Immunoglobulin free light chains in severe asthma patient: Could they be a new biomarker?

BACKGROUND

Increasing evidence is available about the presence of increased serum concentration of immunoglobulin (Ig) free light chains (FLCs) in both atopic and non-atopic inflammatory diseases, including severe asthma, providing a possible new biomarker of disease.

METHODS

We analyzed clinical and laboratory data, including FLCs, obtained from a cohort of 79 asthmatic subjects, clinically classified into different GINA steps. A control group of 40 age-matched healthy donors (HD) was considered. Particularly, HD have been selected according to the absence of monoclonal components (in order to exclude paraproteinemias), were tested for total IgE (that were in the normal ranges) and were negative for aeroallergens specific IgE. Moreover, no abnormality of common inflammatory markers (i.e., erythrocyte sedimentation rate and C-reactive protein) was detectable.

RESULTS

FLC-k levels were significantly increased in the asthmatic population, compared to the control group. Despite the absence of statistically significant differences in FLC-λ levels, the FLC-k/FLC-λ ratio displayed remarkable differences between the two groups. A positive correlation between FLC-κ and FLC-λ levels was found. FLC- λ level displayed a significant negative correlation with the FEV1 value. Moreover, the FLC-κ /FLC- λ ratio was negatively correlated with the SNOT-22 score and a positive correlation was observed between FLCs and Staphylococcus Aureus IgE enterotoxins sensitization.

CONCLUSIONS

Our findings confirmed the role of FLCs in asthma as a potential biomarker in an inflammatory disease characterized by different endotypes and phenotypes. In particular, FLC-κ and FLC-k/FLC-λ ratio could be a qualitative indicator for asthma, while FLC-λ levels could be a quantitative indicator for clinical severity parameters.

Unraveling the parahormetic mechanism underlying the health-protecting effects of grapeseed procyanidins

Proanthocyanidins (PACs), the predominant constituents within Grape Seed Extract (GSE), are intricate compounds composed of interconnected flavan-3-ol units. Renowned for their health-affirming properties, PACs offer a shield against a spectrum of inflammation associated diseases, such as diabetes, obesity, degenerations and possibly cancer. While monomeric and dimeric PACs undergo some absorption within the gastrointestinal tract, their larger oligomeric and polymeric counterparts are not bioavailable. However, higher molecular weight PACs engage with the colonic microbiota, fostering the production of bioavailable metabolites that undergo metabolic processes, culminating in the emergence of bioactive agents capable of modulating physiological processes. Within this investigation, a GSE enriched with polymeric PACs was employed to explore in detail their impact. Through comprehensive analysis, the present study unequivocally verified the gastrointestinal-mediated transformation of medium to high molecular weight polymeric PACs, thereby establishing the bioaccessibility of a principal catabolite termed 5-(3',4'-dihydroxyphenyl)-γ-valerolactone (VL). Notably, our findings, encompassing cell biology, chemistry and proteomics, converge to the proposal of the notion of the capacity of VL to activate, upon oxidation to the corresponding quinone, the nuclear factor E2-related factor 2 (Nrf2) pathway-an intricate process that incites cellular defenses and mitigates stress-induced responses, such as a challenge brought by TNFα. This mechanistic paradigm seamlessly aligns with the concept of para-hormesis, ultimately orchestrating the resilience to stress and the preservation of cellular redox equilibrium and homeostasis as benchmarks of health.

Performance Evaluation of an Immersive Virtual Reality Application for Rehabilitation after Arthroscopic Rotator Cuff Repair

Few studies have evaluated the effectiveness of shoulder rehabilitation in virtual environments. The objective of this study was to investigate the performance of a custom virtual reality application (VR app) with a stereophotogrammetric system considered the gold standard. A custom VR app was designed considering the recommended rehabilitation exercises following arthroscopic rotator cuff repair. Following the setting of the play space, the user's arm length, and height, five healthy volunteers performed four levels of rehabilitative exercises. Results for the first and second rounds of flexion and abduction displayed low total mean absolute error values and low numbers of unmet conditions. In internal and external rotation, the number of times conditions were not met was slightly higher; this was attributed to a lack of isolated shoulder movement. Data is promising, and volunteers were able to reach goal conditions more often than not. Despite positive results, more literature comparing VR applications with gold-standard clinical parameters is necessary. Nevertheless, results contribute to a body of literature that continues to encourage the application of VR to shoulder rehabilitation programs.

A new challenge for urinary free light chains: assessment of the upper reference limit in healthy subjects

OBJECTIVE

Free light chains (FLCs) can be measured in both urine (uFLC) and serum (sFLC) in immunochemistry. We aim to compare FLC levels in serum and urine assessed among healthy volunteers and measured upper reference limits (URLs) of urinary FLC to creatinine ratio (uFLC/uCr) in mg/g to compare with the manufacturer's recommended URLs.

PATIENTS AND METHODS

Eligibility criteria: normal serum and urine FLC measure and negative serum/urinary immunofixation. Immunoturbidimetry was used to assess both κ and λ FLCs. The URLs were calculated with the 97.5th percentile of uFLC concentrations according to the Clinical and Laboratory Standards Institute recommendations.

RESULTS

126 healthy subjects (median age 46 years, 62% females) met the inclusion criteria. Median concentrations of κ and λ sFLCs were similar both for males and females without significant differences. κ and λ uFLCs were significantly higher in males than in females (p < 0.001 and p = 0.004, respectively). Slower clearance for λ FLC compared to κ FLC was observed with an increased κ/λ uFLC ratio in both males and females. URLs for male and female subjects: κ uFLC mg/g uCr = 34.35 vs. 23.18, and λ uFLC mg/g uCr = 3.59 vs. 1.96, respectively compared well with manufacturer's URLs.

CONCLUSIONS

FLC catabolism is gender-dependent and occurs less rapidly in λ FLC than in κ FLC. The determination of the URL of uFLC, as uFLC/uCr, in healthy subjects in morning urine, proved to be consistent with the manufacturer's recommendations, but with a significant difference according to gender.

Preoperative and Postoperative Kinesiophobia Influences Postoperative Outcome Measures Following Anterior Cruciate Ligament Reconstruction: A Prospective Study

The anterior cruciate ligament (ACL) is the most injured ligament of the knee, and the treatment of choice is usually ACL reconstruction. Kinesiophobia refers to an irrational and paralyzing fear of movement caused by the feeling of being prone to injury or reinjury. The aim of the present study is to evaluate the relationship between preoperative and postoperative kinesiophobia with postoperative outcomes of ACL-R evaluated through SF-36, ACL-RSI, KOOS, and OKS scores. Included patients all underwent ACL reconstruction. The preoperative TSK-13 questionnaire and six-month postoperative TSK-13, ACL-RSI, SF-36, KOOS, and OKS questionnaires were assessed in included patients. Normal distribution was assessed using the Shapiro-Wilk test. The study included 50 patients who filled out the questionnaires at the 6-month postoperative follow-up. Correlations between preoperative TSK-13 and postoperative outcome measures revealed a low-moderate negative correlation between preoperative TSK-13 and SF-36 PCS at 6-month follow-up. Correlations between postoperative TSK-13 and postoperative outcome measures revealed a high negative correlation between preoperative TSK-13 and ACL-RSI, KOOS Symptoms, KOOS Pain, KOOS ADL, and OKS at 6-month follow-up. Preoperative and postoperative kinesiophobia were found to influence postoperative ACL-R outcomes negatively, more specifically an increase in kinesiophobia showed a statistically significant correlation with worse postoperative SF-36 PCS scores in patients.

Supervised versus unsupervised rehabilitation following total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Outcomes after total knee arthroplasty (TKA) are strongly influenced by the adequacy of rehabilitation and the consequent functional recovery. The economic impact of rehabilitation it is not negligible. Inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation. This topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery. The aim of this review and meta-analysis is to investigate the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA.

MATERIALS AND METHODS

Following PRISMA guideline, a comprehensive search of PubMed, Cochrane and Scopus databases using combinations of keywords and MeSH descriptors: "total "Knee replacement," "Arthroplasty", "Rehabilitation" was performed from inception to December 2021. All relevant articles were retrieved, and their bibliographies were searched for further relevant references. Only English written randomized controlled trials comparing supervised and unsupervised rehabilitation following TKA were included in this systematic review. The outcomes considered were long-term pain, physical function, knee flexion and extension ROM, 6 minute walking test (6MWT) and timed up and go test (TUG).

