytes of atopic patients displayed a defect in CD2- and CD3-mediated pathways of cell activation; that defect relied on impairment of interleukin 2 (IL-2) production (Romano, M. F., Valerio, G., Turco, M. C., Spadaro, G., Venuta, S., and Formisono, S., Cell. Immunol. 139, 91, 1992). We have subsequently analyzed T cell response to anti-CD2, -CD3, or -CD28 monoclonal antibodies (mAb) in 40 atopic individuals, including patients subjected to immunotherapy. In the latter group T cell response to anti-CD2 mAbs was normal, while IL-2 production and proliferative response in T lymphocytes stimulated via CD3 was still impaired. Costimulation with anti-CD28 mAb rescued both IL-2 production and proliferative response in all tested patients. Response to CD28-mediated stimulation was more pronounced in atopic than that in normal individuals. Our results indicated that CD28 had a major role in T cell proliferation of atopic patients and provided a model for analyzing CD3/CD28 interactions in regulation of IL-2 gene expression.

Identification and characterization of a T cell growth inhibitory factor produced by K562 erythromyeloid cells.

Cells of the human erythroleukemia cell line K562 constitutively secrete a factor that inhibits human T lymphocyte proliferation induced via CD3/Ti. The factor, termed K-TIF (K562-derived T cell inhibitory factor) is produced in either the presence or absence of fetal calf serum in cultures of K562 cells and can be precipitated by 70% NH4SO4. Gel filtration chromatography on Superose 12 resin by FPLC showed that the inhibitory factor has a molecular weight of approximately 30-35 kDa. A protein of this size, metabolically labeled with [35S]methionine, specifically bound human peripheral blood mononuclear cells. Chromatofocusing with Mono P by FPLC (pH gradient 7.2-5) indicates that the inhibitory factor has an isoelectric point of 6.0-6.4.

Mitogenic activity of anti-CD28 MoAb CLB-CD28/1 on peripheral blood mononuclear cells and its cooperation with other anti-T cells MoAb in the activation of purified T lymphocytes.

Human T lymphocyte proliferative response induced via CD28 molecule is analyzed. An anti CD28 MoAb, CLB-CD28/1, induces the proliferation of human peripheral blood mononuclear cells in the absence of other stimuli, indicating that CD28 molecule can directly mediate a mitogenic signal in this system. The mitogenic activity of MoAb CLB-CD28/1 on PBMC does not require MoAb interaction with monocyte Fc receptors, since F(ab')2 fragments from the MoAb are mitogenic to the same extent as whole IgG. Nevertheless, the activity depends on the presence of accessory cells, since purified T lymphocytes require addition of irradiated monocytes and interleukin 2 to proliferate when incubated with MoAb CLB-CD28/1. On the other hand, MoAb CLB-CD28/1 induces response to IL-2 in thymocytes in the absence of accessory cells. Cooperation of MoAb CLB-CD28/1 with three other MoAbs, recognizing CD3, CD5 and HLA Class I antigens, respectively, induces Tac antigen expression and IL-2 responsiveness in purified T lymphocytes. This effect is obtained without cross-linking of the MoAb. It does not rely on a physical association between CD28 and CD3, CD5 or HLA Class I molecules, as demonstrated by co-modulation experiments. These data indicate that expression of IL-2 receptor on T lymphocytes can result from interaction of multiple activation pathways and that some of them, such as those mediated by CD5 and HLA Class I antigens, previously reported to serve as modulatory circuits, can instead act as essential elements in the onset of T lymphocyte proliferation.

Lack of a role of monocytes in the inhibition by monoclonal antibodies to monomorphic and polymorphic determinants of HLA class I antigens of PHA-P-induced peripheral blood mononuclear cell proliferation.

This study aimed at characterizing the mechanism(s) underlying the regulatory role of distinct determinants of HLA Class I antigens in PHA-P-induced T cell proliferation and the involvement of monocytes in this phenomenon. The anti-HLA-A2,A28 monoclonal antibodies (MoAb) CR11-351, the MoAb Q6/64 to a determinant restricted to the gene products of the I antigens HLA-B locus, and the MoAb CR10-215 and W6/32 to distinct monomorphic determinants of HLA Class I antigens were found to inhibit PHA-P-induced peripheral blood mononuclear cell (PBMC) proliferation in a dose-dependent fashion. The inhibition is specific and reflects neither inhibition of PHA-P binding to cells nor a toxic effect of the anti-HLA Class I MoAb. The latter differed in the concentration required to induce inhibition, in the influence of the concentration of PHA-P used as mitogen, in the differential effect on the donors used as a source of PBMC, and/or in the requirement of the Fc portion to induce inhibition. At variance with the information in the literature, the inhibitory effect of anti-HLA Class I MoAb on PHA-P-induced PBMC proliferation neither reflected their interaction with accessory cells nor was mediated by suppressor factors released by monocytes stimulated with PHA-P in the presence of anti-HLA Class I MoAb. Therefore, the regulatory role of HLA Class I antigens in T cell proliferation is not likely to be mediated by monocytes and/or factors released from them, but may reflect an involvement of these molecules in T cell activation pathways.

