Antibody response to four doses of SARS-CoV-2 vaccine in rare autoimmune rheumatic diseases: an observational study

Objective

Antibody responses to coronavirus disease 2019 (COVID-19) vaccines are reduced among immunocompromised patients but are not well quantified among people with rare disease. We conducted an observational study to evaluate the antibody responses to the booster SARS-CoV-2 vaccine in people with rare autoimmune rheumatic diseases (RAIRD).

Methods

Blood samples were collected after second, before third, after third and after fourth vaccine doses. Anti-spike and anti-nucleocapsid antibody levels were measured using an in-house ELISA. Logistic regression models were built to determine the predictors for non-response. Results were compared with age- and sex-matched healthy controls.

Results

Forty-three people with RAIRD were included, with a median age of 56 years. Anti-spike seropositivity increased from 42.9% after second dose to 51.2% after third dose and 65.6% after fourth dose. Median anti-spike antibody levels increased from 33.6 (interquartile range 7.8-724.5) binding antibody units after second dose to 239.4 (interquartile range 35.8-1051.1) binding antibody units after the booster dose (third dose, or fourth dose if eligible). Of the participants who had sufficient antibody levels post-second dose, 22.2% had insufficient levels after the booster, and 34.9% of participants had lower antibodies after the booster than the lowest healthy control had after the second dose. Rituximab in the 6 months prior to booster (P = 0.02) and non-White ethnicity (P = 0.04) were associated with non-response. There was a dose-response relationship between the timing of rituximab and generation of sufficient antibodies (P = 0.03).

Conclusion

Although the booster dose increased anti-spike IgG and seropositivity rates, some people with RAIRD, particularly those on rituximab, had insufficient antibody levels despite three or four doses.

Diagnostic value of two-dimensional echocardiographic measurements of the pulmonary artery diameter and the pulmonary artery distensibility index to detect pulmonary hypertension in horses

INTRODUCTION/OBJECTIVES

Echocardiographic diagnosis of pulmonary hypertension (PH) in horses is usually based on Doppler interrogation of tricuspid (TR) or pulmonic regurgitation (PR). This study aimed at investigating two-dimensional echocardiographic (2DE) variables, including pulmonary artery diameter (PAD) and pulmonary artery distensibility index (PADI), to diagnose PH.

ANIMALS, MATERIALS AND METHODS

41 healthy horses; 82 horses with TR or PR and normal intracardiac pressure gradients; and 35 horses with TR or PR velocities indicating PH. The 2DE variables were compared between groups, cut-offs for the diagnosis of PH were determined, and conditional inference trees served to identify the variable best predicting PH in the absence of TR or PR.

RESULTS

Horses with PH had larger end-diastolic cross-sectional (short-axis) PAD (PADed-sx) (5.8 ± 1.0 cm; mean ± SD) and smaller PADI[/PADps] (15.4 ± 7.7%) than healthy horses (5.0 ± 0.6 cm, P<0.0001; 20.5 ± 4.4%, P<0.001) and horses with TR or PR but no PH (5.3 ± 0.6 cm, P=0.003; 18.8 ± 4.2%, P=0.005). PADed-sx predicted PH with sensitivity (Se) = 36% and specificity (Sp) = 94% (cut-off 6.0 cm, AUC = 0.668, P=0.002), while PADI[/PADps] predicted PH with Se = 43% and Sp = 92% (cut-off 13.7%, AUC = 0.662, P=0.004). In the absence of TR, PADed-sx and the end-diastolic long-axis aortic diameter-to-PADed-sx ratio (AoDed-lx/PADed-sx) were most suitable to diagnose PH.

CONCLUSION

Pulmonary artery crosssectional (short-axis) diameter at end-diastole measured in a right-parasternal long axis view of the left ventricular outflow tract and Pulmonary artery distensibility index were moderately specific but not very sensitive to diagnosing PH. Nonetheless, they may be used as complementary indices suggesting PH in the absence of TR or PR.

Rituximab versus azathioprine for maintenance of remission for patients with ANCA-associated vasculitis and relapsing disease: an international randomised controlled trial

OBJECTIVE

Following induction of remission with rituximab in anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) relapse rates are high, especially in patients with history of relapse. Relapses are associated with increased exposure to immunosuppressive medications, the accrual of damage and increased morbidity and mortality. The RITAZAREM trial compared the efficacy of repeat-dose rituximab to daily oral azathioprine for prevention of relapse in patients with relapsing AAV in whom remission was reinduced with rituximab.

METHODS

RITAZAREM was an international randomised controlled, open-label, superiority trial that recruited 188 patients at the time of an AAV relapse from 29 centres in seven countries between April 2013 and November 2016. All patients received rituximab and glucocorticoids to reinduce remission. Patients achieving remission by 4 months were randomised to receive rituximab intravenously (1000 mg every 4 months, through month 20) (85 patients) or azathioprine (2 mg/kg/day, tapered after month 24) (85 patients) and followed for a minimum of 36 months. The primary outcome was time to disease relapse (either major or minor relapse).

