Novel tricyclic pyrrolo-quinolines as pharmacological correctors of the mutant CFTR chloride channel.

F508del, the most frequent mutation in cystic fibrosis (CF), impairs the stability and folding of the CFTR chloride channel, thus resulting in intracellular retention and CFTR degradation. The F508del defect can be targeted with pharmacological correctors, such as VX-809 and VX-445, that stabilize CFTR and improve its trafficking to plasma membrane. Using a functional test to evaluate a panel of chemical compounds, we have identified tricyclic pyrrolo-quinolines as novel F508del correctors with high efficacy on primary airway epithelial cells from CF patients. The most effective compound, PP028, showed synergy when combined with VX-809 and VX-661 but not with VX-445. By testing the ability of correctors to stabilize CFTR fragments of different length, we found that VX-809 is effective on the amino-terminal portion of the protein that includes the first membrane-spanning domain (amino acids 1-387). Instead, PP028 and VX-445 only show a stabilizing effect when the second membrane-spanning domain is included (amino acids 1-1181). Our results indicate that tricyclic pyrrolo-quinolines are a novel class of CFTR correctors that, similarly to VX-445, interact with CFTR at a site different from that of VX-809. Tricyclic pirrolo-quinolines may represent novel CFTR correctors suitable for combinatorial pharmacological treatments to treat the basic defect in CF.

A LC-MS/MS based methodology for the environmental monitoring of healthcare settings contaminated with antineoplastic agents.

Background: Adverse health events associated with the exposure of healthcare workers to antineoplastic drugs are well documented in literature and are often related to the chemical contamination of work surfaces. It is therefore crucial for healthcare professionals to validate the efficiency of safety procedures by periodic biological and environmental monitoring activities where the main methodological limitations are related to the complexity, in terms of chemical-physical features and chemical-biological stability, of the drugs analyzed. Materials and methods: Here we describe the evaluation and application of a UHPLC-MS/MS based protocol for the environmental monitoring of hospital working areas potentially contaminated with methotrexate, iphosphamide, cyclophosphamide, doxorubicin, irinotecan, and paclitaxel. This methodology was used to evaluate working areas devoted to the preparation of chemotherapeutics and combination regimens at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy). Results: Our analyses allowed to uncover critical aspects in both working protocols and workspace organization, which highlighted, among others, cyclophosphamide and iphosphamide contamination. Suitable adjustments adopted after our environmental monitoring campaign significantly reduced the exposure risk for healthcare workers employed in the unit analyzed. Conclusion: The use of sensitive analytical approaches such as LC-MS/MS coupled to an accurate wiping procedure in routine environmental monitoring allows to effectively improve chemical safety for exposed workers.

The p66Shc Redox Protein and the Emerging Complications of Diabetes.

Diabetes mellitus is a chronic metabolic disease, the prevalence of which is constantly increasing worldwide. It is often burdened by disabling comorbidities that reduce the quality and expectancy of life of the affected individuals. The traditional complications of diabetes are generally described as macrovascular complications (e.g., coronary heart disease, peripheral arterial disease, and stroke), and microvascular complications (e.g., diabetic kidney disease, retinopathy, and neuropathy). Recently, due to advances in diabetes management and the increased life expectancy of diabetic patients, a strong correlation between diabetes and other pathological conditions (such as liver diseases, cancer, neurodegenerative diseases, cognitive impairments, and sleep disorders) has emerged. Therefore, these comorbidities have been proposed as emerging complications of diabetes. P66Shc is a redox protein that plays a role in oxidative stress, apoptosis, glucose metabolism, and cellular aging. It can be regulated by various stressful stimuli typical of the diabetic milieu and is involved in various types of organ and tissue damage under diabetic conditions. Although its role in the pathogenesis of diabetes remains controversial, there is strong evidence regarding the involvement of p66Shc in the traditional complications of diabetes. In this review, we will summarize the evidence supporting the role of p66Shc in the pathogenesis of diabetes and its complications, focusing for the first time on the emerging complications of diabetes.

Impact of Dysfunctional Adipose Tissue Depots on the Cardiovascular System.

