An outbreak of severe invasive meningococcal disease due to a capsular switched Neisseria meningitidis hypervirulent strain B:cc11.

OBJECTIVES: The aim was to investigate an outbreak of invasive meningococcal disease (IMD) in Southern Sardinia. METHODS: Epidemiological and microbiological investigations were performed. The latter included antimicrobial susceptibility testing and whole-genome sequencing (WGS). RESULTS: Seven individuals with severe IMD were found to be infected with serogroup B (MenB) Neisseria meningitidis in the first quarter of 2018. Five of the seven cases (five males; mean age 19 years; range 18-21 years; CFR 40%) were due to a unique strain B:P1.5-1,10-8:F3-6:ST-11(cc11), probably switched from the hypervirulent C-cc11, as confirmed by WGS. All five patients had attended the same nightclub in the 2 weeks prior to symptom onset. Public health measures, including chemoprophylaxis of contacts and active immunization against MenB, were implemented. CONCLUSIONS: We observed five IMD cases due to the same switched MenB strain. The hypervirulent B:P1.5-1,10-8:F3-6:ST-11(cc11) strain, probably switched from C-cc11, is of concern due to the observed high virulence and case fatality rates. All the patients shared the same place of probable exposure. The molecular characterization of the invasive strain allowed the outbreak to be confirmed, which was then controlled through timely public health action.

Pre-Emptive Therapy for the Treatment of Cytomegalovirus After Kidney Transplantation.

BACKGROUND: Cytomegalovirus (CMV) represents the leading cause of viral infection in kidney transplantation patients. The aim of the present study was to evaluate the efficacy and safety of pre-emptive anti-CMV therapy. MATERIALS AND METHODS: We performed a retrospective analysis based on data from 227 consecutive patients transplanted from 2010 to 2015, of whom 38 (16.6%) were from a living donor, considering: incidence of rejection, CMV organ localization, and graft and patient survival. All patients underwent induction immunosuppressive therapy followed by maintenance therapy consisting of corticosteroids, antimetabolites, and tacrolimus (median basal dose = 5.3 ng/mL). The timing for the detection of plasma CMV-DNA in the post-transplantation period was: weekly (first month), quarterly (second through twelfth month), and then half-yearly. RESULTS: CMV viremia was positive in 98 of 227 (43.1%) patients, with an average of 248,482 copies/mL (range: 250 copies/mL to 9,745,000 copies/mL) and the first positivity after a median period of 2.5 months from kidney transplantation (range: 0.2 months to 43 months). A total of 49 of 227 (21.5%) patients were treated with antivirals: 27 of 49 (55.1%) because of CMV organ localization (gastrointestinal = 20, lungs = 3, kidney = 2, liver = 2). Fourteen of 227 (6.1%) patients had a rejection episode, 7 (3.1%) of which were CMV-related. Fifteen of 227 (6.6%) patients died (noninfectious CMV-related complications = 8, cardiovascular causes = 6, bleeding complications = 1). CONCLUSION: Our experience confirms the validity of the pre-emptive anti-CMV therapy in renal transplantation patients.

Outpatient diabetes clinical decision support: current status and future directions.

Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces.

Genome-based study of a spatio-temporal cluster of invasive meningococcal disease due to Neisseria meningitidis serogroup C, clonal complex 11.

OBJECTIVES: To describe a spatio-temporal cluster of invasive meningococcal disease (IMD) due to serogroup C meningococci, occurred in a restricted area of Tuscany between January and October 2015, and the results of whole genome sequencing (WGS). METHODS: Surveillance activities and public health measures were implemented in the Region. Bacterial isolates from IMD cases were characterized by the National Reference Laboratory of the Istituto Superiore di Sanità (ISS), and WGS was performed on available strains. The kSNP software was used to identify core genome SNPs. RESULTS: Overall, 28 IMD cases due to meningococcus C were identified up to 31st October, 2015. Of them, 26 were due to meningococcus C:P1.5-1,10-8: F3-6:ST-11 (cc11) and 2 to C:P1.5-1,10-8: F3-6:ST-2780 (cc11). WGS of 13 meningococci isolated during the outbreak occurred in Tuscany in 2015 showed higher similarity when compared with those of 47 C: P1.5-1,10-8: F3-6:ST-11 (cc11) invasive strains from sporadic cases previously detected in Italy. CONCLUSIONS: A highly aggressive meningococcal C strain was involved in the cluster of severe IMD occurred in Tuscany, a Region with high vaccine coverage among children. Whether this was due to low herd immunity related to the short duration of vaccine protection needs further investigation.

Antitumor activity of epigenetic immunomodulation combined with CTLA-4 blockade in syngeneic mouse models.

