The role of skin tests with polyethylene glycol and polysorbate 80 in the vaccination campaign for COVID-19: results from an Italian multicenter survey.

Summary: Background. International guidelines suggested skin tests with Polyethylene-glycol (PEG) and polysorbate 80 (PS-80), to investigate a possible hypersensitivity to these excipients either to identify subjects at risk of developing allergic reactions to Covid-19 vaccines, or in patients with suspected IgE mediated hypersensitivity reactions (HR) to the Covid-19 vaccine. The main purpose of this study was to investigate the prevalence of PEG and PS sensitization in patients with a clinical history of HR to drugs containing PEG/PS and in patients with a suspected Covid-19 vaccine immediate HR. Methods. This was a multicenter retrospective study conducted by allergists belonging to 20 Italian medical centers. Skin testing was performed in 531 patients with either a clinical history of suspected hypersensitivity reaction (HR) to drugs containing PEG and/or PS-80 (group 1:362 patient) or a suspected HR to Covid-19 vaccines (group 2: 169 patient), as suggested by the AAIITO/SIAAIC guidelines for the "management of patients at risk of allergic reactions to Covid-19 vaccines" [1]. Results. 10/362 (0.02%) had positive skin test to one or both excipients in group 1, 12/169 (7.1%) in group 2 (p less than 0.01). In group 2 HRs to Covid-19 vaccines were immediate in 10/12 of cases and anaphylaxis occurred in 4/12 of patients. Conclusions. The positivity of skin test with PEG and or PS before vaccination is extremely rare and mostly replaceable by an accurate clinical history. Sensitization to PEG and PS has to be investigated in patients with a previous immediate HR to a Covid-19 vaccine, in particular in patients with anaphylaxis.

Cross-reactivity and Tolerability of Ertapenem in Patients With IgE-Mediated Hypersensitivity to ß-Lactams.

BACKGROUND AND OBJECTIVE: Administration of carbapenems to ß-lactam-allergic patients has always been considered potentially harmful because of a 47.4% rate of cross-reactivity to imipenem reported in a single study. Nevertheless, recent studies have shown that the rate of cross-reactivity of imipenem and meropenem with penicillins is lower than 1%. The aim of this study was to evaluate the possibility of using ertapenem in patients with an established IgE-mediated ß-lactam allergy. PATIENTS AND METHODS: We studied all participants who came to our allergy unit and had a clinical history of immediate hypersensitivity reactions to ß-lactams. The inclusion criteria were a positive skin test result to at least 1 ß-lactam molecule and/or positive specific IgE (when available). All participants underwent immediate-type skin tests with several ß-lactam molecules including ertapenem. Challenges with intravenous ertapenem were performed on 2 different days in patients with negative skin test results. RESULTS: We examined 49 patients with a clinical history of immediate reactions to ß-lactams. All the patients had positive skin tests and/or positive specific IgE to at least 1 ß-lactam reagent and negative carbapenem skin tests. Thirty-six patients agreed to undergo the challenges and 35 tolerated the full dose of ertapenem. CONCLUSIONS: The practice of avoiding carbapenems in patients with ß-lactam allergy should be abandoned considering the very low rate of cross-reactivity. ß-Lactam-allergic patients who need ertapenem therapy should undergo skin tests and, if negative, a graded challenge to assess tolerability.

Delayed diagnosed intermuscular lipoma causing a posterior interosseous nerve palsy in a patient with cervical spondylosis: the "priceless" value of the clinical examination in the technological era.

BACKGROUND: Posterior interosseous nerve (PIN) palsy may present with various symptoms, and may resemble cervical spondylosis. CASE REPORT: We report about a 59-year-old patient with cervical spondylosis which delayed the diagnosis of posterior interosseous nerve (PIN) palsy due to an intermuscular lipoma. Initial right hand paraesthesias and clumsiness, together with MR findings of right C5-C6 and C6-C7 foraminal stenosis, misled the diagnostic investigation. The progressive loss of extension of all right hand fingers brought to detect a painless mass compressing the PIN. Electrophysiological studies confirmed a right radial motor neuropathy at the level of the forearm. RESULTS: Surgical tumor removal and nerve decompression resulted in a gradual motor deficits recovery. CONCLUSIONS: A thorough clinical examination is paramount, and electrophysiology may differentiate between cervical and peripheral nerve lesions. Ultrasonography and MR offer an effective evaluation of lipomas, which represent a rare cause of PIN palsy. Surgical decompression and lipoma removal generally determine excellent prognoses, with very few recurrences.

