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Purpose: To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS). Materials and methods: This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020–December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded. Results: 37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positives) 8.5 days [range, 1–18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positives) demonstrated Macklin effect (p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6–96.9), a specificity of 95.6% (95% CI: 90.6–98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3–92.3), a negative PV of 97.1% (95% CI: 74.6–96.9) and an accuracy of 94.2% (95% CI: 89.6–97.2) in predicting PMD/PNX (AUC:0.924). Conclusions: Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.

Background: Non-invasive mechanical ventilation (NIV) is effective for symptom relief and respiratory support in patients with respiratory insufficiency, severe comorbidities and no indication to intubation. Experience with NIV as the ceiling of treatment in severely compromised novel coronavirus disease (COVID-19) patients is lacking. Methods: We evaluated 159 patients with COVID-19-related acute respiratory syndrome (ARDS), 38 of whom with NIV as the ceiling of treatment, admitted to an ordinary ward and treated with continuous positive airway pressure (CPAP) and respiratory physiotherapy. Treatment failure and death were correlated with clinical and laboratory parameters in the whole cohort and in patients with NIV as the ceiling of treatment. Results: Patients who had NIV as the ceiling of treatment were elderly, with a low BMI and a high burden of comorbidities, showed clinical and laboratory signs of multi-organ insufficiency on admission and of rapidly deteriorating vital signs during the first week of treatment. NIV failure occurred overall in 77 (48%) patients, and 27/38 patients with NIV as the ceiling of treatment died. Congestive heart failure, chronic benign haematological diseases and inability/refusal to receive respiratory physiotherapy were independently associated to NIV failure and mortality. Need for increased positive end-expiratory pressures and low platelets were associated with NIV failure. Death was associated to cerebrovascular disease, need for CPAP cycles longer than 12h and, in the subgroup of patients with NIV as the ceiling of treatment, was heralded by vital sign deterioration within 48 h. Conclusions: NIV and physiotherapy are a viable treatment option for patients with severe COVID-19 and severe comorbidities.

Objective: Exploring the association between frailty and mortality in a cohort of patients with COVID-19 respiratory insufficiency treated with continuous positive airway pressure. Methods: Frailty was measured using a Frailty Index (FI) created by using the baseline assessment data on comorbidities and body mass index and baseline blood test results (including pH, lactate dehydrogenase, renal and liver function, inflammatory indexes and anemia). FI > 0.25 identified frail individuals. Results: Among the 159 included individuals (81% men, median age of 68) frailty was detected in 69% of the patients (median FI score 0.3 ± 0.08). Frailty was associated to an increased mortality (adjusted HR 1.99, 95% CI 1.02–3.88, p = 0.04). Conclusions: Frailty is highly prevalent among patients with COVID-19, predicts poorer outcomes independently of age. A personalization of care balancing the risk and benefit of treatments (especially the invasive ones) in such complex patients is pivotal.

The efficacy and safety of continuous positive airway pressure and respiratory physiotherapy outside the ntensive care unit during a pandemic. BACKGROUND: The efficacy and safety of continuous positive airway pressure and respiratory physiotherapy outside the Intensive Care Unit during a pandemic.METHODS: In this cohort study performed in February-May 2020 in a large teaching hospital in Milan, COVID-19 patients with adult respiratory distress syndrome receiving continuous positive airway pressure (positive end-expiratory pressure =10 cm H2O, FiO(2)=0.6, daily treatment duration: 4 x3h-cycles) and respiratory physiotherapy including pronation outside the Intensive Care Unit were followed-up.RESULTS: Of 90 acute respiratory distress syndrome (ARDS) patients treated with continuous positive airway pressure (45/90, 50% pronated at least once) outside the Intensive Care Unit and with a median (interquartile) follow-up of 37 (1146) days, 45 (50%) were discharged at home, 28 (31%) were still hospitalized, and 17 (19%) died. Continuous positive airway pressure failure was recorded for 35 (39%) patients. Patient mobilization was associated with reduced failure rates (P=0.033). No safety issues were observed.CONCLUSIONS: Continuous positive airway pressure with patient mobilization (including pronation) was effective and safe in patients with ARDS due to COVID-19 managed outside the Intensive Care Unit setting during the pandemic.

