Multi-target assessment of advanced oxidation processes-based strategies for indirect potable reuse of tertiary wastewater: Fate of compounds of emerging concerns, microbial and ecotoxicological parameters

Two advanced oxidation processes (AOPs), namely ozone/H2O2 and UV/H2O2, were tested at pilot scale as zero-liquid-discharge alternative treatments for the removal of microbiological (bacteria and viruses), chemical (compounds of emerging concern (CECs)) and genotoxic responses from tertiary municipal wastewater for indirect potable reuse (IPR). The AOP treated effluents were further subjected to granular activated carbon (GAC) adsorption and UV disinfection, following the concept of multiple treatment barriers. As a reference, a consolidated advanced wastewater treatment train consisting of ultrafiltration, UV disinfection, and reverse osmosis (RO) was also employed. The results showed that, for the same electrical energy applied, the ozone/H2O2 treatment was more effective than the UV/H2O2 treatment in removing CECs. Specifically, the ozone/H2O2 treatment, intensified by high pressure and high mixing, achieved an average CECs removal efficiency higher than UV/H2O2 (66.8% with respect to 18.4%). The subsequent GAC adsorption step, applied downstream the AOPs, further improved the removal efficiency of the whole treatment trains, achieving rates of 98.5% and 96.8% for the ozone/H2O2 and UV/H2O2 treatments, respectively. In contrast, the ultrafiltration step of the reference treatment train only achieved a removal percentage of 22.5%, which increased to 99% when reverse osmosis was used as the final step. Microbiological investigations showed that all three wastewater treatment lines displayed good performance in the complete removal of regulated and optional parameters according to both national and the European Directive 2020/2184. Only P. aeruginosa resulted resistant to all treatments with a higher removal by UV/H2O2 when higher UV dose was applied. In addition, E. coli STEC/VTEC and enteric viruses, were found to be completely removed in all tested treatments and no genotoxic activity was detected even after a 1000-fold concentration. The obtained results suggest that the investigated treatments are suitable for groundwater recharge to be used as a potable water source being such a procedure an IPR. The intensified ozone/H2O2 or UV/H2O2 treatments can be conveniently incorporated into a multi-barrier zero-liquid-discharge scheme, thus avoiding the management issues associated with the retentate of the conventional scheme that uses reverse osmosis. By including the chemical cost associated with using 11-12 mg/L of H2O2 in the cost calculations, the overall operational cost (energy plus chemical) required to achieve 50% average CECs removal in tertiary effluent for an hypothetical full-scale plant of 250 m3/h (or 25,000 inhabitants) was 0.183 €/m3 and 0.425 €/m3 for ozone/H2O2 and UV/H2O2 treatment train, respectively.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A novel approach to interpret quasi-collimated beam results to support design and scale-up of vacuum UV based AOPs

UV-C at 254 nm and vacuum UV (VUV) at 185 nm are the two major emission lines of a low-pressure mercury lamp. Upon absorption of VUV photons, water molecules and selected inorganic anions generate hydroxyl (HO^.) and other redox radicals, both capable of degrading organic micropollutants (OMPs), thereby offering the opportunity to reduce H₂O₂ and energy consumption in UV-based advanced oxidation process (AOP). To be successfully scaled-up, the dual-wavelength VUV+UV/H₂O₂ AOP requires laboratory-scale experiments to establish design criteria. The figures of merit typically used for reporting and interpreting quasi-collimated beam results for UV-based AOPs (time, dose, absorbed energy and E_EO) are insufficient and inaccurate when employed for dual-wavelength AOP such as the VUV+UV/H₂O₂ AOP, and do not support system scale-up. In this study, we introduce a novel figure of merit, useful absorbed energy (uAE), defined as fraction of absorbed energy that results in the generation of oxidative radicals. Here, results of quasi-collimated beam VUV+UV/H₂O₂ AOP experiments on four different water matrices are used to introduce 2D plots that employ both uAE_UV and uAE_VUV as a novel method to represent laboratory-scale experiments of VUV+UV/H₂O₂ AOP and demonstrate how the 2D plots sufficiently support scale-up of the AOP.

Optimal integration of vacuum UV with granular biofiltration for advanced wastewater treatment: Impact of process sequence on CECs removal and microbial ecology

