Demonstrating the reliability of in vivo metabolomics based chemical grouping: towards best practice

While grouping/read-across is widely used to fill data gaps, chemical registration dossiers are often rejected due to weak category justifications based on structural similarity only. Metabolomics provides a route to robust chemical categories via evidence of shared molecular effects across source and target substances. To gain international acceptance, this approach must demonstrate high reliability, and best-practice guidance is required. The MetAbolomics ring Trial for CHemical groupING (MATCHING), comprising six industrial, government and academic ring-trial partners, evaluated inter-laboratory reproducibility and worked towards best-practice. An independent team selected eight substances (WY-14643, 4-chloro-3-nitroaniline, 17α-methyl-testosterone, trenbolone, aniline, dichlorprop-p, 2-chloroaniline, fenofibrate); ring-trial partners were blinded to their identities and modes-of-action. Plasma samples were derived from 28-day rat tests (two doses per substance), aliquoted, and distributed to partners. Each partner applied their preferred liquid chromatography-mass spectrometry (LC-MS) metabolomics workflows to acquire, process, quality assess, statistically analyze and report their grouping results to the European Chemicals Agency, to ensure the blinding conditions of the ring trial. Five of six partners, whose metabolomics datasets passed quality control, correctly identified the grouping of eight test substances into three categories, for both male and female rats. Strikingly, this was achieved even though a range of metabolomics approaches were used. Through assessing intrastudy quality-control samples, the sixth partner observed high technical variation and was unable to group the substances. By comparing workflows, we conclude that some heterogeneity in metabolomics methods is not detrimental to consistent grouping, and that assessing data quality prior to grouping is essential. We recommend development of international guidance for quality-control acceptance criteria. This study demonstrates the reliability of metabolomics for chemical grouping and works towards best-practice.

The kinetics of the ice-water interface from ab initio machine learning simulations

Molecular simulations employing empirical force fields have provided valuable knowledge about the ice growth process in the past decade. The development of novel computational techniques allows us to study this process, which requires long simulations of relatively large systems, with ab initio accuracy. In this work, we use a neural-network potential for water trained on the revised Perdew-Burke-Ernzerhof functional to describe the kinetics of the ice-water interface. We study both ice melting and growth processes. Our results for the ice growth rate are in reasonable agreement with previous experiments and simulations. We find that the kinetics of ice melting presents a different behavior (monotonic) than that of ice growth (non-monotonic). In particular, a maximum ice growth rate of 6.5 Å/ns is found at 14 K of supercooling. The effect of the surface structure is explored by investigating the basal and primary and secondary prismatic facets. We use the Wilson-Frenkel relation to explain these results in terms of the mobility of molecules and the thermodynamic driving force. Moreover, we study the effect of pressure by complementing the standard isobar with simulations at a negative pressure (-1000 bar) and at a high pressure (2000 bar). We find that prismatic facets grow faster than the basal one and that pressure does not play an important role when the speed of the interface is considered as a function of the difference between the melting temperature and the actual one, i.e., to the degree of either supercooling or overheating.

RIB induced reactions: Studying astrophysical reactions with low-energy RI beam at CRIB

Astrophysical reactions involving radioactive isotopes (RI) often play an important role in high-temperature stellar environments. The experimental studies on the reaction rates for those are still limited mainly due to the technical difficulties in producing high-quality RI beams. A direct measurement of those reactions would be still challenging in many cases, however, we can make a reliable evaluation of the reaction rates by an indirect method or by studying the resonance prorerties. Here we ntroduce recent examples of experimental studies on such RI-involving astrophysical reactions, performed at Center for Nuclear Study, the University of Tokyo, using the low-energy RI beam separator CRIB. One is for the neutron-induced destruction reactions of 7Be in the Big-Bang nucleosynthesis, and the other is the study on the 22Mg(α, p) reaction relevant in X-ray bursts, which was performed with the resonant scattering method from the inverse reaction channel.

The 12C +16 O fusion reaction in carbon burning: Study at energies of astrophysical interest using the Trojan Horse Method

The carbon-burning process in massive stars mainly occurs via the 12C +12 C. However, at temperatures higher than 109K and considering the increased abundance of 16O produced during the later stages of the heliumburning,the 12C+16O fusion can also become relevant. Moreover, 12C+16O also plays a role in the scenario of explosive carbon burning. Thus, the astrophysical energy region of interest ranges from 3 to 7.2 MeV in the center-of-mass frame. However, the various measurements of the cross-section available in the literature stop around 4 MeV, making extrapolation necessary. To solve this uncertainty and corroborate direct measurement we applied the Trojan Horse Method to three-body processes 16O(14N, α24Mg)2H and 16O(14N, p27Al)2H to study the 12C(16O, α)24Mg and 12C(16O, p)27Al reactions in their entire energy region of astrophysical interest. In this contribution, after briefly describing the method used, the experiment and the preliminary phases of the data analysis will be presented and discussed.

Survival probability during one-year follow-up after index hospitalization for heart failure: an Italian retrospective study

BACKGROUND

Heart failure affects about 64 million people worldwide, and despite the economic resources employed to improve its prognosis, mortality is still alarming. The aim of this study was to investigate the impact of patients' characteristics on survival probability during one-year follow-up after an index hospitalization for heart failure.

STUDY DESIGN

A three-year retrospective study was conducted on the records of the Hospitals belonging the Local Health Unit of L'Aquila, a Healthcare Facility located in the centre of Italy.

METHODS

Patients admitted to hospital with a heart failure event as main diagnosis were selected and followed up for one year after their discharge to obtain data for survival analysis.

RESULTS

During the observational period for 1,929 patients hospitalized with a Heart failure index event, 1,655 (85.8%) of them were discharged alive and followed up for one year after the discharge. Fourteen percent of patients (n = 232) died for reasons related to Heart failure during the follow-up period. Fifty percent of them (n = 116), died within three months from the index hospitalization discharge. Age ≥75 years (HR 3.192, 95% CI 1.964-5.188), discharging to home (HR 0.399, 95% CI 0.297-0.536), length of stay ≥8 days during the index hospitalization (HR 1.533, 95% CI 1.163-2.019), and high education level (HR 0.517, 95% CI 0.273-0.977), were found to be associated with the survival probability.

