Monitoring of the territorial consumption of antibiotics in local health authority of Vercelli as a measure to contrast AMR

In 2022 the Italian Ministry of Health published the National Antibiotic Resistance Plan (PNCAR) 2022 - 2025 which provides the strategic guidelines and operational indications for dealing with the emergency of antimicrobial resistance (AMR). ESAC recorded, in the year 2021, an average consumption of 16.4 DDD/1000 inhab. res. die, with a statistically significant decrease in the period 2012 -2021 for class J01, on total territorial and hospital consumption. Italy is one of the countries with the highest consumption of antibiotics, it ranks 9th with a total hospital and territorial consumption of 17.53 DDD/1000 inhab. res. die. The present study aims to monitor the territorial consumption of antibiotics in ASL VC through the analysis of synthetic indicators and ESAC indicators, comparing them with regional and national values. Through the IQVIA database, a retrospective descriptive study was conducted on the consumption of antibiotics (ATC J01), for the period 2020 - 2022, measuring the synthetic indicators of consumption (DDD1,000 inhab. res. die) and costs (value1,000 inhab. res. die). Subsequently, a second analysis was carried out by measuring the ESAC indicators for the year 2022, comparing them with the previous year or period. With regard to consumption, while a reduction (average -7%) was observed for contracted pharmaceuticals (CONV) in 2021 compared to 2020, followed by an increase in 2022 (average +31%); for private purchase (PRIV), consumption remained constant in 2021 and then increased in 2022 (average +40%). The same trend was observed for the costs of the J01 class. The ESAC indicators show a mild improvement for ASL VC (variable for regional and national level), except for the use of 3rd and 4th generation cephalosporins which recorded an increase in 2022. The reduction in the consumption of antibiotics in 2021, followed by an increase in 2022 can be partly explained by the pandemic period that has just ended which led to the return to the community with the resumption of infectious agents in circulation. It therefore becomes essential to pay particular attention to antibiotic stewardship activities, both in the hospital and on the territory. (community).

Correlations between Sleep Features and Iron Status in Children with Neurodevelopmental Disorders: A Cross-Sectional Study

A high prevalence of sleep disturbances has been reported in children with neurodevelopmental disorders (NDDs), such as autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and intellectual disability (ID). The etiology of sleep disorders in these children is heterogeneous and, recently, iron deficiency has received increasing attention. This study aims to investigate sleep features in children with NDDs and to explore a possible correlation between serum iron status biomarkers and qualitative features of sleep. We included 4- to 12-year-old children with a diagnosis of ASD, ADHD, or ID and assessed their sleep features through the children's sleep habits questionnaire (CSHQ). Venous blood samples were collected to investigate ferritin, transferrin, and iron levels. The mean CSHQ total score exceeds the cut-off in all groups of children. In the ASD group, the Parasomnias subscale negatively correlated with serum ferritin levels (Rho = 0.354; p = 0.029). Our findings may suggest the existence of an association between iron status, sleep quality, and neurodevelopmental processes. In clinical practice, sleep assessment should be included in the routine assessment for patients with NDDs. Furthermore, a routine assessment of iron status biomarkers should be recommended for children with NDDs who have sleep disturbances.

Field efficacy of Metarhizium anisopliae oil formulations against Rhipicephalus microplus ticks using a cattle spray race

Rhipicephalus microplus tick is the main ectoparasite of cattle in Brazil. The exhaustive use of chemical acaricides to control this tick has favored the selection of resistant tick populations. Entomopathogenic fungi, as Metarhizium anisopliae, has been described as a potential biocontroller of ticks. Therefore, the aim of this study was to evaluate the in vivo efficacy of two oil based formulations of M. anisopliae for the control of the cattle tick R. microplus under field conditions using a cattle spray race as a method of treatment. Initially, in vitro assays were carried out with an aqueous suspension of M. anisopliae, using mineral oil and/or silicon oil. A potential synergism between oils and fungus conidia for tick control was demonstrated. Additionally, the usefulness of silicon oil in order to reduce mineral oil concentration, while improving formulation efficacy was illustrated. Based on the in vitro results, two formulations were selected for use in the field trial: MaO1 (10⁷ conidia/mL plus 5% mineral oil) and MaO2 (10⁷ conidia/mL plus 2.5% mineral oil and 0.01% silicon oil). The adjuvants concentrations (mineral and silicon oils) were chosen since preliminary data indicate that higher concentrations caused significant mortality in adult ticks. For this, 30 naturally infested heifers were divided into three groups based on previous tick counts. The control group did not receive treatment. The selected formulations were applied on animals using a cattle spray race. Subsequently, tick load was evaluated weekly by counting. The MaO1 treatment significantly reduced the tick count only on day +21, reaching approximately 55% efficacy. On the other hand, MaO2 showed significantly lower tick counts on days +7, +14, and +21 after treatment, with weekly efficacy achieving 66%. The results showed a substantial reduction of tick infestation, up to day +28, using a novel formulation of M. anisopliae based in the mixture of two oils. Moreover, we have shown, for the first time, the feasibility of employing formulations of M. anisopliae for large-scale treatment methods, such as a cattle spray race, which in turn, may increase the use and adhesion to biological control tools among farmers.

Essential Thrombocythemia Associated with Plasma Cell Neoplasm

Introduction/Objective

The co-occurrence of essential thrombocythemia (ET) and multiple myeloma (MM), two distinct entities with distinct cellular origin, is rare, with a limited number of cases reported.

Methods/Case Report

We report a case of a 63-year-old male who initially presented with thrombocytosis, splenomegaly and elevated LDH. A bone marrow examination showed hypercellularity (90%) with increased abnormal megakaryocytes, as well as a JAK2 V617F mutation, with overall features consistent with involvement by a myeloproliferative neoplasm (MPN), consistent with ET (versus early primary myelofibrosis (PMF)). Additionally, 6% kappa-restricted plasma cells were identified, consistent with involvement by a monoclonal gammopathy of undetermined significance (MGUS). The patient was subsequently treated with hydroxyurea. Four years later, he presented with evidence of paraproteinemia. IgG kappa monoclonal paraprotein was elevated at 3.4 g/dL. A repeat bone marrow examination showed hyper-cellularity (60%), including clusters of abnormal megakaryocytes and mild to moderate reticulin fibrosis. The previously identified kappa-restricted plasma cell population increased to approximately 40% of the total cellularity. Cytogenetic analysis showed a normal male karyotype (46,XY[20]), and a prognostic myeloma-FISH panel including 13q-/-13, 1q32/1q21, p53/NF1, CCND1/IgH t(11;14), FGFR3/IgH t(4;14), IgH/MAF t(14;16) and IgH/MAFB t(14;20) was negative for all tested abnormalities. The overall features were again consistent with involvement by an MPN and progression of the previously identified MGUS.

Results (if a Case Study enter NA)

NA.

