POS0464 IS IT POSSIBLE TO IDENTIFY INDIVIDUALS AT IMMINENT-RISK OF SUB-CLINICAL JOINT INVOLVEMENT?

Background:

In anti-CCP antibody (Ab) positive at-risk individuals with MSK symptoms but without clinical synovitis, the detection of ultrasound (US) subclinical inflammation is associated with an increased risk of progression to inflammatory arthritis (IA) 1. Studies suggest that in these at-risk individuals, MSK symptoms develop before subclinical joint inflammation occurs on US. As such, anti-CCP Ab positive individuals with MSK symptoms in the absence of clinical or sub-clinical inflammation may be at the critical time-point for preventive treatments, before joint inflammation occurs and eventually becomes established (i.e., before the ‘second-hit’ in RA pathogenesis); however, identifying these individuals is challenging.

Objectives:

To identify, in second generation anti-CCP Ab (CCP2+) at-risk individuals with MSK symptoms, but without clinical or sub-clinical synovitis, predictors of US sub-clinical synovitis.

Methods:

In 186 CCP2+ at-risk individuals with normal baseline US scan (i.e., no synovitis or bone erosions), and a complete dataset, US data were analyzed at 6, 12 months, then annually until occurrence of IA. US synovitis was identified according to the EULAR/OMERACT definitions2. Relevant demographic (age and gender), clinical [early morning stiffness (EMS), tenderness in the small joints of the hands] and serological [anti-CCP2 Ab level, third generation anti-CCP Ab (CCP3) and rheumatoid factor (RF)] data were collected at baseline. Regression analyses, Kaplan-Meier analysis and Log-Rank test were performed.

Results:

US synovitis was detected in ≥1 longitudinal US scan in 69/186 (37.1%) at-risk individuals (median time to first developing US synovitis: 53 weeks, IQR 27.0-105.8; median number of joints with US synovitis: 2.0, IQR 1.0-2.0). As shown in Table 1, only anti-CCP3 Ab were significantly associated with development of US sub-clinical synovitis in the multi-variable analysis while borderline results were observed with age.

Table 1.

Regression analyses for the development of US synovitis.

Univariable analysisMultivariableanalysisOR (95% CI)p-valueOR (95% CI)p-valueGender (male)1.02 (0.52-2.02)0.95//Age1.03 (1.01-1.06)<0.011.03 (1.00-1.06)0.03Tenderness in the hands0.86 (0.46-1.61)0.64//EMS1.60 (0.87-2.95)0.13//Anti-CCP2 Ab (high titre)2.79 (1.37-5.67)<0.011.20 (0.50-2.89)0.69Anti-CCP3+4.44 (2.28-8.66)<0.013.30 (1.39-7.89)<0.01RF+2.96 (0.46-1.61)0.011.45 (0.68-3.11)0.33

CCP2+ individuals with positive anti-CCP3 Ab show a significantly reduced sub-clinical synovitis-free survival rate compared with individuals with negative anti-CCP3 Ab (Figure 1). At 1- and 2-year follow-up, respectively 23.3% and 38.3% of individuals with dual CCP2/CCP3 positivity developed sub-clinical synovitis on longitudinal scans, compared with 8.4% and 13.3% of CCP2+ individuals with negative anti-CCP3 Ab (p=0.01) (Figure 1a).

Similar results were observed in the subgroup of high level CCP2+ individuals. At 1- and 2-year follow-up, respectively 24.5% and 39.4% of high level CPP2/anti-CCP3+, but only 6.1% and 15.2% of CCP2+ individuals with negative anti-CCP3 developed sub-clinical synovitis on longitudinal scans (p<0.01) (Figure 1b).

Figure 1.

Kaplan-Meier analysis shows US sub-clinical synovitis free survival time in CCP2+ at-risk individuals.

Conclusion:

In anti-CCP2+ at-risk individuals with MSK symptoms, anti-CCP3 antibodies improve prediction of imminent development of subclinical joint inflammation. This may represent the critical time-point for interventions to prevent the onset of joint disease. This is also a unique population for investigating the drivers of joint involvement in the development of RA.

References:

[1]Duquenne L, et al. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on “At-Risk” Individuals. 2020.

[2]D’Agostino MA, et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce — Part 1: definition and development of a standardised, consensus-based scoring system. 2017.

Disclosure of Interests:

Andrea Di Matteo Grant/research support from: This study was conducted while Andrea Di Matteo was an ARTICULUM Fellow., Kulveer Mankia Speakers bureau: KM reports personal fees from Abbvie, UCB and Eli Lilly (all <$10.000), outside the submitted work., Grant/research support from: Research grants from BMS, Eli Lilly (all <$10.000), Laurence Duquenne: None declared, Edoardo Cipolletta: None declared, Jacqueline Nam: None declared, Leticia Garcia-Montoya: None declared, Richard Wakefield Speakers bureau: RJW has received honoraria from Abbvie, Novartis and GE for ultrasound related educational activities (all <$10.000)., Michael Mahler Employee of: MM is employee of Inova Diagnostics, commercializing CCP3, Paul Emery Speakers bureau: PE reports consultant fees from BMS, AbbVie, Gilead, Galapagos, Lilly, MSD, Pfizer, Novartis, Roche, and Samsung outside the submitted work (all <$10.000)., Grant/research support from: He also reports research grants from UCB, AbbVie, Lilly, Novartis, BMS, Pfizer, MSD and Roche, outside the submitted work. PE is National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) director and BRC funds supported this work. Leticia Garcia-Montoya and Laurence Duquenne are NIHR BRC fellows.

POS0499 WORK ABSENCE DUE TO MUSCULOSKELETAL SYMPTOMS IN PATIENTS AT-RISK OF RHEUMATOID ARTHRITIS IS COMPARABLE TO THOSE WITH ESTABLISHED DISEASE

Background:

Rheumatoid arthritis (RA) is an established cause of disability and work absence; however, little is known about the impact of musculoskeletal (MSK) symptoms on sick leave in patients at-risk of developing the disease.

Objectives:

To describe the sick leave of individuals at-risk of RA, compared to patients who had recently been diagnosed with RA, over a 12-month period. Additionally, to investigate baseline predictors for sick leave within the first 12 months.

Methods:

A prospective observational cohort for individuals at-risk of RA was conducted. A total of 591 consecutive anti-citrullinated protein antibodie positive (ACPA+) individuals, with no clinical synovitis were recruited. A MSK ultrasound scan and a blood test were performed at baseline, and information about employment regime (retired, not in a paid job, part time and full time), days of sick leave and reasons for absences within the previous months were collected every 3 months and analysed at baseline, 6 months, 12 months and at the moment of diagnosis of an inflammatory arthritis (IA) (if the patient had progressed). Subjects who had retired (n=80) were excluded from the analysis.

A comparison was made with 114 RA patients from an observational study. Employment information was collected at pre-treatment, 6 months and 1 year after diagnosis.

Univariable and logistic regression analyses were performed to assess predictors of work absence due to MSK reasons in the next 12 months from baseline for at-risk individuals.

Results:

Even though the reasons for unemployment were not available, there were no statistically significant differences between employment rates across the timepoints of the study for the at-risk individuals’ group (p=0.778). A similar pattern was observed in the RA patient group; which also maintained the same employment rates throughout the study (p=0.311) and these were comparable to the at-risk individuals’ (p=0.480).

Over 35% of at-risk individuals in paid employment had work absences in the 3 months prior to the baseline visit. Of these 65.5% were due to MSK related issues, meaning 23.2% of the total absences were MSK related. The other reasons for work absence can be seen in table 1. This fell to 12.9% of the total absences at 6 months (which probably reflects clinical intervention) and increased to 38% if the patient progressed to an IA (graph 1).

Table 1.

