When the Embryo Meets the Endometrium: Identifying the Features Required for Successful Embryo Implantation.

Evaluation of the optimal number of embryos, their quality, and the precise timing for transfer are critical determinants in reproductive success, although still remaining one of the main challenges in assisted reproduction technologies (ART). Indeed, the success of in vitro fertilization (IVF) treatments relies on a multitude of events and factors involving both the endometrium and the embryo. Despite concerted efforts on both fronts, the overall success rates of IVF techniques continue to range between 25% and 30%. The role of the endometrium in implantation has been recently recognized, leading to the hypothesis that both the "soil" and the "seed" play a central role in a successful pregnancy. In this respect, identification of the molecular signature of endometrial receptivity together with the selection of the best embryo for transfer become crucial in ART. Currently, efforts have been made to develop accurate, predictive, and personalized tests to identify the window of implantation and the best quality embryo. However, the value of these tests is still debated, as conflicting results are reported in the literature. The purpose of this review is to summarize and critically report the available criteria to optimize the success of embryo transfer and to better understand current limitations and potential areas for improvement.

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The Impact of Nutritional Therapy in the Management of Overweight/Obese PCOS Patient Candidates for IVF.

Polycystic ovary syndrome (PCOS) is the most common female endocrine disorder, and it has two main pathological aspects: reproductive and metabolic. Overweight/obesity is a risk factor in terms of adverse effects during hormone stimulation, a reduced response to ovulation induction regimens, reduced success of IVF, and an increased risk of obstetric complications. To resolve this vicious cycle of pathological events, weight loss and lifestyle modifications are promising strategies. Among these possible approaches, the consumption of a very-low-calorie ketogenic diet (VLCKD) or Mediterranean diet (MD) represents a valid option. In our study, 84 obese/overweight PCOS patients were recruited to evaluate the effects induced by the VLCKD and MD on weight, hormonal, and metabolic parameters. BMI decreased significantly among the VLKCD patients compared to the MD patients (both presenting p values < 0.0001 at 90 and 120 days), and a significant reduction in body circumference was observed. At the same time, HOMA index values statistically decreased for the VLCKD patients compared to those on the MD (p value < 0.001 at 90 days and p value < 0.05 at 120 days), and this phenomenon was also observed for AFC at 90 and 120 days (both p values < 0.001) and AMH at 90 days (p value < 0.05). Interestingly, the ovarian hyperstimulation syndrome (OHSS) incidence was statistically lower in the VLKCD patients compared to the MD patients (p < 0.001). We state that these dietary regimes may improve anthropometric parameters (such as BMI) and women's reproductive health, restore menstrual regularity, and reduce the risk of OHSS. Regarding the different nutritional therapies, the results suggest that the VLCKD is an optimal choice for entry into IVF, especially in terms of the time range in which these results are achieved.

Glyphosate-induced glioblastoma cell proliferation: Unraveling the interplay of oxidative, inflammatory, proliferative, and survival signaling pathways.

The aim of the present study was to investigate the impacts of glyphosate herbicide on the survival and proliferation of glioblastoma cells and to explore the molecular mechanisms underlying such effects. For this, cultured human glioblastoma cell line, A172, was exposed to the glyphosate analytical standard, a glyphosate-based herbicide formulation (GBH), or the metabolite aminomethylphosphonic acid (AMPA). The three compounds induced A172 cytotoxicity after 24 h of exposure, with more prominent cytotoxic effects after 48 and 72 h of treatment. Further experiments were performed by treating A172 cells for 6 h with glyphosate, GBH, or AMPA at 0.5 mg/L, which corresponds to the maximum residue limits for glyphosate and AMPA in drinking water in Brazil. Colony forming units (CFU) assay showed that AMPA increased the number of CFU formed, while glyphosate and GBH increased the CFU sizes. The three compounds tested altered the cell cycle and caused DNA damage, as indicated by the increase in γ-H2AX. The mechanisms underlying the pesticide effects involve the activation of Akt and mitogen-activated protein kinases (MAPKs) signaling pathways, oxidative imbalance, and inflammation. Glyphosate led to NLRP3 activation culminating in caspase-1 recruitment, while AMPA decreased NLRP3 immunocontent and GBH did not alter this pathway. Results of the present study suggest that exposure to glyphosate (isolated or in formulation) or to its metabolite AMPA may affect cell signaling pathways resulting in oxidative damage and inflammation, giving glioblastoma cells an advantage by increasing their proliferation and growth.

