Molecular phylogenetic analysis of Echinococcus granulosus sensu lato infecting sheep in Italy

Cystic Echinococcosis (CE), caused by the larval form of Echinococcus granulosus sensu lato, is a neglected zoonosis still threatening public health worldwide. In Italy different epidemiological scenarios were reported depending on the geographical area and associated socio-economic activities. Although in northern Italy the occurrence of E. granulosus is considered sporadic, in the southern regions and, particularly in Sardinia, CE prevalence reaches high levels. We analysed CE cysts collected from infected sheep from various areas of mainland Italy and the Sardinia island, with the main objective to investigate intergenotypic and intragenotypic variations at national level. CE cysts were collected from slaughtered sheep following post mortem inspection at local abattoirs. Total genomic DNA was extracted and amplification and sequencing of the partial mitochondrial genes nad5 and cox1 were performed. A Bayesian phylogenetic tree was estimated on a nad5 dataset (n = 260) composed of E. granulosus samples from this study (n = 126) and all the nad5 haplotypes available in GenBank (n = 134). In addition, haplotype network, diversity and neutrality analysis were performed on nad5 and cox1 sequences of Italian origin obtained in this study. E. granulosus sensu stricto (s.s.) was found to be the only Echinococcus species infecting sheep in Italy, mainly represented by G1 genotype (76 %) and, to a lower extent, by G3 genotype (24 %). Phylogenetic analyses revealed 40 nad5 and 33 cox 1 haplotypes, and the presence of two founder haplotypes, belonging to G1 and G3 genotype, showing 100 % similarity with DNA sequences from different geographic regions. The lack of geographical segregation, high haplotype and low nucleotide diversity coupled with significant negative values of Tajima's D and Fu's Fs observed in this study indicated high genetic variation and demographic expansion of E. granulosus s.s. in Italy.

Molecular Investigation of Theileria and Babesia Species in Domestic Mammals from Sardinia, Italy

Piroplasmoses are tick-borne diseases caused by hemoprotozoan parasites of veterinary and public health significance. This study focuses on the molecular identification and characterization of species belonging to the Theileria/Babesia genera in 152 blood samples, collected from 80 horses and 72 cattle from several farms in Sardinia, by targeting the 18S rRNA gene. The PCR results highlighted that 72% of the samples were positive for Theileria/Babesia spp., with a rate of infection of 68% and 75% for the horses and cattle, respectively. Sequencing and the BLASTn analysis showed that the 18S rRNA generated in this study has 99-100% homology with the B. bigemina, T. orientalis/sergenti/buffeli, T. equi and T. annulata strains isolated from different hosts worldwide. These findings improve the knowledge on Babesia and Theileria infections in domestic mammals and confirm the significant prevalence of piroplasmosis among subclinical and carrier animals throughout the island. Furthermore, the presence of T. annulata, reported for the first time in the study area, expands the repertoire of pathogens already detected in Sardinia. Our results gather updates on the diversity and distribution of piroplasms in Sardinia and suggest the need to develop procedures to improve animal and public health safety.

Real-World Treatment Patterns, Resource Use and Costs in Adult Patients With Atopic Dermatitis Receiving Systemic Treatment: Derma-Atopic Study in Spain

BACKGROUND

Moderate-severe atopic dermatitis (AD) has a significant impact on patients' lives, with many requiring systemic treatment to manage symptoms (e.g., pruritus). Several drugs are used off-label to treat AD. This study describes sociodemographic/clinical characteristics, treatment patterns, health resource use (HRU) and costs in adults with AD who initiated systemic treatment or phototherapy in routine practice.

METHODS

This retrospective observational study of electronic medical records in the BIG-PAC database identified adults with prior diagnosis of AD (ICD-9: 691.8 or 692.9) starting oral corticosteroids, immunosuppressants, biologics or phototherapy between 01/01/2012 and 31/12/2016. Patients were followed for 3 years from treatment initiation, up to 31/12/2019. Data on patient characteristics, treatment patterns, HRU and costs were analyzed descriptively.

RESULTS

Patients (N=1995) had a mean age of 60 years, 64% were female, with a mean time of 23 years since diagnosis (84% were ≥18 years at AD onset). Main comorbidities were anxiety (38%), arterial hypertension (36%) and dyslipidemia (35%). Most patients used oral corticosteroids as first systemic (84%; median duration 29 days) and immunosuppressants in 13% of patients (median duration 117 days, 5% cyclosporine and 4% methotrexate). Half of patients required a second line systemic and 12% a third line. The use of immunosuppressants and biologics increased with treatment lines. About 13% of patients received systemic treatments continuously over the 3-year follow-up. The average 3-year per patient cost was 3835 euros, with an average annual cost of 1278 euros.

CONCLUSIONS

Results suggest a high comorbidity and economic burden in this real-world adult population with AD, and the need for systemic treatments indicated for use in AD.

Real-World Treatment Patterns, Resource Use and Costs in Adult Patients With Atopic Dermatitis Receiving Systemic Treatment: Derma-Atopic Study in Spain

BACKGROUND

Moderate-severe atopic dermatitis (AD) has a significant impact on patients' lives, with many requiring systemic treatment to manage symptoms (e.g., pruritus). Several drugs are used off-label to treat AD. This study describes sociodemographic/clinical characteristics, treatment patterns, health resource use (HRU) and costs in adults with AD who initiated systemic treatment or phototherapy in routine practice.

METHODS

This retrospective observational study of electronic medical records in the BIG-PAC database identified adults with prior diagnosis of AD (ICD-9: 691.8 or 692.9) starting oral corticosteroids, immunosuppressants, biologics or phototherapy between 01/01/2012 and 31/12/2016. Patients were followed for 3 years from treatment initiation, up to 31/12/2019. Data on patient characteristics, treatment patterns, HRU and costs were analyzed descriptively.

RESULTS

Patients (N = 1995) had a mean age of 60 years, 64% were female, with a mean time of 23 years since diagnosis (84% were ≥18 years at AD onset). Main comorbidities were anxiety (38%), arterial hypertension (36%) and dyslipidemia (35%). Most patients used oral corticosteroids as first systemic (84%; median duration 29 days) and immunosuppressants in 13% of patients (median duration 117 days, 5% cyclosporine and 4% methotrexate). Half of patients required a second line systemic and 12% a third line. The use of immunosuppressants and biologics increased with treatment lines. About 13% of patients received systemic treatments continuously over the 3-year follow-up. The average 3-year per patient cost was 3835 euros, with an average annual cost of 1278 euros.

CONCLUSIONS

Results suggest a high comorbidity and economic burden in this real-world adult population with AD, and the need for systemic treatments indicated for use in AD.

