Case Report: An unusual case of a transposition of the great arteries with a double aortic arch: a highly complex fetal diagnosis with an unpredictable outcome

Published data estimate the prevalence of the vascular ring at approximately 7 per 10,000 live births. The association of a double aortic arch with a D-transposition of the great arteries has been rarely described in the literature. In this study, we report the prenatal diagnosis of a 28-year-old woman. A fetal echocardiography at a gestational age of 24 weeks + 6 days showed a D-transposition of the great arteries and a double aortic arch with a ventricular septal defect and pulmonary stenosis. On the first night after birth, the baby experienced an increase in lactate levels, with the rate of oxygen saturation consistently below 80%. A few hours after birth, the patient underwent a Rashkind procedure. An echocardiography, CT chest x-ray, and CT angiogram confirmed a diagnosis with a severe reduction of the tracheal lumen (>85%) and bronchomalacia. Then, the patient underwent posterior tracheopexy and aortopexy and later an arterial switch operation, ventricular septal defect closure, and resection of a part of the infundibular septum, accepting the risk of potential neoaortic obstruction. The literature has reported only two cases of patients with a fetal echocardiogram diagnosis. Therefore, our patient is only the third one with a fetal diagnosis and the second one with a complex intracardiac anatomy, characterized not only by a ventricular septal defect but also by two separate components of the obstruction (a bicuspid valve and a dysplastic valve with a posterior deviation of the infundibular septum). In conclusion, a D-transposition of the great arteries with a double aortic arch remains an extremely unusual association. The clinical outcome of these patients presents a high degree of variability and is entirely unpredictable in prenatal life. Our greatest aim as fetal and perinatal cardiologists is to improve the management and outcome of these patients through a fetal diagnosis, recognizing types of congenital heart disease in newborns who require early neonatal invasive procedures.

Observational study on the associations between milk yield, composition, and coagulation properties with blood biomarkers of health in Holstein cows

The considerable increase in the production capacity of individual cows owing to both selective breeding and innovations in the dairy sector has posed challenges to management practices in terms of maintaining the nutritional and metabolic health status of dairy cows. In this observational study, we investigated the associations between milk yield, composition, and technological traits and a set of 21 blood biomarkers related to energy metabolism, liver function or hepatic damage, oxidative stress, and inflammation or innate immunity in a population of 1,369 high-yielding Holstein-Friesian dairy cows. The milk traits investigated in this study included 4 production traits (milk yield, fat yield, protein yield, daily milk energy output), 5 traits related to milk composition (fat, protein, casein, and lactose percentages and urea), 11 milk technological traits (5 milk coagulation properties and 6 curd-firming traits). All milk traits (i.e., production, composition, and technological traits) were analyzed according to a linear mixed model that included the days in milk, the parity order, and the blood metabolites (tested one at a time) as fixed effects and the herd and date of sampling as random effects. Our findings revealed that milk yield and daily milk energy output were positively and linearly associated with total cholesterol, nonesterified fatty acids, urea, aspartate aminotransferase, γ-glutamyl transferase, total bilirubin, albumin, and ferric-reducing antioxidant power, whereas they were negatively associated with glucose, creatinine, alkaline phosphatase, total reactive oxygen metabolites, and proinflammatory proteins (ceruloplasmin, haptoglobin, and myeloperoxidase). Regarding composition traits, the protein percentage was negatively associated with nonesterified fatty acids and β-hydroxybutyrate (BHB), while the fat percentage was positively associated with BHB, and negatively associated with paraoxonase. Moreover, we found that the lactose percentage increased with increasing cholesterol and albumin and decreased with increasing ceruloplasmin, haptoglobin, and myeloperoxidase. Milk urea increased with an increase in cholesterol, blood urea, nonesterified fatty acids, and BHB, and decreased with an increase in proinflammatory proteins. Finally, no association was found between the blood metabolites and milk coagulation properties and curd-firming traits. In conclusion, this study showed that variations in blood metabolites had strong associations with milk productivity traits, the lactose percentage, and milk urea, but no relationships with technological traits of milk. Specifically, increasing levels of proinflammatory and oxidative stress metabolites, such as ceruloplasmin, haptoglobin, myeloperoxidase, and total reactive oxygen metabolites, were shown to be associated with reductions in milk yield, daily milk energy output, lactose percentage, and milk urea. These results highlight the close connection between the metabolic and innate immunity status and production performance. This connection is not limited to specific clinical diseases or to the transition phase but manifests throughout the entire lactation. These outcomes emphasize the importance of identifying cows with subacute inflammatory and oxidative stress as a means of reducing metabolic impairments and avoiding milk fluctuations.

Comparison of the passive mast cell activation test with the basophil activation test for diagnosis of perioperative rocuronium hypersensitivity

BACKGROUND

Rocuronium is a major cause of perioperative hypersensitivity (POH). Skin tests (STs) and quantification of specific immunoglobulin E antibodies (sIgEs) can yield incongruent results. In such difficult cases, the basophil activation test (BAT) can be helpful. Here, we evaluated the passive mast cell activation test (pMAT) as a substitute of BAT as part of the diagnostic tests for rocuronium allergy.

METHODS

Sera from patients with a suspected POH reaction potentially related to rocuronium were included. All patients had a complete diagnostic investigation, including STs, quantification of sIgEs to morphine and rocuronium, and BAT. For execution of pMAT, human mast cells were generated from healthy donor peripheral blood CD34+ progenitor cells and sensitised overnight with patient sera.

RESULTS

In total, 90 sera were studied: 41 from ST+sIgE+ patients, 13 from ST-sIgE- patients, 20 from ST+sIgE- patients, and 16 from ST-sIgE+ patients. According to BAT results, patients were further allocated into subgroups. Of the 38 BAT+ patients, 25 (66%) showed a positive pMAT as well. Of the 44 BAT- patients, 43 (98%) also showed a negative pMAT. Mast cells that were not passively sensitised did not respond to rocuronium.

CONCLUSIONS

We show that the pMAT, in many cases, can substitute for BAT in the diagnosis of rocuronium hypersensitivity and advance diagnosis in difficult cases with uncertain ST or sIgE results when BAT is not locally available.

Effect of intramammary infection and inflammation on milk protein profile assessed at the quarter level in Holstein cows

In this study we wanted to investigate the associations between naturally occurring subclinical intramammary infection (IMI) caused by different etiological agents (i.e., Staphylococcus aureus, Streptococcus agalactiae, Streptococcus uberis, and Prototheca spp.), in combination with somatic cell count (SCC), on the detailed milk protein profile measured at the individual mammary gland quarter. An initial bacteriological screening (time 0; T0) conducted on individual composite milk from 450 Holstein cows reared in 3 herds, was performed to identify cows with subclinical IMI. We identified 78 infected animals which were followed up at the quarter level at 2 different sampling times: T1 and T2, 2 and 6 wk after T0, respectively. A total of 529 quarter samples belonging to the previously selected animals were collected at the 2 sampling points and analyzed with a reversed phase HPLC (RP-HPLC) validated method. Specifically, we identified and quantified 4 caseins (CN), namely αS1-CN, αS2-CN, κ-CN, and β-CN, and 3 whey protein fractions, namely β-lactoglobulin, α-lactalbumin, and lactoferrin (LF), which were later expressed both quantitatively (g/L) and qualitatively (as a percentage of the total milk nitrogen content, % N). Data were analyzed with a hierarchical linear mixed model with the following fixed effects: days in milk (DIM), parity, herd, SCC, bacteriological status (BACT), and the SCC × BACT interaction. The random effect of individual cow, nested within herd, DIM and parity was used as the error term for the latter effects. Both IMI (i.e., BACT) and SCC significantly reduced the proportion of β-CN and αS1-CN, ascribed to the increased activity of both milk endogenous and microbial proteases. Less evident alterations were found for whey proteins, except for LF, which being a glycoprotein with direct and undirect antimicrobial activity, increased both with IMI and SCC, suggesting its involvement in the modulation of both the innate and adaptive immune response. Finally, increasing SCC in the positive samples was associated with a more marked reduction of total caseins at T1, and αS1-CN at T2, suggesting a synergic effect of infection and inflammation, more evident at high SCC. In conclusion, our work helps clarify the behavior of protein fractions at quarter level in animals having subclinical IMI. The inflammation status driven by the increase in SCC, rather the infection, was associated with the most significant changes, suggesting that the activity of endogenous proteolytic enzymes related to the onset of inflammation might have a pivotal role in directing the alteration of the milk protein profile.