The multifaceted immunomodulatory activity of DNA hypomethylating agents improves immunogenicity and immune recognition of neoplastic cells; thus, we predicted they could be utilized to design new immunotherapeutic combinations in cancer. Testing this hypothesis, the antitumor efficacy of the DNA hypomethylating agent 5-aza-2'-deoxycytidine (5-AZA-CdR) combined with the anti-CTLA-4 monoclonal antibody (mAb) 9H10 in syngeneic transplantable murine models was investigated. Murine mammary carcinoma TS/A or mesothelioma AB1 cells were injected in BALB/c, athymic nude, and SCID/Beige mice that were treated with 5-AZA-CdR, mAb 9H10, or their combination. Tumor volumes were captured at different time-points; molecular and immunohistochemical assays investigated changes in neoplastic and normal tissues. A significant antitumor effect of 5-AZA-CdR combined with mAb 9H10 was found: compared to controls, a 77% (p < 0.01), 54% (p < 0.01) and 33% (p = 0.2) decrease in TS/A tumor growth was induced by 5-AZA-CdR combined with mAb 9H10, 5-AZA-CdR or mAb 9H10, respectively. These antitumor activities were confirmed utilizing the AB1 model. 5-AZA-CdR-based regimens induced a promoter-demethylation-sustained tumor expression of cancer testis antigens. MHC class I expression was up-regulated by 5-AZA-CdR. Antitumor efficacy of 5-AZA-CdR in athymic nude and SCID/Beige mice was not increased by mAb 9H10. In BALB/c mice, combined treatment induced the highest tumor infiltration by CD3+ lymphocytes, which included both CD8+ and CD4+ T cells; no such infiltrates were observed in normal tissues. This significant immune-related antitumor activity of 5-AZA-CdR combined with CTLA-4 blockade, demonstrated in highly aggressive mouse tumor models, provides a strong scientific rationale to implement epigenetically-based immunotherapies in cancer patients.

Draft Genome Sequence of Neisseria gonorrhoeae Sequence Type 1407, a Multidrug-Resistant Clinical Isolate.

Gonorrhea may become untreatable due to the spread of resistant or multidrug-resistant strains. Cefixime-resistant gonococci belonging to sequence type 1407 have been described worldwide. We report the genome sequence of Neisseria gonorrhoeae strain G2891, a multidrug-resistant isolate of sequence type 1407, collected in Italy in 2013.

Changing epidemiology of Infant Meningococcal Disease after the introduction of meningococcal serogroup C vaccine in Italy, 2006-2014.

BACKGROUND: In Italy, the incidence of Invasive Meningococcal Disease (IMD) was around 0.28 per 100,000 over the last years. Since the risk IMD is usually high among infants aged less than 1 year, we decided to evaluate the trend of IMD cases reported between 2006 and 2014 in this age group. In particular, the study aim was to describe the main characteristics of IMD cases in infants following the introduction of MCC vaccine (2005) and to estimate the number of cases which are potentially preventable through early vaccination. METHODS: The National Surveillance System of Bacterial Meningitis was established in 1994 and in 2007 was extended to all invasive bacterial diseases. Clinical data and isolates and/or clinical samples are collected from hospitalized patients throughout the country. IMD cases are reported by clinicians to the local health authorities, and samples are sent to the Reference Laboratory at the Istituto Superiore di Sanità for further characterization and storage at -80°C. In particular, serogroup identification is obtained by agglutination with commercial antisera or by multiplex PCR. RESULTS: The annual incidence for infants <1 year old remained rather stable of 3.6 per 100,000, with several upward and downward oscillations and a peak in 2010. The incidence of IMD among infants was more than 10 times higher than the overall rate of IMD observed in Italy. Finally, serogroup B was more frequently detected among infants aged <1 year, accounting for 65% of the total (p<0.01). CONCLUSIONS: During the study period, IMD incidence reported among infants aged less than one year old was 10 times higher than the overall rate, and serogroup B was the most commonly detected over time. The long-term impact of meningococcal C conjugate vaccine and the effect of the introduction of meningococcal B vaccination among infants need to be evaluated.

Climate, demographic factors and geographical variations in the incidence of invasive meningococcal disease in Italy.

We investigated the effect of climatic, demographic factors and intra-country geographical variations on the incidence of invasive meningococcal disease (IMD) in Italy. For this purpose, incidence rates of IMD cases reported in Italy between 1994 and 2012 were calculated, and a cluster analysis was performed. A geographical gradient was determined, with lower incidence rates in central and southern Italy, compared to the northern parts, where most clusters were observed. IMD rates were higher in medium-sized towns than in villages. Adults were at lower risk of IMD than children aged ⩽4 years. IMD incidence tended to decrease with increasing monthly mean temperatures (incidence rate ratio 0·94, 95% confidence interval 0·90-0·99). In conclusion, geographical variations in IMD incidence were found, where age and temperature were associated with disease occurrence. Whether geographical variations should be considered in national intervention plans is still a matter for discussion.

