Mutational Profile in 75 Patients With Anti-Myelin-Associated Glycoprotein Neuropathy: Clinical and Hematologic Therapy Response and Hints on New Therapeutic Targets

BACKGROUND AND OBJECTIVES

Neuropathy with antibodies to myelin-associated glycoprotein (MAG) is the most common paraproteinemic IgM neuropathy. Recently, the mutational profile of the MYD88 and CXCR4 genes has been included in the diagnostic workup of IgM monoclonal gammopathies. The objective of our study was to assess the prevalence of MYD88 ^L265P and CXCR4 ^S338X gene variants in patients with anti-MAG antibody neuropathy. Secondary aims were to evaluate possible correlations between the mutational profile and neuropathy severity, antibody titers, and treatment response.

METHODS

Seventy-five patients (47 men, mean age at molecular analysis 70.8 ± 10.2 years; mean disease duration 5.1 ± 4.9 years) with anti-MAG antibody neuropathy were recruited. Among them, 38 (50.7%) had IgM monoclonal gammopathy of undetermined significance, 29 (38.7%) Waldenstrom macroglobulinemia (WM), and 8 (10.6%) chronic lymphocytic leukemia/marginal zone lymphoma/hairy cell leukemia variant. Molecular analysis was performed on DNA from the bone marrow mononuclear cells in 55 of 75 patients and from peripheral mononuclear cells in 18 of 75 patients. Forty-five patients were treated with rituximab, 6 with ibrutinib, 2 with obinutuzumab-chlorambucil, and 3 with venetoclax-based therapy. All the patients were assessed with the Inflammatory Neuropathy Cause and Treatment (INCAT) Disability Scale, INCAT Sensory Sum Score, and MRC Sum Score at baseline and follow-up. We considered as responders, patients who improved by at least 1 point in 2 clinical scales.

RESULTS

Fifty patients (66.7%) carried the MYD88^L265P variant, with a higher frequency in WM and naive patients (77.2% vs 33.3%, p = 0.0012). No patients harbored the CXCR4^S338X variant. There were no significant differences in hematologic data (IgM levels, M protein, and anti-MAG antibody titers), neuropathy severity, or response to rituximab in MYD88-altered and MYD88 wild-type patients. Nine of 11 (81.8%) patients treated with novel targeted drug, according to the MYD88 status, responded to treatments.

DISCUSSION

MYD88^L265P variant has a high prevalence (66.7%) in anti-MAG antibody neuropathy representing a potential effective mutational target for Bruton tyrosine kinase inhibitors. MYD88^L265P variant, however, does not seem to be a prognostic factor of neuropathy severity or response to rituximab. In patients not responding or becoming refractory to rituximab, a tailored therapy with new effective target therapies should be considered.

Guillain-Barré Syndrome and COVID-19: a one-year observational multicenter study

Background and purpose

Many single cases and small series of Guillain–Barré syndrome (GBS) associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection were reported during the coronavirus disease 19 (COVID‐19) outbreak worldwide. However, the debate regarding the possible role of infection in causing GBS is still ongoing. This multicenter study aimed to evaluate epidemiological and clinical findings of GBS diagnosed during the COVID‐19 pandemic in northeastern Italy in order to further investigate the possible association between GBS and COVID‐19.

Methods

Guillain–Barré syndrome cases diagnosed in 14 referral hospitals from northern Italy between March 2020 and March 2021 were collected and divided into COVID‐19‐positive and COVID‐19‐negative. As a control population, GBS patients diagnosed in the same hospitals from January 2019 to February 2020 were considered.

Results

The estimated incidence of GBS in 2020 was 1.41 cases per 100,000 persons/year (95% confidence interval 1.18–1.68) versus 0.89 cases per 100,000 persons/year (95% confidence interval 0.71–1.11) in 2019. The cumulative incidence of GBS increased by 59% in the period March 2020–March 2021 and, most importantly, COVID‐19‐positive GBS patients represented about 50% of the total GBS cases with most of them occurring during the two first pandemic waves in spring and autumn 2020. COVID‐19‐negative GBS cases from March 2020 to March 2021 declined by 22% compared to February 2019–February 2020.

Conclusions

Other than showing an increase of GBS in northern Italy in the “COVID‐19 era” compared to the previous year, this study emphasizes how GBS cases related to COVID‐19 represent a significant part of the total, thus suggesting a relation between COVID‐19 and GBS.

The BCL2 Inhibitor Venetoclax Plus Rituximab Is Active in MYD88 Wild-Type Polyneuropathy With Anti-MAG Antibodies

OBJECTIVES

Ibrutinib is active in anti-myelin-associated glycoprotein (MAG) polyneuropathy with MYD88^L265P mutation; however, its efficacy is likely to be low in MYD88 wild-type patients. Venetoclax, an oral inhibitor of BCL2, in combination with rituximab is highly active in ibrutinib-resistant hematologic malignancies. We report on the first patient with anti-MAG polyneuropathy and MYD88 wild-type who responded to venetoclax-rituximab.

