The impact of a second embryo biopsy for preimplantation genetic testing for monogenic diseases (PGT-M) with inconclusive results on pregnancy potential: results from a matched case-control study

PURPOSE

To evaluate whether a second biopsy, following a first diagnostic failure on blastocysts tested for preimplantation genetic testing for monogenic diseases (PGT-M), allows to obtain genetic diagnosis and to what extent this procedure can influence clinical pregnancy and live birth rates compared to the PGT-M process with a successful genetic diagnosis from the first biopsy.

METHODS

Embryos from women who underwent PGT-M in an infertility centre and who had been transferred after two biopsies for genetic analysis (n = 27) were matched in a 1:1 ratio accordingly to women's age (± 1 year) and fertility status (fertile vs infertile), as well as with the study period, with embryos who were transferred after receiving a conclusive PGT result straight after the first biopsy (n = 27). The main evaluated outcome was clinical pregnancy rate following embryo transfers in which healthy embryos were transferred after only one biopsy and those in which an embryo was transferred after being re-biopsied. Live birth rate was the secondary outcome.

RESULTS

Clinical pregnancy rate was 52% (95% CI: 34-69) following the transfer of a single-biopsy blastocyst and 30% (95% CI: 16-48) following the transfer of a re-biopsied blastocyst. The likelihood to have a healthy baby was 33% (95% CI: 19-52) following the transfer of a blastocyst biopsied once and 22% (95% CI: 11-41) following the transfer of a re-biopsied blastocyst.

CONCLUSIONS

The re-biopsy intervention seems to considerably reduce the pregnancy potential of a blastocyst. However, a greater sample size is necessary to clarify this issue definitively.

The relationship between CYP19A1 gene expression in luteinized granulosa cells and follicular estradiol output in women with endometriosis

Endometriosis was claimed to negatively affect the intrafollicular environment, hindering oocyte competence. Previous studies evaluated expression levels of cytochrome P450 aromatase (CYP19A) in granulosa and cumulus oophorus cells collected from endometriosis women, but results are controversial. To further investigate the intrafollicular environment whose alteration may potentially disturb ovarian steroidogenesis in endometriosis, gene expression of CYP19A and of its upstream enzymes, StAR and 3βHSD was assessed in luteinized granulosa cells isolated from follicular fluids (FF) collected during Assisted Reproduction Technology (ART) procedures in women with stage III-IV disease and from subjects without the condition. In a subgroup of patients, cumulus oophorus cells (COCs) were also assessed for CYP19A, StAR and 3βHSD gene expression. No difference in mRNA expression of CYP19A1, StAR and 3βHSD in both granulosa cells and COCs was observed between the two groups of patients. No significant difference was also found between estradiol FF levels detected in endometriosis patients (median=873, IQR=522-1221 ng/ml)) and control patients (median=878, IQR=609-1137 ng/ml). To gain more insight into the intrafollicular regulation of CYP19A in patients with endometriosis, associations between expression of the analyzed genes, systemic and follicular 17β-estradiol levels and ART outcomes were assessed. While in the control group, levels of CYP19A1, StAR and 3βHSD transcripts significantly correlated with follicular estradiol levels (adjusted R² of 0.60), no significant association was detected in affected women (adjusted R² of 0.23). After stratification of the populations based on the presence of the disease, CYP19A1 expression was shown to correlate with the number of oocytes retrieved [β:- 1.214;95%CI: - 2.085 - (-0.343); p = 0.007] in the control group while this association was not present in patients with endometriosis [β:- 0.003; 95%CI:- 0.468-0.461; p = 0.988)]. These results do not support data from the literature indicating a reduced aromatase expression in granulosa cells of affected women, but they highlight a potential subtle mechanism affecting the ovulation process in these women.

The effect of laser-assisted hatching on vitrified/warmed blastocysts: the ALADDIN randomized controlled trial

OBJECTIVE

To evaluate whether laser-mediated assisted hatching (AH) performed on vitrified/warmed blastocysts before embryo transfer can improve live birth rate.

DESIGN

The "pArtiaL zonA pelluciDa removal by assisteD hatchINg of blastocysts (ALADDIN)" is a 2-center comparative study with a parallel randomized controlled design.

SETTING

University hospital.

