Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice

BACKGROUND

Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT.

METHODS

We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score.

RESULTS

The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT.

CONCLUSIONS

NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.

Post-Stroke Detection of Subclinical Paroxysmal Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source in the Real World Practice: The Empoli ESUS Atrial Fibrillation (E 2 AF) Study

BACKGROUND

Subclinical paroxysmal atrial fibrillation (AF) is one of the main occult causative mechanisms of embolic stroke of undetermined source (ESUS). Aim of this study was to identify AF predictors, and to develop a score to predict the probability of AF detection in ESUS.

METHODS

We retrospectively analyzed ESUS patients undergoing 2-week external electrocardiographic monitoring. Patients with and without AF detection were compared. On the basis of multivariate analysis, predictors of AF were identified and used to develop a predictive score, which was then compared with other existing literature scores.

RESULTS

Eighty-two patients, 48 females, mean age±SD 72±10 years, were included. In 36 patients (43.9%) AF was detected. The frequency of age 75 years or above and arterial hypertension, and the median CHA 2 DS 2 -VASc score were significantly higher in patients with AF compared with those without. National Institutes of Health Stroke Scale (NIHSS) score ≥8 was the only independent variable associated with AF detection. We derived the Empoli ESUS-AF (E 2 AF) score (NIHSS ≥8 5 points, arterial hypertension 3 points, age 75 years or above 2 points, age 65 to 74 years 1 point, history of coronary/peripheral artery disease 1 point, left atrial enlargement 1 point, posterior lesion 1 point, cortical or cortical-subcortical lesion 1 point), whose predictive power in detecting AF was good (area under the curve: 0.746, 95% confidence interval: 0.638-0.836) and higher than that of CHA 2 DS 2 -VASc and other scores.

CONCLUSIONS

In our study NIHSS score ≥8 was the only independent predictor of post-ESUS-AF detection. The E 2 AF score appears to have a good predictive power for detecting AF. External validations are required.

Higher activity level after opening wedge high tibial osteotomy compared to medial unicompartimental knee arthroplasty in a selected cohort of advanced age: A propensity score-matched analysis

BACKGROUND

High tibial osteotomy (HTO) and medial unicompartmental knee arthroplasty (mUKA) are accepted treatment for medial knee osteoarthritis (OA). Patients often present meeting indications for both procedures. The purpose of this study was to compare results after MOWHTO and UKA in a matched population of patients older than 50 years.

METHOD

A retrospective analysis searching for patients older than 50 years meeting indication both for UKA and MOWHTO was performed. A propensity score matching (PSM) based on demographics and clinical data was performed. Tegner activity scale (TAS), Lysholm knee score (LKS) and numeric rating scale for pain (NRS) were recorded prospectively prior to surgery, at 6 months and after a minimum of 4 years.

RESULTS

64 UKA and 71 MOWHTO were found. Mean follow up was similar (54,05 ± 4,80 and 52,62 ± 3,91). A significant improvement was found in both groups for all outcomes at 6 months and at final follow up. PSM yielded 29 pairs. Patients treated with MOWHTO showed superior TAS scores at 6 months (3,41 ± 0,50 vs 3,10 ± 0,56; p < 0,05) and at final follow up (3,83 ± 0,80 vs 3,27 ± 0,59; p < 0,005). NRS and LKS were comparable between groups.

CONCLUSIONS

MOWHTO performed using an open wedge technique, with locking plate and a fast rehabilitation protocol guaranteed higher level of activity than UKA in patients older than 50 years. Difference is significant already at 6 months and last longer than 4 years.

LEVEL OF EVIDENCE

III.

Neuroimaging evaluation of unilateral asymptomatic carotid plaque ulceration: preliminary results of the Carotid Artery Multimodality imaging Prognostic study

Background

Carotid plaque ulceration has been associated with imaging characteristics of high risk of future events (plaque vulnerability) in patients with a significant degree of stenosis, while little is known about its role in patients with a lesser degree of stenosis and its association with markers of vascular inflammation.

Purpose

We evaluated the association between imaging characteristics of plaque vulnerability and vascular inflammation detected by different imaging tests.

Methods

One hundred and seven patients with unilateral asymptomatic carotid artery stenosis (40–60% detected by Doppler ultrasound (DUS)), enrolled in the ongoing Carotid Artery Multimodality Prognostic (CAMP) study were prospectively evaluated with computed tomography angiography (CTA), contrast-enhanced magnetic resonance imaging (CEMRA) and, in a subgroup of patients, with 18-F-fluorodeoxyglucose positron emission tomography (PET). Plaque ulceration was detected by CTA. Variables are expressed as median (1st–3rd quartiles) and number (percentages).The Student's t-test or Mann-Whitney and Chi square or Fisher's exact test were used to study associations among variables.

Results

An ulcerated plaque was present in 35% patients (n=33) of those undergoing CTA (n=94), while intraplaque hemorrhage and lipid-rich necrotic core were present in 9% and 15% of those undergoing CEMRA. Compared with patients with non-ulcerated plaques, those with an ulcerated plaque had a significant higher degree of stenosis at DUS, a higher target to background ratio (TBR) at 18F-FDG-PET and a higher high-sensitivity cardiac troponin (cTn) T.

Conclusions

Plaque ulceration is common and associated with higher degree of stenosis, higher indices of wall inflammation and higher serum markers of myocardial injury.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Regione Toscana

AB1543-HPR WAITING ROOM PROJECT: IMPROVING HEALTHCARE OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Systemic lupus erythematosus (SLE) prognosis is determined by a wide range of factors, such as the severity of the disease manifestations, the psychosocial aspects of patients, the proper management of comorbidities, adoption of a healthy lifestyle and adherence to treatment. Studies on chronic diseases highlight the value of patient education to foster treatment adherence and improve prognosis.

