Antibody response to three-dose anti-SARS-CoV-2 mRNA-vaccination in treated solid cancer patients

Solid cancer patients are at higher risk of SARS-CoV-2 infection and severe complications. Moreover, vaccine-induced antibody response is impaired in patients on anticancer treatment. In this retrospective, observational, hypothesis-generating, cohort study, we assessed the antibody response to the third dose of mRNA vaccine in a convenience sample of patients on anticancer treatment, comparing it to that of the primary two-dose cycle. Among 99 patients included, 62.6% were ≥60 years old, 32.3% males, 67.7% with advanced disease. Exactly 40.4% were receiving biological therapy, 16.2% chemotherapy only and 7.1% both treatments. After the third dose, seroconversion rate seems to increase significantly, especially in non-responders to two doses. Heterologous vaccine-type regimen (two-dose mRNA-1273 and subsequent tozinameran or vice versa) results in higher antibody levels. This explorative study suggests that repeated doses of mRNA-vaccines could be associated with a better antibody response in this population. Furthermore, heterologous vaccine-type three-dose vaccination seems more effective in this population. Since this is a hypothesis-generating study, adequately statistically powered studies should validate these results.

Peroneal mononeuropathy and polyneuropathy in adolescents with Anorexia Nervosa: a case report and literature review

Peroneal neuropathy and polyneuropathy are displayed with a variable percentage in subjects affected by eating disorders and in particular by anorexia nervosa. Actually, little is known on features of these complications during the paediatric age. We describe the case of a female adolescent with right peroneal palsy and subclinical polyneuropathy associated with anorexia nervosa (AN). We review previous research about peroneal mononeuropathy and polyneuropathy associated with AN, and we develop a diagnostic and therapeutic protocol to help clinicians recognize and treat these disorders.

Early administration of nirmatrelvir/ritonavir leads to faster negative SARS-CoV-2 nasal swabs than monoclonal antibodies in COVID 19 patients at high-risk for severe disease

PURPOSE

Besides the well-established efficacy in preventing severe COVID-19, the impact of early treatments, namely antivirals and monoclonal antibodies (mAbs), on the time length to negativization of SARS-CoV-2 nasal swabs is still unclear. The aim of this study was to compare the efficacy of different early treatments in reducing the SARS-CoV-2 viral shedding, identifying a single drug that might potentially lead to a more rapid negativization of SARS-CoV-2 nasal swab.

METHODS

This was a single-centre, retrospective, observational study conducted at Ospedale Luigi Sacco in Milan. Data of high-risk COVID-19 patients who received early treatments between 23 December 2021 and March 2023 were extracted. The comparison across treatments was conducted using the Kruskall-Wallis test for continuous variables. Dunn's test with Bonferroni adjustment was performed for post-hoc comparisons of days to negativization. Secondly, a negative binomial regression adjusted for age, sex, number of comorbidities, immunosuppression, and SARS-CoV-2 vaccination status was implemented.

RESULTS

Data from 428 patients receiving early treatments were collected. The majority were treated with Nirmatrelvir/Ritonavir and were affected by SARS-CoV-2 Omicron infection with BA.2 sublineage. The median length time to SARS-CoV-2 nasal swab negativization was 9 days [IQR 7-13 days]. We found that Nirmatrelvir/Ritonavir determined a significant decrease of the length time to SARS-CoV-2 nasal swab negativization compared to mAbs (p = 0.003), but not compared to Remdesivir (p = 0.147) and Molnupiravir (p = 0.156).

CONCLUSION

Our findings highlight the importance of promptly treating high-risk COVID-19 patients with Nirmatrelvir/Ritonavir, as it also contributes to achieving a faster time to negative SARS-CoV-2 nasal swabs.

Long-term effects of SARS-CoV-2 infection in hospitalized children: findings from an Italian single-center study

BACKGROUND

Limited evidence exists regarding the association between COVID-19 and Long COVID manifestations in children, particularly concerning variants of concern (VOCs). We aimed to characterize a cohort of pediatric patients hospitalized with confirmed acute SARS-CoV-2 and monitor them for Long COVID symptoms. Additionally, it seeks to explore any potential correlations between VOCs and clinical symptoms.

METHODS

We conducted a prospective study involving children hospitalized from November 2021 to March 2023, with confirmed acute SARS-CoV-2 infection. A telephone survey was conducted at 3-6-12 months after discharge.

RESULTS

We included 167 patients (77 F/90 M). Upon hospital admission, 95.5% of patients presented as symptomatic. Regarding patients for whom it was feasible to determine the SARS-CoV-2 variant (n = 51), the Delta variant was identified in 11 children (21.6%) and Omicron variant in the remaining 40 patients (78.4%: 27.5% BA.1 variant; 15% BA.2 variant; 57.5% BA.5 variant). 19 patients (16.5%) reported experiencing at least one symptom indicative of Long COVID (weight loss 31.6%, inappetence 26.3%, chronic cough 21.1%, fatigue 21.1%, and sleep disturbances, wheezing, abdominal pain and mood disorders 15.8%). In only 4 patients with Long COVID we could identified a specific SARS-CoV-2 variant (3 Omicron: 2 BA.1 and 1 BA.2; 1 Delta).

CONCLUSIONS

this study underscores that long COVID is a significant concern in the pediatric population. Our data reinforce the importance of continuously monitoring the impact of long-COVID in infants, children, and adolescents. A follow-up following SARS-CoV-2 infection is therefore advisable, with symptom investigation tailored to the patient's age.

Transient ischemic attack and minor stroke as "surgeons affairs": a narrative review

OBJECTIVE

The scope of this paper is to review the subtypes of transient ischemic attack (TIA) and minor stroke (mS) in which a surgical treatment is needed, discussing the importance and the timing of a multidisciplinary approach, in order to achieve an optimized management and prevent major strokes or other critical complications.

MATERIALS AND METHODS

The keywords "transient ischemic attack," "minor stroke," "surgical treatment," "vascular surgery," "heart surgery," "neurosurgery," and "multidisciplinary" were searched using MEDLINE, EMBASE, and Scopus. Relevant search results were discussed by the authors for references inclusion.

RESULTS

Notwithstanding that best medical therapy is usually the first choice for the most part of cases, there are specific but recurrent etiologies that must be properly recognized because of a potential surgical approach, even in urgency. In fact, symptomatic carotid stenosis, or particular cases of hemodynamic cerebrovascular events, should be promptly referred to vascular surgeon, since increasing evidences highlighted a benefit from an early artery revascularization. In addition, beyond arrhythmic causes, cardioembolic events due to bacterial endocarditis and atrial myxoma should be quickly diagnosed, possibly in emergency department, because they are a presumptive urgency for heart surgery. In addition to the above-mentioned conditions, in patients suffering from vertebrobasilar TIA or mS, clinicians should keep in mind the Bow Hunter disease, because surgical artery decompression can represent the only suitable treatment in selected cases.

CONCLUSIONS

TIA and mS require a multidisciplinary in order to discuss therapeutic options, comparing risks and benefits and determining the best timing for an optimized management.

What do we mean by long COVID? A scoping review of the cognitive sequelae of SARS-CoV-2 infection

BACKGROUND AND PURPOSE

Many COVID-19 patients report persistent symptoms, including cognitive disturbances. We performed a scoping review on this topic, focusing primarily on cognitive manifestations.

METHODS

Abstracts and full texts of studies published on PubMed (until May 2023) addressing cognitive involvement persisting after SARS-CoV-2 infection were reviewed, focusing on terms used to name the cognitive syndrome, reported symptoms, their onset time and duration, and testing batteries employed. Reported psychiatric symptoms, their assessment tools, and more general manifestations were also extracted.

RESULTS

Among the 947 records identified, 180 studies were included. Only one third of them used a label to define the syndrome. A minority of studies included patients according to stringent temporal criteria of syndrome onset (34%), whereas more studies reported a minimum required symptom duration (77%). The most frequently reported cognitive symptoms were memory and attentional-executive disturbances, and among psychiatric complaints, the most frequent were anxiety symptoms, depression, and sleep disturbances. Most studies reported fatigue among general symptoms. Thirty-six studies employed cognitive measures: screening tests alone (n = 19), full neuropsychological batteries (n = 25), or both (n = 29); 30 studies performed psychiatric testing. Cognitive deficits were demonstrated in 39% of subjects, the most frequently affected domains being attention/executive functions (90%) and memory (67%).

CONCLUSIONS

Currently, no agreement exists on a label for post-COVID-19 cognitive syndrome. The time of symptom onset after acute infection and symptom duration are still discussed. Memory and attention-executive complaints and deficits, together with fatigue, anxiety, and depression symptoms, are consistently reported, but the objective evaluation of these symptoms is not standardized.

