En-bloc spondylectomy in the lumbar spine: indications, results and complications in a series of 47 patients affected by primary malignant bone tumors

INTRODUCTION

Wide Surgery is the reference treatment for malignant and aggressive benign primary bone tumors in the spine. When located in the lumbar spine, En-Bloc Spondylectomy (EBS) remains a complex challenge. Moreover, surgery is complicated by the presence of the diaphragm in the thoracolumbar junction and the hinderance of the iliac wings at the lumbosacral levels. Therefore, EBS in the lumbar spine frequently requires combined approaches. The purpose of this study is to describe clinical presentation, tumor characteristics and results of a series of 47 consecutive patients affected by malignant primary bone tumors of the lumbar spine who underwent EBS.

MATERIALS AND METHODS

47 patients were reviewed. Complications were distinguished in early and late whether they occurred before or after 30 days from surgery. Overall survival (OS), disease-free survival (DFS) and local recurrence-free survival (LRFS) were calculated by the Kaplan-Meier product-limit method from surgery until relapse or death.

RESULTS

27 patients presented to observation after a first intralesional approach in a non-specialized center. Chordoma was the most represented histotype. Vertebrectomies were: 23 one-level, 10 two-level, 12 three-level and 2 four-level. Reconstructions were always carried out with screws and rods. The main postoperative complication was blood loss, while hardware failure was the main long-term complication. The 5-year LRFS was 75.5%, the 5-year DFS was 54.3%, and 5-year OS was 63.6%.

CONCLUSIONS

The surgical margin obtained during the index surgery was statistically associated with Local Recurrence, DFS and OS, underlining the importance of treating patients in reference centers.

The Long-Term Impacts of an Integrated Care Programme on Hospital Utilisation among Older Adults in the South of England: A Synthetic Control Study

Introduction

Reducing hospital use is often viewed as a possible positive consequence of introducing integrated care (IC). We investigated the impact of an IC programme in North East Hampshire and Farnham (NEHF), in southern England, on hospital utilisation among older adults over a 55 months period.

Method

We used a Generalised Synthetic Control design to investigate the effect of implementing IC in NEHF between 2015 and 2020. For a range of hospital use outcomes, we estimated the trajectory that each would have followed in the absence of IC and compared it with the actual trajectory to estimate the potential impact of IC.

Results

Three years into the programme, emergency admission rates started reducing in NEHF relative to its synthetic control, particularly those resulting in overnight hospital stays. By year 5 of the study overall emergency admission rates were 9.8% lower (95% confidence interval: -17.2% to -0.6%). We found no sustained difference in rates of emergency department (ED) visits, and average length of hospital stay was significantly higher from year 2.

Conclusion

An IC programme in NEHF led to lower than estimated emergency admission rates; however, the interpretation of the impact of IC on admissions is complicated as lower rates did not appear until three years into the programme and the reliability of the synthetic control weakens over a long time horizon. There was no sustained change in ED visit rates.

Pelvic ring reconstruction with tibial allograft, screws and rods following enneking type I and IV resection of primary bone tumors

INTRODUCTION

Surgery of primary malignant tumors involving the sacroiliac joint requires wide resection, which often interrupts the pelvic ring. Nowadays, restoration of the pelvic ring to provide stability and which technique is most fitting remain subject to debate. The aim of this study is to evaluate the results of pelvic reconstruction with pedicle screw instrumentation and tibial allograft following Enneking Type I-IV resections.

PATIENTS AND METHODS

All patients who underwent reconstruction with tibial allograft, screws and rods after resection of areas I and IV for primary bone tumors between 2017 and 2022 were reviewed. Clinical and radiological characteristics, fusion rate and functional results were analyzed. The MSTS score and the TESS were used to evaluate functional results.

RESULTS

Seven patients were included in the study. Chondrosarcoma was the most common histology. Only four patients reported pain. No fractures were observed at tumor diagnosis. Computer-assisted navigation was used in six cases. Reconstruction was performed in four cases with a screw inserted in the homolateral L5 pedicle and in the ischium, in two cases with a screw in the homolateral L4 pedicle and another in the homolateral L5 pedicle, in the last case with two screws inserted in L4 and L5, one screw in the ischium and another one in the residual iliac wing. In this case a contralateral stabilization was also carried out. The spine screws and the iliac screws were connected with a rod. The mean follow-up for all 7 patients was 37 months. One patient (16.6%) died due to general complications not directly related to the surgery; while the others are alive and apparently free of disease. Complete fusion was obtained in four out of seven patients and the average time for fusion was 9 months. The average MSTS score and TESS were 58.7% and 57.8%, respectively.

DISCUSSION

The need for reconstruction is thoroughly debated in literature. The advantages of restoring posterior pelvis stability are the prevention of long-term pain associated with limb shortening and secondary scoliosis. Re-establishment of the pelvic ring can be achieved through synthetic, biologic or hybrid reconstructions.

CONCLUSIONS

More studies that assess the surgical consequences at long-term follow-up and help clarify the indications for reconstruction and the specific technique are necessary to confirm our preliminary results.

