In this paper, we investigate the wellposedness of the non-isentropic compressible Navier-Stokes/Allen-Cahn system with the heat-conductivity proportional to a positive power of the temperature. This system describes the flow of a two-phase immiscible heat-conducting viscous compressible mixture. The phases are allowed to shrink or grow due to changes of density in the fluid and incorporates their transport with the current. We established the global existence and uniqueness of strong solutions for this system in 1-D, which means no phase separation, vacuum, shock wave, mass or heat or phase concentration will be developed in finite time, although the motion of the two-phase immiscible flow has large oscillations and the interaction between the hydrodynamic and phase-field effects is complex. Our result can be regarded as a natural generalization of the Kazhikhov-Shelukhin’s result ([Kazhikhov-Shelukhin. J. Appl. Math. Mech. 41 (1977)]) for the compressible single-phase flow with constant heat conductivity to the non-isentropic compressible immiscible two-phase flow with degenerate and nonlinear heat conductivity.

Obituary PBC Dr Pat Morris JonesDr Morris Jones who was President of SIOP in 1980/81 died on March 16 2020 at the age of 87. She was one of the first doctors in the UK to specialise in the care of children with cancer and over her 40 year career from 1953 to 1993 she saw survival rates improve from cancer being mainly a fatal disease to one where there was a real chance of cure with more than half of children surviving. She was an only child ,born in Oswestry ,close to the border with Wales. She trained in medicine at the Royal Free Medical School in London and found her way to Manchester to specialise in paediatrics. There she came under the influence of Basil Marsden, a paediatric pathologist and Dr Dorothy Pearson a radiotherapist. In 1954 Marsden had established the world’s first population based children’s malignant disease registry which became a prototype for registries all over the world. Dr Pearson was a founding member of SIOP and its second president. In the late 50s and early 60s the only real treatments available were surgery and radiotherapy but the emerging success of chemotherapy pioneered in the US, France and Germany led to a need for paediatricians to sub specialise in paediatric oncology. By the time Pat became involved the antagonism towards giving children chemotherapy had largely dissipated but how to use it to best advantage remained to be determined. She took up this challenge and built up one of the largest units in the UK. For many years she was single handed and absolutely dedicated to the care of children. She rarely took a day off. . Before people were talking about evidence based medicine she was adamant that treatment should be given in trials where we could learn what was best for the future. She was especially interested in Wilms’ tumour and very involved in the Medical Research Council embryonal tumour group and in the MRC UKALL trials. In 1977 she helped found the UK Children’s Cancer Study Group (UKCCSG) which eventually ensured that all children in the UK with cancer had access to the most up to date treatment. The early involvement of Manchester in the pre chemotherapy era using radiotherapy, and the registry, led her to take a real interest in the late effects of treatment. She had a collection of slides which she used to illustrate the late effects of radiotherapy when given to young children. Failure of skeletal growth could ensue from radiotherapy to growing bones and second malignancies occurred within radiation fields. She became heavily involved with Anna Meadows in Philadelphia in setting up the Late Effects Study Group which received substantial funding from NIH. This work was extended and has been perpetuated by Les Robison and his colleagues and has hugely influenced the design of clinical treatment protocols in recent years. She wrote an influential paper in 1990 entitled Childhood Cancer; Cure at what cost? In which she described the evolution of treatment for childhood cancer from one of cure at any cost to cure at least cost. Her fervent hope was that we would eventually get to a stage of cure at no cost. Pat was an inspirational teacher and leader and many of the young aspiring paediatric oncologists in the 70s turned to her for career advice and then once appointed to a post used her as a source of support and advice on patient management. She was most people’s “phone a friend”.The psychosocial problems faced by both children and parents became much more obvious once potentially curative treatments were being used. Paradoxically parents seemed to be able to cope better with the near certainty of death of their child than with the possibility, but by no means certainty, of long term survival. She worked closely with Peter McGuire, a psychiatrist, and with social workers to define the problems faced by children and their families and devised interventions to try and help. It was clear from the early leukaemia trials, which involved cranial irradiation and brain tumours that endocrine insufficiency was a real problem and she worked closely with Professor Steve Shalet, a paediatric endocrinologist, to not only define what these problems were but also how to follow up and screen survivors. She was always much in demand for conferences once causing consternation in Bruges when, invited to take a shot at the men only archery club she hit the bull’s eye first time. The local tradition was that anyone who did this was invited to become a member.Her retirement at the age of 60 was marked by an enormous party in Manchester Town Hall attended by many of the patients whom she had successfully treated and the parents of many of those who had died. She remembered all of their names. She was short in stature but big in personality, loved clothes and is remembered for her leather skirts and red shoes. In later years her hair was often a shade of blue and always well coiffeured . She was always a straight talker and had lots to say in meetings. She was direct and always had strong opinions. She was once quoted in a national newspaper that money was being wasted on sending children to Disneyland.Throughout her career she loved foreign travel which was often associated with scientific meetings. She built up a wide circle of friends including Anna Meadows, Dan D’Angio, Mark Nesbit and Audrey Evans whom she would call upon to offer training places to her aspiring young colleaguesWhen she retired from clinical work in 1993 she decided to move to London. “As a single lady why would I want to move into a country cottage? Soon after her move to central London she met and married her Italian hairdresser, Alfonso Cassarini, and enjoyed 20 blissful years travelling widely and exploring the capital’s culture.Pat Morris Jones was a forceful and formidable pioneer who always had the best interests of children and their families at the forefront of everything that she did. The incredible survival rates for children with cancer in the present era using treatments which are designed to minimise late effects are built on the shoulders of giants like her who dared to try.Alan CraftTim Eden

