Serosurvey against H5 and H7 avian influenza viruses in Italian poultry workers.

Highly pathogenic (HP) and low pathogenic (LP) avian influenza viruses (AIVs) belonging to H5 and H7 subtypes have been found to be associated with human infection as the result of direct transmission from infected poultry. Human infections by AIVs can cause mild or subclinical disease, and serosurveys are believed to represent an important tool to identify risk of zoonotic transmission. Therefore, we sought to examine Italian poultry workers exposed during LPAI and HPAI outbreaks with the aim of assessing serologic evidence of infection with H5 and H7 AIVs. From December 2008 to June 2010 serum samples were collected from 188 poultry workers and 379 nonexposed controls in Northern Italy. The hemagglutination inhibition (HI) assay using horse red blood cells (RBCs) and a microneutralization (MN)-enzyme-linked immunosorbent assay test were used to analyze human sera for antibodies against the following H5 and H7 LPAI viruses: A/Dk/It/4445/07(H5N2); A/Ty/It/2369/09(H5N7); A/Ty/It/218-193/ 10; A/Ck/It/3775/99(H7N1); A/Ty/It/214845/03(H7N3); and A/Dk/It/332145/09(H7N3). Since previous studies identified low antibody titer to AIVs in people exposed to infected poultry, a cutoff titer of > or = 1:10 was chosen for both serologic assays. Only HI-positive results confirmed by MN assay were considered positive for presence of specific antibodies. The Fisher exact test was used to analyze differences in seroprevalence between poultry workers and control groups, with the significance level set at P < 0.05. MN results showed a proportion of H7-seropositive poultry workers (6/188, i.e., 3.2%), significantly higher than that of controls (0/379), whereas no MN-positive result was obtained against three H5 LPAI subtypes recently identified in Italy. In conclusion, the survey indicated that assessing seroprevalence can be an important tool in risk assessment and health,surveillance of poultry workers.

[Work-related accidents and diseases in migrant workers]. / Infortuni e malattie lavoro-correlate nei lavoratori immigrati.

It is estimated that in Italy there are about 4 million migrant workers, accounting for 10% of total workforce. They are heavily involved in the so-called "3D jobs" (dangerous, dirty and demanding/degrading). The available data, from literature as well as national official sources, show an overall higher risk of occupational accidents in migrant workers as compared with the natives and a relevant prevalence of occupational diseases, with an increasing trend in the last few years. Within such a framework, Occupational Physician is clearly called to play a proactive role.

[Occupational health and immigration: skills, perspectives and areas of intervention]. / Medicina del lavoro ed immigrazione: competenze, aree d'intervento e prospettive.

The occupational physician (OP) has nowadays to face health and safety of migrant workers on new ethical, scientific, epidemiologic and legislative basis. Objective of our contribution is to describe area of interventions and perspectives in good medical practices for OP when dealing with migrant workers. Risk assessment should focus on differences of immigrants versus natives as regards exposures and effects, quality of and access to health services, organizational issues. Health surveillance should take into account cultural, educational, religious, life style differences, as well as susceptibility; time must be dedicated by the OP to search and evaluate such differences. Counselling, health promotion and case management are part of good medical practice. The professional role of the OP is depicted, trying to identify weaknesses and strengths, as well as priorities for intervention especially in applied research. In conclusion, migrant workers may suffer from occupational health inequalities. By means of good medical practices in risk assessment, health surveillance, fitness for work and health promotion, OP can proactively improve migrant workers' health and guarantee same levels of protection and prevention in workplaces as for the natives.

[Role of the occupational physician in occupational injuries prevention: across ethics, science and good practices]. / Ruolo del medico competente nella prevenzione degli infortuni sul lavoro: tra etica, scienza e buone prassi.

Occupational injuries (OI) are a relevant issue in workplaces, being responsible for a range of individual and socio-economic consequences, with an enormous toll paid by workers, enterprises and society. Despite all these issues, OI prevention has not received significant field research attention, with studies mainly addressed to reporting data a posteriori instead of evaluating the effectiveness of prevention programs. In addition, the role of occupational physician (OP) seems to be largely underplayed. OP may and should be involved in OI prevention and control, in respect of codes of ethics, current legislation and scientific evidence. A multifaceted intervention in foundries, which showed effectiveness in reducing OI rates and improving quantitative and qualitative outcomes, gave us the opportunity to highlight OP's key role in implementing good occupational health and safety practices in workplaces.