REASONS FOR SICK LEAVE AT BASELINE IN INDIVIDUALS AT-RISK OF RA (%)

MSK related issues65.5Flu-like symptoms20.1Gastrointestinal issues19.4Stress/anxiety14.4Headaches11.5Infection3.6Fatigue1.4Other3.6

The percentage of individuals who took absence from work due to MSK related issues, was similar in both the at risk and RA group, including an initial reduction possibly due to drug intervention (graph 1). However, the median number of days off work 3 months prior baseline, 6 months and 1 year in RA patients tended to be higher than those in the at-risk group (10, 2 and 6 versus 5, 4 and 3 respectively).

Several factors were assessed to predict sick leave within 12 months in at-risk individuals: age, gender, smoking status, ACPA, rheumatoid factor (RF), anti-nuclear antibodies (ANA), C-reactive protein (CRP), early morning stiffness, shared epitope, joint pain, joint tenderness and abnormal findings in the ultrasound scan (erosions or power doppler); however, only RF [OR 0.18; p=0.018; 95% CI (0.04-0.84)] and CRP [OR 1.3; p=0.021; 95%CI (1.04-1.60)] were statistically significant in the multivariable analysis.

Conclusion:

Even though being at-risk of RA is not considered a potential cause of disability, results show that the burden on the workplace, due to MSK related absences, was comparable to subjects diagnosed with RA. Although further investigation is required, initial data suggests that clinical intervention may reduce this burden; which tends to be higher in at-risk individuals with a negative RF and a high CRP.

Graph 1.

Percentage of individuals who had work absences related to MSK issues 3 months prior to each timepoint.

Acknowledgements:

H. Singh

T. Hulland

G. John

- Leeds Cares -

Disclosure of Interests:

None declared

POS0565 IS ACTIVE SYNOVITIS OF METACARPOPHALANGEAL JOINTS A NEUROPATHIC CONDITION IN RHEUMATOID ARTHRITIS PATIENTS? RESULTS FROM A ULTRASOUND STUDY AT LEVEL OF THE PALMAR DIGITAL NERVES

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory arthritis that primarily affects the joints of hands, wrists, and feet. Anatomical damage (at bone, cartilage and tendon level) occurs as a consequence of a persistent synovial inflammation (1). In RA, periarticular soft tissues, including nerves, may also be involved. In particular, there is a high prevalence of neuropathic conditions such as carpal tunnel syndrome (CTS) in RA patients. In fact, the presence of inflammatory changes can frequently be documented by ultrasound (US) at the level of median nerve (2). Currently available very-high frequency US transducers allow high spatial resolution of small anatomical structures, including the palmar digital nerves.

Objectives:

The objectives of this study were: to document the presence of dimensional alterations of the palmar digital nerves, particularly in terms of increased cross-sectional area (CSA), and to determine the variables associated with increased CSA, in RA patients.

Methods:

From September 2020 to December 2020, adult RA patients from a tertiary outpatient clinic were consecutively included regardless of disease activity status. Patients underwent a clinical assessment to determine disease activity using the Clinical Disease Activity Index (CDAI), functional capacity using the QuickDASH, and the presence of neuropathic pain features using the PainDetect Questionnaire (PDQ). In the same visit, patients underwent a US examination of the 2nd to 5th metacarpophalangeal joints (MCPj) of the clinically more involved hand by an operator blinded to the clinical assessment. The presence/absence and US grading of synovitis was recorded for each joint. A third operator, blinded to the clinical and joint US assessment, measured the CSA of each pair of palmar digital nerves from 2nd to 5th finger scanned for assessment joint involvement. The CSA of the palmar digital nerves was measured at the MCPj. The US examinations were conducted with a MyLab Class C (Esaote, Genoa, Italy), with a 6-18 MHz probe for the articular examination, and with an 10-22 MHz probe for the examination of the palmar digital nerves. The serological status, respectively rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA), and the presence of radiographic erosive disease were also recorded for each patient. Statistical analysis was conducted by considering the sum of the CSA for each nerve pair of each finger. CSA was compared with respect to body mass index (BMI), disease duration, disease activity, US synovitis grading, functional capacity, neuropathic pain features, serological characteristics, and erosive status.

Results:

Sixty-three patients with RA were included, 48 women, 15 men, with a mean age of 62.2 (11.8, standard deviation [SD]) years, a mean disease duration of 10.9 (8.2) years, for a total of 252 MCPj and 504 palmar digital nerves. The CSA of the palmar digital nerves taken individually was 2.3 (0.9) mm2, ranging from 1 mm2 to 8 mm2, and 4.2 (1.5) mm2 as a pair for finger. There was a statistically significant association with disease activity as assessed by the CDAI (p <0.001), and with the grading of US synovitis (p <0.001), while there were no significant associations with any of the other variables.

Conclusion:

The presence of active RA, both in terms of clinical and ultrasonographic indices, correlates with an increased CSA of the palmar digital nerves. This alteration is probably due to inflammatory mechanisms of the perineural tissues at the level of the MCPj. Active synovitis during RA can somehow be framed as a condition capable of causing neuropathic damage to the palmar digital nerves.

References:

[1]Filippucci E, Cipolletta E, Mashadi Mirza R, et al. Ultrasound imaging in rheumatoid arthritis. Radiol Med 2019;124(11):1087-1100.

[2]Smerilli G, Di Matteo A, Cipolletta E, et al. Ultrasound assessment of carpal tunnel in rheumatoid arthritis and idiopathic carpal tunnel syndrome. Clin Rheumatol 2020; doi: 10.1007/s10067-020-05293-z.

Disclosure of Interests:

None declared

Measurement of the Fluctuations in the Number of Muons in Extensive Air Showers with the Pierre Auger Observatory

We present the first measurement of the fluctuations in the number of muons in extensive air showers produced by ultrahigh energy cosmic rays. We find that the measured fluctuations are in good agreement with predictions from air shower simulations. This observation provides new insights into the origin of the previously reported deficit of muons in air shower simulations and constrains models of hadronic interactions at ultrahigh energies. Our measurement is compatible with the muon deficit originating from small deviations in the predictions from hadronic interaction models of particle production that accumulate as the showers develop.

The folding and aggregation properties of a single KH-domain protein: Ribosome binding factor A (RbfA) from Pseudomonas aeruginosa

BACKGROUND

Ribosome-binding factor A from the pathogenic bacterium Pseudomonas aeruginosa (PaRbfA) is a small ribosome assembly factor, composed by a single KH domain, involved in the maturation of the 30S subunit. These domains are characterized by the ability to bind RNA or ssDNA and are often located in proteins involved in a variety of cellular functions. However, although the ability of proteins to fold properly, to misfold or to aggregate is of paramount importance for their cellular functions, limited information is available on these dynamic properties in the case of KH domains.

METHODS

PaRbfA thermodynamic stability and folding mechanism: Far-UV CD and fluorescence spectroscopy, stopped-flow kinetics and chevron plot analysis, site-directed mutagenesis. Fibrils characterization: FT-IR spectroscopy, Thioflavin T fluorescence, Transmission Electron Microscopy (TEM) and X-ray fibrils diffraction.

RESULTS

Quantitative analysis of the (un)folding kinetics of PaRbfA show that, in vitro, the protein folds via a 3-states mechanism involving a transiently populated folding intermediate. We also provide experimental evidences that PaRbfA can form ordered fibrils endowed with cross-β structure even in mild conditions.

CONCLUSION

These results lead to the hypothesis that the folding intermediate of PaRbfA may expose (some of) the predicted amyloidogenic regions, which could act as aggregation nuclei in the fibrillogenesis.

GENERAL SIGNIFICANCE

The methodological approach presented herein could be readily adapted to verify the ability of other KH domain proteins to form cross-β structured fibrils and to transiently populate a folding intermediate.