Haemophilia A and B are rare bleeding disorders. Over the past decades, they have been transformed from debilitating diseases to manageable conditions. However, several challenges and unmet needs remain in the treatment of the haemophilia limiting the QoL of the patients. These challenges are now being addressed by EHL recombinant factors, rebalancing and substitution therapies. Gene therapy and genome editing show promise for a definite clinical cure. Herein, we provide an overview of new therapeutic opportunities for haemophilia and their advances and limitations. The database on human medicines from EMA was used and data from rare disease (orphan) designations and EPARs were retrieved for the analysis. Clinical Trial databases were used to query all active studies on haemophilia. Gene therapy medicinal products based on AAV and lentiviral vectors are in development and clinical trials have reported substantial success in ameliorating bleeding tendency in haemophilia patients. The prospect of gene editing for correction of the underlying mutation is on the horizon with considerable potential. We are entering an era of innovation and abundance in treatment options for those affected by bleeding disorders but issues still remain about the affordability and accessibility to patients, the long-term durability, safety and efficacy.

Resource quality can have direct or indirect effects on female oviposition choice, offspring growth and survival, and ultimately on body size and sex ratio. We examined these patterns in Sirex noctilio Fabricus, the globally invasive European pine woodwasp, in South African Pinus patula plantations. We studied how tree position as well as natural variation in biotic and abiotic factors influenced sex-specific density, larval size, tunnel length, male proportion, and survival across development. Twenty infested trees divided into top, middle, and bottom sections were sampled at three time points during larval development. We measured moisture content, bluestain fungal colonization, and co-occurring insect density and counted, measured, and sexed all immature wasps. A subset of larval tunnels was measured to assess tunnel length and resource use efficiency (tunnel length as a function of immature wasp size).  Wasp density increased from the bottoms to the tops of trees for both males and females. However, the largest individuals and the longest tunnels were found in bottom sections. Male bias was strong (~10:1) and likewise differed among sections, with the highest proportion in the middle and top sections. Sex ratios became more strongly male biased due to high female mortality, especially in top and middle sections. Biotic and abiotic factors such as colonization by Diplodia sapinea, weevil (Pissodes sp.) density, and wood moisture explained modest residual variation in our primary mixed effects models (0-22%). These findings contribute to a more comprehensive understanding of sex-specific resource quality for S. noctilio and of how variation in key biotic and abiotic factors can influence body size, sex ratio, and survival in this economically important woodwasp.

