Impact of resistance mutations on efficacy of dolutegravir plus rilpivirine or plus lamivudine as maintenance regimens: a cohort study.

OBJECTIVES: The aim of this study was to evaluate the impact of resistance mutations on efficacy of dolutegravir-based two-drug regimens (2DR). METHODS: Virologically suppressed patients with HIV-1 switching to dolutegravir + lamivudine or rilpivirine or to a dolutegravir-based three-drug regimen (3DR) with pre-baseline genotype were selected. Virological failure (VF) was defined as one HIV-RNA viral load (VL) >200 cps/mL or two consecutive VL >50 cps/mL; treatment failure (TF) was defined as VF or treatment discontinuation (TD). Resistance was defined as at least low-level resistance to at least one drug of the current regimen. Propensity score matching was used to conduct adjusted analyses within a competing risks framework. RESULTS: A total of 971 dolutegravir-based regimens were selected: 339 (34.9%) 2DR and 632 (65.1%) 3DR. The adjusted cumulative 48-week incidence of VF was 4.2% (90% CI 3.1%-5.3%) with 2DR and 4.7% (90% CI 3.5%-5.8%) with 3DR. The cumulative 48-week incidence of TF was 15.8% (90% CI 13.9%-17.9%) with 2DR and 24.5% (90% CI 22.2%-27.0%) with 3DR. For VF, the estimated hazard ratio (HR) for 2DR vs. 3DR was 1.02 (90% CI: 0.78-1.34), with evidence of effect modification by low-level resistance (HR 3.96, 90% CI: 2.10-7.46). The estimated HR of TF for 2DR vs. 3DR was 0.54 (90% CI: 0.48-0.60). The 48-week cumulative incidence of TD was 11.7% (8.7%, 14.6%) in 2DR and 19.6% (16.9%, 22.4%) in 3DR. CONCLUSIONS: Dolutegravir-based 2DR showed high virological efficacy and durability; however, past resistance increased the risk of VF, but not of TD or TF.

96-week results of a dual therapy with darunavir/ritonavir plus rilpivirine once a day vs triple therapy in patients with suppressed viraemia: virological success and non-HIV related morbidity evaluation.

Antiretroviral therapies have been tested with the goal of maintaining virological suppression with a particular attention in limiting drug-related toxicity. With this aim we designed the DUAL study: a randomized, open-label, multicenter, 96 weeks-long pilot exploratory study in virologically suppressed HIV-1+ patients with the aim of evaluating the immunovirological success and the impact on non-HIV related morbidity of switching to a dual therapy with darunavir-ritonavir (DRV/r) and rilpivirine (RPV). We recruited patients who received a PI/r-containing HAART for ≥6 months, HIV-RNA < 50 cp/mL for ≥3 months, eGFR > 60 mL/min/1,73m2, without DRV or RPV RAMs. We randomized patients in arm A: RPV + DRV/r QD or arm B: ongoing triple therapy. The primary endpoint has been defined as the percentage of patients with HIV-RNA < 50 cp/mL at week 48 (ITT). VACS index, Framingham CVD risk (FRS) and urinary RBP (uRBP) were calculated. We used Chi-square or Fisher statistics for categorical variables and Mann-Whitney U for continuous ones. Forty-one patients were enrolled (22 in arm A, 14 in arm B, plus 5 screening failures): 30 patients reached 96 weeks: 100% had HIV-RNA < 50 cp/mL in arm A versus 91.7% in arm B. Similar changes were observed in median CD4/mL between baseline and week 96 (+59 versus - 31, p: n.s.). Thirty-one in arm A and 23 in arm B adverse events took place, whereas only 1 was serious (arm A: turbinate hypertrophy, unrelated to HAART). Among the 6 discontinuations (3 in A, 3 in B), only 1 was related to adverse event (arm A: G3 depression, insomnia, weakness). VACS index, median FRS and median uRBP values did not vary from baseline to week 96. At 96-weeks all patients switched to a QD 2-drug regimen based on DRV/r + RPV maintained HIV-RNA suppression, but a single patient who showed a virological failure at week 4. CD4 counts increased overtime without significant differences between the two arms. The novel dual regimen was well tolerated with the same amount of discontinuation as the control arm. VACS index, FRS and uRBP did not differ between arms at week 96.

