Transthyretin amyloid polyneuropathy in France: A cross-sectional study with 413 patients and real-world tafamidis meglumine use (2009-2019)

OBJECTIVE

We aimed to describe characteristics of patients with ATTR variant polyneuropathy (ATTRv-PN) and ATTRv-mixed and assess the real-world use and safety profile of tafamidis meglumine 20mg.

METHODS

Thirty-eight French hospitals were invited. Patient files were reviewed to identify clinical manifestations, diagnostic methods, and treatment compliance.

RESULTS

Four hundred and thirteen patients (296 ATTRv-PN, 117 ATTRv-mixed) were analyzed. Patients were predominantly male (68.0%) with a mean age of 57.2±17.2 years. Interval between first symptom(s) and diagnosis was 3.4±4.3 years. First symptoms included sensory complaints (85.9%), dysautonomia (38.5%), motor deficits (26.4%), carpal tunnel syndrome (31.5%), shortness of breath (13.3%), and unexplained weight loss (16.0%). Mini-invasive accessory salivary gland or punch skin and nerve biopsies were most common, with a performance of 78.8-100%. TTR genetic sequencing, performed in all patients, revealed 31 TTR variants. Tafamidis meglumine was initiated in 156/214 (72.9%) ATTRv-PN patients at an early disease stage. Median treatment duration was 6.00 years in ATTRv-PN and 3.42 years in ATTRv-mixed patients. Tafamidis was well tolerated, with 20 adverse events likely related to study drug among the 336 patients.

CONCLUSION

In France, ATTRv patients are usually identified early thanks to the national network and the help of diagnosis combining genetic testing and mini-invasive biopsies.

Temporal and spatial differences in nitrogen and phosphorus biogeochemistry and ecosystem functioning of a hypertrophic lagoon (Curonian Lagoon, SE Baltic Sea) revealed via Ecological Network Analysis

In coastal lagoons, eutrophication and hydrology are interacting factors that produce distortions in biogeochemical nitrogen (N) and phosphorus (P) cycles. Such distortions affect nutrient relative availability and produce cascade consequences on primary producer's community and ecosystem functioning. In this study, the seasonal functioning of a coastal lagoon was investigated with a multielement approach, via the construction and analysis of network models. Spring and summer networks, both for N and P flows, have been simultaneously compiled for the northern transitional and southern confined area of the hypertrophic Curonian Lagoon (SE Baltic Sea). Ecological Network Analysis was applied to address the combined effect of hydrology and seasonality on biogeochemical processes. Results suggest that the ecosystem is more active and presents higher N and P fluxes in summer compared to spring, regardless of the area. Furthermore, larger internal recycling characterizes the confined compared to the transitional area, regardless of the season. The two areas differed in the fate of available nutrients. The transitional area received large riverine inputs that were mainly transferred to the sea without the conversion into primary producers' biomass. The confined area had fewer inputs but proportionally larger conversion into phytoplankton biomass. In summer, particularly in the confined area, primary production was inefficiently consumed by herbivores. Most phytoplanktonic N and P, in the confined area more than in the transitional area, were conveyed to the detritus pathway where P, more than N, was recycled, contributing to the unbalance in N:P stoichiometry and favouring N-fixing cyanobacteria over other phytoplankton groups. The findings of this study provide a comprehensive understanding of N and P circulation patterns in lagoon areas characterized by different hydrology. They also support the importance of a stoichiometric approach to trace relative differences in N and P recycling and abundance, that promote blooms, drive algal communities and whole ecosystem functioning.

The art of simplicity: Water-soluble porphyrin-like carbon dots self-assemble into mesmerizing red glow

In this new study, we present an intriguing development in the field of theranostics: the simplistic self-assembly of red-emissive amphiphilic porphyrin-like carbon dots (P-CDs). By harnessing their exceptional photophysical properties, we have revealed a strong candidate as the ideal photosensitizer (PS) for applications, particularly in the realm of imaging. Spanning a remarkable size average between 1-4 nm, these particles exhibit both highly stable and unparalleled emission characteristics between 650 and 715 nm in water in comparison to current carbon dots (CDs) available. Lastly, these CDs were fairly non-toxic when tested against normal human cell lines as well as were found to have favorable imaging capabilities in zebrafish embryo.

Accumulation and Release of Cadmium Ions in the Lichen Evernia prunastri (L.) Ach. and Wood-Derived Biochar: Implication for the Use of Biochar for Environmental Biomonitoring

Biochar (BC) boasts diverse environmental applications. However, its potential for environmental biomonitoring has, surprisingly, remained largely unexplored. This study presents a preliminary analysis of BC's potential as a biomonitor for the environmental availability of ionic Cd, utilizing the lichen Evernia prunastri (L.) Ach. as a reference organism. For this purpose, the lichen E. prunastri and two types of wood-derived biochar, biochar 1 (BC1) and biochar 2 (BC2), obtained from two anonymous producers, were investigated for their ability to accumulate, or sequester and subsequently release, Cd when exposed to Cd-depleted conditions. Samples of lichen and biochar (fractions between 2 and 4 mm) were soaked for 1 h in a solution containing deionized water (control), 10 µM, and 100 µM Cd2+ (accumulation phase). Then, 50% of the treated samples were soaked for 24 h in deionized water (depuration phase). The lichen showed a very good ability to adsorb ionic Cd, higher than the two biochar samples (more than 46.5%), and a weak ability to release the metal (ca. 6%). As compared to the lichen, BC2 showed a lower capacity for Cd accumulation (-48%) and release (ca. 3%). BC1, on the other hand, showed a slightly higher Cd accumulation capacity than BC2 (+3.6%), but a release capacity similar to that of the lichen (ca. 5%). The surface area and the cation exchange capacity of the organism and the tested materials seem to play a key role in their ability to accumulate and sequester Cd, respectively. This study suggests the potential use of BC as a (bio)monitor for the presence of PTEs in atmospheric depositions and, perhaps, water bodies.