RESULTS

11 studies (2.181 patients in total) were included in this systematic review. The long-term pain outcome showed no significant differences (Std. Mean Difference [SMD] = 0.00, 95 % confidence interval [CI] -0.16, 0.017) between the supervised (n = 397) and unsupervised (n = 255). Physical function showed no significant differences among the two groups (mean difference [MD] = 0.84, 95 % CI = -1.82, 3.50). Non-significant differences were also found for knee ROM flexion (mean difference [MD] = -0.46, 95 % CI = -2.95, 2.04) and for knee extension (mean difference [MD] = 0.54, 95 % CI = -0.89, 1.97). At the 52-week follow-up, the unsupervised group showed significant better results in 6MWT (mean difference [MD] = -26.10, 95 % CI = -47.62, -4.59) and in Timed up and go test (mean difference [MD] = 1.33, 95 % CI = 0.50, 2.15).

CONCLUSION

This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therefore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Catecholaminergic polymorphic ventricular tachycardia: risk modulators in patients treated with beta-blockers

Background

Due to the catecholaminergic nature of arrhythmias that define the Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), beta-blockers (BBs) represent the first line therapy for this severe arrhythmogenic syndrome. Despite optimal BB therapy, a proportion of patients continue to suffer breakthrough life-threatening arrhythmias (LAE).

Purpose

To evaluate the role different classes of BBs (β1-selective vs. non-selective) in LAE reduction and to identify risk factors for breakthrough LAE while on BB monotherapy.

Methods

We studied 238 consecutive patients with CPVT and treated with BB monotherapy followed-up prospectively. CPVT was diagnosed according to the 2015 European Society of Cardiology Guidelines. The endpoint was the occurrence of the first LAE (sudden cardiac death, aborted cardiac arrest, or hemodynamically non-tolerated ventricular tachycardia) in BB monotherapy. The follow-up for each patient was calculated from BB therapy start to the occurrence of the endpoint, death from non-arrhythmic cause, the date of last visit, or the initiation of other treatments (i.e.: other antiarrhythmics or left cardiac sympathetic denervation [LCSD]), whichever occurred first.

Multivariable Cox proportional hazards model was used to evaluate the effects of history of LAE before diagnosis of CPVT, occurrence of unexplained syncope before diagnosis of CPVT, genotype, and type of BB therapy, as a time-dependent variable, on the risk of experiencing an LAE during BB monotherapy.

Results

We enrolled 238 CPVT patients (135 probands, 135 females): 226 with typical CPVT (n=216 RYR2; n=10 CASQ2) and 12 with atypical CPVT (n=5 RYR2-Loss-of-Function, n=4 TRDN and n=3 TECRL).

Prior to BB monotherapy, 48/238 (20%) patients had survived an LAE, and 110/238 (46%) patients had experienced an unexplained syncope.

During 1,629 person-years of follow-up during BB monotherapy, 35 patients experienced an LAE (annual LAE rate 2.1%, 95% CI: 1.5%–3.0%; Figure A). Five-year cumulative probability of experiencing an LAE during BB monotherapy was 11.9% (95% CI: 7.0%-16.6%). In this population, multivariable analysis showed that history of LAE before diagnosis (HR 3.6; 95% CI: 1.6–8.1; p=0.002) and syncope before diagnosis (HR 6.1; 95% CI: 2.5–14.9; p&lt;0.001) were clinical risk factors for LAE occurrence. Patients with TRDN mutations were significantly more likely to suffer LAE (HR 20.9; 95% CI: 2.2–196.3; p=0.008). Using nadolol as the gold standard, the use of β1-selective BBs (HR 3.4; 95% CI: 1.4–8.6; p=0.009), but not propranolol (HR: 0.9; 95% CI: 0.2–3.8; p=0.887), was associated with poorer outcome during BB monotherapy (Figure B).

Conclusions

In patients with CPVT, selective BBs are associated with a higher risk of LAE as compared to nadolol. Patients who have survived an LAE and/or experienced an unexplained syncope prior to diagnosis, as well as carriers of TRDN mutations are at high risk of BB failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ricerca Corrente Funding scheme of the Italian Ministry of Health and Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia).

Natural History of Patients with Typical and Atypical Catecholaminergic Polymorphic Ventricular Tachycardia

Background

Recently, a novel genetic-based classification for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) has been proposed to distinguish “typical” (RYR2 and CASQ2 genes) and “atypical” (TRDN, TECRL, CALM1–3, RYR2 loss-of-function [RYR2-LoF]) CPVT variants. Although some genetic forms were reported as malignant forms of CPVT, natural history data comparing typical and atypical CPVT variants are lacking.

Purpose

We compared the natural history of “typical” and “atypical” forms of CPVT in a large cohort of patients with genetically confirmed CPVT.

Methods

CPVT was diagnosed according to the criteria defined in the 2015 European Society of Cardiology Guidelines. Based on the genetic background, we classified the patients in two groups: 1) “Typical” CPVT (i.e., carriers of pathogenic or likely pathogenic mutations in RYR2 and CASQ2 genes); 2) “Atypical” CPVT (i.e., carriers of pathogenic or likely pathogenic mutations in TRDN, TECRL, CALM1–3 and RYR2-LoF). Patients with mutations in the CALM1, CALM2 or CALM3 were not identified in our cohort. The outcome was the occurrence of a life-threatening arrhythmic event (LAE), defined as: sudden cardiac death, aborted cardiac arrest or hemodynamically non-tolerated ventricular tachycardia. The Kaplan-Meier life-table method was used to determine the cumulative probability of experiencing a first LAE before the age of 40 years and in the absence of treatment. Outcomes in two groups were compared using the log-rank test.

Results

The study cohort included 238 patients (56% females, median age at diagnosis 14 years [IQR: 9–28 years]), of whom 226/238 (95%) patients with “typical” CPVT (216 RYR2, 10 CASQ2), and 12/238 (5%) patients with “atypical” CPVT (5 RYR2-LoF, 4 TRDN, 3 TECRL). In the entire population, the cumulative probability of experiencing a first LAE between birth and the diagnosis of CPVT was 2.3%, 21.2 and 40.8% at 5, 20, and 40 years, respectively. At any given age, the probability of a first LAE in the absence of therapy was significantly higher in patients with atypical CPVT (25%, 36%, and 100% at 5, 20, and 40 years, respectively), as compared to patients with typical CPVT (1%, 20%, and 39% at 5, 20, and 40 years, respectively; p=0.003, Figure 1). Patients with atypical CPVT suffered LAEs in early childhood (i.e., by the age of 5 years) significantly more often than patients with typical CPVT (3/5 patients [60%] in atypical CPVT vs. 2/43 patients [5%] in typical CPVT, p&lt;0.001; Figure 2).

Conclusions

The natural history of CPVT is modulated by the genetic cause. Atypical CPVT variants are rare but are characterized by a worse outcome and a greater likelihood of experiencing an LAE since the early childhood, as compared to typical CPVT.

Funding Acknowledgement

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

Efficacy and safety of the ICD in patients with catecholaminergic polymorphic ventricular tachycardia

Background

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) is a potentially fatal genetic arrhythmia syndrome and, despite optimal beta-blocker (BB) therapy, patients often experience life-threatening arrhythmic events (LAE). The role of implantable cardioverter defibrillators (ICD) on reducing mortality in patients with CPVT is debated.

Purpose

1) To assess the survival benefit of ICD in the overall CPVT population; 2) to investigate the benefit-to-harm ratio in the population of CPVT patients carriers of ICD.

Methods

We followed-up consecutive patients with genetically-proven CPVT, treated with optimal BB mono-therapy. The probability of surviving at the occurrence of a first LAE (defined as: sudden cardiac death, aborted cardiac arrest or hemodynamically non-tolerated ventricular tachycardia) during BB mono-therapy was compared between ICD carriers and non-ICD carriers.

In the cohort of ICD carriers, we assessed the rate of a first major complication (i.e., a complication requiring surgical intervention) and we calculated the benefit-to-harm ratio of ICD (defined as rate of appropriate shocks on LAE over rate of major complications).

Results

We enrolled 228 CPVT patients with a pathogenic RYR2 (n=216) or CASQ2 (n=12) mutation, of whom 87 (38%) had an ICD implanted. Overall, during 1,558 person-years of follow-up, 31/228 (14%) patients experienced a first LAE on BB mono-therapy (annual LAE rate 2.0%, 95% CI: 1.4–2.8%).

Of the 31 individuals who experienced an LAE, 21 patients had an ICD when the LAE occurred, and all survived after ICD intervention. Of the remaining 10 patients who were not carriers of an ICD, 6/10 (60%) survived after external defibrillation or spontaneous arrhythmia termination, while 4/10 (40%) died suddenly. The probability of surviving at the occurrence of a first LAE in BB mono-therapy was thirty-fold higher (Odds Ratio: 30.0, 95% CI: 1.4–629.0; p=0.029) in patients with an ICD, as compared to patients without an ICD.