The Impact of Parkinson's Disease on General and Specific Motor Aptitudes: A Study of Older Brazilian Adults.

This study investigated motor aptitude in older adults with and without Parkinson's disease (PD) to further specify known motor-related changes of PD. We divided 671 older adults (23.5% male; Mage = 69.6, SD = 6.6 years) into a Parkinson's Disease Group (PDG) and a non-Parkinson's Disease Group (NPG) and assessed their general motor aptitude (GMA) and their specific motor aptitudes (in Coordinative, Proprioceptive, and Perceptive domains) using the Motor Scale for Older Adults. We used the chi-squared tests and logistic regression to identify and affirm an associations between PD and motor aptitude, we found that most adults without PD showed normal motor aptitude (GMA: 80.7%; Proprioceptive: 82.3%; Perceptive: 81.4%) except for the Coordinative skills, for which 56.4% of these participants had motor impairment. Most partipants with PD showed motor impairments (GMA: 94.7%; Coordinative: 97.4%; Proprioceptive: 97.4%), except in the Perceptive domain, for which 68.4% of participants with PD showed normal aptitude. There were significant associations between PD and GMA (OR = 127.6), Coordinative motor skills (OR = 48.0), and Proprioceptive skills (OR = 204.4), even after the model was adjusted for gender and age. Our use of the Motor Scale for Older Adults in contrasting groups of older Brazilian adults provides further specificity to the motor aptitude characteristics of older adults with PD.

Effect of High-Titer Convalescent Plasma on Progression to Severe Respiratory Failure or Death in Hospitalized Patients With COVID-19 Pneumonia: A Randomized Clinical Trial.

Importance: Convalescent plasma (CP) has been generally unsuccessful in preventing worsening of respiratory failure or death in hospitalized patients with COVID-19 pneumonia. Objective: To evaluate the efficacy of CP plus standard therapy (ST) vs ST alone in preventing worsening respiratory failure or death in patients with COVID-19 pneumonia. Design, Setting, and Participants: This prospective, open-label, randomized clinical trial enrolled (1:1 ratio) hospitalized patients with COVID-19 pneumonia to receive CP plus ST or ST alone between July 15 and December 8, 2020, at 27 clinical sites in Italy. Hospitalized adults with COVID-19 pneumonia and a partial pressure of oxygen-to-fraction of inspired oxygen (Pao2/Fio2) ratio between 350 and 200 mm Hg were eligible. Interventions: Patients in the experimental group received intravenous high-titer CP (≥1:160, by microneutralization test) plus ST. The volume of infused CP was 200 mL given from 1 to a maximum of 3 infusions. Patients in the control group received ST, represented by remdesivir, glucocorticoids, and low-molecular weight heparin, according to the Agenzia Italiana del Farmaco recommendations. Main Outcomes and Measures: The primary outcome was a composite of worsening respiratory failure (Pao2/Fio2 ratio <150 mm Hg) or death within 30 days from randomization. Results: Of the 487 randomized patients (241 to CP plus ST; 246 to ST alone), 312 (64.1%) were men; the median (IQR) age was 64 (54.0-74.0) years. The modified intention-to-treat population included 473 patients. The primary end point occurred in 59 of 231 patients (25.5%) treated with CP and ST and in 67 of 239 patients (28.0%) who received ST (odds ratio, 0.88; 95% CI, 0.59-1.33; P = .54). Adverse events occurred more frequently in the CP group (12 of 241 [5.0%]) compared with the control group (4 of 246 [1.6%]; P = .04). Conclusions and Relevance: In patients with moderate to severe COVID-19 pneumonia, high-titer anti-SARS-CoV-2 CP did not reduce the progression to severe respiratory failure or death within 30 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04716556.

Electrolytes, albumin and acid base equilibrium during laparoscopic surgery.

