CSF levels of soluble HLA-G and Fas molecules are inversely associated to MRI evidence of disease activity in patients with relapsing-remitting multiple sclerosis.

Cerebrospinal fluid (CSF) concentrations of soluble human leukocyte antigen class I (HLA-I) (sHLA-I), HLA-G (sHLA-G) and anti-apoptotic Fas (sFas) molecules were measured by enzyme linked immunosorbent assay technique in 65 relapsing-remitting (RR) MS patients classified according to clinical and magnetic resonance imaging (MRI) evidence of disease activity. Sixty-four patients with other inflammatory neurological disorders (OIND) and 64 subjects with noninflammatory neurological disorders (NIND) served as controls. CSF concentrations were higher in RRMS and in OIND than in NIND patients for sHLA-I (P < 0.02), greater in RRMS than in OIND and in NIND for sHLA-G (P < 0.001 and P < 0.01, respectively) and lower in RRMS than in OIND and in NIND for sFas (P < 0.001 and P < 0.02, respectively). An increase in CSF levels was identified in MRI active RRMS for sHLA-I (P < 0.01) and in MRI stable RRMS for sHLA-G (P < 0.01), whereas CSF values of sFas were decreased in RRMS without Gd-enhancing lesions (P < 0.02). In MS patients with no evidence of MRI disease activity, a trend towards an inverse correlation was found between CSF concentrations of sHLA-G and sHLA-I and between CSF levels of sHLA-G and sFas. Our results indicate that enhanced CSF levels of sHLA-I antigens most likely represent an indirect manifestation of intrathecal immune activation taking place in neuroinflammation. Conversely, reciprocal fluctuations in CSF sHLA-G and sFas levels observed when MRI disease activity resolved suggest that sHLA-G could play an immunomodulatory role in MS through Fas/FasL-mediated mechanisms.

Cerebrospinal fluid and serum levels and intrathecal production of active matrix metalloproteinase-9 (MMP-9) as markers of disease activity in patients with multiple sclerosis.

In this study, we employed a sensitive activity assay system to measure cerebrospinal fluid (CSF) and serum levels of active matrix metalloproteinase-9 (MMP-9) in 37 relapsing-remitting (RR), 15 secondary progressive (SP) and nine primary progressive (PP) multiple sclerosis (MS) patients, grouped according to clinical and magnetic resonance imaging (MRI) evidence of disease activity. We also studied, as neurological controls, 48 patients with other inflammatory neurological disorders (OIND) and 48 with non-inflammatory neurological disorders (NIND). To assess active MMP-9/TIMP-1 circuit, CSF and serum levels of MMP-9 tissue inhibitor TIMP-1 were quantified by ELISA in the same patient population. CSF mean levels of active MMP-9, CSF active MMP-9/TIMP-1 ratios and intrathecal active MMP-9 synthesis, as indicated by specific index, were more elevated in MS than in NIND (P < 0.05, < 0.02 and < 0.02, respectively), serum active MMP-9/TIMP-1 ratio was higher in MS (P < 0.01) and OIND (P < 0.02) than in NIND, and serum TIMP-1 concentrations were lower in MS than in NIND (P<0.05). More importantly, serum active MMP-9 mean levels, serum active MMP-9/TIMP-1 ratio and intrathecal production of active MMP-9 were increased in MS patients with clinical (P < 0.001, < 0.001 and < 0.05, respectively) and MRI (P < 0.001, < 0.001 and < 0.02, respectively) disease activity, whereas CSF mean concentrations of active MMP-9 and CSF active MMP-9/TIMP-1 ratio were enhanced only in MS patients with MRI evidence of disease activity (P < 0.02 and < 0.01, respectively). Altogether, these findings suggest that a shift in MMP-9/TIMP-1 balance towards proteolytic activity of MMP-9 could be relevant in MS immune dysregulation. In addition, our results indicate that CSF and serum levels of active MMP-9 may represent a potential surrogate biomarker for monitoring MS disease activity. In particular, serum active MMP-9/TIMP-1 ratio seems to be a very appropriate indicator of ongoing MS inflammation, since it is easily measurable.

