Erdheim-Chester disease as complex clinical presentation and diagnosis: A case report and concise review of literature

RATIONALE

Erdheim-Chester disease (ECD) is a rare multisystemic disease characterized by the infiltration of multiple organs by foamy CD68 + CD1a-histiocytes. The genetic background consists of gain-of-function somatic mutations in the mitogen-activated protein kinase pathway. The purpose of the present paper is to make a contribution to the scientific literature on ECD by reporting our experience with a complex clinical case report, along with a concise review of the literature. We discussed the unusual clinical presentation, the complex diagnostic process and the comparison with other published cases.

PATIENT CONCERNS

A 70-year-old man presented with arthralgia due to multiple bone areas of sclerosis, first diagnosed with metastases of a prostatic neoplasm. Sequential thorax-abdomen, femoral and homer contrast-enhanced computed tomography (CT) showed pericardial effusion, pulmonary fibrosis, and perirenal fibrous tissue as "hairy kidneys." He underwent. Three bone biopsies were unsuccessful to reach diagnosis.

DIAGNOSES

A xanthelasma biopsy showed histopathological signs compatible with ECD; genetic analysis showed the mutation BRAFV600E.

INTERVENTIONS

The patient underwent targeted therapy with vemurafenib (BRAF-inhibitor), discontinued 2 weeks later due to the onset of a diffuse erythematous papular rash on the trunk and limbs.

OUTCOMES

At the 1-year follow-up, there was only progression of chronic kidney disease (CKD).

LESSONS

The present case report describes how ECD diagnosis could represent a challenge for clinicians, owing to its heterogeneous clinical presentation. Early diagnosis followed by prompt therapy is essential for modifying the natural history of the disease.

Outcome of primary hemophagocytic lymphohistiocytosis: a report on 143 patients from the Italian Registry

Primary hemophagocytic lymphohistiocytosis (pHLH) is a severe, life-threatening hyperinflammatory syndrome caused by defects in genes of the granule-dependent cytotoxic pathway. Here we investigated the clinical presentation and outcome in a large cohort of 143 patients with pHLH diagnosed in the last 15 years and enrolled in the Italian registry. The median age at diagnosis was 12 months (IQR 2-81), and ninety-two patients (64%) fulfilled the HLH-2004 criteria. Out of 111 patients who received first-line combined therapy (HLH-94, HLH-2004, Euro-HIT protocols), 65 (59%) achieved complete response (CR) and 21 (19%) partial response (PR). Thereafter, 33 patients (30%) reactivated, and 92 (64%) received HSCT, 78 of whom (85%) survived and were alive at a median follow-up from diagnosis of 67 months. Thirty-six patients (25%) died before HSCT and 14 (10%) after. Overall, 93 patients (65%) were alive after a median follow-up of 30 months. Unadjusted predictors of non-response were age.

Rare Onset of Erdheim-Chester Disease in Children and Young Adults: A Case Series and Review of the Literature

INTRODUCTION

Erdheim-Chester disease (ECD) is a rare histiocytic neoplasm that affects patients, predominantly males aged 40-70 years, with very heterogeneous clinical presentation and prognosis. In 2020, Goyal et al. proposed consensus recommendations for the management of patients with ECD, remarking on the exceptional presentation of the disease in the pediatric population.

CASE PRESENTATION

The first patient, a 20-year-old male, underwent cervical laminectomy and partial removal of a cervical spine lesion, initially apparently consistent with cervical schwannomas. The second patient, a 9-year-old female, received surgery for an extra-axial lesion of the greater sphenoid wing, radiologically consistent with a meningioma.

CONCLUSION

At present, 15 pediatric cases have been reported in the literature with involvement of the central nervous system, with no consensus on the diagnostic and therapeutic management, as Pegoraro et al. evidenced in their pediatric multicenter case series. The present article adds two new cases of ECD with onset in childhood and young adulthood, who received the diagnosis after neurosurgical procedures.

Genome-Wide Association Study Identifies the First Germline Genetic Variant Associated With Erdheim-Chester Disease

OBJECTIVE

Erdheim-Chester disease (ECD) is rare histiocytosis with a wide range of clinical manifestations. Somatic mutations are key to the pathogenesis of the disease; however, the relationship between germline genetic variants and ECD has not been examined so far. The present study aims to explore the inherited genetic component of ECD by performing the first genome-wide association study.

METHODS

After quality controls, a cohort of 255 patients with ECD and 7,471 healthy donors was included in this study. Afterward, a logistic regression followed by in silico functional annotation was performed.

RESULTS

A signal at the 18q12.3 genomic region was identified as a new susceptibility locus for ECD (P = 2.75 × 10-11 ; Odds Ratio = 2.09). This association was annotated to the SETBP1 gene, which is involved in clonal haematopoiesis. Functional annotation of this region and of the identified suggestive signals revealed additional genes that could be potentially involved in the pathogenesis of the disease.