Overall, 15/87 (17%) patients with an ICD experienced a first major complication over 602 person-years of follow-up (2.5% per year, 95% CI: 1.4%-4.1%). Importantly, no patient died for a pro-arrhythmic effect or complications related to ICD. Comparing the rate of major complications to the rate of appropriate ICD shocks on LAE (LAE rate 4.7% per year, 95% CI: 3.1–7.0%), the benefit-to-harm ratio was 1.9, thus favouring the benefit of ICD therapy.

Conclusions

In our population, ICD therapy conferred a significant survival benefit in patients with CPVT at the occurrence of a first LAE. Overall, the benefit of ICD implant outweighed the harm, as shown by almost two times greater benefit-to-harm ratio. This study provides evidence supporting ICD implantation in patients with high-risk CPVT.

Funding Acknowledgement

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

The dark side of current analytic methods for Bence Jones Proteinuria

OBJECTIVE

Bence Jones proteinuria (BJP) refers to monoclonal free immunoglobulin light chains detected in urine, deriving from the clonal expansion of plasma cells in the bone marrow in patients with plasma cell dyscrasias, associated with monoclonal gammopathies of uncertain origin. This review summarizes routinely diagnostic procedures to assess BJP highlighting critical steps of pre-analytical, analytical, and post-analytical phases.

QUALITATIVE AND QUANTITATIVE METHODS

The best option for BJP detection is the first morning void urine sample and immunofixation electrophoresis detection technique (IFE) the recommended method, with the employment of specific polyvalent antisera. Other qualitative tests for a quick evaluation of BJP are currently available. Densitometric analysis performed on the 24-hour urine is the recommended method to quantify BJP. To overcome the 24-hour collection, it is possible to use morning urine sample and correlate the assessed value of BJP to creatininuria. In addition to the traditional ones, we here reviewed screening methods currently used to avoid false negatives and reduce the time around test (TAT), together with immunochemical quantification methods for increased sensitivity, after checking BJP by IFE. Mass spectrometry emerges as a new challenge in the determination of BJP.

CONCLUSIONS

The employment of different based-assays methods may be useful for diagnostic purposes to improve the accuracy of BJP monitoring in monoclonal gammopathies.

AB1347 ASYMPTOMATIC SACROILIITIS DETECTED BY MAGNETIC RESONANCE ENTEROGRAPHY IN PATIENTS AFFECTED BY CROHN’S DISEASE: PREVALENCE AND ASSOCIATION WITH CLINICAL DATA IN A MULTICENTER STUDY OF ADULT AND PEDIATRIC POPULATION

Background

Magnetic resonance enterography (MRE) is usually performed in patients with Crohn’s disease (CD) for evaluating small bowel involvement. Inflammatory bowel disease (IBD) mainly affect the gastrointestinal tract, although patients may present extraintestinal manifestations (1). Musculoskeletal symptoms are the most frequent extraintestinal manifestation in IBD, especially in CD. Furthermore, sacroiliitis at imaging occurs in about 6-46% of CD patients and may correlate with axial spondyloarthritis (2,3).

Objectives

The primary aim of our study was to assess the prevalence of sacroiliitis in adult and pediatric patients affected by CD who performed MRE. We also evaluated the inter-rater agreement for MRE sacroiliitis and the association between sacroiliitis and patients’ clinical data.

Methods

We included consecutive patients with CD diagnosis (4), who underwent an MRE in the period between December 2012 and May 2020. We excluded patients with a known diagnosis of SpA; patients with confirmed or suspected inflammatory back pain; and patients treated at the time of MRE with systemic Disease-Modifying Antirheumatic Drugs (DMARDs), which influence both bowel and joint disease (i.e., conventional DMARDs, and biologic DMARDs).

Two radiologists assessed the prevalence of sacroiliitis at MRE. We evaluated the inter-rater agreement for sacroiliitis and assessed the correlation between sacroiliitis and demographic, clinical, and endoscopic data.

Results

We retrospectively identified 100 adult and 30 pediatric patients. The prevalence of sacroiliitis at MRE was 20% in adults and 6.7% in pediatric patients. The inter-rater agreement for sacroiliitis was substantial (k=0.62, p<0.001) in the adults, and moderate (k=0.46, p=0.011) in the pediatric cohort. Age ≥50 years and the time between CD diagnosis and MRE (≥86.5 months) were significantly associated with sacroiliitis in adult patients (p=0.049 and p=0.038, respectively).

Conclusion

Asymptomatic sacroiliitis at MRE is a frequent and reliable abnormality in adult patients with CD, associated with age of the patients ≥ 50 years and CD duration. Detecting sacroiliitis at MRE in patients affected by CD may help the appropriate and early referral to the rheumatologist.

References

[1]Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflammatory Bowel Diseases. 2015 Aug 1;21(8):1982–92.

[2]Salvarani C, Fries W. Clinical features and epidemiology of spondyloarthritides associated with inflammatory bowel disease. World J Gastroenterol. 2009 May 28;15(20):2449–55.

[3]Fragoulis GE, Liava C, Daoussis D, Akriviadis E, Garyfallos A, Dimitroulas T. Inflammatory bowel diseases and spondyloarthropathies: From pathogenesis to treatment. World J Gastroenterol. 2019 May 14;25(18):2162–76.

[4]Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. Journal of Crohn’s and Colitis. 2019 Feb 1;13(2):144–64.

Disclosure of Interests

Ivan Giovannini Speakers bureau: not relevant for this study, Lorenzo Cereser: None declared, Ilaria Tinazzi: None declared, Carmelo Cicciò: None declared, Floria Maria Murru: None declared, Matteo Bramuzzo Speakers bureau: not relevant for this study, Marco Marino Speakers bureau: not relevant for this study, Annarita Tullio: None declared, Salvatore De Vita Speakers bureau: not relevant for this study, Alen Zabotti Speakers bureau: not relevant for this study

Exploring the association between specific genes and the onset of idiopathic scoliosis: a systematic review

Background

Idiopathic Scoliosis (IS) is the most common spinal deformity in adolescents, accounting for 80% of all spinal deformities. However, the etiology remains uncertain in most cases, being identified as Adolescent Idiopathic Scoliosis (AIS). IS treatments range from observation and sport to bracing or surgery. Several risk factors including sex and familiarity, have been linked with IS. Although there are still many uncertainties regarding the cause of this pathology, several studies report a greater incidence of the defect in families in which at least one other first degree relative is affected. This study systematically reviews the available literature to identify the most significant genes or variants related to the development and onset of IS.

Methods

The research question was formulated using a PIOS approach on the following databases: Medline, Embase, Cinahl, Scopus, Web of Science and Google Scholar. The search was performed from July to August 2021, and articles from the inception of the database to August 2021 were searched.

Results

24 of the 919 initially identified studies were included in the present review. The 24 included studies observed a total of 16,316 cases and 81,567 controls. All the considered studies stated either the affected gene and/or specific SNPs. CHD7, SH2B1, ESR, CALM1, LBX1, MATN1, CHL1, FBN1 and FBN2 genes were associated with IS development.

Conclusions

Although association can be found in some candidate genes the field of research regarding genetic association with the onset of IS still requires more information.

Prenatal Diagnosis of Clubfoot: Where Are We Now? Systematic Review and Meta-Analysis

The primary methods for prenatal diagnosis of Clubfoot are ultrasound (US) and magnetic resonance imaging (MRI). An ultrasound is performed between the 1st trimester and the 28th week of pregnancy and it is reported to be used as a diagnostic method alone or in combination with MRI. So far, an international consensus on the most effective screening method has not been reached. This systematic review and meta-analysis were performed to establish the most effective and reliable exam for prenatal diagnosis of Clubfoot. The literature search was conducted using a PIOS-approach from May 2021 to June 2021. Studies reporting cases of prenatal diagnosis of Clubfoot made through US and MRI conducted from January 2010 to June 2021 were included in the study and reviewed by 2 authors. The 23 selected studies included 2318 patients. A total of 11 of the studies included details on the accuracy, while the rest were used to obtain information about the primary methodology utilized. In all the selected studies, US was used as the primary diagnostic instrument. Thirteen of the studies used the US exclusively, while three used MRI in addition to US and seven performed karyotyping after US diagnosis. The US has been shown to be the instrument of choice for the prenatal diagnosis of Clubfoot. International guidelines for an ultrasonography classification of congenital clubfoot are required to reduce the inter-variability accuracy of this procedure.