This study explored process synergies attainable by integrating a vacuum ultraviolet-based advanced oxidation process with biofiltration. A comparison using granular activated carbon or granular zeolite as filtration media were examined in context of advanced wastewater treatment for potable reuse. Six biofiltration columns, three with granular activated carbon and three with granular zeolite, were operated in parallel and batch-fed daily with nitrified secondary effluent. After achieving a pseudo-steady state through the filter columns, vacuum ultraviolet treatment was applied as pre-treatment or as post-treatment, at two different applied energies (i.e., VUV-E1=1 kWh/m³ and VUV-E10=10 kWh/m³). Once granular activated carbon had transitioned to biologically activated carbon, as determined based on soluble chemical oxygen demand removal, adsorption was still observed as the main mechanism for contaminants of emerging concern and nitrate removal. Vacuum ultraviolet pre-treatment markedly improved contaminants of emerging concern removal through the integrated system, achieving 40% at VUV-E1 and 90% at VUV-E10. When applied as post-treatment to zeolite column effluents, VUV-E1 and VUV-E10 further increased contaminants of emerging concern removal by 20% and 90%, respectively. In the zeolite system, vacuum ultraviolet pre-treatment also increased soluble chemical oxygen demand removal efficiency, indicating that higher energy vacuum ultraviolet increased biodegradability. Total prokaryotes were two-fold more abundant in biologically activated carbon than in zeolite, with vacuum ultraviolet pretreatment markedly affecting microbial diversity, both in terms of richness and composition. Media type only marginally affected microbial richness in the biofilters but showed a marked impact on structural composition. No clear relationship between compositional structure and depth was observed.

Effect of the substrate on the electrical transport and fluctuation processes in NbRe and NbReN ultrathin films for superconducting electronics applications

NbRe-based superconducting thin films recently received relevant interest in the field of low-temperature electronics. However, for these materials the electrical conduction mechanisms, in particular in the normal state, still need to be investigated in more detail. Here, NbRe and NbReN films of different thicknesses have been deposited on two different substrates, namely monocrystalline Si and [Formula: see text] buffered Si. The films were characterized by DC electrical transport measurements. Moreover, a connection with the charge carriers fluctuation processes has been made by analyzing the electrical noise generated in the normal state region. Despite the films morphology seems not to be affected by the substrate used, a lower noise level has been found for the ones grown on [Formula: see text], in particular for NbReN. From this study it emerges that both NbRe and NbReN ultrathin films are of very good quality, as far as the low-temperature electrical noise and conduction are concerned, with noise levels competitive with NbN. These results may further support the proposal of using these materials in a nanowire form in the field of superconducting electronics.

New-Onset Anemia and Associated Risk of ESKD and Death in Non-Dialysis CKD Patients: A Multi-Cohort Observational Study

Background

Anemia is a common complication of chronic kidney disease (CKD), but its incidence in nephrology settings is poorly investigated. Similarly, the risks of adverse outcomes associated with new-onset anemia are not known.

Methods

We performed a pooled analysis of three observational cohort studies including 1031 non-anemic CKD patients with eGFR <60 mL/min/1.73 m² regularly followed in renal clinics. We estimated the incidence of mild anemia (hemoglobin 11–12 g/dL in women and 11–13 g/dL in men) and severe anemia (hemoglobin <11 g/dL or use of erythropoiesis-stimulating agents) during a 3-year follow-up period. Thereafter we estimated the risk of end-stage kidney disease (ESKD) and all-cause death associated with new-onset mild and severe anemia.

Results

The mean age was 63 ± 14 years, 60% were men and 20% had diabetes. The mean estimated glomerular filtration rate (eGFR) was 37 ± 13 mL/min/1.73 m² and the median proteinuria was 0.4 g/day [interquartile range (IQR) 0.1–1.1]. The incidence of mild and severe anemia was 13.7/100 patients-year and 6.2/100 patients-year, respectively. Basal predictors of either mild or severe anemia were diabetes, lower hemoglobin, higher serum phosphate, eGFR <30 mL/min/1.73 m² and proteinuria >0.50 g/day. Male sex, moderate CKD (eGFR 30–44 mL/min/1.73 m²) and moderate proteinuria (0.15–0.50 g/day) predicted only mild anemia. The incidence of anemia increased progressively with CKD stages (from 8.77 to 76.59/100 patients-year) and the proteinuria category (from 13.99 to 25.02/100 patients-year). During a median follow-up of 3.1 years, 232 patients reached ESKD and 135 died. Compared with non-anemic patients, mild anemia was associated with a higher adjusted risk of ESKD {hazard ratio [HR] 1.42 [95% confidence interval (CI) 1.02–1.98]} and all-cause death [HR 1.55 (95% CI 1.04–2.32)]. Severe anemia was associated with an even higher risk of ESKD [HR 1.73 (95% CI 1.20–2.51)] and death [HR 1.83 (95% CI 1.05–3.19)].

Conclusions

New-onset anemia is frequent, particularly in patients with more severe renal damage and in those with diabetes mellitus. The occurrence of anemia, even of a mild degree, is associated with mortality risk and faster progression towards ESKD.

