A platform for real-3d visualization and planning of left atrial appendage occlusion through mixed reality

Funding Acknowledgements

Type of funding sources: None.

Background

In left atrial appendage occlusion (LAAO), pre-procedural computed tomography (CT) is pivotal to describe the complex and highly variable LAA anatomy and to guide the operator in accurate planning of the intervention. Multiplanar reconstruction and 3D rendering are used for the navigation and analysis of the 3D datasets but they share some limitations that are due to the use of 2D screens; Mixed Reality (MxR) technology aims at overcoming such limitations by allowing for real-3D visualizations with holographic replicas of anatomical models while preserving a sense of presence within the true physical environment by the operator.

Purpose

To develop and test a MxR platform that provides a more intuitive and informative tool for the morphological analysis during the planning phase of LAAO.

Methods

Patients (n = 4) were randomly selected among those referred for a CT scan prior to transcatheter aortic valve replacement, each one characterized by a specific LAA morphology (cauliflower, bilobular, chicken wing, wind-sock). CT scans were performed in diastole at 75% of the R-R interval on a 64-slice scanner, with in-plane resolution 0.38-0.64 mm and slice thickness 0.62 mm. Firstly, the acquisition was cropped to contain the left atrium, the circumflex artery, the left upper pulmonary ridge. Subsequently, an isosurface with high coincidence between the blood cavity border and the endocardium was identified by the user and processed using a marching cube algorithm to obtain the 3D model. Finally, the 3D model was optimized for a MxR platform that allows for moving, zooming and cutting the model, measuring the main LAA linear dimensions and simulating the implant of a virtual replica of a transcatheter occluder.

Results

 

The workflow was successfully applied for all the patients independently from the morphology. All the models were successfully uploaded in the MxR platform (Fig 1.a) and for all the patients the morphological analysis was performed (Fig 1.b) in less than 10 minutes.

The four different morphologies of the LAA were correctly identified allowing a very detailed holographic modeling of the structure, including the neck, the landing zone, the curvature and the position and size of lobes.

For both the identified ostium and landing planes, using a dedicated measuring tool (Fig. 1.c), the operator measured the minimum and maximum diameters, which were later used to define the size of the occluder device to be used in the virtual implant simulation (Fig. 1.d).

Conclusions

The tested MxR platform suggested the potential to overcome the limits of the standard technologies in planning of LAAO thanks to the real-3D perception, potentially leading to a more accurate and faster planning phase. Furthermore, the use of MxR technology may enhance the ability to predict the optimal device size and position within the anatomy to obtain LAA complete sealing.

Abstract Figure.

Beyond waste: new sustainable fillers from fly ashes stabilization, obtained by low cost raw materials

A sustainable economy can be achieved only by assessing processes finalized to optimize the use of resources. Waste can be a relevant source of energy thanks to energy-from-waste processes. Concerns regarding the toxic fly ashes can be solved by transforming them into resource as recycled materials. The commitment to recycle is driven by the need to conserve natural resources, reduce imports of raw materials, save landfill space and reduce pollution. A new method to stabilize fly ash from Municipal Solid Waste Incinerator (MSWI) at room temperature has been developed thanks to COSMOS-RICE LIFE+ project (www.cosmos-rice.csmt.eu). This process is based on a chemical reaction that occurs properly mixing three waste fly ashes with rice husk ash, an agricultural by-product. COSMOS inert can replace critical raw materials (i.e. silica, fluorspar, clays, bentonite, antimony and alumina) as filler. Moreover the materials employed in the stabilization procedure may be not available in all areas. This paper investigates the possibility of substituting silica fume with corresponding condensed silica fume and to substitute flue-gas desulfurization (FGD) residues with low-cost calcium hydroxide powder. The removal of coal fly ash was also considered. The results will be presented and a possible substitution of the materials to stabilize fly ash will be discussed.

A Fusarium graminearum strain-comparative proteomic approach identifies regulatory changes triggered by agmatine

Plant pathogens face different environmental clues depending on the stage of the infection cycle they are in. Fusarium graminearum infects small grain cereals producing trichothecenes type B (TB) that act as virulence factor in the interaction with the plant and have important food safety implications. This study addresses at the proteomic level the effect of an environmental stimulus (such as the presence of a polyamine like agmatine) possibly encountered by the fungus when it is already within the plant. Because biological diversity affects the proteome significantly, a multistrain (n=3) comparative approach was used to identify consistent effects caused on the fungus by the nitrogen source (agmatine or glutamic acid). Proteomics analyses were performed by the use of 2D-DIGE. Results showed that agmatine augmented TB production but not equally in all strains. The polyamine reshaped drastically the proteome of the fungus activating specific pathways linked to the translational control within the cell. Chromatin restructuring, ribosomal regulations, protein and mRNA processing enzymes were modulated by the agmatine stimulus as well as metabolic, structural and virulence-related proteins, suggesting the need to reshape specifically the fungal cell for TB production, a key step for the pathogen spread within the spike.