Pervasive refusal syndrome or anorexia nervosa: a case report with a successful behavioural treatment

PURPOSE

Pervasive refusal syndrome (PRS) is a rare psychiatric disease that affects children. It was first described by Lask in 1991 (Arch Dis Child 66:866-869, 1991). Recently, Otasowie and Collaborators reported a systematic review about PRS. Despite this, PRS has not yet been classified in DSM-5 and ICD-11 and the lack of evidence-based treatment makes this syndrome a real challenge for clinicians. The aim of this paper is to present our experience through the description of a case report and its treatment.

METHODS AND RESULTS

The case reported is a girl aged 11 years that fits the clinical picture described in the literature of PRS. In previous reports, behavioural treatment was not used or appreciated; our case adds new knowledge regarding the PRS diagnosis and the successful behavioural treatment during hospitalization, which we describe in all its phases.

CONCLUSION

PRS is a rare, life-threatening syndrome; it would be extremely important to have an official and evidence-based treatment guide.

LEVEL OF EVIDENCE

Level V, case report.

The diagnostic performance of PIVKA-II in metabolic and viral hepatocellular carcinoma: a pilot study

OBJECTIVE

Hepatocellular carcinoma (HCC) is a primary liver tumor derived from metabolic or viral chronic hepatitis, with few treatment options in advanced cases. New biomarkers that allow improving diagnosis and staging are widely desired. Here, we aim to evaluate the performance of Protein Induced by Vitamin K Absence or Antagonist-II (PIVKA-II) in combination with α-fetoprotein (AFP), in the diagnosis of HCC in patients with metabolic or viral hepatitis.

PATIENTS AND METHODS

We enrolled 60 HCC patients (20 metabolic and 40 viral) and 20 healthy subjects (HS) as negative controls. PIVKA-II, AFP, Matrix metalloproteinase-9 (MMP-9) and Fibroblast growth factor (FGF) serum levels were assessed by immunoassays.

RESULTS

AFP and PIVKA-II levels were obviously higher in patients than in HS. AFP displayed a better diagnostic performance than PIVKA-II for viral HCC while PIVKA-II was better for metabolic HCC. The combination of the two biomarkers did not improve the discriminating ability.

CONCLUSIONS

PIVKA-II may be considered an independent predictor of macrovascular invasion from HCC cells and it can be used to better stratify HCC patients and should be evaluated in prospective studies for early detection of advanced HCC in metabolic subjects.

Lack of association between Vitamin D status and free light chains profile with different chronic HCV-related liver and extrahepatic disorders

OBJECTIVE

A still uncertain association between vitamin D levels and HCV chronic liver diseases has been reported. Increased levels of serum-free light chains (FLCs) and an altered k/λ FLC ratio correlate with Mixed Cryoglobulinemia (MC) vasculitis and/or B-cell non-Hodgkin's lymphoma in HCV-positive patients. We aimed to investigate the possible role of vitamin D, vitamin D Binding Protein (DBP), and FLCs levels as a tool for discriminating different stages of HCV- related MC and chronic liver diseases.

PATIENTS AND METHODS

Sixty-five untreated patients were retrospectively enrolled and 21 healthy blood donors (HBD) were used as controls. Vitamin D, DBP, FLCs, and cryoglobulins levels were measured. Based on cryoglobulins, patients were divided in three subgroups (without cryoglobulins, type II, and type III).

RESULTS

We didn't find any significant differences in vitamin D and DBP levels between HCV patients' main groups and HBD. Serum FLCs levels were significantly higher in HCV patients than in HBD. FLCs ratio among patients' subgroups did not reveal differences.

CONCLUSIONS

Our results confirm the presence of an increased serum level of FLCs in HCV patients and suggest that nor vitamin D and DBP or FLC levels can be considered reliable biomarkers for discriminating different stages of HCV-associated chronic liver diseases and/or HCV-associated extrahepatic manifestation. We confirm that serological FLCs levels are significantly higher in patients than in HBD as a signature of B cell activation in course of HCV infection.

Is mexiletine ready for prime time in patients with Type 2 Long QT Syndrome?

Background

Mexiletine has been proven effective in shortening the duration of ventricular repolarization and reducing the arrhythmic events in type 3 Long QT Syndrome (LQT3). Initial reports indicate that mexiletine might also be effective in patients with type 2 Long QT Syndrome (LQT2, caused by loss-of-functions variants on KCNH2 gene, coding for HERG potassium channel), but this issue has not been investigated in detail.

Purpose

We quantified the electrocardiographic (ECG) effects of mexiletine in a cohort of LQT2 patients.

Methods

Twelve-lead ECGs were collected before and after the administration of mexiletine to evaluate the drug's effect on the heart rate-corrected QT interval (QTc). QTc intervals were classified as being (1) at “high-risk” if &gt;500 ms or (2) “normal” if &lt;460 ms, before and after the administration of the drug. KCNH2 variants were defined as (1) trafficking-deficient or (2) non-trafficking-deficient, based on functional studies.

Results

We tested the maximum tolerated dose of mexiletine in 20 patients (11 males, 55%), who were 17±16 years old at diagnosis, affected by genetically established LQT2. The mean age at the beginning of mexiletine administration was 23±15 years and the mean daily dose administered was 9±2 mg/kg/day.

Before mexiletine, the mean QTc interval was 527±53 ms and 10/20 (50%) patients had high-risk QTc values (i.e. QTc &gt;500 ms).

After mexiletine, the mean QTc interval shortened to 484±47 ms in the overall population (p=0.001). In the majority of patients (18/20, 90%; Figure 1) QTc interval shortened, with a mean shortening of 42±28 ms, and a high-interindividual variability (range of shortening from 86 ms to 8 ms). Just 2 (10%) patients did not show any reduction of the QTc, despite receiving the highest adult dosages of mexiletine in our cohort (up to 10 mg/kg/day).

As compared to baseline conditions, after mexiletine the proportion of patients with high risk QTc values (&gt;500 ms) decreased non-significantly from 50% to 35% (p=0.52). Furthermore, in only 6/20 (30%) patients the QTc normalized (i.e. QTc &lt;460 ms) after the initiation of treatment.

The effect of mexiletine was not influenced by gender (p=0.89) or by the functional effect of the KCNH2 mutation (trafficking-deficient vs. non-trafficking-deficient variants, p=0.41).

The effect of mexiletine in LQT2 patients was inferior to the one previously observed in a cohort of 34 LQT3 patients, who had similar QTc values at baseline and received similar dosages of mexiletine, but showed a significantly higher reduction of the average QTc interval (63±37 ms in LQT3 vs. 42±28 ms in LQT2, p=0.02).

Conclusions

Mexiletine induces a reduction of the QTc interval in most LQT2 patients, but many patients remain with high-risk QTc values after receiving the drug. The demonstration that an average QTc shortening of 42 ms is enough to reduce arrhythmic events is necessary, before the introduction of mexiletine in clinical practice for LQT2.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia)

Automated screening tool for Subcutaneous Implantable Defibrillator in Brugada syndrome has a high eligibility rate which is predicted by simple electrocardiographic parameters

Background

Manual electrocardiographic (ECG) screening tools for the use of subcutaneous cardiac defibrillator (S-ICD) have been associated with high ineligibility rates in Brugada syndrome patients (BrS). Although recent works identified ECG parameters for S-ICD eligibility in general population, automated screening tool (AST) for S-ICD eligibility have not even been assessed in large series of patients with BrS.

Purpose

This study evaluates the AST-derived eligibility rates for an S-ICD in patients with BrS, and ECG parameters associated with S-ICD eligibility.

Methods

Screening for S-ICD eligibility was performed using AST in 194 consecutive patients with BrS. Eligibility was defined when at least one of the three vectors was acceptable both in supine and standing position. Twelve-lead ECGs were registered during the screening. ECG parameters associated with AST eligibility were identified using multivariable logistical regression.

Results

Our study population consisted of 194 patients, with male preponderance (n=165/194; 85%); and were 43±12 years old at the time of screening. Majority of patients presented a spontaneous type 1 pattern during screening (n=128/194; 66%), with an average pattern height of 3±3 mm.

Remarkably, 93% of patients passed the screening with AST. No differences in eligibility rates in terms of gender (93% males vs. 93% females eligible; p=1) and age (48±9 years non-eligible vs. 42±12 eligible; p=0.07) existed. Notably, our eligibility rate was 2.5 times higher than rates reported in literature when using manual screening tools (p=0.023). Independent 12-lead ECG parameters (Table) associated with AST eligibility were duration of S wave &lt;80 ms in aVF and R/T ratio ≥3 in lead II (Figure), which have a high positive predictive value (97% and 99%, respectively) for screening eligibility.