The COVID-19 crisis has forced researchers in Ecology to change the way we work almost overnight. Nonetheless, the pandemic has provided us with several novel components for a new way of conducting international Science. In this perspective piece, we summarize eight central insights that are helping us, as early career researchers, navigate the uncertainties, fears and challenges of advancing Science during the COVID-19 pandemic. We highlight how innovative, collaborative and often Open Science-driven developments that have arisen from this crisis can form a blueprint for a community reinvention in academia. Our insights include personal approaches to managing our new reality, maintaining capacity to focus and resilience in our projects, and a variety of tools that facilitate remote collaboration. We also highlight how, at a community level, we can take advantage of online communication platforms for gaining accessibility to conferences and meetings, and for maintaining research networks and community engagement while promoting a more diverse and inclusive community. Overall, we are confident that these practices can support a more inclusive and kinder scientific culture for the longer term.

Phytolith-occluded carbon (PhytOC) is an important long-term stable carbon fraction in grassland ecosystems, and plays a promising role in global carbon sequestration. Determination of the PhytOC traits of different plants in major grassland types is crucial for precisely assessing their PhytOC sequestration potential. Precipitation is the predominant factor in controlling net primary productivity (NPP) and species composition of the semiarid steppe grasslands. We selected three representative steppe communities of desert steppe, dry typical steppe and wet typical steppe in Northern Grasslands of China along a precipitation gradient, to investigate their species composition, biomass production and PhytOC content for quantifying its long-term carbon sequestration potential. Our results showed that (i) the phytolith and PhytOC contents in plants differed significantly among species, with dominant grass and sedge species having relatively high contents, and the contents are significantly higher in below- than the aboveground parts. (ii) The phytolith contents of plant communities were 16.68, 17.94 and 15.85 g kg-1 in the above- and 85.44, 58.73 and 76.94 g kg-1 in the belowground biomass of desert steppe, dry typical steppe and wet typical steppe, respectively; and the PhytOC contents were 0.68, 0.48 and 0.59 g kg-1 in the above- and 1.11, 0.72 and 1.02 g kg-1 in the belowground biomass of the three steppe types. (iii) Climatic factors affected phytolith and PhytOC production of steppe communities mainly through altering plant production, whereas their effects on phytolith and PhytOC contents were relatively small. Plant aboveground biomass and PhytOC content were strongly associated with the current-year climate and soil bio-available Si content; while plant belowground biomass and PhytOC content were relatively stable, and their variation across the sites is in accordance with the spatial variation in the long-term means of climatic and soil factors, reflecting the perenniality of plant belowground part.