Ecotoxicological effects of atmospheric particulate produced by braking systems on aquatic and edaphic organisms.

Vehicles generate particulate matter (PM) in significant amounts as their brake systems wear. These particles can influence air quality and their transport/deposition may affect the edaphic and aquatic ecosystems. As part of the LOWBRASYS H2020 project, new more eco-friendly brake disc and pad formulations were developed. PMs generated from traditional (FM1-BD1) and innovative (FM4-BD2, FMB-BD7) brake systems in bench tests were studied. The PMs' physical/chemical characteristics were preliminarily investigated. To study the possible environmental impact of the nano-micro particulate, we used a battery of ecotoxicological tests. We employed the microalga Pseudokirchneriella subcapitata, the crustacean Daphnia magna and the bacteria Vibrio fischeri as aquatic bioindicators, while for the edaphic ecosystem we used the seeds of Lepidium sativum and Sorghum saccharatum, the nematode Caenorhabditis elegans, the earthworm Eisenia andrei and the ameba Dictyostelium discoideum. The results showed a higher sensitivity of the freshwater organisms exposed to the soluble PM fraction, with respect to the edaphic ones. FM4-BD2 brake formulation was slightly more toxic for algae (200 mg/L) than FM1-BD1 (500 mg/L). The new system FMB-BD7 particulate was not harmful for crustacean survival, and resulted weakly toxic for algal reproduction only at 500 mg/L. The particulate material per se was found to affect the algal reproduction. No toxic effects were found on nematodes, earthworms and seeds up to 1000 mg/L. However, in D. discoideum the reproduction rate was significantly reduced starting from 100 mg/L; and the lysosomal membrane stability showed a relevant alteration also at minimal concentration (0.1 mg/L). The results demonstrated a minimal risk for biodiversity of the particulates from the different brake systems and highlighted a more eco-friendly performance the new brake-pad FMB-BD7. However, the occurrence of sublethal effects should be considered as a possible contribution of the particle toxicity to the biological effects of the environmental pollution.

Phytotoxicity of wear debris from traditional and innovative brake pads.

Traffic-related emissions include gas and particles that can alter air quality and affect human and environmental health. Limited studies have demonstrated that particulate debris thrown off from brakes are toxic to higher plants. The acute phytotoxicity of brake pad wear debris (BPWD) investigated using cress seeds grown in soil contaminated with increasing concentrations of debris. Two types of pads were used: a commercially available phenol based pad and an innovative cement-based pad developed within of the LIFE+ COBRA project. The results suggested that even through the BPWD generated by the two pads were similar in and morphology, debris from traditional pads were more phytotoxic than that from cementitious pads, causing significant alterations in terms of root elongation and loss of plasma membrane integrity.

(Eco)toxicological maps: A new risk assessment method integrating traditional and in silico tools and its application in the Ledra River (Italy).

Contaminants giving rise to emerging concern like pharmaceuticals, personal care products, pesticides and Endocrine Disrupting Chemicals (EDCs) have been detected in wastewaters, as reported in the literature, but little is known about their (eco)toxicological effects and consequent human health impact. The present study aimed at overcoming this lack of information through the use of in silico methods integrated with traditional toxicological risk analysis. This is part of a pilot project involving the management of wastewater treatment plants in the Ledra River basin (Italy). We obtained data to work up a global risk assessment method combining the evaluations of health risks to humans and ecological receptors from chemical contaminants found in this specific area. The (eco)toxicological risk is expressed by a single numerical value, permitting the comparison of different sampling sites and the evaluation of future environmental and technical interventions.

Air quality in the Olona Valley and in vitro human health effects.