Conclusion

Only a few cases of concurrent ET and MM have been previously reported in the literature, with most of these cases having a temporal association with alkylating agent therapy. However, MM development has also been reported in a patient with non-cytotoxic treatment of ET. In contrast, our patient was diagnosed with ET associated with MGUS at the initial diagnosis. Notably, the co-existence of early PMF with MM appears to be relatively more established. A large study showed that previous PMF was strongly associated with MM development (OR 24.3; 95% CI:2.9-201.5).

Sacubitril-valsartan activates pAMPK and reduces NLRP3, MyD88, cytokines/growth factors and DAMPs in doxorubicin-treated mice improving longitudinal strain and ejection fraction

Background

Doxorubicin-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in breast cancer patients. Sacubitril-valsartan (LCZ 696) is a combination drug, made up of neprilysin inhibitor sacubitril and angiotensin II receptor blocker valsartan, used for the treatment of heart failure in patients with a reduced ejection fraction.

Purpose

We hypothesized that LCZ 696, administered during doxorubicin, could improve cardiac function

Methods

Female C57Bl/6 mice were untreated (Sham, n=6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n=6), LCZ-696 at 60 mg/kg (LCZ, n=6) or doxorubicin combined to LCZ-696 (DOXO-LCZ, n=6). Ejection fraction, radial and longitudinal strain were analyzed through transthoracic echocardiography (Vevo 2100). Cardiac tissue expression of NLRP3 inflammasome, Myd88, DAMPs (galectine 3 and calgranulinS100), pAMPK, NF-kB, and 13 chemokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified through ELISA and western blot methods.

Results

LCZ 696 improved significantly the EF and prevented the reduction of radial and longitudinal strain after 10 days of treatment with doxorubicin. A reduced expression of NLRP3, MyD88, DAMPs and NF-kB in cardiac tissues was seen in DOXO-LCZ group compared to DOXO mice (p<0.001). Cardiac expression of IL-1β, IL-6, TNF-α, G-CSF and GM-CSF were significantly reduced after treatment with LCZ-696 indicating anti-inflammatory properties. Expression of pAMPK was strongly enhanced in LCZ-696-DOXO compared to DOXO group. Levels of Calgranulin S100 and galectine-3 were strongly enhanced in DOXO group; on the other hand their expression were reduced by 47.7 and 52.3% in LCZ-696-DOXO group vs DOXO (p<0.005).

Conclusion

In this preclinical study, LCZ-696 is able to improve cardiac function and reduce biomarkers involved in heart failure and fibrosis. The overall picture of the study pushes the use of Sacubitril-valsartan in prevention of cardiomyopathies induced by anthracyclines in cancer patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Ricerca Corrente, Ministero della Salute

Multimodality imaging to assess severity and outcome in asymptomatic patients with aortic stenosis: a medium-long term follow-up study

Background

Multimodality imaging approach is becoming more and more common in evaluating the severity and outcome of aortic stenosis (AS).

Aim

To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low flow, low gradients (LFLG) severe AS.

Methods

70 (81.4±8.4 years) prospective asymptomatic patients with AS were followed for 2.77±2.01 years with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1.

Results

Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13 (18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p<0.001), pulse pressure (p=0.005) and dilated ascending aorta (p<0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA = 1 cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24 mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p<0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55 AU/m2) and true severe in 12 (3388±1188 AU; 1858±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations.

Conclusions

Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of rest B-lines with the simplified 4-site scan for predicting survival: incremental value over transthoracic echocardiography

Background

Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest.

Methods

After preliminary exclusion of 154 patients lost to follow-up, we analyzed transthoracic echocardiography (TTE) plus LUS (4-site simplified scan) data in 5165 subjects (age 64±11 years) referred to 19 certified centers of 9 countries for known or suspected coronary artery disease (n=3891, 75%), dyspnea (n=591, 12%), or screening in asymptomatic patients with risk factors (n=667, 13%). We analyzed the anterior and lateral hemi-thoraces, scanning from mid-axillary to mid-clavicular lines on the third intercostal space. B-lines score ranged from 0 (normal) to 40 (severely abnormal). By selection, follow-up information was available in all. All-cause death was the predetermined end-point.

Results

Feasibility of B-lines was 100% in all subjects. B-lines (median) were 0.1 [0–1]. Rest B-lines (≥2) were present in 863 patients (16.7%). Ejection fraction was 61±10%. After a median follow-up of 690 (Interquartile range 420–1065) days, 96 all-cause deaths occurred. Two-year mortality was 3.6% in patients with and 1.5% in patients without B-lines (p<0.001) and increased progressively with the increasing number of B-lines, from 2.4% in mild (2–4, n=630), 5.0% in moderate (5–9, n=160) and 8.2% in patients with severe (≥10, n=73) B-lines (see figure). At multivariable analysis, rest B lines (HR 1.812, 95% CI: 1.165–2.916, p=0.008) and ejection fraction (HR 0.987, 95% CI: 0.976–0.998, p=0.020) were independent predictors of all-cause death, in addition to age (HR 1.045, 95% CI: 1.023–01.067, p<0.001) and diabetes (HR 1.643, 95% CI: 1.079–2.503, p=0.021).

Conclusion

In all-comers referred for TTE, resting B-lines assessed by focused LUS with the simplified 4-site scan are detected in 1 out of 4 patients with symptos or coronary risk factors and are associated with worse survival. The severity of pulmonary congestion predicts the severity of outcomes. The prognostic value of resting B-lines is independent and additive over standard clinical and TTE predictors such as diabetes and ejection fraction. Focused LUS for pulmonary congestion can easily be incorporated in standard TTE examination.

Funding Acknowledgement

Type of funding sources: None.

Effect of troxerutin in counteracting hyperglycemia-induced VEGF upregulation in endothelial cells: a new option to target early stages of diabetic retinopathy?

Diabetic retinopathy (DR), one of the most common complications of diabetes mellitus, is characterized by degeneration of retinal neurons and neoangiogenesis. Until today, the pharmacological approaches for DR are limited and focused on counteracting the end-stage of this neurodegenerative disease, therefore efforts should be carried out to discover novel pharmacological targets useful to prevent DR development. Hyperglycemia is a major risk factor for endothelial dysfunction and vascular complication, which subsequently may trigger neurodegeneration. We previously demonstrated that, in the rat retina, hyperglycemia activates a new molecular cascade implicating, up-stream, protein kinase C βII (PKC βII), which in turn leads to a higher expression of vascular endothelial growth factor (VEGF), via the mRNA-binding Hu-antigen R (HuR) protein. VEGF is a pivotal mediator of neovascularization and a well-known vasopermeability factor. Blocking the increase of VEGF via modulation of this cascade can thus represent a new pharmacological option to prevent DR progression. To this aim, proper in vitro models are crucial for drug discovery, as they allow to better identify promising effective molecules. Considering that endothelial cells are key elements in DR and that hyperglycemia triggers the PKCβII/HuR/VEGF pathway, we set up two distinct in vitro models applying two different stimuli. Namely, human umbilical vein endothelial cells were exposed to phorbol 12-myristate 13-acetate, which mimics diacylglycerol whose synthesis is triggered by diabetic hyperglycemia, while human retinal endothelial cells were treated with high glucose for different times. After selecting the optimal experimental conditions able to determine an increased VEGF production, in search of molecules useful to prevent DR development, we investigated the capability of troxerutin, an antioxidant flavonoid, to counteract not only the rise of VEGF but also the activation of the PKCβII/HuR cascade in both in vitro models. The results show the capability of troxerutin to hinder the hyperglycemia-induced increase in VEGF in both models through PKCβII/HuR pathway modulation. Further, these data confirm the key engagement of this cascade as an early event triggered by hyperglycemia to promote VEGF expression. Finally, the present findings also suggest the potential use of troxerutin as a preventive treatment during the early phases of DR.