Genomic epidemiology of the main SARS-CoV-2 variants in Italy between summer 2020 and winter 2021

Since the beginning of the pandemic, SARS-CoV-2 has shown a great genomic variability, resulting in the continuous emergence of new variants that has made their global monitoring and study a priority. This work aimed to study the genomic heterogeneity, the temporal origin, the rate of viral evolution and the population dynamics of the main circulating variants (20E.EU1, Alpha and Delta) in Italy, in August 2020-January 2022 period. For phylogenetic analyses, three datasets were set up, each for a different main lineage/variant circulating in Italy in that time including other Italian and International sequences of the same lineage/variant, available in GISAID sampled in the same times. The international dataset showed 26 (23% Italians, 23% singleton, 54% mixed), 40 (60% mixed, 37.5% Italians, 1 singleton) and 42 (85.7% mixed, 9.5% singleton, 4.8% Italians) clusters with at least one Italian sequence, in 20E.EU1  clade, Alpha and Delta variants, respectively. The estimation of tMRCAs in the Italian clusters (including >70% of genomes from Italy) showed that in all the lineage/variant, the earliest clusters were the largest in size and the most persistent in time and frequently mixed. Isolates from the major Italian Islands tended to segregate in clusters more frequently than those from other part of Italy. The study of infection dynamics showed a positive correlation between the trend in the effective number of infections estimated by BSP model and the Re curves estimated by birth-death skyline plot. The present work highlighted different evolutionary dynamics of studied lineages with high concordance between epidemiological parameters estimation and phylodynamic trends suggesting that the mechanism of replacement of the SARS-CoV-2 variants must be related to a complex of factors involving the transmissibility, as well as the implementation of control measures, and the level of cross-immunization within the population.

Berberine phospholipid exerts a positive effect on the glycemic profile of overweight subjects with impaired fasting blood glucose (IFG): a randomized double-blind placebo-controlled clinical trial

OBJECTIVE

Berberine is a plant alkaloid known to exert positive metabolic effects. Human studies have confirmed its ability to improve the lipid and glycemic profile. This study aimed to evaluate the potential benefit of oral supplementation of Berberine PhytosomeTM (2 tablets/day, 550 mg/tablet) on the metabolic profile of subjects with impaired fasting blood glucose (IFG).

PATIENTS AND METHODS

A total of 49 overweight subjects, 28 females and 21 males, were randomly assigned to either the supplemented group (n=24) or placebo (n=25). We considered glycemia as the primary endpoint and total cholesterol, high-density lipoprotein (HDL), total cholesterol/HLD, low-density lipoprotein (LDL), LDL/HDL, triglycerides, insulin, glycated hemoglobin, Homeostasis Model Assessment (HOMA), ApoA, ApoB, ApoB/ApoA, androgen suppression treatment (AST), alternative lengthening of telomeres (ALT), gamma-glutamyl transferase (GGT), creatinine, and body composition by dual-energy X-ray absorptiometry (DXA) as secondary endpoints. These parameters have been assessed at baseline, after 30 days, and after 60 days.

RESULTS

After two months of treatment, through the use of linear mixed effect models, a statistically significant difference between supplemented and placebo groups was observed for glycemia [β=-0.2495% C.I. (-0.47; -0.06), p=0.004], total cholesterol [β=-0.25, 95% C.I. (-0.45; -0.04), p=0.05], total cholesterol/HDL [β=-0.25, 95% C.I. (-0.43; -0.06), p=0.04], triglycerides [β=-0.14, 95% C.I. (-0.25; -0.02), p=0.05], insulin [β=-1.78, 95% C.I. (-2.87; -0.66), p=0.009], ApoB/ApoA [β=-0.08, 95% C.I. (-0.13; -03), p=0.004], Visceral adipose tissue (VAT) [β=-91.50, 95% C.I. (-132.60; -48.19), p<0.0001] and fat mass [β=-945.56, 95% C.I. (-1,424.42; -441.57), p=0.004].

CONCLUSIONS

The use of berberine had no adverse events, supporting its use as a natural alternative to pharmacological therapies in the case of IFG.

Corrigendum: Definition of the immune parameters related to COVID-19 severity

[This corrects the article DOI: 10.3389/fimmu.2022.850846.].

Clinical efficacy of the first two doses of anti-SARS-CoV-2 mRNA vaccines in solid cancer patients

INTRODUCTION

Cancer patients are frail individuals, thus the prevention of SARS-CoV-2 infection is essential. To date, vaccination is the most effective tool to prevent COVID-19. In a previous study, we evaluated the immunogenicity of two doses of mRNA-based vaccines (BNT162b2 or mRNA-1273) in solid cancer patients. We found that seroconversion rate in cancer patients without a previous exposure to SARS-CoV-2 was lower than in healthy controls (66.7% vs. 95%, p = 0.0020). The present study aimed to evaluate the clinical efficacy of the vaccination in the same population.

METHODS

This is a single-institution, prospective observational study. Data were collected through a predefined questionnaire through phone call in the period between the second and third vaccine dose. The primary objective was to describe the clinical efficacy of the vaccination, defined as the percentage of vaccinated subjects who did not develop symptomatic COVID-19 within 6 months after the second dose. The secondary objective was to describe the clinical features of patients who developed COVID-19.

RESULTS

From January to June 2021, 195 cancer patients were enrolled. Considering that 7 (3.59%) patients tested positive for SARS-CoV-2 and 5 developed symptomatic disease, the clinical efficacy of the vaccination was 97.4%. COVID-19 disease in most patients was mild and managed at home; only one hospitalization was recorded and no patient required hospitalization in the intensive care unit.

DISCUSSION

Our study suggests that increasing vaccination coverage, including booster doses, could improve the prevention of infection, hospitalization, serious illness, and death in the frail population of cancer patients.

Conventional, biological disease-modifying anti-rheumatic drugs and Janus kinase inhibitors and varicella zoster virus

INTRODUCTION

The advent of biological disease-modifying anti-rheumatic drugs (bDMARDs), and more recently of Janus kinase inhibitors (JAKi), has had a major impact on the herpes zoster (HZ) reactivation, which represents an important clinical challenge in the treatment of inflammatory arthritis (IA) in patients with a complete pharmacological control of peripheral inflammation.

AREAS COVERED

In this review, we provide an overview on the effects of conventional DMARDs/ bDMARDs and JAKi on HZ reactivation. Furthermore, we underline the controversial findings and the potential management strategies. We searched PubMed, Medline, and the Cochrane Library for papers published between 1995 and February 2017.

EXPERT OPINION

The overall data showed a slightly higher risk of HZ in patients treated with bDMARDs, and more pronounced for those treated with JAKi. As management strategies, we suggest an effective vaccination campaign and a focus on early diagnosis.

Observational Study on Antibody Response to COVID-19 Vaccines in PAtients with Gastro-Entero-PanCreatic Cancers and NeuroendocrIne NeoplAsms on Systemic TreatmEnts (VACCINATE)

The coronavirus disease-19 (COVID-19) pandemic dramatically impacted oncological patients' care. Since the introduction of vaccines and the demonstration of their benefit on frail patients, COVID-19 vaccinations were indicated to also be beneficial to oncological population. However, data about the impact of anticancer-treatments and the timing between vaccinations and systemic therapy delivery were not available. We aimed to evaluate potential factors influencing the outcome of the COVID-19 vaccination in cancer patients. We prospectively collected data of patients undergoing the COVID-19 vaccination with gastro-entero-pancreatic and neuroendocrine neoplasms, treated at our institute, between 03/2021 and 12/2021. We enrolled 46 patients, 63.1% males; at the time of data collection, 86.9% had received two-doses of Pfizer-BioNTech and the rest had received the Moderna vaccine. All patients obtained a subsequent immune-response. Chemotherapy seems to determinate a significantly lower antibody response after vaccination compared to the other anti-cancer agents (p = 0.004). No significant effect on immune-response was reported for both vaccinations performed ≤7 vs. >7 days from the last systemic treatment (p = 0.77) and lymphocytes count (p = 0.11). The findings suggest that the optimal timing for COVID-19 vaccination and lymphocytes count are not the issue, but rather that the quality of the subset of lymphocytes before the vaccination determine the efficacy level of immune-response in this population.

Maturation of SARS-CoV-2 Spike-specific memory B cells drives resilience to viral escape

Memory B cells (MBCs) generate rapid antibody responses upon secondary encounter with a pathogen. Here, we investigated the kinetics, avidity, and cross-reactivity of serum antibodies and MBCs in 155 SARS-CoV-2 infected and vaccinated individuals over a 16-month time frame. SARS-CoV-2-specific MBCs and serum antibodies reached steady-state titers with comparable kinetics in infected and vaccinated individuals. Whereas MBCs of infected individuals targeted both prefusion and postfusion Spike (S), most vaccine-elicited MBCs were specific for prefusion S, consistent with the use of prefusion-stabilized S in mRNA vaccines. Furthermore, a large fraction of MBCs recognizing postfusion S cross-reacted with human betacoronaviruses. The avidity of MBC-derived and serum antibodies increased over time resulting in enhanced resilience to viral escape by SARS-CoV-2 variants, including Omicron BA.1 and BA.2 sublineages, albeit only partially for BA.4 and BA.5 sublineages. Overall, the maturation of high-affinity and broadly reactive MBCs provides the basis for effective recall responses to future SARS-CoV-2 variants.

Epidemiological and Clinical Features of SARS-CoV-2 Variants Circulating between April-December 2021 in Italy

SARS-CoV-2 is constantly evolving, leading to new variants. We analysed data from 4400 SARS-CoV-2-positive samples in order to pursue epidemiological variant surveillance and to evaluate their impact on public health in Italy in the period of April-December 2021. The main circulating strain (76.2%) was the Delta variant, followed by the Alpha (13.3%), the Omicron (5.3%), and the Gamma variants (2.9%). The B.1.1 lineages, Eta, Beta, Iota, Mu, and Kappa variants, represented around 1% of cases. There were 48.2% of subjects who had not been vaccinated, and they had a lower median age compared to the vaccinated subjects (47 vs. 61 years). An increasing number of infections in the vaccinated subjects were observed over time, with the highest proportion in November (85.2%). The variants correlated with clinical status; the largest proportion of symptomatic patients (59.6%) was observed with the Delta variant, while subjects harbouring the Gamma variant showed the highest proportion of asymptomatic infection (21.6%), albeit also deaths (5.4%). The Omicron variant was only found in the vaccinated subjects, of which 47% had been hospitalised. The diffusivity and pathogenicity associated with the different SARS-CoV-2 variants are likely to have relevant public health implications, both at the national and international levels. Our study provides data on the rapid changes in the epidemiological landscape of the SARS-CoV-2 variants in Italy.