A Chlamydia psittaci Outbreak in Psittacine Birds in Sardinia, Italy

Chlamydia psittaci is an intracellular bacterium belonging to the Chlamydiaceae family. It is the ethiologic agent of psittacosis, an occupational zoonotic disease that mainly concerns people who work in close contact with birds that represent the main infection route for human transmission. In Italy, information about this disease is lacking. This study is the first case of avian chlamydiosis reported from a pet shop in Sardinia, Italy. Chlamydia psittaci detected in psittacine birds by molecular analysis, direct immunofluorescence test together with anatomo-pathological observed lesions, highlighted the importance of focusing the attention over this underestimated zoonosis in a "One Health" prospective.

P313 TAKOTSUBO SYNDROME – FOCAL VARIANT

Takotsubo syndrome (TTS) is a cardiomyopathy induced by physical and/or emotional stress, characterised by transient changes of the regional motion generally extending beyond the territory distribution of one single coronary vessel. The classic form of TTS presents, in 43.7% of cases, with ST segment elevation and in about 80% with cardiac apical ballooning. In 1.5% of TTS cases, however, regional changes in motion are observed which may mimic an acute coronary syndrome. We describe the case of a 77–year–old woman with hypertension and hypercholesterolemia. The patient came to the ER due to polytrauma secondary to an accidental fall. During hospitalisation, the patient complained of a sudden onset of a retrosternal aching chest pain radiating to the back and right shoulder, associated with neurovegetative symptoms. An electrocardiogram showed a normofrequent sinus rhythm and T–negative waves in the infero–lateral region. Upon cardiology consultation, a transthoracic echocardiogram was performed showing a left ventricle with akinesia of the middle and apical segments of the inferolateral wall with compensatory hyperkinesis of the other segments. When an acute coronary syndrome was suspected, urgent coronary imaging was performed, showing coronary arteries without significant stenosis, while ventriculography confirmed the alterations in ventricular motion. Blood chemistry tests showed a phasic increase in myocardial necrosis enzymes and, in particular, in HS troponin values (max value 2714 ng/L). Therapy with an ace–inhibitor and a beta blocker was introduced; seriate echocardiographic controls showed a progressive normalisation of the alterations in motion. A TTS diagnosis was therefore made, according to InterTAK 2018 diagnostic criteria. This case is of particular interest as it is a prime example of a rare variant of TTS: the clinical presentation, the ECG alterations and the regional akinesia may lead to a clinical suspicion of ACS. A good knowledge of the TTS, including the focal variant, enables the cardiologist to make a correct diagnosis and to initiate suitable therapy.

P169 LEFT–DOMINANT ARRHYTHMOGENIC CARDIOMYOPATHY (LDAC)

Arrhythmogenic cardiomyopathy (ACM) is characterised by myocardial structural alterations with fibro–adipose replacement/infiltration, most frequently affecting the right ventricle. Malignant arrhythmias represent the most dangerous clinical manifestation.

We describe the case of a 38–year–old man who came to the Emergency Room of our hospital due to polytrauma. Following the unexpected ECG finding of signs of necrosis in the infero–lateral area and negative T waves in the antero–lateral area, a cardiological examination was performed. The patient, a smoker, had non–contributory family and personal history of cardiovascular diseases and sudden cardiac death. However, he reported several unspecified episodes of “absence seizures”. The transthoracic echocardiogram showed mild reduction in global left ventricular systolic function (EF 45–50%) due to regional changes in motion extending beyond the territory distribution of one single coronary vessel. Holter–ECG showed a Sustained Ventricular Tachycardia (SVT) symptomatic for syncope. A coronary angiography was therefore performed, which excluded any significant coronary stenosis and a cardiac MRI revealed the presence of fibro–adipose replacement of the left ventricle and, to a lesser extent, of the right side of the interventricular septum. Medical therapy with Bisoprolol, Ramipril, Spironolactone was initiated and an ICD was implanted as secondary prevention. No endomyocardial biopsy was carried out due to the high risk of the procedure; genetic testing proved to be negative. A diagnosis of borderline arrhythmogenic cardiomyopathy was therefore made. This case is of special interest as ACM with predominant left ventricular involvement (LDAC) is a rare cardiomyopathy. Diagnosis is made difficult by the presence of phenocopies and by the fact that the diagnostic criteria in use mostly focus on the forms with predominantly right–sided involvement. In the case of suspicious ECG changes, SVT or resuscitated cardiac death with imaging compatible with cardiomyopathy, it is important to raise the diagnostic suspicion of LDAC.

P178 TYPE–A AORTIC DISSECTION IN MARFANOID HABITUS

Aortic dissection (AD) is the tearing of the tunica intima of the aortic wall with creation of a false lumen. Type–A AD, in which the intimal flaps originates in the aortic tract proximal to the left subclavian artery, is a surgical emergency because – if left untreated – it has mortality rates as high as 1–2% every hour, from the onset of symptoms. Certain collagenopathies, such as Marfan Syndrome, are a predisposing condition for AD. We describe the case of a 25–year–old man with Marfanoid habitus who came to the Emergency Room of our facility, with acute pulmonary oedema. He had been complaining about thoraco–abdominal pain, bloody mucus and worsening dyspnoea since the week before. Upon cardiology consultation, a transthoracic echocardiogram showed an aneurysm of the aortic root (70 mm) and the ascending aorta (90 mm), with dissection flap extended beneath the aortic valvular plane, with torrential aortic valve insufficiency and eccentric jet, a left ventricle severely dilated and a severe systolic dysfunction (EF 25%). On urgent CT angiography the dissection flap was observed to extend cranially to the right common carotid artery and caudally to the renal arteries. The patient then underwent cardiac surgery to replace the aortic valve with a mechanical prosthesis and the ascending aorta as per the Bentall procedure and to replace the aortic arch with reimplantation and debranching of the supra–aortic trunks. Four months after discharge, the patient presented again due to sustained ventricular tachycardia (SVT) which was interrupted by electric cardioversion. On this occasion, an ICD implant was indicated as a secondary prevention measure. After one month, recurrence of SVT was observed, which was successfully treated by the implanted ICD, and therefore indication was given for an electrophysiologic study and subsequent transcatheter radiofrequency ablation of the ventricular arrhythmia. The case presented is of particular interest as it highlights the crucial role of a rapid echocardiographic assessment focussed on making a diagnosis and directing treatment, despite a misleading clinical picture due to duration and atypicality of symptoms. It should also be stressed that an overall assessment of the patient, based on habitus and age, plays a major role in establishing a suspected diagnosis and guiding the patient towards the most appropriate treatment.