PATIENTS

Participants were recruited between September 2018 and November 2021. They were aged 18-39 years, underwent nondonor in vitro fertilization cycles, and were scheduled for elective single embryo transfer with vitrified/warmed blastocysts. Those with uterine abnormalities, body mass index of >35 kg/m2, severe male factor infertility, or performing preimplantation genetic testing were excluded.

INTERVENTION

Assisted hatching was performed using a 1,480 nm diode laser, removing approximately one-third of the zona pellucida with continuous 0.2 ms pulses applied from the 1-5 o'clock positions.

MAIN OUTCOME MEASURES

The primary outcome was the live birth rate. Secondary end points included clinical pregnancy, miscarriage, multiple pregnancies, preterm births, obstetric and neonatal complications, and congenital anomalies.

RESULTS

Overall, 698 participants met the inclusion criteria and were randomized: 352 patients were assigned to the AH arm and 346 to the control arm. Of the participants, 105 (29.8%) and 101 (29.2%), respectively, achieved a live birth after treatment. The relative risk of live birth in patients with vitrified/warmed blastocysts treated with AH was 1.02 (95% confidence interval, 0.86-1.19). Exploratory subgroup analyses for women's age, recruiting centers, indications for in vitro fertilization, method of insemination, blastocyst quality, and days of blastocyst development failed to highlight any clinical situation that could benefit from AH in thawed blastocysts.

CONCLUSION

In patients undergoing frozen embryo transfer with vitrified/warmed blastocysts, laser AH does not improve the live birth rate. Further studies are required to rule out milder but potentially interesting benefits in specific subgroups of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03623659.

P-212 Impact of post-thaw blastocyst culture time prior to transfer on live birth rate in frozen-thawed embryo transfer cycles: a retrospective observational study

Study question

Does post-thaw blastocyst culture time prior to transfer influence the live birth rate in frozen-thawed embryo transfer cycles?

Summary answer

Our study revealed that different culture times of frozen-thawed blastocysts prior to transfer does not influence live birth rate.

What is known already

Several studies demonstrated a significantly increased clinical pregnancy rate after a frozen-thawed embryo transfer (FET) compared to a fresh embryo transfer (ET). FET reduces the risk of ovarian hyperstimulation syndrome without facing adverse effects of supraphysiological hormonal levels over endometrial receptivity. However, little is known on the effect of post-thaw embryo culture duration prior to transfer on live birth rate in FET cycles. Recent findings described an improved blastocyst morphological grade after a 20-22h post-thaw culture. Of note, the overnight culture of non-ideal morphology thawed blastocysts prior to transfer resulted in an enhanced live birth rate.

Study design, size, duration

We compared the live birth rate of patients undergoing FET after a short blastocyst culture time (2-4h) prior to transfer to that of patients in whom thawed blastocysts were transferred after a long embryo culture time (20-22h). Frozen-thawed transfers of blastocysts vitrified at Day 5 and subsequently thawed were evaluated. Only transfers of single blastocyst were included.

Participants/materials, setting, methods

The study was conducted at the Infertility Center – Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. We included couples with indications for IVF cycles who underwent frozen-thawed blastocyst transfer procedure on the following natural cycles for freeze-all strategy or to transfer supernumerary embryos from 2014-2021. Data were analyzed using SPSS Statistics software. We evaluated statistically significant differences using various tests including Fisher's test, chi-squared test and Wilcoxon's test.

Main results and the role of chance

A total of 2012 frozen-thawed cycles were included in the analysis; in 977 of them, blastocysts were transferred after a 2-4h post-thaw period and in 1035, blastocysts were transferred after a 20-22h post thaw culture period. The age of the women was comparable (35.4 ± 4.2 and 35.3 ± 4.1; p = 0.5, respectively in the short and long culture period). According to statistical analysis, no significant difference in pregnancy outcomes was found between the two groups. Live birth rate was respectively 40% and 42% ( p = 0.2) in the short and long post-thaw blastocyst culture period prior to transfer.

Limitations, reasons for caution

Our study was limited by the retrospective nature and was performed in a single fertility center. Moreover, only blastocysts vitrified on day 5 were evaluated and findings might not be generalized to day 6 and 7 blastocysts.

Wider implications of the findings

These findings might be useful in the context of the organization of the laboratory workflow. Indeed, the possibility to thaw blastocysts on the day before transfer may represent an advantage in order to avoid an overload of the laboratory procedures during very busy days.