[Ideas, reflections and tools for a modern role of the occupational physician]. / Idee, riflessioni e strumenti operativi per un "nuovo ruolo del medico competente vo".

Over the last few years, following new legislations, events of media impact, transitions in workplaces, Occupational Medicine is at stake. Often, debate is strong about technical-scientific issues in Occupational Physician (OP) activities, ethics and deontology, professional independence, dignity, training and education. The present work develops through personal thoughts, literature data, reporting of concrete personal experience across various occupational settings and risks, with the aim of promoting a "new" role for the OP, enhance his autonomy, professional skills, uniqueness, quality, credibility, while being convinced that it is certainly necessary and possible to conjugate ethics and scientific approach within daily professional activity of the OP, who in turn should be prone to change pace, evaluate effectiveness of his actions, abandon obsolete and useless practices, focussing on a new, proactive, clinical-diagnostic and managerial role, through good medical practices.

[Vaccinations for health care workers exposed to biohazard. Evidences and good medical practices]. / Il Medico Competente e le vaccinazioni nel settore della sanità. Evidenze scientifiche e buone prassi.

Biohazard in healthcare settings is an issue for Occupational Physician (OP), owing to the potential relevant adverse effects for health care workers (HCW) and for the non complete effectiveness of primary prevention. Vaccination represents an effective tool to minimize risk of occupational and nosocomial transmission for many relevant communicable diseases. Implementation of vaccination campaigns may however present some critical aspects. The present study evaluates available scientific evidences and reports an Italian multicenter study (9 Hospitals, 3200 HCW), suggesting good medical practices in vaccination, while highlighting the role of the OP in a multidisciplinary context.

Mutation and phenotypic spectrum in patients with cardio-facio-cutaneous and Costello syndrome.

Cardio-facio-cutaneous (CFC) and Costello syndrome (CS) are congenital disorders with a significant clinical overlap. The recent discovery of heterozygous mutations in genes encoding components of the RAS-RAF-MAPK pathway in both CFC and CS suggested a similar underlying pathogenesis of these two disorders. While CFC is heterogeneous with mutations in BRAF, MAP2K1, MAP2K2 and KRAS, HRAS alterations are almost exclusively associated with CS. We carried out a comprehensive mutation analysis in 51 CFC-affected patients and 31 individuals with CS. Twelve different BRAF alterations were found in twenty-four patients with CFC (47.0%), two MAP2K1 mutations in five (9.8%) and two MAP2K2 sequence variations in three CFC-affected individuals (5.9%), whereas three patients had a KRAS alteration (5.9%). We identified four different missense mutations of HRAS in twenty-eight cases with CS (90.3%), while KRAS mutations were detected in two infants with a phenotype meeting criteria for CS (6.5%). In 14 informative families, we traced the parental origin of HRAS alterations and demonstrated inheritance of the mutated allele exclusively from the father, further confirming a paternal bias in the parental origin of HRAS mutations in CS. Careful clinical evaluation of patients with BRAF and MAP2K1/2 alterations revealed the presence of slight phenotypic differences regarding craniofacial features in MAP2K1- and MAP2K2-mutation positive individuals, suggesting possible genotype-phenotype correlations.

[Susceptibility to varicella-zoster, measles, rosacea and mumps among health care workers in a Northern Italy hospital]. / Suscettibilità per varicella, morbillo, rosolia e parotite negli operatori sanitari di un ospedale del Nord Italia.

BACKGROUND: Nosocomial transmission of varicella (V), rubella (R), mumps (Mu) and measles (Me) may be a significant cause of morbidity in health care workers (HCW). Susceptible HCW might be a relevant part of the workforce. METHODS: A seroprevalence study was performed in a public hospital. Antibodies (Ab) against V, R, Mu and Me were determined by ELISA. Sociodemographic, clinical, occupational data and sera were obtained during health surveillance. RESULTS: 2934 tests on 1106 HCW were performed. Seropositivity was 91% for V, 89% for R, 80% for Mu, 92% for Me. No significant differencies were found for the variables tested, except for age (< 36 years) and certain job tasks (e.g. residents). 22% of HCW tested were seronegative for at least 1 virus. More seronegatives were detected as compared with the majority of literature data. DISCUSSION: This study showed a relevant number of susceptible to V, R, Mu and Me. Seroprevalence data are useful for risk assessment, HCW health surveillance, to evaluate fitness for work and to promote vaccination programmes, according to scientific guidelines. OP should include serological screening for Me, Mu, V and R to protect HCW and third parties.

