Epidemiological analysis to identify predictors of X-linked hypophosphatemia (XLH) diagnosis in an Italian pediatric population: the EPIX project

PURPOSE

X-linked hypophosphatemia (XLH) is a rare multi-systemic disease characterized by low plasma phosphate levels. The aim of this study was to investigate the annual XLH prevalence and internally evaluate predictive algorithms' application performance for the early diagnosis of XLH.

METHODS

The PediaNet database, containing data on more than 400,000 children aged up to 14 years, was used to identify a cohort of XLH patients, which were matched with up to 10 controls by date of birth and gender. The annual prevalence of XLH cases per 100,000 patients registered in PediaNet database was estimated. To identify possible predictors associated with XLH diagnosis, a logistic regression model and two machine learning algorithms were applied. Predictive analyses were separately carried out including patients with at least 1 or 2 years of database history in PediaNet.

RESULTS

Among 431,021 patients registered in the PediaNet database between 2007-2020, a total of 12 cases were identified with a mean annual prevalence of 1.78 cases per 100,000 patients registered in PediaNet database. Overall, 8 cases and 60 matched controls were included in the analysis. The random forest algorithm achieved the highest area under the receiver operating characteristic curve (AUC) value both in the one-year prior ID (AUC = 0.99, 95% CI = 0.99-1.00) and the two-year prior ID (AUC = 1.00, 95% CI = 1.00-1.00) analysis. Overall, the XLH predictors selected by the three predictive methods were: the number of vitamin D prescriptions, the number of recorded diagnoses of acute respiratory infections, the number of prescriptions of antihistamine for systemic use, the number of prescriptions of X-ray of the lower limbs and pelvis and the number of allergology visits.

CONCLUSION

Findings showed that data-driven machine learning models may play a prominent role for the prediction of the diagnosis of rare diseases such as XLH.

A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial

BACKGROUND

Gait disturbances represent one of the most disabling features of Parkinson's disease (PD).

AIM

The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor).

DESIGN

Open-label, monocentric, randomized controlled non-inferiority trial.

SETTING

Outpatients.

POPULATION

Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks.

METHODS

At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2).

RESULTS

Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use.

CONCLUSIONS

Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance.

CLINICAL REHABILITATION IMPACT

Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.

Machine learning-based algorithms applied to drug prescriptions and other healthcare services in the Sicilian claims database to identify acromegaly as a model for the earlier diagnosis of rare diseases

Acromegaly is a rare disease characterized by a diagnostic delay ranging from 5 to 10 years from the symptoms' onset. The aim of this study was to develop and internally validate machine-learning algorithms to identify a combination of variables for the early diagnosis of acromegaly. This retrospective population-based study was conducted between 2011 and 2018 using data from the claims databases of Sicily Region, in Southern Italy. To identify combinations of potential predictors of acromegaly diagnosis, conditional and unconditional penalized multivariable logistic regression models and three machine learning algorithms (i.e., the Recursive Partitioning and Regression Tree, the Random Forest and the Support Vector Machine) were used, and their performance was evaluated. The random forest (RF) algorithm achieved the highest Area under the ROC Curve value of 0.83 (95% CI 0.79-0.87). The sensitivity in the test set, computed at the optimal threshold of predicted probabilities, ranged from 28% for the unconditional logistic regression model to 69% for the RF. Overall, the only diagnosis predictor selected by all five models and algorithms was the number of immunosuppressants-related pharmacy claims. The other predictors selected by at least two models were eventually combined in an unconditional logistic regression to develop a meta-score that achieved an acceptable discrimination accuracy (AUC = 0.71, 95% CI 0.66-0.75). Findings of this study showed that data-driven machine learning algorithms may play a role in supporting the early diagnosis of rare diseases such as acromegaly.

Unpacking the p-factor. Associations Between Maladaptive Personality Traits and General Psychopathology in Female and Male Adolescents

Adolescence is a period of rapid physical, psychological, and neural maturation that makes youth vulnerable to emerging psychopathology, highlighting the need for improved identification of psychopathology risk indicators. Recently, a higher-order latent psychopathology factor (p-factor) was identified that explains latent liability for psychopathology beyond internalizing and externalizing difficulties. However, recent proposals suggest reconceptualizing the p-factor model in terms of impairments in personality encompassing difficulties in both self-regulation (borderline features) and self-esteem (narcissistic features), but this remains untested. To address this, this study examined the p-factor structure and the contribution of borderline and narcissistic features using two cross-sectional data collections. In Study 1, 974 cisgender adolescents (63% assigned females at birth; age range: 13-19; Mage = 16.68, SD = 1.40) reported on internalizing and externalizing problems (YSR) to test via structural equation models (SEM) different theoretical models for adolescent psychopathology. In Study 2, 725 cisgender adolescents (64.5% assigned females at birth; age range: 13-19; Mage = 16.22, SD = 1.32) reported internalizing and externalizing problems (YSR), borderline personality features (BPFSC-11), and narcissistic personality traits (PNI), to explore, via SEM, the contribution of borderline and narcissistic traits to the p-factor and accounting for gender differences. Results confirmed the utility of a bi-factor model in adolescence. Furthermore, findings highlighted the contribution of borderline features and narcissistic vulnerability to general psychopathology. The study provides the first evidence supporting a p-factor model reconceptualized in terms of personality impairments encompassing difficulties in self-regulation and self-esteem in adolescents.

Different epistemic stances for different traumatic experiences: implications for mentalization

Traumatic experiences may impair reflective functioning (RF), making it difficult for individuals to understand their own and others' mental states. Epistemic trust (ET), which enables evaluating social information as reliable and relevant, may vary in association with RF. In this study, we explored the implications of different ET stances (i.e., trust, mistrust, and credulity) in the relation between different childhood traumatic experiences (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and different types of RF impairments (uncertainty and certainty about mental states). A non-clinical community sample of 496 cisgender emerging adults (mage = 24.91, standard deviation = 2.66, 71.85% assigned female at birth, 63.63% heterosexual) reported on their childhood traumatic experiences, ET, and RF. We used structural equation models to examine direct and indirect associations. The results showed significant indirect effects between emotional abuse and uncertainty about mental states through credibility. We also observed significant indirect effects between emotional abuse and certainty about mental states through mistrust and credibility. The findings suggest that a lack of discrimination when evaluating knowledge from others (i.e., credulity) might promote increased uncertainty in RF when emerging adults have experienced emotional abuse in their childhood. Conversely, a tendency to view all information sources as unreliable or ill-intentioned (i.e., mistrust) may foster greater certainty in RF as a protective mechanism against an unreliable and potentially harmful world when combined with childhood emotional abuse. The implications for clinical practice and intervention are discussed.

Phase I clinical trial of intracerebroventricular transplantation of allogeneic neural stem cells in people with progressive multiple sclerosis

We report the analysis of 1 year of data from the first cohort of 15 patients enrolled in an open-label, first-in-human, dose-escalation phase I study (ClinicalTrials.gov: NCT03282760, EudraCT2015-004855-37) to determine the feasibility, safety, and tolerability of the transplantation of allogeneic human neural stem/progenitor cells (hNSCs) for the treatment of secondary progressive multiple sclerosis. Participants were treated with hNSCs delivered via intracerebroventricular injection in combination with an immunosuppressive regimen. No treatment-related deaths nor serious adverse events (AEs) were observed. All participants displayed stability of clinical and laboratory outcomes, as well as lesion load and brain activity (MRI), compared with the study entry. Longitudinal metabolomics and lipidomics of biological fluids identified time- and dose-dependent responses with increased levels of acyl-carnitines and fatty acids in the cerebrospinal fluid (CSF). The absence of AEs and the stability of functional and structural outcomes are reassuring and represent a milestone for the safe translation of stem cells into regenerative medicines.

Non-pegylated liposomal doxorubicin in older adjuvant early breast cancer patients: cardiac safety analysis and final results of the COLTONE study

AIMS

To explore the cardiac safety of adjuvant Non-Pegylated Liposomal Doxorubicin (NPL-DOX) plus Cyclophosphamide (CTX) followed by weekly Paclitaxel, in elderly women (≥ 65 years) with high-risk breast cancer. Previously, we described no symptomatic cardiac events within the first 12 months from starting treatment. We now reported the updated results after a median follow-up 76 months.

METHODS

The cardiac activity was evaluated with left ventricular ejection fraction (LVEF) echocardiograms assessments, before starting chemotherapy and every 6 months, until 30 months from baseline, then yearly for at least 5 years.