Trial registration number

28_2022

P-300 Evaluation of CYP19A1 gene expression in luteinized granulosa cells of women affected by endometriosis undergoing assisted reproductive technology (ART) treatments

Study question

Does endometriosis affect the expression of the aromatase gene CYP19A1 in the cumulus oophorous (COCs) and mural lutein-granulosa cells (GCs) influencing ART procedures?

Summary answer

Endometriosis does not impair CYP19A1 gene expression. However, the correlation between the aromatase expression and the number of oocytes retrieved is lost in endometriosis patients.

What is known already

Endometriosis-related infertility could be associated with a dysregulation of oocytes development. Indeed, endometriosis seems to have a negative effect on the intrafollicular environment, hindering oocyte maturation. A dysregulated synthesis of steroid hormones by GCs in the ovaries of affected women may be at the basis of an inadequate folliculogenesis. In line, some studies have investigated the expression levels of aromatase p450 ( CYP19A1 ) -the key enzyme involved in 17β-estradiol (E2) synthesis - in GCs and COCs collected from endometriosis women, reporting controversial results.

Study design, size, duration

In order to identify novel prognostic factors of ART outcomes in affected women, we set the evaluation of CYP19A1 expression in GCs samples isolated from endometriosis patients undergoing ART in comparison to control women. In a subgroup of patients, COCs were also collected. CYP19A1, StAR and 3βHSD gene expression was evaluated in both cell types. Finally, we evaluated the association between the expression of the analyzed genes and E2 levels with the clinical ART outcomes

Participants/materials, setting, methods

GCs were isolated from follicular fluids(FF) of n = 68 women with stage III-IV endometriosis and of n = 69 control patients. CYP19A1 gene expression was quantified by qPCR. 17β-estradiol levels in FF were assessed using an ELISA kit. In addition to CYP19A1 gene expression, mRNA levels of StAR and 3βHSD both in GCs and COCs (n = 20 endometriosis;n=21 controls) were evaluated in both cell types using qPCR. Differences between the two patients’ groups were estimated using linear regression models.

Main results and the role of chance

qPCR results showed no differences in mRNA expression of CYP19A1, StAR and 3βHSD in both GCs and COCs between the two groups of ART patients. These results were supported by the presence of the same concentration of E2 in the FF of controls (median: 877.7 ng/mL) and endometriosis patients (median: 878.3 ng/mL) (p-value=0.87). Linear regression model including as input variables gene expression values and ART outcomes showed that the blastulation rate was the only ART outcome associated with the expression levels of CYP19A1  (p-value=0.043, 95% CI: 0.001-0.061). In particular, a decrease of aromatase levels was associated with an increase in blastulation rate. After stratification of the population based on the presence of the disease, it emerged that, in the control group, the CYP19A1 expression correlated with the number of oocytes retrieved [β:-1.214;95%CI: -2.085 - (-0.343); p-value=0.007], while in the group of patients with endometriosis this association was no more present [β:-0.003;95%CI:-0.468 - 0.461; p-value=0.988)]. These results do not support data from the literature indicating that aromatase expression is reduced in GCs of affected women, but they highlight a potential disease-related mechanism affecting the ovulation process in these women

Limitations, reasons for caution

These findings need to be validated in a different cohort of samples. An RNA-seq approach is needed in order to validate our results and to obtain the overall transcriptome profiles of GCs and COCs in endometriosis patients.

Wider implications of the findings

Our data do not confirm previous evidence supporting a reduced expression/activity of aromatase in GCs in endometriosis. However, they suggest that aromatase may have a complex and sophisticated regulation of its expression in this cell type, which is not maintained in presence of endometriosis.

Trial registration number

not applicable

Folliculogenesis in random start protocols for oocytes cryopreservation: quantitative and qualitative aspects

Random start protocols are commonly used for oocytes cryopreservation in women with cancer. However, evidence to support their effectiveness is yet modest. This study aims to compare the quality of ovarian response between the ovary carrying the dominant follicle or the corpus luteum (active ovary) and the contralateral ovary (resting ovary). Women with a diagnosis of malignancy who underwent oocytes cryopreservation were reviewed. The main inclusion criterion was the presence of a unilateral dominant follicle or a unilateral corpus luteum on the first day of ovarian hyperstimulation. The primary outcome was the number of mature oocytes retrieved. Intra-patient comparisons between the two ovaries were made using the nonparametric Wilcoxon test for paired data. Forty-three women were included. The number of mature oocytes retrieved from the active and the resting ovaries did not differ, the median [interquartile range-IQR] being 4 [2-7] and 5 [2-8], respectively (p = 0.09). The rate [IQR] of mature oocytes per developed follicle was 58% [40-80%] and 65% [33-87%], respectively (p = 0.42). In addition, no significant difference emerged when repeating the analyses separately for women carrying dominant follicles and for those carrying corpora lutea. This study failed to detect any detrimental effect of the presence of a dominant follicle or a corpus luteus on the ovarian response to hyperstimulation, thus supporting the validity of random start protocols.