The ischemic cascades in contemporary patients: five distinct phenotypes assessed by ABCDE stress echocardiography

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI)

Background

The classical pathophysiological cornerstone of stress cardiac imaging is the ischemic cascade: alterations in coronary flow velocity reserve (CFVR) come first, regional wall motion abnormalities (RWMA) second, and global alterations of left ventricular diastolic and systolic function last.

Aim

To evaluate the ischemic cascade with stress echo (SE) assessed with ABCDE protocol.

Methods

We analyzed 1616 patients (age 66 ± 10 years, 1156, 72% males) with chest pain and angiographically documented coronary artery disease (CAD): 928 (57.4%) with previous myocardial infarction and 1451 (89.8%) with previous coronary revascularization. CAD patients were studied with ABCDE-SE protocol by 13 certified laboratories of 5 countries. Stress modality was exercise in 427 (26.4%) dobutamine in 173 (10.7%) and vasodilator stress in 1016 (62.9%) patients (dipyridamole in 982 – 60.8% and adenosine in 34 – 2.1% patients). Step A assessed RWMA; step B, B-lines (diastolic function); step C, left ventricular contractile reserve based on force; step D, CFVR in left anterior descending artery; step E, heart rate reserve. SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). Follow up was obtained in all patients.

Results

Results were abnormal in 350 (21.7) % for step A, 572 (35.4%) for B, 666 (41.2%) for C, 546 (33.5%) for D and 643 (39.8%) for E. The distribution of positivity is shown in figure. The dominant "solitary phenotype" (only one biomarker abnormal during the test) was step A in 10 (0.6%), step B in 124 (7.7%) step C in 100 (6.2%), step D in 64 (4.0%) and step E in 157 (9.7%) patients. The overall sensitivity for CAD detection including each step of ABCDE score (≥1) was 95.7%. During median follow-up of 22 months [IQ range: 13-37 months] 279 coronary revascularizations occurred. ABCDE score predicted coronary revascularization with score 1: HR: 3.182, 95% CI: 1.699-6.067; score 2: HR: 4.921, 95% CI: 2.571-9.420; score 3: HR: 7.234, 95% CI: 3.743-13.979; score 4: HR: 24.570, 95% CI: 13.390-45.086; and score 5: HR: 38.720, 95% CI: 20.975-71.478

Conclusion

Inducible ischemia with CAD is characterized by the complexity and multiplicity of diagnostic phenotypes. The overall ABCDE score predicts clinically driven revascularization. Abstract Figure. The 5 circles of ischemia biomarkers

Sacubitril-valsartan improves radial and longitudinal strain and ejection fraction in C57Bl/6 mice treated with doxorubicin through NLRP3 mediated pathways and reduction of cytokine storm

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Ricerca Corrente grant, Ministero della Salute (it)

Background

Doxorubicin-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in breast cancer patients. Sacubitril-valsartan (LCZ 696) is a combination drug, made up of neprilysin inhibitor sacubitril and angiotensin II receptor blocker valsartan, used for the treatment of heart failure in patients with a reduced ejection fraction.

Hypothesis

we hypothesized that LCZ 696, administered during doxorubicin, could improve cardiac functions in preclinical models

Methods

 C57Bl/6 mice were untreated (Sham, n = 6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n = 6), LCZ-696 at 60 mg/kg (LCZ, n = 6) or doxorubicin combined to LCZ-696 (DOXO-LCZ, n = 6). Before and after treatments, ejection fraction (EF) and radial and longitudinal strain were analyzed through transthoracic echocardiography (Vevo 2100). After treatment, mice were sacrificed and cardiac tissues were treated for determination of NLRP3 inflammasome, Myd88, NF-kB and cytokines involved in heart failure and arrhythmias (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF).

Results

LCZ 696 improved significantly the EF and prevented the reduction of radial and longitudinal strain after 10 days of treatment with doxorubicin. No significant differences were observed for IVS;d-D, LVID;d-D, LVPW;d-D, LV Mass, LV Vol; d, LV Vol;s between the experimental groups.  A reduced expression of NLRP3, MyD88 and NF-kB in cardiac tissues was seen in DOXO-LCZ group compared to DOXO mice (p < 0.001). Cardiac expression of IL-1β, IL-6, TNF-α, G-CSF and GM-CSF were significantly reduced (p < 0.001) after treatment with LCZ-696 indicating anti-inflammatory and cardioprotective properties.

Conclusion

LCZ-696 improves cardiac functions in mice treated with doxorubicin. Biochemically, these effects are mediated by the downregulation of NLRP3 inflammasome-related pathways and cytokines involved in doxorubicin-mediated heart failure and cardiomyopathies.

Metastatic Neoplasms of the Large Bile Ducts- A Clinicopathological Study

Introduction/Objective

Biliary strictures are often considered malignant until proven otherwise. While the majority of malignant biliary strictures represent a primary neoplasm, secondary involvement by metastasis also rarely occurs. Primary cholangiocarcinoma and metastatic disease have different treatment considerations and likely different prognoses. The aim of this study is to look at the clinico-pathological characteristics of metastatic neoplasms of the bile duct.

Methods/Case Report

We retrospectively searched the pathology archives for biliary biopsies between 1991-2020. Patients with primary biliary, gallbladder, pancreatic, ampullary and hepatic malignancies and all cases of lymphoma were excluded from the study. A total of 20 cases were included.

Results (if a Case Study enter NA)

The median age of the patients was 63 years with a M:F ratio of 1.9:1. The biopsies were taken from the common bile duct (n=17), common hepatic duct (n=2) and left hepatic duct (n=1). 8 patients had synchronous and 12 had metachronous presentation. The overall median interval between the bile duct metastasis and primary was 18 months (Range: 0-100 months) for all patients and 33 months for metachronous cases. For 13 tumors, the primary site of origin was in the gastrointestinal tract (colon: 7; stomach: 4; anal canal: 1; gastro-esophageal junction: 1). Other primary sites included breast (3 cases), lung, endometrium and adrenal (1 each). One case presented with metastatic melanoma with an occult primary. Adenocarcinoma was the most common histological subtype seen in 17 cases. Other histological subtypes were squamous cell carcinoma, adrenocortical carcinoma and melanoma.