Use of antidepressants during COVID19 outbreak: a real-world drug-utilization study

Background

Lockdown measures implementation (LMI) to prevent COVID19 disease diffusion was associated to increased depression and anxiety cases. The main aim was to evaluate whether LMI affected prevalence and incidence of antidepressants (ADs) use, and ADs treatment interruption (TI) in the general population.

Methods

Adults (≥18 years) with at least 1 dispensing of ADs between 01/01/2019-26/09/2020 were selected from a regional Italian healthcare administrative database. Patients presenting an AD dispensing in the year preceding the first observation were considered as prevalent otherwise as incident users. We divided the studied period into 3 parts: pre-lockdown (01/01/2019-08/03/2020), lockdown (09/03/2020-14/06/2020) and post-lockdown (15/06/2020-27/09/2020). The weekly prevalence (WP) and incidence (WI) per 10,000 inhabitants were compared among periods. Incidence of TI (no dispensing refill within 30 days of the end of its validity) was computed among prevalent AD users.

Results

The WP (mean of 552.3 per 10,000 pre-lockdown vs 505.5 lockdown phase; relative change: -9%) and WI (5.2 vs 3.7; -29%) of ADs use decreased after LMI. During the post-lockdown phase WP (505.5 vs 495.9; -2%) decreased whereas the WI (3.7 vs 4.3; 16%) slightly increased in relation to the lockdown period, although differences were not statistically significant. Conversely, the incidence of TI increased during lockdown (344.7 vs 384.3; 12%) and post-lockdown (384.3 vs 394.2; 3%) periods, even not always statistically significant.

Conclusions

Our analysis showed a reduction of ADs use during the early phase of lockdown. Several factors might have impacted on the observed phenomenon (i.e, patient reluctance to start new AD treatment). Considering the mutation of the virus and the potential waves that might occur in the next months, a continuous monitoring of the impact of COVID19 on mental diseases onset and treatment adherence are suggested.

Key messages

In Italy, the implementation of lockdown measures was followed by a reduction in antidepressants use, even though evidences are that diagnoses of psychiatric disorders increased.

Future studies should monitor if these phenomena led to an increase in adverse events potentially correlated with inappropriate treatment of depression.

Field evaluation of BNT162b2 COVID-19 vaccine response in healthcare workers: a 3-month follow-up

Background

Effective and rapid immunologic response to vaccines is a crucial strategy for the control SARS-CoV-2 pandemic. Here, we present the results of an ongoing longitudinal observational study conducted among the healthcare workers (HCWs) of the Pineta Grande Hospital (Castel Volturno, Italy), who were administered the two-dose prime-boost mRNA vaccine BNT162b2.

Methods

Volunteer HCWs underwent either (i) six RT-PCR assay for qualitative detection of SARS-CoV-2 nucleic acid in nasopharyngeal/oropharyngeal swabs; (ii) or six quantitative serology testing for the research of virus-specific immunoglobulins (Ig) through chemiluminescent immunoassay with a reactivity cut-off of an Index of ≥ 1.0. The first tests were taken before the administration of the vaccine and then according to a predefined timeline. An active surveillance follow-up of SARS-CoV-2 infections was set amongst the vaccinees after the end of the study.

Results

Overall, among the 435 HCWs who accepted to participated in the study, 9.3% reported a previous laboratory-confirmed infection with SARS-CoV-2, though all subjects tested negative at the time of first vaccine dose. In the swab cohort, seven subjects tested positive in the first 15 days after the first vaccine dose and one about a week from the second dose. At 45- and 60-day follow-ups all vaccinees tested negative, but two positive tests were registered at the third month. In the second cohort, two weeks after the first vaccine dose anti-SARS-CoV-2 antibodies exceeded the reactivity cut-off in 82.5% the participants. At one-month follow-up, almost all (98.4%) the vaccinees had reached the maximum Index value of 10. No statistically significant associations were found between antibody response and HCWs' characteristics.

Conclusions

Our results showed that surveillance is a critical component of providing safe healthcare during COVID-19 pandemic, also after extended vaccination campaigns, thus enhancing the protection of patients and HCWs.

Key messages

All healthcare facilities should implement continuous post-vaccination surveillance programs in order to ensure patients and healthcare workers safety, and limit in-hospital transmission of SARS-CoV-2.

Longer field follow-ups are indispensable to investigate immunogenicity trends and effectiveness of COVID-19 vaccines over time, and to consider booster doses, especially in high-risk population.

A novel method for identifying care home residents in England: a validation study

Introduction

The ability to identify residents of care homes in routinely collected health care data is key to informing healthcare planning decisions and delivery initiatives targeting the older and frail population. Health-care planning and delivery implications at national level concerning this population subgroup have considerably and suddenly grown in urgency following the onset of the COVID-19 pandemic, which has especially hit care homes. The range of applicability of this information has widened with the increased availability in England of retrospectively collected administrative databases, holding rich patient-level details on health and prognostic status who have made or are in contact with the National Health Service. In practice lack of a national registry of care homes residents in England complicates assessing an individual’s care home residency status, which has been typically identified via manual address matching from pseudonymised patient-level healthcare databases linked with publicly availably care home address information.