Controlling micropollutants in tertiary municipal wastewater by O3/H2O2, granular biofiltration and UV254/H2O2 for potable reuse applications

A comprehensive pilot study was carried out to experimentally assess the potential of newly developed treatment trains integrating two-stage AOPs and biofiltration to reach potable reuse water quality standards from municipal wastewater. The processes consisted of a two-stage AOPs with (carbon or limestone) biofiltration, the first AOP (O₃/H₂O₂) serving as pre-treatment to biofiltration and the second AOP (UV₂₅₄/H₂O₂) serving as post-biofiltration finishing step to ensure advanced disinfection. A comprehensive monitoring campaign was put in place resulting from the combination of targeted, non-targeted and suspect screening measurements. It was found that 13 organic micropollutants were detected from a list of 219 suspects although at ng/L level only. For the treatment conditions piloted in this study (O₃ = 13 ± 0.5 mg/L, H₂O₂ = 11 ± 0.4 mg/L for the O₃/H₂O₂ process, and UV = 410 ± 63.5 mJ/cm², H₂O₂ = 5 mg/l for the UV₂₅₄/H₂O₂ process), it was possible to estimate the overall removal efficacy for each unit process, which was found to follow this order: RO (99%)  > BAC (87%) > O₃-H₂O₂ (78%)  > BAL (67%)  > UV/H₂O₂ (43%)  > AOP contact chamber (19%)  > UF(0%), with the treatment train integrating two AOPs and granular biofiltration with activated carbon (O₃/H₂O₂ + BAC + UV₂₅₄/H₂O₂) showing superior performance with a 99% abatement in total micropollutants. No ecotoxicologically-positive response was generally observed for any of the effluent samples from the tested trains, even when pre-concentration factors up to 100-1000 times were employed to increase the sensitivity of the bioassay methods.

Treatment of acute bone defects in severe lower limb Trauma

PURPOSE

To present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames.

PATIENTS AND METHODS

During a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) RESULTS: The mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues.

DISCUSSION

based on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.

Etoricoxib-induced immune hemolytic anemia: first case presenting acute kidney failure

BACKGROUND

Etoricoxib is a selective inhibitor of cyclooxygenase 2 used mainly to treat osteoarticular pain. Here, we report the case of a patient who developed acute kidney failure and immune hemolytic anemia after the use of etoricoxib.

STUDY DESIGN AND METHODS

An 83-year-old female patient developed immune hemolytic anemia and acute kidney failure after treatment with etoricoxib for articular pain. Given the acute kidney failure, she required five hemodialysis sessions. She was discharged after 17 days. The case of immune hemolytic anemia and kidney failure was fully resolved.

RESULTS

The direct antiglobulin test was not only positive for IgG but also for C3b and C3d, showing a very intense reactivity (++++). The eluate's reactivity was weaker (++) and showed no defined specificity. The investigation of unexpected antibodies in the serum of the patient showed a reactivity pattern similar to the eluate's: weak reactivity without specificity. The serum of the patient was compared to urine and plasma samples of two groups of volunteers. The indirect antiglobulin test showed only a very strong reactivity with the urine samples of the volunteers who had received etoricoxib.

DISCUSSION

Considering that positive eluate is not the typical serologic profile of drug-induced immune hemolytic anemia, developing in-house techniques to show the causal link between them may be of interest to guide the treatment and avoid the empirical use of drugs.

CONCLUSION

Etoricoxib must be considered as a possible cause of acute kidney failure in cases of immune hemolytic anemia.

Exhaustion of Vascular Endowment in Hemodialysis: Proposal for a Permanent Inlet Access

The subcutaneous reservoir is a new vascular access for patients on regular hemodialysis (HD).

A double chamber in Titanium- Pirolytic Carbon with siliconic boreable superior caps is inserted in to a subcutaneous subclavian side, and always in subcutis connected to two siliconic catheters located in the right jugular resulting in the right atrium.

The puncture of each chamber is performed with a special hemodialysis-cannula telescopically assembled on a “dilatation tube”, in which a stylet is inserted.

In correct sequence, the cutaneous planes and the caps are bored, dilated, and finally the HD cannula after sliding over the previous structures is positioned in the inner chamber, closing the HD circuit.

In our study two patients were implanted, with a survival of 24 months, good compliance, no cardiovascular impairments and lack of catheteral pathology.

Prevalence and Correlates of Anemia and Uncontrolled Anemia in Chronic Hemodialysis Patients – The Campania Dialysis Registry

Background

This study investigated prevalence and correlates of anemia and uncontrolled anemia in chronic hemodialysis patients.

Methods

A cross-sectional analysis was performed on registry data for 2,746 chronic (<6 months) hemodialysis patients aged 25–84. Data collection included years of dialysis, hours of dialysis/wk, disease causing hemodialysis, body mass index (BMI), erythropoietin (EPO) treatment, hemoglobin, markers of viral hepatitis, serum albumin, calcium, and phosphorus.

Results

Prevalence was 88.7% for anemia (hemoglobin <11 g/100 mL and EPO treatment at any Hb level), 39.4% for uncontrolled anemia (hemoglobin<11 g/100 mL). Gender, years of dialysis, hereditary cystic kidney disease (HCKD), and low BMI (<24 kg/m2) were independent correlates of anemia (P<0.001). Gender, HCKD, low BMI, serum albumin and calcium were independent correlates of uncontrolled anemia (P<0.05). An interaction was found between age (not correlated with anemia and uncontrolled anemia) and the association of gender with uncontrolled anemia (P<0.05). EPO doses were higher in patients with high prevalence of uncontrolled anemia than in patients with low prevalence (i.e., women vs men, other diseases vs HCKD, low vs not-low BMI, P<0.01). Gender, years of dialysis, HCKD, BMI, serum albumin, and calcium were independent correlates of the hemoglobin/EPO dose ratio in patients on EPO treatment (P<0.05).