RESULTS

Forty-seven women were recruited by two Units of Medical Oncology (Ethics Committee authorization CESM-AOUP, 3203/2011; EudraCT identification number: 2010-024067-41, for Pisa and Pontedera Hospitals). An episode of grade 3 CHF (NCI-CTCAE, version 3.0) occurred after 18 months the beginning of chemotherapy. The echocardiograms assessments were performed comparing the LVEF values of each patient evaluated at fixed period of time, compared to baseline. We observed a slight changed in terms of mean values at 48, 60, 72 and 84 months. At these time points, a statistically significant reduction of - 3.2%, - 4.6%, - 6.4% and - 7.1%, respectively, was observed. However, LVEF remained above 50% without translation in any relevant clinical signs. No other cardiac significant episodes were reported. To this analysis, in 13 patients (28%) occurred disease relapse and,  of them, 11 (23%) died due to metastatic disease. Eight patients died of cancer-unrelated causes.

CONCLUSIONS

The combination including NPL-DOX in elderly patients revealed low rate of cardiac toxic effects. Comparative trials are encouraged.

Problematic internet use in emerging adulthood to escape from maternal helicopter parenting: defensive functioning as a mediating mechanism

The increasing use of the Internet has raised concerns about its problematic use, particularly among emerging adults who grew up in a highly digitalized world. Helicopter parenting, characterized by excessive involvement, overcontrol, and developmentally inappropriate behavior, has been identified as a potential factor contributing to problematic Internet use (PIU). Under these circumstances, considering that emerging adults navigate their adult lives and strive to reduce their sense of being in-between, implicit emotion regulation strategies, such as defense mechanisms, may help comprehend PIU. The present questionnaire-based study investigated the associations between maternal and paternal helicopter parenting and PIU through defensive functioning among a community sample of 401 cisgender emerging adults (71.82% females; 82.04% heterosexuals; Mage=24.85, SD=2.52) living in Italy. About one-fourth (25.19%) reported PIU. Greater maternal, B=0.904, SE=0.235, p<.001, but not paternal, B=0.343, SE=0.188, p=.068, helicopter parenting was significantly associated with PIU through a less mature defensive functioning. Conversely, neither maternal, B=1.158, SE=0.722, p=.109, nor paternal, B=0.355, SE=0.731, p=.628, helicopter parenting had a direct association with PIU. The results suggest the importance for psychotherapists to incorporate individuals' defense mechanisms and parent-child relationship history when designing tailored interventions for effective treatment of PIU. This emphasis is crucial because, in the context of a developmentally appropriate parenting style, relying on more mature defenses after psychotherapeutic intervention can lead to healthier adjustment among emerging adults.

The relationship between genetic liability, childhood maltreatment, and IQ: findings from the EU-GEI multicentric case-control study

This study investigated if the association between childhood maltreatment and cognition among psychosis patients and community controls was partially accounted for by genetic liability for psychosis. Patients with first-episode psychosis (N = 755) and unaffected controls (N = 1219) from the EU-GEI study were assessed for childhood maltreatment, intelligence quotient (IQ), family history of psychosis (FH), and polygenic risk score for schizophrenia (SZ-PRS). Controlling for FH and SZ-PRS did not attenuate the association between childhood maltreatment and IQ in cases or controls. Findings suggest that these expressions of genetic liability cannot account for the lower levels of cognition found among adults maltreated in childhood.

Global incidence and prevalence of differentiated thyroid cancer in childhood: systematic review and meta-analysis

Objective

Differentiated thyroid cancer (DTC) is rare in childhood and adolescence although it represents the most frequent endocrine malignancy in this population. DTC includes both papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). Most pediatric DTCs are PTCs, while FTCs are rare. To date, no systematic reviews on the global epidemiology of pediatric and adolescent DTC have been published. This systematic review and meta-analysis aims to estimate the overall incidence and prevalence of DTCs in patients aged 0-19 years.

Methods

The systematic research was conducted from January 2000 to December 2021 through MEDLINE via PubMed, Cochrane Library, and Embase databases. Two separate meta-analyses were performed for PTC and FTC.

Results

After the selection phase, a total of 15 studies (3,332 screened) met the inclusion criteria and are reported in the present systematic review. Five studies were conducted in Europe, five in North America, two in South America, one in Asia, one reported data for 49 countries and territories across the five continents, and one from both the USA and Africa. Most of the studies (n = 14) reported data obtained from national registries, and only one provided information collected from hospital medical records. Beyond the actual trend over time, our study reported a pooled global incidence rate (IR) of PTC and FTC in the pediatric age of 0.46 (95% CI: 0.33-0.59) and 0.07 (95% CI: 0.02-0.12) per 100,000 person-years, respectively. The highest IRs were recorded among Caucasian girls, and the lowest in black or other races/ethnicities.

Conclusion

Our data confirm that DTC in the pediatric population is a rare condition. The pooled IRs of the studies included in this meta-analysis are ~0.5 for PTC, which is the most common histological type when both genders and all age groups are considered. The implementation of a prospective international registry on pediatric DTC, as part of the wider European Registries for Rare Endocrine Conditions, has been recently proposed. In addition to providing relevant information on the clinical behavior of this rare disease, standardization of data collection will be pivotal to fill current gaps and allow an accurate estimation of the real incidence and risk factors of DTC.

Real-world ANASTASE study of atezolizumab+nab-paclitaxel as first-line treatment of PD-L1-positive metastatic triple-negative breast cancer

The combination of atezolizumab and nab-paclitaxel is recommended in the EU as first-line treatment for PD-L1-positive metastatic triple-negative breast cancer (mTNBC), based on the results of phase III IMpassion130 trial. However, 'real-world' data on this combination are limited. The ANASTASE study (NCT05609903) collected data on atezolizumab plus nab-paclitaxel in PD-L1-positive mTNBC patients enrolled in the Italian Compassionate Use Program. A retrospective analysis was conducted in 29 Italian oncology centers among patients who completed at least one cycle of treatment. Data from 52 patients were gathered. Among them, 21.1% presented de novo stage IV; 78.8% previously received (neo)adjuvant treatment; 55.8% patients had only one site of metastasis; median number of treatment cycles was five (IQR: 3-8); objective response rate was 42.3% (95% CI: 28.9-55.7%). The median time-to-treatment discontinuation was 5 months (95% CI: 2.8-7.1); clinical benefit at 12 months was 45.8%. The median duration of response was 12.7 months (95% CI: 4.1-21.4). At a median follow-up of 20 months, the median progression-free survival was 6.3 months (95% CI: 3.9-8.7) and the median time to next treatment or death was 8.1 months (95% CI: 5.5-10.7). At 12 months and 24 months, the overall survival rates were 66.3% and 49.1%, respectively. The most common immune-related adverse events included rash (23.1%), hepatitis (11.5%), thyroiditis (11.5%) and pneumonia (9.6%). Within the ANASTASE study, patients with PD-L1-positive mTNBC treated with first-line atezolizumab plus nab-paclitaxel achieved PFS and ORR similar to those reported in the IMpassion130 study, with no unexpected adverse events.

Two-Wave Stability of Grandiose and Vulnerable Narcissism During Adolescence: The Mediating Role of Empathy

ABSTRACT

Literature suggests that narcissistic traits may affect socio-affective development from early adolescence. Two interrelated narcissistic domains have been identified, i.e. , narcissistic grandiosity (NG) and narcissistic vulnerability (NV). This study aims to prospectively assess NG and NV during adolescence and to investigate the mediating role of empathy on the stability of narcissistic traits. One-hundred fifty-six adolescents (47.5% females) participated in a longitudinal prospective study. NG, NV, and empathy were assessed at baseline and 24-month follow-up. Compared with NG traits, NV showed a mean-level increasing pattern, albeit with a small effect size. Different empathy domains mediated the developmental trajectories of NG and NV. Specifically, the "fantasy" empathy domain partially mediated the stability of NG, whereas the "personal distress" domain partially mediated the mild increase of NV. The findings suggest that grandiose fantasies and negative activation to others' distress are crucial factors in shaping developmental trajectories of narcissistic traits during adolescence.