Administration of Samital® in children with oral mucositis: a feasibility study

OBJECTIVE

SAMITAL®, a botanical drug containing three highly standardized extracts (Vaccinium myrtillus, Macleaya cordata and Echinacea angustifolia), has shown promising results in treating or preventing oral mucositis (OM) in adult patients, but it has not been fully investigated in children. In this study, we assessed the feasibility of SAMITAL administration in pediatric patients receiving anticancer treatment to prevent or treat OM, focusing on identifying an appropriate dose and evaluating safety and tolerability and palatability and treatment compliance.

PATIENTS AND METHODS

We conducted an open-label, monocentric, prospective study on 18 children receiving anticancer therapy to prevent or treat OM.

RESULTS

No SAMITAL®-related side effects were observed or reported during the study; moreover, no systemic absorption of SAMITAL® metabolites was detected in the bloodstream. However, compliance to SAMITAL® was unsatisfactory and variable (from 2 to 100%), and patients reported low palatability (median taste of 4.8; range 1.0-8.0).

CONCLUSIONS

SAMITAL® administration appears to be safe in the pediatric population, as it is not absorbed in the bloodstream and does not cause any local or systemic side effects. However, the current formulation is only partially suitable for children, and future studies on SAMITAL® in children would need an adapted formulation to increase compliance.

Maturation of SARS-CoV-2 Spike-specific memory B cells drives resilience to viral escape

Memory B cells (MBCs) generate rapid antibody responses upon secondary encounter with a pathogen. Here, we investigated the kinetics, avidity and cross-reactivity of serum antibodies and MBCs in 155 SARS-CoV-2 infected and vaccinated individuals over a 16-month timeframe. SARS-CoV-2-specific MBCs and serum antibodies reached steady-state titers with comparable kinetics in infected and vaccinated individuals. Whereas MBCs of infected individuals targeted both pre- and postfusion Spike (S), most vaccine-elicited MBCs were specific for prefusion S, consistent with the use of prefusion-stabilized S in mRNA vaccines. Furthermore, a large fraction of MBCs recognizing postfusion S cross-reacted with human betacoronaviruses. The avidity of MBC-derived and serum antibodies increased over time resulting in enhanced resilience to viral escape by SARS-CoV-2 variants, including Omicron BA.1 and BA.2 sub-lineages, albeit only partially for BA.4 and BA.5 sublineages. Overall, the maturation of high-affinity and broadly-reactive MBCs provides the basis for effective recall responses to future SARS-CoV-2 variants.

Immunogenicity of two doses of BNT162b2 and mRNA-1273 vaccines for solid cancer patients on treatment with or without a previous SARS-CoV-2 infection

Previous studies on the immunogenicity of SARS-CoV-2 mRNA vaccines showed a reduced seroconversion in cancer patients. The aim of our study is to evaluate the immunogenicity of two doses of mRNA vaccines in solid cancer patients with or without a previous exposure to the virus. This is a single-institution, prospective, nonrandomized study. Patients in active treatment and a control cohort of healthy people received two doses of BNT162b2 (Comirnaty, BioNTech/Pfizer, The United States) or mRNA-1273 (Spikevax, Moderna). Vaccine was administered before starting anticancer therapy or on the first day of the treatment cycle. SARS-CoV-2 antibody levels against S1, RBD (to evaluate vaccine response) and N proteins (to evaluate previous infection) were measured in plasma before the first dose and 30 days after the second one. From January to June 2021, 195 consecutive cancer patients and 20 healthy controls were enrolled. Thirty-one cancer patients had a previous exposure to SARS-CoV-2. Cancer patients previously exposed to the virus had significantly higher median levels of anti-S1 and anti-RBD IgG, compared to healthy controls (P = .0349) and to cancer patients without a previous infection (P < .001). Vaccine type (anti-S1: P < .0001; anti-RBD: P = .0045), comorbidities (anti-S1: P = .0274; anti-RBD: P = .0048) and the use of G-CSF (anti-S1: P = .0151) negatively affected the antibody response. Conversely, previous exposure to SARS-CoV-2 significantly enhanced the response to vaccination (anti-S1: P < .0001; anti-RBD: P = .0026). Vaccine immunogenicity in cancer patients with a previous exposure to SARS-CoV-2 seems comparable to that of healthy subjects. On the other hand, clinical variables of immune frailty negatively affect humoral immune response to vaccination.

New challenges in human monkeypox outside Africa: A review and case report from Italy

BACKGROUND

Human monkeypox (MPX) is a neglected zoonotic disease caused by the MPX virus a double-stranded DNA virus which belongs to the Poxviridae family genus Orthopoxvirus. It is endemic in the rural rainforests of Central and Western Africa where it is responsible of human sporadic cases and outbreaks since 1970. Outside Africa MPXV caused an outbreak in 2003 in the United States linked to importation of infected rodents from Ghana and a few travel-related cases in the USA, United Kingdom, Israel and Singapore. Actually, a worldwide outbreak with more than 1200 confirmed cases mainly concentrated among men who have sex with men is ongoing.

CASE REPORT

We present the case of an Italian man living in Portugal that was diagnosed with MPX at our clinic in Milan, Italy. Monkeypox virus infection was confirmed by a specific homemade Real-Time PCR. Samples obtained from different sites (pharynx, skin lesions, anal ulcer, seminal fluid) turned all positive with different viral load.

CONCLUSIONS

Our report illustrates the challenge of a disease that seems to present in a different way from classic description with possible human-to-human transmission through sexual contact.

Vaccination Opportunities in Multiple Sclerosis Patients Treated with Cladribine Tablets

COVID 19 pandemic and mass vaccination campaigns have revealed the situation of the most vulnerable patients. In this work, we focused our attention to patients who have Multiple Sclerosis (MS), particularly in treatment with cladribine tablets, trying to understand if and when it is possible to administer the vaccine successfully. In light of the novel topic, we studied the existing literature and analysed experiences with previous vaccinations, such as influenza and VZV, as well as data from countries where vaccination campaigns had already begun. Overall, we have taken into account the mechanism of action, the pharmacokinetic/pharmacodynamic of cladribine, and the changes in the immune system after its administration, together with the preliminary data about the humoral response to influenza, VZV, and SARS-CoV-2 vaccinations in cladribine treated patients. In conclusion, data showed that the use of cladribine tablets seems to permit flexibility regarding vaccination timing and we suggest that vaccination in those patients should be safe and effective. The current COVID 19 pandemic has re-ignited the interest in vaccines and vaccination procedures. The importance of including fragile individuals has increased as a result of mass vaccination. Millions of patients with multiple sclerosis (MS) around the world are debating whether they can safely receive their vaccine shot with the same efficacy despite receiving immune-modulating or immune-suppressive treatments. In the absence of conclusive empirical data, we will review and discuss the available evidence and the reasonable conclusions for one specific treatment, namely cladribine tablets (Mavenclad).

The deficiency in Th2-like Tfh cells affects the maturation and quality of HIV-specific B cell response in viremic infection

Optimal T follicular helper (Tfh) cells function is important to promote the development of germinal centers and maturation of high affinity antigen-specific B cells. We have found that the expression of CXCR3 defines distinct Tfh subsets: CXCR3⁺ Th1-like Tfh cells mainly producing single IFN-γ and dual IL-21/IFN-γ and CXCR3^- Th2-like Tfh cells mainly producing single IL-4 and dual IL-21/IL-4 cytokines. CXCR3^- Th2-like Tfhs are significantly reduced during ongoing HIV replication. While the percentage of Th2-like Tfh cells correlates with that of total and cycling HIV-specific B cells, the percentage of CXCR3⁺ Th1-like Tfhs correlates with HIV-specific B cells expressing T-bet and CXCR3. Of note, only IL-4 and IL-21 cytokines boosted efficient maturation of HIV-specific B cells while IFN-γ induced expression of T-bet and CXCR3 in B cells. Interestingly, total and HIV-specific CXCR3⁺ B cells showed lower rate of somatic hypermutation, as compared to CXCR3^- B cells. Therefore, the imbalance in Th2/Th1-like Tfhs affects B cell responses in viremic HIV infection.

Indirect and Direct Effects of SARS-CoV-2 on Human Pancreatic Islets

Recent studies have shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may induce metabolic distress, leading to hyperglycemia in patients affected by coronavirus disease 19 (COVID-19). We investigated the potential indirect and direct effects of SARS-CoV-2 on human pancreatic islets in 10 patients who became hyperglycemic after COVID-19. Although there was no evidence of peripheral anti-islet autoimmunity, the serum of these patients displayed toxicity on human pancreatic islets, which could be abrogated by the use of anti-interleukin-1β (IL-1β), anti-IL-6, and anti-tumor necrosis factor α, cytokines known to be highly upregulated during COVID-19. Interestingly, the receptors of those aforementioned cytokines were highly expressed on human pancreatic islets. An increase in peripheral unmethylated INS DNA, a marker of cell death, was evident in several patients with COVID-19. Pathology of the pancreas from deceased hyperglycemic patients who had COVID-19 revealed mild lymphocytic infiltration of pancreatic islets and pancreatic lymph nodes. Moreover, SARS-CoV-2-specific viral RNA, along with the presence of several immature insulin granules or proinsulin, was detected in postmortem pancreatic tissues, suggestive of β-cell-altered proinsulin processing, as well as β-cell degeneration and hyperstimulation. These data demonstrate that SARS-CoV-2 may negatively affect human pancreatic islet function and survival by creating inflammatory conditions, possibly with a direct tropism, which may in turn lead to metabolic abnormalities observed in patients with COVID-19.

