Real-world use of oral versus subcutaneous semaglutide in a cohort of type 2 diabetic patients: which option to which patient?

PURPOSE

To evaluate the variables influencing the therapeutic choice toward oral versus subcutaneous semaglutide in a cohort of diabetic subjects.

METHODS

We retrospectively collected data of 292 patients followed at the Diabetes Unit of the University Hospital of Siena and the Hospital of Grosseto, who were prescribed oral (n = 115) or subcutaneous (n = 177) semaglutide between October 2021 and October 2022.

RESULTS

Oral semaglutide was preferentially prescribed in older subjects with longer disease duration in replacement of other antidiabetic drugs, while subcutaneous semaglutide was preferentially prescribed in add-on to metformin in subjects with higher body weight and BMI. After 6 months, both formulations significantly improved glycemic control and body weight, however injectable semaglutide showed a greater efficacy on A1c levels, weight loss, BMI and waist circumference reduction. No differences were found in terms of adverse events.

CONCLUSION

In our experience, injectable semaglutide is preferred in patients with excess weight and shorter disease duration, while the oral formulation was used later and especially after therapeutic failure of previous therapies. Follow-up data indicate similar tolerability and efficacy of both formulations, despite subcutaneous semaglutide demonstrated greater efficacy.

Distance follow-up by a remote medical care centre improves adherence to CPAP in patients with obstructive sleep apnoea over the short and long term

BACKGROUND

Adherence to continuous positive air pressure (CPAP) in patients with obstructive sleep apnoea (OSA) has remained invariably low over the last decades. Remote monitoring of the nocturnal CPAP treatment, within telemedicine (TM)-based follow-up programs, in these patients has been suggested as a potential tool to improve adherence and release the workload of sleep units. The aim of this study was therefore to assess whether a follow-up program carried out by a Remote Medical Care Centre (RMCC), outside the sleep unit, improves adherence to CPAP in the short and long term in patients with OSA.

METHODS

In this pilot protocol, we enrolled 37 patients starting CPAP in our Sleep Centre (SC). After three months of standard care in our SC, patients initiated a six-month remote follow-up carried out by the RMCC, functioning as an intermediary between patients and SC. Monthly reports and indication for face-to-face visits were sent to the SC for six months. After this period patients returned to usual care for one year. Results were compared with those obtained in 38 patients (controls) followed with usual care over the same time range.

RESULTS

Mean nightly use of CPAP increased from 3.2 ± 2.4 h pre-RMCC to 5.2 ± 1.9 h post-RMCC (p < 0.0001). Nights/month of CPAP use improved from 19.8 ± 9.2 to 25.2 ± 2.5 (p < 0.05) and nights/month with CPAP use >4 h from 12.5 ± 10 to 21.03 ± 8.9 (p < 0.05). This improvement remained stable after 12 months from the return of patients to usual care. No significant changes in CPAP use were observed in controls over the time.

CONCLUSION

A six-month follow-up through a remote facility can significantly improve adherence to CPAP in the short and long term. This pilot study provides a solid base for the design of multicentre randomized trials focusing on new models which are able to increase the long-term efficacy of TM programs.

Flow induces common and specific transcriptional changes in renal tubular epithelial cells involving the PI3K pathway

Flow-induced shear stress affects renal epithelial cells in the nephron tubule with potential implications for differential functionalities of the individual segments. Disruptions of cellular mechanosensation or flow conditions are associated with the development and progression of various renal diseases. This study investigates the effects of flow on the transcriptome of various renal tubular epithelial cell types. We analyzed the transcriptome of induced renal epithelial cells (iREC) cultured under physiological flow (0.57 ± 0.05 dyn/cm2 ) or in static conditions for 72 h. RNA sequencing showed 861 differentially expressed genes (DEGs), with 503 up- and 358 downregulated under flow. DEGs were linked to extracellular matrix (ECM) components (e.g. Col1a1, Col4a3, Col4a4, Fn1, Smoc2), junctions (Gja1, Tubb5), channel activities (Abcc4, Aqp1), and transcription factors (Foxq1, Lgr6). Next, we performed a meta-analysis comparing our data with three published datasets that subjected epithelial cell lines from distinct segments to flow, including proximal tubule and collecting duct cells. We found that TGF-ß, p53, MAPK, and PI3K are common flow-regulated pathways. Tfrc expression and thus the capability of iron uptake is commonly upregulated under flow. Many DEGs were related to kidney diseases, such as fibrosis (e.g. Tgfb1-3 and Serpine1). To obtain further mechanistic insights we investigated the role of the PI3K pathway in flow sensing. Applying flow and inhibition of PI3K showed significantly altered expression of transcripts related to ECM remodeling, angiogenesis, and ion transport. This suggests that the PI3K pathway is a critical mediator in flow-dependent cellular processes and gene expression, potentially influencing renal development and tissue remodeling. Finally, we derived a cross-cell-line summary of common as well as segment-specific transcriptomic effects, thus providing insights into the molecular mechanisms underlying flow sensing in the nephron tubule.

HNF1B Alters an Evolutionarily Conserved Nephrogenic Program of Target Genes

SIGNIFICANCE STATEMENT

Mutations in hepatocyte nuclear factor-1 β ( HNF1B ) are the most common monogenic causes of congenital renal malformations. HNF1B is necessary to directly reprogram fibroblasts to induced renal tubule epithelial cells (iRECs) and, as we demonstrate, can induce ectopic pronephric tissue in Xenopus ectodermal organoids. Using these two systems, we analyzed the effect of HNF1B mutations found in patients with cystic dysplastic kidney disease. We found cross-species conserved targets of HNF1B, identified transcripts that are differentially regulated by the patient-specific mutant protein, and functionally validated novel HNF1B targets in vivo . These results highlight evolutionarily conserved transcriptional mechanisms and provide insights into the genetic circuitry of nephrogenesis.

BACKGROUND

Hepatocyte nuclear factor-1 β (HNF1B) is an essential transcription factor during embryogenesis. Mutations in HNF1B are the most common monogenic causes of congenital cystic dysplastic renal malformations. The direct functional consequences of mutations in HNF1B on its transcriptional activity are unknown.

METHODS

Direct reprogramming of mouse fibroblasts to induced renal tubular epithelial cells was conducted both with wild-type HNF1B and with patient mutations. HNF1B was expressed in Xenopus ectodermal explants. Transcriptomic analysis by bulk RNA-Seq identified conserved targets with differentially regulated expression by the wild-type or R295C mutant. CRISPR/Cas9 genome editing in Xenopus embryos evaluated transcriptional targets in vivo .