BIOLOGICAL SIGNIFICANCE

Induction of toxin synthesis by plant compounds plays a crucial role in toxin contamination of food and feed, in particular trichothecenes type B produced mainly by F. graminearum on wheat. This work describes the level of diversity of 3 strains facing 2 toxin inducing plant derived compounds. This knowledge is of use for the research community on toxigenic Fusarium strains in cereals for understanding the role of fungal diversity in toxin inducibility. This work also suggests that environmental clues that can be found within the plant during infection (like different nitrogen compounds) are crucial stimuli for reshaping the proteome profile and consequently the specialization profiling of the fungus, ultimately leading to very different toxin contamination levels in the plant.

Comparison between rice husk ash grown in different regions for stabilizing fly ash from a solid waste incinerator

The Stabilization of heavy metals from municipal solid waste incineration (MSWI) fly ash by rice husk ash (RHA) is under intense study as an effective strategy to recover and reuse industrial and agricultural waste together. We compare the metal entrapment performances of RHA from different Asian rice sources – namely from Japonica rice grown in Italy and Indica rice grown in India – Physicochemical and morphological characterization of the final stabilized material show that the same thermal treatment may result in marked structural differences in the silica contained in the two RHA. Remarkably, one of them displays a crystalline silica content, although obtained by a thermal treatment below 800 °C. We also find that the presence of an alkali metal ion (potassium) in the rice husk plays a crucial role in the attainment of the final silica phase. These physicochemical differences are mirrored by different stabilization yields by the two RHA.

Cryogenic-temperature electron microscopy direct imaging of carbon nanotubes and graphene solutions in superacids

Cryogenic electron microscopy (cryo-EM) is a powerful tool for imaging liquid and semiliquid systems. While cryogenic transmission electron microscopy (cryo-TEM) is a standard technique in many fields, cryogenic scanning electron microscopy (cryo-SEM) is still not that widely used and is far less developed. The vast majority of systems under investigation by cryo-EM involve either water or organic components. In this paper, we introduce the use of novel cryo-TEM and cryo-SEM specimen preparation and imaging methodologies, suitable for highly acidic and very reactive systems. Both preserve the native nanostructure in the system, while not harming the expensive equipment or the user. We present examples of direct imaging of single-walled, multiwalled carbon nanotubes and graphene, dissolved in chlorosulfonic acid and oleum. Moreover, we demonstrate the ability of these new cryo-TEM and cryo-SEM methodologies to follow phase transitions in carbon nanotube (CNT)/superacid systems, starting from dilute solutions up to the concentrated nematic liquid-crystalline CNT phases, used as the 'dope' for all-carbon-fibre spinning. Originally developed for direct imaging of CNTs and graphene dissolution and self-assembly in superacids, these methodologies can be implemented for a variety of highly acidic systems, paving a way for a new field of nonaqueous cryogenic electron microscopy.

Morphology dependent field emission of acid-spun carbon nanotube fibers

Acid spun carbon nanotube (CNT) fibers were investigated for their field emission properties and performance was determined to be dependent on fiber morphology. The fibers were fabricated by wet-spinning of pre-made CNTs. Fiber morphology was controlled by a fabrication method and processing conditions, as well as purity, size, and type of the CNT starting material. The internal fiber structure consisted of CNT fibrils held together by van der Waals forces. Alignment and packing density of the CNTs affects the fiber's electrical and thermal conductivity. Fibers with similar diameters and differing morphology were compared, and those composed of the most densely packed and well aligned CNTs were the best field emitters as exhibited by a lower turn-on voltage and a larger field enhancement factor. Fibers with higher electrical and thermal conductivity demonstrated higher maximum current before failure and longer lifetimes. A stable emission current at 3 mA was obtained for 10 h at a field strength of <1 V μm(-1). This stable high current operation makes these CNT fibers excellent candidates for use as low voltage electron sources for vacuum electronic devices.

Detection of multiple mycotoxin occurrences in soy animal feed by traditional mycological identification combined with molecular species identification

Soy products are a main component of animal feed. Because mycotoxins may harm farm animals, undermining productivity and health, a mycological and toxigenic screening was carried out on 36 batches used in animal feed, collected in 2008, 2009 and 2010 in Italy. The investigated mycoflora of a subset of soy seed (n = 6) suggested that Aspergillus spp. and Fusarium spp. frequently colonize soy seeds. Aflatoxins, fumonisins and deoxynivalenol were detected in 88.9%, 72.2% and 30.6% of samples, respectively. Co-occurrence of at least two toxins was observed in 72% of cases. The molecular analysis of the Fusarium spp. population identified Fusarium verticillioides as potential producers of fumonisins, but no known deoxynivalenol producers were detected. It is suggested that the widespread presence of toxins can be due to non-optimal storing conditions of the feed. Moreover, our results suggest that mycotoxin thresholds should be adapted to consider the frequent case of toxin co-occurrence. This approach would better reflect the real toxigenic risk of feedstuffs.