METHODS

A 62-year-old woman with chronic lymphocytic leukemia had IgM/K anti-MAG neuropathy. She needed bilateral support to walk outdoors, despite therapy with rituximab/cyclophosphamide. Tremor and symptoms at arms prevented her capability of performing common tasks. Bone marrow genetic showed lack of MYD88 mutation. Venetoclax was given orally starting from 20 mg up to 400 mg for 24 months. Rituximab was administrated IV, after the ramp-up phase, at 375 mg/m² for the second month and then monthly at 500 mg/m² for months 3-7.

RESULTS

After 12 months of venetoclax IgM levels decreased from 1.16 to 0.52 g/L, the paraproteins became undetectable and anti-MAG antibody titer decreased. The patient regained the capability of walking independently. Tremor disappeared, she is back able to write and knitt.

DISCUSSION

The first patient with anti-MAG neuropathy treated with venetoclax-rituximab shows encouraging results.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that for a patient with relapsed anti-MAG antibody polyneuropathy, MYD88 wild-type, venetoclax plus rituximab is effective.

Informality in the time of COVID-19 in Latin America: Implications and policy options

This paper analyzes the dynamics of the labor market in Latin America during the COVID-19 pandemic. After a decade of a virtuous circle of growth with the creation of formal jobs, the pandemic has had an considerable impact on the region's labor market, generating an unparalleled increase in the proportion of the inactive population, considerable reductions in informality, and, in contrast, smaller fluctuations in formal jobs. In this context, the formal sector, given its lower flexibility, became a "social safety net" that preserved the stability of employment and wages. Based on the findings presented in this paper, it is projected that, starting in 2021, informality will grow to levels higher than those of the pre-COVID-19 era-with 7.56 million additional informal jobs-as a result of the population returning to the labor market to compensate for the declines in incomes. According to the simulations presented, postponing or forgiving income tax payments and social security contributions conditional on the generation of formal jobs could reduce the growth of informality by 50 to 75 percent. Achieving educational improvements has the potential to reduce it by 50 percent.

Guillain-Barré syndrome after SARS-CoV-2 infection in an international prospective cohort study

In the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increasing number of patients with neurological disorders, including Guillain-Barré syndrome (GBS), have been reported following this infection. It remains unclear, however, if these cases are coincidental or not, as most publications were case reports or small regional retrospective cohort studies. The International GBS Outcome Study is an ongoing prospective observational cohort study enrolling patients with GBS within 2 weeks from onset of weakness. Data from patients included in this study, between 30 January 2020 and 30 May 2020, were used to investigate clinical and laboratory signs of a preceding or concurrent SARS-CoV-2 infection and to describe the associated clinical phenotype and disease course. Patients were classified according to the SARS-CoV-2 case definitions of the European Centre for Disease Prevention and Control and laboratory recommendations of the World Health Organization. Forty-nine patients with GBS were included, of whom eight (16%) had a confirmed and three (6%) a probable SARS-CoV-2 infection. Nine of these 11 patients had no serological evidence of other recent preceding infections associated with GBS, whereas two had serological evidence of a recent Campylobacter jejuni infection. Patients with a confirmed or probable SARS-CoV-2 infection frequently had a sensorimotor variant 8/11 (73%) and facial palsy 7/11 (64%). The eight patients who underwent electrophysiological examination all had a demyelinating subtype, which was more prevalent than the other patients included in the same time window [14/30 (47%), P = 0.012] as well as historical region and age-matched control subjects included in the International GBS Outcome Study before the pandemic [23/44 (52%), P = 0.016]. The median time from the onset of infection to neurological symptoms was 16 days (interquartile range 12-22). Patients with SARS-CoV-2 infection shared uniform neurological features, similar to those previously described in other post-viral GBS patients. The frequency (22%) of a preceding SARS-CoV-2 infection in our study population was higher than estimates of the contemporaneous background prevalence of SARS-CoV-2, which may be a result of recruitment bias during the pandemic, but could also indicate that GBS may rarely follow a recent SARS-CoV-2 infection. Consistent with previous studies, we found no increase in patient recruitment during the pandemic for our ongoing International GBS Outcome Study compared to previous years, making a strong relationship of GBS with SARS-CoV-2 unlikely. A case-control study is required to determine if there is a causative link or not.

Oligoclonal IgG bands in chronic inflammatory polyradiculoneuropathies

BACKGROUND

Cerebrospinal fluid (CSF) albumincytologic dissociation represents a supportive diagnostic criterion of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).Few studies have investigated possible systemic or intrathecal humoral immune response activation in CIDP.Aim of our study was to investigate whether the search of oligoclonal IgG bands (OCBs) might provide additional data helpful in CIDP diagnostic work-up.

