Quality of life in dependent older adults living at home

The purpose of medical interventions today is to favor the duration of life and to assure its quality. For a proper evaluation of the quality of life (QoL) of the elderly, it is important to assess not only the health status, but also psychological, functional and existential domains. Up to now, QoL of the dependent older living at home does not seem to have received sufficient attention. This study is a population based, cross-sectional health survey, and tries to give a picture of the QoL conditions of a group of dependent elderly living at home, using a specifically designed structured interview. In addition to this interview the Activities of Daily Living (ADL) Index and the Zung rating scale for Anxiety and Depression (AD) were administered to a total of 167 elderly (60 males and 107 females). The most interesting results of the study are the following: (1) the definition of dependence is often worsen by cultural prejudices; (2) psychopathological factors show a deep negative effect on 'attitudes towards life' of the dependent elderly; (3) QoL of the dependent elderly people in this sample is mainly negatively influenced by the degree of depression. We believe that the 'QoL-oriented' therapeutic strategy should consider more articulated and multidisciplinary geriatric and psychosocial interventions in this population.     

Emergency pancreatoduodenectomy in nontrauma patients

INTRODUCTION: In recent years, the safety of pancreatoduodenectomy has improved, with a low mortality rate and reduced morbidity in institutions with extensive experience in the procedure. The indication for pancreatoduodenectomy has been expanded. Emergency pancreatoduodenectomy has mainly been performed for abdominal trauma. AIMS: To discuss possible indications for emergency pancreatoduodenectomy in nontrauma patients. METHODOLOGY: A series of 417 consecutive pancreatic head resections performed between November 1993 and August 2000 was reviewed for emergency interventions. Indications and outcome of emergency pancreatoduodenectomies were analyzed. RESULTS: The prevalence of emergency pancreatoduodenectomy was 1%. Two patients had duodenopancreatic complications after endoscopic and surgical interventions, and two patients had otherwise uncontrollable bleeding from a penetrating duodenal ulcer and an ampullary tumor. In all four patients, emergency pancreatoduodenectomy was carried out without local complications but with a high morbidity. One patient died after surgery. CONCLUSION: We conclude that emergency pancreatoduodenectomy may be considered, under exceptional circumstances, by surgeons experienced in pancreatic resections, but unfavorable perioperative conditions should be included in the preoperative planning and risk assessment of such patients.     

Insulin secretion and insulin sensitivity defects are a common feature of mild,clinically homogeneous,recently diagnosed type II (Non-insulin-dependent) diabetics

Summary Alteration in insulin secretion and reduced peripheral sensitivity to the hormone have been reported in type II diabetes. In this paper, a comparison is made of basal glucose production (³H-6 glucose), insulin secretion and insulin sensitivityin vivo (hyperglycemic clamp) andin vitro (binding to circulating monocytes) in 24 patients with recently diagnosed type II diabetes, matched for age and fasting glycemia and divided into non-obese (14 subjects) and moderately obese (10 subjects), and in 9 non-obese controls. The non-obese diabetics were slightly hyperinsulinemic during fasting (10.8±1.0vs 4.8±0.8 μU/ml in controls, p < 0.0005), with a significant reduction in early and late insulin secretion (14.0±1.5vs 20.8 ± 2.0 μU/ml, p<0.01 and 24.8±3.3vs 34.7±2.14 μU/ml, p<0.025). The insulin sensitivity index MCR/I was significantly reduced (2.30±0.32vs 4.14±0.40, p<0.005). Endogenous glucose production was significantly increased (107±10.2vs 84±3.7 mg/m² per min, p<0.025) and displayed a positive correlation with fasting glycemia (r=0.51, p<0.05). Insulin binding to monocytes was significantly lower than in controls (2.36±0.22%vs 4.06±0.32%, p<0.0005). Moderately obese diabetics also were significantly hyperinsulinemic in the fasting state (18.1±2.8 μU/ml, p<0.0005vs controls) but, typically, lacked the early secretory phase (20.6±3.6 μU/mlvs baseline, n.s.). A similar increase of hepatic glucose production (107±11.2 mg/m² per min, p<0.025vs controls, n.s.vs non-obese diabetics) and decrease of peripheral sensitivity to insulin (MCR/I=1.78±0.31, p<0.0005vs controls, n.s.vs non-obese diabetics) was found in moderately obsese diabetics, as well as a significant reduction of insulin binding to insolated monocytes (2.62±0.4% p<0.01vs controls, n.s.vs non-obese diabetics). These results confirm that common defects of both non-obese and moderately obese type II diabetics are: lack of early phase of glucose induced insulin secretion, increase in hepatic glucose production and decrease of peripheral insulin sensitivity together with reduction of insulin binding to circulating monocytes. The hypothesis of a unique defect as a cause of hyperglycemia in type II diabetes in early clinical phase is not borne out by the results of this study. Moderate obesity, even if able to reduce insulin sensitivity, seems to be less important in determining hyperglycemia. This study was supported by a grant fromConsiglio Nazionale delle Ricerche, P.F. Medicina Preventiva, SP4,Malattie Degenerative, N. 84.02449.56.     