Objectives

To promote health education to SLE patients and their families providing accessible and comprehensive scientific information, in order to improve adherence to treatment and the patient’s prognosis.

Methods

The Waiting Room Project is linked to the Extension Health Care Program for SLE patients and their families of Universidade Federal de Minas Gerais, Brazil, since 2011. A total of 700 patients under SLE treatment at the Rheumatology Unit of the University Hospital are involved. Medical students and rheumatology fellows, altogether, developed high-quality informative texts, with clear content and layman language appropriate for the patient, under the supervision of the rheumatology professors. The texts are illustrated by the team of the Communication Department of the Medical School and medical students, and are printed in a leaflet format. The material is handed out to the patients, while they wait for their medical appointment, by the students and the care team. The content of the leaflets is discussed, making sure that all the concerns and doubts are properly addressed

Results

The Waiting Room Project has produced 17 leaflets, addressing different aspects of SLE, comorbidities, and treatment. The texts approach the traditional cardiovascular risk factors (Smoking, Arterial Hypertension, Diabetes, Obesity, Physical Activity), and some medical conditions related to general health and SLE treatment (Sun Protection, Healthy Food, Oral Care, Vaccination, Pregnancy, Osteoporosis). In 2020 and 2021, two leaflets about Covid-19 were produced in order to clarify important aspects of this disease, its impact on lupus patients and to solve questions about SLE medications: one regarding the association between Lupus and Covid-19 and another about the treatment of lupus and Covid-19. Other four leaflets were produced concerning SLE treatment, including Adherence to Treatment, the use of Antimalarials, Corticosteroids, and Immunosuppressants. Information about the drugs, general importance on lupus treatment, recommendations and possible adverse events were described. Futhermore, additional content is currently in production with themes such as Intravenous Corticosteroid and Cyclophosphamide, Human Papillomavirus Infection, Malignant Neoplasm, and specific cancers frequently affecting women, such as Colorectal Cancer, Cervical Cancer, and Breast Cancer. The leaflets are also available online on the Medical School website in Portuguese and in English (medicina.ufmg.br/alo/material-didatico/), on the Minas Gerais Rheumatology Society website (reumatologia.org.br/orientacoes-ao-paciente/), and on the Instagram page @lupusufmg

Conclusion

The leaflets have been an important source of information and health education for SLE patients and their families, improving student/physician-patient communication. Despite the adversities caused by the coronavirus pandemic, the Waiting Room Project has kept its purpose to make each patient with SLE an agent of their healthcare. Improving the patients’ access to evidence-based information must be a goal of healthcare professionals that treat patients with SLE

References

[1]Koehn CL, Esdaile JM. Patient education and self-management of musculoskeletal diseases. Best Pract Res Clin Rheumatol. 2008; 22: 395-405.

[2]Navarra SV, Zamora LD, Collante MaTM. Lupus education for physicians and patients in a resource-limited setting. Clinical Rheumatol. 2019; 39:697–702.

[3]Zhang L, Luan W, Geng S, et al. Lack of patient education is risk factor of disease flare in patients with systemic lupus erythematosus in China. BMC Health Serv Res. 2019; 19: 378.

Disclosure of Interests

None declared

Impulsivity traits and awareness of motor intention in Parkinson's disease: a proof-of-concept study

INTRODUCTION

In patients with Parkinson's disease (PD), impulsivity is still a matter of investigation. It has been hypothesized that impulsive personality traits may favour impulse control disorder (ICD) onset during dopaminergic therapy. In healthy subjects, a relationship between the awareness of motor intention and impulsive personality traits assessed by the Barratt impulsivity scale (BIS-11) has been reported. The aim of this study was to evaluate the relationship between the awareness of voluntary action and impulsivity traits in PD.

METHODS

Twenty-eight PD patients (stages I-III on the Hoehn and Yahr scale) underwent an impulsivity trait assessment by the BIS-11 scale and a task based on the Libet's clock. Participants were requested to perform a self-initiated movement and report the time they first feel their intention to move (W-judgement) or the time of the actual movement (M-judgement).

RESULTS

In patients with higher BIS-11 scores, the time lag between the W-judgement and the actual movement was significantly lower than in patients with lower BIS-11. No difference emerged in the M-judgement.

CONCLUSION

Data suggest that also in PD patients, the impulsive personality trait is related to a "delayed" awareness of motor intention and therefore to a shorter interval to allow a conscious "veto" of the impending action. Characterization of the temporal profile of awareness of motor intention could prove useful in identifying PD patients at risk of developing ICDs during dopaminergic treatment.

Age-related burden and characteristics of embolic stroke of undetermined source in the real world clinical practice