CONCLUSION

Overall, this work demonstrates that germline genetic variants can impact on the development of ECD and suggests new pathways with a potential pathogenic role.

Epidemiology and geographic clustering of Erdheim-Chester disease in Italy and France

This geoepidemiological study, performed in Italy and France, shows that Erdheim-Chester disease is increasingly diagnosed and cases cluster in specific geographic areas, namely southern Italy and central France. Disease frequency inversely correlates with the Human Development Index.

Anticoagulation and Thrombotic Events in the Multisystem Inflammatory Syndrome in Children: Experience of a Single-center Cohort and Review of the Literature

The multisystem inflammatory syndrome in children (MIS-C) is a severe clinical entity affecting the coagulative system; although thromboembolic events (TEs) are not common, most patients receive anticoagulation. We retrospectively assessed patients below 18 years admitted with MIS-C at Meyer Children's Hospital (Florence, Italy). Data on baseline clinical and laboratory presentation, treatment, and outcome, including differences between patients with and without thrombotic prophylaxis, were analyzed. Thirty-two children 1 to 15 years were included. Seventeen patients (53.1%) required intensive care admission, 2 (8.7%) had obesity, 7 (30.4%) a central venous catheter, and 14 (43.8%) an impaired cardiac function. Twelve patients (37.5%) received prophylactic anticoagulation: they had more frequent cardiac involvement (91.7 vs. 50%, P =0.02) and higher ferritin levels (median 1240 vs. 501.5 ng/mL, P <0.001). No differences were found in median d -dimers between the 2 groups. Twenty-one patients (65.6%) had d -dimers >5×upper limit of normal but the indication for anticoagulation was not driven by d -dimers. No patient had hemorrhagic events and only 1 patient (3.1%) had a superficial thrombotic event (under thromboprophylaxis). Our series and the available literature data on MIS-C and thromboembolic events suggest that TEs are a rare complication of MIS-C that is frequently associated with high d -dimer values. However, also in MIS-C, the well-established risk factors of pediatric TEs (ie, older age, central venous catheter, obesity, and cancer) should guide thromboembolic risk assessment.

Approaching hemophagocytic lymphohistiocytosis

Hemophagocytic Lymphohistiocytosis (HLH) is a rare clinical condition characterized by sustained but ineffective immune system activation, leading to severe and systemic hyperinflammation. It may occur as a genetic or sporadic condition, often triggered by an infection. The multifaceted pathogenesis results in a wide range of non-specific signs and symptoms, hampering early recognition. Despite a great improvement in terms of survival in the last decades, a considerable proportion of patients with HLH still die from progressive disease. Thus, prompt diagnosis and treatment are crucial for survival. Faced with the complexity and the heterogeneity of syndrome, expert consultation is recommended to correctly interpret clinical, functional and genetic findings and address therapeutic decisions. Cytofluorimetric and genetic analysis should be performed in reference laboratories. Genetic analysis is mandatory to confirm familial hemophagocytic lymphohistiocytosis (FHL) and Next Generation Sequencing is increasingly adopted to extend the spectrum of genetic predisposition to HLH, though its results should be critically discussed with specialists. In this review, we critically revise the reported laboratory tools for the diagnosis of HLH, in order to outline a comprehensive and widely available workup that allows to reduce the time between the clinical suspicion of HLH and its final diagnosis.

Whole-body magnetic resonance imaging for staging Langerhans cell histiocytosis in children and young adults

INTRODUCTION

Radiographic skeletal survey (R-SS) is the standard imaging technique for the initial staging of Langerhans cell histiocytosis (LCH). Whole-body magnetic resonance imaging (WB-MRI) has been proposed as an effective, radiation-free alternative.

METHODS

We prospectively assessed patients with LCH followed at three tertiary centers in Italy and Austria. Two national study protocols were independently designed, and data were then pooled to increase the power of their findings. R-SS and WB-MRI were performed at diagnosis and repeated at the follow-up to confirm the nature of the identified lesions and to study their evolution.

RESULTS

Data from 67 patients were analyzed (52 from Italy and 15 from Austria). Compared to R-SS, WB-MRI identified 29 additional skeletal lesions in 14 patients (including two false-positive lesions). Two skeletal lesions were detected at R-SS and missed at WB-MRI (false negative). Per-lesion sensitivity rates were 78.6% (95% CI: 71.0-85.9) for R-SS and 98.4% (95% CI: 94.4-99.8) for WB-MRI, respectively. Based on WB-MRI findings, six patients would have been upstaged to a higher risk class than staging with R-SS.

CONCLUSIONS

WB-MRI had a significantly higher detection rate for skeletal lesions compared to R-SS. Clinical and radiology expertise is required to avoid upstaging and overtreatment.

