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Alobar holoprosencephaly (HPE) is easily detected during a first-trimester screening examination, conversely, recognizing the lesser varieties may be difficult even in the second trimester.To describe the imaging findings of a cohort of fetuses with holoprosencephaly (HPE) and to elucidate the appearances of the different anatomical varieties.We reviewed medical records and stored images of pregnant women referred to our clinic because of a diagnosis or the suspicion of various forms of HPE. We reported the imaging characteristics, the presence of other associated anomalies, magnetic resonance findings, karyotype and autoptic examinations when available.Alobar forms show great distortion of normal brain anatomy, with a single ventricle detectable during the first trimester of pregnancy. Extracerebral, face and karyotype abnormalities are often associated. In semilobar and lobar forms the septum pellucidum is typically absent in axial planes, with fused frontal horns, while posterior fossa is often normal. At multiplanar neurosonogram, anomalies involving corpus callosum and cortex development can be detected. Face abnormalities are mild in lobar forms: receding forehead, various degrees of hypotelorism and the presence of a single central maxillary incisor are reported.The alobar forms are detectable since the first trimester, with a peculiar single ventricle and extremely frequent extracerebral and karyotype abnormalities. The semilobar and lobar forms are more challenging and the diagnosis is easily missed in a mid-trimester screening exam unless a careful evaluation of both

OBJECTIVES: Hepatocellular carcinoma (HCC) has become a major issue in coinfected HIV/HCV patients with liver cirrhosis. We aimed to determine the rate of HCC occurrence after a direct-acting antiviral (DAA) treatment and to evaluate the factors associated with the risk of HCC in this population. DESIGN: We conducted a retrospective multicenter observational study including cirrhotic HIV/HCV-coinfected patients treated with DAAs, between October 2014 and January 2017. METHODS: We collected demographics characteristics, data regarding HIV and HCV infections and treatment with DAAs. We investigated the rate and the time of occurrence of HCC. Statistical analysis explored the factors associated to development of liver cancer. RESULTS: During a median follow-up of 55 months, 24 out of 232 patients developed HCC, after a median of 22.5 months from starting DAAs. Factors associated with HCC were a higher Child--Pugh Turcotte (CPT) score (P = 0.002), HCV genotype 3 (P = 0.04), previous HCC (P

Objective: The aim of this study was to report the rate of additional anomalies detected exclusively at prenatal magnetic resonance imaging (MRI) in fetuses with isolated severe ventriculomegaly undergoing neurosonography. Method: Multicenter, retrospective, cohort study involving 20 referral fetal medicine centers in Italy, United Kingdom, Spain and Denmark. Inclusion criteria were fetuses affected by isolated severe ventriculomegaly (≥15 mm), defined as ventriculomegaly with normal karyotype and no other additional central nervous system (CNS) and extra-CNS anomalies on ultrasound. In all cases, a multiplanar assessment of fetal brain as suggested by ISUOG guidelines on fetal neurosonography had been performed. The primary outcome was the rate of additional CNS anomalies detected exclusively at fetal MRI within two weeks from neurosonography. Subgroup analyses according to gestational age at MRI (

Cervicomental contour represents an important aesthetic problem.This research evaluates the safety and the efficacy of a new non-invasive system delivering microwave energy for the treatment of submental skin laxity and fat.Forty-eight subjects underwent submental treatment with the device at hand at Poliambulatorio San Michele, Reggio Emilia, Italy. The treatment was performed on the submental area starting from 1.5 cm below the lower border of the mandible up to the hyoid bone. Treatment consisted of 6 sessions of 10 min, with a 2-week interval between each session. At the baseline and upon follow-up 12 weeks from the last treatment, the following evaluations were performed: Photographic evaluation, Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), Submental Skin Laxity Grade (SMSLG), Five-Point Likert Scale Questionnaire (LSQ) for Skin Laxity, Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and Numeric Rating Scale (NRS) for pain evaluation.Mean submental fat and laxity scores evaluation significantly decrease respectively from 3.4 ± 0.5 and 3.7 ± 0.5 at baseline to 1.7 ± 0.6 and 2.4 ± 0.6 (p 0.01) at 12-week follow-up after the last treatment. The treatment was well-tolerated according to the NRS results. Out of the 47 participants (70.2%), 33 were very satisfied or satisfied. Most patients denied experiencing any discomfort during and after the treatment with the non-invasive device delivering microwaves. The submental subcutaneous fat reduction, the improvement of submental skin tightening, and aesthetic results are confirmed also by photographic evaluation. No side effects were observed.Our results showed the potential microwaves role in the treatment of localized submental subcutaneous adiposities and skin laxity.

Objectives: To assess the role of fetal magnetic resonance imaging (MRI) in detecting associated anomalies in fetuses presenting with mild or moderate isolated ventriculomegaly (VM) undergoing multiplanar ultrasound evaluation of the fetal brain. Methods: This was a multicenter, retrospective, cohort study involving 15 referral fetal medicine centers in Italy, the UK and Spain. Inclusion criteria were fetuses affected by isolated mild (ventricular atrial diameter, 10.0–11.9 mm) or moderate (ventricular atrial diameter, 12.0–14.9 mm) VM on ultrasound, defined as VM with normal karyotype and no other additional central nervous system (CNS) or extra-CNS anomalies on ultrasound, undergoing detailed assessment of the fetal brain using a multiplanar approach as suggested by the International Society of Ultrasound in Obstetrics and Gynecology guidelines for the fetal neurosonogram, followed by fetal MRI. The primary outcome of the study was to report the incidence of additional CNS anomalies detected exclusively on prenatal MRI and missed on ultrasound, while the secondary aim was to estimate the incidence of additional anomalies detected exclusively after birth and missed on prenatal imaging (ultrasound and MRI). Subgroup analysis according to gestational age at MRI (< 24 vs ≥ 24 weeks), laterality of VM (unilateral vs bilateral) and severity of dilatation (mild vs moderate VM) were also performed. Results: Five hundred and fifty-six fetuses with a prenatal diagnosis of isolated mild or moderate VM on ultrasound were included in the analysis. Additional structural anomalies were detected on prenatal MRI and missed on ultrasound in 5.4% (95% CI, 3.8–7.6%) of cases. When considering the type of anomaly, supratentorial intracranial hemorrhage was detected on MRI in 26.7% of fetuses, while polymicrogyria and lissencephaly were detected in 20.0% and 13.3% of cases, respectively. Hypoplasia of the corpus callosum was detected on MRI in 6.7% of cases, while dysgenesis was detected in 3.3%. Fetuses with an associated anomaly detected only on MRI were more likely to have moderate than mild VM (60.0% vs 17.7%; P < 0.001), while there was no significant difference in the proportion of cases with bilateral VM between the two groups (P = 0.2). Logistic regression analysis showed that lower maternal body mass index (adjusted odds ratio (aOR), 0.85 (95% CI, 0.7–0.99); P = 0.030), the presence of moderate VM (aOR, 5.8 (95% CI, 2.6–13.4); P < 0.001) and gestational age at MRI ≥ 24 weeks (aOR, 4.1 (95% CI, 1.1–15.3); P = 0.038) were associated independently with the probability of detecting an associated anomaly on MRI. Associated anomalies were detected exclusively at birth and missed on prenatal imaging in 3.8% of cases. Conclusions: The incidence of an associated fetal anomaly missed on ultrasound and detected only on fetal MRI in fetuses with isolated mild or moderate VM undergoing neurosonography is lower than that reported previously. The large majority of these anomalies are difficult to detect on ultrasound. The findings from this study support the practice of MRI assessment in every fetus with a prenatal diagnosis of VM, although parents can be reassured of the low risk of an associated anomaly when VM is isolated on neurosonography. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Stone disease in the pediatric age is an increasing issue. Percutaneous Nephrolithotomy (PNL) can be used for larger and complex stones. As in adults it can be performed in the supine or prone position.We retrospectively reviewed two centers' experience in prone and supine PNL in children to analyze its results and complications.33 patients underwent prone and 19 supine procedures. Patients in the prone group were younger than in the supine, while no significant differences were found in stone burden, access size, operative time or complications. Complications were: 8 and 4 Clavien 1 for the prone and supine group, respectively, one case of urosepsis (4b) in the prone and 2 cases of Clavien 3 in the supine group (double J stent placement for renal colic and ureteroscopy for steinstrasse). Tubeless procedures and mean nephrostomy time were in favor of the supine group, whereas fluoroscopy time and ureteral drainage stay were in support of the prone group. Stone free rate was better in the supine group (83.3 vs 66.6%), possibly reflecting the capability to perform a combined approach in 12 patients (allowing to reach all the calyx with simultaneous anterograde and retrograde access) or younger age in the prone group (13 vs 2 patients ≤5 years), with no differences in stone burden.Supine approach seems to guarantee higher stone-free rates. Larger series are necessary to determine what the best technique is in terms of X-ray exposure, operative time and complications.