Few data are available on age-related burden and characteristics of embolic stroke of undetermined source (ESUS) in the real world clinical practice. The aim of our study was to provide information about it. We retrospectively analyzed data of patients consecutively admitted to our Stroke Unit along 1 year (2017, November 1st-2018, October 31st). The etiology of ischemic stroke was defined at hospital discharge; ESUS was considered as a subset of cryptogenic stroke, and defined according to the 2014 international criteria. In the analyzed period, 306 patients, 52.3% females, mean age ± SD 77.9 ± 11.9 years, were discharged with diagnosis of ischemic stroke. Ischemic strokes of cardioembolic and lacunar origin were the most frequent subtypes: 30.1% and 29.4%, respectively. Cardioembolic strokes were particularly frequent in patients ≥ 75 years, and almost always associated with atrial fibrillation. Overall, in 80 patients (26.1%) the etiology of stroke was undetermined; in 25 (8.2%) it remained undefined because of death or severe comorbidity, making further diagnostic work-up not worthy. Cryptogenic stroke occurred in 55 patients (18%), and ESUS criteria were satisfied in 39 of them (12.7%). According to age, cryptogenic stroke was diagnosed in 21.1% (21.1% ESUS) of patients < 65 years, 24.2% (19.4% ESUS) of patients aged 65-74 years, 15.5% (9.2% ESUS) of patients ≥ 75 years. After diagnostic work-up, patent foramen ovale was most commonly associated with ESUS (17.9%), especially in patients < 65 years (62.5%); covert paroxysmal atrial fibrillation was detected in 10.5% of ESUS patients ≥ 75 years. In the real world clinical practice, the frequency of ischemic strokes of undetermined etiology, and of those satisfying ESUS criteria, is not negligible, especially in younger patients. A thorough diagnostic work-up, with an age-specific approach, is therefore necessary and of the utmost importance for the identification of stroke etiology, in order to optimize secondary stroke prevention strategies.

Synovial and serum levels of NGF in osteoarthritis and rheumatic diseases: a systematic review

NGF has raised interest as a target molecule in the treatment of OA, after the clinical evidences that antagonization of NGF axis provides symptoms relief in OA. Thus, we conducted a systematic review of the literature to investigate the evidence of NGF being overexpressed during OA. We conducted a database search on Medline using keywords including NGF, serum, synovial fluid, AND osteoarthritis or arthritis. We included study conducted on human, with serum or synovial specimens and an OA cohort. Nine studies met the inclusion criteria. Serum levels ranged from non-detectable to 153.5±28.6 pg/ml. Synovial fluid levels ranged from non-detectable to nearly 210±82 pg/ml. One study supported the evidence of an increased level of NGF in SF and serum of OA patients. The concentration of NGF reported in these studies is controversial and evidence of overexpression of NGF is low.

Axial and rotational alignment of lower limb in a Caucasian aged non-arthritic cohort

Background

The alignment of human lower limb has been an area of ongoing study for decades. The purpose of this study was to analyze the axial and rotational alignment from hip to ankle in a Caucasian aged non-arthritic cohort.

Methods

A non-arthritic cohort of aged patients was retrospectively analyzed by computer tomography. Anatomical–mechanical angle of femur (AMA), femur inclination (FI), femoral anteversion (FA), posterior condylar angle (PCA), proximal tibial torsion (TEAs-PTC and TEAs-PTT) and tibial fibular torsion (PTC-TFA) were measured.

Results

The median age of the patients was 76 years (range 67 to 91 years). Regarding axial alignment, the AMA was 5 (2.94; 6.80). No significance differences were reported by side and age. AMA was significantly lower in men. The FI was 125.3 (120.0; 134.8) with no differences in terms of side, age or gender. Regarding torsion alignment, the median values of FA, PTC-TFA and TEAs-PTT were, respectively, 16.8, 28.5 and − 1.4. No differences were reported by age. Right tibia was externally rotated by 1.5 degrees as compared to the left side (P 0.035).

Conclusion

The broad variability of the parameters analyzed highlights the necessity for a more anatomical and individualized approach during surgery of lower limb. The present study offers the fundament to understand and treat lower limb deformities. Hence, these data can constitute the normal reference values useful to investigate lower limb malalignment. Moreover, it helps to assess the possible changes of axial and rotational alignment in idiopathic OA of lower limb.

Level of evidence III

Retrospective cohort study

Ultrasound examination of coelomic viscera through the plastron in stranded green sea turtles (Chelonia mydas)

Many projects have been developed in the last years for the conservation of sea turtles. Young green turtles (Chelonia mydas) often nest on the Brazilian coast. Because they nest in beaches along the coastline and islands, green turtles are susceptible to fishing and accidental ingestion of anthropogenic debris. Early detection of ingested debris is crucial for the survival of rescued sea animals. Ultrasound (US) has emerged as a viable imaging technique for visceral examination in veterinary medicine. Previous studies have suggested the left and right cervicobrachial, axillary, pre- and post-femoral areas as the only viable approaches for US examination, but the acoustic windows available for imaging of coelomic structures are limited. It is important to notice that a detailed evaluation of all gastrointestinal tracts, especially the duodenum, is crucial for detecting foreign bodies and intestinal obstructive processes, as well as obtaining essential information such as intestinal motility and heart frequency. Intestinal motility and heartbeats are not detected through radiographic examination or through the acoustic windows available so far. This study aimed to establish the viability of US examination of coelomic viscera through the plastron in stranded green turtles. Eleven young green turtles rescued by the GREMAR Institute were examined. Turtles were placed in the dorsal decubitus position during US examination, which did not require anesthesia. Even though the plastron is constituted of bones and cartilage, the present research has proven the viability of obtaining US images through it, making it possible to visualize structures undetectable through the acoustic windows previously suggested. The following organs were evaluated through the plastron: heart, stomach, duodenum, jejunum, colon, liver, gallbladder, kidneys, bladder, and spleen (in case of splenomegaly). US imaging through the plastron is a viable approach for detecting ingested artificial debris, which represents one of the leading causes of death among sea turtles.