Conclusion

Anemia and uncontrolled anemia are more frequent in hemodialysis patients with short-term dialysis, diseases other than HCKD, low BMI, and female gender. Gender effect was lower in elderly patients. Uncontrolled anemia was also associated with low serum albumin and calcium, suggesting that these parameters are indices of EPO resistance.

Higher serum sclerostin levels and insufficiency of vitamin D are strongly associated with vertebral fractures in hemodialysis patients: a case control study

In hemodialysis patients, vertebral fractures were associated with elevated sclerostin levels, suggesting that sclerostin could reflect bone fragility in these patients.

INTRODUCTION

Fragility fractures are common in hemodialysis patients. The aims of our study were to determine the prevalence of vertebral fracture and analyze associations between sclerostin serum levels and vertebral fractures in hemodialysis patients.

METHODS

Ninety-two hemodialysis patients and 100 controls matched for age and sex were studied. Bone mineral density was measured by ultrasonography at non-dominant heel. The markers of bone turnover included serum osteocalcin, C-terminal telopeptide, and sclerostin. All participants underwent radiography of the thoracic and lumbar spine to ascertain the presence of vertebral fractures.

RESULTS

Bone ultrasound parameters at calcaneus were significantly lower in hemodialysis patients compared with controls; bone turnover markers and parathyroid hormone level were significantly higher, while serum of 25-OH-D3 was significantly lower in hemodialysis group. One or more moderate or severe vertebral fractures were found in 38 hemodialysis patients, whereas in control group, 10 patients had a vertebral fracture. In hemodialysis group, the comparison between patients with and without vertebral fractures showed that the patients with vertebral fractures had the serum sclerostin levels statistically higher than patients without vertebral, while serum levels of 25-OH-D3 was significantly lower in patients with vertebral fractures compared to the patients without vertebral fractures. Multivariate analysis disclosed that sclerostin levels were associated with an increased risk of vertebral fractures in hemodialysis patients after adjusting for multiple variables.

CONCLUSIONS

Our data shows high prevalence of vertebral fractures in hemodialysis patients and that it is associated with elevated sclerostin levels, reflecting bone fragility in these patients.

A novel inhaled phosphodiesterase 4 inhibitor (CHF6001) reduces the allergen challenge response in asthmatic patients

CHF6001 is an inhaled phosphodiesterase 4 (PDE4) inhibitor in development for the treatment of obstructive lung diseases. The efficacy and safety of CHF6001 were investigated in a double blind, placebo controlled, 3-way cross-over study using the allergen challenge model. Thirty-six atopic asthmatics who were not taking inhaled corticosteroids and who demonstrated a late asthmatic response (LAR) to inhaled allergen at screening were randomised to receive CHF6001 400 μg or 1200 μg or placebo administered once a day using a dry powder inhaler. The three treatment periods were 9 days; allergen challenges were performed on day 9 and induced sputum was obtained after 10 h from challenge. Washout periods between treatments were up to 5 weeks. Both CHF6001 doses significantly attenuated the LAR; the primary endpoint analysis showed that CHF6001 400 μg and 1200 μg caused reductions of 19.7% (p = 0.015) and 28.2% (p < 0.001) respectively of the weighted FEV1 AUC4-10h compared with placebo. The difference between the CHF6001 doses was not statistically significant (p = 0.223). Compared with placebo, CHF6001 caused greater reduction in sputum eosinophil counts, although these changes were not statistically significant. CHF6001 was well tolerated, with similar numbers of adverse events in each treatment period. This inhaled PDE4 inhibitor has the potential to provide clinical benefits in patients with atopic asthma.

Thyroid hormone autoantibodies: are they a better marker to detect early thyroid damage in patients with hematologic cancers receiving tyrosine kinase inhibitor or immunoregulatory drug treatments?

BACKGROUND

Unlike cytotoxic agents, novel antineoplastic drugs can variably affect thyroid function and so impair patient outcomes. However, the widely used standard thyroid tests have demonstrated low sensitivity for detecting early thyroid damage that leads to dysfunction of the gland. To find a more reliable thyroid marker, we assessed the presence of antibodies binding thyroid hormones (thAbs) in a cancer population undergoing potentially thyrotoxic treatment.

METHODS

From April 2010 to September 2013, 82 patients with hematologic malignancies treated with tyrosine kinase inhibitors or immunoregulatory drugs were recruited. Healthy volunteers (n = 104) served as control subjects. Thyroid function, autoimmunity tests, thAbs, and thyroid sonography were assessed once during treatment.

