Detection of mostly viral pathogens and high proportion of antibiotic treatment initiation in hospitalised children with community-acquired pneumonia in Switzerland - baseline findings from the first two years of the KIDS-STEP trial

AIMS OF THE STUDY

Globally, since the introduction of conjugate-vaccines against encapsulated bacteria, respiratory viruses have caused most hospitalisations for community-acquired pneumonia. The aim of this study was to describe pathogens detected and their association with clinical findings in Switzerland.

METHODS

Baseline data were analysed for all trial participants enrolled between September 2018 and September 2020 into the KIDS-STEP Trial, a randomised controlled superiority trial on the effect of betamethasone on clinical stabilisation of children admitted with community-acquired pneumonia. Data included clinical presentation, antibiotic use and results of pathogen detection. In addition to routine sampling, nasopharyngeal specimens were analysed for respiratory pathogens using a panel polymerase chain reaction test covering 18 viral and 4 bacterial pathogens.

RESULTS

138 children with a median age of 3 years were enrolled at the eight trial sites. Fever (obligatory for enrolment) had been present for median 5 days before admission. Most common symptoms were reduced activity (129, 93.5%) and reduced oral intake (108, 78.3%). Oxygen saturation <92% was found in 43 (31.2%). Forty-three participants (29.0%) were already on antibiotic treatment prior to admission and 104 participants (75.4%) received antibiotic treatment on admission. Pathogen testing results were available from 132 children: 31 (23.5%) had respiratory syncytial virus detected, 21 (15.9%) human metapneumovirus. The pathogens detected showed expected seasonal and age preponderance and were not associated with chest X-ray findings.

CONCLUSIONS

In the context of the predominantly viral pathogens detected, the majority of antibiotic treatment is probably unnecessary. The ongoing trial, as well as other studies, will be able to provide comparative pathogen detection data to compare pre- and post-COVID-19-pandemic settings.

DNA-damage response as a novel pathogenic mechanism of heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome characterized by impaired left ventricular (LV) diastolic function, with normal LV ejection fraction. The most common cause is aortic valve stenosis, which provokes sustained pressure overload (PO) (1). HFpEF cardiac remodeling comprises cardiomyocyte (CM) hypertrophy and fibrotic matrix deposition (2). A link between HFpEF pathogenesis and DNA damage response (DDR) activation emerged from in vivo studies (3). DNA damage activates DDR kinases, producing the phosphorylation of H2AX histone and checkpoint proteins, CHK1 and CHK2, to orchestrate cell recovery. DDR activation contributes to mouse CM hypertrophy and inflammation, promoting cardiac remodeling and HF (4)(5). No studies of this molecular mechanism have been performed on HFpEF patient samples yet. Moreover, known the pivotal role of the stromal compartment in the myocardial response to PO (6)(7), the effects of DDR activation on cardiac mesenchymal stromal cells (C-MSC) are still to be investigated.

Purpose

Our aim is to address the aforementioned gaps, unraveling the effects of C-MSC DDR persistent activation on C-MSC phenotypes.

Methods

We collected LV septum samples from patients with HFpEF undergoing aortic valve surgery (n=7) and healthy controls (HC; n=7), both for tissue analyses and C-MSC isolation. PO-induced mechanical stimuli has been simulated in vitro by cyclic unidirectional stretch.

Results

Histological analyses of HFpEF tissues showed enlarged nuclei and hypertrophic cardiac fibers, increased collagen deposition, higher apoptosis and oxidative stress than HC tissues. HFpEF samples revealed DNA damage (% γH2AX positive cells p=0.047), in both CM and C-MSC. γH2AX, pCHK1, pCHK2 protein expression was higher in HFpEF total tissue (γH2AX/GAPDH p= 0.033; pCHK1/GAPDH p= 0.018; pCHK2/GAPDH p= 0.049). Primary human C-MSC isolated from HFpEF and HC cardiac tissues confirmed the increased γH2AX (γH2AX/GAPDH p=0.0030) and phosphorylated checkpoint protein expression (pCHK1/GAPDH p= 0.045; pCHK2/GAPDH p= 0.039), suggesting C-MSC involvement in DDR-driven remodeling. HFpEF C-MSC express also more pro-fibrotic and pro-inflammatory factors than HC cells.

In response to in vitro mechanical stimulation, HC C-MSC increased DNA damage (% γH2AX positive cells non-stretched vs. stretched cells p=0.022) and phosphorylated checkpoint proteins, suggesting PO-guided activation of DDR. Stretched C-MSC secreted more pro-inflammatory and pro-fibrotic molecules compared to static control.

Conclusion

HFpEF sustained PO induces DDR persistent activation not only in CM but also in C-MSC. On C-MSC, DDR impairments are linked to inflammation and fibrosis, with direct effects on C-MSC protein expression and secretome. The factors released by C-MSC could further impair CM function. Future studies will unravel the potential anti-fibrotic and anti-hypertrophic effects of DDR inhibitors in HFpEF context.

Prevalence of retained/transmigrated permanent and persistence of primary teeth associated with odontomas in young children

AIM

Odontomas are odontogenic tumours of the jaws; they are generally asymptomatic with an unknown aetiology. This study was conducted on non-syndromic children aged 9 to 14 years to explore the side effects deriving from the presence of these benign tumours, as retention, transmigration, ectopic eruption of permanent teeth and the permanence of primary teeth in the affected area.

METHODS

Two hundred panoramic (OPT) and 92 Cone Beam Computed Tomography radiographs (CBCT) of patients (130 males and 70 females) were analysed from February 2018 to December 2019. Two hundred odontomas (145 compound and 55 complex type) and 800 teeth (160 primary and 640 permanent) were included.