Intrathecal synthesis of soluble HLA-G and HLA-I molecules are reciprocally associated to clinical and MRI activity in patients with multiple sclerosis.

The aim of this study was to provide further insight into the effective contribution of classical soluble HLA-A, B and C class Ia (sHLA-I) and non-classical soluble HLA-G class Ib (sHLA-G) molecules in immune dysregulation occurring in multiple sclerosis (MS). We evaluated by enzyme-linked immunosorbent assay (ELISA) technique intrathecal synthesis and cerebrospinal fluid (CSF) and serum levels of sHLA-I and sHLA-G in 69 relapsing-remitting (RR), 21 secondary progressive (SP) and 13 primary progressive (PP) MS patients stratified according to clinical and magnetic resonance imaging (MRI) evidence of disease activity. We also tested, as neurological controls, 91 patients with other inflammatory neurological disorders (OIND) and 92 with non-inflammatory neurological disorders (NIND). Eighty-two healthy volunteers served as further controls for sHLA-I and sHLA-G determinations. An intrathecal production of sHLA-I and sHLA-G detected by specific indexes was significantly more frequent in MS patients than in controls (P<0.01). An intrathecal synthesis of sHLA-I was prevalent in clinically (P<0.02) and MRI active (P<0.001) MS, whereas a CSF-restricted release of sHLA-G predominated in clinically (P<0.01) and MRI stable (P<0.001) MS. sHLA-I levels were low in the serum of clinically active (P<0.001) and high in the CSF of MRI active (P<0.01) MS. Conversely, sHLA-G concentrations were decreased in the serum of clinically stable MS (P<0.01) and increased in the CSF of MRI inactive MS (P<0.001). The trends towards a negative correlation observed between CSF and serum concentrations and intrathecal synthesis of sHLA-I and sHLA-G in patients without evidence of clinical and MRI activity confirmed that intrathecal production and fluctuations in CSF and serum concentrations of sHLA-I and sHLA-G were reciprocal in MS. Our results suggest that, in MS, a balance between classical sHLA-I and non-classical sHLA-G products modulating both MRI and clinical disease activity in opposite directions may exist.

[The experience of the Operative Unit SETIL in Puglia]. / L'esperienza dell'Unità Operativa SETIL in Puglia.

(Epidemiological study on childhood tumors and leukaemia) study is an epidemiological case-control study, conducted in 15 Italian regions, including Apulia, to assess the possible risk of childhood cancer (leukaemia, LNH, and Neuroblastomes) resulting from exposures to electromagnetic fields (EMFs).

[Assessment of biological risk of blood transmission among health workers at a Bari university hospital]. / Valutazione del rischio biologico a trasmissione ematica negli operatori di una Azienda Ospedaliera-Universitaria di Bari.

We have examined all occupational exposures to biological materials, occurred from September 2001 to December 2002, among health workers of Bari polyclinic. The reported exposures, through an appropriate questionnaire expressly predisposed, have been a total of 114. The nurses were the most exposed category (46.5%) followed by physicians (27.2%). The highest load of accidents happened in surgical area (53%) and at a greater extent after the first three hours of the work shift (60%). The instruments that have caused endermic lesions have been more frequently the hollow bone needles (53.2%). The serology for HBV, HCV, and HIV of source-patients was known in the 87.8% of cases: 13 patients were positive for HCV, 1 for HIV and 2 were HbsAg positive. All injured workers were submitted to serological screening for HBV, HCV, HIV; for nobody of them seroconversions were observed.

Assessment of HIV-intrathecal humoral immune response in AIDS-related neurological disorders.