Sudden Cardiac Death (SCD) remains a global threat.1The most common causes of SCD are ischemic heart diseases and structural cardiomyopathies in the elderly. Additional causes can be arrhythmogenic, respiratory, metabolic, or even toxigenic.2,3,4 Despite the novel diagnostic tools and our deeper understanding of pathologies and genetic associations, there remains a subset of patients for whom a trigger is not identifiable. When associated with a pattern of Ventricular Fibrillation, the diagnosis of exclusion is deemed Idiopathic Ventricular Fibrillation (IVF).2,5 IVF accounts for 5% of all SCDs6 – and up to 23% in the young male subgroup5 – and has a high range of recurrence rates (11-45%).7,8,9 There are still knowledge gaps in the initial assessment, follow-up approach, risk stratification and subsequent management for IVF.1,10,11 While subsets of IVF presentations have been better characterized into channelopathies, such as Brugada’s syndrome (BrS), Long QT Syndrome (LQTS), Early Repolarization Syndrome (ERS), Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), much remains to be discovered.12,13 Implantable Cardioverter Device (ICD) placement as secondary prevention for IVF is the standard of care. This is warranted in the setting of high recurrence rates of arrhythmias (11-43%). Multiple studies have shown potential complications from ICDs and a significant number of cases experiencing inappropriate shock after ICD placement.14In their article, Stampe et al. aim to further understand clinical presentation and assessment, and risk factors for recurrent ventricular arrhythmias in IVF patients. Using a single-centered retrospective study, they followed a total of 84 Danish patients who were initially diagnosed with IVF and received a secondary ICD placement between December 2007 and June 2019. Median follow-up time was 5.2 years (ICR=2-7.6). To ensure detection of many possible underlying etiologies ranging from structural, ischemic, arrhythmogenic, metabolic, or toxicologic, the researchers found that a wide array of diagnostic tools were necessary: standard electrocardiograms (ECGs), high-precordial leads ECGs, standing ECGs, Holter monitoring, sodium-channel blocker provocation tests, exercise stress tests, echocardiograms, cardiac magnetic resonance imaging, coronary angiograms, cardiac computed tomography, electrophysiological studies, histological assessment, blood tests, toxicology screens, and genetic analysis.The study by Stampe et al. highlights the importance of thorough and continuous follow-up with rigorous evaluation: Three (3.6%) patients initially diagnosed with IVF were later found to have underlying cardiac abnormalities (LQTS and Dilated Cardiomyopathy) that explained their SCA. Like other studies, the burden of arrhythmia was found to be high, but unlike reported data, the overall prognosis of IVF was good. Despite the initial pattern of ventricular fibrillation in those who experienced appropriate ICD placement (29.6%), ventricular tachycardia and ventricular fibrillation had a comparable predominance. As for patients with inappropriate ICD placements, atrial fibrillation was a commonly identified pathological rhythm (16.7%). Recurrent cardiac arrest at presentation (19.8%) was a risk factor for appropriate ICD therapy (HR=2.63, CI=1.08-6.40, p=0.033). However, in contrast to previous studies, early repolarization detected on baseline ECG (12.5%), was not found to be a risk factor (p=0.842).The study by Stampe et al. has few limitations. First, the study design, a retrospective cohort, precluded standardized follow-up frequencies and diagnostic testing. Second, while the study was included many of the cofounders tested in previous studies (baseline characteristics, baseline ECG patterns, comorbidities), medication use was not included. Third, the follow-up period may have been insufficient to detect effect from some of the confounding factors. Finally, the sample size was small and it was from a single center.There are several strengths of the Stampe et al. study. Firstly, the wide range of diagnostic tests used at index presentation and during the follow-up period ensured meticulous detection of most underlying etiologies. Secondly, appropriate and well-defined inclusion and exclusion criteria were used. Thirdly, funding by independent parties ensured no influence on study design, result evaluation, and interpretation. Finally, the study has succeeded in improving our understanding of IVF. Future studies should include though a larger population size and a more diverse population.References:1.AlJaroudi WA, Refaat MM, Habib RH, Al-Shaar L, Singh M, et al. Effect of Angiotensin Converting Enzyme Inhibitors and Receptor Blockers on Appropriate Implantable Cardiac Defibrillator Shock: Insights from the GRADE Multicenter Registry. Am J Cardiol Apr 2015; 115 (7): 115(7):924-31.2. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary. J Am Coll Cardiol 2018;72:e91–e220.3. Refaat MM, Hotait M, London B: Genetics of Sudden Cardiac Death. Curr Cardiol Rep Jul 2015; 17(7): 6064. Priori SG, Wilde AA, Horie M, Cho Y, Behr ER, Berul C, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm 2013;10:1932–1963.5. Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36(41):2793-2867.6. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998;98:2334–2351.7. Ozaydin M, Moazzami K, Kalantarian S, Lee H, Mansour M, Ruskin JN. Long-term outcome of patients with idiopathic ventricular fibrillation: a meta-analysis. J Cardiovasc Electrophysiol 2015;26:1095–1104.8. Herman AR, Cheung C, Gerull B, Simpson CS, Birnie DH, Klein GJ, et al. Outcome of apparently unexplained cardiac arrest: results from investigation and follow-up of the prospective cardiac arrest survivors with preserved ejection fraction registry. Circ Arrhythm Electrophysiol 2016;9:e003619.9. Siebermair J, Sinner MF, Beckmann BM, Laubender RP, Martens E, Sattler S, et al.Early repolarization pattern is the strongest predictor of arrhythmia recurrence in patients with idiopathic ventricular fibrillation: results from a single centre long-term follow-up over 20 years. Europace 2016;18:718-25.10. Refaat MM, Hotait M, Tseng ZH: Utility of the Exercise Electrocardiogram Testing in Sudden Cardiac Death Risk Stratification. Ann Noninvasive Electrocardiol 2014; 19(4): 311-318.11. Gray B, Ackerman MJ, Semsarian C, Behr ER. Evaluation after sudden death in the young: a global approach. Circ Arrhythm Electrophysiol 2019;12: e007453.12. Herman AR, Cheung C, Gerull B, Simpson CS, Birnie DH, Klein GJ, et al. Response to Letter Regarding Article, Outcome of apparently unexplained cardiac arrest: results from investigation and follow-up of the prospective cardiac arrest survivors with preserved ejection fraction registry”. Circ Arrhythm Electrophysiol 2016;9:e004012.13. Chen Q, Kirsch GE, Zhang D, Brugada R, Brugada J, Brugada P, Potenza D, et al. Genetic basis and molecular mechanism for idiopathic ventricular fibrillation. Nature 1998;392:293–296.14. Baranchuk A, Refaat M, Patton KK, Chung M, Krishnan K, et al. What Should You Know About Cybersecurity For Cardiac Implantable Electronic Devices? ACC EP Council Perspective. J Am Coll Cardiol Mar 2018; 71(11):1284-1288.