METHODS

Forty-eight consecutive patients with CIDP (34 men, mean age 59.4, range 16-83) were recruited. CSF analysis included nephelometric measurement of albumin and IgG concentrations, calculation of Q_ALB, QAlb_LIM and intrathecal IgG synthesis, and OCBs detection with isoelectric focusing. Data were compared with those from CSF and serum of 32 patients with Guillain-Barré syndrome (GBS), 18 patients with anti-myelin associated glycoprotein (MAG) antibody neuropathy, 4 patients with multifocal motor neuropathy and 32 patients with non-inflammatory neuropathies (NINPs).

RESULTS

Patients with CIDP and anti-MAG antibody neuropathy had significantly higher CSF albumin concentrations and Q_ALB values than NINPs (p=0.0003 and p=0.0095, respectively). A total of 9 (19%) patients with CIDP presented identical serum and CSF OCBs ('mirror pattern') versus 3 patients (16.6%) with anti-MAG antibody neuropathy, 13 patients (40.6%) with GBS and 12.5% patients with NINPs. Only one patient with CIDP showed unique-to-CSF OCBs. First-line therapy was effective in 80.4% of patients with CIDP, irrespective of CSF findings.

CONCLUSIONS

Compared with NINP, CIDP, GBS and anti-MAG antibody neuropathies had a significantly increased CSF protein and blood-spinal nerve root barrier damage. Intrathecal humoral immune response is rare in our patients with CIDP. Systemic oligoclonal activation is more frequent, but not significantly different from what was detected in the control groups.

Levels of Polychlorinated Dibenzo-p-Dioxins/Furans and Polychlorinated Biphenyls in Free-Range Hen Eggs in Central Italy and Estimated Human Dietary Exposure

ABSTRACT

The aim of the present study was to evaluate the contamination levels of some classes of persistent organic pollutants in free-range hen eggs and to estimate the related human dietary exposure in a site of national interest, characterized by a serious state of environmental pollution in the Bussi sul Tirino area in central Italy. For these purposes, 17 samples of free-range hen eggs collected in home-producing farms located in the site of national interest territory were analyzed for 17 polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs), 12 dioxin-like polychlorinated biphenyls (dl-PCBs), and 6 non-dioxin-like PCBs (ndl-PCBs). Dietary exposure was assessed assuming a standard consumption of eggs per week. The concentration of ∑PCDD/Fs plus dl-PCBs ranged from 0.463 to 8.028 pg toxic equivalent g-1 fat, whereas the mean contamination level of the ∑ndl-PCBs ranged from 0.234 to 7.741 ng toxic equivalent g-1 fat. PCDD/Fs and PCBs contamination levels were lower than maximum values established by the Commission Regulation (European Union) 1259/2011, except for one sample. The estimated weekly intake, calculated to evaluate the contribution in terms of the monitored pollutants of the locally produced eggs to the diet, was lower than the tolerable weekly intake established by the European Food Safety Authority.

HIGHLIGHTS

Guillain-Barré syndrome and COVID-19: an observational multicentre study from two Italian hotspot regions

OBJECTIVE

Single cases and small series of Guillain-Barré syndrome (GBS) have been reported during the SARS-CoV-2 outbreak worldwide. We evaluated incidence and clinical features of GBS in a cohort of patients from two regions of northern Italy with the highest number of patients with COVID-19.

METHODS

GBS cases diagnosed in 12 referral hospitals from Lombardy and Veneto in March and April 2020 were retrospectively collected. As a control population, GBS diagnosed in March and April 2019 in the same hospitals were considered.

RESULTS

Incidence of GBS in March and April 2020 was 0.202/100 000/month (estimated rate 2.43/100 000/year) vs 0.077/100 000/month (estimated rate 0.93/100 000/year) in the same months of 2019 with a 2.6-fold increase. Estimated incidence of GBS in COVID-19-positive patients was 47.9/100 000 and in the COVID-19-positive hospitalised patients was 236/100 000. COVID-19-positive patients with GBS, when compared with COVID-19-negative subjects, showed lower MRC sum score (26.3±18.3 vs 41.4±14.8, p=0.006), higher frequency of demyelinating subtype (76.6% vs 35.3%, p=0.011), more frequent low blood pressure (50% vs 11.8%, p=0.017) and higher rate of admission to intensive care unit (66.6% vs 17.6%, p=0.002).

CONCLUSIONS

This study shows an increased incidence of GBS during the COVID-19 outbreak in northern Italy, supporting a pathogenic link. COVID-19-associated GBS is predominantly demyelinating and seems to be more severe than non-COVID-19 GBS, although it is likely that in some patients the systemic impairment due to COVID-19 might have contributed to the severity of the whole clinical picture.