Effect of letrozole on follicular fluid steroids concentrations in cancer patients undergoing oocytes cryopreservation

PURPOSE

To investigate the impact of letrozole administration on follicular steroid hormones during controlled ovarian hyperstimulation for fertility preservation.

METHODS

One hundred and nineteen women with cancer undergoing oocytes retrieval for fertility preservation were recruited. All women underwent ovarian hyperstimulation according to a random start protocol. Those with hormone-sensitive tumors also received letrozole, an aromatase inhibitor aimed at keeping peripheral estrogen levels low. At the time of oocytes retrieval, a sample of follicular fluid was collected and frozen. All samples were assayed concomitantly after thawing, by liquid chromatography tandem mass spectrometry. The concentration of 15 steroid hormones was determined and results were compared between women who did and did not receive letrozole.

RESULTS

Fifty-two women were treated with letrozole, while 67 were not. Statistically significant differences emerged for 12 of the 15 tested steroids. They were the following: cortisol, 11-deoxycortisol, 21-deoxycortisol, dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), estradiol, androstenedione, testosterone, dihydrotestosterone (DHT), 17-hydroxyprogesterone, progesterone and corticosterone. The most striking differences were observed for testosterone that showed a more than 200-time increase in women receiving letrozole. Estradiol was conversely reduced to a third.

CONCLUSIONS

The endocrine microenvironment surrounding oocytes is markedly perturbed by the concomitant assumption of letrozole. Robust clinical evaluation is pressingly needed to rule out any detrimental effect on the chance of live birth with the use of these oocytes.

Prediction of lithium response using clinical data

OBJECTIVE

Promptly establishing maintenance therapy could reduce morbidity and mortality in patients with bipolar disorder. Using a machine learning approach, we sought to evaluate whether lithium responsiveness (LR) is predictable using clinical markers.

METHOD

Our data are the largest existing sample of direct interview-based clinical data from lithium-treated patients (n = 1266, 34.7% responders), collected across seven sites, internationally. We trained a random forest model to classify LR-as defined by the previously validated Alda scale-against 180 clinical predictors.

RESULTS

Under appropriate cross-validation procedures, LR was predictable in the pooled sample with an area under the receiver operating characteristic curve of 0.80 (95% CI 0.78-0.82) and a Cohen kappa of 0.46 (0.4-0.51). The model demonstrated a particularly low false-positive rate (specificity 0.91 [0.88-0.92]). Features related to clinical course and the absence of rapid cycling appeared consistently informative.

CONCLUSION

Clinical data can inform out-of-sample LR prediction to a potentially clinically relevant degree. Despite the relevance of clinical course and the absence of rapid cycling, there was substantial between-site heterogeneity with respect to feature importance. Future work must focus on improving classification of true positives, better characterizing between- and within-site heterogeneity, and further testing such models on new external datasets.

Characteristics of depressive and bipolar disorder patients with mixed features

OBJECTIVE

To assess differences between subjects with vs. without mixed features in major affective disorders.

METHODS

In 3099 out-patient subjects with DSM-5 major depressive disorder (MDD, n = 1921) or bipolar disorders (BD, n = 1178), we compared those with (Mx) vs. without (Non-Mx) mixed features (agitated-irritable depression or dysphoric [hypo]mania) in an index episode.