RESULTS

Overall, thAb positivity was recorded in 13% of the entire cohort. In most cases, the thAbs were of a single type, with a predominance of T3 immunoglobulin G. More specifically, thAbs were detected in 11 cancer patients; and abnormal levels of thyroid-stimulating hormone, thyroglobulin antibody, and thyroperoxidase antibody were detected in 6 (p = 0.05), 0 (p = 0.0006), and 2 cancer patients (p = 0.001) respectively. Ultrasonographic alterations of the thyroid were observed in 12 cancer patients. In contrast, of the 104 healthy control subjects, only 1 was positive for thAbs (1%).

CONCLUSIONS

We have demonstrated for the first time that thAbs are a reliable marker of early thyroid dysfunction when compared with the widely used standard thyroid tests. A confirmatory prospective trial aiming at evaluating thAbs at various time points during treatment could clarify the incidence and timing of antibody appearance.

Medication is an additional source of phosphate intake in chronic kidney disease patients

BACKGROUND AND AIMS

Hyperphosphatemia increases the risk of cardiovascular morbidity but the use of medicines as a source of phosphate has not been investigated yet. This study aims to explore the use of absorbable phosphate-containing drugs in CKD patients.

METHODS AND RESULTS

Incident CKD patients were identified within the Arianna database (containing data from 158,510 persons in Caserta (Southern Italy) registered with 123 general practitioners) from 2005 to 2011. Drugs prescribed to these patients were classified as phosphate-containing based on the summary of product characteristics (SPC), PubChem and Micromedex. The number and duration of prescriptions for these drugs as well as the overall intake of phosphate were estimated. Out of 1989 CKD patients, 1381 (70%) were prescribed 266 medicinal products containing absorbable phosphate over a median follow-up of 6 years (interquartile range (IQR) = 5.2-6.0). Most patients were prescribed ATC A (650; 47.1%) and C (660; 47.8%) phosphate-containing drug products targeting the gastrointestinal and cardiovascular system for a median of 232 (IQR: 56-656) and 224 (IQR: 56-784) days respectively.

CONCLUSIONS

Several medications, especially chronically prescribed ones, contain absorbable phosphate. This study's findings confirm the relevance of medicines as a phosphate source for the first time.

Association of VDR gene polymorphisms with heart disease in chronic kidney disease patients

OBJECTIVES

It has been postulated that VDR polymorphisms influence mortality in CKD by directly modifying VDR protein levels or VDR sensitivity in target organs. Here we aimed at evaluating the possible association of VDR FokI and BsmI gene polymorphisms with co-morbid conditions of CKD at different stages.

DESIGN AND METHODS

The patients included in this study were a Sicilian cohort of 171 subjects, at CKD stage 1-2 (n=49), stage 3 (n=34), stage 4-5 (n=34), and hemodialysis (HD) (n=54). Almost 70% of patients were also suffering from heart disease, with/without diabetes and/or hypertension, and 40% were also suffering of hypertension, with/without diabetes and/or heart disease; only around 20% had no co-morbid conditions.

RESULTS

A highly significant association was found between the BsmI B minor allele and heart disease in all CKD stages. Indeed, the odds ratio calculation showed that patients bearing either the bB or BB genotype had, respectively, a seven-fold and around twelve-fold increased risk for heart disease. Instead, the presence of bb wild-type genotype was associated with a fifty-fold reduced risk for heart disease, suggesting that the b allele may display a protective effect. No association was found for FokI genotypes with the different co-morbid conditions.

CONCLUSIONS

We first demonstrated that the VDR BsmI B allele may be considered as a genetic determinant for heart disease and hypertension in CKD, independently from disease stage. Thus, the screening for VDR variants should be regarded as a way to better address preventive strategies and improving the management of CKD co-morbid conditions.

Mechanistic modeling of vacuum UV advanced oxidation process in an annular photoreactor

A novel mechanistic model that describes the vacuum UV advanced oxidation process in an annular photoreactor initiated by 172 nm and 185 nm (in combination with 253.7 nm, with and without exogenous H2O2) is presented in this paper. The model was developed from first principles by incorporating the vacuum UV-AOP kinetics into the theoretical framework of in-series continuous flow stirred tank reactors. After conducting a sensitivity analysis, model predictions were compared against experiments conducted under a variety of conditions: (a) photo-induced formation of hydrogen peroxide by water photolysis at 172 nm (for both air- and oxygen-saturated conditions); (b) photo-induced formation of hydrogen peroxide by water photolysis at 185 + 253.7 nm (in the presence of formic acid, with and without the initial addition of hydrogen peroxide); (c) direct photolysis of hydrogen peroxide by 253.7 nm; (d) degradation of formic acid by 185 + 253.7 nm (with and without initial addition of hydrogen peroxide); and (e) degradation of formic acid by 253.7 nm (with the addition of exogenous hydrogen peroxide). In all cases, the model was able to accurately predict the time-dependent profiles of hydrogen peroxide and formic acid concentrations. Two newly recognized aspects associated with water photolysis were identified through the use of the validated model. Firstly, unlike the 185 nm and 253.7 nm cases, water photolysis by the 172 nm wavelength revealed a depth of photoactive water layer an order of magnitude greater (∼230-390 μm, depending on the specific operating conditions) than the 1-log photon penetration layer (∼18 μm). To further investigate this potentially very important finding, a computational fluid dynamics model was set up to assess the role of transport mechanisms and species distributions within the photoreactor annulus. The model confirmed that short-lived hydroxyl radicals were present at a radial distance far beyond the ∼18 μm photon penetration layer. Secondly, kinetic simulations showed that the higher penetration depth of hydroxyl radicals was not caused by diffusive or convective transport phenomena but rather the effect of non-linear behavior of the complex reaction kinetics involved in the process.