Advancing glioblastoma imaging: Exploring the potential of organic fluorophore-based red emissive carbon dots

Over time, the interest in developing stable photosensitizers (PS) which both absorb and emit light in the red region (650 and 950 nm) has gained noticeable interest. Recently, carbon dots (CDs) have become the material of focus to act as a PS due to their high extinction coefficient, low cytotoxicity, and both high photo and thermal stability. In this work, a Federal and Drug Association (FDA) approved Near Infra-Red (NIR) organic fluorophore used for photo-imaging, indocyanine green (ICG), has been explored as a precursor to develop water-soluble red emissive CDs which possess red emission at 697 nm. Furthermore, our material was found to yield favorable red-imaging capabilities of glioblastoma stem-like cells (GSCs) meanwhile boasting low toxicity. Additionally with post modifications, our CDs have been found to have selectivity towards tumors over healthy tissue as well as crossing the blood-brain barrier (BBB) in zebrafish models.

Investigation into Red Emission and Its Applications: Solvatochromic N-Doped Red Emissive Carbon Dots with Solvent Polarity Sensing and Solid-State Fluorescent Nanocomposite Thin Films

In this work, a NIR emitting dye, p-toluenesulfonate (IR-813) was explored as a model precursor to develop red emissive carbon dots (813-CD) with solvatochromic behavior with a red-shift observed with increasing solvent polarity. The 813-CDs produced had emission peaks at 610 and 698 nm, respectively, in water with blue shifts of emission as solvent polarity decreased. Subsequently, 813-CD was synthesized with increasing nitrogen content with polyethyleneimine (PEI) to elucidate the change in band gap energy. With increased nitrogen content, the CDs produced emissions as far as 776 nm. Additionally, a CD nanocomposite polyvinylpyrrolidone (PVP) film was synthesized to assess the phenomenon of solid-state fluorescence. Furthermore, the CDs were found to have electrochemical properties to be used as an additive doping agent for PVP film coatings.

Securing wider EU commitment to the elimination of hepatitis C virus

In 2016, the Hepatitis B and C Public Policy Association (HepBCPPA), gathered all the main stakeholders in the field of hepatitis C virus (HCV) to launch the now landmark HCV Elimination Manifesto, calling for the elimination of HCV in the EU by 2030. Since then, many European countries have made progress towards HCV elimination. Multiple programmes-from the municipality level to the EU level-were launched, resulting in an overall decrease in viremic HCV infections and liver-related mortality. However, as of 2021, most countries are not on track to reach the 2030 HCV elimination targets set by the WHO. Moreover, the COVID-19 pandemic has resulted in a decrease in HCV diagnoses and fewer direct-acting antiviral treatment initiations in 2020. Diagnostic and therapeutic tools to easily diagnose and treat chronic HCV infection are now well established. Treating all patients with chronic HCV infection is more cost-saving than treating and caring for patients with liver-related complications, decompensated cirrhosis or hepatocellular carcinoma. It is more important than ever to reinforce and scale-up action towards HCV elimination. Yet, efforts urgently need the dedicated commitment of policymakers at all governmental and policy levels. Therefore, the third EU Policy Summit, held in March 2021, featured EU parliamentarians and other key decision makers to promote dialogue and take strides towards securing wider EU commitment to advance and achieve HCV elimination by 2030. We have summarized the key action points and reported the 'Call-to-Action' statement supported by all the major relevant European associations in the field.

Biogeochemical modelling of a tropical coastal area undergoing seasonal upwelling and impacted by untreated submarine outfall

A coupled 3D hydrodynamic-ecological model was applied to the Santa Marta Coastal Area (SMCA, Colombian Caribbean) to provide insights into the role of external stressors (e.g. wastewater outfall and upwelling) on the water quality and benthic - pelagic coupling. The model was calibrated and validated based on benthic metabolic measurements, satellite-derived chlorophyll-a (Chl-a) and sea surface temperature (SST) maps, field and literature water quality data. The model was able to reproduce the complex dynamics and fast transitions of temperature, nutrients, and phytoplankton, including the stratification and mixing periods during the non-upwelling (NUPW) and upwelling (UPW) seasons. Wide and fast changes in the temperatures and the highly flushed environment prevented excess phytoplankton growth and nutrient accumulation in the benthic and pelagic compartments. The model proved to be a reliable research tool to analyze the interactive effects of upwelling and untreated wastewater on the functioning of a tropical bay.

Surgical management of hip prosthetic failure in metallosis: A case series and literature review

Local and remote complications can be observed in hip prosthesis failures associated with metallosis. Structural changes in the periprosthetic bone and soft tissues may not always be precisely assessed preoperatively due to metal artifacts. The unpredictability of the damage extension, potentially leading to complex and insidious surgeries, requires the availability of alternative surgical plan(s) for the reconstruction of the joint. The aim of the study is to present and analyze, with the literature data support, practical tips for the revision of the prosthetic components, the management of ARMD and of intraoperative complications in the unusual scenario of metallosis.