Inter-ethnic differences in lymphocyte sensitivity to glucocorticoids reflect variation in transcriptional response.

Glucocorticoids (GCs) are steroid hormones widely used as pharmaceutical interventions, which act mainly by regulating gene expression levels. A large fraction of patients (∼30%), especially those of African descent, show a weak response to treatment. To interrogate the contribution of variable transcriptional response to inter-ethnic differences, we measured in vitro lymphocyte GC sensitivity (LGS) and transcriptome-wide response to GCs in peripheral blood mononuclear cells from African-American (AA) and European-American (EA) healthy donors. We found that transcriptional response after 8 h treatment was significantly correlated with variation in LGS within and between populations. We found that NFKB1, a gene previously found to predict LGS within populations, was more strongly downregulated in EAs on average. NFKB1 could not completely explain population differences, however, and we found an additional 177 genes with population differences in the average log2 fold change (false discovery rate<0.05), most of which also showed a weaker transcriptional response in AAs. These results suggest that inter-ethnic differences in GC sensitivity reflect variation in transcriptional response at many genes, including regulators with large effects (for example, NFKB1) and numerous other genes with smaller effects.

SNP discovery, expression and cis-regulatory variation in the UGT2B genes.

UGT2B enzymes metabolize multiple endogenous and exogenous molecules, including steroid hormones and clinical drugs. However, little is known about the inter-individual variation in gene expression and its determinants. We re-sequenced candidate regulatory regions and the partial coding regions (41.1 kb) of UGT2B genes and identified 332 genetic variants. We measured gene expression in normal breast and liver samples and observed different patterns. The expression levels varied greatly across individuals in both tissues and were significantly correlated with each other in liver. Genotyping of tagging single-nucleotide polymorphisms (SNPs) in the same samples and association tests between genotype and transcript levels identified 62 variants that were associated with at least one UGT2B mRNA levels in either tissue. Most of these cis-regulatory SNPs were not shared between tissues, suggesting that this gene family is regulated in a tissue-specific manner. Our results provide insight into studying the role of UGT2B variation in hormone-dependent cancers and drug response.

Evolutionary adaptations to dietary changes.

Through cultural innovation and changes in habitat and ecology, there have been a number of major dietary shifts in human evolution, including meat eating, cooking, and those associated with plant and animal domestication. The identification of signatures of adaptations to such dietary changes in the genome of extant primates (including humans) may shed light not only on the evolutionary history of our species, but also on the mechanisms that underlie common metabolic diseases in modern human populations. In this review, we provide a brief overview of the major dietary shifts that occurred during hominin evolution, and we discuss the methods and approaches used to identify signals of natural selection in patterns of sequence variation. We then review the results of studies aimed at detecting the genetic loci that played a major role in dietary adaptations and conclude by outlining the potential of future studies in this area.

Prediction of CYP3A4 enzyme activity using haplotype tag SNPs in African Americans.

The CYP3A locus encodes hepatic enzymes that metabolize many clinically used drugs. However, there is marked interindividual variability in enzyme expression and clearance of drugs metabolized by these enzymes. We utilized comparative genomics and computational prediction of transcriptional factor binding sites to evaluate regions within CYP3A that were most likely to contribute to this variation. We then used a haplotype tagging single-nucleotide polymorphisms (htSNPs) approach to evaluate the entire locus with the fewest number of maximally informative SNPs. We investigated the association between these htSNPs and in vivo CYP3A enzyme activity using a single-point IV midazolam clearance assay. We found associations between the midazolam phenotype and age, diagnosis of hypertension and one htSNP (141689) located upstream of CYP3A4. 141689 lies near the xenobiotic responsive enhancer module (XREM) regulatory region of CYP3A4. Cell-based studies show increased transcriptional activation with the minor allele at 141689, in agreement with the in vivo association study findings. This study marks the first systematic evaluation of coding and noncoding variation that may contribute to CYP3A phenotypic variability.

