Public Health and Hospitals: a Common Area for Clinical and Public Health Medicine.

Contrary to what has happened so far, hospitals should become a setting which jointly exercise Clinical and Public Health Medicine. The areas of activity that require the presence of multidisciplinary teams and can bring benefits both to the patients and to the community is briefly described.

Parathyroid adenoma in pregnancy: A case report and systematic review of the literature.

Objective: Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature. Study design: A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded. Results: A 34-year-old woman at her 25 weeks' gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55-2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%). Conclusion: Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

Economic evaluation of the treatment of Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) from the national payer perspective: introduction of a new treatment to the patient journey. A simulation of three European countries.

Background: The aim of this study was to develop a spending predictor model to evaluate the direct costs associated with the management of ABSSSIs from the National health-care provider's perspective of Italy, Romania, and Spain. Methodology: A decision-analytic model was developed to evaluate the diagnostic and clinical pathways of hospitalized ABSSSI patients based on scientific guidelines and real-world data. A Standard of Care (SoC) scenario was compared with a dalbavancin scenario in which the patients could be discharged early. The epidemiological and cost parameters were extrapolated from national administrative databases (i.e., hospital information system). A probabilistic sensitivity analysis (PSA) and one-way sensitivity analysis (OWA) were performed. Results: Overall, the model estimated an average annual number of patients with ABSSSIs of approximately 50,000 in Italy, Spain, and Romania. On average, the introduction of dalbavancin reduced the length of stay by 3.3 days per ABSSSI patient. From an economic perspective, dalbavancin did not incur any additional cost from the National Healthcare perspective, and the results were consistent among the countries. The PSA and OWA demonstrated the robustness of these results. Conclusion: This model represents a useful tool for policymakers by providing information regarding the economic and organizational consequences of an early discharge approach in ABSSSI management.

[Multicentric study to evaluate the quality of discharge abstract coding of admissions in which the treatment was not performed and to identify a possible appropriateness indicator]. / Studio multicentrico sulla valutazione della qualità della codifica della scheda di dimissione ospedaliera relativamente ai ricoveri per acuti in cui non è stato eseguito il trattamento. Individuazione di un possibile indicatore di appropriatezza organizzativa.

The aim of this study was to assess the quality of discharge abstract data regarding admissions in which the planned treatment was not performed, in 4 hospitals in the Rome metropolitan area. The main objective was to evaluate the appropriateness of admissions through use of the Italian version of the Appropriateness Evaluation Protocol (AEP/PRUO). Inconsistencies between discharge abstract forms and hospital records were found in 95/142 (66,9%) of examined records. These were subsequently evaluated through the Appropriateness Evaluation Protocol and overall , 95,6% of inconsistent records were found to be inappropriate admissions. Monitoring V64 codes may represent an indirect indicator of appropriateness.

Use of armored RNA as a standard to construct a calibration curve for real-time RT-PCR.

Armored Enterovirus RNA was used to standardize a real-time reverse transcription (RT)-PCR for environmental testing. Armored technology is a system to produce a robust and stable RNA standard, trapped into phage proteins, to be used as internal control. The Armored Enterovirus RNA protected sequence includes 263 bp of highly conserved sequences in 5' UTR region. During these tests, Armored RNA has been used to produce a calibration curve, comparing three different fluorogenic chemistry: TaqMan system, Syber Green I and Lux-primers. The effective evaluation of three amplifying commercial reagent kits, in use to carry out real-time RT-PCR, and several extraction procedures of protected viral RNA have been carried out. The highest Armored RNA recovery was obtained by heat treatment while chemical extraction may decrease the quantity of RNA. The best sensitivity and specificity was obtained using the Syber Green I technique since it is a reproducible test, easy to use and the cheapest one. TaqMan and Lux-primer assays provide good RT-PCR efficiency in relationship to the several extraction methods used, since labelled probe or primer request in these chemistry strategies, increases the cost of testing.

Mutations in the 3A genomic region of two cytopathic strains of hepatitis A virus isolated in Italy.

Two strains of hepatitis A virus (HAV) were isolated in cell culture and found to induce a cytopathic effect at early passages. The nucleotide sequences of the 5' non-translated region (5'NTR) and of genes 2B, 2C, 3A and 3B were determined for these strains and found to contain mutations similar to those detected in cell-culture adapted variants of HAV strain HM175. In addition, gene 3A shows a deletion of three aspartic acid residues near the N-terminus of the polypeptide. In combination with variations in the 5'NTR and in genes 2B and 2C, the absence of an aspartic acid residue in position 4 of gene 3A of three cytopathic clones of HM175 suggests a possible role of the 3A protein in determining the cytopathic phenotype.