Objectives

To examine a novel methodology based on linking unique care home address identifiers with primary care patient registration data, enabling routine identification of care home residents in health-care data.

Methods

This study benchmarks the proposed strategy against the manual address matching standard approach through a diagnostic assessment of a stratified random sample of care home post codes in England.

Results

Derived estimates of diagnostic performance, albeit showing a non-insignificant false negative rate (21.98%), highlight a remarkable true negative rate (99.69%) and positive predictive value (99.35%) as well as a satisfactory negative predictive value (88.25%).

Conclusions

The validation exercise lends confidence to the reliability of the novel address matching method as a viable and general alternative to manual address matching.

Combining robotics with enhanced serotonin-driven cortical plasticity improves post-stroke motor recovery

Despite recent progresses in robotic rehabilitation technologies, their efficacy for post-stroke motor recovery is still limited. Such limitations might stem from the insufficient enhancement of plasticity mechanisms, crucial for functional recovery. Here, we designed a clinically relevant strategy that combines robotic rehabilitation with chemogenetic stimulation of serotonin release to boost plasticity. These two approaches acted synergistically to enhance post-stroke motor performance. Indeed, mice treated with our combined therapy showed substantial functional gains that persisted beyond the treatment period and generalized to non-trained tasks. Motor recovery was associated with a reduction in electrophysiological and neuroanatomical markers of GABAergic neurotransmission, suggesting disinhibition in perilesional areas. To unveil the translational potentialities of our approach, we specifically targeted the serotonin 1A receptor by delivering Buspirone, a clinically approved drug, in stroke mice undergoing robotic rehabilitation. Administration of Buspirone restored motor impairments similarly to what observed with chemogenetic stimulation, showing the immediate translational potential of this combined approach to significantly improve motor recovery after stroke.

The economic impact of air pollution: a European assessment

Background

In 2017, the Global Burden of Disease Study estimated that in Europe 0.42 million deaths and 8.9 million disability-adjusted life years were attributable to air pollution. Monetizing this burden is a key step for estimating benefits of exposure reduction strategies. However, robust and synthetic estimates of direct (e.g. due to hospitalizations or medications) and indirect (e.g. due to premature mortality or loss of productivity) health-related costs of air pollution seem to be still lacking. We carried out a systematic review, aimed at identifying evidence from research in Europe.

Methods

We searched 5 electronic databases (MEDLINE, EMBASE, Cochrane Library, SCOPUS, Web Of Science) in which we applied algorithms tracing keywords such as “cost of illness”, “health care costs”, “economics” and synonyms, together with “air pollution” and synonyms. We limited our search to articles written in English and Italian, without date restriction.

Results

The initial search retrieved 2420 records. 200 were classified as relevant, and 38 fulfilled inclusion criteria. Most of them (68%) were published after 2010. 26% were multi-country studies, while the remaining focused on a single country or city. Investigated pollutants were usually particulate matter (79% of the studies) and nitrogen oxides (37%). The approaches to the economic analysis were heterogeneous: estimates could include direct and/or indirect costs. Among the studies, the most comprehensive one (12 countries) estimated that complying with WHO guidelines would avert €31 billion yearly, of which €19 million due to hospitalizations.

Conclusions

Over the last decade, progress has been made in evaluating the economic burden of air pollution. However, estimates based on indirect costs are affected by high levels of uncertainty, while those based on direct costs are more robust and should be further investigated, since they are crucial information for healthcare policy makers.

Key messages

Air pollution poses a high economic burden on European countries, mainly due to social costs. More attention should be devoted to estimating direct healthcare costs of air pollution, in order to properly inform policy makers about the impact on healthcare systems.

Cardiovascular diseases burden in Italy, 1990–2017: the Global Burden of Disease Study

Background

Cardiovascular diseases (CVDs) are still the leading cause of mortality, morbidity and disability in Europe. Consequently, an exhaustive estimation of CVDs burden and cardiovascular risk factors impact is crucial for healthcare planning and resource allocation. In Italy, data on CVDs burden are sparse. This study aims to assess the global Italian CVDs burden and to analyze time changes from 1990 to 2017 within the country and in comparison to other European states.

Methods

We used data from the 2017 Global Burden of Diseases (GBD) study to estimate CVDs prevalence, mortality and disability-adjusted life-years (DALYs) in Italy from 1990 to 2017. We also analyzed burden attributable to CVDs-related risk factors. Finally, Italian estimations were compared to those of the other 28 European Union countries.

Results

CVDs were still the first cause of death (34.8% of total mortality) in Italy in 2017. A significant decrease in CVDs burden was observed since 1990: age-standardized prevalence (-12.7%), mortality rate (-53.75%), and DALYs rate (-55.54%) all decreased. Similar patterns were observed also in the majority of European countries. Despite these trends, all-ages CVDs prevalent cases increased from 5.75 million to 7.49 million. More than 80% of CVDs burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high LDL cholesterol, and impaired kidney function.