Clinical phenotypes and long-term outcome of kidney involvement in Erdheim-Chester histiocytosis

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis that frequently infiltrates the peri-kidney space ("hairy kidney" appearance), kidney pelvis and proximal ureters, leading to obstructive uropathy. Here, we analyzed the clinical characteristics, imaging findings and long-term kidney outcome of a large multicenter cohort comprising 195 consecutive patients with ECD. Retroperitoneal peri-kidney or peri-ureteral involvement was detected at diagnosis in 147 patients. Of them, 70 had hydronephrosis (bilateral in 47), and 16 with kidney atrophy (unilateral in 14). Kidney vascular peduncle infiltration was found in 60 patients, and kidney artery stenosis in 31. The estimated glomerular filtration rate (eGFR) at diagnosis was significantly lower in patients with than in those without peri-kidney involvement (median 74 vs. 98 mL/min/1.73 m²). Ureteral stenting often failed to achieve kidney function recovery. A total of 181 patients received medical therapies: first-line treatments included interferon-α (61%), BRAF-inhibitors (17%), mTOR-inhibitors (7%), or other drugs (15%). These therapies were efficacious for ECD but rarely induced kidney function improvement (one-year eGFR increase over 25% in under 10% of patients). After a median of 43 months, 19% of patients died and 5% developed kidney failure. Among patients with peri-kidney involvement, 44% developed chronic kidney disease (CKD) 3-5 at five years vs. 5% of those without. Unadjusted predictors of advanced CKD and kidney failure/death were age over 50 years, hypertension, BRAFV600E mutation, and baseline eGFR. At multivariable analysis, cardiovascular comorbidities were associated with advanced CKD, and age over 50 years with kidney failure/death. Thus, kidney involvement is common in ECD and can lead to CKD or kidney failure despite effective medical therapies or urological procedures.

Targeted treatment of solid tumors in pediatric precision oncology

The treatment of childhood solid cancer has markedly evolved in recent years following a refined molecular characterization and the introduction of novel targeted drugs. On one hand, larger sequencing studies have revealed a spectrum of mutations in pediatric tumors different from adults. On the other hand, specific mutations or immune dysregulated pathways have been targeted in preclinical and clinical studies, with heterogeneous results. Of note, the development of national platforms for tumor molecular profiling and, in less measure, for targeted treatment, has been essential in the process. However, many of the available molecules have been tested only in relapsed or refractory patients, and have proven poorly effective, at least in monotherapy. Our future approaches should certainly aim at improving the access to molecular characterization, to obtain a deeper picture of the distinctive phenotype of childhood cancer. In parallel, the implementation of access to novel drugs should not only be limited to basket or umbrella studies but also to larger, multi-drug international studies. In this paper we reviewed the molecular features and the main available therapeutic options in pediatric solid cancer, focusing on available targeted drugs and ongoing investigations, aiming at providing a useful tool to navigate the heterogeneity of this promising but complex field.

DR4/DQ2 haplotype confers susceptibility to T1DM with early clinical disease onset: A retrospective analysis in a tertiary-care hospital in Italy

INTRODUCTION

T1DM is the most frequent form of diabetes in children. It has a multifactorial pathogenesis in which genetic, environmental and immunological factors are involved. Among genetic explanations a major role is attributed to second class HLA genes, with the greatest risk associated with the simultaneous presence of the haplotypes DR3DQ2 and DR4DQ8. Based on results obtained in other countries, the aim of this research is to verify a possible association between the haplotype DRB1 * 04: 05-DQA1 * 03-DQB1 * 02 and the onset of T1DM among Italian children with possible genotype-phenotype correlations. Greater knowledge of genes which increase or decrease susceptibility is important for genome analysis.

MATERIALS AND METHODS

165 patients with type 1 diabetes treated at the Diabetology Unit of the Meyer Children's University Hospital, were clinically analyzed. Data relating to age at diagnosis, pancreatic anti-beta cell autoimmunity, comorbidities with date of diagnosis and family history were retrospectively collected from medical data. A case-control study was conducted to investigate the HLA types of the patients compared to a control group of 819 Tuscan donors enrolled in the National Bone Marrow Donor Register. Typing was carried out using the Eurospital "DIABEGEN" kit, currently in use at the immunology laboratory of the Meyer Children's University Hospital.

RESULTS

Mean age at diagnosis was 9.3 years; most children (97%) had anti-pancreatic beta cell autoimmunity; the anti-insulin antibody (IAA) was more frequent among children with early clinical disease onset (0-5 years of age). From the case control comparison performed on HLA typing, it emerged that the greatest risk for the development of type 1 diabetes is conferred by the haplotypes DR3DQ2 and DR4DQ8, but in addition to these haplotypes, already known in other countries, we identified another haplotype, DR4DQ2 (DRB1 * 04: 05-DQA1 * 03-DQB1 * 02) which appears to predispose children to type 1 diabetes (p value 2.80E-08) and it is associated with early clinical disease onset (p-value = 0.002).