RESULTS

Rituximab was superior to azathioprine in preventing relapse: HR 0.41; 95% CI 0.27 to 0.61, p<0.001. 19/85 (22%) patients in the rituximab group and 31/85 (36%) in the azathioprine group experienced at least one serious adverse event during the treatment period. There were no differences in rates of hypogammaglobulinaemia or infection between groups.

CONCLUSIONS

Following induction of remission with rituximab, fixed-interval, repeat-dose rituximab was superior to azathioprine for preventing disease relapse in patients with AAV with a prior history of relapse.

TRIAL REGISTRATION NUMBER

NCT01697267; ClinicalTrials.gov identifier.

Anatomical inferences on aerial bud protection of three Eugenia shrub species from the Cerrado

Location and degree of protection of aerial buds are important functional traits in disturbance- or stress-prone environments since aerial buds ensure the development of new organs under favourable growing conditions. This study was carried out in a Brazilian Cerrado area under regeneration after long-term Pinus cultivation, where the trees were clear-cut in 2012 and the remaining material was burned in 2014. After the fire treatment, several species resprouted from belowground organs and their aboveground organs were directly exposed to full sunlight. We collected 15 terminal branches with fully expanded leaves from three individuals of each of three Eugenia species to investigate if those with well-developed belowground organs invest in bark for aboveground bud protection. The samples were analysed using light and electron microscopy. In addition to terminal and axillary buds, all species presented accessory buds, and the number varied according to the node analysed. None of the aerial buds were protected by bark, but all were well protected by cataphylls and densely pubescent leaf primordia. There were also inter- and intra-petiolar colleters that released a mucilaginous protein exudate. The distance between the shoot apical meristem and the outer surface was longer in the terminal bud than in axillary buds. The bud leaf primordia covering the shoot apical meristem had a thick cuticle, unicellular non-glandular trichomes that accumulate phenolic and lipophilic compounds, and secretory cavities. Our study shows that all three Eugenia species studied here had highly protected aerial buds allocated from belowground organs. These morphological traits may improve the chances of the species' persistence in areas subjected to frost events, low relative humidity, high irradiance and harmful UV levels.

Is off-label thrombolysis safe and effective in a real-life primary stroke center? A retrospective analysis of data from a 5-year prospective database

BACKGROUND

Intravenous thrombolysis (IVT) use for acute ischemic stroke (AIS) varies among countries, partly due to guidelines and product labeling changes. The study aim was to identify the characteristics of patients with AIS treated with off-label IVT and to determine its safety when performed in a primary stroke center (PSC).

METHODS

This observational, single-center study included all consecutive patients admitted to Perpignan PSC for AIS and treated with IVT and patients transferred for EVT, between January 1, 2015 and December 31, 2019. Data of patients treated with IVT according to ("in-label group") or outside ("off-label") the initial guidelines and manufacturer's product specification were compared. Safety was assessed using symptomatic intracerebral hemorrhage (SIH) as the main adverse event.

RESULTS

Among the 892 patients in the database (834 screened by MRI, 93.5%), 746 were treated by IVT: 185 (24.8%) "in-label" and 561 (75.2%) "off-label". In the "off-label" group, 316 (42.4% of the cohort) had a single criterion for "off-label" use, 197 (26.4%) had two, and 48 (6.4%) had three or more criteria, without any difference in IVT safety pattern among them. SIH rates were comparable between the "off-label" and "in-label" groups (2.7% vs. 1.1%, P=0.21); early neurological deterioration and systematic adverse event due to IVT treatment were similar in the 2 groups. "Off-label" patients had higher in-hospital (8.7% vs. 3.8%, P=0.05) and 3-month mortality rates (12.1% vs 5.4%, P<0.01), but this is explained by confounding factors as they were older (76 vs 67 years, P<0.0001) and more dependent (median modified Rankin scale score 0.4 vs 0.1, P<0.0001) at admission.

CONCLUSIONS

"Off-label" thrombolysis for AIS seems to be safe and effective in the routine setting of a primary stroke center.

Humoral and cellular immunity in patients with rare autoimmune rheumatic diseases following SARS-CoV-2 vaccination

Objectives

COVID-19 vaccine responses in rare autoimmune rheumatic diseases (RAIRD) remain poorly understood, in particular there is little known about whether people develop effective T cell responses. We conducted an observational study to evaluate the short-term humoral and cell-mediated T cell response after the second SARS-CoV-2 vaccination in RAIRD patients compared with healthy controls (HC).

Methods

Blood samples were collected after the second dose and anti-spike, anti-nucleocapsid antibody levels and SARS-CoV-2 specific T cell responses were measured and compared with HC. Activation induced marker and deep phenotyping assays were used to identify differences in T cells between high and low/no antibody groups, followed by multi-dimensional clustering.