Features of the Energy Spectrum of Cosmic Rays above 2.5×10^{18} eV Using the Pierre Auger Observatory

We report a measurement of the energy spectrum of cosmic rays above 2.5×10^{18}  eV based on 215 030 events. New results are presented: at about 1.3×10^{19}  eV, the spectral index changes from 2.51±0.03(stat)±0.05(syst) to 3.05±0.05(stat)±0.10(syst), evolving to 5.1±0.3(stat)±0.1(syst) beyond 5×10^{19}  eV, while no significant dependence of spectral features on the declination is seen in the accessible range. These features of the spectrum can be reproduced in models with energy-dependent mass composition. The energy density in cosmic rays above 5×10^{18}  eV is [5.66±0.03(stat)±1.40(syst)]×10^{53}  erg Mpc^{-3}.

OP0112 IN INDIVIDUALS AT RISK OF INFLAMMATORY ARTHRITIS, PATIENT REPORTED OUTCOMES DETERIORATE IN THE 12 WEEKS BEFORE PROGRESSION TO CLINICAL DISEASE

Background:

Subjects with clinically significant arthralgia who will eventually develop inflammatory arthritis (IA) had a higher HAQ at baseline (1). Here we investigated the change in patients reported outcomes (PRO) over time in ACPA+ at risk of IA subjects.

Objectives:

In ACPA+ subjects at risk of developing IA, to analyse the change in PRO results in order to identify an imminent phase of progression.

Methods:

In a single centre prospective observational cohort, PRO from 109 ACPA+ subjects without clinical arthritis were collected prospectively at 0, 12, 26, 39 weeks; the last time-point was 52 weeks for the individuals who did not progress to IA (non-progressors) or the last visit preceding progression (within 12 weeks) for those who developed IA (progressors). Data on the following PRO were collected: HAQ, “general health” (GH-VAS), “fatigue” (fatigue-VAS), and “global pain” (GP-VAS) using visual analogic scale measures graded 0 to 100. We firstly used mixed models repeated measures ANOVA analysis then included covariates such as gender, shared epitope (SE) (HLA DRB1*01, *04 and/or *10), anti-CCP2 antibody (CCP2) and/or rheumatoid factor (RF) high titre (≥3ULN), and smoking exposure (Ever/Never).

Results:

All analysis met sphericity assumption. In this selection, 20% of subjects (24/109) developed IA within a median of 77 weeks (Range 37-369.43), non-progressors were followed for a median of 216 weeks (Range 50-590), 74 subjects were SE positive (68%), 81 had a CCP2 and/or RF high titre (74%), and 66 were previous or current smokers (61%).

Analysis revealed significant differences between both groups for the last visit, and within the progressor group for the last visit compared to all previous visits regarding the GH-VAS, GP-VAS and HAQ (Table 1, figure 1). Between subject analysis showed a significant influence of GH-VAS and GP-VAS change on progression. Covariate analysis showed a significant influence of previous smoking history on HAQ results (p=0.033, F=2.645 (4,408), Eta = 0.025).

Table 1.

Mixed Models repeated measures

General HealthGlobal PainHAQFatigueWithin subject effects;VAS change over time depending on group.P= 0.004F(4, 428) = 3.883Partial Eta Square= 0.35P < 0.001F(4, 400) = 5.754Partial Eta Squared = 0.054P = 0.115P = 0.459Pairwise comparison within groupNon-progressors:all p > 0.05Non-progressors:all p > 0.05Non-progressors:all p > 0.05Non-progressors:all p > 0.05Progressors:Time-point 1 to 5:p = 0.010SE = 4.199Time-point 2 to 5:p = 0.001SE = 4.709Time-point 3 to 5:P = 0.001SE = 3.842Time-point 4 to 5:P = 0.043SE = 4.239Progressors:Time-point 1 to 5:p < 0.001SE = 6.172Time-point 2 to 5:p < 0.001SE = 5.518Time-point 3 to 5:P = 0.002SE = 5.246Time-point 4 to 5:P = 0.001SE = 5.333Progressors:Time-point 1 to 5:p = 0.215Time-point 2 to 5:P = 0.036SE = 0.068Time-point 3 to 5:P = 0.040SE = 0.062Time-point 4 to 5:P = 0.017SE = 0.066Progressors:Time-point 1 to 5:p = 0.448Time-point 2 to 5:P =0.292Time-point 3 to 5:P = 0.047SE = 5.421Time-point 4 to 5:P = 0.202Pairwise comparison between groupLast visit:P = 0.009SE = 5.454All other visits:P > 0.05Last visit:P = 0.003SE = 7.082All other visits:P > 0.05Last visit:P = 0.016SE = 0.119All other visits:P > 0.05P-value > 0.05Mauchly’s test of sphericityP = 0.099P = 0.050P = 0.057P = 0.722N (Progressors/total)24/10915/10224/10719/102Figure 1.

Repeated measure ANOVA between groups

Conclusion:

These results show for the first time a significant deterioration in the PRO of general health, global pain, and HAQ weeks just preceding clinical arthritis development. This phase prior progression needs to be thoroughly studied to improve the accuracy of predicting imminent progression.

References:

[1]Ten Brinck RM et al. Functional limitations in the phase of clinically suspect arthralgia are as serious as in early clinical arthritis; a longitudinal study. RMD open. 2017;3(1):e000419.

Disclosure of Interests:

Laurence Duquenne: None declared, Kulveer Mankia: None declared, Leticia Garcia-Montoya: None declared, Jacqueline Nam: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)

Empowering crop resilience to environmental multiple stress through the modulation of key response components

Crop plants have developed a multitude of defense and adaptation responses to protect themselves against invading pathogens and challenging environmental stresses, mostly operating jointly. The plant perception of overall stress induces a coordinated response mediated by complex signaling networks. Experimental evidences proved that plant response to combined biotic and abiotic stresses substantially diverge from the responses to individual stresses. Moreover, the cross-talk of signaling pathways involved in responding to biotic and abiotic stresses is pivoted on several converging elements able to simultaneously modulate the timing and amplitude of the overall plant response. Comprehensively, the interaction between biotic and abiotic stresses can dramatically changes the plant response to the individual stress and the phenotypical outcome of each stress factor. System biology and data mining can synergistically help biologists in finding out regulative mechanisms and key genes controlling the response to biotic and abiotic stresses. Deploying new genetic engineering solutions can rely on the modification of genes involved in resistance/tolerance processes and/or in the modulation of regulatory elements. Finally, a model of the engineered crop for enhanced tolerance to pressures resulting from invasive pathogens and abiotic constraints in semiarid and warm environment is discussed.

Deep-sequencing of Solanum commersonii small RNA libraries reveals riboregulators involved in cold stress response

Among wild species used in potato breeding, Solanum commersonii displays the highest tolerance to low temperatures under both acclimated (ACC) and non-acclimated (NACC) conditions. It is also the first wild potato relative with a known whole genome sequence. Recent studies have shown that abiotic stresses induce changes in the expression of many small non-coding RNA (sncRNA). We determined the small non-coding RNA (sncRNAome) of two clones of S. commersonii contrasting in their cold response phenotypes via smRNAseq. Differential analysis provided evidence that expression of several miRNAs changed in response to cold stress conditions. Conserved miR408a and miR408b changed their expression under NACC conditions, whereas miR156 and miR169 were differentially expressed only under ACC conditions. We also report changes in tasiRNA and secondary siRNA expression under both stress conditions. Our results reveal possible roles of sncRNA in the regulatory networks associated with tolerance to low temperatures and provide useful information for a more strategic use of genomic resources in potato breeding.

P5416A single-center, thirty-year experience of heart transplantation: analysis of the evolution of patients profile and long term outcomes

Background

Heart Transplantation is still the gold standard therapy for patients suffering from end-stage cardiomyopathy and has been successfully performed in our center since 1985. Over this 30 years period there has been a significant evolution in patients characteristics and in candidate selection (either as a donor and as recipient) as shown by the recent benchmark from International Society of Heart and Lung Transplantation (ISHLT). Here we analyze the evolution of patients profile in our population and we correlated such evolution to the clinical outcomes and to the overall data from ISHLT.