CONCLUSIONS

We report a new haplotype which increases susceptibility to type 1 diabetes among Italian children and which is associated with early clinical disease onset. Given the central role attributed to genetic factors in the pathogenesis of T1DM and to the II class HLA genes, this new haplotype ought to be recognized as a risk factor and included in tests routinely carried out to identify patients with a genetic predisposition to type I diabetes in Italy. These findings could have practical implications in research and prevention programs.

Contrast-enhanced ultrasound in pediatric blunt abdominal trauma: a systematic review

PURPOSE

Intra-abdominal injury is a major cause of morbidity in children. Computed tomography (CT) is the reference standard for the evaluation of hemodynamically stable abdominal trauma. CT has an increased risk of long-term radiation induced malignancies and a possible risk associated with the use of iodinated contrast media. Contrast-enhanced ultrasound (CEUS) might represent an alternative to CT in stable children with blunt abdominal trauma (BAT). Nonetheless, CEUS in pediatrics remains limited by the lack of strong evidence. The purpose of this study was to offer a systematic review on the use of CEUS in pediatric abdominal trauma.

METHODS

Electronic search of PubMed, EMBASE and Cochrane databases of studies investigating CEUS for abdominal trauma in children. The risk of bias was assessed using the ROBINS-I tool.

RESULTS

This systematic review included 7 studies. CEUS was performed with different ultrasound equipment, always with a curvilinear transducer. Six out of seven studies used a second-generation contrast agent. No immediate adverse reactions were reported. The dose of contrast agent and the scanning technique varied between studies. All CEUS exams were performed by radiologists, in the radiology department or at the bedside. No standard training was reported to become competent in CEUS. The range of sensitivity and specificity of CEUS were 85.7 to 100% and 89 to 100%, respectively.

CONCLUSION

CEUS appears to be safe and accurate to identify abdominal solid organ injuries in children with BAT. Further research is necessary to assess the feasibility of CEUS by non-radiologists, the necessary training, and the benefit-cost ratio of CEUS as a tool to potentially reduce CT scans.

Gastrointestinal, hepatic and pancreatic manifestations of COVID-19 in children

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a well-established respiratory tract pathogen. Recent studies in adults and children have shown an increasing number of patients reporting gastrointestinal manifestations of SARS-CoV-2 infection such as diarrhoea, nausea, vomiting and abdominal pain. SARS-CoV-2 RNA can be detected in faeces for an extended period, even after respiratory samples have tested negative and patients are asymptomatic. However, faecal-oral transmission has not yet been proven. In this article, the latest evidence on gastrointestinal, hepato-biliary, and pancreatic manifestations in children with coronavirus disease-19 and multisystem inflammatory syndrome will be analysed.

Case Report: Clinical and Hematological Characteristics of εγδβ Thalassemia in an Italian Patient

INTRODUCTION

εγδβ thalassemia is a rare form of β-thalassemia mostly described in children originating from Northern Europe. Only anecdotic cases from the Mediterranean area are reported. The diagnosis is challenging, considering the rarity of the disease and its heterogeneous clinical presentation. Most patients have neonatal microcytic anemia, sometimes requiring in utero and/or neonatal transfusions, and typically improving with age.

CASE DESCRIPTION

We report on an Italian newborn presenting with severe neonatal anemia that required red blood cell transfusion. After the first months of life, hemoglobin levels improved with residual very low mean corpuscular volume. β and α thalassemia, IRIDA syndrome, and sideroblastic anemia were excluded. Finally, a diagnosis of εγδβ thalassemia was made after microarray analysis of single nucleotide polymorphisms revealed a 26 kb single copy loss of chromosome 11p15.4, including the HBD, HBBP1, HBG1, and HBB genes.

CONCLUSIONS

Despite its rarity, the diagnosis of εγδβ thalassemia should be considered in newborns with severe neonatal anemia requiring in utero and/or neonatal transfusions, but also in older infants with microcytic anemia, after excluding more prevalent red blood cell disorders.

