Co-hydrothermal carbonization with process water recirculation as a valuable strategy to enhance hydrochar recovery with high energy efficiency

This study aims at valorizing the residual aqueous phase from hydrothermal carbonization (HTC) of Sicilian agro-wastes in order to enhance the hydrochar recovery, positively affecting the process energy balance. Process waters (PW) obtained from HTC and co-HTC using orange peel waste and fennel plant residues were used as recycled solvent in experiments carried out at the temperatures of 180 and 230 °C. The results showed that an additional hydrochar formation was promoted during recirculation of solvent, leading to average increments of solid mass yield of 10.5 wt% for tests conducted at 180 °C and 3.9 wt% for 230 °C. After five consecutive recirculation phases in co-HTC runs, the hydrochar yield increased up to 18.2 wt%. The low H/C and O/C atomic ratios values, found after recirculation, indicate that organic acids, accumulated in the PW, may catalyze the process and promote the biomass deoxygenation by boosting dehydration and decarboxylation. The recovered PWs from conversion steps with deionized water were also carbonized in absence of the solid feedstock in order to quantify their contribution in hydrochar formation during recirculation and thus the synergistic interactions. After recirculation, energy recovery averagely augmented by more than threefold, showing that the proposed strategy could significantly improve the sustainability of HTC.

Role of acidic hydrochar on dechlorination of waste PVC in high temperature hydrothermal treatment and fuel properties enhancement of solid residues

In this study, the chlorine mitigation from waste polyvinyl chloride (WPVC) during high temperature co-hydrothermal treatment (co-HTT) and the properties of the generated solid products were assessed. WPVC was co-fed with acidic hydrochar (AHC), which was produced via hydrothermal carbonization of pineapple waste in the presence of citric acid water solution. High temperature co-HTT experiments were performed at 300-350 °C, 0.25-4 h of reaction time, and 0-20 wt% AHC loading. Co-HTT solid products (co-HTT_SP) were characterized via proximate analysis, ultimate analyses, combustion analysis, and ash analysis. The results show that the addition of 5% AHC enhances the dechlorination efficiency (DE) of WPVC from 89.35% to 97.66% at 325 °C and 0.5 h. The highest DE, reaching 99.46%, was achieved at 350 °C and 1 h in the presence of 5 wt% AHC. Furthermore, loading 5% AHC improved the higher heat value (HHV) of the solid products from 23.09 to 31.25 MJ/kg at 325 °C and 0.5 h. The maximum HHV (34.77 MJ/kg) of a solid product was achieved at 350 °C, 4 h, in the presence of 5 wt% of AHC. The co-HTT solids shown low slagging indices, fouling indices, alkali indices, and medium chlorine contents. These findings support the viability of WPVC conversion into clean solid fuel via co-HTT.

Cardiovascular risk and the COVID-19 pandemic: A retrospective observational study in a population of healthcare professionals

BACKGROUND AND AIM

To contain the spread of COVID-19, many countries imposed several restrictive measures, leading to radical changes in daily life behaviors. Healthcare workers experienced additional stress due to the increased risk of contagion, possibly causing an increase in unhealthy habits. We investigated changes in cardiovascular (CV) risk assessed by the SCORE-2 in a healthy population of healthcare workers during the COVID-19 pandemic; an analysis by subgroups was also conducted (sportspeople vs sedentary subjects).

METHODS AND RESULTS

We compared medical examination and blood tests in a population of 264 workers aged over 40, performed yearly before (T0) and during the pandemic (T1, T2). We found a significant increase in the average CV risk, according to SCORE-2, during the follow-up in our healthy population, with a shift from a mean low-moderate risk profile at T0 (2.35%) to a mean high-risk profile at T2 (2.80%). Furthermore, in sedentary subjects was observed a greater and early increase in SCORE-2 compared to sportspeople.

CONCLUSIONS

Since 2019, we observed an increase in CV risk profile in a healthy population of healthcare workers, particularly in sedentary subjects, highlighting the need to reassess SCORE-2 every year to promptly treat high-risk subjects, according to the latest Guidelines.

Phytotoxicity and genotoxicity of agro-industrial digested sludge hydrochar: The role of heavy metals