Conclusions

Data showed a decline in cardiovascular mortality and DALYs, which reflects the success in terms of reducing disability, premature death and early incidence of CVDs. However, the burden of CVDs is still high, as population aging and the increased prevalent cases require more access to care and generate more years lived with disability, which in turn leads to higher costs for the National Health Service and society. More efficient prevention strategies at community and individual level are needed.

Key messages

Despite decreasing trends in CVDs mortality and DALYs, the burden of CVDs is still high in Italy. A joined approach of the National Health System stakeholders is needed to keep reducing the CVDs burden.

An exploration of cancer-related mortality attributable to infections in Italy

Background

Previous attempts estimated the impact of infectious agents on cancer incidence in Italy, but the burden of carcinogenic infections on cancer mortality remains unknown. Therefore, we aimed to conduct a preliminary analysis in order to estimate this burden at country level.

Methods

We applied the global, regional, or national population attributable fractions for Helicobacter pylori, hepatitis B virus (HBV), hepatitis C virus (HCV), high-risk human papillomavirus (HPV) types, Epstein-Barr virus (EBV), human herpesvirus type 8 (HHV-8), and human T-cell lymphotropic virus type 1 (HTLV-1) - all microorganisms ranked as group 1 carcinogenic agents in human beings by the International Agency for Research on Cancer - to 2015 cancer-related deaths recorded according to the 10th International Classification of Diseases coding system in Italy.

Results

We estimated a total of 14,120 deaths attributable to carcinogenic infections, being 8.3% of the total of cancer-related deaths (n = 170,339). 58.8% of those occurred in men. H. pylori, HCV, HBC, and HPV accounted for 96.4% of the whole mortality burden attributable to carcinogenic infections in both sexes. H. pylori was responsible for 8,116 (57.5%) deaths due to gastric carcinoma (non-cardia and non-Hodgkin lymphoma). Hepatitis-related liver cancer accounted for a total 4,372 deaths: 3,812 due to HCV infection and 560 to HBV. Cancers related to HPV infection represented the third most frequent cause of deaths due to carcinogenic infections in women.

Conclusions

We estimated that one out of 12 cancer deaths in Italy was attributable to an infection sustained by carcinogenic agents. Such mortality burden is potentially avoidable, given that these infections are both potentially preventable and treatable. Thus, these estimates provide actionable metric of the burden for the implementation of specific public health measures. Further analyses will provide more accurate estimates of this disease burden.

Key messages

In Italy, one out of 12 cancer-related deaths is attributable to infections sustained by preventable or treatable carcinogenic agents. These estimates provide metric of carcinogenic infections for the implementation of specific public health measures to avert the related mortality burden.

Eco-Physiological Screening of Different Tomato Genotypes in Response to High Temperatures: A Combined Field-to-Laboratory Approach

High temperatures represent a limitation for growth and development of many crop species. Several studies have demonstrated that the yield reduction of tomato under high temperatures and drought is mainly due to a photosynthetic decline. In this paper, a set of 15 tomato genotypes were screened for tolerance to elevated temperatures by cultivating plants under plastic walk-in tunnels. To assess the potential tolerance of tomato genotypes to high temperatures, measurements of chlorophyll fluorescence, pigments content and leaf functional traits have been carried out together with the evaluation of the final yields. Based on the greenhouse trials, a group of eight putative heat-sensitive and heat-tolerant tomato genotypes was selected for laboratory experiments aimed at investigating the effects of short-term high temperatures treatments in controlled conditions. The chlorophyll fluorescence induction kinetics were recorded on detached leaves treated for 60 min at 35 °C or at 45 °C. The last treatment significantly affected the photosystem II (PSII) photochemical efficiency (namely maximum PSII quantum efficiency, F_v/F_m, and quantum yield of PSII electron transport, Φ_PSII) and the non-photochemical quenching (NPQ) in the majority of genotypes. The short-term heat shock treatments also led to significant differences in the shape of the slow Kautsky kinetics and its significant time points (chlorophyll fluorescence levels minimum O, peak P, semi-steady state S, maximum M, terminal steady state T) compared to the control, demonstrating heat shock-induced changes in PSII functionality. Genotypes potentially tolerant to high temperatures have been identified. Our findings support the idea that chlorophyll fluorescence parameters (i.e., Φ_PSII or NPQ) and some leaf functional traits may be used as a tool to detect high temperatures-tolerant tomato cultivars.

A versatile robotic platform for the design of natural, three-dimensional reaching and grasping tasks in monkeys

OBJECTIVE

Translational studies on motor control and neurological disorders require detailed monitoring of sensorimotor components of natural limb movements in relevant animal models. However, available experimental tools do not provide a sufficiently rich repertoire of behavioral signals. Here, we developed a robotic platform that enables the monitoring of kinematics, interaction forces, and neurophysiological signals during user-defined upper limb tasks for monkeys.

APPROACH

We configured the platform to position instrumented objects in a three-dimensional workspace and provide an interactive dynamic force-field.