Demographic characteristics of the 1902 transthyretin amyloid cardiomyopathy patients treated by tafamidis through the French early access program

Background

Transthyretin amyloidosis (ATTR) is a rare and serious, systemic disease characterized by deposits of amyloid fibrils in various tissues and organs. Tafamidis meglumine is a potent and selective stabilizer of TTR, indicated since 2011 in the treatment of neurological forms of the disease. The French “Agence Nationale de Sécurité du Médicament et des produits de santé” (ANSM) granted a temporary recommendation for use (RTU) on November 28th 2018, based on ATTR-ACT, the pivotal trial results, and designed to enable use of tafamidis meglumine in ATTR cardiomyopathy (ATTR-CM) patients with NYHA I, II and III before marketing authorization. This RTU has been a unique opportunity in France to collect real world data of ATTR-CM patients treated by tafamidis meglumine.

Objective

We aimed to describe the characteristics of ATTR-CM patient treated by tafamidis in the setting of the RTU, over 2 years from November 28th 2018 to November 27th 2020.

Methods

Demographic and clinical data about the diagnosis pathway of patients included in the RTU were prospectively collected using questionnaires, as requested by ANSM to be completed by physicians at the time of tafamidis prescription. A second version of the inclusion form, introduced in May 2020, has allowed collection of additional clinical information.

Results

Overall, 1902 ATTR-CM patients have been included by 189 physicians from 107 centers. Nine centers included each at least 50 patients, accounting for 1092, or 57.4% of all patients. The median age of the patients was 82 years (IQR=9 years), 82% were male, and, 12.4%, 58.8% and 28.7% of patients had a NYHA class of I, II and III, respectively. For almost all patients, the diagnosis of restrictive/infiltrative heart failure was based on heart MRI and/or echocardiography (98.5%; among the 601 patients included from May 2020 28.8% had both exams, 69.7% echo only and 1.6% MRI only), the infiltrative nature of the cardiomyopathy had been confirmed by bone scintigraphy (99.3%), and the absence of light chains had been confirmed by protein electrophoresis or Bence Jones proteinuria (96.6%). Genetic test was performed in 1205 patients (69.4%). Out of the 884 patients who had a genetic test result available at the time of initial prescription, 762 (86.2%) were affected with the wild-type form and 122 (13.8%) with the hereditary form. Among the 601 patients included from May 2020, a hospitalization for cardiovascular condition within the 6 months preceding tafamidis initiation was reported for 22.3% of them, and tafamidis was initiated within 12 months after diagnosis for 92% of them (only 8% initiated the treatment beyond that period).

Conclusion

The RTU program has provided 1902 ATTR-CM patients with early access to tafamidis over 24 months, in France. Overall, as compared to patients included in ATTR-ACT, the pivotal trial, RTU patients were older, the proportion of wild-type was slightly higher, and NYHA distributions were similar.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Early access program sponsored by Pfizer

Hot moments and hotspots of cyanobacteria hyperblooms in the Curonian Lagoon (SE Baltic Sea) revealed via remote sensing-based retrospective analysis

A temporally and spatially detailed historical (1985-2018) analysis of cyanobacteria blooms was performed in the Curonian Lagoon (Lithuania, Russia), the largest coastal lagoon in the Baltic Sea. Satellite data allowed the mapping of cyanobacteria surface accumulations, so-called "scums", and of chlorophyll-a concentration. The 34-year time series shows a tendency towards later occurrence (October-November) of the cyanobacteria scum presence, whereas the period of its onset (June-July) remains relatively constant. The periods when scums are present, "hot moments", have been consistently increasing in duration since 2008. The differences in the starting, ending and annual duration of cyanobacteria blooms have been significantly altered by hydro-meteorological conditions (river discharge, water temperature, and wind conditions) and their year-round patterns. The most important environmental factors that determined the temporal changes of the scum presence and area were the standing stock of cyanobacteria and the ambient wind conditions. The "hotspots", the areas where the blooms most likely occur, were distributed in the south-southwestern and central parts of the lagoon. The least affected areas were the northern part, which is connected to the coastal waters of the Baltic Sea, and the Nemunas River delta region. The longstanding, well-established spatial patterns of cyanobacteria blooms were linked to hydrodynamic features, namely water renewal time and current patterns, and to potential nutrient sources that included muddy sediments and the locations of colonies of piscivorous birds. Our findings confirmed that the annual and seasonal variations of cyanobacteria blooms and their regulation are a complex issue due to interactions between multiple factors over spatially and temporally broad scales. Despite great progress in the prevention and control of eutrophication and cyanobacteria blooms, the lagoon is still considered to be in a poor ecological status. This work provides a new and missing understanding on the spatial and temporal extent of cyanobacteria blooms and the factors that govern them. Such an understanding can help in planning management strategies, forecasting the magnitude and severity of blooms under changing nutrient loads and potential climate scenarios.

Denitrification, Nitrogen Uptake, and Organic Matter Quality Undergo Different Seasonality in Sandy and Muddy Sediments of a Turbid Estuary