Aims The primary aim of the present study was to assess the association between levator ani muscle (LAM) integrity and function on the one hand, and the risk of urinary incontinence (UI) on the other. A secondary objective was to assess the association between fundal pressure in the second stage of labor (Kristeller maneuver) and the risk of postpartum UI. Methods In this prospective cohort study, women underwent a clinical and transperineal ultrasound examination at rest, at pelvic floor muscle contraction (PFMC), and at Valsalva maneuver 3-6 months after their first vaginal delivery. LAM avulsion and levator hiatal area (LHA) were evaluated. In addition, women were interviewed about the presence of UI, whether stress (SUI) or urgency (UUI). Results Overall, data of 244 women were analyzed. SUI was reported in 50 (20.5%), while UUI was reported in 19 (7.8%) women. Women who reported SUI had a higher prevalence of LAM avulsion and less proportional reduction in LHA from rest to a maximum contraction in comparison to women with no SUI. Women who reported UUI had a greater LHA at rest, during contraction, and during maximal Valsalva in comparison to women without UUI. No significant association was found between the Kristeller maneuver and the incidence of any UI. Conclusion Levator ani avulsion and less proportional reduction of LHA with PFMC appear to be associated with a higher risk of postpartum urinary stress incontinence.

BACKGROUND: Abnormal sulcation of the brain is frequently associated with severe malformations, but the prenatal diagnosis is challenging, especially in early pregnancy. OBJECTIVE: Our study aimed to investigate the value of Sylvian fossa sonographic biometry in the diagnosis of cerebral malformation in the second trimester of gestation. STUDY DESIGN: We prospectively established the normal values of the Sylvian fossa depth in a cohort of nonconsecutive patients, with singleton pregnancies and normal fetuses between 18+0 and 23+0 weeks’ gestation. For each patient, a coronal view of the fetal brain, with a clear visualization of the anterior complex and the Sylvian fissure, was acquired by 1 sonologist, who also measured the depth of the fossa. Reproducibility for each parameter was assessed by a second sonologist using stored images. We also retrospectively acquired the same measurements in second trimester fetuses with central nervous system anomalies. RESULTS: In 103 fetuses with a normal sonogram, the mean depth of the Sylvian fossa was 3.9±0.8 mm Interobserver reproducibility analysis demonstrated good results. Notably, 11 of 31 fetuses with cerebral malformations had a Sylvian fossa depth of

Sir, We read with interest the paper written by Hasegawa and colleagues analyzing the obstetric factors associated with uterine rupture [1]. The authors found that fundal pressure in the second stage (Kristeller’s maneuver) was applied in approximately one every four women with uterine rupture, and in one every three women with rup- ture on unscarred uterus. Kristeller’s maneuver remains one of the most contro- versial and underreported obstetric practices [2,3]. Very little evidence exist on the benefits and safety of the Kristeller’s maneuver. Recently, the World Health Organization issued a document stating fundal pressure in the second stage is not recommended [4]. The authors developing the document declared to have “serious con- cerns about the potential for harm to mother and baby with this procedure” [4]. In addition to these concerns, one of the main problems in research performed on the maneuver is that it is frequently unreported. In a recent study published by our group on Kristeller’s maneuver, we found that in 90% of cases it is not reported in the women’s file [5]. We believe that under- or the total absence of reporting of the maneuver is as challenging and risky as the maneuver itself. Over the past 5 years, in our University Hospital we aimed at reducing the rate of Kristeller’s maneuver and to increase its reporting using a systematic approach. This approach included conducting research to investigate the risks of the maneuver on the pelvic floor, increasing caregivers’ awareness on the con- cerns and evidence regarding the maneuver, and audit- ing the incidence of the application of the maneuver and the rate of its reporting over time.

Background: The impact of drug resistance mutational load and APOBEC editing in heavily treatment-experienced (HTE) people living with multidrug-resistant HIV has not been investigated. Material and Methods: This study explored the HIV-DNA and HIV-RNA mutational load of drug resistance and APOBEC-related mutations through next-generation sequencing (NGS, Illumina MiSeq) in 20 failing HTE participants enrolled in the PRESTIGIO registry. Results: The patients showed high levels of both HIV-DNA (4.5 [4.0–5.2] log10 copies/106 T-CD4+ cell) and HIV-RNA (4.5 [4.1–5.0] log10 copies/mL) with complex resistance patterns in both compartments. Among the 255 drug-resistant mutations found, 66.3% were concordantly detected in both HIV-DNA and HIV-RNA; 71.3% of mutations were already present in historical Sanger genotypes. At an intra-patient frequency > 5%, a considerable proportion of mutations detected through DNA-NGS were found in historical genotypes but not through RNA-NGS, and few patients had APOBEC-related mutations. Of 14 patients who switched therapy, the five who failed treatment had DNA resistance with higher intra-patient frequency and higher DNA/RNA mutational load in a context of tendentially less pronounced APOBEC editing compared with those who responded. Conclusions: Using NGS in HIV-DNA and HIV-RNA together with APOBEC editing evaluation might help to identify HTE individuals with MDR who are more prone to experience virological failure.

