Reel syndrome: a rare presentation of a rare cause of cardiac resynchronization malfunction.

Abstract: Reel syndrome is a rare cause of pacemaker lead displacement. This case report shows a rare presentation of Reel syndrome highlighting the importance of an early diagnosis and discussing the underlying mechanism, management and prevention.

In vitro fertilization and autoimmunity: Evidence from an observational study.

INTRODUCTION: The aim of this study was to evaluate the prevalence of antiphospholipid antibodies (aPLs) in infertile women undergoing in vitro fertilization (IVF). METHOD OF STUDY: From January 2012 to December 2017, 520 consecutive clinical records of infertile women undergoing IVF were evaluated. Among them, 100 consecutive clinical records of patients with positive autoantibodies were selected. RESULTS: In 100/520 (19.23%) women, positive auto-antibodies were detected: 35/520 (6.73%) fulfilled classification criteria for a systemic disease. Positive aPLs were observed in 43 women (8.27%): 17/520 (3.27%) fulfilled diagnostic criteria for PAPS/APS, whereas patients with positive aPLs, who fulfilled diagnostic criteria for a systemic autoimmune disease other than APS were 18/520 (3.46%). LA and aCL were the main aPLs detected 53.49% and 44.19% respectively, whereas aB2GPI were found in 25.58%. CONCLUSIONS: we suggest that women with infertility may represent a subpopulation of patients with underhanded systemic autoimmune syndromes in which the main symptoms represented are obstetrical complications. We, therefore, recommend evaluating aPLs in all patients undergoing IVF with the aim of recognizing women at a higher risk of miscarriage or pregnancy morbidity.

Polyclonal intravenous immunoglobulin: an important additional strategy in sepsis?

Sepsis syndrome is characterized by a systemic inflammatory response to infection potentially leading to acute organ failure and rapid decline to death. Polyclonal intravenous immune globulin, a blood product derived from human donor blood, in addition to antiinfective activities, also exerts a broad antiinflammatory and immunomodulating effect. Intravenous immunoglobulin (IVIg) has been proposed as adjuvant therapy for sepsis even though the clinical studies demonstrating their efficacy and safety are relatively small. Several systematic reviews and meta-analyses of intravenous immunoglobulin treatment in sepsis have been performed. As a result of heterogeneity across studies and inconsistencies in results, the majority have concluded that more evidence, coming from large, well-conducted randomized controlled trials (RCTs), is required. Moreover the appropriate timing of administration and the identification of specific clinical settings represent a key factor to maximizing their beneficial effect. The authors, in this revision, review the basic mechanisms of action of IVIg, the rationale for their use, and their clinical applications.

A case of subacute cutaneous lupus erythematosus in a patient with mixed connective tissue disease: successful treatment with plasmapheresis and rituximab.

A 30-year-old woman affected by Mixed Connective Tissue Disease with scleroderma spectrum developed a facial eruption, a clinical and histological characteristic of subacute cutaneous lupus erythematosus (SCLE). Speckled anti-nuclear antibodies, high-titer anti-ribonucleoprotein1, anti-Sm, anti-Cardiolipin (aCL) IgG/IgM, and anti-Ro/SSA antibodies were positive. SCLE was resistant to Azathioprine, Hydroxychloroquine, and Methotrexate while Mycophenolate Mofetil was suspended due to side effects. Subsequently, the patient was treated with three cycles of therapeutic plasma exchange (TPE) followed, one month after the last TPE, by the anti-CD20 antibody Rituximab (RTX) (375 mg/m(2) weekly for 4 weeks). Eight and 16 months later the patient received other two TPE and RTX cycles, respectively. This therapeutic approach has allowed to obtain a complete skin healing persistent even after 8-month follow-up. Moreover, mitigation of Raynaud's phenomenon, resolution of alopecia, and a decline of aCL IgG/IgM and anti-Ro/SSA antibodies were observed.

Influenza vaccine administration in rheumatoid arthritis patients under treatment with TNFalpha blockers: safety and immunogenicity.

Twenty-eight patients with low-moderate, stable rheumatoid arthritis (RA), under treatment with tumor necrosis factor (TNF) alpha blockers, were immunized at least once with non-adjuvanted trivalent influenza vaccine during three consecutive influenza seasons. Antibodies toward A influenza antigens significantly increased and reached protective levels, still detectable 6 months after vaccination, both in RA patients and healthy controls. Response to B antigen instead was only observed from the second year for healthy controls and in the third year for patients. No significant difference in disease activity and anti-nuclear antibodies was observed as a consequence of vaccine administration, whereas T regulatory cells showed a significant increase 30 days after immunization in RA patients. This study confirms safety of influenza vaccine administration in RA patients treated with TNFalpha blockers. The cohort follow-up revealed the overcoming of poor B vaccine antigen immunogenicity via repeated vaccinations. Finally, protective antibody response was still observed 6 months after vaccination.