Results

50 patients with RAIRD were included (31 with AAV, 4 with other systemic vasculitis, 9 with SLE and 6 with myositis). Median anti-spike levels were significantly lower in RAIRD compared with HC (p< 0.0001). 15 (33%) patients had undetectable and 26 (57%) had lower levels than the lowest HC. Rituximab in the last 12 months (p= 0.003) was associated with reduced immunogenicity compared with a longer pre-vaccination period. There was a significant difference in B cell percentages (p= 0.03) and spike-specific CD4+ T cells (p= 0.02) between no/low antibody vs. high antibody groups. Patients in the no/low antibody group had a higher percentage of terminally differentiated (exhausted) T cells.

Conclusions

Following two doses, most RAIRD patients have lower antibody levels than the lowest HC and lower anti-spike T cells. RAIRD patients with low/no antibodies have diminished numbers and poor quality of memory T cells which lack proliferative and functional capacities.

The impact of RF wattage level on local impedance and procedural parameters in AF ablation cases

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance (LI) measurement can provide information on catheter tip contact, but also changes in LI during ablation can inform the extent and effectiveness of RF energy delivery. To date the relationship between highly LI measurements and contact force (CF) during atrial fibrillation (AF) ablation at different levels of energy delivery is still lacking.

Purpose

We aimed to evaluate the impact of power setting on LI and key procedural parameters in AF ablation cases.

Methods

A novel CF ablation catheter equipped with dedicated algorithm was used to measure LI at the distal electrode of this catheter. Radiofrequency (RF) catheter applications ≥45 watts were categorized as high power (HP) and applications &lt;45w as standard power (SP). Ablations were also grouped according to different levels of CF (&lt;5g, 5-14g, 15-24g and ≥25g). Data are reported as mean±SD.

Results

Sixty-two consecutive pts undergoing RF catheter ablation of AF from the CHARISMA registry were included A total of 4619 ablation spots performed around PVs were analyzed (58% paroxysmal, 84% de novo, RF deliveries per pt=76±27, RF delivery time=9.1±5s, CF=12.3±8g). The majority of these were HP applications (n=4192, 91%). The mean LI was 158±17Ω prior to ablation and 138±14Ω after ablation (p&lt;0.0001, absolute LI drop of 21.9±8Ω) with a LI drop rate equal to 4.4±3Ω/s. HP ablations had significantly shorter RF delivery times, 8.8±4s vs 12±7s (p&lt;0.0001), larger LI drops (22.2±8Ω vs 19.3±9Ω, p&lt;0.0001) and higher LI drop rates (4.5±3Ω/s vs 3.6±2Ω/s, p&lt;0.0001) than SP, respectively. For both HP and SP settings, the magnitude of LI drop increased and RF delivery time decreased with increasing amounts of CF. The largest differences between HP and SP were found when CF was &lt;15g (RF delivery time: 9±5s at HP vs 12.9±7s at SP, percentage of difference 26.3%, p&lt;0.0001; LI drop: 21.2±8Ω at HP vs 18.6±9Ω, percentage of difference -14.3%, p&lt;0.0001). No major complications occurred during the procedures. All PVs were successfully isolated.

Conclusions

This preliminary experience suggests that, HP ablation is effective and safe and resulting in shorter RF delivery times and larger LI drops than SP ablation.

P14 PROCEDURAL SAFETY, SHORT AND LONG–TERM FOLLOW UP AFTER PACEMAKER IMPLANTATION IN NONAGENARIANS

Background

Permanent cardiac stimulation is increasingly necessary in very old patients, due to the augmented life expectancy. This raise concerns in physicians, patients and caregivers, because pacemaker (PM) implantation can be perceived as too invasive for frail patients with significant comorbidities. The aim of the present study is to provide data about peri–operative complications, short and long–term survival and their predictors in this specific setting.

Materials and Methods

All consecutive patients aged ≥ 90 years undergoing pacemaker implantation in our Centre from 2008 to 2020 were enrolled in the registry. Their baseline and follow up data were recorded in a specific database.

Results

Among the 2437 patients undergoing PM implantation in a 13–year period, 153 were nonagenarians (6.3%). Mean age was 92.7 ± 2.3 years. Most of the patients (66.7%) received a ventricular single chamber PM. High–degree atrio–ventricular block was the first indication for implant (59.5%), followed by sick sinus syndrome or atrial fibrillation with slow ventricular response (30.1%). 15.7% patients needed temporary pacing at presentation. 4 patients (2.6%) experienced acute complications: 3 pneumothorax, 1 ventricular lead displacement with need of repositioning. Mean follow up duration was 2.5 ± 2.0 years. 117 patients (78.5%) died during the follow up. Death occurred after a mean of 2.47 years after pacemaker implantation (range 1 – 3272 days). Survival rates were 70.0%, 35.3% and 10.0% at 1, 3 and 5 years respectively. No pacemaker–related long–term complication was recorded during the follow up. 2 patients underwent generator replacement due to battery end of life. Chronic kidney insufficiency (p = 0.030) and congestive heart failure (p = 0.021) but not age were predictors of precocious mortality (within 1 month). Age at implant and longer length of hospital stay before PM implantation were predictors of long–term death (p = 0.001 and p = 0.043 respectively).

