Undiagnosed sagittal synostosis as cause of "idiopathic" intracranial hypertension

PURPOSE

Idiopathic intracranial hypertension (IIH) is a rare condition in children, but if diagnosed needs to be promptly treated to avoid clinical sequalae. The main purpose of this paper was to test our clinical experience with a cohort of normocephalic children with craniosynostosis who do not present in the routine way to craniofacial services, due to the normal head shape and age, diagnosed with IIH.

METHODS

We retrospectively reviewed all children who were referred to neurosurgery from 2012 to 2022 for management of IIH on our prospectively kept database. We determined what treatments were offered and if there was an associated craniosynostosis.

RESULTS

In total, 19 children were identified with an average age at referral of 11.5 years (st dev 4.0 years) with 11 male and 8 female. The most common presenting symptoms and signs were papilloedema (18/19), headaches (15/19), visual deterioration (9/19), nausea and vomiting (7/19) and diplopia (4/19). Five out of 19 children (26.3%) had a sagittal suture fused that was not identified at the time of treatment and all children were normocephalic.

CONCLUSION

There is a cohort of children with IIH who will have concomitant craniosynostosis and ideally would benefit from cranial vault expansion as primary surgery rather than cerebrospinal fluid (CSF) diversion. We suggest all children with IIH requiring neurosurgical intervention have cross-sectional imaging to look for occult craniosynostosis prior to intervention.

Safety and efficacy of tixagevimab/cilgavimab for pre-exposure prophylaxis in kidney transplant recipients: a multicenter retrospective cohort study

BACKGROUND

Immunocompromised patients show an impaired vaccine response and remain at high risk of severe COVID-19, despite vaccination. Neutralizing monoclonal antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been developed for prophylaxis and treatment. The combination tixagevimab/cilgavimab (AZD7442) has been authorized for emergency use as pre-exposure prophylaxis for COVID-19, but data on safety and efficacy in kidney transplant recipients during the Omicron period are limited.

METHODS

We conducted a multicenter retrospective cohort study including 253 kidney transplant recipients, of whom 98 were treated with tixagevimab/cilgavimab 150 mg/150 mg and 155 who received only four doses of the BNT162b2 mRNA vaccine.

RESULTS

Only 13.3% of patients developed SARS-CoV-2 infection after the administration of tixagevimab/cilgavimab; in comparison, 34.2% of patients had been infected after the fourth dose of vaccine (p = 0.00013). Most infected patients in the AZD7442 group remained asymptomatic (92.3% vs 54.7%), 7.7% had mild symptoms and none had severe disease, need for hospitalization or died, while in the control group, 9.4% of patients had moderate or severe disease (p = 0.04). Using Kaplan-Meier curves we demonstrated that the controls presented early infection compared to the AZD7442 group (p = 0.000014). No changes in eGFR or proteinuria, assessed before and after the administration, were observed.

CONCLUSIONS

In conclusion, our study showed that tixagevimab/cilgavimab 150/150 mg is effective and safe in preventing infection and severe disease when administered to patients with weak or no response to COVID-19 vaccine.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

Blood-brain barrier damage associates with glia-related cytokines in the cerebrospinal fluid of patients with Multiple Sclerosis

BACKGROUND

The presence of Blood-Brain Barrier (BBB) dysfunction is defined by albumin quotient (QALB) and characterize a group of Multiple Sclerosis (MS) patients at clinical onset. We evaluated the concentration in cerebrospinal fluid (CSF) of 87 cytokines, to better characterize the CSF inflammatory pattern in presence of BBB damage.

MATERIALS AND METHOD

In an exploratory cohort, CSF cytokines were evaluated by means of Multiplex technology (Bio-Plex Pro-Human Cytokine, GF and Diabetes 27-Plex Panel, Bio-Plex Pro-Human Chemokines 40-Plex Panel, Bio-Plex Pro-Human Inflammation Assays 37-Plex Panel) in a cohort of Other Not Inflammatory Neurological Disorders (ONIND) and in cohort of patients with MS, stratified according to BBB damage into QALB+ and QALB- MS patients. In the validation cohort, we evaluated the relevant molecules in a cohort of MS patients, stratified again into QALB+ and QALB-, including also Neurofilament Light (NfL) and Chitinase 3-like 1 (CHI3L1) CSF concentration.

RESULTS

While MIP-1α, CXCL-13, and CCL-22 CSF concentrations were higher in both MS groups compared to ONIND, in QALB+ MS CSF concentrations of CXCL-9 (17.85 ± 4.69 pg/mL), CXCL-10 (476.5 ± 324.3 pg/mL), and IL-16 (96.08 ± 86.17 pg/mL) were higher than in QALB- MS (8.98 ± 5368 pg/mL, p < 0.005, 281.0 ± 180.9 pg/mL, p < 0.05, and 47.35 ± 36.87 pg/mL, p < 0.005, respectively) and ONIND (8.98 ± 5368 pg/mlL, p < 0.005, 281.0 ± 180.9 pg/mL, p < 0.005, and 47.35 ± 36.87 pg/mL, p < 0.001, respectively). A strong correlation was observed between CXCL-9 and CXCL-10 in all MS groups (all r>0.75, all p < 0.001). In the validation cohort again CXCL-10 CSF concentration were higher in QALB+ MS than in QALB- MS (94.25 ± 64.75 vs 153.8 ± 99.52, p < 0.05), while no difference was observed in serum. CSF NfL (1642 ± 1963 vs 3231 ± 3492 pg/mL, p < 0.05) and CHI3L1 (183.9 ± 86.62 vs 262 ± 137.5 ng/mL, p < 0.05) were increased in QALB+ MS.

CONCLUSIONS

BBB damage in MS is linked to a specific CSF cytokines pattern (CXCL-9, CXCL-10, IL-16), that are also involved in astrocyte-microglia interaction. To what extent their continuous production in the CNS may mark a more severe disease course merits to be investigated.

Prevalence and severity of sexual disorders in the third trimester of pregnancy

BACKGROUND

Female sexual function in pregnancy is an under-investigated topic by care providers. This study aimed to investigate the sexual function and the impact of traditional risk factors for pelvic floor disorders (PFDs) during the third trimester of pregnancy.

METHODS

This is a secondary analysis of a multicenter cross-sectional study conducted in eight hospitals in Italy and Italian-speaking Switzerland. Women at the third trimester of pregnancy aged 18 years and over completed the Italian-PFQPP questionnaire anonymously.

RESULTS

Overall, 927 patients in the third trimester of pregnancy answered the questionnaire. About 29.5% of women reported reduced or absent sexual activity. The less reported symptom was coital incontinence (1.3%), while painful intercourses was the most frequent one (50.3%). Nicotine abuse was associated with traumatic sexual intercourses, impaired vaginal sensibility, and negative impact on sexual life and well-being. Familiarity for pelvic floor disorder resulted as a risk factor for coital incontinence (OR=3.61).

CONCLUSIONS

Sexual symptoms, with pain during intercourses being the most widely reported, are extremely common in the third trimester of pregnancy and can greatly affect quality of life. Familiarity for pelvic floor disorders and nicotine abuse resulted as significant risk factors for at least one sexual symptom.