RESULTS

HNF1B is essential for reprogramming mouse fibroblasts to induced renal tubular epithelial cells and induces development of ectopic renal organoids from pluripotent Xenopus cells. The mutation R295C retains reprogramming and inductive capacity but alters the expression of specific sets of downstream target genes instead of diminishing overall transcriptional activity of HNF1B. Surprisingly, targets associated with polycystic kidney disease were less affected than genes affected in congenital renal anomalies. Cross-species-conserved transcriptional targets were dysregulated in hnf1b CRISPR-depleted Xenopus embryos, confirming their dependence on hnf1b .

CONCLUSIONS

HNF1B activates an evolutionarily conserved program of target genes that disease-causing mutations selectively disrupt. These findings provide insights into the renal transcriptional network that controls nephrogenesis.

Could the Improvement of Supraspinatus Muscle Activity Speed up Shoulder Pain Rehabilitation Outcomes in Wheelchair Basketball Players?

Shoulder pain (SP) is a common clinical complaint among wheelchair basketball (WB) players, since their shoulders are exposed to intense overload and overhead movements. The supraspinatus tendon is the most exposed to WB-related injuries and it is primarily responsible for SP in WB athletes. In these cases, SP rehabilitation remains the main treatment, but there is still a lack of specific protocols which should be customized to WB players' peculiarities and to the supraspinatus muscle activity monitor, and the improvement of rehabilitation outcomes is slow. Thus, the aim of this study was to verify if the improvement of supraspinatus muscle activity, monitored in real time with surface electromyography (sEMG) during the execution of therapeutic exercises, could speed up SP rehabilitation outcomes in WB players. Thirty-three athletes were enrolled. They were divided into two groups. Both groups underwent the same shoulder rehabilitation program, but only the Exercise Plus sEMG Biofeedback Group executed therapeutic exercises while the activity of the supraspinatus muscles was monitored using sEMG. Participants were evaluated at enrollment (T0), at the end of 4 weeks of the rehabilitation program (T1), and 8 weeks after T1 (T2), using the following outcome measures: supraspinatus muscle activity as root mean square (RMS), Wheelchair User's Shoulder Pain Index (WUSPI), shoulder abduction, and external rotation range of motion (ROM). The Exercise Plus sEMG Biofeedback Group improved more and faster for all the outcomes compared to the Exercise Group. The monitoring and improvement of supraspinatus muscle activity seems to be an effective way to speed up SP rehabilitation outcomes in WB players, since it makes the performance of therapeutic exercise more precise and finalized, obtaining better and faster results in terms of recovery of shoulder function.

Kidney Development: Recent Insights from Technological Advances

The kidney is a complex organ, and how it forms is a fascinating process. New technologies, such as single-cell transcriptomics, and enhanced imaging modalities are offering new approaches to understand the complex and intertwined processes during embryonic kidney development.

Deep Learning-Assisted Nephrotoxicity Testing with Bioprinted Renal Spheroids

We used arrays of bioprinted renal epithelial cell spheroids for toxicity testing with cisplatin. The concentration-dependent cell death rate was determined using a lactate dehydrogenase assay. Bioprinted spheroids showed enhanced sensitivity to the treatment in comparison to monolayers of the same cell type. The measured dose-response curves revealed an inhibitory concentration of the spheroids of IC₅₀ = 9 ± 3 μM in contrast to the monolayers with IC₅₀ = 17 ± 2 μM. Fluorescent labeling of a nephrotoxicity biomarker, kidney injury molecule 1 indicated an accumulation of the molecule in the central lumen of the spheroids. Finally, we tested an approach for an automatic readout of toxicity based on microscopic images with deep learning. Therefore, we created a dataset comprising images of single spheroids, with corresponding labels of the determined cell death rates for training. The algorithm was able to distinguish between three classes of no, mild, and severe treatment effects with a balanced accuracy of 78.7%.

Disinfection of roof harvested rainwater inoculated with E. coli and Enterococcus and post-treatment bacterial regrowth: Conventional vs solar driven advanced oxidation processes

Solar driven advanced oxidation processes (AOPs) (an alternative solar photo Fenton like process (SPF), sunlight/H₂O₂ (SHP) and sunlight/chlorine (SCL)) and respective dark conditions, were compared for the first time to conventional (chlorination and UV-C radiation) disinfection processes, in the inactivation of E. coli and Entero strains inoculated in real roof-harvested rainwater (RHRW), to evaluate their possible safe use for crop irrigation. In this regard, bacterial regrowth was also evaluated 6, 12, 24 and 48 h after disinfection treatment. The SPF, using iminodisuccinic acid (IDS)-Cu complex as catalyst, was optimized (H₂O₂/IDS-Cu 55/1 best molar ratio) under mild conditions (spontaneous pH) and sunlight. The faster inactivation kinetics were observed for the SCL process (k = 1.473 min^-1, t_1/2 = 0.47 min for E. coli and k = 1.193 min^-1, t_1/2 = 0.57 min for Entero), while the most effective processes in controlling bacterial regrowth were SPF and SCL. Although UV-C radiation (0-1.3 × 10⁴ μW s cm^-2 dose range) was the second faster disinfection process (k = 1.242 min^-1, t_1/2 = 0.55 min for E. coli and k = 1.150 min^-1, t_1/2 = 0.60 min for Entero), it was the less effective process in controlling bacterial regrowth (>10 CFU 100 mL^-1 already after 6 h post-treatment incubation). According to the bacterial inactivation and regrowth tests carried out in this work, SPF and SCL are interesting options for RHRW disinfection, in case of effluent use for crop irrigation.

Clinical, echocardiographic and hemodynamic predictors of right heart failure after LVAD placement

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implant is associated with increasing morbidity and mortality. The aim of this study was to identify the best predictors of RVF post LVAD-implant among biochemical, haemodynamic and echocardiographic parameters. From 2009 to 2019, 38 patients who underwent LVAD implantation at our centre were prospectively enrolled. Preoperative clinical, laboratory, echocardiographic and haemodynamic parameters were reported. Overall, eight patients (21%) developed RVF over time, which revealed to be strongly related to overall mortality. Pulmonary artery pulsatility index (PAPi) resulted to be the most significant right heart catheterization index in discriminating RVF vs no RVF patients [(1.32 ± 0.26 vs. 3.95 ± 3.39 respectively) p = 0.0036]. Regarding transthoracic echocardiography, RVF was associated with reduced free wall right ventricular longitudinal strain (fw-RVLS) (- 7.9 ± 1.29 vs. - 16.14 ± 5.83) (p < 0.009), which was superior to other echocardiographic determinants of RVF. Among laboratory values, N-terminal pro-brain natriuretic peptide (NT-proBNP) was strongly increased in RVF patients [(10,496.13 pg/ml ± 5272.96 pg/ml vs. 2865, 5 pg/ml ± 2595.61 pg/ml) p = 0.006]. PAPi, NT-proBNP and fwRVLS were the best pre-operative predictors of RVF, a post-LVAD implant complication which was confirmed to have a great impact on survival. In particular, fwRVLS has been proven to be the strongest independent predictor.