Identification of a cis-acting factor modulating the transcription of FUM1, a key fumonisin-biosynthetic gene in the fungal maize pathogen Fusarium verticillioides

Fumonisins, toxic secondary metabolites produced by some Fusarium spp. and Aspergillus niger, have strong agro-economic and health impacts. The genes needed for their biosynthesis, named FUM, are clustered and co-expressed in fumonisin producers. In eukaryotes, coordination of transcription can be attained through shared transcription factors, whose specificity relies on the recognition of cis-regulatory elements on target promoters. A bioinformatic analysis on FUM promoters in the maize pathogens Fusarium verticillioides and Aspergillus niger identified a degenerated, over-represented motif potentially involved in the cis-regulation of FUM genes, and of fumonisin biosynthesis. The same motif was not found in various FUM homologues of fungi that do not produce fumonisins. Comparison of the transcriptional strength of the intact FUM1 promoter with a synthetic version, where the motif had been mutated, was carried out in vivo and in planta for F. verticillioides. The results showed that the motif is important for efficient transcription of the FUM1 gene.

Genotype-phenotype studies of VCP-associated inclusion body myopathy with Paget disease of bone and/or frontotemporal dementia

Valosin containing protein (VCP) disease associated with inclusion body myopathy, Paget disease of the bone and frontotemporal dementia is a progressive autosomal dominant disorder caused by mutations in Valosin containing protein gene. To establish genotype-phenotype correlations we analyzed clinical and biochemical markers from a database of 190 members in 27 families harboring 10 missense mutations. Individuals were grouped into three categories: symptomatic, presymptomatic carriers and noncarriers. The symptomatic families were further divided into ten groups based on their VCP mutations. There was marked intra and inter-familial variation; and significant genotype-phenotype correlations were difficult to establish because of small numbers. Nevertheless when comparing the two most common mutations, R155C mutation was found to be more severe, with an earlier onset of myopathy and Paget (p = 0.03). Survival analysis of all subjects revealed an average life span after diagnosis of myopathy and Paget of 18 and 19 years respectively, and after dementia only 6 years. R155C had a reduced survival compared to the R155H mutation (p = 0.03).We identified amyotrophic lateral sclerosis (ALS) was diagnosed in 13 individuals (8.9%) and Parkinson's disease in five individuals (3%); however, there was no genotypic correlation. This study represents the largest dataset of patients with VCP disease and expands our understanding of the natural history and provides genotype-phenotype correlations in this unique disease.

Expert recommendations for the laboratory diagnosis of MPS VI

Mucopolysaccharidosis VI (MPS VI) is a lysosomal storage disease caused by a deficiency of N-acetylgalactosamine 4-sulfatase (arylsulfatase B, ASB). This enzyme is required for the degradation of dermatan sulfate. In its absence, dermatan sulfate accumulates in cells and is excreted in large quantities in urine. Specific therapeutic intervention is available; however, accurate and timely diagnosis is crucial for maximal benefit. To better understand the current practices for diagnosis and to establish diagnostic guidelines, an international MPS VI laboratory diagnostics scientific summit was held in February of 2011 in Miami, Florida. The various steps in the diagnosis of MPS VI were discussed including urinary glycosaminoglycan (uGAG) analysis, enzyme activity analysis, and molecular analysis. The following conclusions were reached. Dilute urine samples pose a significant problem for uGAG analysis and MPS VI patients can be missed by quantitative uGAG testing alone as dermatan sulfate may not always be excreted in large quantities. Enzyme activity analysis is universally acknowledged as a key component of diagnosis; however, several caveats must be considered and the appropriate use of reference enzymes is essential. Molecular analysis supports enzyme activity test results and is essential for carrier testing, subsequent genetic counseling, and prenatal testing. Overall the expert panel recommends caution in the use of uGAG screening alone to rule out or confirm the diagnosis of MPS VI and acknowledges enzyme activity analysis as a critical component of diagnosis. Measurement of another sulfatase enzyme to exclude multiple sulfatase deficiency was recommended prior to the initiation of therapy. When feasible, the use of molecular testing as part of the diagnosis is encouraged. A diagnostic algorithm for MPS VI is provided.

Low temperature conductivity of carbon nanotube aggregates

We compare, over wide temperature ranges, the transport properties of single-wall carbon nanotubes arranged in the form of aligned arrays or in the form of fibres. The experimental data show that both the forms of aggregates present a crossover in the transport mechanism from three-dimensional hopping of the electrons between localized states at high temperature to fluctuation-induced tunnelling across potential barriers at low temperature. The role of the junctions formed between the bundles in the array and between the nanotubes inside the fibres is discussed on the basis of the experimental results.

Role of AAO template filling process parameters in controlling the structure of one-dimensional polymer nanoparticles

Solution template wetting is a common technique used to fabricate elongated polymer nanostructures; however, the parameters controlling the resulting morphology remain unclear. The purpose of this investigation was to elucidate the effects of process variables on the types of nanostructures obtained and to understand the physical mechanisms associated with structure development. 1 wt% polystyrene-THF solutions were infiltrated into commercial and homemade anodized aluminum oxide (AAO) templates. The wetting interaction between the AAO template and the polymer solution was examined through contact angle measurements. In general, for moderate dipping times (<18 h), the morphology of the nanopolymer was rod-like at low molecular weights, while tubes were observed at high molecular weight, even at this low concentration. Nanorods were obtained for all molecular weights for extended dipping times. The data suggest that phase separated layers may grow sequentially from the pore walls and yield nanotubes if the growth is interrupted or produce nanorods for unhindered deposition over long periods.

