[Digitization and Virtual Healthcare in a teaching hospital (Pisa, Italy) during COVID-19 emergency]. / Digitalizzazione e Virtual Healthcare nell'Azienda Ospedaliero Universitaria Pisana (AOUP) ai tempi dell'emergenza COVID-19.

The initial phases of COVID-19 emergency in Italy highlighted the technical delay that the national health system has accumulated in health services digitalization. Italian hospitals rapidly applied a demand systems for virtual health services based on tele-triage, tele-consultation and tele-visits procedures. This led, in the following months, the integration of virtual healthcare services applicable to the Azienda Ospedaliero Universitaria Pisa (AOUP). In particular, BCure system represents an important technological investment for the remote management of care protocols and the analysis of the complete use of health services. This is a unique system for sharing information between specialists, general practitioners and patients.

Psoriasis in Latin America and the Caribbean: a systematic review.

Psoriasis is a chronic inflammatory disease that generally affects the skin, nails and joints. The burden of psoriatic disease in Latin America and the Caribbean (LAC) remains largely unknown. To estimate the burden of psoriasis in LAC. We conducted a systematic review following the MOOSE and PRISMA statements. We searched published studies in MEDLINE, EMBASE, LILACS and CENTRAL from 1st January 2000 to 5th August 2015. We included studies that reported incidence, prevalence, health resource use and health expenditures, treatment patterns, comparative effectiveness of different drugs, patients reported outcomes, adherence to treatment and patient preferences in LAC. Risk of bias was assessed evaluating selection of participants, control of cofounders, measurement of exposure and outcome and conflict of interest. Pairs of reviewers independently selected, extracted and assessed the bias risk of the studies. The systematic review was registered at PROSPERO (CRD42016038325). A total of 18 studies from 12 LAC countries were included. Most were observational studies, between which there was a large heterogeneity of outcomes. Population-based studies were not found and most data came from hospital registries. One study reported an incidence of psoriatic arthritis in 6.26 cases per 100 000 person-years. Another study found an incidence of psoriasis 1020 per 100 000 patient-year attending at a dermatology clinic. The prevalence reported in the Argentinean health service was 74 cases per 100 000. Further, psoriasis has been shown to have a substantial negative impact on quality of life. A number of studies also indicated that non-communicable disease burden increases with the presence and severity of psoriasis. With regard to treatment pattern, methotrexate was the dominant systemic therapy. In conclusion, there is an important lack of information from LAC concerning the burden of psoriasis. Further studies investigating the burden of psoriasis in representative LAC populations are needed.

Chyloperitoneum: Diagnostic and Therapeutic Options.

Chyloperitoneum is not rare and is often associated with other chylous disorders particularly in more complex clinical conditions. An accurate diagnostic study is indispensable to plan the correct therapeutic approach, and we examined the long-term outcomes of our experience in the management of primary and secondary chyloperitoneum in fifty-eight patients (50 adults and 8 children; 34 primary and 24 secondary forms). Diagnostic assessment consisted of aracentesis, whole body lymphoscintigraphy, lymphangio-MR, and lymphangio-CT (LAG-CT). The management of chyloperitoneum consisted initially of non-operative procedures (MCT diet, TPN, octreotide). Surgical treatment was performed in patients not responsive to conservative methods and involved different options using surgical and microsurgical approaches. Microsurgical techniques included chylousvenous shunts connecting chyliferous vessels and mesenteric veins. Fibrin glue or platelet gel injection at the site of the chylous leakage was also used to treat one case of refractory secondary chyloperitoneum. Patients were followed clinically and instrumentally (echography and labs tests) for 6 months to over 5 years. We found that LAG-CT was the primary diagnostic modality to provide precise topographic information concerning the site, cause, and extension of chylous pathology, all of which allowed proper planning of therapeutic procedures. Thirty-four patients did not have a relapse of the chyloperitoneum and 22 patients had a persistence of a small quanitity of ascites with no protein imbalance. We observed early relapse of chylous ascites in 2 cases that required a peritoneal-jugular shunt leading to good outcomes. An accurate diagnostic study (above all LAG-CT) and a microsurgical approach proved to represent an effective management of chyloperitoneum refractory to non-operative treatment.