MAIN RESULTS

We show the relevance of our platform for fundamental and translational studies with three example applications. First, we study the kinematics of natural grasp in response to variable interaction forces. We then show simultaneous and independent encoding of kinematic and forces in single unit intra-cortical recordings from sensorimotor cortical areas. Lastly, we demonstrate the relevance of our platform to develop clinically relevant brain computer interfaces in a kinematically unconstrained motor task.

SIGNIFICANCE

Our versatile control structure does not depend on the specific robotic arm used and allows for the design and implementation of a variety of tasks that can support both fundamental and translational studies of motor control.

Landau-Type Theory of Planar Crystal Plasticity

We show that nonlinear continuum elasticity can be effective in modeling plastic flows in crystals if it is viewed as a Landau theory with an infinite number of equivalent energy wells whose configuration is dictated by the symmetry group GL(2,Z). Quasistatic loading can be then handled by athermal dynamics, while lattice-based discretization can play the role of regularization. As a proof of principle, we study dislocation nucleation in a homogeneously sheared 2D crystal and show that the global tensorial invariance of the elastic energy foments the development of complexity in the configuration of collectively nucleating defects. A crucial role in this process is played by the unstable higher symmetry crystallographic phases, typically thought to be unrelated to plastic flow.

455Prediction of major bleeding in patients receiving DOACs for venous thromboembolism: a prospective cohort study

Background

The accuracy of currently available bleeding scores in patients on treatment with direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) is undefined.

Purpose

In a prospective cohort of patients with VTE treated with DOACs, we evaluated the accuracy of the ATRIA, HAS-BLED, Kuijer, ORBIT, RIETE and VTE-BLEED risk scores in predicting major bleeding (according to ISTH definition).

Methods

The accuracy of different scores to correctly classify subjects into a defined risk category was assessed by the c-statistic.

Results

Overall, 1141 patients were evaluated and 1034 included in the study. The index event was pulmonary embolism in 509 patients (49.2%) and proximal deep vein thrombosis in the remaining patients (50.8%). During the 12-month study period, 26 major bleedings occurred in 25 patients (2.8% patient-year): 14 major bleedings occurred in the first 6 months of treatment and 12 from 6 to 12 months in the 654 patients remained on treatment.

In the 12-month study period, the VTE-BLEED score showed the best predictive value for bleeding complications (c-statistics 0.674, 95% CI 0.593–0.755). The lowest incidence of major bleeding (0.3%) was observed in the low risk category of VTE-BLEED which includes 38% of patients. The highest incidence of major bleeding (7.1%) was observed in the high-risk category of ORBIT which includes 10.9% of patients.

Conclusions

The VTE-BLEED score had the best accuracy in predicting major bleeding during treatment with DOACs for VTE. Whether the VTE-BLEED score can be used for decision making on anticoagulation should be tested in a management study.

Effect on secondary care of providing enhanced support to residential and nursing home residents: a subgroup analysis of a retrospective matched cohort study

BACKGROUND

Thirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively.

METHODS

Using linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression.

RESULTS

Residents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome.

CONCLUSIONS

The enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents' needs or the context of providing care in that setting.

Value of Information: Sensitivity Analysis and Research Design in Bayesian Evidence Synthesis

Suppose we have a Bayesian model that combines evidence from several different sources. We want to know which model parameters most affect the estimate or decision from the model, or which of the parameter uncertainties drive the decision uncertainty. Furthermore, we want to prioritize what further data should be collected. These questions can be addressed by Value of Information (VoI) analysis, in which we estimate expected reductions in loss from learning specific parameters or collecting data of a given design. We describe the theory and practice of VoI for Bayesian evidence synthesis, using and extending ideas from health economics, computer modeling and Bayesian design. The methods are general to a range of decision problems including point estimation and choices between discrete actions. We apply them to a model for estimating prevalence of HIV infection, combining indirect information from surveys, registers, and expert beliefs. This analysis shows which parameters contribute most of the uncertainty about each prevalence estimate, and the expected improvements in precision from specific amounts of additional data. These benefits can be traded with the costs of sampling to determine an optimal sample size. Supplementary materials for this article, including a standardized description of the materials available for reproducing the work, are available as an online supplement.

Peritoneal mesothelioma mortality in Italy: Spatial analysis and search for asbestos exposure sources

BACKGROUND

This study is part of a national plan of epidemiological surveillance of malignant mesothelioma (MM) mortality in Italy. The paper shows the results of malignant peritoneal mesothelioma (MPeM) mortality study in Italian Regions and municipalities.

METHODS

National Bureau of Statistics data for MPeM municipal mortality (ICD-10, Code C45.1) were analyzed in the time-window 2003-2014: mortality standardized rates (reference Italian population, census 2011), temporal trends of the annual national rates, Standardized Mortality Ratios and a municipal clustering analysis were performed.