Air quality is a major point in current health policies in force globally to protect human health and ecosystems. Cardiovascular and lung diseases are the pathologies most commonly associated with air pollution and it has been estimated that exposure to particulate matters and ground-level ozone and nitric oxides caused >500.000 premature deaths in Europe. Although air quality was generally improved in the recent years, further efforts are required to reduce the impact of air pollution on humans. The present study applied a multidisciplinary approach to estimate the adverse effects on the health of the inhabitants of the Olona Valley in the north of Italy. Chemical analyses quantified the air levels of metals, dioxins, PCBs, PAHs and some macropollutants, including total, fine and coarse airborne particles. These results were used as input for the health risk assessment and in vitro bioassays were used to evaluate possible adverse effects on the respiratory tract due to the organic pollutants adsorbed on the airborne particulate matter. Critical alerts were identified from the air characterization and from the chemical-based risk assessment in view of the levels of arsenic, nickel, benzene, fine and coarse particulate matters found in the investigated zone, which can induce severe adverse effects on human health. These findings were confirmed by bioassays with A549 and BEAS-2B cells. We also used the cell transformation assay with BALB/c 3T3 cells to assess the carcinogenicity of the organic extracts of collected particles as an innovative tool to establish the possible chronic effects of inhaled pollutants. No significant changes in morphological transformation were found suggesting that, although the extracts contain compounds with proven carcinogenic potential, in our experimental conditions the levels of these pollutants were too low to induce carcinogenesis as resulted also by the chemical-based risk assessment.

Time Required to Rectify Inhaler Errors Among Experienced Subjects With Faulty Technique.

BACKGROUND: Regardless of the device used, many patients have difficulty maintaining proper inhaler technique over time. Repeated education from caregivers is required to ensure persistence of correct inhaler technique, but no information is available to evaluate the time required to rectify inhaler errors in experienced users with a baseline faulty technique and whether this time of re-education to restore inhaler mastery can differ between devices. METHODS: This was a multi-center, single-visit, open-label, cross-sectional study in a large group of 981 adult subjects (mean ± SD age 64 ± 15 y) experienced with inhaler use, mainly suffering from COPD and asthma, who showed faulty inhaler technique at a follow-up visit in chest clinics. These subjects received face-to-face practical education from trained caregivers until proper inhaler use could be demonstrated, and the time of instruction was recorded. RESULTS: The mean times (95% CIs) in minutes of instruction required for rectifying misuse and demonstrating inhaler mastery were 5.0 (3.6-6.4) min for the Diskus (n = 199), 5.3 (3.7-6.8) min for the HandiHaler (n = 219), 8.1 (5.6-10.5) min for the metered-dose inhaler (MDI) (n = 532), and 6.0 (5.0-7.0) min for the Turbuhaler (n = 169). The time to demonstrate good inhaler use for MDIs was higher (P < .05) than for all dry powder inhalers (DPIs). Between the DPIs, only the HandiHaler required more time for achieving mastery than the Diskus (P = .005). The variables associated with increasing time for correcting inhaler errors were an older age (0.05 min/y, 95% CI 0.03-0.07), a lower level of education (0.4 min/schooling level, 95% CI 0.7-0.1), and no reported previous instruction in inhaler use (1.96 min, 95% CI 1.35-2.58). CONCLUSIONS: In experienced subjects with baseline faulty inhaler use, the mean time of education required to achieve and demonstrate mastery with DPIs was lower than with MDIs.

Chemical characterization and ecotoxicity of three soil foaming agents used in mechanized tunneling.

The construction of tunnels and rocks with mechanized drills produces several tons of rocky debris that are today recycled as construction material or as soil replacement for covering rocky areas. The lack of accurate information about the environmental impact of these excavated rocks and foaming agents added during the excavation process has aroused increasing concern for ecosystems and human health. The present study proposes an integrated approach to the assessment of the potential environmental impact of three foaming agents containing different anionic surfactants and other polymers currently on the market and used in tunnel boring machines. The strategy includes chemical characterization with high resolution mass spectrometry techniques to identify the components of each product, the use of in silico tools to perform a similarity comparison among these compounds and some pollutants already listed in regulatory frameworks to identify possible threshold concentrations of contamination, and the application of a battery of ecotoxicological assays to investigate the impact of each foaming mixture on model organisms of soil (higher plants and Eisenia andrei) and water communities (Daphnia magna). The study identified eleven compounds not listed on the material safety data sheets for which we have identified possible concentrations of contamination based on existing regulatory references. The bioassays allowed us to determine the no effect concentrations (NOAECs) of the three mixtures, which were subsequently used as threshold concentration for the product in its entirety. The technical mixtures used in this study have a different degree of toxicity and the predicted environmental concentrations based on the conditions of use are lower than the NOAEC for soils but higher than the NOAEC for water, posing a potential risk to the waters due to the levels of foaming agents in the muck.