Obesity with its associated complications represents a social, economic and health problem of utmost importance worldwide. Specifically, obese patients carry a significantly higher risk of developing cardiovascular disease compared to nonobese individuals. Multiple molecular mechanisms contribute to the impaired biological activity of the distinct adipose tissue depots in obesity, including secretion of proinflammatory mediators and reactive oxygen species, ultimately leading to an unfavorable impact on the cardiovascular system. This review summarizes data relating to the contribution of the main adipose tissue depots, including both remote (i.e., intra-abdominal, hepatic, skeletal, pancreatic, renal, and mesenteric adipose fat), and cardiac (i.e., the epicardial fat) adipose locations, on the cardiovascular system. Finally, we discuss both pharmacological and non-pharmacological strategies aimed at reducing cardiovascular risk through acting on adipose tissues, with particular attention to the epicardial fat.

Implementation of Predictive Algorithms for the Study of the Endarterectomy LOS.

BACKGROUND: In recent years, the length of hospital stay (LOS) following endarterectomy has decreased significantly from 4 days to 1 day. LOS is influenced by several common complications and factors that can adversely affect the patient's health and may vary from one healthcare facility to another. The aim of this work is to develop a forecasting model of the LOS value to investigate the main factors affecting LOS in order to save healthcare cost and improve management. METHODS: We used different regression and machine learning models to predict the LOS value based on the clinical and organizational data of patients undergoing endarterectomy. Data were obtained from the discharge forms of the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital (Salerno, Italy). R2 goodness of fit and the results in terms of accuracy, precision, recall and F1-score were used to compare the performance of various algorithms. RESULTS: Before implementing the models, the preliminary correlation study showed that LOS was more dependent on the type of endarterectomy performed. Among the regression algorithms, the best was the multiple linear regression model with an R2 value of 0.854, while among the classification algorithms for LOS divided into classes, the best was decision tree, with an accuracy of 80%. The best performance was obtained in the third class, which identifies patients with prolonged LOS, with a precision of 95%. Among the independent variables, the most influential on LOS was type of endarterectomy, followed by diabetes and kidney disorders. CONCLUSION: The resulting forecast model demonstrates its effectiveness in predicting the value of LOS that could be used to improve the endarterectomy surgery planning.

Is It Possible to Predict the Length of Stay of Patients Undergoing Hip-Replacement Surgery?

The proximal fracture of the femur and hip is the most common reason for hospitalization in orthopedic departments. In Italy, 115,989 hip-replacement surgeries were performed in 2019, showing the economic relevance of studying this type of procedure. This study analyzed the data relating to patients who underwent hip-replacement surgery in the years 2010-2020 at the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital of Salerno. The multiple linear regression (MLR) model and regression and classification algorithms were implemented in order to predict the total length of stay (LOS). Lastly, using a statistical analysis, the impact of COVID-19 was evaluated. The results obtained from the regression analysis showed that the best model was MLR, with an R2 value of 0.616, compared with XGBoost, Gradient-Boosted Tree, and Random Forest, with R2 values of 0.552, 0.543, and 0.448, respectively. The t-test showed that the variables that most influenced the LOS, with the exception of pre-operative LOS, were gender, age, anemia, fracture/dislocation, and urinary disorders. Among the classification algorithms, the best result was obtained with Random Forest, with a sensitivity of the longest LOS of over 89%. In terms of the overall accuracy, Random Forest and Gradient-Boosted Tree achieved a value of 71.76% and an error of 28.24%, followed by Decision Tree, with an accuracy of 71.13% and an error of 28.87%, and, finally, Support Vector Machine, with an accuracy of 65.06% and an error of 34.94%. A significant difference in cardiovascular disease, fracture/dislocation, and post-operative LOS variables was shown by the chi-squared test and Mann-Whitney test in the comparison between 2019 (before COVID-19) and 2020 (in full pandemic emergency conditions).

Multiple regression model to analyze the total LOS for patients undergoing laparoscopic appendectomy.