RFC1 expansions are a common cause of idiopathic sensory neuropathy

After extensive evaluation, one-third of patients affected by polyneuropathy remain undiagnosed and are labelled as having chronic idiopathic axonal polyneuropathy, which refers to a sensory or sensory-motor, axonal, slowly progressive neuropathy of unknown origin. Since a sensory neuropathy/neuronopathy is identified in all patients with genetically confirmed RFC1 cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we speculated that RFC1 expansions could underlie a fraction of idiopathic sensory neuropathies also diagnosed as chronic idiopathic axonal polyneuropathy. We retrospectively identified 225 patients diagnosed with chronic idiopathic axonal polyneuropathy (125 sensory neuropathy, 100 sensory-motor neuropathy) from our general neuropathy clinics in Italy and the UK. All patients underwent full neurological evaluation and a blood sample was collected for RFC1 testing. Biallelic RFC1 expansions were identified in 43 patients (34%) with sensory neuropathy and in none with sensory-motor neuropathy. Forty-two per cent of RFC1-positive patients had isolated sensory neuropathy or sensory neuropathy with chronic cough, while vestibular and/or cerebellar involvement, often subclinical, were identified at examination in 58%. Although the sensory ganglia are the primary pathological target of the disease, the sensory impairment was typically worse distally and symmetric, while gait and limb ataxia were absent in two-thirds of the cases. Sensory amplitudes were either globally absent (26%) or reduced in a length-dependent (30%) or non-length dependent pattern (44%). A quarter of RFC1-positive patients had previously received an alternative diagnosis, including Sjögren's syndrome, sensory chronic inflammatory demyelinating polyneuropathy and paraneoplastic neuropathy, while three cases had been treated with immune therapies.

Nerve ultrasound in hereditary transthyretin amyloidosis: red flags and possible progression biomarkers

Background

Diagnostic delay of hereditary transthyretin amyloidosis (ATTRv, v for variant) prevents timely treatment and, therefore, concurs to the mortality of the disease. The aim of the present study was to explore with nerve ultrasound (US) possible red flags for early diagnosis in ATTRv patients with carpal tunnel syndrome (CTS) and/or polyneuropathy and in pre-symptomatic carriers.

Methods

Patients and pre-symptomatic carriers with a TTR gene mutation were enrolled from seven Italian centers. Severity of CTS was assessed with neurophysiology and clinical evaluation. Median nerve cross-section area (CSA) was measured with US in ATTRv carriers with CTS (TTR-CTS). One thousand one hundred ninety-six idiopathic CTS were used as controls. Nerve US was also performed in several nerve trunks (median, ulnar, radial, brachial plexi, tibial, peroneal, sciatic, sural) in ATTRv patients with polyneuropathy and in pre-symptomatic carriers.

Results

Sixty-two subjects (34 men, 28 women, mean age 59.8 years ± 12) with TTR gene mutation were recruited. With regard to CTS, while in idiopathic CTS there was a direct correlation between CTS severity and median nerve CSA (r = 0.55, p < 0.01), in the subgroup of TTR-CTS subjects (16 subjects, 5 with bilateral CTS) CSA did not significantly correlate with CTS severity (r = − 0.473). ATTRv patients with polyneuropathy showed larger CSA than pre-symptomatic carriers in several nerve sites, more pronounced at brachial plexi (p < 0.001).

Conclusions

The present study identifies nerve morphological US patterns that may help in the early diagnosis (morpho-functional dissociation of median nerve in CTS) and monitoring of pre-symptomatic TTR carriers (larger nerve CSA at proximal nerve sites, especially at brachial plexi).

Prevalence survey of healthcare-associated infections in a large teaching hospital

BACKGROUND

Healthcare-associated infection (HAI) is the most frequent adverse event in healthcare settings. It is associated with increased mortality and antimicrobial resistance, leading to prolonged hospital stays and consistent financial loss for healthcare systems. The objective of this study was to estimate the burden of HAIs and antimicrobial use in the Teaching Hospital Policlinico Umberto I (THPUI) of Rome and to identify the most critical areas for intervention.

METHODS

Data were collected according to the most recent ECDC point prevalence survey protocol in November 2018. Descriptive statistics for all variables were calculated. Univariate analysis was used to assess possible associations between variables and HAIs. Variables with a significance level of p<0.25 were included in a multiple logistic regression model.

RESULTS

A total of 799 patients were included in the analysis; of these, 13.3% presented with at least one HAI. Bloodstream infection was the most common, accounting for 30.9% of total infections. Overall, 125 microorganisms were isolated, with Enterobacteriaceae being the most frequent (32%). At the time of the survey, 49.1% patients were receiving antimicrobial therapy. The multivariate analysis showed a significant association between HAI and use of medical devices (OR=34.30; 95% CI:3.69-318.66), length of stay (OR=1.01; 95% CI:1.00-1.02) and exposure to prophylactic antimicrobial therapy (OR=0.23; 95% CI:0.11-0.47).

CONCLUSIONS

The ECDC methodology proved to be applicable to THPUI, where HAI prevalence was higher than the European standard (6.7%). This highlights the need to implement targeted measures to prevent and control HAIs, including continuous monitoring to evaluate the effectiveness of such interventions.