We show in this paper a Lipschitz stability result for a crack inverse problem in half space. The direct problem is a Laplace equation with zero Neumann condition on the top boundary. The forcing term is a discontinuity across the crack. This formulation can be related to geological faults in elastic media or to irrotational incompressible flows in a half space minus an inner wall. The direct problem is well posed in an appropriate functional space. We study the related inverse problem where the jump across the crack is unknown, and more importantly, the geometry and the location of the crack are unknown. The data for the inverse problem is of Dirichlet type over a portion of the top boundary. We prove that this inverse problem is uniquely solvable under some assumptions on the geometry of the crack. The highlight of this paper is showing a stability result for this inverse problem. Assuming that the crack is planar, we show that reconstructing the plane containing the crack is Lipschitz stable despite the fact that the forcing term for the underlying PDE is unknown. This uniform stability result holds under the assumption that the forcing term is bounded above and the Dirichlet data is bounded below away from zero in appropriate norms.

Objective: To assess whether folic acid supplementation ameliorates hot flushes. Design: Double-blind, placebo-controlled randomised trial. Setting: Nine hospitals in England. Population: Postmenopausal women experiencing ≥50 hot flushes weekly. Methods: Women (n=164) were randomly assigned in a 1:1 ratio to receive folic acid 5mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-weekly intervals. Main Outcome Measures: The change in daily Hot Flush Score at week-12 from randomisation based on Sloan Diary Composite Score B calculation. Results: Data of 143 (87%) women was available for the primary outcome. The mean change (SD) in Hot Flush Score at week-12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI: -5.68, 0.87), p=0.149 and in the adjusted mean change was -2.61 (95% CI: -5.72, 0.49) with p=0.098. There was an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week-8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI: 1.16, 9.28) and 1.88 (95% CI: 0.23, 3.52) for total and emotional score, respectively. Conclusions: Folic acid had a greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo; however, the difference did not reach statistical significance. Definitive evidence of benefit requires a larger study.