Are antigen tests useful as screening for the identification of SARS-CoV-2 in emergency rooms?

Background

A quick and accurate case identification in the Emergency Department (ED) during the SARS-CoV-2 pandemic is crucial for clinical management and to prevent spread of infections. The gold standard for diagnosing SARS-CoV-2 infection is the real-time reverse transcription polymerase chain reaction (RT-PCR) test in upper airways swabs. However, the procedure is available in few specialized laboratories and requires an average sample processing time of about 6 hours from its inception. The development of reliable but cheaper and faster point-of-care tests was expected to be useful either for population-screening or as first aid tests in the ED. Rapid antigenic diagnostic tests (Ag-RDTs), directly detect SARS-CoV-2 proteins produced by the replicating virus in respiratory specimens, were proved to be candidates in both cases. However, data on their effectiveness are still few and controversial. The aim of the study is to establish the accuracy of antigen tests to identify SARS-CoV-2 in a high prevalence setting.

Methods

Results of 324 patients, consecutively admitted to the ED of San Luigi Gonzaga University Hospital in Orbassano (Turin, Italy) between 26 October and 10 November 2020 and subjected to both molecular and antigen tests, were compared.

Results

Using RT-PCR as gold standard, specificity and sensitivity of Ag-RDT were 0.94 (95%CI: 0.90-0.98) and 0.80 (95%CI: 0.75-0.85), respectively. The Ag-RDT positive predictive value was 0.96 (95%CI 0.93- 0.99), and the negative predictive value was 0.72 (95% CI: 0.65-0.79). Patients that tested negative to Ag-RDT but presented with fever and cough or had pneumonia at imaging were more likely to be false negatives. Ag-RDTs best performance occurs in the first days after symptom onset.

Conclusions

These results confirm the limits of antigenic tests as first line screening tests and suggest that the antigenic test should be integrated with clinical judgement, based on physical and instrumental examinations.

Key messages

Antigenic tests have a limited effectiveness as first line screening tests. In a high-prevalence setting these tests incorrectly judge as negative many COVID-19 symptomatic patients, making necessary to integrate their results with clinical judgement.

Local impedance characteristics and advanced mapping capabilities to better understand pulmonary veins reconnections during repeat AF ablation procedures: insight from the CHARISMA registry

Background

Detailed characterization of pulmonary veins (PV) reconnection during repeat AF ablation through high-density mapping (HDM) and local impedance (LI) algorithm is still lacking.

Purpose

We aimed to characterize PV gaps and underlying electrical activity during and after ablation of PVs in AF patients (pts).

Methods

Consecutive patients (pts) undergoing redo AF ablation from the CHARISMA registry with complete characterization of PV gaps (PVG) at 8 Italian centers were included. Rhythmia mapping system was used to map the left atrium and PVs before and after ablation. LI characteristics were collected through a RF ablation catheter equipped with a dedicated LI algorithm (DirectSense). A novel map analysis tool (Lumipoint) that automatically identifies split potentials and continuous activation was used sequentially on each PV component, in order to better assess PVG. Each PVG was characterized in terms of LI and its variations during the procedure. Ablation endpoint was PVI as assessed by entrance and exit block.

Results

Fifty PVGs were automatically identified through the Lumipoint tool in 23 cases, mostly at anterior sites (21, 42%), followed by posterior (15, 30%) and carina (10, 20%) sites. One PVG was identified in 7 (28%) pts, 2 gaps in 10 (43.5%) pts and &gt;2 gaps in 6 (26.1%) pts. The mean LI at PVG sites was 111.3±12Ω prior to ablation: it was significantly higher than LI at scar tissue closer to PVG (99.3±8Ω, p&lt;0.0001) but was significantly lower than LI at healthy tissue (120.8±11Ω, p=0.0015). The mean linear extension of PVGs detected through Lumipoint was significantly lower than the one recognized through voltage map (11.5±8 mm vs 13.3±9 mm, p=0.01) whereas was comparable to the one identified through conventional activation map (11.8±7 mm, p=0.1161 vs Lumipoint). Complete identification of the whole area of PVG was achieved in 31 (62%) and 42 (84%) cases through voltage and activation map, respectively whereas the identification was only partial in 18 (36%) and 7 (14%) cases, respectively. In 1 case both voltage and activation map failed to identify a PVG. No complications during the procedures were reported. All PVs were successfully isolated in all study pts.

Conclusion

Advanced mapping capabilities were useful to pinpoint the search for PVGs, enabling a more targeted ablation approach vs relying on voltage mapping. LI values correlated well with PVGs characteristics and they significantly differ from both scar and healthy tissue.

Funding Acknowledgement

Type of funding sources: None.

Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center

INTRODUCTION

Converting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines.

PATIENTS AND METHOD

For this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database.

RESULTS

During the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262min (100-485min). The median (range) intra-hospital times were: 20min (2-58min) for door-to-imaging, 57min (30-155min) for imaging-to-puncture, 55min (15-180min) for puncture-to-recanalization, and 137min (59-319min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0-2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT.

DISCUSSION AND CONCLUSION

Our results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.

A potential risk assessment tool to monitor pathogens circulation in coastal waters

The present study reports data on a 20 months campaign monitoring enteric viruses (hepatitis A, norovirus, rotavirus, astrovirus, sapovirus, and aichivirus) and bacteria (Salmonella spp.) in seawater. The aim of this work was to assess the potential correlation among the presence of viruses/bacteria and different environmental factors like seasonality, water discharge sources (treated and untreated wastewater, mixed waters and raw water) as well as influence of the Italian lockdown measure against COVID-19 pandemic. Results showed different prevalence of the investigated viruses with values equal to 16 % for norovirus GI, 15.1 % for norovirus GII, followed by 13.8 % for astrovirus, and 13.3 % for sapovirus. Rotavirus was detected in the 8.4 % of samples and aichivirus was detected with the lowest prevalence of 3.5 %. Hepatitis A virus was never identified in the monitoring campaign. Salmonella spp. was detected with a prevalence of 36.6 %. Statistical analysis displayed a high correlation for the two noroviruses simultaneous detection (NGI and NGII) while a lower correlation was found for co-presence of noroviruses with astrovirus, sapovirus or Salmonella spp. A significant decrease of enteric pathogens in seawater was observed during the restrictions period. Results on seasonality highlighted a higher viral prevalence correlated to the wet season for all the pathogens but rotavirus and aichivirus, which instead showed an opposite trend and a higher incidence in the dry season. With respect to discharge typology, some viruses displayed a higher prevalence in treated waters (astrovirus, rotavirus, sapovirus and aichivirus) while the other investigated pathogens (noroviruses and Salmonella spp.) showed a higher prevalence in mixed waters. The main observations of this work were used to define a potential monitoring strategy that could be useful for sanitary Authorities to implement surveillance plans aimed at preventing possible sanitary outbreaks and/or environmental quality deterioration.

Current emerging SARS-CoV-2 pandemic: Potential direct/indirect negative impacts of virus persistence and related therapeutic drugs on the aquatic compartments

The purpose of the present work is to provide a complete overview of possible direct/indirect implications on the quality of aquatic compartments due to the recent SARS-CoV-2 outbreak. With this aim, the environmental impacts are mainly related to i) the virus persistence in sewage and wastewaters, and ii) possible fate in aquatic compartments of drugs tested and administered to SARS-CoV-2 infected patients. Because SARS-CoV-2 spread is very recent, and there is a lack of specific studies on this strain, the virus persistence in wastewaters, the parameters influencing the persistence, as well as the detection methodologies are referenced to the general coronaviruses group. However, the present detailed report of up-to-date knowledge on this topic can provide a useful source for further studies focusing on more deepened investigations of SARS-CoV-2 behaviour in the environment. Such a perspective is significant not only for the control of virus diffusion but also represents a crucial point for the identification of produced alteration to the environmental quality.

Simultaneous removal of Cr(III) from high contaminated soil and recovery of lactic acid from the spent solution

It is proposed a closed-loop treatment cycle for Cr(III) removal from contaminated soils (2080 mg/kg). The treatment includes the use of lactic acid as washing agent, and the recovery of both Cr(II) and lactic acid from the spent solution. Results indicate that Cr(III) removal efficiency can be very high, passing 70% in all tested operative conditions. The metal forms strong complexes with lactic acid, and therefore cannot be eliminated through direct precipitation simply increasing the pH value. Therefore, lactic acid is preliminarily extracted from the solution using n-butanol at very acidic pH. The obtained extraction degree is generally high, varying between 0.5 and 1 according to the amount of used n-butanol solution. After lactic acid extraction, almost 100% of chromium can be recovered through precipitation in alkaline conditions. Lactic acid, in turns, can be purified and reused for a new washing treatment, separating it from n-butanol solution through water extraction. The extraction efficiency is once more satisfying (around 0.5), and not dependent on the operative pH.

Guided mode resonance flat-top bandpass filter for terahertz telecom applications

In this work, we design and experimentally demonstrate a novel terahertz (THz) filter exhibiting a flattened spectral response in the atmospheric transmission window around the central frequency of 300 GHz. The innovative concept behind this filter is the coupling of Fabry-Perot and guided mode resonances. The latter arise from a two-dimensional patch array patterned on an aluminum layer deposited on a low loss cyclo-olefin polymer. The filter experimental performance shows high transmittance in the flat-top band, with less than 3 dB losses, and high out-of-band rejection, as theoretically expected. This kind of component provides a cost-effective, functional solution for narrowband filtering in emerging THz devices and systems with possible applications in wireless telecommunications.