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Skin Lesions in Neurofibromatosis Type 2: Diagnostic and Prognostic Significance of Cutaneous (Plexiform) Schwannomas

Background

Neurofibromatosis type 2 (NF2) is a genetic disease characterized by the appearance of multiple tumours in the nervous system. Cutaneous lesions are common and may provide useful diagnostic and prognostic information, but they have not been widely studied.

Objectives

To characterize cutaneous lesions in a Spanish cohort of patients with NF2 and investigate associations with clinical and genetic severity.

Methods

We studied the clinical and histologic characteristics of cutaneous lesions in 49 patients with NF2 and analysed correlations with phenotype‐ and genotype‐based severity scores. We collected information on the presence/absence of cutaneous lesions, location, age at onset, type of lesion, and histologic features. We also studied level of systemic involvement and genetic mutations involved.

Results

Forty‐nine patients (31 women [63.3%] and 18 men [36.7%]) were analysed, and 33 (67.3%) had cutaneous lesions presumed to be schwannomas. According to their clinical form, they were distributed as follows: 24 patients (48%) had deep tumours, 21 (42%) had plaque‐like lesions, and 3 (6%) had superficial tumours. Histologic examination from 27 lesions analysed out 23 patients showed classic schwannoma or hybrid schwannoma‐neurofibroma features in the 8 deep tumours biopsied and plexiform schwannoma features in the 17 plaque‐like lesions and the 2 superficial tumours analysed. Early onset (first 2 decades of life) was reported by all patients with plaques and superficial tumours. In our cohort, 100% of the patients with plaque‐like lesions and superficial tumours with microscopic features of plexiform schwannoma were in the 2 groups with the most severe clinical phenotypes, and 82.6% of them were in the 3 most severe genotype‐based classes.

Conclusions and Relevance

Cutaneous lesions, specially plexiform schwannomas, are common in NF2, and they usually appear at an early age providing useful diagnostic and prognostic information. These tumours are part of the spectrum of cutaneous manifestations in this disease. Although its diagnostic and prognostic value has been pointed out, there are few studies focussed on their analysis.

A Case of Prolonged Hospital Acquired COVID-19 Pneumonia in a Lung Transplant Recipient: Management and Outcome

Introduction

Lung transplant recipients are at increased risk of SARS-CoV2 infection due to immunosuppression and their management has yet to be standardized. We report a case of prolonged COVID-19 infection in a lung recipient acquired after transplant during the hospital stay.

Case Report

A 52-year-old lady with interstitial disease associated to systemic sclerosis underwent bilateral lung transplantation on 04/10/21. Donors and recipient microbiological tests for SARS-CoV2 were negative on molecular swabs performed before transplantation (04/07 and 04/10). Transplantation was uneventful and the recipient was extubated the subsequent day. Twelve days later, a surveillance molecular nose-pharyngeal swab was positive for SARS-CoV2. The positivity for subgenomic analysis revealed productive infection. At first monitoring biopsy, multiple foci of diffuse alveolar damage, significant cytopathic features of pneumocytes, microthrombi of capillaries, and extensive edema were highly suggestive of COVID-19 pneumonia. High viral load was also detected in lung biopsy by RT-PCR. She presented mild respiratory symptoms (cough with low oxygen supplementation) and the CT scan revealed an area of consolidation at the right lower lobe. Monoclonal antibody therapy (Bamlanivimab and Etesevimab) associated with remdesevir was started, IV immunoglobulins were administered while mycophenolate mofetil was discontinued. The patient was closely monitored until the nose-pharyngeal swab turned negative two months after the first positivity associated with a significant clinical improvement. At the last follow-up, five months after transplantation, she had good pulmonary function, no immunological disorders and no signs related to long COVID-19.

Summary

This is a case of prolonged hospital acquired COVID-19 related pneumonia in a lung recipient. Immunocompromized patients present a longer viral clearance. In this fragile population a strict clinical, radiological and histopathological monitoring associated with encouragement of vaccination are mandatory.

Microtubular Assessment of C6 Rat Glioma Cell Spheroids Developed in Transparent Liquid Marbles or Hanging Drops

Glioblastoma is a brain tumour frequently used as an experimental model to exploit innovative therapeutic approaches due to its high lethality and refractoriness to therapies. Part of these innovative anticancer therapies address cytoskeletal microtubules (MTs) since specific tubulin post-translational modifications (PTMs) are considered markers of tumour plasticity. In vitro studies, which traditionally employ two-dimensional (2D) culture systems, are now being replaced by three-dimensional (3D) systems that more closely mimic in vivo physiological conditions and allow a better understanding of the signalling between cells. In this work, we compared 2 liquid base 3D methods for the generation of spheroids from C6 rat glioma cells (RGCs) using 30 µL of liquid marble (LM) or the hanging drops (HDs), which contained 2 different cell numbers (5000 or 15,000). After 24 or 48 h of in vitro culture (IVC), the morphology of the spheroids was observed and the behaviour of the two main tubulin PTMs, tyrosinated α-tubulin (Tyr-T) and acetylated α-tubulin (Ac-T), was evaluated by fluorescence and Western blot (WB). RGCs spontaneously formed spherical agglomerates more rapidly in the LM than in the HD system. Cell density influenced the size of the spheroids, which reached a larger size (> of 300 µm Ø), with 15,000 cells compared to 5000 cells (150 µm Ø). Moreover, an increase in Tyr-T and Ac-T was observed in both the HD and LM system from 24 to 48 h, with the highest values shown in the 48 h/LM spheroids of 5000 cells (p < 0.05). In conclusion, by comparing the morphology and microtubular architecture of spheroids from C6 rat glioma cells developed by LM or HD methodology, our findings demonstrate that the use of a fumed silica microbioreactor boosts the induction and maintenance of a high plasticity state in glioma cells. RGCs cultured in LM express levels of tubulin PTMs that can be used to evaluate the efficacy of new anticancer therapies.