Thromboembolic complications in children with COVID-19 and MIS-C: A narrative review

COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have been associated with a higher incidence of hypercoagulability and thromboembolic events (TEs), even in children, leading to relevant morbidity, and mortality. However, our understanding of such complications in childhood is limited. To better understand the incidence, clinical manifestations, risk factors, and management of COVID-19 and MIS-C-related TEs in children, a review of the current literature and a brief update on pathophysiology are given. Sixty-two studies, describing 138 patients with TEs associated with COVID-19 or MIS-C, were included. The overall number of TEs was 157, as 16 patients developed multiple TEs: venous TEs represented the majority (54%), followed by arterial thrombosis (38%, mainly represented by arterial ischemic stroke-AIS), and intracardiac thrombosis (ICT) (8%). Within the venous TEs group, pulmonary embolism (PE) was the most frequent, followed by deep venous thrombosis, central venous sinus thrombosis, and splanchnic venous thrombosis. Notably, 10 patients had multiple types of venous TEs, and four had both venous and arterial thrombosis including a newborn. Most of them (79 cases,57%) had at least one predisposing condition, being obesity the most frequent (21%), especially in patients with PE, followed by malignancy (9%). In 35% of cases, no data about the outcome were available About one-third of cases recovered, 12% improved at discharge or follow-up, and 6% had persistent neurological sequelae. The mortality rate was 12%, with death due to comorbidities in most cases. Most fatalities occurred in patients with arterial thrombosis. Pediatricians should be aware of this life-threatening possibility facing children with SARS-CoV-2 infection or its multisystemic inflammatory complication, who abruptly develop neurological or respiratory impairment. A prompt intensive care is essential to avoid severe sequelae or even exitus.

Weight change and glycemic control in type 2 diabetes patients during COVID-19 pandemic: the lockdown effect

PURPOSE

The aim of this study was to evaluate the impact of the COVID-19 lockdown occurred in Italy from March 9th to May 18th, 2020 on anthropometric parameters and glycemic control in patients with type 2 diabetes mellitus (T2DM).

METHODS

One hundred twenty-eight consecutive patients with T2DM (median age 70 years, 74 males) were retrospectively evaluated at the end of the lockdown period. Data on metabolic control were collected at different time: within three months before the lockdown (visit 0) and within the first six weeks after it (visit 1).

RESULTS

During the lockdown, a significant increase in body weight (from 79.7 ± 18.7 kg to 81.4 ± 19.4 kg, p < 0.001), body mass index (BMI, from 29.5 ± 6 kg/m² to 30.1 ± 6.3 kg/m², p < 0.001), waist circumference (from 103.8 ± 13 cm to 105 ± 13.6 cm, p < 0.001), fasting plasma glucose (FPG; from 138.1 ± 29.4 mg/dL to 146.6 ± 36.4 mg/dL) and glycated hemoglobin (HbA1c; from 7 ± 0.8 to 7.3 ± 0.9%, p < 0.001) was observed. Weight gain was directly associated with HbA1c increase (β 0.085, C.I. 95% 0.05-0.121; p < 0.001) while insulin therapy resulted to be the only significant independent predictor of HbA1c worsening at the multivariate logistic regression analysis (OR 2.40, C.I. 1.06-5.45; p = 0.035).

CONCLUSIONS

The lockdown due to COVID-19 pandemic had a negative impact on body weight and glucose control in T2DM patients, in particular in those on insulin treatment. This finding provides a further rationale to optimize the diabetes management during eventually new period of home confinement.

Occupational Exposures and Smoking in Eosinophilic Granulomatosis With Polyangiitis: A Case-Control Study

OBJECTIVE

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Environmental agents and occupational exposures may confer susceptibility to EGPA, but data are scarce. This study was undertaken to investigate the association between occupational exposures (e.g., silica, farming, asbestos, and organic solvents) and other environmental agents (e.g., smoking) and the risk of EGPA.

METHODS

Patients with newly diagnosed EGPA (n = 111) and general population controls (n = 333) who were matched for age, sex, and geographic area of origin were recruited at a national referral center for EGPA. Exposures were assessed using a dedicated questionnaire administered by a specialist in occupational medicine, under blinded conditions. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Exposures to silica (OR 2.79 [95% CI 1.55-5.01], P = 0.001), organic solvents (OR 3.19 [95% CI 1.91-5.34], P < 0.001), and farming (OR 2.71 [95% CI 1.71-4.29], P < 0.001) were associated with an increased risk of EGPA. Co-exposure to silica and farming yielded an OR of 9.12 (95% CI 3.06-27.19, P < 0.001), suggesting a multiplicative effect between these 2 exposures. Smoking (current and former smokers combined) was significantly less frequent among patients with EGPA compared to controls (OR 0.49 [95% CI 0.29-0.70], P < 0.001). The pack-year index was also lower among patients with EGPA (OR 0.96 [95% CI 0.94-0.98], P < 0.001). The association of silica and farming was primarily aligned with ANCA-positive EGPA, while the association of smoking status and organic solvents was primarily aligned with ANCA-negative EGPA.

CONCLUSION

The environment can influence susceptibility to EGPA. Exposure to silica, farming, or organic solvents is associated with an increased risk of EGPA, while smoking is associated with a lower risk. These exposures seem to have distinct effects on different EGPA subsets.