Materials and methods

Overall 1122 patients underwent heart transplantation at our center from November 19th1985 to date. To analyze the evolution patients profile and donor criteria, patient population was divided in 4 groups according era of transplantation following ISHLT model (Group A from 1985 to 1991; Group B from 1992 to 2003; Group C from 2004 to 2008 and Group D from 2009 to date). Patients characteristics at time of transplantation, donor criteria ad clinical outcomes were analyzed and compared within 4 groups. An overall comparison of our results to the data from ISHLT was also performed.

Results

Overall Kaplan-Meier survival curve correlates favourably with ISHLT data showing a 20 years survival approaching 40%. Patients age at transplantation changed significantly among 4 groups from a median of 49 years (95% CI 47 to 51) in Group A to 54 years (95% CI 50 to 57) in Group D (p<0.001). Likewise donor age also changed significantly from a median of 24 years (95% CI 22 to 28) in Group A to 43 years (95% CI 39 to 47) in group D (p<0.001). Time on waiting list also changed significantly from a median of 115 days (95% CI 94 to 137) in Group A to 293 (95% CI 200 to 401) in Group D (p<0.001). As a marker of evolution of accepted donor criteria also ischemic time changed from 125±52 minutes of Group A to 153±61 minutes of Group D (p<0.001). As showed in Fig 1, Kaplan-Meier survival curves demonstrated a worse 1-year survival in Group D compared to others 3 Group.

Figure 1

Conclusions

The significant changing characteristics of both recipients and donors, over 30 years of activity, had a significant impact in early (1 year) postoperative survival following heart transplantation. Although medium/long term outcomes are still satisfactory in patients surviving at least 1 year, these data clearly suggest a more accurate patients selection and the need of alternative treatment before patients conditions deteriorate while on waiting list for heart transplantation

Ultrasound in the assessment of musculoskeletal involvement in systemic lupus erythematosus: state of the art and perspectives

Musculoskeletal manifestations are extremely common in patients with systemic lupus erythematosus. Transient and migratory arthralgia is frequently reported even without clinical signs of joint or tendon inflammation. In less than 15% of patients, joints may be more severely affected by deforming (Jaccoud's arthropathy) and/or erosive arthropathy (Rhupus syndrome). In recent years, ultrasound has emerged as a promising imaging technique for the assessment of musculoskeletal involvement in systemic lupus erythematosus, having demonstrated the ability to detect inflammation and structural damage both at articular and periarticular level. Recent ultrasound studies have also revealed new insights into musculoskeletal involvement in patients with systemic lupus erythematosus, some of them questioning the traditional concepts of systemic lupus erythematosus arthropathy, with potential clinical, prognostic and therapeutic implications. In daily clinical practice, the use of ultrasound in the assessment of joint and tendon involvement in patients with systemic lupus erythematosus is still limited. Several methodological issues encountered in ultrasound studies evaluating musculoskeletal involvement in systemic lupus erythematosus patients need to be addressed in order to improve both the reliability and clinical usefulness of ultrasound findings. This paper reviews ultrasound studies assessing musculoskeletal involvement in patients with systemic lupus erythematosus, highlighting certainty, limits, potential applications and future perspectives of ultrasound use in systemic lupus erythematosus patients.

Systemic lupus erythematosus arthropathy: the sonographic perspective

Background Despite being promising, the use of ultrasound (US) in the assessment of musculoskeletal manifestations of systemic lupus erythematosus (SLE) is still limited. Literature on this topic is scarce and the spectrum and clinical relevance of US abnormalities has not yet been outlined. With this paper, we aim to explore the panel of joint and tendon US findings in a group of SLE patients. Methods Twenty-five consecutive SLE patients, with current or medical history of musculoskeletal symptoms, were studied. All patients underwent routine clinical examination and US evaluation. The US examination targeted sites clinically involved in the physical examination and/or indicated as painful in the patient's medical history. Results One or more US changes were found in all the patients. US abnormalities were detected in 85 out of the 243 scanned joints (35%), in 70 out of the 215 scanned tendons (32.6%) and in 10 out of the 41 scanned entheses (24.4%). Synovial effusion, synovial hypertrophy, "mixed" synovitis (coexistence of synovial effusion and synovial hypertrophy), joint dislocation, bone erosion, and cartilage damage were found in 9.5%, 11.5%, 14%, 3.7%, 2.1%, and 4.5% of the scanned joints, respectively. Tenosynovitis, tendon dislocation, tendon tear, tendon thinning, and tendinitis/peritendinitis were detected in 17.7%, 8.4%, 0.9%, 4.2%, and 4.7% of the scanned tendons, respectively. Power Doppler signal, hypoechogenicity, thickening, enthesophytes, calcifications, and bone erosions were detected at the entheseal level in 12.2%, 9.8%, 12.2%, 7.3%, 7.3%, and in 0% of the scanned entheses, respectively. Conclusions This study revealed an unexpectedly wide heterogeneity of US pathologic findings in the joints and tendons of patients with SLE. A broad spectrum of US changes also involving anatomic structures not considered in previous investigations, including entheses and tendons with no synovial sheath, was detected. These preliminary results suggest that US is able to identify several US "patterns" whose clinical, prognostic, and pathogenetic significance is still to be defined.

N6L pseudopeptide interferes with nucleophosmin protein-protein interactions and sensitizes leukemic cells to chemotherapy

NPM1 is a multifunctional nucleolar protein implicated in several processes such as ribosome maturation and export, DNA damage response and apoptotic response to stress stimuli. The NPM1 gene is involved in human tumorigenesis and is found mutated in one third of acute myeloid leukemia patients, leading to the aberrant cytoplasmic localization of NPM1. Recent studies indicated that the N6L multivalent pseudopeptide, a synthetic ligand of cell-surface nucleolin, is also able to bind NPM1 with high affinity. N6L inhibits cell growth with different mechanisms and represents a good candidate as a novel anticancer drug for a number of malignancies of different histological origin. In this study we investigated whether N6L treatment could drive antitumor effect in acute myeloid leukemia cell lines. We found that N6L binds NPM1 at the N-terminal domain, co-localizes with cytoplasmic, mutated NPM1, and interferes with its protein-protein associations. N6L toxicity appears to be p53 dependent but interestingly, the leukemic cell line harbouring the mutated form of NPM1 is more resistant to treatment, suggesting that NPM1 cytoplasmic delocalization confers protection from p53 activation. Moreover, we show that N6L sensitizes AML cells to doxorubicin and cytarabine treatment. These studies suggest that N6L may be a promising option in combination therapies for acute myeloid leukemia treatment.

Structural investigation of nucleophosmin interaction with the tumor suppressor Fbw7γ

Nucleophosmin (NPM1) is a multifunctional nucleolar protein implicated in ribogenesis, centrosome duplication, cell cycle control, regulation of DNA repair and apoptotic response to stress stimuli. The majority of these functions are played through the interactions with a variety of protein partners. NPM1 is frequently overexpressed in solid tumors of different histological origin. Furthermore NPM1 is the most frequently mutated protein in acute myeloid leukemia (AML) patients. Mutations map to the C-terminal domain and lead to the aberrant and stable localization of the protein in the cytoplasm of leukemic blasts. Among NPM1 protein partners, a pivotal role is played by the tumor suppressor Fbw7γ, an E3-ubiquitin ligase that degrades oncoproteins like c-MYC, cyclin E, Notch and c-jun. In AML with NPM1 mutations, Fbw7γ is degraded following its abnormal cytosolic delocalization by mutated NPM1. This mechanism also applies to other tumor suppressors and it has been suggested that it may play a key role in leukemogenesis. Here we analyse the interaction between NPM1 and Fbw7γ, by identifying the protein surfaces implicated in recognition and key aminoacids involved. Based on the results of computational methods, we propose a structural model for the interaction, which is substantiated by experimental findings on several site-directed mutants. We also extend the analysis to two other NPM1 partners (HIV Tat and CENP-W) and conclude that NPM1 uses the same molecular surface as a platform for recognizing different protein partners. We suggest that this region of NPM1 may be targeted for cancer treatment.