Hydrochar is a new carbonaceous product obtained via hydrothermal carbonization of wet biomass, such as sludges or digested sludges, which often have disposal problems, also due to the presence of contaminants such as heavy metals. The properties of the hydrochar led to an interest in using it as an amendment, but the agro-environmental properties must be considered for its safe use. Raw hydrochar produced by agro-industrial digestate and relative three acidic post-treated hydrochars (for heavy metals removal) have been assessed considering their effect on phytotoxicity, soil, plant growth, mutagenicity, and genotoxicity. The chemical characterization showed the effect of post-treatment on heavy metals contents reduction, except for Cu content (hydrochar, 650 mg/kg; post-treated hydrochars, 940 mg/kg, 287 mg/kg, and 420 mg/kg). The acidic post-treatment also reduces the phytotoxicity compared to raw hydrochar (the germination index at 16 % of hydrochar concentration was: hydrochar, 61.48 %; post-treated hydrochars, 82.27 %, 58.28 %, and 82.26 %), but the low pH and the impact on N-cycle probably have caused the detrimental effect on plant growth of post-treated hydrochar. No mutagenic activity was observed in bacteria using Ames test, while all the samples induced chromosomal aberrations in plant cells (Allium cepa test). The approach adopted, which considers phytotoxicity, plant growth-soil effects, and mutagenicity/genotoxicity bioassays has been proven effective for a proper evaluation of organic products derived from waste to promote a sustainable and circular recovery of materials.

Highly ordered CaO from cuttlefish bone calcination for the efficient adsorption of methylene blue from water

The aim of this study is to synthesize cheap and highly ordered CaO from cuttlefish bone (CFB) as a green alternative to conventional adsorbents such as activated carbon. This study focuses on the synthesis of highly ordered CaO via calcination of CFB, at two different temperatures (900 and 1000°C) and two holding times (0.5 and 1 h), as a potential green route for water remediation. The as-prepared highly ordered CaO was tested as an adsorbent using methylene blue (MB) as a model compound for dye contaminants in water. Different CaO adsorbent doses (0.05, 0.2, 0.4, and 0.6 g) were used, keeping the MB concentration fixed at 10 mg/L. The morphology and crystalline structure of the CFB before and after calcination was characterized via scanning electron microscope (SEM) and X-ray diffraction (XRD) analyses, while the thermal behavior and surface functionalities were characterized by thermogravimetric analysis (TGA) and Fourier transform infrared (FTIR) spectroscopy, respectively. Adsorption experiments using different doses of CaO synthesized at 900°C for 0.5 h showed an MB removal efficiency as high as 98% by weight using 0.4 g (adsorbent)/L(solution). Two different adsorption models, the Langmuir adsorption model and the Freundlich adsorption model, along with pseudo-first-order and pseudo-second-order kinetic models, were studied to correlate the adsorption data. The removal of MB via highly ordered CaO adsorption was better modeled by the Langmuir adsorption isotherm giving (R² =0.93), thus proving a monolayer adsorption mechanism following pseudo-second-order kinetics (R²= 0.98), confirming that chemisorption reaction occurs between the MB dye molecule and CaO.

P39 ATRIAL MASS IN HEART TRANSPLANTED PATIENT WITH CLINICAL HISTORY OF LYMPHOMA

Atrial thrombosis is an uncommon complication of cardiac transplant, especially when performed with standard technique. Pathogenetic mechanisms might involve atrial anatomy distortion and abnormalities in its contractile function, which induce flow stasis and thrombus formation, mostly on the surgical suture. A 77–year–old man underwent orthotopic heart transplantation in 2000 for post–ischemic dilated cardiomyopathy. In 2019 he was diagnosed with diffuse large B–cell lymphoma treated with chemotherapy. On March 2021, during follow up period, he had a total body CT scan which showed a submandibular space–occupying lesion, likely as a disease recurrence, and a large atrial mass (30x50 mm). For this reason, he was admitted to the emergency department. Echocardiography documented a massive hyperechogenic formation in an enlarged left atrium. In order to rule out a neoplastic nature, a cardiac CMR was performed, confirming the presence of an oval mass adhering to the posterior left atrial wall with partial involvement of pulmonary veins ostia, with inhomogeneous isointense signal on T1–weighted sequences and hyper–isointense signal on T2–weighted sequences, without significant contrast enhancement, likely representing an endoluminal thrombotic formation. Given the patient’s clinical status and his hemodynamic stability, a surgical excision was deferred. The patient was discharged on oral anticoagulant therapy with Warfarin (INR target 2–3). Three months later, a chest CT showed a meaningful mass reduction (11x18mm), which was no longer visible at echocardiography. About 9 months later, complete disappearance of the atrial mass was found at a CT scan. According to scientific literature, differential diagnosis of a newly discovered atrial mass in a transplanted heart includes thrombosis or neoplasia. Thrombosis occurs usually early after surgery, but due to promoting factors, it can arise after many years. The most likely triggering condition is an acquired prothrombotic status: in our case the likely lymphoma recurrence may have led to thrombogenesis. In order to exclude with confidence cardiac metastasis, histological examination would have been necessary. Nevertheless, the meaningful mass reduction, as early as three months after starting oral anticoagulation, and its disappearance nine months after, strongly suggests for atrial thrombosis.