Polypharmacy but not Potential Inappropriate Prescription Was Associated with Frailty in Older Adults from a Middle-Income Country Outpatient Clinic

OBJECTIVES

the aims of the present study were: (1) investigate the prevalence and association of polypharmacy and pre-frailty or frailty in a middle-income country sample of older adults; and (2) evaluate the prevalence of potential inappropriate prescription (PIP) and its association with pre-frailty or frailty.

DESIGN

Cross-sectional observational study.

SETTING

Outpatient center at a university-based hospital in the state of São Paulo, Brazil.

PARTICIPANTS

629 older adults from both sexes evaluated between June 2014 and July 2016.

MEASUREMENTS

Frailty was identified through the FRAIL scale. All medications received were analyzed by research staff. Presence of PIP was evaluated according to the 2015 updated Beers list. Binary logistic regression tested the association between 4 definitions of polypharmacy (≥ 3, 4, 5, and 6 drugs), and presence of PIP, and the dependent variable pre-frailty and frailty.

RESULTS

15.7% of participants were frail. Polypharmacy was present in 219 (34.8%), and PIP was observed in 184 (29.3%) older adults. All definitions of polypharmacy were significantly associated with frailty (OR between 2.05 to 2.34, p < 0.001). Polypharmacy with 4 or 5 or more drugs were associated with pre-frailty (OR 1.53 and 1.47, respectively). PIP was not associated with frailty (OR 1.47, p = 0.149).

CONCLUSIONS

Several definitions of polypharmacy were associated with frailty, but only two were associated with pre-frailty. The presence of PIP was not associated with pre-frailty or frailty.

Ultra-bright γ-ray emission and dense positron production from two laser-driven colliding foils

Matter can be transferred into energy and the opposite transformation is also possible by use of high-power lasers. A laser pulse in plasma can convert its energy into γ-rays and then e⁻e⁺ pairs via the multi-photon Breit-Wheeler process. Production of dense positrons at GeV energies is very challenging since extremely high laser intensity ~10²⁴ Wcm⁻² is required. Here we propose an all-optical scheme for ultra-bright γ-ray emission and dense positron production with lasers at intensity of 10^22–23 Wcm⁻². By irradiating two colliding elliptically-polarized lasers onto two diamondlike carbon foils, electrons in the focal region of one foil are rapidly accelerated by the laser radiation pressure and interact with the other intense laser pulse which penetrates through the second foil due to relativistically induced foil transparency. This symmetric configuration enables efficient Compton back-scattering and results in ultra-bright γ-photon emission with brightness of ~10²⁵ photons/s/mm²/mrad²/0.1%BW at 15 MeV and intensity of 5 × 10²³ Wcm⁻². Our first three-dimensional simulation with quantum-electrodynamics incorporated shows that a GeV positron beam with density of 2.5 × 10²² cm⁻³ and flux of 1.6 × 10¹⁰/shot is achieved. Collective effects of the pair plasma may be also triggered, offering a window on investigating laboratory astrophysics at PW laser facilities.

Electron Weibel instability in relativistic counterstreaming plasmas with flow-aligned external magnetic fields

The Weibel instability driven by two symmetric counterstreaming relativistic electron plasmas, also referred to as current-filamentation instability, is studied in a constant and uniform external magnetic field aligned with the plasma flows. Both the linear and nonlinear stages of the instability are investigated using analytical modeling and particle-in-cell simulations. While previous studies have already described the stabilizing effect of the magnetic field, we show here that the saturation stage is only weakly affected. The different mechanisms responsible for the saturation are discussed in detail in the relativistic cold fluid framework considering a single unstable mode. The application of an external field leads to a slight increase of the saturation level for large wavelengths, while it does not affect the small wavelengths. Multimode and temperature effects are then investigated. While at high temperature the saturation level is independent of the external magnetic field, at low but finite temperature the competition between different modes in the presence of an external magnetic field leads to a saturation level lower with respect to the unmagnetized case.

Pressure anisotropy and small spatial scales induced by velocity shear

By including the full pressure tensor dynamics in a fluid plasma model, we show that a sheared velocity field can provide an effective mechanism that makes the initial isotropic pressure nongyrotropic. This is distinct from the usual gyrotropic anisotropy related to the fluid compressibility and usually accounted for in double-adiabatic models. We determine the time evolution of the pressure agyrotropy and discuss how the propagation of "magnetoelastic perturbations" can affect the pressure tensor anisotropization and its spatial filamentation, which are due to the action of both the magnetic field and the flow strain tensor. We support this analysis with a numerical integration of the nonlinear equations describing the pressure tensor evolution.