Leveraging Genetics to Address the Role of GALNT2 on Atherogenic Dyslipidemia

Several studies have shown that downregulation of GALNT2 (Polypeptide N-Acetylgalactosaminyltransferase 2), encoding polypeptide N-acetylgalactosaminyltransferase 2, decreases high-density lipoprotein cholesterol (HDL-C) and increases triglycerides levels by glycosylating key enzymes of lipid metabolism, such as angiopoietin like 3, apolipoprotein C-III, and phospholipid transfer protein. GALNT2 is also a positive modulator of insulin signaling and action, associated with in vivo insulin sensitivity and during adipogenesis strongly upregulates adiponectin. Thus, the hypothesis that GALNT2 affects HDL-C and triglycerides levels also through insulin sensitivity and/or circulating adiponectin, is tested. In 881 normoglycemic individuals the G allele of rs4846914 SNP at the GALNT2 locus, known to associate with GALNT2 downregulation, is associated with low HDL-C and high values of triglycerides, triglycerides/HDL-C ratio, and theHomeostatic Model Assessment of insulin resistance HOMAIR (p-values = 0.01, 0.027, 0.002, and 0.016, respectively). Conversely, no association is observed with serum adiponectin levels (p = 0.091). Importantly, HOMAIR significantly mediates a proportion of the genetic association with HDL-C (21%, 95% CI: 7-35%, p = 0.004) and triglyceride levels (32%, 95% CI: 4-59%, p = 0.023). The results are compatible with the hypothesis that, besides the effect on key lipid metabolism enzymes, GALNT2 alters HDL-C and triglyceride levels also indirectly through a positive effect on insulin sensitivity.

Circulating metabolites improve the prediction of renal impairment in patients with type 2 diabetes

INTRODUCTION

Low glomerular filtration rate (GFR) is a leading cause of reduced lifespan in type 2 diabetes. Unravelling biomarkers capable to identify high-risk patients can help tackle this burden. We investigated the association between 188 serum metabolites and kidney function in type 2 diabetes and then whether the associated metabolites improve two established clinical models for predicting GFR decline in these patients.

RESEARCH DESIGN AND METHODS

Two cohorts comprising 849 individuals with type 2 diabetes (discovery and validation samples) and a follow-up study of 575 patients with estimated GFR (eGFR) decline were analyzed.

RESULTS

Ten metabolites were independently associated with low eGFR in the discovery sample, with nine of them being confirmed also in the validation sample (ORs range 1.3-2.4 per 1SD, p values range 1.9×10-2-2.5×10-9). Of these, five metabolites were also associated with eGFR decline (ie, tiglylcarnitine, decadienylcarnitine, total dimethylarginine, decenoylcarnitine and kynurenine) (β range -0.11 to -0.19, p values range 4.8×10-2 to 3.0×10-3). Indeed, tiglylcarnitine and kynurenine, which captured all the information of the other three markers, improved discrimination and reclassification (all p<0.01) of two clinical prediction models of GFR decline in people with diabetes.

CONCLUSIONS

Further studies are needed to validate our findings in larger cohorts of different clinical, environmental and genetic background.

Albuminuria improves R2CHA2DS2-VASc score in predicting mortality in high cardiovascular risk population

BACKGROUND AND AIMS

The CHA₂DS₂-VASc score estimates the risk of cardioembolism in patients with atrial fibrillation (AF). It also predicts vascular events and death in different clinical settings, even in the absence of AF. The R₂CHA₂DS₂-VASc score, obtained by adding the glomerular filtration rate to CHA₂DS₂-VASc, shows a higher prediction ability for new events and all-cause mortality. The present study aims to assess whether the addition of albuminuria to R₂CHA₂DS₂-VASc score further improves its discrimination ability in predicting all-cause mortality in a sample of high cardiovascular risk population.

METHODS AND RESULTS

Prospective, monocentric, observational study, evaluating a subset of 737 subjects consecutively undergoing to coronary angiography at Coronary Unit of Scientific Institute "Casa Sollievo della Sofferenza" from June 2016 to December 2018. The presence of albuminuria was significantly associated with all-cause mortality (p < 0.0001). Any one-point increase of Alb-R₂CHA₂DS₂-VASc score increased mortality of about 1.5-fold (adjusted HR 1.49; 95%CI: 1.37-1.63; p < 0.0001). Considering tertiles of Alb-R₂CHA₂DS₂-VASc, the third tertile showed a 9.5-fold increased risk of mortality (HR 9.52; 95% CI: 5.15-17.60, p < 0.001). Comparing the two scores, the Alb-R₂CHA₂DS₂-VASc score (C-statistic = 0.751; 95%CI: 0.69-0.81) outperformed the R₂-CHA₂DS₂-VASc score (C-statistic = 0.736; 95%CI: 0.68-0.961) in predicting mortality (delta C-statistic = 0.015; 95%CI: 0.001-0.029). The better prediction ability of the Alb-R₂CHA₂DS₂-VASc score was also proven by an IDI of 0.024 (p < 0.0001) and a relative IDI of 24.11% (p < 0.0001), with an NRI = 0.608 (p < 0.00001).

CONCLUSIONS

The addition of albuminuria to R₂CHA₂DS₂-VASc significantly and independently predicts the risk of all-cause mortality in a sample of high CV risk patients. Moreover, Alb-R₂CHA₂DS₂-VASc outperforms R₂CHA₂DS₂-VASc.

Multiscale modelling of chromatin 4D organization in SARS-CoV-2 infected cells

SARS-CoV-2 is able to re-structure chromatin organization and alters the epigenomic landscape of the host genome, though the mechanisms that produce such changes are still poorly understood. Here, we investigate with polymer physics chromatin re-organization of the host genome, in space and time upon SARS-CoV-2 viral infection. We show that re-structuring of A/B compartments is well explained by a re-modulation of intra-compartment homotypic affinities, which leads to the weakening of A-A interactions and enhances A-B mixing. At TAD level, re-arrangements are physically described by a general reduction of the loop extrusion activity coupled with an alteration of chromatin phase-separation properties, resulting in more intermingling between different TADs and spread in space of TADs themselves. In addition, the architecture of loci relevant to the antiviral interferon (IFN) response, such as DDX58 or IFIT, results more variable within the 3D single-molecule population of the infected model, suggesting that viral infection leads to a loss of chromatin structural specificity. Analysis of time trajectories of pairwise gene-enhancer and higher-order contacts reveals that such variability derives from a more fluctuating dynamics in infected case, suggesting that SARS-CoV-2 alters gene regulation by impacting the stability of the contact network in time. Overall, our study provides the first polymer-physics based 4D reconstruction of SARS-CoV-2 infected genome with mechanistic insights on the consequent gene mis-regulation.

Final results of the real-life observational VICTOR-6 study on metronomic chemotherapy in elderly metastatic breast cancer (MBC) patients

Nowadays, treatment of metastatic breast cancer (MBC) has been enriched with novel therapeutical strategies. Metronomic chemotherapy (mCHT) is a continuous and frequent administration of chemotherapy at a lower dose and so whit less toxicity. Thus, this strategy could be attractive for elderly MBC patients. Aim of this analysis is to provide insights into mCHT's activity in a real-life setting of elderly MBC patients. Data of patients ≥ 75 years old included in VICTOR-6 study were analyzed. VICTOR-6 is a multicentre, Italian, retrospective study, which collected data on mCHT in MBC patients treated between 2011 and 2016. A total of 112 patients were included. At the beginning of mCHT, median age was 81 years (75-98) and in 33% of the patients mCHT was the first line choice. Overall Response Rate (ORR) and Disease Control Rate (DCR) were 27.9% and 79.3%, respectively. Median PFS ranged between 7.6 and 9.1 months, OS between 14.1 and 18.5 months. The most relevant toxicity was the hematological one (24.1%); severe toxicity (grade 3-4) ranged from 0.9% for skin toxicity up to 8% for hematologic one. This is a large study about mCHT in elderly MBC patients, providing insights to be further investigated in this subgroup of frail patients.

Maladaptive Personality Traits and Internalizing and Externalizing Problems: The Role of Borderline and Narcissistic Features in Adolescence

Objective

Research has shown the importance of delving into the variables associated with externalizing and internalizing behaviors in adolescence, highlighting gender-related differences in their presentations. This two-wave longitudinal study aims to address gaps in understanding the concurrent contribution of borderline and narcissistic personality traits to the presence and maintenance of internalizing and externalizing problems in adolescence.

Method

We recruited 705 adolescents (65% females; age range 13-19 years old; Mage = 15.84, SD = 1.31) to self-report on behavioral problems (YSR-112), borderline (BPFSC-11) and narcissistic traits (PNI) at baseline and again on behavioral problems after 12 months.

Results

Data highlighted significant differences between males and females for all variables except externalizing problems. Hierarchical regression models showed that borderline traits are a prominent risk factor for all behavioral problems in males and females at baseline and after 12 months. Moreover, regardless of gender, higher grandiose narcissism contributes to lower internalizing problems only when the direct contribution of vulnerable presentations of narcissism is considered. Grandiose narcissism is also a risk factor for externalizing problems after 12 months in females, whereas vulnerable narcissism significantly increases the likelihood of internalizing trajectories improving over 12 months.