RESULTS

747 deaths for MPeM were recorded (0.10/100,000): 464 in men (0.14/100,000) and in 283 women (0.07/100,000). No significant MPeM mortality temporal trend was found. Seventeen municipalities showed excesses of mortality for MPeM in at least one gender and/or overall population. Four clusters in male population, and one in women were identified.

CONCLUSIONS

The study identifies some areas where remediation activities and/or health care actions may be warranted.

Detection and genotyping of HPV-DNA through different types of diagnostic platforms in liquid-based cervical-cytology samples

BACKGROUND

At present cervical cancer represents the second most common cancer in women worldwide and it reaches a global mortality rate of 52%. Only the early detection and the adequate treatment of pre-neoplastic lesions and early-stage cervical cancer decrease the mortality rate for this type of cancer. Cervical carcinoma screening, as a method of second prevention, is currently feasible through molecular research of high-risk HPV genotypes and in lots of organized screening programs the Pap-test is performed only in women with positive HPV-test. Currently, there are various diagnostic platforms detecting and molecular genotyping HPV, which are based on different procedures, determining uneven viral genotypes panels and using diverse type of vials to collect and store the samples. Previous studies have pointed out that DNA-HPV test can be negative in pre-neoplastic lesions, even of high grade, or in presence of cervical cancer. Therefore, it's important to assess the risk of false negative diagnoses using DNA-HPV molecular test, because in this circumstance women do not undergo immediately Pap-test, but they are submitted to second round screening with DNA-HPV test after 5 years: this protocol could increase the incidence of "interval cancers". The present study aims at comparing the results of HPV detection and genotyping on liquid based cervical cytology, using some of the most relevant diagnostic platforms in commerce.

METHODS

The study is based on a group of patients which went to their private gynecologist in a contest of opportunistic screening. The vial used in the examined population has been EASYPREP^® preservative solution (YD Diagnostics CORP-Republic of Korea); liquid-based cervical cytology sampling has been done using a single device (plastic brush), allowing to collect simultaneously cytological material from exocervix and endocervix (Rovers^® Cervex-Brush^®). The diagnostic platforms employed have been the following: A) Digene HC2 HPV DNA Test, on RCS System (QIAGEN); B) BD Onclarity^™ HPV test, on automate platform BD Viper^™ LT (Becton Dickinson); C) Xpert^® HPV, on GeneXpert^® Infinity Systems platform (Cepheid). Every platform researched high-risk HPV genotypes panels (hr-HPV). Part of the clinical records has also been analyzed through PCR and genes L1 and E6/E7 complete sequencing, in order to further typing the viral population.

RESULTS

We have examined 1284 samples of women aged 16 to 73 years: 1125 have been tested using HC2 procedure, 272 samples with Onclarity method, 159 with Xpert^® method and 55 samples have been analyzed using PCR and sequencing of gene L1 and gene E6/E7. HPV-DNA was detected with Onclarity method in 15,07%, with Xpert^® method in 13,83% and using HC2 procedure in 12,27% of samples. The comparison between the three molecular methods revealed diagnostic discrepancies in 3,14% of our records between Onclarity test and Xpert® method and in 2,20% (6/272) between HC2 test and Onclarity test. Globally, in 431 tests, compared using different diagnostic platforms, discrepant diagnoses, referring to hr-HPV presence or to detected genotype, have been observed 11 times (2,55%). Genotype 16 appeared the most expressed in the positive samples (20,99%), whereas genotype 18 resulted the less expressed in the examined population (4,94%).

DISCUSSION

The present study highlights the following: 1) Positive results' percentage for high-risk HPV-DNA genotypes, deriving from the three diagnostic platforms used and with the same vial to collect and store samples, does not significantly vary on the basis of the type of equipment and it is congruent with the Italian percentage already detected during organized screening programs. 2) Even the molecular diagnostic approach could give false negative results, preventing the detection in the screened population of cervical HPV-related lesions and theoretically endangering women to develop "interval cancer". 3) In the population examined, genotype 16 has been the most expressed, whereas genotype 18 was among the less frequently detected. Other genotypes often noticed have been: 56-59-66 (Onclarity P3 group), 31, 51 and 35-39-68 (Onclarity P2 group). This remark emphasizes the importance of HPV infection and genotypes distribution's continuous monitoring, considering that HPV-vaccines planned in Italy in the "National vaccination prevention program 2017-2019" are not specific for the majority of these genotypes. 4) The necessity to improve the screening program to identify cervical carcinomas and pre-neoplastic cervical lesions is remarked by the detection during HPV-test of possible coinfection (present at least in 8,76% of our records). In fact, the risk of development of cervical cancer might be associated with type-specific interactions between genotypes in multiple infections and, in addition, other genotypes, not targeted by quadrivalent HPV-vaccine, can increase the risk of cervical carcinoma. 5) As there's a different combination of HPV-genotypes in diagnostic categories used by the HPV screening platforms, it's important that anyone who is in charge of this diagnostic analysis promotes among clinicians the adequate rendition of the laboratory's data in the patient records, reporting both the diagnostic result and the method through which it has been obtained.