Physiological Effects of Nonimmune Platelet Associated Immunoglobulin G

The function of nonimmune IgG associated with platelets is unknown. In a series of experiments we have investigated this problem, relating amount of platelet-associated IgG (PAIgG) to platelet volume, serotonin release, adherence of platelets to monocytes and platelet senescence. Most of these studies were performed with human platelets. Platelets freed of preexisting PAIgG by incubation at 22° C were incubated with IgG in a series of concentrations ranging from 0.4 — 27.0 X10-6 M. The IgG preparations used were demonstrably free of aggregated forms of the protein. The amount of PAIgG bound to platelets was determined by the use of fluorescein isothiocyanate-conjugated anti-IgG antibody (F-anti-IgG antibody) which was quantified in a fluorospectrophotometer. Newly bound IgG was assayed similarly by the use of F-IgG. A dose-dependent increase in platelet volume was associated with the binding of nonimmune IgG by platelets. The process which leveled off at an IgG concentration of 1.2 —1.5 X10-5 M was almost fully reversible and was not due to platelet shape change or aggregation. Release of serotonin from IgG-treated platelets was relatively small but to the extent that it occurred was positively related to the IgG concentration to which platelets were exposed. Adherence to autologous monocytes studied quantitatively by the use of formaldehyde-fixed cells was also positively related to the amount of IgG on the platelets. Normal or IgG-defident serum had a potent inhibitory (noncompetitive) action on the binding of F-IgG and F-anti-human IgG antibody to human platelets. Cohorts of platelets prepared in rabbits during the recovery phase of immunological thrombocytopenia induced by injection of heterologous antiserum, showed an age-dependent increase of PAIgG and of IgG binding. These results suggest that PAIgG plays a role in the clearance of senescent platelets.

Long-Term Survival and Prognostic Factors for 2170 Breast Cancer Patients Treated at Two Cancer Centers: (Milan and Houston)

Data on 2170 consecutive patients with breast cancer submitted to curative surgery with or without combined radiotherapy in the period 1968–1972 at the National Cancer Institute of Milan (Italy) and at the University of Texas M.D. Anderson Cancer Center of Houston (Texas, USA) were analyzed to evaluate the prognosis of breast cancer patients after loco-regional treatment only and to verify if different prognostic factors have the same relevance. Forty-four percent of patients were alive without evidence of disease at the end of the follow-up in both centers: 14% of patients treated in Milan died without evidence of breast cancer with an intercurrent disease, whereas the death rate for intercurrent disease was 27 % in Houston. Thirty-seven percent of the patients in Milan and 26% of the patients in Houston died from breast cancer. A considerable percentage of patients (23.4 % in Milano, 38.2% in Houston) had one or more of the required items not specified in the clinical chart. Since the lack of information was considered a possible source of bias, the series were divided into two groups: the first collecting patients with all information available, the second gathering patients with at least one of the required items missing. The latter group was defined « unknown ». Multivariate analysis of survival, carried out by means of Cox's regression model, showed that mortality of these patients for all causes was significantly affected by the following criteria: status of regional nodes (P = 2 × 10−18), unknown (P = 10−9), maximum diameter of primary tumor (P = 7 × 10−10), age of the patients (P = 10−4), site of primary (P = 0.01), and Center (P = 0.04). A significant interaction was found between center and a) age of the patients, b) menopausal status and c) unknown. The relative P values were 6 × 10−7 for age and center, 8 × 10−3 for menopausal and center, 3 × 10−2 for unknown and center. Multivariate analysis of breast cancer mortality was significantly affected by: status of regional nodes (P = 10−18), diameter of primary (P = 5 × 10−14), unknown (P = 2 × 10−13), center (P = 2 × 10−6), site of primary (P = 0.002), and age of the patients (P = 0.03). The same significant interaction as for mortality from all causes was found. It is concluded that comparability of results obtained in different institutions may be dependent on the standardization and availability of patients data. The lack of information may introduce considerable biases in the evaluation of results, as was shown by the relevance of the variable unknown on mortality for all causes and for breast cancer. As regards the number of positive lymph nodes as a criterion to define subgroups of patients with different risks of death, we were unable to identify a definite breaking point. The most widely used categorization of this variable (1–3 positive nodes and 4 or more positive) was not supported by our data.

Early Glial Tumor Metastases through a Ventriculo-Atrial Shunt

A girl of 12 with a pontine polymorphous astrocytoma diffusely metastasizing to the spinal cord leptomeninges suddenly died 20 hours after the insertion of a right ventriculo–atrial shunt. Many severely damaged glial neoplastic cells were found in the blood vessels of the lung and liver.

Skeletal involvement in type 1 Gaucher disease: Not just bone mineral density

Gaucher disease is characterized by multi-organ infiltration of phospholipid-laden macrophages. Bone involvement is characterized by typical deformities, osteopenia/osteoporosis, pathological fractures, and bone marrow infiltration (avascular osteonecrosis, infarction). Estimation of skeletal disease includes bone quality that contributes substantially to bone strength. We studied 23 type 1 Gaucher patients (median age 22years, range 3-73) on Enzyme Replacement Therapy from 2months to 26years (median 7years); 4 patients had pathological fractures, 10 bone infarctions, 6 avascular osteonecrosis. We noninvasively assessed bone quality by trabecular microarchitecture and macroscopic geometry, using two innovative dual-energy X-ray absorptiometry tools: Trabecular Bone Score (TBS) and Hip Structural Analysis (HSA). Bone quality parameters distinguished the patients with skeletal complications. TBS was significantly lower in patients with avascular osteonecrosis (p=0.049) and pathological fractures (p=0.024), while it could not identify those with bone infarctions. Among HSA parameters, the Cross Sectional Area of the intertrochanteric region and the Buckling Ratio of the narrow neck allowed the distinction of patients with avascular osteonecrosis. BMD was low in 11 patients (50%); neither BMD nor HSA were associated with pathological fractures. The combined evaluation of bone quality and bone quantity is useful to identify GD patients with more severe skeletal involvement.