Intrathecal synthesis of IgG directed to HIV antigens was investigated by antibody specific index (ASI), affinity-mediated immunoblot (AMI) and Western blot (WB) assay in a group of 88 AIDS patients of which 28 with HIV-associated neurological disorders (HAND), 13 without associated neurological disorders (WAND) and 47 with non-HIV-associated neurological disorders (non-HAND). CD4+ count was above 50 cells/mm3 (CD4+>50) in 30 and below 50/mm3 (CD4+<50) in 58 patients, respectively. A significantly higher frequency for CSF complete anti-gag profile (p<0.001), and for HIV-specific oligoclonal patterns ("mixed" pattern=p<0.01) was observed in HAND as compared to patterns from the other clinical groups. A decrease in complete anti-env, anti-pol and anti-gag reactivity was present in CSF of patients with CD4+<50 as compared to those with CD4+>50. Our findings suggest that AIDS appears to be characterized by an anti-HIV intrathecal humoral immune response which is principally directed to env products with a prevalence of oligoclonal patterns and CSF complete anti-gag profile in HIV-associated neurological involvement.

Early predictors of intractability in childhood epilepsy: a community-based case-control study in Copparo, Italy.

OBJECTIVES: To identify early predictors of intractability in childhood and adolescence epilepsy. MATERIALS AND METHODS: We carried out a community-based case-control study using the incidence cohort of epileptic patients living in the district of Copparo, in the province of Ferrara, Italy. The comparative study was performed in 31 cases and 95 controls. Cases were patients who averaged at least 1 unprovoked seizure per month during an observational period of at least 2 years. Controls were subjects having achieved remission for at least 5 years regardless of current therapy. RESULTS: Onset at age <1 year, remote symptomatic etiology and high frequency of seizures before therapy were found to be independent early predictors of intractability. CONCLUSION: Our study suggested that the risk of developing intractable epilepsy may, to some extent, be predicted at the time of initial diagnosis in children with early-onset epilepsy of remote symptomatic etiology, especially if seizure propensity is initially high.

Temporal trend and factors associated with delayed hospital admission of stroke patients.

The effectiveness of stroke treatment depends on the time interval between onset of symptoms and admission to hospital. The purpose of our investigation was to assess, over a 10-year period, the mean delay in admission to hospital in stroke patients to determine factors which might be associated with this delay, to define the putative number of patients available for accrual in clinical trials, and to identify strategies aimed at decreasing the time to admission. We collected data on all stroke patients consecutively admitted to our clinic from 1986 to 1995. The following variables were investigated: age, sex, educational and occupational level, home accommodation, family and personal history of vascular disease or factors known to affect the risk of vascular disease, and type and severity of stroke. The individual and independent contribution of these variables was assessed by univariate and multivariate analysis. The accurate time of stroke onset was established for 760 patients. Of these, 24.7% were admitted within 1 h from the onset of symptoms, 41% within 2 h, 54% within 4 h and 72.5% within 12 h. The mean delay was 21 +/- 2 h (SE) and the median was 3.5 h. Acute onset of neurological deficits, stroke severity and family history of cerebrovascular disease were associated with earlier presentation. According to the current guidelines for thrombolytic therapy, only 16% of the patients could have been included in a clinical trial. This study suggests that despite a relatively short time to hospital admission in most patients and an altered help-seeking behavior over time, many stroke patients did not present early enough to be recruited for clinical trials or to benefit from new treatments. The majority of patients with timely presentation were not eligible for acute treatment, or were subjects with severe stroke for whom caution is advised before initiating thrombolytic therapy. It has been suggested that the patient's indecision to seek medical help is the most important reason for a delayed hospital admission of stroke patients. These results underscore the importance of interventions aimed at reducing the delay in stroke treatment induced by patients who are unaware of the decisive role of the time of treatment induction. The finding that earliest admissions for stroke comprised patients with a previous history of cerebrovascular disease suggests that an education campaign might highlight the importance of an early admission.

Advanced laboratory techniques for diagnosing Toxoplasma gondii encephalitis in AIDS patients: significance of intrathecal production and comparison with PCR and ECL-western blotting.