Conclusion

Secondary involvement of the bile duct by metastasis is rare. Most cases are metastasis from the lumenal gastrointestinal tract, with colon being the most common primary site. They are more likely to have a metachronous presentation with rare instances of bile duct metastasis as the first presentation. Awareness of secondary involvement of the biliary tree by metastasis is important as they can have prognostic and therapeutic significance.

Ipilimumab and Nivolumab exertes cardiotoxic and pro-fibrotic effects in mice through the overexpression of NLRP3 inflammasome, chemokines and leukotrienes

Background

Several strategies based on immune checkpoint inhibitors (ICIs) have been developed for cancer therapy, opening to advantages in cancer outcomes. However, several ICIs-induced side effects emerged in these patients, especially a rare but clinically significant cardiotoxicity with high rate of mortality.

Purpose

We studied cytotoxic and pro-inflammatory properties of Ipilimumab and Nivolumab in cellular and preclinical models

Methods

Co-cultures of human cardiomyocytes and hPBMCs were exposed to Ipilimumab or Nivolumab at 100 nM; cell viability and expression of leukotrienes, NLRP3 inflammasome, MyD88 (myddosome) and p65/NF-kB were performed. C57 mice were untreated (Sham; n=6) or treated with Ipilimumab (IPI, n=6) (15 mg/kg); analysis of fractional shortening, ejection fraction, radial and longitudinal strain were made before and after treatments through 2D-echocardiography (Vevo 2100). Expression of NLRP3, MyD88, p65/NF-kB, leukotrienes and 12 cytokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IFN-γ, TNF-α, G-CSF, and GM-CSF) have been analyzed in murine myocardium.

Results

Nivolumab and Ipilimumab induced cell death and apoptosis in cardiomyocutes. Both ICIs increased NLRP3, MyD88 and p65/NF-kB expression compared to untreated cells, however the most pro-inflammatory and cardiotoxic effects were seen after exposure to Ipilimumab. Mice treated with Ipilimumab showed a significant decrease of fractional shortening and radial strain compared to untreated mice. Metabolic studies clearly indicates that ipilimumab increases leukotrienes production and NLRP3 expression in heart tissues, probably due to increased iROS content (iROS are key inductors of leukotrienes expression). High expression of IL-6, IL-1 and IL-17 were also seein in mice treated with ipilimumab (p<0,001).

Conclusions

Nivolumab and Ipilimumab exert cytotoxic effects mediated by NLRP3 inflammasome, leukotrienes and pro-inflammatory cytokines in heart tissues.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministero della Salute, Ricerca Corrente Project

Prognostic value of ABCDE stress echocardiography

Background

Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B-lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, EKG-based heart rate reserve. Aim: to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicenter, international, effectiveness study.

Methods

From July 2016 to November 2020, we enrolled 3,574 all-comers (age 65±11 years, 2,070 males, 58%; ejection fraction 60±10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent ABCDE-SE. The employed stress modality was exercise (n=952, with semi-supine bike, n=887, or treadmill, n=65 with adenosine for step D) or pharmacological stress (n=2,622, with vasodilator, n=2,151; or dobutamine, n=471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only end-point.

Results

Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D and 37% for E step. During a median follow-up of 21 months, 73 deaths occurred. At univariable analysis, predictors of all-cause mortality were step B (hazard ratio, HR: 2.621, 95% Confidence Intervals, CI: 1.654–4.152, p<0.001), step D (HR: 2.578, 95% CI: 1.624–4.093, p<0.001), and step E (HR: 2.955, 95% CI: 1.848–4.725, p<0.001), but not step A (HR: 1.333, 95% CI: 0.731–2.430, p=0.349) and step C (HR1.581, 95% CI: 0.997–2.506, p=0.051). At multivariable analysis, ABCDE-SE was an independent predictor of mortality with score 3 (HR: 3.472, 95% CI: 1.483–8.135, p=0.004), 4 (HR: 4.045, 95% CI: 1.595–10.259, p=0.003) and 5 (HR: 5.678, 95% CI: 2.106–15.313, p=0.001) (Figure). Annual mortality rate ranged from 0.4% person/year for score 0 up to 2.4% person/year for score 5.

Conclusion

ABCDE-SE allows an effective risk stratification of patient global vulnerability.

Funding Acknowledgement

Type of funding sources: None. Survival curves based on ABCDE score

Consequences on the right ventricular to pulmonary circulation coupling of COVID-19 infection

Background

Right Ventricular (RV) dysfunction and pulmonary hypertension (PH) are two very likely acute and long term targets of COVID-19 pneumonia, with a potential prognostic implications.

Purpose

To determine the COVID-19 pneumonia effects on the right ventricular to pulmonary circulation coupling through bedside echocardiography and extend its implications to prognostic assessment.

Methods

Single-centre study including consecutive subjects hospitalized for COVID-19 pneumonia who underwent a clinical indicated echocardiogram between March 2020 and December 2020. Extensive analysis of cardiac function was performed offline by an operator blinded to clinical data, laboratory findings and CT scans.

Results

133 patients were enrolled (mean age 69±12 years, 57% men), 38% of whom already had cardiac disease in their medical history. In-hospital mortality was 26% (35 pts), during a mean hospital stay of 26±16 days. Non survivors had higher pulmonary artery systolic pressure (PASP) and worse RV function, assessed with both standard parameters (i.e. TAPSE) and with the novel speckle tracking analysis by RV-Global Longitudinal Strain (RV-GLS) and RV-Free Wall Longitudinal Strain (RV-FWLS). The combination of these two variables in TAPSE/PASP ratio allows assessment of RV to pulmonary circulation (Pc) coupling and was strongly associated with in-hospital death (HR 0.73, 95% CI 0.59–0.89, p=0.003) and patients with TAPSE/PASP<0.57 mm/mmHg had a more than 4-fold increased risk of in-hospital death (HR 4.8, 95% CI 1.7–13.1, p=0.003). In patients where speckle tracking analysis was feasible, we examined RV-GLS/PASP and RV-FWLS/PASP and found that it was associated with in-hospital mortality. The best cut-offs for predicting in-hospital mortality was 0.51 for RV-GLS/PASP (94% sensitivity and 59% specificity) and 0.49 for RV-free wall LS (87% sensitivity and 70% specificity). At the multivariable analysis RV to Pc remained associated with in-hospital death after adjustments for age, PaO2/FiO2, LVEF, and severity of lung involvement at the CT.

Conclusions

Either PH and RV dysfunction predict in-hospital mortality in patients with COVID-19 pneumonia. The assessment of RV to Pc coupling, however, better describes the adaptive RV response to increased PASP and gives additional prognostic information in a population with a relevant prevalence of comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Factors affecting progression to permanent atrial fibrillation in an unselected population of patients with non-permanent form of atrial fibrillation

Background

Natural history of atrial fibrillation (AF) shows a progression of arrhythmia from non-permanent to permanent AF. Permanent AF was found associated with a worse prognosis than non-permanent one.