Mast Cell-Targeting Therapies in Mast Cell Activation Syndromes

PURPOSE OF REVIEW

Provide an overview of the expanding landscape of mast cell (MC)-targeting treatments in mast cell activation syndromes (MCAS).

RECENT FINDINGS

Tyrosine-kinase inhibitors (TKIs) targeting wild-type and mutated KIT can efficiently induce MC depletion. Avapritinib and midostaurin can also temper IgE-mediated degranulation. Avapritinib has been recently approved by the FDA for the treatment of indolent systemic mastocytosis (ISM). Targeting activation pathways and inhibitory receptors is a promising therapeutic frontier. Recently, the anti Siglec-8 antibody lirentelimab showed promising results in ISM. MCAS is a heterogeneous disorder demanding a personalized therapeutic approach and, especially when presenting as anaphylaxis, has not been formally captured as outcome in prospective clinical trials with TKI. Long-term safety of TKI needs to be addressed. New drugs under investigation in diseases in which non-neoplastic MCs play a pivotal role can provide important inputs to identify new efficient and safe treatments for MCAS.

Novel insights into the associations between immune cell population distribution in mammary glands and milk minerals in Holstein cows

Udder health has a crucial role in sustainable milk production, and various reports have pointed out that changes in udder condition seem to affect milk mineral content. The somatic cell count (SCC) is the most recognized indicator for the determination of udder health status. Recently, a new parameter, the differential somatic cell count (DSCC), has been proposed for a more detailed evaluation of intramammary infection patterns. Specifically, the DSCC is the combined proportions of polymorphonuclear neutrophils and lymphocytes (PMN-LYM) on the total SCC, with macrophages (MAC) representing the remainder proportion. In this study, we evaluated the association between DSCC in combination with SCC on a detailed milk mineral profile in 1,013 Holstein-Friesian cows reared in 5 herds. An inductively coupled plasma-optical emission spectrometry was used to quantify 32 milk mineral elements. Two different linear mixed models were fitted to explore the associations between the milk mineral elements and first, the DSCC combined with SCC, and second, DSCC expressed as the PMN-LYM and MAC counts, obtained by multiplying the proportion of PMN-LYM and MAC by SCC. We observed a significant positive association between SCC and milk Na, S, and Fe levels. Differential somatic cell count showed an opposite behavior to the one displayed by SCC, with a negative association with Na and positive association with K milk concentrations. When considering DSCC as count, Na and K showed contrasting behavior when associated with PMN-LYM or MAC counts, with decreasing of Na content and increasing K when associated with increasing PMN-LYM counts, and increasing Na and decreasing K when associated with increasing MAC count. These findings confirmed that an increase in SCC is associated with altered milk Na and K amounts. Moreover, MAC count seemed to mirror SCC patterns, with the worsening of inflammation. Differently, PMN-LYM count exhibited patterns of associations with milk Na and K contents attributable more to LYM than PMN, given the nonpathological condition of the majority of the investigated population. An interesting association was observed for milk S content, which increased with increasing of inflammatory conditions (i.e., increased SCC and MAC count) probably attributable to its relationship with milk proteins, especially whey proteins. Moreover, milk Fe content showed positive associations with the PMN-LYM population, highlighting its role in immune regulation during inflammation. Further studies including individuals with clinical condition are needed to achieve a comprehensive view of milk mineral behavior during udder health impairment.

Diagnostic Significance of Tryptase for Suspected Mast Cell Disorders

Tryptase has proven to be a very useful and specific marker to demonstrate mast cell activation and degranulation when an acute (i.e., within 4 h after the event) and baseline value (i.e., at least 24 h after the event) are compared and meet the consensus formula (i.e., an increase of 20% + 2). The upper limit of normal determined by the manufacturer is 11.4 ng/mL; however, this boundary has been the subject of debate. According to ECNM and AIM experts, the normal range of baseline tryptase should be 1 to 15 ng/mL. A genetic trait, hereditary alpha tryptasemia, characterized by an increased alpha coding TPSAB1 copy number is associated with a baseline value above 8 ng/mL. Elevated tryptase can also be found in chronic kidney disease, obesity, and hematological neoplasms. A tryptase > 20 ng/mL serves as a minor criterion to diagnose systemic mastocytosis and an increase in tryptase > 20% + 2 during an acute event is a required criterion in the diagnosis of mast cell activation syndrome. The goal of this review is to demonstrate the (in)significance of tryptase using some clinical vignettes and to provide a practical guide on how to manage and interpret an elevated tryptase level.

The Severity and Frequency of Systemic Reactions to Hazelnut Are Significantly Higher in Hazelnut Allergic Patients Monosensitized to Cor a 8 than in Patients Polysensitized to Cor a 1, Cor a 8, and Cor a 9

INTRODUCTION

Hazelnuts are a leading trigger of food allergy. To date, several molecular components of hazelnut are available for component-resolved diagnosis. However, little is known about how simultaneous sensitization to multiple allergens affects the severity of the hazelnut-induced reaction. In a previous study, our group demonstrated a lower risk of systemic reactions to peach in patients sensitized to both Pru p 3 and Pru p 1 than in the patient monosensitized to peach LTP. We aimed to assess whether this was also true in hazelnut allergy in a cohort of adult patients.

METHODS

Patients were selected based on a history of symptoms such as urticaria, vomiting, diarrhea, asthma, and anaphylaxis indicative of hazelnut IgE-mediated food allergy and graded according to a clinical severity scale. For all patients, specific IgE was determined for Cor a 1 and Cor a 8 and, for most patients, also Cor a 9. Patients were offered an oral food challenge in open format (OFC) with a cocoa-based roasted hazelnut spread on a voluntary basis in order to prescribe an appropriate diet.

RESULTS

A total of two hundred and fourteen patients were recruited. Among these, 43 patients were monosensitized to Cor a 8. One hundred and seventy-one patients were sensitized to Cor a 1 (79.9%), and, among them, 48/171 (28.1%) were also Cor a 8 positive. Cor a 9 was evaluated in 124/214 patients, testing positive in 21/124 (16.9%). Patients monosensitized to Cor a 8 experienced systemic reactions more frequently than those sensitized to Cor a 1 ± Cor a 8 (p < 0.00001), with significantly more severe reactions (p < 0.0005) and testing more frequently positive at OFC (p < 0.0001). Regarding Cor a 9, the sensitized patients were significantly younger (p = 0.0013) and showed reactions of similar severity to patients who tested Cor a 9 negative, and these reactions were milder than in patients monosensitized only to Cor a 8.