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P86 IN–HOSPITAL OUTCOMES OF PORTICO TRANSCATHETER AORTIC VALVE IMPLANTATION WITH THE FLEXNAV AS COMPARED TO THE FIRST–GENERATION DELIVERY SYSTEM

Introduction

technological advancements in transcatheter heart valve platforms, along with increasing operator experience and careful patient selection, are essential to reach high standards of efficacy and safety in transcatheter aortic valve replacement (TAVR). Aim of this study was to evaluate the performance of the new version of the Portico valve delivery system (FlexNav) as compared to the first–generation device.

Materials and Methods

we report the results of a single–center, observational study on patients with severe aortic valve stenosis undergoing TAVR with the Portico valve at our Institution. Consecutive patients treated with the new FlexNav delivery system (DS), available since May, 2020, were compared with patients treated with the first–generation delivery system (1st Gen–DS). In–hospital outcomes were self–adjudicated according to the Valve Academic Research Consortium–3 definition.

Results

50 patients were included in this study; 22 were treated with the FlexNav–DS and the remaining with the 1st Gen–DS. Clinical characteristics were similar between group, expect for older age (82.6 ± 3.6 vs 80.7 ± 3.8; p = 0.07) and higher prevalence of female gender (68.2% vs 39.3%; p = 0.04) in FlexNav–DS group as compared to 1st Gen–DS group, respectively. We observed similar rates of procedural success but higher rate of moderate–to–severe paravalvular leak in 1st Gen–DS as compared to FlexNav–DS group (28.6% vs 4.6%; p = 0.03); major vascular complications were reduced, although not significantly, in the FlexNav–DS as compared to 1st Gen–DS group (4.5% vs 10.7%; p = 0.64).

Conclusion

Our data suggest that the FlexNav DS, thanks to lower profile and enhanced stability during valve deployment, has the potential to allow for to better procedural and clinical results of TAVR with the Portico valve as compared to the 1st Gen–DS.

Valorization of cow manure via hydrothermal carbonization for phosphorus recovery and adsorbents for water treatment

The increased quantities of manure being generated by livestock and their extensive agronomic use have raised concerns around run-off impacting soil and groundwater quality. Manure contains valuable nutrients (especially phosphorus) that are critical to agriculture, but when directly land-applied the run-off of such nutrients contributes to eutrophication of waterways. This study investigates the hydrothermal carbonization of cow manure at two industrially feasible process extremes: 190 °C, 1 h and 230 °C, 3 h, to concentrate and then recover phosphorus from the solid hydrochar via acid leaching and precipitation. Up to 98 wt% of phosphorus initially present in the hydrochar (88% in the raw manure) can be recovered, with the dominant crystalline species being hydroxyapatite. Acid leached hydrochars were subsequently pyrolyzed at 600 °C for 30 min, and then evaluated as adsorbent materials for water remediation by using methylene blue as a model adsorbate. Although pyrolyzed hydrochars have surface areas an order of magnitude higher (160-236 m²/g) than the non-pyrolyzed acid leached hydrochars (11-23 m²/g), their adsorption capacity is three times lower. Furthermore, while the higher carbonization temperature leads to greater recovery of phosphorus, it likewise leads to higher heavy metal concentrations in the precipitate (ranging from 0.1 to 100 mg_metal/g_ppt). As such, lower temperature carbonization followed by acid-extraction - without further solid processing - is a potential pathway to recover phosphorus and adsorbent materials.

Changes in admissions, and hospitalization outcomes of IBD patients in an Italian tertiary referral center over a 13-year period

OBJECTIVE

The management of Inflammatory Bowel Disease (IBD) has changed significantly in recent years, mainly due to the introduction of biologic medications, however, other factors may also have a role. The aim of this study was to evaluate the evolution of IBD admissions, including trends, modality of admission and rates of surgical intervention, in a tertiary care center.

PATIENTS AND METHODS

Hospitalization of patients with a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were identified between 2000 and 2013, using ICD-9-CM codes for IBD, from our hospital database. The following parameters were evaluated for each admission: type of admission (ordinary vs. day care service), mode of admission (elective vs. emergency care, for ordinary admissions only), admission code, surgical procedures and complication rates. Comparison between pre- and post-biologic therapy introduction years was also performed.

RESULTS

Between 2000 and 2013 a total of 8834 IBD-related admissions were recorded. Hospitalizations increased linearly reaching a peak in 2006, with a downward trend in the following years. The downward trend was especially marked for patients younger than 40 years. No significant differences in hospitalization trends between CD and UC were recorded. Disease flare represented the cause of hospitalization in approximately 50% of cases. Overall, 10.8% of patients underwent surgery with no difference between the two conditions. Complications occurred in 28.7% of admissions.

CONCLUSIONS

Hospitalizations for IBD patients have decreased in recent years, especially in younger patients. However, a significant proportion of patients are still admitted to complete diagnostic workup, indicating the need to better implement outpatient services. A clear reduction in surgery occurrence over time could not be observed in our study.

