Tratamento percutâneo vs. cirúrgico da persistência do canal arterial em crianças e adolescentes

INTRODUÇÃO: Estudos comparando os métodos percutâneo e cirúrgico no tratamento da persistência do canal arterial (PCA) são raros na literatura. Nosso objetivo foi realizar análise comparativa entre os dois métodos de tratamento da PCA, enfatizando os aspectos de eficácia e morbidade. MÉTODOS: Estudo observacional com 2 coortes de crianças e adolescentes > 5 kg e < 14 anos, portadores de PCA, tratados durante um projeto de avaliação de incorporação de novas tecnologias ao Sistema Único de Saúde (SUS), realizado em um hospital cardiológico de excelência, em parceria com o Ministério da Saúde do Brasil. Foi feita análise prospectiva no grupo percutâneo entre 2009 e 2011 e retrospectiva no grupo cirúrgico entre 2006 e 2011. RESULTADOS: Foram incluídos 80 pacientes no grupo percutâneo (60% do sexo feminino) e 39 no grupo cirúrgico (51% do sexo feminino; P = 0,37). A mediana de idade e de peso dos grupos percutâneo e cirúrgico foi de 39,4 meses vs. 25,5 meses (P = 0,04) e de 14 kg vs. 11,1 kg (P = 0,052), respectivamente. No grupo percutâneo, 78 pacientes (92%) tinham PCA do tipo A e o diâmetro mínimo do canal à angiografia foi de 2,5 ± 1,2 mm. As próteses mais utilizadas foram Amplatzer®, molas de Gianturco e CeraTM. A técnica cirúrgica mais utilizada foi a clipagem. A taxa de sucesso dos procedimentos foi de 100% nos dois grupos. O grupo cirúrgico apresentou maiores taxas de complicação, incluindo quilotórax, infecções, necessidade de hemoderivados, hipertensão arterial sistêmica e uso de opioides, como também maior necessidade de terapia intensiva. A mediana do tempo de internação foi de 1,3 dia no grupo percutâneo e de 7,9 dias no grupo cirúrgico (P < 0,01). À alta hospitalar, as taxas de oclusão foram semelhantes nos dois grupos (91% no grupo percutâneo e 87% no grupo cirúrgico; P = 0,71). CONCLUSÕES: Em decorrência da menor morbidade, do menor tempo de internação e da igual eficácia, o tratamento percutâneo da PCA deve ser considerado a modalidade terapêutica de escolha para pacientes selecionados.

Role of soluble triggering receptor expressed on myeloid cells-1 for diagnosing ventilator-associated pneumonia after cardiac surgery: an observational study

Abstract Background The diagnosis of ventilator-associated pneumonia (VAP) is a challenge, particularly after cardiac surgery. The use of biological markers of infection has been suggested to improve the accuracy of VAP diagnosis. We aimed to evaluate the usefulness of soluble triggering receptor expressed on myeloid cells (sTREM)-1 in the diagnosis of VAP following cardiac surgery. Methods This was a prospective observational cohort study of children with congenital heart disease admitted to the pediatric intensive care unit (PICU) after surgery and who remained intubated and mechanically ventilated for at least 24 hours postoperatively. VAP was defined by the 2007 Centers for Disease Control and Prevention criteria. Blood, modified bronchoalveolar lavage (mBAL) fluid and exhaled ventilator condensate (EVC) were collected daily, starting immediately after surgery until the fifth postoperative day or until extubation for measurement of sTREM-1. Results Thirty patients were included, 16 with VAP. Demographic variables, Pediatric Risk of Mortality (PRISM) and Risk Adjustment for Congenital Heart Surgery (RACHS)-1 scores, duration of surgery and length of cardiopulmonary bypass were not significantly diferent in patients with and without VAP. However, time on mechanical ventilation and length of stay in the PICU and in the hospital were significantly longer in the VAP group. Serum and mBAL fluid sTREM-1 concentrations were similar in both groups. In the VAP group, 12 of 16 patients had sTREM-1 detected in EVC, whereas it was undetectable in all but two patients in the non-VAP group over the study period (p = 0.0013) (sensitivity 0.75, specificity 0.86, positive predictive value 0.86, negative predictive value 0.75, positive likelihood ratio (LR) 5.25, negative LR 0.29). Conclusion Measurement of sTREM-1 in EVC may be useful for the diagnosis of VAP after cardiac surgery.