Testing Hadronic Interactions at Ultrahigh Energies with Air Showers Measured by the Pierre Auger Observatory

Ultrahigh energy cosmic ray air showers probe particle physics at energies beyond the reach of accelerators. Here we introduce a new method to test hadronic interaction models without relying on the absolute energy calibration, and apply it to events with primary energy 6-16 EeV (E_{CM}=110-170  TeV), whose longitudinal development and lateral distribution were simultaneously measured by the Pierre Auger Observatory. The average hadronic shower is 1.33±0.16 (1.61±0.21) times larger than predicted using the leading LHC-tuned models EPOS-LHC (QGSJetII-04), with a corresponding excess of muons.

Entheseal involvement in systemic lupus erythematosus: are we missing something?

Background Musculoskeletal involvement is extremely common in patients with systemic lupus erythematosus (SLE). Continuing the research initiated in patients with inflammatory arthritis, recent studies have shown the potential role of musculoskeletal ultrasound (MSUS) in the evaluation of clinical and subclinical lupus synovitis. The inflammatory process in SLE is traditionally considered to be localized at synovial tissue areas while enthesis is not included among the possible targets of the disease. Patients and methods Entheses included in the Glasgow Ultrasound Enthesitis Scoring System were scanned in a cohort of 20 SLE patients serving as disease controls in an MSUS study aimed at assessing enthesitis in patients with psoriatic arthritis. We describe in detail four cases with unexpected and unequivocal expressions of MSUS enthesitis according to the OMERACT definition. Three out of four patients had no predisposing factors for enthesopathy. Case no. 2 was treated with a variable-dose prednisone regimen. Results In the four cases MSUS examination revealed relevant grey-scale and power Doppler abnormalities at the entheseal level, most commonly at the distal insertion of the patellar tendon. Signs of clinical enthesitis were detected in only one patient. Conclusions This case series shows for the first time the presence of clearly evident MSUS findings indicative of enthesitis in four out of 20 SLE patients (20%), raising the hypothesis that enthesis could be a missing target in the clinical evaluation of SLE patients. Our case series justifies further investigations for a better evaluation of the prevalence, characteristics and clinical relevance of entheseal involvement in SLE.

Measurement of the Radiation Energy in the Radio Signal of Extensive Air Showers as a Universal Estimator of Cosmic-Ray Energy

We measure the energy emitted by extensive air showers in the form of radio emission in the frequency range from 30 to 80 MHz. Exploiting the accurate energy scale of the Pierre Auger Observatory, we obtain a radiation energy of 15.8±0.7(stat)±6.7(syst)  MeV for cosmic rays with an energy of 1 EeV arriving perpendicularly to a geomagnetic field of 0.24 G, scaling quadratically with the cosmic-ray energy. A comparison with predictions from state-of-the-art first-principles calculations shows agreement with our measurement. The radiation energy provides direct access to the calorimetric energy in the electromagnetic cascade of extensive air showers. Comparison with our result thus allows the direct calibration of any cosmic-ray radio detector against the well-established energy scale of the Pierre Auger Observatory.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Prevention of acute renal failure post-contrast imaging in cardiology: a randomized study

BACKGROUND

The contrast-induced nephropathy (CIN) is the third most common cause of acute renal failure (ARF) and the worsening in a pre-existing chronic renal failure (CRF), with a foreseeable increase of morbidity, mortality, length of the stay in hospital and, as a consequence, of the health costs. We studied the effectiveness of N-acetylcysteine (NAC) associated with sodium bicarbonate (Na2HCO3) infusion in order to prevent CIN in patients undergoing coronary angiography with administration of contrast medium.

MATERIALS AND METHODS

296 patients with indication to perform coronary angiography were included in a randomized, observational study. All patients were randomly assigned to receive pre- and post-contrast hydration with 1500 ml of 0.9% saline solution infusion (Group A) or NAC (1200 mg × 2 days) + Na2HCO3 (Group B). The primary end-point was to examine CIN appearance, defined as a raise in serum values of Cr (Creatinine) ≥ 0.5 mg/dl or ≥ 25% within 24-72 hours after the exposure to the contrast medium.

RESULTS

It has been observed a frequency of CIN of 9.4% in Gr. A compared to 7.2% in Gr. B. Nevertheless, when we put these results through a more accurate screening according to gender, degree of raise in creatinine levels and the extent of change in GFR (glomerular filtration rate), we observed a very different behaviour. In patients with normal Cr and CrCl (Clearance of Creatinine) the frequency of CIN was similar in both group A and B (approximately 5%). In patients with normal Cr but reduced ClCr the use of NAC was more effective than hydration in preventing CIN (0% vs 18% in prevalence respectively in B and A group). In patients with moderately reduced Cr and CrCl, hydration with saline solution was more effective than NAC + Na2HCO3 (8.6% vs 17.6%) while in patients with severe CRF the combined use of NAC + Na2HCO3 showed off to be very successful in preventing CIN compared to the merely hydration (0% vs 50%).

CONCLUSIONS

In patients affected by severe CRF who are undergoing investigations with contrast medium administration, such as coronary angiography, the combined use of NAC + Na2HCO3 infusion significantly reduces the risk of developing CIN. In other circumstances the final result is related to the degree of previous GFR or creatinine values alteration or to gender. In such situations the combined use of both substances is more questionable and sometimes ineffective.

Stimulating visual exploration of the neglected space in the early stage of stroke by hemifield eye-patching: a randomized controlled trial in patients with right brain damage

BACKGROUND

It has been well established that the presence of neglect is a predictor of poor functional outcome after stroke. Most rehabilitation studies on neglect have been performed with at least two months post-stroke. However, a recent series of stroke management indications highlight the importance of early rehabilitation treatment and evidence regarding neglect rehabilitation in the early phase after stroke is needed.

AIM

To evaluate the effectiveness of right half-field patches in treating neglect in patients during the early phase of stroke.

DESIGN

Randomized controlled trial.

SETTING

Acute care setting in an urban general hospital.

POPULATION

Eighteen patients with left unilateral neglect recruited among 56 patients consecutively admitted with right hemispheric stroke.

METHODS

The patients were evaluated at pre-treatment, post-treatment, and at a 7-day follow-up. The experimental group received right half-field patch treatment (n=10) for approximately 8 hours a day for 15 consecutive days. The control group received visual scanning training (n=8) for 40 minutes every weekday in a 15 day period.

RESULTS

Both groups significantly improved their performance in all outcome measures. No difference in the amount of improvement between the two groups was found.

CONCLUSION

Right half-field eye patching could be a promising technique for treating visual spatial neglect during the early stages of stroke.

CLINICAL REHABILITATION IMPACT

The eye-patching technique may represent an easily applicable and inexpensive method for neglect rehabilitation in the early stage after stroke.

Efficacy of calcium channel blockers in the treatment of the myocardial bridging: a pilot study

BACKGROUND

Myocardial Bridging (MB) is defined as a segment of a major epicardial coronary artery, the "tunnelled artery", that goes intramurally through the myocardium beneath the muscle bridge.

MATERIALS AND METHODS

A 69-year-old male patient with a story of arterial hypertension and dyslipidemia in treatment with converting enzyme inhibitors (ACE-I), antiplatelet therapy and HMG-CoA reductase inhibitors and calcium channel blockers, presented with anginal-like chest pain and dyspnea. The coronary angiography showed a myocardial bridging and no hemodynamically significant coronary artery disease.