Ultrahigh-quality factor resonant dielectric metasurfaces based on hollow nanocuboids

In this work, a dielectric metasurface consisting of hollow dielectric nanocuboids, with ultrahigh quality factor, is theoretically proposed and demonstrated. The variation of the hole size of the cuboid allows for the tuning of the resonant anapole mode in the nanoparticles. The metasurface is designed to operate in two complementary modes, namely electromagnetically induced transparency and narrowband selective reflection. Thanks to the non-radiative nature of the anapole resonances, the minimal absorption losses of the dielectric materials, and the near-field coupling among the metasurface nanoparticles, a very high quality factor of Q=2.5×10⁶ is achieved. The resonators are characterized by a simple bulk geometry and the subwavelength dimensions of the metasurface permit operation in the non-diffractive regime. The high quality factors and strong energy confinement of the proposed devices open new avenues of research on light-matter interactions, which may find direct applications, e.g., in non-linear devices, biological sensors, laser cavities, and optical communications.

Experimental Determination of Irreversible Entropy Production in out-of-Equilibrium Mesoscopic Quantum Systems

By making use of a recently proposed framework for the inference of thermodynamic irreversibility in bosonic quantum systems, we experimentally measure and characterize the entropy production rates in the nonequilibrium steady state of two different physical systems-a micromechanical resonator and a Bose-Einstein condensate-each coupled to a high finesse cavity and hence also subject to optical loss. Key features of our setups, such as the cooling of the mechanical resonator and signatures of a structural quantum phase transition in the condensate, are reflected in the entropy production rates. Our work demonstrates the possibility to explore irreversibility in driven mesoscopic quantum systems and paves the way to a systematic experimental assessment of entropy production beyond the microscopic limit.

Complement receptor CD46 co-stimulates optimal human CD8+ T cell effector function via fatty acid metabolism

The induction of human CD4+ Th1 cells requires autocrine stimulation of the complement receptor CD46 in direct crosstalk with a CD4+ T cell-intrinsic NLRP3 inflammasome. However, it is unclear whether human cytotoxic CD8+ T cell (CTL) responses also rely on an intrinsic complement-inflammasome axis. Here we show, using CTLs from patients with CD46 deficiency or with constitutively-active NLRP3, that CD46 delivers co-stimulatory signals for optimal CTL activity by augmenting nutrient-influx and fatty acid synthesis. Surprisingly, although CTLs express NLRP3, a canonical NLRP3 inflammasome is not required for normal human CTL activity, as CTLs from patients with hyperactive NLRP3 activity function normally. These findings establish autocrine complement and CD46 activity as integral components of normal human CTL biology, and, since CD46 is only present in humans, emphasize the divergent roles of innate immune sensors between mice and men.

Long-term outcomes of daily oral vs. pulsed intravenous cyclophosphamide in a non-trial setting in ANCA-associated vasculitis

We aimed to compare risk of death, relapse, neutropenia and infection requiring hospital admission between unselected ANCA-associated vasculitis (AAV) patients according to whether cyclophosphamide induction was by daily oral (PO) or pulse intravenous (IV) route. We identified all newly diagnosed AAV patients treated with PO or IV cyclophosphamide between March 2007 and June 2013. We used Cox and logistic regression models to compare mortality, relapse and adverse events and adjusted these for age, renal function and other significant confounders. Fifty-seven patients received PO and 57 received IV cyclophosphamide. One-year survival was 86.0% in PO and 98.2% in IV patients; all-time adjusted hazard ratio (HR) for PO compared to that of IV cyclophosphamide was 1.8 (95% CI 0.3–10.6, P = 0.54). One-year relapse-free survival was 80.7% in PO compared to 87.3% in IV patients, all-time adjusted HR 3.8 (0.2–846, P = 0.37). During the first 12 months, neutropenia of ≤ 0.5 × 10⁹/L occurred in 9 (16%) PO and 0 (0%) IV cyclophosphamide patients (P = 0.003). The number of patients admitted with one or more infections was 16 (28%) in the PO group and 9 (16%) in the IV group, adjusted OR 2.2 (0.6–8.6, P = 0.23). We observed an increased risk of neutropenia, a trend towards increased risk of death and an admission with infection with PO cyclophosphamide. This adds certainty to previous studies, indicating that PO administration induces greater marrow toxicity. Infection-related admissions within 12 months of starting cyclophosphamide were higher than those in clinical trials, possibly reflecting the unselected nature of this cohort.