Probabilistic tsunami forecasting for early warning

Tsunami warning centres face the challenging task of rapidly forecasting tsunami threat immediately after an earthquake, when there is high uncertainty due to data deficiency. Here we introduce Probabilistic Tsunami Forecasting (PTF) for tsunami early warning. PTF explicitly treats data- and forecast-uncertainties, enabling alert level definitions according to any predefined level of conservatism, which is connected to the average balance of missed-vs-false-alarms. Impact forecasts and resulting recommendations become progressively less uncertain as new data become available. Here we report an implementation for near-source early warning and test it systematically by hindcasting the great 2010 M8.8 Maule (Chile) and the well-studied 2003 M6.8 Zemmouri-Boumerdes (Algeria) tsunamis, as well as all the Mediterranean earthquakes that triggered alert messages at the Italian Tsunami Warning Centre since its inception in 2015, demonstrating forecasting accuracy over a wide range of magnitudes and earthquake types.

Integrated thermochemical conversion process for valorizing mixed agricultural and dairy waste to nutrient-enriched biochars and biofuels

Hydrothermal carbonization (HTC) and pyrolysis are two promising thermochemical conversion strategies to valorize agricultural wastes, yet neither process can be implemented alone to sustainably upgrade both wet and dry feedstocks. HTC is ideal for wet feedstocks, such as manure, but its solid hydrochars suffer from low surface area and stability. Pyrolysis is well suited to dry agricultural residues, but pyrolysis biochars have low nutrient contents and bio-oils are often highly oxygenated. We propose an integrated process that co-pyrolyzes a nutrient-rich cow manure hydrochar with raw agricultural residues, which effectively reduces the environmental impact of these wastes while producing value-added bioproducts. Biochars produced from the proposed process are more suitable for soil amendments due to their enhancement in bioavailable nutrients and surface area than the manure hydrochars and raw biomass. Co-pyrolysis of blends enriched with cow manure yield oils higher in alkanes and alkenes with fewer oxygenated compounds.

Hydrothermal carbonization coupled with anaerobic digestion for the valorization of the organic fraction of municipal solid waste

Hydrothermal carbonization (HTC) was evaluated as a promising treatment to enhance the biomethane potential during anaerobic digestion (AD) of the organic fraction of municipal solid waste (OFMSW). The OFMSW was carbonized at different conditions and HTC products were tested for biomethane potential into AD. Results proved that the use of HTC liquid and slurry into AD led to an increase in biomethane production up to 37% and 363%, respectively, compared to OFMSW. Methane production increased as the HTC process severity decreased, reaching its maximum at 180 °C, 1 h for both HTC products. Energy assessment demonstrated that the combustion of biogas produced by AD of HTC liquid and slurries covers up to 30% and 104% of the HTC thermal demand, respectively. When the energy from hydrochar and biogas combustion was recovered, the process efficiency reached 60%. Hence, HTC coupled with AD demonstrates to be an efficient way to valorize OFMSW.

Streptococcus pneumoniae in hospitalized patients with pneumonia: epidemiology and implications

Background

Streptococcus pneumoniae (SP) is a major cause of pneumonia worldwide representing a significant problem from the public health viewpoint. The aim of our study was to assess the frequency of SP in hospitalized patients with pneumonia and investigate its relationship with patients' characteristics.

Methods

A deterministic record linkage of hospital discharge and microbiology laboratory surveillance databases of a teaching hospital in Rome was used to identify all patients over 15 years old (y) with a diagnosis of pneumonia and a microbiological ascertainment between November 2010 and March 2013. Pneumonia ICD-9-CM codes were used to identify the study population. The frequency of SP was assessed with respect to patients' characteristics.

Results

1216 (64% males) of a mean age 65 (SD = 18) y patients with pneumonia were identified. Of them, 707 (58%) had a positive microbiological result. Among the latter, mixed bacterial co-infections were detected in 552 (74%) cases. The most frequently isolated organism was SP in 288 (41%) cases. Nevertheless, SP was the sole isolated agent in only 6 (0.8%) cases. There were no significant differences between men and women with respect to the frequency of SP. Eventually, the frequency of SP among patients with a positive microbiological result was higher in the age group 15-64 y than in 65+ y (45% vs 37%, p = 0.038). When considering only subjects with at least one comorbidity the frequency of SP was higher among the 15-64 y age group (53% vs 44% in 15-64 y and 65+ y respectively, p = 0.040).

Conclusions

Our study revealed that SP was the most frequent isolated pathogen in hospitalized patients with pneumonia. However, the SP coexistence with other pathogens was present in the vast majority of cases. Interestingly, SP was highly frequent among people with comorbidities, in particular in the age group 15-64 y. This emphasizes the importance of vaccination in this group of patients.