The interaction between microbial communities and benthic algae as nitrogen (N) regulators in poorly illuminated sediments is scarcely investigated in the literature. The role of sediments as sources or sinks of N was analyzed in spring and summer in sandy and muddy sediments in a turbid freshwater estuary, the Curonian Lagoon, Lithuania. Seasonality in this ecosystem is strongly marked by phytoplankton community succession with diatoms dominating in spring and cyanobacteria dominating in summer. Fluxes of dissolved gas and inorganic N and rates of denitrification of water column nitrate (D_w) and of nitrate produced by nitrification (D_n) and sedimentary features, including the macromolecular quality of organic matter (OM), were measured. Shallow/sandy sites had benthic diatoms, while at deep/muddy sites, settled pelagic microalgae were found. The OM in surface sediments was always higher at muddy than at sandy sites, and biochemical analyses revealed that at muddy sites the OM nutritional value changed seasonally. In spring, sandy sediments were net autotrophic and retained N, while muddy sediments were net heterotrophic and displayed higher rates of denitrification, mostly sustained by D_w. In summer, benthic oxygen demand increased dramatically, whereas denitrification, mostly sustained by D_n, decreased in muddy and remained unchanged in sandy sediments. The ratio between denitrification and oxygen demand was significantly lower in sandy compared with muddy sediments and in summer compared with spring. Muddy sediments displayed seasonally distinct biochemical composition with a larger fraction of lipids coinciding with cyanobacteria blooms and a seasonal switch from inorganic N sink to source. Sandy sediments had similar composition in both seasons and retained inorganic N also in summer. Nitrogen uptake by microphytobenthos at sandy sites always exceeded the amount loss via denitrification, and benthic diatoms appeared to inhibit denitrification, even in the dark and under conditions of elevated N availability. In spring, denitrification attenuated N delivery from the estuary to the coastal area by nearly 35%. In summer, denitrification was comparable (~100%) with the much lower N export from the watershed, but N loss was probably offset by large rates of N-fixation.

Zebra Mussel Holobionts Fix and Recycle Nitrogen in Lagoon Sediments

Bivalves are ubiquitous filter-feeders able to alter ecosystems functions. Their impact on nitrogen (N) cycling is commonly related to their filter-feeding activity, biodeposition, and excretion. A so far understudied impact is linked to the metabolism of the associated microbiome that together with the host constitute the mussel's holobiont. Here we investigated how colonies of the invasive zebra mussel (Dreissena polymorpha) alter benthic N cycling in the shallow water sediment of the largest European lagoon (the Curonian Lagoon). A set of incubations was conducted to quantify the holobiont's impact and to quantitatively compare it with the indirect influence of the mussel on sedimentary N transformations. Zebra mussels primarily enhanced the recycling of N to the water column by releasing mineralized algal biomass in the form of ammonium and by stimulating dissimilatory nitrate reduction to ammonium (DNRA). Notably, however, not only denitrification and DNRA, but also dinitrogen (N2) fixation was measured in association with the holobiont. The diazotrophic community of the holobiont diverged substantially from that of the water column, suggesting a unique niche for N2 fixation associated with the mussels. At the densities reported in the lagoon, mussel-associated N2 fixation may account for a substantial (and so far, overlooked) source of bioavailable N. Our findings contribute to improve our understanding on the ecosystem-level impact of zebra mussel, and potentially, of its ability to adapt to and colonize oligotrophic environments.

The effects of hydrological extremes on denitrification, dissimilatory nitrate reduction to ammonium (DNRA) and mineralization in a coastal lagoon

Hydrological extremes of unusually high or low river discharge may deeply affect the biogeochemistry of coastal lagoons, but the effects are poorly explored. In this study, microbial nitrogen processes were analyzed through intact core incubations and ¹⁵N-isotope addition at three sites in the eutrophic Sacca di Goro lagoon (Northern Adriatic Sea) both under high discharge (spring) and after prolonged low discharge (late-summer) of the main freshwater inputs. Under high discharge/nitrate load, denitrification was the leading process and there was no internal recycling. The site located at the mouth of the main freshwater input and characterized by low salinity exhibited the highest denitrification rate (up to 1150 ± 81 μmol N m^-2 h^-1), mostly sustained by nitrification stimulated by burrowing macrofauna. In contrast, we recorded high internal recycling under low discharge, when denitrification dropped at all sites due to low nitrate concentrations, reduced bioturbation and nitrification. The highest recycling was measured at the sites close to the sea entrance and characterized by high salinity and particularly at the clams cultivated area (up to 1003 ± 70 μmol N m^-2 h^-1). At this site, internal recycling was sustained by ammonification of biodeposits, bivalve excretion and dissimilatory nitrate reduction to ammonium (DNRA), which represented 30% of nitrate reduction. Flash floods and high nitrate loads may overwhelm the denitrification capacity of the lagoon due to the reduced residence time and to the saturation of microbial enzymatic activity, resulting in high transport of nitrate to the sea. Prolonged dry periods favor large internal recycling, due to a combination of high temperatures, low oxygen solubility and low bioturbation, which may prolong the extent of algal blooms with negative effects on lagoon biogeochemical services. We conclude that hydrological extremes, which are expected to become more frequent under climate change scenarios, strongly alter N cycling in coastal sediments.

N2 fixation dominates nitrogen cycling in a mangrove fiddler crab holobiont

Mangrove forests are among the most productive and diverse ecosystems on the planet, despite limited nitrogen (N) availability. Under such conditions, animal-microbe associations (holobionts) are often key to ecosystem functioning. Here, we investigated the role of fiddler crabs and their carapace-associated microbial biofilm as hotspots of microbial N transformations and sources of N within the mangrove ecosystem. 16S rRNA gene and metagenomic sequencing provided evidence of a microbial biofilm dominated by Cyanobacteria, Alphaproteobacteria, Actinobacteria, and Bacteroidota with a community encoding both aerobic and anaerobic pathways of the N cycle. Dinitrogen (N₂) fixation was among the most commonly predicted process. Net N fluxes between the biofilm-covered crabs and the water and microbial N transformation rates in suspended biofilm slurries portray these holobionts as a net N₂ sink, with N₂ fixation exceeding N losses, and as a significant source of ammonium and dissolved organic N to the surrounding environment. N stable isotope natural abundances of fiddler crab carapace-associated biofilms were within the range expected for fixed N, further suggesting active microbial N₂ fixation. These results extend our knowledge on the diversity of invertebrate-microbe associations, and provide a clear example of how animal microbiota can mediate a plethora of essential biogeochemical processes in mangrove ecosystems.