Environmental Contamination by Echinococcus spp. Eggs as a Risk for Human Health in Educational Farms of Sardinia, Italy

Cystic Echinococcosis (CE) is a severe zoonosis caused by the larval stage of the tapeworm Echinococcus granulosus. These parasites are naturally transmitted between canid definitive hosts that harbour the adult stage in the intestine, and mainly ungulate intermediate hosts, with larval cysts developing in their internal organs. The close coexistence between dog and sheep with incorrect hygiene management are the most important factors for the persistence of this parasitic pathology. The Educational Farms (EF) are farms and agritourisms suitably equipped to carry out training activities for people interested in farm practices and agricultural processing, in particular student groups. Public attendance of farms represents a new potential risk factor for the zoonoses transmission. Consumption of contaminated food and water in combination with contact or playing with domestic dogs (Canis familiaris) are possible routes of zoonoses human infection. In fact, Echinococcus spp. eggs may persist in the environment up to several months at low temperatures and moist conditions, having the chance of contaminating different matrices and surfaces. The aim of this investigation was to study environmental contamination by parasitic elements as a risk for zoonoses, such as Echinococcus spp. A total of 116 samples (35 of water, 33 of soil, 23 of vegetables, 25 of dog faeces) were collected in 30 EF in Sardinia. Samples were subjected to biomolecular investigation for the research of specific gene sequences of Echinococcus granulosus, Echinococcus multilocularis and Taenia spp. The study allowed to identify eight positive EF due to the presence of Echinococcusgranulosus in eight dog faeces samples and one positive EF due to the presence of Taenia spp. in a water sample. The work has allowed to develop and harmonise the diagnostic methods and operating protocols essential for controlling the spread of the CE to create “One Health” intervention plans in high endemic areas through the implementation of SOP (standard operating procedures) for monitoring the pathology in animals, humans and environment.

Vitrification of In Vitro Matured Oocytes Collected from Adult and Prepubertal Ovaries in Sheep

In livestock, in vitro embryo production systems can be developed and sustained thanks to the large number of ovaries and oocytes that can be easily obtained from a slaughterhouse. Adult ovaries always bear several antral follicles, while in pre-pubertal donors the maximal numbers of oocytes are available at 4 weeks of age, when ovaries bear peak numbers of antral follicles. Thus, 4 weeks old lambs are considered good donors, even if the developmental competence of prepubertal oocytes is lower compared to their adult counterpart. Basic research and commercial applications would be boosted by the possibility of successfully cryopreserving vitrified oocytes obtained from both adult and prepubertal donors. The vitrification of oocyte collected from prepubertal donors would also allow shortening the generation interval and thus increasing the genetic gain in breeding programs. However, the loss of developmental potential after cryopreservation makes mammalian oocytes probably one of the most difficult cell types to cryopreserve. Among the available cryopreservation techniques, vitrification is widely applied to animal and human oocytes. Despite recent advancements in the technique, exposures to high concentrations of cryoprotective agents as well as chilling injury and osmotic stress still induce several structural and molecular alterations and reduce the developmental potential of mammalian oocytes. Here, we describe a protocol for the vitrification of sheep oocytes collected from juvenile and adult donors and matured in vitro prior to cryopreservation. The protocol includes all the procedures from oocyte in vitro maturation to vitrification, warming and post-warming incubation period. Oocytes vitrified at the MII stage can indeed be fertilized following warming, but they need extra time prior to fertilization to restore damage due to cryopreservation procedures and to increase their developmental potential. Thus, post-warming culture conditions and timing are crucial steps for the restoration of oocyte developmental potential, especially when oocyte are collected from juvenile donors.

Seasonal Effect on Developmental Competence, Oxidative Status and Tubulin Assessment of Prepubertal Ovine Oocyte

Simple Summary

Oocytes obtained from the ovaries of slaughtered prepubertal ewes can be incorporated into an in vitro embryo production system. The collection of this material is possible at two different times of the year, spring and autumn. The first period is linked to the natural reproductive cycle of the sheep. The second, on the other hand, is linked to the manipulation of the reproductive seasonality which allows the oestrus cycle to be controlled artificially. The analysis highlighted that the collection season influences oocytes quality from prepubertal donors in terms of improved energetic and oxidative status, microtubular organization, and developmental competence in oocytes recovered in spring. Data obtained underline that oocytes seem to be genetically and evolutionarily programmed to give their best in spring, this being the most favorable period for newborns.

Abstract

The reproductive seasonality of domestic animals is often manipulated in order to have more reproductive periods for commercial purposes related to the production of milk and meat. It is scientifically proven that such an alteration of the reproductive activity in sheep entails a deterioration in oocyte quality, leading to an inability to generate embryos. Since oocytes obtained from prepubertal ewes can be incorporated into an in vitro embryo production system and considering that their quality is crucial to the success of in vitro procedures, the aim of this work was to investigate the effect of seasons on the quality of prepubertal ovine oocytes collected in autumn and spring. Ovaries were collected from a local slaughterhouse from 30–40-day-old suckling lambs during both seasons. Following 24 h of in vitro maturation, oocytes developmental competence, reactive oxygen species (ROS) intracellular levels, and mitochondrial activity were evaluated, and a tubulin assessment was performed. The results on embryo production, as a percentage of first divisions and number of blastocysts obtained, were significantly higher in oocytes collected in the spring. Mitochondrial activity in oocytes was higher, and ROS production significantly lower, in spring than in autumn. Tubulin PTMs (tyrosinated and acetylated α-tubulin) showed a higher immunoreactivity in oocytes collected in spring compared with autumn sampling. Our data showed that seasons may affect the developmental competence, energetic status, and tubulin assessment of oocytes recovered from prepubertal ewes. Therefore, special care should be taken when choosing the period of the year for prepuberal ovine oocytes collection aimed at in vitro embryo reproduction programs.

A report on the impact of rapid prenatal exome sequencing on the clinical management of 52 ongoing pregnancies: a retrospective review

OBJECTIVE

Studies have shown that prenatal exome sequencing (PES) improves diagnostic yield in cases of fetal structural malformation. We have retrospectively analysed PES cases from two of the largest fetal medicine centres in the UK to determine the impact of results on management of a pregnancy.

DESIGN

A retrospective review of clinical case notes.

SETTING

Two tertiary fetal medicine centres.

POPULATION

Pregnancies with fetal structural abnormalities referred to clinical genetics via a multidisciplinary team.

METHODS

We retrospectively reviewed the notes of all patients who had undergone PES. DNA samples were obtained via chorionic villus sampling or amniocentesis. Variants were filtered using patient-specific panels and interpreted using American College of Medical Genetics guidelines.

RESULTS

A molecular diagnosis was made in 42% (18/43) ongoing pregnancies; of this group, there was a significant management implication in 44% (8/18). A positive result contributed to the decision to terminate a pregnancy in 16% (7/43) of cases. A negative result had a significant impact on management in two cases by affirming the decision to continue pregnancy.

CONCLUSIONS

We demonstrate that the results of PES can inform pregnancy management. Challenges include variant interpretation with limited phenotype information. These results emphasise the importance of the MDT and collecting phenotype and variant data. As this testing is soon to be widely available, we should look to move beyond diagnostic yield as a measure of the value of PES.

TWEETABLE ABSTRACT

Prenatal exome sequencing can aid decision-making in pregnancy management; review ahead of routine implementation in NHS.