Conclusions

Most BrS patients (93%) are eligible for S-ICD when AST is used. S wave &lt;80 ms in aVF, and R/T ratio ≥3 in lead II have a high positive predictive value for S-ICD eligibility.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia)

Characterization of arrhythmic presentation in patients with arrhythmogenic cardiomyopathy

Background/Introduction

Arrhythmogenic cardiomyopathy (ACM) is one of the most arrhythmogenic conditions known to man. ACM is caused by desmosomal mutations in most cases, resulting in progressive replacement of the myocardium by adipose and fibrous tissue. It comes as no surprise that ACM is one of the leading causes of sudden cardiac death (SCD). Nonetheless, the characteristics of arrhythmic manifestations have not dissected after the release of most recent criteria.

Purpose

This study investigates different types of ventricular tachyarrhythmias which had occurred at first arrhythmic event in patients with ACM.

Methods

We investigated 91 consecutive patients with documented evidence of sustained ventricular tachyarrhythmias from 291 ACM patients followed at our center up to this date. Diagnosis of ACM was made using 2010 Task Force Criteria, and patients were defined as having an advanced disease if they had more than 4 TFC points at diagnosis. Presenting ventricular tachyarrhythmias were divided into (1) life-threatening arrhythmic event (LAE; ventricular fibrillation or hemodynamically unstable polymorphic ventricular tachycardia) and (2) hemodynamically stable monomorphic ventricular tachycardia (MMVT). Right ventricular (RV) involvement was defined as a presence of RV wall motion abnormalities and RV dilation at transthoracic echocardiography or cardiac magnetic resonance.

Results

Our study population was constituted of a predictably higher number of males (n=68; 75%), with an average age at the first arrhythmic event of 38±15 years of age.

At first documented arrhythmia, majority of patients studied experienced a stable MMVT (n=53; 58%), while 38 patients experienced an LAE (n=38; 42%). The patients suffering an LAE as first arrhythmic event were slightly younger than the patients who experienced a stable MMVT (35±14 years vs. 40±15 years; p=0.076) but there were no statistically significant gender differences (28/38 males with LAE vs. 40/53 males with stable MMVT; p= n.s.).

Interestingly, patients who presented with stable MMVT were more likely to have an advanced disease at diagnosis (OR=6.52; 95% CI 2.02–20.99; p=0.002). This is supported by the fact that RV involvement was significantly more common in patients presenting with stable MMVT (OR=4.38; 95% CI 1.26–15.26; p=0.021). Additionally, patients with stable MMVT were more commonly carriers of variants on PKP2 gene (OR=3.6; 95% CI 1.1–11.91; p=0.021).

Conclusions

Our data suggest that two types of arrhythmia reflect the two different stages of the disease. The early stage of the ACM is characterized by LAE in absence of RV structural involvement; while, stable MMVT is typical of PKP2 carriers and advanced stage of ACM with RV involvement.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia)

Mutation site-specific risk profile in patients with Type 1 Long QT Syndrome

Background

Type 1 Long QT Syndrome (LQT1) is an arrhythmogenic disorder, caused by loss-of-function mutations on KCNQ1 gene, coding for Kv7.1 potassium channel. Although LQT1 is described as the most benign form of LQTS, patients still experience arrhythmic events and there is an unmet need for personalized risk stratification. Attempts have been made to correlate the location of mutations with outcome, but the results are unequivocal.

Purpose

We provide in the present study a new mutation site-specific risk profile obtained from a large cohort of LQT1 patients.

Methods

We gathered data on 963 patients with the diagnosis of LQT1 and divided the Kv7.1 channel into 5 functional regions: the N-terminus (NT), the voltage sensor (VS, including transmembrane segments S1 to S4), the cytoplasmic loops (CL), the pore (PO, including the transmembrane segments S5, S6 and the S5-S6 extracellular linker), the C-terminus (CT).

Results

We studied 963 LQT1 patients: 518 (54%) females; average age 20±17 years; mean QTc at baseline ECG 465±38ms. During a mean follow-up of 8±7 years, 172 (18%) patients experienced arrhythmic events: 31 (3%) experienced one or more cardiac arrests, while 141 (15%) experienced one or more syncopal spells. We identified 188 different variants in the KCNQ1 gene, with the following distribution: 15 (8%) in the NT, 33 (18%) in the VS, 27 (14%) in the CL, 43 (23%) in the PO, 70 (37%) in the CT. The frequency of pathogenic variants per number of amino acids (a.a.) was higher in the CL region, as compared to the other domains (1 mutation every 1.4 a.a.). The duration of QTc interval was significantly longer for patients with mutations in the PO region (473±40 ms) and in the CL region (468±38 ms) as compared to the other regions (p&lt;0.01).

Importantly, in a multivariate analysis PO and CL regions were associated with a higher probability of experiencing arrhythmic events (OR 2.89, 95% CI 1.95–4.29, p=0.019 and OR 1.61, 95% CI 1.0–2.49, p=0.05, respectively. Figure) than the other regions. Interestingly, the risk was independent from QTc interval duration.

Conclusions

Mutations affecting the PO and the CL region of the Kv7.1. channel are associated with a higher probability of experiencing arrhythmic events. This finding is clinically relevant, because it will allow for a more personalized, mutation site-specific risk stratification.

Mutation site and arrhythmic events

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia)

A novel biomarker score for the screening and management of patients with plasma cell proliferative disorders

OBJECTIVE

Monoclonal plasma cell proliferative disorders comprise a wide spectrum of diseases associated to clonal B-cell expansion. Serum protein electrophoretic profile (SPEP) and circulating free light chains (FLCs) levels are the mainstay of diseases management. Recently, soluble (s) Syndecan-1 (SDC1, CD138) produced by myeloma plasma cells has been suggested in the monitoring and follow-up of patients with myeloma. The aim of our study is to evaluate sCD138 in addition with FLCs and SPEP for the screening of patients with different evolutive disease pathways.

PATIENTS AND METHODS

Sera from 73 patients with monoclonal gammopathy of undetermined significance (MGUS), 120 smoldering and 42 multiple myeloma (SMM and MM, respectively), 70 HCV-related mixed cryoglobulinemia (MC), 35 B-cell non-Hodgkin's lymphoma (B-NHL) and sera from 50 healthy donors (HD), were tested for sCD138, FLCs (assessed by means of ELISA and turbidimetric assay, respectively) and electrophoresis pattern (performed on Capillarys system) for the generation of a novel biomarker score (BS).

RESULTS

Our results were grouped according to the two main lines of disease progression (vs. MM or B-NHL): in one group we found BS mean values of 0.2, 3.4, 5.3, 7.1 for HD, MGUS, SMM and MM, respectively; in the other group of 0.2, 4.4, 6.7 for HD, MC and B-NHL.

CONCLUSIONS

We showed that BS mean values follow the ingravescence disease status towards the two main lines of progression to cancerous conditions; it could represent an additional useful tool in the management of screening and/or follow-up.

Biomarkers in HCV-related mixed cryoglobulinemia patients withnon-Hodgkin lymphoma

OBJECTIVE

Chronic Hepatitis C virus (HCV) infection can cause severe extrahepatic manifestations, such as mixed cryoglobulins (MC), up to the development of B cell nonHodgkin's lymphoma (B-NHL). Mechanisms transforming of HCV infection into lymphoproliferative and/or autoimmune disorders are still poorly understood. In course of HCV infection, the sustained virus-driven antigenic stimulation may probably induce a B-cell clonal expansion. Measurements of serum free light chains (FLCs) levels, considered as a direct marker of B cell activity, are analyzed with increasing interest in clinical practice, for diagnosis, monitoring and follow-up of plasma cell dyscrasia. Syndecan-1 (CD138) is a transmembrane heparan sulfate proteoglycan expressed and actively shed by most myeloma cells. Membrane CD138 represents the major receptor protein for HCV attachment to the hepatocyte surface and high levels of circulating sCD138 levels are detected in patients at early stage of B-cell chronic lymphocytic leukemia. This study is aimed to evaluate sCD138 and FLC levels as diagnostic biomarkers of HCV-related MC with B-NHL.

PATIENTS AND METHODS

We enrolled 35 HCV-MC-NHL patients, characterized for the specific type of cryoglobulins, and 25 healthy blood donors (HBD) as negative control. Serum sCD138 levels were determined using ELISA kits specific for human sCD138. Serum FLCs were assessed by means of the turbidimetric assay.

RESULTS

We found that serum levels of sCD138, as well as FLCs, were significantly higher in patients than in HBD (p<0.001).

CONCLUSIONS

In agreement with the definition of HCV-driven lymphoproliferative disorders as the consequence of a multifactorial and multistep pathogenetic process, we suggest that sCD138 and FLCs could be considered putative independent markers of worsening progression of the disease.