Key messages

This study shows that more than 40% of pneumonia with a positive microbiological result are caused by Streptococcus pneumoniae. Preventive strategies to limit Streptococcus pneumoniae infections among adults and individuals affected by comorbidities are needed.

Hyperuricemia and Risk of Cardiovascular Outcomes: The Experience of the URRAH (Uric Acid Right for Heart Health) Project

The latest European Guidelines of Arterial Hypertension have officially introduced uric acid evaluation among the cardiovascular risk factors that should be evaluated in order to stratify patient's risk. In fact, it has been extensively evaluated and demonstrated to be an independent predictor not only of all-cause and cardiovascular mortality, but also of myocardial infraction, stroke and heart failure. Despite the large number of studies on this topic, an important open question that still need to be answered is the identification of a cardiovascular uric acid cut-off value. The actual hyperuricemia cut-off (> 6 mg/dL in women and 7 mg/dL in men) is principally based on the saturation point of uric acid but previous evidence suggests that the negative impact of cardiovascular system could occur also at lower levels. In this context, the Working Group on uric acid and CV risk of the Italian Society of Hypertension has designed the Uric acid Right for heArt Health project. The primary objective of this project is to define the level of uricemia above which the independent risk of CV disease may increase in a significantly manner. In this review we will summarize the first results obtained and describe the further planned analysis.

One stage olive mill waste streams valorisation via hydrothermal carbonisation

An olive waste stream mixture, coming from a three phase-continuous centrifugation olive oil mill industry, with a typical wet basis mass composition of olive pulp 39 wt%, kernels 5 wt% and olive mill waste water 56 wt%, was subjected to hydrothermal carbonisation (HTC) at 180, 220 and 250 °C for a 3-hour residence time in a 2-litre stainless steel electrically heated batch reactor. The raw feedstock and corresponding hydrochars were characterised in terms of proximate and ultimate analyses, higher heating values and energy properties. Results showed an increase in carbonisation of samples with increasing HTC severity and an energy densification ratio up to 142% (at 250 °C). Hydrochar obtained at 250 °C was successfully pelletised using a lab scale pelletiser without binders or expensive drying procedures. Energy characterisation (HHV, TGA), ATR-FTIR analysis, fouling index evaluation and pelletisation results suggested that olive mill waste hydrochars could be used as energy dense and mechanical stable bio-fuels. Characterisation of HTC residues in terms of mineral content via induced coupled plasma optical emission spectroscopy (ICP-OES) as well as Total and Dissolved Organic Carbon enabled to evaluate their potential use as soil improvers. Nutrients and polyphenolic compounds in HTC liquid fractions were evaluated for the estimation of their potential use as liquid fertilisers. Results showed that HTC could represent a viable route for the valorisation of olive mill industry waste streams.

Spent coffee enhanced biomethane potential via an integrated hydrothermal carbonization-anaerobic digestion process

This study reports the implications of using spent coffee hydrochar as substrate for anaerobic digestion (AD) processes. Three different spent coffee hydrochars produced at 180, 220 and 250 °C, 1 h residence time, were investigated for their biomethane potential in AD process inoculated with cow manure. Spent coffee hydrochars were characterized in terms of ultimate, proximate and higher heating value (HHV), and their theoretical bio-methane yield evaluated using Boyle-Buswell equation and compared to the experimental values. The results were then analyzed using the modified Gompertz equation to determine the main AD evolution parameters. Different hydrochar properties were related to AD process performances. AD of spent coffee hydrochars produced at 180 °C showed the highest biomethane production rate (46 mL CH₄/gVS^.d), a biomethane potential of 491 mL/gVS (AD lasting 25 days), and a biomethane gas daily composition of about 70%.

Hydrothermal carbonization of Opuntia ficus-indica cladodes: Role of process parameters on hydrochar properties

Opuntia ficus-indica cladodes are a potential source of solid biofuel from marginal, dry land. Experiments assessed the effects of temperature (180-250°C), reaction time (0.5-3h) and biomass to water ratio (B/W; 0.07-0.30) on chars produced via hydrothermal carbonization. Multivariate linear regression demonstrated that the three process parameters are critically important to hydrochar solid yield, while B/W drives energy yield. Heating value increased together with temperature and reaction time and was maximized at intermediate B/W (0.14-0.20). Microscopy shows evidence of secondary char formed at higher temperatures and B/W ratios. X-ray diffraction, thermogravimetric data, microscopy and inductively coupled plasma mass spectrometry suggest that calcium oxalate in the raw biomass remains in the hydrochar; at higher temperatures, the mineral decomposes into CO₂ and may catalyze char/tar decomposition.