BACKGROUND: The rapid growth in the complexity of services and stringent quality requirements present a challenge to all healthcare facilities, especially from an economic perspective. The goal is to implement different strategies that allows to enhance and obtain health processes closer to standards. The Length Of Stay (LOS) is a very useful parameter for the management of services within the hospital and is an index evaluated for the management of costs. In fact, a patient's LOS can be affected by a number of factors, including their particular condition, medical history, or medical needs. To reduce and better manage the LOS it is necessary to be able to predict this value. METHODS: In this study, a predictive model was built for the total LOS of patients undergoing laparoscopic appendectomy, one of the most common emergency procedures. Demographic and clinical data of the 357 patients admitted at "San Giovanni di Dio e Ruggi d'Aragona" University Hospital of Salerno (Italy) had used as independent variable of the multiple linear regression model. RESULTS: The obtained model had an R2 value of 0.570 and, among the independent variables, the significant variables that most influence the total LOS were Age, Pre-operative LOS, Presence of Complication and Complicated diagnosis. CONCLUSION: This work designed an effective and automated strategy for improving the prediction of LOS, that can be useful for enhancing the preoperative pathways. In this way it is possible to characterize the demand and to be able to estimate a priori the occupation of the beds and other related hospital resources.

Regression Models to Study the Total LOS Related to Valvuloplasty.

Background: Valvular heart diseases are diseases that affect the valves by altering the normal circulation of blood within the heart. In recent years, the use of valvuloplasty has become recurrent due to the increase in calcific valve disease, which usually occurs in the elderly, and mitral valve regurgitation. For this reason, it is critical to be able to best manage the patient undergoing this surgery. To accomplish this, the length of stay (LOS) is used as a quality indicator. Methods: A multiple linear regression model and four other regression algorithms were used to study the total LOS function of a set of independent variables related to the clinical and demographic characteristics of patients. The study was conducted at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" of Salerno (Italy) in the years 2010-2020. Results: Overall, the MLR model proved to be the best, with an R2 value of 0.720. Among the independent variables, age, pre-operative LOS, congestive heart failure, and peripheral vascular disease were those that mainly influenced the output value. Conclusions: LOS proves, once again, to be a strategic indicator for hospital resource management, and simple linear regression models have shown excellent results to analyze it.

New approach to implement cancer patient care: The valutazione percorso rete oncologica campana (ValPeROC)-experience from an Italian oncology network.

OBJECTIVE: The primary goal of the Campania Oncology Network (ROC) was to reduce cancer delay and care fragmentation through the establishment of cancer-specific multidisciplinary oncologic groups (GOMs) and diagnostic and therapeutic assistance paths (PDTAs). METHODS: Five cancer centres of the ROC, with their own cancer specific GOM, were selected. In our analysis, we have focused on four neoplasms: lung, colon, ovarian and prostate cancers. The median time for pre-GOM and GOM Times was calculated for each tumour site. Univariate and multivariate logistic regressions were performed to individuate risk factors for pre-GOM and GOM Time. RESULTS: Significant differences were observed for prostate cancer compared to other patients either for pre-GOM or GOM Times. Significant risks were found for ovarian and prostate cancers in pre-GOM time and for prostate cancer in GOM-Time. CONCLUSIONS: This experience will produce knowledge and data to guide decision-making and to manage more effectively the challenges of fighting cancer in Campania region. The Valutazione Percorso Rete Oncologica Campana (ValPeROC) study evaluates, for the first time, the ROC activity, through the analysis of key performance indices. Pre-GOM and GOM Time represent the quality of the entire regional health system and are useful to define models, which can evaluate the performance of the ROC over time.

Comprehensive Analysis of Combinatorial Pharmacological Treatments to Correct Nonsense Mutations in the CFTR Gene.