Specific disruption of calcineurin-signaling in the distal convoluted tubule impacts the transcriptome and proteome, and causes hypomagnesemia and metabolic acidosis

Adverse effects of calcineurin inhibitors (CNI), such as hypertension, hyperkalemia, acidosis, hypomagnesemia and hypercalciuria, have been linked to dysfunction of the distal convoluted tubule (DCT). To test this, we generated a mouse model with an inducible DCT-specific deletion of the calcineurin regulatory subunit B alpha (CnB1-KO). Three weeks after CnB1 deletion, these mice exhibited hypomagnesemia and acidosis, but no hypertension, hyperkalemia or hypercalciuria. Consistent with the hypomagnesemia, CnB1-KO mice showed a downregulation of proteins implicated in DCT magnesium transport, including TRPM6, CNNM2, SLC41A3 and parvalbumin but expression of calcium channel TRPV5 in the kidney was unchanged. The abundance of the chloride/bicarbonate exchanger pendrin was increased, likely explaining the acidosis. Plasma aldosterone levels, kidney renin expression, abundance of phosphorylated sodium chloride-cotransporter and abundance of the epithelial sodium channel were similar in control and CnB1-KO mice, consistent with a normal sodium balance. Long-term potassium homeostasis was maintained in CnB1-KO mice, but in-vivo and ex-vivo experiments indicated that CnB1 contributes to acute regulation of potassium balance and sodium chloride-cotransporter. Tacrolimus treatment of control and CnB1-KO mice demonstrated that CNI-related hypomagnesemia is linked to impaired calcineurin-signaling in DCT, while hypocalciuria and hyponatremia occur independently of CnB1 in DCT. Transcriptome and proteome analyses of isolated DCTs demonstrated that CnB1 deletion impacts the expression of several DCT-specific proteins and signaling pathways. Thus, our data support a critical role of calcineurin for DCT function and provide novel insights into the pathophysiology of CNI side-effects and involved molecular players in the DCT.

Traditional and Novel Imaging of Right Ventricular Function in Patients with Heart Failure and Reduced Ejection Fraction

PURPOSE OF REVIEW

This review attempts to summarize the role of standard and advanced echocardiographic techniques together with CMR in the evaluation of the RV in HF, providing an outlook on the recent evidence.

RECENT FINDINGS

In the last decade, there has been growing interest in the study of the RV, and it is now widely established that RV function is a strong predictor of mortality, in several cardiovascular diseases, in particular in the setting of heart failure (HF). The evaluation of RV function might be particularly challenging, which justifies the necessity of multi-modality imaging. The echocardiographic assessment remains the mainstay technique even though it might be complex, due to RV crescent shape and its position in the chest, requiring both qualitative and quantitative parameters. Cardiac magnetic resonance (CMR) represents a complementary exam which is particularly useful when precise structural and functional assessment are needed, considering the most recently developed sequences. Despite the technological improvement attested over the last years, there is still no universally accepted parameter that univocally defines RV function, hence the necessity to evaluate several parameters, combining different imaging techniques.

Scalable fabrication of renal spheroids and nephron-like tubules by bioprinting and controlled self-assembly of epithelial cells

Scalable fabrication concepts of 3D kidney tissue models are required to enable their application in pharmaceutical high-throughput screenings. Yet the reconstruction of complex tissue structures remains technologically challenging. We present a novel concept reducing the fabrication demands, by using controlled cellular self-assembly to achieve higher tissue complexities from significantly simplified construct designs. We used drop-on-demand bioprinting to fabricate locally confined patterns of renal epithelial cells embedded in a hydrogel matrix. These patterns provide defined local cell densities (cell count variance < 11 %) with high viability (92 ± 2 %). Based on these patterns, controlled self-assembly leads to the formation of renal spheroids and nephron-like tubules with a predefined size and spatial localization. With this, we fabricated scalable arrays of hollow epithelial spheroids. The spheroid sizes correlated with the initial cell count per unit and could be stepwise adjusted, ranging from Ø = 84, 104, 120 to 131 µm in diameter (size variance < 9 %). Furthermore, we fabricated scalable line-shaped patterns, which self-assembled to hollow cellular tubules (Ø = 105 ± 22 µm). These showed a continuous lumen with prescribed orientation, lined by an epithelial monolayer with tight junctions. Additionally, upregulated expression of kidney-specific functional genes compared to 2D cell monolayers indicated increased tissue functionality, as revealed by mRNA sequencing. Furthermore, our concept enabled the fabrication of hybrid tubules, which consisted of arranged subsections of different cell types, combining murine and human epithelial cells. Finally, we integrated the self-assembled fabrication into a microfluidic chip and achieved fluidic access to the lumen at the terminal sites of the tubules. With this, we realized flow conditions with a wall shear stress of 0.05 ± 0.02 dyne/cm² driven by hydrostatic pressure for scalable dynamic culture towards a nephron-on-chip model.

Health and Gender Medicine Clinic: 2 years of multidisclipinary team experience

Background

Cardiovascular disease (CVD) is the leading cause of mortality in western countries and the first cause of mortality in women.

Purpose

Women generally do not concern about CVD and that represents the main risk for them.

Methods

Misericordia Hospital, Grosseto, started a Clinic of Health and Gender Medicine on 2017. On the first and third Monday of every month, we evaluate &lt; 60 years patients who are at risk for traditional CVD, depression, early menopause, polycystic ovary, autoimmune and rheumatic disease. On the first visit, medical history, arterial pressure, electrocardiogram, body mass index, waist circumference and lipid profile, were collected. We also supply questionnaires to evaluate diabetes and depression risk by Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9) and food diary. Two weeks later, a multidisciplinary team (cardiologist-diabetologist-nutritionist-gynecologist-psychiatrist and a nurse) evaluates the patients defining the personal risk profile.

Results

From 2017 to December 2019, 74 females and 7 males belonging to the target population were examined. Age group: &lt;45(61%), 46-50(26%), 51-60(48%), &gt;60(19%). Clinical characteristics: Hypertension: 64%; Obesity 5%; Unknown dyslipidemia 44%; Risk of diabetes: 39%; Gestational diabetes: 5%; Gestational hypertension: 5% CVD risk: 42%; Depression: 33% Autoimmune disease: 30%. From them 60.5% have needed further investigation. Follow-up is going on.