Colchicine anti-inflammatory therapy for non-intensive care unit hospitalized COVID-19 patients: results from a pilot open-label, randomized controlled clinical trial

Systemic inflammation is a hallmark of severe coronavirus disease-19 (COVID-19). Anti-inflammatory therapy is considered crucial to modulate the hyperinflammatory response (cytokine storm) in hospitalized COVID-19 patients. There is currently no specific, conclusively proven, cost-efficient, and worldwide available anti-inflammatory therapy available to treat COVID-19 patients with cytokine storm. The present study aimed to investigate the treatment benefit of oral colchicine for hospitalized COVID-19 patients with suspected cytokine storm. Colchicine is an approved drug and possesses multiple anti-inflammatory mechanisms. This was a pilot, open-label randomized controlled clinical trial comparing standard of care (SOC) plus oral colchicine (colchicine arm) vs. SOC alone (control arm) in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. Colchicine treatment was initiated within first 48 hours of admission delivered at 1.5 mg loading dose, followed by 0.5 mg b.i.d. for next 6 days and 0.5 mg q.d. for the second week. A total of 96 patients were randomly allocated to the colchicine (n=48) and control groups (n=48). Both colchicine and control group patients experienced similar clinical outcomes by day 14 of hospitalization. Treatment outcome by day 14 in colchicine vs control arm: recovered and discharged alive: 36 (75.0%) vs. 37 (77.1%), remain admitted after 14-days: 4 (8.3%) vs. 5 (10.4%), ICU transferred: 4 (8.3%) vs. 3 (6.3%), and mortality: 4 (8.3%) vs. 3 (6.3%). The speed of improvement of COVID-19 acute symptoms including shortness of breath, fever, cough, the need of supplementary oxygen, and oxygen saturation level, was almost identical in the two groups. Length of hospitalization was on average 1.5 day shorter in the colchicine group. There was no evidence for a difference between the two groups in the follow-up serum levels of inflammatory biomarkers including C-reactive protein (CRP), D-dimer, lactate dehydrogenase (LDH), ferritin, interleukin-6 (IL-6), high-sensitivity troponin T (hs-TnT) and N-terminal pro b-type natriuretic peptide (NT pro-BNP). According to the results of our study, oral colchicine does not appear to show clinical benefits in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. It is possible that the anti-inflammatory pathways of colchicine are not crucially involved in the pathogenesis of COVID-19.

Tension-Type Headache in Early Adolescents: Exploring the Predictive Role of Anxiety and Alexithymia

Introduction

Primary Headache, including Tension-Type Headache (TTH), represents one of the most common somatic disorders in children and adolescents with a strong impact on quality of life. Several risk factors, as environmental, familiar, and psychological features, including personality traits, are related to the development of Primary Headache. However, studies on specific subgroups of TTH are relatively few in early adolescents.

Objectives

Therefore, this cross-sectional pilot study aims at exploring the role of anxiety and alexithymia in early adolescents with and without TTH.

Methods

A sample of 70 early adolescents (M_age=14.59, SD=1.85; 71% females) consisting of a clinical group (31 with TTH) enrolled in an Italian Child Neuropsychiatry Clinic and a comparison group (38 without TTH) enrolled in schools, matched on gender and age, completed: 1) Multidimensional Anxiety Scale for Children (MASC) to detect the Total levels of Anxiety, also in their factor of Physical Symptoms, Social Anxiety, Harm Avoidance, and Separation Anxiety; 2) the Toronto Alexithymia Scale (TAS-20) to detect the Total levels of Alexithymia, also in their factor of Difficulty to Identifying and to Describing Feelings and Externally Oriented Thinking.

Results

TTH outcome positively correlated with Harm Avoidance (rho=.68, p<.001) and Total Alexithymia (rho=.72, p<.001). In a logistic regression, Harm Avoidance and Total Alexithymia predicted 69% of the variance in TTH outcome (p<.032).

Conclusions

This disorder may be a maladaptive strategy to cope with problems and feeling emotions, then early adolescents could be fostered in the acquisition of more adaptive emotion regulation abilities.

Disclosure

No significant relationships.

Multimethod Assessment of Mentalizing and its relations with Somatic Symptoms in Adolescents with Primary Headache

Introduction

Difficulties in mentalizing (i.e., the ability to reflect on self and others’ internal mental states, operationalized as reflective functioning [RF]; Fonagy et al., 2012) have been associated with psychological symptoms (Luyten et al., 2020), including somatic symptoms (Bizzi et al., 2019). Therefore, the assessment of its dimensions may be clinically relevant for young patients with somatic symptoms, as with Primary Headache (PH), representing one of the most common somatic complaints in children and adolescents.

Objectives

This study aimed to assess RF with a multi-method approach, exploring its relation with somatic symptoms.

Methods

48 adolescents diagnosed with PH (M_age=14.83, SD=2.81; 67% females) were recruited from an Italian Child Neuropsychiatry Clinic. RF was measured both through the Child and Adolescent Reflective Functioning (CRFS) applied to the Child Attachment Interview transcripts and the self-report Reflective Functioning Questionnaire (RFQ), while the Children’s Somatization Inventory (CSI-24) was used to measure the perceived severity of somatic symptoms.

Results

Different relations with somatic symptoms depended on the method used to evaluate RF: no significant correlations were found with the CRFS subscales (General, Other, Self ), while a negative significant correlation was found with the RFQ subscale Certainty about mental states (RFQ_C) (r=-.46, p=.016). All subscales of CRFS were negatively correlated with RFQ_C (p=.05), but not with the other RFQ subscale (Uncertainty about mental states; RFQ_U).

Conclusions

This suggests that two measures may lead to different dimensions of the same construct, thus a multi-method assessment of RF would be advisable in clinical practice.

Disclosure

No significant relationships.

Doravirine/tenofovir disoproxyl fumarate/lamivudine-induced alopecia: A case report

We report here a case of alopecia probably caused by the fixed dose combination of doravirine/tenofovir disproxil fumarate/lamivudine (DOR/TDF/3TC) in a 46-year-old male living with HIV, previously treated with tenofovir disproxil fumarate and lamivudine-containing antiretroviral combinations. After having excluded other causes of hair loss such as sexually transmitted disease or drugs associated with alopecia, as well as poor immune-virologic conditions (i.e. low CD4⁺ cell count and/or high HIV viral load), a toxic effect of doravirine might be hypothesized. DOR/TDF/3TC was immediately stopped and rilpivirine plus tenofovir alafenamide fumarate/emtricitabine was started. Four weeks after changing the antiretroviral regimen, the patient reported signs of hypopigmented hair regrowth. The association between the episode of alopecia and DOR/TDF/3TC was scored as probable according to the Naranjo causality scale. We concluded that alopecia was probably related to DOR but whether it is self-limiting, cannot be predicted at this stage.

Definition of the Immune Parameters Related to COVID-19 Severity

A relevant portion of patients with disease caused by the severe acute respiratory syndrome coronavirus 2 (COVID-19) experience negative outcome, and several laboratory tests have been proposed to predict disease severity. Among others, dramatic changes in peripheral blood cells have been described. We developed and validated a laboratory score solely based on blood cell parameters to predict survival in hospitalized COVID-19 patients. We retrospectively analyzed 1,619 blood cell count from 226 consecutively hospitalized COVID-19 patients to select parameters for inclusion in a laboratory score predicting severity of disease and survival. The score was derived from lymphocyte- and granulocyte-associated parameters and validated on a separate cohort of 140 consecutive COVID-19 patients. Using ROC curve analysis, a best cutoff for score of 30.6 was derived, which was associated to an overall 82.0% sensitivity (95% CI: 78–84) and 82.5% specificity (95% CI: 80–84) for detecting outcome. The scoring trend effectively separated survivor and non-survivor groups, starting 2 weeks before the end of the hospitalization period. Patients’ score time points were also classified into mild, moderate, severe, and critical according to the symptomatic oxygen therapy administered. Fluctuations of the score should be recorded to highlight a favorable or unfortunate trend of the disease. The predictive score was found to reflect and anticipate the disease gravity, defined by the type of the oxygen support used, giving a proof of its clinical relevance. It offers a fast and reliable tool for supporting clinical decisions and, most important, triage in terms of not only prioritization but also allocation of limited medical resources, especially in the period when therapies are still symptomatic and many are under development. In fact, a prolonged and progressive increase of the score can suggest impaired chances of survival and/or an urgent need for intensive care unit admission.

