COVERT HEPATIC ENCEPHALOPATHY: DIAGNOSIS, REVERSIBILITY AFTER LIVER TRANSPLANT AND ROLE OF GUT MICROBIOTA

Background. Hepatic encephalopathy (HE) produces a wide spectrum of nonspecific neurological and psychiatric manifestations. Mild HE that does not produce disorienting in time/space or asterixis is called covert HE (CHE). It occurs in 20%–80% of patients with cirrhosis. While significant progress has been made in understanding the importance of CHE, to date there is no consensus guidelines regarding the screening procedures for CHE and all the recognized techniques, although more or less sensitive and objective, require some kinds of equipment. Furthermore, the diagnosis of CHE can be confounded by other factors (as chronic alcohol misuse or HCV infection), which can cause cognitive alterations. It is also important to identify CHE in patients awaiting liver transplantation (LT) for the proper interpretation of cognitive disorders that may occure after transplantation. Infact, the influence of LT on mental performance is debated; as is the role of pretransplant HE. Notable, recent data on LT suggest that the cognitive dysfunction may not be totally reversible. Another important issue regards the treatment of CHE, in particular the effect of treatments on gut microorganism and ammonia production by microbial activity. HE treatment with prebiotics, antibiotics and probiotics, generally evidences a reduction of photogenic/ ammoniagenic bacteria and an increase in neurocognitive tests and mental status in patients. Nevertheless from a strictly microbiological point of view, little is known about the dynamics, interaction and metabolite production of the main bacterial groups in liver diseases. Aims. The present study aims to: 1) test a simple verbal psychometric test, called Animal Naming Test (ANT1), in the detection of CHE; 2) to evaluate the role of alcohol misuse, HCV infections, diabetes, aging and level of education as potential confounding factors in the diagnosis of CHE; 3) to evaluate the time course of the neuropsychological and electroencephalogram (EEG) features of patients with cirrhosis before and after LT with respect to prior HE and 4) to investigate how the HE treatments (by the use of lactulose, rifaximin and a probiotc mixture) affects gut microbial composition, determining changes in ammonia production. Materials and methods. For Aim 1: 208 healthy subjects and 327 consecutive patients with cirrhosis underwent the ANT1. Patients with cirrhosis were assessed by the Psychometric Hepatic Encephalopathy Score (PHES), a subgroup of 146 underwent also a quantified EEG and 95 the Critical Flicker Frequency. 202 patients were followed up for the occurrence of overt HE (OHE) and death. For Aim 2: a comprehensive neuropsychological profile and EEG spectral parameters were obtained in six age-matched groups of 30 subjects each: (i) HCV-related hepatitis without cirrhosis, (ii) chronic alcohol abusers, (iii) patients with HCV-related cirrhosis, (iv) alcohol-related cirrhosis, (v) cirrhosis not related to alcohol or HCV and (vi) healthy subjects. Cirrhotic patients were matched for MELD score. For Aim 3: the study population included 65 patients with cirrhosis on the transplant waiting list; 23 had a history of OHE. Each patient underwent an extensive psychometric assessment (10 tests, including paper and pencil tests and a computerized test) and an EEG before and 9 to 12 months after LT. EEGs were analyzed spectrally, and the mean dominant frequencies were obtained. For Aim 4: independent batch culture fermentations with controlled pH (6.8) were inoculated with fecal samples from six patients with cirrhosis (age 66±3.3 years; Child-Pugh A n=5 and B n=1); average MELD score 9±2.8). Seven different treatments with lactulose, rifaximin and VSL#3 or their combination were performed. Microbial populations were enumerated using flow cytometry Fluorescent in Situ Hybridization, while an ammonia concentration was determined at 0, 4, 10 and 24 hours. Results. Aim 1: in controls, the ANT1 was found relevantly affected only by extremely low levels of education (80 yrs; p15, 1=S-ANT1 10-15, 2=S-ANT1<10 sensitivity 83%, specificity 84%, respectively vs. PHES) that was correlated both to PHES (p<0.0001) and EEG (p=0.007). In the follow up, the S-ANT1 resulted to have prognostic value on the risk of OHE and death, so that a prognostic index could be computed. Aim 2: the factor ‘cirrhosis’ was associated with low Phonemic Verbal Fluency (PVF) and Difference between Trail Making Test B and A (TMT B-A) (p<0.001). Chronic alcohol misuse was associated with low PVF, TMT (B-A), Memory with Interference Task at 10 (ITM 10) and 30s (ITM 30) (all p<0.05). An interaction was found between the factors ‘cirrhosis’, ‘alcohol misuse’ and tests (p<0.01). HCV hepatitis reduced ITM 10 (p<0.05), but no interaction was found between ‘cirrhosis’, ‘HCV infection’ and tests (p= 0.14). The EEG parameters were mainly influenced by ‘cirrhosis’ (p<0.05), and EEG alterations were more pronounced in patients with alcoholic cirrhosis (p=0.04). Aim 3: Patients with a history of OHE before LT had worse cognitive performances (p<0.001) and EEG performances in comparison with their counterparts with a negative history. They also showed greater cognitive improvement after LT (p<0.01); however, their global cognitive performance remained slightly impaired (p <0.01). After LT, EEGs normalized for 98% of the patients (p <0.01), regardless of any history of OHE. Aim 4: Lactulose treatment significantly increased total bacteria, Bifidobacteria and Fecalibacterium prausnitzii after 5 hours (p≤0.05); in contrast Rifaximin and a probiotic mixture (VSL#3) have no significant effect. After 24 hours the combination of lactulose/Rifaximine/VSL#3 significantly increased total bacteria and Bifidobacteria. At time 5 h, lactulose significanly reduced ammonia, whereas rifaximin had no significant effect. VSL#3 alone had never significant affect in reducing ammonia, whereas at 24 h, in combination with lactulose and rifaximin, reduced significantly ammonia. Conclusions. The ANT1 is an easy first-line measure useful for detection of CHE. The diagnosis of CHE should considered the concomitant presence of alcohol misuse and low educational level, which had a synergistic effect with cirrhosis in damaging cognitive functions, and thus they should be considered as possible confounders when testing for CHE. After LT, patients with a history of HE showed greater improvements than patients with a negative history, but their global cognitive function remained slightly worse; in contrast, EEGs normalized in both groups. Regarding HE treatments, microbial modulation by prebiotic, antibiotic and probiotic differently affect the population dynamics and metabolism. The strong increase in beneficial bacteria, reduction of ammonia and regulation of metabolite production seen using lactulose and its combination with VSL#3, emphasize the importance of gut microbiota handling in HE treatment