Conclusions

according with the literature, more than 50% of the cohort was unconsciously at high risk of CVD. So a multidisciplinary approach is needed in order to frame a complex health status. Thus we established collaboration with patients to improve lifestyles as CVD-prevention's tool.

Key messages

Cardiovascular disease represent often an hidden health problem, especially in women. Multidisciplinary approach is needed to face CVD.

The Influence of Diabetes Mellitus on the Outcome of Superficial Femoral Artery Recanalization is Debatable

Notwithstanding technological improvements in endovascular devices treatment of steno-obstructive lesions of the superficial femoral artery (SFA) remains a challenge for today's vascular surgeon. Current opinion dictates that the diabetic population may have worse outcome after revascularization of the lower extremities. Herein we examine the effects of endovascular treatment on steno-obstructive lesions of the SFA in diabetic and non-diabetic patients.

METHODS

A retrospective analysis was carried out on 110 patients who had undergone endovascular treatment of the SFA from 2010 to 2017 comparing outcomes in diabetic (DM) vs non-diabetic patients (nDM).

RESULTS

56 (50.9%) of the patients were diabetic and 54 were non-diabetic (49.1%). 52.7% (62.7% DM vs 35.2% nDM, p = 0.0003) were patients with critical limb ischemia. SFA occlusion was present in 65.5% (60.7% DM vs 70.4% nDM, p = 0.29) of all patients. All had undergone PTA of the SFA and 40.9% had received adjunctive stenting (44.6% DM vs 37.0% nDM, p = 0.41). A multilevel treatment was executed in 39.1% (51.8% DM vs 25.9% nDM) of the cases whereas an infra-popliteal procedure was associated in 27.3% (37.5% DM vs 16.7% nDM). In both groups the presence of diabetes was significantly associated (p = 0.005 e p = 0.014, respectively). Reintervention rate was 22.7%; 13 in the diabetic group (23.2%) and 12 in the non-diabetic group (22.2%). Of those who had had reintervention (p = 0.77); 9 patients (8.2%) had undergone an open surgical operation, 6 of whom had diabetes (p = 0.32). 5 patients (4.5%) had had major amputation, 4 of whom were diabetic (p = 0.20). Curves assessing freedom from target lesion restenosis were substantially overlapping between the two groups.

CONCLUSION

No statistical associations between diabetes and reintervention or amputation rates were found. Indication to treat the SFA were not influenced by the presence of diabetes but further investigation is required to verify our hypothesis.

Removal of carbamazepine, diclofenac and trimethoprim by solar driven advanced oxidation processes in a compound triangular collector based reactor: A comparison between homogeneous and heterogeneous processes

Contaminants of emerging concern (including pharmaceuticals) are not effectively removed by municipal wastewater treatment plants (WWTPs), so particular concern is related to agricultural wastewater reuse due to their possible uptake in crops irrigated with WWTPs effluents. Advanced oxidation processes (AOPs) and solar AOPs have been demonstrated to effectively remove pharmaceuticals from different aqueous matrices. In this study, an heterogeneous photocatalytic process using powdered nitrogen-doped TiO₂ immobilized on polystyrene spheres (sunlight/N-TiO₂) was compared to the benchmark homogenous AOP sunlight/H₂O₂ in a compound triangular collector reactor, to evaluate the degradation of three pharmaceuticals (carbamazepine (CBZ), diclofenac (DCF), trimethoprim (TMP)) in water. The degradation of the contaminants by sunlight and sunlight-AOPs well fit the pseudo-first order kinetic model (but for TMP under sunlight). High removal efficiency by solar photolysis was observed for DCF (up to 100%, half-life sunlight cumulative energy Q_S,1/2 = 2 kJ L^-1, half-life time t_1/2 = 32 min), while CBZ (32%, Q_S,1/2 = 28 kJ L^-1, t_1/2 = 385 min) and TMP (5% removal after 300 min) removal was poor. The degradation rate of CBZ, TMP and DCF was found to be slower during sunlight/H₂O₂ (Q_S,1/2 = 5 kJ L^-1, t_1/2 = 77 min; Q_S,1/2 = 20 kJ L^-1, t_1/2 = 128 min; Q_S,1/2 = 4 kJ L^-1, t_1/2 = 27 min, respectively) compared to sunlight/N-TiO₂ (Q_S,1/2 = 4 kJ L^-1, t_1/2 = 55 min; Q_S,1/2 = 3 kJ L^-1, t_1/2 = 42 min; Q_S,1/2 = 2 kJ L^-1, t_1/2 = 25 min, respectively). These results are promising in terms of solar technology upscale because the faster degradation kinetics observed for sunlight/N-TiO₂ process would result in smaller treatment volume, thus possibly perspective compensating the cost of the photocatalyst.

P4545ACUTE HF score: a new multi-parametric score for the prognostication of acute heart failure

Background

Prognosis of patients with acute heart failure (AHF) and different etiologies remains a challenging issue for the Cardiologist.

Purpose

We aimed to evaluate clinical and echocardiographic indexes and blood tests values of patients admitted to Intensive Care Unit (ICU) for AHF to test their capability to predict events at short-, medium- and long-term follow-up.

Methods

We retrospectively enrolled 830 patients who entered the ICU of our third-level hospital between 2010 and 2013 for AHF. Exclusion criteria included: active malignances, heart transplantation, patients with left ventricular assist device. We evaluated in each subject: cause of admission, medical history, chest congestion severity at admission, blood tests, echocardiographic parameters and administered drugs during in-hospital stay. Primary endpoints included: mortality rate at 30 days, 6 months and 5 years after dismission, days of ICU stay and cardiology ward stay. Indexes with statistical significance at univariate analysis, were then tested by multivariate analysis.

Results

The study population (average age 72.2±13 y) had an ejection fraction (EF) 36±12% at ICU admission. Best predictors of prognosis in the populations, after multivariate analysis, resulted to be: renal failure, EF, age, mitral regurgitation (MR) more than mild, use of non-invasive ventilation support during ICU stay, previous stroke or transient ischemic attack (TIA). With these indexes, we created a multi-parametric prognostic score composed by: 0.7*[age >76 years] + 1.4*[plasmatic creatinine >2mg/dl] + 0.8*[non-invasive mechanical ventilation] + 0.9*[previous stroke/TIA] + 0.8*[EF <30%] + + 0.7*[previous hospitalization for AHF] + 0.5*[moderate/severe MR]. According to the score, we stratified the population in 3 tertiles with increasing mortality risk: low if <1.5, medium if 1.5–3, high risk if >3 (Figure 1). At ROC curve analysis, the score showed a greater prognostic accuracy than each parameter (30 days AUC 0.75, 6 months AUC 0.78, 5 years AUC 0.79).