Aim

To assess the factors associated with progression to permanent AF in an unselected population of AF patients with non-permanent AF.

Methods

In this prospective study we enrolled in- as well as out-patients with non-permanent AF and age ≥18 years, with at least one episode of ECG-documented AF within 1 year. The patients were followed-up at 1 month and every 6 months thereafter.

Results

Out of 523 patients, 314 (60%) were in non-permanent AF (80 [25.5%] paroxysmal AF, 165 [52.5%] persistent AF, 69 [2%] first diagnosed AF), mostly male (188, 59.9%), median age 71 years (IQ range 62–77), median CHA2DS2VASc 3 (1–4), median HATCH score 1 (1–2). After a median follow-up of 701 (IQ range 437–902) days, 66 patients (21%) showed permanent AF.

CHA2DS2VASc and HATCH scores were incrementally associated to progression to permanent AF (CHA2DS2VASc χ2 p=0.001; HATCH χ2 p=0.017; p for trend CHA2DS2VASc <0.001, HATCH p=0.001).

At multivariable Cox proportional hazard regression the following variables were significantly associated with AF progression: age (hazard ratio [HR] 1.041; 95% CI: 1.004–1.079; p=0.028), at least moderate left atrial (LA) enlargement (>42 ml/m2) (HR 2.092; 95% CI: 1.132–3.866; p=0.018), antiarrhythmics drugs after the enrollment (HR 0.087; 95% CI: 0.011–0.662; p=0.018), EHRA score >2 (HR 0.351; 95% CI: 0.158–0.779; p=0.010) and Valvular HD (HR 2.161; 95% CI: 1.057–4.420; p=0.035). Adding LA dilation to HATCH score (HATCH-LA) and assigning 2 points based on multivariable Cox regression, HATCH-LA was statistically better in ROC curves in prediction of AF progression vs HATCH score (area under the curve 0.695 vs 0.636; DeLong p=0.0225). Survival-free curves on freedom from permanent AF using as discriminator HATCH-LA score ≤2 vs >2 led to a statistically significant difference (χ2=16.080 p<0.001), but the same was not found for HATCH score (χ2 =3.099; p=0.078).

Conclusions

In patients without permanent AF, progression of AF was independentely related to age, LA dilation, AF symptoms severity, antiarrhythmic drugs and Valvular HD. HATCH score predicted AF progression and adding to it LA dilation (at least moderate) improved patients stratification for the risk of evolution to permanent AF.

Funding Acknowledgement

Type of funding source: None

Is raphe only an innocent bystander finding or a predictor of complications in bicuspid aortic valve patients? Experience of Italian REBECCA registry

Background

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5%–2% of the general population. It is associated with valvular dysfunction (aortic stenosis and/or regurgitation, endocarditis) but also with a wide spectrum of aortopathy with unpredictable clinical presentations. The role of the raphe is still controversial.

Methods

The REgistro della Valvola Aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging is a retrospective/prospective, multicenter, observational registry, with definitive diagnosis of BAV. Anamnestic, demographic, clinical, and instrumental data are collected into dedicated software at first evaluation and during follow-up. Aortopathy was defined as: annulus ≥14 mm/m2; root ≥20 mm/m2; sino-tubular junction (STJ) ≥16 mm/m2; ascending aorta (AA) ≥17 mm/m2; it was classified in: type A, dilation of the ascending aorta; type B, dilation of the aortic root and the ascending aorta; and type C, isolated dilation of the aortic root. Patients were divided in two groups; those with raphe and those without.

Results

At December 2019, 800 patients with BAV (Male, 73.3%; M:F ratio 2.9; Mean Age at diagnosis 44±23 years) have been included in the registry. Prevalence of hypertension was 29%, diabetes mellitus 3%, smoking-habit 8%. We reported a majority (42.7%, 342) of patients with type 1, followed by type 2 (10.2%, 82) and type 3 (3.7%, 30). No gender differences were observed according to BAV phenotypes, while male gender was associated to higher prevalence of aortic valve regurgitation (p=0.0003). Moreover, in patients with raphe, aortic stenosis (49.8% vs 38.4%; p=0.014) and aortopathy (57.4% vs 46.1%; p=0.034) were significantly prevalent (see Table 1). Of note no difference about aortic regurgitation (62.8% vs 48.7%; p=0.064) between two groups were detected. At univariable logistic regression analysis the presence of raphe was significantly associated with aortopathy [OR: 1.57; 95% CI: 1.02–1.42; p=0.037] especially with Type B Aortopathy [OR: 0.55: 95% CI: 0.33–0.93: p=0.02].

Conclusion

Preliminary data from Italian Multicenter REBECCA registry highlight that, in patients with BAV, the raphe is not an innocent bystander but a risk factor for aortic stenosis and type B aortopathy.

Funding Acknowledgement

Type of funding source: None

Isolated and combined organic acids in diets of broiler chickens challenged with Eimeria acervulina

ABSTRACT This study aimed to evaluate the effect of isolated or combined citric and benzoic acids added to the diets of broiler chickens on performance, allometry of the digestive system organs, intestinal pH and quantity of microorganisms in the jejunum. A total of 840 male Cobb broiler chicks were utilized, distributed in a complete random design in 2 × 2 factorial scheme, supplemented or not with citric acid, and sodium benzoate, with seven replications. At 14 days old, 1mL of a solution containing 1 × 105 sporulated oocysts of Eimeria acervulina per bird was inoculated orally. There was no effect of the acids on the broiler’s performance in the 1 to 21-day period. In the total period (1 to 42 days), the broilers fed with a blend of citric and benzoic acid presented greater feed intake, without increment in weight gain. The data of allometry of the digestive system organs and the jejunal pH values were not influenced by the treatments. The citric acid increased the bacterial quantity of gram-positive coccus and total anaerobes in the jejunum. Under the conditions of the present study, we conclude that the citric and benzoic acids, isolated or combined, do not benefit the nutrition of broilers challenged with E. acervulina.

THU0616-HPR EXPIRATORY FLOW ACCELERATOR (EFA) IN SYSTEMIC SCLEROSIS PATIENTS WITH MUCUS HYPERSECRETION, PRODUCTIVE COUGH AND DYSPNOEA: PRELIMINARY RESULTS FROM A HOME-BASED AIRWAY CLEARANCE TECHNIQUE DAILY PROGRAM

Background:

Systemic sclerosis (SSc) is a chronic disease with frequent lung involvement. As mucociliary clearance is impaired, mucus retention and frequent pulmonary infections, increase morbidity and mortality (1).

Airway clearance techniques (ACT) enhance removal of mucus from the airways. Expiratory flow accelerator (EFA) is a new technology that promotes deep and gentle drainage of the bronchial secretions, through the Venturi effect. No respiratory effort is required and no negative pressure is generated, avoiding risk of bronchial collapse (2).

Objectives:

The aim of this study was to describe the effectiveness of EFA in improving pulmonary symptoms in SSc patients.