Methods. Describing the complications that an older patient under- went during his hospital stay.Results. An 87-year-old man was admitted to the San Raffaele Hos- pital for a transient loss of consciousness (LOC). He was hospitalized for assessing the causes of the LOC. The LOC lasted 2 minutes, was associated with bilateral upper limb clonus and subsequent confu- sion. The patient was severely comorbid: he suffered from metabolic syndrome, chronic kidney failure, hemodynamically significant carotid atheromasia, anemia, and he had a dubious history of epilepsy. More- over, the patient was cognitively impaired and many episodes of LOC were reported in his medical history. During the hospital stay the patient developed many complications: a fall, nosocomial pneumonia, urinary retention and deconditioning.Conclusions. Global aging poses several challenges to society and public health systems. The traditional models of care are not suitable to face the complex needs of frail older people for whom standard deci- sional algorithms are seldom applicable. The context of hospitalization, though necessary, may be hazardous risky for the health of older peo- ple, especially the frailer ones.

BackgroundRespiratory infections can be complicated by acute brain failure. We assessed delirium prevalence, predictors and outcomes in COVID-19 ED patients.MethodsThis was a retrospective observational study conducted at the San Raffaele ED (Italy). Patients age >18 years attending the ED between 26 February 2020 and 30 May 2020 and who had a positive molecular nasopharyngeal swab for SARS-CoV-2 were included. The Chart-Based Delirium Identification Instrument (CHART-DEL) was used to retrospectively assess delirium. Univariable and multivariable logistic regression analyses were used to evaluate delirium predictors. Univariable binary logistic regression analyses, linear regression analyses and Cox regression analyses were used to assess the association between delirium and clinical outcomes. Age-adjusted and sex-adjusted models were then run for the significant predictors of the univariable models.ResultsAmong the 826 included patients, 123 cases (14.9%) of delirium were retrospectively detected through the CHART-DEL method. Patients with delirium were older (76.9±13.15 vs 61.3±14.27 years, pConclusionsChart review frequently identified ED delirium in patients with COVID-19. Age, dementia, epilepsy and polypharmacy were significant predictors of ED delirium. Delirium was associated with an increased in-hospital mortality and with a reduced probability of being discharged home after hospitalisation. The findings of this single-centre retrospective study require validation in future studies.

Every year, the pharmaceutical and food industries produce over 1000 tons of essential oils (EOs) exploitable in different fields as the development of eco-friendly and safe antimicrobial inhibitors. In this work we investigated the potential of some EOs, namely Cinnamomum verum, Cymbopogon martini, Cymbopogoncitratus and Cymbopogon flexuosus, on the growth, biofilm formation and gene expression in four strains of enterohemorrhagic Escherichia coli O157:H7. All EOs were analyzed by gas chromatography-mass spectrometry (GC-MS). The antimicrobial activity was performed by using dilutions of EOs ranging from 0.001 to 1.2% (v/v). Subinhibitory doses were used for biofilm inhibition assay. The expression profiles were obtained by RT-PCR. E. coli O157:H7 virulence was evaluated in vivo in the nematode Caenorhabditis elegans. All EOs showed minimal inhibitory concentrations (MICs) ranging from 0.0075 to 0.3% (v/v). Cinnamomum verum bark EO had the best activity (MIC of 0.0075% (v/v) in all strains) while the C. verum leaf EO had an intermediate efficacy with MIC of 0.175% (v/v) in almost all strains. The Cymbopogon spp. showed the more variable MICs (ranging from 0.075 to 0.3% (v/v)) depending on the strain used. Transcriptional analysis showed that C. martini EO repressed several genes involved in biofilm formation, virulence, zinc homeostasis and encoding some membrane proteins. All EOs affected zinc homeostasis, reducing ykgM and zinT expression, and reduced the ability of E. coli O157:H7 to infect the nematode C. elegans. In conclusion, we demonstrated that these EOs, affecting E. coli O157:H7 infectivity, have a great potential to be used against infections caused by microorganisms.