Multicomponent Electron-Hole Superfluidity and the BCS-BEC Crossover in Double Bilayer Graphene

Superfluidity in coupled electron-hole sheets of bilayer graphene is predicted here to be multicomponent because of the conduction and valence bands. We investigate the superfluid crossover properties as functions of the tunable carrier densities and the tunable energy band gap E_{g}. For small band gaps there is a significant boost in the two superfluid gaps, but the interaction-driven excitations from the valence to the conduction band can weaken the superfluidity, even blocking the system from entering the Bose-Einstein condensate (BEC) regime at low densities. At a given larger density, a band gap E_{g}∼80-120  meV can carry the system into the strong-pairing multiband BCS-BEC crossover regime, the optimal range for realization of high-T_{c} superfluidity.

Piecewise affine stress-free martensitic inclusions in planar nonlinear elasticity

We consider a partial differential inclusion problem which models stress-free martensitic inclusions in an austenitic matrix, based on the standard geometrically nonlinear elasticity theory. We show that for specific parameter choices there exist piecewise affine continuous solutions for the square-to-oblique and the hexagonal-to-oblique phase transitions. This suggests that for specific crystallographic parameters the hysteresis of the phase transformation will be particularly small.

Repeated Stand-Replacing Crown Fires Affect Seed Morphology and Germination in Aleppo pine

Post-fire reproductive niche of Aleppo pine (Pinus halepensis) is deeply interlaced with fire products. Indeed, the high pH and low osmotic potentials of ash beds under burnt crowns constitute the main constraints to seed germination. In this study, we aim to investigate whether fire recurrence, through the physico-chemical constraints imposed by the ash beds, affects the reproduction ability of P. halepensis at the germination stage. To this aim, Aleppo pine seeds were collected in neighboring even-aged stands subjected to 0, 1, or 2 fires (namely fire cohorts), and seed morphology and germination performance, in terms of cumulative germination and germination kinetics, were studied under increasing osmotic potentials (from 0.0 to -1.2 MPa) and pH (from 6 to 11). Besides fire history, the role of ontogenetic age of mother plants on seed morphology and germination was also investigated. Differences in seed morphology among the three cohorts have been highlighted in a multivariate context, with anisotropic enlargement of the seeds produced by pine stands experiencing repeated fires. The patterns of seed germination varied primarily in relation to the fire cohort, with seeds from the pine stand experiencing repeated fires exhibiting enhanced tolerance to pH stress. Conversely, germination performances under osmotic constraints mainly depends on tree ontogenetic stage, with an involvement of fire history especially in the timing of seed germination. Our results suggest that, at least in the short term, fire recurrence does not constrain the reproduction ability of Aleppo pine. These results highlight the need for further research to elucidate the mechanisms behind these responses to recurrent fires.

Changing Patterns of Undiagnosed HIV Infection in the Netherlands: Who Benefits Most from Intensified HIV Test and Treat Policies?

OBJECTIVES

To estimate HIV prevalence, the number of people living with HIV/AIDS (PLWHA) and the undiagnosed proportion in the Netherlands for 2012, and to compare these with published 2007 estimates.

DESIGN

Synthesis of all available data sources.

METHODS

Multi-Parameter Evidence Synthesis (MPES) was used to obtain estimates in mutually exclusive key populations at higher risk in three geographical regions (Amsterdam, Rotterdam, rest of the Netherlands). Data sources included HIV prevalence surveys, diagnoses at STI clinics, and registered cases in HIV care. Group specific estimates were reported as Bayesian posterior medians and 95% credible intervals (CrI).

RESULTS

The 2012 model estimated 24,350 PLWHA (95% CrI 20,420-31,280) aged 15-70 years; 2,906 (+14%) more than in 2007. The estimated population HIV prevalence was 0.20% (95% CrI 0.17-0.26%). The overall proportion of undiagnosed HIV was lower in 2012 (34%, 95% CrI 22-49%) compared to 2007 (40%, 95% CrI 25-55%). After MSM, migrants from sub-Saharan Africa and the Caribbean formed the largest groups of PLWHA, but proportions of undiagnosed HIV remained high in these groups, 48% and 44% respectively. Amsterdam had lowest proportions undiagnosed for most key populations at higher risk, including MSM and migrants.

CONCLUSIONS

In 2012, the number of PLWHA was higher compared to 2007, while the proportion of undiagnosed HIV was lower, especially among MSM. Higher HIV testing rates, earlier treatment, and an improved life expectancy may explain these differences. HIV interventions need to be expanded in all key populations at higher risk, with special focus on migrants and key populationsliving outside of Amsterdam.