Endoscopic third ventriculostomy for hydrocephalus after craniovertebral decompression for Chiari malformation type I: technical nuances and surgical pitfalls

PURPOSE

Hydrocephalus after craniovertebral decompression (CVD) for Chiari I malformation (CM-1) is a well-recognised complication. The mainstay of management involves medical management with high-dose steroids and/or acetazolamide, repeated lumbar punctures, external ventricular drainage (EVD) or insertion of a ventriculoperitoneal shunt (VPS). Endoscopic third ventriculostomy (ETV) has only been used a handful of times to treat this type of hydrocephalus with controversial outcomes. Not much is known about this or the technical nuances of this procedure. We report our experience.

METHODS

All children who underwent ETV to treat hydrocephalus post CVD done for CM-1 were identified from a prospectively kept database.

RESULTS

Three children were identified (13F, 11F, 13F). The average time to presentation of hydrocephalus was 8 days after craniovertebral decompression. Two were successfully treated with ETV with brain imaging showing a reduction in the size of the ventricles post-operatively and not requiring any further cerebrospinal fluid drainage. In one patient, the procedure had to be abandoned after the peel away catheter was introduced into the right ventricle because CSF egressed under high pressure with ventricle walls collapse resulting in an obstructed view. This child ultimately required a VPS.

CONCLUSION

ETV can be used to successfully treat post CVD hydrocephalus in CM-1 patients depending on the aetiology of the hydrocephalus. There are technical and anatomical commonalities between these cases which make it more challenging than an ETV performed in "typical" obstructive hydrocephalus. We describe our experience and review the cases previously reported in the literature.

Supercooled solutions of sodium perchlorate in TIP4P/2005 water: The effect of martian solutes on thermodynamics and structure

We study the thermodynamic behavior of sodium perchlorate solutions in supercooled water through molecular dynamics numerical simulations. These solutions are of special interest because of the recent experimental results that led to hypothesize the presence of liquid water in perchlorate solutions beneath the Martian soil. We model water using the TIP4P/2005 potential. The results we obtain for solutions with concentrations 1.63 and 15.4 wt% are in agreement with those of a system undergoing a liquid-liquid phase transition where the liquid-liquid critical point shifts to slightly higher temperatures and lower pressures. The structure of the system is also analyzed, and we come to the conclusion that, even at the highest concentration considered, water retains its anomalous behavior.

Prevalence and severity of lower urinary tract symptoms in the third trimester of pregnancy

INTRODUCTION AND HYPOTHESIS

Pregnancy is a risk factor for urinary disorders, mainly in the third trimester. Lower urinary tract symptoms (LUTS) are often underreported by health care professionals and significantly impact the quality of life of pregnant women. Our objective is to analyse lower urinary tract function during the third trimester of pregnancy and assess the impact of traditional risk factors for pelvic floor dysfunctions on bladder health in pregnant women.

METHODS

This is a secondary analysis of a multicentre cross-sectional study. Third-trimester pregnant women aged 18 years or older anonymously filled in the "Italian Pelvic Floor Questionnaire for pregnant and postpartum women" questionnaire, validated for pelvic floor disorders in pregnancy and postpartum.

RESULTS

A total of 927 pregnant patients completed the questionnaire. Among them, 97.3% complained of at least one urinary disorder. Frequency was the symptom reported most often (77.3%), whereas nocturnal enuresis was the least reported (17%). Despite the high prevalence of LUTS in our sample, only 13.4% reported that they negatively impact their quality of life. Overweight and obesity, advanced maternal age, smoking, family history of pelvic floor disorders and poor pelvic floor contraction capacity were confirmed to be risk factors for the onset of LUTS, even in our population.

CONCLUSIONS

Urinary symptoms are extremely common in the third trimester and significantly affect the quality of life of pregnant women. Since overweight, obesity, smoking and reduced pelvic floor contractility emerged as modifiable risk factors for the development of these symptoms, prevention and adequate counselling are cornerstones of pregnancy care.

Prevalence and severity of bowel disorders in the third trimester of pregnancy

BACKGROUND

Bowel-related disorders are common conditions associated with pregnancy and are a cause of significant distress and healthcare burden. However, there is a lack of data in the literature about these disorders.

OBJECTIVE

This study aimed to investigate bowel dysfunctions during the third trimester of pregnancy in a large cohort of women using the validated bowel domain of the Italian version of the Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

STUDY DESIGN

This was a secondary analysis of a multicenter cross-sectional study conducted in hospitals in Italy and Italian-speaking Switzerland. Women in the third trimester of pregnancy were asked to complete the Italian Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

RESULTS

During the study period, 927 pregnant women in the third trimester of pregnancy responded to the questionnaire and were included in the analysis. Overall bowel dysfunctions were reported by 29.6% of patients. Constipation was reported by 66.6% of pregnant women, whereas symptoms of obstructed defecation were reported by 49.9% of patients. In contrast, urgency was reported by 41.1% of patients. Incontinence to flatus and incontinence to stool were reported by 45.1% and 2.8% of patients, respectively. Moreover, age >35 years, familiarity with pelvic floor disorders, nicotine abuse, and pelvic floor contraction inability were identified as independent risk factors for at least 1 bowel symptom.

CONCLUSION

Bowel symptoms are extremely common in the third trimester of pregnancy and can greatly affect a patient's quality of life; therefore, bowel symptoms deserve to be investigated and managed properly. The use of validated questionnaires represents a precious tool to investigate functional symptoms that could be very frequent and disabling in this particular period of life for women.

Kinetics of humoral immune response and severity of infection after three doses of SARS-CoV-2 mRNA vaccine in a large cohort of kidney transplant recipients

BACKGROUND

COVID-19 in kidney transplant recipients is associated with high morbidity and mortality. In this study we aimed to evaluate: (i) the seroconversion rate after BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine, (ii) factors associated with humoral response, (iii) clinical outcome of COVID-19 in kidney transplanted patients.

METHODS

We enrolled a cohort of 743 kidney transplant recipients followed up from March 2020 until April 2022. A subset of 336 patients, who received three-doses of SARS-CoV-2 vaccine, was analyzed in terms of kinetics of humoral immune response and compared to a control group of 94 healthcare workers. Antibody response was tested before vaccination (T₀), 15 and 90 days after the second dose (T₁ and T₂), on the day of the third dose (T₃) and one month after the third dose (T₄).

RESULTS

We observed that 66 out of 743 subjects had COVID-19 infection pre-vaccination: 65.2% had severe symptoms, 27.3% were hospitalized (9 deaths), none were asymptomatic. After three doses, 51 patients had COVID-19 infection, 60.8% were asymptomatic, 27.5% reported mild symptoms, 3.9% showed severe symptoms, 7.8% were hospitalized (2 deaths). In the subset of 336 vaccinated patients, an antibody level > 0.8 U/ml was detected at T₁, that increased at T₂ and T_3, peaking at T₄. Independent factors associated with a negative antibody titer at T₄ were decreasing estimated glomerular filtration rate, time from transplantation, and antimetabolites (all p < 0.001) and age (p = 0.007).