Prevalence of dermatophytes and other superficial fungal organisms in asymptomatic guinea pigs in Southern Italy

OBJECTIVES

Guinea pigs have been indicated as a potential source of zoophilic dermatophytes that cause human dermatomycosis. The purpose of this study was to evaluate the prevalence of dermatophytes as well as saprophytic fungi in asymptomatic pet guinea pigs in Southern Italy.

METHODS

Two-hundred pet guinea pigs were enrolled from both private veterinary clinics and pet shops in the Campania region, Italy, from August 2012 to September 2013. Samples were collected using the MacKenzie's toothbrush technique. The plates were incubated for four weeks at 25°C and identification of the fungal colonies was based on both macroscopic and microscopic characteristics.

RESULTS

Two pathogenic dermatophytes were isolated in 9 (4·5%) of 200 guinea pigs; Epidermophyton species in 2 (1%) and Scopulariopsis species in 7 (3·5%). Saprophytic dermatophytes were isolated from 151 (75·5%) animals enrolled. No fungal growth was observed in 40 (20%) guinea pigs.

CLINICAL SIGNIFICANCE

The results of this study indicate a low prevalence of pathogenic dermatophytes in pet guinea pigs in Southern Italy but the presence of Epidermophyton and Scopulariopsis species in asymptomatic pet guinea pigs.

Survey of zoonotic dermatoses in client-owned exotic pet mammals in southern Italy

Several 'exotic' mammalian species (e.g. rabbits, rodents, ferrets and hedgehogs) live in close proximity to humans as companion pets. Skin diseases (SD) are frequent causes of morbidity in exotic pet mammals, and most of those SDs have a zoonotic potential. The purpose of this study was to determine the frequencies and types of zoonotic dermatosis (ZD) in client-owned, exotic pet mammals in Southern Italy. Six-hundred and fifty-five medical records of exotic pet mammals examined between 2011 and 2012, across twenty private practice veterinary clinics around the Naples area (Italy), were retrospectively evaluated and screened for animals diagnosed with SDs (rabbits n = 455, guinea pigs n = 93, ferrets n = 64, hedgehogs n = 19, chinchillas n = 13 and rats n = 11). The records of animals diagnosed with SD, whose causative agents had a zoonotic potential, were selected for analysis. The Mann-Whitney independent test was used for statistical analysis. A P value ≤ 0.05 was considered statistically significant. Eighty-two records (12.5%) of animals with ZD were identified. Of those, 56.1% (46/82) were affected by fungal infections and 42.7% (35/82) by parasitic infections. No zoonotic bacterial or viral infections were diagnosed. Dermatophytosis was significantly diagnosed more frequently in younger animals. The results of this survey indicate that exotic pet mammals may serve as active carriers for many highly contagious pathogens with zoonotic potential. Awareness and vigilance by the veterinary practitioner is crucial in the prevention of occurrences of ZDs. Children frequently come in close contact with exotic pets. To prevent the unplanned transmission of pathogen from pet to human, an active routine screening examination and preventative treatments are strongly recommended for every newly purchased pet mammal.

Distribution of K and L cells in the feline intestinal tract

Glucose-dependent insulinotropic peptide (GIP), glucagon-like peptide (GLP)-1 and GLP-2 are hormones secreted from specialized K cells (GIP) and L cells (GLP-1, GLP-2) in the intestinal mucosa. These hormones play major roles in health and disease by modulating insulin secretion, satiety, and multiple intestinal functions. The aim of this study was to describe the distribution of K cells and L cells in the intestines of healthy cats. Samples of duodenum, mid-jejunum, ileum, cecum, and colon were collected from 5 cats that were euthanized for reasons unrelated to this study and had no gross or histologic evidence of gastrointestinal disease. Samples stained with rabbit-anti-porcine GIP, mouse-anti-(all mammals) GLP-1, or rabbit-anti-(all mammals) GLP-2 antibodies were used to determine the number of cells in 15 randomly selected 400× microscopic fields. In contrast to other mammals (eg, dogs) in which K cells are not present in the ileum and aborally, GIP-expressing cells are abundant throughout the intestines in cats (>6/high-power field in the ileum). Cells expressing GLP-1 or GLP-2 were most abundant in the ileum (>9/high-power field) as in other mammals, but, although GLP-1-expressing cells were abundant throughout the intestines, GLP-2-expressing cells were rarely found in the duodenum. In conclusion, the distribution of GIP-secreting K cells in cats is different from the distribution of K cells that is described in other mammals. The difference in distribution of GLP-2- and GLP-1-expressing cells suggests that more than 1 distinct population of L cells is present in cats.