Decompressive craniectomy for medically refractory intracranial hypertension due to meningoencephalitis: report of three patients.

BACKGROUND: Meningoencephalitis may sometimes cause medically refractory intracranial hypertension and brain herniation. In such patients death is common. There are a limited number of reports on the use of decompressive craniectomy as a life saving measure in these circumstances with some good results. The aim of the study was to report experience in three further patients. MATERIALS AND METHODS: In a 15-month period, three patients affected by acute meningoencephalitis were surgically treated by decompressive craniectomy at the Department of Neurosurgery of the Polytechnic University of Ancona. In all patients common symptoms at presentation were headache, fever and neck rigidity, rapidly followed by the development of focal neurological deficits and coma. Intracranial pressure monitoring was always performed and correlated with serial CT scan examinations. Because of the development of severe intracranial hypertension refractory to conventional medical treatment, a decompressive hemicraniectomy was performed in two patients and a bifrontal decompressive craniectomy in the third one. Bacterial meningoencephalitis was diagnosed in two patients, viral meningoencephalitis in the remaining one. FINDINGS: One patient died 3 days after surgery. The remaining two completely recovered consciousness, with no residual focal neurological deficit. CONCLUSIONS: Surgery resulted in an immediate reduction of intracranial pressure in two of the three patients with severe meningoencephalitis. Decompressive craniectomy may be a useful option in the management of a patient with medically refractory intracranial hypertension caused by meningoencephalitis. Early intervention may enhance its benefits.

Adjusting the focus on human variation.

Studies of nuclear sequence variation are accumulating, such that we can expect a good description of the structure of human variation across populations and genomic regions in the near future. This description will help to elucidate the evolutionary forces that shape patterns of variability. Such an understanding will be of general biological interest, but could also facilitate the design and interpretation of disease-mapping studies. Here, we integrate the results from surveys of nuclear sequence variation. When nuclear sequences are considered together with mtDNA and microsatellites, it becomes clear that neither the standard neutral model, nor a simple long-term exponential growth model, can account for all the available human variation data. A possible explanation is that a subset of loci are not evolving neutrally; even so, more-complex models of effective population size and structure might be necessary to explain the data.

Sublingual immunotherapy: from safety to mechanism of action.

Allergen specific immunotherapy is an important option for the treatment of respiratory allergy and its clinical efficacy has been clearly demonstrated by several studies. However, the injective route of administration and the possibility of severe side effects has limited its use in children and led to the introduction of new forms of administration. Sublingual immunotherapy (SLIT) has proven to be an effective and safe treatment for respiratory allergy. However, its mechanism of action is still debated. Pharmacokinetic studies showed that, differently from nasal mucosa, allergen extracts administered by SLIT are not immediately adsorbed but are long retained before being drained to local lymph nodes. This difference may be responsible of the absence of severe side effects and instead of short-lasting local symptoms. Studies by biopsies of the oral mucosa should greatly help in defining the presence and the role of cells involved in the mechanisms of oral tolerance.

Microsatellite mutations and inferences about human demography.

Microsatellites have been widely used as tools for population studies. However, inference about population processes relies on the specification of mutation parameters that are largely unknown and likely to differ across loci. Here, we use data on somatic mutations to investigate the mutation process at 14 tetranucleotide repeats and carry out an advanced multilocus analysis of different demographic scenarios on worldwide population samples. We use a method based on less restrictive assumptions about the mutation process, which is more powerful to detect departures from the null hypothesis of constant population size than other methods previously applied to similar data sets. We detect a signal of population expansion in all samples examined, except for one African sample. As part of this analysis, we identify an "anomalous" locus whose extreme pattern of variation cannot be explained by variability in mutation size. Exaggerated mutation rate is proposed as a possible cause for its unusual variation pattern. We evaluate the effect of using it to infer population histories and show that inferences about demographic histories are markedly affected by its inclusion. In fact, exclusion of the anomalous locus reduces interlocus variability of statistics summarizing population variation and strengthens the evidence in favor of demographic growth.