Complete nucleotide sequence of a cytopathic hepatitis A virus strain isolated in Italy.

The molecular basis of the cytopathic effect induced in cell culture by some hepatitis A virus (HAV) strains and variants has not been determined. In order to assess the molecular mechanism(s) underlying this particular phenotype the genome of an Italian cytopathic isolate (strain FG) was sequenced from cDNAs obtained by RT-PCR. Sequence analysis revealed the presence of mutations common to either adapted or cytopathic variants of HAV. In particular, amino acid deletions in proteins VP1 and 3A were detected. Expression of protein 3A in E. coli showed that the N-terminal deletion renders this protein toxic to bacteria.

Effect of isoflavans and isoflavenes on the infection of Frp/3 cells by hepatitis A virus.

The effect of 6,4'-dichloroflavan and of isoflavan and isoflavene derivatives on hepatitis A virus (HAV) infection in a monkey cell line (Frp/3 cells) was studied. These compounds were not virucidal and had no measurable effect on the adsorption of virus to the cells at 0 degrees C, whereas they exerted an inhibitory effect on viral antigen synthesis when incubated with the infected cells during HAV multiplication. Among the substances tested, 6,4'-dichloroflavan and 6,4'-dichloroisoflavan showed the highest activity. These compounds are postulated to interact with an early stage (penetration and/or uncoating) of HAV infection.

Prevalence of hepatitis A antibodies in Italy.

Prevalence of hepatitis A antibodies among 5005 naval recruits aged 18-26 from all parts of Italy was almost double in the south and islands (83.3%) as compared to the north and central regions (45.2%). Social-demographic variables such as education and number of siblings are associated with prevalence of anti-HAV. Hepatitis A infection is still an early acquired infection in Italy, particularly in the south where among the 18-26-year-old recruits with education limited to lower middle school or less and eight siblings or more, prevalence of anti-HAV was 95%. Good correlation exists in Italy between prevalence of anti-HAV and incidence of reported cases of hepatitis.

Ultrafiltration: an efficient second step for hepatitis A virus and poliovirus concentration.

The efficiency of seeded hepatitis A virus and poliovirus recovery from 1 l of dechlorinated tap water or different buffer was evaluated using a molecular filtration system. All the experiments were performed using a polysulfonate membrane of 10,000 molecular weight limit. Under standard conditions hepatitis A virus recovery was 100% of the input, but the percentage was reduced dramatically when the inflow pressure was increased. In contrast, poliovirus recovery was low under standard conditions, but it improved when the membranes were pretreated with different buffers. The best recovery was obtained using beef extract at neutral pH.

Depuration of Mytilus galloprovincialis experimentally contaminated with hepatitis A virus.

Mussels (Mytilus galloprovincialis) were contaminated with known amounts of laboratory strains of hepatitis A virus and Poliovirus 1 and the effectiveness of a self-cleansing mechanism was studied using a pilot depuration system. Both viruses were rapidly bioaccumulated by mussels and the maximal concentration of about 10(4) TCID50/ml was reached within 1.5 hours. Depuration was carried out up to 24 h; infectivity titer decreased to 10(2) TCID50/ml and 10(3.2) TCID50/ml within 6 h in hepatitis A virus and Poliovirus 1 contaminated mussels, respectively, but only a very slight further decrease was obtained after 24 h. E. coli was used as a control; within 24 h the concentration decreased from 40 to 2 bacteria/ml of mussel (MPN). The elimination of bacteria is not a reliable parameter to control the effectiveness of viral depuration.

Concomitant poliovirus infection during an outbreak of hepatitis A.