DISCUSSION/CONCLUSION

Sensitization to Cor a 1 seems to protect from the development of the severe systemic reactions induced by Cor a 8 sensitization, Cor a 9 does not influence the severity of symptoms in adult patients. The OFC with roasted hazelnut may help in dietary guidance.

Impact of innovative rearing strategies for the Italian heavy pigs: Technological traits and chemical composition of dry-cured hams

To explore the influence of 4 feeding strategies on dry-cured ham quality, 336 barrows and gilts (3 batches, 112 pigs/batch) of 90 kg body weight (BW), were divided into 4 groups and housed in 8 pens with automated feeders. In the control group (C), the pigs were fed restrictively medium-protein feeds and slaughtered at 170 kg BW (SW) and 265 d of slaughter age (SA). With the older age (OA) treatment, the pigs were restrictively fed low protein feeds and slaughtered at 170 kg SW and 278 d SA. The other two groups were fed ad libitum high protein feeds, the younger age (YA) group was slaughtered at 170 kg SW and 237 d SA, the greater weight (GW) at 265 d of SA and 194 kg SW. The hams were dry-cured and seasoned for 607 d, weighed before and after seasoning and deboning. Sixty hams were sampled and sliced. The lean and the fat tissues were separated and analyzed for proximate composition and fatty acid profile. The model of analysis considered sex and treatment as fixed factors. With respect to C: i) OA lowered the ham weight, the lean protein content, increased marbling and decreased the PUFA proportion in intramuscular and subcutaneous fat; ii) YA hams had thicker fat cover with lower PUFA in intramuscular and subcutaneous fat; iii) GW increased the deboned ham weight, fat cover depth and marbling, reduced PUFA in intramuscular and subcutaneous fat, without alteration of the lean moisture content. Sex had a negligible impact.

Associations between subclinical intramammary infection and milk fatty acid profile at the quarter level in Holstein cattle

Mastitis, especially the subclinical form, is the most common economic and health problem in dairy cows. Little is known about changes in milk fatty acid (FA) composition according to infection/inflammation status of the mammary gland. The aim of this study was to investigate the associations between naturally occurring subclinical intramammary infection (IMI) from different pathogens, i.e. Streptococcus agalactiae, Staphylococcus aureus, Streptococcus uberis and Prototheca spp., and the detailed milk FA profile assessed at quarter level in Holstein cows. After an initial bacteriological screening (T0) on 450 Holstein cows reared in three dairy herds, we identified 78 cows positive at the bacteriological examination. These animals were followed up at the quarter level two weeks (T1) and six weeks (T2) after T0. In total, 600 single-quarter samples were obtained at T1 and T2. Individual FAs were determined using the gas chromatography analytical method. Investigated traits were 70 individual FAs, 12 FA groups, and six desaturation indices. The associations between subclinical IMI combined with somatic cell count (SCC) and milk FA profile were investigated using a hierarchical linear mixed model (i.e., observational unit was quarter within cow) with the following fixed effects: days in milk (DIM), parity, herd, SCC, bacteriological status (BACT, positive and negative), and the SCC × BACT interaction. The random effect of individual cow nested within herd, DIM and parity was used as the error term for the latter effects. The most significant associations were detected at T2. Notably, IMI reduced the proportions of individual short-chain FA, especially 4:0 and 6:0 (-14%), but increased the proportion of the most abundant medium-chain FA (MCFA), 16:0 (+4%). A reduction in the desaturation indices was observed mostly for 14:1 index (-9%), in line with the reduction in 14:1 (-10%). Somatic cell count significantly affected 14 individual FAs. In particular, samples with high SCC (≥200 000) had significantly lower proportions of 8:0, 10:0, 11:0, 12:0, and 13:0 compared with samples with low SCC (<200 000). Increasing SCC in animals positive at the bacteriological examination were associated with a reduction in total MCFA at T2 (while in negative animals, they remained constant across SCC classes), possible evidence that elongation of the FA chain from 11 to 16 carbons is affected by a combination of infection and SCC. This study showed that subclinical IMI and SCC are mainly associated with reductions in the synthesis of FA and the desaturation process in the mammary gland.

Associations between the detailed milk mineral profile, milk composition, and metabolic status in Holstein cows

The causes of variation in the milk mineral profile of dairy cattle during the first phase of lactation were studied under the hypothesis that the milk mineral profile partially reflects the animals' metabolic status. Correlations between the minerals and the main milk constituents (i.e., protein, fat, and lactose percentages), and their associations with the cows' metabolic status indicators were explored. The metabolic status indicators (MET) that we used were blood energy-protein metabolites [nonesterified fatty acids, β-hydroxybutyrate (BHB), glucose, cholesterol, creatinine, and urea], and liver ultrasound measurements (predicted triacylglycerol liver content, portal vein area, portal vein diameter and liver depth). Milk and blood samples, and ultrasound measurements were taken from 295 Holstein cows belonging to 2 herds and in the first 120 d in milk (DIM). Milk mineral contents were determined by ICP-OES; these were considered the response variable and analyzed through a mixed model which included DIM, parity, milk yield, and MET as fixed effects, and the herd/date as a random effect. The MET traits were divided in tertiles. The results showed that milk protein was positively associated with body condition score (BCS) and glucose, and negatively associated with BHB blood content; milk fat was positively associated with BHB content; milk lactose was positively associated with BCS; and Ca, P, K and S were the minerals with the greatest number of associations with the cows' energy indicators, particularly BCS, predicted triacylglycerol liver content, glucose, BHB and urea. We conclude that the protein, fat, lactose, and mineral contents of milk partially reflect the metabolic adaptation of cows during lactation and within 120 DIM. Variations in the milk mineral profile were consistent with changes in the major milk constituents and the metabolic status of cows.

Mastocytosis and related entities: a practical roadmap

Mastocytosis is a complex heterogenous multisystem disorder that is characterized by pathologic activation or accumulation of neoplastic mast cells (MCs) in one or more organs. This clonal MC expansion is often associated with a somatic gain-of-function mutation (D816V in most of the cases) in the KIT gene, encoding for the MC surface receptor KIT (CD117), a stem cell growth factor receptor. Based on clinical and biochemical criteria, the World Health Organization (WHO) divided mastocytosis into different subclasses. The exact prevalence of mastocytosis remains elusive, but it is estimated that the disease affects approximately 1 in 10,000 persons. The clinical presentation of mastocytosis varies significantly, ranging from asymptomatic patients to a life-threatening disease with multiple organ involvement, potentially leading to cytopenia, malabsorption, hepatosplenomegaly, lymphadenopathy, ascites or osteolytic bone lesions with pathological fractures. Patients with mastocytosis may experience symptoms related to release of MC mediators, such as flushing or diarrhea or even more severe symptoms such as anaphylaxis. Recently, a new genetic trait, hereditary alpha tryptasemia (HaT), was described which involves a copy number variation in the TPSAB1-gene. Its role as standalone multisystem syndrome is heavily debated. There is emerging evidence suggesting there might be a link between HaT and due to the increased prevalence of HaT in patients with SM. The aim of this review is to provide a practical roadmap for diagnosis and management of mastocytosis and its associated entities, since there are still many misconceptions about these topics.Abbreviations: AdvSM: Advanced systemic mastocytosis; ASM: Aggressive systemic mastocytosis; aST: acute serum tryptase; BM: Bone marrow; BMM: Bone marrow mastocytosis; bST: baseline serum tryptase; CM: Cutaneous mastocytosis; DCM: Diffuse cutaneous mastocytosis; HVA: Hymenoptera venom allergy; HaT: Hereditary alpha tryptasemia; ISM: Indolent systemic mastocytosis; MC: Mast cell; MCA: Mast cell activation; MCAS: Mast cell activation syndrome; MCL: Mast cell leukemia; MIS: Mastocytosis in the skin; MMAS: Monoclonal mast cell activation syndrome; MPCM: Maculopapular cutaneous mastocytosis; SM: Systemic mastocytosis; SM-AHN: Systemic mastocytosis with associated hematological neoplasm; SSM: Smouldering systemic mastocytosis; VIT: Venom immunotherapy.