CONCLUSIONS

The kinetics of humoral response after three doses of vaccine in kidney transplant patients is characterized by a late but effective immune response against SARS-CoV-2, reducing morbidity and mortality.

The Communicative-Relational Operating Model of the Italian National Institute of Health for an Effective Telephone Intervention in Public Health, Structured on Basic Counselling Skills

Introduction

Communication has a crucial role in public health, because it becomes an essential component of prevention; it is also a proactive tool in health promotion. From a planning perspective, it is appropriate to use communication means that can help the bidirectional communication process, such as face-to-face communication and telephone communication.

Materials and methods

In relation to this, the Italian National Institute of Health has developed the "Modello Operativo Comunicativo-Relazionale" (the "Communicative-Relational Operating Model"). It is based on the fundamental skills of the counselling, this gives a protocol to the health professionals that is replicable and organized and it allows health professionals to carry out a telephone communication that is efficient with the user through technical-scientific and communication-relational skills. The goal is to answer in a customized way to the various users' health needs. The Operating Model was created by experts of the National AIDS and Sexually Transmitted Infections Helpline of the Operational Unit of Psycho-Socio-Behavioural Research, Communication, Training, of the Infectious Diseases Department. Later, the Operating Model was proposed to the experts of the Helplines in the National Centre on Addictions and Doping and the National Helpline of the National Centre for Rare Diseases in the National Institute of Health that integrated this method into their telephone approach.

Results

The Operating Model illustrated above was applied to several helplines of the National Institute of Health as an example of correct scientific information, updated and customized on sexual transmitted infections, addictions and rare diseases.

Conclusions

This article aims to illustrate the Operating Model, the theoretical prerequisites that subtend it and its possible application in the different public health structures that use the telephone for a profes-sional relationship with their users.

Survey on the interest and commitment of AIFM members to scientific activities (SicAS) - The initiative of the FutuRuS working group

PURPOSE

The "FutuRuS" working group of the Italian Association of Medical Physics and Health Physics (AIFM) designed a survey (SicAS) to get feedback from its members regarding their interests and their experience in taking part in scientific activities and events, with the objective of focusing future efforts of the AIFM towards increasing the scientific activity of the medical physics expert (MPE).

METHODS

SicAS was sent out in March 2022 to all AIFM members by newsletter and official communication. SicAS was structured into three sections: personal information and institution of affiliation information, involvement in scientific activities, interest in and commitment to scientific activities. Responses were collected in a fully anonymised mode from the Google Forms platform and analysed with descriptive statistics.

RESULTS

Out of 1289 members (active at the end of 2021), 467 responded to the Survey (response rate of 36%). The Survey results highlighted that AIFM members ranked the involvement of the MPE in scientific activities as highly relevant to the profession. However, 34.7% indicated devoting less than 10% of their working time to scientific activities. 67.5% of the respondents were dissatisfied with the time spent on scientific activities. The primary barrier was the lack of time (77%), followed by a lack of mentoring (32%).

CONCLUSIONS

SicAS highlighted the need for AIFM initiatives to support members' scientific activities. National societies should help develop and support networks between members, create links among universities, hospitals, research institutions and industries, and provide guidelines and learning platforms for enhancing the MPEs' involvement in scientific activities.

Trampoline-Associated Cranial and Spinal Injuries: A 10-Year Study in a Pediatric Neurosurgery Center

OBJECTIVE

 There has been an increasing use of trampolines for recreation by children in recent years. Many studies have explored the different types of injuries sustained due to falls from trampolines, but so far none have focused specifically on cranial and spinal injuries. In this study, we describe the pattern of cranial and spinal injuries sustained by pediatric patients that were associated with the use of trampolines and their management in a tertiary pediatric neurosurgery unit over a period of 10 years.

METHODS

 This is a retrospective study of all children less than 16 years of age with suspected or confirmed trampoline-associated cranial or spinal injuries, managed by a tertiary pediatric neurosurgery unit from 2010 to 2020. Data collected included the patient's age at the time of injury, gender, neurological deficits, radiological findings, management, and clinical outcome. The data were analyzed to highlight any trends in the pattern of injuries.

RESULTS

 A total of 44 patients with a mean age of 8 years (ranging from one year and five months to 15 years and five months) were identified. 52% patients were male. 10 patients (23%) had a reduced Glasgow Coma Scale (GCS) score. In terms of imaging findings, 19 patients (43%) had a radiologically positive head injury, nine (20%) had a craniovertebral junction (CVJ) injury, including the first (C1) and second (C2) cervical vertebrae, and six (14%) had an injury involving other parts of the spine. No patient sustained concurrent head and spinal injuries. Eight (18%) patients had normal radiological findings. Two (5%) had incidental findings on radiology that required subsequent surgery. A total of 31 patients (70%) were managed conservatively. 11 patients (25%) underwent surgery for their trauma, of which seven were cranial. Two further patients underwent surgery for their incidental intracranial diagnoses. One child died from an acute subdural hemorrhage.

CONCLUSIONS

 This study is the first to focus on trampoline-associated neurosurgical trauma and report the pattern and severity of cranial and spinal injuries. Younger children (less than five years of age) are more likely to develop a head injury, whereas older children (more than 11 years of age) are more likely to develop a spinal injury following the use of a trampoline. Although uncommon, some injuries are severe and require surgical intervention. Therefore, trampolines should be used prudently with the appropriate safety precautions and measures.

Endoscopic fenestration of the superior medullary velum for the treatment of a trapped fourth ventricle-technical note

A trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to an enlargement of the fourth ventricle secondary to obstruction to its outflow. This condition is most commonly observed in ex-preterm patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, through a supratentorial or an infratentorial approach, treatment of trapped fourth ventricle entailed high rates of complications, repeated procedures and consequent morbidity. We describe the first case of successful treatment of trapped fourth ventricle by fenestration of superior medullary velum through an infratentorial approach in a 20-month-old child with a functional supratentorial ventriculoperitoneal shunt and an aqueductal anatomy not favourable for stenting. To the best of our knowledge, this is the first reported case of utilisation of this technique in a patient with a trapped fourth ventricle, and we wish to highlight this new alternative approach in cases where conventional aqueductoplasty and stenting may not be feasible.

The Communicative-Relational Operating Model of the Italian National Institute of Health for an Effective Telephone Intervention in Public Health, Structured on Basic Counselling Skills

Introduction

Communication has a crucial role in public health, because it becomes an essential component of prevention; it is also a proactive tool in health promotion. From a planning perspective, it is appropriate to use communication means that can help the bidirectional communication process, such as face-to-face communication and telephone communication.

Materials and methods

In relation to this, the Italian National Institute of Health has developed the "Modello Operativo Comunicativo-Relazionale" (the "Communicative-Relational Operating Model"). It is based on the fundamental skills of the counselling, this gives a protocol to the health professionals that is replicable and organized and it allows health professionals to carry out a telephone communication that is efficient with the user through technical-scientific and communication-relational skills. The goal is to answer in a customized way to the various users' health needs. The Operating Model was created by experts of the National AIDS and Sexually Transmitted Infections Helpline of the Operational Unit of Psycho-Socio-Behavioural Research, Communication, Training, of the Infectious Diseases Department. Later, the Operating Model was proposed to the experts of the Helplines in the National Centre on Addictions and Doping and the National Helpline of the National Centre for Rare Diseases in the National Institute of Health that integrated this method into their telephone approach.