Acute phytotoxicity of seven metals alone and in mixture: Are Italian soil threshold concentrations suitable for plant protection?

Metals can pollute soils in both urban and rural areas with severe impacts on the health of humans, plants and animals living there. Information on metal toxicity is therefore important for ecotoxicology. This study investigated the phytotoxicity of different metals frequently found as pollutants in soils: arsenic, cadmium, chromium, lead, mercury, nickel and zinc. Cucumber (Cucumis sativus), sorghum (Sorghum saccharatum) and cress (Lepidium sativum) seeds were used as models for other plants used in human nutrition such as cereals, rice, fruits and vegetables. The 72-h germination rate and root elongations were selected as short-term ecotoxicological endpoints in seeds exposed to single metals and mixtures. Metals were spiked onto OECD standard soils in concentrations comparable to current Italian contamination threshold concentrations for residential and commercial soils. Arsenic, chromium, mercury and nickel were the most toxic metals in our experimental conditions, particularly to cress seeds (5.172, 152 and 255.4 mg/kg as 72 h IC50 for arsenic, mercury and nickel respectively). Italian limits were acceptable for plant protection only for exposure to each metal alone but not for the mixtures containing all the metals concentrations expected by their respective legislative threshold. The effects of the mixture were class-specific: trends were comparable in dicots but different in monocots. The response induced by the mixture at high concentrations differed from that theoretically obtainable by summing the effects of the individual metals. This might be due to partial antagonism of the metals in soil or to the formation of complexes between the metals, which reduce the bioavailability of the pollutants for plants.

Soil quality in the Lomellina area using in vitro models and ecotoxicological assays.

Soil quality is traditionally evaluated by chemical characterization to determine levels of pollutants. Biological tools are now employed for soil monitoring since they can take account of the global biological effects induced by all xenobiotics. A combined monitoring of soils based on chemical analyses, human-related in vitro models and ecotoxicological assay was applied in the Lomellina, a semirural area of northern Italy. Chemical characterization indicated overall good quality of the soils, with low levels of toxic and carcinogenic pollutants such as heavy metals, PAHs, PCDD/Fs and PCBs. HepG2 cells were used as a model for the human liver and BALB/c 3T3 cells to evaluate carcinogenic potential. Cells were treated with soil extractable organic matter (EOM) and the MTS assay, DNA release and morphological transformation were selected as endpoints for toxicity and carcinogenicity. Soil EOMs induced dose-dependent inhibition of cell growth at low doses and cytotoxicity only at doses of 500 and 1000 mg soil equivalents/ml. Potential issues for human health can be hypothesized after ingestion of soil samples from some sites. No statistically significant inductions of foci were recorded after exposure to EOMs, indicating that the levels of the soil-extracted organic pollutants were too low to induce carcinogenesis in our experimental conditions. An acute phytotoxicity test and studies on Caenorhabditis elegans were used as ecotoxicological assays for plants and small invertebrates. No significant alerts for ecotoxicity were found. In this proposed case study, HepG2 cells detected differences in the toxicity of soil EOMs, indicating that this cell line could be appropriate to assess the potential harm caused by the ingestion of contaminated soil. Additional information on the carcinogenic potential of mixtures was provided by the cell transformation assay, strengthening the combined approach.

Chemical-based risk assessment and in vitro models of human health effects induced by organic pollutants in soils from the Olona Valley.