RESULTS

Prevalence of Mx averaged 21.9% [CI: 20.5-23.4] overall, ranking: BD-II > BD-I > MDD, and in BD depression ≥ [hypo]mania > MDD. Mx subjects were significantly more likely than Non-Mx cases to (i) have other mixed episodes, (ii) have higher irritable and agitated ratings, (iii) have more substance abuse, (iv) switch into mixed episodes, (v) have more suicide attempts and higher suicidal ratings, (vi) change diagnosis from depression to BD, (vii) have higher hypomania scores when depressed or depression scores when [hypo]manic, (viii) be unmarried or separated with fewer children and siblings, (ix) be diagnosed more with BD than MDD, (x) be unemployed, (xi) have BD, suicide and divorce among first-degree relatives, (xii) be female, (xiii) be younger at illness-onset. Both BD and MDD Mx subjects also received antidepressants less, but antipsychotics and mood-stabilizers more, alone and in combination with antidepressants.

CONCLUSIONS

Mood disorder subjects with agitated-irritable depression or dysphoric [hypo]mania differed from those without such mixed features, including having a less favorable clinical course and repeated mixed episodes. They may represent a distinct and prevalent, syndromal clinical subtype with prognostic and therapeutic significance.

Effect of On-Line Hemodiafiltration with Endogenous Reinfusion (HFR) on the Calcium-Phosphorus Metabolism: Medium-Term Effects

Aim

The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. Methods: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1–84 PTH, 7–84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, β2-microglobulin, CRP. All the variations found were evaluated through mean values ± SD, t-tests, multivariate analysis.

Results

We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 ± 82.8 and 35.8 ± 49.8 at the end of HD to 63.4 ± 23.9 and 16.0 ± 8.7 at the end of HFR, respectively, and 1–84 PTH from 317.5 ± 264.6 pg/mL at the end of HD to 287.5 ± 258.9 pg/mL at the end of the 3rd month of HFR. β2-microglobulin was reduced from 32.9 ± 16.1 mg/L at the end of HD to 26.4 ± 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 ± 2.6 mg/dL at the beginning of the study to 1.3 ± 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents.

Conclusion

We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate substraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia. (Int J Artif Organs 2006; 29: 1042–52)

Solar insolation in springtime influences age of onset of bipolar I disorder

OBJECTIVE

To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder.

METHOD

Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density.

RESULTS

There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001).

CONCLUSION

A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

Age at menarche predicts age at onset of major affective and anxiety disorders

BACKGROUND

Menarche age has been associated inconsistently with the occurrence, timing or severity of major depressive disorder (MDD), but rarely studied in women with bipolar (BDs) or anxiety disorders.

METHODS

We investigated women patients at a Sardinian mood disorder center for associations of age at menarche with age at illness onset for major affective or anxiety disorders, year of birth, and other selected factors, using bivariate comparisons and multivariate regression modeling.

RESULTS

Among women (n=1139) with DSM-IV MDD (n=557), BD-I (n=223), BD-II (n=178), or anxiety disorders (n=181), born in 1904-1998, of mean age 42.9 years, menarche age averaged 12.8 [CI: 12.7-12.9] years. Illness onset age averaged 30.9 [30.1-31.8] years, ranking: BD-I, 25.8; anxiety disorders, 28.0; BD-II, 30.3; MDD, 34.1 years. Menarche age declined secularly over birth years, and was associated with younger illness-onset, having no or fewer siblings, more psychiatrically ill first-degree relatives, living in rural environments, being suicidal, substance abuse, and being unemployed. Earlier menarche and earlier illness-onset were significantly associated for onset age groups of ≤ 20, 20-39, and > 40 years. Menarche age versus diagnosis ranked: BD-II<BD-I<anxiety disorders<MDD.

CONCLUSIONS

Age at menarche in Sardinia, as elsewhere, has declined over the past decades. It was strongly associated with age at onset of bipolar and anxiety, as well as major depressive disorders across the age range, suggesting sustained effects of biological maturational factors.

Comparison of psychotic bipolar disorder, schizoaffective disorder, and schizophrenia: an international, multisite study

OBJECTIVE

Nosological distinctions among schizoaffective disorder (SA), bipolar I disorder with psychotic features (BDp), and schizophrenia (SZ) remain unresolved.

METHOD

We compared 2269 subjects with psychotic features in DSM-IV-TR diagnoses (1435 BDp, 463 SZ, 371 SA) from 8 collaborating international sites, by 12 sociodemographic and clinical measures, all between diagnostic pairs.