Follow-up Study of Unknowingly Pregnant Women Vaccinated Against Rubella in Brazil, 2001–2002

Background. Brazil conducted mass immunization of women of childbearing age in 2001 and 2002. Surveillance was initiated for vaccination of women during pregnancy to monitor the effects of rubella vaccination on fetal outcomes. Methods. Women vaccinated while pregnant or prior to conception were reported to the surveillance system. Susceptibility to rubella infection was determined by anti-rubella immunoglobulin (Ig) M and IgG immunoassays. Susceptible women were observed through delivery. Live-born infants were tested for anti-rubella IgM antibody; IgM-seropositive newborns were tested for viral shedding and observed for 12 months for signs of congenital rubella syndrome. Incidence of congenital rubella infection was calculated using data from 7 states. Results. A total of 22 708 cases of rubella vaccination during pregnancy or prior to conception were reported nationwide, 20 536 (90%) of which were from 7 of 27 states in Brazil. Of these, 2332 women were susceptible to rubella infection at vaccination. Sixty-seven (4.1%) of 1647 newborns had rubella IgM antibody (incidence rate, 4.1 congenital infections per 100 susceptible women vaccinated during pregnancy [95% confidence interval, 3.2–5.1]). None of the infants infected with rubella vaccine virus was born with congenital rubella syndrome. Conclusions. As rubella elimination goals are adopted worldwide, evidence of rubella vaccine safety aids in planning and implementation of mass adult immunization.

Identification of Drosophila heart-specific Cis-Regulatory Modules under Hox control

Cardiac morphogenesis is a complex process governed by evolutionarily conserved transcription factors and signaling molecules. The Drosophila cardiac tube is linear, made of 52 pairs of cardiomyocytes (CMs), which express specific transcription factor genes that have human homologues implicated in Congenital Heart Diseases (CHDs) (NKX2-5, GATA4 and TBX5). The Drosophila cardiac tube is linear and composed of a rostral portion named aorta and a caudal one called heart, distinguished by morphological and functional differences controlled by Hox genes, key regulators of axial patterning. Overexpression and inactivation of the Hox gene abdominal-A (abd-A), which is expressed exclusively in the heart, revealed that abd-A controls heart identity. The aim of our work is to isolate the heart-specific cisregulatory sequences of abd-A direct target genes, the realizator genes granting heart identity. In each segment of the heart, four pairs of cardiomyocytes (CMs) express tinman (tin), homologous to NKX2-5, and acquire strong contractile and automatic rhythmic activities. By tyramide amplified FISH, we found that seven genes, encoding ion channels, pumps or transporters, are specifically expressed in the Tin-CMs of the heart. We initially used online available tools to identify their heart-specific cisregutatory modules by looking for Conserved Non-coding Sequences containing clusters of binding sites for various cardiac transcription factors, including Hox proteins. Based on these data we generated several reporter gene constructs and transgenic embryos, but none of them showed reporter gene expression in the heart. In order to identify additional abd-A target genes, we performed microarray experiments comparing the transcriptomes of aorta versus heart and identified 144 genes overexpressed in the heart. In order to find the heart-specific cis-regulatory regions of these target genes we developed a new bioinformatic approach where prediction is based on pattern matching and ordered statistics. We first retrieved Conserved Noncoding Sequences from the alignment between the D.melanogaster and D.pseudobscura genomes. We scored for combinations of conserved occurrences of ABD-A, ABD-B, TIN, PNR, dMEF2, MADS box, T-box and E-box sites and we ranked these results based on two independent strategies. On one hand we ranked the putative cis-regulatory sequences according to best scored ABD-A biding sites, on the other hand we scored according to conservation of binding sites. We integrated and ranked again the two lists obtained independently to produce a final rank. We generated nGFP reporter construct flies for in vivo validation. We identified three 1kblong heart-specific enhancers. By in vivo and in vitro experiments we are determining whether they are direct abd-A targets, demonstrating the role of a Hox gene in the realization of heart identity. The identified abd-A direct target genes may be targets also of the NKX2-5, GATA4 and/or TBX5 homologues tin, pannier and Doc genes, respectively. The identification of sequences coregulated by a Hox protein and the homologues of transcription factors causing CHDs, will provide a mean to test whether these factors function as Hox cofactors granting cardiac specificity to Hox proteins, increasing our knowledge on the molecular mechanisms underlying CHDs. Finally, it may be investigated whether these Hox targets are involved in CHDs.