RESULTS

On admission in our Department, the exercise cyclo ergometer test was significant for > 3 mm ST segment depression in the anterior and lateral leads (V3, V4, V5, V6) associated with chest pain. The coronary angiography revealed a 40% stenosis of the distal tract of the right coronary artery (RCA), a 30% stenosis of the proximal tract of the left anterior descending artery (LAD) and 40% of the proximal tract of the first diagonal branch. A 30% stenosis in the middle tract of the left circumflex coronary artery (LCX) was then detected. A marked systolic localized narrowing (90%) on the middle tract of the LAD, after the second diagonal branch (a myocardial bridge) was also detected. After eight months, the exercise cyclo ergometer test using a standard Bruce protocol was normal and, after sixteen months, no significant coronary artery disease (< 50%) and no myocardial bridging were detected by the coronary 64-multislice spiral computed tomography. Two years later, the patient was readmitted to our Department because of angina-like chest pain during light exertion in the last two months. The coronary angiography of the right system revealed a 30% stenosis of the proximal tract and a 50% stenosis of the distal tract of the RCA. The coronary angiography of the left system showed a 30% stenosis of the proximal tract of the LAD and 85% of the middle tract of the first diagonal branch. A 40% stenosis in the middle tract of the left circumflex coronary artery (LCX) was then detected. No MB of the middle tract of the LAD was detected, and a bare metal stent (Presillion 2.5 x 12 mm) was deployed in the middle tract of the first diagonal branch.

CONCLUSIONS

After 2 years, the administration of the calcium channel blockers has been effective in the treatment of the MB but no effect on the atherosclerotic plaque growth has been demonstrated.

Catheter ablation of atrial tachycardia after interatrial defect repair with patch apposition

A 54-year-old woman with history of septal atrial mixoma surgically treated and drug-refractory supraventricular tachyarrhythmia underwent catheter ablation of macro-reentry areas near the pericardial patch placed to repair an interatrial defect. The use of ablative therapy has been successful to cure this arrhythmia.

High-throughput genomics enhances tomato breeding efficiency

Tomato (Solanum lycopersicum) is considered a model plant species for a group of economically important crops, such as potato, pepper, eggplant, since it exhibits a reduced genomic size (950 Mb), a short generation time, and routine transformation technologies. Moreover, it shares with the other Solanaceous plants the same haploid chromosome number and a high level of conserved genomic organization. Finally, many genomic and genetic resources are actually available for tomato, and the sequencing of its genome is in progress. These features make tomato an ideal species for theoretical studies and practical applications in the genomics field. The present review describes how structural genomics assist the selection of new varieties resistant to pathogens that cause damage to this crop. Many molecular markers highly linked to resistance genes and cloned resistance genes are available and could be used for a high-throughput screening of multiresistant varieties. Moreover, a new genomics-assisted breeding approach for improving fruit quality is presented and discussed. It relies on the identification of genetic mechanisms controlling the trait of interest through functional genomics tools. Following this approach, polymorphisms in major gene sequences responsible for variability in the expression of the trait under study are then exploited for tracking simultaneously favourable allele combinations in breeding programs using high-throughput genomic technologies. This aims at pyramiding in the genetic background of commercial cultivars alleles that increase their performances. In conclusion, tomato breeding strategies supported by advanced technologies are expected to target increased productivity and lower costs of improved genotypes even for complex traits.

Reversine increases multipotent human mesenchymal cells differentiation potential

Among different human stem cell sources, adult mesenchymal stem cells from bone marrow (BMSCs), and more recently from adipose tissues (ASCs), have shown their capability to differentiate into a variety of different cell types, including osteoblasts, adipocytes, and muscle cells. However, mesenchymal stem cell differentiation toward certain cell types (including skeletal and cardiac muscle), while shown to be achievable, still suffers of low yields and needs to be greatly improved before any therapeutic application could be foreseen. A possible way of achieving this goal is by using a chemical-pharmacological approach to increase stem cell plasticity. Along this line, we envisioned the possibility of pre-treating BMSCs and ASCs with reversine, a synthetic purine that has been shown to induce adult cells de-differentiation. In the current study we tested reversine effects on both BMSCs and ASCs to increase their differentiation toward osteoblasts, smooth and skeletal muscle cells. Reversine pre-treatment, at very low concentration (50 nM), caused a marked increase in the differentiation yields of both BMSCs and ASCs.

The role of extracellular conditions during CaCo-2 cells growth: a preliminary study for numerical model validation

OBJECTIVES

One important limitation in cell therapy protocols, and regenerative medicine (an innovative and promising strategy for different pathologies treatment), is the lack of knowledge about cells engraftment, proliferation and differentiation. In order to allow an efficient and successful cell transplant, it is necessary to predict the logistics, economic and timing issues during cellular injection. It has been reported that several parameters, such as cells number, temperature and extracellular pH (pH0) value can influence metabolic pathways and cellular growth. Numerical analysis and model can help to reduce and understand the effects of the above environmental conditions on cell survival. The aim of this paper is to develop the first step of cells transplantation in order to identify "in vitro", which parameters can be useful to develop and validate a numerical model, able to evaluate "in vivo" cells engraftment and proliferation.

MATERIAL AND METHODS

We studied the variation of extracellular parameters--such as medium volume, buffer system, nutrient concentrations and temperature on human colon carcinoma cells (CaCo-2) "in vitro culture"--pursuing the goal of understanding in deeper details cellular processes such as growth, metabolic activity, survival and pH0.

RESULTS

Results showed that CaCo-2 cells growth and mortality increase after two days in culture when cells were suspended in 3.5 ml volume to respect of 10 ml volume. Different temperature values influenced CaCo-2 cells growth and metabolic activity showing a direct relationship with the volume of the medium.

CONCLUSIONS

Our results describe as CaCo-2 cell growth, metabolic activity, mortality and extracellular pH were influenced by extracellular parameters, enabling us to develop and validate a numerical model to be use to predict cells engraftment and proliferation.

Myocardial ischemia in cocaine-user with anomalous origin of the left circumflex coronary artery

The prevalence of anomalous coronary artery is approximately 0.6-1.7% in patients who undergo coronary angiography. These anomalies may cause angina, acute myocardial infarction, syncope and sudden death. Cocaine abuse is now a major health hazard: more than 5 million of Americans are current users. Cocaine abuse can result in coronary artery vasocostriction and the association between cocaine abuse, myocardial ischemia and infarction in the absence of coronary artery disease has been reported. We report the case of a patient with a story of nasally inhaled cocaine abuse presented with exertional chest pain and a perfusion defect of the anterior and inferior-lateral walls of the left ventricle during myocardial perfusion SPECT. The anomalous origin of the left circumflex coronary artery from the righ sinus of Valsalva was detected during coronary angiography and confirmed by the multislice computed tomography (MSCT). Although the coronary angiography is the gold standard of cardiac imaging technique for the diagnosis of coronary artery disease the identification of anomalous coronary arteries is frequently difficult with conventional coronary angiography because of the lack of 3-dimensional (3D) information related to the course of the coronary arteries to the great vessels. The MSCT provides a high spatial resolution, which allows a successful identification of the congenital coronary artery anomalies. This case report provides further a supportive evidence for the role of MSCT in the detection of the coronary artery anomalies.

[PICC: central venous access by the peripheral route. Medical-nursing aspects]

To have access to central vein, for the infant in NICU,often have a role, for their, life-preserving. The increase of survival in the VLBW, and specially in the ELBW,is guaranteed, in the first days of the life also by a safe vascular access, in fact we can, in this way, to supply with parenteral nutrition to all the requirements that these special patients have. In the first approach to the seriously ill newborn, the umbilical vessels, are the first choice to use,we have the way more fast, stable and easy, to guarantee: the emergency therapy, monitoring and caloric requirements. After 6-7 days, however, specially in the ELBW, it is important to find a more stable vascular access, through we can to provide high osmolarity solutions without complications, to supplement the MEF (Minimal Enteral Feeding) with parenteral nutrition optimizing energy intake and caloric. At this time, for the preterm baby is more safe and easy choice the central venous catheter peripherally inserted (PICC). The Authors assess the medical nurse aspects related to this method starting from the choice of vase, the techniques of cannulation and dressing, then linger on the management and prevention of complications. We will, finally, show our data on PICC related to 212 preterms admitted in our NICU with weight <1500 gr and/o E.G. <30 ws.; from the year 2006 to 2009, that correspond to the our precence to the Vermont Oxford Network (VON).