Draft Genome Sequence of C:P1.5-1,10-8:F3-6:ST-11 Meningococcal Clinical Isolate Associated with a Cluster on a Cruise Ship.

Meningococcal serogroup C strains, in particular those belonging to the ST-11 clonal complex, are known to cause invasive diseases worldwide. We report the genome sequence of a Neisseria meningitidis strain linked to a cluster of cases of invasive meningococcal disease on a cruise ship that was described in 2012.

Diversity of Neisseria meningitidis invasive isolates in Italy in the period 2008-2010.

In the period 2008-2010, 309 Neisseria meningitidis, isolated in Italy within the National Surveillance of the Invasive Meningococcal Diseases, have been tested for their phenotypic and genotypic characteristics. The main results obtained are: (a) an increase of the strains of serogroup B and a decrease of serogroup C; (b) a phenotypic and genotypic variability of the ST-41/44 clonal complex, the most frequently isolated among serogroup B strains; (c) a decrease of ST-8 clonal complex among serogroup C meningococci whereas strains belonging to ST-11 clonal complex are nowadays the most frequently isolated.

Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012.

We describe a cluster of four cases of invasive meningococcal disease that occurred on a cruise ship sailing along the Italian coast in October 2012. All four cases were hospitalised with severe illness and one of them died. This report illustrates the importance of rapid implementation of emergency control measures such as administration of prophylaxis to all crew members and passengers to prevent the spread of the disease in such a close environment.

Laparoscopic treatment of incarcerated hernia through right broad ligament in patients with bilateral parametrium defects.

We present the first case reported in the literature of small bowel obstruction due to internal incarcerated hernia through a diagnosed bilateral broad ligament defect, and treated by laparoscopy. A 36-year-old white woman, gravida 0, para 0, was admitted to our hospital with intestinal obstruction symptoms. A laparoscopic approach was performed with 3 trocars and internal incarcerated hernia due to a defect in the right broad ligament was found. There was a similar defect in the left broad ligament. The small bowel, once reduced, appeared viable. Closure of both defects was carried out by laparoscopy with 2-0 monofilament absorbable running suture. The patient's postoperative course was unremarkable and she was discharged from the hospital 4 days after the surgical procedure. The classification of defect was a bilateral fenestrae type I defect. Congenital ethiology is plausible because of the presence of bilateral defects and the absence of surgical trauma, pregnancy, pelvic inflammatory disease, endometriosis in the clinical history.

Characterisation of Neisseria meningitidis C strains causing two clusters in the north of Italy in 2007 and 2008.

Two clusters of invasive meningococcal disease in the north of Italy both due to serogroup C/ST-11 clonal complex are here described. The objective of the investigation was to analyse the phenotype and the genotype of meningococci involved in the two clusters which were of national relevance due to the fatal outcome of the majority of cases (six of the total of 10 cases). All the strains were C:2a:P1.5 ST-11/ET-37 clonal complex. Two pulsed field gel electrophoresis (PFGE) and variable number tandem repeats (VNTR) profiles were identified, one for each cluster. VNTRs were different from those detected in Italy for C/ST-11 strains isolated from sporadic cases in the same period. This laboratory surveillance report highlights the importance and the crucial role of molecular characterisation to confirm the relatedness among meningococci responsible for clusters of cases.

Another case of cystic fibrosis complicated by meconium ileus associated with Hirschsprung's disease: a rare and important association.

We are reporting the case of a neonate which died on 16th day of life due to a fatal evolution of a rare association of cystic fibrosis and Hirschsprung's disease.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis.

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.

[Abdominal tuberculosis: clinical features, diagnosis and role of surgery]. / La tubercolosi addominale: aspetti clinico-diagnostici e ruolo della chirurgia.