Broadly neutralizing antibodies overcome SARS-CoV-2 Omicron antigenic shift

The recently emerged SARS-CoV-2 Omicron variant encodes 37 amino acid substitutions in the spike protein, 15 of which are in the receptor-binding domain (RBD), thereby raising concerns about the effectiveness of available vaccines and antibody-based therapeutics. Here we show that the Omicron RBD binds to human ACE2 with enhanced affinity, relative to the Wuhan-Hu-1 RBD, and binds to mouse ACE2. Marked reductions in neutralizing activity were observed against Omicron compared to the ancestral pseudovirus in plasma from convalescent individuals and from individuals who had been vaccinated against SARS-CoV-2, but this loss was less pronounced after a third dose of vaccine. Most monoclonal antibodies that are directed against the receptor-binding motif lost in vitro neutralizing activity against Omicron, with only 3 out of 29 monoclonal antibodies retaining unaltered potency, including the ACE2-mimicking S2K146 antibody¹. Furthermore, a fraction of broadly neutralizing sarbecovirus monoclonal antibodies neutralized Omicron through recognition of antigenic sites outside the receptor-binding motif, including sotrovimab², S2X259³ and S2H97⁴. The magnitude of Omicron-mediated immune evasion marks a major antigenic shift in SARS-CoV-2. Broadly neutralizing monoclonal antibodies that recognize RBD epitopes that are conserved among SARS-CoV-2 variants and other sarbecoviruses may prove key to controlling the ongoing pandemic and future zoonotic spillovers.

Broadly neutralizing antibodies overcome SARS-CoV-2 Omicron antigenic shift

The recently emerged SARS-CoV-2 Omicron variant harbors 37 amino acid substitutions in the spike (S) protein, 15 of which are in the receptor-binding domain (RBD), thereby raising concerns about the effectiveness of available vaccines and antibody therapeutics. Here, we show that the Omicron RBD binds to human ACE2 with enhanced affinity relative to the Wuhan-Hu-1 RBD and acquires binding to mouse ACE2. Severe reductions of plasma neutralizing activity were observed against Omicron compared to the ancestral pseudovirus for vaccinated and convalescent individuals. Most (26 out of 29) receptor-binding motif (RBM)-directed monoclonal antibodies (mAbs) lost in vitro neutralizing activity against Omicron, with only three mAbs, including the ACE2-mimicking S2K146 mAb ¹ , retaining unaltered potency. Furthermore, a fraction of broadly neutralizing sarbecovirus mAbs recognizing antigenic sites outside the RBM, including sotrovimab ² , S2X259 ³ and S2H97 ⁴ , neutralized Omicron. The magnitude of Omicron-mediated immune evasion and the acquisition of binding to mouse ACE2 mark a major SARS-CoV-2 mutational shift. Broadly neutralizing sarbecovirus mAbs recognizing epitopes conserved among SARS-CoV-2 variants and other sarbecoviruses may prove key to controlling the ongoing pandemic and future zoonotic spillovers.

Anti-SARS-CoV-2 Immunoglobulin Isotypes, and Neutralization Activity Against Viral Variants, According to BNT162b2-Vaccination and Infection History

Purpose

To compare SARS-CoV-2 antigen-specific antibody production and plasma neutralizing capacity against B.1 wild-type-like strain, and Gamma/P.1 and Delta/B.1.617.2 variants-of-concern, in subjects with different Covid-19 disease and vaccination histories.

Methods

Adult subjects were: 1) Unvaccinated/hospitalized for Covid-19; 2) Covid-19-recovered followed by one BNT162b2 vaccine dose; and 3) Covid-19-naïve/2-dose BNT162b2 vaccinated. Multiplex Luminex® immunoassays measured IgG, IgA, and IgM plasma levels against SARS-CoV-2 receptor-binding domain (RBD), spike-1 (S), and nucleocapsid proteins. Neutralizing activity was determined in Vero E6 cytopathic assays.

Results

Maximum anti-RBD IgG levels were similar in Covid-19‑recovered individuals 8‒10 days after single-dose vaccination and in Covid-19-naïve subjects 7 days after 2nd vaccine dosing; both groups had ≈2‑fold higher anti-RBD IgG levels than Unvaccinated/Covid-19 subjects tracked through 2 weeks post-symptom onset. Anti-S IgG expression patterns were similar to RBD within each group, but with lower signal strengths. Viral antigen-specific IgA and IgM levels were more variable than IgG patterns. Anti-nucleocapsid immunoglobulins were not detected in Covid-19-naïve subjects. Neutralizing activity against the B.1 strain, and Gamma/P.1 and Delta/B.1.617.2 variants, was highest in Covid‑19-recovered/single-dose vaccinated subjects; although neutralization against the Delta variant in this group was only 26% compared to B.1 neutralization, absolute anti-Delta titers suggested maintained protection. Neutralizing titers against the Gamma and Delta variants were 33‒77% and 26‒67%, respectively, versus neutralization against the B.1 strain (100%) in the three groups.

Conclusion

These findings support SARS-CoV-2 mRNA vaccine usefulness regardless of Covid-19 history, and confirm remarkable protection provided by a single vaccine dose in people who have recovered from Covid-19.

PD-1 blockade counteracts post-COVID-19 immune abnormalities and stimulates the anti-SARS-CoV-2 immune response

A substantial proportion of patients who have recovered from coronavirus disease-2019 (COVID-19) experience COVID-19–related symptoms even months after hospital discharge. We extensively immunologically characterized patients who recovered from COVID-19. In these patients, T cells were exhausted, with increased PD-1⁺ T cells, as compared with healthy controls. Plasma levels of IL-1β, IL-1RA, and IL-8, among others, were also increased in patients who recovered from COVID-19. This altered immunophenotype was mirrored by a reduced ex vivo T cell response to both nonspecific and specific stimulation, revealing a dysfunctional status of T cells, including a poor response to SARS-CoV-2 antigens. Altered levels of plasma soluble PD-L1, as well as of PD1 promoter methylation and PD1-targeting miR–15-5p, in CD8⁺ T cells were also observed, suggesting abnormal function of the PD-1/PD-L1 immune checkpoint axis. Notably, ex vivo blockade of PD-1 nearly normalized the aforementioned immunophenotype and restored T cell function, reverting the observed post–COVID-19 immune abnormalities; indeed, we also noted an increased T cell–mediated response to SARS-CoV-2 peptides. Finally, in a neutralization assay, PD-1 blockade did not alter the ability of T cells to neutralize SARS-CoV-2 spike pseudotyped lentivirus infection. Immune checkpoint blockade ameliorates post–COVID-19 immune abnormalities and stimulates an anti–SARS-CoV-2 immune response.

Acute Posterior Ocular Toxoplasmosis: An Optical Coherence Tomography Angiography and Dye Angiography Study

PURPOSE

To compare Indocyanine Green (ICGA) and fundus fluorescein angiography (FFA) with Optical Coherence Tomography Angiography (OCTA) findings in toxoplasmic chorioretinitis (TCR).

METHODS

Patients affected by active TCR were included. FFA, ICGA, and OCTA images were analyzed and lesions were compared between different modalities. Satellite dark dots (SDD) were compared between modalities.

RESULTS

Fifteen patients were enrolled. The mean lesion area was similar between fundus photography (FP), FFA, and OCTA-Retina. The mean lesion area was similar between ICGA and OCTA-Choroid slab. ICGA and OCTA-Choroid showed a larger extension of the lesion compared to FP, FFA, and OCTA-Retina (p = .01, 0.0001, and 0.0002 for ICG angiography and p = .03, 0.008, and 0.0002 for OCTA-Choroid, respectively). On OCTA B-scans, the retinal flow defects were smaller than the underlying choroidal non-perfusion. The number of SDD was similar between ICGA and OCTA.

CONCLUSIONS

OCTA is a reliable method to assess retinal and choroidal involvement in TCR. OCTA confirmed a wider involvement of the choroid than the retina.

Broad betacoronavirus neutralization by a stem helix-specific human antibody

The spillovers of betacoronaviruses in humans and the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants highlight the need for broad coronavirus countermeasures. We describe five monoclonal antibodies (mAbs) cross-reacting with the stem helix of multiple betacoronavirus spike glycoproteins isolated from COVID-19 convalescent individuals. Using structural and functional studies, we show that the mAb with the greatest breadth (S2P6) neutralizes pseudotyped viruses from three different subgenera through the inhibition of membrane fusion, and we delineate the molecular basis for its cross-reactivity. S2P6 reduces viral burden in hamsters challenged with SARS-CoV-2 through viral neutralization and Fc-mediated effector functions. Stem helix antibodies are rare, oftentimes of narrow specificity, and can acquire neutralization breadth through somatic mutations. These data provide a framework for structure-guided design of pan-betacoronavirus vaccines eliciting broad protection.

Anti-tumour necrosis factor α antibodies and circulating lymphocyte phenotypes in inflammatory bowel disease

OBJECTIVE

Circulating lymphocyte subtypes are not fully explored parameters for monitoring chronic T cell activation during inflammatory bowel disease (IBD). Tumor necrosis factor α (TNFα), one of the main mediators of IBD related inflammation induces expression of CD70 on T cells. CD70 limits T cell expansion and controls CD27 receptor on activated B lymphocytes. Aim of this study was to assess the number and the frequency of CD70+ T cells and CD27+ B cells in IBD patients during inactive phase of the disease under or without anti-TNFα treatment.

DESIGN

We studied 91 patients with inactive IBD, 31 untreated, 29 treated with infliximab (IFX), and 31 treated with adalimumab (ADA). Lymphocyte phenotypes were assessed by flow cytometry using anti-CD45, CD19, CD27, CD3, and CD70 monoclonal antibodies. IFX and ADA actual capacity of TNFα neutralization in serum was estimated by the recoveryELISA technique.