Establishing pathological cut-offs of brain atrophy rates in multiple sclerosis

OBJECTIVE

To assess whether it is feasible to establish specific cut-off values able to discriminate 'physiological' or 'pathological' brain volume rates in patients with multiple sclerosis (MS).

METHODS

The study was based on the analysis of longitudinal MRI data sets of patients with MS (n=206, 87% relapsing-remitting, 7% secondary progressive and 6% primary progressive) and healthy controls (HC; n=35). Brain atrophy rates were computed over a mean follow-up of 7.5 years (range 1-12) for patients with MS and 6.3 years (range 1-12.5) for HC with the SIENA software and expressed as annualised per cent brain volume change (PBVC/y). A weighted (on the follow-up length) receiver operating characteristic analysis and the area under the curve (AUC) were used for statistics.

RESULTS

The weighted PBVC/y was -0.51±0.27% in patients with MS and -0.27±0.15% in HC (p<0.0001). There was a significant age-related difference in PBVC/y between HC older and younger than 35 years of age (p=0.02), but not in patients with MS (p=0.8). The cut-off of PBVC/y, as measured by SIENA that could maximise the accuracy in discriminating patients with MS from HC, was -0.37%, with 67% sensitivity and 80% specificity. According to the observed distribution, values of PBVC/y as measured by SIENA that could define a pathological range were above -0.52% with 95% specificity, above -0.46% with 90% specificity and above -0.40% with 80% specificity.

CONCLUSIONS

Our evidence-based criteria provide values able to discriminate the presence or absence of 'pathological' brain volume loss in MS with high specificity. Such results could be of great value in a clinical setting, particularly in assessing treatment efficacy in MS.

Spine bone texture assessed by trabecular bone score (TBS) to evaluate bone health in thalassemia major

Due to the increasing survival of thalassemic patients, osteopathy is a mounting clinical problem. Low bone mass alone cannot account for the high fracture risk described; impaired bone quality has been speculated but so far it cannot be demonstrated noninvasively. We studied bone quality in thalassemia major using trabecular bone score (TBS), a novel texture measurement extracted from spine dual-energy X-ray absorptiometry (DXA), proposed in postmenopausal and secondary osteoporosis as an indirect index of microarchitecture. TBS was evaluated in 124 adult thalassemics (age range 19-56 years), followed-up with optimal transfusional and therapeutical regimens, and in 65 non-thalassemic patients (22-52 years) undergoing DXA for different bone diseases. TBS was lower in thalassemic patients (1.04 ± 0.12 [range 0.80-1.30]) versus controls (1.34 ± 0.11 [1.06-1.52]) (p < 0.001), and correlated with BMD. TBS and BMD values correlated with age, indicating that thalassemia negatively affects both bone quality and quantity, especially as the patient gets older. TBS was 1.02 ± 0.11 [0.80-1.28] in the osteoporotic thalassemic patients, 1.08 ± 0.12 [0.82-1.30] in the osteopenic ones and 1.15 ± 0.10 [0.96-1.26] in those with normal BMD. No gender differences were found (males: 1.02 ± 0.13 [0.80-1.30], females 1.05 ± 0.11 [0.80-1.30]), nor between patients with and without endocrine-metabolic disorders affecting bone metabolism. Our findings from a large population with thalassemia major show that TBS is a valuable tool to assess noninvasively bone quality, and it may be related to fragility fracture risk in thalassemic osteopathy.

Human exposure to lead, cadmium and mercury through fish and seafood product consumption in Italy: a pilot evaluation

The presence of selected toxic heavy metals, such as cadmium (Cd), lead (Pb) and mercury (Hg), was investigated in fish and seafood products, namely, blue mussel, carpet shell clam, European squid, veined squid, deep-water rose shrimp, red mullet, European seabass, gilthead seabream, Atlantic cod, European hake, Atlantic bluefin tuna and swordfish so as to assess their human exposure through diet. Metals were detected by quadrupole inductively coupled plasma mass spectrometry (Q-ICP-MS) and hydride generation atomic absorption spectrometry (Hg-AAS). Measurements of Cd, Pb and Hg were performed by means of analytical methods validated in compliance with UNI CEI EN ISO/IEC 17025 [2005. General requirements for the competence of testing and calibration laboratories. Milano (Italy): UNI Ente Nazionale Italiano di Unificazione]. The exposure assessment was undertaken matching the levels of Cd, Pb and total Hg with consumption data related to fish and seafood products selected for this purpose. In order to establish human health implications, the estimated weekly intakes (EWIs) for Cd, Pb and Hg were compared with the standard tolerable weekly intakes (TWI) for Cd and provisional tolerable weekly intakes (PTWIs) for Pb and Hg stipulated by the European Food Safety Authority (EFSA) and the Food and Agriculture Organization/World Health Organization (FAO/WHO) Joint Expert Committee on Food Additives (JECFA). The found metal concentrations were largely below the maximum levels (MLs) established at the European Union level with the exception of Cd. This metal exceeded the MLs in squid, red mullet, European hake and Atlantic cod. Squid and blue mussel showed the highest Pb concentrations which accounted for 60% and 10% of the MLs, respectively. Highest Hg levels were found in predatory fish. The concentrations of Hg in swordfish, Atlantic bluefin tuna and red mullet accounted for 50%, 30% and 30% of the MLs, respectively. The EWIs for Cd, Pb and Hg related to the consumption of fish and seafood products by the median of the Italian total population accounted for 20%, 1.5% and 10% of the standard TWI for Cd as well as PTWIs for Pb and Hg, respectively. Furthermore, the EWIs estimated using consumption data concerning Italian consumers did not exceed the standard TWI and PTWIs, except for Cd at 95th percentile.