Cystic fibrosis (CF) is caused by loss of function of the CFTR chloride channel. A substantial number of CF patients carry nonsense mutations in the CFTR gene. These patients cannot directly benefit from pharmacological correctors and potentiators that have been developed for other types of CFTR mutations. We evaluated the efficacy of combinations of drugs targeting at various levels the effects of nonsense mutations: SMG1i to protect CFTR mRNA from nonsense-mediated decay (NMD), G418 and ELX-02 for readthrough, VX-809 and VX-445 to promote protein maturation and function, PTI-428 to enhance CFTR protein synthesis. We found that the extent of rescue and sensitivity to the various agents is largely dependent on the type of mutation, with W1282X and R553X being the mutations most and least sensitive to pharmacological treatments, respectively. In particular, W1282X-CFTR was highly responsive to NMD suppression by SMG1i but also required treatment with VX-445 corrector to show function. In contrast, G542X-CFTR required treatment with readthrough agents and VX-809. Importantly, we never found cooperativity between the NMD inhibitor and readthrough compounds. Our results indicate that treatment of CF patients with nonsense mutations requires a precision medicine approach with the design of specific drug combinations for each mutation.

Partial Rescue of F508del-CFTR Stability and Trafficking Defects by Double Corrector Treatment.

Deletion of phenylalanine at position 508 (F508del) in the CFTR chloride channel is the most frequent mutation in cystic fibrosis (CF) patients. F508del impairs the stability and folding of the CFTR protein, thus resulting in mistrafficking and premature degradation. F508del-CFTR defects can be overcome with small molecules termed correctors. We investigated the efficacy and properties of VX-445, a newly developed corrector, which is one of the three active principles present in a drug (Trikafta®/Kaftrio®) recently approved for the treatment of CF patients with F508del mutation. We found that VX-445, particularly in combination with type I (VX-809, VX-661) and type II (corr-4a) correctors, elicits a large rescue of F508del-CFTR function. In particular, in primary bronchial epithelial cells of CF patients, the maximal rescue obtained with corrector combinations including VX-445 was close to 60-70% of CFTR function in non-CF cells. Despite this high efficacy, analysis of ubiquitylation, resistance to thermoaggregation, protein half-life, and subcellular localization revealed that corrector combinations did not fully normalize F508del-CFTR behavior. Our study indicates that it is still possible to further improve mutant CFTR rescue with the development of corrector combinations having maximal effects on mutant CFTR structural and functional properties.

Environmental and biological monitoring of formaldehyde inside a hospital setting: a combined approach to manage chemical risk in workplaces.

BACKGROUND: The safety of healthcare workers exposed to formaldehyde remains a great matter of concern for healthcare management units. This work aimed at describing the results of a combined monitoring approach (environmental and biological) to manage occupational exposure to formaldehyde in a hospital setting. DESIGN AND METHODS: Environmental monitoring of working spaces and biological monitoring of urinary formaldehyde in 16 exposed healthcare workers of the Anatomic Pathology Unit of a University Hospital in Southern Italy was performed on a four-year timescale (2016-2019). RESULTS: Values of aero-dispersed formaldehyde identified were on average low; although workers' urinary formaldehyde levels were also minimal, the statistical analysis highlighted a slight weekly accumulation. CONCLUSIONS: Our data confirm that both environmental and biological monitoring are important to identify risk situations, in particular when values of hazardous compounds are below the accepted occupational exposure levels.

Lean Six Sigma Approach for Reducing Length of Hospital Stay for Patients with Femur Fracture in a University Hospital.

Surgical intervention within 48 h of hospital admission is the gold standard procedure for the management of elderly patients with femur fractures, since the increase in preoperative waiting time is correlated with the onset of complications and longer overall length of stay (LOS) in the hospital. However, national evidence demonstrates that there is still the need to provide timely intervention for this type of patient, especially in some regions of central southern Italy. Here we discuss the introduction of a diagnostic-therapeutic assistance pathway (DTAP) to reduce the preoperative LOS for patients undergoing femur fracture surgery in a university hospital. A Lean Six Sigma methodology, based on the DMAIC cycle (Define, Measure, Analyze, Improve, Control), is implemented to evaluate the effectiveness of the DTAP. Data were retrospectively collected and analyzed from two groups of patients before and after the implementation of DTAP over a period of 10 years. The statistics of the process measured before the DTAP showed an average preoperative LOS of 5.6 days (standard deviation of 3.2), thus confirming the need for corrective actions to reduce the LOS in compliance with the national guidelines. The influence of demographic and anamnestic variables on the LOS was evaluated, and the impact of the DTAP was measured and discussed, demonstrating the effectiveness of the improvement actions implemented over the years and leading to a significant reduction in the preoperative LOS, which decreased to an average of 3.5 days (standard deviation of 3.60). The obtained reduction of 39% in the average LOS proved to be in good agreement with previously developed DTAPs for femur fracture available in the literature.