Transcriptome dynamics in the asexual cycle of the chordate Botryllus schlosseri

Background: We performed an analysis of the transcriptome during the blastogenesis of the chordate Botryllus schlosseri, focusing in particular on genes involved in cell death by apoptosis. The tunicate B. schlosseri is an ascidian forming colonies characterized by the coexistence of three blastogenetic generations: filter-feeding adults, buds on adults, and budlets on buds. Cyclically, adult tissues undergo apoptosis and are progressively resorbed and replaced by their buds originated by asexual reproduction. This is a feature of colonial tunicates, the only known chordates that can reproduce asexually. Results: Thanks to a newly developed web-based platform (http://botryllus.cribi.unipd.it), we compared the transcriptomes of the mid-cycle, the pre-take-over, and the take-over phases of the colonial blastogenetic cycle. The platform is equipped with programs for comparative analysis and allows to select the statistical stringency. We enriched the genome annotation with 11,337 new genes; 581 transcripts were resolved as complete open reading frames, translated in silico into amino acid sequences and then aligned onto the non-redundant sequence database. Significant differentially expressed genes were classified within the gene ontology categories. Among them, we recognized genes involved in apoptosis activation, de-activation, and regulation. Conclusions: With the current work, we contributed to the improvement of the first released B. schlosseri genome assembly and offer an overview of the transcriptome changes during the blastogenetic cycle, showing up- and down-regulated genes. These results are important for the comprehension of the events underlying colony growth and regression, cell proliferation, colony homeostasis, and competition among different generations