Every year, the pharmaceutical and food industries produce over 1000 tons of essential oils (EOs) exploitable in different fields as the development of eco-friendly and safe antimicrobial inhibitors. In this work we investigated the potential of some EOs, namely Cinnamomum verum, Cymbopogon martini, Cymbopogon citratus and Cymbopogon flexuosus, on the growth, biofilm formation and gene expression in four strains of enterohemorrhagic Escherichia coli O157:H7. All EOs were analyzed by gas chromatography-mass spectrometry (GC-MS). The antimicrobial activity was performed by using dilutions of EOs ranging from 0.001 to 1.2% (v/v). Subinhibitory doses were used for biofilm inhibition assay. The expression profiles were obtained by RT-PCR. E. coli O157:H7 virulence was evaluated in vivo in the nematode Caenorhabditis elegans. All EOs showed minimal inhibitory concentrations (MICs) ranging from 0.0075 to 0.3% (v/v). Cinnamomum verum bark EO had the best activity (MIC of 0.0075% (v/v) in all strains) while the C. verum leaf EO had an intermediate efficacy with MIC of 0.175% (v/v) in almost all strains. The Cymbopogon spp. showed the more variable MICs (ranging from 0.075 to 0.3% (v/v)) depending on the strain used. Transcriptional analysis showed that C. martini EO repressed several genes involved in biofilm formation, virulence, zinc homeostasis and encoding some membrane proteins. All EOs affected zinc homeostasis, reducing ykgM and zinT expression, and reduced the ability of E. coli O157:H7 to infect the nematode C. elegans. In conclusion, we demonstrated that these EOs, affecting E. coli O157:H7 infectivity, have a great potential to be used against infections caused by microorganisms.

E. coli O157:H7 has three sodC genes encoding for Cu,Zn superoxide dismutase. We evaluated the expression of chromosomal sodC in distinct phases of growth in different strains, and we examined the mutual capability of chromosomal and prophagic genes to influence their expression.We used One Step real-time RT-PCR technology to study the expression of sodC genes in several E. coli strains.In three of four analysed E. coli O157:H7 strains the chromosomal sodC gene was more expressed in exponential phase than in stationary phase, unlike it occurs in the E. coli K12 strain. The expression of the chromosomal gene was always higher than that of the prophagic copies. Deletion of prophagic or chromosomal sodC genes had no effect on the expression of the residual gene.Our study highlights an inherent variability in number and level of expression of sodC genes in E. coli O157:H7 strain.

A 67-year-old man with an 11-month history of ANCAnegative eosinophilic granulomatosis with polyangiitis (EPGA) was evaluated in our department for weight loss of 5 kg over 2 months and progressive fatigue. He had a 20-year history of asthma, for which he was taking maintenance therapy with an inhaled corticosteroid twice daily. He later developed glomerulonephritis, peripheral eosinophilia, and sinusitis, and a histological sample of a nasal polyp confirmed the diagnosis of EPGA (small-sized vessel inflammatory arteriopathy with fibrinoid necrosis, granulomata, and perivascular eosinophilic infiltration). The patient achieved clinical remission after high doses of glucocorticoids and started daily oral prednisone 5 mg and mycophenolate mofetil (MMF) 2 g as a maintenance regimen. MMF was chosen because of its low renal toxicity, given the patient’s renal failure secondary to glomerulonephritis (creatinine clearance 17.6 mL/min). At clinical examination, multiple cutaneous lesions on the neck and limbs’ extremities were observed. He reported that a sore and purplish skin lesion on the right leg appeared 6 weeks before admission (Figure 1, A) and then a few of similar, fast-growing lesions came up (Figure 1, B). He was afebrile, hemodynamically stable, and maintained a room air oxygen saturation of 94%. Superficial lymph nodes were not palpable. Blood tests revealed normal complete blood count, inflammatory indexes, and biochemistry. Percutaneous tissue biopsy was performed, and histologic analysis revealed spindle cell proliferation suggestive of Kaposi’s sarcoma (KS)