Sural nerve biopsy: current role and comparison with serum neurofilament light chain levels

The diagnosis of peripheral neuropathies can be challenging with consequent difficulties in patients' management. The aim of this study was to explore the current diagnostic role of sural nerve biopsy and to compare pathological findings with serum neurofilament light chain levels (NfL) as biomarkers of axonal damage. We collected demographic, clinical, and paraclinical data of patients referred over 1 year to the Neurology Unit, University of Verona, Italy, to perform nerve biopsy for diagnostic purposes, and we analyzed NfL levels in available paired sera using a high sensitive technique (Quanterix, Simoa). Eighty-two patients were identified (37.8% females, median age 65.5 years). Neuropathy onset was frequently insidious (68.3%) with a slowly progressive course (76.8%). Lower limbs were usually involved (81.7%), with a predominance of sensory over motor symptoms (74.4% vs 42.7%). The most common neuropathological findings were a demyelinating pattern (76.8%), clusters of regenerations (58.5%), and unmyelinated fibers involvement on ultrastructural evaluation (52.4%). A definite pathological diagnosis was achieved in 29 cases, and in 20.7% of patients, the referral clinical diagnosis was modified. Coexistent hematological conditions and hepatitis were diagnostic confounding factors (p = 0.012 and 0.034, respectively). In the analyzed paired sera (n = 37), an inverse despite not significant relationship between NfL values and fiber density was observed (Spearman's rho - 0.312, p = 0.056). In addition, we noted increased serum NfL values of patients with active axonal degeneration. Nerve biopsy remains a useful diagnostic investigation to achieve a correct diagnosis and guide patients' management in selected cases of peripheral neuropathy. Serum NfL is an accessible and potential valuable marker of axonal damage in these conditions.

The Bruton tyrosine kinase inhibitor ibrutinib improves anti-MAG antibody polyneuropathy

Objective

To assess whether neuropathy with anti-myelin-associated glycoprotein (MAG) antibody may improve after treatment with ibrutinib, an oral inhibitor of Bruton tyrosine kinase, we prospectively treated with ibrutinib a cohort of 3 patients with anti-MAG neuropathy and Waldenström macroglobulinemia (WM).

Methods

All 3 patients underwent bone marrow biopsy showing WM, with MYD88^L265P mutated and CXCR4^S338X wild type, and were started on ibrutinib 420 mg/die. Patients were assessed at baseline, at 3-6-9 months, and at 12 months in 2 patients with a longer follow-up, using Inflammatory Neuropathy Cause and Treatment (INCAT) Disability Score, INCAT sensory sum score, and Medical Research Council sum score. The modified International Cooperative Ataxia Rating Scale was performed in 2 patients, whereas it was not used in the patient with Parkinson disease as a major comorbidity. Responders were considered the patients improving by at least one point in 2 clinical scales.

Results

All the patients reported an early and subjective benefit, consistent with the objective improvement, especially of the sensory symptoms as shown by clinical scales. Treatment was well tolerated.

Conclusion

These preliminary data point to a possible efficacy of ibrutinib in anti-MAG antibody neuropathy, which is the most common disabling paraproteinemic neuropathy, where active treatment is eagerly needed.

Classification of evidence

This study provides Class IV evidence that for patients with anti-MAG antibody neuropathy, ibrutinib improves neuropathy symptoms.

Prevalence survey of healthcare associated infections in a large teaching hospital

Background

Healthcare Associated Infection (HAI) is the most frequent adverse event in healthcare settings. It is associated with an increased mortality and antimicrobial resistance, prolonged hospital stays and consistent financial loss for the healthcare systems. The objective of this study was to estimate the burden of HAIs and antimicrobial use in the Teaching Hospital Policlinico Umberto I (THPUI) of Rome to identify the most critical areas for interventions.

Methods

Data were collected according to the most recent ECDC Point Prevalence Survey protocol in November 2018. Descriptive statistics for all variables were calculated. Univariate analysis was used to assess possible associations between variables and HAIs. Variables with a significance level of p &lt; 0.25 were included in a multiple logistic regression model.

Results

A total of 799 patients were included in the analysis; of these, 13.3% presented at least one HAI. Bloodstream infection was the most common, accounting for 30.9% of the total infections. Globally, 125 microorganisms were isolated, with Enterobacteriaceae being the most frequent (32%). At the time of the survey, 49.1% patients were receiving antimicrobial therapy. The multivariate analysis showed a significant association between HAI and use of medical devices (OR = 34.30,IC95%:3.69-318.66), length of stay (OR = 1.01, IC95%:1.00-1.02) and the exposure to prophylactic antimicrobial therapy (OR = 0.23, IC95%:0.11 -0.47).

Conclusions

Our HAI prevalence was higher than the European standard (6.7%). This highlights the need of implementing targeted measures to prevent and control HAIs and a continuous monitoring to evaluate the effectiveness of such interventions. Another step could be the elaboration of a survey to investigate the knowledge, attitudes and practices of healthcare workers towards HAIs in order to raise awareness, enhance surveillance strategies and promote educational interventions.