Figure 1

Conclusions

A combined clinical, humoral and echocardiographic score could represent a new tool in the prognostication of patients with AHF since the admission in ICU.

Actividad física y sedentarismo en profesionales de la salud

La prescripción de la actividad física, el ejercicio y evitar las conductas sedentarias poseen un invalorable referente en el personal de salud. El objetivo de esta investigación fue estudiar el nivel de actividad física y sedentarismo en un grupo profesionales de la salud mediante el uso de acelerometría. También se indagó acerca del estado nutricional de los sujetos y su relación con los niveles de actividad física y sedentarismo. Los sujetos del presente estudio reportaron ser activos (76%) pero se registraron un promedio de 592 minutos de tiempo sedentario, indicando que la mayoría de las personas pasan más de 9 horas sentadas. Los profesionales estudiados si bien parecen ser activos, son extremadamente sedentarios. La indicación de ejercicio como terapéutica sería más creíble si los profesionales fuesen activos, realizaran ejercicio regularmente, y además evitaran prolongados tiempos de conducta sedentaria.

Interleukin 31 is involved in intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder characterized by maternal itching and altered liver function. Interleukin (IL)-31 is known to be involved in the pathogenesis of pruritic inflammatory skin diseases. In a three-year period, 13 women with a singleton pregnancy and a diagnosis of intrahepatic cholestasis (ICP) were enrolled together with 26 healthy single pregnant women who concluded an uncomplicated pregnancy. The inclusion criteria were itching and elevated levels of liver transaminases. Median serum levels of IL-31 were significantly higher in ICP patients than in the control group (p = 0.004). Furthermore, IL-31 values were directly dependent on liver transaminase levels.

Diffusion-Weighted Magnetic Resonance Imaging and ADC Maps in the Diagnosis of Intracranial Cystic or Necrotic Lesions

This study evaluated the usefulness of diffusion-weighted (DW) magnetic resonance imaging (MRI) and ADC maps in the differential diagnosis of brain abscesses from cystic or necrotic neoplasms. MR images of 49 patients with 54 lesions were examined retrospectively. All patients underwent conventional MRI and DWI, and ADC values were calculated by placing ROIs of 30 mm2 manually over the cystic part of the lesions. On DWI, all cystic portions of abscesses were hyperintense. Mean ADC values were 0.48×10 mm2/s (range 0.41–0.54×10 mm/s) for pyogenic abscesses, 0.73×10 mm2/s (range 0.65–0.91×10 mm/s) for mycotic abscesses and 0.6 mm2/s for Nocardia abscess. Cystic areas appeared hypointense on DWI in 33/44 tumours (mean value ADC 1.96 mm2/s). Eleven tumours (11/44) appeared hyperintense on DWI: eight metastases from lung cancer (mean ADC value 0.86 mm2/s, range 0.75–1.2 mm2/s), two GBMs (mean 0.7 mm2/s, range 0.67–0.76 mm2/s) and one anaplastic astrocytoma (ADC value 1.24 mm2/s). ADC values may help in differentiating pyogenic abscess from brain tumors or metastatic lesions.

Modelling umbilical vein blood flow normograms at 14-40 weeks of gestation by quantile regression analysis

OBJECTIVE

To construct reference limits for gestation of umbilical vein blood flow (UVBF) in normal singleton pregnancies between 14 and 40 weeks of gestation using quantile regression.

METHODS

We ultrasonographycally examined 852 fetuses from low-risk pregnancies between 16 and 40 weeks of gestation in a prospective cross-sectional study. UV diameter and time-averaged maximum velocity (TAMXV) were measured in UV intra-abdominal portion by real time and Doppler ultrasonography. A semi-automatic measurement software was used to obtain UV diameter values. UVBF was then calculated from UV diameter and TAMXV measurements and expressed both as absolute value and as value normalized for fetal abdominal circumference (UVBF/AC). Individual centile values of the variables investigated were established by quantile regression in the gestational interval considered. In 50 cases UVBF was measured twice by the same investigator or by a second investigator and the intra- and inter-observer agreement were calculated.

RESULTS

A significant increase in UV diameter, TAMXV, UVBF absolute value and UVBF/AC was evidenced in the gestational period considered. Growth charts were established based on these measurements. The intra- and inter-observer intraclass correlation coefficients resulted as 0.92 (0.87-0.96) and 0.89 (0.84-0.97), respectively, for UBVF.

CONCLUSIONS

In this study we constructed UVBF charts using quantile regression in a large cohort of low-risk pregnancies. These charts offer the advantage of specific estimated regression parameters for each percentile, better defining the normal range of UVBF. This promises to be useful in the diagnosis and management of fetuses with abnormal fetal growth.

Customized Fetal Growth Charts for Parents' Characteristics, Race, and Parity by Quantile Regression Analysis: A Cross-sectional Multicenter Italian Study

OBJECTIVES

The purpose of this study was to construct fetal biometric charts between 16 and 40 weeks' gestation that were customized for parental characteristics, race, and parity, using quantile regression analysis.

METHODS

In a multicenter cross-sectional study, 8070 sonographic examinations from low-risk pregnancies between 16 and 40 weeks' gestation were analyzed. The fetal measurements obtained were biparietal diameter, head circumference, abdominal circumference, and femur diaphysis length. Quantile regression was used to examine the impact of parental height and weight, parity, and race across biometric percentiles for the fetal measurements considered.

RESULTS

Paternal and maternal height were significant covariates for all of the measurements considered (P < .05). Maternal weight significantly influenced head circumference, abdominal circumference, and femur diaphysis length. Parity was significantly associated with biparietal diameter and head circumference. Central African race was associated with head circumference and femur diaphysis length, whereas North African race was only associated with femur diaphysis length.

CONCLUSIONS

In this study we constructed customized biometric growth charts using quantile regression in a large cohort of low-risk pregnancies. These charts offer the advantage of defining individualized normal ranges of fetal biometric parameters at each specific percentile corrected for parental height and weight, parity, and race. This study supports the importance of including these variables in routine sonographic screening for fetal growth abnormalities.