Excess of rare amino acid polymorphisms in the Toll-like receptor 4 in humans.

The Toll-like receptor 4 protein acts as the transducing subunit of the lipopolysaccharide receptor complex and assists in the detection of Gram-negative pathogens within the mammalian host. Several lines of evidence support the view that variation at the TLR4 locus may alter host susceptibility to Gram-negative infection or the outcome of infection. Here, we surveyed TLR4 sequence variation in the complete coding region (2.4 kb) in 348 individuals from several population samples; in addition, a subset of the individuals was surveyed at 1.1 kb of intronic sequence. More than 90% of the chromosomes examined encoded the same structural isoform of TLR4, while the rest harbored 12 rare amino acid variants. Conversely, the variants at silent sites (intronic and synonymous positions) occur at both low and high frequencies and are consistent with a neutral model of mutation and random drift. The spectrum of allele frequencies for amino acid variants shows a significant skew toward lower frequencies relative to both the neutral model and the pattern observed at linked silent sites. This is consistent with the hypothesis that weak purifying selection acted on TLR4 and that most mutations affecting TLR4 protein structure have at least mildly deleterious phenotypic effects. These results may imply that genetic variants contributing to disease susceptibility occur at low frequencies in the population and suggest strategies for optimizing the design of disease-mapping studies.

Heterogeneity of microsatellite mutations within and between loci, and implications for human demographic histories.

Microsatellites have been widely used to reconstruct human evolution. However, the efficient use of these markers relies on information regarding the process producing the observed variation. Here, we present a novel approach to the locus-by-locus characterization of this process. By analyzing somatic mutations in cancer patients, we estimated the distributions of mutation size for each of 20 loci. The same loci were then typed in three ethnically diverse population samples. The generalized stepwise mutation model was used to test the predicted relationship between population and mutation parameters under two demographic scenarios: constant population size and rapid expansion. The agreement between the observed and expected relationship between population and mutation parameters, even when the latter are estimated in cancer patients, confirms that somatic mutations may be useful for investigating the process underlying population variation. Estimated distributions of mutation size differ substantially amongst loci, and mutations of more than one repeat unit are common. A new statistic, the normalized population variance, is introduced for multilocus estimation of demographic parameters, and for testing demographic scenarios. The observed population variation is not consistent with a constant population size. Time estimates of the putative population expansion are in agreement with those obtained by other methods.

Supratentorial cavernomas in eloquent brain areas: application of neuronavigation and functional MRI in operative planning.

AIM: Cavernomas located in eloquent areas of cerebral hemispheres represent a challenge for the neurosurgeon. An accurate surgical approach is essential to completely remove the lesion with function preservation. Aim of this study was to evaluate the usefulness of integration between standard magnetic resonance imaging (MRI) for neuronavigation and functional MRI (fMRI) in preoperative planning and intraoperative removal of cavernomas. METHODS: Between June 2000 and December 2002, 21 patients underwent surgery for supratentorial subcortical cavernomas. Eleven lesions were located adjacent to eloquent brain areas. All the patients in the series underwent MRI for neuronavigation and, since January 2002, in 6 cases of lesions located in eloquent areas, fMRI was also performed, with subsequent images fusion. The surgical approach was performed via the transgyral route under conventional and ultrasound-guided neuronavigation. RESULTS: All the lesions were totally removed. No morbidity was seen in patients harbouring lesions in non eloquent areas. Four patients with lesions in critical areas suffered transient focal deficits, but only one patient of this series was operated on by the auxilium of image fusion. In 7 patients operated on by conventional image-guided surgery and affected by preoperative seizures, no further seizures were observed after surgery. In 3 patients more hosting lesions neighbouring critical areas, the perilesional ring was not removed, observing persistence of seizures pharmacologically treated. In 4 of the 6 patients (all affected by seizures), operated on by fMRI auxilium, lesion removal was associated to the removal of the perilesional ring. No further epilepsy was seen in these patients. CONCLUSIONS: In all the cases the use of neuronavigation allowed minimally invasive approaches and radical excision of the lesions. Moreover, fMRI seemed to provide important additional information in patients with lesions in eloquent brain areas, allowing a more aggressive approach on the perilesional tissue to the aim of resolving seizures, in absence of an increase in the morbidity rate.