Confocal investigation on colocalization between tubulin posttranslational modifications and associated proteins in rat C6 glioma cells

Glioblastoma multiforme is the most lethal brain tumor. In the study of mechanisms underlying its development attention has been paid to the microtubular network of its cells, mainly on βIII tubulin, considered as a marker of malignancy. In the present work, we chose to investigate the tubulin code in glioblastoma cells, analyzing the degree of interaction between tubulin post-translational modifications and different proteins associated with them. The pattern of diverse associated proteins such as EB-1, CLIP-170 and kinesin-1 and their degree of co-distribution with the most abundant post-translational tubulin modifications (tyrosination, acetylation and polyglutamylation) were evaluated. Through immunofluorescence we have shown that EB-1, CLIP-170 and kinesin-1 were well detectable in glioblastoma cells. The double fluorescence and colocalization index between the post-translational modifications of tubulin and associated proteins showed that tyrosinated α-tubulin has significantly high affinity with EB-1, CLIP-170 and kinesin-1, while for acetylated and polyglutamylated tubulin, the degree of interaction with the three associated proteins evaluated was less apparent. Data presented in this paper underline the importance of a thorough analysis of the microtubular mechanics in glioblastoma cells. This may suggest new experimental therapeutic approaches able to act more selectively on the microtubular network of cells in this type of cancer.

Quantum Signature of a Squeezed Mechanical Oscillator

Recent optomechanical experiments have observed nonclassical properties in macroscopic mechanical oscillators. A key indicator of such properties is the asymmetry in the strength of the motional sidebands produced in the probe electromagnetic field, which is originated by the noncommutativity between the oscillator ladder operators. Here we extend the analysis to a squeezed state of an oscillator embedded in an optical cavity, produced by the parametric effect originated by a suitable combination of optical fields. The motional sidebands assume a peculiar shape, related to the modified system dynamics, with asymmetric features revealing and quantifying the quantum component of the squeezed oscillator motion.

Morphological features and microtubular changes in vitrified ovine oocytes

Cryobanking of oocytes collected from prepubertal donors may supply a virtually unlimited number of female gametes for both basic research and commercial applications. Prepubertal oocytes show some structural and functional limitations compared to the adult ones that may impair their ability to recover damages from cryopreservation. In oocytes, the meiotic spindle is acutely sensitive to temperature deviation, but capable of regeneration following cryopreservation. In the present work, we studied the effects of vitrification and post-warming incubation on the microtubular cytoskeleton and the tubulin post-translational modifications (tyrosination and acetylation) in prepubertal and adult oocytes. Obtained results showed that prepubertal oocytes are more affected by vitrification-induced injuries than adult ones. In fact, prepubertal oocytes showed more severe alterations of the meiotic spindle conformation and a higher percentage of parthenogenetic activation compared to adult ones. Moreover, in the adult oocytes the equilibrium between tyrosinated and acetylated α-tubulin was restored after 4 h of post-warming incubation. Diversely, in prepubertal oocytes the imbalance between tyrosinated and acetylated α-tubulin was increased during post-warming incubation. Our study shows that prepubertal oocytes react differently to the insults provoked by vitrification compared to adult oocytes, showing an impaired ability to recover from vitrification-induced injuries. In the evaluation of oocyte ability to recover from vitrification-induced injuries, tubulin post-translational modifications represent an important indicator for assessing oocyte quality.

Influence of permafrost, rock and ice glaciers on chemistry of high-elevation ponds (NW Italian Alps)

Permafrost degradation, rock-glacier thawing, and glacier retreat are influencing surface water quality at high elevations. However, there is a lack of knowledge on the dominant geochemical reactions occurring in different cryospheric conditions and how these reactions change during the ice-free season. In the Col d'Olen area (LTER site, NW Italian Alps), four ponds with similar sizes, located in basins with different cryospheric features (glacier, permafrost, rock glacier, none of these), are present in a geographically limited area. All ponds were sampled weekly in 2015 and partially in 2014. Major ions, selected trace elements, and biotic parameters (dissolved organic carbon-DOC, fluorescence index-FI, and nitrate) are examined to evidence the effect of different cryospheric features on water characteristics. Where cryospheric conditions occur chemical weathering is more intensive, with strong seasonal increase of major ions. Sulphide oxidation dominates in glacier and permafrost lying on acid rocks, probably driven by enhanced weathering of freshly exposed rocks in subglacial environment and recently deglaciated areas, and active layer thickness increase. Differently, carbonation dominates for the rock glacier lying on ultramafic rocks. There, high Ni concentrations originate from dissolution of Mg-bearing rocks in the landform. In all settings, pH neutralisation occurs because of the presence of secondary carbonate lithology and ultramafic rocks. Nitrate highest concentrations and changes occur in cryospheric settings while DOC and FI do not show strong differences and seasonal variations. The establishment of more frequent monitoring for water quality in high-elevated surface waters is necessary to provide greater statistical power to detect changes on longer time scales.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Efficacy and safety of a T-type calcium channel blocker in patients with neuropathic pain: A proof-of-concept, randomized, double-blind and controlled trial

BACKGROUND

T-type calcium channels have been shown to play an important role in the initiation and maintenance of neuropathic pain and represent a promising therapeutic target for new analgesic treatments. Ethosuximide (ETX), an anticonvulsant and a T-type channel blocker has shown analgesic effect in several chronic pain models but has not yet been evaluated in patients with neuropathic pain.

METHODS

This proof-of-concept, multicentre, double-blind, controlled and randomized trial compared the efficacy and safety of ETX (given as add-on therapy) to an inactive control (IC) in 114 patients with non-diabetic peripheral neuropathic pain. After a 7-day run-in period, eligible patients aged over 18 years were randomly assigned (1:1) to ETX or IC for 6 weeks. The primary outcome was the difference between groups in the pain intensity (% of change from the baseline to end of treatment) assessed in the intention-to-treat population. This study is registered with EudraCT (2013-004801-26) and ClinicalTrials.gov (NCT02100046).

RESULTS

The study was stopped during the interim analysis due to the high number of adverse events in the active treatment group. ETX failed to reduce total pain and showed a poor tolerance in comparison to IC. In the per-protocol analysis, ETX significantly reduced pain intensity by 15.6% (95% CI -25.8; -5.4) from baseline compared to IC (-7.8%, 95% CI -14.3; -1.3; p = 0.033), but this result must be interpreted with caution because of a small subgroup of patients.

CONCLUSION

Ethosuximide did not reduce the severity of neuropathic pain and induces, at the doses used, many adverse events.

SIGNIFICANCE

This article shows that ETX is not effective to treat neuropathic pain. Nevertheless, per-protocol analysis suggests a possible analgesic effect of ETX. Thus, our work adds significant knowledge to preclinical and clinical data on the benefits of T-type calcium channel inhibition for the treatment of neuropathic pain.