Introduction: The objective of the study was to provide more detailed data about fetal isolated upward rotation of the cerebellar vermis rotation (Blake’s pouch cyst) in particular regarding pregnancy outcome. Methods: This is a retrospective study of all cases of fetal isolated upward rotation of the cerebellar vermis (URCV) diagnosed in 3 referral centers in Italy from January 2009 to November 2019. Whenever possible, prenatal magnetic resonance imaging (MRI) was performed and a fetal karyotype was obtained. A detailed follow-up was obtained by consultation of medical records, interview with the parents, and the pediatricians. Results: Our study population included 111 patients with a prenatal diagnosis of isolated URCV made at a median gestational age of 21 weeks +3 days (interquartile range (IQR) 21 + 0–22 + 2). The median brain stem-vermis (BV) angle was 27° (IQR 24–29°). In 37.9% of the cases, a regression of the finding with restoration of normal anatomy was noted at a follow-up scan or at postnatal checks. A BV angle of 25° or less predicted regression with a probability in excess of 90%. MRI was performed in utero or at birth in 101 patients and always confirmed sonographic diagnosis. Fetal CGH array and/or karyotype was available in 97 cases and was always normal, but in 1 case. A postnatal follow-up was available in 102 infants (mean 7 months, range 0–10 years of age) and documented a normal neurologic development in all the cases. Conclusions: Isolated URCV is most likely a normal variant of fetal anatomy without clinical consequences, at least at an early follow-up. A BV angle of 25° or less predicts intrauterine regression of the finding, but the outcome is good in all the cases. When a confident sonographic diagnosis is made, MRI is not mandatory. The risk of a chromosomal anomaly in these cases is probably low.

Background: Malpositions and deflexed cephalic malpresentations are well recognized causes of dysfunctional labor, may result in fetal and maternal complications, and are diagnosed more precisely with an ultrasound examination than with a digital examination. Objective: This study aimed to assess the incidence of malpositions and deflexed cephalic malpresentations at the beginning of the second stage of labor and to evaluate the role of the sonographic diagnosis of deflexion in the prediction of the mode of delivery. Study design: Women in labor with a singleton pregnancy at term with fetuses in a cephalic presentation at 10 cm of cervical dilatation were prospectively examined. A transabdominal ultrasound was performed to assess the fetal head position by demonstrating the fetal occiput or the eyes. Deflexion was assessed by the measurement of the occiput-spine angle when the occiput was anterior or transverse and by qualitative assessment of the relationship between chin and thorax when the occiput was posterior. Transperineal ultrasound was performed in occiput posterior fetuses to discriminate between sinciput, brow, and face presentation. Maternal, labor, and neonatal parameters including maternal age, induction of labor, use of epidural, birthweight, arterial pH, and neonatal intensive care unit admission were recorded. Patients were divided into 2 groups according to the sonographic diagnosis of head deflexion. Adjusted odds ratios were calculated using multivariate logistic regression to determine the association between cesarean delivery and the 2 groups. In addition, labor and neonatal characteristics were compared between occiput anterior and occiput posterior-occiput transverse fetuses. Results: Of the 200 women at the beginning of the second stage, the fetus was in occiput anterior position in 156 (78%), transverse in 11 (5.5%), and posterior in 33 (16.5%) cases. Deflexion was diagnosed in 33 of 156 (21.2%) occiput anterior fetuses and 19 of 44 (43.2%) occiput posterior and occiput transverse fetuses. Cesarean deliveries were significantly associated with fetal head deflexion both in occiput anterior (P=.001) and occiput posterior (P

International audience; Facioscapulohumeral muscular dystrophy (FSHD) is characterized by incomplete penetrance and intra-familial clinical variability. The disease has been associated with the genetic and epigenetic features of the D4Z4 repetitive elements at 4q35. Recently, D4Z4 hypomethylation has been proposed as a reliable marker in the FSHD diagnosis. We exploited the Italian Registry for FSHD, in which FSHD families are classified using the Clinical Comprehensive Evaluation Form (CCEF). A total of 122 index cases showing a classical FSHD phenotype (CCEF, category A) and 110 relatives were selected to test with the receiver operating characteristic (ROC) curve, the diagnostic and predictive value of D4Z4 methylation. Moreover, we performed DNA methylation analysis in selected large families with reduced penetrance characterized by the co-presence of subjects carriers of one D4Z4 reduced allele with no signs of disease or presenting the classic FSHD clinical phenotype. We observed a wide variability in the D4Z4 methylation levels among index cases revealing no association with clinical manifestation or disease severity. By extending the analysis to family members, we revealed the low predictive value of D4Z4 methylation in detecting the affected condition. In view of the variability in D4Z4 methylation profiles observed in our large cohort, we conclude that D4Z4 methylation does not mirror the clinical expression of FSHD. We recommend that measurement of this epigenetic mark must be interpreted with caution in clinical practice.

Objective: To estimate the procedure-related risk of miscarriage in pregnancies undergoing amniocentesis (AC) following inconclusive results for a chorionic villus sampling (CVS). Methods: This was a multicentric retrospective cohort study of patients in which both CVS at 11–13 weeks’ gestation and AC at 16–22 weeks were performed between January 1st, 2008, and July 31st, 2017. The primary outcome measure was pregnancy loss prior to 24 weeks gestation; the secondary one was intrauterine demise after 24 weeks. Results: A total of 287 patients underwent transabdominal CVS and AC. Nine patients were lost at follow-up; therefore, the analysis was conducted on a population of 278 patients (275 singletons and 3 dichorionic twin pregnancies). AC was performed because of placental mosaicism (93.6%), failure of direct/semidirect preparation of trophoblastic cells (3.2%), or targeted genetic testing after the diagnosis of an anomaly in the second trimester (3.2%). In continuing pregnancies, there were no fetal losses prior to 24 weeks’ gestation. Two intrauterine demises (including 1 fetus with multiple anomalies and growth restriction) in the third trimester were recorded. Conclusion: Patients undergoing midtrimester AC because of an inconclusive result of CVS can be reasonably reassured that in general the risk of miscarriage and fetal loss following the procedure is very small.

OBJECTIVES To compare the efficiency of electronic spatiotemporal image correlation (eSTIC) with that of conventional STIC to acquire four-dimensional (4D) fetal cardiac volumes of diagnostic quality. METHODS This was a randomized controlled trial of 100 patients in mid-gestation with normal sonograms. In half of the cases, STIC volumes of the fetal heart were obtained with a conventional mechanical 4D probe and in the remaining cases eSTIC volumes were obtained with an electronic 4D probe. Examinations were kept within the timeframe allotted for a standard examination of fetal anatomy, and a maximum of two attempts were made at obtaining a 4D cardiac volume. Datasets were stored on a computer and subsequently analyzed and categorized as being of optimal, satisfactory or inadequate quality, depending on whether or not it was possible to perform an extended basic cardiac examination, including obtaining a three vessels and trachea view, as well as a clear reconstruction of both the aortic and ductal arches in the sagittal plane. RESULTS The eSTIC volume datasets were more frequently of optimal or satisfactory diagnostic quality compared with conventional STIC (94% vs 76%, P < 0.0001). Failure to obtain an eSTIC volume of adequate quality was in all cases the consequence of an unfavorable position of the fetus. CONCLUSIONS Compared with a standard mechanical probe, the electronic 4D probe facilitates acquisition of sonographic cardiac volumes in mid-trimester fetuses. In our hands, eSTIC volumes of optimal or satisfactory diagnostic quality, allowing a detailed offline evaluation of the fetal heart, were obtained in more than 90% of cases within the time frame of a standard examination of fetal anatomy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Both reduced and increased umbilical cord coiling patterns have been associated with fetal distress and adverse perinatal outcomes, including fetal death. Prenatal diagnosis of cord coiling anomalies is challenging but potentially very useful for identifying those that may benefit from a more intensive monitoring. Nevertheless, there is no standardized approach for this potentially lethal complication when suspected. We report a case of fetal Doppler alterations and cardiotocographic anomalies likely due to hypercoiled cord in a 29-week primigravida referred to our clinic, who therefore underwent an emergency cesarean section. This case could help clinicians to consider cord anomalies as a possible cause of fetal distress.