Are glucocorticoids a consistent risk factor for infections in rheumatoid arthritis patients under treatment with methotrexate and etanercept?

OBJECTIVE: To evaluate the incidence of infections in subjects with rheumatoid arthritis (RA), treated with an anti-TNFalpha blocker during one year follow-up. The aim of the study was focused to evaluate the number of infectious episodes in two groups of patients treated with etanercept (ETN) plus methotrexate (MTX) or ETN plus MTX and glucocorticoid drugs (GCs/prednisone) for a 12 months period. MATERIALS AND METHODS: Sixty-nine out of 122 RA patients treated with an anti-TNFalpha drug (ETN) were included in an outpatient control system within the Immunology Department Sapienza-University of Rome-II; School of Medicine. RA patients were studied during the first year after ETN introduction. Particularly 20 RA patients have been included in a subgroup. For these 20 patients infections have been monitored for 2 years: 12 months before and 12 months after ETN treatment starting. RESULTS: According to drugs administration protocols, after a careful screening aiming to exclude latent tuberculosis infection, 20 patients have been treated with ETN (10 of them received treatment in association to MTX, while 10 were given a GCs therapy plus MTX). During the one-year ETN treatment period, 7 infections have been described in the group treated with ETN, MTX and GCs and no infection in the group treated with ETN and MTX. After analysing the infection number in the two groups of patients, in the year preceding biological treatment no significant change arose. CONCLUSIONS: The risk of infections in subjects treated with the biological drug ETN is well known. Our data show that after one year therapy the [ETN+MTX+GCs] group is marked by a greater frequency of infectious episodes compared to the subjects treated with ETN plus MTX. Therefore, the additional infectious risk appears to be related to steroid therapy itself, though infections were not serious.

Clonality among Enterococcus faecium clinical isolates.

In the course of a survey to determine the epidemiology of enterococcal infections in Italy, a sudden increment, in a 1-year time, was noted in the number of glycopeptide resistant Enterococcus faecium isolated from different wards of the University Hospital in Rome, Italy. The isolates were characterized for clonal relatedness by comparing SmaI gel electropherotypes, presence of vancomycin-resistance genes, and expression of virulence factors. PFGE identified in a single pulsed type all the glycopeptide-resistant isolates but one. Resistance to high levels of aminoglycosides was expressed by these same isolates, which also included a majority of non biofilm-forming strains. Two esp gene-carrying strains were also identified in different PFGE types. Data indicates that a specific clone acquired, in the clinical setting, the genetic determinant for glycopeptide resistance, thus improving environmental adaptation and favoring its persistence and spread.

Polyurethanes loaded with antibiotics: influence of polymer-antibiotic interactions on in vitro activity against Staphylococcus epidermidis.

Acidic or basic polyurethanes were loaded with antibiotics to develop materials to prevent medical device-related infections. A correlation between polymer-antibiotic interactions and amount of drug absorbed by polymers and released over time was found. Since the employed antibiotics, i.e. amoxicillin, cefamandole nafate, rifampin and vancomycin, possessed at least an acidic group in their structural formula, the introduction of basic tertiary amines in the polyurethane side-chain resulted in an increased polymer ability to adsorb antibiotics. However, a stronger ionic interaction between this polymer and the antibiotics caused a release of lower amount of drug over time. Antibiotics released from polymers inhibited Staphylococcus epidermidis growth on agar. Antibiotic-loaded polyurethanes kept in water for increasing times were still able to show inhibition zones of bacterial growth. The antibacterial activity lasted up to 3 hours for amoxicillin, 24 hours for vancomycin, 8 days for cefamandole nafate and 8 months for rifampin.

Analysis of virulence factors in cases of enterococcal endocarditis.

Eleven isolates of Enterococcus faecalis causing endocarditis were screened for possible virulence factors with PCR and phenotypic assays. The gene coding for the enterococcal surface protein (esp) was detected in one isolate only, and haemolysin was produced by two isolates. Aggregation substance, biofilm formation and gelatinase were present in seven, nine and eight isolates, respectively. Predisposing factors, particularly hospitalisation and multiple antibiotic therapy, appeared to be more relevant to the development of enterococcal endocarditis following bloodstream infections than the pattern of virulence factors.