RESULTS

The prevalence of these tumours in both male and female subjects was 65% and 35%, respectively; the prevalence of compound odontomas in maxillary and mandibular bones was respectively 27.58% and 72.41%. The prevalence of complex odontomas in maxillary bones in female and male subjects was 37.5% and 62.5% respectively. It was observed the presence of a primary tooth in 81% of cases, the presence of retained teeth in 16.5% and a dental transmigration in the remaining 2.5% of cases in the compound type. Gender (p?=0.158) has no significant correlation.

CONCLUSIONS

An early diagnosis and removal of odontomas in primary dentition is crucial in order to prevent later dental complications. Since the detection of odontomas is mainly an accidental radiological finding, the need for routine radiographic analysis should be highlighted.

Randomised placebo-controlled multicentre effectiveness trial of adjunct betamethasone therapy in hospitalised children with community-acquired pneumonia: a trial protocol for the KIDS-STEP trial

INTRODUCTION

Community-acquired pneumonia (CAP) causes around 10 hospitalisations per 1000 child-years, each associated with an average 13 non-routine days experienced and more than 4 parent workdays lost. In adults, steroid treatment shortens time to clinical stabilisation without an increase in complications in patients with CAP. However, despite promising data from observational studies, there is a lack of high-quality evidence for the use of steroids.

METHODS AND ANALYSIS

The KIDS-STEP trial is a multicentre, randomised, double-blind, placebo-controlled superiority trial of betamethasone treatment on outcome of hospitalised children with CAP. Children are enrolled in paediatric emergency departments of hospitals across Switzerland and randomised to adjunct oral betamethasone for 2 days or matching placebo in addition to standard of care treatment. The co-primary outcomes are the proportion of children clinically stable 48 hours after randomisation and the proportion of children with CAP-related readmission within 28 days after randomisation. Secondary outcomes include length of hospital stay, time away from routine childcare and healthcare utilisation and total antibiotic prescriptions within 28 days from randomisation.Each of the co-primary outcomes will be analysed separately. We will test clinical stability rates using a proportion test; to test non-inferiority in readmission rates, we will construct 1-α % CI of the estimated difference and test if it contains the pre-defined margin of 7%. Success is conditional on both tests. A simulation-based sample size estimation determined that recruiting 700 patients will ensure a power of 80% for the study.

ETHICS AND DISSEMINATION

The trial protocol and materials were approved by ethics committees in Switzerland (lead: Ethikkommission Nordwest und Zentralschweiz) and the regulatory authority Swissmedic. Participants and caregivers provide informed consent prior to study procedures commencing. The trial results will be published in peer-reviewed journals and at national and international conferences. Key messages will also be disseminated via press and social media where appropriate.

TRIAL REGISTRATION NUMBER

NCT03474991 and SNCTP000002864.

Will a tumor pandemic come after the COVID-19 pandemic? Head and Neck cancer perspective

The COVID-19 pandemic demands a reassessment of head and neck oncology treatment paradigms by posing several challenges for oncology services, with unprecedented pressure on the regional health care system. Since February 2020 this has severely disrupted health-care services, leading to accumulating clinic caseload and substantial delays for operations. The head and neck cancer services have been faced with the difficult task of managing the balance between infection risk to health-care providers and the risk of disease progression from prolonged waiting times. Herein, we share our experience in Firenze (Italy) and propose our action plan on the management of head and neck cancer services via multi-institution collaboration.

The surgical treatment of unilateral vocal cord paralysis (UVCP): qualitative review analysis and meta-analysis study

PURPOSE

The objectives of this meta-analysis were to summarize the key surgical procedures for UVCP and to evaluate which of these is associated with better results in terms of vocal improvement.

METHODS

A systematic review of the literature was conducted in search of articles focused on the comparison of voice outcome between different techniques for the UVCP treatment. Then, a quantitative analysis was carried out for papers published from 2013 onwards, reporting only adult patients with unilateral paralysis for each study, and each surgical technique was evaluated for its capability of achieving good functional outcomes in terms of GRBAS-I scale and maximum phonation time in seconds (MPT).

RESULTS

The search identified 1853 publications. A total of 159 articles were stratified and included according to our selection criteria. 21 out of 159 articles were selected for quantitative synthesis. For trans-oral techniques: the mean GRBAS-I scale were 2.33 before injection and 0.41 after injection. The mean MPT before injection were 4.78 and 12.50 after injection. For open techniques the mean GRBAS-I scale were 2.43 before surgery and 0.68 after surgery. For open technique, the mean MPT were 3.50 before surgery and 12.40 after surgery.

CONCLUSIONS

The two types of techniques lead to an improvement in terms of vocal outcomes emphasizing that from the examined literature an indication emerges to perform an early injection because this could reduce the possible need for a more invasive intervention of permanent medialization in the future.

A STAT4 variant increases liver fibrosis risk in Caucasian patients with chronic hepatitis B

BACKGROUND

Host genetic modifiers of the natural history of chronic hepatitis B (CHB) remain poorly understood. Recently, a genome-wide association study (GWAS)-identified polymorphism in the STAT4 gene that contributes to the risk for hepatocellular carcinoma (HCC) was shown to be associated with the full spectrum of hepatitis B virus (HBV) outcomes in Asian patients. However, the functional mechanisms for this effect are unknown and the role of the variant in modulating HBV disease in Caucasians has not been investigated.

AIMS

To determine whether STAT4 genetic variation is associated with liver injury in Caucasian patients with CHB and to investigate potential mechanisms mediating this effect.