Novel CAPN3 variant associated with an autosomal dominant calpainopathy

AIMS

The most common autosomal recessive limb girdle muscular dystrophy is associated with the CAPN3 gene. The exclusively recessive inheritance of this disorder has been recently challenged by the description of the recurrent variants, c.643_663del21 [p.(Ser215_Gly221del)] and c.598_612del15 [p.(Phe200_Leu204del)], associated with autosomal dominant inheritance. Our objective was to confirm the existence of autosomal dominant calpainopathies.

METHODS

Through our activity as one of the reference centres for genetic diagnosis of calpainopathies in France and the resulting collaborations through the French National Network for Rare Neuromuscular Diseases (FILNEMUS), we identified four families harbouring the same CAPN3 heterozygous variant with supposedly autosomal dominant inheritance.

RESULTS

We identified a novel dominantly inherited CAPN3 variant, c.1333G>A [p.(Gly445Arg)] in 14 affected patients from four unrelated families. The complementary phenotypic, functional and genetic findings correlate with an autosomal dominant inheritance in these families, emphasizing the existence of this novel transmission mode for calpainopathies. The mild phenotype associated with these autosomal dominant cases widens the phenotypic spectrum of calpainopathies and should therefore be considered in clinical practice.

CONCLUSIONS

We confirm the existence of autosomal dominant calpainopathies as an entity beyond the cases related to the in-frame deletions c.643_663del21 and c.598_612del15, with the identification of a novel dominantly inherited and well-documented CAPN3 missense variant, c.1333G>A [p.(Gly445Arg)]. In addition to the consequences for genetic counselling, the confirmation of an autosomal dominant transmission mode for calpainopathies underlines the importance of re-assessing other myopathies for which the inheritance is considered as strictly autosomal recessive.

Estimation of the number of HCV-positive patients in Italy

Background

HCV is one of the main causes of cirrhosis, hepatocellular carcinoma (HCC) and liver transplantation.

Aim

The aim of this study was to estimate the number of living individuals diagnosed with hepatitis C in Italy. This study also aimed to stratify these subjects as diagnosed and cured, diagnosed awaiting a cure, and undiagnosed (individuals who were not diagnosed, living or lived with hepatitis C).

Methods

To quantify the number of ill patients in Italy, an inquiry was conducted based on questionnaires submitted to three nationally representative regions, namely, Campania, Lazio and Piemonte, as representatives of the three main areas of Italy (North, Centre and South regions). The data were collected through a questionnaire to acquire demographic and clinical information on patients in the participating hospitals. The questionnaires contained 6 questions on sex, age, region of residence, disease condition, type of exemption and category. The questionnaires were administered individually to consecutive patients through face-to-face interviews conducted by specialised personnel in each centre. Data were collected between September 2017 and January 2018.

Results

In total, 2,860 questionnaires were analysed. They were completed by the patients (55% male), who had an average age of 61 years (64 years for women and 59 years for men). In total, 54% of the sample declared that they were still infected with HCV (1,548 patients out of 2,860 respondents), while the remaining subjects declared that they had been cured. The inquiry showed that 46.6% of the sample had at least a 016 exemption (chronic hepatitis), while more than 51% (1,469 interviewed patients out of 2,860 respondents) had a different type of exemption. Only 2% of the respondents declared that they had no exemption. Assuming that the analysed sample is representative of the actual HCV-positive population in Italy and considering the number of 016 exempt patients in the regional data, the model estimates that there are 443,491 cured and HCV-positive living patients and 240,043 ill patients who have yet to be treated.

Conclusions

Although this study has limitations, it represents a considerable improvement over the previously available studies. This study can help decision-makers implement more effective strategic planning to eliminate hepatitis C.

An ounce of prevention is worth a pound of cure: Managing macrophytes for nitrate mitigation in irrigated agricultural watersheds

Although ubiquitous elements of agricultural landscapes, the interest on ditches and canals as effective filters to buffer nitrate pollution has been raised only recently. The aim of the present study was to investigate the importance of in-ditch denitrification supported by emergent aquatic vegetation in the context of N budget in agricultural lands of a worldwide hotspot of nitrate contamination and eutrophication, i.e. the lowlands of the Po River basin (Northern Italy). The effectiveness of N abatement in the ditch network (>18,500 km) was evaluated by extrapolating up to the watershed reach-scale denitrification rates measured in a wide range of environmental conditions. Scenarios of variable extents of vegetation maintenance were simulated (25%, 50% and 90%), and compared to the current situation when the natural development occurs in only 5% of the ditch network length, subjected to mechanical mowing in summer. Along the typical range of nitrate availability in the Po River lowlands waterways (0.5-8 mg N L^-1), the current N removal performed by the ditch network was estimated in 3300-4900 t N yr^-1, accounting for at most 11% of the N excess from agriculture. The predicted nitrate mitigation potential would increase up to 4000-33,600 t N yr^-1 in case of vegetation maintenance in 90% of the total ditch length. Moreover, a further significant enhancement (57% on average) of this key ecosystem function would be achieved by postponing the mowing of vegetation at the end of the growing season. The simulated outcomes suggest that vegetated ditches may offer new agricultural landscape management opportunities for effectively decreasing nitrate loads in surface waters, with potential improved water quality at the watershed level and in the coastal zones. In conclusion, ditches and canals may act as metabolic regulators and providers of ecosystem services if conservative management practices of in-stream vegetation are properly implemented and coupled to hydraulic needs.