New polymer-antibiotic systems to inhibit bacterial biofilm formation: a suitable approach to prevent central venous catheter-associated infections.

Intravascular catheters are widely employed in medical practice. However, complications such as local or systemic infections are frequently related to their use. The significant increase in this type of nosocomial infection has prompted the search for new strategies to prevent them. This paper reports on an experimental model to prevent catheter-related infections based on the adsorption of a beta-lactam antibiotic (cefamandole nafate) on functionalized urethane polymers. The polyurethanes synthesized were used to coat a commercial central venous catheter. The influence of functional groups on the polymer-antibiotic interaction was analyzed and the kinetics of the antibiotic release from the catheters was dynamically studied. We were able to realize a polymer-antibiotic system able to inhibit bacterial growth up to 7 days. These promising results have encouraged us to extend this experimental model to other polymer-antibiotic systems in order to identify those allowing bacterial growth inhibition for longer times.

Antibiotic resistance and genotypic characterization by PFGE of clinical and environmental isolates of enterococci.

Fifty-four Enterococcus faecalis and 20 Enterococcus faecium isolates from clinical and non-human sources in Rome, Italy, were characterized by antibiotic resistance and pulsed field gel electrophoresis (PFGE). Resistance to vancomycin, teicoplanin, ampicillin, and ciprofloxacin was more frequent in E. faecium than in E. faecalis, whereas high-level resistance to aminoglycoside was found primarily in E. faecalis. Multi-resistance was found primarily among clinical isolates, but was also observed among environmental isolates. Common genotypes shared among clinical and environmental isolates were observed, however, the majority of isolates occurred as unique, source-specific clones. Several PFGE types were associated with shared features in their antibiotic resistance patterns; evidences of clonal spread between and within wards were also noted. This is the first report indicating clonal relatedness between human and environmental enterococci isolated in Italy.

Is melatonin circadian rhythm a physiological feature associated with healthy longevity? A study of long-living subjects and their progeny.

The study investigates the circadian rhythm (CR) of urinary 6-sulphatoxy-melatonin (aMT6s) in long-living (longevous) subjects and their progeny. The aim is to detect whether or not the melatonin CR is a physiological feature associated with healthy longevity. The aMT6s CR was investigated in 10 longevous subjects, 8 of their children and 9 of their grandchildren, all in good health. Control data were obtained respectively from 13 adult subjects and 9 young subjects, in good health, but characterized by a negative family history for longevity. All the subjects were born and living in the same city. The study was performed in the summer of 1996. The aMT6s CR was found to persist in longevous subjects, being characterized by a lower mesor and amplitude. The aMT6s CR was found not to show properties consistently different in children and grandchildren as compared respectively to their adult and young controls. Because of its preservation in longevous subjects, it can be argued that the melatonin CR is a physiological feature associated with healthy longevity. Because of the comparability of aMT6s CR in children and grandchildren, with respect to their controls without a positive family history of longevity, it can be argued that the melatonin CR is not a marker that can be used for an earlier identification of the candidates for longevity.

Enterococcus spp. produces slime and survives in rat peritoneal macrophages.

Enterococcal clinical isolates were investigated for the ability to form biofilm on inert surfaces, as a measure of slime production, in an attempt to find new possible virulence factors for these microorganisms. This property was commonly found among Enterococcus faecalis. Also E. faecium isolates were able to form biofilm, although to a lesser extent; for this species, however, biofilm formation seemed more frequently associated with isolates from infection rather than with environmental strains or isolates from healthy individuals. Biofilm formation was strongly affected by the presence of an additional carbohydrate source in the medium, or by iron deprivation, indicating a role of slime for survival in stressful conditions. Slime-producing E. faecalis were able to survive inside peritoneal macrophages for extended periods compared to slime-negative strains or to slime-positive bacteria grown in conditions depressing slime production. In particular, slime-producing and slime-negative cells showed a decrease of 1 and 2 log units, respectively, at 1 h after infection; slime-negative cells were then rapidly killed, with clearance of bacterial cells at 24 h. Slime-producing bacteria persisted up to 48 h, which was the last time point examined, as after that time viability of both infected and non-infected macrophages started to decline. Scanning electron microscopy observations showed the presence of abundant amorphous extracellular material, of possible polysaccharide nature, embedding bacterial cells to form a multilayered biofilm. Even in conditions not supporting biofilm formation, bacterial cells appeared capsulated, suggesting that capsule and slime might represent different structures. Genes belonging to the epa locus or to a putative icaA homolog did not seem to be involved in synthesis and export of slime.