Single blind, multicentre, randomized, controlled trial testing the effects of a novel nutraceutical compound on plasma lipid and cardiovascular risk factors: Results of the interim analysis

BACKGROUND AND AIMS

The clustering of high levels of LDL cholesterol (LDL-C) and other risk factors represents a predisposing condition for atherosclerotic disease development. Cardiovascular prevention is based on effective control of these conditions. In adult subjects with mild hypercholesterolemia we compared in the real life the effects of a new combination of nutraceuticals on lipid and glucose metabolism and blood pressure with those of an established nutraceutical combination.

METHOD AND RESULTS

This multicenter, controlled, randomized, single-blind trial was designed to compare the effect of Armolipid Plus^® versus that of LopiGLIK^® on lipid and glucose levels and blood pressure (BP) in subjects with mild hypercholesterolemia not on statin therapy. Primary outcome was the proportion of subjects achieving therapeutic targets of LDL-C (<130 mg/dl); secondary outcomes were the effects on HDL-C, glycated haemoglobin and insulin levels. Data from an overall sample of 359 adult individuals (age 55.2 ± 11.1 years, women 57.7%, LDL-C 157.3 ± 22.6 mg/dl, HDL-C 50.7 ± 13.0 mg/dl) are reported. 72% of subjects treated with LopiGLIK^® and 43% treated with Armolipid Plus^® achieved the primary endpoint (p < 0.0001). Both treatments reduced plasma levels of total and LDL-C and triglycerides (p < 0.001 for all comparisons). The treatments also reduced systolic and diastolic blood pressure, plasma levels of glycated haemoglobin, insulin and HOMA index. The changes induced by LopiGLIK^® in all these metabolic parameters were greater than those obtained with Armolipid Plus^®.

CONCLUSIONS

The present analysis shows that LopiGLIK^® may represent a more effective tool for clinical management of CV risk factors in subjects with mild hypercholesterolemia.

Abstract P2-08-03: Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer

Background: In vitro mechanisms link IL-6 to poor outcome in breast cancer via inflammatory pathways, activated JAK/STAT tumor signaling and upregulation of aromatase, leading to an aggressive tumor phenotype. Epidemiological data from our group and others support these mechanisms in women with ER-positive (+) disease. We therefore hypothesized that the JAK inhibitor, ruxolitinib (RUX, INCB018424; Incyte), would enhance activity of exemestane (EXE) in women with ER+ breast cancer who relapsed after non-steroidal aromatase inhibitor therapy, particularly among carriers of a germ-line polymorphism in IL-6, conferring elevated levels of IL-6 in the tumor microenvironment.

Methods: The “JAKEE trial” is a phase II trial to determine the safety and efficacy of RUX + EXE in postmenopausal women with relapsed, ER+ advanced breast cancer. Eligible patients were required to have progressed on a non-steroidal AI and either measureable or bone-only disease. CRP, a putative biomarker of tumor microenvironment inflammation, was measured at baseline and serially during treatment. Using a Simon 2-stage design, we treated 15 patients with RUX at 25 mg BID and EXE at 25mg daily on a continuous 28-day schedule. First stage results were previously presented (AACR, 2014). Accrual proceeded to second stage after no patient met the pre-defined stopping rule of grade (G) 3/4 toxicity requiring discontinuation from the study within the first treatment cycle. Due to the substantial rate of anemia requiring dose reductions, however, RUX dose was reduced to 15 mg BID in second stage.

Results: A total of 25 patients were enrolled; 24/25 had progressed on AI in metastatic setting; 1 relapsed on adjuvant AI. RUX+EXE was well-tolerated overall, with only 2 G4 events (creatinine elevation, hepatic failure); both were due to disease progression. 16% had G3 fatigue, anemia or hypertension; 12% had G3 neutropenia or depression. Other lower grade toxicities in &gt;20% included musculoskeletal pain, increased ALT, and headache. Overall, patients stayed on therapy for a median of 3 cycles (range 2 – 21). There were no CR or PR, but 6/25 (24%) had prolonged disease control (SD&gt; 6 months). Median CRP at study entry was 6.4 (range 0.3-38.9), with 8/25 (32%) having CRP&gt;10. Achieving SD&gt;6 months was not associated with baseline CRP (CRP&gt;10 in 32% with vs. 33% without SD&gt;6 months, p(exact)=1.0). A novel pharmacodynamic assay to assess STAT3 phosphorylation in peripheral blood mononuclear cells after RUX exposure demonstrated differential effects in patients with response.

Conclusions: Targeting JAK/STAT signaling in AI-resistant breast cancer with RUX+EXE was safe and well-tolerated. 24% of patients had prolonged SD, but baseline CRP level did not predict response. Correlative studies to determine whether host and/or tumor biomarkers predict response to therapy, including germline IL-6 genotype, immune profiles, p-STAT3 and estradiol levels, are currently underway.

Citation Format: DeMichele AM, Clark AS, Holmes R, Volpe M, Medrano C, Troxel A, Fox K, Domchek S, Matro J, Bradbury A, Shih N, Feldman M, Hexner E, Bromberg J. Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-08-03.