Lymphocyte proliferative response to mitogenic monoclonal antibodies in systemic sclerosis. Evidence for unresponsiveness to murine monoclonal antibodies of IgG1 isotype.

Proliferative response of peripheral blood mononuclear cells to phitohemoagglutinin and anti-CD3 mitogenic monoclonal antibodies (MoAbs) of the IgG2a (OKT3) and IgG1 (PanT2, CLB T3/4.1) isotypes was studied in 39 patients with systemic sclerosis (SSc) and in 82 control subjects. The effect of IL-2 on this response was also investigated. No difference in the response to PHA and to IgG2a anti-CD3 MoAb OKT3 was seen between scleroderma patients and controls. Both the patient and control groups contained responders and non-responders to IgG1 anti-CD3 MoAbs. The percentage of non-responders was significantly higher in scleroderma patients than in controls. When purified lymphocytes from non-responder scleroderma patients were cultured with monocytes from control responders, proliferative response to IgG1 MoAbs was restored. Our results show that monocytes from patients with systemic sclerosis bear a defect leading to IgG1 unresponsiveness by T lymphocytes.

Enhancing effect of anti-HLA class I monoclonal antibodies on T cell proliferation induced via CD2 molecule.

The mAb 131 to a determinant preferentially expressed on the gene products of the HLA-A locus, the mAb Q6/64 and 4E to determinants preferentially expressed on the gene products of the HLA-B locus, the anti-HLA-A2,A28 mAb CR11-351, HO-2, HO-3, HO-4, and KS1, and the anti-HLA-B7 cross-reacting group mAb KS4 enhanced proliferation of T cells in most, if not all, the PBMC preparations stimulated with the anti-CD2 mAb 9-1 + 9.6. The mAb CR10-215, W6/32, and 6/31 to distinct monomorphic determinants of HLA class I antigens enhanced CD2-induced T cell proliferation in at most 30% of the PBMC preparations tested. The anti human beta 2-microglobulin (beta 2-mu) mAb NAMB-1 displayed no detectable effect on the proliferation of T cells stimulated with the mAb 9-1 + 9.6. The enhancing effect of anti-HLA class I mAb is specific, is dose dependent, is not abrogated by the addition of exogenous IL-1 and IL-2 to the cultures, and reflects the interaction of anti-HLA class I mAb with T cells. Enhancement of CD2 mediated proliferation of T cells is not a unique property of anti-HLA class I mAb, since the anti-HLA class II mAb Q5/6 and Q5/13 also had a similar effect. Analysis of the kinetics of the enhancing effect of anti-HLA class I mAb suggests that they modulate an early event of T cell activation and may affect the interaction of T cells with mAb 9-1. Phenotyping of T lymphocytes activated by mAb 9-1 + 9.6 in the presence of anti-HLA class I mAb suggests that the enhancing effect of anti-HLA class I mAb may reflect the recruitment of a higher percentage of T cells. The present study has shown for the first time that certain, but not all, the determinants of the HLA class I molecular complex are involved in the proliferation of T cells stimulated with the anti-CD2 mAb 9-1 + 9.6. Furthermore, the inhibitory effect of mAb CR11-351, KS1, Q6/64, and W6/32 on the proliferation of T cells stimulated with mAb OKT3 or with mAb BMA 031 indicates that the same determinants of HLA class I antigens play a differential regulatory role in T cell proliferation induced via the CD2 and CD3 pathway.

Heterogeneity in the mitogenic response of peripheral blood mononuclear cells to a pan T monoclonal antibody.

Peripheral blood mononuclear cells (PBMC) from 80 normal donors were studied for their capacity to proliferate in response to Pan T2, an IgG1 monoclonal antibody (MoAb), that recognizes the CD3 complex. Forty percent of this population, regardless of sex or age, were found to be non-responders. However, the binding of MoAb Pan T2 to T cells as studied by indirect immunofluorescence was positive in all the donors. The addition of IL 1 or IL 2 to Pan T2-stimulated non-responder lymphocytes did not activate T cell proliferation, while the addition of responder monocytes restored the proliferation capacity in non-responder PBMC. The data indicate the existence of a heterogeneous responsiveness among normal individuals to a mitogenic IgG1 MoAb, and are in agreement with reports obtained using other anti-T3 MoAbs of IgG1 isotype, i.e. UCHT1, Leu4 and WT31. This defect is reported to be a function of monocytes, related to a polymorphism of Fc receptors for mouse IgG1 on human monocytic cells.

Differential regulatory role of monomorphic and polymorphic determinants of histocompatibility leukocyte antigen class I antigens in monoclonal antibody OKT3-induced T cell proliferation.