CONCLUSION

Study results indicate that older patients, especially those with a low educational level, those with longer index hospitalization, and those not sent directly to home, deserve more care and attention after discharge.

P113 HIDDEN POCKET. LEFT ATRIAL SEPTAL POUCH: VARIANT OF NORMALITY OR CARDIOEMBOLIC SOURCE?

During embryological period the blood flows from right to left atrium trought patent interatial septum. Embryon’s interatrial semptum consists on the apposition of Septum Secundum (SS) over Septum Primum (SP) that go to seal each other just afther birth. Sometimes this fusion doesn’t happen or partially happens, leading respectively to patent foramen ovale (PFO) or the less known eventuality of Atrial Septal Pouch (ASP).

48–year–old woman, history of chronic anemia treated with blood transfusions, underwent a routine transthoracic echocardiogram (TTE) as recommended by her transfusion center. The patients is asymptomatic, denies cardiovascular risk factors, denies any signs or symptoms suggestive of recent infectious or inflammatory disease. The TTE documented preserved left ventricular sistolic function, normal sized cardiac chembers, no valvular abnormalities, evidence of linear formation (10 x 5 mm), near foramen ovale, on the left side of interatrial septum, increased in echogenicity. It was performed a transesophageal echocardiogram (TEE) which confirmed the finding at SIA level. It was therefore recommended in depth study with cardiac magnetic resonance (CMR) which described the same mobile formation, characterized by the same signal strength as the atrial walls, both before and afther contrat administration, compatible in the first hypotesis with an embryonic residue (Left Atrial Septal Pouch, LASP).

There is still much uncertainty regarding the clinical significance of LASP, however, its large prevalence among general population suggests that its potential embolism requires other predisposing conditions in order to be of real clinical relevance. CMR represents a usefull test for cardiac structures analysis owing its better tissue characterization cormpared to other diagnostic tests. In the event of an occasional finding and in absence of any other indication for anticoagulant therapy, no therapeutic measures are currently indicated. These patients could be followed up in order to promptly identify the onset of prothrombotic conditions likely to expose them to higher risk compared with patients who do not have LASP.

P168 A RARE CASE OF HYPERTROPHIC CARDIOMYOPATHY WITH HIGH RISK OF SUDDEN CARDIAC DEATH: WHAT CAN WE DO UNTIL MIECTOMY?

A 43–year–old Indian man with obstructive hypertrophic cardiomyopathy (HCMO) and a family history of sudden death presented with heart palpitations associated with chest discomfort and syncope during moderate physical activity despite beta–blocker therapy at maximum dose (New York Heart Association–NYHA III). Transthoracic echocardiography demonstrated ejection fraction 55% and ventricular septum (SIV) (23 mm) and posterior wall hypertrophy (12 mm). There was evidence of dynamic left ventricular outflow tract obstruction (maximum LVOT gradient 30 mmHg at baseline and 45 mmHg after Valsalva) and systolic anterior movement of the amterior mitral flap responsible of moderate regurgitation. It also showed a bicuspid aortic valve with fusion of the right and left cusps and mild regurgitation. ECG Holter showed sporadic supraventricular premature ectopic beats and abnormality of the ventricular repolarization that were accentuated during exercise. Exercise stress test showed 3 mm ST depression in V4–V5 leads. Cardiac magnetic resonance (CMR) and Cardio–CT confirmed HCMO diagnosis and showed a junctional origin of the coronaries, a bifurcated interventricular artery, coronaries free from significant stenosis, intramural late gadolinium enhancement (LGE) of the mid–ventricular SIV and sub–endocardium LGE of the basal SIV. The high HCM– Sudden Cardiac Death Risk score and the presence of LGE on CMR identified a high–risk status and prompt consideration for primary prevention automatic implantable cardioverter defibrillator (AICD) therapy. Thus, in order to treat major life–threatening ventricular arrhythmias, AICD was placed (ESC guidelines 2014 Class IIa). Invasive treatment is indicated for symptomatic patients, NYHA class III and IV refractory to optimized medication and who have gradients in the LVOT. Aortic transvalvular–myectomy is the procedure with the longest experience and considered the gold standard. However, in this case surgical treatment was temporarily postponed. So a sequential rhythm pacing with reduced A–V delay was set up in order to induce a left bundle branch block and a “paradoxical” movement of the SIV with reduction of LVOT gradient. After 2 weeks the LVOT gradient was 20 mmHg and the symptoms were improved. This case suggests the usefulness of a single device for the treatment of different aspects in HCMO waiting to undergo surgical treatment: prevention of sudden cardiac death and improvement of symptoms refractory to medical therapy.

First measurement of 25Al+p resonant scattering relevant to the astrophysical reaction 22Mg(α,p)25Al

Type I X-ray bursts (XRBs) are the most frequently observed thermonuclear explosions in nature. The 22Mg(α,p)25Al reaction plays a critical role in XRB models. However, experimental information is insufficient to deduce a precise 22Mg(α,p)25Al reaction rate for the respective XRB temperature range. A new measurement of 25Al+p resonant scattring was performed up to the astrophysically interested energy region of 22Mg(α,p)25Al. Several resonances were observed in the excitation functions, and their level properties have been determined based on an R-matrix analysis. In particular, proton widths and spin-parities of four natural-parity resonances above the α threshold of 26Si, which can contribute the reaction rate of 22Mg(α,p)25Al, were first experimentally determined.