Methods:

SSc patients with daily productive cough, frequent pulmonary exacerbations, exertional dyspnea and/or reduced physical activity were selected. All of them underwent a home-based ACT program with EFA. A Respiratory Physiotherapist (RT) trained each patient to use the device 3 times a day, 15 minutes each session. Every subject compiled the Saint George’s Respiratory Questionnaire (SGRQ) and scleroderma Health Assessment Questionnaire (SHAQ) at baseline, 30, 90 and 180 days from the beginning. Statistical analysis has been carried out with General linear model for repeated measures. A value of p<0.05 was considered statistically significant.

Results:

8 patients were enrolled (M:F=1:7), median age 54 (IC95% 46-69) years. Interstitial lung disease affected the majority of them (7/8). SGRQ total score and SHAQ domain for respiratory symptoms decreased over time (p= 0.003 and p= 0.005). In particular, there was an improvement in two SGRQ domains: activities (p= 0.013) and symptoms (p= 0.005) (fig.1).

Figure 1

Conclusion:

This is the first study to investigate the effect of EFA technology on airway clearance in SSc patients. The observations suggest the importance of a daily ACT program with EFA in improving respiratory symptoms. This technology appear to be extremely promising in SS patient management as it is well tolerated and it has the potential to slow down the pulmonary disease progression by limiting bronchial infections.

References:

[1]Tyndall AJ et al. Causes and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database. Ann Rheum Dis 2010;69:1809–15.

[2]Zampogna E, et al. Expiratory Flow Accelerator (EFA) technique on mucus hypersecretion of COPD patients with reduced cough efficiency after a severe exacerbation. Int Clin Med 2019;3:1-6.

Disclosure of Interests:

Silvia faverzani: None declared, Andrea Becciolini Speakers bureau: Sanofi-Genzyme, UCB and AbbVie, ernesto crisafulli: None declared, filippo nocera: None declared, eleonora di donato: None declared, Flavio Mozzani: None declared, michele riva: None declared, Daniele Santilli: None declared, lorenza monica: None declared, annalisa barbieri: None declared, lissette barone: None declared, maurizio marvisi: None declared, veronica alfieri: None declared, annalisa frizzelli: None declared, Alfredo Chetta: None declared, ALARICO ARIANI: None declared

P752 Mitral regurgitation in patients with severe aortic stenosis: role of valvular calcification in the persistence of mitral regurgitation after aortic valve replacement

Introduction

mitral regurgitation is often associated with severe aortic stenosis but the indications for its correction at the time of aortic valve surgery are still unclear. Despite the indication for mitral valve repair or replacement in the case of severe secondary mitral regurgitation, many patients are left untreated. This is due to the common belief that secondary mitral regurgitation mostly improves after the aortic valve is treated.

Purpose

the aim of the study is to investigate the prevalence and distribution of mitral calcifications, their role in the development of mitral regurgitation and in its reduction after aortic valve replacement.

Methods

we reviewed all patient’s records who underwent aortic valve replacement for aortic stenosis at our institution from 12/2014 to 12/2016. Pre and post-operative echocardiograms were reviewed by experienced echocardiographer. Patients were then divided into 4 categories (functional, mild, moderate and severe calcification) on the basis of the presence, distribuition and severity of calcification on the mitral apparatus.

Results

at the end 651 patients were collected and analyzed. Mean age was 74yo. 334 (51,4%) of them were males. Most patients (63,1%) had only mild mitral regurgitation but 147 (22,6%) of them had moderate or severe mitral regurgitation. The presences of moderate or severe calcification of the mitral apparatus resulted to be a risk factor for the presence of mitral regurgitation associated with aortic stenosis as shown in Table 1. After surgical aortic valve replacement less than 21% of the patients showed a reduction of the degree of mitral regurgitation. We found no statistical difference between groups about mitral regurgitation changes after aortic valve replacement.

Conclusions

Mitral regurgitation is a common finding in patients with severe aortic stenosis and it’s prevalence is higher in patients with mitral calcifications. Few patients, however showed a reduction in the degree of mitral regurgitation after surgical aortic valve replacement with no difference related to the severity of annular or leaflets calcifications.

TABLE 1 Logistic regression for the presence of mitral regurgitation Mitral Regurgitation Change after Aortic Valve Replacement CALCIFICATION DEGREE OR C.I. 95% p Reduced p Unchanged p Increased p Functional 53(21%) 176(71%) 18(7%) Mild 1.244571 0.81 - 1.93 0.32 28(20%) 0.86 105(76%) 0.43 6(4%) 0.34 Moderate 1.637297 1.05 - 2.56 0.03* 25(17%) 0.41 109(76%) 0.34 9(6%) 0.86 Severe 2.369245 1.46 - 3.85 &lt;0.01* 29(25%) 0.48 78(68%) 0.67 7(6%) 0.86 OR= Odds Ratio; C.I.=Confidence Interval; Functional= no calcification; Mild, Moderate and Severe= degree of mitral annular and leaflets calcifications.

P5716Cardioprotective anti inflammatory effects of empaglifozin in doxorubicin induced cardiotoxicity: the role of leukotriene B4 and interleukin 1

Background

Empagliflozin (EMPA), a selective inhibitor of the sodium glucose co-transporter 2 (SGLT2), reduces the risk of hospitalization for heart failure or cardiovascular death in type 2 diabetic patients.

Purpose

We studied the putative cardioprotective and anti-inflammatory effects of EMPA in Doxorubicin (DOXO)-Induced cardiotoxicity.

Methods

For this purpose, we tested the effects of EMPA (at 100 or 500 nM) alone or in combination with DOXO (20 μM) in HL-1 adult cardiomyocytes evaluating: mitochondrial viability, lipid peroxidation (quantifying cellular Malondialdehyde [MDA] and 4-hydroxynonenal [4-HNA]), Leukotriene-B4 expression, p65-NF-κB activation and Interleukin 1β, 8 and 6 secretion. Preclinical studies were also performed in C57BL6 mice, dividing them in 4 groups (n=6): Sham (untreated mice), EMPA (mice treated with EMPA at 10 mg/kg/day, administrated orally for 7 days); DOXO (mice treated with DOXO at 2.25 mg/kg/day, intraperitoneally administered for 7 days); EMPA-DOXO (pre-treatment with EMPA for 3 days and 7 days of co-administration EMPA and DOXO). As predictor of cardiotoxicity, the Global Longitudinal Strain (GLS) was measured using 2D speckle tracking echocardiography. Cardiac lysates were processed for analysis of pro-inflammatory interleukins.