Conclusions

This study provides more evidence of the associations between maladaptive personality traits and adolescent internalizing and externalizing problems: (1) confirming that borderline traits are crucial beyond gender, (2) stressing the importance of considering both grandiose and vulnerable narcissistic traits, and (3) highlighting the adaptive value of narcissistic vulnerability in capturing the adolescent crisis. The implications for clinical practice and intervention are also discussed.

The largest prehistoric mound in Europe is the Bronze-Age Hill of Udine (Italy) and legend linked its origin to Attila the Hun

Prehistoric monuments often constitute evident landmarks and sometimes, after falling into disuse, fascinated local people enough to stimulate speculations about their origin over time. According to legend, the Hill of Udine (NE Italy) was built by Attila the Hun's soldiers, but its origin (natural or anthropogenic) has been debated until now. Our research analyzed five new 40-m long stratigraphic cores, investigating for the first time the total thickness of the hill and compared the data with the available archaeological information. Moreover, we considered other hills and mounds in northern Italy and other European regions where folklore traditions relate their origin to Attila. The geoarchaeological and ethnographic data prove that the Hill of Udine is a Bronze Age anthropogenic mound erected between 1400 and 1150 BCE and that, later, folklore has transformed the ancestral memory of its origin into legend. By measuring 30 m in height and over 400,000 m³ in volume, the flat-topped hill is the largest prehistoric mound in Europe. This discovery reveals unprecedented skills in earth construction and confirms significant anthropogenic modifications of the environment during Bronze Age.

Identifying Predictors Associated with Risk of Death or Admission to Intensive Care Unit in Internal Medicine Patients with Sepsis: A Comparison of Statistical Models and Machine Learning Algorithms

Background: Sepsis is a time-dependent disease: the early recognition of patients at risk for poor outcome is mandatory. Aim: To identify prognostic predictors of the risk of death or admission to intensive care units in a consecutive sample of septic patients, comparing different statistical models and machine learning algorithms. Methods: Retrospective study including 148 patients discharged from an Italian internal medicine unit with a diagnosis of sepsis/septic shock and microbiological identification. Results: Of the total, 37 (25.0%) patients reached the composite outcome. The sequential organ failure assessment (SOFA) score at admission (odds ratio (OR): 1.83; 95% confidence interval (CI): 1.41-2.39; p < 0.001), delta SOFA (OR: 1.64; 95% CI: 1.28-2.10; p < 0.001), and the alert, verbal, pain, unresponsive (AVPU) status (OR: 5.96; 95% CI: 2.13-16.67; p < 0.001) were identified through the multivariable logistic model as independent predictors of the composite outcome. The area under the receiver operating characteristic curve (AUC) was 0.894; 95% CI: 0.840-0.948. In addition, different statistical models and machine learning algorithms identified further predictive variables: delta quick-SOFA, delta-procalcitonin, mortality in emergency department sepsis, mean arterial pressure, and the Glasgow Coma Scale. The cross-validated multivariable logistic model with the least absolute shrinkage and selection operator (LASSO) penalty identified 5 predictors; and recursive partitioning and regression tree (RPART) identified 4 predictors with higher AUC (0.915 and 0.917, respectively); the random forest (RF) approach, including all evaluated variables, obtained the highest AUC (0.978). All models' results were well calibrated. Conclusions: Although structurally different, each model identified similar predictive covariates. The classical multivariable logistic regression model was the most parsimonious and calibrated one, while RPART was the easiest to interpret clinically. Finally, LASSO and RF were the costliest in terms of number of variables identified.

Psychological Characteristics of Women with Perinatal Depression Who Require Psychiatric Support during Pregnancy or Postpartum: A Cross-Sectional Study

Antenatal depression may be distinct from postpartum depression in terms of prevalence, severity of symptoms, comorbidities, prognosis, and risk factors. Although risk factors for perinatal depression have been identified, it is unclear whether there are differences in the onset of perinatal depression (PND). This study explored the characteristics of women requiring mental health support during pregnancy or postpartum. A sample of 170 women (58% in pregnancy; 42% postpartum) who contacted the SOS-MAMMA outpatient clinic was recruited. Clinical data sheets and self-report questionnaires (EPDS, LTE-Q, BIG FIVE; ECR; BSQ; STICSA) were administered, hypothesizing possible risk factors, such as personality traits, stressful life events, body dissatisfaction, attachment style, and anxiety. Hierarchical regression models were carried out in the pregnancy (F_10;36 = 8.075, p < 0.001, adjR2 = 0.877) and postpartum groups (F_10;38 = 3.082, p < 0.05, adjR2 = 0.809). Recent stressful life events and conscientiousness were associated with depression in both the pregnant (29.3%, 25.5% of variance) and postpartum groups (23.8%, 20.7% of variance). In pregnant women, "openness" (11.6%), body dissatisfaction (10.2%), and anxiety (7.1%) symptoms were predictive of depression. In the postpartum group, "neuroticism" (13.8%) and insecure romantic attachment dimensions (13.4%; 9.2%) were the strongest predictors. Perinatal psychological interventions should consider the differences between mothers with depression during pregnancy and postpartum.

The innovative 52g Mn for positron emission tomography (PET) imaging: Production cross section modeling and dosimetric evaluation

BACKGROUND

Manganese is a paramagnetic element suitable for magnetic resonance imaging (MRI) of neuronal function. However, high concentrations of Mn^{2 +} can be neurotoxic. ^52g Mn may be a valid alternative as positron emission tomography (PET) imaging agent, to obtain information similar to that delivered by MRI but using trace levels of Mn^{2 +} , thus reducing its toxicity. Recently, the reaction n a t $^{nat}$ V(α,x)^52g Mn has been proposed as a possible alternative to the standard n a t $^{nat}$ Cr(p,x)^52g Mn one, but improvements in the modeling were needed to better compare the two production routes.

PURPOSE

This work focuses on the development of precise simulations and models to compare the ^52g Mn production from both reactions in terms of amount of activity and radionuclidic purity (RNP), as well as in terms of dose increase (DI) due to the co-produced radioactive contaminants, versus pure ^52g MnCl₂ .

METHODS

The nuclear code Talys has been employed to optimize the n a t $^{nat}$ V(α,x)^52g Mn cross section by tuning the parameters of the microscopic level densities. Thick-target yields have been calculated from the expression of the rates as energy convolution of cross sections and stopping powers, and finally integrating the time evolution of the relevant decay chains. Dosimetric assessments of [ x x $^{xx}$ Mn]Cl₂ have been accomplished with OLINDA software 2.2.0 using female and male adult phantoms and biodistribution data for ^52g MnCl₂ in normal mice. At the end, the yield of x x $^{xx}$ Mn radioisotopes estimated for the two production routes have been combined with the dosimetric results, to assess the DI at different times after the end of the irradiation.

RESULTS

Good agreement was obtained between cross-section calculations and measurements. The comparison of the two reaction channels suggests that n a t $^{nat}$ V(α,x)^52g Mn leads to higher yield and higher purity, resulting in more favorable radiation dosimetry for patients.

CONCLUSIONS

Both n a t $^{nat}$ V(α,x) and n a t $^{nat}$ Cr(p,x) production routes provide clinically acceptable ^52g MnCl₂ for PET imaging. However, the n a t $^{nat}$ V(α,x)^52g Mn reaction provides a DI systematically lower than the one obtainable with n a t $^{nat}$ Cr(p,x)^52g Mn and a longer time window in which it can be used clinically (RNP ≥ 99%).