BACKGROUND: Surgery, causing inflammation, disrupts endothelial permeability leading to movement of fluids and albumin across the vascular barrier. Fluid therapy for restoring circulatory homeostasis may lead to positive fluid balance which has been shown to increase morbidity and mortality in surgical patients. The current investigation aims to describe physio-pathological changes in circulating albumin, fluid and electrolyte balance, and acid-base equilibrium in a cohort of patients undergoing laparoscopic surgery under general anesthesia. METHODS: Single-center prospective observational study. Patients undergoing laparoscopic colorectal surgery were screened for eligibility. Before surgery, the baseline fasting conditions were homogenized. Hemoglobin, urinary and plasmatic were collected before surgery and then at pre-defined timepoints. Albumin/creatinine ratio was measured before and after surgery. Expected and actual circulating Sodium concentrations were compared according to a physiological theoretical model. Assessment and quantification of changes in major electrolytes, albumin and acid-base balance was defined as the primary outcome of the study. RESULTS: Thirty-eight patients were enrolled in the protocol. Patients had a positive electrolytes (Na+ 295 [244-375] mmol, Cl- 234 [195-295] mmol, K+ 16.8 [12.0-21.4] mmol) and fluid balance (2165 [1727-2728] mL). The positive fluid balance was associated with stable chloride (105 [103-107], end study vs. 103 [102-106] mmol/L, baseline, P not significant) and potassium (4.2 [3.8-4.4], end study vs. 4.1 [3.6-4.4] mmol/L, baseline, P not significant) levels, but sodium concentrations decreased over time (138 [137-140], end study vs. 139 [138-141] mmol/L, baseline, P<0.05). The albumin/creatinine ratio was higher at the end of surgery 134 [61-267] vs. 7 [4-14], P<0.001). CONCLUSIONS: Data from patients undergoing colorectal laparoscopic surgery showed a positive fluid balance, decreased circulating albumin and increased albuminuria. A positive sodium balance was not always associated with an increase in sodium plasma concentration.

Apneic Tracheostomy in COVID-19 Patients on Veno-Venous Extracorporeal Membrane Oxygenation.

COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory failure calling for an extracorporeal approach (veno-venous ECMO). In this scenario, most of these patients need an early tracheostomy procedure to be carried out, which creates the risk of distribution of aerosol particles, possibly leading to personnel infection. The use of apneic tracheostomy has been proposed for COVID-19 patients, but in case of ECMO it may produce lung derecruitment, severe hypoxemia, and sudden worsening of respiratory mechanics. We developed an apneic tracheostomy technique and applied it in over 32 patients supported by veno-venous ECMO. We present data showing the safety and feasibility of this technique in terms of patient care and personnel protection. Gas exchange and pH did not show statistically significant changes after the tracheostomy, nor did respiratory mechanics data or the need for inspiratory pressure and FiO2. The use of apneic tracheostomy was a safe option for patient care during ECMO and reduced the possibility of virus spreading.

Effects of postnatal ethanol exposure and maternal separation on mood, cognition and hippocampal arborization in adolescent rats.

Ethanol exposure and early life stress during brain development are associated with an increased risk of developing psychiatric disorders. We used a third-trimester equivalent model of fetal alcohol spectrum disorders combined with a maternal separation (MS) protocol to evaluate whether these stressors cause sexually dimorphic behavioral and hippocampal dendritic arborization responses in adolescent rats. Wistar rat pups were divided into four experimental groups: 1) Control; 2) MS (MS, for 3 h/day from postnatal (PND) 2 to PND14); 3) EtOH (EtOH, 5 g/kg/day, i.p., PND2, 4, 6, 8, and 10); 4) EtOH + MS. All animals were divided into two cohorts and subjected to a battery of behavioral tests when they reached adolescence (PND37-44). Animals from cohort 1 were submitted to: 1) the open field test; 2) self-cleaning behavior (PND38); and 3) the motivation test (PND39-41). Animals from cohort 2 were submitted to: 1) the novel object recognition (PND37-39); 2) social investigation test (PND40); and 3) Morris water maze test (PND41-44). At PND45, the animals were euthanized, and the brains were collected for subsequent dendritic analysis. Postnatal ethanol exposure (PEE) caused anxiety-like behavior in females and reduced motivation, and increased hippocampal dendritic arborization in both sexes. MS reduced body weight, increased locomotor activity in females, and increased motivation, and hippocampal dendritic arborization in both sexes. We found that males from the EtOH + MS groups are more socially engaged than females, who were more interested in sweets than males. Altogether, these data suggest that early life adverse conditions may alter behavior in a sex-dependent manner in adolescent rats.