The PRECEDE-PROCEED model as a tool in Public Health screening: a systematic review

OBJETCTIVE

The aim of this systematic review was to summarize the scientific literature concerning the use of the Precede-Proceed model (PPM) applied to educational programs and health screenings contextsV.

STUDY DESIGN

Systematic review.

METHODS

The search process was based on a selection of publications listed in Medline and Scopus. The keywords used were "Precede-Proceed" AND ("screening" OR "educational programs"). Studies included in the systematic review were subdivided into those applying the model in a screening context, and those applying it within educational programs.

RESULTS

Twenty-seven studies were retrieved, mostly performed in the USA and, generally, the promoting center was the University. In the context of cancer screening, the PPM model was most of all applied to Mammography Screening (5 of 13 studies in cancer screening), and Cervical Cancer Screening (5 of 13). Another three studies within the cancer field investigated Menopause-Inducing Cancer Treatments, Oral cancer prevention, and cancer screening in general. In the remaining studies, the model was applied in various screening areas, particularly chronic and degenerative diseases. There were many different study designs, most of which cross-sectional (8), though several RTCs (8) and focus groups (5) were also found. For the cross-sectional studies the methodological quality varied between 3/10 and 9/10, whilst for the RCTs it ranged from 2/5 to 3/5.

CONCLUSIONS

The PPM provides an excellent framework for health intervention programs especially in screening contexts, and could improve the understanding of the relationship between variables such as knowledge and screening. Given the complexity of a behavioral change process, certain important predisposing factors could be measured in future studies, and during health intervention planning.

Visceral and subcutaneous adipose tissue as markers of local and systemic inflammation: a comparison between celiac and obese patients using MRI

BACKGROUND

Celiac disease (CD) is a systemic inflammatory disease, which primarily affects the gastrointestinal tract. It has been recently demonstrated that adipose-tissue infiltration by proinflammatory immune cells causes a chronic low-grade inflammation in obese patients. Magnetic resonance imaging (MRI) has already proved to be useful in evaluation of inflammatory states. The aim of the present study was to determine whether alterations of visceral and subcutaneous adipose tissue, identified with MRI, could serve as markers of local and systemic inflammation in patients with CD.

METHODS

A pilot study was conducted comparing alterations in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) in CD patients vs obese patients and healthy controls. Fifty patients were enrolled and assigned to one of the following groups: Group A: 11 active CD patients; Group B: 11 CD patients in remission; Group C: 16 obese patients; Group D: 12 healthy controls. A 3-T MRI unit was used and T2-weighted TSE images of VAT and SAT were obtained in specific regions of interest. Serum cytokine concentrations (TNF-α, IL-6, adiponectin, leptin, IL-2, IFN-γ) were determined.

RESULTS

There was a significant difference in VAT T2 relaxation time between Group A and B (p < 0.001), A and D (p < 0.01), B and C (p < 0.001). There was a statistically significant difference in SAT T2 relaxation time between Group A and B (p < 0.001), A and C (p < 0.05), A and D (p < 0.001), B and C (p < 0.01). In addition, VAT/SAT T2 relaxation time ratio showed a statistically significant difference between Group A and C (p < 0.05) and between Group B and C (p < 0.01). Only TNF-α and IL-6 significantly correlated with both VAT and VAT/SAT ratio in active CD.

CONCLUSIONS

MRI showed similar increased visceral inflammatory signals in patients with active CD and obese patients. However, subcutaneous inflammatory signals were higher in active CD than in all the other groups. These data show that there is a systemic inflammatory state in active CD, whereas chronic inflammation appears confined to VAT in obesity. These data were only partially confirmed by serological cytokine profiles, which showed less specificity than MRI.

Injury narratives in occupational safety and health prevention in Italy

BACKGROUND

Storytelling is an effective information source when coupled with technical-scientific evidence. It can promote a structured relationship between evidence-based knowledge and field experience of workplace safety and prevention services (WSPS) inspectors. This is key to identifying the causes of workplace injuries and to set priorities for prevention strategies.

AIMS

The main aim was to describe and report how story collection can be used for deriving validated indications for injury prevention. The specific objectives were to report the results of the creation and dissemination on the web of the story collection and the experience of setting up a community of practice (CoP) to develop preventive recommendations.

METHODS

WSPS inspectors from local health boards in Piedmont (northwest Italy) were asked to write injury stories. They identified the key elements of their stories and developed a narrative of witness accounts to explore the critical issues identified during the investigation. In sessions with the CoP, the inspectors validated the indications for prevention elaborated in each story to reduce bias and standardize recommendations.

RESULTS

Between 2012 and 2017, 60 WSPS inspectors wrote 53 injury stories which were collected and published on the institutional website. Twenty-two stories were selected for discussion during peer review sessions in the CoP and the indications for prevention were transformed as preventive solutions.

CONCLUSIONS

Occupational safety and health prevention can benefit from a narrative-based approach that provides a more comprehensive look at health and safety by facilitating knowledge improvement and sharing.

Customer satisfaction survey in Friuli Venezia Giulia university canteens

Background

Customer satisfaction represents an innovative approach to measure strengths and weaknesses of an organization and is useful for a customer-focused management and culture development. Our survey’s aim was to investigate perceived quality and needs of customers in the university canteen sector.

Methods

Between April and June 2018, an anonymous online questionnaire was distributed by “agenzia regionale per il diritto agli studi superiori” (ARDISS) among university students in Friuli Venezia Giulia, Italy. The questions covered 3 thematic areas: attendance of the service, quality of services and opinions on new initiatives. Furthermore, there was an open question to collect students’ suggestions or proposals to improve the service. Satisfaction about the service was evaluated through five topics: environments, hygiene, staff, meals, global satisfaction. Collected data were analyzed with descriptive, univariate and multivariate analyses. Statistical analyses were performed using 9.4 SAS software.

Results

Response rate was 20.5% (1933/9404). Multiple logistic regression analyses showed a difference in meal choice (entire vs reduced) between institutional canteen and partner cafeterias users (p &lt; 0.0001) and that male (p &lt; 0.0001) and foreign students (p 0.0003) prefer entire meal instead of reduced. Percentage of students who prefer entire meal is reduced (p &lt; 0.0001) if price range increases. Univariate and multivariate analyses showed that high quality perception is associated with lower price range and no suggestions about food and environments (p &lt; 0.0001); multivariate analyses also showed an association between high quality perception and high canteen attendance (p &lt; 0.05).

Conclusions

The survey showed an association between meal choice and students’ profile and between perceived quality and customer’s features. These data and further analyses may help to select areas where an intervention could improve service quality and, therefore, customer satisfaction.

Key messages

Customer satisfaction is an important tool to measure and improve university canteen service quality. These results helped us to identify services’ strengths and weaknesses according to students’ opinions; this could be useful to select improvement areas.

Vaccination of classmates for an immunosuppressed child’s protection in a school in the LHA Roma 1

Issue/problem

One of the duty of a State is to guarantee the protection of the health of all citizens, both safeguarding the sick individual needing care and protecting the healthy individual. An important objective of the vaccination prevention programs is to protect people most at risk of contracting infections because of their health conditions.

Description of the problem

In April 2019 the District 14 of Local Health Autority Roma 1 was asked by a father of an immunosuppressed child (6 years old), worried about infectious diseases, to verify the safeness of his child school attendance (the first class of primary school). First, a list of the class mates was asked to the school, in order to check their vaccination status by interrogating the web based regional vaccination register. Then, the District asked to the school to plan a meeting with classmates’ parents and teachers, in order to inform about the importance of a complete immunization both for the classmates and the immunosuppressed child protection.

Results

Preliminary results show that, among 18 classmates, 77.8% had full vaccination coverage for the second dose measles and fourth dose whooping cough (not mandatory for children aged less than 7 years), 22.2% were immunized for chicken pox. Among the parents attending the meeting, 15 agreed to complete their children vaccination cycle, all the teachers agreed to undergo whooping cough and chicken pox vaccination in order to allow a safe school attendance to the immunosuppressed child. Parents and teachers were given an appointment in a vaccination center for the week following the meeting.

Lessons

It is important to promote a real ’vaccination culture’ starting from the school, in order to develop greater citizenship awareness about the potential of vaccinations and to contrast fake news and ignorance leading to dangerous prejudices.

Key messages

The active collaboration between institutions (sanitary and school) allows, through the integration between different competences, to achieve health objectives to protect the community. Talking to pupils’ parents about infectious diseases and their prevention makes it possible to increase knowledge and therefore awareness of the importance of adult and children health protection.