Abstract P1-11-04: Assessing the clinico-pathological characteristics of HER2 positive metastatic breast cancer patients experiencing radiologic complete response in a nationwide cohort

Background: Up to 6% of patients (pts) with HER2 positive (pos) metastatic breast cancer (MBC) experience a radiologic complete response (rCR) to a first line of therapy, but these results mostly derive from dated and/or limited cohorts. Aim of this study was to define the clinico-pathological characteristics of HER2 positive (pos) MBC pts experiencing a rCR. Methods: Pts were selected from the database of the GIM14 study (NCT02284581) and classified according to the best radiologic response obtained to the first line chemotherapy (CT) and upon time-to-treatment-failure (TTF). rCR was defined as complete response (CR) with a TTF &gt; 3 months. The association across variables was tested through logistic regression and their prognostic impact in terms of overall survival (OS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Results: Of the 3,423 pts included in the GIM14 study, 814 had HER2 pos MBC. After exclusion of pts treated with first line endocrine therapy and/or with TTF &lt; 3 months, 656 pts were included in the present analysis, of which 96 (14.6%) experienced a rCR. Instead, the best response was a partial response for 295 pts (45.0%), stable disease for 221 pts (33.7%), and progression for 44 pts (6.7%). Most pts (59.8%) presented de novo MBC; 379 pts (57.8%) had visceral metastases (mets), 609 pts (92.8%) did not have central nervous system (CNS) involvement and 318 pts (48.5%) had only 1 site of distant mets. Also, 445 pts (67.9%) had hormone receptor (HR) pos disease, a HER2 3+ score at immunohistochemistry (IHC) was present in 59.8% of cases versus 40.2% with HER2 2+ at IHC and in situ hybridization (ISH) + disease. Taxanes were the main CT backbone (489 pts, 74.5%), 341 pts (52.0%) had received a Trastuzumab-Pertuzumab doublet. At multivariable analysis, higher odds of experiencing a rCR were reported for presence of non-visceral mets (OR 1.87, 95%CI 1.10-3.17), low number of metastatic sites (OR 2.42, 95%CI 0.80-7.33 for 1 site only) and HER2 3+ score at IHC (OR 1.80, 95%CI 1.09-2.98). Disease-free interval (DFI) was associated to rCR at univariable but not at multivariable analysis. HR status, CT backbone and type of anti-HER2 regimen were not associated with rCR neither at univariable nor at multivariable analysis. Median follow-up was 76.2 months. Amongst pts with TTF&gt;12 months, those with rCR had a significantly higher OS compared to those not experiencing a rCR (median OS 133 and 90 months, respectively; p=0.0191). OS rates in pts with TTF ≥ 12 months were 97.8% at 2-year follow-up and 59.4% at 5-year follow-up. Instead, in pts with TTF ≥ 60 months, OS rates were 76.7% at 10-year follow-up. Amongst the 96 pts experiencing a CR, 38 had a rCR with TTF between 12 and 60 months, while 22 pts had a rCR with a TTF ≥ 60 months. The remaining pts had a CR with a TTF &lt; 12 months. Pts with HR negative (neg) disease were found to be more likely to experience a rCR with a with TTF between 12 and 60 months, whilst pts with HR pos disease had a higher probability to experience a rCR with a TTF ≥ 60 months (p=0.0074). Pts with HER2 3+ score at IHC had a higher probability to achieve a rCR with a TTF ≥ 12 months compared to pts with HER2 2+ score at IHC and ISH + (p=0.0216). Age at diagnosis, menopausal status, DFI, number and site of mets, CT backbone and anti-HER2 therapy did not influence the duration of the rCR obtained. Conclusions: This study characterized a real-world cohort of HER2 positive MBC patients experiencing radiologic complete response to a first line treatment. Based on these results a clinical trial focused on liquid biopsy-based minimal residual disease is being designed. Novel anti-HER2 agents are gaining momentum as ever increasingly effective treatments and future de-escalation strategies after complete response will represent a growing need.

Citation Format: Linda Cucciniello, Eva Blondeaux, Claudia Bighin, Simona Gasparro, Stefania Russo, Arianna Dri, Palma Pugliese, Andrea Fontana, Giuseppe Naso, Antonella Ferzi, Ferdinando Riccardi, Valentina Sini, Luca Boni, Alessandra Fabi, Filippo Montemurro, Michelino De Laurentiis, Grazia Arpino, Lucia Del Mastro, Lorenzo Gerratana, Fabio Puglisi. Assessing the clinico-pathological characteristics of HER2 positive metastatic breast cancer patients experiencing radiologic complete response in a nationwide cohort [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-04.

The Relationship Between Obsessive-Compulsive Symptoms and Dissociation: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate the relationship between dissociation and obsessive-compulsive symptoms (OCS) and disorder (OCD). Specifically, the study aimed to (a) estimate the pooled prevalence of dissociative disorders among individuals with OCD; (b) systematically review the prevalence of OCD among individuals with dissociative disorders; (c) compare the severity of dissociative symptoms between individuals with OCD and non-clinical controls; (d) estimate the association between OCS and dissociative symptoms in the clinical and non-clinical populations. A systematic search was carried out in biomedical databases from inception to January 2022 according to PRISMA guidelines. A total of 41 studies met inclusion criteria (n = 9,438, 34.3% males). The pooled prevalence of dissociative disorders in adult samples with OCD was 8% (95% CI [3, 15], k = 5). Studies on adolescent and adult patients with dissociative disorders found that 17-32% reported comorbid OCD, while a prospective study of patients with early-onset dissociative disorders found no evidence of association with OCD. Individuals affected by OCD reported more dissociative symptoms than non-clinical controls (g = .67, 95% CI [.18, 1.16], k = 9). A moderate correlation between dissociative symptoms and OCS was detected (r = .43, 95% CI [.36, .51], k = 18). Sensitivity analyses showed small/moderate correlations between dissociative experiences and specific types of obsessions and compulsions. Findings suggest that dissociative symptoms are moderately related to OCS in both clinical and non-clinical populations. Interventions aimed to reduce dissociation might improve treatment response of patients suffering from OCD.

CDK4/6 Inhibitors Overcome Endocrine ESR1 Mutation-Related Resistance in Metastatic Breast Cancer Patients

ESR1 mutations contribute to endocrine resistance and occur in a high percentage of hormone-receptor-positive (HR+) metastatic breast cancer (mBC) cases. Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) changed the treatment landscape of HR+ mBC, as they are able to overcome estrogen resistance. The present retrospective study investigates the clinical benefit of CDK4/6i in ESR1 mutant HR+ mBC patients treated with a CDK4/6i as first- or second-line therapy. Plasma was collected at baseline prior to CDK4/6i plus hormone therapy as a first- or second-line treatment. Circulating free DNA (cfDNA) was extracted from plasma, and ESR1 mutation analysis was performed on a ddPCR. Statistical analyses were performed to investigate the predictive power of ESR1 mutations and any association with clinical factors. A total of 42 patients with mBC treated with CDK4/6i plus endocrine therapy as first- (n = 35) or second-line (n = 7) were enrolled. Twenty-eight patients received hormonal therapy (AI or tamoxifen) in the adjuvant setting. ESR1 mutation status in blood was associated with shorter median disease-free survival (DFS) (30 vs. 110 months; p = 0.006). Multivariate analysis confirmed ESR1 mutations as independent factors of resistance in adjuvant hormone therapy. On the contrary, no difference in progression-free survival (PFS) was observed in the presence or absence of an ESR1 mutation in patients treated with CDK4/6i as first-line treatment (p = 0.29). No statistically significant correlation between the best response to CDK4/6i and ESR1 mutation was found (p = 0.46). This study indicates that the ESR1 mutation detected in cfDNA is an independent predictive factor of clinical recurrence in the adjuvant setting and that CDK4/6i can overcome ESR1-dependent resistance.

Evaluation of inherited germline mutations in cancer susceptibility genes among pancreatic cancer patients: a single-center study

BACKGROUND

Germline mutations in cancer susceptibility genes were identified in pancreatic cancer (PanC) patients with a sporadic disease and in those unselected for family cancer history.

METHODS

With the aim to determine the prevalence of germline predisposition genes mutations in PanC, and to evaluate whether they were associated with the presence of PanC, we profiled a custom AmpliSeq panel of 27 cancer susceptibility genes in 47 PanC patients and 51 control subjects by using the Ion Torrent PGM system.

RESULTS

Multigene panel testing identified a total of 31 variants in 27 PanC (57.4%), including variants with pathogenic/likely pathogenic effect, those of uncertain significance, and variants whose clinical significance remains currently undefined. Five patients carried more than one variant in the same gene or in different genes. Eight patients (17.0%) had at least one pathogenic/likely pathogenic variant in four main genes: CFTR (10.6%), BRCA2 (8.5%), ATM and CHEK2 (2.1%). Pathogenic/likely pathogenic mutation were identified in patients with positive PanC family history (20%) or in patients without first-degree relatives affected by PanC (13.6%). All the BRCA2 mutation carriers were unselected PanC patients. The presence of mutations in BRCA2 was significantly associated with an increased occurrence of PanC and with positive family history for endometrial cancer (p = 0.018).

CONCLUSIONS

This study confirmed the potential remarkable contribution of BRCA2 in assessing the presence of PanC. Overall our findings supported the recommendation of offering the germline testing to all the PanC patients with the intent to reduce the number of underdiagnosed carriers of mutations in predisposition genes, and not to preclude their relatives from the opportunity to benefit from surveillance programs.