Saneamento básico inadequado impacta no desenvolvimento infantil / Inadequate sanitation impacts child development

O objetivo desta pesquisa foi avaliar o desenvolvimento motor de pré-escolares, associando o impacto das condições socioambientais no desenvolvimento motor. Foram avaliadas 342 crianças entre três e quatro anos de idade (36 a 57 meses) de duas regiões distintas: 203 escolares em uma cidade do sul do Brasil e 139 em um município nordestino. O protocolo utilizado para identificar as disfunções motoras (dispraxias) nas áreas da coordenação (fina e global); propriocepção (equilíbrio e esquema corporal); e percepção (organização espacial e temporal) foi a Escala de Desenvolvimento Motor ­ EDM. Os dados relacionados ao saneamento básico foram extraídos de documentos oficiais reconhecidos nacionalmente. Foram encontradas diferenças significativas no desenvolvimento das crianças entre os dois municípios. Os resultados mostram maior prevalência de transtornos motores no município do nordeste, totalizando 40 crianças (28,8%); enquanto no Sul, 26 crianças (12,8%) apresentaram déficits. Todos os dados que se referem ao saneamento básico e índices sociais, encontrados na literatura específica, foram inferiores na cidade nordestina quando comparados ao município da região sul. O presente estudo mostra que carências nas condições socioambientais podem impactar negativamente o desenvolvimento motor de pré-escolares, aumentando a prevalência das dispraxias.

The aim of this research was to assess the motor development in preschoolers, associating the impact of socio-environmental conditions in motor development. A total of 342 children between the ages of 3 and 4 years (36 to 57 months) from two distinct parts of Brazil participated in the study: 203 from a city in the south of Brazil and 139 in a northeast city. The tool used to identify motor dysfunction (dyspraxia) in motor coordination (fine and global), proprioception (balance and body scheme), and perception (spatial and temporal organization) was the Motor Development Scale - MDS. Data related to basic sanitation were extracted from official documents. Significant differences were found between children in the two cities. Results show a higher prevalence of motor dysfunction in the northeast city (total of 40 children - 28.8%), while in the south, 26 children (12.8%) had deficits. All data referring to basic sanitation and social indexes, found in the specific literature, were lower in the northeastern city when compared to the city of the southern region. The present study shows that deficiencies in social and environmental conditions can negatively impact motor development of preschoolers, increasing the prevalence of dyspraxia.

The role of endoscopy as non-invasive procedure to manage gastrointestinal complications during extracorporeal membrane oxygenation.

INTRODUCTION: Gastrointestinal bleeding is a life-threatening complication in patients undergoing extracorporeal membrane oxygenation support. Despite data on increased mortality due to gastrointestinal bleeding, there is little data on the treatment of such conditions under extracorporeal membrane oxygenation, and on the possibilities of advanced endoscopic therapy to non-invasively solve these bleeding complications. No clear treatment in the case of extracorporeal membrane oxygenation support is recommended in the guidelines. METHODS: Retrospective observational cohort study including 134 veno-venous extracorporeal membrane oxygenation patients for acute respiratory failure from 2009 to 2018 at IRCCS-ISMETT (Italy). Patients were divided into two groups according to gastrointestinal bleeding episodes and reviewed for type of endoscopic therapy. Gastrointestinal bleeding group was characterized for pre-extracorporeal membrane oxygenation characteristics, management variables-including amount of transfusions and clinical outcomes. RESULTS: Fourteen (14) patients (10.4%) experienced upper (n = 13) or lower (n = 1) gastrointestinal bleeding. Gastrointestinal bleeding and no-gastrointestinal bleeding group had similar characteristics apart from higher creatinine in the gastrointestinal bleeding group (1.9 mg/dL (1.3-4.9) vs 1.2 mg/dL (0.7-1.8), p = 0.03). In 3 of the 14 patients (21%), endoscopy showed no signs of active bleeding (nasogastric or feeding tube decubitus), and no specific intervention was performed. Active bleeding was recognized in 11 of the 14 patients (79 %). No patients died of fatal bleeding in the gastrointestinal bleeding group. Endoscopic therapy was feasible, with a complete bleeding control in all the cases: five Hemospray®, two fibrin glue, two metallic clips, one combined approach metallic clips with epinephrine, and one cyanoacrylate. The extracorporeal membrane oxygenation course was significantly longer in the gastrointestinal bleeding group: 19.5 (15-36) days vs 13.5 (8-25) days, p = 0.01. No significant differences in mortality were found between the two groups (all p values > 0.05). CONCLUSION: Advanced endoscopic therapy during veno-venous extracorporeal membrane oxygenation may contribute to reducing the negative effects on mortality for gastrointestinal bleeding episodes.