Biomimetica per l'ingegneria tissutale dell'osso

Reconstruction of bone is needed for high bone loss due to congenital deformities, trauma or neoplastic diseases. Commonly, orthopaedic surgical treatments are autologus or allogenic bone implant or prosthetic implant. A choice to the traditional approaches could be represented by tissue engineering that use cells (and/or their products) and innovative biomaterials to perform bone substitutes biologically active as an alternative to artificial devices. In the last years, there was a wide improvement in biology on stem cells potential research and in biomedical engineering through development of new biomaterials designed to resemble the physiological tissues. Tissue engineering strategies and smart materials aim together to stimulate in vivo bone regeneration. This approaches drive at restore not only structure integrity and/or function of the original tissue, but also to induce new tissue deposition in situ. An intelligent bone substitute is now designed like not only a scaffold but also as carrier of regeneration biomolecular signals. Biomimetics has helped to project new tissue engineered devices to simulate the physiological substrates architecture, such extracellular matrix (ECM), and molecular signals that drive the integration at the interface between pre-existing tissue and scaffold. Biomimetic strategies want to increase the material surface biological activity with physical modifications (topography) o chemical ones (adhesive peptides), to improve cell adhesion to material surface and possibly scaffold colonization. This study evaluated the effects of biomimetic modifications of surgical materials surface, as poly-caprolattone (PCL) and titanium on bone stem cells behaviour in a marrow experimental model in vitro. Two biomimetic strategies were analyzed; ione beam irradiation, that changes the surface roughness at the nanoscale, and surface functionalization with specific adhesive peptides or Self Assembled Monolayers (SAMs). These new concept could be a mean to improve the early (cell adhesion, spreading..) and late phases (osteoblast differentiation) of cell/substrate interactions.

Trasmissione post-natale del citomegalovirus attraverso il latte materno al neonato VLBW

Introduction Postnatal human cytomegalovirus (CMV) infection is usually asymptomatic in term babies, while preterm infants are more susceptible to symptomatic CMV infection. Breastfeeding plays a dominant role in the epidemiology of transmission of postnatal CMV infection, but the risk factors of symptomatic CMV infection in preterm infants are unknown. Patients and Methods Between December 2003 and August 2006, eighty Very Low Birth Weight (VLBW) preterm infants (gestational age ≤ 32 weeks and birth weight < 1500 g), admitted to the Neonatal Intensive Care Unit of St Orsola-Malpighi General Hospital, Bologna were recruited. All of them were breastfed for at least one month. During the first week of life, serological test for CMV was performed on maternal blood. Furthermore, urinary CMV culture was performed in all the infants in order to exclude a congenital CMV infection. Urine samples from each infant were collected and processed for CMV culture once a week. Once every 15 days a blood sample was taken from each infant to evaluate the complete blood count, the hepatic function and the C reactive protein. In addition, samples of fresh breast milk were processed weekly for CMV culture. A genetic analysis of virus variant was performed in the urine of the infected infants and in their mother’s milk to confirm the origin of infection. Results We evaluated 80 VLBW infants and their 68 mothers. Fifty-three mothers (78%) were positive for CMV IgG antibodies, and 15 (22%) were seronegative. In the seronegative group, CMV was never isolated in breast milk, and none of the 18 infants developed viruria; in the seropositive group, CMV was isolated in 21 out of 53 (40%) mother’s milk. CMV was detected in the urine samples of 9 out of 26 (35%) preterm infants, who were born from 21 virolactia positive mothers. Six of these infants had clinically asymptomatic CMV infection, while 3 showed a sepsis-like illness with bradycardia, tachypnea and repeated desaturations. Eight out of nine infants showed abnormal hematologic values. The detection of neutropenia was strictly related to CMV infection (8/9 infected infants vs 17/53 non infected infants, P<.005), such as the detection of an increase in conjugated bilirubin (3/9 infected infants vs 2/53 non infected infants, P<.05). The degree of neutropenia was not different between the two groups (infected/non infected). The use of hemoderivatives (plasma and/or IgM–enriched immunoglobulin) in order to treat a suspected/certain infection in newborn with GE< 28 ws was seen as protective against CMV infection (1/4 infected infants vs 18/20 non infected infants [GE<28 ws]; P<.05). Furthermore, bronchopulmonary dysplasia (defined both as oxygen-dependency at 30 days of life and 36 ws of postmenstrual age) correlated with symptomatic infection (3/3 symptomatic vs 0/6 asymptomatic: P<.05). Conclusion Our data suggest that CMV infection transmitted to preterm newborn through human milk is always asymptomatic when newborns are clinically stable. Otherwise, the infection can worsen a preexisting disease such as bronchopulmonary dysplasia. Human milk offers many nutritional and psychological advantages to preterm newborns: according to our data, there’s no reason to contraindicate it neither to pasteurize the milk of all the mothers of preterm infants who are CMV seropositive.