METHODS

STAT4 rs7574865 was genotyped in 1085 subjects (830 with CHB and 255 healthy controls). STAT4 expression in liver, PBMCs and NK cells, STAT4 phosphorylation and secretion of interferon-gamma (IFN-γ) according to STAT4 genetic variation was examined.

RESULTS

STAT4 rs7574865 genotype was independently associated with hepatic inflammation (OR: 1.42, 95% CI: 1.07-2.06, P = 0.02) and advanced fibrosis (OR: 1.83, 95% CI: 1.19-2.83, P = 0.006). The minor allele frequency of rs7574865 was significantly lower than that in healthy controls. rs7574865 GG risk carriers expressed lower levels of STAT4 in liver, PBMCs and in NK cells, while NK cells from patients with the risk genotype had impaired STAT4 phosphorylation following stimulation with IL-12/IL-18 and a reduction in secretion of IFN-γ.

CONCLUSION

Genetic susceptibility to HBV persistence, hepatic inflammation and fibrosis in Caucasians associates with STAT4 rs7574865 variant. Downstream effects on NK cell function through STAT4 phosphorylation-dependent IFN-γ production likely contribute to these effects.

AEgIS at ELENA: outlook for physics with a pulsed cold antihydrogen beam

The efficient production of cold antihydrogen atoms in particle traps at CERN's Antiproton Decelerator has opened up the possibility of performing direct measurements of the Earth's gravitational acceleration on purely antimatter bodies. The goal of the AEgIS collaboration is to measure the value of g for antimatter using a pulsed source of cold antihydrogen and a Moiré deflectometer/Talbot-Lau interferometer. The same antihydrogen beam is also very well suited to measuring precisely the ground-state hyperfine splitting of the anti-atom. The antihydrogen formation mechanism chosen by AEgIS is resonant charge exchange between cold antiprotons and Rydberg positronium. A series of technical developments regarding positrons and positronium (Ps formation in a dedicated room-temperature target, spectroscopy of the n=1-3 and n=3-15 transitions in Ps, Ps formation in a target at 10 K inside the 1 T magnetic field of the experiment) as well as antiprotons (high-efficiency trapping of [Formula: see text], radial compression to sub-millimetre radii of mixed [Formula: see text] plasmas in 1 T field, high-efficiency transfer of [Formula: see text] to the antihydrogen production trap using an in-flight launch and recapture procedure) were successfully implemented. Two further critical steps that are germane mainly to charge exchange formation of antihydrogen-cooling of antiprotons and formation of a beam of antihydrogen-are being addressed in parallel. The coming of ELENA will allow, in the very near future, the number of trappable antiprotons to be increased by more than a factor of 50. For the antihydrogen production scheme chosen by AEgIS, this will be reflected in a corresponding increase of produced antihydrogen atoms, leading to a significant reduction of measurement times and providing a path towards high-precision measurements.This article is part of the Theo Murphy meeting issue 'Antiproton physics in the ELENA era'.

AEg̅IS latest results

The validity of the Weak Equivalence Principle (WEP) as predicted by General Relativity has been tested up to astounding precision using ordinary matter. The lack hitherto of a stable source of a probe being at the same time electrically neutral, cold and stable enough to be measured has prevented highaccuracy testing of the WEP on anti-matter. The AEg̅IS (Antimatter Experiment: Gravity, Interferometry, Spectroscopy) experiment located at CERN's AD (Antiproton Decelerator) facility aims at producing such a probe in the form of a pulsed beam of cold anti-hydrogen, and at measuring by means of a moiré deflectometer the gravitational force that Earth's mass exerts on it. Low temperature and abundance of the H̅ are paramount to attain a high precision measurement. A technique employing a charge-exchange reaction between antiprotons coming from the AD and excited positronium atoms is being developed at AEg̅IS and will be presented hereafter, alongside an overview of the experimental apparatus and the current status of the experiment

Towards the first measurement of matter-antimatter gravitational interaction

The AEgIS (Antimatter Experiment: Gravity, Interferometry, Spectroscopy) is a CERN based experiment with the central aim to measure directly the gravitational acceleration of antihydrogen. Antihydrogen atoms will be produced via charge exchange reactions which will consist of Rydberg-excited positronium atoms sent to cooled antiprotons within an electromagnetic trap. The resulting Rydberg antihydrogen atoms will then be horizontally accelerated by an electric field gradient (Stark effect), they will then pass through a moiré deflectometer. The vertical deflection caused by the Earth's gravitational field will test for the first time the Weak Equivalence Principle for antimatter. Detection will be undertaken via a position sensitive detector. Around 103 antihydrogen atoms are needed for the gravitational measurement to be completed. The present status, current achievements and results will be presented, with special attention toward the laser excitation of positronium (Ps) to the n=3 state and the production of Ps atoms in the transmission geometry.

Colonization of Legionella spp. In dental unit waterlines

Legionella spp. are ubiquitous in aquatic habitats and water distribution systems, including dental unit waterlines. Surveys have shown that the percentage of samples taken at different dental sites that were positive for Legionella spp. were highly variable and ranged from 0% to 100%. Cultivation is the principal approach to evaluating bacterial contamination employed in the past, but applying this approach to testing for Legionella spp. may result in false-negative data or underestimated bacterial counts. PCR and direct fluorescent counts can detect viable non-cultivable bacteria, which are not counted by plating procedures. Legionella spp., commonly form such viable non-culturable cells and it is likely that they contribute to the difference between plate count results and those of PCR and fluorescent-antibody detection. However, studies have shown that Legionella is present in the municipal water source in spite of the current filtration and chlorination procedures. Once Legionella reaches the building water system, it settles down into a biofilm layer of stagnant water. By means of this layer, Legionella can protect itself from antimicrobial agents and then multiply. Dental unit waterlines may be contaminated with opportunistic bacteria. The water quality in the dental units should be controlled to eliminate opportunistic pathogens and to provide water for dental treatment that meets public health standards for potable water.