Results

The Operating Model illustrated above was applied to several helplines of the National Institute of Health as an example of correct scientific information, updated and customized on sexual transmitted infections, addictions and rare diseases.

Conclusions

This article aims to illustrate the Operating Model, the theoretical prerequisites that subtend it and its possible application in the different public health structures that use the telephone for a professional relationship with their users.

Trapped Fourth Ventricle: Pathophysiology, History and Treatment Strategies

Trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to enlargement and dilatation of fourth ventricle secondary to obstruction to its outflow. There are several causative mechanisms for the development of trapped fourth ventricle, including previous haemorrhage, infection or inflammatory processes. However, this condition is most commonly observed in ex preterm paediatric patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, treatment of trapped fourth ventricle was associated with high rates of reoperation and complications resulting in morbidity. With the advent of new endoscopic techniques, supratentorial and infratentorial approaches for aqueductoplasty and stent insertion have revolutionised the treatment of trapped fourth ventricle. Fourth ventricular fenestration and direct shunting remain viable options in cases where aqueduct anatomy and length of obstruction is not surgically favourable for endoscopic approaches. In this book chapter, we explore the background, historical developments,$ and surgical treatment strategies in the management of this challenging condition.

Levels of non-dioxin-like PCBs (NDL-PCBs) in liver of loggerhead turtles (Caretta caretta) from the Tyrrhenian Sea (Southern Italy)

The levels of six non-dioxin-like polychlorinated biphenyls (PCBs 28, 52, 101, 138, 153, and 180) were determined in the liver of 84 loggerhead turtles (Caretta caretta) stranded along the coasts of the Tyrrhenian Sea in Campania Region (Southern Italy), from 2017 to 2021. The average value of the sum (∑₆PCB_IND) was 28.0 ± 52.2 ng/g (w.w.). The hexachlorobiphenyls PCB 153 and PCB 138 and the heptachlorobiphenyl PCB 180 were the main contributors to the ∑₆PCB_IND. A weak positive correlation was found between CCL and highly chlorinated PCBs, with adult females having lower PCB concentrations than juvenile females and adult males. This study provides more comprehensive information on the levels of NDL-PCB in Mediterranean loggerhead turtles and sets the basis for assessing anthropogenic impacts on this species.

Bioaccumulation of PCDD/Fs and PCBs in free-range hens: Congener fingerprints and biotransfer factors

The bioaccumulation of lipophilic environmental contaminants in farm animals is an important issue to control and prevent human exposure to toxic pollutants. Free-range hens were used as a model to assess the transfer and the bioaccumulation of PCDD/Fs, DL-PCBs and NDL-PCBs from the soil to eggs in an area in the Campania region particularly affected by pollution, the "Land of Fires". We determined the following ranges of concentrations in eggs: 0.90-5.51 pg WHO-TEQ g^-1 fat for PCDD/Fs; 1.63-4.24 pg WHO-TEQ g^-1 fat for DL-PCBs; 2.77-9.75 pg WHO-TEQ g^-1 fat for the sum of PCDD/Fs and DL-PCBs and 12.53-30.94 ng g^-1 fat for NDL-PCBs. Higher contamination levels were observed in the eggs from free-range hens, compared to those of the control group, that is hens raised indoors; this indicates that soil remains a major source of contamination. Livers showed low levels of contamination for both outdoor and indoor reared hens. Biotransfer factors (BTFs) were calculated for each of the 35 PCDD/F and PCB congeners analysed. The BTFs highlighted that the transfer and bioaccumulation depend on chlorination degree and substitution pattern, in particular they increase with increasing chlorination degree up to the hexa-chlorinated congeners and then decrease. An exception to these finding was observed for 2,3,7,8 TCDD and 2,3,7,8 TCDF, which showed very high BTFs. These results demonstrate the importance of promoting studies on the environmental contaminants bioaccumulation as they provide an effective support for the risk assessment and management of exposure to toxic chemicals.

Long-term renal and cardiovascular outcome of living kidney donors: A single-center retrospective observation study

Background

The nephrectomy for donation reduces the renal parenchyma and glomerular filtration rate (GFR). It is important to understand the clinical consequences of kidney donation by a living donor.

Methods

In this single-center, observational, retrospective study, we defined the renal and cardiovascular outcomes of living kidney donors. We analyzed data of 124 donors who donated at the Kidney Transplant Center (TC) of Bari between February 2002 and December 2018. Biometric data collected at visit 0, that is, at the time of the study of the donor candidate, and at visit 1, or rather at the last nephrological checkup (October-2018/August-2019) were compared.

Results

An overall drop in GFR of 29 mL/min was observed over the analyzed period of 81+/-59 months. At visit 1, two donors developed chronic renal failure, including one in ESKD who underwent a kidney transplant. No relationship between age at donation and GFR drop was found. A trend toward an increase in obese people was reported; 28% of patients had compensated dyslipidemia and 35% were treated for hypertension. During the follow-up time, 3% had major cardiovascular events and 24% were lost to follow-up. One patient died.

Conclusion

The age of the donor does not represent a basic element for reducing GFR or for the occurrence of major cardiovascular events. Furthermore, older donor candidates, in optimal health, should not be excluded from the donation. It is important to promote careful and timely follow-up of the donor, preventing the most common clinical consequences of nephrectomy, in consideration of the poor compliance of a large part of donors over the long-term post-donation period.

Development and validation of a method for determination of 17 endocrine disrupting chemicals in milk, water, blood serum and feed by UHPLC-MS/MS

The concern for human exposure to bisphenol A (BPA) has led to the introduction of other bisphenols to be used as substitutes in industrial processes. These compounds show activity similar to BPA as endocrine disruptors and could be already widespread both in the environment and in food. To monitor their possible occurrence in the food chain, an analytical method based on affinity chromatography clean-up and UHPLC coupled to tandem mass spectrometry detection was developed and in-house validated according to European law, for simultaneous determination of 17 bisphenols in milk and blood serum from bovine and buffalo, in drinking water and in feed. The analytical performance parameters of the method for these matrices were determined. The results showed satisfactory precision in terms of relative standard deviation (3.3%-21.4%), overall good trueness as mean percentage recoveries (77.0%-119.4%), with the only exception of bisphenol PH and bisphenol S in milk and BPA diglycidyl ether in serum. The high specificity and sensitivity of the method allowed us to determine the analytes at very low concentrations, that is, 0.01-1.0 ng/mL in water, 0.1-2.0 ng/mL in milk, 0.01-1.0 ng/g in blood serum and 1.0-10.0 ng/g in feed.