Il ruolo dell'ecografia prenatale nell'infezione congenita da Citomegalovirus

OBJECTIVE: To assess the effectiveness of ultrasound in the antenatal prediction of symptomatic congenital cytomegalovirus infection. STUDY DESIGN: The sonograms of 650 fetuses from mothers with primary cytomegalovirus infection were correlated to fetal/neonatal outcome. Infection status was disclosed by viral urine isolation at birth or CMV tissue inclusions at autopsy. Classification of symptomatic disease was based on postnatal clinical/laboratory findings or macroscopic evidence of tissue damage at autopsy. RESULTS: Ultrasound abnormalities were found in 51/600 (8.5%) mothers with primary infection and in 23/154 congenitally infected fetuses (14.9%). Symptomatic congenital infection resulted in 18/23 and 68/131 cases with or without abnormal sonographic findings, respectively. Positive predictive values of ultrasound versus symptomatic congenital infection was 35.3% relating to all fetuses/infants from mothers with primary infection and 78.3% relating to fetuses/infants with congenital infection. CONCLUSION: When fetal infection status is unknown, ultrasound abnormalities only predict symptomatic congenital infection in a third of cases.

Significato prognostico dell'ecografia cerebrale nei neonati con infezione congenita da citomegalovirus

Background: Congenital cytomegalovirus (CMV) infection may lead to cerebral injury and neurodevelopmental delay. Cranial computed tomography (CT) is currently the standard imaging technique for predicting the outcome of CMV infected patients. Ultrasound (US) is a safe means to assess the extent of cerebral injury due to CMV infection in neonates, and unlike CT, is readily available at the bedside. Aim: To report the accuracy of US in predicting neurodevelopmental and sensorineural outcome in patients with congenital CMV infection. Study design: 57 newborns with congenital CMV infection underwent brain US and were followed prospectively for motor skills, developmental quotient and hearing function. Results: An abnormal US was found in 12/57 newborns. At least one sequela (Developmental Quotient < 85, motor delay, sensorineural hearing loss) was present in 10/11 surviving children with abnormal US (1 patient died in the neonatal period) vs 3/45 newborns with normal US (OR for death or poor outcome: 154, CI 17.3-1219.6, p<0.001, positive predictive value 91.7%, negative predictive value 93.3%). Conclusion: A good correlation is shown between ultrasound abnormalities and the prediction of outcome, suggesting that US may be used to study and follow CMV infected neonates. Our findings await confirmation in a larger population.

Outcome respiratorio a lungo termine nei soggetti affetti da cardiopatia congenita sottoposti ad intervento cardiochirurgico