Bone resorption in syndromes of the Ras/MAPK pathway

Disorders of the Ras/mitogen-activated protein kinase (MAPK) pathway have an overlapping skeletal phenotype (e.g. scoliosis, osteopenia). The Ras proteins regulate cell proliferation and differentiation and neurofibromatosis type 1 (NF1) individuals have osteoclast hyperactivity and increased bone resorption as measured by urine pyridinium crosslinks [pyridinoline (Pyd) and deoxypyridinoline (Dpd)]. Pyd and Dpd are hydroxylysine-derived crosslinks of collagen found in bone and cartilage and excreted in the urine. Dpd is most abundant in bone. The aim of this study was to evaluate if other syndromes of the Ras/MAPK pathway have increased bone resorption, which may impact the skeletal phenotype. Participants were individuals with Noonan syndrome (n = 14), Costello syndrome (n = 21), and cardiofaciocutaneous (CFC) syndrome (n = 14). Pyridinium crosslinks from two consecutive first morning urines were extracted after acid hydrolysis and analyzed by high performance liquid chromatography. Three separate analyses of covariance were performed to compare Pyd, Dpd, and Dpd/Pyd ratio of each group to controls after controlling for age. Data were compared to 99 healthy controls. The Dpd and the Dpd/Pyd ratio were elevated (p < 0.0001) in all three conditions compared to controls suggesting that collagen degradation was predominantly from bone. The data suggest that the Ras/MAPK signal transduction pathway is important in bone homeostasis.

Genetic Fusarium chemotyping as a useful tool for predicting nivalenol contamination in winter wheat

Fusarium graminearum [teleomorph Gibberella zeae] and Fusarium culmorum together with Fusarium poae are the main species known to produce nivalenol (NIV). The NIV content in wheat (Triticum aestivum L.) harvested in Luxembourg was investigated in 2007 and 2008 at 17 different locations. Species determination and genetic chemotyping of F. graminearum and F. culmorum were used to understand the spatial distribution of NIV producers in wheat from Luxembourg. Three hundred thirteen F. graminearum, 175 F. culmorum and 117 F. poae strains respectively were isolated. Chemotypes of the first two species were determined by PCR and confirmed on a sub-sample of single isolates by LC-MS/MS analysis. The 15-acetylated DON chemotype of F. graminearum was dominant in both years representing 94.2% of the population while the NIV chemotype represented 5.8%. The F. culmorum chemotypes were rather evenly distributed, with 3-acetylated DON and NIV profiles present with similar abundances (53.2% and 46.8%, respectively). NIV presence in wheat flour obtained from the 17 sites was correlated with the number of F. culmorum (NIV chemotype) isolated from 100 seeds, suggesting its primary role in NIV production on grains. The predictive power for identifying NIV contamination in grains based on NIV chemotype presence was confirmed by coupling the isolation procedure with a cut-off value, resulting in the successful identification (100%, p=0.008) of NIV contamination in grains collected from 9 additional experimental sites. In conclusion, the results highlight the importance of chemotyping for improved prediction of toxin contamination in wheat.

First Report of the Nivalenol Chemotype of Fusarium graminearum Causing Head Blight of Wheat in the Grand Duchy of Luxembourg

Head blight caused by Fusarium graminearum is one of the major diseases of wheat (Triticum aestivum L.) in Luxembourg (2) and there is concern for mycotoxins in diseased grain. Isolates of F. graminearum have been assigned to chemotypes based on the particular toxins produced. Ten wheat fields representing different topoclimatological areas of Luxembourg were surveyed in 2007 and 2008 to determine the frequency and distribution of chemotypes. Partially blighted wheat heads were collected, and diseased grains were plated on Fusarium-selective agar (dichloran-chloramphenicol-peptone) for 12 days at 22 ± 2°C with a 12-h light period. Monoconidial isolates of F. graminearum (79 in 2007 and 85 in 2008) were obtained by conidia dilution on 2% water agar and needle selection under a microscope. F. graminearum isolates showed rapid growth on potato dextrose agar, dense aerial mycelium with red pigment deposits in the plate, macroconidia with five to six defined septa, and a basal cell with the typical foot shape. Microconidia were absent. To confirm species identification, a PCR reaction was carried out using the F. graminearum species-specific primers Fg16F (5'-CTCCGGATATGTTGCGTCAA-3') and Fg16R (5'-GGTAGGTATCCGACATGGCAA-3') according to Demeke et al. (1). Chemotype of each isolate was determined according to Ward et al. (4). In particular, PCR primer 12CON (5' CATGAGCATGGTGATGTC-3') coupled with primer 12NF (5'-TCTCCTCGTTGTATCTGG-3') and primer 3CON (5'-TGGCAAAGACTGGTTCAC-3') coupled with primer 3NA (5'-GTGCACAGAATATACGAGC-3') identified the nivalenol chemotype, primer 12CON coupled with primer 12-15F (5'-TACAGCGGTCGCAACTTC-3') and primer 3CON coupled with primer 3D15A (5'-ACTGACCCAAGCTGCCATC-3') identified the 15-acetylated deoxynivalenol (DON) chemotype, while primer 12CON coupled with primer 12-3F (5'-CTTTGGCAAGCCCGTGCA-3') and primer 3CON coupled with primer 3D3A (5'-CGCATTGGCTAACACATG-3') identified 3-acetylated DON chemotype. Reactions were repeated two times and positive controls (provided by Kerry O'Donnell, NRRL collection, Peoria, IL) and a negative control (water) were used in each reaction. Frequency of the nivalenol chemotype was found to be 2.5% in 2007 and 1% in 2008. Interestingly, the nivalenol chemotype was absent in southern Luxembourg. According to this finding, nivalenol was likely to be present at low levels in grain from Reisdorf and Echternach in 2007 (central Luxembourg) and in 2008 from grain of Troisvierges (northern Luxembourg). The remaining isolates in both years belonged to the 15-acetylated DON chemotype and the 3-acetylated DON chemotype was not detected. Compared with a previous report from the Netherlands (3), the nivalenol chemotype in Luxembourg is less frequent and widespread. To our knowledge, this is the first report of the nivalenol chemotype of F. graminearum causing head blight on wheat in Luxembourg. References:(1) T. Demeke et al. Int. J. Food Microbiol. 103:271, 2005. (2) F. Giraud et al. Plant Dis. 92:1587, 2008. (3) C. Waalwijk et al. Eur. J. Plant Pathol. 109:743, 2003. (4) T. J. Ward et al. Fung. Genet. Biol. 45:473, 2008.

