L'epatite E nei suidi: epidemiologia, diagnosi e filogenesi

Hepatitis E is an infectious viral disease with clinical and morphological features of acute hepatitis. The aetiological agent is the Hepatitis E virus (HEV). The disease represents an important Public Health problem in developing countries where is frequently epidemic and primarily transmitted by fecal-oral route. In the last few years, a certain number of sporadic cases have been also described in industrialized countries, Italy included. A swine HEV was first identified in 1997 and is now considered an ubiquitous virus. Human and swine strains from the same geographical region have shown to have a high level of nucleotidic omology and in experimental infections, the possibility of interspecific transmission of swine strains to humans and of human strains to non-human primates has been demonstrated. Furthermore, some seroepidemiological studies have demonstrated that people working in contact with swine have a higher risk to get infected than normal blood donors. Recently, cases of HEV hepatitis have been directly associated to the ingestion of uncooked tissues from pigs, wild boar or deer and today the disease is considered an emerging zoonosis. The aims of this thesis were: evaluate HEV prevalence in Italian swine herds (both in fattening and in breeding animals); investigate the possibility of finding HEV in livers used for human consumption; investigate if there is any correlation between HEV infection and the presence of macroscopical lesions; investigate HEV prevalence in a demographic managed wild boar population; phylogenetically analyse viral strains identified. During an internship period at Veterinary Laboratories Agency (Weybridge, UK), furthermore, swine samples at different stages of production and slurry lagoons have been analysed. Six swine herds located in North Italy have been sampled at different stage of production. The overall prevalence resulted 42%, and both breeding and fattening animals were positive for HEV infection. A longitudinal study has been conducted in a herd across all stages of production until the slaughtering age. Livers have been collected from the animals at the abattoir and 11.8% of them were positive for HEV infection. No correlations have been identified between HEV infection and macroscopical lesions in pigs affected by different pathological conditions. Of 86 wild boars tested 22 (25%) were positive for HEV. Of the swine tested in UK 21,5 % and 2 of the 9 slurry lagoons (22,2%) were positive for HEV infection. All the strains identified belonged to genotype 3 and showed high percentages of nucleotidic identity with humans and swine strains identified in Europe. The high prevalence detected in these studies confirms the widespread diffusion of HEV in swine populations in Italy and in UK. Phylogenetical analysis of identified strains, similar to those identified in autochthonous human hepatitis E cases of the same geographical area, confirm the hypothesis that pigs can be a font of zoonotical infection. The finding that a fraction of the livers inserted in the food chain are positive for HEV infection it’s of some concern for Public Health. The finding of a high HEV prevalence in all examined farms, together with the observation that infection may be sub-clinical and affect animals at slaughtering age, raise concern because of the possible risk of transmission of HEV to humans by either direct contact with infected pigs, indirect contact with environment and working instruments contaminated with pig feces, or ingestion of contaminated undercooked meat.

Evidenze micropaleontologiche e sedimentologiche di cicli deposizionali e climatici circa millenari nei Depositi Tardoquaternari della Piana dell'Arno e del Delta del Po