Introduction: In the last years cardiac surgery for congenital heart disease (CHD) reduced dramatically mortality modifying prognosis, but, at the same time, increased morbidity in this patient population. Respiratory and cardiovascular systems are strictly anatomically and functionally connected, so that alterations of pulmonary hemodynamic conditions modify respiratory function. While very short-term alterations of respiratory mechanics after surgery were investigated by many authors, not as much works focused on long-term changes. In these subjects rest respiratory function may be limited by several factor: CHD itself (fetal pulmonary perfusion influences vascular and alveolar development), extracorporeal circulation (CEC), thoracotomy and/or sternotomy, rib and sternal contusions, pleural adhesions and pleural fibrosis, secondary to surgical injury. Moreover inflammatory cascade, triggered by CEC, can cause endothelial damage and compromise gas exchange. Aims: The project was conceived to 1) determine severity of respiratory functional impairement in different CHD undergone to surgical correction/palliation; 2) identify the most and the least CHD involved by pulmonary impairement; 3) find a correlation between a specific hemodynamic condition and functional anomaly, and 4) between rest respiratory function and cardiopulmonary exercise test. Materials and methods: We studied 113 subjects with CHD undergone to surgery, and distinguished by group in accord to pulmonary blood flow (group 0: 28 pts with normal pulmonary flow; group 1: 22 pts with increased flow; group 2: 43 pts with decreased flow; group 3: 20 pts with total cavo-pulmonary anastomosis-TCPC) followed by the Pediatric Cardiology and Cardiac Surgery Unit, and we compare them to 37 age- and sex-matched healthy subjects. In Pediatric Pulmonology Unit all pts performed respiratory function tests (static and dynamic volumes, flow/volume curve, airway resistances-raw- and conductance-gaw-, lung diffusion of CO-DLCO- and DLCO/alveolar volume), and CHD pts the same day had cardiopulmonary test. They all were examined and had allergological tests, and respiratory medical history. Results: restrictive pattern (measured on total lung capacity-TLC- and vital capacity-VC) was in all CHD groups, and up to 45% in group 2 and 3. Comparing all groups, we found a significant difference in TLC between healthy and group 2 (p=0.001) and 3 (p=0.004), and in VC between group 2 and healthy (p=0.001) and group 1(p=0.034). Inspiratory capacity (IC) was decreased in group 2 related to healthy (p<0.001) and group 1 (p=0.037). We showed a direct correlation between TLC and VC with age at surgery (p=0.01) and inverse with number of surgical interventions (p=0.03). Reduced FEV1/FVC ratio, Gaw and increased Raw were mostly present in group 3. DLCO was impaired in all groups, but up to 80% in group 3 and 50% in group 2; when corrected for alveolar volume (DLCO/VA) reduction persisted in group 3 (20%), 2 (6.2%) and 0 (7.1%). Exercise test was impaired in all groups: VO2max and VE markedly reduced in all but especially in group 3, and VE/VCO2 slope, marker of ventilatory response to exercise, is increased (<36) in 62.5% of group 3, where other pts had anyway value>32. Comparing group 3 and 2, the most involved categories, we found difference in VO2max and VE/VCO2 slope (respectively p=0.02 and p<0.0001). We evidenced correlation between rest and exercise tests, especially in group 0 (between VO2max and FVC, FEV1, VC, IC; inverse relation between VE/VCO2slope and FVC, FEV1 and VC), but also in group 1 (VO2max and IC), group 2 (VO2max and FVC and FEV1); never in group 3. Discussion: According with literature, we found a frequent impairment of rest pulmonary function in all groups, but especially in group 2 and 3. Restrictive pattern was the most frequent alteration probably due to compromised pulmonary (vascular and alveolar) development secondary to hypoperfusion in fetal and pre-surgery (and pre-TCPC)life. Parenchymal fibrosis, pleural adhesions and thoracic deformities can add further limitation, as showed by the correlation between group 3 and number of surgical intervention. Exercise tests were limited, particularly in group 3 (complex anatomy and lost of chronotropic response), and we found correlations between rest and exercise tests in all but group 3. We speculate that in this patients hemodynamic exceeds respiratory contribution, though markedly decreased.