Radiosurgery-assisted gingival displacement: a proof of concept technique to enhance the efficiency of intraoral digital impression

Nowadays, an increasing number of dentists are using intraoral scanners (IOS) in their daily practice as an alternative to conventional impression taking. One of the main concerns is related to the capability of scanning the subgingival anatomy of the die, usually very challenging due to the limited operative field and the presence of oral fluids. The radiosurgery assisted gingival displacement technique (RAGD) may enhance the intraoral optical scanning of the finish line and neighbor tooth anatomy. The contour of the interim prosthesis is used to drive the tip of radiosurgery electrode along the tooth surface and open selectively the gingival crevice with a prosthetically-driven and minimally invasive approach. The clinical implication of this technique is related to increasing the efficiency and accuracy of the digital impression technique in the critical zone of the prosthetic shoulder.

Focus on periodontal disease and development of endocarditis

Infective endocarditis is a devastating disease with high morbidity and mortality. The link to oral bacteria has been known for many decades and has caused ongoing concern for dentists, patients and cardiologists. The microbiota of the mouth is extremely diverse and more than 700 bacterial species have been detected. Half of them are uncultivable so far. Oral microbiota is not uniform, specific sites exist in the mouth such as tongue, palate, cheek, teeth and periodontal pockets that have their own microbiota. Factors involved in the development of a bacterial endocarditis are difficult to define but a vulnerable surface (i.e. a damaged endocardium) and a high bacterial load in the blood seems to be decisive. The cause of microorganisms, in 90% of cases, are staphylococcus, streptococcus and enterococcus. Oral streptococci belong to viridans group (streptococcus mutans and streptococcus sanguis). As they are part of dental plaque, they could enter the bloodstream causing bacteraemia through daily habits like chewing or tooth brushing. Effective treatment of periodontal infections is important to reduce local inflammation and bacteraemia. In addition, poor periodontal health appears to increase the risk of cardiovascular disease, pulmonary disease, and preterm and low birth weight.

CONCLUSIONS

Long-standing oral disease prevention protocols reduce the risk of developing periodontal disease. Data suggests that methods used to prevent cases of IE that originate from oral bacteria should focus on improving oral hygiene and reducing or eliminating gingivitis, which should reduce the incidence of bacteraemia after tooth-brushing and the need to extract teeth owing to periodontal disease and caries.

Randomised clinical trial: sofosbuvir and ledipasvir in patients with transfusion-dependent thalassaemia and HCV genotype 1 or 4 infection

BACKGROUND

Patients with thalassaemia major depend on blood transfusions. In Italy, up to 80% of thalassaemia patients bear HCV antibodies due to HCV contaminated transfusions before 1990. Thalassaemia patients with HCV infection have high risk of developing HCC. Treatment based on Pegylated-IFN (Peg-IFN) and Ribavirin (RBV) was limited by relevant side effects.

AIM

To evaluate the impact of Sofosbuvir/Ledipasvir (SOF/LDV) fixed dose combination for 12 weeks without RBV, in patients with thalassaemia major and HCV Genotype 1 or 4 (GT1/4).

METHODS

Open label, historically-controlled, nationwide multicentre study in thalassaemia patients including naïve with cirrhosis and prior treatment failure without cirrhosis. SOF/LDV single pill was administered for 12 weeks to 100 patients of whom 16% had cirrhosis. The control group included 96 patients with comparable baseline characteristics treated with Peg-IFN/RBV. The primary end point was sustained virologic response at follow-up week 12 or 24 after IFN-free or Peg-IFN/RBV, respectively.

RESULTS

In the study group, sustained virological response (SVR) was reported in 98% of patients (95% CI 95.3%-100%). Cirrhotic as well as prior treatment failure achieved 100% SVR. In the control group, SVR was 47.9% (95% CI 37.9%-57.9%). Adverse events including fatigue, headache, nausea, decrease in haemoglobin or increase in ferritin levels were rare and significantly less common in the study than in the historical control group.

CONCLUSIONS

In conclusion, SOF/LDV for 12 weeks provides simple, highly effective and safe Peg-IFN/RBV-free treatment for HCV GT1/4 thalassaemia patients. EUDRACT number 2015-002401-1.

Streamlined bioreactor-based production of human cartilage tissues

Engineered tissue grafts have been manufactured using methods based predominantly on traditional labour-intensive manual benchtop techniques. These methods impart significant regulatory and economic challenges, hindering the successful translation of engineered tissue products to the clinic. Alternatively, bioreactor-based production systems have the potential to overcome such limitations. In this work, we present an innovative manufacturing approach to engineer cartilage tissue within a single bioreactor system, starting from freshly isolated human primary chondrocytes, through the generation of cartilaginous tissue grafts. The limited number of primary chondrocytes that can be isolated from a small clinically-sized cartilage biopsy could be seeded and extensively expanded directly within a 3D scaffold in our perfusion bioreactor (5.4 ± 0.9 doublings in 2 weeks), bypassing conventional 2D expansion in flasks. Chondrocytes expanded in 3D scaffolds better maintained a chondrogenic phenotype than chondrocytes expanded on plastic flasks (collagen type II mRNA, 18-fold; Sox-9, 11-fold). After this "3D expansion" phase, bioreactor culture conditions were changed to subsequently support chondrogenic differentiation for two weeks. Engineered tissues based on 3D-expanded chondrocytes were more cartilaginous than tissues generated from chondrocytes previously expanded in flasks. We then demonstrated that this streamlined bioreactor-based process could be adapted to effectively generate up-scaled cartilage grafts in a size with clinical relevance (50 mm diameter). Streamlined and robust tissue engineering processes, as the one described here, may be key for the future manufacturing of grafts for clinical applications, as they facilitate the establishment of compact and closed bioreactor-based production systems, with minimal automation requirements, lower operating costs, and increased compliance to regulatory guidelines.