Slime production and expression of the slime-associated antigen by staphylococcal clinical isolates.

The ability to produce slime and to express a slime-associated antigen was examined in a collection of staphylococcal clinical isolates. Slime-producing strains were found among coagulase-negative staphylococci in percentages comparable to those reported in other studies; surprisingly, a high percentage of Staphylococcus aureus strains also were able to produce this extracellular material. In the latter case, this ability was strongly dependent on the presence of an additional carbohydrate source in the growth medium. Expression of the slime-associated antigen appeared to be species specific and confined to the Staphylococcus epidermidis sensu stricto isolates; its strong association with the ability of these strains to produce thicker biofilms indicated slime-associated antigen as a possible virulence marker for S. epidermidis.

[Streptococcus bovis endocarditis. Clinical and microbiological observations and review of the literature]. / Endocardite da Streptococcus bovis. Analisi clinico-microbiologica retrospettiva e rassegna della letteratura.

Fourteen patients (11 men and 3 women) with Streptococcus bovis infective endocarditis have been observed by the Infectious Disease Section of our Department of Clinical Medicine between the years 1988-1998. The mean age was 63.2 years (range 35-85 years); 5 patients previously suffered valvular disease or had a valvular prosthesis, the infection involved the mitral valve in 6 patients, the aortic in 8, the prosthetic valve in 1. No patient developed cardiac failure or died during hospitalization; only 1 episode of major embolism (spleen) was observed. No patient required cardiac surgery. All patients became afebrile after starting antibiotic treatment; no cases of Streptococcus bovis relapse have been observed, during a six-month follow-up after antibiotics discontinuation, in 13 patients fully evaluated. The remaining patient was lost to follow-up. An underlying asymptomatic colonic neoplasm was diagnosed at colonoscopy in 7 of 11 evaluated patients. This study confirms that Streptococcus bovis infective endocarditis is relatively benign, but it stresses the frequency and potential severity of the associated colonic lesions, requiring colonoscopy and making the treatment of high risk lesion mandatory.

Anaerobic bacteria in postsurgical infections: isolation rate and antimicrobial susceptibility.

Three hundred clinical samples, obtained from post-surgical infections, were evaluated. 37% of samples were positive for anaerobes, 99 samples (33%) for aerobes and anaerobes in mixed culture, and 13 (4%) only for anaerobes. One hundred forty-nine anaerobic strains were isolated: Bacteroides and Clostridia occurred most frequently (34% and 23% respectively). Antimicrobial susceptibility of the isolates was tested by means of a commercial broth microdilution method. In addition, the standardized agar dilution method was performed to evaluate the susceptibility to 8 antibiotics of the 51 Bacteroides strains.

[Teichoplanin: a clinical study of treatment of serious infections in hospitalized patients]. / La teicoplanina: studio clinico nel trattamento di gravi infezioni in pazienti ospedalizzati.

The study was performed to evaluate the efficacy and the safety of teicoplanin in the treatment of serious Gram positive bacteria infections in hospitalized patients at high risk of complications. In a twelve month period, 13 patients were treated. Six of whom presented generalized infections with bacteremia and seven severe localized infections. Safety evaluation included pre, during and post treatment measurements of haematological and serum chemistry parameters. Clinical successes with microbiological eradication of pathogens were obtained in 11 out of 13 cases (84.6%). One persistence of infection (7.7%) and one Gram negative superinfection (7.7%) presented. Only in one patient we noted a transitory increase of creatinine level. Teicoplanin showed to be useful in the treatment of serious Gram positive infections in hospitalized patients.

[Pheochromocytoma-gastric leiomyoblastoma association. A possible expression of Carney's triad. A case report]. / Associazione feocromocitoma-leiomioblastoma gastrico. Possibile espressione di triade di Carney. Un caso di nostra osservazione.

The case of a 28 yrs old female patient affected by pheochromocytoma and gastric leiomyoblastoma was described. The simultaneous presence of these neoplasms in a young woman supported the diagnosis of the clinical syndrome known as "Carney's triad".

[Amyloidosis: state of the art]. / Amiloidosi: lo stato dell'arte.

Amyloidosis is characterized by a heterogeneous group of diseases due to deposition of a fibrillar, proteinaceous material, in different tissues. In this review pathogenetic mechanisms, clinical and therapeutic findings of the most important aspects of the disease, are described.