A multidisciplinary study was carried out on the Late Quaternary-Holocene subsurface deposits of two Mediterranean coastal areas: Arno coastal plain (Northern Tyrrhenian Sea) and Modern Po Delta (Northern Adriatic Sea). Detailed facies analyses, including sedimentological and micropalaeontological (benthic foraminifers and ostracods) investigations, were performed on nine continuously-cored boreholes of variable depth (ca. from 30 meters to100 meters). Six cores were located in the Arno coastal plain and three cores in the Modern Po Delta. To provide an accurate chronological framework, twenty-four organic-rich samples were collected along the fossil successions for radiocarbon dating (AMS 14C). In order to reconstruct the depositional and palaeoenvironmental evolution of the study areas, core data were combined with selected well logs, provided by local companies, along several stratigraphic sections. These sections revealed the presence of a transgressive-regressive (T-R) sequence, composing of continental, coastal and shallow-marine deposits dated to the Late Pleistocene-Holocene period, beneath the Arno coastal plain and the Modern Po Delta. Above the alluvial deposits attributed to the last glacial period, the post-glacial transgressive succession (TST) consists of back-barrier, transgressive barrier and inner shelf deposits. Peak of transgression (MFS) took place around the Late-Middle Holocene transition and was identified by subtle micropalaeontological indicators within undifferentiated fine-grained deposits. Upward a thick prograding succession (HST) records the turnaround to regressive conditions that led to a rapid delta progradation in both study areas. Particularly, the outbuilding of modern-age Po Delta coincides with mud-belt formation during the late HST (ca. 600 cal yr BP), as evidenced by a fossil microfauna similar to the foraminiferal assemblage observed in the present Northern Adriatic mud-belt. A complex interaction between allocyclic and autocyclic factors controlled facies evolution during the highstand period. The presence of local parameters and the absence of a predominant factor prevent from discerning or quantifying consequences of the complex relationships between climate and deltaic evolution. On the contrary transgressive sedimentation seems to be mainly controlled by two allocyclic key factors, sea-level rise and climate variability, that minimized the effects of local parameters on coastal palaeoenvironments. TST depositional architecture recorded in both study areas reflects a well-known millennial-scale variability of sea-level rising trend and climate during the Late glacial-Holocene period. Repeated phases of backswamp development and infilling by crevasse processes (parasequences) were recorded in the subsurface of Modern Po Delta during the early stages of transgression (ca. 11,000-9,500 cal yr BP). In the Arno coastal plain the presence of a deep-incised valley system, probably formed at OSI 3/2 transition, led to the development of a thick (ca. 35-40 m) transgressive succession composed of coastal plain, bay-head delta and estuarine deposits dated to the Last glacial-Early Holocene period. Within the transgressive valley fill sequence, high-resolution facies analyses allowed the identification and lateral tracing of three parasequences of millennial duration. The parasequences, ca. 8-12 meters thick, are bounded by flooding surfaces and show a typical internal shallowing-upward trend evidenced by subtle micropalaeontological investigations. The vertical stacking pattern of parasequences shows a close affinity with the step-like sea-level rising trend occurred between 14,000-8,000 cal years BP. Episodes of rapid sea-level rise and subsequent stillstand phases were paralleled by changes in climatic conditions, as suggested by pollen analyses performed on a core drilled in the proximal section of the Arno palaeovalley (pollen analyses performed by Dr. Marianna Ricci Lucchi). Rapid shifts to warmer climate conditions accompanied episodes of rapid sea-level rise, in contrast stillstand phases occurred during temporary colder climate conditions. For the first time the palaeoclimatic signature of high frequency depositional cycles is clearly documented. Moreover, two of the three "regressive" pulsations, recorded at the top of parasequences by episodes of partial estuary infilling in the proximal and central portions of Arno palaeovalley, may be correlated with the most important cold events of the post-glacial period: Younger Dryas and 8,200 cal yr BP event. The stratigraphic and palaeoclimatic data of Arno coastal plain and Po Delta were compared with those reported for the most important deltaic and coastal systems in the worldwide literature. The depositional architecture of transgressive successions reflects the strong influence of millennial-scale eustatic and climatic variability on worldwide coastal sedimentation during the Late glacial-Holocene period (ca. 14,000-7,000 cal yr BP). The most complete and accurate record of high-frequency eustatic and climatic events are usually found within the transgressive succession of very high accommodation settings, such as incised-valley systems where exceptionally thick packages of Late glacial-Early Holocene deposits are preserved.

Combined Evaluation of ST-segment Elevation in lead AVR and ST-segment Depression in other Leads Enhances Prediction of in-hospital Cardiovascular Death in Patients with Non ST-segment Elevation Acute Coronary Syndrome