Testing of Coding Algorithms for Inflammatory Bowel Disease Identification, as Indication for Use of Biological Drugs, Using a Claims Database from Southern Italy

Background

Inflammatory bowel diseases (IBDs), Crohn's disease (CD) and ulcerative colitis (UC), are chronic diseases that have been increasingly treated with biological drugs in recent years. Newly developed coding algorithms for IBD identification using claims databases are needed to improve post-marketing surveillance of biological drugs.

Objective

To test algorithms to identify CD and UC, as indication for use of biological drugs approved for IBD treatment, using a claims database.

Methods

Data were extracted from the Caserta Local Health Unit database between 2015 and 2018. CD/UC diagnoses reported by specialists in electronic therapeutic plans (ETPs) were considered as gold standard. Five algorithms were developed based on ICD-9-CM codes as primary cause of hospital admissions, exemption from healthcare service co-payment codes and drugs dispensing with only indication for CD/UC. The accuracy was assessed by sensitivity (Se), specificity (Sp), positive (PPV) and negative predicted values (NPV) along with computation of the Youden Index and F-score.

Results

In the study period, 1205 subjects received at least one biological drug dispensing approved for IBD and 134 (11.1%) received ≥1 ETP with IBD as use indication. Patients with CD and CU were 83 (61.9%) and 51 (38.1%), respectively. Sensitivity of the different algorithms ranged from 71.1% (95% CI: 60.1-80.5) to 98.8 (95% CI: 93.5-100.0) for CD and from 64.7% (95% CI: 50.1-77.6) to 94.1 (95% CI: 83.8-98.8) for UC, while specificity was always higher than 91%. The best CD algorithm was "Algorithm 3", based on hospital CD diagnosis code OR CD exemption code OR [IBD exemption code AND dispensing of non-biological drugs with only CD indication] (Se: 98.8%; Sp: 97.2%; PPV: 84.5%, NPV: 99.8%), achieving the highest diagnostic accuracy (Youden Index=0.960). The best UC algorithm was "Algorithm 3", based on specific hospital UC diagnosis code OR UC exemption code OR [IBD exemption code AND golimumab dispensing] OR dispensing of non-biological drugs with only UC indication (Se: 94.1%; Sp: 91.6%; PPV: 50.0%; NPV: 99.4%), and achieving the highest diagnostic accuracy (Youden Index=0.857).

Conclusion

In a population-based claims database, newly coding algorithms including diagnostic and exemption codes plus specific drug dispensing yielded highly accurate identification of CD and UC as distinct indication for biological drug use.

Emerging personality in adolescence: developmental trajectories, internalizing and externalizing problems, and the role of mentalizing abilities

INTRODUCTION

Identifying longitudinal trajectories of emerging personality (EP) is crucial to highlight developmental patterns that might foster personality pathology in adolescence and early adulthood. Research on the exacerbation of personality pathology in adolescence identifies the significant contribution of internalizing and externalizing problems and suggests the importance of considering aspects such as mentalization, while accounting for gender differences.

METHODS

In our study, we adopted a mixed-model approach to (1) explore longitudinally EP (Adolescent Personality Structure Questionnaire; APS-Q) over 12 months in a sample of adolescents (N = 178, 62% females, mAGE = 15.04, SD = 1.27), accounting for gender effects. Moreover, (2) we assessed the longitudinal effect of internalizing and externalizing problems (Youth Self-Report; YSR-112) on EP. Finally, (3) we addressed the moderating role of mentalization (Movie Assessment for Social Cognition; MASC) in this developmental pathway.

RESULTS

Results highlighted a two-way pattern of EP. No changes were found in the level of difficulties in Self-acceptance, Investments and Goals, and Relationships with family dimensions. However, significant changes were found in personality functioning in the dimensions of Sense of Self, Aggression, and Relationships with friends. More, changes in difficulties in Sexuality emerged only in females. Also, gender differences emerged in the level of severity of EP. In addition, Internalizing and Externalizing problems differentially predicted difficulties in personality dimensions. Finally, mentalizing features moderated the relationship between Internalizing problems and Sense of Self and Internalizing problems and Self-acceptance, respectively.

CONCLUSIONS

Our contribution aligns with recent developmental models of personality pathology, suggesting that different personality dimensions develop at different paces. More, it highlights the predictive power of externalizing and internalizing problems on difficulties in personality dimensions. Finally, it advances the discussion on the contribution of mentalizing abilities to EP.

Polarization Control in Integrated Graphene-Silicon Quantum Photonics Waveguides

We numerically investigated the use of graphene nanoribbons placed on top of silicon-on-insulator (SOI) strip waveguides for light polarization control in silicon photonic-integrated waveguides. We found that two factors mainly affected the polarization control: the graphene chemical potential and the geometrical parameters of the waveguide, such as the waveguide and nanoribbon widths and distance. We show that the graphene chemical potential influences both TE and TM polarizations almost in the same way, while the waveguide width tapering enables both TE-pass and TM-pass polarizing functionalities. Overall, by increasing the oxide spacer thickness between the silicon waveguide and the top graphene layer, the device insertion losses can be reduced, while preserving a high polarization extinction ratio.

Gut microbiota composition in COVID-19 hospitalized patients with mild or severe symptoms

Background and aim

COVID-19, the infectious disease caused by SARS-CoV-2 virus that has been causing a severe pandemic worldwide for more than 2 years, is characterized by a high heterogeneity of clinical presentations and evolution and, particularly, by a varying severity of respiratory involvement. This study aimed to analyze the diversity and taxonomic composition of the gut microbiota at hospital admission, in order to evaluate its association with COVID-19 outcome. In particular, the association between gut microbiota and a combination of several clinical covariates was analyzed in order to characterize the bacterial signature associate to mild or severe symptoms during the SARS-CoV-2 infection.

Materials and methods

V3–V4 hypervariable region of 16S rRNA gene sequencing of 97 rectal swabs from a retrospective cohort of COVID-19 hospitalized patients was employed to study the gut microbiota composition. Patients were divided in two groups according to their outcome considering the respiratory supports they needed during hospital stay: (i) group “mild,” including 47 patients with a good prognosis and (ii) group “severe,” including 50 patients who experienced a more severe disease due to severe respiratory distress that required non-invasive or invasive ventilation. Identification of the clusters of bacterial population between patients with mild or severe outcome was assessed by PEnalized LOgistic Regression Analysis (PELORA).

Results

Although no changes for Chao1 and Shannon index were observed between the two groups a significant greater proportion of Campylobacterota and Actinobacteriota at phylum level was found in patients affected by SARS-CoV-2 infection who developed a more severe disease characterized by respiratory distress requiring invasive or non-invasive ventilation. Clusters have been identified with a useful early potential prognostic marker of the disease evolution.

Discussion

Microorganisms residing within the gut of the patients at hospital admission, were able to significantly discriminate the clinical evolution of COVID-19 patients, in particular who will develop mild or severe respiratory involvement. Our data show that patients affected by SARS-CoV-2 with mild or severe symptoms display different gut microbiota profiles which can be exploited as potential prognostic biomarkers paving also the way to new integrative therapeutic approaches.

CHA2DS2-VASc and R2CHA2DS2-VASc scores predict mortality in high cardiovascular risk population

BACKGROUND

The CHA₂ DS₂ -VASc score, widely used to estimate cardioembolic risk in patients with atrial fibrillation (AF), appears to be useful also in predicting vascular adverse events and death in different sets of patients without AF. The R₂ CHA₂ DS₂ -VASc score, which includes renal impairment, allows a better prediction of death and thromboembolism in patients without AF. The aims of our study were to assess, in a large sample of patients at high cardiovascular (CV) risk, (i) the correlation between CHA₂ DS₂ -VASc and R₂ CHA₂ DS₂ -VASc with all-cause mortality, and (ii) to compare the performances of CHA₂ DS₂ -VASc and R₂ CHA₂ DS₂ -VASc in predicting all-cause mortality.

METHODS

In this single-centre prospective observational study, conducted at the Research Hospital 'Casa Sollievo della Sofferenza' between June 2016 and December 2018, 1017 CV patients at high risk of undergoing coronary angiography were enrolled.

RESULTS

CHA₂DS₂-VASc and R₂ CHA₂ DS₂ -VASc scores significantly associated with all-cause mortality. For each one-point increase in CHA₂ DS₂ -VASc or R₂ CHA₂ DS₂ -VASc scores, mortality increased by almost 1.5-fold. The R₂ CHA₂ DS₂ -VASc score (C-statistic = 0.71; 95% CI = 0.65-76) outperformed the CHA₂ DS₂ -VASc score (C-statistic = 0.66; 95% CI = 0.61-0.71) in predicting 4-year mortality (delta C-statistic = 0.05; 95% CI = 0.02-0.07). The better predictive ability of the R-CHA₂ DS₂ -VASc score was also demonstrated by an IDI = 0.027 (95% CI = 0.021-0.034, p < .00001) and a relative IDI = 62.8% (95% CI = 47.9%-81.3%, p < .00001). The R₂ CHA₂ DS₂ -VASc score correctly reclassified the patients with a NRI = 0.715 (95% = 0.544-0.940, p < .00001).