[Pathophysiology of secondary hyperparathyroidism: the role of FGF23 and Klotho]

Secondary hyperparathyroidism is a complex metabolic alteration secondary to chronic kidney disease (CKD). Reduction of 1,25(OH)2D3 synthesis is the first derangement, followed by an increase in PTH, and, lastly, calcium and phosphate modifications. Vitamin D is a hormone whose actions take place through a specific receptor, the vitamin D receptor (VDR), which is ubiquitous. Accordingly, heterogeneous biological effects can be added to the classical effects on mineral bone metabolism. In the pathophysiology of secondary hyperparathyroidism, an important role is also played by alterations of calcium transport, which is under the control of two receptors: VDR and CaSR (calcium-sensing receptor). The expression of these receptors is reduced during CKD. Recent findings have allowed to identify a new hormonal system, the FGF23-Klotho axis, that integrates the old and simple, but now inadequate, PTH-Vit D axis. FGF23 is a circulating factor produced by osteocytes that inhibits renal phosphate reabsorption and 1-alpha-hydroxylase activity. As such, FGF23 is involved in phosphate homeostasis and its serum levels increase along with the progression of CKD. Interestingly, FGF23 has very low affinity for its receptor and requires the activity of Klotho, an anti-aging gene, to become active. These new actors allow us to identify a bone-kidney axis, whose real physiological importance is still under evaluation.

[Understanding the different functions of vitamin D]

Exposure of the skin to sunlight is now considered the most important source of vitamin D in Western countries. It is presumed to contribute approximately two thirds of the total requirement, leaving the remaining one third to the few foods naturally rich in this vitamin. In the skin, vitamin D is synthesized as a cholesterol chain which undergoes structural modifications following exposure to UVB rays. Once produced in the skin or absorbed in the gut as cholecalciferol, vitamin D enters the blood to be transported by a specific vitamin D binding protein, which is synthesized in the liver and has a powerful buffering capacity. The transport system carries the metabolites to the sites of further activation (25-hydroxylation in the liver and 1alpha-hydroxylation in the kidney), ultimately resulting in the production of calcitriol. This last compound, now regarded as a hormone, circulates freely in minimal amounts and, compared with the other metabolites, shows the highest affinity for the vitamin D receptor (VDR). The mechanism of VDR activation is rather complex, resulting in either stimulation or inhibition of protein synthesis. Importantly, besides its presence in parathyroid, bone, kidney and intestine, this receptor has been demonstrated in several tissues, where its stimulation results in a reduced proliferation rate and increased differentiation. Accordingly, vitamin D is now regarded as a complex hormonal system, involved not only in the regulation of divalent ions and bone, but also in the proliferation and differentiation of numerous cell types with potential involvement in several diseases like cancer, immune diseases, diabetes, hypertension and heart failure.

Noninvasive measurement of phenylalanine by iontophoretic extraction in patients with phenylketonuria

Phenylketonuria is an autosomal recessive disorder characterized by elevated concentrations of phenylalanine. Elevated phenylalanine concentrations can impair intellectual functions and the disease is treated with a lifelong diet and frequent monitoring of plasma phenylalanine concentrations. Previous in vitro studies have demonstrated the feasibility of iontophoretically enhanced transdermal transport of phenylalanine. Here we evaluate the feasibility of transdermal iontophoretic extraction of phenylalanine in vivo. Phenylalanine was iontophoretically extracted from the skin of healthy volunteers and of patients with phenylketonuria for up to 6 h and concentrations were compared with those measured in plasma. The amount of phenylalanine iontophoretically extracted from the skin declined over time, suggesting contribution of phenylalanine from the skin in the initial extraction. Phenylalanine iontophoretically extracted from skin correlated with plasma phenylalanine levels at plasma levels above 300 micromol/L. This correlation supports the feasibility of iontophoretic phenylalanine extraction for monitoring phenylketonuria.