Effect of c-kit ligand on in vitro human megakaryocytopoiesis.

An evaluation of the effects of a recombinant, soluble form of the c-kit ligand alone and in combination with either granulocyte-macrophage colony-stimulating factor (GM-CSF) or interleukin-3 (IL-3) on the regulation of human megakaryocytopoiesis was performed using a serum-depleted clonal assay system and a long-term bone marrow culture system. The effects of the c-kit ligand on the primitive megakaryocyte (MK) progenitor cell, the burst-forming unit-megakaryocyte (BFU-MK), and the more differentiated colony-forming unit-megakaryocyte (CFU-MK) were determined. The c-kit ligand alone had no megakaryocyte colony-stimulating activity (MK-CSA) but was capable of augmenting the MK-CSA of both GM-CSF and IL-3. The range of synergistic interactions of c-kit ligand varied with the class of MK progenitor cell assayed. In the case of the BFU-MK, the c-kit ligand synergistically augmented the numbers of colonies formed in the presence of IL-3, but not GM-CSF, but increased the size of BFU-MK-derived colonies cloned in the presence of both of these cytokines. However, at the level of the CFU-MK, c-kit ligand synergized with both GM-CSF and IL-3 by increasing both colony numbers and size. Although the c-kit ligand alone exhibited limited potential in sustaining long-term megakaryocytopoiesis in vitro, it synergistically augmented the ability of IL-3, but not GM-CSF, to promote long-term megakaryocytopoiesis. These data indicate that multiple cytokines are necessary to optimally stimulate the proliferation of both classes of MK progenitor cells and that the c-kit ligand plays a significant role in this process by amplifying the MK-CSA of both GM-CSF and IL-3.     

Heterogeneity in social and epidemiological factors determines the risk of measles outbreaks

Political and environmental factors—e.g., regional conflicts and global warming—increase large-scale migrations, posing extraordinary societal challenges to policymakers of destination countries. A common concern is that such a massive arrival of people—often from a country with a disrupted healthcare system—can increase the risk of vaccine-preventable disease outbreaks like measles. We analyze human flows of 3.5 million (M) Syrian refugees in Turkey inferred from massive mobile-phone data to verify this concern. We use multilayer modeling of interdependent social and epidemic dynamics to demonstrate that the risk of disease reemergence in Turkey, the main host country, can be dramatically reduced by 75 to 90% when the mixing of Turkish and Syrian populations is high. Our results suggest that maximizing the dispersal of refugees in the recipient population contributes to impede the spread of sustained measles epidemics, rather than favoring it. Targeted vaccination campaigns and policies enhancing social integration of refugees are the most effective strategies to reduce epidemic risks for all citizens.