Risk assessment of soils is usually based on chemical measurements and assuming accidental soil ingestion and evaluating induced toxic and carcinogenic effects. Recently biological tools have been coupled to chemical-based risk assessment since they integrate the biological effects of all xenobiotics in soils. We employed integrated monitoring of soils based on chemical analyses, risk assessment and in vitro models in the highly urbanized semirural area of the Olona Valley in northern Italy. Chemical characterization of the soils indicated low levels of toxic and carcinogenic pollutants such as PAHs, PCDD/Fs, PCBs and HCB and human risk assessment did not give any significant alerts. HepG2 and BALB/c 3T3 cells were used as a model for the human liver and as a tool for the evaluation of carcinogenic potential. Cells were treated with soil extractable organic matters (EOMs) and the MTS assay, LDH release and morphological transformation were selected as endpoints for toxicity and carcinogenicity. Soil EOMs induced dose-dependent inhibition of cell growth at low doses and cytotoxicity after exposure to higher doses. This might be the result of block of cell cycle progression to repair DNA damage caused by oxidative stress; if this DNA damage cannot be repaired, cells die. No significant inductions of foci were recorded after exposure to EOMs. These results indicate that, although the extracts contain compounds with proven carcinogenic potential, the levels of these pollutants in the analyzed soils were too low to induce carcinogenesis in our experimental conditions. In this proposed case study, HepG2 cells were found an appropriate tool to assess the potential harm caused by the ingestion of contaminated soil as they were able to detect differences in the toxicity of soil EOMs. Moreover, the cell transformation assay strengthened the combined approach giving useful information on carcinogenic potential of mixtures.

PCDD/Fs and PCBs in ambient air in a highly industrialized city in northern Italy.

Ambient air samples were collected in five locations around a polychlorobiphenyl (PCB) production plant in a highly industrialized city in the north of Italy, for the analysis of polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) and PCBs. PCDD/F atmospheric concentrations were lower than those generally detected in urban areas, while PCB concentrations were higher than in urban and industrialized areas in other countries, especially in the locations closest to the plant. To identify source emissions responsible for air pollution we used principal component analysis (PCA) to compare the "fingerprint" of the air in Brescia with some source-related experimental and published data. This analysis showed that the PCDD/F fingerprints were more similar to steel plant emission data, while none of the PCB air patterns were comparable to emission profiles, indicating that different sources are responsible for the concentration of these two pollutants. The highest PCB concentrations detected in the areas closest to the chemical plant are indicative of its impact on the surrounding environment.

Concentrations of PCDD/PCDF in soil close to a secondary aluminum smelter.

Polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans (PCDDs/Fs) were analyzed in samples of the emissions from a secondary aluminum smelter (ALS) and soil samples around the plant. The purpose was to estimate the impact of the emissions on the surrounding environment. PCDD/F soil concentrations were higher in the proximity of the plant, exceeding the limit adopted in Italy in soils for green areas and residential uses and the upper limit of several reference concentrations. The most contaminated sites were less than 500 m from the plant and the dioxin concentration with the distance from the ALS. Principal component analysis (PCA) showed that emissions from the ALS were the source of PCDD/F contamination in the soils closest to the plant. Multivariate data analyses such as PCA are therefore useful to identify sources of emission causing contamination.

Inhaler mishandling remains common in real life and is associated with reduced disease control.

Proper inhaler technique is crucial for effective management of asthma and COPD. This multicentre, cross-sectional, observational study investigates the prevalence of inhaler mishandling in a large population of experienced patients referring to chest clinics; to analyze the variables associated with misuse and the relationship between inhaler handling and health-care resources use and disease control. We enrolled 1664 adult subjects (mean age 62 years) affected mostly by COPD (52%) and asthma (42%). Respectively, 843 and 1113 patients were using MDIs and DPIs at home; of the latter, the users of Aerolizer®, Diskus®, HandiHaler® and Turbuhaler® were 82, 467, 505 and 361. We have a total of 2288 records of inhaler technique. Critical mistakes were widely distributed among users of all the inhalers, ranging from 12% for MDIs, 35% for Diskus® and HandiHaler® and 44% for Turbuhaler®. Independently of the inhaler, we found the strongest association between inhaler misuse and older age (p = 0.008), lower schooling (p = 0.001) and lack of instruction received for inhaler technique by health caregivers (p < 0.001). Inhaler misuse was associated with increased risk of hospitalization (p = 0.001), emergency room visits (p < 0.001), courses of oral steroids (p < 0.001) and antimicrobials (p < 0.001) and poor disease control evaluated as an ACT score for the asthmatics (p < 0.0001) and the whole population (p < 0.0001). We conclude that inhaler mishandling continues to be common in experienced outpatients referring to chest clinics and associated with increased unscheduled health-care resource use and poor clinical control. Instruction by health caregivers is the only modifiable factor useful for reducing inhaler mishandling.