A vaccination campaign in a Roma community in Rome: an experience of the Local Health Autority Roma1

Issue/problem

About 8,000 Roma and Sinti live in the city of Rome, distributed in 33 settlements. This population is particularly at risk of health problems, due to social marginality and reduced access to health and social services. An important challenge for public health is therefore to guarantee and improve the right to health and the availability of health care. In Italy, a new vaccination law was approved in July 2017 and 10 vaccinations became mandatory for minors attending schools.

Description of the problem

In 2018 the District 14 of the Local Health Authority Rome1 (LHA Rome1) organized a vaccination campaign for the Roma and Sinti community being in its area. The aim of the campaign was to analyse the vaccination status of children under-18 living in the camp, based on the local police census data, crossed with the web based regional vaccination registry, to offer free vaccination for those without a regular status, in order to allow school attendance.

Results

Among 109 children living in the targeted Roma and Sinti camp, only 6 (5.5%) had a regular vaccination status according to the Italian law. Two different vaccination opportunity were offered to the community during 2018: a dedicated vaccination session in the local vaccination center, during which 6 children were vaccinated; four vaccination days offered directly at the Roma camp (a total of 53 children were vaccinated). At the end of 2018, the new Police census identified 114 minors resident in the camp instead of 109; of these, 48 (42.1%) had reached a regular vaccination status.

Lessons

Addressing hard-to-reach communities in order to improve the access to health and social services is one of the LHA objectives. The intervention performed in the Roma camp was also an opportunity to promote the importance of vaccination and to inform the target community about various LHA services, in particular maternal and infant services, including those for Temporarily Present Foreigners.

Key messages

The interventions performed straight into communities living in unfavorable health and social conditions are useful to improve the access to health and social services. Vaccination of people living in a social marginality is an important challenge for public health in order to guarantee specific protection measures and promoting the right to health.

Serum immunoglobulin free light chain levels in systemic autoimmune rheumatic diseases

Several reports have highlighted the abnormal increments of serum immunoglobulin free light chains (FLCs) in the course of systemic autoimmune rheumatic diseases (SARD), but a comparative analysis among different conditions is still lacking. A strong association between elevated FLC and hepatitis C virus (HCV)-related mixed cryoglobulinaemia (HCVMC) has been well established. Here, we aimed to analyse serum FLC levels in patients with four different SARD in comparison with HCVMC. Using a turbidimetric assay, free κ and λ chains were quantified in sera from 198 SARD patients (37 rheumatoid arthritis, RA; 47 systemic lupus erythematosus, SLE; 52 anti-phospholipid syndrome, APS; 62 primary Sjogren's syndrome, pSS), 62 HCVMC and 50 healthy blood donors (HD). All patient groups showed increased κ levels when compared to HD: 33·5 ± 2·6 mg/l in HCVMC, 26·7 ± 2·3 mg/l in RA, 29·7 ± 1·9 mg/l in SLE, 23·8 ± 1·1 mg/l in APS, 24·2 ± 1·1 mg/l in pSS; 10·1 ± 0·6 mg/l in HD. Free λ levels displayed a significant increase only for HCVMC (20·4 ± 1·4 mg/l) and SLE (18·4 ± 1·0 mg/l) compared to HD (13·6 ± 0·9 mg/l). The increase of κ compared to λ takes into account a κ /λ ratio of 1·6 for all groups. Our results substantially analyse and strengthen the association between FLC and SARD focusing the questions regarding their role in the pathogenesis and diagnosis of human diseases. Unfortunately, the biochemical differences distinguishing normal from pathological FLC have not been identified. Production of different isotypes is probably connected to still-unknown pathways.

New Limit on the Permanent Electric Dipole Moment of ^{129}Xe Using ^{3}He Comagnetometry and SQUID Detection

We report results of a new technique to measure the electric dipole moment of ^{129}Xe with ^{3}He comagnetometry. Both species are polarized using spin-exchange optical pumping, transferred to a measurement cell, and transported into a magnetically shielded room, where SQUID magnetometers detect free precession in applied electric and magnetic fields. The result from a one week measurement campaign in 2017 and a 2.5 week campaign in 2018, combined with detailed study of systematic effects, is d_{A}(^{129}Xe)=(1.4±6.6_{stat}±2.0_{syst})×10^{-28}  e cm. This corresponds to an upper limit of |d_{A}(^{129}Xe)|<1.4×10^{-27}  e cm (95% C.L.), a factor of 5 more sensitive than the limit set in 2001.

6123A novel ECG parameter predicts lack of eligibility for Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) in patients with Brugada Syndrome

Background

A conclusive estimate of the eligibility rate for the use of subcutaneous implantable cardioverter defibrillators (S-ICD) in patients with Brugada Syndrome (BrS) is lacking.

Objective

We aimed to: 1) evaluate the eligibility for S-ICD in patients with BrS using a novel automated tool; 2) investigate predictors of ineligibility for S-ICD, based on baseline 12-lead electrocardiogram.

Methods

Automated screening for S-ICD was performed in 118 consecutive BrS patients using the programmer provided by the S-ICD producer. The system automatically assessed the acceptability of each of the three sense vectors used by the S-ICD for the detection of cardiac rhythm. Eligibility was defined when at least one vector was acceptable both in supine and standing position.

Results

The clinical characteristics of 118 BrS patients were as follow: age 43±11 years; 89% males; 2% with aborted cardiac arrest; 14% with a history of syncope; 81% with spontaneous type 1 ECG pattern; 21% with a familial history of sudden cardiac death; 24% with an SCN5A mutation. No patients had an indication for pacing. Only 8/118 (7%) patients were ineligible for S-ICD. Of note, 5/8 (63%) patients who failed the screening exhibited a slurred S wave of ≥80 ms duration in the peripheral lead aVF on the 12-lead baseline electrocardiogram, vs. 4/110 (4%) of those who passed the screening (sensitivity of S wave in aVF for screening failure 63%, specificity 97%; p<0.001). Remarkably, the presence of a slurred S wave of ≥80 ms duration in lead aVF remained significantly associated to the failure of eligibility for S-ICD (odds ratio 50, p<0.001) in a multivariable analysis that included the previous history of symptoms, the presence of a spontaneous type 1 ECG pattern, the gender and the presence of SCN5A mutations.

ECG predictor of S-ICD screening

Conclusion

Up to 93% of BrS patients are eligible for S-ICD when the automated screening tool is used. The presence of a slurred S wave in lead aVF on the 12-lead electrocardiogram is a powerful predictor of screening failure.

6081Efficacy and limitations of quinidine therapy in patients with Brugada Syndrome

Background

Quinidine at high-dose is used in patients with Brugada Syndrome (BrS), but its efficacy to prevent life-threatening arrhythmic events (LAE) in BrS is unproven and its use is limited by side effects.

Objective

We assessed whether low-dose quinidine in BrS patients reduces: 1) the occurrence of a first LAE; 2) the arrhythmic burden in the high-risk group of cardiac arrest survivors.

Methods

We first compared the clinical course of 53 BrS patients treated with quinidine to that of 441 untreated controls, matched by sex, age, and symptoms. Furthermore, we calculated the annual incidence of LAEs off- and on-quinidine in 123 BrS patients who had survived a cardiac arrest.

Results

First, we compared the clinical course of 53 BrS patients treated with quinidine (i.e. “cases”: 89% males, median age 40 years) to that of 441 untreated, clinically-matched BrS patients (i.e. “controls”: 91% males, median age 41 years) present in our database of patients with inherited arrhythmias. Cases received quinidine (median dose of 450 mg per day) for 5.0±3.7 years. Quinidine was interrupted in only 3/53 cases (6%) for side effects and it conferred a nonsignificant reduction of the risk of a first LAE in cases versus controls (HR 0.74, 95% CI 0.22–2.48, P=0.62).

Secondly, we calculated the annual recurrence of LAE off- and on-quinidine in 123 BrS cardiac arrest survivors, 27 of whom were treated with quinidine for 7.0±3.5 years. The annual rate of recurrent LAEs decreased significantly from 14.7% while off-quinidine to 3.9% while on-quinidine (P=0.03). Notably, recurrent life-threatening arrhythmic events were recorded in 4/27 (15%) symptomatic patients while on-quinidine.

Conclusion

We demonstrated for the first time in the long-term that low-dose quinidine reduces the recurrence of life-threatening arrhythmias in symptomatic BrS patients, with few side effects. Remarkably, about one-fifth of symptomatic patients experience life-threatening arrhythmias while on-treatment, suggesting that quinidine cannot replace implantable defibrillators in high-risk subjects.

Distribution and age of onset of psychopathological risk in a cohort of children with Down syndrome in developmental age

Background

Aim of the study is to intercept specific characteristics and psychiatric comorbidity in Down Syndrome (DS). The study describes the distribution and the age of specific aspects of behavioral phenotype in a sample of subjects with DS.