Quantitative assessment of the impacts of stoppa repair and total extraperitoneal repair on the lower extremity muscular functions in cases of unilateral inguinal hernia: a randomized controlled study.

PURPOSE: Choosing the best operative technique for unilateral inguinal hernia is a challenge for surgeons. Therefore, anticipating loss of strength in the lower extremity muscles could be the initial step to make the right decision. To this end, this prospective randomized controlled study compared the physical activity parameters of the lower extremity muscles in patients who underwent total extraperitoneal repair (TEP) and Stoppa repair. METHODS: Fifty patients with unilateral inguinal hernia who were 18-65 years of age were admitted to a single institution in a metropolitan city in Turkey. Patients were randomized in a 1:1 ratio to parallel study arms of TEP and STOPPA repair. They were evaluated in the preoperative period and on the postoperative day 3 for an objective isometric and isokinetic assessment of the pain-related functional changes in the lower extremity muscles. RESULTS: The measurement results obtained with the Cybex device on the postoperative day 3 were presented as numeric parameters in the digital setting, where the Stoppa repair resulted in a higher loss of strength in the lower extremities compared to the TEP repair. With respect to the total workforce loss in isokinetic muscular measurements at 90 °C/s extension, 90 °C/s flexion, 180 °C/s extension and 180 °C/s flexion, the difference between the TEP repair and Stoppa repair was statistically significant in favor of TEP repair (p < 0.05). CONCLUSION: This study is the first comparative study in the literature to demonstrate the favorable impact of the laparoscopic hernia repair on the physical activity on the same anatomic site compared to the open surgical procedure by using quantitative values. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02813057.

Structural and metabolic differentiation between bipolar disorder with psychosis and substance-induced psychosis: An integrated MRI/PET study.

BACKGROUND: Bipolar disorder (BD) may be characterized by the presence of psychotic symptoms and comorbid substance abuse. In this context, structural and metabolic dysfunctions have been reported in both BD with psychosis and addiction, separately. In this study, we aimed at identifying neural substrates differentiating psychotic BD, with or without substance abuse, versus substance-induced psychosis (SIP) by coupling, for the first time, magnetic resonance imaging (MRI) and positron emission tomography (PET). METHODS: Twenty-seven BD type I psychotic patients with (n=10) or without (n=17) substance abuse, 16 SIP patients and 54 healthy controls were enrolled in this study. 3T MRI and 18-FDG-PET scanning were acquired. RESULTS: Gray matter (GM) volume and cerebral metabolism reductions in temporal cortices were observed in all patients compared to healthy controls. Moreover, a distinct pattern of fronto-limbic alterations were found in patients with substance abuse. Specifically, BD patients with substance abuse showed volume reductions in ventrolateral prefrontal cortex, anterior cingulate, insula and thalamus, whereas SIP patients in dorsolateral prefrontal cortex and posterior cingulate. Common alterations in cerebellum, parahippocampus and posterior cingulate were found in both BD with substance abuse and SIP. Finally, a unique pattern of GM volumes reduction, with concomitant increased of striatal metabolism, were observed in SIP patients. CONCLUSIONS: These findings contribute to shed light on the identification of common and distinct neural markers associated with bipolar psychosis and substance abuse. Future longitudinal studies should explore the effect of single substances of abuse in patients at the first-episode of BD and substance-induced psychosis.

Obsessive-compulsive disorder in the elderly: A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS).

INTRODUCTION: Obsessive-compulsive disorder (OCD) is a highly disabling condition, with frequent early onset. Adult/adolescent OCD has been extensively investigated, but little is known about prevalence and clinical characterization of geriatric patients with OCD (G-OCD≥65years). The present study aimed to assess prevalence of G-OCD and associated socio-demographic and clinical correlates in a large international sample. METHODS: Data from 416 outpatients, participating in the ICOCS network, were assessed and categorized into 2 groups, age

Antiretroviral treatment of men infected with human immunodeficiency virus type 1 reduces the incidence of heterosexual transmission. Italian Study Group on HIV Heterosexual Transmission.