Objective This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries. Data Sources The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov , Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied. Study Eligibility Criteria Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery. Methods The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) >0% was used to identify heterogeneity. Results A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77–1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04–0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed. Conclusion Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.

Objective Patients with acute respiratory failure due to COVID-19 have a high likelihood of needing prolonged intubation and may subsequently require tracheotomy. Usually, the choice of technique (percutaneous dilatational tracheotomy [PDT] versus open surgical tracheotomy [OST]) depends on the preference of surgeons and patient-related factors. In case of COVID-19, airborne spread of viral particles and limited time of apnea must be considered in the choice of the safest technique. The aim of this study is to compare the complication rates and offer an assessment of relative risks and benefits of PDT versus OST in patients with severe COVID-19. Methods We performed a retrospective study considering 47 consecutive patients affected by severe acute respiratory distress syndrome due to SARS-CoV-2 infection, needing invasive mechanical ventilation and subsequent tracheostomy. This study was performed at the Intensive Care Unit of our tertiary referral center. Complication rates were analyzed. Results Seventeen patients underwent PDT and 30 patients were submitted to OST. Twenty-six patients (55.3%) had post-operative complications (local infection, hemorrhage, subcutaneous emphysema) with no significant difference between PDT and OST. Conclusion PDT and OST are characterized by similar postoperative complication rates in severe COVID-19 patients. These findings suggest that OST might be preferred if expert ENT surgeons are available, as PDT could result in longer apnea and exposure to generated aerosol. However, authors recommend considering either OST or PDT at the discretion of the medical staff involved, according to the personal experience of the operators performing the procedure.

Background The Italian Clinical network for FSHD (ICNF) has established the Italian National Registry for FSHD (INRF), collecting data from patients affected by Facioscapulohumeral dystrophy (FSHD) and their relatives. The INRF has gathered data from molecular analysis, clinical evaluation, anamnestic information, and family history from more than 3500 participants. Methods A data management framework, called Mediator Environment for Multiple Information Sources (MOMIS) FSHD Web Platform, has been developed to provide charts, maps and search tools customized for specific needs. Patients’ samples and their clinical information derives from the Italian Clinical network for FSHD (ICNF), a consortium consisting of fourteen neuromuscular clinics distributed across Italy. The tools used to collect, integrate, and visualize clinical, molecular and natural history information about patients affected by FSHD and their relatives are described. Results The INRF collected the molecular data regarding FSHD diagnosis conducted on 7197 subjects and identified 3362 individuals carrying a D4Z4 Reduced Allele (DRA): 1634 were unrelated index cases. In 1032 cases the molecular testing has been extended to 3747 relatives, 1728 carrying a DRA. Since 2009 molecular analysis has been accompanied by clinical evaluation based standardized evaluation protocols. In the period 2009–2020, 3577 clinical forms have been collected, 2059 follow the Comprehensive Clinical Evaluation form (CCEF). The integration of standardized clinical information and molecular data has made possible to demonstrate the wide phenotypic variability of FSHD. The MOMIS (Mediator Environment for Multiple Information Sources) data integration framework allowed performing genotype–phenotype correlation studies, and generated information of medical importance either for clinical practice or genetic counseling. Conclusion The platform implemented for the FSHD Registry data collection based on OpenClinica meets the requirement to integrate patient/disease information, as well as the need to adapt dynamically to security and privacy concerns. Our results indicate that the quality of data collection in a multi-integrated approach is fundamental for clinical and epidemiological research in a rare disease and may have great value in allowing us to redefine diagnostic criteria and disease markers for FSHD. By extending the use of the MOMIS data integration framework to other countries and the longitudinal systematic collection of standardized clinical data will facilitate the understanding of disease natural history and offer valuable inputs towards trial readiness. This approach is of high significance to FSHD medical community and also to rare disease research in general.

Background Septic shock is characterized by breakdown of the endothelial glycocalyx and endothelial damage, contributing to fluid extravasation, organ failure and death. Albumin has shown benefit in septic shock patients. Our aims were: (1) to identify the relations between circulating levels of syndecan-1 (SYN-1), sphingosine-1-phosphate (S1P) (endothelial glycocalyx), and VE-cadherin (endothelial cell junctions), severity of the disease, and survival; (2) to evaluate the effects of albumin supplementation on endothelial dysfunction in patients with septic shock. Methods This was a retrospective analysis of a multicenter randomized clinical trial on albumin replacement in severe sepsis or septic shock (the Albumin Italian Outcome Sepsis Trial, ALBIOS). Concentrations of SYN-1, S1P, soluble VE-cadherin and other biomarkers were measured on days 1, 2 and 7 in 375 patients with septic shock surviving up to 7 days after randomization. Results Plasma concentrations of SYN-1 and VE-cadherin rose significantly over 7 days. SYN-1 and VE-cadherin were elevated in patients with organ failure, and S1P levels were lower. SYN-1 and VE-cadherin were independently associated with renal replacement therapy requirement during ICU stay, but only SYN-1 predicted its new occurrence. Both SYN-1 and S1P, but not VE-cadherin, predicted incident coagulation failure. Only SYN-1 independently predicted 90-day mortality. Albumin significantly reduced VE-cadherin, by 9.5% (p = 0.003) at all three time points. Conclusion Circulating components of the endothelial glycocalyx and of the endothelial cell junctions provide insights into severity and progression of septic shock, with special focus on incident coagulation and renal failure. Albumin supplementation lowered circulating VE-cadherin consistently over time. Clinical Trial Registration: ALBIOS ClinicalTrials.gov number NCT00707122.

Background Pro-protein convertase subtilisin/kexin 9 (PCSK9) is a proenzyme primarily known to regulate low-density lipoprotein receptor re-uptake on hepatocytes. Whether PCSK9 can concurrently trigger inflammation or not remains unclear. Here, we investigated the potential association between circulating levels of PCSK9 and mortality in patients with severe sepsis or septic shock. Methods Plasma PCSK9 levels at days 1, 2 and 7 were measured in 958 patients with severe sepsis or septic shock previously enrolled in the Albumin Italian Outcome Sepsis (ALBIOS) trial. Correlations between levels of PCSK9 and pentraxin 3 (PTX3), a biomarker of disease severity, were evaluated with ranked Spearman's coefficients. Cox proportional hazards models were used to assess the association of PCSK9 levels at day 1 with 28- and 90-day mortality. Results Median plasma PCSK9 levels were 278 [182-452] ng mL-1 on day 1. PCSK9 correlated positively with PTX3 at the three time-points, and patients with septic shock within the first quartile of PCSK9 showed higher levels of PTX3. Similar mortality rates were observed in patients with severe sepsis across PCSK9 quartiles. Patients with septic shock with lower PCSK9 levels on day 1 (within the first quartile) showed the highest 28- and 90-day mortality rate as compared to other quartiles. Conclusion In our sub-analysis of the ALBIOS trial, we found that patients with septic shock presenting with lower plasma PCSK9 levels experienced higher mortality rate. Further studies are warranted to better evaluate the pathophysiological role of PCSK9 in sepsis.