231 USE OF SOFT SUBSTRATES TO PROMOTE AND MAINTAIN OCT4 EXPRESSION IN EPIGENETICALLY ERASED FIBROBLASTS

Pluripotency and commitment are driven by transcription factors that act as molecular switches to activate or repress specific gene expression programs. Among these, the POU transcription factor OCT4 (encoded by POU class 5 homeobox 1, POU5F1) is known to be a regulator in pluripotent cells and it is essential for the maintenance of a high plasticity state in mammalian cells. In recent years, particular attention has been given to the importance of physical extracellular matrix properties in regulating pluripotent cell maintenance and differentiation. In particular, recent studies demonstrated that high plasticity cells are intrinsically soft and respond optimally to physical forces when cultured on a “low stiffness” substrate that matches their intrinsic softness. To investigate these aspects, here we used a protocol where terminally differentiated cells are driven into a high plasticity/OCT4-positive state through the use of the epigenetic eraser, 5-aza-cytidine (5-aza-CR) and we observed the effect of substrate stiffness on the maintenance of OCT4 expression. To this purpose, human skin fibroblasts were plated either on standard plastic dishes (group A) or on polyacrylamide gels (PAA) of low stiffness (1 kPa; group B). Cells were treated with 1 μM 5-aza-CR for 18 h and were subsequently maintained and cultured in embryonic stem cell medium for 14 days. Assessment of OCT4 was carried out both by real-time PCR and immunocytochemical analysis, at different time points: untreated fibroblasts (T0), after 5-aza-CR treatment, and on Days 2, 4, 6, 8, 10, and 14 of culture. The results obtained indicate that untreated fibroblasts (T0) were negative for OCT4, whereas, after 5-aza-CR exposure, cells actively expressed the pluripotency marker, in both the A and B groups. However, whereas group A cells progressively down-regulated OCT4 expression and eliminated its positivity by Day 6, group B cells steadily transcribed and were homogeneously immunopositive for the pluripotency factor until Day 14, when cultures were arrested. Overall, the data obtained suggest that a soft substrate, matching the intrinsic stiffness distinctive of high plasticity cells, may help in promoting their maintenance, via a biophysical mechanism of low-traction/low-stiffness-dependent manner. Study was supported by Carraresi Foundation.

Safety of vitamin K antagonist treatment for splanchnic vein thrombosis: a multicenter cohort study

BACKGROUND

The treatment of splanchnic vein thrombosis (SVT) is challenging, due to the increased risk of bleeding and potentially life-threatening complications. Current recommendations are based on evidence from the treatment of venous thrombosis in usual sites, but small observational studies in SVT population suggest that the bleeding risk may offset the benefit of anticoagulant treatment in this setting. The aim of this study was to evaluate the safety of vitamin K antagonists (VKAs) in SVT patients.

METHODS

We retrospectively included SVT patients treated with VKAs followed by 37 Italian anticoagulation clinics, until June 2013. The primary outcome was the incidence of major bleeding (MB), according to the ISTH definition, during VKA treatment. Vascular events, including both arterial and venous thrombosis, and mortality were also documented.

RESULTS

Three hundred and seventy-five patients were included (median age 53 years; 54.7% males). During a median VKA treatment duration of 1.98 years, 15 MB events occurred, corresponding to an incidence rate of 1.24 (95% confidence interval [CI], 0.75-2.06) per 100 patient-years. Gastrointestinal bleeding represented 40% of all MB events. At multivariate analysis, the presence of esophageal varices emerged as independent predictor of MB (hazard ratio 5.4; 95% CI, 1.4-21.1). The incidence rate of vascular events on treatment was 1.37 (95% CI, 0.84-2.23) per 100 patient-years and the mortality rate was 0.83 (95% CI, 0.44-1.54) per 100 patient-years.

CONCLUSIONS

Selected SVT patients followed by anticoagulation clinics for the management of VKA treatment show a low rate of major bleeding and vascular events.

Potential use of acupuncture in the treatment of first bite syndrome

OBJECTIVES

First bite syndrome (FBS) is an early postoperative pain syndrome characterized by the sudden onset of pain in the parotid region at the first bite of each meal. The etiology is not certain, hence a standardized therapy does not exist.

METHODS

A 50-year old woman referred to us complaining of a swelling in the right parotid region. Fine-needle aspiration biopsy (FNAB) was diagnostic for pleomorphus adenoma of the deep lobe of the parotid gland. A 50-year old man presented with a mass in the right side of the neck, FNAB was diagnostic for parapharyngeal space neurinoma. The first patient was submitted to total parotidectomy with facial nerve preservation, the second to extracapsular dissection of the tumor. A week after surgery both patients developed FBS. A qualitative/quantitative description of pain was obtained by means of a self-coded questionnaire. The score ranges from 8 to 44, corresponding to the lowest and the highest discomfort possible, respectively. Acupuncture was used to treat these 2 patients. The treatment protocol comprised 6 sessions, one per week, lasting 30 minutes each.