Development and Improvement of an Effective Method for Air and Surfaces Disinfection with Ozone Gas as a Decontaminating Agent.

Background and objectives: Ozone has been one of the most investigated and discussed sanitization methods. This paper reports a procedure to sanitize air hospital environments, in particular chirurgical surgery rooms that require high levels of disinfection. The purpose of this work was the development and implementation of a cleansing and sanitizing procedure for critical clinical settings with ozone, to prevent hospital infections by the elimination of all toxic and harmful microorganisms in the air, and ensure safe use for operators and patients. Materials and Methods: The protocol for the study involved a structured selection of a representative environment of healthcare structures such as high, medium, and low-risk settings in air and examples of hospital furniture. Results: The concentration of ozone was measured during sanitization treatment and the estimation of the total microbial count in the air and on different surfaces before and after the sanitization operations was performed. The results demonstrated a significant reduction in the microbial count that always fell below the threshold value. Conclusions: Currently, there are no air treatment strategies available for inactivating airborne organisms during hospital outbreaks, which is most probably due to the lack of approved protocols.

TRPV4 and purinergic receptor signalling pathways are separately linked in airway epithelia to CFTR and TMEM16A chloride channels.

KEY POINTS: Eact is a putative pharmacological activator of TMEM16A. Eact is strongly effective in recombinant Fischer rat thyroid (FRT) cells but not in airway epithelial cells with endogenous TMEM16A expression. Transcriptomic analysis, gene silencing and functional studies in FRT cells reveal that Eact is actually an activator of the Ca2+ -permeable TRPV4 channel. In airway epithelial cells TRPV4 and TMEM16A are expressed in separate cell types. Intracellular Ca2+ elevation by TRPV4 stimulation leads to CFTR channel activation. ABSTRACT: TMEM16A is a Ca2+ -activated Cl- channel expressed in airway epithelial cells, particularly under conditions of mucus hypersecretion. To investigate the role of TMEM16A, we used Eact, a putative TMEM16A pharmacological activator. However, in contrast to purinergic stimulation, we found little effect of Eact on bronchial epithelial cells under conditions of high TMEM16A expression. We hypothesized that Eact is an indirect activator of TMEM16A. By a combination of approaches, including short-circuit current recordings, bulk and single cell RNA sequencing, intracellular Ca2+ imaging and RNA interference, we found that Eact is actually an activator of the Ca2+ -permeable TRPV4 channel and that the modest effect of this compound in bronchial epithelial cells is due to a separate expression of TMEM16A and TRPV4 in different cell types. Importantly, we found that TRPV4 stimulation induced activation of the CFTR Cl- channel. Our study reveals the existence of separate Ca2+ signalling pathways linked to different Cl- secretory processes.

[The impact of day surgery on primary care]. / Day Surgery Ortopedico: analisi del modello organizzativo con integrazione ospedale-territorio.

UNLABELLED: What impact does day surgery have on primary treatment? AIMS: highlighting the impact that day surgery has on the system of primary treatment. RESULTS: The study highlighted a lack in continuity of treatment due to a breakdown in communication between hospital specialists and general practitioners. This reflects the growing habit in the medical field whereby hospital surgeons take charge of surgical indications and carrying out the operation, thus focusing their attention on their own limited scope of action. On the other hand general practitioners are called upon merely to hand out prescriptions and certificates. However, it seems obvious that general practitioners should be involved in the selection phase and discharge of the patient, as occurs in countries where one-day surgery is now in widespread use. That is the only way to improve the quality of healthcare assistance and contain costs to the national health service.