Objective: To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury. Methods: This was a prospective case–control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3–6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion. Results: During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29–4.51)). Conclusion: The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Objectives: Patients with acute respiratory failure due to coronavirus disease 2019 (COVID-19) have a high likelihood of needing prolonged intubation and may subsequently require tracheotomy. Indications and timing for performing tracheotomy in patients affected by severe COVID-19 pneumonia are still elusive. The aim of this study is to analyze the role of tracheotomy in the context of this pandemic. Moreover, we report the timing of the procedure and the time needed to complete weaning and decannulation in our center. Methods: This retrospective, observational cohort study included adults (≥18 years) with severe COVID-19 pneumonia who were admitted to the intensive care unit (ICU) of the tertiary care center of Reggio Emilia (Italy). All patients underwent orotracheal intubation with invasive mechanical ventilation, followed by percutaneous or open surgical tracheotomy. Indications, timing of the procedure, and time needed to complete weaning and decannulation were reported. Results: Forty-four patients were included in the analysis. Median time from orotracheal intubation to surgery was 7 (range 2-17) days. Fifteen (34.1%) patients died during the follow-up period (median 22 days, range 8-68) after the intubation. Weaning from the ventilator was first attempted on median 25th day (range 13-43) from orotracheal intubation. A median of 35 (range 18-79) days was required to complete weaning. Median duration of ICU stay was 22 (range 10-67) days. Mean decannulation time was 36 (range 10-77) days from surgery. Conclusions: Since it is not possible to establish an optimal timing for performing tracheotomy, decision-making should be made on case-by-case basis. It should be adapted to the context of the pandemic, taking into account the availability of intensive care resources, potential risks for health care workers, and benefits for the individual patient.

International audience; Facioscapulohumeral muscular dystrophy (FSHD) has been associated with the genetic and epigenetic molecular features of the CpG-rich D4Z4 repeat tandem array at 4q35. Reduced DNA methylation of D4Z4 repeats is considered part of the FSHD mechanism and has been proposed as a reliable marker in the FSHD diagnostic procedure. We considered the assessment of D4Z4 DNA methylation status conducted on distinct cohorts using different methodologies. On the basis of the reported results we conclude that the percentage of DNA methylation detected at D4Z4 does not correlate with the disease status. Overall, data suggest that in the case of FSHD1, D4Z4 hypomethylation is a consequence of the chromatin structure present in the contracted allele, rather than a proxy of its function. Besides, CpG methylation at D4Z4 DNA is reduced in patients presenting diseases unrelated to muscle progressive wasting, like Bosma Arhinia and Microphthalmia syndrome, a developmental disorder, as well as ICF syndrome. Consistent with these observations, the analysis of epigenetic reprogramming at the D4Z4 locus in human embryonic and induced pluripotent stem cells indicate that other mechanisms, independent from the repeat number, are involved in the control of the epigenetic structure at D4Z4.

COVID-19 infection can cause a wide spectrum of symptoms. The audio-vestibular system can also be involved, but there is still debate about this so findings need to be considered carefully. Furthermore, mother to fetus intrauterine transmission of COVID-19 infection in pregnant women is controversial. Few studies are available about the audio-vestibular symptomatology of newborns with intrauterine COVID19 exposure. Objectives This study investigates the possible correlation between the COVID19 gestational infection and hearing impairment onset in newborns. The involvement of hearing in COVID19 is verified so the timing and methodology of audiological evaluation of children can be planned. Methods Children were subject to newborn hearing screening and audiological evaluation. Newborn hearing screening is carried out prior to hospital discharge using the Automatic Transient Evoked Otoacoustic Emissions test. Audiological evaluation is performed within the child age of 4 months by using maternal, pregnancy, and perinatal case history, COVID19 case history, otoscopy, acoustic immittance test, Distortion Product Otoacoustic Emissions test, and the Auditory Brainstem Response test. Results 63 children were included in the study. 82.5% of these children were subjects of the newborn hearing screening program. The remaining 11 newborns were not subjected to hearing screening due to isolation measures and their audiological evaluation was carried out directly. Only one of 52 screened neonates showed a bilateral REFER test result but hearing threshold was normal at audiological evaluation. Audiological evaluation showed normal bilateral ABR thresholds in 59/63 children. Four children (6.3% of the total) had ABR threshold alterations but two showed normal threshold at ABR retest performed within 1 month of the first. The other two infants showed monolateral ABR alterations but one of these had a concomitant middle ear effusion. In conclusion, only one child (1.6% of the sample) had an altered ABR. This child had shown one positive SARS-CoV-2 swab in the absence of risk factors for hearing loss. Conclusion This study finds no evidence that maternal COVID19 infection is a risk factor in the development of congenital hearing loss in newborns.

The 5′ and 3′ termini of RNA play important roles in many cellular processes. Using Förster resonance energy transfer (FRET), we show that mRNAs and lncRNAs have an intrinsic propensity to fold in the absence of proteins into structures in which the 5′ end and 3′ end are ≤7 nm apart irrespective of mRNA length. Computational estimates suggest that the inherent proximity of the ends is a universal property of most mRNA and lncRNA sequences. Only guanosine-depleted RNA sequences with low sequence complexity are unstructured and exhibit end-to-end distances expected for the random coil conformation of RNA. While the biological implications remain to be explored, short end-to-end distances could facilitate the binding of protein factors that regulate translation initiation by bridging mRNA 5′ and 3′ ends. Furthermore, our studies provide the basis for measuring, computing and manipulating end-to-end distances and secondary structure in RNA in research and biotechnology., It was previously suggested that formation of RNA secondary structure tends to bring the 5′ and 3′ ends of RNA into close proximity. Here the authors use experimental and computational approaches to show that mRNAs and lncRNAs have an intrinsic propensity to fold into structures in which the 5′ end and 3′ end are ≤7 nm apart irrespective of length.

The heterotrimeric NF-Y complex is a pioneer factor that binds to CCAAT-genes and regulates their transcription. NF-Y cooperates with multiple transcription factors and co-regulators in order to positively or negatively influence gene transcription. The recruitment of NF-Y to CCAAT box is significantly enriched in cancer-associated gene promoters loci and positively correlates with malignancy. NF-Y subunits, in particular the DNA-binding subunit NF-YA and the histone-fold subunit NF-YC, appear overexpressed in specific types of cancer. Here we demonstrate that NF-Y subunits expression is finely regulated through transcriptional and post-translational mechanisms thus allowing control over basal expression levels. NF-Y negatively regulates the transcription of the genes encoding for its subunits. DNA pull-down/affinity purification assay coupled with Mass Spectrometry identified putative co-regulators, such as Lamin A, involved in NF-YA gene transcription level. We also evidentiate how the stability of the complex is severely affected by the absence of one subunit. Our results identified for the first time one of the mechanisms responsible for NF-Y expression, which may be involved in the aberrant expression and activity observed in tumor cells and other pathological conditions.