Experimental studies on astrophysical reactions at the low-energy RI beam separator CRIB

Experimental studies on astrophysical reactions involving radioactive isotopes (RI) often accompany technical challenges. Studies on such nuclear reactions have been conducted at the low-energy RI beam separator CRIB, operated by Center for Nuclear Study, the University of Tokyo. We discuss two cases of astrophysical reaction studies at CRIB; one is for the 7Be+n reactions which may affect the primordial 7Li abundance in the Big-Bang nucleosynthesis, and the other is for the 22Mg(α, p) reaction relevantin X-raybursts.

Decreased inferior vena cava diameter as an early marker in postpartum hemorrhage

OBJECTIVES

To examine the association between inferior vena cava (IVC) diameter and postpartum blood loss and assess whether IVC diameter is a useful marker in the evaluation of intravascular volume status in women with postpartum hemorrhage (PPH).

METHODS

This was a prospective case-control study conducted in a university medical teaching center in Afula, Israel, between November 2018 and March 2020. The study cohort consisted of women with a singleton pregnancy who delivered vaginally at term. The PPH group included women diagnosed with PPH based on visually estimated blood loss of 1000 mL or more at the time of enrolment. Hemodynamically unstable women or women with major bleeding at the time of diagnosis were not included. The control group consisted of women with an uneventful fourth stage of labor. IVC diameter was measured using transabdominal ultrasonography during inspiration (IVCi diameter) and expiration (IVCe diameter), and the collapsibility index was calculated ((IVCe - IVCi)/IVCe × 100). The primary outcome was the percentage difference in IVC diameter and collapsibility index between the PPH group and controls. The performance of the IVC collapsibility index in the prediction of the need for blood transfusion in women with PPH was assessed. In order to demonstrate a difference of 20% with a power of 80% and alpha of 0.05, 108 women, at a ratio of 1:2 in the study and control groups, respectively, were needed.

RESULTS

Overall, 36 and 72 women were included in the final analysis in the PPH and control groups, respectively. IVCi and IVCe diameters were significantly smaller in the PPH group (0.93 ± 0.30 cm and 1.26 ± 0.32 cm, respectively) than in controls (1.42 ± 0.31 cm and 1.75 ± 0.28 cm, respectively) (P = 0.001 for both). The percentage reductions in IVCi and IVCe diameters in the PPH group compared with controls were 35.0% and 28.0%, respectively. IVC collapsibility index was increased significantly, by 42.9% (26.04 ± 8.67% vs 18.15 ± 5.07%; P = 0.001) in the PPH group compared with controls. IVC collapsibility index was a significant predictor of the need for blood transfusion and correctly predicted 81% of cases. Logistic regression analysis demonstrated that IVC collapsibility index was also a significant predictor of a drop in hemoglobin level of ≥ 2 g/dL (P = 0.001).

CONCLUSIONS

IVC diameter changes in response to postpartum blood loss. Measurement of IVC diameter using transabdominal ultrasonography is an objective and useful non-invasive method for the early evaluation of intravascular volume status in women with PPH and for the prediction of cases that might require blood transfusion. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Advancement of Photospheric Radius Expansion and Clocked Type-I X-Ray Burst Models with the New ^{22}Mg(α,p)^{25}Al Reaction Rate Determined at the Gamow Energy

We report the first (in)elastic scattering measurement of ^{25}Al+p with the capability to select and measure in a broad energy range the proton resonances in ^{26}Si contributing to the ^{22}Mg(α,p) reaction at type I x-ray burst energies. We measured spin-parities of four resonances above the α threshold of ^{26}Si that are found to strongly impact the ^{22}Mg(α,p) rate. The new rate advances a state-of-the-art model to remarkably reproduce light curves of the GS 1826-24 clocked burster with mean deviation <9% and permits us to discover a strong correlation between the He abundance in the accreting envelope of the photospheric radius expansion burster and the dominance of ^{22}Mg(α,p) branch.

Deprescribing for community-dwelling elderly: A systematic review of economic evaluations

Background

Multimorbidity among the elderly represents a serious challenge for health systems. Older adults are often exposed to polypharmacy and inappropriate medication, which are associated with adverse events and increased healthcare use. This study aims to identify and synthetize the economic evidence of deprescribing interventions among community-dwelling elderly.

Methods

Literature was systematically reviewed on the cost and effectiveness of deprescribing interventions in adults aged ≥65 years living in the community. MEDLINE, EconLit, Scopus, Web of Science, CEA-TUFTS, CRD York and Google Scholar databases were searched from inception to February 2021. Grey literature was also explored. Titles and abstracts, and subsequently full-text articles were screened according to inclusion and exclusion criteria. Studies' quality was appraised using the extended Consensus on Health Economics Criteria list.

Results

A total of 6,154 articles were identified, of which 89 were retrieved for full-text review, yielding 14 studies. Most were conducted in Europe (n = 9), followed by North (n = 3) and South America (n = 1), and China (n = 1). Settings included community pharmacies, primary care/general practices and patientś homes. Most deprescribing interventions were delivered within a pharmacist-doctor collaboration. Twelve studies were trial-based economic evaluations with a time horizon varying from 2 to 12 months. Cost-effectiveness ranged from dominant to an incremental cost-effectiveness ratio of $112,932/QALY. Nine studies scored &gt;80% (good) and two scored ≤50% (low) on critical quality appraisal.

Conclusions

There are few economic evaluations of deprescribing interventions focused on community-dwelling elderly. Although results varied across settings, time horizon and intervention complexity, most interventions were cost-effective according to the WHO threshold. Deprescribing interventions are promising from an economic viewpoint, but more studies are needed.

Key messages

There is a paucity of economic evaluation studies conducted on deprescribing interventions of community-dwelling elderly. Research suggests that most interventions are cost-effective or even dominant compared to usual care.

Right ventricular longitudinal strain measured using feature-tracking cardiac magnetic resonance is an independent predictor of all cause mortality in patients with severe tricuspid regurgitation

Introduction

Tricuspid regurgitation imposes a volume overload on the right ventricle (RV) that can lead to progressive RV dilation and dysfunction. Overt RV dysfunction is associated with poor prognosis and increased operative risk. Abnormalities of myocardial strain may provide the earliest evidence of ventricular dysfunction. CMR feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of RV strain measured using CMR feature-tracking have prognostic value in patients with tricuspid regurgitation is unknown

Purpose

To evaluate the prognostic value of CMR feature-tracking derived RV free wall longitudinal strain (RVFWLS) in a large multicenter population of patients with severe tricuspid regurgitation.