Antidepressant Effects of Probucol on Early-Symptomatic YAC128 Transgenic Mice for Huntington's Disease.

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder caused by a trinucleotide expansion in the HD gene, resulting in an extended polyglutamine tract in the protein huntingtin. HD is traditionally viewed as a movement disorder, but cognitive and neuropsychiatric symptoms also contribute to the clinical presentation. Depression is one of the most common psychiatric disturbances in HD, present even before manifestation of motor symptoms. Diagnosis and treatment of depression in HD-affected individuals are essential aspects of clinical management in this population, especially owing to the high risk of suicide. This study investigated whether chronic administration of the antioxidant probucol improved motor and affective symptoms as well as hippocampal neurogenic function in the YAC128 transgenic mouse model of HD during the early- to mild-symptomatic stages of disease progression. The motor performance and affective symptoms were monitored using well-validated behavioral tests in YAC128 mice and age-matched wild-type littermates at 2, 4, and 6 months of age, after 1, 3, or 5 months of treatment with probucol (30 mg/kg/day via water supplementation, starting on postnatal day 30). Endogenous markers were used to assess the effect of probucol on cell proliferation (Ki-67 and proliferation cell nuclear antigen (PCNA)) and neuronal differentiation (doublecortin (DCX)) in the hippocampal dentate gyrus (DG). Chronic treatment with probucol reduced the occurrence of depressive-like behaviors in early- and mild-symptomatic YAC128 mice. Functional improvements were not accompanied by increased progenitor cell proliferation and neuronal differentiation. Our findings provide evidence that administration of probucol may be of clinical benefit in the management of early- to mild-symptomatic HD.

Total cellular HIV-1 DNA decreases after switching to raltegravir-based regimens in patients with suppressed HIV-1 RNA.

BACKGROUND: The integrase inhibitor raltegravir has been used to intensify antiretroviral therapy in patients with undetectable plasma HIV-1RNA, resulting in variable perturbation of HIV-1 nucleic acids levels in peripheral blood. OBJECTIVES: We aimed at monitoring residual plasma HIV-1RNA and total cellular HIV-1DNA in virologically suppressed patients switching to raltegravir-based regimens. STUDY DESIGN: Fifty-eight subjects on protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens, with plasma HIV-1RNA levels <40 copies/ml for ≥6 months and CD4 counts >200cells/µl for ≥12 months were enrolled. Thirty-four patients were from the treatment simplification RASTA randomized study switching standard therapy to a raltegravir-based regimen (RASTA group), while 24 continued a PI or NNRTI based-regimen (controls). Residual plasma HIV-1RNA (5-40copies/mL) and HIV-1DNA were assessed at 0, 24 and 48 weeks. RESULTS: At week 0 (W0), HIV-1DNA was detected in all patients while at W48 it was detectable in 82.4% of the RASTA group vs 100% of controls (p=0.03). There was a significant decline of HIV-1DNA at W48 in the RASTA group (mean change from baseline -0.21 [95% CI -0.41; -0.01] log10 copies/106 CD4; p=0.03) but not in controls. Ultrasensitive HIV-1RNA was detectable at baseline in 50% of RASTA group vs 67% of controls and at W48 in 32.4% vs 42%, respectively. No differences were found between HIV-1RNA levels at baseline and W48 within and between groups. CONCLUSIONS: Switching successful therapy to raltegravir-based regimens may be associated with a decrease of the HIV-1 reservoir, as measured by peripheral blood cellular HIV-1DNA levels.

