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Improved survival has been reported for diffuse malignant peritoneal mesothelioma (DMPM) treated by cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). The issue of treatment failure has never been extensively addressed. The present study assessed the failure pattern, management, and outcome of progressive DMPM following comprehensive treatment. Clinical data on 70 patients with DMPM undergoing cytoreduction and HIPEC were prospectively collected; after a median follow-up of 43 months, disease progression occurred in 38 patients. Progressive disease distribution in 13 abdominopelvic regions was analyzed. In 28 patients undergoing adequate cytoreduction (residual tumor ≤2.5 mm), clinicopathological factors correlating to disease progression in each region were investigated. Median time to progression was 9 months [95% confidence interval (CI) 1.6–35.9]. Median survival from progression was 8 months (95% CI 4–16.2). The failure pattern was categorized as peritoneal progression ( n  = 31), liver metastases ( n  = 1), abdominal lymph-node involvement ( n  = 2), pleural seeding ( n  = 4). Small bowel was the single site most commonly involved ( n  = 27). Residual tumor ≤2.5 mm (versus no visible) was the only independent risk factor for disease progression in epigastric region ( P  = 0.047), upper ileum ( P  = 0.029), upper jejunum ( P  = 0.034), and lower jejunum ( P  = 0.002). Progressive disease was treated with second HIPEC in 3 patients, debulking in 4, systemic chemotherapy in 16, and supportive care in 15. At multivariate analysis, time to progression <9 months ( P  = 0.009), poor performance status ( P  = 0.005), and supportive care ( P  = 0.003) correlated to reduced survival from progression. We conclude that minimal residual disease, compared with macroscopically complete cytoreduction, correlated to failure in critical anatomical areas, suggesting the need for maximal cytoreductive surgical efforts. In selected patients, aggressive management of progressive disease seems worthwhile.

The experimental fusion reactor ITER will feature two (or three) heating neutral beam injectors (NBI) capable of delivering 33(or 50) MW of power into the plasma. A NBI consists of a plasma source for production of negative ions (extracted negative ion current up to 329 A/m 2 in H and 285 A/m 2 in D) then accelerated up to 1 MeV for one hour. The negative ion beam is neutralized, and the residual ions are electrostatically removed before injection. The beamline was designed for a beam divergence between 3 and 7 mrad. The ion source in ITER NBIs relies on RF-driven, Inductively-Coupled Plasmas (ICP), based on the prototypes developed at IPP Garching; RF-driven negative-ion beam sources have never been employed in fusion devices up to now. The recent results of SPIDER, the full size ITER NBI ion source operating at NBTF in Consorzio RFX, Padova, measure a beamlet divergence minimum of 12mrad and highlighted beam spatial non-uniformity. SPIDER results confirmed the experimental divergence found in smaller prototype sources, which is larger compared to filament-arc ion sources. Although prototype experiments have shown that the extracted current requirement can be achieved with minor design improvements, the beamlet divergence is expected to marginally achieve the design value of 7 mrad, which in multi-grid long accelerators results in unexpected heat loads over the accelerator grids. A contributor to the beam divergence is the energy/temperature of the extracted negative ions, so it is believed that plasma differences between the two source types play a role. Research is focused on the plasma parameters in the ion source. One RF driver, identical to the ones used in SPIDER, installed in a relatively small-scale experimental set-up, inherently more flexible than large devices, is starting operations devoted to the investigation of the properties of RF-generated plasmas, so as to contribute to the assessment of negative ion precursors, and of their relationship with the plasma parameters, particularly when enhancing plasma confinement. The scientific questions, that have arisen from the preliminary results of SPIDER, guided the design of the test stand, which are described in this contribution, together with the diagnostic systems and related simulation tools. The test stand, which shares with the larger experiment all the geometrical features and constraints, will allow technological developments and optimized engineering solutions related to the ICP design for the ITER NBIs.