AIM: Nowadays the incidence of tuberculosis is increasing in some population groups (subjects immigrated from developing countries, affected from HIV infection, or undergoing immunosuppressive therapy) and to the development of multidrug-resistance. The clinical manifestations, routine laboratory and radiographic analyses of abdominal tuberculosis are nonspecific and surgery plays a fundamental role because 25-75% of such patients are operated. METHODS: Six patients, 4 male and 2 female (age 23-62 years) underwent laparotomy or laparoscopy. Five patients were not European, 1 was Italian. The surgical indications were: intestinal occlusion in 3 patients; perforation in 1 patient; peritonitis in 2 patients. RESULTS: The most frequent clinical manifestations were pyrexia, weight loss, anemia, ascites. Chest X-ray was normal in all patients. All patients were found ARB-negative in sputum and in ascitic fluid, while 1 was positive to culture of sputum and 3 of ascitic fluid. In all patients histopathologic examination showed typical findings of tuberculosis. CONCLUSIONS: The surgical indication is made for diagnostic aim or due to the presence of complications. Laparoscopy is the gold standard in the diagnosis,since it allows whole exploration of abdomen and taking of sample for biopsy and ascitic fluid to find micobacterium. In fact, abdominal tuberculosis is a paucibacillar disease and rarely it is possible to demonstrate the direct presence of M. Tuberculosis, but nowadays the methods of the genome amplification allow to demonstrate the sequence of the chromosomial DNA of M. Tuberculosis from small fragments of bioptic material.

Modulation of P-glycoprotein activity by acridones and coumarins from Citrus sinensis.

Bioguided fractionation of the roots of Citrus sinensis (Rutaceae) led to the isolation and identification of five coumarins, namely, clausarin, suberosin, poncitrin, xanthyletin and thamnosmonin, seven acridones, namely, acrimarine B, 2-methoxycitpressine I, citpressine I, buntanine, acrimarine E, honyumine and acrimarine C, and one terpenoid, namely, limonin. Among these compounds, clausarin, 2-methoxycitpressine I and acrimarine E inhibited P-glycoprotein-mediated drug efflux in K562/R7 human leukemic cells over-expressing P-glycoprotein.

Characterisation of invasive meningococcal isolates from Italian children and adolescents.

Meningococcal invasive disease is a life-threatening infection that affects mostly children and adolescents. The present study was performed during 2003-2005 to compare the phenotypic characteristics of meningococcal isolates from these two main groups at risk with those of isolates from other age groups to assess whether strategies for treatment and prevention implemented elsewhere can also be applied in Italy. The results showed that serogroup C meningococci were predominant, and that a dramatic increase in the circulation of strains with decreased susceptibility to penicillin was associated mainly with a prevalent phenotype C:2b:P1.5,2, which belongs to the hyper-virulent ST8/A4 cluster.

Long-term predominance of a rare meningococcal phenotype in a small geographical area.

Reported here is a predominant clone of Neisseria meningitidis B:14:P1.13 that persisted over a 6-year period in the northernmost province of Italy, where it was responsible for a higher incidence of meningococcal disease compared to the rest of the country. Genetic relatedness of isolates was confirmed by multilocus sequence typing, pulsed-field gel electrophoresis and PorA variable region typing. All strains examined belonged to the ST44 complex/lineage III. Risk factors for infection were evaluated through a case-control study conducted with 21 cases and 63 age- and sex-matched controls. Risk factors for infection in the seven patients younger than 13 years were (i) residence in a rural area, (ii) exposure to passive smoke, and (iii) living in a home with rooms rented to tourists (all odds ratios infinite). The only risk factor for the older patients was previous influenza-like illness (odds ratio, 41.9; 95% confidence interval, 1.6-1068.9). Guidelines for the early treatment of patients and public information campaigns were successfully implemented to reduce disease transmission and the case fatality rate in the region.

T-cell immune response assessment as a complement to serology and intranasal protection assays in determining the protective immunity induced by acellular pertussis vaccines in mice.

The relative value of antibodies and/or T-cell immune responses to Bordetella pertussis antigens in the immunity induced by acellular pertussis (aP) vaccines is still an open issue, probably due to the incomplete knowledge on the mechanisms of protective immunity to pertussis. The relevance of T-cell immune responses in protection from pertussis has been demonstrated in murine and human models of infection; thus, in this study, the ability of different vaccine preparations of three component (pertussis toxin, filamentous hemagglutinin, and pertactin) aP vaccines to induce T-cell responses was investigated in mice. All vaccine preparations examined passed the immunogenicity control test, based on antibody titer assessment, according to European Pharmacopoeia standards, and protected mice from B. pertussis intranasal challenge, but not all preparations were able to prime T cells to pertussis toxin, the specific B. pertussis antigen. In particular, one vaccine preparation was unable to induce proliferation and gamma interferon (IFN-gamma) production while the other two gave borderline results. The evaluation of T-cell responses to pertussis toxin antigen may provide information on the protective immunity induced by aP vaccines in animal models. Considering the critical role of the axis interleukin-12-IFN-gamma for protection from pertussis, our results suggest that testing the induction of a key protective cytokine such as IFN-gamma could be an additional tool for the evaluation of the immune response induced by aP vaccines.