RESULTS

Our questionnaire was administered before and after treatment and the score dropped from 33 to 25 in the female, from 30 to 15 in the male patient.

CONCLUSION

FBS is a complication of upper cervical surgery with a high morbidity rate. We describe the first two cases of FBS that were successfully treated with acupuncture in our ENT department. We believe that this procedure may represent a valid therapeutic alternative in the future.

Subtotal gastrectomy for gastric cancer: long term outcomes of Billroth I reconstruction at a single European institute

BACKGROUND/AIMS

The role of Billroth I (BI) subtotal gastrectomy (SG) for gastric cancer (GC) remains controversial in Western countries. The aim of the study is to critically analyze the long term outcomes of this procedure in a large single-institution experience.

METHODOLOGY

Between 1990 and 2004, 158 patients underwent BI SG for GC at the Regina Elena Cancer Institute of Rome. Evaluation focused on cancer recurrence of the gastric stump, functional outcome and endoscopic findings.

RESULTS

Actuarial survival rate 10 years after resection in stage I-II was 70.7 per cent. After curative resection, primary cancer of the gastric stump occurred in one patient seven years after resection (0.7 per cent), whereas two patients had early recurrence (1.4 per cent) one and three years postoperatively. There were no oesophageal cancers. In survivors, Visick grades I and II achieved 95 per cent, and postoperative endoscopy showed no evidence of mucosal changes in 85 per cent of the patients. Twelve per cent of the patients took acid blocker regularly, however, the incidence of functional failure was 5 per cent.

CONCLUSIONS

In selected patients, Billroth I subtotal gastrectomy is a safe and effective procedure that provides long-term survival and very good functional outcome.

Salvage surgery after unsuccessful radiotherapy in early glottic cancer

Surgery is the main therapeutic option to control recurrent laryngeal cancer after radiotherapy (RT) relapse. Most RT-recurred cancer is treated aggressively; although, conservative laryngeal surgery was attempted in selected cases. Here, we report our experiences with salvage laryngeal surgery for early glottic cancers that did not respond to RT. We analyzed files from 1980 to 2006 and selected 173 patients surgically treated for a RT-failed early glottic carcinoma (stage I-II according to 2010 TNM: 114 T1N0, 59 T2N0). Among them, 47 patients (27%) underwent a salvage partial laryngectomy (SPL) and 126 (73%) had a salvage total laryngectomy (STL). When compared with initial T staging, we found 61% of lesions were up-staged, 31% had the same staged lesion, and only 8% were down-staged (according to rTNM). No statistically significant differences were found in terms of disease-free survival and overall survival when SPL and STL patients were compared. Univariate analysis showed that T, rT, and rTNM were prognostic factors for overall survival (p = 0.045, p = 0.028, and p = 0.037, respectively); yet, these significances were lost in multivariate analysis. Our results suggest that salvage surgery is feasible in most cases of RT-recurred early glottic cancer; although, a conservative approach achieves good oncological and functional results only in select RT-recurred patients.

Energy dependence of the transverse momentum distributions of charged particles in pp collisions measured by ALICE

Differential cross sections of charged particles in inelastic pp collisions as a function of p_T have been measured at [Formula: see text] at the LHC. The p_T spectra are compared to NLO-pQCD calculations. Though the differential cross section for an individual [Formula: see text] cannot be described by NLO-pQCD, the relative increase of cross section with [Formula: see text] is in agreement with NLO-pQCD. Based on these measurements and observations, procedures are discussed to construct pp reference spectra at [Formula: see text] up to p_T=50 GeV/c as required for the calculation of the nuclear modification factor in nucleus-nucleus and proton-nucleus collisions.

Directed flow of charged particles at midrapidity relative to the spectator plane in Pb-Pb collisions at √(s(NN))=2.76 TeV

The directed flow of charged particles at midrapidity is measured in Pb-Pb collisions at √(s(NN))=2.76 TeV relative to the collision symmetry plane defined by the spectator nucleons. A negative slope of the rapidity-odd directed flow component with approximately 3 times smaller magnitude than found at the highest RHIC energy is observed. This suggests a smaller longitudinal tilt of the initial system and disfavors the strong fireball rotation predicted for the LHC energies. The rapidity-even directed flow component is measured for the first time with spectators and found to be independent of pseudorapidity with a sign change at transverse momenta p(T) between 1.2 and 1.7  GeV/c. Combined with the observation of a vanishing rapidity-even p(T) shift along the spectator deflection this is strong evidence for dipolelike initial density fluctuations in the overlap zone of the nuclei. Similar trends in the rapidity-even directed flow and the estimate from two-particle correlations at midrapidity, which is larger by about a factor of 40, indicate a weak correlation between fluctuating participant and spectator symmetry planes. These observations open new possibilities for investigation of the initial conditions in heavy-ion collisions with spectator nucleons.