Consorzio RFX and INFN-LNL have designed, built and operated the compact radiofrequency negative ion source NIO1 (Negative Ion Optimization phase 1) with the aim of studying the production and acceleration of H- ions. In particular, NIO1 was designed to keep plasma generation and beam extraction continuously active for several hours. Since 2020 the production of negative ions at the plasma grid (the first grid of the acceleration system) has been enhanced by a Cs layer, deposited though active Cs evaporation in the source volume. For the negative ion sources applied to fusion neutral beam injectors, it is essential to keep the beam current and the fraction of co-extracted electrons stable for at least 1 h, against the consequences of Cs sputtering and redistribution operated by the plasma. The paper presents the latest results of the NIO1 source, in terms of caesiation process and beam performances during continuous (6{\\div}7 h) plasma pulses. Due to the small dimensions of the NIO1 source (20 x (diam.)10 cm), the Cs density in the volume is high (10^15 \\div 10^16 m^-3) and dominated by plasma-wall interaction. The maximum beam current density and minimum fraction of co-extracted electrons were respectively about 30 A/m^2 and 2. Similarly to what done in other negative ion sources, the plasma grid temperature in NIO1 was raised for the first time, up to 80 {\\deg}C, although this led to a minimal improvement of the beam current and to an increase of the co-extracted electron current.

We described a case of IPEX syndrome successfully controlled with dupilumab, an anti-IL4 receptor alpha subunit inhibitor. IPEX syndrome is a rare and generally fatal genetic disorder characterized by immune dysregulation, polyendocrinopathy and enteropathy, mostly diagnosed in early childhood. Nonetheless, cases reported in the last 20 years demonstrated that IPEX clinical spectrum encompasses more than the classical triad of early-onset intractable diarrhea, type 1 diabetes and eczema. Atypical cases of IPEX include patients with late-onset of symptoms, single-organ involvement, mild disease phenotypes or rare clinical features. A 21-year-old caucasian man presented with immune dysregulation (hypereosinophilia and elevated IgE), protein-losing enteropathy, polyendocrinopathy (thyroiditis, osteoporosis, delayed puberty), weight loss, eczema manifestations and celiac disease. IPEX syndrome was diagnosed because of the presence of a hemizygous mutation in FOXP3 gene (c.543C>T (p.S181S) in the exon 5). During the course of the disease, the patient developed erosive proctitis, pyoderma gangrenosum, and erythema nodosum. Symptoms improved only after enteral and parenteral corticosteroid therapy and the patient soon developed steroid-dependence. Notwithstanding various therapies including azathioprine, sirolimus, tacrolimus, adalimumab, vedolizumab, the patient failed to achieve a good control of symptoms without steroids. Almost exclusive enteral nutrition with a hypoallergenic, milk-protein free, amino acid-based food for special medical purposes. He continued to lose weight (BMI 14.5 kg/m2) with a consequent high limitation of physical activity and a progressive worsening of the quality of life. In consideration of the poor response to conventional immunosuppressants and the presence of type 2 inflammatory manifestations, treatment with dupilumab at an initial dose of 600 mg, followed by a maintenance dose of 300 mg every other week, according to atopic dermatitis labeled dose, was started and combined to oral budesonide 6 mg/day and 6-mercaptopurine 75 mg/day. The patient experienced a rapid improvement in bowel and skin symptoms, leading to a progressive tapering of steroids. By our knowledge, this is the first report of IPEX syndrome successfully treated by antiIL-4/IL-13 therapy. In this case dupilumab demonstrated to be an effective, safe and steroid-sparing option.