Heart imaging: the accuracy of the 64-MSCT in the detection of coronary artery disease

At present, coronary angiography represents the gold standard technique for the diagnosis of coronary artery disease. Our aim is to compare the conventional coronary angiography to the coronary 64-multislice spiral computed tomography (64-MSCT), a new and non-invasive cardiac imaging technique. The last generation of MSCT scanners show a better imaging quality, due to a greater spatial and temporal resolution. Four expert observers (two cardiologists and two radiologists) have compared the angiographic data with the accuracy of the 64-MSCT in the detection and evaluation of coronary vessels stenoses. From the data obtained, the sensibility, the specificity and the accuracy of the coronary 64-MSCT have been defined. We have enrolled 75 patients (57 male, 18 female, mean age 61.83 +/- 10.38; range 30-80 years) with known or suspected coronary artery disease. The above population has been divided into 3 groups: Group A (Gr. A) with 40 patients (mean age 60.7 +/- 12.5) affected by both non-significant and significant coronary artery disease; Group B (Gr. B) with 25 patients (mean age 60.3 +/- 14.6) who underwent to percutaneous coronary intervention (PCI); Group C (Gr. C) with 10 patients (mean age 54.20 +/- 13.7) without any coronary angiographic stenoses. All the patients underwent non-invasive exams, conventional coronary angiography and coronary 64-MSCT. The comparison of the data obtained has been carried out according to a per group analysis, per patient analysis and per segment analysis. Moreover, the accuracy of the 64-MSCT has been defined for the detection of >75%, 50-75% and <50% coronary stenoses. Coronary angiography has identified significant coronary artery disease in 75% of the patients in the Gr. A and in 73% of the patients in the Gr. B. No coronary stenoses have been detected in Gr. C. According to a per segment analysis, in Gr. A, 36% of the segments analysed have shown a coronary stenosis (37% stenoses >75%, 32% stenoses 50-75% and 31% stenoses <50%). In Gr. B, 32% of the segments have shown a coronary stenosis (33% stenoses >75%, 29% stenoses 50-75% and 38% stenoses <50%). In-stent disease has been shown in only 4 of the 29 coronary stents identified. In Gr. A, coronary 64-MSCT has confirmed the angiographic results in the 93% of cases (sensibility 93%, specificity 100%, positive predictive value 100% and negative predictive value 83%) while, in Gr. B, this confirm has been obtained only in 64% of cases (sensibility 64%, specificity 100%, positive predictive value 100% and negative predictive value 50%). In Gr. C, we have observed a complete agreement between angiographic and CT data (sensibility, specificity, positive predictive value and negative predictive value 100%). According to a per segment analysis, the angiographic results have been confirmed in 98% of cases in Gr. A (sensibility 98%, specificity 94%, positive predictive value 90% and negative predictive value 94%) but only in 55% of cases in Gr. B (sensibility 55%, specificity 90%, positive predictive value 71% and negative predictive value 81%). Moreover, only 1 of the 4 in-stent restenoses has been detected (sensibility 25%, specificity 100%, positive predictive value 100% and negative predictive value 77%). Coronary angiography has detected a greater number of coronary stenoses than the 64-MSCT. 64-MSCT has demonstrated better accuracy in the study of coronary vessels wider than 2 mm, while its accuracy is lower for smaller vessels (diameter < 2.5 mm) and for the identification of in-stent restenosis, because there is a reduced image quality for these vessels and therefore a lower accuracy in the coronary stenosis detection. Nevertheless, 64-MSCT shows high accuracy and it can be considered a comparative but not a substitutive exam of the coronary angiography. Several technical limitations of the 64-MSCT are responsible of its lower accuracy versus the conventional coronary angiography, but solving these technical problems could give us a new non-invasive imaging technique for the study of coronary stents.

The endovascular treatment of traumatic isthmic aortic rupture: three years follow-up

The isthmic aortic rupture represents the main cause of death in car crash accidents, because of closed chest trauma. Early medical and surgical care and endovascular prosthesis treatment with semi-invasive method can improve short and mid term survival. Nine patients with traumatic isthmic aortic rupture underwent endoprosthesis aortic implantation. All the patients were male, mean age 42.48 +/- 17.66 years. Operations included 5 acute cases and 4 chronic cases (chance diagnosis). In all cases the diagnosis was performed by tomodensitometric exam. Cloth prostheses were used (self-expansible Goretex- or Dacron-stent). Three years after the endoprosthesis implantation, we obtained the complete thrombosis of the false aortic lumen in all patients, both acute and chronic, as well as the levelling of the false aneurysms without complications of any kind.

Ab initio calculations of electron affinity and ionization potential of carbon nanotubes

By combining ab initio all-electron localized orbital and pseudopotential plane-wave approaches we report on calculations of the electron affinity (EA) and the ionization potential (IP) of (5, 5) and (7, 0) single-wall carbon nanotubes. The role played by finite-size effects and nanotube termination has been analysed by comparing several hydrogen-passivated and not passivated nanotube segments. The dependence of the EA and IP on both the quantum confinement effect, due to the nanotube finite length, and the charge accumulation on the edges, is studied in detail. Also, the EA and IP are compared to the energies of the lowest unoccupied and highest occupied states, respectively, upon increasing the nanotube length. We report a slow convergence with respect to the number of atoms. The effect of nanotube packing in arrays on the electronic properties is eventually elucidated as a function of the intertube distance.

Myocardial bridging: cases reports

We report 2 cases of Myocardial Bridge (MB). MB, even though a very frequent anomaly (found out in 85% of autopsies), often is asymptomatic. It is hard to diagnose in patients affected by coronary artery disease, seldomly found out on selective coronary angiograms (in 16-20% of chest pain cases). MB can be considered as one of the causes of coronary artery disease.

Morphological and functional changes of cardiovascular system in postmenopausal women

BACKGROUND

The incidence of cardiovascular events in reproductive age women is 3 times lower than in men, whereas this ratio noticeably changes on menopausal beginning. Postmenopausal women are more exposed to the effects of risk factors, which are present in a noticeably different entity in physiological or surgical menopause; and in the latter whether on substitutive hormonal treatment or not.

METHODS

This study, carried out in Rome and Latina, has involved 743 postmenopausal women, of whom 545 with physiological menopause and 198 with iatrogenic menopause.

RESULTS

The average blood pressure value as well as the incidence of hypertension, hypercholesterolemia, diabetes mellitus, obesity and smoking have a significantly different trend in physiological versus iatrogenic postmenopausal women; and in the latter whether on substitutive hormonal treatment or not.

CONCLUSIONS

Studying life-style and evaluating risk factors in postmenopausal women, and giving an up-to-date view about the prevalence oh health conditions at risk, will allow us to promote both primary and secondary prevention actions.

The crystal structure of polygalacturonase-inhibiting protein (PGIP), a leucine-rich repeat protein involved in plant defense

Polygalacturonase-inhibiting proteins (PGIPs) are plant cell wall proteins that protect plants from fungal invasion. They interact with endopolygalacturonases secreted by phytopathogenic fungi, inhibit their enzymatic activity, and favor the accumulation of oligogalacturonides, which activate plant defense responses. PGIPs are members of the leucine-rich repeat (LRR) protein family that in plants play crucial roles in development, defense against pathogens, and recognition of beneficial microbes. Here we report the crystal structure at 1.7-A resolution of a PGIP from Phaseolus vulgaris. The structure is characterized by the presence of two beta-sheets instead of the single one originally predicted by modeling studies. The structure also reveals a negatively charged surface on the LRR concave face, likely involved in binding polygalacturonases. The structural information on PGIP provides a basis for designing more efficient inhibitors for plant protection.