Clinical criteria and diagnostic assessment of fibromyalgia: position statement of the Italian Society of Neurology-Neuropathic Pain Study Group

BACKGROUND

The role of central and/or peripheral nervous system dysfunction is basically fundamental in fibromyalgia.

AIM

The aim of this position statement on behalf of the Neuropathic Pain Study Group of the Italian Society of Neurology is to give practical guidelines for the clinical and instrumental assessment of fibromyalgia (FM) in the neurological clinical practice, taking into consideration recent studies.

METHODS

Criteria for study selection and consideration were original studies, case-controls design, use of standardized methodologies for clinical practice, and FM diagnosis with ACR criteria (2010, 2011, 2016).

RESULTS

ACR criteria were revised. For diagnostic procedure of small-fiber pathology, 47 studies were totally considered. Recent diagnostic criteria should be applied (ACR, 2016). A rheumatologic visit seems mandatory. The involvement of small fibers should request at least 2 among HRV + SSR and/or laser-evoked responses and/or skin biopsy and/or corneal confocal microscopy, eventually followed by monitoring of metabolic and/or immunological/ and or/paraneoplastic basis, to be repeated at 1-year follow-up.

CONCLUSIONS

The correct diagnostic approach to FM could promote the exclusion of the known causes of small-fiber impairment. The research toward common genetic factors would be useful to promote a more specific therapeutic approach.

A review of cannabis allergy in the early days of legalization

Cannabis allergy is a burgeoning field; consequently, research is still in its infancy and allergists' knowledge surrounding this topic is limited. As cannabis legalization expands across the world, it is anticipated that there will be an increase in cannabis use. Thus, we hypothesize that a concomitant rise in the incidence of allergy to this plant can be expected. Initiatives aimed at properly educating health care professionals are therefore necessary. This review presents the most up-to-date information on a broad range of topics related to cannabis allergy. Although the clinical features of cannabis allergy are becoming more well described and recognized, the tools available to make a correct diagnosis are meager and often poorly accessible. In addition, research on cannabis allergy is still taking its first steps, and new and potentially groundbreaking findings in this field are expected to occur in the next few years. Finally, although therapeutic approaches are being developed, patient and physician education regarding cannabis allergy is certainly needed.

Predicting milk protein fractions using infrared spectroscopy and a gradient boosting machine for breeding purposes in Holstein cattle

In recent years, increasing attention has been focused on the genetic evaluation of protein fractions in cow milk with the aim of improving milk quality and technological characteristics. In this context, advances in high-throughput phenotyping by Fourier transform infrared (FTIR) spectroscopy offer the opportunity for large-scale, efficient measurement of novel traits that can be exploited in breeding programs as indicator traits. We took milk samples from 2,558 Holstein cows belonging to 38 herds in northern Italy, operating under different production systems. Fourier transform infrared spectra were collected on the same day as milk sampling and stored for subsequent analysis. Two sets of data (i.e., phenotypes and FTIR spectra) collected in 2 different years (2013 and 2019-2020) were compiled. The following traits were assessed using HPLC: true protein, major casein fractions [α_S1-casein (CN), α_S2-CN, β-CN, κ-CN, and glycosylated-κ-CN], and major whey proteins (β-lactoglobulin and α-lactalbumin), all of which were measured both in grams per liter (g/L) and proportion of total nitrogen (% N). The FTIR predictions were calculated using the gradient boosting machine technique and tested by 3 different cross-validation (CRV) methods. We used the following CRV scenarios: (1) random 10-fold, which randomly split the whole into 10-folds of equal size (9-folds for training and 1-fold for validation); (2) herd/date-out CRV, which assigned 80% of herd/date as the training set with independence of 20% of herd/date assigned as the validation set; (3) forward/backward CRV, which split the data set in training and validation set according with the year of milk sampling (FTIR and gold standard data assessed in 2013 or 2019-2020) using the "old" and "new" databases for training and validation, and vice-versa with independence among them; (4) the CRV for genetic parameters (CRV-gen), where animals without pedigree as assigned as a fixed training population and animals with pedigree information was split in 5-folds, in which 1-fold was assigned to the fixed training population, and 4-folds were assigned to the validation set (independent from the training set). The results (i.e., measures and predictions) of CRV-gen were used to infer the genetic parameters for gold standard laboratory measurements (i.e., proteins assessed with HPLC) and FTIR-based predictions considering the CRV-gen scenario from a bi-trait animal model using single-step genomic BLUP. We found that the prediction accuracies of the gradient boosting machine equations differed according to the way in which the proteins were expressed, achieving higher accuracy when expressed in g/L than when expressed as % N in all CRV scenarios. Concerning the reproducibility of the equations over the different years, the results showed no relevant differences in predictive ability between using "old" data as the training set and "new" data as the validation set and vice-versa. Comparing the additive genetic variance estimates for milk protein fractions between the FTIR predicted and HPLC measures, we found reductions of -19.7% for milk protein fractions expressed in g/L, and -21.19% expressed as % N. Although we found reductions in the heritability estimates, they were small, with values ranging from -1.9 to -7.25% for g/L, and -1.6 to -7.9% for % N. The posterior distributions of the additive genetic correlations (r_a) between the FTIR predictions and the laboratory measurements were generally high (>0.8), even when the milk protein fractions were expressed as % N. Our results show the potential of using FTIR predictions in breeding programs as indicator traits for the selection of animals to enhance milk protein fraction contents. We expect acceptable responses to selection due to the high genetic correlations between HPLC measurements and FTIR predictions.

A quarter of a century fundamental and translational research in perioperative hypersensitivity and anaphylaxis at the Antwerp university hospital, a Belgian Centre of Excellence of the World Allergy Organization

Perioperative hypersensitivity constitutes an important health issue, with potential dramatic consequences of diagnostic mistakes. However, safe and correct diagnosis is not always straightforward, mainly because of the application of incorrect nomenclature, absence of easy accessible in-vitro/ex-vivo tests and uncertainties associated with the non-irritating skin test concentrations. In this editorial we summarize the time line, seminal findings, and major realizations of 25 years of research on the mechanisms, diagnosis, and management of perioperative hypersensitivity.