Combination of enzyme analysis, allele-specific PCR and sequencing to detect mutations in the GALT gene

Newborn screening can identify patients with classical galactosaemia, and their diagnosis needs to be confirmed with assay of the activity of galactose-1-phosphate uridyltransferase (GALT). Unfortunately, in many cases the results can be ambiguous and further testing is required. Here we report a combination of biochemical analysis of GALT enzyme activity and mutation analysis of the most common mutations in the corresponding gene. Samples (n = 243) submitted for confirmatory testing for classical galactosaemia were analysed simultaneously for GALT enzyme activity and allele-specific PCR/fragment analysis for seven mutations and two polymorphisms in the GALT gene (mutations IVS2-2A>G, p.S135L, p.T138M, p.L195P, p.K285N, p.Q188R, p.Y209C; polymorphisms p.N314D, p.L218L). Mutation detection accorded with biochemical analysis in 93% of samples. Subsequently, a total of 34 samples with either discordant results between the above methods or low enzyme activity were fully sequenced, identifying previously reported pathogenic mutations and seven novel variations (p.P185H, p.R201C, p.E220K, p.R223S, p.I278N, p.L289F and p.L218X) in the GALT gene. This approach further increased concordance between genetic and biochemical analysis to 99% of all alleles tested. Our results indicate that DNA testing can help to verify biochemical enzymatic data and improve distinction of borderline enzyme activities where a patient may still benefit from treatment.

Levocetirizine in persistent allergic rhinitis and asthma: effects on symptoms, quality of life and inflammatory parameters

Background Levocetirizine (LCZ) has been shown to be effective in allergic rhinitis. We evaluated its clinical efficacy, antinflammatory actions and its effects on quality of life (QoL) with a specific instrument in the asthma-rhinitis comorbidity. Methods Fifty adult patients with persistent rhinitis with/without asthma were enrolled. After a 1-week run-in for baseline evaluation, they were randomized to LCZ or placebo for 8 weeks. Cromolyn and salbutamol were permitted on demand. Rhinoconjunctivitis and asthma symptoms were evaluated by diary cards. QoL was assessed by the specific Rhinasthma questionnaire and the generic SF-36 at different time-points. Nasal scrapings and lavages were also performed for inflammatory cell count and mediator assessment. Results Ten patients dropped out for unrelated reasons and the remaining completed the study with no side-effect. Symptoms began to decrease in the active group at the second week of treatment when the difference with the placebo group became significant (0.05) and so remained until the end of the trial. Starting from 2 weeks of therapy, there was a significant decrease vs. baseline in all the four components of the Rhinasthma questionnaire only in the active group. The intergroup comparison became significant (P<0.05) at 4 weeks. The SF-36 detected only sporadic differences between groups. Eosinophils and neutrophils in nasal scraping were significantly decreased in the LCZ group vs. baseline at all times. Nasal mediators were under the detection limits and no analysis could be performed. In the active group, only two patients used rescue medications compared with 13 patients in the placebo group. Conclusions LCZ is clinically effective and capable of improving the rhinitis-asthma-related QoL.

Utilization of guidelines for the management of hypertension in cardiovascular risk scoring of renal patients

BACKGROUND

Recent guidelines for the management of hypertension by the European Societies of Hypertension and Cardiology (ESH-ESC), consider, besides normal and normal high blood pressure, also early renal failure as a significant factor scoring the individual cardiovascular (CV) risk in each patient. Considering that the nephrologists have not yet adopted a similar system to score CV risk in renal failure, we believed reasonable to evaluate whether the ESH-ESC guidelines were applicable to renal patients and to what extent useful to estimate the CV risk in chronic renal disease.

PATIENTS AND METHODS

According to the above-mentioned guidelines, CV risk score was evaluated in 386 ambulatory patients (212 M/174 F; aged 53 +/- 15 years) with the following clinical diagnosis: hypertension (n=48), lithiasis (n=49), chronic renal failure (n=182), transplantation (n=61) and dialysis (n=46).

RESULTS

We obtained a "no score" group and five progressive risk classes graded from 1 to 5. Infact thirthyfour cases were not scored because of "optimal" blood pressure control, whilst the remaining 352 averaged a score of 3.9 +/- 1.1 ("high" CV risk condition). In these, all the scores were present and the distribution of cases evidenced a prevailing of score 4 and 5 in chronic renal failure (19 and 52% of the cases, respectively) and in transplantation (26% and 39%), but not in hypertension and lithiasis. In dialysis, only score 4 and 5 (35% and 59% respectively) occurred, while 4 cases (6%) were not scored due to "optimal" blood pressure values. Target organ damage, acquired clinical conditions, modifiable and non-modifiable risk factors had all a positive correlation with the risk score.

CONCLUSIONS

Our study suggests that ESH-ESC guidelines for the management of hypertension can be used to obtain a global CV risk score also in chronic kidney diseases, with the exception of dialysis. In chronic renal failure, the risk of underestimating the real incidence of future CV events might be overcome, at least partially, by the possibility of highlighting in individual patients the concomitance of risk factors requiring a very early preventive and aggressive therapy.