Peritoneal dialysis throughout pregnancy with successful outcome: A case report

We present the case of a 28-year-old woman who was para 1, with end-stage renal failure secondary to reflux nephritis. She conceived after two years on peritoneal dialysis. She successfully continued this throughout pregnancy, although her antenatal course was complicated by an episode of peritonitis. Induction at 34 weeks resulted in a vaginal birth of a live boy. Her postnatal course was uncomplicated. We reviewed the literature regarding peritoneal dialysis in pregnancy. A recent systematic review identified 14 cases. When the outcomes of these women were compared with those receiving haemodialysis in pregnancy, there was a significantly higher proportion of small for gestational age fetuses, but other parameters were comparable. Two cases of peritonitis complicating peritoneal dialysis in pregnancy have been reported, both successfully treated. We conclude that peritoneal dialysis may be continued in pregnancy with successful maternal and fetal outcome, particularly in women with some residual renal function.

Flexible terahertz wire grid polarizer with high extinction ratio and low loss

An aluminum-based terahertz (THz) wire grid polarizer is theoretically investigated and experimentally demonstrated on a subwavelength thin flexible and conformal foil of the cyclo-olefin Zeonor polymer. THz time-domain spectroscopy characterization, performed on both flat and curved configurations, reveals a high extinction ratio between 40 and 45 dB in the 0.3-1 THz range and in excess of 30 dB up to 2.5 THz. The insertion losses are lower than 1 dB and are almost exclusively due to moderate Fabry-Perot reflections, which vanish at targeted frequencies. The polarizer can be easily fabricated with low-cost techniques such as roll-to-roll and/or large-area electronics processes and promises to open the way for a new class of flexible and conformal THz devices.

Can we routinely measure patient involvement in treatment decision-making in chronic kidney care? A service evaluation in 27 renal units in the UK

Background

Shared decision making is considered an important aspect of chronic disease management. We explored the feasibility of routinely measuring kidney patients' involvement in making decisions about renal replacement therapy (RRT) in National Health Service settings.

Methods

We disseminated a 17-item paper questionnaire on involvement in decision-making among adult patients with established kidney failure who made a decision about RRT in the previous 90 days (Phase 1) and patients who had been receiving RRT for 90–180 days (Phase 2). Recruitment rates were calculated as the ratio between the number of included and expected eligible patients (I : E ratio). We assessed our sample's representativeness by comparing demographics between participants and incident patients in the UK Renal Registry.

Results

Three hundred and five (Phase 1) and 187 (Phase 2) patients were included. For Phase 1, the I : E ratio was 0.44 (range, 0.08–2.80) compared with 0.27 (range, 0.04–1.05) in Phase 2. Study participants were more likely to be white compared with incident RRT patients (88 versus 77%; P < 0.0001). We found no difference in age, gender or social deprivation. In Phases 1 and 2, the majority reported a collaborative decision-making style (73 and 69%), and had no decisional conflict (85 and 76%); the median score for shared decision-making experience was 12.5 (Phase 1) and 10 (Phase 2) out of 20.

Conclusion

Our study shows the importance of assessing the feasibility of data collection in a chronic disease context prior to implementation in routine practice. Routine measurement of patient involvement in established kidney disease treatment decisions is feasible, but there are challenges in selecting the measure needed to capture experience of involvement, reducing variation in response rate by service and identifying when to capture experience in a service managing people's chronic disease over time.

Identification of the G protein-coupled estrogen receptor (GPER) in human prostate: expression site of the estrogen receptor in the benign and neoplastic gland

Estrogens are involved in growth, differentiation and pathogenesis of human prostate through the mediation of the classical estrogen receptors ERα and ERβ. The G protein-coupled estrogen receptor (GPER) is a 'novel' mediator of estrogen signaling which has been recently recognized in some human reproductive tissues, but its expression in the prostate gland is still unknown. Here, we investigated GPER in benign (from 5 patients) and neoplastic prostatic tissues (from 50 patients) by immunohistochemical analysis and Western blotting. Normal areas of benign prostates revealed a strong GPER immunoreactivity in the basal epithelial cells while luminal epithelial cells were unreactive and stromal cells were weakly immunostained. GPER was also immunolocalized in adenocarcinoma samples but the immunoreactivity of tumoral areas decreased from Gleason pattern 2 to Gleason pattern 4. Furthermore, a strong GPER immunostaining was also revealed in cells of pre-neoplastic lesions (high-grade prostatic intra-epithelial neoplasia). Western blot analysis of benign and tumor protein extracts showed the presence of a ~42 kDa band, consistent with the GPER molecular weight. An increase in both pAkt and p cAMP-response-binding protein (pCREB) levels was also observed in poorly differentiated PCa samples. Finally, this work identified GPER in the epithelial basal cells of benign human prostate, with a different localization with respect to the classical estrogen receptors. Furthermore, the expression of GPER in prostatic adenocarcinoma cells was also observed but with a modulation of the immunoreactivity according to tumor cell arrangements.

Thermal transport in out-of-equilibrium quantum harmonic chains

We address the problem of heat transport in a chain of coupled quantum harmonic oscillators, exposed to the influences of local environments of various nature, stressing the effects that the specific nature of the environment has on the phenomenology of the transport process. We study in detail the behavior of thermodynamically relevant quantities such as heat currents and mean energies of the oscillators, establishing rigorous analytical conditions for the existence of a steady state, whose features we analyze carefully. In particular, we assess the conditions that should be faced to recover trends reminiscent of the classical Fourier law of heat conduction and highlight how such a possibility depends on the environment linked to our system.