In this article we describe the identification of unprecedented ATP-competitive ChoKα inhibitors starting from initial hit NMS-P830 that binds to ChoKα in an ATP concentration-dependent manner. This result is confirmed by the co-crystal structure of NMS-P830 in complex with Δ75-ChoKα. NMS-P830 is able to inhibit ChoKα in cells resulting in the reduction of intracellular phosphocholine formation. A structure-based medicinal chemistry program resulted in the identification of selective compounds that have good biochemical activity, solubility and metabolic stability and are suitable for further optimization. The ChoKα inhibitors disclosed in this article demonstrate for the first time the possibility to inhibit ChoKα with ATP-competitive compounds.

Introduction Elder abuse in recent times has reached a remarkable international importance. This complex phenomenon is still little understood and studied in Italy. The aim of this study was to explore Italian healthcare professionals’ attitude and barriers toward elder abuse, with a glimpse on the current scenario and evidences to develop an action plan. Materials and methods 42 healthcare professionals filled a questionnaire with 13 open-ended questions, analyzed with a qualitative content analysis. Data were grouped under the following 4 core-themes: description of elder abuse, abuse detection and perception, barriers to reporting, and professional orientation and approach; then they were analyzed to find their central component and discussed jointly. Results The respondents described physical (64%) and psychological (50%) abuse and neglect (50%) as the three main characteristics of elder abuse; the 59% of them reported at least one experience in detecting or suspecting elder abuse. The 76% of participants believed the report has to be submitted to the Judicial Authority only in presence of compelling evidences. Furthermore, the 73% of the sample perceived that healthcare professionals are the main figures who have to cope with elder abuse, however they did not feel as their exclusive role the assessment of the patients’ potential abuse. Conclusion Knowledge about elder abuse was limited to physical/psychological issues and, moreover, the legal obligation to report was only poorly known. Imperative is the creation of specific education and training courses, in addition to the need for a multidisciplinary and empathetic approach.

Background Bronchial thermoplasty (BT) is a non-pharmacological intervention for severe asthma whose mechanism of action is not completely explained by a reduction of airway smooth muscle (ASM). In this study we analyzed the effect of BT on nerve fibers and inflammatory components in the bronchial mucosa at 1 year. Methods Endobronchial biopsies were obtained from 12 subjects (mean age 47 ± 11.3 years, 50% male) with severe asthma. Biopsies were performed at baseline (T0) and after 1 (T1), 2 (T2) and 12 (T12) months post-BT, and studied with immunocytochemistry and microscopy methods. Clinical data including Asthma Quality of Life Questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ) scores, exacerbations, hospitalizations, oral corticosteroids use were also collected at the same time points. Results A statistically significant reduction at T1, T2 and T12 of nerve fibers was observed in the submucosa and in ASM compared to T0. Among inflammatory cells, only CD68 showed significant changes at all time points. Improvement of all clinical outcomes was documented and persisted at the end of follow up. Conclusions A reduction of nerve fibers in epithelium and in ASM occurs earlier and persists at one year after BT. We propose that nerve ablation may contribute to mediate the beneficial effects of BT in severe asthma. Trial registration Registered on April 2, 2013 at ClinicalTrials.gov Identifier: NCT01839591.

Purpose: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). Methods: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. Results: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to- treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02- 1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). Conclusions: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted ; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS.

Early repair of obstetric anal sphincter injuries is crucial in the prevention of anal incontinence, but the diagnostic accuracy of the clinical examination after delivery is poor. Endoanal ultrasound imaging is now regarded as the gold standard for diagnosing anal sphincter injuries, and it improves the diagnosis of these lacerations. Four-dimensional transperineal ultrasound imaging has been proposed as an effective and less invasive alternative to endoanal ultrasound imaging in the diagnosis of anal sphincter injuries.The purpose of this study was to evaluate the feasibility and accuracy of the assessment of anal sphincter contraction by dynamic 2-dimensional transperineal ultrasound imaging immediately after delivery and its correlation with anal incontinence at the 4-month follow-up evaluation.A nonconsecutive series of nulliparous women with low-risk singleton term pregnancies were recruited in the labor room after vaginal delivery for the purpose of this study from January 2017 to July 2017. All enrolled patients had a clinical examination of the perineum by the caregiver that was repeated by an experienced research fellow. For each patient, a further dynamic 2-dimensional transperineal ultrasound imaging were carried out. Before the perineal repair, the women were asked to contract the anal sphincter during 2-dimensional transperineal ultrasound imaging; they were divided in 2 groups according to the sonographic findings: women with sonographic evidence of anal sphincter contraction (group A) and women with no evidence of contraction at ultrasound imaging (group B). A follow-up examination of anal sphincter integrity with 4-dimensional transperineal ultrasound imaging was carried out 4 months after delivery. At this time, the levator ani integrity was evaluated with the use of 4-dimensional transperineal ultrasound imaging, as previously described.Over the study period 69 women were enrolled. In 55 women (80%), there was evidence of proper anal sphincter contraction (group A); in 14 cases (20%), it was not possible to identify anal sphincter contraction with dynamic 2-dimensional transperineal ultrasound imaging (group B). Obstetric anal sphincter injuries that were detected through clinical examination were significantly more frequent in group B than in group A (13/14 [93%] vs 7/55 [12%]; P.001). At the 4-month postpartum follow up, the previously recognized obstetric anal sphincter injuries were found to be repaired correctly; a third-degree perineal tear that had not been reported previously was diagnosed by 4-dimensional transperineal ultrasound imaging . Anal incontinence was reported in 8 of 69 patients (11%); it was more frequent in group B when compared with group A (4/14 [29%] vs 4/55 [7%]; P=.047).Dynamic 2-dimensional transperineal ultrasound imaging is a feasible technique and a useful supporting tool for the assessment of anal sphincter integrity in the labor room before suturing. Anal incontinence at the 4-month follow-up evaluation is more frequent among women with no evidence of anal sphincter contraction at dynamic 2-dimensional transperineal ultrasound imaging after delivery.

Background Intrapartum ultrasound scanning has been proposed as an ancillary tool in the decision-making process of instrumental vaginal delivery. Objective The purpose of this study was to evaluate the correlation between the sonographic visualization with a transperineal scan of the fetal occiput or forehead distal to the pubic symphysis with anterior or posterior presentation, respectively (fetal occiput or forehead sign), and the outcome of a vacuum delivery. Study Design We conducted a retrospective cohort study of patients who underwent a vacuum application in our hospital from 2011–2017, excluding outlet applications. In each case, a preliminary transperineal scan was performed to confirm fetal presentation and position and to demonstrate the presence or absence of the fetal occiput or forehead sign. The head direction, angle of progression, and the head perineum distance were also noted. The primary outcome measure was the success of the vacuum. The secondary outcome measures included fetal complications and perineal lacerations. Results A total of 196 consecutive patients were enrolled in the study. The occiput or forehead sign was present in 150 and was associated with a successful vaginal extraction in all cases. Of the 46 cases without the sign, 5 babies (10.8%) were delivered by cesarean section after a failed vacuum (P=.0006). The occiput or forehead sign was also associated with fewer grade 3–4 perineal lacerations (10.7% vs 35.7%; P=.0005) and cephalohematomas, although the difference was not statistically significant (1.4% vs 4.3%). There was a good correlation between the occiput or forehead sign and the other sonographic methods that previously had been proposed to predict a successful vacuum extraction, such as head direction, angle of progression, and head perineum distance. Conclusion In our hands, the fetal occiput or forehead sign was associated strongly with successful vacuum application and with a very low rate of maternal and fetal complications.