Promoting the psychological well-being of healthcare providers facing the burden of adverse events: a systematic review of second victim support resources

Given the negative impact of adverse events on the wellbeing of healthcare providers, easy access to psychological support is crucial. We aimed to describe the types of support resources available in healthcare organizations, their benefits for second victims, peer supporters' experiences, and implementation challenges. We also explored how these resources incorporate aspects of Safety I and Safety II. We searched six databases up to 19 December 2019 and additional literature, including weekly search alerts until 21 January 2021. Two reviewers independently performed all methodological steps (search, selection, quality assessment, data extraction, formal narrative synthesis). The 16 included studies described 12 second victim support resources, implemented between 2006 and 2017. Preliminary data indicated beneficial effects not only for the affected staff but also for the peer responders who considered their role to be challenging but gratifying. Challenges during program implementation included persistent blame culture, limited awareness of program availability, and lack of financial resources. Common goals of the support programs (e.g., fostering coping strategies, promoting individual resilience) are consistent with Safety II and may promote system resilience. Investing in second victim support structures should be a top priority for healthcare institutions adopting a systemic approach to safety and striving for just culture

Response of the Cardiac Autonomic Control to Exposure to Nanoparticles and Noise: A Cross-Sectional Study of Airport Ground Staff

Airport activity causes the emission of particulate matter and noise, two environmental contaminants and potential health hazards, particularly for the personnel operating nearby taxiways. We explored the association between exposure to fine/ultrafine particles (UFPs) and noise with heart rate variability (HRV), an early indicator of cardiovascular autonomic response, among a sample of airport ground staff. Between May and June 2018, thirty-four male operators (mean age = 43 years and SD = 6.7) underwent personal monitoring of exposure to nanoparticles and noise, and HRV during their work activity. We conducted univariate and multivariate analysis to test the effect of UFP and noise exposure HRV. Total Lung Deposition Surface Area (LDSA) was significantly associated with a decrease in HRV Total Power and Triangular index (beta = -0.038 p = 0.016 and beta = -7.8 x 10(-5), p = 0.042, respectively). Noise peak level showed an opposite effect, which was significant for Total Power (beta = 153.03, p = 0.027), and for Triangular index (beta = 0.362, p = 0.035). Further investigation is warranted to clarify the effect of the concurrent exposure to UFPs and noise on early changes of cardiac autonomic regulation

Exploring the vaccine conversation on TikTok in Italy: beyond classic vaccine stances

TikTok, a social media platform for creating and sharing short videos, has seen a surge in popularity during the COVID-19 pandemic. To analyse the Italian vaccine conversation on TikTok, we downloaded a sample of videos with a high play count (Top Videos), identified through an unofficial Application Programming Interface (consistent with TikTok’s Terms of Service), and collected public videos from vaccine sceptic users through snowball sampling (Vaccine Sceptics’ videos). The videos were analysed using qualitative and quantitative methods, in terms of vaccine stance, tone of voice, topic, conformity with TikTok style, and other characteristics. The final datasets consisted of 754 Top Videos (by 510 single users) plus 180 Vaccine Sceptics’ videos (by 29 single users), posted between January 2020 and March 2021. In 40.5% of the Top Videos the stance was promotional, 33.9% were indefinite-ironic, 11.3% were neutral, 9.7% were discouraging, and 3.1% were ambiguous (i.e. expressing an ambivalent stance towards vaccines); 43% of promotional videos were from healthcare professionals. More than 95% of the Vaccine Sceptic videos were discouraging. Multiple correspondence analysis showed that, compared to other stances, promotional videos were more frequently created by healthcare professionals and by females, and their most frequent topic was herd immunity. Discouraging videos were associated with a polemical tone of voice and their topics were conspiracy and freedom of choice. Our analysis shows that Italian vaccine-sceptic users on TikTok are limited in number and vocality, and the large proportion of videos with an indefinite-ironic stance might imply that the incidence of affective polarisation could be lower on TikTok, compared to other social media, in the Italian context. Safety is the most frequent concern of users, and we recorded an interesting presence of healthcare professionals among the creators. TikTok should be considered as a medium for vaccine communication and for vaccine promotion campaigns