K(S)0 and Λ production in Pb-Pb collisions at √(s(NN))=2.76 TeV

The ALICE measurement of K(S)(0) and Λ production at midrapidity in Pb-Pb collisions at √(s(NN))=2.76 TeV is presented. The transverse momentum (p(T)) spectra are shown for several collision centrality intervals and in the p(T) range from 0.4 GeV/c (0.6 GeV/c for Λ) to 12 GeV/c. The p(T) dependence of the Λ/K(S)(0) ratios exhibits maxima in the vicinity of 3 GeV/c, and the positions of the maxima shift towards higher p(T) with increasing collision centrality. The magnitude of these maxima increases by almost a factor of three between most peripheral and most central Pb-Pb collisions. This baryon excess at intermediate p(T) is not observed in pp interactions at √s=0.9 TeV and at √s=7 TeV. Qualitatively, the baryon enhancement in heavy-ion collisions is expected from radial flow. However, the measured p(T) spectra above 2 GeV/c progressively decouple from hydrodynamical-model calculations. For higher values of p(T), models that incorporate the influence of the medium on the fragmentation and hadronization processes describe qualitatively the p(T) dependence of the Λ/K(S)(0) ratio.

Charmonium and e+e- pair photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]

The ALICE Collaboration at the LHC has measured the J/ψ and ψ' photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]. The charmonium is identified via its leptonic decay for events where the hadronic activity is required to be minimal. The analysis is based on an event sample corresponding to an integrated luminosity of about 23 μb-1. The cross section for coherent and incoherent J/ψ production in the rapidity interval -0.9 Collapse

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Hanging of the hepatic veins septa: a safe control prior and during outflow anastomosis in liver transplantation

Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the "piggyback" technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.

Prognostic role of internal jugular vein preservation in neck dissection for head and neck cancer

BACKGROUND AND OBJECTIVES

Sparing internal jugular vein (IJV) in neck dissection for head and neck cancer is controversial. We aimed at evaluating the prognostic impact of IJV preservation.

METHODS

We examined 206 files of head and neck cancer patients who underwent radical or modified radical neck dissection at the Otolaryngology University of Florence. The site of primary tumor was larynx and hypopharynx in 44.66%, oropharynx in 25.24%, oral cavity in 23.3%, unknown in 4.85%, salivary glands and rhinopharynx in 0.97%. In 60.19% the IJV was resected, in 39.81% preserved. Prognostic impact of IJV preservation was assessed by Kaplan-Meier and multivariate analysis.

RESULTS

Neck recurrence occurred in 25.2%: the IJV was resected in 42.31%, in 57.69% preserved (P = 0.02). At multivariate analysis, neck recurrence resulted significantly associated to extracapsular spread (ECS) (P = 0.009), IJV preservation (P = 0.01), positive margins (P = 0.02). In ECS positive patients, a higher risk of neck recurrence was documented for IJV preservation (P = 0.012). A worse prognosis was observed for patients with IJV spared (P = 0.06).

CONCLUSIONS

IJV preservation is associated with an increased risk of neck failure and a worse outcome, mainly in patients with ECS of nodes.

J/ψ elliptic flow in Pb-Pb collisions at √(s(NN))=2.76 TeV

We report on the first measurement of inclusive J/ψ elliptic flow v2 in heavy-ion collisions at the LHC. The measurement is performed with the ALICE detector in Pb-Pb collisions at √(s(NN))=2.76 TeV in the rapidity range 2.5<y<4.0. The dependence of the J/ψ v2 on the collision centrality and on the J/ψ transverse momentum is studied in the range 0≤p(T)<10 GeV/c. For semicentral Pb-Pb collisions at √(s(NN))=2.76 TeV, an indication of nonzero v2 is observed with a largest measured value of v2=0.116±0.046(stat)±0.029(syst) for J/ψ in the transverse momentum range 2≤p(T)<4 GeV/c. The elliptic flow measurement complements the previously reported ALICE results on the inclusive J/ψ nuclear modification factor and favors the scenario of a significant fraction of J/ψ production from charm quarks in a deconfined partonic phase.

Predicting outcome after stroke: the role of basic activities of daily living predicting outcome after stroke

BACKGROUND

Very few studies have investigated the influence of single activities of daily living (ADL) at admission as possible predictors of functional outcome after rehabilitation.

AIM

The aim of the current study was to investigate admission functional status and performance of basic ADLs as assessed by Functional Independence Measure (FIM) scale as possible predictors of motor and functional outcome after stroke during inpatient rehabilitation.

DESIGN

This is a prospective and observational study.

SETTING

Inpatients of our Department of Physical Medicine and Rehabilitation.

POPULATION

Two hundred sixty consecutive patients with primary diagnosis of stroke were enrolled and 241 patients were used in the final analyses.

METHODS

Two backward stepwise regression analyses were applied to predict outcome. The first backward stepwise regression had age, gender, stroke type, stroke-lesion size, aphasia, neglect, onset to admission interval, Cumulative Illness Rating Scale, National Institute of Health Stroke Scale (NIHSS), Fugl-Meyer Scale, Trunk Control Test, and FIM (total, motor and cognitive scores) as independent variables. The second analyses included the above variables plus FIM items as an independent variable. The dependent variables were the discharge scores and effectiveness in total and motor-FIM, and discharge destination.

RESULTS

The first multivariate analysis showed that admission Fugl-Meyer, neglect, total, motor and cognitive FIM scores were the most important predictors of FIM outcomes, while admission NIHSS score was the only predictor of discharge destination. Conversely, when admission single FIM items were included in the statistical model, admission Fugl-Meyer, neglect, grooming, dressing upper body, and social interaction scores were the most important predictors of FIM outcomes, while admission memory and bowel control scores were the only predictors of discharge destination.

CONCLUSION

Our study indicates that performances of basic ADLs are important stroke outcome predictors and among which social interaction, grooming, upper body dressing, and bowel control are the most important.

CLINICAL REHABILITATION IMPACT

The results of this study suggests that, when designing other studies on stroke outcome predictions, researchers should also include tests which assess performances of basic ADLs as independent variables, because this may allow identification of new prognostic indicators that can be helpful for the physician for managing stroke patients at the end of the rehabilitation period.