Essential and Non-Essential Elements in Razor Clams (Solen marginatus, Pulteney, 1799) from the Domitio Littoral in Campania (Southwestern Tyrrhenian Sea, Italy)

The levels of essential (Cu, Cr, Co, Mn, Se, Zn) and non-essential (As, Be, Bi, Cd, Cs, Ga, Ni, Pb, Sr, Tl, U, V) trace elements were studied in razor clams (Solen marginatus) collected from the Tyrrhenian coast of Southern Italy at five selected sites along the Domitio littoral in the Campania region. The main objectives of this study were to assess the contamination status of these bivalve mollusks and to evaluate the risks to the environment and consumers due to metal contamination. The concentrations of 18 trace elements were determined after microwave-assisted mineralization and by inductively coupled plasma mass spectrometry (ICP-MS). Concentrations of the toxic elements Pb and Cd were below the maximum levels established by Commission Regulation (EC) 1881/2006, while higher average concentrations of arsenic were found at each of the five sites studied. Regarding the other trace elements, contamination levels followed the order: Zn > Sr > Mn > Cu > Se > Cr > V > Ni > Co > Ga > Cs > Be > U > Bi > Tl. No significant differences among the sites were found with regard to any of the trace elements analyzed, and element levels in razor clams did not reflect sediment contamination. The results demonstrated the substantial food safety of the razor clams in this area with respect to heavy metals but revealed a potential health risk due to arsenic contamination in all the areas sampled.

Leadless Pacemaker in Twiddler's Syndrome: A Case Report

Twiddler's syndrome is a rare cause of pacemaker lead dislodgement. We present the case of a 49-year-old male patient with Down's syndrome implanted with a dual chamber pacemaker showing high ventricular impedance, no sensing, and complete loss of capture for both leads at the 3-month follow-up due to Twiddler Syndrome. The dislocated device was removed, and an endocardial leadless pacing system was implanted. This article is protected by copyright. All rights reserved.

Management of traumatic atlanto-occipital dislocation in a 10-year-old with noninvasive halo immobilization: A case report

Background

Traumatic atlanto-occipital dislocation is an unstable injury of the craniocervical junction. For pediatric patients, surgical arthrodesis of the occipitocervical junction is the recommended management. While having a high success rate for stabilization, the fusion comes with obvious morbidity of limitation in cervical spine flexion, extension, and rotation. An alternative is external immobilization with a conventional halo.

Case Description

We describe the case of a 10-year-old boy who was treated successfully for traumatic AOD with a noninvasive pinless halo. Following initial brain trauma management, we immobilized the craniocervical junction with a pinless halo after reducing the atlanto-occipital dislocation. The pinless halo was kept on at all times for the next 3 months. The craniocervical junction alignment was monitored with weekly cervical spine X-rays and CT craniocervical junction on day 15th, day 30th, and day 70th. A follow-up MRI C-spine 3 months from presentation confirmed resolution of the soft-tissue injury and the pinless halo was removed. Dynamic cervical spine X-rays revealed satisfactory alignment in both flexion and extension views. The patient has been followed up for 2 years postinjury and no issues were identified.

Conclusion

Noninvasive pinless halo is a potential treatment option for traumatic pediatric atlanto-occipital dislocation. This should be considered bearing in mind multiple factors including age and weight of the patient, severity of the atlanto-occipital dislocation (Grade I vs. Grade II and incomplete vs. complete), concomitant skull and scalp injury, and patient's ability to tolerate the halo. It is vital to emphasize that this necessitates close clinicoradiological monitoring.

MO186: Third COVID-19 Vaccine Dose Maximizes Antibody Titer in Kidney Transplant Recipients

BACKGROUND AND AIMS

COVID-19 infection in solid organ transplant recipients (SOT) is associated with increased morbidity and mortality due to comorbidities and immunosuppression state (Chaudhry ZS et al, 2020). Although vaccines represent the greatest hope to control COVID-19 pandemic, several studies showed the low immunogenicity of a two-dose mRNA COVID-19 vaccine regimen in SOT as compared with general population (Boyarsky BJ et al, 2021). Based on this evidence, on September 2021, the Italian Medicine Agency (AIFA) authorized a third vaccine administration as additional primary dose to immunocompromised patients.

The aim of this study is to evaluate the seroconversion rate after the third dose of BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 mRNA vaccine in kidney transplant recipients (KTRs) and to investigate the baseline factors associated with the absence of the antibody response.

METHOD

we performed a prospective and observational study on a monocentric cohort of 329 consecutive Caucasian KTRs given three doses of the BNT162b2 COVID-19 vaccine. Key exclusion criteria were a previous history of COVID-19 infection and transplantation or having underwent chemotherapy treatment within the last year. Antibody response against the spike protein was tested on blood sample collected before the administration of vaccine (T₀), at 15 and 90 days after the second dose (T₂ and T_3, respectively) and one month after the third dose (T₅). The level of antibodies was assessed using the Roche Elecsys anti–SARS-CoV-2 S enzyme immunoassay (positive cut-off ≥ 0.8 U/mL). A total of 22 patients were excluded from the analysis because categorized as SARS-CoV-2-pre-immunized according to the antibodies’ baseline status (T₀) above the positivity cut-off.

The Local Ethics Committees approved the study protocol and written informed consent was obtained before enrolment.

RESULTS

The study population of 307 KTRs was 57.10 ± 13.10 years, with a predominance of male sex (64.2%). Median time from transplantation to vaccine was 10 [IQR 5–17] years. Blood analysis at baseline revealed mean eGFR assessed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to be 56.95 ± 23.04 mL/min/1.73 m².

The standard immunosuppressive regimen consisted of glucocorticoids in all patients, calcineurin inhibitors (88.6% of patients), antimetabolites (73.3% of patients) and mTOR inhibitors (in 15.6% of patients). The first two doses were administered 21 days apart, and the third dose was administrated 172 ± 4 days after the second dose.

In our cohort, 43.3% patients (133/307) responded to the vaccine at T₂. The proportion of responders increased to 68.4% (186/272) at T₃ (median antibody level: 5.2 [0.40–74.07]). One month after the third dose, a positive antibody titer was detected in 251 of 307 patients (81.8%) (median antibody titre: 1137.50 [9.32–4189.75]). The response curve starting at T₂ and increasing at T₃ makes apparent that there is a distinctive kinetic of humoral response in immunocompromised patients compared to immunocompetent individuals (Walsh EE et al., 2020). A multivariate analysis showed that the negative response to the third primary dose was associated with antimetabolite immunosuppressants (P = .001), lower estimated glomerular filtration rate (P < .001) and female sex (P = .04) (Figure 1). No serious adverse events were reported. Neither denovo DSAs nor change in proteinuria were reported after vaccination.

The limitation of this study is the absence of assays for cellular immune response.

CONCLUSION

Although the exact threshold of antibody titer for protection against SARS-CoV-2 infection remains unclear, the ability of the additional mRNA COVID-19 vaccine dose to increase both immune response (Figure 2A) and the prevalence of seroconversion rate (Figure 2B) associated with the acceptable safety profile supports its use after an initial 2-dose mRNA COVID-19 primary vaccine series in immunocompromised patients.