RESULTS

Whereas CD3+ T cells were increased in treated compared to untreated patients, the percentage of the CD70+ T cells was significantly lower in treated patients indicating a 'cooling' effect of the biological therapy. This effect differs between samples according to the therapeutic range of the circulating drug. Although the CD19+ B-cell percentage tended to be lower in treated patients, CD19+27+ memory B cells did not show significant differences between groups.

CONCLUSIONS

Frequency of peripheral blood CD70+ T cells was significantly reduced by treatment with anti-TNFα antibodies. Monitoring of this parameter of T cells can give better insight to the disease progression and therapy application in IBD patients.

P–401 Frozen-thawed embryo-transfer adjuvant therapy: one size DOES NOT fit all

Study question

Does adjuvant therapy after frozen-thawed embryo-transfer (FRET) with CardioAspirin and Prednisone enhance clinical pregnancy rate (CPR) and live birth rate (LBR)?

Summary answer

Adjuvant therapy enhanced CPR and LBR in study-group. A significant correlation was found confronting blastocyst FRET in study-group versus controls.

What is known already

Embryo implantation is a rate-limiting step of FRET cycles. It’s a complex process resulting from a balance between inflammation pathways and maternal immune tolerance. Low-dose aspirin unlocks Prostaglandin-F2 synthesis by Cyclooxygenase–1, thus increasing uterine vascular permeability and attachment reaction while reducing vasoconstriction. Pregnancy results from a balance between helper and regulatory T-cells (Treg), the latter protect the embryo from maternal immune attack. Treg cells’ immunosuppressive function is pivotal in pregnancy establishment. Prednisone increases the proportion of Treg cells thus inhibiting inflammation. Many therapy schedules for implantation enhancement are currently used worldwide, although there is no consistent shared evidence.

Study design, size, duration

Retrospective cohort-control study including 237 subjects who underwent FRET after artificial endometrial-preparation from January 2018 to March 2020. Estrogenic stimulation was either oral or transdermic. The study-group received luteal support (vaginal Progesterone 600 mg/die) and adjuvant therapy (CardioAspirin and Prednisone 25–5 mg); the control-group received luteal support only. Pregnancy test (PT) was scheduled 10–14 days post-transfer (blastocysts or cleavage stage embryos). Second PT and ultrasound were performed 7 days later if the first was positive.

Participants/materials, setting, methods

Patients referred to Padua University Hospital’s Human Reproduction Pathophysiology Unit. Exclusion criteria: &gt;50/&lt;18 years, fresh embryo-transfer cycles, oocyte-thawing cycles, natural/natural-modified cycles. Male factor was the prevalent fertility issue. Single embryo-transfer was performed in both groups. Mean endometrial thickness was 9 mm trilaminar in both groups. Statistical analysis were carried out using JMP Pro 14 software. Categorical variables were analyzed using Chi-square test or Fisher’s exact test where appropriate.

Main results and the role of chance

In the study-group, 87 subjects were given luteal support and adjuvant therapy, while in the control-group, 150 subjects received luteal support only. Groups were homogeneous for age, number of embryos transferred, endometrial thickness, endometrial features (trilaminarity) and fertilization tecniques (108 IVF/ 127 ICSI). CPR and LBR were significantly higher in the study-group. CPR was 31.4% in study-group versus 14.8% in controls (p = 0.002), LBR was 27.4% in study-group versus 11.6% in controls (p = 0.002). Since heterogeneity between groups was found regarding the type of embryo transferred (55.3% cleavage-stage versus 44.7% blastocyst, p &lt; 0.01), the groups were split analyzed basing upon the type if embryo transferred. In the cleavage-stage FRET condition no relevant correlation was found between groups. However in blastocyst-FRET group CPR (34.5% study-group versus 18% controls, p = 0.04) and LBR (30.9% study-group versus 12% controls, p = 0.017) were significantly higher in the study-group, thus showing that adjuvant therapy could improve CPR and LBR.

Limitations, reasons for caution

Limited sample size negatively impacts the study’s power. It would be appropriate to expand the sample to obtain more reliable results.

Wider implications of the findings: Although no unanimous consent exists for tout-court adjuvant therapy administration, scientific literature shows that such therapy can help patients with repeated implantation failures or anti-nuclear-antibodies positivity. Assuming that a single-therapy-regimen could perfectly fit all patients is not realistic. We have to move towards patient-tailored adjuvant therapy thinking.

Trial registration number

Not applicable

O-140 Uterine septum: clinical implications on fertility and obstterics outcomes. A systematic review and meta-analysis

Study question

How does the septate uterus and his metroplasty influence pregnancy rate (PR), live birth rate (LBR), spontaneous abortion rates (SA) and preterm labour rates (PL)?

Summary answer

Uterine septum is associated with a poor reproductive outcome. Metroplasty reduce the rate of SA but non-conclusive evidence can be extrapolated about PR and PL.

What is known already

Different studies evaluated the correlation between uterine septum and reproductive outcomes. On one hand, studies reported its association with poor obstetrics outcomes. On the other hand, recent studies raised doubts about the effectiveness of septum metroplasty to improve reproductive outcomes, although recent position papers continue to propose metroplasty in patients with a septate uterus and a history of infertility or miscarriages. Debate is still ongoing on reproductive outcomes of uterine septum on infertile patients and especially on patients with recurrent miscarriage, leading to an unanswered question whether or not these women should be treated.

Study design, size, duration

Systematic review and meta-analysis of published studies that evaluated the clinical impact of uterine septum and its metroplasty on reproductive and obstetrics outcomes. The meta-analysis included study with infertile patients or patients with a history of recurrent miscarriage.

Searches were conducted using the following search terms: uterine septum, septate uterus, metroplasty, pregnancy rate, live birth rate, spontaneous miscarriage, infertility, preterm delivery. Primary outcomes were PR and LBR. Secondary outcomes were SA and PL.

Participants/materials, setting, methods

The meta-analysis was written following the PRISMA guidelines. Fifty-nine full-text articles were preselected based on title and abstract. Endpoints were evaluated in three subgroups: 1) infertile/recurrent miscarriage patients with septum versus no septum 2) infertile/recurrent miscarriage patients with treated versus untreated septum 3) infertile/recurrent miscarriage patients before-after septum removal. Odds-ratios (OR) with 95% confidence intervals (CI) were calculated for outcome measures. Random-effect meta-analysis was performed and a p-value less than 0.05 was considered statistically significant.

Main results and the role of chance

Data from 37 articles were extracted. In the first subgroup (10 studies), a lower PR and LBR were associated with septate uterus vs. controls, respectively (OR 0.39, 95% CI 0.26 to 0.58; p &lt; 0.000; low-heterogeneity and OR 0.21, 95% CI 0.12 to 0.39; p &lt; 0.0001; small-heterogeneity) and a higher proportion of SA and PL was associated with septate uterus vs. controls, respectively (OR 4.17, 95% CI 2.83 to 6.15; p &lt; 0.000; moderate-heterogeneity and OR 2.18, 95% CI 1.27 to 3.76; p = 0.005; low-heterogeneity). In the second subgroup (8 studies), PR and PL were not different in removed vs. unremoved septum, respectively (OR 1.10, 95% CI 0.49 to 2.49; p = 0.82; moderate heterogeneity and OR 0.44, 95% CI 0.18 to 1.08; p = 0.08;low-heterogeneity) and a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.40, 95% CI 0.17 to 0.95; p = 0.001; substantial-heterogeneity). In the third subgroup (19 studies), the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93 to 82.13; p &lt; 0.0001; moderate-heterogeneity) and the proportion of SA and PL was lower after the removal of septum, respectively (OR 0.02, 95% CI 0.02 to 0.04; p &lt; 0.000; moderate-heterogeneity and OR 0.05, 95% CI 0.03 to 0.08; p = &lt;0.000; low-heterogeneity).

Limitations, reasons for caution

The present meta-analysis is limited by the observational design of included studies because, in literature, there are no prospective randomized controlled trials (RCTs). In the second and third subgroup of analysis clinical heterogeneity within and between studies represents another limitation.

Wider implications of the findings

The results of this meta-analysis confirm the detrimental effect of uterine septum on PR, LBR, SA and PL. Its treatment seems to reduce the rate of SA. Metroplasty should still be considered as good clinical practice in patients with a history of infertility and recurrent abortion.

Trial registration number

Not applicable

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.

P–680 Thyroid function in euthyroid women during controlled ovarian stimulation (COH): does the TSH fluctuations have an impact on IVF outcomes?

Study question

TSH blood levels play a role in terms of ovarian stimulation and pregnancy? Do we need to treat patients with TSH out of range?

Summary answer

Euthyroid patients with negative autoantibodies during COS should not be treated even if basal TSH is higher than 2.5 U/L

What is known already

Abnormal thyroid function is associated with adverse pregnancy outcomes, being essential during embryo implantation and early pregnancy. TSH receptors can be found in endometrial and ovarian tissues and during controlled ovarian stimulation TSH levels suffer modifications because of hyperestrogenemia. Subclinical hypothyroidism is defined as a TSH level greater than 4.5 mIU/L with normal FT4 levels. It is controversial whether or not to use first-trimester pregnancy and infertility thresholds for upper limit of 2.5 mIU/L TSH. However, neither American Thyroid Association nor the American Society Reproductive Medicine recommendations have clearly defined how infertile patients need to be treated.