OBJECTIVE: To determine the incidence of heterosexual human immunodeficiency virus type 1 disease transmission and the effect of zidovudine therapy on this risk of transmission. DESIGN: A cohort of 436 monogamous seronegative female sexual partners of human immunodeficiency virus type 1-infected males was followed up for 740 person-years with regular structured interviews and laboratory tests. PATIENTS: At enrollment of the women, 50% of their infected partners had one or more signs of disease progression (symptoms of acquired immunodeficiency syndrome, p24 antigen positivity, or CD4+ cell counts lower than 0.4 x 10(9)/L) and 15% were treated with zidovudine. MAIN OUTCOME MEASURE: Incidence rates of seroconversion were calculated and relative risks were estimated as incidence rate ratios. RESULTS: Twenty-seven women seroconverted during follow-up, and the incidence of seroconversion was 3.7 per 100 person-years. Seroconversion was about six times more frequent (relative risk, 5.8; 95% confidence interval, 2.2 to 15.3) in couples not using condoms. Men with signs of disease progression transmitted infection to their partners more frequently and were more frequently treated with zidovudine. When the risk of transmission was estimated accounting for disease progression, the rate of transmission in zidovudine-treated men was lower than in untreated men (relative risk, 0.5; 95% confidence interval, 0.1 to 0.9). CONCLUSION: Treatment of human immunodeficiency virus type-1 infected men with zidovudine reduces, but does not eliminate, heterosexual transmission of infection. Behavioral counseling that encourages sexual practices with a lower risk of transmission remains the most important method of prevention.

Evaluation of laparoscopic transperitoneal adrenalectomy: is it feasible for large masses?

AIM: The aim of this paper was to determine whether laparoscopic adrenalectomy (LA) is a safe and effective treatment for the management of large adrenal tumors. METHODS: We retrospectively evaluated the data of patients who underwent LA at our institution between September 2002 and September 2012. Seventy-six transperitoneal LA were performed by the same surgical team. Patients with invasive tumors to adjacent organs or distant metastasis were excluded from the study. All patients were operated using the 450 oblique position as transperitoneal approach. RESULTS: The mean age of the patients was 48.3 years (range 20-68 years). The mean tumor size was 5.37 cm (range 2-15 cm). Sixteen patients had tumor size over 8 cm. The mean tumor weight was 31.2 gr (range 2-156 g). The lesions were localized on the right side in 42 (55%) patients and on the left side in 34 (45%) patients. The mean intraoperative blood loss was 114 mL (range 20-400 mL) and the mean operative time was 112 min (range 55-300 min). Six patients (7%) required conversion to open procedure. The mean hospitalization time was 2.5 days (range 1-4 days). Five patients (6%) had post-operative minor complications. There were no incidents of capsular invasion or adverse cardiovascular events. CONCLUSION: LA is safe and feasible for both malign and benign adrenal lesions. Good preoperative assessment, surgical skills, team work and adherence to anatomical and surgical principles are the key to success for large adrenal masses.

Quantum chemical calculations and interpretation of electronic transitions and spectroscopic characteristics belonging to 1-(3-Mesityl-3-methylcyclobutyl)-2-(naphthalene-1-yloxy)ethanone.