D meson elliptic flow in noncentral Pb-Pb collisions at sqrt[sNN]=2.76 Tev

Azimuthally anisotropic distributions of D0, D+, and D*+ mesons were studied in the central rapidity region (|y|<0.8) in Pb-Pb collisions at a center-of-mass energy sqrt[sNN]=2.76  TeV per nucleon-nucleon collision, with the ALICE detector at the LHC. The second Fourier coefficient v2 (commonly denoted elliptic flow) was measured in the centrality class 30%-50% as a function of the D meson transverse momentum pT, in the range 2-16  GeV/c. The measured v2 of D mesons is comparable in magnitude to that of light-flavor hadrons. It is positive in the range 2<pT<6  GeV/c with 5.7σ significance, based on the combination of statistical and systematic uncertainties.

Measurement of inelastic, single- and double-diffraction cross sections in proton-proton collisions at the LHC with ALICE

Measurements of cross sections of inelastic and diffractive processes in proton-proton collisions at LHC energies were carried out with the ALICE detector. The fractions of diffractive processes in inelastic collisions were determined from a study of gaps in charged particle pseudorapidity distributions: for single diffraction (diffractive mass MX <200 GeV/c2) [Formula: see text], and [Formula: see text], respectively at centre-of-mass energies [Formula: see text]; for double diffraction (for a pseudorapidity gap Δη>3) σDD/σINEL=0.11±0.03,0.12±0.05, and [Formula: see text], respectively at [Formula: see text]. To measure the inelastic cross section, beam properties were determined with van der Meer scans, and, using a simulation of diffraction adjusted to data, the following values were obtained: [Formula: see text] mb at [Formula: see text] and [Formula: see text] at [Formula: see text]. The single- and double-diffractive cross sections were calculated combining relative rates of diffraction with inelastic cross sections. The results are compared to previous measurements at proton-antiproton and proton-proton colliders at lower energies, to measurements by other experiments at the LHC, and to theoretical models.

Net-charge fluctuations in Pb-Pb collisions at sqrt[sNN]=2.76 TeV

We report the first measurement of the net-charge fluctuations in Pb-Pb collisions at sqrt[sNN]=2.76  TeV, measured with the ALICE detector at the CERN Large Hadron Collider. The dynamical fluctuations per unit entropy are observed to decrease when going from peripheral to central collisions. An additional reduction in the amount of fluctuations is seen in comparison to the results from lower energies. We examine the dependence of fluctuations on the pseudorapidity interval, which may account for the dilution of fluctuations during the evolution of the system. We find that the fluctuations at the LHC are smaller compared to the measurements at the BNL Relativistic Heavy Ion Collider, and as such, closer to what has been theoretically predicted for the formation of a quark-gluon plasma.

Transverse momentum distribution and nuclear modification factor of charged particles in p+Pb collisions at sqrt[s(NN)] = 5.02 TeV

The transverse momentum (p(T)) distribution of primary charged particles is measured in minimum bias (non-single-diffractive) p+Pb collisions at sqrt[s(NN)]=5.02 TeV with the ALICE detector at the LHC. The p(T) spectra measured near central rapidity in the range 0.5<p(T) <20 GeV/c exhibit a weak pseudorapidity dependence. The nuclear modification factor R(pPb) is consistent with unity for p(T) above 2 GeV/c. This measurement indicates that the strong suppression of hadron production at high p(T) observed in Pb+Pb collisions at the LHC is not due to an initial-state effect. The measurement is compared to theoretical calculations.

Pseudorapidity density of charged particles in p+Pb collisions at √(s(NN))=5.02 TeV

The charged-particle pseudorapidity density measured over four units of pseudorapidity in nonsingle-diffractive p+Pb collisions at a center-of-mass energy per nucleon pair √(s(NN))=5.02 TeV is presented. The average value at midrapidity is measured to be 16.81±0.71 (syst), which corresponds to 2.14±0.17 (syst) per participating nucleon, calculated with the Glauber model. This is 16% lower than in nonsingle-diffractive pp collisions interpolated to the same collision energy and 84% higher than in d+Au collisions at s√(s(NN))=0.2 TeV. The measured pseudorapidity density in p+Pb collisions is compared to model predictions and provides new constraints on the description of particle production in high-energy nuclear collisions.

Charge separation relative to the reaction plane in Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

Measurements of charge-dependent azimuthal correlations with the ALICE detector at the LHC are reported for Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV. Two- and three-particle charge-dependent azimuthal correlations in the pseudorapidity range |η| < 0.8 are presented as a function of the collision centrality, particle separation in pseudorapidity, and transverse momentum. A clear signal compatible with a charge-dependent separation relative to the reaction plane is observed, which shows little or no collision energy dependence when compared to measurements at RHIC energies. This provides a new insight for understanding the nature of the charge-dependent azimuthal correlations observed at RHIC and LHC energies.

Pion, kaon, and proton production in central Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

In this Letter we report the first results on π(±), K(±), p, and p production at midrapidity (|y|<0.5) in central Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV, measured by the ALICE experiment at the LHC. The p(T) distributions and yields are compared to previous results at sqrt[s(NN)] = 200 GeV and expectations from hydrodynamic and thermal models. The spectral shapes indicate a strong increase of the radial flow velocity with sqrt[s(NN)], which in hydrodynamic models is expected as a consequence of the increasing particle density. While the K/π ratio is in line with predictions from the thermal model, the p/π ratio is found to be lower by a factor of about 1.5. This deviation from thermal model expectations is still to be understood.