Key messages

It was important to quantify the burden of HAIs in the THPUI in order to identify the main areas for interventions. Several activities will be implemented to contain this problem.

Limitations in daily activities and general perception of quality of life: Long term follow-up in patients with anti-myelin-glycoprotein antibody polyneuropathy

In this study, we assessed the modifications over time of daily activities and quality of life (QoL) in 32 subjects with anti-myelin-glycoprotein (MAG) antibody neuropathy. A widespread panel including clinical scores and patient-reported questionnaires, in compliance of the terms by the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO), was employed at enrollment (T0) and at follow-up evaluation (T1) after a mean interval of 15.4 ± 5.7 months. The Sensory Modality Sum score (SMS) at four limbs showed a significant worsening over time (mean score 27.2 ± 3.9 at T0 vs 25.7 ± 3 at T1 at upper limbs, P = .03; 20.5 ± 4.8 at T0 vs 18.6 ± 5.9 at T1 at lower limbs, P = .04). The Visual Analogue Scale (VAS) for pain significantly worsened at upper limbs at T1 (mean values 0.84 ± 1.95 at T0 vs 1.78 ± 2.6 at T1, P = .03). All the other tests did not show significant differences between T0 and T1. In the subgroup who underwent rituximab (15/32 treated before T0, 3/32 patients treated between T0 and T1 with median interval of 1 year), no significant differences were observed between T0 and T1. Despite the quite long follow-up, statistical significance was not achieved either for the limited number of patients or for the lack of sensitive outcome measures. In our cohort, the significant worsening of the SMS and VAS after a median of 14 months can be considered as a reliable expression of the natural history of the disease, and suggest that these scales might represent possible outcome measures in anti-MAG antibody neuropathy.

Abstract P5-01-02: Glandular dose in contrast-enhanced dual-energy mammography

INTRODUCTION

Estimation of the Average Glandular Dose (AGD) absorbed by the breast during x-ray based examination is an established part of quality control procedures for breast imaging, both for standard mammography and new techniques as digital breast tomosynthesis (DBT) and contrast enhanced digital mammography (CEDM). It is however fundamental that every optimization program obtains an adequate imaging quality. In our study we evaluated the AGD absorbed by the breast, during CEDM examinations, performed with Dual Energy (DE) technique in our Department.

MATERIALS AND METHODS

We retrospectively evaluated 37 DE mammograms; we reported and analyzed AGD, Entrance Skin Exposure (ESE), anode/filter combinations, breast thickness, kV (kilovolt), mAs (milliAmpere per second), and compression in daN (decaNewton) values, for each mammography view obtained on high and low energy. In 10 Patients, it was possible to compare DE with a recent standard mammography performed on the same mammography unit.

RESULTS

AGD values for the entire DE study, in craniocaudal and mediolateral oblique views, resulted between 4.23 mGy and 13.44 mGy; based on the breast thickness (27-79 mm) and on the anod/filter combination. We found out a significantly lower AGD for small breast thicknesses and Mo/Rh and Mo/Cu combination compared to Rh/Rh and Rh/Cu.

In the whole study evaluation, the AGD percentage report due to low and high energy acquisitions resulted between 76.8% and 81.6%, and between 18.4% and 23.2%, respectively.

For the 10 Patients in which was possible a direct comparison with the data obtained with recent standard mammography, resulted a ratio between DE AGD and standard mammography AGD variable from 1.43 to 2.48 (mean value: 2.0), again with lower AGD values obtained with Mo/Rh - Mo/Cu combination and for small breast thicknesses.

AGD ratio between low energy and standard mammography acquisition resulted between 1.23 and 3.31.

DISCUSSION

CEDM is proving to have all the potential to get a definite role in diagnosis and breast tumor staging, providing a direct correlation between morphologic and functional imaging.

In our study we assessed the dosimetry to determine if an additional x-ray exposure will be a limit to DE use and, if that is the case, in which measure. Data in the literature on DE dosimetry are still spare and extremely heterogenous.

In any case, the increase of delivered dose could be justifiable when compared to the great benefits given by this technique in breast cancer early diagnosis and staging, especially in dense breast tissue, in the follow-up of Patients with breast cancer history and in case of MRI incompatibility.

Furthermore, when compared to MRI, CEDM is an easy-access, low-cost, fast and well accepted exam by the patient.

CONCLUSIONS

Although the risk of induced carcinogenesis associated with x-ray breast modalities is small, dosimetric aspects should be considered both for the risk evaluation and for optimization of acquisition systems; with the advance of the technologies we will be able to have a dose reduction by maintaining high quality standards.

Results obtained from this preliminary study needs to be extended by a larger case study to get a complete evaluation and comprehension of the phenomenon.