Study design, size, duration

Between April 2016 and December 2019, we performed a retrospective observational study at the University Hospital of Padua, including patients who underwent IVF/ICSI treatments. We included patients with idiopathic or tubal infertility or with poor ovarian reserve, in presence of basal TSH≤ 4,5 U/L and negative anti-TPO Ab and anti-Tg Ab. Exclusion criteria were severe male factor, TSH&lt;0,2 or &gt; 4,5 U/L, BMI higher than 30, oncologic patients, uterine disease.

Participants/materials, setting, methods

We enrolled a total of 389 patients. We checked TSH blood levels on the day before starting stimulation (T0). We divided our patients according to TSH level &lt; 2,5U/L (group A) or ≥ 2,5U/L (group B). We then checked TSH on the day of hCG trigger (ThCG). Delta TSH (ThCG-T0) was calculated and correlated to endometrial thickness, number of occytes retrieved, embryos obtained and frozen, Clinical Pregnancy Rate (CPR) and Live Birth Rate (LBR).

Main results and the role of chance

Group A (251) and group B (138) were homogeneous for age, body mass index, AMH levels, antral follicular count. Short ovarian stimulation cycle with GnRH antagonist and long cycle with GnRH agonist proportions were similar in both groups. Also, FSH recombinant and hMG gonadotropin use and total amount were similar for the two groups. No statistically significant difference was found between the groups in terms of endometrial thickness, follicles greater than 14 mm as medium diameter, number of oocytes retrieved, number of mature oocytes (MII), embryos obtained, number of embryos cryopreserved, CPR and LBR. However, when considering the Delta TSH, we found possible correlations in group A. In particular, the number of oocytes retrieved was higher in Delta TSH positive (3.4±2.2) rather than in Delta negative women (2.6±1.7) with a p value of 0.002. Moreover, mature oocytes (MII) were retrieved more frequently in Delta TSH positive (5.7±3.8) rather than in Delta negative women (4.5±3) with a p value of 0.008. Group B Delta TSH did not show any possible statistically significant correlations.

Limitations, reasons for caution

This is a retrospective study and results must be confirmed on a well-designed randomized controlled study. Moreover, since we use strict eligibility criteria, we enrolled few patients. Correlations must be considered with caution since the role of TSH is under study, especially when considering LBR outcome.

Wider implications of the findings: Our results are congruent with previous studies. In particular, we suggest not to treat patients with TSH levels on range (between 0.2mIU/L and 4.5 mIU/L). TSH increase during COS in euthyroid patients could be interpreted as a positive physiological response and it is associate with better COS outcomes.

Trial registration number

N/A

H3K4me3 Histone ChIP-Seq Analysis Reveals Molecular Mechanisms Responsible for Neutrophil Dysfunction in HIV-Infected Individuals

Peripheral neutrophils in HIV-infected individuals are characterized by impairment of chemotaxis, phagocytosis, bactericidal activity, and oxidative burst ability regardless of whether patients are receiving antiretroviral therapy or not. Neutrophil dysfunction leads not only to increased susceptibility to opportunistic infections but also to tissue damage through the release of reactive oxygen species (ROS), proteases, and other potentially harmful effector molecules contributing to AIDS progression. In this study, we demonstrated high levels of histone H3 lysine K4 trimethylated (H3K4me3) and dysregulation of DNA transcription in circulating neutrophils of HIV-infected subjects. This dysregulation was accompanied by a deficient response of neutrophils to LPS, impaired cytokine/chemokine/growth factor synthesis, and increased apoptosis. Chromatin immunoprecipitation sequencing (ChIPseq) H3K4me3 histone analysis revealed that the most spectacular abnormalities were observed in the exons, introns, and promoter-TSS regions. Bioinformatic analysis of Gene Ontology, including biological processes, molecular function, and cellular components, demonstrated that the main changes were related to the genes responsible for cell activation, cytokine production, adhesive molecule expression, histone remodeling via upregulation of methyltransferase process, and downregulation of NF-κB transcription factor in canonical pathways. Abnormalities within H3K4me3 implicated LPS-mediated NF-κB canonical activation pathway that was a result of low amounts of κB DNA sites within histone H3K4me3, low NF-κB (p65 RelA) and TLR4 mRNA expression, and reduced free NF-κB (p65 RelA) accumulation in the nucleus. Genome-wide survey of H3K4me3 provided evidence that chromatin modifications lead to an impairment within the canonical NF-κB cell activation pathway causing the neutrophil dysfunction observed in HIV-infected individuals.

Impact of the COVID-19 pandemic in the MR availability for iron overloaded patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The E-MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and Bayer).

Background

The T2* magnetic resonance imaging (MRI) technique for the noninvasive quantification of iron overload has significantly improved the survival of patients with hemoglobinopathies by tailoring the chelation therapy. In Italy, the E-MIOT (Extension-Myocardial Iron Overload in Thalassemia) Network, a collaborative project among MRI and hematological centers, has assured high-quality quantification of iron in vital organs such as heart, liver, and pancreas. The COVID-19 pandemic has disrupted healthcare services around the world, also leading to postpone  or delete deferable diagnostic evaluations.

Aim

  We evaluated the impact of the COVID-19 pandemic on MRI services for iron overload quantification in Italy.

Methods

The activity of the MRI centers of the E-MIOT Network in the year 2020 was compared to the activity in the same months of 2019. A specific survey was filled out by the MRI operators to evaluate if the availability of MRI slots for patients with hemoglobinothies was reduced and the reasons.

Results

In comparison with the year 2019, in 2020 there was a significant reduction in the number of T2* MRIs performed (350 vs 656; P < 0.0001). The comparison month by month between the two years highlighted a marked decline (86.9%) in the four-month period March-June 2020, a reduction in the gap between the two years in the three-month period July-September, and a new decline (41.4%) in the three-month period October-December (Figure 1). No patient with hemoglobinopathy could undergo an MRI scan during the Italian lockdown (9 March-10 May 2020).

Figure 2 shows the percentage of  decline (year 2020 vs 2019) in the number of T2*MRI scans for each MRI center. If no decline or an increase were present, the vertical axis was set at 0. All centers experienced a significant drop in the number of the T2* MRIs in the four-month period March-June (from 75 to 100%). In the three-month period July-September only the centers of Pisa and Taranto dropped the number of T2* MRIs due to the rescheduling of the other MRI appointments deleted during the lockdown. In the three-month period October-December a reduction of the T2* MRI scans was experienced by all centers, except for Campobasso. In the centers of Ferrara and Lamezia Terme the reduction was the consequence of the general reduction in the number of the total MRIs scheduled per day for the  sanitation procedures. In the other centers, the availability for T2* MRI scans was unchanged in comparison to 2019, but the patients refused the MRI follow up for fear of getting sick of COVID.

Conclusion

The COVID-19 pandemic is having a strong negative impact on the quantification of iron overload by MRI, which may seriously worsen the prognosis of patients with hemoglobinopathies. Strategies to ensure proved lifesaving MRI exam and to reassure patients about the health safety of the hospitals are recommended.

Normal CMR bi-atrial and biventricular reference values in sickle cell disease patients without heart damage

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A., ApoPharma Inc.).

Background. Cardiac function indices in patients with hemoglobinopathies are different from those in healthy population, mainly due to chronic anemia. Normal reference values specific for SCD patients are not available by CMR.

Aim. We aimed to define the normal cut-off value in SCD patients for bi-atrial and biventricular cardiac magnetic resonance (CMR) parameters.

Methods. We considered forty-eight adult SCD patients with no known risk factors or cardiac disease, normal electrocardiogram, no macroscopic myocardial fibrosis, and all cardiac segments with T2*≥20 ms, consecutively enrolled in the MIOT network (Myocardial iron overload in thalassemia). SCD patients were compared with ninety-six healthy controls and 96 thalassemia major (TM) patients without cardiac damage, both matched for age and gender. Nine pediatric SCD patients were also analysed in comparison with 9 TM patients and 9 healthy subjects matched for age and gender. Cine images were acquired to quantify biventricular function parameters: LV and RV end-diastolic volume (EDV), end-systolic volume (ESV) and stroke volume (SV) were normalized for body surface area (EDVI, ESVI, SVI), as well as biventricular mass and atrial areas. Myocardial iron overload was assessed by segmental T2* technique. Late gadolinium enhancement (LGE) images were acquired for evaluation of macroscopic myocardial fibrosis.

Results. In all three groups males showed higher biventricular volumes and mass indexes than females. SCD male patients had significantly higher LVEDVI (p &lt; 0.0001), LVESVI (p = 0.010), LVSVI (p = 0.003), cardiac index (p = 0.002), LV and RV mass index  (p = 0.008 and p = 0.001, respectively) and left and right atrial areas (p &lt; 0.001 and p = 0.011) than healthy subjects. No significant differences were found in RVEDVI, EVESVI and biventricular EF. Compared to healthy volunteers, females with SCD showed a larger LVEDVI (p = 0.020), LVSVI (p = 0.039), RV mass index (p = 0.002) and left atrial area (p = 0.008).

SCD and TM patients showed comparable values of bi-atrial and biventricular volumes and function. When compared to TM, SCD patients showed a larger LV (p &lt; 0.001) and RV mass index (p = 0.001) in male group and a larger RV mass index (p = 0.001) in female group. Table 1 shows the cut-offs for bi-atrial and biventricular MR parameters for adult SCD patients by gender.