Methods

Consecutive patients with severe tricuspid regurgitation undergoing CMR at four US medical centers were included in this study. Feature-tracking RVFWLS was calculated from 4 chamber cine-views (Figure-left panel). The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between RVFWLS and death. The incremental prognostic value of RVFWLS was assessed in nested models.

Results

Of the 406 patients in this study,115 died during a median follow-up of 8.8 years. By Kaplan-Meier-analysis, patients with RVFWLS ≥median (−16%) had significantly reduced event free survival compared to those with RVFWLS &lt; median (log-rank p&lt;0.001) (Figure-right panel). By Cox multivariable regression modeling, each 1% worsening in RVFWLS was associated with a 13% increased risk-of-death after adjustement for clinical and imaging risk factors (HR=1.13 per %; p&lt;0.001). Addition of RVFWLS in this model resulted in significant-improvement in the global-chi-square (26 to 65; p&lt;0.0001).

Conclusions

CMR feature-tracking derived RVFWLS is an independent predictor of mortality in patients with severe tricuspid regurgitation, incremental to common clinical and imaging risk factors.

Funding Acknowledgement

Type of funding source: None

Clinical outcome with NOACs vs VKAs in patients with atrial fibrillation and severe chronic kidney disease: results of a retrospective, multicenter, real-world study

Background

Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) are at higher risk of both bleeding and thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) are licensed to be used in these patients, although they were excluded from phase III controlled randomized trials comparing NOACs vs warfarin in AF. Thus, current evidence on NOACs use in such setting of patients is not definitive.

Purpose

Aim of our multicenter study was to perform a real-world comparison of clinical outcome with NOACs vs vitamin K antagonist anticoagulants (VKAs) also in AF patients having an estimated glomerular filtration rate (eGFR) 15–29 mL/min.

Methods

We retrospectively included a total of 266 patients receiving NOACs (N=159) or VKAs (N=107). Primary outcome measure was the cumulative incidence of the net composite endpoint including ischemic stroke, systemic thromboembolism or any bleeding. Mean follow-up was 2.6 years.

Results

CHA2DS2-VASc and HAS-BLED scores at baseline were similar in the two groups (3.4±1.3 with NOACs vs 3.4±0.9 with VKAs and 3.1±1.0 vs 3.0±0.7, respectively); eGFR and hemoglobin values were also comparable (31.8±12.3 vs 32±11.9 mL/min and 10.2±2.1 vs 11.0±2.3 g/dL, respectively). NOACs were not inferior to VKAs for the primary net composite endpoint: incidence 20.7% vs 29.9%, p&lt;0.01 for non-inferiority, p=0.11 for superiority. In proportional Cox regression model, hazard ratio for the primary outcome measure with NOACs use was 0.74 (95% CI 0.45–1.21, p=0.22). In the NOAC group there was a trend towards reduction in minor bleeding complications (p=0.08).

Conclusions

Our real-world data indicate that in patients with AF and severe renal failure NOACs are not inferior to VKAs for both safety and efficacy. The use of NOACs was associated with a numerically lower incidence of minor bleeding.

Funding Acknowledgement

Type of funding source: None

Master athletes'ECG and the diagnostic accuracy of contemporary ECG interpretation criteria

Background

Over the last years, several efforts have been made to refine the ECG criteria for interpretation of young (16–35 years) competitive athlete's ECG in order to improve specificity maintaining good sensitivity. However, few data exist about the efficacy of such interpretation criteria in master athletes (over 35 years). We aimed to assess the diagnostic performance of screening based on 2017 International ECG recommendation (2017-International), 2010 European Society of Cardiology recommendation (2010-ESC) and Seattle criteria in a cohort of master athletes competing at regional and national level.

Methods

506 Caucasian master athletes (mean ages 47.9±8.7, 85,6% male, 65% endurance athletes) underwent standardized medical history, physical examination, resting and exercise ECG during their pre-participation screening. ECGs were retrospectively interpreted based on 2010-ESC, Seattle-criteria and 2017-International. For the purpose of the study we included also a transthoracic echocardiography as reference, to calculate the sensibility and specificity, area under the ROC curve (AUC) was estimated as measure of discriminative ability of each ECG criteria. Athletes with abnormalities underwent further examinations according to the European Guidelines.

Results

Twelve athletes (2,3%) were diagnosed with a condition potentially related to SCD (1 hypertrophic cardiomyopathy, 1 Type1 Brugada Syndrome, 4 Chronic Coronary Syndromes, 2 Dilated Cardiomyopathy, 3 Aortic Dilation, 1 Moderate aortic stenosis) during the pre-participation screening. International criteria failed to identify two athletes with DCM and left axis deviation on ECG while no athletes with complete right bundle branch block showed serious structural abnormalities. The most common ECG abnormalities were left axis deviation (7,1%), left atrial enlargement (4,2%) and T wave inversion (3%). 29 athletes (5,7%) exhibited a long QT interval according to 2010-ESC and 1 athlete according to International and Seattle criteria. The false positive ECG rate was 15% for 2017-International based screening, 21,9% for Seattle based screening and 30,40% for 2010-ESC based screening while the diagnostic accuracy for pathologies at risk of SCD was 0,73 (95% CI 0,69–0,77) for 2017 International based screening; 0,81 (95% CI 0,77–0,84) for Seattle Criteria based screening and 0,77 (95% CI 0,73–0,80) for 2010-ESC based screening.

Conclusion

In master athletes the 2017-International ECG criteria showed inferior accuracy compared to the Seattle criteria and 2010-ESC, the least showing a higher false positive rate mostly due to lower cut-off for long QT. Furthermore complete right bundle branch block may be considered a normal finding also in master asymptomatic athletes.