Switch to raltegravir-based regimens and HIV DNA decrease in patients with suppressed HIV RNA.

INTRODUCTION: Raltegravir intensification is associated with an increase in 2-LTR episomal HIV DNA= circles, indicating a persistent low-level replication, in some individuals in ART with suppressed HIV RNA. We aimed at monitoring residual plasma HIV RNA and cellular HIV DNA in virologically suppressed patients switching to a raltegravir-based regimen. MATERIALS AND METHODS: Forty-six HIV-infected subjects on PI or NNRTI based-regimens, with plasma HIV RNA level <40 copies/mL for ≥6 months and CD4 >200 cells/µL for ≥12 months were enrolled. Thirty-four patients switched to raltegravir-based regimen (RASTA study group) and 12 continued a PI or NNRTI based-regimen (control group). Ultrasensitive HIV residual viremia and total PBMC HIV DNA were assessed at baseline (W0), 24 (W24) and 48 (W48) weeks. HIV RNA levels were determined by an ultrasensitive test derived from a commercial real time PCR (limit of detection 5 copies/ml). A real time PCR was used to quantify HIV DNA copy numbers in PBMCs. RESULTS: At W0, HIV DNA was detected in all patients while at W48 it was detectable in 82.3% of RASTA group vs 100% of controls (p=0.01). The difference between the average values of HIV DNA log10 copies/10°6 CD4 at W0 (median 3.11, IQR 2.70-3.45) and W48 (median 2.87, IQR 2.24-3.38) was statistically significant for RASTA group (p=0.035). Male gender (mean difference -0.37 log10 copies/10°6 PBMC, p=0.023) and previous PI based-ART (mean difference +0.39 log10 copies/10°6 PBMC, p=0.036) were predictive of HIV DNA level at W0. After adjusting for previous PI based-ART, male gender was the only variable independently associated with HIV DNA size at W0 (mean difference -0.326 log10 copies/10°6 PBMC, 95% CI -0.641, -0.011 p=0.043). Ultrasensitive HIV-1 RNA was detectable at W0 in 50% of RASTA group versus 66.7% of controls and at W48 in 32.4% versus 45.5%, respectively. No differences were found between HIV RNA levels at W0 and W48 within and between the two groups. CONCLUSIONS: Switching to raltegravir-based regimens may be associated with a decrease of HIV reservoir, as measured by total PBMC HIV DNA. A larger sample size is required to confirm this finding.

Bone mineral density improvement after 48 weeks of switch to maraviroc+darunavir/ritonavir 300/800/100 mg QD, preliminary results of GUSTA study.

INTRODUCTION: Low bone mineral density (BMD) and osteoporosis are prevalent in HIV-infected patients and were associated with HIV infection and tenofovir-containing ART. MATERIALS AND METHODS: The GUSTA study (GUided Simplification with Tropism Assay) is a two-arm, prospective, multicenter, 1:1 randomized controlled trial designed to demonstrate the non-inferiority of therapeutic switch to maraviroc+darunavir/ritonavir (MVC+DRV/r) 300/800/100 mg QD against the continuation of previous triple cART in patients with stable virological suppression. Enrolment criteria include HIV1-RNA <50 copies/mL for >6 months, R5 tropism and CD4>200 cells/µL for >3 months. Dual energy X-ray absorptiometry scans of proximal femur and lumbar spine were performed at baseline and week 48. Bone composition was evaluated using L2-L4 lumbar column and proximal femoral BMD, T-score and the Z-score. At the same timepoints, plasma bone metabolism biomarkers were measured. Linear regression was used to compare means of differences between arms. The association between BMD changes and the baseline variables was assessed by linear regression. RESULTS: 27 patients were included, 13 from study group and 14 from control group, 74.1% were males, 44.4% heterosexuals, 81.5% Caucasian, median age was 47 years (IQR 41-53), time from HIV diagnosis 13.4 years (9-19), CD4 553/µL (406-739), nadir CD4 201/µL (76-283). At baseline, median ART duration was 10.5 years (5.7-15.3), the majority of patients (70.4%) was on tenofovir, 63% was on a PI-based regimen and 14,8% on an NNRTI-based regimen. Mean proximal femur BMD from baseline increased over 48 weeks by 2.06% (SD 2.24) in the study arm and decreased by -2.77% (SD 4.63) in control arm (p=0.003). The change over 48 weeks in proximal femur T-score was significantly different between the study (+0.11, SD 0.22) and control arm (-1.14, SD 0.27, p=0.016). Also the changes in total alkalin phosphatase (-20 U/L vs -1.5, p=0.003) was significant between the two groups. After adjusting for time from HIV diagnosis and years of ART, study group was the only factor associated to higher mean percentage change from baseline femoral BMD (MVC+DRV/r +4.83, p=0.044). CONCLUSIONS: The study demonstrated a significant improvement in femoral BMD and T-score after treatment simplification with MVC+DRV/r.