Background: Minimally invasive mitral valve(MV) surgery(MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcome and secondary organ function effects in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 345 patients were included after propensity-matching: 95 sternotomy patients and 250 MIVT patients. Endpoints focused on survival, quality of MV repair and organ function effects through analysis of biomarkers and functional parameters. Despite longer cardiopulmonary bypass(sternotomy: 96.0(IQR34)min – MIVT:134.0(IQR42)min, p<0.001) and cardioplegic arrest times(sternotomy: 61.0(IQR26)min – MIVT:87.0(IQR34)min, p<0.001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p=0.751 – ureum, p=0.538 - glomerular filtration, p=0.848), myocardial damage by troponine I level (sternotomy:1.8±3.9ng/ml – MIVT:1.2±1.3ng/ml, p=0.438) and ventilatory support > 24 hours(sternotomy:5.5% - MIVT:9.5%, p=0.240) were comparable. Systemic inflammatory reaction by postoperative CRP count was markedly lower for MIVT(p<0.001). Increased rhadomyolysis was found after MIVT surgery, based on significant elevation of creatinine-kinase levels(sternotomy: 431±237U/L – MIVT: 701±595U/L, p<0.001). Conclusion: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, excepted for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted when procedural times tend to exceed the critical time threshold for severe limb ischemia.

Abstract Lockdown, quarantine, self-isolation, personal protection equipment, social distancing have become words of daily usage ever since the world health organisation declared COVID-19 as a pandemic. The impact of COVID 19 extends over the medical field, economy, education and politics. Though the knowledge of the virus is evolving, we are yet to find a solution. India, country with the 2nd largest population, went into a phase of lockdown from 25th March 2020 to 31st May 2020. There was phased measure to “Unlock” starting from1st June 2020. This has affected the clinical practise and training of the resident. The challenges faced during this unprecedented time are multi-faceted which includes overcrowding, health care system, educational background. Indian Association of Cardiovascular-Thoracic Surgeons kept continuing the educational program through a series of “Masterclass”.

Cardiopulmonary bypass and extracorporeal membrane oxygenation are commonly used adjuncts to lung transplantation. These techniques are not without associated morbidity and mortality, and the surgeon must be aware of the possibility of aberrant anatomy that could lead to vascular injury during cannulation. In this report, we describe a patient with congenital absence of the inferior vena cava undergoing lung transplantation who required perioperative cardiopulmonary support. A percutaneous dual lumen cannula, Protek Duo, was connected in an Oxy-RVAD configuration to provide right ventricular and oxygenation support both intraoperatively and postoperatively to this patient.

Cardiac injury presents a great challenge to the emergency doctors because these injuries require urgent intervention to prevent death. Sometimes serious cardiac injury may manifest only subtle or occult symptoms or signs. Cardiac foreign bodies induced cardiac penetrating injury infrequently and may lead to unpredictable complications, especially for those with sharp nature. However, we know little about the migrating paths or the foreign bodies location changes of such cases. As there is a rarely reported case of cardiac penetrating injury caused by a self-inflicted needle that migrated from the neck to the heart, we herein present a review of such injury on dynamic monitoring using perioperative echocardiography showed the needle shuttled through the ventricular wall along with increasing pericardial effusion.

Background The prevalence of allergy to cat is expanding worldwide. Allergen-specific immunotherapy (AIT) has advantages over symptomatic pharmacotherapy and promises long lasting disease control in allergic patients. However, there is still a need to improve cat AIT regarding efficacy, safety and adherence to the treatment. Here we aim to boost immune tolerance to the major cat allergen Fel d 1 by increasing the anti-inflammatory activity of AIT with the established immunomodulatory adjuvant CpG, but at a higher dose than previously used in AIT. Methods Together with CpG, we used endotoxin-free Fel d 1 as therapeutic allergen throughout the study in a BALB/c model of allergy to Fel d 1, thus mimicking the conditions of human AIT trials. Multidimensional immune phenotyping including mass cytometry was applied to analyze AIT-specific immune signatures. Results We show that AIT with high-dose CpG in combination with endotoxin-free Fel d 1 reverts all major hallmarks of allergy. High dimensional CyTOF analysis of the immune cell signatures initiating and sustaining the AIT effect indicates the simultaneous engagement of both, the pDC-Treg and -B cell axis, with the emergence of a systemic GATA3+ FoxP3hi biTreg population. The regulatory immune signature also suggests the involvement of the anti-inflammatory TNF/TNFR2 signaling cascade in NK and B cells at an early stage and in Tregs later during AIT. Conclusion Our results highlight the potential of CpG adjuvant in a novel formulation to be further exploited for inducing allergen-specific tolerance in patients with cat allergy or other allergic diseases in the future.