Novel antidiabetic drugs and cardiovascular risk: Primum non nocere

AIMS

Diabetes treatments aim at preventing undesirable metabolic effects of hyperglycemia and at preventing/reducing tissue damage, including cardiovascular (CV) events. For approval, novel diabetes drugs undergo early systematic investigation to assess CV safety. This review provides an updated analysis of the results of recent studies examining novel diabetes medications and CV outcomes.

DATA SYNTHESIS

The new regulatory guidelines enforce adjudication of all CV events when testing novel diabetes drugs. Endpoints of CV mortality, myocardial infarction (MI), stroke and hospitalization for heart failure (HF) were included in the most recent clinical studies on novel antihyperglycemics. These are: the incretin mimetics glucagon-like peptide 1 (GLP-1) receptor agonists (GLP1-RA), the incretin enhancers dipeptidylpeptidase-4 (DPP-4) inhibitors (DPP4-I or gliptins), and the sodium-glucose cotransporter (SGLT2) inhibitors (SGLT2-I or gliflozins). The studies ELIXA and EXAMINE, testing lixisenatide and alogliptin, respectively, revealed non-inferiority versus placebo in terms of CV safety. The SAVOR-TIMI 53 results confirmed overall CV safety of saxagliptin, but raised a warning related to the increase in the risk of hospitalization for HF in the saxagliptin group. Recently, TECOS revealed a particularly favorable CV profile for sitagliptin while EMPA-REG showed a significant CV risk reduction in empagliflozin treated subjects. Ongoing studies will provide additional data on CV safety for other GLP1-RAs, DPP4-I and SGLT2-I.

CONCLUSIONS

Results of safety outcome studies focused on CV events, including HF and mortality for CV causes, are not homogeneous. A critical analysis of these studies may help cardiologists and diabetes specialists to adapt their therapeutic choices to individual patients.

C2238/αANP modulates apolipoprotein E through Egr-1/miR199a in vascular smooth muscle cells in vitro

Subjects carrying the T2238C ANP gene variant have a higher risk to suffer a stroke or myocardial infarction. The mechanisms through which T2238C/αANP exerts detrimental vascular effects need to be fully clarified. In the present work we aimed at exploring the impact of C2238/αANP (mutant form) on atherosclerosis-related pathways. As a first step, an atherosclerosis gene expression macroarray analysis was performed in vascular smooth muscle cells (VSMCs) exposed to either T2238/αANP (wild type) or C2238/αANP. The major finding was that apolipoprotein E (ApoE) gene expression was significantly downregulated by C2238/αANP and it was upregulated by T2238/αANP. We subsequently found that C2238/αANP induces ApoE downregulation through type C natriuretic peptide receptor (NPR-C)-dependent mechanisms involving the upregulation of miR199a-3p and miR199a-5p and the downregulation of DNAJA4. In fact, NPR-C knockdown rescued ApoE level. Upregulation of miR199a by NPR-C was mediated by a reactive oxygen species-dependent increase of the early growth response protein-1 (Egr-1) transcription factor. In fact, Egr-1 knockdown abolished the impact of C2238/αANP on ApoE and miR199a. Of note, downregulation of ApoE by C2238/αANP was associated with a significant increase in inflammation, apoptosis and necrosis that was completely rescued by the exogenous administration of recombinant ApoE. In conclusion, our study dissected a novel mechanism of vascular damage exerted by C2238/αANP that is mediated by ApoE downregulation. We provide the first demonstration that C2238/αANP downregulates ApoE in VSMCs through NPR-C-dependent activation of Egr-1 and the consequent upregulation of miR199a. Restoring ApoE levels could represent a potential therapeutic strategy to counteract the harmful effects of C2238/αANP.

Clinical management of patients with hypertension and high cardiovascular risk in specialised centers and in general practice. Analysis from an Italian Survey Questionnaire

BACKGROUND AND AIM

Hypertension control remains poorly achieved worldwide, despite the use of modern diagnostic tools and advanced therapeutic strategies. We aimed to evaluate the preferences expressed by either specialised physicians (SPs) or general practitioners (GPs) for the clinical management of hypertension and high cardiovascular risk in Italy.

METHODS AND RESULTS

A predefined questionnaire was anonymously administered to a large community sample of physicians, stratified according to clinical expertise. From a total of 64 questions, 557 physicians (478 male, mean age 54.2 ± 7.1 years, average age of medical activity 28.0 ± 8.1 years), including 261 (46.9%) SPs and 296 (53.1%) GPs, provided 9564 answers to the survey questionnaire. Involved clinicians spent the majority of their time and practice for hypertension management and control. SPs aimed to achieve the recommended BP targets (<140/90 mmHg), whereas GPs tended to achieve more rigorous BP goals (<130/80 mmHg); nonetheless, they both reported a very high rate of BP control (about 70%). Concomitant presence of diabetes, organ damage, as well as comorbidities, was reported to be relatively frequent (26-50%), mostly by SPs. ESH/ESC 2007 risk score stratification was preferred by SPs compared to GPs, who favored a comprehensive clinical evaluation. ACE inhibitors or ARBs were considered the best pharmacological option to start antihypertensive treatment, thus adding diuretics or calcium-channel blockers, if needed.