Monoclonal antibodies (mAb) to monomorphic and polymorphic determinants on the heavy chain of histocompatibility leukocyte antigen (HLA) class I antigens inhibit mAb OKT3-induced T cell proliferation, whereas the anti-beta 2-microglobulin mAb NAMB-1 does not affect it. The inhibitory effect of anti-HLA class I mAb is specific, is not an Fc-mediated phenomenon, does not require accessory cells, and does not involve early stages of T cell activation. Distinct determinants of HLA class I antigens regulate T cell proliferation by different mechanisms, because the anti-HLA-A2, A28 mAb CR11-351, and the mAb W6/32 to a framework determinant of HLA class I antigens block interleukin 2 (IL-2) secretion and IL-2 receptor expression, whereas the mAb CR10-215 to a monomorphic determinant blocks only IL-2 receptor expression. The mAb CR10-215 and W6/32 induced a 50% of maximal inhibition of T cell proliferation, when added after 27 and 12 hr, respectively, of incubation of peripheral blood mononuclear cells with mAb OKT3. On the other hand, the mAb CR11-351 inhibited T cell proliferation even when added after 38 hr of incubation of peripheral blood mononuclear cells with mAb OKT3 and was the only one to inhibit proliferation of cycling T lymphocytes. It is suggested that HLA class I antigens regulate T cell proliferation by interacting with cell-surface molecules involved in T cell activation. The differential inhibitory activity of the anti-HLA class I monoclonal antibodies tested may reflect the different ability of the corresponding determinants to interact with activation molecules.

Prevalence of diabetes mellitus and impaired glucose tolerance in a rural area of Italy.

The prevalence of diabetes in subjects aged 18 yr and over was evaluated in a rural community of Southern Italy (Sanza). Among the 1,154 participants examined by using a 75 g oral glucose load according to the recent WHO diagnostic criteria, the diabetes prevalence was 6.6% in men and 6.8% in women; impaired glucose tolerance occurred in 5.1% of men and 7.9% of women. The frequency of positive family history of diabetes was no higher in subjects with diabetes and impaired glucose tolerance, than in controls. Obesity was clearly related to diabetes (p less than 0.05 in men and p less than 0.01 in women 40 yr old and over). The level of physical activity was significantly lower in subjects with diabetes than in normal subjects. The results suggest that a remarkable reduction in physical activity, along with an increased caloric intake, may have importance in determining the prevalence and time of appearance of non-insulin-dependent diabetes.

Soybean protein diets in the management of type II hyperlipoproteinaemia.

The efficacy of soybean protein treatment of stable type II hyperlipoproteinaemia was evaluated in 57 patients assigned to the following protocols: (i) substitution of animal protein with soybean protein (19 subjects) and (ii) addition of soybean protein to a standard low-lipid diet (38 subjects). After 16 weeks of treatment, plasma cholesterol was reduced by 29.5% in the first group, and by 29.9% in the second; the difference was not significant. Similarly the reduction in LDL cholesterol was not significantly different between the 2 groups (39% in the first group and 36% in the second). Plasma triglycerides fell by 11.8% and 18.2%, respectively. HDL cholesterol was not modified to any significant extent by soybean protein regimens. These results provide that the addition of soybean protein to a standard low-lipid diet is effective in inducing a significant cholesterol decrease in patients with type II hyperlipoproteinaemia.

Prevalence of impaired glucose tolerance, diabetes mellitus and ischemic heart disease in an Italian rural community. The Sanza Survey.

Coronary heart disease rates were estimated in three groups of people participating in the Sanza Survey - newly diagnosed non insulin dependent diabetics, subjects with impaired glucose tolerance and control subjects with normal glucose tolerance. The prevalence of Minnesota-coded ECG abnormalities showed a significant gradient with an approximately twofold excess in both the newly detected diabetic and impaired glucose tolerance cases over the subjects with normal glucose tolerance. The doubling of ECG ischemic changes found in subjects with impaired glucose tolerance and diabetes mellitus appeared to operate almost equally in the absence or presence of several other recognized risk factors for coronary ischemic damage. It is concluded that a relatively low degree of glucose intolerance alone may be important in determining coronary heart disease.

[Effects of 2 thymus extracts on blood levels of cholesterol and glucose in the rat]. / Influenze di due estratti timici sui livelli ematici di colesterolo e glucosio nel ratto.

The effects of two calf thymus extracts (fraction III and Tp1) on the haematic levels of cholesterol and glucose in the rat on a fat diet have been compared. The fraction III carries out a very marked decrease of cholesterolemia without changes in the levels of glycemia. On the contrary the Tp1 determines only a moderate decrease of cholesterolemia but a very marked decrease of glycemia. Thherefore these results seem both to confirm the differences between the two thymus extracts and the metabolic actions of thymus.

[In vivo effects of rapid glycemic variations on HbA1c]. / Effetti in vivo di rapide variazioni glicemiche sull'HbA1c.

The percent of variations of glycosylated haemoglobin before and after rapid glycemic increases inducted in diabetics and healthy subjects are not significant (p greater than 0,05). The same results were obtained using both the chromatographic method on Bio-Rex 70 microcolumns and the colorimetric method with 2-thiobarbituric acid. The usefulness of HbA1c as a parameter in controlling the glycemic equilibrium is confirmed.