Pulse-driven self-reconfigurable meta-antennas

Wireless communications and sensing have notably advanced thanks to the recent developments in both software and hardware. Although various modulation schemes have been proposed to efficiently use the limited frequency resources by exploiting several degrees of freedom, antenna performance is essentially governed by frequency only. Here, we present an antenna design concept based on metasurfaces to manipulate antenna performances in response to the time width of electromagnetic pulses. We numerically and experimentally show that by using a proper set of spatially arranged metasurfaces loaded with lumped circuits, ordinary omnidirectional antennas can be reconfigured by the incident pulse width to exhibit directional characteristics varying over hundreds of milliseconds or billions of cycles, far beyond conventional performance. We demonstrate that the proposed concept can be applied for sensing, selective reception under simultaneous incidence and mutual communications as the first step to expand existing frequency resources based on pulse width.

A very late onset AChR and MuSK double positive myasthenia gravis: a case description and literature review

AChR and MuSK double positive myasthenia gravis has been rarely reported. Generally, it occurs in children and adults after thymectomy or immunotherapy. Furthermore, in a few patients with bulbar or respiratory involvement, MuSK antibodies might be detected after clinical deterioration. We report a man with a very late onset myasthenia gravis (86-year-old) and the coexistence of both antibodies at the time of the diagnosis. Despite the presence of MuSK antibodies, he manifested no bulbar symptoms and had a favorable clinical outcome. However, side effects related to low dose pyridostigmine were evident. Hence, double positivity can also occur in elderly and in more benign forms of myasthenia gravis. Other cases of AChR and MuSK double positive myasthenia gravis could allow a better definition of this condition.

Basophil Activation Test Shows Poor Sensitivity in Immediate Amoxicillin Allergy

BACKGROUND

In light of the pandemic of spurious penicillin allergy, correct diagnosis of amoxicillin (AX) allergy is of great importance. The diagnosis of immediate hypersensitivity reactions relies on skin tests and specific IgE, and although reliable, these are not absolutely predictive. Therefore, drug challenges are needed in some cases, which contain the risk of severe reactions. Safe in vitro diagnostics as an alternative for the drug challenge in the diagnostic workup of AX allergy would be more than welcome to fill this gap. In this respect, the basophil activation test (BAT) has shown potential, but its clinical reliability is doubtful.

OBJECTIVE

To investigate the reliability of the BAT to AX and determining its exact place in the diagnostic algorithm of AX allergy.

METHODS

BAT for AX was performed in 70 exposed control individuals and 66 patients diagnosed according to the European Academy of Allergy and Clinical Immunology guidelines for AX allergy. Upregulation of both CD63 and CD203c was flow-cytometrically assessed.

RESULTS

Analyses revealed that 1370 μmol/L and 685 μmol/L were the most discriminative stimulation concentrations for CD63 and CD203c upregulation, respectively, and a diagnostic threshold of 9% for positivity for both markers was identified. At these concentrations, sensitivity and specificity for CD63 upregulation were 13% and 100%, respectively, and for CD203c upregulation, 23% and 98%.

CONCLUSIONS

BAT with dual analysis of CD63 and CD203c is of poor performance to document AX allergy. The sensitivity is too low to let it occupy a prominent role in the diagnostic algorithm.

Allergenic and Mas-Related G Protein-Coupled Receptor X2-Activating Properties of Drugs: Resolving the Two

Since the seminal description implicating occupation of the Mas-related G protein-coupled receptor X2 (MRGPRX2) in mast cell (MC) degranulation by drugs, many investigations have been undertaken into this potential new endotype of immediate drug hypersensitivity reaction. However, current evidence for this mechanism predominantly comes from (mutant) animal models or in vitro studies, and irrefutable clinical evidence in humans is still missing. Moreover, translation of these preclinical findings into clinical relevance in humans is difficult and should be critically interpreted. Starting from our clinical priorities and experience with flow-assisted functional analyses of basophils and cultured human MCs, the objectives of this rostrum are to identify some of these difficulties, emphasize the obstacles that might hamper translation from preclinical observations into the clinics, and highlight differences between IgE- and MRPGRX2-mediated reactions. Inevitably, as with any subject still beset by many questions, alternative interpretations, hypotheses, or explanations expressed here may not find universal acceptance. Nevertheless, we believe that for the time being, many questions remain unanswered. Finally, a theoretical mechanistic algorithm is proposed that might advance discrimination between MC degranulation from MRGPRX2 activation and cross-linking of membrane-bound drug-reactive IgE antibodies.

Mas-related G protein-coupled receptor MRGPRX2 in human basophils: Expression and functional studies

Background

Occupancy of MRGPRX2 heralds a new era in our understandings of immediate drug hypersensitivity reactions (IDHRs), but a constitutive expression of this receptor by basophils is debated.

Objective

To explore the expression and functionality of MRGPRX2 in and on basophils.

Methods

Basophils from patients with birch pollen allergy, IDHRs to moxifloxacin, and healthy controls were studied in different conditions, that is, in rest, after stimulation with anti-IgE, recombinant major birch pollen allergen (rBet v 1), moxifloxacin, fMLP, substance P (SP), or other potential basophil secretagogues. In a separate set of experiments, basophils were studied after purification and resuspension in different media.

Results

Resting whole blood basophils barely express MRGPRX2 on their surface and are unresponsive to SP or moxifloxacin. However, surface MRGPRX2 is quickly upregulated upon incubation with anti-IgE or fMLP. Pre-stimulation with anti-IgE can induce a synergic effect on basophil degranulation in IgE-responsive subjects after incubation with SP or moxifloxacin, provided that basophils have been obtained from patients who experienced an IDHR to moxifloxacin. Cell purification can trigger a "spontaneous" and functional upregulation of MRGPRX2 on basophils, not seen in whole blood cells, and its surface density can be influenced by distinct culture media.

Conclusion

Basophils barely express MRGPRX2 in resting conditions. However, the receptor can be quickly upregulated after stimulation with anti-IgE, fMLP, or after purification, making cells responsive to MRGPRX2 occupation. We anticipate that such "conditioned" basophils constitute a model to explore MRGPRX2 agonism or antagonism, including IDHRs originating from the occupation of this receptor.

Impact of somatic cell count combined with differential somatic cell count on milk protein fractions in Holstein cattle

Udder health in dairy herds is a very important issue given its implications for animal welfare and the production of high-quality milk. Somatic cell count (SCC) is the most widely used means of assessing udder health status. However, differential somatic cell count (DSCC) has recently been proposed as a new and more effective means of evaluating intramammary infection dynamics. Differential SCC represents the combined percentage of polymorphonuclear neutrophils and lymphocytes (PMN-LYM) in the total SCC, with macrophages (MAC) accounting for the remaining proportion. The aim of this study was to evaluate the association between SCC and DSCC and the detailed milk protein profile in a population of 1,482 Holstein cows. A validated reversed-phase HPLC method was used to quantify 4 caseins (CN), namely α_S1-CN, α_S2-CN, κ-CN, and β-CN, and 3 whey protein fractions, namely β-lactoglobulin, α-lactalbumin, and lactoferrin, which were expressed both quantitatively (g/L) and qualitatively (as a percentage of the total milk nitrogen content, %N). A linear mixed model was fitted to explore the associations between somatic cell score (SCS) combined with DSCC and the protein fractions expressed quantitatively and qualitatively. We ran an additional model that included DSCC expressed as PMN-LYM and MAC counts, obtained by multiplying the percentages of PMN-LYM and MAC by SCC for each cow in the data set. When the protein fractions were expressed as grams per liter, SCS was significantly negatively associated with almost all the casein fractions and positively associated with the whey protein α-lactalbumin, while DSCC was significantly associated with α_S1-CN, β-CN, and α-lactalbumin, but in the opposite direction to SCS. We observed the same pattern with the qualitative data (i.e., %N), confirming opposite effects of SCS and DSCC on milk protein fractions. The PMN-LYM count was only slightly associated with the traits of concern, although the pattern observed was the same as when both SCS and DSCC were included in the model. The MAC count, however, generally had a greater impact on many casein fractions, in particular decreasing both β-CN content (g/L) and proportion (%N), and exhibited the opposite pattern to the PMN-LYM count. Our results show that information obtained from both SCS and DSCC may be useful in assessing milk quality and protein fractions. They also demonstrate the potential of MAC count as a novel udder health trait.