A Design to Study Flow Induced Crystallization in a Multipass Rheometer

The design and performance of a flow geometry for the multipass rheometer (MPR) is described, creating an experimental setup to study in-situ and ex-situ structure and morphology development with a proper control over the processing conditions and shear history. The slit used is equipped with diamond windows, to combine flow with different experimental techniques, such as optical microscopy (OM), birefringence and X-ray scattering. In this paper we present preliminary results, obtained on isotactic polypropylene, that demonstrate the possibilities of this device for more extended future research. The focus is on the in-situ birefringence measurements of crystallization and the relation with the final morphology.

Combined physico-chemical treatment of secondary settled municipal wastewater in a multifunctional reactor

In this paper, the physico-chemical treatment of municipal wastewater for the simultaneous removal of pollutant indicators (chemical oxygen demand (COD) and total coliforms) and organic contaminants (total phenols) was investigated and assessed. A secondary settled effluent was subjected to coagulation, disinfection and absorption in a multifunctional reactor by dosing, simultaneously, aluminum polychloride (dose range: 0-150 μL/L), natural zeolites (dose range: 0-150 mg/L), sodium hypochlorite (dose range: 0-7.5 mg/L) and powder activated carbon (dose range: 0-30 mg/L). The treatment process was optimized using computational fluid dynamics (CFD) and response surface methodology. Specifically, a Latin square technique was employed to generate 16 combinations of treating agent types and concentrations which were pilot tested on an 8 m(3)/h multifunctional reactor fed by a secondary effluent with COD and total coliform concentrations ranging from ≈20 to 120 mg/L and from 10(5) to 10(6) CFU/100 mL, respectively. Results were promising, indicating that removal yields up to 71% in COD and 5.4 log in total coliforms were obtained using an optimal combination of aluminum polychloride (dose range ≈ 84-106 μL/L), powder activated carbon ≈ 5 mg/L, natural zeolite (dose range ≈ 34-70 mg/L) and sodium hypochlorite (dose range ≈ 3.4-5.6 mg/L), with all treating agents playing a statistically significant role in determining the overall treatment performance. Remarkably, the combined process was also able to remove ≈ 50% of total phenols, a micropollutant known to be recalcitrant to conventional wastewater treatments.

Predictors of response among patients with panic disorder treated with medications in a naturalistic follow-up: the role of adult separation anxiety

BACKGROUND

Efficacy of treatments for panic disorder is well established, but not all patients respond. Adult separation anxiety has been found to predict poorer response to CBT, but its effect on response to medication has not been previously explored.

STUDY AIM

The aim of this study is to investigate if panic-agoraphobic spectrum factors, including 'separation anxiety' factor predict treatment outcome in patients with panic disorder.

STUDY SAMPLE

Participants who met criteria for PD (n=57) completed baseline assessment and 12 months follow-up. Patients were administered the Panic Agoraphobic Spectrum Self-Report (PAS-SR, Lifetime and Last-Month Versions), and the Panic Disorder Severity Scale (PDSS). We examined patients who met the following criteria at baseline: 1) PDSS total score>7; 2) no current Axis I comorbidity with major depression; 3) no lifetime or current bipolar disorder. All patients were treated with evidence-based psychopharmacological treatment for panic disorder during the 12-month observation period.

RESULTS

Twenty eight patients (48.1%) achieved remission during the follow-up period. In a logistic regression model, controlling for baseline severity, gender and age, only the last-month PAS-SR 'separation anxiety' factor was associated with a lower likelihood of remission.

CONCLUSIONS

Signs and symptoms of separation anxiety in adulthood, as assessed with the PAS-SR Last Month version, are predictors of poor treatment outcome in patients with PD. We submit that the assessment of panic-agoraphobic spectrum features, including adult separation anxiety, should become routine of clinical assessment of patients with PD. It is likely that a better psychopathological characterization of patients may inform treatment selection, and result in better treatment outcome.

Radon hazard in shallow groundwaters II: dry season fracture drainage and alluvial fan upwelling