Elbow Medial Ulnar Collateral Ligament chronic isolated insufficiency: anatomical M-UCL reconstruction technique and clinical experience in a mid-term follow-up

PURPOSE

This study aims to clinically evaluate, at mid-term follow-up, a group of patients treated by the senior author in the last 6 years with our anatomical double-bundle reconstruction surgical technique for the medial ulnar collateral ligament (M-UCL) insufficiency.

METHODS

In this study, we included only patients affected by chronic valgus elbow instability, diagnosed with an accurate clinical evaluation combined with an MRI, without associated fractures that had been surgically treated in the past and without additional instability detected during the first checkup and in the preoperative evaluation under anesthesia. The nine patients enrolled were operated by the senior author between 2011 and 2014 (from 16 to 49 years old at surgery, all amateur sportsmen). The average follow-up is 4 years (47.6 months). The values of the range of movement were recorded and compared. Pain assessment was performed using the VAS scoring system. The recovery of daily activities was evaluated through the validated MEPS and Quick-DASH score scales. All patients underwent an X-ray in two standard projections and a preoperative and follow-up MRI.

RESULTS

The recovery of the range of motion was complete in six cases. The remaining three patients had minor loss of extension. None of the patients reported flexion deficits nor pronation-supination at follow-up. All patients achieved subjectively perceived stability and clinically objectified stability at follow-up. Five patients referred a total lack of pain at follow-up. Seven patients achieved full marks in the Mayo Elbow Performance Score and an excellent improvement in the Quick-DASH score.

CONCLUSIONS

Excellent functional results indicate that M-UCL isolated reconstruction with autologous hamstrings described in this study is a reliable and replicable technique with a reduced incidence of complications. Resuming sports is consistently successful in our patients.

Pleomorphic clinical spectrum of metallosis in total hip arthroplasty

PURPOSE

To summarize the biological effects of metal debris from hip arthroplasties which characterize a polymorphic clinical spectrum of local and remote manifestation.

METHODS

Retrospective study. Patient, implant, and surgical characteristics were collected, including implant survival, clinical manifestations, cause of arthroplasty revision or implant failure, and peri- and intra-operative complications. The primary endpoint was implant survivorship. Hip revision arthroplasty was decided considering clinical signs and symptoms, abnormal imaging (XR, MR, TC, echotomography, scintigraphy), and blood metal ion level. An ad hoc electronic form was used to collect demographic, epidemiological, and clinical variables. In-between group comparisons of quantitative variables were performed with the Student t test and the Mann-Whitney for parametric and non-parametric variables, respectively. Logistic regression analyses were carried out to assess the relationship between clinical and radiographic characteristics and stem and cup revision. Radiographic measurements of implant positioning validity and reliability were assessed using Krippendorff's alpha reliability coefficient. The statistical software STATA version 15 (StatsCorp, TX) was used to perform statistical computations.

RESULTS

In this MoM THA series, the most incident cause of implant failure was ARMD in 11 out of 14 (78.6%) patients. All clinical failure manifestations, revision surgery highlights, and intra-operative findings are reported.

CONCLUSIONS

The local adverse reactions include lesions of different clinical relevance from small asymptomatic soft tissue lesions to dramatic osteolysis, necrosis, effusion, and growing masses which can cause secondary pathological effects. Symptoms of systemic toxicity are rarely described but may have been largely unreported in literature. Despite the extensive literature on the topic, the patient's management is still uncertain and challenging. Every metallic implant (e.g., screws, plates, spinal instrumentations) has a potential local or systemic adverse effect. Organizing a national registry of arthroplasty should be mandatory, in order to collect data about the patients, the surgery, the implanted device (with a careful post-marketing tracking), and the follow-up for all the procedures performed at a national level. The data collected in the registry will allow to analyze the implant survival and to better recognize the undesirable and sometimes unexpected effects of different biomaterials on the whole body.

Environmental Drivers Controlling Bacterial and Archaeal Abundance in the Sediments of a Mediterranean Lagoon Ecosystem

The environmental factors controlling the abundance of Bacteria and Archaea in lagoon ecosystems are poorly understood. Here, an integrated physico-chemical, biogeochemical, and microbiological survey was applied in the Sacca di Goro lagoon (Po River Delta, Italy) to investigate the variation of bacterial and archaeal abundance, as assessed by Fluorescence In Situ Hybridization, along winter and summer environmental gradients. We hypothesised that bacterial and archaeal cells respond differentially to physico-chemical parameters of the sediment, which can be manifested in variations of total cells number. Our results suggest that Archaea are an important component of microbial communities (up to 20%) and they are also quite constant along the sediment depth investigated, while Bacteria tend to decrease in the subsurface sediments. The abiotic (i.e. temperature, ammonium, pH) and trophic parameters (i.e. chlorophyll a) explain differentially the variations of bacterial and archaeal distribution, and raise interesting questions about the ecological significance of the microbial composition in this area.