Accuracy of ECG criteria

Funding Acknowledgement

Type of funding source: None

Airborne bacteria structure and chemical composition relationships in winter and spring PM10 samples over southeastern Italy

The Redundancy Discrimination Analysis (RDA) and Spearman correlation coefficients were used to investigate relationships between airborne bacteria at the phylum and genus level and chemical species in winter and spring PM10 samples over Southeastern Italy. The identification of main chemical species/pollution sources that were related to and likely affected the bacterial community structure was the main goal of this work. The 16S rRNA gene metabarcoding approach was used to characterize airborne bacteria. Seventeen phyla and seventy-nine genera contributing each by mean within-sample relative abundance percentage > 0.01% were identified in PM10 samples, which were chemically characterized for 33 species, including ions, metals, OC, and EC (organic and elemental carbon, respectively). Chemical species were associated with six different pollution sources. A shift from winter to spring in both bacterial community structure and chemical species mass concentrations/sources and the relationships between them was observed. RDA triplots pointed out significant correlations for all tested bacterial phyla (genera) with other phyla (genera) and/or with chemical species, in contrast to correlation coefficient results, which showed that few phyla (genera) were significantly correlated with chemical species. More specifically, in winter Bacillus and Chryseobacterium were the only genera significantly correlated with chemical species likely associated with particles from soil-dust and anthropogenic pollution source, respectively. In spring, Enterobacter and Sphingomonas were the only genera significantly correlated with chemical species likely associated with particles from the anthropogenic pollution and the marine and soil-dust sources, respectively. The results of this study also showed that the correlation coefficients were the best tool to obtain unequivocal identifications of the correlations of phyla (genera) with chemical species. The seasonal changes of the PM10 chemical composition, the microbial community structure, and their relationships suggested that the seasonal changes of atmospheric particles may have likely contributed to seasonal changes of bacterial community in the atmosphere.

Rules on informed consent and advance directives at the end-of-life: the new Italian law

End-of-life decisions are an emergent issue for bioethical debates and practical concerns among health professionals. On December 2017, Italy enacted a new law named "Rules about informed consent and advance directives", which promotes the relationship of care in a fiduciary sense through the implementation of a correct and exhaustive information. It is also prescribed to record in writing all the patients' decisions about consent or refusal. Furthermore, the law explicitly forbids unreasonable therapeutic obstinacy for terminal patient, legitimizing deep palliative sedation. Finally, the law establishes the use of "advance directives" as a written document by which adults and capable people can express their wishes regarding health treatments and diagnostic tests in anticipation of a possible future incapacity. The law provides that doctors must comply with these directives, unless they appear clearly incongruous or not corresponding to the patient's current clinical condition.

Disentangling the molecular mechanisms of multiple sclerosis: The contribution of twin studies

Twin studies of disease concordance are useful to weight the relative contribution of genetic and environmental factors to the cause of common complex disorders. In multiple sclerosis (MS) different twinning rates from geographic areas at different prevalence suggested that heritable and non-heritable factors contribute in different proportions and ways to MS risk in diverse populations. This concept prompted genome-wide association studies, and the implementation of the co-twin control design, that allows stringent experimental approaches in MS-discordant identical pairs, controlling for genetic influences and many other known and unknown factors. The co-twin control design provided important clues on MS molecular model. These studies will be reviewed, focusing on those showing significant differences between affected and healthy co-twins. In some cases, differences that emerged in non-twin patients compared to matched controls were not confirmed in identical MS-discordant pairs, suggesting an 'MS subclinical trait'. Early patterns of magnetic resonance imaging and predictive biomarkers that characterize 'healthy' co-twins may be useful for the identification of a prodromal reversible phase of the disease.

Study of the neutron induced reaction 17O(n,α)14C at astrophysical energies via the Trojan Horse Method

Neutron induced reactions are fundamental for the nucleosynthesis of elements in the universe. Indeed, to correctly study the reactions involved in the well-known s-process in stars, which produce about half of the elements beyond the iron peak, it is mandatory to know the neutron abundance available in those stars. The 17O(n, a)14C reaction is one of the so-called “neutron poisons” for the pro- cess and it could play an important role in the balance of the neutron abundance. The reaction is therefore investigated in the energy range of astrophysical inter- est between 0 and 350 keV in the center of mass by applying the Trojan Horse Method to the three body reaction 2H(17O, a14C)H.

Study of 3He(n,p)3H reaction at cosmological energies with trojan horse method

In the network of reactions present in the Big Bang nucleosynthesis, the 3He(n, p)3H has an important role which impacts the final 7Li abundance. The Trojan Horse Method (THM) has been applied to the 3He(d, pt)H reaction in order to extract the astrophysical S(E)-factor of the 3He(n, p)3H in the Gamow energy range. The experiment will be described in the present work together with the first preliminary results.

Preliminary results for the 19F(ρ,α)16O reaction cross section measured at INFN-LNS

The 19F(ρ,α)16O reaction is an important fluorine destruction chan- nel in the proton-rich outer layers of asymptotic giant branch (AGB) stars and it might also play a role in hydrogen-deficient post-AGB star nucleosynthesis. At present, theoretical models overproduce F abundances in AGB stars with re-spect to the observed values, thus calling for further investigation of the nuclear reaction rates involved in the production and destruction of fluorine. In the last years, new direct and indirect measurements improved significantly the knowl- edge of 19F(ρ,α)16O cross section at deeply sub-Coulomb energies (below 0.8 MeV). However, those data are larger by a factor of 1.4 with respect the previ- ous data reported in the NACRE compilation in the energy region 0.6-0.8 MeV. Using the Large High resolution Array of Silicons for Astrophysics (LHASA), we performed a new direct measurement of the 19F(ρ,α)16O. The goal of this experiment is to reduce the uncertainties in the nuclear reaction rate of the 19F(ρ,α)16O reaction. Here, experimental details, the calibration procedure and angular distributions are presented.