Purpose Patients undergoing hematopoietic stem cell transplantation (HSCT) usually experienced respiratory muscle weakness. Inspiratory muscle training (IMT) at HSCT has not been studied yet. Thus, it is important to evaluate the safety, feasibility, and preliminary effectiveness of IMT for hospitalized patients undergoing HSCT with an unstable and acute clinical condition. Methods This is a randomized controlled feasibility study. Thirty-one hospitalized patients undergoing HSCT were randomized to the conventional physical rehabilitation (CON) or to the IMT group (conventional physical rehabilitation + IMT). IMT was carried out at 40% of maximal inspiratory pressure (MIP), 5 sessions weekly, 10–20 min/session. Primary outcomes were safety and feasibility (recruitment, adherence, and attrition rates) of IMT. Secondary outcomes were respiratory strength, respiratory rate, oxygen saturation, and frequency of patients with oxygen desaturation, bleeding, dyspnea, and acute pulmonary edema. Results Patients were allocated to the IMT ( N  = 15; 43.6 years) or to the CON group ( N  = 16; 46.6 years). The recruitment rate was 100%, the adherence rate was 91%, and attrition was 13% to IMT. Two events were observed in 126 IMT sessions (1.5%). MIP increased in the IMT group ( P  < 0.01). No differences were observed in respiratory rate and oxygen saturation between groups. Trends to negative outcomes were observed in the CON in comparison to IMT group for a need of oxygen therapy (18% vs. 6%), bleeding (12% vs. 6%), dyspnea (25% vs. 13%), and acute pulmonary edema (6% vs. 0%). Conclusions IMT is safe, feasible, and improves the inspiratory muscle strength in hospitalized patients undergoing HSCT. Trial registration Clinical trial registration: NCT03373526

The premutation of the fragile X messenger ribonucleoprotein 1 (FMR1) gene is characterized by an expansion of the CGG trinucleotide repeats (55 to 200 CGGs) in the 5’ untranslated region and increased levels of FMR1 mRNA. Molecular mechanisms leading to fragile X-premutation-associated conditions (FXPAC) include cotranscriptional R-loop formations, FMR1 mRNA toxicity through both RNA gelation into nuclear foci and sequestration of various CGG-repeat-binding proteins, and the repeat-associated non-AUG (RAN)-initiated translation of potentially toxic proteins. Such molecular mechanisms contribute to subsequent consequences, including mitochondrial dysfunction and neuronal death. Clinically, premutation carriers may exhibit a wide range of symptoms and phenotypes. Any of the problems associated with the premutation can appropriately be called FXPAC. Fragile X-associated tremor/ataxia syndrome (FXTAS), fragile X-associated primary ovarian insufficiency (FXPOI), and fragile X-associated neuropsychiatric disorders (FXAND) can fall under FXPAC. Understanding the molecular and clinical aspects of the premutation of the FMR1 gene is crucial for the accurate diagnosis, genetic counseling, and appropriate management of affected individuals and families. This paper summarizes all the known problems associated with the premutation and documents the presentations and discussions that occurred at the International Premutation Conference, which took place in New Zealand in 2023.

Background. High neutrophil to lymphocyte ratio (NLR) has shown to be a predictor of poor outcomes in various malignancies, including pancreatic cancer. Methods. We assessed 70 consecutive pts with histologically confirmed mPC who received chemotherapy with nab-paclitaxel/gemcitabine at two different European oncologic centers between January 2012 and November 2015. Variables assessed for prognostic correlations included age ≥ 66, sex, Karnofsky PS score, primary tumor site, baseline CA19.9 level ≥ 59xULN, 12-week decrease of the CA19.9 level ≥ 50% from baseline, basal bilirubin level, baseline NLR, biliary stent implantation, and liver metastasis. Survival analyses were generated according to the Kaplan-Meier method. Univariate and multivariate analyses were performed by a Cox proportional hazard model. Results. According to NLR values, the patients were divided into two groups: high and low. Low group patients showed a better median PFS (7 months versus 5 months) and median OS (13 months versus 7 months) in respect to high group patients. At multivariate analysis, Karnofsky PS < 80% (HR = 0.4; CI 0.2–1.2), liver metastases (HR = 0.4; CI 0.18–0.82), and NLR ≥ 5 (HR = 2.7; 95% CI 1.4–5.2) were predictors of poorer OS. Based on the presence of one or more independent prognostic factors, three risk categories were identified: good-risk, intermediate-risk and poor-risk. The median OS was 22, 10, and 7 months, respectively. Conclusions. Baseline NLR is an independent predictor of survival of patients with mPC receiving palliative chemotherapy and could be useful to develop a simple clinical score to identify a subgroup of patients with a low chance to benefit from chemotherapy.