The polymerase chain reaction (PCR) for detection of cerebral spinal fluid (CSF) Toxoplasma gondii DNA was combined with the study of intrathecal antibody synthesis by antibody specific index calculation (ASI) and the detection of specific oligoclonal IgG bands (OCB) by affinity mediated immunoblotting (AMI) in 11 AIDS patients with T. gondii encephalitis (TE) and in 20 control patients with or without neurological disorders. Enhanced chemiluminescence (ECL) western-blot technique was employed to evaluate the antigenic specificity of CSF-IgG towards individual T. gondii antigens. PCR was positive in all TE patients which displayed brain-derived or blood-derived specific OCB, even when comparative ASI failed. Four TE patients had a unique anti-T. gondii OCB restricted to the CSF and a strong antibody response toward the 29 kDa band by ECL western blot. This response could be an important marker to discriminate TE from other opportunistic central nervous system (CNS) infections in the course of AIDS.

Hypokaliemic rhabdomyolysis associated with liquorice ingestion: report of an atypical case.

We here present an unusual case of hypokaliemic rhabdomyolysis, characterised by a sthenic deficit exclusively involving the distal muscles of the upper limbs and secondary to chronic glycyrrhizic acid intoxication, and by the absence of even ictal arterial hypertension. We discuss the etiopathogenetic bases and the risks related to the development of this secondary hypokaliemic syndrome, also in relation to other concomitant risk factors such as prolonged physical exercise and exposure to low temperatures.

Exogenous gangliosides and Guillain-Barré syndrome. An observational study in the local health district of Ferrara, Italy.

A retrospective study was carried out in the Ferrara Local Health District, Italy, for the period 1981-1993 (average resident population: 177,235 inhabitants) to establish whether people exposed to exogenous gangliosides had a higher risk of Guillain-Barré syndrome. The incidence of Guillain-Barré syndrome of 1.9/100,000 population/year [95% confidence interval (CI): 1.3-2.5] reported in Ferrara Local Health District in the same period was used as a reference for comparison. The data bank of Ferrara Local Health District made it possible, first to estimate the number of individuals exposed to gangliosides in the resident population of Ferrara Local Health District (3.7%), the number of ganglioside prescriptions and the number of cases of Guillain-Barré syndrome who had treatment with gangliosides (nine patients, 20.9%), and, secondly, to verify the sequence of events between the ganglioside injection and the onset of the disease. Seven of the nine patients (77.8%) received gangliosides as treatment for peripheral neuropathy (Guillain-Barré syndrome onset before gangliosides were prescribed). For the other two patients (22.2%) a possible appropriate temporal sequence between ganglioside injection and onset of Guillain-Barré syndrome was found. Based on two possible ganglioside-related cases, the risk of Guillain-Barré syndrome was higher in the exposed (0.53/100,000 population/month following ganglioside injection; 95% CI: 0.06-1.91) compared with the unexposed population, but the difference was not significant. When only individuals prescribed with mixed gangliosides were considered (both possible ganglioside-related Guillain-Barré syndrome cases received mixed gangliosides), the risk of Guillain-Barré syndrome was higher (0.64/100,000 population/month following ganglioside injection; 95% CI: 0.08-2.31) but the difference from the risk in unexposed individuals was not statistically significant. The relative risk for the exposure to mixed gangliosides was borderline (relative risk = 4.3; 95% CI: 1.0-17.8). The wide 95% confidence intervals were a consequence of sample size limitations. Considering also that the exposed and unexposed groups differed in age (those exposed were older than those unexposed and the age-specific incidence of Guillain-Barré syndrome in the study population increased with increasing age), the present findings question either a strong increased risk of Guillain-Barré syndrome in people exposed to exogenous gangliosides or an immunogenic role of these agents in humans. However, because of the limited sample size, the results are not conclusive.

Prognosis of childhood epilepsy: a community-based study in Copparo, Italy.