Bilateral Symmetry of Visual Function Loss in Cone-Rod Dystrophies.

PURPOSE: To investigate bilateral symmetry of visual impairment in cone-rod dystrophy (CRD) patients and understand the feasibility of clinical trial designs treating one eye and using the untreated eye as an internal control. METHODS: This was a retrospective study of visual function loss measures in 436 CRD patients followed at the Ophthalmology Department of the Catholic University in Rome. Clinical measures considered were best-corrected visual acuity, focal macular cone electroretinogram (fERG), and Ganzfeld cone-mediated and rod-mediated electroretinograms. Interocular agreement in each of these clinical indexes was assessed by t- and Wilcoxon tests for paired samples, structural (Deming) regression analysis, and intraclass correlation. Baseline and follow-up measures were analyzed. A separate analysis was performed on the subset of 61 CRD patients carrying likely disease-causing mutations in the ABCA4 gene. RESULTS: Statistical tests show a very high degree of bilateral symmetry in the extent and progression of visual impairment in the fellow eyes of CRD patients. CONCLUSIONS: These data contribute to a better understanding of CRDs and support the feasibility of clinical trial designs involving unilateral eye treatment with the use of fellow eye as internal control

Evaluation of antibody response to BNT162b2 mRNA COVID-19 vaccine in patients affected by immune-mediated inflammatory diseases up to 5&nbsp;months after vaccination

SARS-CoV-2 vaccination with mRNA product BNT162b2 elicited high immunogenicity in healthy subjects in trials. This study aims to better understand the factors that influence the humoral immune response to vaccination against SARS-CoV-2 in patients with immune-mediated inflammatory diseases (IMIDs). We enrolled patients and healthy healthcare workers control group (HCW) that underwent mRNA BNT162b2 vaccination and measured the serum IgG anti-S-RBD response at booster dose (T1), one month after booster dose (T2) and up to 5&nbsp;months (T3). Demographic, disease-specific and vaccination data were recorded. Vaccination response of 551 participants naïve to SARS-CoV-2 infection were included in HCW and 102 in the IMID group, analyzing separately those on anti-CD20. At T2 all naïve HCW developed anti-S-RBD-IgG, while 94% of IMID responded (p &lt; 0.001). IMID patients had a significantly different level of IgG than HCW at both T1 (p = 0.031), T2 (p &lt; 0.001), while there was no significant difference at T3. There were no statistically significant differences according to the IMID type or to ongoing treatment with immunosuppressants, corticosteroids or biological drugs other than anti-CD20. The proportion and magnitude of response was significantly lower in IMID treated with anti-CD20 drugs. There was a correlation with age at T1 and at T2 but not at T3, stronger in patients than in HCW. Immune response close after BNT162b2 vaccination is reduced in patients with IMID, but there is no significant difference at 5&nbsp;months. The measured reduction is related to age and the disease itself rather than treatments, with the exception of anti-CD20 drugs

A review of the main genetic factors influencing the course of COVID-19 in Sardinia: the role of human leukocyte antigen-G