Human migration represents a complex phenomenon influencing in several interconnected ways the economy, the healthcare, and the social cohesion of whole countries (1–7). However, it is only recently that the availability of massive datasets opened to new advancements in modeling and understanding such complexity (8–16), addressing the urgent need for effective, large-scale intervention policies toward managing the consequences of massive migration flows (5).Here, we focus our attention on Turkey, a country facing a humanitarian emergency of unprecedented levels (17). In the last decade, more than 3.5 million (M) Syrians, displaced by the war, have sought refuge in Turkey. The arrival of a huge amount of people with different economic, health, and living conditions, and from a country where the healthcare system has been almost completely disrupted, may raise serious concerns about the risks of the Turkish health system being overburdened.Turkish infectious-disease specialists are concerned that the crisis of Syrian refugees may impose serious risks to Turkey by bringing back infectious diseases previously eliminated or in the process of being eliminated (18, 19). According to the latest reports from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) (20), immunization coverage in Syria dropped from more than 80% before the war to a worrying 41% in 2015 for the most basic vaccines, resulting in millions of unvaccinated children. Direct consequences of this alarming situation are a high risk of epidemic outbreaks [e.g., evidence for polio (21) and measles (22–24) has been reported] and a potential increase of mortality due to diseases which could be prevented with vaccines (25). Countries, such as Turkey, Lebanon, and Jordan, hosting a great concentration of Syrians perceive the lack of an appropriate immunization coverage as a potential risk of epidemic outbreaks for the local population (18).The aim of this study is to investigate the risk of observing widespread measles epidemics in Turkey and how this risk is affected by the level of mixing between refugees and the local populations. After the influx of Syrian refugees, an increase of measles cases has been observed (24), and two measles outbreaks in 2013 and 2018 have been reported (24, 26, 27). In order to reduce the risk of vaccine-preventable diseases, the Ministry of Health of Turkey—in collaboration with UNICEF—conducted several vaccination campaigns between 2013 and 2014. Syrian children living in and out of temporary shelters have been vaccinated free of charge and are now included in the Turkish National Childhood Vaccination Program. Refugees have been receptive to vaccination, and recent estimates suggest that a 95% vaccine uptake was reached in the temporary shelters. However, in this country, more than 90% of the Syrian population lives in communities where immunity levels might be significantly lower, and seeking vaccination services remains a problem because of high mobility and lack of knowledge about refugee health centers (23).The contribution of our work is twofold. On the one hand, we quantify the epidemic risks associated with measles in Turkey and how appropriate policies devised to enhance social integration between refugees and local populations may significantly reduce the risk of observing widespread epidemics. On the other hand, we highlight crucial epidemiological and socio-demographic components shaping these risks, identifying high-risk areas in the country that should be prioritized by public health interventions aimed at reducing current immunity gaps.     

Patterns of intermediate filaments, VLA integrins and HLA antigens in a new human biliary epithelial cell line sensitive to interferon-γ

Background/Aims: Intra-hepatic bile ducts are the primary site of damage in several immunologically mediated liver diseaes. However, immunological processes underlying biliary epithelial cell recognition by T lymphocytes are poorly understood. Therefore, a convenient in vitro model that could mimic these immunologic disorders would be of great interest.Methods: A human cell line (HuGB) was established from a metastasis of gallbladder adenocarcinoma in the liver. Intermediate filament expression was analysed by immunostaining, and gamma-glutamyl transpeptidase and albumin secretion were measured. VLA integrin expression pattern, expression of HLA class I and II antigens and ICAM-1 protein were analysed by flow cytometry and their modulation by interferon-γ was quantitated using a QIFIKIT commercial kit.Results: Histological analysis showed high similarity between the initial gallbladder adenocarcinoma and the established cell line. Cytokeratins 8 and 19 and vimentin showed strong positive staining in the established cell line. Gamma-glutamyl transpeptidase was secreted by these cells while albumin expression was negative. HuGB cells also expressed VLA-α2, VLA-α3, VLA-α6, VLA-β1, but not VLA-α1, VLA-α4 and NCAM, a pattern of adhesion molecule expression compatible with the biliary epithelium. Also, similar to the biliary epithelium found in normal liver, HuGB cells expressed abundant HLA class I but few HLA class II antigens. We found that the expression of HLA antigens and ICAM-1 protein were increased during interferon-γ treatment of HuGB cell line.Conclusions: Both phenotypic and morphological characteristics of HuGB cells suggested their biliary origin. Sensitivity of HuGB cells to interferon-γ suggests that this new cell line could represent a suitable model to investigate the up-regulation of membrane antigens occurring in immune diseases involving biliary epithelial cells.