Churg–Strauss syndrome can be associated with Loeffler-like eosinophilic endocarditis. We report a case of a young woman in which the diagnosis of Churg–Strauss syndrome was made subsequently to the magnetic resonance demonstration of eosinophilic endocarditis associated to left ventricle apical thrombosis. In our report, this rare condition evolved in an unusual complication: the embolic migration of the left ventricle apical thrombus in the abdominal aorta as showed by multi-detector-computed-tomography angiography.

We describe a transfection system that induces terminal deletions at specific chromosome ends in malaria parasites using a linear construct containing telomeric repeats at one end and plasmodial sequences able to drive homologous recombination at the other. A site-specific deletion was generated at one extremity of chromosome 5 ofPlasmodium berghei, which was stably maintained in the parasite population selected after transfection. The telomeric repeat array introduced with the construct reached the average length observed in natural telomeres of Plasmodium, indicating that in vivo telomere addition occurred at the newly formed extremity. The expression of a mutant dhfr/ts gene conferring pyrimethamine resistance, used as a selectable marker, was not affected by the proximity to the telomeric sequences, either in the presence or absence of drug pressure. In addition, no transcriptional silencing was observed on insertion of the mutant dhfr/ts gene either in subtelomeric or internal positions that are transcriptionally silent in blood-stage parasites. This suggests that the activity of its promoter is not affected by the chromatin organization of the chromosomal context.

The putative gene for gamma-glutamylcysteine synthetase, the rate-limiting enzyme in glutathione biosynthesis, has been characterized both in Plasmodium berghei and Plasmodium falciparum. Protein sequence comparison between these two species reveals large conserved regions sharing more than 80% similarity, separated by less conserved portions. When the comparison is extended to known gamma-glutamylcysteine synthetases from other eukaryotes, a number of high similarity blocks are observed which may help in identifying sequence essential for protein function.

To study efficacy and toxicity of treatments for nephritis in a series of consecutive lupus patients.The case records of 40 patients with lupus nephritis followed up in a single center between 1992 and 2011 (median duration = 8.37 years) were retrieved to determine efficacy and toxicity of the treatments. Patients with class III/IV/V lupus nephritis were included.Sustained responses were 21/40 (52.5%) at six months, 33/40 (82.5%) at 18 months and 30/40 (75.0%) at 36 months. Three deaths were observed after 18, 104 and 164 months of follow-up respectively, with one possibly associated with immunosuppression. Kidney survival was 100% at 18 months and 97.7% at 36 months. Kaplan-Meier's survival algorithm estimated a mean overall survival of 236.05 ± 11.56 months and a kidney survival of 240.77 ± 11.07 months. Kidney and overall survival were not significantly different among patients with different nephritis classes. Complications occurred in 12/40 (30.0%). Amenorrhea occurred in 20.7% of patients and was associated with higher cumulative doses of cyclophosphamide. Patients who achieved remission at 36 months or later had lower levels of proteinuria at 6 months (mean ± SD = 0.93 ± 0.97 g/24 h versus 2.60 ± 2.11 g/24 h, p = 0.002) than non-responder patients.The data demonstrate that in the overall Caucasian population with lupus nephritis the combination of available therapeutic tools is effective and relatively well tolerated.

Walking and jumping procedures were employed to obtain a consensus map of the 35–40 kb subtelomeric region shared by many chromosomal extremities in Plasmodium falciparum strain 3D7, and to characterise the portions flanking the rep20 tract, which is known to contain tandemly repeated, apparently degenerate, 21-bp repeats. The borders of rep20 were shown to harbour short (possibly locally homogenised) patterns of non-degenerate 12-, 17-, 23- and 28-bp repeats. The central repetitious portion of the consensus map was estimated to be about 18 kb in length, and to be separated from the telomere by approx. 11 kb of non-repetitious sequence, maintained with high fidelity at different chromosomal ends. Several kilobases of similarly conserved, non-repetitious sequence flank rep20 on its proximal side. Computer analysis of the rep20 sequence suggested that a peculiar superhelical winding originates from the conservation of identical nucleotide groups in phase with the pitch of the double helix, overcoming the effect of repeat degeneration in other positions of the 21-bp unit.

