A self-repair history: compensatory effect of a de novo variant on the FANCA c.2778+83C>G splicing mutation.

Introduction: Fanconi anemia (FA) is a genome instability condition that drives somatic mosaicism in up to 25% of all patients, a phenomenon now acknowledged as a good prognostic factor. Herein, we describe the case of P1, a FA proband carrying a splicing variant, molecularly compensated by a de novo insertion. Methods and Results: Targeted next-generation sequencing on P1's peripheral blood DNA detected the known FANCA c.2778 + 83C > G intronic mutation and suggested the presence of a large deletion on the other allele, which was then assessed by MLPA and RT-PCR. To determine the c.2778 + 83C > G splicing effect, we performed a RT-PCR on P1's lymphoblastoid cell line (LCL) and on the LCL of another patient (P2) carrying the same variant. Although we confirmed the expected alternative spliced form with a partial intronic retention in P2, we detected no aberrant products in P1's sample. Sequencing of P1's LCL DNA allowed identification of the de novo c.2778 + 86insT variant, predicted to compensate 2778 + 83C > G impact. Albeit not found in P1's bone marrow (BM) DNA, c.2778 + 86insT was detected in a second P1's LCL established afterward, suggesting its occurrence at a low level in vivo. Minigene assay recapitulated the c.2778 + 83C > G effect on splicing and the compensatory role of c.2778 + 86insT in re-establishing the physiological mechanism. Accordingly, P1's LCL under mitomycin C selection preserved the FA pathway activity in terms of FANCD2 monoubiquitination and cell survival. Discussion: Our findings prove the role of c.2778 + 86insT as a second-site variant capable of rescuing c.2778 + 83C > G pathogenicity in vitro, which might contribute to a slow hematopoietic deterioration and a mild hematologic evolution.

How to 'SAVE' antibiotics: effectiveness and sustainability of a new model of antibiotic stewardship intervention in the internal medicine area.

BACKGROUND: Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period. METHODS: The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model. RESULTS: A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention. CONCLUSIONS: The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.

Things come in threes: A new complex allele and a novel deletion within the CFTR gene complicate an accurate diagnosis of cystic fibrosis.

BACKGROUND: Despite consolidated guidelines, the clinical diagnosis and prognosis of cystic fibrosis (CF) is still challenging mainly because of the extensive phenotypic heterogeneity and the high number of CFTR variants, including their combinations as complex alleles. RESULTS: We report a family with a complicated syndromic phenotype, which led to the suspicion not only of CF, but of a dominantly inherited skeletal dysplasia (SD). Whereas the molecular basis of the SD was not clarified, segregation analysis was central to make a correct molecular diagnosis of CF, as it allowed to identify three CFTR variants encompassing two known maternal mutations and a novel paternal microdeletion. CONCLUSION: This case well illustrates possible pitfalls in the clinical and molecular diagnosis of CF; presence of complex phenotypes deflecting clinicians from appropriate CF recognition, and/or identification of two mutations assumed to be in trans but with an unconfirmed status, which underline the importance of an in-depth molecular CFTR analysis.

Correlation between olfactory function, age, sex, and cognitive reserve index in the Italian population.

PURPOSE: Loss of smell decreases the quality of life and contributes to the failure in recognizing hazardous substances. Given the relevance of olfaction in daily life, it is important to recognize an undiagnosed olfactory dysfunction to prevent these possible complications. Up to now, the prevalence of smell disorders in Italy is unknown due to a lack of epidemiological studies. Hence, the primary aim of this study was to evaluate the prevalence of olfactory dysfunction in a sample of Italian adults. METHODS: Six hundred and thirty-three participants (347 woman and 286 men; mean age 44.9 years, SD 17.3, age range 18-86) were recruited from 10 distinct Italian regions. Participants were recruited using a convenience sapling and were divided into six different age groups: 18-29 years (N = 157), 30-39 years (N = 129), 40-49 years (N = 99), 50-59 years (N = 106), > 60 years (N = 142). Olfactory function, cognitive abilities, cognitive reserve, and depression were assessed, respectively, with: Sniffin' Sticks 16-item Odor Identification Test, Montreal Cognitive Assessment, Cognitive Reserve Index, and the Beck Depression Inventory. Additionally, socio-demographic data, medical history, and health-related lifestyle information were collected. RESULTS: About 27% of participants showed an odor identification score < 12 indicating hyposmia. Multiple regression analysis revealed that OI was significantly correlated with age, sex, and cognitive reserve index, and young women with high cognitive reserve index showing the highest olfactory scores. CONCLUSION: This study provides data on the prevalence of olfactory dysfunction in different Italian regions.