Disinfection of urban wastewater by solar driven and UV lamp - TiO₂ photocatalysis: effect on a multi drug resistant Escherichia coli strain

The effect of TiO₂ photocatalysis on the inactivation of an antibiotic resistant Escherichia coli strain selected from an urban wastewater treatment plant (UWWTP) effluent was investigated. Different light sources including a 250 W wide spectrum lamp, a 125 W UV-A lamp and solar radiation, as well as, photocatalysts loadings (TiO₂ Degussa P25) in the range from 0.05 to 2.00 g TiO₂ L(-1) were evaluated. The higher efficiency (total bacterial inactivation after 10 min of irradiation) was observed in the absence of TiO₂ when the wastewater was irradiated using the 250 W lamp. In the presence of TiO₂ a decreasing inactivation trend was observed (99.76% and 72.22% inactivation after 10 min irradiation at 0.10 and 2.00 g TiO₂ L(-1) respectively). Under solar simulated conditions the highest inactivation efficiency (93.17%) after 10 min of irradiation was achieved at the lower photocatalyst loading (0.05 g TiO₂ L(-1)). The concept of "reactor optical thickness" was introduced to explain the rates of disinfection observed. The optimum photocatalyst loading estimated by radiation absorption-scattering modeling was found to be 0.1 g TiO₂ L(-1) for all lamps. The difference between experimental tests and modeling may be due to TiO₂ particles aggregation. Comparative kinetic tests between solar and solar simulated photocatalytic (SSP) processes using 0.05 g TiO₂ L(-1) in suspension showed a quite similar inactivation behavior up to 30 min of irradiation, but only the SSP process resulted in a total inactivation of bacteria after 60 min of exposure. Antibiotic resistant test (Kirby-Bauer) on survived colonies showed that the SSP and SP processes affected in different ways the resistance of E. coli strain to the target antibiotics.

Isolation and characterisation of the fungus Spiromastix asexualis sp. nov. from discospondylitis in a German Shepherd dog, and review of Spiromastix with the proposal of the new order Spiromastixales (Ascomycota)

The genus Spiromastix consists of several fungal species that have been isolated from soil and animal dung in various parts of the world. However, these species are considered to be of low pathogenic potential, as no cases of infections caused by these fungi have been reported. Here, we describe the clinical course of discospondylitis in a dog from which a fungus was cultured from a biopsy and identified as a Spiromastix species by morphologic characteristics and sequencing. Phylogenetic analysis determined this to be a new species, Spiromastix asexualis, which is described, and a new order, Spiromastixales, is proposed.

Tumour necrosis factor-α plus interleukin-10 low producer phenotype predicts acute kidney injury and death in intensive care unit patients

Genetic polymorphism studies of cytokines may provide an insight into the understanding of acute kidney injury (AKI) and death in intensive care unit (ICU) patients. The aim of this study was to investigate whether the genetic polymorphisms of -308 G < A tumour necrosis factor (TNF)-α, -174 G > C interleukin (IL)-6 and -1082 G > A IL-10 may predispose ICU patients to the development of AKI and/or death. In a prospective nested case-control study, 303 ICU patients and 244 healthy individuals were evaluated. The study group included ICU patients who developed AKI (n = 139) and 164 ICU patients without AKI. The GG genotype of TNF-α (low producer phenotype) was significantly lower in the with AKI than without AKI groups and healthy individuals (55 versus 62 versus 73%, respectively; P = 0·01). When genotypes were stratified into four categories of TNF-α/IL-10 combinations, it was observed that low TNF-α plus low IL-10 producer phenotypes were more prevalent in patients with AKI, renal replacement therapy and death (P < 0·05). In logistic regression analysis, low TNF-α producer plus low IL-10 producer phenotypes remained as independent risk factors for AKI and/or death [odds ratio (OR) = 2·37, 95% confidence interval (CI): 1·16-4·84; P = 0·02] and for renal replacement therapy (RRT) and/or death (OR = 3·82, 95% CI: 1·19-12·23; P = 0·02). In this study, the combination of low TNF-α plus low IL-10 producer phenotypes was an independent risk factor to AKI and/or death and RRT and/or death in critically ill patients. Our results should be validated in a larger prospective study with long-term follow-up to emphasize the combination of these genotypes as potential risk factors to AKI in critically ill patients.

Metal fractionation in soils and assessment of environmental contamination in Vallecamonica, Italy

Metal contamination was investigated in soils of the Vallecamonica, an area in the northern part of the Brescia province (Italy), where ferroalloy industries were active for a century until 2001. The extent in which emissions from ferroalloy plants affected metal concentration in soils is not known in this area. In this study, the geogenic and/or anthropogenic origin of metals in soils were estimated. A modified Community Bureau of Reference sequential chemical extraction method followed by inductively coupled plasma optical emission spectroscopy (ICP-OES) analyses were employed to evaluate the potential bioavailability of Al, Cd, Mn, Fe, Cr, Zn, and Pb in soils. Principal component analysis (PCA) was used to assess the relationships among metal sources in soil samples from different locations. This approach allowed distinguishing of different loadings and mobility of metals in soils collected in different areas. Results showed high concentrations and readily extractability of Mn in the Vallecamonica soils, which may suggest potential bioavailability for organisms and may create an environmental risk and potential health risk of human exposure.

Pulmonary embolism due to popliteal vein aneurysm: approach and surgical treatment - a case report

Pulmonary embolism is the first presentation in 70-80% in patients with aneurysm of popliteal vein. We present a case of young man admitted in our hospital with respiratory distress, tachycardia and D-dimer >3000 mg/dL. The observation of pulmonary embolism required the placement of a caval temporary filter before the surgical treatment. The use of temporary filter is recommended in symptomatic patients for thromboembolic phenomena, and when ultrasound detects the presence of floating thrombus.

Endotension-related aortic sac rupture treated by endograft relining

Endovascular aortic aneurysm repair is an effective alternative to open surgical repair in high risk patient. Endotension is an unpredictable late and rare complication of EVAR. Clinical significance and choice of technique for treatment are controversial. At present, there are no cases of endotension-related aneurysmal sac rupture reported in literature, altough it is frequently associated with late surgical conversion. In this case report is described a case of a patient treated with a first generation Gore Excluder(TM) endograft for abdominal aortic aneurysm, with late aneurysmal sac enlargement without evidence of endoleak and subsequent contained rupture without anemia and shock. We have successfully treated the patient by endovascular procedure, through bilateral percutaneous femoral approach, with relining technique. Three years CT scan follow-up showed the endograft patency and size sac reduction.