Tubulin posttranslational modifications in in vitro matured prepubertal and adult ovine oocytes

Microtubules (MTs), polymers of alpha/beta-tubulin heterodimers, are involved in crucial functions in eukaryotic cells. MTs physiology can be influenced by a variety of post-translational modifications (PTMs), including tyrosination, detyrosination, delta 2 modification, acetylation, polyglutamylation, polyglycylation. In mammalian oocytes, MTs are essential for meiosis, regulating the formation of meiotic spindle and chromosomes movements. Considering that the patterns of tubulin PTMs (tyrosination, detyrosination, acetylation, polyglutamylation and delta 2 modification) have not been investigated in ovine oocytes, this study has been designed to investigate their presence and quantification in in vitro matured (IVM) adult and prepubertal ovine oocytes. Oocytes from adult and lamb Sarda ewes, regularly slaughtered at the local abattoir, were in vitro matured, fixed, and processed by indirect immunofluorescence and confocal microscopy analyses at metaphase II stage. Our results revealed a well detectable signal for total, tyrosinated and acetylated α-tubulin in meiotic spindle of both sheep and lamb oocytes. On the other hand, no immunopositivity were appreciable for detyrosinated, polyglutamylated, and delta 2 tubulin in meiotic spindle of both sheep and lamb oocytes. As regard the tyrosinated and the acetylated α-tubulin PTMs, through the quantification of the fluorescence intensity, we did not find significant differences in their expression in meiotic spindle of sheep, while in lamb the acetylated tubulin levels were predominant in comparison with tyrosinated. Our results in addition to investigating for the first time the different tubulin PTMs in the spindle organization of ovine oocytes, showed a different microtubule pattern between adult and prepubertal oocytes. The microtubule cytoskeleton survey may thus suggest further cues to better understand skill-related problems in in the acquisition of oocyte competence.

Imaging Correlations in Heterodyne Spectra for Quantum Displacement Sensing

The extraordinary sensitivity of the output field of an optical cavity to small quantum-scale displacements has led to breakthroughs such as the first detection of gravitational waves and of the motions of quantum ground-state cooled mechanical oscillators. While heterodyne detection of the output optical field of an optomechanical system exhibits asymmetries which provide a key signature that the mechanical oscillator has attained the quantum regime, important quantum correlations are lost. In turn, homodyning can detect quantum squeezing in an optical quadrature but loses the important sideband asymmetries. Here we introduce and experimentally demonstrate a new technique, subjecting the autocorrelators of the output current to filter functions, which restores the lost heterodyne correlations (whether classical or quantum), drastically augmenting the useful information accessible. The filtering even adjusts for moderate errors in the locking phase of the local oscillator. Hence we demonstrate the single-shot measurement of hundreds of different field quadratures allowing the rapid imaging of detailed features from a simple heterodyne trace. We also obtain a spectrum of hybrid homodyne-heterodyne character, with motional sidebands of combined amplitudes comparable to homodyne. Although investigated here in a thermal regime, the method's robustness and generality represents a promising new approach to sensing of quantum-scale displacements.

Glucogenic treatment creates an optimal metabolic milieu for the conception period in ewes

This study determined the influence of a short-term glucogenic nutritional treatment on circulating concentrations of glucose, insulin, insulin-like growth factor 1 (IGF-1), nonesterified fatty acids (NEFA), and urea, and on their correspondent levels in follicular fluid (FF) collected 12 h after the end of the treatment. After estrous synchronization with intravaginal progestagen-impregnated sponges, 20 Sarda ewes were randomly allocated into two experimental groups (GLU and WAT) and, from day 7 to day 10 (day 0 = day of sponge removal), the GLU group was gavaged with a glycogenic mixture, whereas the WAT group was gavaged with water (control group). Follicular development was stimulated by FSH administration from day 8 to 10. At day 11, ovaries were collected and follicular fluid processed. Plasma changes were assessed from day 6 to 11. In GLU group, circulating concentration of glucose (P < 0.0001), insulin (P < 0.0001), and IGF-1 (P < 0.01) rose significantly, whereas NEFA and urea concentrations decreased (P < 0.0001), as compared with controls. In particular, in FF the higher glucose concentrations found in GLU ewes compared with controls (P < 0.0001) were not accompanied by any increase in insulin and IGF-1 concentrations. NEFA (P < 0.0001) and urea (P < 0.0001) were lower in FF of GLU than WAT group, although NEFA clearance in the ovary proved to be less efficient than at the systemic level. No significant difference between groups was found in FF concentrations of pregnancy-associated plasma protein A (a protease regulating the levels of free IGF-1 in follicles), glutathione, and in its total antioxidant capacity. These results suggest that glycogenic mixture administration creates a suitable follicular microenvironment for the conception period in dairy ewes.

[The pain-emotion: Advocating pain as an emotion]

OBJECTIVES

Pain is a common experience, both physical and emotional. However we often feel powerless with our patients suffering pain. This paper aims to give a new heuristic and psychological understanding of pain.

METHODOLOGY

According to new theories, recent researches as well as different points of view, we form an analogy between pain and emotion. Throughout historical considerations pain has always been perceived through theories and beliefs, changing its definition. This is also the case for emotion. Could they be two ways of expressing a single phenomenon?

RESULTS

First, we must clarify the definition of emotion. In past, emotion was considered as a multiple-conditioned notion. To be considered as an emotion the pain had to fill numerous features, which differ according to the scientific opinions. The emotion may be considered as a physical expression or perceived only as the consequences of a real emotion, i.e., the subjective feeling. We propose as a way of thinking that emotion brings together these two concepts. We support a flexible vision of emotion. To investigate the field of the emotion different mental steps may be thought of: we should conceive of the emotion as a stimulus, as an emotional evaluation and as a tendency to action, which becomes an emotional response. These steps are colored by subjective feelings. It can be summarized in three levels: the situation decoding (1), the response organization (2) and the effectiveness of the response (3). Second pain can be considered as a complex notion involving personal and subjective feelings. We can use multidimensional patterns and consider emotion with its multiple features: the generating mechanisms, the pain perception, the pain behavior and the environment. Each stage can be divided in different ways. Hence pain treatment could be approached as an emotional treatment. Indeed, we can make a link between generating mechanisms and emotion situation decoding, between pain perception and emotion situation decoding and response organization, between pain behavior and environment and emotion response effectiveness and consequences. A heuristic analogy can be formed enriching therapeutic possibilities. First, emotion and pain could be considered as a unique phenomenon that can be expressed in different ways. We can let aside the opposition between psychological and physiological: these are two different levels of a same phenomenon. This point of view can be helpful to treat pain disorders because the skills to manage emotion disorders are well known.