²²²Rn concentrations have been measured in a well located on the edge of a large Pleistocene-Holocene fan and belonging to the shallow pyroclastic aquifer of the Pietramelara Plain, southern Italy. The aim of this study has been both to characterise the hydrological inputs that determine the influx of ²²²Rn to the shallow aquifer and to understand the correlations between ²²²Rn, major ions, physical-chemical parameters and rainfall. Results obtained from the time series indicate that the studied well shows a ²²²Rn variability that is inconsistent with a mechanism of pure hydrological amplification, such as described in Radon hazard in shallow groundwaters: Amplification and long term variability induced by rainfall (De Francesco et al., 2010a). On the contrary, in this well hydrological amplification appears to be mainly tied to the upwelling of alluvial fan waters, rich in radon, in response to pistoning from recharge in the carbonate substrate. This upwelling of alluvial fan waters occurs during almost the whole period of the annual recharge and is also responsible of the constant increase in ²²²Rn levels during the autumn-spring period, when both the water table level and weekly rainfall totals drop. Furthermore, a rapid delivery mechanism for ²²²Rn likely operates through fracture drainage in concomitance with the very first late summer-early autumn rains, when rainfall totals appear largely insufficient to saturate the soil storage capacity. Results obtained from this study appear to be particularly significant in both radon hazard zoning in relation to the shallow aquifer and possibly also for indoor radon, owing to possible shallow aquifer-soil-building exchanges. Moreover, both the spike-like events and the long wave monthly scale background fluctuations detected can also have potential significance in interpreting ²²²Rn time series data as seismic and/or volcanic precursors. Finally, ²²²Rn has proved to be an excellent tracer for hydrological inputs to the shallow aquifer when combined with major ions, physical-chemical data and geological and geomorphological controls.

1H and 10B NMR and MRI investigation of boron- and gadolinium-boron compounds in boron neutron capture therapy

(10)B molecular compounds suitable for Boron Neutron Capture Therapy (BNCT) are tagged with a Gd(III) paramagnetic ion. The newly synthesized molecule, Gd-BPA, is investigated as contrast agent in Magnetic Resonance Imaging (MRI) with the final aim of mapping the boron distribution in tissues. Preliminary Nuclear Magnetic Resonance (NMR) measurements, which include (1)H and (10)B relaxometry in animal tissues, proton relaxivity of the paramagnetic Gd-BPA molecule in water and its absorption in tumoral living cells, are reported.

Vascular access for hemodialysis and cardiovascular complications

Native arterio-venous fistula (AVF), is the first choice of the vascular access for hemodialysis treatment. In comparison with other vascular accesses such as prosthetic arterio-venous graft or permanent central venous catheter, AVF has shown a significant reduction in cardiovascular mortality. It needs, of course, an appropriate blood flow that provides a flow of 400-800 mL/min in the distal seat and a flow of 800-1500 ml/min in the proximal seat. As a consequence, the creation of AVF may be associated with changes in blood flow, pulmonary pressure and cardiac output. All these haemodynamic changes may not have any cardiac consequences, or they could lead to congestive heart disease particularly when the blood flow of AVF is greater than 2000 ml/min. For this reason, the patient's cardiac status should determine the choice of dialysis and the type of vascular access. Cardiac function monitoring is essential, particularly when dealing with patients at high risk for congestive heart disease and AVF in the proximal seat. Vascular access reduction surgery may be effective in some cases, otherwise a suitable alternative could be that of closing AVF. However, the likely side effects that can be generated by closing arterio-venous AVF such as a sudden increase of venous peripheral systemic should be taken into account.

Occult hepatitis B virus infection in a cohort of HIV-positive patients: correlation with hepatitis C virus coinfection, virological and immunological features

BACKGROUND

An evaluation of the prevalence of occult hepatitis B virus (HBV) infection in HIV-positive individuals is important as HBV infection may have an impact on the outcome of the liver disease in these patients.

MATERIALS AND METHODS

Of the 1,593 HIV-positive subjects enrolled in the Italian Cohort Naïve Antiretroviral (ICONA) program, 175 (10.9%) were selected for inclusion in the study on the basis of hepatitis B surface antigen (HBsAg) negativity and antibody to hepatitis B core antigen (anti- HBc) positivity; 101/175 (58%) were also anti-hepatitis C virus (HCV) positive. HBV-DNA was detected in plasma using a highly sensitive PCR assay (detection limit: 2.6 copies/ml). Two different genomic regions were assayed. Quantification was performed by real-time PCR. The HBV genotype was determined in 20 cases with occult HBV infection. Data on the antiretroviral therapy (ART) regimen was obtained in 169 individuals: 53 (31.4%) patients were ART-naive, 46 (27.2%) were under ART without lamivudine or tenofovir, and the remaining 70 (41.4%) were under ART including lamivudine or tenofovir.

RESULTS

27/175 (15%) patients had detectable HBV-DNA in their plasma: 21/101 (21%) were anti-HCV positive and 6/74 (8%) were anti-HCV negative. Genotype D was invariably found in the 20 cases analyzed. Occult HBV infection was significantly higher in HCV-coinfected subjects: adjusted OR 5.02, 95% CI 1.31-19.26, p = 0.02. The value was not associated with immune status, HIV load, or ART regimen.

CONCLUSIONS

In relation to the high prevalence of occult HBV infection, particularly in HIV/HCV-coinfected individuals, it is necessary to clarify the clinical impact of this cryptic infection by monitoring HBV-DNA in plasma using the correct approach. Similarly to HBsAg-positive individuals of the Mediterranean area, HBV genotype D is invariably detected in this cohort of HIV-infected patients with occult HBV infection.