No significant differences in MR parameters were found among the pediatric groups.

Conclusions. Normal reference ranges of bi-atrial and biventricular MR parameters for adult males and females SCD patients were established. The use of these reference values will prevent possible misdiagnosis of cardiomyopathy in patients with SCD.

4D Flow analysis of intracavitary blood flow dynamics and energetics in the systemic right ventricle

Funding Acknowledgements

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

Background

The systemic position of a morphologically right ventricle (SRV) makes it vulnerable to fail, leading to high incidence of heart failure and cardiac death [1]. Understanding SRV intracavitary blood flow dynamics and energetics could improve patient risk stratification.

Purpose

Testing the potential of three-dimensional time-resolved phase contrast cardiac magnetic resonance (4D Flow) in quantifying SRV blood flow dynamics and energetics.

Methods

4D Flow prototype sequences were acquired on 3 patients (1 male, 2 females) with SRV in D-loop transposition of great arteries after atrial switch operation (D-TGA/ASO), 3 male patients with SRV in L-loop TGA (L-TGA) and healthy controls (2 males, 1 female).

Kinetic energy (KE), viscous energy loss (EL), dissipation index (DI) calculated as EL to KE ratio, and hemodynamics forces (HFs) resulting from pressure gradients, were computed for the D-TGA/ASO and L-TGA SRVs, and for the control left ventricles (LVs) and right ventricles (RVs). HFs were decomposed in inferior-anterior, septal-lateral and basal-apical components (HFIA, HFSL, HFBA, respectively)

Results

Figure 1 reports the time-course of HF components and the general features of the enrolled subjects.

In systole, all SRVs (Figure 1a-1b) presented a dominant HFIA and a minor HFSL, similarly to RVs (Figure 1c); however, HFSL had a positive peak, indicating septal contraction towards the SRV cavity, opposite to its normal motion. HFBA magnitude was similar to LVs (Figure 1d), suggesting that the shortening of the tricuspid anulus towards the apex is more pronounced than in RVs (Figure 1c).

Over the whole cardiac cycle, DI values were highest in D-TGA/ASO SVRs (0.40-0.55); in L-TGA SRVs, DI values (0.24-0.45) were comparable to healthy LVs (0.22-0.37) and RVs (0.23-0.36). This difference may be related to the fact that in DTGA/ASO the left atrium is functionally replaced by a pulmonary venous baffle, which lacks efficient contraction, as highlighted by the absence of a distinctive A-wave in the KE time-course (Figure 2a).

Due to the adaptation to systemic afterload, SRVs were hypertrophic (Figure 1a-1b), with indexed mass higher than normal RVs (Figure 1c), and presented reduced compliance to the diastolic filling, as suggested by increased KE E-wave slope in L-TGA (Figure 2b) compared to controls (Figure 2c-2d).

Conclusions

Intracavitary HFs in SRVs reveal a partial shift from a RV towards LV pattern. This occurs at the expenses of a higher energetic consumption in D-TGA/ASO than L-TGA, enlightening the crucial role of atrial contribution to impaired SRV diastolic filling. These findings corroborate the previous evidence that patients with D-TGA/ASO have abnormal decrease in stroke volume during exercise whereas L-TGA patients can reach values comparably to healthy controls [2].

Acute and long-term disruption of glycometabolic control after SARS-CoV-2 infection

Patients with coronavirus disease 2019 (COVID-19) are reported to have a greater prevalence of hyperglycaemia. Cytokine release as a consequence of severe acute respiratory syndrome coronavirus 2 infection may precipitate the onset of metabolic alterations by affecting glucose homeostasis. Here we describe abnormalities in glycometabolic control, insulin resistance and beta cell function in patients with COVID-19 without any pre-existing history or diagnosis of diabetes, and document glycaemic abnormalities in recovered patients 2 months after onset of disease. In a cohort of 551 patients hospitalized for COVID-19 in Italy, we found that 46% of patients were hyperglycaemic, whereas 27% were normoglycaemic. Using clinical assays and continuous glucose monitoring in a subset of patients, we detected altered glycometabolic control, with insulin resistance and an abnormal cytokine profile, even in normoglycaemic patients. Glycaemic abnormalities can be detected for at least 2 months in patients who recovered from COVID-19. Our data demonstrate that COVID-19 is associated with aberrant glycometabolic control, which can persist even after recovery, suggesting that further investigation of metabolic abnormalities in the context of long COVID is warranted.

Sensitivity of SARS-CoV-2 B.1.1.7 to mRNA vaccine-elicited antibodies

Transmission of SARS-CoV-2 is uncontrolled in many parts of the world; control is compounded in some areas by the higher transmission potential of the B.1.1.7 variant1, which has now been reported in 94 countries. It is unclear whether the response of the virus to vaccines against SARS-CoV-2 on the basis of the prototypic strain will be affected by the mutations found in B.1.1.7. Here we assess the immune responses of individuals after vaccination with the mRNA-based vaccine BNT162b22. We measured neutralizing antibody responses after the first and second immunizations using pseudoviruses that expressed the wild-type spike protein or a mutated spike protein that contained the eight amino acid changes found in the B.1.1.7 variant. The sera from individuals who received the vaccine exhibited a broad range of neutralizing titres against the wild-type pseudoviruses that were modestly reduced against the B.1.1.7 variant. This reduction was also evident in sera from some patients who had recovered from COVID-19. Decreased neutralization of the B.1.1.7 variant was also observed for monoclonal antibodies that target the N-terminal domain (9 out of 10) and the receptor-binding motif (5 out of 31), but not for monoclonal antibodies that recognize the receptor-binding domain that bind outside the receptor-binding motif. Introduction of the mutation that encodes the E484K substitution in the B.1.1.7 background to reflect a newly emerged variant of concern (VOC 202102/02) led to a more-substantial loss of neutralizing activity by vaccine-elicited antibodies and monoclonal antibodies (19 out of 31) compared with the loss of neutralizing activity conferred by the mutations in B.1.1.7 alone. The emergence of the E484K substitution in a B.1.1.7 background represents a threat to the efficacy of the BNT162b2 vaccine.

N-terminal domain antigenic mapping reveals a site of vulnerability for SARS-CoV-2

The SARS-CoV-2 spike (S) glycoprotein contains an immunodominant receptor-binding domain (RBD) targeted by most neutralizing antibodies (Abs) in COVID-19 patient plasma. Little is known about neutralizing Abs binding to epitopes outside the RBD and their contribution to protection. Here, we describe 41 human monoclonal Abs (mAbs) derived from memory B cells, which recognize the SARS-CoV-2 S N-terminal domain (NTD) and show that a subset of them neutralize SARS-CoV-2 ultrapotently. We define an antigenic map of the SARS-CoV-2 NTD and identify a supersite (designated site i) recognized by all known NTD-specific neutralizing mAbs. These mAbs inhibit cell-to-cell fusion, activate effector functions, and protect Syrian hamsters from SARS-CoV-2 challenge, albeit selecting escape mutants in some animals. Indeed, several SARS-CoV-2 variants, including the B.1.1.7, B.1.351, and P.1 lineages, harbor frequent mutations within the NTD supersite, suggesting ongoing selective pressure and the importance of NTD-specific neutralizing mAbs for protective immunity and vaccine design.

How to Manage COVID-19 Vaccination in Immune-Mediated Inflammatory Diseases: An Expert Opinion by IMIDs Study Group

Since March 2020, the outbreak of Sars-CoV-2 pandemic has changed medical practice and daily routine around the world. Huge efforts from pharmacological industries have led to the development of COVID-19 vaccines. In particular two mRNA vaccines, namely the BNT162b2 (Pfizer-BioNTech) and the mRNA-1273 (Moderna), and a viral-vectored vaccine, i.e. ChAdOx1 nCoV-19 (AstraZeneca), have recently been approved in Europe. Clinical trials on these vaccines have been published on the general population showing a high efficacy with minor adverse events. However, specific data about the efficacy and safety of these vaccines in patients with immune-mediated inflammatory diseases (IMIDs) are still lacking. Moreover, the limited availability of these vaccines requires prioritizing some vulnerable categories of patients compared to others. In this position paper, we propose the point of view about the management of COVID-19 vaccination from Italian experts on IMIDs and the identification of high-risk groups according to the different diseases and their chronic therapy.

Hyaluronic acid in vulvar and vaginal administration: evidence from a literature systematic review

Vulvovaginal pathology impairs the quality of life of both women in menopause and those who are not. Different therapies have been proposed, mainly related to estrogen therapy in postmenopausal women. However, some contraindications limit its use, and different moisturizers or lubricants have been tested. Hyaluronic acid is a promising and widely used vaginal medical treatment with a moisturizing action and appears to provide a solution. For this reason, we performed a systematic review of the literature. We searched for original articles without date restriction until 30 April 2020. We included all clinical trials which administered local hyaluronic acid in the vulva or vagina. Only English studies and those performed in humans were eligible. Seventeen original studies were included in the review (from randomized controlled trials to longitudinal studies). Hyaluronic acid was generally found to be effective in improving vulvovaginal symptoms (dyspareunia, itching, burning, dryness) and signs (bleeding, atrophy, vaginal pH). In conclusion, hyaluronic acid has the properties to be an efficient moisturizer for women suffering from vulvovaginal atrophy who have contraindications for estrogen therapy and for vulvovaginal signs and symptoms affecting sexual well-being. However, a well-designed randomized controlled trial is needed in order to clarify its efficacy and safety profile.