ANC experiments for nuclear astrophysics

Among the indirect methods to determine nuclear cross-section present in literature, the so-called Asymptotic Normalization Coefficient (ANC) has proven to be useful in retrieving the direct part of a radiative capture cross-section in reactions of interest for astrophysics. In this work, the method will be presented, and some results obtained in collaboration between NPI CAS and INFN-LNS will be presented.

Personalized medicine in psychiatric disorders: prevention and bioethical questions

Personalized medicine is an emerging approach to medicine that applies scientific knowledge to predict individual susceptibility to certain pathologies and to identify their response to pharmacological treatments. The aim of the study is to analyze the ethical implications of the use of personalized medicine in the prevention of psychiatric disorders, through the study of specific genetic variations and epigenetic modifications. However, the use of technologies aimed at studying the human genome, in order to prevent these pathologies, cause many bioethical questions.

3225Global longitudinal strain measured using feature-tracking cardiac magnetic resonance imaging is an independent predictor of all cause mortality in patients with preserved ejection fraction

Introduction

Ejection fraction is the principal measure used clinically to assess cardiac mechanics and provides significant prognostic information. However, echocardiographic strain imaging has shown significant abnormalities of myocardial deformation can be present despite preserved ejection fraction, which maybe associated with adverse prognosis. Cardiac-Magnetic-Resonance (CMR) feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of strain measured using CMR feature-tracking have prognostic value in patients with preserved ejection fraction is unknown.

Purpose

To evaluate the prognostic value of CMR feature-tracking derived global longitudinal strain (GLS) in a large multicenter population of patients with preserved ejection fraction.

Methods

Consecutive patients with preserved ejection fraction (EF ≥50%) and a clinical indication for CMR at four US medical centers were included in this study. Feature-tracking GLS was calculated from 3 long-axis-cine-views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between GLS and death. The incremental prognostic value of GLS was assessed in nested models.

Results

Of the 1274 patients in this study, 115 died during a median follow-up of 6.2 years. By Kaplan-Meier analysis, patients with GLS ≥ median (−20%) had significantly reduced event free survival compared to those with GLS < median (log-rank p<0.001) (Figure, top panel). The continuous relationship between GLS and the hazard of death is shown in the cubic spline (Figure, lower panel). By Cox multivariable regression modeling, each 1% worsening in GLS was associated with a 23.6% increased risk-of-death after adjustment for clinical and imaging risk factors (HR=1.236 per %; p<0.001). Addition of GLS in this model resulted in significant-improvement in the global-chi-square (67 to 168; p<0.0001) and Harrel's C-statistic (0.716 to 0.825; p<0.0001).

Conclusions

CMR feature-tracking derived GLS is a powerful independent predictor of mortality in patients with preserved ejection fraction, incremental to common clinical and imaging risk factors.

Response to letter to the Editor regarding physical restraint in psychiatric setting

The following letter addresses the issues of the applicability of physical restriction, with particular attention to the therapeutic regime and its meaning as a therapeutic or restrictive provision, while considering possible alternative measures in the context of Italian jurisprudence. The letter, in response to the questions posed by Cioffi and Tomassini, examines the possible legal implications for doctors and suggests that the integration of jurisprudence and psychiatry seems to be mandatory to define the operational protocols for the management of physical restraint. La seguente lettera affronta il problema relativo all'applicabilità della contenzione fisica, con particolare riferimento al regime terapeutico, nonché la sua valenza giuridica quale misura terapeutica o restrittiva, considerando eventuali approcci alternativi. La lettera, in risposta alle domande poste da Cioffi e Tomassini, esamina le possibili implicazioni legali cui possono incorrere i medici nell'applicare la contenzione fisica, suggerendo la necessità di un'integrazione tra le norme giurisprudenziale e la scienza psichiatrica, al fine di definire i protocolli operativi di gestione della contenzione fisica.

The importance of Post Mortem Computed Tomography (PMCT) in the reconstruction of the bullet trajectory

INTRODUCTION

Post Mortem Computed Tomography (PMCT) and 3D reconstruction provide a powerful tool in the evaluation of the causes of death, distinguishing between those findings related to traumas and those related to post mortal changes. It has proven to be extremely useful in case of violent deaths as a support to the traditional autopsy.

AIM OF THE STUDY

The aim of the study is to prove the essential role of PMCT in the determination of the cause of death. For this purpose, we present a case of homicide where CT scans were performed before the autopsy, thus bringing to the resolution of an otherwise controversial death.

CASE PRESENTATION

A 17 years old male died from a gunshot fired by a policeman during a chase. There were some controversies in this case that brought it to the national mediatic attention. PMCT reconstructed images showed the entry point and the ballistic trajectory of the bullet, moreover, PMCT high sensitivity in the evaluation of bone lesions, made the technique diriment in the clarification of the sequence of events that brought to the death of the subject, resolving the controversies of the case. In fact, it showed that the trajectory of the bullet could have not been compatible with the victim's family thesis.

Is it time for international guidelines on physical restraint in psychiatric patients?

The freedom-restraining measures used during Involuntary Health Treatment (IHT) are highly criticized in the medical community. Physical restraint techniques are currently largely used worldwide in Psychiatry. The use of restraints against the patient's will can be considered a serious intrusion of basic human rights and even an act of violence against the patient. In all cases, the restraint should not lead to injuries or damage to the patient's health and should be implemented with a respect of the human rights and dignity. Generally, the use of restraint should be considered as a last resource, when all the other methods have failed. Since it represents the principal freedom-limitation measure, it should be constantly monitored by physicians who apply these methods. The case of a 58 years-old white male, affected by chronic schizoaffective disorder and cannabinoid dependence, was under involuntary medical treatment as a consequence of antisocial behavior. During the IHT he suffered firstly a pharmacological restraint and then a physical restraint in order to suppress a slight state of agitation. The patient was completely blocked to the bed for more than 80 hours and died after three days of hospitalization. The aim of this study is to evaluate the suitability of restrictive methods for psychiatric patients in order to establish specific rules to prevent abuse of restraint techniques and even to help physicians to treat psychiatric patients.