ERICA: A multiparametric toxicological risk index for the assessment of environmental healthiness.

A risk assessment strategy considering the impact of chemicals on the whole ecosystem has been developed in order to create a sound and useful method for quantifying and comparing the global risk posed by the main different hazardous chemicals found in the environment. This index, called Environmental Risk Index for Chemical Assessment (ERICA), merges in a single number the environmental assessment, the human health risk assessment and the uncertainty due to missing or uncertain data. ERICA uses a dedicated scoring system with parameters for the main characteristics of the pollutants. The main advantage is that it preserves a simple approach by condensing in this single value an analysis of the risk for the area under observation. ERICA quantifies and compares the global risk posed by hazardous chemicals found in the environment and can be considered a diagnostic and prognostic method for environmental contaminants in critical and potentially dangerous sites, such as incinerators, landfills and industrial areas or in broader geographical areas. The application of the proposed integrated index provides a preliminary quantitative analysis of possible environmental alert due to the presence of one or some pollutants in the investigated site. This paper presents the method and the equations behind the index and a first case study based on the Italian legislation and a pilot study located on the Italian seacoast.

Smoking cessation in patients requiring bronchoscopy: the Bronchoscopy AntiSmoking Study (BASIS).

We investigated the readiness to quit and the smoking cessation rates of smokers requiring bronchoscopy and receiving advice quitting. This randomized controlled trial evaluated the effectiveness of two smoking cessation interventions, either a brief advice (control group), or a longer support, delivered at the time of bronchoscopy. We consecutively enrolled 233 adult smokers, regardless of the initial level of motivation to quit. Their mean (SD) age was 57 (12) years; males were 192. They had smoked a median of 44.5 pack-years. Their mean (SD) Fagerstrom score was 8 (2). There was no difference between groups. Surprisingly, 45% of participants were in the action stage at baseline; these 105 subjects had quit in the week immediately prior to the bronchoscopy. At 6- and 12-months follow-up visits, respectively 41% and 29% of participants in the intervention group and 27% and 13% in the control group objectively showed a 1-week point prevalence abstinence. The difference was significant at 6 months (p<0.05) but not at 1-year visit (p=0.052), even if there was a trend towards greater cessation rate in the intervention group. In multivariable logistic models, at the final visit being a quitter was positively associated with having been in the action stage at baseline and negatively with the Fagerstrom score and the presence of smokers in household. We conclude that the time of bronchoscopy may possibly predispose smokers to quit. Further efforts are needed to clear whether more protracted support might achieve higher long-term smoking cessation rates.

PCDD/Fs in ambient air in north-east Italy: the role of a MSWI inside an industrial area.

The stack gases of a municipal solid waste incinerator (MSWI), and ambient air were sampled in four locations around the plant for the analysis of polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans (PCDDs/Fs). The sampling area was close to an industrial area near Trieste, in north-east Italy. The purpose of the study was to estimate the impact of the MSWI emissions and to distinguish the contribution of these emissions from other potential emission sources in the industrial area. PCDD/F atmospheric concentrations were similar to those generally detected in urban-rural areas with one location about 2-3 times more contaminated than the others. Since the most contaminated location was inside the industrial area but upwind of the MSWI, principal component analysis (PCA) was used to establish whether other sources were the cause. This analysis clearly showed that a local steel plant's emission was the main source of PCDDs/Fs in ambient air. This study highlights the usefulness of multivariate data analysis such as PCA to identify, among different potential emission sources, the one really responsible for the contamination.