A previously healthy 69-year-old Italian man presented with ascites and abdominal pain. He had no history of allergy, drug use, smoking, or ethanol abuse. Two months earlier, he was hospitalized for bilateral deep vein thrombosis of the lower limbs with pulmonary embolism. Laboratory tests revealed 23.23 10 white blood cells/L, peripheral blood eosinophilia (PBE; 11.33 10/L), and 75 3 10 platelets/L. He had no risk factors for congenital prothrombosis and no history of travel to geographic areas where helminthic infections are endemic. Cultures of stool for parasites and results from serum analyses for anti-Schistosoma and antiToxoplasma species antibodies or Aspergillus species or cryptococcal antigens were negative. The patient was treated with warfarin and discharged, and hematologic analyses were performed. Fourweeks later, he complained of abdominal enlargement and pain in the left hypochondrium. Physical examination revealed moderate-volume ascites, hepatomegaly without splenomegaly, and enlarged right axillary lymph nodes. Counts of blood cells revealed 8.2 3 10 eosinophils/L (49% white blood cells) and 12.1 g/dL hemoglobin; peripheral blood smear analysis produced normal results. Serum levels of creatinine and results from urinalysis and urinary sediment analysis were normal. Levels of alanine and aspartate aminotransferase, alkaline phosphatase, and g-glutamyltransferase were 127 U/L (normal, 6-55 U/L), 98 U/ L (normal, 5-41 U/L), 329 U/L (normal, 56-199 U/L), and 262 U/L (normal, 11-50 U/L), respectively, whereas serum levels of troponin and tryptase were normal. The erythrocyte sedimentation rate was 24 mm/h (normal, 0-15 mm/h); the level of C-reactive protein was 38 mg/L (normal, 0-6 mg/L), and that of lactate dehydrogenasewas 262U/L (normal, 125-220U/L). Serum levels of vitamins, IgA, IgM, IgG, and IgG subclasses were normal, whereas the total level of IgE was 151 IU/mL (normal, 1-100 IU/mL). The international normalized ratio was 4.95 on oral anticoagulant therapy. Repeated cultures of blood, urine, and stool

Background Highly virulent enterohemorrhagic Escherichia coli O157:H7 strains possess three sodC genes encoding for periplasmic Cu, Zn superoxide dismutases: sodC, which is identical to the gene present in non-pathogenic E. coli strains, and sodC-F1 and sodC-F2, two nearly identical genes located within lambdoid prophage sequences. The significance of this apparent sodC redundancy in E. coli O157:H7 has not yet been investigated. Results We report that strains deleted of one or more sodC genes are less resistant than the wild type strain to a challenge with hydrogen peroxide, thus confirming their involvement in the bacterial antioxidant apparatus. To understand if the different sodC genes have truly overlapping functions, we have carried out a comparison of the functional, structural and regulatory properties of the various E. coli O157:H7 SodC enzymes. We have found that the chromosomal and prophagic sodC genes are differentially regulated in vitro. sodC is exclusively expressed in aerobic cultures grown to the stationary phase. In contrast, sodC-F1 and sodC-F2 are expressed also in the logarithmic phase and in anaerobic cultures. Moreover, the abundance of SodC-F1/SodC-F2 increases with respect to that of SodC in bacteria recovered from infected Caco-2 cells, suggesting higher expression/stability of SodC-F1/SodC-F2 in intracellular environments. This observation correlates with the properties of the proteins. In fact, monomeric SodC and dimeric SodC-F1/SodC-F2 are characterized by sharp differences in catalytic activity, metal affinity, protease resistance and stability. Conclusion Our data show that the chromosomal and bacteriophage-associated E. coli O157:H7 sodC genes have different regulatory properties and encode for proteins with distinct structural/functional features, suggesting that they likely play distinctive roles in bacterial protection from reactive oxygen species. In particular, dimeric SodC-F1 and SodC-F2 possess physico-chemical properties which make these enzymes more suitable than SodC to resist the harsh environmental conditions which are encountered by bacteria within the infected host.