This comprehensive study reports the synthesis of the title compound, 1-(3-Mesityl-3-methylcyclobutyl)-2-(naphthalene-1-yloxy)ethanone (C26H28O2), and identification of the molecule by means of the standard experimental methods such as single-crystal X-ray diffraction, ultra violet-visible (UV-vis) spectra, Fourier transform infrared (FTIR) spectra, (13)C and (1)H NMR chemical shifts and quantum chemical calculations using density functional theory (B3LYP) method for the first time. The experimental results observed display that the synthesis of the C26H28O2 compound is perfectly conducted without any impurities. Additionally, the little deviations are noticed on the bond lengths and bond angles, confirming that the strong intra-molecular charge transfers appear in the due to the presence of the electron engagements and conjugative effects (bond weakening). Besides, the intermolecular C-H⋯O distance presents the interaction between the methylcyclobutyl C-H group and oxygen atom in the ethanone group. At the same time, the absorption wavelength (λmax) appears at 292 nm and interval 297-269 nm in the solvent of chloroform and THF as a consequence of the presence of effective π-π(∗) conjugated segments in the molecule studied. Besides, optical band gap energy of 3.22/3.25 eV (chloroform/THF), verifies the existence of the strong electronic donating groups in the structure. As for the quantum chemical computations, the determination of the optimized molecular structures, vibrational frequencies including infrared intensities, vibrational wavenumbers, thermodynamic properties, atomic charges, electronic transitions, dipole moment (charge distribution), optical band gap energy, (1)H and (13)C NMR chemical shifts are conducted using density functional theory/Becke-3-Lee-Yang-Parr (DFT/B3LYP) method with the standard 6-311++G(2d,2p) level of theory. The results obtained show that the strong intra-molecular charge transfer (ICT) appears between the donor and acceptor in the title compound due to the existence of the strong electronic donating groups and effective π-π(∗) conjugated segments with high electronic donor ability for the electrophilic attack (intermolecular interactions). Additionally, the presence of the non-uniform charge distributions (polar behavior) on the various atoms makes the title compound be useful to bond metallically.

Augmentative repetitive Transcranial Magnetic Stimulation (rTMS) in the acute treatment of poor responder depressed patients: a comparison study between high and low frequency stimulation.

BACKGROUND: While the efficacy of repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Disorder (MDD) is well established, the debate is still open in relation to bipolar depression and to a possible different effectiveness of high vs. low stimulation. The present study was aimed to assess and compare the efficacy and tolerability of different protocols of augmentative rTMS in a sample of patients with current Major Depressive Episode (MDE), poor drug response/treatment resistance and a diagnosis of MDD or bipolar disorder. METHODS: Thirty-three patients were recruited in a 4-week, blind-rater, rTMS trial and randomised to the following three groups of stimulation: (1) (n=10) right dorsolateral prefrontal cortex (DLPFC) 1 HZ, 110% of the motor threshold (MT), 420 stimuli/day; (2) (n=10) right DLPFC, 1Hz, 110% MT, 900 stimuli/day; (3) (n=13) left DLPFC, 10Hz, 80% MT, 750 stimuli/day. RESULTS: Twenty-nine patients completed the treatment, showing a significant reduction of primary outcome measures (HAM-D, MADRS and CGI-S total scores: t=8.1, P<0.001; t=8.6, P<0.001; t=4.6, P<0.001 respectively). No significant differences in terms of efficacy and tolerability were found between high vs. low frequency and between unipolar and bipolar patients. Side effects were reported by 21% of the sample. One of the 4 dropouts was caused by a hypomanic switch. CONCLUSIONS: Augmentative rTMS appeared to be effective and well tolerated for the acute treatment of unipolar and bipolar depression with features of poor drug response/treatment resistance, showing a comparable effectiveness profile between protocols of high and low frequency stimulation.

Zidovudine prophylaxis after accidental exposure to HIV: the Italian experience. The Italian Study Group on Occupational Risk of HIV Infection.

OBJECTIVES: To evaluate the use of zidovudine prophylaxis in HIV-exposed health-care workers (HCW) in Italy and to determine its short-term toxicity. DESIGN: Longitudinal, open study with retrospective and prospective collection of data. SETTING: All Italian clinical centres that care for HIV-infected patients and are licensed by the Ministry of Health to dispense zidovudine and 30 hospitals participating in the Italian Multicentre Study on Occupational Risk of HIV Infection. STUDY POPULATION: HCW and other individuals who accepted zidovudine prophylaxis after accidental exposure to HIV. RESULTS: Data were collected for 224 HIV-exposed individuals until 30 June 1991. An increase in zidovudine prophylaxis was observed. All but 10 subjects received 1000-1250 mg zidovudine per day. Anaemia (five cases), neutropenia (one case) and an increase in serum alanine aminotransferase levels (two cases) were the only haematochemical side-effects observed; none of the subjects ceased prophylaxis because of side-effects. More than 50% of subjects had constitutional reactions; as a result, prophylaxis was stopped by 29 patients. These adverse effects began within 10 days of prophylaxis; all resolved after prophylaxis was stopped. No HIV-antibody seroconversions were observed after a mean follow-up of 8 months. CONCLUSIONS: Zidovudine prophylaxis has become a feature of the management of occupational exposures to HIV in health-care settings; short-term toxicity is mild, dose-related and reversible. Further studies are needed to assess the risk of long-term sequelae.