RESULTS

In bivariate comparisons, SA was consistently intermediate between BDp and SZ for 11/12 features (except onset stressors), and SZ vs. BDp differed in all 12 factors. SA differed from both BDp and SZ in 9/12 factors: SA and BDp were similar in education and suicidal ideation or acts; SA and SZ were similar in education, onset stressors, and substance abuse. Meta-analytic comparisons of diagnostic pairs for 10 categorical factors indicated similar differences of SA from both SZ and BDp. Multivariate modeling indicated significantly independent differences between BDp and SZ (8 factors), SA vs. SZ (5), and BDp vs. SA (3). Measurement variance was similar for all diagnoses.

CONCLUSION

SA was consistently intermediate between BDp and SZ. The three diagnostic groups ranked: BDp > SA > SZ related to lesser morbidity or disability. The findings are not consistent with a dyadic Kraepelinian categorization, although the considerable overlap among the three DSM-IV diagnostic groups indicates uncertain boundaries if they represent distinct disorders.

A case of complicated otomastoiditis

We describe the case of a child who, at her first episode of clinically evident acute otitis media, has developed a bilateral mastoiditis, though with unilateral simptomatology. The mastoiditis was complicated by the spontaneous drainage of the postauricular abscess in the subcutaneous tissue. According to the literature, we believe that the temporal bone computed tomography scan is the fundamental examination to properly define an anusual case of mastoiditis, plan adequate therapy (medical o surgical), and rule out other possible complications.

Human and entomological surveillance of Toscana virus in the Emilia-Romagna region, Italy, 2010 to 2012

Toscana virus (TOSV), transmitted by phlebotomine sandflies, is recognised as one of the most important causes of viral meningitis in summer in Mediterranean countries. A surveillance plan based on both human and entomological surveys was started in 2010 in the Emilia-Romagna region, Italy. Clinical samples from patients with neurological manifestations were collected during 2010 to 2012. The surveillance protocol was improved during these years, allowing the detection of 65 human infections. Most of these infections were recorded in hilly areas, where sandflies reach the highest density. Entomological sampling around the homes of the patients resulted in a low number of captured sandflies, while later sampling in a hilly area with high number of human cases (n=21) resulted in a larger number of captured sandflies. Using this approach, 25,653 sandflies were sampled, of which there were 21,157 females, which were sorted into 287 pools. TOSV RNA was detected by real-time PCR in 33 of the pools. The results highlighted the role of Phlebotomus perfiliewi as the main vector of TOSV and a potential link between vector density and virus circulation. This integrated system shows that an interdisciplinary approach improves the sensitiveness and effectiveness of health surveillance.

Cardiovascular responses during free-diving in the sea

Cardiac output has never been assessed during free-diving diving in the sea. Knowledge of human diving response in this setting is therefore scarce. 3 immersions were performed by 7 divers: at depths of 10 m, 20 m and 30 m. Each test consisted of 3 apnea phases: descent, static and ascent. An impedance cardiograph provided data on stroke volume, heart rate and cardiac output. Mean blood pressure, arterial O2 saturation and blood lactate values were also collected. Starting from a resting value of 4.5±1.6 L∙min(-1), cardiac output at 10 m showed an increase up to 7.1±2.2 L∙min(-1) (p<0.01) during the descent, while conditions during the static and ascent phases remained unchanged. At 20 m cardiac output values were 7.3±2.4 L∙min(-1) and 6.7(±1).2 L∙min(-1) during ascent and descent, respectively (p<0.01), and 4.3±0.9 L∙min(-1) during static phase. At 30 m cardiac output values were 6.5±1.8 L∙min(-1) and 7.5±2 L∙min(-1) during descent and ascent, respectively (p<0.01), and 4.7±2.1 L∙min(-1) during static phase. Arterial O2 saturation decreased with increasing dive depth, reaching 91.1±3.4% (p<0.001 vs. rest) upon emergence from a depth of 30 m. Blood lactate values increased to 4.1±1.2 mmol∙L(-1) at the end of the 30 m dive (p<0.001 vs. rest). Results seem to suggest that simultaneous activation of exercise and diving response could lead to an absence of cardiac output reduction aimed at an oxygen-conserving effect.

Sprint vs. intermittent training in young female basketball players

AIM

This study aimed at comparing the effects of intermittent and repeated sprint ability training on physiological variables.

METHODS

Sixteen young female basketball players were randomly allocated to intermittent training (IT=8) or repeated sprint ability training (RST=8) groups. The following outcomes were measured at baseline and after 6 weeks of training: Yo-Yo intermittent recovery (Yo-Yo) and repeated sprint ability (RSA) tests.