Laboratório de Biologia e Ecologia de Culicídeos (LaBEC)

A atuação do laboratório de pesquisa de Taubaté excedeu, em muito, a proposta inicial que lhe deu origem. No ano de 1985, foi implantado o Programa de Vigilância e Controle dos Vetores de Dengue, e, nas atividades que visavam dimensionar a expansão geográfica de seu principal transmissor, Aedes aegypti, foi possível registrar, já em 1986, o primeiro encontro de Aedes albopictus no estado de São Paulo, dando início às atividades de pesquisa científica relacionadas à bioecologia desses vetores...

Chylopericardium: a case report demonstrating utility of lymphography combined with 3D computed tomography for corrective surgical treatment using VATS.

We present a case of a 58 year-old woman with primary chylopericardium associated with chylothorax. Chylopericardium is a condition in which chylous fluid containing a high concentration of triglycerides accumulates in the pericardial cavity, and it can form for many different reasons. 3D computed tomography with lymphography precisely depicted the specific location of the lymphatic leak in this patient, which was successfully repaired using targeted video assisted thoracic surgery (VATS).

Surgical prevention and treatment of lymphedema after lymph node dissection in patients with cutaneous melanoma.

Despite the development of minimal access dissection techniques, use of superficial groin dissection alone, and other recommendations to reduce morbidity in melanoma treatment, the incidence of lymphedema is still significant. The purpose of the current study was to assess the efficacy of microsurgical methods to limit the morbidity of inguinal lymphadenectomy. We conducted a retrospective review of patients who underwent groin dissection for melanoma treatment from February 2006 to April 2009. A total of 59 melanoma patients with positive groin lymph nodes comprised 18 patients (T-group) with melanoma in the trunk and 41 patients (E-group) who had melanoma in an extremity and currently have lymphedema. The T-group patients underwent primary prevention of lymphedema with microsurgical lymphatic-venous anastomoses (LVA) performed simultaneously with groin dissection. The E-group patients underwent LVA to treat the secondary lymphedema after an accurate oncological and lymphological assessment. Limb volume measurements and lymphoscintigraphy were performed pre- and postoperatively to assess short and long term outcome. No lymphedema occurred after microsurgical primary preventive approach in the T- group. Significant (average 80% reduction of pre-op excess volume) reduction of lymphedema resulted after microsurgical treatment for secondary leg lymphedema. Post-operative lymphoscintigraphy in 35 patients demonstrated patency of microsurgical anastomoses in all cases with an average follow-up of 42 months. Study results demonstrate that microsurgical LVA primary prevention prevented lymphedema after inguinal lymphadenectomy in the T-group patients. In addition, lymphatic-venous multiple anastomoses proved to be a successful treatment for clinical lymphedema with particular success if treated at the early stages.

F-18 FDG PET/CT in the assessment of patients with unexplained CEA rise after surgical curative resection for colorectal cancer.

PURPOSE: We evaluated the role of quantitative assessment by maximum standardized uptake value (SUVmax) on F-18 fluorodeoxyglucose [F-18]FDG positron emission tomography/computed tomography (PET/CT) in stratifying colorectal cancer (CRC) patients with unexplained carcinoembryonic antigen (CEA) rise after surgical curative resection. MATERIAL AND METHODS: Forty asymptomatic patients (mean age, 64 ± 12 years) with previous CRC and current serum CEA levels >5 ng/ml underwent [F-18] FDG PET/CT 13 ± 3 months after complete surgical resection. The SUVmax was registered on anastomosis and peri-anastomotic tissue lesions, if present. The patients were followed for 24 ± 9 months thereafter. Re-intervention, evidence of newly discovered distant metastases, and death were recognized as main events and constituted surrogate end points. The receiver-operator-curve (ROC) analysis was performed to estimate the optimal SUVmax cut-off to predict patients at high risk of main events. PET/CT results were then related to disease outcome (overall survival; OS). RESULTS: The mean SUVmax at the anastomotic site was 6.2 ± 3 (range 2.6-15). At multivariate logistic regression analysis, the anastomotic SUVmax remained as the only significant contributor to the prediction of the events (p = 0.004; OR 1.97). The ROC analysis recognized that the optimal threshold of SUVmax to differentiate patients was 5.7. A worse OS was observed in patients presenting with a SUVmax greater than 5.7 as compared to those having lesser (median survival: 16 vs. 31 months; p = 0.002). CONCLUSIONS: The quantitative assessment by SUVmax on [F-18]FDG PET/CT may be helpful in patients presenting with unexplained CEA rise after curative resection of CRC, by identifying those at risk of main events.

A composite score combining waist circumference and body mass index more accurately predicts body fat percentage in 6- to 13-year-old children.