We performed a community-based study among children and adolescents with idiopathic and cryptogenic epilepsy and onset of the seizures between 0 and 19 years of age on the prognosis of being seizure-free. The study population was recruited during a descriptive investigation in the Local Health Service of Copparo (USL 34), Ferrara, Northern Italy. We included 111 patients (61 males and 50 females). The average length of follow-up was 18.8 years (ranging from 7 to 24 years). The cumulative probability of being in remission was 81.2% at 15 years after onset and the estimated percentage of patients in remission without therapy was 56% for the same time period. At 15 years after the onset of epilepsy, approximately 20% of patients continued to have seizures; nearly 25% continued to take antiepileptic drugs but had been free of seizures for at least 5 years; nearly 56% had been without seizures and free of medication for at least 5 years. Seizure type, gender, age at onset of the illness, epileptic abnormalities on EEG, family history of convulsive disorders, number and frequency of seizures prior to the start of treatment were found not to be helpful as prognostic factors. This community study, carried out on patients without the well known factors that adversely affect prognosis, confirms that the prospect of seizure control and for withdrawal of therapy is (generally) good.

Phenytoin-induced gingival overgrowth: a community-based cross-sectional study in Ferrara, Italy.

A community-based cross-sectional study was carried out in Ferrara, Northern Italy, to verify the frequency of gingival overgrowth in chronic phenytoin (PHT) users and the risk factors associated with its development. All subjects taking phenytoin were identified using the computerized list of drug prescriptions available in the study area. Most of the subjects were interviewed and underwent an oral examination to evaluate their periodontal condition. The prevalence of gingival enlargement in chronic PHT users was about 40%. In our study, sex, age age at onset of therapy, treatment duration, and oral hygiene were not significantly associated with the risk of developing gingival overgrowth. A direct relationship with daily dose was found to be an independent risk factor. Younger age and poorer oral hygiene seemed to predispose to the severest level of gingival involvement. These results support data from experimental studies by suggesting that drug-induced gingival overgrowth is a dose-dependent side effect whose severity could be affected by local factors.

Multiple sclerosis in Italy. A reappraisal of incidence and prevalence in Ferrara.

BACKGROUND: Previous descriptive surveys on multiple sclerosis (MS) in the province of Ferrara, northern Italy, carried out by our own epidemiological research group, pointed out that this area was not at low-medium risk for MS. OBJECTIVE: To verify the morbidity estimates and update the temporal trend of MS. DESIGN AND METHODS: We used a complete enumeration approach by reviewing all the possible sources of case collection available in Ferrara for 1965 through 1993. We included all patients with definite and probable MS according to the criteria of Poser et al. RESULTS: The mean annual incidence rate was 2.3 per 100,000 population (95% confidence interval, 2.0-2.6 per 100,000), 3.0 per 100,000 for women and 1.5 per 100,000 for men. On December 31, 1993, 249 patients (170 women and 79 men) suffering from definite or probable MS were living in the province of Ferrara, giving a crude prevalence rate per 100,000 population of 69.4 (95% confidence interval, 61.2-78.7), 90.8 for women and 46.0 for men. CONCLUSION: The data confirm that in Ferrara, MS occurs more frequently than previously suggested by the latitude-related epidemiological model, supporting the view that northern Italy is a high-risk area for the disease. While the prevalence rate is much higher than in our previous studies, probably owing to the increasing survival of the patients because of improving supportive care, the incidence rates, similar in magnitude to those observed in high-risk areas of northern and central Europe, have remained relatively stable over time.

A prospective study on the predictive value of CSF oligoclonal bands and MRI in acute isolated neurological syndromes for subsequent progression to multiple sclerosis.