Variation in benthic metabolism and nitrogen cycling across clam aquaculture sites

As bivalve aquaculture expands globally, an understanding of how it alters nitrogen is important to minimize impacts. This study investigated nitrogen cycling associated with clam aquaculture in the Sacca di Goro, Italy (Ruditapes philipinarum) and the Eastern Shore, USA (Mercenaria mercenaria). Ammonium and dissolved oxygen fluxes were positively correlated with clam biomass; R. philippinarum consumed ~6 times more oxygen and excreted ~5 times more NH₄⁺ than M. mercenaria. There was no direct effect of clams on denitrification or dissimilatory nitrate reduction to ammonium (DNRA); rather, nitrate availability controlled the competition between these microbial pathways. Highest denitrification rates were measured at sites where both water column nitrate and nitrification were elevated due to high densities of a burrowing amphipod (Corophium sp.). DNRA exceeded denitrification where water column nitrate was low and nitrification was suppressed in highly reduced sediment, potentially due to low hydrologic flow and high clam densities.

Relationship between Clinical, MRI, and Arthroscopic Findings: A Guide to Correct Diagnosis of Meniscal Tears

Purpose  The aim of this prospective study was to compare and correlate clinical, MRI, and arthroscopic findings in cases of suspected meniscal tears. Using arthroscopic findings as the gold standard, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of clinical investigation and MRI were evaluated to determine if is possible, after a careful examination, to bypass MRI and perform directly arthroscopy in suspected cases.

Methods  A total of 80 patients with a history of knee trauma, preoperative RX, and MRI underwent arthroscopy over an 8-month period at our department. All patients had a clinical examination performed by an experienced knee surgeon. These examiners evaluated and recorded the results of three tests: medial and lateral joint line tenderness test, McMurray's test, and Apley's test. The injury was classified as a meniscal tear if there were at least two positive tests. Finally, using the arthroscopic findings as the gold standard, sensibility, specificity, accuracy, positive and negative predictive values of clinical examination, and MRI were evaluated and compared.

Results  Clinical examination performed by an experienced knee surgeon reported better sensitivity (91 vs. 85%), specificity (87 vs. 75%), accuracy (90 vs. 82%), positive predictive value (94 vs. 88%), and negative predictive value (81 vs. 71%) than MRI for medial meniscal tears. These parameters showed minimal differences for lateral meniscal tears.

Conclusion  Clinical examination performed by an experienced knee surgeon provided equal or better results to diagnose meniscal injuries in comparison to MRI. MRI is not necessary to confirm these lesions and should not be used as the primary diagnostic tool.

Level of Evidence  Level II, prospective study.

HCV - Estimation of the number of diagnosed patients eligible to the new anti-HCV therapies in Italy

OBJECTIVE

The present research wants to take a picture of the current epidemiological scenario regarding HCV infection in Italy. Studies used to estimate HCV burden of illness in Italy were so far local and performed a number of years ago, not mirroring the state of the art. EpaC wanted to provide a real number of diagnosed patients, eligible to new anti-HCV therapies.

PATIENTS AND METHODS

EpaC is the most important Italian NGO for hepatopathic patients. A number of sources were cross-checked. Starting from all regional data regarding HCV-related exemptions, a correction/integration was performed with online questionnaire to associated patients (from which we derived patients cured and also other/no exemptions); survey to all prescribing centers in Italy (from which we derived the percentage of ineligible patients); prevalence of particular subpopulations was also collected (prisoners and HIV/HCV coinfected); calculations of new diagnosed, dead and cured patients in 2015. Excluded patients were illegal immigrants and active drug addicts (subpopulations currently rarely cured).

RESULTS

A total of 221,549 patients were derived from regional exemptions databases and the mean national prevalence was 0.364%. Adding patients without exemptions/other exemptions, total was 308,624. We deducted the yearly deaths, cured and not eligible patients and, last, integrated with coinfected and prisoner special groups. Prevalence was also estimated at regional level, highlighting a reduction of the typical North-to-South prevalence gradient. Applying the above-mentioned corrections/integrations, total diagnosed and eligible HCV patients in Italy who can be immediately cured are supposed to range 163,148-187,756.

CONCLUSIONS

This is a research aimed at filling an informative gap able to provide useful actual information in terms of HCV patients real-life management and future resource allocation. These data may be considered the basis for policy- and decision-makers to plan and manage patients ready to be cured. The research does not provide information on patients not yet diagnosed.

Relationship between Damage Accrual, Disease Flares and Cumulative Drug Therapies in Juvenile-Onset Systemic Lupus Erythematosus

Our objective was to investigate the pattern of damage accumulation in patients with juvenile-onset systemic lupus erythematosus (JSLE) and the relationship between damage accrual, disease flares and cumulative drug therapies. All patients with SLE followed prospectively in three tertiary care centres were identified. Only patients who presented within 12 months of diagnosis and were followed for at least three years were included. Damage was measures based on chart review using the SLICC/ACR damage index (SDI), which was modified (M-SDI) by adding the item growth failure. Mild-moderate and severe disease flares were defined by the increase in SLEDAI-2K. The cumulative duration of drug therapies was calculated in each patient. Fifty-seven patients were included. The mean M-SDI score for the whole patient group increased over time, from 0.1 at one year to 0.8 at three years to 1.5 at five years. Ocular and renal damage and growth failure were observed most frequently. Compared to patients with stable damage, patients who accrued new damage had a significantly greater frequency of severe disease flare in the first three years of follow-up. No significant difference was observed in any cumulative drug therapy between patients who accrued damage and those who did not. Damage accrual was associated with severe disease flares, suggesting that judicious use of immunosuppressive agents to achieve prompt control of severe exacerbation of disease activity is important in minimizing damage in patients with JSLE.