Sindrome di Down e fattori di rischio nel declino neurocognitivo

Down syndrome (DS) or Trisomy 21, occurring in 1/700 and 1/1000 livebirths, is the most common genetic disorder, characterized by a third copy of the human chromosome 21 (Hsa21). DS is associated with various defects, including congenital heart diseases, craniofacial abnormalities, immune system dysfunction, mental retardation (MR), learning and memory deficiency. The phenotypic features in DS are a direct consequence of overexpression of genes located within the triplicated region on Hsa21. In addition to developmental brain abnormalities and disabilities, people with DS by the age of 30-40 have a greatly increased risk of early-onset of Alzheimer’s disease (AD) and an apparent tendency toward premature aging. Many of the immunological anomalies in DS can be enclosed in the spectrum of multiple signs of early senescence. People with DS have an increased vulnerability to oxidative damage and many factors, including amyloid beta protein (Abeta), genotype ApoE4, oxidative stress, mutations in mitochondrial DNA (mtDNA), impairment of antioxidant enzymes, accelerated neuronal cell apoptosis, are related to neuronal degeneration and early aging in DS. SUBJECTS and METHODS: Since 2007 a population of 50 adolescents and adults with DS, 26 males and 24 females (sex-ratio: M/F = 1.08), has been evaluated for the presence of neurological features, biomarkers and genetic factors correlated with neuronal degeneration and premature aging. The control group was determined by the mother and the siblings of the patients. A neuropsychiatric evaluation was obtained from all patients. The levels of thyroid antibodies (antiTg and antiTPO) and of some biochemical markers of oxidative stress, including homocysteine (tHcy), uric acid, cobalamin, folate were measured. All patients, the mother and the siblings were genotyped for ApoE gene. RESULTS: 40% of patients, with a mild prevalence of females aged between 19 and 30 years, showed increased levels of antiTg and antiTPO. The levels of tHcy were normal in 52% patients and mildly increased in 40%; hyperomocysteinemia was associated with normal levels of thyroid antibodies in 75% of patients (p<0.005). The levels of uric acid were elevated in 26%. Our study showed a prevalence of severe MR in patients aged between 1-18 years and over 30 years. Only 3 patients, 2 females and one male, over 30 years of age, showed dementia. According to the literature, the rate of Down left-handers was high (25%) compared to the rest of population and the laterality was associated with increased levels of thyroid antibodies (70%). 21.5% of patients were ApoE4 positive (ApoE4+) with a mean/severe MR. CONCLUSIONS: Until now no biochemical evidence of oxidative damage and no deficiency or alteration of antioxidant function in our patients with DS were found. mtDNA sequencing could show some mutations age-related and associated with oxidative damage and neurocognitive decline in the early aging of DS. The final aim is found predictive markers of early-onset dementia and a target strategy for the prevention and the treatment of diseases caused by oxidative stress. REFERENCES: 1) Rachidi M, Lopes C: “Mental retardation and associated neurological dysfunctions in Down syndrome: a consequence of dysregulation in critical chromosome 21 genes and associated molecular pathways.” - Eur J Paediatr Neurol. May;12(3):168-82 (2008). 2) Lott IT, Head E: “Down syndrome and Alzheimer's disease: a link between development and aging.” - Ment Retard Dev Disabil Res Rev, 7(3):172-8 (2001). 3) Lee HC, Wei YH: “Oxidative Stress, Mitochondrial DNA Mutation, and Apoptosis in Aging.” - Exp Biol Med (Maywood), May;232(5):592-606 (2007).

Operative Therapie des gastrooesophagealen Refluxes im Kindesalter unter besonderer Berücksichtigung von Kindern mit Behinderung