A prospective study in patients with a clinical acute isolated brainstem or spinal cord disorder was undertaken. The aim was to evaluate the predictive value of IgG intrathecal synthesis (through the detection of oligoclonal bands in CSF) and MRI lesions at presentation, for the subsequent progression to multiple sclerosis. Forty four patients took part in this study: 22 had a brainstem disorder and 22 a spinal cord disorder. After a mean period of 26 (SD 22) months, 30 patients (68.2%) developed clinically definite multiple sclerosis. The remaining 14 patients were followed up for more than seven years. Twenty six (59.1%) patients had oligoclonal bands in CSF, with a sensitivity of 80.0%, specificity of 85.7%, and a predictive value of 92.2%. Magnetic resonance imaging showed disseminated white matter lesions in 22 patients (50.0%), with a sensitivity of 60.0%, a specificity of 71.4%, and a predictive value of 81.7%. The difference between patients with multiple sclerosis and patients without the disease was statistically significant for the findings of an IgG intrathecal synthesis (P < 0.001). It was only borderline for the MRI findings (P = 0.052). Thus the detection of an intrathecal synthesis at presentation seemed to be a better prognostic indicator of the progression to multiple sclerosis in patients affected by acute isolated brainstem or spinal cord syndromes.

The incidence of Guillain-Barre syndrome in Ferrara, Italy: is the disease really increasing?

The Guillain-Barre syndrome (GBS) incidence has been updated in the area of the Local Health District of Ferrara, Unita Sanitaria Locale n. 31 (USL 31), Northern Italy, (where a previous survey found an average annual incidence of 1.26/10000 population) in order to verify a supposed increase in GBS occurrence. The updated mean annual incidence over the years from 1981 to 1993 (average resident population: 177235 inhabitants) was 1.87/100000 population (1.66/100000 when age-adjusted). The rate increased progressively in the four subsequent time intervals into which the study period was subdivided (from 1.09/100000 in the years 1981-1984 to 2.73/100000 in the years 1991-1993) with a significant temporal variation (0.025

Risk factors for idiopathic generalized seizures: a population-based case control study in Copparo, Italy.

We examined the etiopathogenetic role of preperinatal risk factors in the history of epileptic patients, identified in a previous descriptive study performed in Copparo, Italy. A community-based case control study of a group of epileptic patients with idiopathic generalized seizures was performed. The population consisted of 55 patients aged < 35 years as of December 31, 1988, residing in Copparo. Symptomatic patients were not included in the present study. The control sample consisted of 165 randomly selected healthy individuals, matched with patients for sex, age, and residence in the study area. The interview for detection of history of presumed risk factors was based on the Protocol of the Italian League Against Epilepsy. Obstetric, neurologic, and neonatal hospital charts were also reviewed. A family history of epilepsy, febrile seizures, and other perinatal factors (such as continual physical stress during pregnancy, maternal age > 35 years, and birth order > 3) were significantly more common in patients as compared with controls. Our data support the hypothesis of genetic propensity for generalized and febrile seizures, which may represent early expression of a low seizure threshold that subsequently develops into epilepsy.

Intracranial gliomas in Ferrara, Italy, 1976 to 1991.

INTRODUCTION: We planned a descriptive study on the incidence of intracranial gliomas spanning a 16-year period (1976-1991) in the Local Health Service 31 of Ferrara, Northern Italy. MATERIAL AND METHODS: We used a complete enumeration approach by reviewing all the possible sources of case collection available in the study area. RESULTS: The mean annual incidence rate was 5.8 new cases per 100,000 population (6.96 for men and 4.78 for women; p < 0.05), resulting in 4.7 per 100,000 when directly adjusted to the Italian population. The age-specific incidences showed a small peak in childhood, an increase with age, reaching a maximum in the age group 60 to 64 and then a decline in the elderly. This pattern is similar for both sexes. The adjusted rates increased from 3.94 per 100,000 population in the first five-year period to 5.6 per 100,000 in the third (a nonsignificant difference). The distribution of cases within the study area was substantially uniform. CONCLUSION: The incidence rates of Ferrara fell into the middle-high values so far reported and confirmed the male preponderance found in previous studies. The age-related pattern is similar to that observed, with few exceptions, in other surveys. Like other authors we did not find a significant temporal trend, although the incidence rates tended to increase with time. The data encourage further, wider epidemiological studies of a prospective nature.