Introduction: A large number of risk and protective factors have been identified during the SARS-CoV-2 pandemic which may influence the outcome of COVID-19. Among these, recent studies have explored the role of HLA-G molecules and their immunomodulatory effects in COVID-19, but there are very few reports exploring the genetic basis of these manifestations. The present study aims to investigate how host genetic factors, including HLA-G gene polymorphisms and sHLA-G, can affect SARS-CoV-2 infection. Materials and Methods: We compared the immune-genetic and phenotypic characteristics between COVID-19 patients (n = 381) with varying degrees of severity of the disease and 420 healthy controls from Sardinia (Italy). Results: HLA-G locus analysis showed that the extended haplotype HLA-G*01:01:01:01/UTR-1 was more prevalent in both COVID-19 patients and controls. In particular, this extended haplotype was more common among patients with mild symptoms than those with severe symptoms [22.7% vs 15.7%, OR = 0.634 (95% CI 0.440 – 0.913); P = 0.016]. Furthermore, the most significant HLA-G 3’UTR polymorphism (rs371194629) shows that the HLA-G 3’UTR Del/Del genotype frequency decreases gradually from 27.6% in paucisymptomatic patients to 15.9% in patients with severe symptoms (X2 = 7.095, P = 0.029), reaching the lowest frequency (7.0%) in ICU patients (X2 = 11.257, P = 0.004). However, no significant differences were observed for the soluble HLA-G levels in patients and controls. Finally, we showed that SARS-CoV-2 infection in the Sardinian population is also influenced by other genetic factors such as β-thalassemia trait (rs11549407C&gt;T in the HBB gene), KIR2DS2/HLA-C C1+ group combination and the HLA-B*58:01, C*07:01, DRB1*03:01 haplotype which exert a protective effect [P = 0.005, P = 0.001 and P = 0.026 respectively]. Conversely, the Neanderthal LZTFL1 gene variant (rs35044562A&gt;G) shows a detrimental consequence on the disease course [P = 0.001]. However, by using a logistic regression model, HLA-G 3’UTR Del/Del genotype was independent from the other significant variables [ORM = 0.4 (95% CI 0.2 – 0.7), PM = 6.5 x 10-4]. Conclusion: Our results reveal novel genetic variants which could potentially serve as biomarkers for disease prognosis and treatment, highlighting the importance of considering genetic factors in the management of COVID-19 patients

A sex-informed approach to improve the personalised decision making process in myelodysplastic syndromes: a multicentre, observational cohort study