The α-decay of the Hoyle state in 12C: a new high-precision investigation

The αdecay path of the Hoyle state in 12C (Ex = 7:654MeV) represents one ofthe most challenging questions of modern nuclear physics. Its knowledge can help in theunderstanding of cluster configurations in light nuclei and the possible existence of Bose-Einstein condensates in nuclei. In stars, it is involved in the so-called 3αprocess, wherethe 12C nucleosynthesis occurs. We studied the 14N(d; α2)12C(7:654) reaction at 10:5MeVincident energy to probe its direct decay component. We found, with a precision higherof a factor 5 than any other previous experiment, an almost total absence of direct decaysby-passing the ground state of 8Be. From our analysis, a new upper limit of such decayis found at 0:043% (95% C.L.). Astrophysical 3α process reaction rate calculations haveto be accordingly revised.

Chlamydia Pneumoniae in Asymptomatic Carotid Atherosclerosis

We evaluated, in 415 patients with asymptomatic carotid atherosclerosis: (i) the prevalence of C. pneumoniae DNA in atherosclerotic carotid plaques and peripheral blood mononuclear cells (PBMC); (ii) the distribution of C. pneumoniae in atherosclerotic carotid plaques and PBMC from the same patients; (iii) the correlation between circulating anti-chlamydial antibodies and the presence of C. pneumoniae DNA. Overall, 160 atherosclerotic carotid plaques and 174 PBMC specimens from patients with asymptomatic carotid atherosclerosis were examined by ompA nested touchdown PCR for presence of C. pneumoniae. In addition, C. pneumoniae DNA was detected in 81 specimens of atherosclerotic carotid plaque and PBMC obtained from the same patients. C. pneumoniae DNA was found in 36.9% of atherosclerotic carotid plaques and in 40.2% of PBMC specimens examined (P=NS). With regard to 81 patients, C. pneumoniae DNA was detected in 27.2% of atherosclerotic carotid plaques and in 44.4% of PBMC specimens (P=0.05). In 18 patients, the presence of C. pneumoniae DNA in PBMC specimens and atherosclerotic carotid plaques coincided (P=0.005). No statistically significant association was found between anti-C pneumoniae antibodies (IgG and IgA) and positive PCR results. In conclusion, our results suggest that the detection of C. pneumoniae DNA in PBMC specimens seems to be a first-choice method to identify the patients at risk for endovascular chlamydial infection.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

PDD-NOS, psychotic features and executive function deficits in a boy with proximal 22q11.2 microduplication: Evolution of the psychiatric symptom profile from childhood to adolescence

22q11.2 microduplication (22q11.2DupS) is associated with a broad spectrum of phenotypes, including normality. Psychiatric disorders are described in 13% of these patients, including Attention Deficit and Hyperactivity Disorder (ADHD), Intellectual Deficiency (ID), and Autism Spectrum Disorder (ASD), but not schizophrenia. We report changes in the psychiatric symptom profile in the course of development of a young boy with a 22q11.2DupS syndrome, from early childhood to adolescence. The boy's psychiatric presentation was characterized by features of Pervasive Developmental Disorder (PDD), with ADHD in early childhood, a single psychotic episode in mid-infancy, and executive impairment in adolescence. We discuss the importance of an in-depth assessment of cognitive functions in children with22q11.2DupS throughout their development.

ANC experiments for nuclear astrophysics in NPI CAS

Asymptotic Normalization Coefficients method is one of the indirect methods used in nuclear astrophysics. The method allows to deduce a direct part of a radiative capture cross section from the measurement of a two body reaction under specific conditions. The experimental works started in collaboration of NPI CAS, TAMU and INFN LNS from 90-ties and continue till the present. The introduction to this method is presented and experimental experiences from NPI CAS and the collaboration are shared.

The Treiman-Yang Criterion: validating the Trojan Horse Method by experimentally probing the reaction mechanism

Proper selection of the quasi-free (QF) break-up channel in a three-body reaction is a key aspect for the applicability of the Trojan Horse Method (THM). The Treiman-Yang (TY) Criterion is a model-independent experimental test for the dominance of the QF mechanism, and hence constitutes one of the strongest validity tests of the THM. An experiment was performed at LNS to apply the test to the d(10B, 7Be α)n reaction. Here, the criterion is described and some preliminary data from the experiment are shown.

The 19F(α, p)22Ne and 23Na(p,α)20Ne reaction in AGB nucleosynthesis via THM

In AGB environment, fluorine and sodium abundances are still matter of debate. About 19F (only stable isotope of fluorine), its abundance in the universe is strictly related to standard and extra-mixing processes taking place inside AGB-stars, that are considered to be the most important sites for its production. Nevertheless the way in which it is destroyed is far from being well understood. On the other hand, 23Na presence in Globular Clusters, along with is well-known anticorrelation with oxygen has made clear that this element must be produced in previous generations stars, and intermediatemass AGB stars are one of the possible candidates for its production. For this reason we studied the 19F(α,p)22Ne and 23Na(p,α)20Ne reactions in the energy range of relevance for astrophysics via the Trojan Horse Method (THM), using the three-body reactions 6Li(19F, p22Ne)d and 23Na(d, pn)20Ne.

Development of the ELISSA array: prototype testing at Laboratori Nazionali del Sud

The Extreme Light Infrastructure-Nuclear Physics (ELI-NP) facility, underconstruction in Magurele near Bucharest in Romania, will provide high-intensity andhigh-resolution gamma ray beams that can be used to address hotly debated problems in nuclear astrophysics, such as the accurate measurements of the cross sections of the24Mg(γ,α)20Ne reaction

For this purpose, a silicon strip detector array (named ELISSA) will be realized in acommon effort by ELI-NP and Laboratori Nazionali del Sud (INFN-LNS), in order to measure excitation functions and angular distributions over a wide energy and angular range. A prototype of ELISSA was built and tested at INFN-LNS in Catania (Italy) with the support of ELI-NP. In this occasion, we have carried out experiments with alpha sources and with a 11 MeV 7Li beam that show up a very good energy resolution (better than 1%) and very good position resolution, of the order of 1 mm. Moreover, a threshold of 150 keV can be easily achieved with no cooling.