AIM OF THE STUDY: The present study was designed to evaluate the possible co-infection, with other enteric viruses, during an outbreak of hepatitis A (HA). MATERIAL AND METHODS: Forty-two stool samples and sera were collected during an outbreak of hepatitis A. Sera were analysed by the Abbott test for IgG-IgM anti-HAV antibodies. Stool samples were used to identify the presence of enteric viruses. HAV genome was identified by a RT-PCR test, other enteric viruses were identified, after cell passage and seroneutralization test on BGM cells, by RT-PCR and RFLP assay. RESULTS: The samples were obtained from 27 employees of an industrial plant, nine household contacts and six non-employee controls. The attack rate was 12.5%, whereas the overall prevalence was 63%. In the employee group, 12 out of 27 stool samples were positive for the presence of HAV by reverse transcriptase polymerase chair reaction (RT-PCR). All the other samples (30) were negative. Five samples from employees, three from household contacts and one from non-employees were also found positive for enteroviruses. These viruses were classified by seroneutralization as poliovirus and RFLP assay as Sabin poliovirus type 1. Four samples were positive both for HAV and poliovirus. CONCLUSIONS: This study confirms co-infection with different enteric viruses may occur and also emphasizes the wide circulation of HAV and the existence of silent infection with poliovirus.

Effect of inhibitors of cytoplasmic structures and functions on rabies virus infection in vitro.

The effect in vitro of some cytoplasmic structure and function inhibitors on the different stages of rabies virus infection was investigated. Treatment of fibroblasts (CER) and human neuroblastoma cells (IMR-32) with substances acting on low pH intracellular compartments (methylamine and monensin) prevented rabies virus genome delivery in the cytosol. An early inhibition of viral infection was also obtained in the presence of B and D cytochalasins and trifluoperazine which interact with microfilament structures. Treatment with colchicine and vinblastine did not affect rabies multiplication, suggesting that microtubules are not involved in this process. However, the multiplication of prebound virions did not take place in the presence of inhibitors of oxidative phosphorylation (sodium azide and CCCP) and of glycolysis (2-deoxy-D-glucose) indicating that rabies virus replication is largely energy-dependent in both host cells examined.

Influence of polyions on the early steps of enterovirus infection.

The influence of electric charged molecules on the early phases of enterovirus infection was studied in order to select antiviral compounds able to prevent viral attachment. The effect of different polyelectrolytes on the multiplication of coxsackie virus B3, echovirus 6 and hepatitis A virus was investigated in susceptible cells by adding the drug before, during or after the viral adsorption period. Among polyanions, the polysaccharides heparin and dextran sulfate inhibited viral infectivity, dextran sulfate being the most effective mainly towards hepatitis A virus infection. DEAE-dextran and protamine sulfate, generally recognized as enhancers of infectivity of naked and enveloped viruses, exhibited an inhibitory effect towards the three picornaviruses tested. Only in the case of hepatitis A did DEAE-dextran slightly improve viral antigen synthesis. The inhibitory effect shown by compounds belonging to positive and negative polyions suggests that the electric charge is not sufficient by itself to explain the antiviral activity of these drugs.

Effect of amantadine on rhabdovirus infection.

Enveloped viruses enter host cells by fusion or viropexis. The latter mechanism is the prevalent entry pathway of rhabdoviruses into susceptible cells. Amantadine, a lysosomotropic agent, inhibits the multiplication of various groups of viruses. The effect of this drug was investigated on vesicular stomatitis virus and rabies fixed virus strain replication in fibroblasts. Amantadine was added to cells before, during and after infection to detect the phase of viral replication affected by the drug. Cells were inoculated with viruses at 4 degrees C and the incubation temperature was progressively raised to 37 degrees C in order to observe the effect of amantadine on attachment and early stages of viral replication. Experimental results indicated that the compound inhibited rhabdovirus infection in CER cells. Viral attachment and penetration did not appear to be affected by the drug, while later steps were inhibited, probably at the level of uncoating when the virus is released from the lysosomes into the intracytoplasmic compartment.

[Proposal for changing the ministerial instructions for antirabies prophylaxis in the light of the experience of the Centro Antirabbico di Roma]. / Contributi per una proposta di modifica delle istruzioni ministeriali per la profilassi antirabbica alla luce dell'esperienza del Centro Antirabbico di Roma.

Records of clinical assistance and of post-exposure antirabies prophylaxis from 4820 outpatients who attended the Antirabies Center of Rome following animal bites in 1986 were analysed. We observed a high proportion of people submitted to active immunization (44% received at least one shot of HDCV vaccine) in spite of the fact that rabies is absent from Central Italy since many decades in both wild and domestic animals. These considerations suggest the opportunity of a major revision of the official recommendations for rabies prevention, and we feel that different policies should be adopted in rabies enzootic areas (such as Northern Italy) compared to those where the risk is only potential. Immunization should be avoided after bites by rodents; passive immunization should be added to the vaccine after bites by wild animals in enzootic areas, while bites by cats and dogs, even uncaptured, will not be necessarily followed by vaccination in non enzootic areas.