Purinergic signaling modulates human visceral adipose inflammatory responses: implications in metabolically unhealthy obesity

Obesity is accompanied by chronic inflammation of VAT, which promotes metabolic changes, and purinergic signaling has a key role in a wide range of inflammatory diseases. Therefore, we addressed whether fat inflammation could be differentially modulated by this signaling pathway in the MUO and in individuals who remain MHO. Our results show that the necrotized VAT of both groups released greater levels of ATP compared with lean donors. Interestingly, MUO tissue SVCs showed up-regulation and engagement of the purinergic P2X7R. The extracellular ATP concentration is regulated by an enzymatic process, in which CD39 converts ATP and ADP into AMP, and CD73 converts AMP into adenosine. In VAT, the CD73 ectoenzyme was widely distributed in immune and nonimmune cells, whereas CD39 expression was restricted to immune CD45PAN⁺ SVCs. Although the MUO group expressed the highest levels of both ectoenzymes, no difference in ATP hydrolysis capacity was found between the groups. As expected, MUO exhibited the highest NLRP3 inflammasome expression and IL-1β production. MUO SVCs also displayed up-regulation of the A2AR, allowing extracellular adenosine to increase IL-1β local secretion. Additionally, we demonstrate that metabolic parameters and BMI are positively correlated with purinergic components in VAT. These findings indicate that purinergic signaling is a novel mechanism involved in the chronic inflammation of VAT underlying the metabolic changes in obesity. Finally, our study reveals a proinflammatory role for adenosine in sustaining IL-1β production in this tissue.

Sirolimus-based graft-versus-host disease prophylaxis promotes the in vivo expansion of regulatory T cells and permits peripheral blood stem cell transplantation from haploidentical donors

Hematopoietic stem cell transplantation (HSCT) from human leukocyte antigen (HLA) haploidentical family donors is a promising therapeutic option for high-risk hematologic malignancies. Here we explored in 121 patients, mostly with advanced stage diseases, a sirolimus-based, calcineurin-inhibitor-free prophylaxis of graft-versus-host disease (GvHD) to allow the infusion of unmanipulated peripheral blood stem cell (PBSC) grafts from partially HLA-matched family donors (TrRaMM study, Eudract 2007-5477-54). Conditioning regimen was based on treosulfan and fludarabine, and GvHD prophylaxis on antithymocyte globulin Fresenius (ATG-F), rituximab and oral administration of sirolimus and mycophenolate. Neutrophil and platelet engraftment occurred in median at 17 and 19 days after HSCT, respectively, and full donor chimerism was documented in patients' bone marrow since the first post-transplant evaluation. T-cell immune reconstitution was rapid, and high frequencies of circulating functional T-regulatory cells (Treg) were documented during sirolimus prophylaxis. Incidence of acute GvHD grade II-IV was 35%, and occurrence and severity correlated negatively with Treg frequency. Chronic GvHD incidence was 47%. At 3 years after HSCT, transpant-related mortality was 31%, relapse incidence 48% and overall survival 25%. In conclusion, GvHD prophylaxis with sirolimus-mycophenolate-ATG-F-rituximab promotes a rapid immune reconstitution skewed toward Tregs, allowing the infusion of unmanipulated haploidentical PBSC grafts.

[Study on the efficacy of personal protective equipment for skin against nicotine absorption through the skin route in tobacco workers]

During a previous assessment on the efficacy of some recently installed general dust extraction systems in a tuscan cigar manufacture line, both environmental and biologic monitoring were performed. Although the analysis of environmental samples supported the efficacy of the new general protection implant, these data did not parallel the results from the biologic monitoring, suggesting that nicotine skin absorption needed to be further investigated. We, therefore, carried out a study aimed at evaluating the efficacy of three different kind of PPE for skin (two nitrile gloves of different thickness and one latex glove), to be used by tobacco workers. The results of this study showed that the performance of these three materials in stopping nicotine transfer through the gloves was significantly different. The 0.22 mm thick nicotine gloves resulted, by far, the best gloves in protecting the workers' skin against nicotine exposure.

[Assessment of urinary cotinine in a group occupationally exposed to nicotine]

In a Tobacco processing company, located in central Italy, both air nicotine and, one of its metabolites, the urinary cotinine were assessed, as part of the evaluation of the effectiveness of recently implemented technical preventive controls. Urinary cotinine measurements ranged from 9,63 to 234,09 microg/gr creat. in non-smokers and from 178,79 to 2476,19 microg/gr creat. in smokers. Urinary cotinine proved useful as an exposure biological index especially in terms of population monitoring. On the contrary, the meaning of the measured values were less clear in single workers, because of significant both intra- and inter-individual variability.