Variability at the uridine diphosphate glucuronosyltransferase 1A1 promoter in human populations and primates.

Variation at the UDP-glucuronosyltransferase (UGT) 1A1 gene promoter is present in humans. Variable numbers of TA repeats in the TATA box of this gene are found which are inversely related to levels of gene expression. We investigated this polymorphism in 658 individuals from a worldwide sample of 15 aboriginal and two admixed human populations. This study shows that there is a great deal of variability across ethnic groups with regard to UGT1A1 allele frequencies, with the most common allele varying in frequency from 33% to 91%. Populations of African origin harbor four different alleles while non-African populations appear to have only two alleles. In addition, alleles associated with lower gene expression levels reach the highest frequencies in populations of African origin and lowest among Asians and Amerindians. Thus, more variability in the metabolism of drugs eliminated by UGT1A1 glucuronidation should be expected in populations of Sub-Saharan African origin. The sequence analysis of nine primate species shows that the number of TA repeats has increased during primate evolution achieving the largest number in humans. We suggest that the UGT1A1 promoter variability does not reflect historical relationships between populations and that it may be maintained by natural selection. Our findings are consistent with the proposal that the TA repeat variation is a balanced polymorphism.

Phenotype-genotype correlation of in vitro SN-38 (active metabolite of irinotecan) and bilirubin glucuronidation in human liver tissue with UGT1A1 promoter polymorphism.

BACKGROUND: Hepatic uridine diphosphate glucuronosyltransferase (UGT) isoform 1A1 (UGT1A1) is primarily responsible for the glucuronidation of SN-38 (7-ethyl-10-hydroxycamptothecin), the active metabolite of the anticancer agent irinotecan. UGT1A1, also catalyzing the glucuronidation of bilirubin, has been shown to have reduced activity in Gilbert's syndrome. The presence of an additional TA repeat [(TA)7TAA] in the TATA sequence of UGT1A1 has been associated with Gilbert's syndrome. OBJECTIVE: To evaluate the relationship between UGT1A1 phenotypic activity and UGT1A1 promoter polymorphism. METHODS: Phenotypic measurements included in vitro SN-38 and bilirubin glucuronidation in human liver microsomes (n = 44). A recently developed genotyping test was used to determine TATA sequence polymorphisms in UGT1A1. Genotypes were assigned as follows: 7/7, homozygous for the (TA)7TAA allele; 6/6, homozygous for the (TA)6TAA allele; and 6/7, heterozygous with 1 of each allele. RESULTS: Nine percent of screened liver samples were found to be homozygous for allele 7 (7/7), 43% were homozygous for allele 6 (6/6), and 48% were heterozygous (6/7). Frequencies of (TA)7TAA and (TA)6TAA alleles were 0.33 and 0.67, respectively. A significant trend toward a decrease in SN-38 and bilirubin glucuronidation rates was found as the number of TA repeats increased (6/6 > 6/7 > 7/7). Glucuronidation rates of both substrates were significantly lower in the 7/7 and 6/7 groups compared with the 6/6 group. CONCLUSIONS: The results indicate a significant association of UGT1A1 phenotype and genotype based on in vitro phenotypic measurements. The clinical significance of our finding remains to be established.

Modulation of cell growth and host protein synthesis during HIV infection in vitro.