Hepatitis A virus detection in wastewater by PCR and hybridization.

Hepatitis A virus is a member of the Picornaviridae family and is a principal agent of acute hepatitis worldwide, causing from mild to severe illness. Although the incidence of hepatitis A is in decline, the risk of this disease is still high in the Mediterranean area. Detection of hepatitis A in the environment is difficult because this virus needs a prolonged incubation in cell culture, therefore we used an antigen capture PCR (AC-PCR) followed by a hybridization on membrane to identify HAV in wastewater samples. The raw sewage, concentrated by ultrafiltration, showed 8 positive samples out of 10 (80%), while after the oxidation step of the sewage, 2 out of 10 (20%) and 3 out of 10 (30%) were found positive respectively after concentration by electronegative (HAWP Millipore) and electropositive (1MDS Cuno-Div.) membranes. In the final effluent the positivity was 1 out of 10 (10%) for the electronegative membranes and 3 out of 10 (30%) for the electropositive membranes. Our results indicate: i) the possibility of HAV to cross the wastewater treatment plant and contaminate water and food (such as mussels); ii) PCR-hybridization as a rapid method for HAV identification in the environment.

Fate of bacterial indicators, viruses and protozoan parasites in a wastewater multi-component treatment system.

The extent of reduction in selected microrganisms was tested at a multi-component wastewater treatment plant that treats sewage for a potential re-use in agriculture. The aim of the investigation was to evaluate possible reciprocal correlation among the different microrganisms and to compare the removal of two encysted pathogenic protozoa with that of microbial indicators, Clostridium perfringens spores, enteroviruses and bacteriophages. Samples collected included the raw wastewater, the chlorinated effluent and the effluent after an ultraviolet light treatment. All of the raw sewage samples were positive for Cryptosporidium oocysts and Giardia cysts, as well as for the other microorganisms tested but the bacteriophage B40-8. The data obtained confirm the removal efficiency of the entire process for indicator bacteria but also show the low and variable removal efficiency for the other microbial parameters, such as Giardia and Cryptosporidium, enteroviruses and Clostridium perfringens spores. Reciprocal correlation between Cryptosporidium and Giardia (oo)cysts and the other microbial groups was not demonstrated. The results confirm the resistance of Clostridium perfringens spores, enteroviruses and protozoa to chlorination and demonstrate the relative persistence of these organisms in the effluents even during the ultraviolet light treatment. The yields also emphasise the influence of the analytical method for the determination of protozoan parasites.

Evidence of hepatitis E virus replication on cell cultures.

Several human and animal cell lines have been used to grow hepatitis E virus. The strain SAR-55 was adapted only on PLF/PLC/5 cell line without any visible cytopathic effect. The growth of the SAR-55 was monitored by examining the positive and the negative strands of HEV-RNA. Stool samples, obtained from hospitalised acute hepatitis patients at the Fever Hospital of Alexandria (Egypt), were used to confirm the susceptibility of PLF/PLC/5 cells. After more than one-week's cultivation, three stool samples out of 17 IgM anti-HEV positive and 1 from 52 IgG anti-HEV positive patients showed a specific RT-PCR amplification product. The nucleotide sequences of the methyltransferase region of the genome in the isolates revealed the maximum homology with Burma strain with several point mutations.

Susceptibility of mammalian, avian, fish, and mosquito cell lines to rabies virus infection.

The relationship between plasma membrane receptor organization and cell susceptibility in vitro was investigated in mammalian, avian, fish, and arthropod cell lines infected with fixed rabies virus. IMR32, HeLa, CER, and EPC cells were widely susceptible to infection with CVS virus, whereas a lower level of specific viral antigens was detectable in A. albopictus cells. In spite of these differences, the amount of infectious virus particles bound to the various cell surfaces was similar. Competition experiments carried out with plasma membranes extracted from ability of these components to bind the virus and to prevent infection. The different cellular permissiveness to rabies infection described here did not correlate with significant differences in number or in chemical structure of the receptor binding sites, but more likely with events following virus adsorption.