Randomized double-blind controlled study with sublingual carbamylated allergoid immunotherapy in mild rhinitis due to mites

BACKGROUND

The clinical efficacy of sublingual immunotherapy (SLIT) in mite allergy and in mild disease is still a matter of debate, thus we performed a long-term clinical trial.

METHODS

The study was randomized, double-blind and placebo-controlled. After a 1-year assessment, 68 patients with mild rhinitis with/without asthma due to mites were randomized to drugs + placebo or drugs + SLIT for 2 years. Sublingual immunotherapy was given as soluble tablets of monomeric carbamylated allergoid. Clinical scores for asthma and rhinitis (0, absent to 3, severe) and drug consumption were assessed by diary card in the period November-February. Quality of life was assessed before and after each observation period and pharmaco-economy data were evaluated as well.

RESULTS

Fifty-six patients completed the study. The rate of dropouts was similar in the two groups. No relevant side effect was reported. There was a significant reduction of total clinical scores (P < 0.05) in the active group vs placebo at the first year, but not at the second whereas nasal obstruction significantly improved in both years (P < 0.05). The reduction of drug intake score was significant only at the first year. No change was observed concerning most of the Short Form-36 items, because at baseline all patients displayed a normal profile. A significant change in SLIT group was seen for the item 'change in health status'. The need for extra visits was significantly lower in the active group (25%vs 43%).

CONCLUSIONS

Sublingual immunotherapy was clinically effective and safe in mite-induced mild disease.

Impact of children's respiratory allergies on caregivers

BACKGROUND

Despite the great attention that has been paid to HRQoL in children with respiratory allergy, few studies have addressed this aspect in relation to caregivers. The aim of our study was to evaluate the impact of childhood respiratory allergies on caregivers by means of a new method.

METHODS

119 parents of children suffering from allergies (75 suffering from asthma and 44 suffering from rhinitis) were recruited from three Italian Allergy Units. Parents were asked to complete the Disease Impact On Caregiver (DIOC), a new non disease specific questionnaire, validated on the Italian population. The questionnaire consists of 31 items grouped in four factors (Performance, Personal gratification, Psychophysical endurance, Socio-emotional domain) and covers the life aspects that could be affected by the assistance duties towards an ill family member.

RESULTS

Child's asthma resulted to have a worse impact on many aspects of a parents' life than rhinitis. Differences resulted to be statistically significant in 19 aspects out of the 31 assessed. The worse impact of asthma versus rhinitis was confirmed in the following domains: Performance (24.0 +/- 18.2 vs 11.5 +/- 17.8), Personal gratification (26.3 +/- 20.5 vs 12.1 +/- 16.5) and Psychophysical endurance (35.0 +/- 24.8 vs 18.8 +/- 21.7). In the Socio-emotional domain no difference emerged.

CONCLUSIONS

Compared to parents of rhinitics, parents of asthmatic children appear to be more compromised in their resistance to stress, mood, emotional stability, amount of spare time and leisure activities. Our results suggest the need of giving the due attention to these problems both in clinical practice and in research, in order to avoid possible interferences of the caregiver's distress in the optimization of treatment outcome.

Chronic cough and QoL in allergic and respiratory diseases measured by a new specific validated tool-CCIQ

Even though chronic cough (CC) is a bothersome symptom, only a small number of studies have evaluated its specific burden on health-related quality of life (HRQL). The aim of the present study was to assess how the presence of CC interferes with HRQL. A total of 95 outpatients were enrolled during medical consultation at our "Chronic Cough Center". A health status measure (SF-36) and a new HRQL questionnaire specific for CC (CCIQ) were administered before the initial visit. Compared to the reference sample, CC patients reported significantly lower scores in 5 of 8 SF-36 domains: Social functioning (t=10.292), Physical role limitation (t=9.667), Emotional role limitation (t=7.712), General health (t=5.154) and Vitality (t=4.426). The analysis of CCIQ scores showed a disability due to CC, independent of its etiology. The greatest disabilities were observed in the Social relationship (58.33) domain, followed by Sleep/Concentration (54.26), Mood (51.49) and Daily activities (47.69). Sleep, disturbing the partner, and irritability were the three outstanding aspects, affecting 80% of patients. These results show that CC has a high negative impact on HRQL, and they further suggest that the CCIQ is a useful tool for obtaining a global evaluation including its impact and therapeutic options.

A new tool to evaluate the impact of chronic urticaria on quality of life: chronic urticaria quality of life questionnaire (CU-QoL)

BACKGROUND

Health-related quality of Life in patients with chronic urticaria is evaluated by mean of generic instruments or questionnaire designed for skin diseases. No disease-specific tool is now available for the assessment of chronic urticaria impact from patients' viewpoint.

OBJECTIVE

The aim of our study is to develop and validate a new questionnaire specifically designed for the assessment of quality of life in chronic urticaria (Chronic Urticaria Quality of Life Questionnaire -- CU-Q(2)oL).

METHODS

In the development phase of CU-Q(2)oL an initial list of items of 37 items was compiled and given to 80 patients with chronic urticaria; the 23 most significant items were selected and converted into questions evaluating the answers on a Likert scale of five steps. The validation procedure involved 125 patients (86 F and 39 M) (age 42.17 +/- 9.24 years).