PURPOSE: Body mass index (BMI) and waist circumference (WC) are widely used to predict % body fat (BF) and classify degrees of pediatric adiposity. However, both measures have limitations. The aim of this study was to evaluate whether a combination of WC and BMI would more accurately predict %BF than either alone. METHODS: In a nationally representative sample of 2,303 6- to 13-year-old Swiss children, weight, height, and WC were measured, and %BF was determined from multiple skinfold thicknesses. Regression and receiver operating characteristic (ROC) curves were used to evaluate the combination of WC and BMI in predicting %BF against WC or BMI alone. An optimized composite score (CS) was generated. RESULTS: A quadratic polynomial combination of WC and BMI led to a better prediction of %BF (r (2) = 0.68) compared with the two measures alone (r (2) = 0.58-0.62). The areas under the ROC curve for the CS [0.6 * WC-SDS + 0.4 * BMI-SDS] ranged from 0.962 ± 0.0053 (overweight girls) to 0.982 ± 0.0046 (obese boys) and were somewhat greater than the AUCs for either BMI or WC alone. At a given specificity, the sensitivity of the prediction of overweight and obesity based on the CS was higher than that based on either WC or BMI alone, although the improvement was small. CONCLUSION: Both BMI and WC are good predictors of %BF in primary school children. However, a composite score incorporating both measures increased sensitivity at a constant specificity as compared to the individual measures. It may therefore be a useful tool for clinical and epidemiological studies of pediatric adiposity.

[Evolution of antimicrobial resistance against Pseudomonas aeruginosa in a French university hospital between 2002 and 2006]. / Evolution de la résistance aux antibiotiques de Pseudomonas aeruginosa dans un centre hospitalier universitaire entre 2002 et 2006.

AIM OF STUDY: Monitor evolution of antibiotic resistance of Pseudomonas aeruginosa from 2002 to 2006 in our hospital to optimize antibiotherapy. PATIENTS AND METHOD: The infections/colonizations with P. aeruginosa have been identified by the hospital's informatic database. Bacteriological samples realized 48hours after patient's admission was considered as nosocomial. A Cochran-Armitage test was conducted to assess the evolution of resistance. RESULTS: During this period, 2098 infections/colonizations with P. aeruginosa have been identified. Bacteriological samples (68.5%) were nosocomial. Among the beta-lactam antibiotics, ceftazidime and imipenem were the most active (R=16.8% and 15.2%, respectively), followed by piperacillin and piperacillin-tazobactam (R=24.8%, 18.4%, respectively). Amikacin and tobramycin were more active than gentamicin (R=19.9%; 22.2% and 40.6%, respectively). 28.9% of strains were resistant to ciprofloxacin. Nosocomial strains were significantly more resistant than non-hospital strains: ceftazidime: 17.9% versus 14.2%, p=0.0346; ticarcillin-clavulanic acid: 47.5% versus 39.6%, p=0.0009; piperacillin-tazobactam: 20.0% versus 14.8%, p=0.0046; ciprofloxacin: 30.7% versus 25.2%, p=0.0112. A significant increase in the resistance of nosocomial strains to ceftazidime, ticarcillin-clavulanic acid and piperacillin-tazobactam was noted. Resistance from non-hospital strains to fluoroquinolones, aminoglycosides, ceftazidime, piperacillin and ticarcillin-clavulanic acid decreased significantly. CONCLUSION: P. aeruginosa is a predominantly nosocomial microorganism. There is a decrease of resistance for non-hospital strains. But the resistance of nosocomial strains to antibiotics widely prescribed in hospital is worrying.

Double excitations in finite systems.

Time-dependent density-functional theory (TDDFT) is widely used in the study of linear response properties of finite systems. However, there are difficulties in properly describing excited states, which have double- and higher-excitation characters, which are particularly important in molecules with an open-shell ground state. These states would be described if the exact TDDFT kernel were used; however, within the adiabatic approximation to the exchange-correlation (xc) kernel, the calculated excitation energies have a strict single-excitation character and are fewer than the real ones. A frequency-dependent xc kernel could create extra poles in the response function, which would describe states with a multiple-excitation character. We introduce a frequency-dependent xc kernel, which can reproduce, within TDDFT, double excitations in finite systems. In order to achieve this, we use the Bethe-Salpeter equation with a dynamically screened Coulomb interaction W(omega), which can describe these excitations, and from this we obtain the xc kernel. Using a two-electron model system, we show that the frequency dependence of W does indeed introduce the double excitations that are instead absent in any static approximation of the electron-hole screening.