The endogenous caspase-8 inhibitor c-FLIPL regulates ER morphology and crosstalk with mitochondria

Components of the death receptor-mediated pathways like caspase-8 have been identified in complexes at intracellular membranes to spatially restrict the processing of local targets. In this study, we report that the long isoform of the cellular FLICE-inhibitory protein (c-FLIP(L)), a well-known inhibitor of the extrinsic cell death initiator caspase-8, localizes at the endoplasmic reticulum (ER) and mitochondria-associated membranes (MAMs). ER morphology was disrupted and ER Ca(2+)-release as well as ER-mitochondria tethering was decreased in c-FLIP(-/-) mouse embryonic fibroblasts (MEFs). Mechanistically, c-FLIP ablation resulted in enhanced basal caspase-8 activation and in caspase-mediated processing of the ER-shaping protein reticulon-4 (RTN4) that was corrected by re-introduction of c-FLIP(L) and caspase inhibition, resulting in the recovery of a normal ER morphology and ER-mitochondria juxtaposition. Thus, the caspase-8 inhibitor c-FLIP(L) emerges as a component of the MAMs signaling platforms, where caspases appear to regulate ER morphology and ER-mitochondria crosstalk by impinging on ER-shaping proteins like the RTN4.

Impact of TB on the survival of people living with HIV infection in England, Wales and Northern Ireland

INTRODUCTION

The impact of TB disease on survival in people living with HIV in high resource settings is not well documented in the antiretroviral treatment (ART) era. We calculated TB incidence rates and compared the mortality of persons with and without HIV-TB in a UK HIV cohort in the post-ART era, to determine the impact of HIV-TB on survival in the UK.

METHODS

We linked the national cohort of persons (aged ≥15 years) diagnosed with HIV between 2000 and 2008 in England, Wales and Northern Ireland with the national TB register and deaths from the Office of National Statistics. We compared all-cause and AIDS-specific mortality in patients with and without TB by estimating HRs using Cox regression modelling allowing for potential predictors.

RESULTS

Overall, 3188 (7.2%) individuals developed TB infection among a cohort of 44 050 HIV-diagnosed persons and 149 663 person-years. The cumulative TB incidence rate was 2.13 per 100 person-years with a spike within the first 6 months after HIV diagnosis. TB coinfected patients comprised 18% of the 1880 deaths during follow-up and 79% of deaths (n=967) in the year following HIV diagnosis. TB coinfection (HR 4.77, 95% CI 4.11 to 5.54) was significantly associated with increased all-cause mortality. Analysis of AIDS-related survival showed similar results.

DISCUSSION

The unexpected high mortality in patients with HIV-TB in a population with good healthcare access and ART availability highlights the importance of improving active and latent TB case-finding among patients with HIV, and HIV-testing among patients with TB, to ensure appropriate and prompt treatment initiation for both diseases.

Comparative analysis of heterogeneity of primary photosynthe-tic processes within fruticose lichen thalli: Preliminary study of interspecific differences ( Short Communication )

Two species of fruticose lichens from different habitats and of distinct color, Usnea antarctica and Stereocaulon vesuvianum, were compared using chlorophyll fluorescence imaging in order to study the distribution of primary photosynthetic processes within the thalli. The thallus of U. antarctica is yellow with black tips: in this species chlorophyll containing cells were mostly located in the middle region of the thallus and the highest PS II efficiency was detected in the middle to basal region, as shown by the FV/FM and ΦPSII values. No chlorophyll fluorescence was detected in the apical part of the thallus, indicating that little or no photosynthesis takes place in these tissues. The lichen S. vesuvianum is homogeneously pale grayish green and chlorophyll containing cells are distributed along the thallus with maximum concentration in the middle region. In S. vesuvianum, the highest PS II efficiency was detected in the apical to middle region of the thallus, while the basal portion was found to have the lowest efficiency of primary photochemical reactions. Quenching analysis data confirmed the uneven patterns of primary photosynthetic processes within the thalli of these fruticose lichens.

An unanticipated role for survivin in organ transplant damage

Ischemia/reperfusion (I/R) injury is a major determinant of graft survival in kidney transplantation. Survivin, an inhibitor of apoptosis that participates in the control of mitosis and cell cycle progression, has been implicated in renal protection and repair after I/R injury; however, no study has been performed in the transplant setting. We investigated the role of survivin in modulating posttransplant I/R injury in syngeneic and allogeneic kidney grafts, and studied whether protection from I/R injury impacted on the recipient immune system, on chronic allograft nephropathy and rejection. We used genetically engineered mice with survivin haploinsufficiency and WT mice in which survivin over-expression was induced by gene-delivery. Survivin haploinsufficiency in syngeneic grafts was associated with exuberant I/R tissue injury, which triggered inflammation eventually resulting in graft loss. Conversely, survivin over-expression in the grafts minimized I/R injury and dysfunction in syngeneic grafts and in a clinically relevant fully MHC-mismatched allogeneic combination. In the latter, survivin over-expression translated into limited anti-donor adaptive immune response and less long-term allograft injury with protection from renal parenchymal damage. Our data support survivin over-expression in the graft as a novel target for protocols aimed at limiting tissue damage at the time of transplant ultimately modulating the recipient immune system.

Sterically driven synthesis of ruthenium and ruthenium–silver N-heterocyclic carbene complexes

A sterically driven synthetic route from non-bulky silver NHC to novel Ru(NHC) complexes and from bulky Ag(NHC) to unprecedented heterobimetallic Ru–Ag(NHC) complexes is presented.