RESULTS

For all the variables investigated the effect of training type showed a different trend respect at current knowledge. In the RSA, best time (BT) was a significant main effect of training time (pre- vs. post-) (P<0.0001), and of the interaction training type/time (P=0.03). The RST showed a decrease in BT of 3.1% (P=0.005) while the IT showed a decrease of 6.2% (P<0.0001). In the IT there was a significant main effect of time for the total distance with an increment of 26.9%, and a significant main effect of time in the final speed with an increment of 1.23%.

CONCLUSION

These findings suggest that the two training methods used in this study can be an effective training strategy for inducing anaerobic and basketball-specific training schedules. Besides, even when IT training is not done at very high speed, it can increase the maximum speed of the RSA.

Measurement of pulmonary gas exchange variables and lactic anaerobic capacity during field testing in elite indoor football players

AIM

The aims of this study were: 1) to examine the gas exchange responses of elite indoor football players to a repeated sprint ability (RSA) test; and 2) to verify whether or not the excess of carbon dioxide production (CO2excess) correlates with blood lactate accumulation during RSA field testing.

METHODS

Eleven elite male indoor football players were recruited. A preliminary incremental exercise test on a treadmill was performed to elicit V'O2max. Then, participants underwent an RSA test consisting in a shuttle running through a course with various changes of direction while wearing a portable gas analyzer able to provide values of oxygen uptake, carbon dioxide production, and CO2excess. BLa concentrations during recovery were also measured.

RESULTS

The main results were that: 1) during the RSA test subjects did not reached the V'O2max level achieved in the preliminary test; 2) during the RSA test BLa levels were higher compared with the preliminary test; 3) the peak BLa concentration during recovery was significantly correlated with the average CO2excess

CONCLUSION

It was concluded that the RSA test did not appear to be useful to elicit V'O2max. Rather, it seemed suitable to recruit subjects' lactic anaerobic capacity. Moreover, CO2excess appeared suitable for qualitatively estimate BLa accumulation during field testing.

Assessment of circulatory adjustments during underwater apnoea in elite divers by means of a portable device

AIM

Considering that sympathetic activation is induced by exercise, it is reasonable to assume that hemodynamic adjustments to exercise act in opposition to those elicited by the diving response. However, cardiovascular measurements have never been performed during underwater dynamic apnoea (DA), and this hypothesis remains speculative.

METHODS

Data concerning heart rate (HR), stroke volume (SV) and cardiac output (CO) during static apnoea (SA) and DA were collected from 12 elite divers by means of an impedance cardiograph adapted to the underwater environment. Mean arterial pressure (MBP), systemic vascular resistance (SVR) and arterial oxygen saturation (SaO(2)) were also assessed. Five trials were performed by the divers: head-out immersion during normal breathing (test A); 3 min of SA immersed at the surface (B) and at 3 m depth (C); DA till exhaustion immersed at the surface (D) and at 3 m depth (E).

RESULTS

Both B and C conditions led to bradycardia (-17%) compared to A and also induced a decrement in SV (-8%) and in CO (-25%), while MBP was maintained because of an increase in SVR. A significant MBP increment (+11%) was detected only during tests D and E, when a SaO(2) drop was also present, whereas HR, SV and CO remained unchanged.

CONCLUSION

We concluded that typical diving response was present only during SA, while sympathetic activation was induced by exercise during DA, which partially obscured the effects of the diving response.

Field studies on Culicoides (Diptera: Ceratopogonidae) activity and response to deltamethrin applications to sheep in northeastern Spain

An enclosure trapping experiment compared numbers and engorgement of Culicoides spp. taken from treated sheep (7.5% deltamethrin) to Culicoides from untreated sheep. Attack rates were low (0.2/min), but 58% of Culicoides obsoletus s.l. and 67% of Culicoides parroti Kieffer engorged on untreated sheep, and no engorgement occurred on treated sheep on 0 and 4 d posttreatment. A UV light trap in a livestock barn collected eight Culicoides spp. (510 individuals), dominated by C. obsoletus (Meigen) (68%), Culicoides imicola Kieffer (19%), Culicoides circumscriptus Kieffer (8%), and Culicoides alazanicus Dzhafarov (4%). A more powerful but nonattractive fan trap collected five species (121 individuals) dominated by C. obsoletus (48%), C. imicola (36%), C. alazanicus (8%), and C. circumscriptus (7%). Parity of C. obsoletus and C. imicola did not vary between the light and fan traps. Engorged Culicoides in the barn (33 C. obsoletus and three C. imicola) had fed on sheep or goats (precipitin test).