Determination of 20 Endocrine-Disrupting Compounds in the Buffalo Milk Production Chain and Commercial Bovine Milk by UHPLC-MS/MS and HPLC-FLD

Simple Summary

The restriction of the use of bisphenol A (BPA) in industrial production has led manufacturers to employ several BPA analogues. The endocrine-disrupting activity of these substitutes has been proven, and some of them are already widespread in the environment. The intake of these endocrine-disrupting chemicals through diet represents a public concern, and food contamination data are still scarce in scientific literature. To investigate the levels of BPA and its analogues in the production chain of buffalo milk, we developed and validated two analytical methods based on UHPLC–MS/MS and HPLC–FLD. The methods were used to analyse feed and feed additives, raw milk, drinking water, and blood serum samples from buffalo farms in the Campania region, Southern Italy. BPA was found to be the most abundant contaminant, proving that the presence of this compound is still significant and should be monitored.

Abstract

Bisphenol A (BPA) and some of its analogues are well known as endocrine-disrupting chemicals (EDCs), i.e., compounds that can affect the physiological hormonal pathways in both animals and humans, causing adverse health effects. The intake of these substances through diet represents a public concern, compounded by the scarce data in the literature about contamination levels in food. In the framework of a research project, funded by the Italian Ministry of Health, we determined the contamination levels of BPA and 19 EDCs in the production chain of buffalo milk, analysing feed, drinking water, buffalo milk, and blood sera. Overall, 201 feed, 9 feed additive, 62 drinking water, 46 milk, and 190 blood serum samples were collected from 10 buffalo farms in the Campania region, Southern Italy, between 2019 and 2020, and analysed. Moreover, 15 retail bovine milk samples packaged both in Tetra Pak and in PET were analysed to further evaluate consumers’ exposure to EDCs. The results of our work showed no contamination by EDCs in drinking water samples, whereas in 43% of all of the other samples from the farms at least one bisphenol was detected. The most abundant bisphenol detected was BPA (32% of the samples from the farms and 80% of the retail milk samples), thus proving that this compound is still widely used for plastic production.

The Management of Idiopathic and Refractory Syringomyelia

Idiopathic syringomyelia (IS) and refractory syringomyelia (RS) are types of syringomyelia that often pose a management challenge and are associated with long-term clinical sequela. They are usually an epiphenomenon reflecting an underlying pathology where the treatment of the primary cause should be the aim for any surgical intervention. In the case of IS, the initial step is agreeing on the definition of the terms idiopathic and syringomyelia. After a rigorous exhaustive clinic-radiological workup, only IS patients with progressive neurology are treated, usually unblocking subarachnoid cerebrospinal fluid (CSF) pathway obstruction somewhere in the thoracic spinal canal and reserving shunting techniques to nonresponsive cases. Similar to IS, also RS is multifactorial, and its management varies based on the initial pathology, strongly supported by radiological and clinical features. We aim to address this topic focusing on the etiopathology, investigation paradigm, and surgical pathway, formulating algorithms of management with available evidence in literature. Surgical techniques are discussed in detail.

A 10-year retrospective observational study on the utility and prescription standards of dexamethasone in pediatric neuro-oncosurgery in a tertiary care center

OBJECT

This study aimed to retrospectively assess dexamethasone utility in pediatric CNS tumor patients over a 10-year period, to better understand dosing variability, and highlight optimal practice.

METHODS

All pediatric CNS tumor cases managed operatively for a 10-year period at a single center were reviewed. Information was gathered on demographics, dexamethasone doses, course durations, weaning regimes, PPI co-prescription, adverse events, and route of administration. Comparison within these groups was analyzed through use of statistical testing.

RESULTS

One hundred twenty-seven patients received 193 dexamethasone courses. Median age was 7 years, with a median weight of 27.9 kg. Most common tumor type was astrocytoma (24.8%). Median daily dose was 8 mg, with twice-daily dosing most common. Median course duration was 8 days, ranging from 1 to 1103 days. Median weaning duration was 11.5 days. Daily dose was not correlated with patient weight and the median daily dose per kg was 0.2319 mg/kg. Incidence of adverse effects was 14.5% across all course lengths, with weight gain most common. The short-term course duration (<14 days) had the lowest adverse event incidence, with direct correlation between course length and adverse effect incidence. Dexamethasone dose per kg was not significantly different between patients with and without adverse effects. No relationship was noted between adverse effects incidence and administration route (intravenous compared to oral). 64.2% of patients received concurrent PPI with 35.8% receiving no PPI, with 1 gastrointestinal side effect noted in the PPI-receiving population.

CONCLUSIONS

Large variation was seen in practice, with prescriptions appearing based on clinician preference and symptom severity rather than patient age or weight. Future guidelines should consider lower dose regimens than are currently presented with less frequent dosing as these may benefit quality of life. Weaning period can be relatively rapid for most patients, taking place in 2-3 days. PPI co-prescription does not seem to add significant benefit. We recommend using a standardized guideline of 0.2 mg/kg/day (max 8 mg/day) given OD or BD, with PPI cover where necessary. For acute presentations, we recommend limiting dexamethasone treatment to <14 days. These recommendations can be adjusted for individual cases to yield optimal results.

Prevalence and severity of pelvic floor disorders in pregnant and postpartum women

OBJECTIVE

This multicenter study aimed to evaluate risk factors, prevalence and severity of pelvic floor disorders (PFDs) as well as their consequences on women's emotional well-being, using a questionnaire validated specifically for pregnancy and postpartum.

METHODS

Prospective study conducted in eight teaching hospitals in Italy and Italian-speaking Switzerland. Pregnant and postpartum women completed the Italian Pelvic Floor Questionnaire for Pregnancy and Postpartum anonymously. Prevalence of, severity of, and risk factors for PFDs were evaluated for all the four domains considered: bladder, bowel, prolapse, and sexual function.

RESULTS

A total of 2007 women were included: 983 of the patients were bothered by at least one kind of PFD: bladder, bowel, and sexual dysfunction were more frequently reported. There were no significant differences in PFD prevalence between pregnancy and postpartum, except for bladder disorders, which were more prevalent in pregnancy. Familiarity for PFDs, pelvic floor contraction inability, cigarette smoking, body mass index more than 25 (calculated as weight in kilograms divided by the square of height in meters), and age more than 35 years were confirmed risk factors for the development of PFDs during pregnancy and postpartum.

CONCLUSION

Almost half of the women included in the study suffered from PFD-related symptoms with important consequences on quality of life. Validated questionnaires are fundamental in early diagnosis and treatment of PFDs.

Dioxins and dioxin-like PCBs in buffalo milk from the Campania region (Italy): Decreasing trend and baseline assessment over 10 years (2008-2018)

Polychlorodibenzo-p-dioxins, polychlorodibenzo-furans (PCDD/Fs) and dioxin-like polychlorobiphenyls (DL-PCBs) enter the food chain from the environment. In this study, we report the 2008-2018 time-trends in the PCDD/F and DL-PCB contamination of milk from buffaloes fed on local forage in rural areas of the Campania region. Validated according to QA/QC criteria, the dataset (N = 808 on a total of 2068 samples, after excluding follow-up results and outliers) was computed on the upper-bound value pg WHO-TEQ₂₀₀₅ g^-1fat. We assessed time-trends and assayed baseline contamination levels, which displayed log-normal distribution. A significant decreasing trend (p < 0.01) was observed from 2008 to 2009 and 2010; the P50-P95 range fell from 2.37-8.48 pg WHO-TEQ₂₀₀₅ g^-1fat (N = 393) in 2008 to 1.73-4.61 in 2009 (N = 86) and to 0.67-1.46 in 2010 (N = 42). From 2010 to 2018 (N = 329), no significant variation was found among years and the related dataset fitted a log-normal distribution (p < 0.05). Occurrence descriptors indicated that the baseline contamination of dairy products (mean = 0.54; P50-P95 = 0.47-1.24) in the Campania Region was well below the EU regulatory limit in force (5.5 pg WHO-TEQ₂₀₀₅ g^-1fat). Given the Tolerable Weekly Intake of 2 pg WHO-TEQ kg^-1 body weight (bw) proposed by the EFSA for PCDD/Fs and DL-PCBs, this level of baseline contamination is discussed with regard to the orientation of food safety and food security risk connected with buffalo mozzarella cheese production.