Objective: To investigate the prognostic significance of ST-segment elevation (STE) in aVR associated with ST-segment depression (STD) in other leads in patients with non-STE acute coronary syndrome (NSTE-ACS). Background: In NSTE-ACS patients, STD has been extensively associated with severe coronary lesions and poor outcomes. The prognostic role of STE in aVR is uncertain. Methods: We enrolled 888 consecutive patients with NSTE-ACS. They were divided into two groups according to the presence or not on admission ECG of aVR STE≥ 1mm and STD (defined as high risk ECG pattern). The primary and secondary endpoints were: in-hospital cardiovascular (CV) death and the rate of culprit left main disease (LMD). Results: Patients with high risk ECG pattern (n=121) disclosed a worse clinical profile compared to patients (n=575) without [median GRACE (Global-Registry-of-Acute-Coronary-Events) risk score =142 vs. 182, respectively]. A total of 75% of patients underwent coronary angiography. The rate of in-hospital CV death was 3.9%. On multivariable analysis patients who had the high risk ECG pattern showed an increased risk of CV death (OR=2.88, 95%CI 1.05-7.88) and culprit LMD (OR=4.67,95%CI 1.86-11.74) compared to patients who had not. The prognostic significance of the high risk ECG pattern was maintained even after adjustment for the GRACE risk score (OR = 2.28, 95%CI:1.06-4.93 and OR = 4.13, 95%CI:2.13-8.01, for primary and secondary endpoint, respectively). Conclusions: STE in aVR associated with STD in other leads predicts in-hospital CV death and culprit LMD. This pattern may add prognostic information in patients with NSTE-ACS on top of recommended scoring system.

Recupero della funzione renale in pazienti con acute kidney injury (AKI) sottoposti a terapia sostitutiva renale

L’insufficienza renale acuta(AKI) grave che richiede terapia sostitutiva, è una complicanza frequente nelle unità di terapia intensiva(UTI) e rappresenta un fattore di rischio indipendente di mortalità. Scopo dello studio é stato valutare prospetticamente, in pazienti “critici” sottoposti a terapie sostitutive renali continue(CRRT) per IRA post cardiochirurgia, la prevalenza ed il significato prognostico del recupero della funzione renale(RFR). Pazienti e Metodi:Pazienti(pz) con AKI dopo intervento di cardiochirurgia elettivo o in emergenza con disfunzione di due o più organi trattati con CRRT. Risultati:Dal 1996 al 2011, 266 pz (M 195,F 71, età 65.5±11.3aa) sono stati trattati con CRRT. Tipo di intervento: CABG(27.6%), dissecazione aortica(33%), sostituzione valvolare(21.1%), CABG+sostituzione valvolare(12.6%), altro(5.7%). Parametri all’inizio del trattamento: BUN 86.1±39.4, creatininemia(Cr) 3.96±1.86mg/dL, PAM 72.4±13.6mmHg, APACHE II score 30.7±6.1, SOFAscore 13.7±3. RIFLE: Risk (11%), Injury (31.4%), Failure (57.6%). AKI oligurica (72.2%), ventilazione meccanica (93.2%), inotropi (84.5%). La sopravvivenza a 30 gg ed alla dimissione è stata del 54.2% e del 37.1%. La sopravvivenza per stratificazione APACHE II: <24=85.1 e 66%, 25-29=63.5 e 48.1%, 30-34=51.8 e 31.8%, >34=31.6 e 17.7%. RFR ha consentito l’interruzione della CRRT nel 87.8% (86/98) dei survivors (Cr 1.4±0.6mg/dL) e nel 14.5% (24/166) dei nonsurvivors (Cr 2.2±0.9mg/dL) con un recupero totale del 41.4%. RFR è stato osservato nel 59.5% (44/74) dei pz non oligurici e nel 34.4% dei pz oligurici (66/192). La distribuzione dei pz sulla base dei tempi di RFR è stata:<8=38.2%, 8-14=20.9%, 15-21=11.8%, 22-28=10.9%, >28=18.2%. All’analisi multivariata, l’oliguria, l’età e il CV-SOFA a 7gg dall’inizio della CRRT si sono dimostrati fattori prognostici sfavorevoli su RFR(>21gg). RFR si associa ad una sopravvivenza elevata(78.2%). Conclusioni:RFR significativamente piu frequente nei pz non oligurici si associa ad una sopravvivenza alla dimissione piu elevata. La distribuzione dei pz in rapporto ad APACHE II e SOFAscore dimostra che la sopravvivenza e RFR sono strettamente legati alla gravità della patologia.