Safety and therapeutic efficacy of the switch to maraviroc+darunavir/ritonavir in HIV/HCV coinfected patients: initial results from GUSTA study.

INTRODUCTION: HIV/HCV coinfection is a risk factor for hepatic injury in patients receiving HAART and previous studies support a favourable effect of antiretroviral regimens including maraviroc (MVC) on the course of coinfection compared with other antiretroviral drugs. There are few observations about MVC use in simplified treatment of coinfected patients. OBJECTIVE: To evaluate the efficacy and the safety of simplification to darunavir (DRV)/ritonavir (r)/maraviroc (MVC) in virologically HIV-suppressed patients and to explore the effect of simplified treatment on coinfected patients. MATERIAL AND METHODS: GUSTA study is a randomized two arms trial that compares the switch to DRV/r/MVC with standard HAART with three drugs. The study enrols patients with HIV-1 RNA<50cp/mL>6 months, R5 tropism, CD4>200 cells/mm. Survival analysis was used to analyze factors associated to time-to a single viral load (VL) over 50cp/mL and FIB-4>1.45. RESULTS: We included 62 patients with at least the 24 week follow-up for FIB-4 analysis: males 75.8%, heterosexuals 48.4%, HCV+12.9% median age 48.3 years (IQR41.1;53.5), time from HIV diagnosis 11.0 years (IQR7.3;16.7), CD4 cells 659/mm (IQR478;882), nadir CD4 203/mm (IQR115;286), FPR 46 (IQR30;70), baseline (BL) FIB-4 1.11 (IQR0.75;1.35). At BL no differences were observed in the two arms, except for platelets (-34.96 109/L, in the study arm, p=0.028) and CD4 at nadir (-70cell/µL, p0.051). After 24 weeks a significant reduction in total bilirubin (TB) (-0.55 mg/dL, p=0.025) and alkaline phosphatase(AP) (-12.96 UI/L, p=0.002) was observed in the study group. A statistically significant difference in mean change of TB (0.61 mg/dL, p=0.016) and AP (13.23 UI/L, p=0.04) at 24 week between control and study group was observed. No grade 3/4 transaminase elevation was observed for any patient even if HIV/HCV coinfected and receiving MVC. A single HCV negative patient in the control arm had grade 3 bilirubin increase. Including all patients with at least one follow-up HCV status was not associated with an increased risk of detectable VL (n=114, 4072 person-week-follow-up [IQR12;51.6]), nor with FIB-4>1.45 (n=98, 3513 person-week-follow-up [IQR11.4;50.9]). CONCLUSIONS: The initial results from GUSTA study show that ART-regimen including MVC did not increase the incidence of adverse events or severe laboratory liver abnormalities in HIV-1-infected patients with or without HCV coinfection. Coinfected patients did not show an increased risk of failure on simplification treatment with MVC/DRV/r.

First report of spondylodiscitis due to vancomycin heteroresistant Staphylococcus capitis in immunocompetent host.

We report a successfully treated case of spondylodiscitis and bloodstream infection due to vancomycin heteroresistant Staphylococcus capitis, in an adult immunocompetent patient with multiple antibiotics intolerance. S. capitis is rarely involved in osteomyelitis and, to our knowledge, this is the first report of vancomycin heteroresistance phenomenon in an S. capitis strain causing spondylodiscitis.

Treatment of HCV infection with the novel NS3/4A protease inhibitors.