Extensive chromosome size polymorphism arises in Plasmodium berghei during in vivo mitotic multiplication. Size differences between homologous chromosomes involve rearrangements occurring in the subtelomeric portions while internal chromosomal regions do not contribute significantly to chromosome size polymorphism. Differences in the copy number of a 2.3-kb subtelomeric repeated unit are shown to correlate with size variations, and in at least one case to account completely for the size difference between two variants of the same chromosome.

Background IgG4-related disease (IgG4-RD) is a rare fibro-inflammatory condition characterized by expansive lesions, serum IgG4 elevation in the majority of cases, and a prompt response to glucocorticoids (GCs) [1]. The diagnosis of IgG4-RD might be challenging because clinical manifestations are largely non-specific and overlap with other inflammatory and neoplastic conditions. The current gold standard for the diagnosis of IgG4-RD is the identification of characteristic histological features that are strikingly similar across the full range of organs affected. These features include a dense tissue fibrosis with a storiform pattern, a diffuse lymphoplasmacytic infiltrate with abundant IgG4-positive plasma cells, mild to moderate eosinophilia, and obliterative phlebitis [2]. GCs represent the first-line treatment for induction of remission, and typically lead to dramatic clinical responses in the majority of cases with both pancreatic and extra-pancreatic disease [3]. Objectives To describe the clinical features, treatment response and follow-up of a large cohort of Italian patients with IgG4-related disease (IgG4-RD) referred to a single tertiary care centre. Methods Clinical, laboratory, histological and imaging features were retrospectively reviewed. IgG4-RD was classified as “definite” or “possible” according to international consensus guidelines and comprehensive diagnostic criteria for IgG4-RD. Disease activity was assessed by means of the IgG4-RD Responder Index (IgG4-RD RI). Results Forty-one patients (14 females, 27 males) were included in this study, 20 with “definite” IgG4-RD, and 21 with “possible” IgG4-RD. The mean age at disease onset was 62 years. The mean follow-up was 34 months (range 6-83 months). A history of atopy was present in 30% of patients. Pancreas, retroperitoneum, and major salivary glands were the most frequently involved organs. Clinical characteristics of the patients9 cohort at IgG4-RD onset are summerized in table 1. Serum IgG4 were elevated in 68% of cases. Thirty-six patients were initially treated with glucocorticoids for inducing remission. IgG4-RD RI decreased from a mean of 7.8 at baseline to 2.9 after 1 month of therapy. Relapse occurred in 19/36 patients (53%) and required additional immunosuppressive drugs to maintain long-term remission. No further relapses were observed. A single case of orbital pseudotumor did not respond to medical therapy and underwent surgical debulking. Conclusions IgG4-RD is an elusive inflammatory disease to be considered in the differential diagnosis of isolated or multiple tumefactive lesions. Long-term disease control can be achieved with corticosteroids and immunosuppressive drugs in the majority of cases. References Stone JH, Zen Y, Deshpande V. IgG4-related disease. N Engl J Med 2012;366:539–51. Deshpande V, Zen Y, Chan JK, et al. Consensus statement on the pathology of IgG4-related disease. Mod Pathol 2012;25(9):1181-92. Kamisawa T, Okazaki K, Kawa S, et al. Japanese consensus guidelines for management of autoimmune pancreatitis. III. Treatment and prognosis of AIP. J Gastroenterol 2010;45:471-7. Disclosure of Interest None declared