Drug-induced sweat gland necrosis in a non-comatose patient: a case presentation

BACKGROUND

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity often associated with drug-induced coma.

SUBJECT

We report a case with clinical and histopathologic findings characteristic of blisters and sweat gland necrosis occurring in a non-comatose patient.

CONCLUSIONS

Skin blisters with underlying sweat gland necrosis is an entity previously reported to occur in comatose patients, our findings open new questions about the role of the drugs in the pathogenesis of those conditions.

On-line predilution hemofiltration versus ultrapure high-flux hemodialysis: a multicenter prospective study in 23 patients. Sardinian Collaborative Study Group of On-Line Hemofiltration

The aims of the present prospective multicenter study were to assess the clinical tolerance and well being, the correlation between nPCr and Kt/V and the pretreatment beta 2-microglobulin level in patients sequentially treated with high-flux dialysis with ultrapure bicarbonate hemodialysis (HD; phase 1) and predilution hemofiltration (HF) with on-line prepared bicarbonate substitution fluid (phase II). The same monitor (Gambro AK 100 ULTRA) and membrane (polyamide) were used. Twenty-three patients, all in a stable clinical condition, entered the study. The treatment was targeted to an equilibrated Kt/V (eqKt/V) of 1.4 for HD and 1.0 for HF. No mortality or relevant morbidity were observed. The number of hypotensive episodes was 1.78 +/- 2.8 per patient and month during HD vs. 1.17 +/- 3.1 during HF (p = 0.003) and the number of the hypertensive episodes 1.28 +/- 2.8 during HD vs. 0.42 +/- 0.8 during HF (p = 0.04). Incidences of arrhythmia, muscular cramps and headache were significantly less frequent during HF. Interdialytic cramps, arthralgia and fatigue were also significantly less frequent during the HF period. The average beta 2-microglobulin level was 27.1 +/- 14.7 mg/dl at the start of the study, 22.9 +/- 4.9 mg/dl at the beginning of phase II and 22.4 +/- 4 mg/dl at the end of phase II (p = 0.01 compared to the start). A significant linear correlation between the normalized protein catabolic rate and eqKt/V was obtained faster during HD than during HF (45 vs. 120 days) indicating that HF affects the nutritional status with mechanisms different from HD. The present study is in agreement with the hypothesis that HF gives and adequate nutritional status with improved clinical stability and well being at a lower Kt/V compared to HD. Both therapies were efficient in controlling the pretreatment beta 2-microglobulin level.

[Current trends in the treatment of Graves' disease]

Between 1973 and 1992 153 patients with Graves' disease were observed at the Surgery and Oncology Institute-Cagliari University. 103 underwent subtotal (70) or total (33) thyroidectomy, while 50(after 1985) were submitted to radioactive-iodine therapy. Surgical indications were failure of antithyroid drug therapy, signs of compression and large size goitre. Until 1988, all patients were submitted to subtotal thyroidectomy with thyroid remnant of about 8 g. From 1988 the choice of total thyroidectomy came out from: similar complications (paralysis of recurrent nerve and hypoparathyroidism), lack of relapse and suppression of risk of occult carcinoma. After subtotal thyroidectomy definitive hypoparathyroidism in 1 patient (1.8%), transitory hypoparathyroidism in 5 (9.4%), clinical hypothyroidism in 17 (31.5%), recidive hyperthyroidism in 3 patients (5.5%) were observed. After total thyroidectomy 1 patient presented definitive paralysis of recurrent nerve (3%), 1 definitive hypoparathyroidism (3%), 8 transitory hypoparathyroidism (24%): small (44 patients) or large goitre (3 patients) or relapse (3 patients) were indications to radioactive-iodine therapy. At median follow-up of 16 months no relapses of hyperthyroidism were observed, while clinical signs of hypothyroidism were present in 33% of patients. Authors stress that, after a first attempt with antithyroid drugs therapy, radioiodine treatment is elective in Graves' disease. Surgery still remains the treatment of choice during pregnancy, in patients with large goitres, signs of compression or in presence of scintigraphic "cold" area.