Establishing diagnostic strategies for cannabis allergy

INTRODUCTION

Cannabis is the most widely consumed illicit drug in the world and carries a risk of severe IgE-mediated allergic reactions, requiring appropriate diagnostic management. Currently available diagnostics are still relatively limited and require careful interpretation of results to avoid harmful over- and underdiagnosis.

AREAS COVERED

This review focuses on the most up-to-date understandings of cannabis allergy diagnosis, starting with the main clinical features of the disease and the allergenic characteristics of Cannabis sativa, and then providing insights into in vivo, in vitro, and ex vivo diagnostic tests.

EXPERT OPINION

At present, the diagnosis of IgE-mediated cannabis allergy is based on a three-step approach that starts with accurate history taking and ends with a confirmation of sensitization to the whole extract and, finally, molecular components. Although much has been discovered since its first description in 1971, the diagnosis of cannabis allergy still has many unmet needs. The lack of commercial standardized and validated extracts and in vitro assays makes a harmonized workup of cannabis allergy difficult. Furthermore, the epidemiological characteristics, and clinical implications of sensitization to different molecular components are not yet fully known. Future research will complete the picture and likely result in an individualized and standardized approach.

Streptococcus agalactiae and Prototheca spp. induce different mammary gland leukocyte responses in Holstein cows

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Streptococcus agalactiae increased polymorphonuclear neutrophils in milk samples.

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Prototheca infection greatly increased total T lymphocytes and T-helper lymphocytes in milk samples.

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Prototheca spp. trigger an adaptive immune response and chronic inflammation.

In this study, we investigated the association between natural subclinical intramammary infection (IMI) caused by Streptococcus agalactiae and Prototheca spp. and milk differential cell counts assessed by cytofluorimetric analysis in Holstein cows. After an initial bacteriological screening on 188 animals and a second assessment carried out 2 wk later aimed at confirming the bacteriological status, we collected milk samples from 47 animals and performed (1) milk composition analyses; (2) somatic cell counts and differential somatic cell counts (DSCC); and (3) cytofluorimetric analyses. Before statistical analyses, animals with co-infections were filtered out. Bacteriological status (negative, positive for Strep. agalactiae, or positive for Prototheca spp.) significantly affected the investigated traits. Compared with culture-negative samples, those that were positive for Strep. agalactiae and Prototheca spp. had higher SCS (+61% and +49%, respectively), DSCC (+4% and +19%, respectively), log polymorphonuclear neutrophil (PMN)-lymphocyte (LYM) counts (+59% and +71%, respectively), and log macrophage (MAC) counts (+63% and +72%, respectively). The individual leukocyte populations determined by cytofluorimetric analysis confirmed that mastitis infection increased the proportion of PMN in the milk samples compared with culture-negative samples, particularly when caused by Strep. agalactiae (+51%). In the case of MAC, the 2 pathogens behaved in opposite ways: Strep. agalactiae increased MAC by 41%, whereas Prototheca decreased MAC by 25%. Prototheca infection strongly increased the proportion of total T lymphocytes (TL; +87%) and T-helper lymphocytes (+83%). Accordingly, the (PMN+MAC):TL ratio increased with Strep. agalactiae infection (+95%) and decreased with Prototheca infection (−43%) compared with culture-negative samples. These results suggest the prevalence of an adaptive immune response and chronic inflammation in Prototheca infection, and an innate immune response to Strep. agalactiae. This knowledge might provide an important contribution to the development of novel and effective diagnostics and therapeutics.

Maximizing the forward scattering of dielectric nanoantennas through surface impedance coatings

In this Letter, we discuss a novel, to the best of our knowledge, approach for designing passive nanoantennas with maximum forward and almost-zero backward scattering. The proposed approach is based on the use of high-index dielectric spheres supporting dipolar magnetic resonances, which are coated by ultra-thin surface impedance coatings. It is shown that, by properly engineering the radius of the coat and its surface reactance, it is possible to introduce an additional electric dipolar resonance and to make this overlap with the magnetic one sustained by the high-index dielectric sphere. A realistic design that is based on graphene and works in the low-THz range is also proposed and verified with full-wave simulations. Compared to earlier techniques based on the combination of multipoles or on the use of ellipsoidal particles, the proposed one is quite robust toward realistic ohmic losses and preserves the isotropic behavior of the nanoantenna.

Associations between Milk Fatty Acid Profile and Body Condition Score, Ultrasound Hepatic Measurements and Blood Metabolites in Holstein Cows

Dairy cows have high incidences of metabolic disturbances, which often lead to disease, having a subsequent significant impact on productivity and reproductive performance. As the milk fatty acid (FA) profile represents a fingerprint of the cow’s nutritional and metabolic status, it could be a suitable indicator of metabolic status at the cow level. In this study, we obtained milk FA profile and a set of metabolic indicators (body condition score, ultrasound liver measurements, and 29 hematochemical parameters) from 297 Holstein–Friesian cows. First, we applied a multivariate factor analysis to detect latent structure among the milk FAs. We then explored the associations between these new synthetic variables and the morphometric, ultrasonographic and hematic indicators of immune and metabolic status. Significant associations were exhibited by the odd-chain FAs, which were inversely associated with β-hydroxybutyrate and ceruloplasmin, and positively associated with glucose, albumin, and γ-glutamyl transferase. Short-chain FAs were inversely related to predicted triacylglycerol liver content. Rumen biohydrogenation intermediates were associated with glucose, cholesterol, and albumin. These results offer new insights into the potential use of milk FAs as indicators of variations in energy and nutritional metabolism in early lactating dairy cows.

SARS-CoV-2 in a Neonate with Truncus Arteriosus: Management and Surgical Correction Timing

Children seem to be less affected by SARS-CoV-2 infection. High risk categories should include patients with Congenital Heart Disease (CHD), both children and adults. We describe the case of a newborn with a postnatal diagnosis of Truncus Arteriosus (TA) type A1 without 22.q.11 deletion syndrome. Soon after birth, SARS-CoV-2 infection was transmitted by the father. Due to the onset of heart failure symptoms, diuretic therapy has been set up. For worsening of clinical conditions, inotropic support with milrinone was added. A progressive reduction of N-terminal-pro hormone BNP over the days has been observed. Fourteen days after the negativization of the nasopharyngeal swab, the patient underwent surgical repair with Cardiopulmonary Bypass (CPB). Postoperative course was not complicated and the patient was discharged in good clinical conditions. There is very little evidence suggesting the optimal timing for surgery in SARS-CoV-2 positive patients. With a lack of specific guidelines, current strategy suggests a symptom-based or a polymerase chain reaction (PCR) test-based approach. In our case it was challenging to determine COVID-19 impact on heart failure symptoms. Our case is the first describing the surgical correction of CHD in a 40 days year old patient, performed in CPB after 14 days from SARS-CoV-2 infection negativization.