HCV NS3/4A serine protease inhibitors are the first class of direct acting antivirals (DAA) introduced in clinical practice. The first generation agents, selective against HCV genotype 1, are used in association with pegylated interferons and ribavirin allowing increased cure rates at the price of increased toxicity, significant drug interactions and high risk of selecting mutants conferring cross-resistance to the entire class. A large number of second-wave HCV protease inhibitors are currently in clinical development. Advancements include higher potency, activity against a wider number of genotypes, improved tolerability, easier dosing schedules, although their genetic barrier to resistance remains low, especially for subtype 1a, except for the most recent grazoprevir and ACH-2684. The most relevant progress regards the combination with other classes of DAA allowing construction of interferon-free regimens of short duration, good tolerability with exceptionally high cure rates.

Longitudinal analysis of HIV-1 coreceptor tropism by single and triplicate HIV-1 RNA and DNA sequencing in patients undergoing successful first-line antiretroviral therapy.

OBJECTIVES: Maraviroc has been shown to be effective in patients harbouring CCR5-tropic HIV-1. While this CCR5 antagonist has initially been used in salvage therapy, its excellent safety profile makes it ideal for antiretroviral treatment simplification strategies in patients with suppressed plasma viraemia. The aim of this study was to compare HIV-1 tropism as detected in baseline plasma RNA and peripheral blood mononuclear cell (PBMC) DNA prior to first-line therapy and to analyse tropism evolution while on successful treatment. METHODS: HIV-1 tropism was determined using triplicate genotypic testing combined with geno2pheno[coreceptor] analysis at a 10% false positive rate in 42 patients. Paired pre-treatment plasma RNA and PBMC DNA and two subsequent PBMC DNA samples (the first obtained after reaching undetectable plasma HIV-1 RNA and the second after at least 2 years of suppression of plasma viraemia) were evaluated. RESULTS: Coreceptor tropism was completely concordant in paired pre-treatment RNA and DNA, with 26.2% of HIV-1 sequences predicted to be non-CCR5-tropic. During follow-up, coreceptor tropism switches were detected in 4 (9.5%) patients without any preferential direction. Although false positive rate discrepancies within triplicates were common, the rate of discordance of coreceptor tropism assignment among triplicate results in this mostly CCR5-tropic dataset was only 2.1%, questioning the added value of triplicate testing compared with single testing. CONCLUSIONS: HIV-1 coreceptor tropism changes during virologically successful first-line treatment are infrequent. HIV-1 DNA analysis may thus support the choice of a CCR5 antagonist in treatment switch strategies; however, maraviroc treatment outcome data are required to confirm this option.

Virological and immunological response to antiretroviral regimens containing maraviroc in HIV type 1-infected patients in clinical practice: role of different tropism testing results and of concomitant treatments.

We assessed the immunovirological response to antiretroviral regimens containing maraviroc in HIV-infected viremic patients with viral tropism predicted by different assays. We selected antiretroviral treatment-experienced HIV-1-infected patients initiating regimens containing maraviroc after different phenotypic or genotypic viral tropism assays, with at least one HIV-1 RNA determination during follow-up. Survival analysis was employed to assess the virological response as time to HIV-1 RNA <50 copies/ml and immunological response as time to a CD4 cell count increase of ≥ 100/µl from baseline. Predictors of these outcomes were analyzed by multivariate Cox regression models. In 191 treatments with maraviroc, virological response was achieved in 65.4% and the response was modestly influenced by the baseline viral load and concomitant drug activity but not influenced by the type of tropism assay employed. Immunological response was achieved in 58.1%; independent predictors were baseline HIV-1 RNA (per log10 higher: HR 1.29, 95% CI 1.05-1.60) and concomitant therapy with enfuvirtide (HR 2.05, 0.96-4.39) but not tropism assay results. Of 17 patients with baseline R5-tropic virus and available tropism results while viremic during follow-up on maraviroc, seven (41%) showed a tropism switch to non-R5 virus. A significant proportion of experienced patients treated with regimens containing maraviroc achieved virological response. The tropism test type used was not associated with immunovirological response and concomitant treatment with enfuvirtide increased the chance of immunological response. More than half of virological failures with maraviroc were not accompanied by tropism switch.