Urban wastewater treatment plants as hotspots for the release of antibiotics in the environment: a review

Urban wastewater treatment plants (UWTPs) are among the main sources of antibiotics' release into various compartments of the environment worldwide. The aim of the present paper is to critically review the fate and removal of various antibiotics in wastewater treatment, focusing on different processes (i.e. biological processes, advanced treatment technologies and disinfection) in view of the current concerns related to the induction of toxic effects in aquatic and terrestrial organisms, and the occurrence of antibiotics that may promote the selection of antibiotic resistance genes and bacteria, as reported in the literature. Where available, estimations of the removal of antibiotics are provided along with the main treatment steps. The removal efficiency during wastewater treatment processes varies and is mainly dependent on a combination of antibiotics' physicochemical properties and the operating conditions of the treatment systems. As a result, the application of alternative techniques including membrane processes, activated carbon adsorption, advanced oxidation processes (AOPs), and combinations of them, which may lead to higher removals, may be necessary before the final disposal of the effluents or their reuse for irrigation or groundwater recharge.

Urban wastewater treatment plants as hotspots for antibiotic resistant bacteria and genes spread into the environment: a review

Urban wastewater treatment plants (UWTPs) are among the main sources of antibiotics' release into the environment. The occurrence of antibiotics may promote the selection of antibiotic resistance genes (ARGs) and antibiotic resistant bacteria (ARB), which shade health risks to humans and animals. In this paper the fate of ARB and ARGs in UWTPs, focusing on different processes/technologies (i.e., biological processes, advanced treatment technologies and disinfection), was critically reviewed. The mechanisms by which biological processes influence the development/selection of ARB and ARGs transfer are still poorly understood. Advanced treatment technologies and disinfection process are regarded as a major tool to control the spread of ARB into the environment. In spite of intense efforts made over the last years to bring solutions to control antibiotic resistance spread in the environment, there are still important gaps to fill in. In particular, it is important to: (i) improve risk assessment studies in order to allow accurate estimates about the maximal abundance of ARB in UWTPs effluents that would not pose risks for human and environmental health; (ii) understand the factors and mechanisms that drive antibiotic resistance maintenance and selection in wastewater habitats. The final objective is to implement wastewater treatment technologies capable of assuring the production of UWTPs effluents with an acceptable level of ARB.

Acoustic Radial Force Impulse as an effective tool for a prompt and reliable diagnosis of hepatocellular carcinoma - preliminary data

ARFI (Acoustic Radiation Force Impulse) is a novel method based on the use of shear acoustic waves remotely induced by the radiation force of a focused ultrasonic beam. Recently, ARFI has been investigated as a non-invasive method for the assessment of liver fibrosis. The reproducibility of ARFI technology was proved in determining liver fibrosis: in detail, for cirrhosis Fibroscan had its best cut-off at >/= 11 kPa (AUROC of 0.80) whereas ARFI >/= 2.0 m/s (AUROC of 0.89). By pair-wise comparison of AUROC, ARFI was significantly more accurate than TE for a diagnosis of significant and severe fibrosis. Due to the low amount of collagen deposition within hepatocellular carcinoma (HCC) nodules in a context of "hard" cirrhotic parenchyma, ARFI propose itself also as a novel, specific method for an early identification of primitive neoplastic nodules during the follow up of cirrhotic patients. The diagnostic accuracy can be demonstrated either versus the surrounding liver tissue or versus dysplastic or metastatic nodules. Further studies are required to confirm ARFI as a useful tool for HCC follow-up.

Effect of solar radiation on multidrug resistant E. coli strains and antibiotic mixture photodegradation in wastewater polluted stream

The effect of solar radiation on the inactivation of multidrug resistant Escherichia coli (MDR) strains selected from an urban wastewater treatment plant (UWWTP) effluent and the change of their resistance to a mixture of three antibiotics (evaluated in terms of minimum inhibit concentration (MIC)) in wastewater polluted stream were investigated. The solar photodegradation of the mixture of the three target antibiotics (amoxicillin (AMX), ciprofloxacin (CPX), and sulfamethoxazole (SMZ)) was also evaluated. Additionally, since UWWTP effluents are possible sources of antibiotics and antibiotic resistant bacteria, the disinfection by conventional chlorination process of the UWWTP effluent inoculated with MDR strains was investigated too. Solar radiation poorly affected the inactivation of the two selected antibiotic resistant E. coli strains (40 and 60% after 180 min irradiation). Moreover, solar radiation did not affect strain resistance to AMX (MIC>256 μg/mL) and SMZ (MIC>1024 μg/mL), but affected resistance of the lower resistance strain to CPX (MIC decreased by 33% but only after 180 min of irradiation). Chlorination of wastewater sample strongly decreased the number of the two selected antibiotic resistant E. coli strains (99.667 and 99.999%), after 60 min of contact time at 2.0 mg/L initial chlorine concentration, but the resistance of survived colonies to antibiotics was unchanged. Finally, the solar photodegradation rate of the antibiotic mixture (1mg/L initial concentration respectively) resulted in the following order (half-life time): CPX (t(1/2)=24 min)<AMX (t(1/2)=99 min)<SMZ (t(1/2)=577 min). Accordingly, the risk of the development of resistance to SMZ in surface water is significantly higher compared to CPX and AMX.

Urgent Carotid Surgery: Is It Still out of Debate?

Patients with symptomatic tight carotid stenosis have an increased short-time risk of stroke and an increased long-term risk of ischaemic vascular events compared with the general population. The aim of this study is to assess the safety, efficacy, and limitations of urgent CEA or CAS, in patients with carotid stenosis greater than 70% and clinically characterized by recurrent TIA or brain damage following a stroke (<2.5 cm). This study involved 28 patients divided into two groups. Group A consisted of sixteen patients who had undergone CEA, and group B consisted of twelve patients who had undergone CAS. Primary endpoints were mortality, neurological morbidity (by NIHSS) and postoperative hemorrhagic cerebral conversion, at 30 days. Ten patients (62.5%) of group A experienced an improvement in their initial neurological deficit while in 4 cases (26%) the deficit remained stable. Two cases of neurologic mortality are presented. At 1 month, 9 patients (75%) of group B experienced an improvement in their initial neurological deficit while 3 patients (25%) had a neurological impairment. Urgent or deferred surgical or endovascular treatment have a satisfactory outcome considering the profile in very high-risk patient population. Otherwise in selected patients CEA seems to be preferred to CAS.

No progression of Eschmann tube: case report

A 74-year-old patient was submitted to urgent surgery for intestinal occlusion. After the induction of the anaesthesia, tracheal intubation failed since no progression of Eshmann tracheal tube introducer was possible. The ventilation was difficult and a laryngeal mask was inserted. After oxygenation, the tracheal tube with a rigid catheter was positioned. The larynx was visible but there was a spur that obstacled the progression of the Eshmann tracheal tube introducer. The spur derived from a previous tracheostomy.