CONCLUSIONS

The CHA₂DS₂-VASc and R₂ CHA₂ DS₂ -VASc scores are useful predictors of all-cause mortality in subjects at high CV risk, with the R₂ CHA₂ DS₂ -VASc score being the best performer.

Concomitant administration of proton pump inhibitors does not significantly affect clinical outcomes in metastatic breast cancer patients treated with ribociclib

BACKGROUND

Gastric pH changes by proton-pump-inhibitors (PPIs) were found to affect progression-free survival (PFS) in metastatic breast cancer (mBC) patients treated with palbociclib. The current study was aimed at investigating whether the same effect could occur in patients treated with ribociclib.

PATIENTS AND METHODS

Patients with hormone-positive/HER-2-negative mBC candidates for first-line treatment with ribociclib were enrolled in this retrospective-cohort study. Patients were classified as "no concomitant PPIs" or "concomitant PPIs"; PPI administration covered the entire or not less than 2/3 of treatment with ribociclib. All clinical interventions were made according to clinical practice.

RESULTS

A total of 128 patients were consecutively enrolled in the study; 78 belonged to the "no concomitant PPIs" group and 50 to the "concomitant PPIs" group. One hundred and six patients were endocrine-sensitive and received ribociclib and letrozole, while 22 were endocrine-resistant and were treated with ribociclib and fulvestrant. The most prescribed PPI was lansoprazole. According to PFS, patients taking PPIs had a PFS almost superimposable to those assuming ribociclib and endocrine therapy alone (35.3 vs. 49.2 months, p = 0.594). No difference in PFS was observed in estrogen-sensitive or estrogen-resistant mBC in the presence or absence of concomitant PPI treatment (p = 0.852). No correlation with adverse events was found including grade>2 hematological toxicities.

CONCLUSIONS

The present study supports the hypothesis that the concomitant use of PPIs does not compromise the efficacy of ribociclib in a real-life setting.

Development and testing of diagnostic algorithms to identify patients with acromegaly in Southern Italian claims databases

Acromegaly is a rare disease characterized by an excessive production of growth-hormone and insulin-like growth factor 1, typically resulting from a GH-secreting pituitary adenoma. This study was aimed at comparing and measuring accuracy of newly and previously developed coding algorithms for the identification of acromegaly using Italian claims databases. This study was conducted between January 2015 and December 2018, using data from the claims databases of Caserta Local Health Unit (LHU) and Sicily Region in Southern Italy. To detect acromegaly cases from the general target population, four algorithms were developed using combinations of diagnostic, surgical procedure and co-payment exemption codes, pharmacy claims and specialist’s visits. Algorithm accuracy was assessed by measuring the Youden Index, sensitivity, specificity, positive and negative predictive values. The percentage of positive cases for each algorithm ranged from 7.9 (95% CI 6.4–9.8) to 13.8 (95% CI 11.7–16.2) per 100,000 inhabitants in Caserta LHU and from 7.8 (95% CI 7.1–8.6) to 16.4 (95% CI 15.3–17.5) in Sicily Region. Sensitivity of the different algorithms ranged from 71.1% (95% CI 54.1–84.6%) to 84.2% (95% CI 68.8–94.0%), while specificity was always higher than 99.9%. The algorithm based on the presence of claims suggestive of acromegaly in ≥ 2 different databases (i.e., hospital discharge records, copayment exemptions registry, pharmacy claims and specialist visits registry) achieved the highest Youden Index (84.2) and the highest positive predictive value (34.8; 95% CI 28.6–41.6). We tested four algorithms to identify acromegaly cases using claims databases with high sensitivity and Youden Index. Despite identifying rare diseases using real-world data is challenging, this study showed that robust validity testing may yield the identification of accurate coding algorithms.

Abstract 1492: Hsa-miR-27a-5p expression in breast cancer and its association with patient outcome

MicroRNA-27a-5p (miR-27a-5p) has been closely related to the pathogenesis of different solid tumors, showing potentials as both useful biomarker and druggable target of clinical application. In our study, we performed the expression analysis of miR-27a-5p in a retrospective cohort of 232 breast cancer (BC) patients with a median follow-up of 99.4 months enrolled according to the REMARK guidelines. Of those patients, 9 showed synchronous metastases (MTX), 45 developed metastases during the follow-up time (M0&gt;M1), and 178 were free from metastases after a follow-up of at least 5 years (M0). As controls, 13 normal breast tissues (NBTs) from reductive mammoplasty and 11 pre-invasive breast lesions (PreBr) were also profiled. Overall, miR-27a-5p showed higher levels in NBTs (Median 2.28, IQR 1.50-5.40) and pre-invasive breast lesions (Median 3.32, IQR 1.68-4.32) compared to tumour samples. In particular, miR-27a-5p was less expressed in patients with synchronous (Median 1.03 IQR 0.83-1.58) or metachronous (Median 1.83, IQR 1.29-3.17) metastases than in patients free from metastases after a 5-year follow-up (Median 2.17, IQR 1.19-3.64). Thus, we found that miR-27a-5p expression (log values) is negatively correlated with breast pathology evolution (R= -0.13, P=0.038). Next, we assessed the potentialities of miR-27a-5p as BC-specific prognostic biomarker in the subgroup of patients without metastases at diagnosis (n=222). Moreover, increased miR-27a-5p levels were associated with reduced risk of disease progression (Progression Free Survival (PFS) HR 0.43, 95%CI 0.18-0.99, P=0.048), metastases development (Metastases Free survival (MFS) HR 0.42, 95%CI 0.18-0.96, P=0.039), and cancer-related death (Overall Survival (OS) HR 0.30, 95%CI 0.12-0.74, P=0.009) in the subgroup of HER2-amplified tumours (n=26). Then, we extended our analysis to the TCGA BRCA dataset by selecting a total of 561 cases without synchronous metastases, for whom miR-27a-5p expression levels, and clinical and follow-up data were available. Among them, 19 were HER2 amplified according to clinical guidelines (i.e. score 3+ at immunostaining or FISH-positive). Similarly to our internal cohort, high miR-27a-5p was associated to reduced risk of disease progression (PFS HR 0.61, 95%CI 0.10-3.61) and death (OS HR 0.62, 95%CI 0.08-5.05) in the subgroup of HER2-amplified cases, although the association did not reach statistical significance. Overall, our data support the tumour suppressive role of miR-27a-5p in breast cancer, and suggest miR-27a-5p as putative prognostic biomarker in HER2-amplified tumours.

Citation Format: Barbara Pasculli, Andrea Fontana, Serena Barile, Morritti Maria, Luigi Ciuffreda, Paolo Graziano, Evaristo Maiello, Paola Parrella. Hsa-miR-27a-5p expression in breast cancer and its association with patient outcome [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1492.

Global Cushing's disease epidemiology: a systematic review and meta-analysis of observational studies

PURPOSE

Cushing's disease (CD), 70% of endogenous hypercortisolism cases, is a rare disease caused by adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. To date, no systematic reviews and meta-analyses on its global epidemiology have been published. We provide a systematic review and meta-analysis of CD global epidemiology, also evaluating the quality of study reporting for the identified studies.

METHODS

MEDLINE and EMBASE databases were searched for studies on CD epidemiology from inception until November 30th, 2020, including original observational studies in English about CD prevalence and/or incidence for well-defined geographic areas. Two reviewers independently extracted data and assessed reporting quality. CD prevalence/incidence pooled estimates were derived from a random-effects meta-analysis. Reporting quality was assessed using a STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist adapted for observational studies on rare diseases, heterogeneity using the Cochran's Q-test and its derived measure of inconsistency (I²).

RESULTS

Thirteen studies were included. The pooled CD prevalence was 2.2 [95% CI 1.1-4.8] per 100,000, while the incidence rate was 0.24 [95% CI 0.15-0.33] per 100,000 person-years. For both parameters, considerable between-studies heterogeneity was found (I² = 78.8% and 87.8%, respectively). The quality of study reporting was rated as medium for 11 (84.6%) studies and as low for 2 (15.4%).