Background Dermatomyositis (DM) and polymyositis (PM) are systemic inflammatory diseases affecting skeletal muscles, skin and variable other organs (1). Steroids are the mainstay of DM and PM therapy, but a first-line immunosuppressive drug like methotrexate (MTX) or azathioprine (AZA) have to be added in case of steroid inefficacy or need of sparing steroids (2). Unfortunately an untrivial fraction of patients maintains active disease despite adequate first-line therapy (3). Second-line treatments utilised for refractory disease are intravenous immunoglobulins (IVIg), rituximab (RTX), cyclosporine (CYC), cyclophosphamide (CTX) and mycophenolate mophetil (MMF). Tacrolimus is a calcineurin inhibitor that has been successfully used in previous reports of interstitial lung disease (ILD) associated with DM/PM; in these patients it demonstrated a good efficacy in muscular involvement too (4-5). Objectives To evaluate efficacy of second-line treatment with tacrolimus for refractory DM and PM. Methods We retrospectivelly studied patients with DM or PM followed at our Center between 2007 and 2011. Tacrolimus has been used if clinically needed only in case of refractoriness to first-line drugs. We have analyzed disease response to therapy of patients treated with tacrolimus as second-line immunosuppressive drug. Results 34 DM or PM patients entered in our study: 21 females and 13 males, median age 57 years. 20 patients suffered of DM ad 14 of PM. All of them received steroid therapy, while 28 needed one o more adjunctive drugs: 21 MTX, 10 AZA, 12 others (MMF, CYC, CTX o RTX) and 4 patients IVIg. 9 of our 34 patients (8 females and 1 male, mean age 41 years) received tacrolimus for disease refractory to steroid and at least one immunosuppressive drug (Fig 1). One of these has PM, while 8 have DM (one case of overlap DM with systemic sclerosis and systemic lupus erythematosus). 6 patients had ILD. 8 of these 9 patients had a satisfactory response to tacrolimus: 5 cases of complete remission (i.e. normalisation of CK, regression of skin involvement without signs of active ILD) and 3 of partial response (i.e. improvement of CK and skin involvement without progressive ILD). The patient suffering of overlap disease did not satisfied these response criteria but achieved disease stability. Severe adverse events were not observed during follow-up. One patient had a transient elevation of creatininemia, and another suffered from mild hand tremors. Conclusions In our patients tacrolimus has shown a good efficacy in DM and PM refractory to first-line immunosuppressive drugs. Considering its good tolerability, we suggest that it may represents the drug of choice in patient resistant or intolerant to first-line immunosuppressive treatments. References Dalakas M.C., Hohlfeld R. Polymyositis and dermatomyositis. Lancet 2003; 362: 971-82. Marie I., Mouthon L. Therapy of polymyositis and dermatomyositis. Autoimmun Rev. 2011; 11(1):6-13. Jaffe M. M., et al. Drug therapy of the idiopathic inflammatory myophaties: predictors of response to prednisone, azathioprine and methotrexate and a comparison of their efficacy. Am J Med 1993; 94: 379-87. Waite E. L., Madhok R. Tacrolimus – a potential therapy for polymyositis? Rheumathology 2009; 48: 858-859. Oddis C. V., et al. Tacrolimus in refractory polymyositis with interstitial lung disease. Lancet 1999; 353:1762-3. Disclosure of Interest None Declared