During HIV infection of CEM cells cultured in vitro, significant differences in growth rate and protein turnover were observed with different viral preparations. There was a significant inhibition of proliferation after infection with crude HIV supernatants. On the other hand, infection with purified HIV particles obtained by filtration, differential centrifugation, and isopycnic sedimentation led to a progressively increasing stimulation of cell growth. This early stimulation was prevented by neutralizing the virus with soluble CD4 molecules. Study of cell growth in the presence of a purified membrane preparation indicated that membrane fragments contaminating the crude HIV supernatant were responsible for the observed growth inhibition. Interestingly, the stimulation of proliferation was also observed with heat-inactivated virus or after inhibition of viral replication with ZDV. In the presence of purified HIV virions, the rate of general protein synthesis was not inhibited, as is usually observed with crude viral supernatants. However, a marked reduction in protein content and increased protein degradation was found in cultures infected with either crude or purified HIV preparations.

Radial nerve palsy caused by spontaneously occurring nerve torsion. Case report.

An 18-year-old man presented with a spontaneously occurring radial nerve palsy that spared the triceps muscle. At surgery, the portion of the radial nerve located at the midarm level had an hourglass-like appearance. Under magnification, an external-internal neurolysis of the narrowed portion of the hourglass-shaped portion revealed nerve torsion. Straightening of the twisted nerve and fixation accomplished using epiperineurium-fascia stitches to avoid a new torsion resulted in complete functional recovery of the radial nerve.

[Morphological changes of the corpus callosum in schizophrenia]. / Alteraciones morfológicas del corpus callosum en esquizofrénicos.

Morphological brain alterations have long been noted in schizophrenia, although it is unclear whether they are a consequence of an early disturbance in brain development or represent a deterioration of a normal brain structure. The purpose of the present study is to establish a relationship between corpus callosum (CC) surface and perimeter. A female right handed schizophrenic group (n = 31) was compared with a control group (n = 25) of comparable sex, age (range: 40-68 years) and handedness on measures of the CC area from a midsagittal T1 weighted image magnetic resonance imaging. Patients completed DSM IV criteria for Residual Schizophrenia. Patients with a known history of brain injury or neurologic illness were excluded. All had received neuroleptic drugs but no electroconvulsive treatment. Control and schizophrenic groups were subdivided into two age-ranges (E1 < or = 54 years and E2 > 54 years). Mean +/- SE (cm2) of CC surface in controls E < or = 54 and E > 54 were respectively 7.09 +/- 0.42 and 8.97 +/- 0.62 (p < 0.01) and in schizophrenics E < or = 54 and E > 54 were respectively 7.61 +/- 0.24 and 6.60 +/- 0.29 (p < 0.05). Among control and schizophrenic E > 54 sub-groups there were significant differences (p < 0.01). Statistically significant differences among sub-group values were obtained through analysis of variance. Correlation coefficient (r) between age and surface in control and schizophrenic groups were respectively 0.55; p < 0.05 and -0.45; p < 0.02. Our results provide evidence that chronic female schizophrenic patients have diminished CC surface and altered proportionality among surface and perimeter, that increases with age. However, in the control group, there is an increment of corpus callosum surface without altered perimeter proportionality.

[Recurrent laryngeal nerve and inferior thyroid artery. Anatomo-surgical considerations]. / Nervio laringeo recurrente y arteria tiroidea inferior. Consideraciones anatomo-quirúrgicas.

Among the diverse complications of thyroidectomy, it is mostly the cordial sequels from the recurrent laryngeal nerve damage. This is why anatomical and surgical considerations are made upon the vulnerable areas of this nerve and the circumstances in which it is damaged. The relationship between the recurrent laryngeal nerve and the inferior thyroid artery, location most frequently injured, was investigated on 55 adult formulated cadavers. It was found that on the right side in 54.5% the nerve passes behind the artery, in 38.1% it passes in front of it, and between its terminal branches in 7.2%. Regarding the left side, in 67.2% the nerve passes behind the artery, in 27.2% it does so in front of it, and in 5.4% between its terminal branches; being the right nerve more anterior an lateral than the left one which would possibly explain the higher index of nervous damage on this side.