Ein pathologischer Gastrooesophagealer Reflux (GÖR) tritt häufig bei Kindern mitBehinderung und nach einer Operation am Oesophagus auf wie zum Beispiel nach Korrektureiner Oesophagusatresie. Bei diesen Kindern ist eine medikamentöse Therapie überwiegendzum Scheitern verurteilt und eine Therapie wie die der Antirefluxoperation wird notwendig.In der vorliegenden Arbeit werden die 100 Kinder beschrieben, die mit derVerdachtsdiagnose GÖR in den Jahren 1983 bis 1998 vorgestellt wurden. 68 Kinderbenötigten eine Antirefluxoperation. Schwerpunktmäßig werden neurologisch behinderteKinder (85%), bei denen erwartungsgemäß häufig ein GÖR vorliegt, untersucht. Mitbesonderem Interesse werden dabei das Vorliegen und Zusammentreffen mehrerer GÖRprädisponierenderErkrankungen (Behinderung und Zustand nach Korrektur einerOesophagusatresie) untersucht, um Hinweise für eine mögliche Differenzierung prae- undpostoperativer Bilder des GÖR und seine Komplikationen zu gewinnen.Weiterhin werden Aussagen gewonnen bezüglich des Alters der Kinder zum Zeitpunkt desAuftretens der Symptome und zum Zeitpunkt der Operation. Diese werden ebenso wie dieZeiträume zwischen dem Auftreten der Symptome und der Diagnosenstellung, bzw. demOperationszeitpunkt mit den Aussagen in der Literatur verglichen.Ferner wird überprüft, ob sich für die einzelnen Personengruppen (Kinder mit cerebralen undmotorischen Retardierungen (85%), Kinder mit angeborener Oesophagusatresie (4%), Kindermit beiderlei GÖR-prädisponierender Erkrankungen (3%) und Kinder ohne prädisponierendeErkrankungen (8%)) differenzierte Aussagen finden.A pathological gastroesophageal reflux (GER) is often found in handicapped children andafter surgical treatment at the esophagus e. g. after correction of esophagusatresia. Here,medical treatment is often ineffective and an antireflux plasty is needed.In this study 100 children are examined, who had the suspected diagnosis of GER in the years1983 – 1998. 68 children needed a surgical treatment. The majority form the neurologicalhandicapped children (85%), who are predisposed to GER as expected.A special interest of the study is on the existence and coincidence of several GERpredisposingdiseases (disability and esophagusatresia), in order to get an indication forpossible differentiations of pre- and postoperative symptoms and complications of GER.Furthermore evidence is obtained on the age of the children, when the symptoms appearedfirst and when the operation took place. These data and the period of time between theappearence of symptoms and the time of diagnosis and operation are compared with theinformation given in the literature.Moreover the different evidences between the four groups (children with cerebral andmotorial retardation (85%), children with congenital esophagusatresia (4%), children withboth (3%) and children without GER-predisposing diseases (8%)) are analysed.

Computational investigations of ion conduction mechanisms using enhanced sampling methods

Proper ion channels’ functioning is a prerequisite for a normal cell and disorders involving ion channels, or channelopathies, underlie many human diseases. Long QT syndromes (LQTS) for example may arise from the malfunctioning of hERG channel, caused either by the binding of drugs or mutations in HERG gene. In the first part of this thesis I present a framework to investigate the mechanism of ion conduction through hERG channel. The free energy profile governing the elementary steps of ion translocation in the pore was computed by means of umbrella sampling simulations. Compared to previous studies, we detected a different dynamic behavior: according to our data hERG is more likely to mediate a conduction mechanism which has been referred to as “single-vacancy-like” by Roux and coworkers (2001), rather then a “knock-on” mechanism. The same protocol was applied to a model of hERG presenting the Gly628Ser mutation, found to be cause of congenital LQTS. The results provided interesting insights about the reason of the malfunctioning of the mutant channel. Since they have critical functions in viruses’ life cycle, viral ion channels, such as M2 proton channel, are considered attractive targets for antiviral therapy. A deep knowledge of the mechanisms that the virus employs to survive in the host cell is of primary importance in the identification of new antiviral strategies. In the second part of this thesis I shed light on the role that M2 plays in the control of electrical potential inside the virus, being the charge equilibration a condition required to allow proton influx. The ion conduction through M2 was simulated using metadynamics technique. Based on our results we suggest that a potential anion-mediated cation-proton exchange, as well as a direct anion-proton exchange could both contribute to explain the activity of the M2 channel.

Utilizzo dell'esame dermoscopico nella valutazione clinica e nel follow up dei nevi melanocitici in sede acrale dell'età pediatrica: studio retrospettivo osservazionale