Objective: To evaluate the efficiency of real-time volume contrast imaging in the A plane (VCI-A) of fetal extremities, compared with conventional two-dimensional ultrasound (2D). Methods: This was a randomized controlled trial of 100 patients undergoing midtrimester sonography. The fetal limbs were imaged with either 2D or VCI-A with a four-dimensional (4D) electronic probe. Time required for the examination, number of images stored, and quality of the documentation were compared. During the study, 6 fetuses with abnormal extremities were scanned with both 2D and VCI-A, and the diagnostic accuracy and quality of the images were also compared. Results: In the VCI-A group, the fetal extremities were imaged more rapidly (2.3 ± 1.1 vs. 3.3 ± 0.9 min, p < 0.0001), less images were required to document the examination (5.6 ± 1.4 vs. 7.3 ± 1.6), and an optimal documentation was more frequently obtained (84 vs. 54%, p < 0.0001) compared with the 2D group. In malformed fetuses, a precise diagnosis was achieved with both techniques, although images obtained with VCI-A were found to be of superior quality. Conclusions: Real-time VCI-A with a 4D electronic probe is an effective tool for imaging the fetal extremities in midtrimester examinations and carries some advantages over conventional 2D sonography.

NUP98-fusion transcripts characterize different biological entities within acute myeloid leukemia: a report from the AIEOP-AML group

Background The long pentraxin PTX3 is a key component of the humoral arm of innate immunity related to sepsis severity and mortality. We evaluated the clinical and prognostic significance of circulating PTX3 in the largest cohort ever reported of patients with severe sepsis or septic shock. Design Plasma PTX3 was measured on days 1, 2 and 7 after randomization of 958 patients to albumin or crystalloids for fluid resuscitation in the multicenter Albumin Italian Outcome Sepsis (ALBIOS) trial. We tested the association of PTX3 and its changes over time with clinical severity, prevalent and incident organ dysfunctions, 90-day mortality, and treatment. Results PTX3 was high at baseline (72 [33-186] ng/mL) and rose with the severity and number of organ dysfunctions (p

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4\%) answered the survey. More than 90\% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.

// Sebastian Fantini 1 , Valentina Salsi 1, 2 , Luca Reggiani 3 , Antonino Maiorana 3 , Vincenzo Zappavigna 1 1 Department of Life Sciences, Modena 41125, Italy 2 Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto, University of Modena and Reggio Emilia, Modena 41125, Italy 3 Dipartimento di Medicina Diagnostica, Clinica e di Sanita Pubblica, University of Modena and Reggio Emilia, Modena 41124, Italy Correspondence to: Vincenzo Zappavigna, email: zappavigna.vincenzo@unimore.it Keywords: colorectal cancer, gene regulation, gene expression, molecular mechanisms, molecular carcinogenesis Received: April 18, 2016 Accepted: November 11, 2016 Published: November 25, 2016 ABSTRACT Objective: To explore the possible misexpression of the microRNA miR-196b in colorectal cancer (CRC) and its role in controlling the expression of GATA6, a putative target gene crucial to intestinal cell homeostasis and tumorigenesis. Design: The expression of miR-196b was analysed by qRT-PCR in surgical resection samples from a cohort of sporadic colon cancer patients. Manipulations of miR-196b expression were performed to demonstrate its inhibition of GATA6 protein levels. Results: We found that miR-196b is significantly upregulated in pre-treatment surgical resection samples from a cohort of sporadic colon cancer patients. The upregulation of miR-196b correlates with less severe clinicopathological characteristics, such as early tumor stage and absence of lymph node metastases. We show that in CRC cells, miR-196b targets the mRNA of GATA6, a transcription factor involved in the homeostasis and differentiation of intestinal epithelial cells, and a positive regulator of the Wnt/β-catenin pathway. We moreover found that the increase of miR-196b correlates with a reduced GATA6 protein expression in colon cancer patients. Conclusion: Our results establish miR-196b as a post-transcriptional inhibitor of GATA6 in CRC cells, implicating miR-196b function in gene regulatory pathways crucial to intestinal cell homeostasis and tumorigenesis. Our results furthermore suggest a role of miR-196b expression in CRC, as an antagonist of GATA6 function in tumor cells, thus providing the basis for a potential targeting strategy for the treatment of CRC.

Objective: To compare the policy of prenatal diagnosis versus first trimester screening of trisomy 21 among pregnant women of advanced age. Methods: A retrospective study was conducted on patients aged ≥35 divided in two groups: patients who requested first trimester combined test and only in case of screen-positive result underwent invasive testing (group A); patients undergoing chorionic villous sampling or amniocentesis as first investigation (group B). The following outcome variables were compared: antenatal detection of trisomy 21, occurrence of trisomy 21 at birth, miscarriage rate, hospitals' costs. Results: 4527 women were included. Of these, 534 (11.80\%) underwent T21 screening whereas 3993 (88.20\%) requested primary invasive testing. In group A, 64 combined test were positive (11.99\%) and 8 trisomy 21 cases were diagnosed (1.50\%); the loss of euploid fetuses after invasive procedure was 4.55\% (2/44). No false-negative case was observed. In group B 57 cases of trisomy 21 were diagnosed (1.43\%), and pregnancy loss rate of chromosomally normal fetuses was 0.45\% (17/3806). The estimated cost was, respectively, 67.720€ for the primary screening versus 1.996.500€ for direct prenatal diagnosis. Conclusion: First trimester screening of trisomy 21 is highly accurate and cost saving among women ≥35.

NUP98 is a recurrent partner gene in translocations causing acute myeloid leukemias and myelodisplastic syndrome. The expression of NUP98 fusion oncoproteins has been shown to induce mitotic spindle defects and chromosome missegregation, which correlate with the capability of NUP98 fusions to cause mitotic checkpoint attenuation. We show that NUP98 oncoproteins physically interact with the APC/C(Cdc20) in the absence of the NUP98 partner protein RAE1, and prevent the binding of the mitotic checkpoint complex to the APC/C(Cdc20). NUP98 oncoproteins require the GLEBS-like domain present in their NUP98 moiety to bind the APC/C(Cdc20). We found that NUP98 wild-type is a substrate of APC/C(Cdc20) prior to mitotic entry, and that its binding to APC/C(Cdc20) is controlled via phosphorylation of a PEST sequence located within its C-terminal portion. We identify S606, within the PEST sequence, as a key target site, whose phosphorylation modulates the capability of NUP98 to interact with APC/C(Cdc20). We finally provide evidence for an involvement of the peptidyl-prolyl isomerase PIN1 in modulating the possible conformational changes within NUP98 that lead to its dissociation from the APC/C(Cdc20) during mitosis. Our results provide novel insight into the mechanisms underlying the aberrant capability of NUP98 oncoproteins to interact with APC/C(Cdc20) and to interfere with its function.