Citation Format: Cossu E, Castellani F, Fiaschetti V, Mariateresa M, Tiziana R, Angelo T. Glandular dose in contrast-enhanced dual-energy mammography [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-01-02.

Cyst of canal of Nuck in a young woman affected by kniest syndrome: ultrasound and MRI features

Swelling of the inguinal region in a woman is a frequent finding in daily clinical practice. We focused our attention on the possible differential diagnoses, giving emphasis to the less common causes of this frequent female disorder and describing their characteristics in ultrasound and magnetic resonance imaging. The causes of swelling in this region may be multiple and in this paper, we will show a rare case of diagnosis of Nuck's canal cyst in a patient with Kniest Syndrome.

Imaging in the pre-operative staging of ovarian cancer

The main prognostic factor in ovarian cancer is the stage of disease at diagnosis. The staging system in use (FIGO classification, updated in 2014) is based on the surgical-pathological findings. Although surgical staging is the gold standard in ovarian cancer, the initial patient management depends on the imaging-based pre-surgical staging assessment, in order to identify unresectable or difficult to resect disease. Radiologists need to be aware of the strengths of the available imaging modalities, as well as the imaging pitfalls. Clear understanding of pattern of disease spread and review areas are critical for accurate staging and treatment planning. The current standard of care for pre-surgical staging is CT of the thorax, abdomen, and pelvis. This allows a rapid evaluation of disease extent and is fairly accurate in identifying bulky disease but has definite limitations in assessing the extent of small volume disease and in the confirmation of certain sites of disease beyond the abdomen. Functional MRI has been reported to be superior in detecting small peritoneal deposits. PET/CT may be used as a problem-solving tool in some patients where determination remains unclear, particularly in confirmation of advanced stage beyond the abdomen.

Dietary supplementation with dried olive pomace in dairy cows modifies the composition of fatty acids and the aromatic profile in milk and related cheese

This study aimed to evaluate the effect of dietary integration of dried olive pomace (DOP), a by-product of olive oil separation, on nutritional and aromatic properties of milk and cheese. Twenty dairy cows were divided into 2 groups that were balanced for milk yield, parity, and days in milk. The control group was fed a conventional diet (20 kg of dry matter/head per day), whereas the experimental group (EG) received the conventional diet supplemented with DOP as 10% of dry matter. During the trial, milk yield was recorded and the samples of milk, cheese, total mixed rations, and DOP were collected and analyzed to determine the chemical-nutritional composition and aromatic profile. Atherogenic and thrombogenic indices were calculated on the basis of the fatty acid (FA) profile of milk and cheese. Data were analyzed according to the mixed model for milk yield and chemical composition, including cows nested within treatment as a random effect, whereas the general linear model was used for the analysis of cheese parameters. Differences were assessed by Tukey's test. The EG diet had a lower content of palmitic, stearic, and linoleic acids and a higher level of oleic acid compared with the control. Dietary DOP integration did not affect milk yield and composition with the exception of protein content, which was greater in EG and significantly affected by diet and period. Instead, period was found to be significant for fat and casein in both groups. Dietary supplementation with DOP modified the FA profile of milk and cheese. There was a decrease in short- and medium-chain FA, but significance was achieved only for palmitic acid. The stearic, isomer trans of oleic (in particular vaccenic acid), oleic, and isomer trans of linoleic acids significantly increased. Monounsaturated FA increased in EG milk and cheese and saturated FA were significantly lower, whereas no difference was marked between the groups regarding level of polyunsaturated FA. Supplementation with DOP reduced atherogenic and thrombogenic indices and increased conjugated linoleic acid in both milk and cheese. The free fatty acids, ketones, lactones, esters, and phenylalanine catabolites were increased in raw milk, whereas only leucine metabolism was affected by diet in pasteurized milk cheese at both 1 and 30 d of ripening. The present results pointed out that DOP supplementation may improve the nutritional and nutraceutical properties and modify the aroma of milk and derived cheese.

Incidentally discovered well-differentiated retroperitoneal liposarcoma with inguinal canal herniation: report of 2 cases

Well-differentiated retroperitoneal liposarcomas are slow growing and low-grade tumors, reaching usually huge size before being symptomatic and so diagnosed, therefore with increase of the surgical risk and of the probability of dedifferentiation. Inguinal location of these tumors is unusual and rarely diagnosed.