La dermoscopia, metodica non invasiva, di pratico utilizzo e a basso costo si è affermata negli ultimi anni come valido strumento per la diagnosi e il follow up delle lesioni cutanee pigmentate e non pigmentate. La presente ricerca è stata incentrata sullo studio dermoscopico dei nevi melanocitici a localizzazione palmo-plantare, acquisiti e congeniti, in età pediatrica: a questo scopo sono state analizzate le immagini dei nevi melanocitici acrali nei pazienti visitati c/o l’ambulatorio di Dermatologia Pediatrica del Policlinico Sant’Orsola Malpighi dal 2004 al 2011 per definire i principali pattern dermoscopici rilevati ed i cambiamenti osservati durante il follow up videodermatoscopico. Nella nostra casistica di immagini dermoscopiche pediatriche abbiamo notato un cambiamento rilevante (inteso come ogni modificazione rilevata tra il pattern demoscopico osservato al baseline e i successivi follow up) nell’88,6% dei pazienti ed in particolare abbiamo osservato come in un’alta percentuale di pazienti (80%), si sia verificato un vero e proprio impallidimento del nevo melanocitico e in un paziente è stata evidenziata totale regressione dopo un periodo di tempo di 36 mesi. E’ stato interessante notare come l’impallidimento della lesione melanocitaria si sia verificata per lo più in sedi sottoposte ad una sollecitazione meccanica cronica, come la pianta del piede e le dita (di mani e piedi), facendoci ipotizzare un ruolo del traumatismo cronico nelle modificazioni che avvengono nelle neoformazioni melanocitarie dei bambini in questa sede.

Caratteristiche ortopediche-ortodontiche in pazienti affetti da Sindrome di Nooan

La sindrome di Noonan (SN) è una patologia a trasmissione autosomica dominante caratterizzata da bassa statura, difetti cardiaci congeniti, dismorfia facciale. In letteratura sono stati pubblicati pochi case reports riguardanti le condizioni orali-facciali in pazienti affetti da SN. Obiettivo. Individuare patologie di pertinenza ortopedico-ortodontica caratteristiche della sindrome utilizzando un campione di pazienti con diagnosi di SN. Metodi. Un gruppo di 10 pazienti affetti da SN è stato sottoposto a esame obiettivo extraorale ed intraorale, ortopantomografia, teleradiografia latero-laterale, impronte delle arcate dentarie. Le misurazioni sulle TLL sono state effettuate sulla base dell'analisi MBT; i valori palatali provengono dai modelli di studio dell’arcata superiore. È stata utilizzato il test t-Student per mettere a confronto il gruppo di studio e il gruppo di controllo riguardo le misure cefalometriche e i valori palatali. Risultati. Nel gruppo di studio sono state rilevate anomalie di numero (un dente deciduo soprannumerario e una agenesia di un dente permanente). Il test t-Student rivela differenze statisticamente significative per 7 variabili cefalometriche su 13 e per 2 variabili palatali. Conclusioni. Basandosi su questo studio è possibile concludere che i pazienti con SN mostrano II classe scheletrica di tipo mandibolare, crescita iperdivergente, tendenza al morso aperto scheletrico, palatoversione degli incisivi superiori, palato stretto. Questi risultati possono fornire informazioni utili sia per la diagnosi di SN sia per la pianificazione del corretto trattamento ortodontico.

Down Syndrome: Neuropsychological phenotype and mitochondrial DNA

Introduction. Down Syndrome (DS) is the most known autosomal trisomy, due to the presence in three copies of chromosome 21. Many studies were designed to identify phenotypic and clinical consequences related to the triple gene dosage. However, the general conclusion is a senescent phenotype; in particular, the most features of physiological aging, such as skin and hair changes, vision and hearing impairments, thyroid dysfunction, Alzheimer-like dementia, congenital heart defects, gastrointestinal malformations, immune system changes, appear in DS earlier than in normal age-matched subjects. The only established risk factor for the DS is advanced maternal age, responsible for changes in the meiosis of oocytes, in particular the meiotic nondisjunction of chromosome 21. In this process mitochondria play an important role since mitochondrial dysfunction, due to a variety of extrinsic and intrinsic influences, can profoundly influence the level of ATP generation in oocytes, required for a correct chromosomal segregation. Aim. The aim of this study is to investigate an integrated set of molecular genetic parameters (sequencing of complete mtDNA, heteroplasmy of the mtDNA control region, genotypes of APOE gene) in order to identify a possible association with the early neurocognitive decline observed in DS. Results. MtDNA point mutations do not accumulate with age in our study sample and do not correlate with early neurocognitive decline of DS subjects. It seems that D-loop heteroplasmy is largely not inherited and tends to accumulate somatically. Furthermore, in our study sample no association of cognitive impairment and ApoE genotype is found. Conclusions. Overall, our data cast some doubts on the involvement of these mutations in the decline of cognitive functions observed in DS.