To the Editor.The beneficial effects of Allergen Specific Immunotherapy (AIT) relies on the induction of allergen-specific Regulatory T-cells (Tregs) (1). Tregs, a subpopulation of CD4+CD25+T-cells expressing the specific transcription factor Foxp3, are not functionally homogeneous and their detection is complex and uncertain due to FoxP3 intracellular localization. Furthermore, FoxP3+ Tregs might become unstable and halt the production of their functional suppressive cytokines in inflammatory conditions (2) (1). In its place, the surface antigen CD127, whose expression inversely correlates with FoxP3, conveniently identifies Tregs as CD4+CD25+CD127negcells (3) (2), so surmounting the problems of FoxP3 stability and intracellular detection. Tregs also constitutively express the inhibitory antigen CD39, enhanced in highly suppressive memory Tregs (4) (3). Furthermore, HLA-DR expression is a monitor of Treg differentiation status and identifies a functionally and greatly suppressive population (1,5) (1,5). Lack of CD45RA characterizes memory T cells enabled to survive for long periods, even in absence of specific antigen, showing increased activity upon re-exposure and able to induce apoptosis in target cells (6) (3). CD4+CD25highCD39+CD127negcells are subtyped as Resting (CD45RA+/HLA-DRneg: rTreg), Activated (CD45RAnegHLA-DRneg: aTreg) and Effector (CD45RAnegHLA-DRlow/high: eTreg) Tregs (6) (6). This latter subtype includes terminally differentiated Tregs, the most highly suppressive (5) (7) (Supplementary Figure 1). They are different from secreting or type III Tregs expressing CD127 that represent a short-lived terminally differentiated population (5,6,8) . In order verify possible correlations between specific subsets of Treg and the effectiveness of AIT, we applied this analytical approach to study Treg profile in adolescents suffering from mite allergic rhinitis, pre and 12 months post Sublingual Immunotherapy (SLIT) with mite monomeric allergoid, an acid-resistant allergen known to elicit early T reg-activation (7,8). The study was approved by the Ethical Committee of University “G. d’Annunzio”, Chieti-Pescara. All patients and parents signed a written informed consent after having been informed about the procedures of the study.Twenty patients diagnosed with mite-allergic persistent rhinitis with or without asthma were enrolled. Allergic rhinitis (AR) was graded according to ARIA guidelines in 1) intermittent mild, 2) intermittent moderate/severe, 3) persistent mild and 4) persistent moderate/severe. At the enrollment, each patient marked in a 100 mm visual analogic scale (VAS) the level of its health status related to allergy with 0 the best status and 100 the worst.All patients were treated by SLIT with mite monomeric allergoid (LAIS - Lofarma, Milan, Italy) at 1000 UA four times/week every other day, for 12-months. No adverse local and systemic reactions were detected. The effectiveness of SLIT was established comparing VAS, ARIA grading and ACT questionnaire performed after 12-months of treatment with their basal values. Two blood samples were drawn pre/post SLIT to be analyzed for Regulatory T-cells. Clinical and demographic details of the studied population, analytical methods, statistical approach and the outline of the study are detailed in the online supplementary material .Rhinitis scores VAS and ARIA significantly decreased after SLIT (Table 1), with the same statistical significance (Wilcoxon z -3.7236; p = 0.0002). Improvement was evidenced also in the subgroup of asthmatic patients (n=7) since ACT scores significantly increased from the baseline value of 18 (16-19) up to 24 (20-25) after 12 months of treatment (the low number of patients does not allow application of efficient statistics).Tregs were analyzed as frequency of total Treg cells and their three subsets, namely Resting (rTregs), Activated (aTregs) and