Enhancement of maximum attainable ion energy in the radiation pressure acceleration regime using a guiding structure

Radiation pressure acceleration is a highly efficient mechanism of laser-driven ion acceleration, with the laser energy almost totally transferrable to the ions in the relativistic regime. There is a fundamental limit on the maximum attainable ion energy, which is determined by the group velocity of the laser. In the case of tightly focused laser pulses, which are utilized to get the highest intensity, another factor limiting the maximum ion energy comes into play, the transverse expansion of the target. Transverse expansion makes the target transparent for radiation, thus reducing the effectiveness of acceleration. Utilization of an external guiding structure for the accelerating laser pulse may provide a way of compensating for the group velocity and transverse expansion effects.

Laser-driven Rayleigh-Taylor instability: plasmonic effects and three-dimensional structures

The acceleration of dense targets driven by the radiation pressure of high-intensity lasers leads to a Rayleigh-Taylor instability (RTI) with rippling of the interaction surface. Using a simple model it is shown that the self-consistent modulation of the radiation pressure caused by a sinusoidal rippling affects substantially the wave vector spectrum of the RTI, depending on the laser polarization. The plasmonic enhancement of the local field when the rippling period is close to a laser wavelength sets the dominant RTI scale. The nonlinear evolution is investigated by three-dimensional simulations, which show the formation of stable structures with "wallpaper" symmetry.

Dynamics of self-generated, large amplitude magnetic fields following high-intensity laser matter interaction

The dynamics of magnetic fields with an amplitude of several tens of megagauss, generated at both sides of a solid target irradiated with a high-intensity (~10(19) W/cm(2)) picosecond laser pulse, has been spatially and temporally resolved using a proton imaging technique. The amplitude of the magnetic fields is sufficiently large to have a constraining effect on the radial expansion of the plasma sheath at the target surfaces. These results, supported by numerical simulations and simple analytical modeling, may have implications for ion acceleration driven by the plasma sheath at the rear side of the target as well as for the laboratory study of self-collimated high-energy plasma jets.

Coupling between whistler waves and ion-scale solitary waves: cluster measurements in the magnetotail during a substorm

We present a new model of self-consistent coupling between low frequency, ion-scale coherent structures with high frequency whistler waves in order to interpret Cluster data. The idea relies on the possibility of trapping whistler waves by inhomogeneous external fields where they can be spatially confined and propagate for times much longer than their characteristic electronic time scale. Here we take the example of a slow magnetosonic soliton acting as a wave guide in analogy with the ducting properties of an inhomogeneous plasma. The soliton is characterized by a magnetic dip and density hump that traps and advects high frequency waves over many ion times. The model represents a new possible way of explaining space measurements often detecting the presence of whistler waves in correspondence to magnetic depressions and density humps. This approach, here given by means of slow solitons, but more general than that, is alternative to the standard approach of considering whistler wave packets as associated with nonpropagating magnetic holes resulting from a mirror-type instability.

Solitary versus shock wave acceleration in laser-plasma interactions

The excitation of nonlinear electrostatic waves, such as shock and solitons, by ultraintense laser interaction with overdense plasmas and related ion acceleration are investigated by numerical simulations. Stability of solitons and formation of shock waves is strongly dependent on the velocity distribution of ions. Monoenergetic components in ion spectra are produced by "pulsed" reflection from solitary waves. Possible relevance to recent experiments on "shock acceleration" is discussed.

Radiation-pressure-dominant acceleration: Polarization and radiation reaction effects and energy increase in three-dimensional simulations

Polarization and radiation reaction (RR) effects in the interaction of a superintense laser pulse (I>10(23) W cm-2) with a thin plasma foil are investigated with three dimensional particle-in-cell (PIC) simulations. For a linearly polarized laser pulse, strong anisotropies such as the formation of two high-energy clumps in the plane perpendicular to the propagation direction and significant radiation reactions effects are observed. On the contrary, neither anisotropies nor significant radiation reaction effects are observed using circularly polarized laser pulses, for which the maximum ion energy exceeds the value obtained in simulations of lower dimensionality. The dynamical bending of the initially flat plasma foil leads to the self-formation of a quasiparabolic shell that focuses the impinging laser pulse strongly increasing its energy and momentum densities.

New ion-wave path in the energy cascade

We present the results of kinetic numerical simulations that demonstrate the existence of a novel branch of electrostatic nonlinear waves driven by particle trapping processes. These waves have an acoustic-type dispersion with phase speed comparable to the ion thermal speed and would thus be heavily Landau damped in the linear regime. At variance with the ion-acoustic waves, this novel electrostatic branch can exist at a small but finite amplitude even for low values of the electron to ion temperature ratio. Our results provide a new interpretation of observations in space plasmas, where a significant level of electrostatic activity is observed in the high frequency region of the solar-wind turbulent spectra.