Toxicity of Jatropha curcas L. as a biofuel crop and options for management

Abstract

There are high expectations of Jatropha curcas L. as a new crop for biofuel production in the tropics and sub-tropical areas, as evidenced by the forecast expansion of its cultivation in various areas, especially in Asia. The definitive confirmation of the crop as realistic and suitable feedstock for biodiesel will come about when it is able to exploit the vast marginal areas present in many countries, demonstrating the economic sustainability of the whole Jatropha biodiesel chain. Increasing seed yield and oil content remain the main goals, but a valorization of the extruded seed cake, as animal feed, currently prevented by the presence of phorbol esters (PE) toxins, could contribute to a significant improvement in the economic sustainability of the crop. At present, the only reliable process is the seed cake detoxification by washing treatments with solvents and by biotransformation, but these treatments are expensive, not environmentally friendly and difficult to apply in developing countries. In the near future, the solution may come from non-toxic J. curcas accessions, which can be used in breeding programmes to recombine non-toxic traits into elite toxic varieties. In general, a plant free of PE would be more acceptable, opening additional market opportunities for the farmers. Strategies for breeding improved non-toxic varieties could be accelerated by DNA-based molecular marker technology, utilizing the simple sequence repeat (SSR) markers associated with toxicity. The whole genome of plant was recently sequenced and this important acquisition is expected to accelerate the process of molecular breeding in J. curcas.

Pressure induced magnetic phase separation in La0.75Ca0.25MnO3 manganite

The pressure dependence of the Curie temperature T(C)(P) in La(0.75)Ca(0.25)MnO(3) was determined by neutron diffraction up to 8 GPa, and compared with the metallization temperature T(IM)(P) (Postorino et al 2003 Phys. Rev. Lett. 91 175501). The behavior of the two temperatures appears similar over the whole pressure range, suggesting a key role of magnetic double-exchange also in the pressure regime where the superexchange interaction is dominant. The coexistence of antiferromagnetic and ferromagnetic peaks at high pressure and low temperature indicates a phase separated regime which is well reproduced with a dynamical mean-field calculation for a simplified model. A new P-T phase diagram has been proposed on the basis of the whole set of experimental data.

Reparability of Aged Silorane With Methacrylate-Based Resin Composite: Micro-Shear Bond Strength and Scanning Electron Microscopy Evaluation

Aged silorane composite restorations can be repaired with a methacrylate-based resin composite by using a phosphate-methacrylate–based adhesive as the intermediate layer.

Persistence of Jahn-Teller distortion up to the insulator to metal transition in LaMnO3

High pressure, low temperature Raman measurements performed on LaMnO3 up to 34 GPa provide the first experimental evidence for the persistence of the Jahn-Teller distortion over the entire stability range of the insulating phase. This result resolves the ongoing debate about the nature of the pressure driven insulator to metal transition (IMT), demonstrating that LaMnO3 is not a classical Mott insulator. The formation of domains of distorted and regular octahedra, observed from 3 to 34 GPa, sheds new light on the mechanism behind the IMT suggesting that LaMnO3 becomes metallic when the fraction of undistorted octahedra domains increases beyond a critical threshold.

A comparison between metabolic syndrome post-hematopoietic stem cell transplantation and spontaneously occurring metabolic syndrome

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is used in the treatment of several hematological and non-hematological disorders. An increasing number of long-term survivors recover from their primary disease, but they are at risk of adverse late effects, including metabolic syndrome (MS), which seems to be common in long-term survivors of HSCT.

AIM

To compare common metabolic parameters and adipohormone profiles in post-transplant and spontaneously occurring or "classic" MS patients.

SUBJECTS AND METHODS

Post-transplant MS patients (15 women and 14 men; 49.8±9.3 yr) were compared to "classic" MS patients (15 women and 14 men; 52.9±8.0 yr). For each subject a record of conventional clinical parameters was made; moreover, serum leptin, insulin, quantitative C-reactive protein (CRP), tumor necrosis factor-α [TNF-α], and adiponectin concentrations were measured.

RESULTS

The patients with post-HSCT MS had significantly higher levels of leptin, CRP, and TNF-α than the patients with "classic" MS. A generalized linear model comprising serum insulin (p=0.022), body mass index (p<0.001), gender (p<0.001), and group (i.e. healthy, post-HSCT with MS, or suffering from "classic" MS; p<0.001) explained serum leptin variability (adjusted R(2)=0.741). Serum leptin concentrations and BMI were related in the patients with "classic" MS but not in those with post-HSCT MS.

CONCLUSIONS

A possible pathogenetic mechanism in the development of MS after HSCT could be hyperleptinemia. A potential interaction among circulating leptin, components of MS, and immune function might explain the role of this adipokine in mediating cardiovascular risk after HSCT.

Epilepsy after neuroimaging normalization in a woman with tacrolimus-related posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is known to occur after solid organ transplantation, and is caused by immunosuppressive agents such as tacrolimus. PRES onset usually occurs within the first 2months after liver transplantation. Clinical findings include seizures, headache, focal neurological deficits, visual disturbances, and altered mental status. These are associated with characteristic imaging features of subcortical white matter lesions on brain MRI. Atypical localizations of this posterior leukoencephalopathy have been reported. Expeditious recognition of the syndrome may lead to a complete recovery. Abnormalities of EEG during follow-up might be associated with unfavorable seizure outcome, even when neuroimaging changes resolve. We report a case of late-onset PRES with atypical localization following liver transplantation. The patient developed epilepsy despite resolution of MRI lesions at 8 months of follow-up. EEG was a prognostic factor of seizure persistence, suggesting an incomplete recovery of brain lesions in contrast to neuroimaging findings.