Man-to-woman sexual transmission of HIV: longitudinal study of 343 steady partners of infected men.

To study incidence and risk factors of heterosexually transmitted HIV infection, we followed a cohort of 343 seronegative women, stable, monogamous partners of infected men whose only risk of acquiring HIV was sexual exposure to the infected partner. Nineteen seroconversions occurred in 529.6 person years (py) of observation, yielding an incidence rate of 3.6 per 100 py. The incidence rate was 7.2 per 100 py among women who did not always use or never used condoms and 1.1 among those who always used them [relative risk (RR) 6.6, 95% confidence interval (CI) 1.9-21.9]. Anal sex was associated with a risk increase in only those women not always using condoms (RR 1.4, 95% CI 0.4-4.8). No seroconversions were observed among 22 women using oral contraceptives. One of the women using intrauterine devices seroconverted. In couples who did not always use condoms, seroconversions occurred more frequently in partners of men with symptomatic diseases, with a low CD4+ cell number (< 400 per mm3) or with a detectable p24 antigen. In couples not always using condoms and where the man had a low CD4+ cell count, the joint presence of blood viral antigens and AIDS symptoms conditioned a fivefold increased risk of seroconversion of the woman (RR 5.4, CI 1.4-20.3). At multivariate analysis, women with longer relationships (> or = 1 year) showed a lower risk of seroconversion (RR 0.3, CI 0.1-0.8), and those partners of men positive for p24 antigen in serum had an increased risk of seroconversion (RR = 4.0, CI 0.1-0.8).

Can localization studies be used to direct focused parathyroid operations?

BACKGROUND: There is considerable controversy today concerning the most appropriate surgical approach for patients with primary hyperparathyroidism. The conventional surgical operation involves a bilateral neck exploration through a collar incision with identification of all parathyroid tissue and removal of abnormal parathyroid glands while the patient is under general anesthesia. The success rate of this operation is about 95% or greater in the hands of an experienced endocrine surgeon. Preoperative localization techniques are generally considered to be unnecessary before initial parathyroid operations. The purpose of this investigation was (1) to evaluate the individual and combined accuracy of ultrasonography and technetium 99m sestamibi scans in localizing abnormal parathyroid glands and (2) to determine whether such scans could be used to direct a focused operation. METHODS: We retrospectively studied 338 patients with sporadic primary hyperparathyroidism who had preoperative neck localization studies, ultrasonography and/or technetium 99m sestamibi scans, and parathyroid exploration (238 patients or, reexploration, 60 patients) from January 1996 to April 2000 at the University of California San Francisco/Mount Zion Medical Center. The preoperative localization studies were recorded as true-positive, false-positive, and false-negative and compared with the surgical and pathologic findings and with the outcome of the operation. RESULTS: All of the abnormal parathyroid glands were correctly identified by ultrasonography in 184 of 303 patients (60.7%) and by technetium 99m sestamibi scanning in 183 of 237 patients (77.2%). The sensitivities of ultrasonography and sestamibi were 65% and 80%, respectively. Among the 202 patients who received both ultrasonography and sestamibi scans, a parathyroid tumor was identified at the same site in 105 (52%) of them. When both techniques identified a parathyroid tumor at the same site, the tests were correct in 101 of 105 patients and the sensitivity increased to 96%. CONCLUSIONS: When both the ultrasonography and sestamibi scans identified the same, solitary parathyroid tumor in patients with sporadic primary hyperparathyroidism, this was the only abnormal parathyroid gland in 96% of the patients. A focused parathyroidectomy could therefore be performed in such patients with an acceptable ( approximately 95%) success rate.

Localization and reoperation results for persistent and recurrent parathyroid carcinoma.