Effector (eTregs), within the parental population of CD4+cells. Total Tregs did not change significantly; rTreg significantly decreased (Wilcoxon z-3.6214, p<0.0003), while, the abundance of aTregs and eTregs significantly incremented (Wilcoxon z-2.9011, p<0.05 and z-3.077, p=0.002, respectively) (Table 1). A significant negative correlation has been observed between the decrease in rTreg and the increase in aTreg (Spearman’s ρ-0.69391, p<0.02) and increase in eTreg cells (Spearman’s ρ-0.56845, p<0.02) (Figure 3 in supplementary material).HLA-DR resulted significantly up-regulated in all Tregs from 4.93±3.1 to 6.92±5.1 MFI (Wilcoxon z-4.2026, p <0.00001). HLA-DR increased on aTregs from 3.4±3.03 to 4.91±3.2 MFI (Wilcoxon z-3.2479, p=0.001) and on eTregs from 1.54±0.66 to 2.0±1.45 MFI (Wilcoxon z-2.9664, p=0.005). CD39 was found differently expressed in the three subsets of Tregs at baseline, with Resting<Activated<Effector. After 12 months of SLIT, CD39 surface expression was found significantly increased in all Tregs from 6.9±4 to 8.02±5 MFI (Wilcoxon z-3.1049, p=0.001) (HLA-DR and CD39 changes are reported in Table 1). We found some interesting correlations between laboratory data and clinical parameters. Changes in eTregs significantly correlated with both ARIA (Spearman’s ρ=0.58728, p=0.013) (Figure 1A) and VAS (Spearman’s ρ=0.49172, p=0.044) (Figure 1B) variations after SLIT. While a significant negative correlation was found between rTregs and clinical parameter changes after treatment (Spearman’s ρ-0.48482, p=0.0491). Changes in HLA-DR expression on all Treg cells significantly correlated with variation in VAS pre-/post-SLIT (Spearman’s ρ=0.54104, p= 0.01376) (Figure 1C). No other correlations were found except for the lowest increase (< 8%) of memory Tregs (CD45RAneg) detected in patients with the lowest levels of mite-specific serum IgE (not shown).To our knowledge this is the first report on successful SLIT being associated with re-patterning of the differentiation status of Tregs, with high rates of the most suppressive Treg subtypes: activated and effector, characterized by higher expression of HLA-DR and CD39 both playing inhibitory function in Tregs. Moreover, effective SLIT seems to be associated with the generation of cells lacking CD45RA that characterizes memory T cells with increased activity upon re-exposure to the antigen. Our results suggest that SLIT also induced empowerment of Treg inhibitory function, likely compensating the under-representation of Tregs observed in allergic patients (9) (9). In AR children, there are evidences that Tregs have defect in suppressing IgE production and that they can be incremented by mite SLIT.Next step of our study will be to evidence if such relationship between effective SLIT and Treg re-patterning is present in the first months of SLIT, with a view to profiling Tregs for the early identification of SLIT responders/non-responders by mean of a straightforward and non-invasive blood test.

A 30-year-old man, who had no travel history to COVID-19 prone areas whereas he had the characteristics signs and symptoms of COVID-19. Chest X-ray and rRT-PCR revealed his confirmed COVID-19. This study recommends the early identification and management of COVID-19.

Key Clinical Message: In patients presenting with hyperinsulinaemic hypoglycaemia with a non-pancreatic neuroendocrine tumour, the diagnosis of an ectopic insulin-secreting tumour should be considered, and investigated further with confirmatory insulin staining.

Three COVID-19 cases were simultaneously confirmed as deep venous thrombosis (DVT). Ultrasound-guided IVCF implantation is an effective method that can be considered as a precautionary strategy for preventing lethal pulmonary embolism occurrence, especially for critical DVT-COVID-19 patients who are not suitable to be transferred to a routine X-ray operation room.