Can we reliably predict the level of anticoagulation after enoxaparin injection in elderly patients with renal failure?

OBJECTIVES: The aim of this study was to evaluate the activity of anti-activated factor X (anti-Xa) in patients with different degrees of chronic renal failure (CRF), treated with therapeutic doses of low molecular weight heparin. DESIGN: This prospective study evaluated the effect of age, renal function, BMI, gender, in determining the efficacy and safety of treatment with enoxaparin, evaluated by assessing the anti-Xa. The therapeutic anticoagulant range was set between 0.20 and 0.70 U/mL. SETTING: Two hospital geriatric units. PARTICIPANTS: 98 patients (64 men, 34 women, mean age 82 years) with CRF, treated with enoxaparin at therapeutic dosage, for deep vein thrombosis or acute coronary syndrome. MEASUREMENTS: Anti-Xa was assessed 4 h after the third administration of LMWH using Chromogenix test. Renal function was assessed by calculating creatinine clearance according to Cockcroft formula. RESULTS: The dose of enoxaparin ranged between 53 and 200 U/kg; total 4000-16000 U/day. The mean anti-Xa was 0.41 U/mL (95% CI 0.36-0.45). Multiple regression analysis selected only the dose of enoxaparin, but not age, creatinine clearance, BMI, gender, as a predictor of anti-Xa serum levels. In seven patients anti-Xa was above the range but none of them received more than 150 U/Kg enoxaparin (100 U/kg if creatinine clearance <30 mL/min). Ten patients (eight men, two women) showed suboptimal levels of anti-Xa, regardless enoxaparin dose or creatinine clearance. CONCLUSION: Enoxaparin dose reduction according to renal function decreases the risk of overdosing and potentially the risk of bleeding. The risk of under dosing seems less predictable; therefore, anti-Xa assay may be useful in severe clinical situations that require higher anticoagulant activity.

Longitudinal body composition changes in old men and women: interrelationships with worsening disability.

BACKGROUND: Few studies have evaluated prospectively age-related body composition changes and their relationships with worsening disability in the elderly population. METHODS: Ninety-seven women and 62 men aged 71.4+/-2.2 and 71.6+/-2.2 years, respectively, at baseline underwent dual-energy x-ray absorptiometry determinations at baseline and at 2- and 5.5-year follow-up intervals to measure total body and leg fat (FM) and total, appendicular, and leg fat-free mass (FFM). Height, weight, body mass index (BMI), and waist circumference (as well as reported disabilities using a four-level scale) were evaluated at baseline and at 2- and 5.5-year follow-up. RESULTS: In both sexes, total FM did not change significantly, while total, appendicular, and leg FFM significantly decreased over the study follow-up. In men and women losing weight, BMI, total and leg FM, and total, appendicular, and leg FFM significantly decreased. In weight-stable men and women, appendicular and leg FFM significantly decreased and BMI, waist circumference, and total FM significantly increased. Men lost significantly more total, appendicular, and leg FFM than did women, irrespective of whether they maintained or lost weight. Over the follow-up period, 43.3% of women and 43.5% of men declined in one or more levels of reported disability. We evaluated the effect of age, baseline BMI, FM, FFM, number of diseases, baseline 6-minute walking test, categories of weight change, total, appendicular, or leg FFM changes, total FM and waist changes on the probability of a decline in one or more levels of reported disability score over the follow-up period, taking into account sex. Patients losing appendicular and leg FFM were 2.15 and 2.53 times, respectively, more likely to report increased disability than were patients without FFM loss. CONCLUSIONS: Reduction in appendicular or leg FFM was the main predictor of decline in one or more levels of reported disability in older men and women, and accounted for about a 2-fold increase in risk.