Mitochondrial evidence supports a Nearctic origin for the spreading limicolous earthworm Sparganophilus tamesis Benham, 1892 (Clitellata, Sparganophilidae)

We analysed samples of Sparganophilus taken at the corners of its distribution area in Europe (UK, Germany and Italy). No mitochondrial genetic divergence within and amongst them was found, neither in COI nor in 16S. Further, the COI haplotype was also identical to two sequences from Ontario, Canada in the Barcoding of Life Data System (BOLD) database. Our European COI and 16S sequences showed only minimal differentiation (only 1 or 2 substitutions) from specimens newly collected in Illinois and Washington states (USA), as well as from a COI haplotype from Tennessee (USA) in BOLD. An additional COI haplotype from Illinois (found in BOLD) is 2.1% different from the other haplotypes but clearly belongs to the same lineage of Sparganophilus . This geographically broad but genetically compact group fits the morphological diagnosis of S. tamesis Benham, 1892 as revised by Jamieson (1971) and is seen as evidence that all European populations 1) belong to the same species, 2) derive from a recent introduction, 3) are conspecific with the most widespread species of Sparganophilus in North America, and that 4) S. tamesis is a senior synonym of S. eiseni Smith, 1895. The single European haplotype does not refute the possibility of its spread from a single introduced source population.

Clinical massively parallel sequencing for the diagnosis of myopathies

Massively parallel sequencing, otherwise known as high-throughput or next-generation sequencing, is rapidly gaining wide use in clinical practice due to possibility of simultaneous exploration of multiple genomic regions. More than 300 genes have been implicated in neuromuscular disorders, meaning that many genes need to be considered in a differential diagnosis for a patient affected with myopathy. By providing sequencing information for numerous genes at the same time, massively parallel sequencing greatly accelerates the diagnostic processes of myopathies compared to the classical "gene-after-gene" approach by Sanger sequencing. In this review, we describe multiple advantages of this powerful sequencing method for applications in myopathy diagnosis. We also outline recent studies that used this approach to discover new myopathy-causing genes and to diagnose cohorts of patients with muscular disorders. Finally, we highlight the key aspects and limitations of massively parallel sequencing that a neurologist considering this test needs to know in order to interpret the results of the test and to deal with other issues concerning the test.

Nitrogen inputs to a river course in a heavily impacted watershed: a combined hydrochemical and isotopic evaluation (Oglio River Basin, N Italy)

This study aims at evaluating sources and processes affecting NO₃(-) concentrations in the Oglio River. Five sampling campaigns considered the main watercourse, tributaries, point pollution sources, springs, and groundwater. Physico-chemical parameters, N forms, B, Sr(2+), stable isotopes (δ(2)HH₂O, δ(18)OH₂O, δ(15)NNO₃, δ(18)ONO₃, δ(11)B) and discharge were measured. Hydrological modelling was performed using mass balance and End Member Mixing Analysis equations. During the irrigation period, in the upstream reach, up to 90% of the natural river flow is diverted for irrigation and industrial purposes; excess water drained from agricultural fields is returned to river in the downstream reach. Results evidenced, in the middle reach, a large input of NO₃(-)-rich groundwater which could be quantified using hydrological modelling. Groundwater inputs are responsible for the sharp, tenfold increase in NO₃(-) in the river water, from 2.2-4.4 up to 33.5 mgL(-1), and are more evident in summer, when discharge is lower. Nevertheless, river water preserves its natural B isotopic composition, indicating that the two tracers do not have a common origin and are not co-migrant. In the lower plain, surface-groundwater interconnections and human disturbances in the water cycle favour the recycling of the compounds in the environment, and lead to a similarity in composition of the different water bodies (Oglio River, tributaries and groundwater). The long lasting agronomical practices have profoundly modified the surface-groundwater equilibrium and chemical characteristics, resulting in a highly buffered system. Infiltrating irrigation water leaches down NO₃(-) which is subsequently denitrified; when returned to the Oglio River, groundwater modifies the river water composition by dilution, in the case of NO₃(-), or by addition, for other constituents (e.g. Cl(-), B). The results of this study indicate that, in order to reduce the NO3(-) transport towards the Adriatic Sea, groundwater contamination should be addressed first, with expected long recovery times.

Nitrogen budget in a lowland coastal area within the Po River basin (northern Italy): multiple evidences of equilibrium between sources and internal sinks

Detailed studies on pollutants genesis, path and transformation are needed in agricultural catchments facing coastal areas. Here, loss of nutrients should be minimized in order to protect valuable aquatic ecosystems from eutrophication phenomena. A soil system N budget was calculated for a lowland coastal area, the Po di Volano basin (Po River Delta, Northern Italy), characterized by extremely flat topography and fine soil texture and bordering a network of lagoon ecosystems. Main features of this area are the scarce relevance of livestock farming, the intense agriculture, mainly sustained by chemical fertilizers, and the developed network of artificial canals with long water residence time. Average nitrogen input exceeds output terms by ~60 kg N ha(-1) year(-1), a relatively small amount if compared to sub-basins of the same hydrological system. Analysis of dissolved inorganic nitrogen in groundwater suggests limited vertical loss and no accumulation of this element, while a nitrogen mass balance in surface waters indicates a net and significant removal within the watershed. Our data provide multiple evidences of efficient control of the nitrogen excess in this geographical area and we speculate that denitrification in soil and in the secondary drainage system performs this ecosystemic function. Additionally, the significant difference between nitrogen input and nitrogen output loads associated to the irrigation system, which is fed by the N-rich Po River, suggests that this basin metabolizes part of the nitrogen excess produced upstream. The traditionally absent livestock farming practices and consequent low use of manure as fertilizer pose the risk of excess soil mineralization and progressive loss of denitrification capacity in this area.