Is ethosuximide a risk factor for generalised tonic-clonic seizures in absence epilepsy?

The occurrence of generalised tonic-clonic seizures (GTCS) was investigated in patients with absence epilepsy (AE), evaluating the opinion that ethosuximide does not protect against GTCS. Our retrospective study included 238 patients with absences and generalised 3-Hz spike waves (SW). We analysed the efficacy of antiepileptic drugs (AED) and the occurrence of GTCS before, during and after treatment. We surveyed family history, treatment delay and EEG findings. Family history of epilepsy was positive in 28%. Children with 3-Hz SW lasting >10 s suffered less frequently from GTCS (p=0.002). Photosensitivity (3-Hz SW during photic stimulation) recorded in 47 children was more frequent in juvenile AE (p=0.0001), but not associated with higher rates of GTCS. GTCS occurred in 27 children (11%) before treatment, in 14 (5.8%) during treatment and in 8 (4.8%) after tapering AED. Valproate and ethosuximide monotherapy were equally effective on absences, carrying the same low risk of GTCS during treatment (2 valproate, 1 ethosuximide). Most GTCS occurred on drug combinations considered effective against GTCS. Risk factors for relapses after tapering AED were photosensitivity (p=0.002) and GTCS during treatment (p=0.02). GTCS are rare in patients with typical AE. Our data do not support the current opinion that ethosuximide is inefficacious on GTCS in AE.

Mortality attributable to nosocomial infection: a cohort of patients with and without nosocomial infection in a French university hospital.

OBJECTIVE: To assess nosocomial infection (NI) as a risk factor for death and to estimate the population-attributable risk of death from NI. DESIGN: A prospective cohort study of patients with and without NI. SETTING: Nimes University Hospital, Nimes, France. PATIENTS: Patients were recruited from May 7, 2001, to January 10, 2003. Patients in acute care and long-term care units who had NI were enrolled, and patients without NI were randomly selected and matched with patients with NI for age, sex, type of care (acute care vs. long-term care) and length of stay in hospital at study inclusion. OUTCOME MEASURES: Vital status within 60 days after study inclusion was assessed. We used conditional logistic regression to estimate the relative death risk from NI after adjusting for comorbidities, severity of the underlying disease, and all other confounding factors. The adjusted population-attributable risk was assessed using the Mantel-Haenszel method. RESULTS: We recruited 1,914 patients with NI and 5,172 patients without NI. The median age of the patients with NI was 73 years; 1,045 (54.6%) were female. NI was associated with death within 60 days (adjusted odds ratio, 1.7 [95% confidence interval {CI}, 1.4-;2.2]; P<.001). The adjusted population-attributable risk of death for all sites of infection was 1.7% (95% CI, 1.4-2.1). If we consider the NI incidence to be 3%-6% in French hospitals, the population-attributable risk of death from NI would range from 2.1% (95% CI, 1.7%-2.5%) to 4.0% (95% CI, 3.3%-4.9%). CONCLUSION: In this study, NI appeared to have a significant impact on mortality. Multicenter studies will be needed to confirm these results.

Correlations between motor performance and cognitive functions in children born < 1250 g at school age.

Very low birth weight born children manifest a higher prevalence of motor and cognitive impairments than term children. Seventy-four prospectively enrolled children born < 1250 g underwent testing of motor (Zurich neuromotor assessment ZNA: timed motor performances and associated movements) and cognitive functions (Kaufman-ABC) at age six years. Children with cerebral palsy or mental retardation were excluded. Adaptive motor tasks (pegboard and dynamic balance) and visuomotor cognitive functions were specifically impaired, and a distinct correlation pattern between motor and cognitive abilities was detected. The adaptive fine motor task (pegboard) correlated with visuomotor functions of the Kaufman-ABC ("triangles", r = 0.35; "matrix analogies", r = 0.39), while pure motor tasks of the ZNA (repetitive, alternating, and sequential movements) did not in spite of impaired motor performance. Timed motor performance below the 10th percentile correlated strongly with cognitive delay (IQ < 85: adaptive fine motor: OR 6.0 [95% CI] 4.7-7.3; adaptive gross motor: OR 7.0 [CI 5.6-8.4]; static balance: OR 9.6 [CI 8.2-11.0]). In conclusion, motor deficits in children born < 1250 g without severe disabilities correlate with specific cognitive impairments, in particular of the visuomotor domain. The correlation pattern may indicate specific dysfunction in visuomotor transformation, the intermediate process between visual-perceptual input and motor output. Early assessment of both motor and cognitive functions using standardized assessment tools is important to determine the extent and combination of specific developmental disturbances and to tailor therapeutic intervention.