Transcriptomic signature of high dietary organic selenium supplementation in sheep: A nutrigenomic insight using a custom microarray platform and gene set enrichment analysis

The objective of this study was to investigate the effect of a high dietary Se supplementation on the whole transcriptome of sheep. A custom sheep whole-transcriptome microarray, with more than 23,000 unique transcripts, was designed and then used to profile the global gene expression of sheep after feeding a high dietary supplementation of organic Se. Lactating crossbred ewes ( = 10; 3 to 4 yr of age and 55 to 65 kg BW) at late lactation (100 ± 8 d in milk) were acclimated to indoor individual pen feeding of a basal control diet (0.40 mg Se/d, sodium selenite) for 4 wk. Sheep were then kept on a diet with an extra (high) supplementation of organic Se (1.45 mg Se/d as Sel-Plex; Alltech Biotechnology Pty Ltd, Dandenong, Victoria, Australia) for 40 d. Whole blood was collected at 2 time points (last day of the acclimatization period [T0] and after 40 d of the organic Se supplementation [T40]), and then total RNA was isolated and labeled for the subsequent microarray analysis. Significance Analysis of Microarrays, using the -statistic, of the microarray data (T40 versus T0) evidenced the up- and downregulation of 942 and 244 transcripts (false discovery rate < 0.05), respectively. Seven genes showed the same trend of expression (up- or downregulation) when tested by quantitative real-time PCR (qPCR) in a cross-validation step. The microarray showed significant upregulation of the following selenoproteins at T40: selenium binding protein 1 (SELENBP1), selenoprotein W1 (SEPW1), glutathione peroxidase 3 (GPX3), and septin 8 (SEPT8). And the expression trends for SEPW1 and SEPT8 were validated using qPCR. Functional annotation of the differentially expressed genes showed the enrichment of several immune system-related biological processes (lymphocyte activation, cytokine binding, leukocyte activation, T cell differentiation, and B cell activation) and pathways (cytokine and interleukin signaling). Moreover, Gene Set Enrichment Analysis evidenced the enrichment of B and T cell receptors signaling pathways, with an enrichment score of 0.63 and 0.59, respectively. Overall, from a global gene expression (whole-transcriptome) point of view, short-term supplementation of a high dietary organic Se to Se-nondeficient sheep results in a transcriptomic signature that mainly reflects an induced immune system and a modulation of transcription effect. Also, the present study provides a custom whole-transcriptome microarray platform that can be used in further global gene expression studies in the ovine species.

Zinner syndrome diagnosed by magnetic resonance imaging and computed tomography: role of imaging to identify and evaluate the uncommon variation in development of the male genital tract

Seminal vesicle cysts are a very rare condition and its often associated with ipsilateral renal agenesis. The diagnosis of seminal vesicle cysts may be delayed or missed because of the non-specific symptoms of this condition. This article reports a triad of right renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction (Zinner syndrome) in a 56 years old man.

Geometrical Characterization of an Electropore from Water Positional Fluctuations

We present here a new method for calculating the radius of a transmembrane pore in a phospholipid bilayer. To compare size-related properties of pores in bilayers of various compositions, generated and maintained under different physical and chemical conditions, reference metrics are needed. Operational metrics can be associated with some observed behavior. For example, pore size can be defined by the largest object that will pass through the length of the pore. The novelty of the present approach resides in the characterization of electropore geometry via a statistical approach, based on essential dynamics rules. We define the pore size geometrically with an algorithm for determining the pore radius. In particular, we extract the radius from the tri-dimensional surface of a defined pore region. The method is applied to a pore formed in a phospholipid bilayer by application of an external electric field. Although the details described here are specific for lipid pores in molecular dynamics simulations, the method can be generalized for any kind of pores for which appropriate structural information is available.

Qualitative pain classification in hospice and pain therapy unit

In this study, we investigated patient's meaning attribution to pain in hospice and pain therapy unit, using a qualitative approach: narrative-based medicine. The data presented here were related to patients (n = 17) hospitalized in Rimini Hospice (Italy). These data were compared to those of patients (n = 21) with noncancer pain (control sample). The interviews were then analyzed according to the technique of thematic narrative analysis. The results of our research identified a differential process in pain processing in relationship to the meaning that the patient attributed to pain. The thematic analysis of the interviews allowed the inductive construction of a specific network of pain dimensions, which were summarized in "the pain chronogram."

Assignment of the nonexchanging protons of the alpha-spectrin SH3 domain by two- and three-dimensional 1H-13C solid-state magic-angle spinning NMR and comparison of solution and solid-state proton chemical shifts

The assignment of nonexchanging protons of a small microcrystalline protein, the alpha-spectrin SH3 domain (7.2 kDa, 62 residues), was achieved by means of three-dimensional (3D) heteronuclear (1H-13C-13C) magic-angle spinning (MAS) NMR dipolar correlation spectroscopy. With the favorable combination of a high B(0)-field, a moderately high spinning frequency, and frequency-switched Lee-Goldburg irradiation applied during 1H evolution, a proton linewidth < or =0.5 ppm at 17.6 Tesla was achieved for the particular protein preparation used. A comparison of the solid-state 1H chemical shifts with the shifts found in solution shows a remarkable similarity, which reflects the identical protein structures in solution and in the solid. Significant differences between the MAS solid- and liquid-state 1H chemical shifts are only observed for residues that are located at the surface of the protein and that exhibit contacts between different SH3 molecules. In two cases, aromatic residues of neighboring SH3 molecules induce pronounced upfield ring-current shifts for protons in the contact area.