Results

We demonstrated that EMPA, co-incubated with DOXO, increases cardiomyocyte viability of 33,6 and 82% at 100 and 500 nM, respectively (compared to only DOXO treated cells). EMPA inhibits the lipid peroxidation by decreasing MDA and 4-HNA production of around 23,6 and 28,7%, at 100 nM and of 47,8 and 52,1% at 500 nM, respectively, compared to untreated cells (p<0,01 for all). Moreover, EMPA has anti-inflammatory activity reducing the Leukotriene B4 and p65-NFkb expression of 37,4% and 31% at 100 nM and of 58,4 and 64,3% at 500 nM, respectively (all compared to only DOXO treated cells). EMPA also decreased the expression of Interleukin 1β (of 28,5 and 68,8%), Interleukin-8 (of 21,2 and 57,3%) and Interleukin-6 (of 28,1 and 49,8%) at 100 and 500 nM, respectively, compared to only DOXO exposed cells (p<0,05 for all). In our in vivo studies, after 7 days with DOXO, the GLS decreased. Interestingly, in mice treated with EMPA/DOXO, we observed that EMPA prevents the GLS's reduction: GLS was −19.24±1.5 (p<0,01) vs DOXO alone, indicating cardioprotective effects. In DOXO-EMPA groups the cardiac IL-1β, IL-6 and IL-8 were reduced of 48, 54,4 and 58%, compared to only DOXO group (p<0,001 for all).

Conclusion

EMPA has strong anti-inflammatory and cardioprotective effects in DOXO-Induced cardiotoxicity and these effects are mainly mediated by a reduction of the lipid peroxidation, Leukotriene-B4 and NF-κB activation bringing to a strong inhibition of the Interleukin 1β, 8 and 6 production.

P1537Cardiotoxicity induced by the combinatorial treatment based on the immune checkpoint inhibitor pembrolizumab associated to trastuzumab

Background

The immunotherapy has revolutionized the world of oncology in the last decades with considerable advantages in terms of overall survival in cancer patients. A combination therapy based on the co-administration of Pembrolizumab (an antibody against PD-1) and Trastuzumab (the humanized anti-Her2 mAb) was recently proposed in clinical trials for the treatment of Trastuzumab-resistant advanced HER2-positive breast cancer. Although immunotherapies are frequently associated with a wide spectrum of immune-related adverse events, the cardiac toxicity has not been properly studied.

Purpose

We studied, for the first time, the putative cardiotoxic effects of Pembrolizumab associated to Trastuzumab turning the light on the pro-inflammatory effects of this novel combined therapy

Methods

Cell viability, intracellular calcium quantification and pro-inflammatory assays (analyzing the production of Interleukin 1β, 6 and 8 as well as the expression of p65/NFkB and Leukotriene B4) were performed in human fetal cardiomyocytes in vitro. Preclinical studies were also performed in vivo on C57BL6 mice untreated (Sham) or treated with Pembrolizumab and Trastuzumab alone or in combination by analyzing (in cardiac tissue extracts) the same markers of inflammation used in cellular studies.

Results

Combination therapy leads to an increase of the intracellular calcium overload (more than 3 times compared to untreated cells) and to a reduction of the cardiomyocytes viability (of more than 65 and 20–25%, compared to untreated and Pembrolizumab or Trastuzumab treated cells, respectively) thus indicating cardiotoxic effects. Notably, combination therapy increases the inflammation of cardiomyocytes enhancing significantly the production of p65/NFkB and Interleukins. Moreover, in in vivo studies on mice, the association of Pembrolizumab and Trastuzumab shows pro-inflammatory effects in cardiac tissue by stimulating the Interleukin 1β, 8 and 6 expression of 40–50% more than the single treatments; the expression of p65/NFkB and Leukotriene B4 was also increased indicating pro-inflammatory effects.

Conclusion

Combination therapy based on Pembrolizumab associated to Trastuzumab leads to significant cardiac pro-inflammatory effects mediated by overexpression of NFkB/p65 and Leukotriene B4 related pathways

Cardiotoxicity and pro-inflammatory effects of the immune checkpoint inhibitor Pembrolizumab associated to Trastuzumab

BACKGROUND

The immunotherapy has revolutionized the world of oncology in the last decades with considerable advantages in terms of overall survival in cancer patients. The association of Pembrolizumab and Trastuzumab was recently proposed in clinical trials for the treatment of Trastuzumab-resistant advanced HER2-positive breast cancer. Although immunotherapies are frequently associated with a wide spectrum of immune-related adverse events, the cardiac toxicity has not been properly studied.

PURPOSE

We studied, for the first time, the putative cardiotoxic and pro-inflammatory effects of Pembrolizumab associated to Trastuzumab.

METHODS

Cell viability, intracellular calcium quantification and pro-inflammatory studies (analyses of the production of Interleukin 1β, 6 and 8, the expression of NF-kB and Leukotriene B4) were performed in human fetal cardiomyocytes. Preclinical studies were also performed in C57BL6 mice by analyzing fibrosis and inflammation in heart tissues.

RESULTS

The combination of Pembrolizumab and Trastuzumab leads to an increase of the intracellular calcium overload (of 3 times compared to untreated cells) and to a reduction of the cardiomyocytes viability (of 65 and 20-25%, compared to untreated and Pembrolizumab or Trastuzumab treated cells, respectively) indicating cardiotoxic effects. Notably, combination therapy increases the inflammation of cardiomyocytes by enhancing the expression of NF-kB and Interleukins. Moreover, in preclinical models, the association of Pembrolizumab and Trastuzumab increases the Interleukins expression of 40-50% compared to the single treatments; the expression of NF-kB and Leukotriene B4 was also increased.

CONCLUSION

Pembrolizumab associated to Trastuzumab leads to strong cardiac pro-inflammatory effects mediated by overexpression of NF-kB and Leukotriene B4 related pathways.

Complex trauma, PTSD and complex PTSD in African refugees

Background: The introduction of the diagnosis of complex posttraumatic stress disorder (CPTSD) by ICD-11 is a turning point in the field of traumatic stress studies. It's therefore important to examine the validity of CPTSD in refugee groups exposed to complex trauma (CT) defined as a repeated, prolonged, interpersonal traumatic event. Objective: The objective of this study was to compare DSM-5 and ICD-11 post-traumatic stress disorder diagnoses and to evaluate the discriminant validity of ICD-11 PTSD and CPTSD constructs in a sample of treatment-seeking refugees living in Italy. Method: The study sample included 120 treatment-seeking African refugees living in Italy. All participants were survivors of at least one CT. PTSD and CPTSD diagnoses were assessed according to both DSM-5 and ICD-11 criteria. Results: Findings revealed that 79% of the participants met the DSM-5 criteria for PTSD, 38% for ICD-11 PTSD and 30% for ICD-11 CPTSD. Generally, ICD-11 CPTSD items evidenced strong sensitivity and negative predictive power, low specificity and positive predictive power. Latent class analysis results identified two distinct groups: (1) a PTSD class, (2) a CPTSD class. None of the demographic and trauma-related variables analysed was significantly associated with diagnostic group. On the other hand, the months spent in Italy were significantly associated with PCL-5 score. Conclusions: Findings extend the current evidence base to support the discriminant validity of PTSD and CPTSD amongst refugees exposed to torture and other gross violations of human rights. The results suggest also that, in the post-traumatic phase, the time spent in a 'safe place' condition contributes to improve the severity of post-traumatic symptomatology, but neither this variable nor other socio-demographic factors seem to contribute to the emergence of complex PTSD. Further investigations are needed to clarify which specific vulnerability factors influence the development of PTSD or CPTSD in refugees exposed to complex trauma.