HYPOTHESIS: Reoperation is safe and benefits patients with persistent and recurrent parathyroid carcinoma. DESIGN: Retrospective study. The mean follow-up time was 8.1 years (median, 7 years; range, 1-23 years). SETTING: A university tertiary referral center. PATIENTS: Eighteen patients treated for parathyroid carcinoma from 1966 to 1999. RESULTS: The mean serum calcium level was 13.7 mg/dL (3.43 mmol/L), and the parathyroid hormone (PTH) level was 1.6 to 20 times the upper limit of normal. Fourteen of 18 patients had persistent or recurrent parathyroid carcinoma and underwent 54 reoperations (28 at our institution). Mean time to recurrence was 4.8 years (range, 1-20 years). Symptoms of hyperparathyroidism were relieved in 86% of patients who had reoperation (P<.05). Reoperation for parathyroid carcinoma (25 locoregional and 3 distant) significantly reduced and normalized the serum calcium and PTH levels in 75% and 62% of the cases, respectively (P<.001). The preoperative serum calcium level was a significant predictor of postreoperative normalization of the serum calcium level but not extent of initial resection, PTH level, time to recurrence, concordance of localization studies, or patient age and sex (P<.01). Surgical complications consisted of 5 unilateral and 1 bilateral permanent recurrent laryngeal nerve palsies (2 intentionally resected en bloc), 1 transient hypoparathyroidism, 1 wound seroma, and 1 tracheoesophageal fistula. The sensitivity rates of sestamibi scan (n = 14), magnetic resonance imaging (n = 15), computed tomographic scan (n = 6), ultrasound (n = 13), and selective venous catheterization with PTH measurement (n = 6) were 79%, 93%, 67%, 69%, and 83%, respectively. CONCLUSIONS: Recurrence is common in patients with parathyroid carcinoma. Patients with this disease should have frequent, lifelong follow-up to ensure early detection of recurrence. Although reoperation for persistent or recurrent parathyroid carcinoma provides significant symptomatic relief and normalizes serum calcium and PTH levels in most patients, it is associated with some morbidity. Localizing studies of parathyroid carcinoma are helpful but do not detect all tumor foci.

Implementation of an Italian multicentric care network for early HIV infection diagnosis: 1999-2001 report.

BACKGROUND: Diagnosis of a new HIV infection during the primary phase (PHI) is sometimes misleading in a primary care setting. Since 1999 the Italian network for the study of acute HIV infection (ISAI) has been operative. At the time of PHI diagnosis the case is reported to the coordinating centre and enrolled in the National Register which records all epidemiological, demographic and clinical information. PATIENTS AND METHODS: From 1999 to September 2001, 51 symptomatic or asymptomatic patients with diagnosis of primary HIV infection were signalled to the coordinating centre. At screening, assessments were: interview to collect demographic and epidemiological data, clinical history (regarding PHI signs and symptoms) and, if available, relevant index case information; physical examination; routine hematology and chemistry; lymphocyte count; plasma HIV-RNA. In a subset of patients PBMC HIV-DNA, HIV-RNA, resistance genotyping and HIV subtype characterization were assessed. RESULTS: 74.5% of patients were males and all but four were Italian. Hetero and homosexual contacts were the prevalent route of HIV transmission. Forty-five patients (89%) were symptomatic and the most frequent signs and symptoms were: fever, lymphadenopathy, malaise and pharyngodinia. Baseline reverse-transcriptase (RT) and protease (PR) genotyping analysis was available for 29 patients. Only one of 29 patients harbored a virus with a resistance-associated mutation in the RT region (215Y); NNRTI mutations were identified in 3 of 29 patients. In the remaining 20 (69%) patients no mutations were found in the RT region. Sequence data from PR region were successfully obtained in 21 patients. Only one of these had a high-level resistance mutation (46L); in an additional 10 cases 1 or more secondary mutations were identified. The remaining 10 patients harbored a PR region wild type virus. One patient presenting two secondary mutations in the PR region, even if highly adherent and tolerant to drug regimen, showed a slow viral load decrease. CONCLUSIONS: Our cohort confirms the uptrend of new infections through unsafe sexual contacts involving both homosexual and heterosexual couples. Genotype sequencing for antiretroviral resistant viral variants describes a low prevalence of RT resistance-associated mutations, as well as primary mutations in the PR region. On the contrary, a higher prevalence of PR gene polymorphisms and mutations is not known with any certainty to confer resistance to NRTI and NNRTI. The identification of antiretroviral drug resistant HIV strains is strategic for clinical and therapeutical intervention, even though from a public health point of view cost-efficacy must be considered.