CONCLUSIONS

This predefined analysis of a survey questionnaire showed relatively different opinions with respect to recommended BP targets and distributions of cardiovascular risk profile, and similar diagnostic and therapeutic choices between GPs and SPs.

Serum uric acid and its relationship with metabolic syndrome and cardiovascular risk profile in patients with hypertension: insights from the I-DEMAND study

BACKGROUND AND AIMS

The independent role of serum uric acid (SUA) as a marker of cardio-renal risk is debated. The aim of this study was to assess the relationship between SUA, metabolic syndrome (MS), and other cardiovascular (CV) risk factors in an Italian population of hypertensive patients with a high prevalence of diabetes.

METHODS AND RESULTS

A total of 2429 patients (mean age 62 ± 11 years) among those enrolled in the I-DEMAND study were stratified on the basis of SUA gender specific quartiles. MS was defined according to the NCEP-ATP III criteria, chronic kidney disease (CKD) as an estimated GFR (CKD-Epi) <60 ml/min/1.73 m(2) or as the presence of microalbuminuria (albumin-to-creatinine ratio ≥2.5 mg/mmol in men and ≥3.5 mg/mmol in women). The prevalence of MS, CKD, and positive history for CV events was 72%, 43%, and 20%, respectively. SUA levels correlated with the presence of MS, its components, signs of renal damage and worse CV risk profile. Multivariate logistic regression analysis revealed that SUA was associated with a positive history of CV events and high Framingham risk score even after adjusting for MS and its components (OR 1.10, 95% CI 1.03-1.18; P = 0.0060; OR 1.28, 95% CI 1.15-1.42; P < 0.0001). These associations were stronger in patients without diabetes and with normal renal function.

CONCLUSIONS

Mild hyperuricemia is a strong, independent marker of MS and high cardio-renal risk profile in hypertensive patients under specialist care. Intervention trials are needed to investigate whether the reduction of SUA levels favorably impacts outcome in patients at high CV risk.

Growth factors in preeclampsia: a vascular disease model. A failed vasodilation and angiogenic challenge from pregnancy onwards?

Preeclampsia is the major cause of maternofetal and neonatal morbi-mortality including intrauterine growth retardation, miscarriages and stillbirths. Inadequate vascular dilation and angiogenesis represent the crucial underlying defect of gravidic hypertension, denoting a failed response to the vasodilatory and pro-angiogenic challenge imposed by pregnancy, especially if multifetal. A similar pathogenesis appears involved in gestational diabetes. In this review we aimed to provide a hint on understanding the deeply involved angiogenic disorders which eventually culminate in utero-placental failure. The key players in these complex processes may be found in an intricate network of growth factors (GFs) and GF inhibitors, controlled by several vascular risk factors modulated by environment and genes, which eventually impact on early and late cardiovascular outcomes of mother and fetus.

Breath tests sustainability in hospital settings: cost analysis and reimbursement in the Italian National Health System

The high demand of Breath Tests (BT) in many gastroenterological conditions in time of limited resources for health care systems, generates increased interest in cost analysis from the point of view of the delivery of services to better understand how use the money to generate value. This study aims to measure the cost of C13 Urea and other most utilized breath tests in order to describe key aspects of costs and reimbursements looking at the economic sustainability for the hospital. A hospital based cost-analysis of the main breath tests commonly delivery in an ambulatory setting is performed. Mean salary for professional nurses and gastroenterologists, drugs/preparation used and disposable materials, purchase and depreciation of the instrument and the testing time was used to estimate the cost, while reimbursements are based on the 2013 Italian National Health System ambulatory pricelist. Variables that could influence the model are considered in the sensitivity analyses. The mean cost for C13--Urea, Lactulose and Lactose BT are, respectively, Euros 30,59; 45,20 and 30,29. National reimbursement often doesn't cover the cost of the analysis, especially considering the scenario with lower number of exam. On the contrary, in high performance scenario all the reimbursement could cover the cost, except for the C13 Urea BT that is high influenced by the drugs cost. However, consideration about the difference between Italian Regional Health System ambulatory pricelist are done. Our analysis shows that while national reimbursement rates cover the costs of H2 breath testing, they do not cover sufficiently C13 BT, particularly urea breath test. The real economic strength of these non invasive tests should be considered in the overall organization of inpatient and outpatient clinic, accounting for complete diagnostic pathway for each gastrointestinal disease.