Background Sex is a major source of diversity among patients and a sex-informed approach is becoming a new paradigm in precision medicine. We aimed to describe sex diversity in myelodysplastic syndromes in terms of disease genotype, phenotype, and clinical outcome. Moreover, we sought to incorporate sex information into the clinical decision-making process as a fundamental component of patient individuality. Methods In this multicentre, observational cohort study, we retrospectively analysed 13 284 patients aged 18 years or older with a diagnosis of myelodysplastic syndrome according to 2016 WHO criteria included in the EuroMDS network (n=2025), International Working Group for Prognosis in MDS (IWG-PM; n=2387), the Spanish Group of Myelodysplastic Syndromes registry (GESMD; n=7687), or the Dusseldorf MDS registry (n=1185). Recruitment periods for these cohorts were between 1990 and 2016. The correlation between sex and genomic features was analysed in the EuroMDS cohort and validated in the IWG-PM cohort. The effect of sex on clinical outcome, with overall survival as the main endpoint, was analysed in the EuroMDS population and validated in the other three cohorts. Finally, novel prognostic models incorporating sex and genomic information were built and validated, and compared to the widely used revised International Prognostic Scoring System (IPSS-R). This study is registered with ClinicalTrials.gov, NCT04889729. Findings The study included 7792 (58middot7%) men and 5492 (41middot3%) women. 10 906 (82middot1%) patients were White, and race was not reported for 2378 (17middot9%) patients. Sex biases were observed at the single-gene level with mutations in seven genes enriched in men (ASXL1, SRSF2, and ZRSR2 p<0middot0001 in both cohorts; DDX41 not available in the EuroMDS cohort vs p=0middot0062 in the IWG-PM cohort; IDH2 p<0middot0001 in EuroMDS vs p=0middot042 in IWG-PM; TET2 p=0middot031 vs p=0middot035; U2AF1 p=0middot033 vs p<0middot0001) and mutations in two genes were enriched in women (DNMT3A p<0middot0001 in EuroMDS vs p=0middot011 in IWG-PM; TP53 p=0middot030 vs p=0middot037). Additionally, sex biases were observed in co-mutational pathways of founding genomic lesions (splicing-related genes, predominantly in men, p<0middot0001 in both the EuroMDS and IWG-PM cohorts), in DNA methylation (predominantly in men, p=0middot046 in EuroMDS vs p<0middot0001 in IWG-PM), and TP53 mutational pathways (predominantly in women, p=0middot0073 in EuroMDS vs p<0middot0001 in IWG-PM). In the retrospective EuroMDS cohort, men had worse median overall survival (81middot3 months, 95% CI 70middot4-95middot0 in men vs 123middot5 months, 104middot5-127middot5 in women; hazard ratio [HR] 1middot40, 95% CI 1middot26-1middot52; p<0middot0001). This result was confirmed in the prospective validation cohorts (median overall survival was 54middot7 months, 95% CI 52middot4-59middot1 in men vs 74middot4 months, 69middot3-81middot2 in women; HR 1middot30, 95% CI 1middot23-1middot35; p<0middot0001 in the GEMSD MDS registry; 40middot0 months, 95% CI 33middot4-43middot7 in men vs 54middot2 months, 38middot6-63middot8 in women; HR 1middot23, 95% CI 1middot08-1middot36; p<0middot0001 in the Dusseldorf MDS registry). We developed new personalised prognostic tools that included sex information (the sex-informed prognostic scoring system and the sex-informed genomic scoring system). Sex maintained independent prognostic power in all prognostic systems; the highest performance was observed in the model that included both sex and genomic information. A five-to-five mapping between the IPSS-R and new score categories resulted in the re-stratification of 871 (43middot0%) of 2025 patients from the EuroMDS cohort and 1003 (42middot0%) of 2387 patients from the IWG-PM cohort by using the sex-informed prognostic scoring system, and of 1134 (56middot0%) patients from the EuroMDS cohort and 1265 (53middot0%) patients from the IWG-PM cohort by using the sex-informed genomic scoring system. We created a web portal that enables outcome predictions based on a sex-informed personalised approach. Interpretation Our results suggest that a sex-informed approach can improve the personalised decision making process in patients with myelodysplastic syndromes and should be considered in the design of clinical trials including low-risk patients. Copyright (c) 2022 Published by Elsevier Ltd. All rights reserved

Potential for Circular Autopoietic Economy in High River Po Valley

This Gigamap aims to describe and summarize a student work carried out during the semester course Open Systems Design at Politecnico di Torino. This is one of the outputs from an analysis of the High River Po Valley area in the Italian Piedmont (Southwest of Turin) and subsequently an in-depth study of the relationships and “flows” with certain “currencies” between some selected economic and public actors. The analysis was conducted through five economic sectors: nature & ecosystem services, tourism, mobility and infrastructure, local craft activities and agri-food. The investigation of the territorial economy was carried out by giving particular attention to the production sectors characteristic of the territory and examine their production lines. The holistic diagnosis has highlighted the existence of several problems related to the linearity of the production processes. Through the five types of system flows (material, CO2 emissions/energy, water, economic and social flows), we designed new opportunities, new activities and new potential companies, thinking circularly and systemically. The Gigamap will be presented to stakeholders in a public hearing and used to illustrate and incubate a more circular economy that is more resilient and more regenerative. Reading the map The reader can find in the first part an abstract with the aim of the Gigamap, the five topics for the investigation and actors’ selection, a timeline about important events and some peculiarities of the territory. In the middle, the territorial map of a suggested improved territorial economy based on circular flows: the 16 actors are localized on the territory with new circular flows “designed in” between them. The boxes describe connections for new circular opportunities, with flows explained under the territorial map—finally, some data about the territory and the three main outputs emerging from the new circular linkages