Intracellular CHO Cell Metabolite Profiling Reveals Steady-State Dependent Metabolic Fingerprints in Perfusion Culture

Perfusion cell culture processes allow the steady-state culture of mammalian cells at high viable cell density, which is beneficial for overall product yields and homogeneity of product quality in the manufacturing of therapeutic proteins. In this study, the extent of metabolic steady state and the change of the metabolite profile between different steady states of an industrial Chinese hamster ovary (CHO) cell line producing a monoclonal antibody (mAb) was investigated in stirred tank perfusion bioreactors. Matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF-MS) of daily cell extracts revealed more than a hundred peaks, among which 76 metabolites were identified by tandem MS (MS/MS) and high resolution Fourier transform ion cyclotron resonance (FT-ICR) MS. Nucleotide ratios (Uridine (U)-ratio, nucleotide triphosphate (NTP)-ratio and energy charge (EC)) and multivariate analysis of all features indicated a consistent metabolite profile for a stable culture performed at 40 × 10⁶ cells/mL over 26 days of culture. Conversely, the reactor was operated continuously so as to reach three distinct steady states one after the other at 20, 60, and 40 × 10⁶ cells/mL. In each case, a stable metabolite profile was achieved after an initial transient phase of approximately three days at constant cell density when varying between these set points. Clear clustering according to cell density was observed by principal component analysis, indicating steady-state dependent metabolite profiles. In particular, varying levels of nucleotides, nucleotide sugar, and lipid precursors explained most of the variance between the different cell density set points. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 33:879-890, 2017.

Possible antioxidant effect of Lycium barbarum polysaccharides on hepatic cadmium-induced oxidative stress in rats

The aim of this study was to investigate the potential protective effect of Lycium barbarum polysaccharides (LBP) pretreatment against cadmium (Cd)-induced hepatotoxicity in rats. Wistar rats were divided into control group, LBP group (300 mg/kg orally, once a day, for 30 days), Cd group (CdCl₂ 4 mg/kg i.p. once), and LBP + Cd group (LBP 300 mg/kg orally, once a day, for 30 days + CdCl₂ 4 mg/kg i.p. 24 h after the last treatment). Cd liver injury was examined by morphological/histological changes, transaminases, total protein concentration, and oxidative stress evaluated by MDA, 3NT, GSH, SOD, and TEAC activities. Cd intoxication caused gross morphological changes with hyperemia of the parenchyma, increased volume, and disappearance of the anatomical limits of the lobes associated with an increase of ALT, GSH, and TEAC in plasma and a decrease of MDA, GSH, and TEAC in liver, SOD, and total proteins in plasma. LBP pretreatment caused a slight improvement in the histological architecture and in the 3NT amount together with a significant improvement of hematic parameters. On the basis of the obtained results, we can affirm that LBP pretreatment can ameliorate liver conditions, but further studies are needed to better evaluate the protective antioxidant effects of LBP against Cd-induced toxicity.

Possible antioxidant effect of Lycium barbarum polysaccharides on hepatic cadmium-induced oxidative stress in rats

The aim of this study was to investigate the potential protective effect of Lycium barbarum polysaccharides (LBP) pretreatment against cadmium (Cd)-induced hepatotoxicity in rats. Wistar rats were divided into control group, LBP group (300 mg/kg orally, once a day, for 30 days), Cd group (CdCl₂ 4 mg/kg i.p. once), and LBP + Cd group (LBP 300 mg/kg orally, once a day, for 30 days + CdCl₂ 4 mg/kg i.p. 24 h after the last treatment). Cd liver injury was examined by morphological/histological changes, transaminases, total protein concentration, and oxidative stress evaluated by MDA, 3NT, GSH, SOD, and TEAC activities. Cd intoxication caused gross morphological changes with hyperemia of the parenchyma, increased volume, and disappearance of the anatomical limits of the lobes associated with an increase of ALT, GSH, and TEAC in plasma and a decrease of MDA, GSH, and TEAC in liver, SOD, and total proteins in plasma. LBP pretreatment caused a slight improvement in the histological architecture and in the 3NT amount together with a significant improvement of hematic parameters. On the basis of the obtained results, we can affirm that LBP pretreatment can ameliorate liver conditions, but further studies are needed to better evaluate the protective antioxidant effects of LBP against Cd-induced toxicity.

First-generation phosphodiesterase type 5 inhibitors dropout: a comprehensive review and meta-analysis

The discontinuation rate with phosphodiesterase type 5 inhibitors (PDE5i) remains very high. The aim of this study was to review and meta-analyze currently available data regarding dropout of the first-generation of PDE5i including sildenafil, vardenafil, and tadalafil. An extensive Medline Embase and Cochrane search was performed including the following words: 'PDE5i', 'discontinuation'. All observational studies reporting the dropout rate of PDE5i and its specific causes without any arbitrary restrictions were included. Out of 103 retrieved articles, 22 were included in the study. Retrieved trials included a total of 162,936 patients with a mean age of 58.8 ± 7.9 years. Prevalence of reported comorbid diabetes and hypertension were 27.7% and 36.9%, respectively. PDE5i were associated with a mean discontinuation rate of 4% per month (almost 50% after one year). This rate was higher in younger subjects and in those reporting a higher prevalence of associated morbidities. Six main reasons of PDE5i dropout were identified in the evaluated trials. Partner-related problems and lack of efficacy represented the most important reasons for PDE5i discontinuation, although no significant difference among factors was detected. In conclusion, despite their high efficacy and easy administration, the discontinuation rate and dissatisfaction with PDE5i are still very high. Our data showed that no single factor plays a major role in PDE5i dropout, suggesting that the discontinuation rate is usually because of a combination of both medical problems and psychosocial and relational factors.

Predictors and clinical consequences of starting androgen therapy in men with low testosterone: results from the SIAMO-NOI registry

PURPOSE

Management of late onset hypogonadism (LOH) is not homogenous. The aim of the study is to observe the management of patients with low testosterone (T) in highly specialized Italian centres.

METHODS

The SIAMO-NOI is an observational longitudinal disease registry for the evaluation of the clinical management of patients with low T levels (total T < 12 nmol/L, calculated free T < 225 pmol/l or already in treatment) in 15 Italian centers members of the Italian Society for Andrology and Sexual Medicine (SIAMS). Clinical and biochemical data were collected for four visits during 12 months of observation.