Observation of magnetized soliton remnants in the wake of intense laser pulse propagation through plasmas

Slowly evolving, regularly spaced patterns have been observed in proton projection images of plasma channels drilled by intense (≳10¹⁹ W cm⁻²) short (∼1  ps) laser pulses propagating in an ionized gas jet. The nature and geometry of the electromagnetic fields generating such patterns have been inferred by simulating the laser-plasma interaction and the following plasma evolution with a two-dimensional particle-in-cell code and the probe proton deflections by particle tracing. The analysis suggests the formation of rows of magnetized soliton remnants, with a quasistatic magnetic field associated with vortexlike electron currents resembling those of magnetic vortices.

Continuous spectrum of shear Alfvén waves within magnetic islands

The radial structure of the shear Alfvén wave continuous spectrum is calculated inside the separatrix of a magnetic island. We find that, within a magnetic island, there is a continuous spectrum very similar to that of tokamak plasmas, where a generalized safety factor q can be defined and a wide frequency gap is formed, analogous to the ellipticity induced Alfvén eigenmode gap in tokamaks. This is due to the strong eccentricity of the island cross section. In this gap, a magnetic-island induced Alfvén eigenmode (MIAE) can exist as a bound state, essentially free of continuum damping, which can be resonantly excited by energetic particles and interact nonlinearly with the magnetic island. Because of the frequency dependence of the shear Alfvén wave continuum on the magnetic-island size, the possibility of utilizing MIAE frequency scalings as a novel magnetic-island diagnostic is also discussed.

Dynamic formation of a hot field reversed configuration with improved confinement by supersonic merging of two colliding high-β compact toroids

A hot stable field-reversed configuration (FRC) has been produced in the C-2 experiment by colliding and merging two high-β plasmoids preformed by the dynamic version of field-reversed θ-pinch technology. The merging process exhibits the highest poloidal flux amplification obtained in a magnetic confinement system (over tenfold increase). Most of the kinetic energy is converted into thermal energy with total temperature (T{i}+T{e}) exceeding 0.5 keV. The final FRC state exhibits a record FRC lifetime with flux confinement approaching classical values. These findings should have significant implications for fusion research and the physics of magnetic reconnection.

Unlimited ion acceleration by radiation pressure

The energy of ions accelerated by an intense electromagnetic wave in the radiation pressure dominated regime can be greatly enhanced due to a transverse expansion of a thin target. The expansion decreases the number of accelerated ions in the irradiated region resulting in an increase in the ion energy and in the ion longitudinal velocity. In the relativistic limit, the ions become phase locked with respect to the electromagnetic wave resulting in unlimited ion energy gain.

"Light sail" acceleration reexamined

The dynamics of the acceleration of ultrathin foil targets by the radiation pressure of superintense, circularly polarized laser pulses is investigated by analytical modeling and particle-in-cell simulations. By addressing self-induced transparency and charge separation effects, it is shown that for "optimal" values of the foil thickness only a thin layer at the rear side is accelerated by radiation pressure. The simple "light sail" model gives a good estimate of the energy per nucleon, but overestimates the conversion efficiency of laser energy into monoenergetic ions.

Time window for magnetic reconnection in plasma configurations with velocity shear

It is shown that the rate of magnetic field line reconnection can be clocked by the evolution of the large-scale processes that are responsible for the formation of the current layers where reconnection can take place. In unsteady plasma configurations, such as those produced by the onset of the Kelvin-Helmholtz instability in a plasma with a velocity shear, qualitatively different magnetic structures are produced depending on how fast the reconnection process develops on the external clock set by the evolving large-scale configuration.

Numerical evidence of undriven, fast reconnection in the solar-wind interaction with earth's magnetosphere: formation of electromagnetic coherent structures

We give evidence for the first time of the onset of undriven fast, collisionless magnetic reconnection during the evolution of an initially homogeneous magnetic field advected in a sheared velocity field. We consider the interaction of the solar wind with the magnetospheric plasma at low latitude and show that reconnection takes place in the layer between adjacent vortices generated by the Kelvin-Helmholtz instability. This process generates coherent magnetic structures with a size comparable to the ion inertial scale, much smaller than the system dimensions but much larger than the electron inertial scale. These magnetic structures are further advected in the plasma in a complex pattern but remain stable over a time interval much longer than their formation time. These results can be crucial for the interpretation of satellite data showing coherent magnetic structures in the Earth's magnetosheath or the magnetotail.

Competing mechanisms of plasma transport in inhomogeneous configurations with velocity shear: the solar-wind interaction with earth's magnetosphere

Two-dimensional simulations of the Kelvin-Helmholtz instability in an inhomogeneous compressible plasma with a density gradient show that, in a transverse magnetic field configuration, the vortex pairing process and the Rayleigh-Taylor secondary instability compete during the nonlinear evolution of the vortices. Two different regimes exist depending on the value of the density jump across the velocity shear layer. These regimes have different physical signatures that can be crucial for the interpretation of satellite data of the interaction of the solar wind with the magnetospheric plasma.