Clinical Features of Wheat Allergy Are Significantly Different between Tri a 14 Sensitized Patients and Tri a 19 Sensitized Ones

INTRODUCTION

Wheat is the most important cereal for human nutrition but its high consumption is associated to an increasing complaint of wheat-related disorders, many of which are allergic in nature and different in respect to the involved allergens. In this study, we compared the clinical aspects of wheat allergy presented by patients sensitized to Tri a 19 in respect to those presented by patients sensitized to Tri a 14.

METHODS

With this aim, we selected patients sensitized to 1 or both of the 2 allergens, and among these we identified those who were really wheat allergic and reactive on the basis of a standardized methodology. We evaluated the clinical features such as the kind and severity of symptoms, the coexistence of triggering factors such as physical exercise and NSAIDs and alcohol consumption, and the association with other allergens and with various immunologic parameters. Wheat allergy in Tri a 19 sensitized patients was confirmed through a questionnaire while the patients sensitized to Tri a 14 underwent wheat challenge with 100 g of pasta followed by exercise on a treadmill.

RESULTS

Seventy-nine patients sensitized to Tri a 14 and 40 patients sensitized to Tri a 19 were recruited. The 2 sensitizations were independent with a significant inverse relation (p < 0.00001). The Tri a 19 sensitized patients presented, in respect to the Tri a 14 sensitized ones, an older age (p = 0.0017), a higher risk to be wheat allergic (p < 0.0001), a higher severity of the reactions (p < 0.00001) and a higher association with some cofactors, namely alcohol (p < 0.0005) and physical exercise (p = 0.003). On the contrary, Tri a 14 sensitization was associated with atopy (p < 0.0001), with a higher probability of patients being asymptomatic (p < 0.0001) and being sensitized to other foods, in particular to nuts and cereals (p < 0.00001).

CONCLUSIONS

Sensitization to Tri a 19 or Tri a 14 determines different clinical pictures. In particular, sensitization to Tri a 19 implies a higher probability of severe reactions, even dependent on daily triggers, while that to Tri a 14 implies a higher cross-reactivity with other foods but it's more frequently asymptomatic, making a food challenge necessary to prevent useless food avoidance.

Adult-onset mitochondrial movement disorders: a national picture from the Italian Network

Introduction

Both prevalence and clinical features of the various movement disorders in adults with primary mitochondrial diseases are unknown.

Methods

Based on the database of the “Nation-wide Italian Collaborative Network of Mitochondrial Diseases”, we reviewed the clinical, genetic, neuroimaging and neurophysiological data of adult patients with primary mitochondrial diseases (n = 764) where ataxia, myoclonus or other movement disorders were part of the clinical phenotype.

Results

Ataxia, myoclonus and movement disorders were present in 105/764 adults (13.7%), with the onset coinciding or preceding the diagnosis of the mitochondrial disease in 49/105 (46.7%). Ataxia and parkinsonism were the most represented, with an overall prevalence at last follow-up of 59.1% and 30.5%, respectively. Hyperkinetic movement disorders were reported in 15.3% at last follow-up, being the less common reported movement disorders. The pathogenic m.8344A > G and POLG variants were always associated with a movement disorder, while LHON variants and mtDNA single deletions were more commonly found in the subjects who did not present a movement disorder. The most common neuroimaging features were cortical and/or cerebellar atrophy, white matter hyperintensities, basal ganglia abnormalities and nigro-striatal degeneration. Almost 70% of patients with parkinsonism responded to dopaminergic therapy, mainly levodopa, and 50% with myoclonus were successfully treated with levetiracetam.

Conclusion

Movement disorders, mainly ataxia and parkinsonism, are important findings in adult primary mitochondrial diseases. This study underlies the importance of looking for a mitochondrial etiology in the diagnostic flowchart of a movement disorder and may help direct genetic screening in daily practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10697-1.

Neuroendocrine predictors of vasoplegia after cardiopulmonary bypass

PURPOSE

Vasoplegia often complicates on-pump cardiac surgery. Systemic inflammatory response induced by extracorporeal circulation represents the major determinant, but adrenal insufficiency and postoperative vasopressin deficiency may have a role. Pathophysiological meaning of perioperative changes in endocrine markers of hydro-electrolyte balance has not still fully elucidated. Objectives of the present research study were to estimate the incidence of vasoplegia in a homogeneous cohort of not severe cardiopathic patients, to define the role of presurgical adrenal insufficiency, to evaluate copeptin and NT-proBNP trends in the perioperative.

METHODS

We conducted a prospective cohort study in the cardiac intensive care unit of a tertiary referral center. We evaluated 350 consecutive patients scheduled for cardiac surgery; 55 subjects completed the study. Both standard and low-dose corticotropin stimulation tests were performed in the preoperative; copeptin and NT-proBNP were evaluated in the preoperative (T0), on day 1 (T1) and day 7 (T2) after surgery.

RESULTS

Nine subjects (16.3%) developed vasoplegic syndrome with longer bypass and clamping time (p < 0.001). Reduced response to low-dose ACTH test was not associated to vasoplegia. Preoperative copeptin > 16.9 pmol/L accurately predicted the syndrome (AUC 0.86, 95% CI 0.73-0.94; OR 1.17, 95% CI 1.04-1.32). An evident correlation was observed at 7 days postoperative between NT-proBNP and copeptin (r 0.88, 95% CI 0.8-0.93; p < 0.001).

CONCLUSION

Preoperative impaired response to low-dose ACTH stimulation test is not a risk factor for post-cardiotomic vasoplegia; conversely, higher preoperative copeptin predicts the complication. On-pump cardiac surgery could be an interesting model of rapid heart failure progression.

Chronic inflammatory demyelinating polyradiculoneuropathy: can a diagnosis be made in patients not fulfilling electrodiagnostic criteria?

BACKGROUND AND PURPOSE

The aim was to identify the clinical and diagnostic investigations that may help to support a diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in patients not fulfilling the European Federation of Neurological Societies and Peripheral Nerve Society (EFNS/PNS) electrodiagnostic criteria.

METHODS

The data from patients with a clinical diagnosis of CIDP included in a national database were retrospectively reviewed.

RESULTS

In all, 535 patients with a diagnosis of CIDP were included. This diagnosis fulfilled the EFNS/PNS criteria in 468 patients (87.2%) (definite in 430, probable in 33, possible in three, while two had chronic immune sensory polyradiculopathy). Sixty-seven patients had a medical history and clinical signs compatible with CIDP but electrodiagnostic studies did not fulfill the EFNS/PNS criteria for CIDP. These patients had similar clinical features and frequency of abnormal supportive criteria for the diagnosis of CIDP compared to patients fulfilling EFNS/PNS criteria. Two or more abnormal supportive criteria were present in 40 (61.2%) patients rising to 54 (80.6%) if a history of a relapsing course as a possible supportive criterion was also included. Increased cerebrospinal fluid proteins and response to immune therapy most frequently helped in supporting the diagnosis of CIDP. Response to therapy was similarly frequent in patients fulfilling or not EFNS/PNS criteria (87.3% vs. 85.9%).