Spontaneous NaCl-doped ices Ih, Ic, III, V and VI. Understanding the mechanism of ion inclusion and its dependence on the crystalline structure of ice

Direct coexistence simulations on a microsecond time scale have been performed for different types of ice (I_h, I_c, III, V, and VI) in contact with a NaCl aqueous solution at different pressures. In line with the previous results obtained for ice I_h [Conde et al., Phys. Chem. Chem. Phys., 2017, 19, 9566-9574], our results reveal the spontaneous growth of a new ice doped phase and the formation of a brine rejection phase in all ices studied. However, both the preferential incorporation of ions into the ice lattice and the inclusion mechanisms depend on the crystalline structure of each ice. This work shows the inclusion of Cl^- and Na⁺ ions in ice from salt using molecular dynamics simulation, in agreement with the experimental evidence found in the literature. The model used for water is TIP4P/2005. For NaCl we employ a set of potential parameters that uses unit charges for the ions.

Multiple sclerosis epidemiological trends in Italy highlight the environmental risk factors

Italy is definitely a high-risk country for multiple sclerosis (MS). Over the last 50 years, several epidemiological studies, including longitudinal surveys, have disclosed that MS incidence and prevalence in Italy mainland and Islands (Sardinia and Sicily) have progressively increased, picturing a semi-parabolic curve. Based on the comprehensive scrutiny of 58 papers, we conclude that the latitude risk gradient does not fit to the Italian map of MS. The genetic heterogeneity of the Italian ethnicities, that likely forms the basis of MS predisposition, does not account for the dramatic increase of MS incidence and prevalence observed in Italy over the last half century that, rather, seems better explained by the effect of environmental factors.

Concentrations of trace elements in tissues of loggerhead turtles (Caretta caretta) from the Tyrrhenian and the Ionian coastlines (Calabria, Italy)

Toxic trace elements from both, natural and anthropogenic origin, pose a threat to aquatic environments and marine wildlife due to their long-range transport, bioaccumulative nature, and biomagnification through the food chain. Being long-lived and migratory animals, sea turtles can be exposed to elevated levels of toxic elements, and are therefore considered sentinel species for chemical pollution. In this study, concentrations of trace elements (arsenic, cadmium, lead, mercury) were determined in tissues of 46 loggerhead sea turtles (Caretta caretta) stranded along Tyrrhenian and Ionian coasts of Calabria, in Southern Italy, between 2014 and 2020. Curved carapace length (CCL), curved carapace width (CCW), body mass (BM), and sex were determined and the correlations of these parameters with toxic elements concentrations were investigated. During necropsy, kidney, liver, and muscle tissues were collected and the concentration and distribution of metals determined. Muscle tissues showed the lowest toxic element burdens, except for As that showed the highest mean concentrations in this tissue. The kidney was the main accumulation organ for Cd, while similar levels of Hg and Pb were measured in kidney, liver, and muscle tissues. The risk assessment performed for Cd, Hg, and Pb in sea turtles' liver highlighted possible negative effects on sea turtles' health and the need for marine turtle toxicology researches. This is the first study reporting levels and distribution of toxic elements in tissues of Caretta caretta turtles from the Tyrrhenian and Ionian coasts of Calabria.

Contamination by Aflatoxins B/G in Food and Commodities Imported in Southern Italy from 2017 to 2020: A Risk-Based Evaluation

This study reports the results of aflatoxins B/G monitoring in food of vegetal origin, imported in Southern Italy from extra-European Union countries. From 2017 to 2020, we analyzed 1675 samples using an accredited HPLC method with fluorescence detection. We found out 295 samples (17.6%) were contaminated by aflatoxin B1, 204 by aflatoxins B/G (12.2%), while 75 (4.5%) resulted non-compliant to maximum limits set by the European Union law. Most of the batches tested were unprocessed food; the distribution of contamination levels, incidence of non-compliant samples, inference for different kinds of food are reported. The study focuses on the food more susceptible to contamination by aflatoxins; nuts are the food more controlled, showing the higher number of non-compliant samples. Our study confirms that pistachio nuts, hazelnuts and almonds are the major sources of exposure for consumers. Still, other products, such as chili pepper and Brazil nuts, need to get more information about their contamination levels. The study's findings are discussed in the perspective of the last opinion by EFSA about chronic exposure to aflatoxins. A case study to evaluate not compliance of a composed food to the European Union law is reported.

Guideline for the management of long tunnelled external ventricular drains in chronic hydrocephalus

This article reports on the journey of a child with an inoperable hypothalamic-origin pilocytic astrocytoma causing hydrocephalus, which was refractory to treatment with shunts, and required a new approach. With multidisciplinary support, excellent nursing care and parental education, the child's hydrocephalus was managed long term in the community with bilateral long-tunnelled external ventricular drains (LTEVDs). This article describes the patient's journey and highlights the treatment protocols that were created to achieve this feat. Despite the difficulties in initially setting up these protocols, they proved successful and thus the team managing the patient proposed that LTEVDs are a viable treatment option for children with hydrocephalus in the context of inoperable tumours to help maximise quality of life.

Droplet Digital PCR (ddPCR) Analysis for the Detection and Quantification of Cow DNA in Buffalo Mozzarella Cheese

Simple Summary

Buffalo mozzarella cheese, sold as a Protected Designation of Origin (PDO) product, is made exclusively from Mediterranean buffalo (Bubalus bubalis) milk. To maximize their profits and overcome seasonal shortages of buffalo milk, some producers have started to produce “PDO” buffalo mozzarella cheese by adulterating buffalo milk with milk from different species. such as bovine, thus defrauding consumers. This practice has led the Italian government to reinforce controls on food mislabeling and fraud through traceability mechanisms. The aim of this work is the development of a molecular assay—droplet digital Polymerase Chain Reaction technique (ddPCR)—able to detect the DNA of cow and/or buffalo milk in PDO buffalo mozzarella cheese, thus revealing fraud. The results have highlighted that, thanks to its high precision and sensitivity, the ddPCR could represent an efficacious means of supporting the official controls aimed at combating the adulteration of buffalo mozzarella cheese with bovine milk.