RESULTS

Following a statistical analysis, CU-Q(2)oL showed a six-dimensional structure and good levels of internal consistency for the extracted factors: Pruritus (0.79), Swelling (0.65), Impact on life activities (0.83), Sleep problems (0.77), Looks (0.83) and Limits (0.74). In stable conditions CU-Q(2)oL showed a good reliability, ranged between 0.64 and 0.92. Responsiveness to clinical changes was accomplished.

DISCUSSION

These results provide evidence that CU-Q(2)oL has specificity enough for being a valid tool for detecting the relative burden of CU on subjective wellbeing, and for obtaining a global evaluation both of CU impact and of treatments, taking into account the patient's point of view. The CU-Q(2)oL was easily and quickly filled up and well accepted by the patients.

A new tool to assess and monitor the burden of chronic cough on quality of life: Chronic Cough Impact Questionnaire

INTRODUCTION

Chronic cough, one of the most frequent causes for a patient to consult a medical practitioner, limits the course of normal activities in everyday life of the patient affected (work, physical activities, social relations, night sleep). By now, there are few validated questionnaires for the evaluation of the impact of this symptom in the patient's quality of life (QoL). For this reason, we created a new questionnaire for the assessment of QoL in patients affected by chronic cough (Chronic Cough Impact Questionnaire, CCIQ).

MATERIALS AND METHODS

In the development procedure of CCIQ an initial questionnaire of 40 items was compiled and given to a first pool of 170 patients, each coming to our attention because of chronic cough; then the 25 most significant items were detected and converted into questions evaluating the answers on a Likert scale of five steps. Consequently, this final questionnaire underwent a validation procedure to assess its construct validity, internal consistency, reliability, and responsiveness. 95 patients (44.2% F, 55.8% M) were evaluated (age 53.69 +/- 11.7 years).

RESULTS

Following a statistical analysis, CCIQ showed a four-dimensional structure and good levels of internal consistency for the extracted factors: sleep/concentration (79.98), relationship (86.98), daily life impact (69.04), and mood (65.41). In stable conditions CCIQ showed a good reliability, ranged between 0.67 and 0.88. Responsiveness to clinical changes was accomplished.

DISCUSSION

These results provide evidence that CCIQ has specificity enough for being a valid tool for detecting the relative burden of cough on subjective well-being, and for obtaining a global evaluation both of chronic cough impact and of treatments for it, taking into account the patient's point of view. The CCIQ was easily and quickly filled in by the patients while waiting, and it was accepted by the patients.

Nickel and cobalt recycling from lithium-ion batteries by electrochemical processes

The presence of LiCoO(2) and LiCo(x)Ni((1-x))O(2) in the cathodic material of Li-ion and Li-polymer batteries has stimulated the recovery of Co and Ni by hydrometallurgical processes. In particular, the two metals were separated by SX method and then recovered by electrochemical (galvanostatic and potentiostatic) processes. The metallic Ni has been electrowon at 250 A/m(2), pH 3-3.2 and 50 degrees C, with 87% current efficiency and 2.96 kWh/kg specific energy consumption. Potentiostatic electrolysis produces a very poor Ni powder in about 1 h with current efficiency changing from 70% to 45% depending on Ni concentration in the electrolyte. Current efficiency of 96% and specific energy consumption of 2.8 kWh/kg were obtained for Co at 250 A/m(2), pH 4-4.2 and 50 degrees C, by using a solution containing manganese and (NH(4))(2)SO(4). The Co powder, produced in potentiostatic conditions (-0.9 V vs. SCE, pH 4, room temperature) appears particularly suitable for Co recycling as cobaltite in new batteries.

Antihistamines: do they work? Further well-controlled trials involving larger samples are needed

Histamine is one of the most important steps in the phlogistic allergic reaction. Its activity is due to the link to specific receptors on the cellular surface. H1-receptors of second generation are the most currently prescribed drugs in allergic diseases for their high selectivity, little or no central sedative effect, rapid onset of action and long half lives. Antihistamines can modulate part of immunological mechanisms involved in the pathogenesis of allergic inflammation reducing mediator release and expression of adhesion molecules, regulating the release of cytokines, chemokines and consequently inflammatory cells recruitment. The anti-inflammatory effects of cetirizine, desloratadine and levocetirizine are reviewed. Quality of life is considered too, as a main parameter in a global evaluation of the antihistamine's effects.

Carnitine transporter defect due to a novel mutation in the SLC22A5 gene presenting with peripheral neuropathy

The carnitine transporter defect (McKusick 212140) is an autosomal recessive disorder caused by mutations in the SLC22A5 gene, which encodes the high-affinity carnitine transporter OCTN2 (Wang et al 2001). Diagnosis is suspected when plasma carnitine levels are extremely low and secondary causes of carnitine loss are excluded. The disease can present with recurrent Reye-like episodes of hypoketotic hypoglycaemia or with cardiomyopathy associated with myopathy (Stanley et al 1991). Here we report novel clinical findings in a 3-year-old with primary carnitine deficiency.