[The need for integrated care of patients with chronic nephropathies: the epidemiology of 'late referral']

BACKGROUND

The recent need for information has prompted this collaboration between health system epidemiologists (Basilicata) and clinicians to compare models of 'local' epidemiology in the management of diseases. The referral of patients to a nephrologist represents a working hypothesis of research- intervention.

METHODS

Analysis of renal registry (RR) and administrative databases (hospital discharge abstracts/HDA, ambulatory);ad hoc surveys.

RESULTS

Patients on dialysis between 1994 and 1998 are 594, cumulative deaths are 190 (32%). Males and the elderly (age = 65 years) are associated with more than 50% and threefold increase in relative risk of death, and with a diabetic nephropathy of 60% vs other renal diseases. Of 570 patients alive in 1996, 442 are linked with 2,628 HAD. Comorbid conditions are underreported in the RR (the Charlson index has been computed using HDA). Of 66 new dialysis cases, 31 are referred to a nephrologist only 6 months before the start of dialysis (47%) (22% diabetics). Patients discharged with chronic nephropathies (CN) and diabetes are 21% of CN patients (5% of diabetics). Of 100 patients with pre-end stage renal disease and diabetes, only 11-14 are discharged from the nephrology ward. At the local level, 3 out of 4 patients with serum creatinine higher than 1.5 mg/dl are not referred to a nephrologist. The prevalence of CN may vary from 0.4% to more than 1%.

CONCLUSIONS

While an improvement in health databases in the regions is underway, collaboration studies are essential for planning specific interventions for prevention and management of diabetic nephropathy to improve the use of resources in nephrology.

Structural requirements of endopolygalacturonase for the interaction with PGIP (polygalacturonase-inhibiting protein)

To invade a plant tissue, phytopathogenic fungi produce several cell wall-degrading enzymes; among them, endopolygalacturonase (PG) catalyzes the fragmentation and solubilization of homogalacturonan. Polygalacturonase-inhibiting proteins (PGIPs), found in the cell wall of many plants, counteract fungal PGs by forming specific complexes with them. We report the crystal structure at 1.73 A resolution of PG from the phytopathogenic fungus Fusarium moniliforme (FmPG). The structure of FmPG was useful to study the mode of interaction of the enzyme with PGIP-2 from Phaseolus vulgaris. Several amino acids of FmPG were mutated, and their contribution to the formation of the complex with PGIP-2 was investigated by surface plasmon resonance. The residues Lys-269 and Arg-267, located inside the active site cleft, and His-188, at the edge of the active site cleft, are critical for the formation of the complex, which is consistent with the observed competitive inhibition of the enzyme played by PGIP-2. The replacement of His-188 with a proline or the insertion of a tryptophan after position 270, variations that both occur in plant PGs, interferes with the formation of the complex. We suggest that these variations are important structural requirements of plant PGs to prevent PGIP binding.

Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities

The purpose of this nonrandomized case-review study was to compare the outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities in our department. Outcome was evaluated by independent physicians. A total of 85 patients underwent saphenous vein stripping in association with phlebectomy and 90 patients underwent CHIVA cure. The duration of follow-up was 3 years. Study criteria were (1) presence of varicose veins as a cause of failure (1.1% in the CHIVA group vs. 15.3% in the stripping group), (2) appearance of telangiectasia (8.9% in the CHIVA group vs. 65.9% in the stripping group), (3) patient dissatisfaction rate (3.3% in the CHIVA group vs. 16.5% in the stripping group), (4) postoperative symptoms as a cause of failure (1.1% in the CHIVA group vs. 21.2% in the stripping group), and (5) saphenous nerve injury (1 patient in the CHIVA group vs. 16 in the stripping group). Differences between all five criteria were significantly in favor of the CHIVA group as compared to saphenous vein stripping with phlebectomy. Clinical results at 3 years are better for patients treated with CHIVA than stripping with regard to presence of varicose veins, clinical symptoms, presence of telangiectasia, cosmetic satisfaction, and neurologic complications. Data in our series of CHIVA treatments are comparable to those reported in the literature and better than those described in three series of stripping procedures with 3-year follow-up. A prospective randomized study is now underway to confirm these findings.

Reversal of cachexia in patients treated with potent antiretroviral therapy

The introduction of HAART has changed the nutritional status of HIV patients. In the pre-protease inhibitor (PI) era, more than 60% of HIV-positive persons presented with protein energy malnutrition (PEM) and vitamin and mineral deficit. This caused progressive physical-metabolic wasting (wasting syndrome/cachexia) and increased susceptibility to opportunistic infections and drug toxicity. PEM was a concurrent cause in 80% of deaths attributed to AIDS. Since 1996, the year in which PIs were introduced, the number of patients dying as a result of AIDS has decreased by two thirds, and cachexia is no longer the AIDS terminal phase in developed countries. But different patterns of nutritional status changes have appeared in association with the use of newer anti-HIV therapies and with longer survival of HIV-infected patients. A new clinical and laboratory syndrome--lipodystrophy syndrome--now affects patients receiving PI-based therapy. This syndrome consists of changes in body shape that are caused by an abnormal redistribution of fat. Fat accumulates in the abdominal area (truncal and visceral obesity), in the axillary pads (bilateral symmetric lipomatosis), and in the dorsocervical pads ("buffalo hump," "bull neck") but decreases in the legs, arms, and nasolabial and cheek pads (peripheral lipodystrophy). Hyperlipidemia and insulin resistance are also frequently present (metabolic syndrome X). Pathogenic mechanisms of lipid and fat tissue disturbances are discussed in this article, and the clinical approach to patient management and therapeutic options for lipodystrophy and lipid dysmetabolism is evaluated.

Lymphoblastic lymphoma of the pre-B phenotype with cutaneous presentation

Lymphoblastic lymphoma (LBL) is a neoplasm of lymphoid precursors presenting usually as acute leukemia with bone marrow and peripheral blood involvement. Primary cutaneous involvement of LBL with a pre-B phenotype has to be considered an extremely uncommon occurrence, accounting for less than 1% of all non-Hodgkin lymphomas. A child with an LBL involving a single cutaneous manifestation of 6 months duration is presented. At the time of presentation, the lesion consisted of a rapidly enlarging deeply infiltrated tumor on the upper arm. Immunophenotypic analysis performed an paraffin-embedded and frozen tissue sections revealed 2 pre-B phenotype of the tumor cells. Similar results were obtained from lymph node and bone marrow biopsy specimens. After 26 months of polychemotherapy, the patient is currently in complete remission. We wish to add this case to the current literature of LBL with cutaneous involvement, emphasizing the importance of a correct diagnosis and the excellent response to the therapeutic regimen.

Assessment of an indirect ELISA in milk for the diagnosis of ovine Brucellosis

The possibility of using an ELISA for the diagnosis of ovine brucellosis in milk (M-ELISA) was investigated. The aim of the study was to establish whether the specificity and sensitivity of the M-ELISA would be high enough to detect low levels of Brucella antibodies in ewe milk. The diagnostic performances of the test under study were established by means of reference standards and compared with conventional screening and confirmatory tests under field conditions. The diagnostic specificity of the M-ELISA established on a number of samples from Brucella-free flocks was 100% while relative to RBT and CFT positive reactors the M-ELISA demonstrated sensitivity of 65 and 83% respectively. Its sensitivity relative to culture positive animals was of 92%. The course of Brucella antibodies in milk of positive sheep was evaluated in colostrum and in mature milk for a period of 30 days after delivery and it appeared that concentrations of immunoglobulins in milk tend to sharply decrease soon after parturition while in blood serum these remained constantly high. It was concluded that the M-ELISA for Brucella antibodies in ewe milk can be regarded as a complementary diagnostic tool for individual testing but it would be poorly viable if used as a screening test applied to pooled flock milks.