Characterisation and measurement of signals generated by DVB-H 'GAP-filler' repeaters

DVB-H (Digital Video Broadcasting Handheld) is the standard developed by DVB Project and approved by ETSI with the aim of providing the reception of DVB signals even in mobility but also data transfers and multimedia services. The introduction and development of the DVB-H system is still ongoing. In this context, this work focuses on the temporal trend of electromagnetic impact of an urban DVB-H repeater (called 'gap-filler') for exposure assessment purposes; it also describes a method for its measurement by means of narrow band instrumental chains.

Inhibitory Effect of Somatostatin on Abnormal GH Response to TRH in Primary Hypothyroidism

Thyrotropin releasing hormone (TRH) does not promote GH secretion in normal subjects but it stimulates GH in a proportion of hypothyroid patients. In this study the response of GH to thyrotropin releasing hormone (TRH) was evaluated in 21 patients with primary hypothyroidism of different origin: 12 with autoimmune thyroiditis, 3 idiopathic, 3 congenital, 3 iatrogenic. 11 of these patients had never been treated, the others were tested after a drug-free period of at least two weeks. Basal plasma concentration of GH was normal in all patients; after TRH administration, a significant increase in plasma GH was observed in 4 patients. In these responsive patients, somatostatin infusion inhibited the abnormal GH response to TRH. It is suggested that the abnormal GH response to TRH in primary hypothyroidism might be caused by a relative deficiency of somatostatinergic control, which is corrected by exogenous somatostatin administration.

Translational mini-review series on immunology of vascular disease: mechanisms of vascular inflammation and remodelling in systemic vasculitis

Vessel walls are the primary inflammatory sites in systemic vasculitides. In most cases the initiating event is unknown, and a self-sustaining circuit attracts and activates inflammatory leucocytes in the wall of vessels of various size and anatomical characteristics. Recent studies have revealed homeostatic roles of vascular inflammation and have identified the action of humoral innate immunity, in particular injury-associated signals and acute phase proteins, on the activation of circulating leucocytes, platelets and endothelial cells. These advances have provided clues to the molecular mechanisms underlying the vicious circle that maintains and amplifies vessel and tissue injury.

[Antibiotic resistance patterns of enterococci isolated from estuarine waters]

The introduction of antibiotic-resistant bacteria to the environment, affects its hygienic-sanitary quality. The objective of this work is to study the prevalence and the antibiotic resistance patterns of enterococci species isolated from Bahía Blanca estuarine waters. One hundred and three isolates were biochemically identified as Enterococcus spp. The diffusion technique was implemented, by using disks of: vancomycin (Van 30 microg), gentamicin (GenH 120 microg), streptomycin (StrH 300 microg), teicoplanin (T 30 microg), ampicillin (Am 10 microg) and ciprofloxacin (CIP 5 microg) according to the Clinical and Laboratory Standards Institute. Seven Enterococcus species were identified, being Enterococcus faecium and Enterococcus faecalis the most frequent. High level resistance to aminoglycosides was shown by 1.9% of the enterococci whereas 12.6% of the isolates were resistant to CIP. No isolates showed simultaneous resistance to StrH and GenH. Neither resistance to glycopeptides nor to Am was detected. Thirty four per cent of the isolates exhibited susceptibility to all antibiotics tested. Surveillance studies on antimicrobial resistance are usually based upon microorganisms isolated from clinical samples. The findings of this work constitute relevant data for the control of resistant strains, which were believed to be circumscribed to the hospital environment, but are also widespread in the natural sites.

Metal complexes of retinoid derivatives with antiproliferative activity: synthesis, characterization and DNA interaction studies

9-cis-Retinal thiosemicarbazone and its Co(III), Ni(II) and Cu(II) complexes are synthesized and characterized. Central Co(III) atom is in an octahedral environment while Ni(II) and Cu(II) atoms are in a square planar environment. DNA binding constants and spectroscopic data show an intercalative behavior for the nickel complex; an external binding mode is envisaged for the ligand and its copper complex. No DNA interaction can be hypothesized for the cobalt complex. The free ligand and its Ni(II) and Cu(II) complexes have a good lipophilic degree for an efficient uptake by the cells. The metal complexes exhibit a proliferation inhibition action against cell line U937 at micromolar concentration. Cu(II) complex also induces apoptosis, while Ni(II) complex has a strong interaction with CT-DNA.

A promoter polymorphism in the CD14 gene is associated with elevated levels of soluble CD14 but not with IgE or atopic diseases

BACKGROUND

A polymorphism in the promoter region of the CD14 gene, C-159T, has been shown to be associated with increased levels of soluble CD14 (sCD14) and decreased serum immunoglobulin E (IgE) and the expression of a more severe atopic phenotype in previous studies.

METHODS

To test if these associations are consistently found in different populations and different age groups, we genotyped 2048 children of different age groups as well as 888 adults from different regions of Germany for the CD14 C-159T polymorphism.

RESULTS

While an association between this promoter polymorphism and levels of sCD14 could be confirmed in our study population (CC: 1017 ng/ml vs TT: 1370 ng/ml, P = 0.03), no association between CD14 C-159T genotypes and IgE levels or the prevalence of atopic diseases was seen.

CONCLUSIONS

The lack of association between CD14 genotypes and IgE as well as atopic outcomes in this large German study population seems to indicate that CD14 genotypes may not directly be involved in the development of allergies during childhood.

Evaluation of the CD14 C-159 T polymorphism in the German Multicenter Allergy Study cohort

BACKGROUND

Multiple genetic studies have shown linkage of atopy-related phenotypes to chromosome 5q31. In this region several candidate genes for atopy are localized such as the Th2 cytokines IL-4, IL-5 and IL-13, but also CD14, a receptor for LPS. Recently, a functional CD14 promoter polymorphism was related to total and specific IgE responsiveness.