How the essential pre-mRNA splicing factor U2AF65 recognizes the polypyrimidine (Py) signals of the major class of 3′ splice sites in human gene transcripts remains incompletely understood. We determined four structures of an extended U2AF65–RNA-binding domain bound to Py-tract oligonucleotides at resolutions between 2.0 and 1.5 Å. These structures together with RNA binding and splicing assays reveal unforeseen roles for U2AF65 inter-domain residues in recognizing a contiguous, nine-nucleotide Py tract. The U2AF65 linker residues between the dual RNA recognition motifs (RRMs) recognize the central nucleotide, whereas the N- and C-terminal RRM extensions recognize the 3′ terminus and third nucleotide. Single-molecule FRET experiments suggest that conformational selection and induced fit of the U2AF65 RRMs are complementary mechanisms for Py-tract association. Altogether, these results advance the mechanistic understanding of molecular recognition for a major class of splice site signals., The pre-mRNA splicing factor U2AF65 recognizes 3′ splice sites in human gene transcripts, but the details are not fully understood. Here, the authors report U2AF65 structures and single molecule FRET that reveal mechanistic insights into splice site recognition.

Women in unstable housing or who are homeless experience disruptions of occupational engagement and performance. Little is known about their perspective on their occupational needs and priorities.This study aimed to determine how patterns of occupational engagement and performance are facilitated or hindered by personal factors and resources available to sheltered women.A participatory, descriptive mixed-methods study design was used. Twenty-one residents were interviewed using the Canadian Occupational Performance Measure, the Goal Attainment Scale, and a time-use inventory. Nineteen residents participated in semistructured qualitative interviews. Qualitative data were analysed using interpretive description.Participants spent most time on sleep and passive leisure and identified occupational performance issues and goals related to active leisure and employment. Participants' occupational lives were described as transitional journeys comprising five subthemes: seeking safety and stability, being sheltered, shaping one's identity, developing resilience, and engaging in contemplation, contribution, and connectedness through occupation.Trauma-informed and strengths-based approaches are recommended for this population. Future research should study the implementation of occupation-based interventions in community settings.

Elder abuse appears to be widely underestimated by health professionals. We aimed to evaluate the recognition of elder abuse among Italian nurses and nursing students related to their professional, personal experiences and socio-demographic characteristics. 193 nursing students and 76 nurses attending a post-graduate nursing management master's degree at the University of Bologna (Italy) completed the Caregiving Scenario Questionnaire measuring the ability to recognize elder abuse. Data on age, gender, previous professional and personal experiences as well as nursing school teaching were collected. Regarding abusive items, preventing elder's movements by putting a table over the elder's lap was identified by almost all participants, while locking someone at home was identified by half of them. Neglect was recognized by 25 % of nurses and 20 % of students, respectively. The majority of nurses and students correctly identified non-abusive strategies. Reporting being taught on elder abuse was inversely associated with a good performance in detecting neglect. Italian nurses' and nursing students' uncertainty in identifying abusive strategies, especially neglect, was consistent with results of previous studies in other countries. Standardized education in healthcare core curriculum, reference guidance and training are strongly needed to improve elder abuse recognition in Italy.

The miR-196 miRNA gene family located within the Hox gene clusters has been shown to function during embryogenesis and to be aberrantly expressed in various malignancies, including leukaemia, melanoma, and colorectal cancer. Despite its involvement in numerous biological processes , the control of miR-196 expression is still poorly defined. We identified the miR-196b promoter and found that the mature miR-196b originates from a large, non-coding primary transcript , which starts within an autonomous TATA box promoter and is not in physical continuity with either the Hoxa10 or Hoxa9 main primary transcripts. A ~ 680 bp genomic fragment , spanning the pri-miR-196b transcription start site , is sufficient to recapitulate the neural tube expression pattern of miR-196 during embryogenesis. This region contains potential binding sites for Cdx and 5′Hox transcription factors. Two of these sites revealed to be necessary for neural tube expression and were bound in vivo by Cdx2 and Hoxd13. We show that Cdx2 is required for miR-196 expression and that both Cdx2 and 5′Hox, but not 3′Hox, are able to activate the miR-196b promoter. The possible role of Cdx2- and 5′Hox-mediated regulation of miR-196 expression in vertebrate anterior–posterior (AP) axis formation during embryogenesis is discussed.

Objective: To evaluate the ability of intrapartum ultrasound to differentiate occipitoposterior (OP) rotation with normal flexion of the head from deflexion, to compare the accuracy of ultrasound with the digital examination, and to assess the outcome of labor according to the type of presentation. Patients and Methods: A retrospective study of patients with abnormal labor because of either prolongation and/or abnormal cardiotocography and OP rotation who underwent intrapartum sonography. Results: Normal flexion was inferred in 36/42 cases by a longitudinal sonographic view of the fetal face demonstrating the chin approaching the chest. In the remaining 6, deflexion was diagnosed by visualizing the chin separate and distant from the chest. In 3 of these cases, the orbits were at the same level of the pubis suggesting brow presentation. In the remaining 3 cases, the orbits were above the pubis, and sinciput presentation was inferred. Head deflexion was diagnosed more accurately with ultrasound than clinically and always required a cesarean section versus 36% of cases with OP flexed presentation (p = 0.0052). Conclusions: Fetuses with abnormal labor and OP rotation had deflexed presentations in 14% of cases and were never delivered vaginally. Sonography was far more accurate than the digital examination.

Objectives: The aim of this paper was to assess the feasibility and reliability of a new automated method for the measurement of the angle of progression (AoP) in labor. Methods: AoP was assessed using two-dimensional transperineal ultrasound by two operators in 52 women in active labor to evaluate intra- and interobserver reproducibility. The intermethod agreement between automated and manual techniques was analyzed by means of the intraclass correlation coefficient and Bland-Altman method. Results: Automated measurements were feasible in all cases. Automated assessments correctly depicted the pubic symphysis and fetal head in 133 (85.3%) out of 156 on first assessments and in all 156 after repeating measurements once in case of incorrect first evaluation. The automated technique showed good intra- and interobserver reproducibility and very good agreement with the manual technique. AoP measured by the automated method were significantly wider than those done by the manual technique (119 ± 20° vs. 130 ± 20°, p = 0.005). Conclusions: Automated assessment AoP is feasible and reproducible. However, measurements performed by the automated software are significantly different from those resulting from the previously published manual technique. In the light of our data, the automated technique does not seem ready yet for clinical use, and the AoP should be exclusively measured by the previously suggested manual technique.

Objective The aim of this study was to present a new method for fetal Kell genotyping by means of the allelic discrimination of K1 and K2 in real-time polymerase chain reaction (PCR). Methods Real-time quantitative polymerase chain reaction incorporating an allele-specific primer was developed for detecting the K allele of KEL. Results By means of this method, the K1/K2 genotype was able to be determined in all blood samples analyzed. Results using cell-free fetal DNA (cffDNA) from two Kell-negative pregnant women confirmed the Kell-positive genotype of fetuses. The real-time PCR analysis also allowed the determination of the fetal fraction using the quantification of Kell-positive DNA. Conclusion An efficient and reliable strategy for Kell genotyping is herein presented. The method was optimized on cffDNA to create a non-invasive prenatal test which could be routinely used for the prevention of hemolytic disease of the fetus and the newborn (HDFN).