RESULTS

432 patients (mean age 50.9 ± 14.9 years) were enrolled. Of them, 247 men were receiving androgen therapy, whereas 145 were naive. After the first visit (V0), 80 men started androgen therapy, whereas 55 remained untreated during the entire observation. Younger age [odds ratio (OR) 0.57 (0.35-0.92)], total T < 8 nmol/l [OR 4.69 (1.59-13.81)], complaining at least one sexual symptom [OR 11.55 (2.01-66.35)] and reporting more severe lower urinary tract symptoms [OR 1.27 (1.01-1.60)] predicted starting an androgen therapy. Sixty-four men started therapy immediately after V0 and maintained it until the observation end. When compared to V0, they reported an increase in all the domains of the International Index of Erectile Function-15 (IIEF-15), in the sexual and physical subdomains of the Aging Male Scale as well as in the International Prostate Symptom Score. Conversely, the untreated group reported a significant improvement, although lower than the treated group, only in the erectile function domain of the IIEF-15.

CONCLUSIONS

Management of LOH in SIAMS centres is in line with the international guidelines and the newest knowledge about the role of T on prostate health. Androgen therapy is associated with an improvement in all the aspects of sexual life and in the perception of physical strength.

Dynamical Two-Mode Squeezing of Thermal Fluctuations in a Cavity Optomechanical System

We report the experimental observation of two-mode squeezing in the oscillation quadratures of a thermal micro-oscillator. This effect is obtained by parametric modulation of the optical spring in a cavity optomechanical system. In addition to stationary variance measurements, we describe the dynamic behavior in the regime of pulsed parametric excitation, showing an enhanced squeezing effect surpassing the stationary 3 dB limit. While the present experiment is in the classical regime, our technique can be exploited to produce entangled, macroscopic quantum optomechanical modes.

Landscape structure in the Pirapó, Paranapanema 3 and 4 Hydrographic Unit, in the state of Paraná, Brazil

The aim of this study is to characterize the Pirapó, Paranapanema 3 and 4 Hydrographic Unit, emphasizing its physical attributes and processes of use and occupation, responsible for the structure of the current landscape and the state of its water resources. The recognition of the landscape's spatial structure in the hydrographic unit and its drainage basins was obtained by integrated analysis of the main elements that compose it: geology, landforms (hypsometric and slope), soils, climate and land use. Analysis revealed that within each drainage basin several variations in the spatial structure of the landscape occur which produce an internal compartmentalization. Each compartment is defined by its own geo-ecological structure, physiognomic standards and dynamics, reflected in its potentialities and vulnerabilities and in the conditions of water resources in the wake of occupation and use over time.

Hemodynamic profile of portopulmonary hypertension

Portopulmonary hypertension (PPHTN) refers to the development of pulmonary arterial hypertension in the setting of portal hypertension with or without chronic hepatic failure. This syndrome is characterized by marked alternations of pulmonary vascular tone and obstruction of pulmonary arterial blood flow. An increased pulmonary blood flow, which is a hallmark of the hyperdynamic circulation of cirrhotic patients, seems to be present in almost all patients who develop PPHTN. The elevations of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) along with the transpulmonary gradient (TPG) have been considered in diagnosing PPHTN. Only a high TPG reflects the severity of obstruction to pulmonary blood flow and differentiates an elevated PAP with concomitant elevated PVR from the situation where the increase in PAP is due only to the hyperdynamic flow and elevated volume. A considerable risk for cardiovascular death arises when PAP increases significantly; this may occur in rapidly evolving syndromes, in very advanced disease, or during a complicated liver transplantation. The distinction between PPHTN and elevated PAP in the context of a hyperdynamic state is of great importance; a PAP increase of hyperkinetic origin, as opposed to PPHTN, is apparently not associated with a high risk for adverse effects during and following liver transplantation.

Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms

OBJECTIVE

To assess reliability and construct validity of the Kellgren-Lawrence (K&L) scale in posttraumatic ankle osteoarthritis (OA); additionally evaluate the validity of including tibiotalar tilting in the scale.

METHOD

One-hundred and fifty ankle radiographs (75 patients, unilateral malleolar fractures) evaluated at average of 18 years after surgery. American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot (HF) score and pain (visual analog scale) were recorded. Grading of OA according to K&L criteria and identification of OA features was performed on standardized radiographs by four physicians. Minimal joint space width, sclerosis, and talar tilt angle were quantified by digital measurements. A modified K&L scale including talar tilting is presented. Validity of original and modified scale was evaluated and expressed as ability to (1) Identify those with clinical symptoms of ankle OA; and (2) Distinguish between different degrees of fracture severity.

RESULTS

Inter- and intra-observer reliability of OA assessment according to K&L were good (ICC 0.61 and 0.75). Original and modified K&L grades significantly increased with decreasing AOFAS ankle-HF scores and greater pain. A talar-tilt angle > 2° compared with ≤ 2° in grade 3 was associated with significantly higher pain levels (VAS pain 4.2 vs 1.4, respectively; mean difference 2.8, 95% CI 0.5-5.1). More severe fracture patterns at time of surgery were more often in patients with the highest K&L grades.

CONCLUSIONS

The K&L scale is a valid and reliable radiographic grading system for assessment of ankle OA. Inclusion of the talar tilt angle might allow for better differentiation with respect to clinical outcomes.

Squeezing a thermal mechanical oscillator by stabilized parametric effect on the optical spring

We report the confinement of an optomechanical micro-oscillator in a squeezed thermal state, obtained by parametric modulation of the optical spring. We propose and implement an experimental scheme based on parametric feedback control of the oscillator, which stabilizes the amplified quadrature while leaving the orthogonal one unaffected. This technique allows us to surpass the -3  dB limit in the noise reduction, associated with parametric resonance, with a best experimental result of -7.4  dB. While the present experiment is in the classical regime, in a moderately cooled system our technique may allow squeezing of a macroscopic mechanical oscillator below the zero-point motion.

Liver transplantation in children with congenital cardiac defects: a case report and a short literature review

Advances in surgical techniques and follow-up of patients with complex congenital heart disease who were corrected in childhood increasingly survive to adolescence or adulthood. Increasingly anesthesiologists encounter these cases for major noncardiac surgery, including orthotopic liver transplantation (OLT) wherein there is an augmented risk of significant perioperative hemodynamic instability. We performed a successful OLT in a 12-year-old boy with end-stage cryptogenetic liver fibrosis and hepatopulmonary syndrome who was born with a double outflow right ventricle, pulmonary atresia, and pulmonary artery hypoplasia corrected at the age of 1 month. By the time he was considered for OLT his altered pulmonary valve apparatus resulted in severe pulmonary regurgitation, dilated right atrium and ventricle, and elevated right heart pressures. After a temporarily successful angioplasty he was at first placed on the waiting list, then removed, and finally relisted following implantation of a prosthetic pulmonary valve that resulted in significant reduction of right heart pressures.