A Geant4-based Monte Carlo Tool for Nuclear Astrophysics

Present and future gamma-beam facilities represent a great opportunity to validate and evaluate the cross-sections of many photonuclear reactions at near-threshold energies, whose data mostly come from theoretical calculations. We developed a Monte Carlo (MC) software that makes use of the validatedtracking Geant4 libraries and the n-body event generator of ROOT libraries in order to provide a fast, realiable and complete MC tool to be used for nuclear physics experiments, with a particular focus on photo-nuclear processes. We discuss the results of the MC simulations performed in order to evaluate the effects of the electromagnetic background, the straggling of the emitted particles due to the target thickness and the resolution of the silicon detectors. Finally we present the preliminary results on some nuclear reactions involved in the p-process, which will be studied with ELISSA and the GBS at ELI-NP.

Improved information on astrophysical S-factor for the 10B(p,α0)7Be reaction using the Trojan Horse method

The 10B(p,α0)7Be reaction has been studied by applying the Trojan Horse method to the 2H(10B,α0 7Be)n reaction. The bare-nucleus astrophysical S(E)-factor in absolute units was extracted in a wide energy range, from 2.2 MeV to 3 keV and normalized to the direct experimental data, thus allowing determination of the electron screening potential for which a value of Ue=391±74 eV was obtained.

Neuroactive steroids and diabetic complications in the nervous system

Important complications of diabetes mellitus in the nervous system are represented by diabetic peripheral neuropathy and diabetic encephalopathy. In this context, an important link is represented by neuroactive steroids (i.e., steroids coming from peripheral glands and affecting nervous functionality as well as directly synthesized in the nervous system). Indeed, diabetes does not only affect the reproductive axis and consequently the levels of sex steroid hormones, but also those of neuroactive steroids. Indeed, as will be here summarized, the levels of these neuromodulators present in the central and peripheral nervous system are affected by the pathology in a sex-dimorphic way. In addition, some of these neuroactive steroids, such as the metabolites of progesterone or testosterone, as well as pharmacological tools able to increase their levels have been demonstrated, in experimental models, to be promising protective agents against diabetic peripheral neuropathy and diabetic encephalopathy.

26Mg target for nuclear astrophysics measurements

Two nuclear reactions of astrophysical interest, 26Mg(3He,d)27Al and 26Mg(d,p)27Mg, were measured for extraction of the Asymptotic Normalization Coefficients. Investigation of the target composition is presented, as well as the effects that showed up during analysis of the in-beam data obtained on CANAM accelerators in the Nuclear Physics Institute of the Czech Academy of Sciences (NPI CAS).

Intestinal Permeability in Relapsing-Remitting Multiple Sclerosis

Changes of intestinal permeability (IP) have been extensively investigated in inflammatory bowel diseases (IBD) and celiac disease (CD), underpinned by a known unbalance between microbiota, IP and immune responses in the gut. Recently the influence of IP on brain function has greatly been appreciated. Previous works showed an increased IP that preceded experimental autoimmune encephalomyelitis development and worsened during disease with disruption of TJ. Moreover, studying co-morbidity between Crohn's disease and MS, a report described increased IP in a minority of cases with MS. In a recent work we found that an alteration of IP is a relatively frequent event in relapsing-remitting MS, with a possible genetic influence on the determinants of IP changes (as inferable from data on twins); IP changes included a deficit of the active mechanism of absorption from intestinal lumen. The results led us to hypothesize that gut may contribute to the development of MS, as suggested by another previous work of our group: a population of CD8+CD161high T cells, belonging to the mucosal-associated invariant T (MAIT) cells, a gut- and liver-homing subset, proved to be of relevance for MS pathogenesis. We eventually suggest future lines of research on IP in MS: studies on IP changes in patients under first-line oral drugs may result useful to improve their therapeutic index; correlating IP and microbiota changes, or IP and blood-brain barrier changes may help clarify disease pathogenesis; exploiting the IP data to disclose co-morbidities in MS, especially with CD and IBD, may be important for patient care.

Expression of FK506-binding protein 51 (FKBP51) in Mycosis fungoides

BACKGROUND

Mycosis fungoides (MF) is the major subtype of cutaneous T-cell lymphomas (CTCL). It usually has a prolonged indolent clinical course with a minority of cases acquiring a more aggressive biological profile and resistance to conventional therapies, partially attributed to the persistent activation of nuclear factor-kappa B (NF-κB) pathway. In the last decade, several papers suggested an important role for the FK506-binding protein 51 (FKBP51), an immunophilin initially cloned in lymphocytes, in the control of NF-κB pathway in different types of human malignancies.

OBJECTIVES

We aimed to investigate the possible value of FKBP51 expression as a new reliable marker of outcome in patients with MF.

METHODS

We assessed by immunohistochemistry (IHC) FKBP51 expression in 44 patients with MF, representative of different stages of the disease. Immunohistochemical results were subsequently confirmed at mRNA level with quantitative PCR (qPCR) in a subset of enrolled patients. In addition, IHC and qPCR served to study the expression of some NF-κB-target genes, including the tumour necrosis factor receptor-associated factor 2 (TRAF2).

RESULTS

Our results show that FKBP51 was expressed in all evaluated cases, with the highest level of expression characterizing MFs with the worst prognosis. Moreover, a significant correlation subsisted between FKBP51 and TRAF2 IHC expression scores.

CONCLUSIONS

We hypothesize a role for FKBP51 as a prognostic marker for MF and suggest an involvement of this immunophilin in deregulated NF-κB pathway of this CTCL.