Construction of the World Health Organization child growth standards: selection of methods for attained growth curves.

The World Health Organization (WHO), in collaboration with a number of research institutions worldwide, is developing new child growth standards. As part of a broad consultative process for selecting the best statistical methods, WHO convened a group of statisticians and child growth experts to review available methods, develop a strategy for assessing their strengths and weaknesses, and discuss methodological issues likely to be faced in the process of constructing the new growth curves. To select the method(s) to be used, the group proposed a two-stage decision-making process. First, to select a few relevant methods based on a list of set criteria and, second, to compare the methods using available tests or other established procedures. The group reviewed 30 methods for attained growth curves. Using the pre-defined criteria, a few were selected combining five distributions and two smoothing techniques. Because the number of selected methods was considered too large to be fully tested, a preliminary study was recommended to evaluate goodness of fit of the five distributions. Methods based on distributions with poor performance will be eliminated and the remaining methods fully tested and compared.

TW3 bone age: RUS/CB and gender differences of percentiles for score and score increments.

BACKGROUND: Longitudinal data on bone age progression is scarce. AIM: The study aimed to present reference values for Tanner-Whitehouse 3 (TW3) bone age score and score increments, and to provide means and standard deviations of appearance time for all TW3 stages. Gender differences and differences between radio ulna and short bones (RUS) and carpal bone (CB) scores were studied. SUBJECTS AND METHODS: Bone age data collected for ages 3 months to 20 years in 232 subjects during the First Zurich Longitudinal Study (1954-1976) were used. Smoothed empirical percentiles of TW3 RUS and CB scores for age, of score increments for age and of score increments for attained score are presented. Means and standard deviations of the appearance times are calculated by parametric censored regression. RESULTS: There are clear differences between the RUS and CB scores and between the genders. Boys are delayed with respect to girls, with different delays for RUS and CB. For RUS, differences in maturation reflect the known differences of physical growth, with a later and more intense peak in boys. For CB, there is little difference in timing and intensity. However, girls reach the final score about 2 years earlier than boys. The consistently earlier mean appearance times in girls indicate that skeletal maturation is, already in childhood, more rapid in girls than in boys. There are significant gender differences in the sequence of appearance. CONCLUSION: Reference values for TW3 score and score increments and mean appearance times for stages add to existing knowledge and indicate important RUS/CB and gender differences, whose sources are largely unknown.

Plant regeneration from callus of apomictic and sexual lines of Paspalum simplex and RFLP analysis of regenerated plants.

Culture conditions have been established for the induction of callus from different explants of Paspalum simplex. Fast-growing calli were obtained from hypocotyls and roots excised from 5-day-old seedlings on culture medium containing 2,4-dichlorophenoxyacetic acid and kinetin. Rapid plant regeneration from both apomictic and sexual lines was achieved when the medium was supplemented with alpha-naphthaleneacetic acid and benzylaminopurine. Restriction fragment length polymorphism analysis of the apomixis-controlling region of the regenerated plants showed an absence of restriction site variation for the loci analysed, whereas various degrees of variation were detected for the DNA methylation sites of the same loci.

Long-term follow up of children with congenital complete atrioventricular block and the impact of pacemaker therapy.

AIMS: This study assessed survival, morbidity and impact of pacemaker (PM) therapy in children with Congenital Complete Atrioventricular Block (CCAVB). METHODS AND RESULTS: Data of 32 children, diagnosed as showing CCAVB at a median age of 0.4 years (range foetal-10 years), were retrospectively analysed. For comparison of clinical data patients were separated into two groups: CCAVB without structural heart disease (group 1; n = 23) and with structural heart disease (group 2; n = 9). Median follow-up time was 10.2 years. Pacemakers (PM) were implanted in 17 group 1 and all group 2 children. Frequency of PM therapy, age and symptoms before PM implantation did not differ significantly between the groups. Indications for PM implantation were bradycardia in 15, decreased exercise tolerance in 6, syncope in 3 and heart failure in 2 children. PM system related complications occurred in 11/26 (42%) children. Although 1 child died due to PM exit block no further CCAVB related symptoms were recorded in children with PM. CONCLUSION: PM therapy reduces mortality and morbidity in children with CCAVB when compared with natural history data. Although children with PM are free from CCAVB related symptoms limited morbidity remains due to PM system related complications.