Comparison of transient elastography and acoustic radiation force impulse for non-invasive staging of liver fibrosis in patients with chronic hepatitis C

OBJECTIVES

Transient elastography (TE) is adequate for a diagnosis of cirrhosis, but its accuracy for milder stages of fibrosis is much less satisfactory. The objective of this study was to compare the performance and the discordance rate of acoustic radiation force impulse (ARFI) and TE with liver biopsy in a cohort of chronic hepatitis C (CHC) patients.

METHODS

One hundred thirty-nine consecutive patients with CHC were enrolled in two tertiary centers, and evaluated for histological (Metavir score) and biochemical features. All patients underwent TE and ARFI.

RESULTS

TE was unreliable in nine patients (6.5%), while in no cases (0%) were ARFI invalid measurements recorded (P=0.029). By area under receiver operating characteristic curve (AUROC), the best cutoff values for TE and ARFI for significant fibrosis (≥F2) were ≥6.5 kPa (AUROC: 0.78) and ≥1.3 m/s (AUROC: 0.86), respectively. For severe fibrosis (F3-F4), these cutoff values were 8.8 kPa (AUROC: 0.83) for TE and 1.7 m/s (AUROC: 0.94) for ARFI. For cirrhosis, TE had its best cutoff at ≥11 kPa (AUROC: 0.80) and ARFI at ≥2.0 m/s (AUROC: 0.89). By pairwise comparison of AUROC, ARFI was significantly more accurate than TE for a diagnosis of significant and severe fibrosis (P=0.024 and P=0.002, respectively), while this difference was only marginal for cirrhosis (P=0.09). By partial AUROC analysis, ARFI performance results significantly higher for all three stages of fibrosis. The average concordance rates of TE and ARFI vs. liver biopsy were 45.4 and 54.7%, respectively. By multivariate analysis, ARFI was not associated with alanine aminotransferase (ALT), body mass index, Metavir grade, and liver steatosis, while TE was significantly correlated with the ALT value (P=0.027).

CONCLUSIONS

In a cohort of patients with CHC, ARFI imaging was more accurate than TE for the non-invasive staging of both significant and severe classes of liver fibrosis.

Inactivation and injury assessment of Escherichia coli during solar and photocatalytic disinfection in LDPE bags

Solar disinfection (SODIS) of Escherichia coli suspensions in low-density polyethylene bag reactors was investigated as a low-cost disinfection method suitable for application in developing countries. The efficiency of a range of SODIS reactor configurations was examined (single skin (SS), double skin, black-backed single skin, silver-backed single skin (SBSS) and composite-backed single skin) using E. coli suspended in model and real surface water. Titanium dioxide was added to the reactors to improve the efficiency of the SODIS process. The effect of turbidity was also assessed. In addition to viable counts, E. coli injury was characterised through spread-plate analysis using selective and non-selective media. The optimal reactor configuration was determined to be the SBSS bag (t(50)=9.0min) demonstrating the importance of UVA photons, as opposed to infrared in the SODIS disinfection mechanism. Complete inactivation (6.5-log) was achieved in the presence of turbidity (50NTU) using the SBSS bag within 180min simulated solar exposure. The addition of titanium dioxide (0.025gL(-1)) significantly enhanced E. coli inactivation in the SS reactor, with 6-log inactivation observed within 90min simulated solar exposure. During the early stages of both SODIS and photocatalytic disinfection, injured E. coli were detected; however, irreversible injury was caused and re-growth was not observed. Experiments under solar conditions were undertaken with total inactivation (6.5-log) observed in the SS reactor within 240min, incomplete inactivation (4-log) was observed in SODIS bottles exposed to the same solar conditions.

Iloprost in the management of peripheral arterial disease in patients with diabetes mellitus

Diabetic complications in the lower extremities, especially those secondary to diabetic macroangiopathy, have increasingly become a clinical emergency, given the high prevalence and progression of the disease. Until recently, the only approach to treating advanced stage disease was medical therapy and major amputation; however, the advent of revascularization procedures has radically improved the prognosis of patients with critical lower limb ischemia. In this setting, iloprost holds a dual position: as first-choice therapy in patients ineligible for revascularization and as complementary therapy in candidates for surgical or endovascular revascularization.

A Randomized Controlled Trial to Examine the Efficacy and Safety of a New Super-Oxidized Solution for the Management of Wide Postsurgical Lesions of the Diabetic Foot

This randomized trial was done to test the effectiveness and safety of using a novel antiseptic solution (Dermacyn® Wound Care [DWC], Oculus Innovative Sciences, Petaluma, CA) in the management of the postoperative lesions on the infected diabetic foot. 40 patients with postsurgical lesions wider than 5 cm2 left open to heal by secondary intention were randomized into 2 groups. Group A was locally treated with DWC, whereas group B received povidone iodine as local medication, both in adjunct to systemic antibiotic therapy and surgical debridement if needed. Ischemia, renal failure, bilateral lesions, or immunodepression were considered as exclusion criteria. Patients were followed up weekly for 6 months. The primary endpoint was healing rate at 6 months, while secondary endpoints were healing time, time to achieve negative cultures, duration of antibiotic therapy, number of reinterventions, and adverse events. Healing rates at 6 months were significantly shorter in group A (90%) than in group B (55%; P < .01). The time taken for cultures to become negative and duration of antibiotic therapy were also significantly (P < .05) shorter in group A than in group B, whereas the number of reinterventions was significantly higher in group B (P < .05). No difference was noted in the adverse events except that for reinfections, which were more frequent in group B than in group A (P < .01). DWC is as safe as and more effective than standard local antiseptics in the management of wide postsurgical lesions in the infected diabetic foot.

Degradation of fifteen emerging contaminants at microg L(-1) initial concentrations by mild solar photo-Fenton in MWTP effluents

The degradation of 15 emerging contaminants (ECs) at low concentrations in simulated and real effluent of municipal wastewater treatment plant with photo-Fenton at unchanged pH and Fe=5 mg L(-1) in a pilot-scale solar CPC reactor was studied. The degradation of those 15 compounds (Acetaminophen, Antipyrine, Atrazine, Caffeine, Carbamazepine, Diclofenac, Flumequine, Hydroxybiphenyl, Ibuprofen, Isoproturon, Ketorolac, Ofloxacin, Progesterone, Sulfamethoxazole and Triclosan), each with an initial concentration of 100 microg L(-1), was found to depend on the presence of CO(3)(2-) and HCO(3)(-) (hydroxyl radicals scavengers) and on the type of water (simulated water, simulated effluent wastewater and real effluent wastewater), but is relatively independent of pH, the type of acid used for release of hydroxyl radicals scavengers and the initial H(2)O(2) concentration used. Toxicity tests with Vibrio fisheri showed that degradation of the compounds in real effluent wastewater led to toxicity increase.