Abstract

Buffalo mozzarella cheese is one of the most appreciated traditional Italian products and it is certified as a Protected Designation of Origin (PDO) product under the European Commission Regulation No. 1151/2012. It is obtained exclusively from buffalo milk. If made from cow milk, or a mixture of buffalo and cow milk, buffalo mozzarella cheese does not qualify as a PDO product. In order to maximize their profits, some producers market buffalo mozzarella that also contains cow milk as a PDO product, thus defrauding consumers. New methods for revealing this fraud are therefore needed. One such method is the droplet digital Polymerase Chain Reaction (ddPCR). Thanks to its high precision and sensitivity, the ddPCR could prove an efficacious means for detecting the presence of cow milk in buffalo mozzarella cheese that is marketed as a PDO product. ddPCR has proved able to detect the DNA of cow and/or buffalo milk in 33 buffalo mozzarella cheeses labelled as PDO products, and experimental evidence could support its application in routine analyses.

Third ventricular colloid cyst causing acute hydrocephalus during early pregnancy: Clinical lessons from a case

Background

Colloid cysts of third ventricle are rare lesions which may present with symptoms of acute hydrocephalus. We report a case of acute obstructive hydrocephalus secondary to third ventricular colloid cyst and its management during 1^st trimester pregnancy.

Case Description

A 31-years-old lady presented to the emergency department with reduced consciousness. Computed tomography head showed obstructive hydrocephalus and an obstructing lesion near foramen of Monro suggestive of third ventricle colloid cyst. She underwent endoscopic resection of colloid cyst. Her pregnancy was only confirmed after surgery and she delivered a healthy neonate at full term. She has remained clinically well and had resumed her work as a general practitioner.

Conclusion

This case illustrates that urinary pregnancy test may show false negative result but pregnancy should not preclude radiological investigation and neurosurgical intervention in patients with deteriorating neurological function.

DelCFHR3-1 influences graft survival in transplant patients with IgA nephropathy via complement-mediated cellular senescence

IgA nephropathy (IgAN) is a frequent cause of chronic kidney disease (CKD) and progressive renal impairment. A native renal biopsy diagnosis of IgAN is a predictor of graft loss, with a relative risk of 47% but it is difficult to predict graft survival and progressive allograft dysfunction in these patients. Deletion of complement factor H-related genes 1 and 3 (delCFHR3-1) has been associated with a decreased risk of developing IgAN on native kidneys, but the impact on the graft in IgAN-transplanted patients is unknown. We hypothesized that delCFHR3-1 is also associated with the processes that influence graft survival in transplant recipients with IgAN and tested whether cellular senescence is involved in mediating graft damage. We found that patients carrying two copies of CFHR1-3 had a worse outcome (P = .000321) and presented increased FHR1 deposits at glomerular and tubulointerstitial level associated with higher expression of the senescence marker p16^INK4a (P = .001) and tubulointerstitial fibrosis (P = .005). Interestingly, FHR1 deposits were associated with increased complement activation as demonstrated by C5b-9 deposits. These data support both the role of FHR1 in mediating complement activation and tubular senescence, and suggest the possibility of genotyping delCFHR3-1 to predict graft survival in IgAN-transplanted patients.

Polycystic Ovary Syndrome and Probiotics: A Natural Approach to an Inflammatory Disease

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Polycystic ovary syndrome (PCOS) is a condition that affects about 15% of women of reproductive age and is correlated with infertility, insulin resistance, and obesity. The etiology of PCOS is multifactorial and genetic, endocrine, and metabolic causes are involved.

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New evidence suggests a link between microorganisms residing in the digestive tracts of humans and the development of PCOS. Moreover, an imbalance in the gut microbial community could be a possible factor for the onset of insulin resistance and obesity. Hyperandrogenism, a key feature of PCOS, could also play a critical role in shaping the microbiome community.

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Probiotics could modify the gut microbiota and serve as a potential treatment for PCOS. Here we disclose the association between PCOS and intestinal microbiota and the possible role of probiotics as a new treatment approach.

Atlantoaxial limited dorsal myeloschisis: A report of two cases and review of literature

Introduction

Limited dorsal myeloschisis (LDM) is a rare form of spinal dysraphism that is characterised by a distinctive fibroneural stalk connecting the spinal cord to the overlying skin lesion. The skin lesions associated with LDM can appear benign clinically and careful evaluation with an MRI scan is essential for diagnosing LDM and to differentiate this entity from other forms of spinal dysraphism and benign causes of skin lesions.

Research question

There is a lack of reported atlantoaxial LDM in the literature. We sought to report the clinical presentation, radiological features and surgical management of the first two reported atlantoaxial LDM.

Material and methods

Clinical findings and radiological images of the two cases of atlantoaxial LDM that underwent surgical intervention at our institution were retrieved from the medical notes, operative records and imaging system.

Results

Both cases of atlantoaxial LDM (C0-1 and C1-2 respectively) underwent successful resection of the overlying cutaneous lesions and stalks to release the tethered spinal cords.

Discussion

The surgical management of LDM have been associated with good outcomes and consists of resecting the fibroneural stalk close to the underlying cord, releasing the tethered spinal cord and removing the overlying cutaneous lesion.

Conclusion

These are the first two reported cases of atlantoaxial LDM in the literature. We aim to raise awareness of this pathological entity and highlight the importance of establishing the correct diagnosis to guide definitive management, and report the favourable neurological outcome in these cases despite the rostral location.

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Limited dorsal myeloschisis is a rare form of closed spinal dysraphism.

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These are the first two reported cases of atlantoaxial limited dorsal myeloschisis.

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Favourable surgical outcomes can be achieved despite the rostral location.

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Dorsal midline cutaneous lesions should be investigated further with MRI scan.

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The fibroneural stalk connects the overlying cutaneous lesion to the spinal cord.

Polychlorinated organic pollutants (PCDD/Fs and DL-PCBs) in loggerhead (Caretta caretta) and green (Chelonia mydas) turtles from Central-Southern Tyrrhenian Sea

This study assesses for the first time the levels of PCDD/Fs and DL-PCBs in sea turtles coming from Tyrrhenian Sea. The concentrations measured in liver of the 24 specimens analysed were 6.90 vs 5.65 pg g^-1 wet weight (ww) for PCDD/Fs and 10.95 vs 0.79 ng g^-1 ww for DL-PCBs in Caretta caretta and Chelonia mydas, respectively. The DL-PCB levels resulted very higher in Caretta caretta than Chelonia mydas probably due to the different eating habits between the two species investigated. Furthermore, the highest levels of DL-PCBs were determined in livers of the adult Caretta caretta turtles of male sex. Positive correlations were found out between PCB-81 and the body mass (BM) of turtles (r² = 0.6561; p = 0.001) and between PCB-81 and the curved carapace length (CCL) (r² = 0.6250; p = 0.006) suggesting that the body burden of contaminants is related to the body size. The mean TEQ values, as a matter of risk assessment for turtles, were 3.64 vs 1.62 pg TEQ g^-1 ww for PCDD/Fs and 8.72 vs 2.16 pg TEQ g^-1 ww for DL-PCBs in Caretta caretta and Chelonia mydas, respectively. The results reported in this study increase the data available about the consequences of the Mediterranean Sea contamination by organochlorine pollutants and highlight an evident PCDD/F and PCB bioaccumulation in sea turtle tissues that threatens the survival of these marine organisms.