Translocation of a gut pathobiont drives autoimmunity in mice and humans

Despite multiple associations between the microbiota and immune diseases, their role in autoimmunity is poorly understood. We found that translocation of a gut pathobiont, Enterococcus gallinarum, to the liver and other systemic tissues triggers autoimmune responses in a genetic background predisposing to autoimmunity. Antibiotic treatment prevented mortality in this model, suppressed growth of E. gallinarum in tissues, and eliminated pathogenic autoantibodies and T cells. Hepatocyte-E. gallinarum cocultures induced autoimmune-promoting factors. Pathobiont translocation in monocolonized and autoimmune-prone mice induced autoantibodies and caused mortality, which could be prevented by an intramuscular vaccine targeting the pathobiont. E. gallinarum-specific DNA was recovered from liver biopsies of autoimmune patients, and cocultures with human hepatocytes replicated the murine findings; hence, similar processes apparently occur in susceptible humans. These discoveries show that a gut pathobiont can translocate and promote autoimmunity in genetically predisposed hosts.

Protein Loss after Radical Mastectomy as a Cause of Postoperative Hypoalbuminemia

The concentrations of serum albumin and the cumulative loss of albumin through the drainage tubes were followed in 14 patients who underwent radical mastectomy for cancer. The concentration of serum albumin declined during the postoperative period, and the nadir was on the 5th day. On the first 5 days a good correlation was observed between hypoalbuminemia and loss of albumin from the wound. After this period, hypoalbuminemia persisted unchanged although small quantities of albumin continued to be lost through the drains. It is concluded that in surgery complicated by abundant serum discharge, the albumin loss may be the main cause of postoperative hypoalbuminemia.

Non-Functioning Parathyroid Carcinoma: A Case Report

Non-functioning parathyroid carcinoma is a very rare disease. Only 12 cases have been reported in the literature. The clinical behavior is characterized by the appearance and growth of a neck mass or nodule, which often has been present for many years, and is not accompanied by clinical or laboratory evidence of hypercalcemia or elevated levels of parathyroid hormone (PTH) in peripheral blood. Pathologic findings are similar to those of functioning tumors, and the proof of malignancy is established on the basis of an increased mitotic index only. Data on survival from cases reported in the literature are not conclusive; however, the non-functioning type of parathyroid carcinoma seems to be a more aggressive disease. Radiotherapy seems to be effective in the local control of the disease, but most patients become metastatic. Even if no data are available on response to chemotherapy, the course of the disease is relatively indolent.

Ineffectiveness of 5-Fluorouracil and Cis-Platin as Second-Line Chemotherapy in Head and Neck Cancer

Seventeen patients with heavily pretreated head and neck squamous cell carcinoma were submitted to a combination of 5-fluorouracil, 500 mg/m2 on days 1–4, and cis-platin, 50 mg/m2 on day 5, repeated every 21 days. Before administration of 5-fluorouracil, N5,N10-methyl-tetrahydrofolate, 200 mg/m2 i.v., was given. Only 1 partial response and 4 stable disease were observed, and the median survival of the entire group was 5 months. Although all patients had been heavily pretreated and a considerable percentage (6/17, 35.2 %) of these showed resistance to first-line therapy, this combination seems to be ineffective as second-line therapy in head and neck cancer.

Highlight on the solution processes occurring on silver(i)-assembling porphyrins in the presence of an excess of silver salt

Coordination cages obtained upon complexation of pyridyl functionalized porphyrins by Ag⁺ disassemble when overtaking a 1 : 2 stoichiometric amount of silver salt. An excess of Ag⁺ then leads to unusual chemical processes, here analyzed in detail, which permanently transform the monomeric porphyrins. The observed processes, discussed with reference to model compounds devoid of polyether substituted pyridyl residues, evidence a peculiar reactivity for meso 2,6-dimethylphenyl substituted porphyrins.

A Novel Cooling Device for Targeted Brain Temperature Control and Therapeutic Hypothermia: Feasibility Study in an Animal Model

Background

Therapeutic hypothermia (i.e., temperature management) is an effective option for improving survival and neurological outcome after cardiac arrest and is potentially useful for the care of the critically ill neurological patient. We analyzed the feasibility of a device to control the temperature of the brain by controlling the temperature of the blood flowing through the neck.

Methods

A lumped parameter dynamic model, with one-dimensional heat transfer, was used to predict cooling effects and to test experimental hypotheses. The cooling system consisted of a flexible collar and was tested on 4 adult sheep, in which brain and body temperatures were invasively monitored for the duration of the experiment.

Results

Model-based simulations predicted a lowering of the temperature of the brain and the body following the onset of cooling, with a rate of 0.4 °C/h for the brain and 0.2 °C/h for the body. The experimental findings showed comparable cooling rates in the two body compartments, with temperature reductions of 0.6 (0.2) °C/h for the brain and 0.6 (0.2) °C/h for the body. For a 70 kg adult human subject, we predict a temperature reduction of 0.64 °C/h for the brain and 0.43 °C/h for the body.

Conclusions

This work demonstrates the feasibility of using a non-invasive method to induce brain hypothermia using a portable collar. This device demonstrated an optimal safety profile and represents a potentially useful method for the administration of mild hypothermia and temperature control (i.e., treatment of hyperpyrexia) in cardiac arrest and critically ill neurologic patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s12028-016-0257-7) contains supplementary material, which is available to authorized users.

Infections and autoimmunity: role of human cytomegalovirus in autoimmune endothelial cell damage

Molecular mimicry between infectious agents and normal human host cell proteins represents one of the possible mechanisms responsible for autoimmunity. Among infectious agents, human cytomegalovirus (HCMV) is an ideal candidate for involvement in autoimmune disorders because of its lifelong persistence through periods of reactivation and latency and because of the extensive manipulation of innate and adaptive immunity. HCMV has been implicated in the pathogenesis of vascular damage in systemic sclerosis (SSc) and atherosclerosis. Based on our data, which demonstrate a cause-and-effect relationship between HCMV and endothelial cell aggression in SSc and atherosclerosis, we propose that immune responses to particular HCMV proteins may result in autoaggression through a mechanism of molecular mimicry of normally expressed endothelial cell surface molecules.

Genetic parameters for body weight in meat quail

The aim of this study was to estimate genetic parameters for BW in meat quail at different ages. A total of 24,382 weight records from 3,652 quail, born between 2009 and 2011, were evaluated. Weekly BW was measured from hatch until 42 d of age. The genetic parameters were estimated by the restricted maximum likelihood method using a multivariate animal model. Heritability of BW ranged from 0.03 to 0.23. Genetic correlations were mainly high and positive. Selection for BW at 28 d of age yielded good indirect genetic progress in BW at 42 d of age.