CONCLUSIONS

Patients with a clinical diagnosis of CIDP had similar clinical findings, frequency of abnormal supportive criteria and response to therapy compared to patients fulfilling EFNS/PNS criteria. The presence of abnormal supportive criteria may help in supporting the diagnosis of CIDP in patients with a medical history and clinical signs compatible with this diagnosis but non-diagnostic nerve conduction studies.

Light propagation through metamaterial temporal slabs: reflection, refraction, and special cases

Time-varying metamaterials are artificial materials whose electromagnetic properties change over time. Similar to a spatial medium discontinuity, a sudden change in time of the metamaterial refractive index induces the generation of reflected and refracted light waves. The relationship between the incident and emerging fields at one temporal interface has been subject of investigation in earlier studies. Here, we extend the study to a temporal slab, i.e., a uniform homogeneous medium that is present in the whole space for a limited time. The scattering coefficients have been derived as a function of the refractive indices and application time, demonstrating that the response of the temporal slab can be controlled through the application time, which acts similarly to the electrical thickness of conventional spatial slabs. The results reported in this Letter pave the way to creating novel devices based on temporal discontinuities, such as temporal matching networks, Bragg grating, and dielectric mirrors, which exhibit zero space occupancy by exploiting the time dimension, instead of the spatial dimension.

Metasurface-bounded open cavities supporting virtual absorption: free-space energy accumulation in lossless systems

We investigate an anomalous scattering phenomenon exhibited by a lossless system based on metasurfaces. Electromagnetic energy is neither reflected nor transmitted but stored within the system to be available again at a different time. We analytically derive the proper excitation conditions and verify the response of the system through a proper set of full-wave simulations, demonstrating the key role of the metasurface in enabling such a zero-scattering condition. The practical feasibility and the opportunities offered by the proposed metasurface-based system may open the door to the design of virtual absorbers with dynamic properties in energy absorbing, storing, and releasing.

Long-term treatment with subcutaneous immunoglobulin in patients with chronic inflammatory demyelinating polyradiculoneuropathy: a follow-up period up to 7 years

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is a rare and heterogeneous acquired sensory-motor polyneuropathy with autoimmune pathogenesis. Intravenous immunoglobulins (IVIG) are a well-established therapy for CIDP: it is well known that at least two-thirds of these patients need these infusions for several years. More recently, Subcutaneous Immunoglobulins (SCIg) have been proved to be effective: this finding has been confirmed either in isolated cases or in few randomized trials. However, it appeared that the longest SCIg treatment follow up lasted no longer than 48 months. We report herein the results of a long-term SCIg treatment with a follow up period up to 7 years (84 months), considering safety, tolerability and patients’ perception of SCIg treatment in a CIDP population. We studied 17 patients (10 M; 7 F) with a diagnosis of CIDP, defined according to the EFNS/PNS criteria, successfully treated with IVIG every 4/6 weeks before being switched to SCIg treatment. Clinical follow-up included, apart from a routinely clinical assessment, the administration of Medical Research Council (MRC) sum-score, the Overall Neuropathy Limitation Scale (ONLS) and the Life Quality Index questionnaire (LQI). The results showed that, in the majority of this pre-selected group of CIDP patients (16/17), SCIg were well tolerated and were preferred over IVIG. Strength and motor functions remained stable or even improved during the long term follow-up (up to 84 months) with benefits on walking capability and resistance, manual activity performances and fatigue reduction.

Hydrological and hydraulic behaviour of a surface flow constructed wetland treating agricultural drainage water in northern Italy

A surface flow constructed wetland (SFCW) treating agricultural drainage water was investigated with the aim to detect modifications in hydrological and hydraulic characteristics after more than a decade of operation. Ponded infiltration tests were conducted to estimate the saturated hydraulic conductivity, K_s, of the surface soil layer at the point scale. At the global scale, infiltration rate, i, was computed from the water balance to detect leakages from the pervious wetland surface. Tracer tests were conducted to analyse the existence of preferential flow inside the system and to estimate its hydraulic retention time (HRT). Clogging phenomena occurred given a mean K_s value of 30 mm h^-1 was measured near the SFCW inlet, that was 9.61 times lower than the value at the outlet zone. The estimated infiltration losses were two orders of magnitude lower than infiltration measured at the point scale. The results also confirmed the existence of a moderate amount of preferential flow paths and dead zones in the SFCW as the actual HRT (6.7 days) was shorter than the nominal one (8.1 days). Despite this, it can be concluded that the system performance is still good after 17 years of operation.

Prenatal echocardiographic assessment of right aortic arch

OBJECTIVES

To report our experience with fetal diagnosis of right aortic arch (RAA) variants based on the ductus arteriosus (DA) anatomy and brachiocephalic vessel branching pattern in relation to the trachea, and to establish whether the echocardiographic 'V-shaped' or 'U-shaped' appearance of the junction between the DA and aortic arch (AA) in the fetal upper mediastinal view is sufficiently accurate for assessment of fetal AA anatomy.

METHODS

This was a retrospective study of pregnancies with a prenatal diagnosis of fetal RAA that had postnatal confirmation of AA anatomy, referred to our tertiary center during 2011-2017. Prenatal and postnatal medical records, including echocardiographic and computed tomography (CT)/magnetic resonance imaging (MRI) scan reports, were reviewed, and cardiac and extracardiac abnormalities and the results of genetic testing were recorded.

RESULTS

Of 55 consecutive pregnancies with a prenatal diagnosis of fetal RAA, six were lost to follow-up, one was terminated and three were excluded due to lack of postnatal confirmation of AA anatomy. Of the remaining 45 pregnancies, AA anatomy was assessed postnatally by CT in 39, by MRI in one and by direct examination at cardiac surgery in five. A U-shaped appearance was found in 37/45 (82.2%) patients, all of which had a complete vascular ring (CVR). Of these 37 patients, on postnatal confirmation, 21 (56.8%) had RAA with Kommerell's diverticulum, left posterior ductus arteriosus (LPDA) and aberrant left subclavian artery (ALSA) (RAA/LPDA/ALSA), 11 (29.7%) had a double AA (DAA), four (10.8%) had RAA with Kommerell's diverticulum, LPDA and mirror-image (MI) branching (RAA/LPDA/MI), and one (2.7%) had RAA with Kommerell's diverticulum, LPDA and aberrant left innominate artery (ALIA) (RAA/LPDA/ALIA). A V-shaped appearance was found in 3/45 (6.7%) patients, all of which had RAA with right DA not forming a CVR and MI branching. In the 5/45 (11.1%) fetuses with neither U- nor V-shaped appearance, RAA with left anterior DA arising from the left innominate artery and MI branching, not forming a CVR, was found. Twelve (26.7%) fetuses had a congenital heart defect (CHD). RAA forming a CVR (U-shaped appearance) was associated with a septal defect in 6/37 (16.2%) fetuses, while RAA not forming a CVR (V-shaped appearance or no U- or V-shaped appearance) was associated with major CHD in 6/8 (75.0%) fetuses.

CONCLUSIONS

In fetuses with RAA, V-shaped appearance of the junction between the DA and AA indicates only that the transverse AA and DA run together on the same side of the thorax (trachea) while a U-shaped appearance is always a sign of a CVR. Among fetuses with a CVR, RAA/LPDA/MI is more frequent than described previously. Finally, RAA forming a CVR is not usually associated with complex CHD, as opposed to RAA not forming a CVR. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.