OBJECTIVE

The aim of our study was to evaluate the role of this single nucleotide polymorphism (SNP) in a large German birth cohort.

METHODS

Atopy-related phenotypes were longitudinally carefully evaluated in over 800 children from birth to the age of 10 years. Yearly visits included standardized interviews, physical examinations and determination of total and specific IgE antibodies. Pulmonary function tests and histamine provocations were performed at the age of seven. Eight-hundred and seventy-two children of the Multicenter Allergy Study (MAS) cohort were genotyped using melting curve and restriction digest analyses.

RESULTS

CD14-159 allele frequencies were consistent with previous reports, however, no association of the SNP with asthma, atopic dermatitis, allergic rhinitis, total or specific IgE levels could be observed.

CONCLUSION

The CD14-159 SNP might not play a major role in the development of atopy in German children.

Benefits of immunotherapy with a standardized Dermatophagoides pteronyssinus extract in asthmatic children: a three-year prospective study

BACKGROUND

Although widely practiced for over 80 years, the role of specific immunotherapy (SIT) in pediatric asthma treatment is still controversial. We assessed the effects of a 3-year period of subcutaneous administration of a standardized preparation of Dermatophagoides pteronyssinus (D pt) on the respiratory health in a group of asthmatic children monosensitized to house dust mite (HDM).

METHODS

A randomized clinical trial was performed after 1-year run-in period. Fifteen children receiving SIT for HDM and 14 controls (four drop-outs), matched for age, allergen sensitization, asthma severity, lung function, and non-specific bronchial reactivity (BHR), were studied during the 3-year treatment period. During the whole trial, respiratory symptoms, pharmacological and respiratory function parameters were regularly evaluated. Skin prick tests and methacholine challenge were performed at the beginning and end of the study.

RESULTS

In the SIT group significant improvement in asthmatic symptoms and marked reduction in drug intake was observed. The SIT group also showed a significant decrease in non-specific bronchial BHR. No new sensitivity occurred during the study period in the SIT group only. No major local or systemic side-effects were reported during the study.

CONCLUSIONS

Our results confirm that SIT is effective in asthmatic children sensitive to mites. It is associated with a decrease in BHR and it may prevent the development of new sensitizations in monosensitized subjects.

Benefits of immunotherapy with a standardized Dermatophagoides pteronyssinus extract in asthmatic children: a three-year prospective study

BACKGROUND

Although widely practiced for over 80 years, the role of specific immunotherapy (SIT) in pediatric asthma treatment is still controversial. We assessed the effects of a 3-year period of subcutaneous administration of a standardized preparation of Dermatophagoides pteronyssinus (D pt) on the respiratory health in a group of asthmatic children monosensitized to house dust mite (HDM).

METHODS

A randomized clinical trial was performed after 1-year run-in period. Fifteen children receiving SIT for HDM and 14 controls (four drop-outs), matched for age, allergen sensitization, asthma severity, lung function, and non-specific bronchial reactivity (BHR), were studied during the 3-year treatment period. During the whole trial, respiratory symptoms, pharmacological and respiratory function parameters were regularly evaluated. Skin prick tests and methacholine challenge were performed at the beginning and end of the study.

RESULTS

In the SIT group significant improvement in asthmatic symptoms and marked reduction in drug intake was observed. The SIT group also showed a significant decrease in non-specific bronchial BHR. No new sensitivity occurred during the study period in the SIT group only. No major local or systemic side-effects were reported during the study.

CONCLUSIONS

Our results confirm that SIT is effective in asthmatic children sensitive to mites. It is associated with a decrease in BHR and it may prevent the development of new sensitizations in monosensitized subjects.

Treatment of benign nodular goitre with mildly suppressive doses of L-thyroxine: effects on bone mineral density and on nodule size

OBJECTIVES

To evaluate (i) the demineralizing effect of L-thyroxine (LT4) therapy at doses mildly inhibiting serum thyroid stimulating hormone (TSH) in patients with benign nodular goitre; (ii) the efficacy of treatment on nodule size.

DESIGN

Cross-sectional study comparing euthyroid women with nodular goitre treated with LT4 for > or = 2 years (52 +/- 32 months, range 24-138, median 42) and a matched group with untreated goitre.

SUBJECTS

A total of 89 female outpatients (53.3 +/- 9 years; 36 pre- and 53 postmenopausal), 43 treated and 46 untreated.

MAIN OUTCOME MEASURES

Bone mineralization was measured with total body and regional mineralometry [dual energy X-ray absorptiometry (DEXA)], and indirectly evaluated with biochemical parameters (alkaline phosphatase, osteocalcin). Efficacy of LT4 therapy was assessed by measuring the nodule size during ultrasonography. The adequacy of the treatment was evaluated on the basis of serum TSH levels.

RESULTS

No significant differences were found at DEXA for total body and regional mineralization (P > 0.05 for all comparisons) in treated and untreated patients, both in pre- and postmenopausal states. Evaluation of the nodule size during the ultrasound scan showed a reduction of > or = 30% in 11 of 43 treated patients (26%) versus none of the untreated, an unchanged size in 29 treated patients (67%) versus 18 untreated, an increase of nodules and/or new nodule development in three treated patients (7%) versus 28 untreated (61%).

CONCLUSIONS

L-thyroxine (LT4) treatment at doses slightly suppressing TSH does not significantly affect bone mineralization, nor does it represent a risk factor for osteoporosis, even in postmenopausal patients. The efficacy of this therapeutic schedule on goitre size is comparable with the effects previously reported with suppressive doses.