Methods

Psychopathological risk has been evaluated in a 97 DS patient cohort, aged 1 to 18 years, during regular follow-up neuropsychiatric visit and through administration of Child Behavior Checklist (CBCL); Childhood Autism Rating Scale (CARS-T) was assessed to verify the presence of autistic behaviors.

Results

The results show the presence of specific psychopathological risk factors in 90% of the sample. 7% of sample presents autistic features. The risk of psychopathology is independent of the degree of intellectual disability.

Conclusion

The high frequency of psychopathological risk factors indicates the need for accurate monitoring to intercept specific characteristics, such as in the case of comorbidity for autism. The search for specific psychopathological factors is a little explored aspect to date, as evidenced by the literature. Despite the studies available to date highlight the presence of psychopathological vulnerability in DS, so far there are only few reports that explore this issue systematically.

Circulation dynamics of Salmonella enterica subsp. enterica ser. Gallinarum biovar Gallinarum in a poultry farm infested by Dermanyssus gallinae

Dermanyssus gallinae (Mesostigmata: Dermanyssidae, De Geer, 1778) is an ectoparasite of poultry, suspected to play a role as a vector of Salmonella enterica subsp. enterica ser. Gallinarum. Despite an association between them being reported, the actual dynamics in field remain unclear. Therefore, the present study aimed to confirm the interactions among mites, pathogen and chickens. The study was carried out in an industrial poultry farm infested by D. gallinae, during an outbreak of fowl typhoid. The presence of S. Gallinarum in mites was assessed and quantified by a semi-nested polymerase chain reaction (PCR) and real-time PCR, respectively, in mites collected during two subsequent productive cycles and the sanitary break. The anti-group D Salmonella antibodies were quantified by an enzyme-linked immunosorbent assay. During the outbreak and the sanitary break, S. Gallinarum was constantly present in mites. In the second cycle, scattered positivity was observed, although hens did not exhibit signs of fowl typhoid, as a result of the vaccination with BIO-VAC SGP695 (Fatro, Ozzano Emilia Bo, Italy). The data strongly suggest that D. gallinae acts as reservoir of S. Gallinarum, thus allowing the pathogen to persist in farms. Furthermore, the present study has highlighted the interactions among D. gallinae, S. Gallinarum and hens with respect to enhancing the mite-mediated circulation of S. Gallinarum in an infested poultry farm.

Avian-inspired energy-harvesting from atmospheric phenomena for small UAVs

Fixed-wing small, unmanned aerial vehicles usually fly in atmospheric boundary layers that are often under the influence of turbulent environments. Inspired by nature's flyers, an application of an energy-harvesting flight strategy for increasing the energy state of the aircraft is presented. This paper provides basic longitudinal flight dynamic model exposing the physics behind the process. It shows significant power savings in flight with a sinusoidal and stochastic wind profile with active control of energy-harvesting. The active control based on optimized proportional gains was implemented for energy extraction from realistic atmospheric conditions, leading to significant energy savings for a 'bird-sized' vehicle. The paper reveals the equipment and necessary preparations for the flight test campaign. Moreover, it describes the design of a custom controller and its calibration in the wind tunnel against roll movements during pitching maneuvers. Finally, it investigates the benefits and potential of the automated process of energy-harvesting with simple proportional control through flight tests in a turbulent environment, validating the concept through the increased energy state of the aircraft.

C-Myc Deregulation is Involved in Melphalan Resistance of Multiple Myeloma: Role of PDGF-BB

Oncogenes are important regulators of cancer growth and progression and their action may be modulated by proteins of the growth factor family, such as angiogenic cytokines, known to be strongly involved in neoplastic evolution. Reciprocal interactions between oncogenes and angiogenic modulators may represent, in haematological neoplasms, including multiple myeloma (MM), a possible mechanism of drug resistance. The aim of this work is to investigate in vitro and in vivo whether or not c-myc deregulation is involved in the melphalan resistance elicited by myeloma patients and consequently to clarify the role of the angiogenic factor PDGF-BB in modulating c-myc protein expression. Fifty-one MM patients on chemotherapy with melphalan were analyzed for structural alterations of the c-myc gene, c-Myc protein expression, as well as for serum PDGF-BB release. For the in vitro study, two M14-derived established cell clones, differing for the c-Myc protein expression (c-Myc low -expressing or constitutively expressing clones) were used. Our results show that PDGF-BB is able to up-regulate Myc expression and reduce melphalan sensitivity of tumor cell clones, constitutively expressing c-myc gene product. In addition, down-regulation of c-Myc protein induces the expression of PDGF-β receptor molecules and reduces PDGF-BB release. In agreement with these results, in vivo data show that melphalan-resistant MM patients present overexpressed c-Myc protein and higher serum PDGF-β receptor levels compared to minor responding patients.

Prognosis of Juvenile Rheumatoid Arthritis-Associated Uveitis

Purpose

To evaluate the clinical characteristics and the visual prognosis of uveitis in juvenile rheumatoid arthritis (JRA).

Methods

The authors examined 63 patients with uveitis and JRA observed from January 1985 to December 2000. The following characteristics of each patient were considered: age at first visit, age at onset of uveitis and arthritis, sex, laterality and localization of uveitis, ocular complications, antinuclear antibody (ANA) and human leukocyte antigen (HLA) DR11 positivity, and follow-up. A retrospective study on mid-time visual outcome and ocular complications was performed on 42 patients with more than 12 months of follow-up.

Results

A total of 76.2% of the patients were female, with a mean age of 8.1 years. Chronic anterior uveitis was bilateral in 77.8% of the cases and unilateral in 22.2%. Arthritis was oligoarticular at onset in 87.3% of cases, and polyarticular in 12.7%. Mean age at arthritis onset was 4.5 years and mean age at uveitis onset was 5.4 years. ANA were positive in 92% of cases and HLA DR11 was present in 36 of the 43 patients tested (83.7%). Among the 42 patients with more than 12 months of follow-up, ocular complications occurred in 90.5% of cases and the most frequent were cataract (64.4% of eyes) and band keratopathy (59.2% of eyes). Secondary glaucoma (25% of eyes) was associated with the worst visual prognosis. A total of 64.5% of eyes maintained a visual acuity between 20/33 and 20/20 at the end of the follow-up.

Conclusions

Visual prognosis of uveitis associated with JRA is improving, owing to earlier diagnosis and intensive treatment. Ocular complications occurred frequently in patients with uveitis and JRA but they did not seem to seriously affect the final visual outcome. The authors did not observe any correlation between prognosis and sex, age at the onset of uveitis or arthritis, pattern of arthritis, or positivity for ANA or HLA DR11. In a percentage of cases, uveitis may develop before arthritis or years after the onset of arthritis; therefore, continuous ophthalmologic examinations are needed in young people with JRA.

[Ethical, pedagogical, socio-political and anthropological implications of quaternary prevention]

The concept of quaternary prevention, resulting from a reflection on the doctor-patient relationship, is presented as a renewal of the ageold ethical requirement: first, a doctor must not harm; second, the doctor must control himself/herself. The origin of the concept, its endorsement by the World Organization of Family Doctors (WONCA) and the European Union of General Practitioners (UEMO), its dissemination, and the debates to which it has given rise, are presented by a panel of authors from 12 countries and 3 continents. This collective text deals more specifically with the ethics of prevention, the importance of teaching Quaternary prevention and Evidence Based Medicine, the social and political implications of the concept of quaternary prevention, and its anthropological dimensions.

Localization of neuroglobin in the brain of R6/2 mouse model of Huntington's disease

Neuroglobin (Ngb) is expressed in the central and peripheral nervous system, cerebrospinal fluid, retina, and endocrine tissues where it is involved in binding O₂ and other gasotransmitters. Several studies have highlighted its endogenous neuroprotective function. Huntington's disease (HD), a dominant hereditary disease, is characterized by the gradual loss of neurons in discrete areas of the central nervous system. We analyzed the expression of Ngb in the brain tissue of a mouse model of HD, in order to define the role of Ngb with respect to individual cell type vulnerability in HD and to gender and age of mice. Our results showed different expressions of Ngb among neurons of a specific region and between different brain regions. We evidenced a decreased intensity of Ngb at 13 weeks of age, compared to 7 weeks of age. The double immunofluorescence and fluorescence resonance energy transfer (FRET) experiments showed that the co-localization between Ngb and huntingtin at the subcellular level was not close enough to account for a direct interaction. We also observed a different expression of Ngb in the striatum, depending on the sex and age of animals. These findings provide the first experimental evidence for an adaptive response of Ngb in HD, suggesting that Ngb may exert neuroprotective effects in HD beyond its role in reducing sensitivity to oxidative stress.