Background Zinc is an essential element for all living cells. Recent studies have shown that the ZnuABC zinc uptake system significantly contributes to the ability of several pathogens to multiply in the infected host and cause disease, suggesting that zinc is scarcely available within different tissues of the host. To better understand the role of zinc in bacterial pathogenicity, we have undertaken a functional characterization of the role of the ZnuABC-mediated zinc uptake pathway in enterohemorrhagic Escherichia coli O157:H7. Results In this work we have analyzed the expression and the role in metal uptake of ZnuA, the periplasmic component of the ZnuABC transporter, and of ZinT, another periplasmic protein which has been shown to contribute to zinc recruitment. We report that the expression of zinT and znuA, regulated by Zur, is induced in zinc-poor media, and that inactivation of either of the genes significantly decreases E. coli O157:H7 ability to grow in zinc depleted media. We also demonstrate that ZinT and ZnuA have not a redundant function in zinc homeostasis, as the role of ZinT is subordinated to the presence of ZnuA. Moreover, we have found that znuA and zinT are strongly induced in bacteria adhering to cultured epithelial cells and that lack of ZnuA affects the adhesion ability. In addition we have found that a fraction of apo-ZinT can be secreted outside the cell where the protein might sequester environmental zinc, inducing a condition of metal starvation in surrounding cells. Conclusions The here reported results demonstrate that ZnuABC plays a critical role in zinc uptake also in E. coli O157:H7 and that ZinT contributes to the ZnuA-mediated recruitment of zinc in the periplasmic space. Full functionality of the zinc import apparatus is required to facilitate bacterial adhesion to epithelial cells, indicating that the microbial ability to compete with the host cells for zinc binding is critical to establish successful infections. The observation that ZinT can be secreted when it is in the apo-form suggests that its presence in the extracellular environment may somehow contribute to metal uptake or facilitate bacterial colonization of the intestinal epithelia.

Starting from previous evidence indicating that some features are shared by several Plasmodium falciparum chromosomal extremities, a subtelomeric region present on most P. falciparum 3D7 chromosomes has been mapped. It was shown to occupy about 40 kb, and to include the proximal portion of pPftel. 1, the only telomeric clone described for P. falciparum [12], the complete 21-bp repetitive cluster and some conserved sites (PstI, EcoRI) proximally located with respect to this cluster.

Superposition of two unrelated processes, namely terminal reticulocyte differentiation and synchronous plasmodial development, takes place in experimental infections of Plasmodium berghei . The first process is shown to be responsible for the appearance of some discrete restriction bands of host origin when DNA is extracted from leucocyte-free blood containing synchronous parasites at early stages of infection. These discrete DNA fragments cross-hybridise with host cell mitochondrial DNA. Purification steps are suggested to reduce this effect, which might be relevant also in the case of other plasmodial species exhibiting preference for reticulocytes as host cell.

The telomeric sequence cloned from Plasmodium berghei (see M. Ponzi et al. (1985) EMBO J. 4, 2991–2995) was tested for species specificity. A telomeric and a subtelomeric fragment of the cloned insert served as separate, labelled probes on pulsed field gradient electropboretical patterns and on genomic digests from the rodent malarias Plasmodium yoelii, Plasmodium chabaudi and from the human malaria Plasmodium falciparum. Results indicate that the subtelomeric fragment, abundantly represented in two chromosomes of P. berghei, is not present in the other DNA tested, while the telomeric fragment is present in every chromosome-sized molecule in all the species tested. The telomeric location in the other genomes of the sequences homologous to the P. berghei telomeric probe is confirmed by experiments with Ba1 31 exonuclease. In all cases, the TaqI site appears to delimit the common telomeric portion.

At the end of 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak spread from China all around the world, causing thousands of deaths. In Italy, the hardest hit region was Lombardy, with the first reported case on 20 February 2020. San Raffaele Scientific Institute — a large tertiary hospital and research centre in Milan, Italy — was immediately involved in the management of the public health emergency. Since the beginning of the outbreak, the elective surgical activity of the hospital was rapidly reduced and large areas of the hospital were simultaneously reorganised to admit and assist patients with coronavirus disease 2019 (COVID-19). In addition, the hospital became the regional referral hub for cardiovascular emergencies in order to keep ensuring a high level of health care to non-COVID-19 patients in northern Italy. In a few days, a COVID-19 emergency department was created, improving the general ward capacity to a total number of 279 beds dedicated to patients with COVID-19. Moreover, the number of intensive care unit (ICU) beds was increased from 28 to 72 (54 of them dedicated to patients with COVID-19, and 18 to cardiology and cardiac surgery hub emergencies), both converting pre-existing areas and creating new high technology spaces. All the involved health care personnel were rapidly trained to use personal protection equipment and to manage this particular category of patients both in general wards and ICUs. Furthermore, besides clinical activities, continuously important research projects were carried out in order to find new strategies and more effective therapies to better face an unprecedented health emergency in Italy.