CONCLUSION

Overall, our systematic meta-analysis demonstrated CD epidemiology to be similarly reported across different areas of the world, with some exceptions regarding regional differences or observation period intervals. Keeping into account the methodological differences between each paper, large-scale studies on CD epidemiology are warranted. Setting up national specific registries, based on standardized diagnostic and clinical parameters, with clearly defined selection and analysis criteria, and a strong cooperation between the scientific national societies for endocrinology is crucial to exclude other causes of variability (i.e. geographical differences due to other factors like (epi)genetic changes), and to support public health decision making.

PASTEC - a prospective, single-center, randomized, cross-over trial of pure physical versus physical plus attentional training in children with cancer

Despite recent improvements in survival rates in children with cancer, long-term toxicities remain a major concern. Physical activity could reduce the impact of long-term sequelae, notably in neuropsychological and physical areas. We report of a randomized trial of pure physical versus physical/attentional training in pediatric oncology patients. Twenty-two patients aged 6-18 y.o. were included, irrespective of their clinical diagnosis or treatment status, stratified by age and randomized 1:1 into pure physical vs. physical/attentional activity arms, with a cross-over at study midpoint. Neurological, motor and neuropsychological assessments were performed at inclusion, start, crossover and end of the program. Feasibility, defined as > 80% patients attending > 80% of sessions, was the primary endpoint. Secondary outcomes were improvements in neuropsychological and motor performance tests. While 68% of patients attended more than 80% of sessions during the pre-crossover phase of the study, this dropped to 36% post-crossover. Our study therefore failed to meet our primary endpoint. Nonetheless, significant improvements in anxiety (p<0.001), emotional control (p = 0.04), organization skills (p = 0.03), as well as motor deficit scores (p = 0.04) were observed. We noted no significant difference between the pure physical and the physical/attentional training arms, or when analyzing subgroups by age or sequence of intervention. We conclude that physical activity has a positive impact on anxiety, emotional and organizational aspects as well as motor deficits. Attendance dropped during the course of the study and motivational interventions should be included in future studies or equivalent programs.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.1994677 .

A new route to produce 52gMn with high purity for MultiModal Imaging

The 52gMn radionuclide is suitable for the innovative MultiModal Imaging technique, and in particular for a PET/MRI scan, due to its physical properties. The standard cyclotron-based production of 52gMn relies on the nuclear reaction NatCr(p,x)52gMn, but we have investigated theoretically the possibility of an alternative and competitive route, the reaction NatV(α,x)52gMn, which has not been considered for this purpose so far. By using the nuclear reaction code TALYS, we found some discrepancies between the theoretical calculations of the cross sections and the corresponding experimental data. Therefore we tuned the parameters governing the nuclear level densities in the microscopic models implemented in TALYS, thus improving the agreement with the data. Then, by studying the cross sections for 52gMn and its contaminants, we have identified an optimal energy window for the production of high purity 52gMn, around 40 MeV. We have also calculated the time evolution of the number of nuclei of the different Mn isotopes, for an irradiation in this energy window, finding that this route is expected to lead to a higher yield and Radionuclidic Purity with respect to the standard reaction with NatCr. The study suggests the reaction NatV(α,x)52gMn as a promising alternative route for the production of 52gMn.

Theoretical study of 47Sc production for theranostic applications using proton beams on enriched titanium targets

Recently, scandium-47 has attracted attention in the scientific community thanks to its promising features, making it suitable for targeted radiotherapy and theranostic applications, also in combination with the β+ emitters 43Sc/44Sc. However, in view of possible pre-clinical and clinical studies, finding efficient production routes is still a current research topic. In this work we investigate 47Sc cyclotron production using proton beams on enriched titanium targets. The analysis of the cross sections and yields of both 47Sc (T1/2 = 3.35 d) and its main contaminant 46Sc (T1/2 = 83.79 d) has been performed with the nuclear reaction code Talys (v.1.95). The experimental data (scarce and relatively old) are compared with model calculations and some discrepancies emerge even after the tuning of parameters defining the nuclear level densities, involved in the compound nucleus formation. The 49Ti case allows a more precise cross sections reproduction, conversely the 50Ti case requires further theoretical investigations. Preliminary yields analysis has been carried out for both 47Sc and 46Sc.

Improvement of nuclear reaction modeling for the production of 47Sc on natural vanadium targets for medical applications

The proton-induced reaction on natural vanadium targets is studied for the production of the innovative theranostic radionuclide 47Sc as well as of its contaminants, mainly 46Sc. The theoretical excitation functions are calculated using the nuclear reaction code TALYS and are compared with the most recent experimental data. A better agreement between the theoretical curves and the data is achieved with an optimization of the nuclear level density parameters. The obtained improvements represent a useful and important result for accurate evaluations of yields and purities which are needed quantities for subsequent dosimetric studies, in view of the radiopharmaceutical applications of 47Sc. The optimization procedure is explained and shown for 47Sc and 46Sc, and also a comparison among the theoretical and experimental cumulatives is given (for the main contaminant) in addition to an estimation of the production yields for two irradiation conditions for both nuclides.

Impact of healthcare-associated infections on functional outcome of severe acquired brain injury during inpatient rehabilitation

To describe healthcare-associated infections in inpatient neuro-rehabilitation and their impact on functional outcome, a multicenter observational study with severe acquired brain injury (sABI) patients was performed. Patients were divided into infected (INF-group) or not infected (noINF-group) and assessed at admission and discharge, by means of the Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), the Disability Rating Scale (DRS), and the modified Barthel Index (mBI). One hundred-nineteen patients were included in the INF-group, and 109 in the noINF-group. Culture specimens were found positive for bloodstream (43.8%), respiratory tract (25.7%), urinary tract (16.2%), gastro-intestinal system (8.6%) and skin (2.4%) infections. Multiple microorganisms were the most frequent (58.1%) and 55.5% of patients needed functional isolation due to multidrug resistant germs. The functional status of both groups improved after rehabilitation, but multivariable analyses showed that the INF-group showed a significantly lower gain to GCS (p = 0.008), DRS (p = 0.020) and mBI (p = 0.021) compared to the noINF-group. Length of stay (LOS) and number of skipped rehabilitative sessions were not statistically different between the groups; mortality rate was significantly higher in the INF-group (p = 0.04). Infected sABI patients showed longer LOS, significant increased mortality, and a lower functional outcome than not infected patients.

A pharmacogenetic interaction analysis of bevacizumab with paclitaxel in advanced breast cancer patients

To investigate pharmacogenetic interactions among VEGF-A, VEGFR-2, IL-8, HIF-1α, EPAS-1, and TSP-1 SNPs and their role on progression-free survival (PFS) in metastatic breast cancer (MBC) patients treated with bevacizumab plus first-line paclitaxel or with paclitaxel alone. Analyses were performed on germline DNA, and SNPs were investigated by real-time PCR technique. The multifactor dimensionality reduction (MDR) methodology was applied to investigate the interaction between SNPs. The present study was an explorative, ambidirectional cohort study: 307 patients from 11 Oncology Units were evaluated retrospectively from 2009 to 2016, then followed prospectively (NCT01935102). Two hundred and fifteen patients were treated with paclitaxel and bevacizumab, whereas 92 patients with paclitaxel alone. In the bevacizumab plus paclitaxel group, the MDR software provided two pharmacogenetic interaction profiles consisting of the combination between specific VEGF-A rs833061 and VEGFR-2 rs1870377 genotypes. Median PFS for favorable genetic profile was 16.8 vs. the 10.6 months of unfavorable genetic profile (p = 0.0011). Cox proportional hazards model showed an adjusted hazard ratio of 0.64 (95% CI, 0.5–0.9; p = 0.004). Median OS for the favorable genetic profile was 39.6 vs. 28 months of unfavorable genetic profile (p = 0.0103). Cox proportional hazards model revealed an adjusted hazard ratio of 0.71 (95% CI, 0.5–1.01; p = 0.058). In the 92 patients treated with paclitaxel alone, the results showed no effect of the favorable genetic profile, as compared to the unfavorable genetic profile, either on the PFS (p = 0.509) and on the OS (p = 0.732). The pharmacogenetic statistical interaction between VEGF-A rs833061 and VEGFR-2 rs1870377 genotypes may identify a population of bevacizumab-treated patients with a better PFS.

Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study

Background: A significant proportion of patients with coronavirus disease 2019 (COVID-19) suffer from delirium during hospitalization. This single-center observational study investigates the occurrence of delirium, the associated risk factors and its impact on in-hospital mortality in an Italian cohort of COVID 19 inpatients. Methods: Data were collected in the COVID units of a general medical hospital in the South of Italy. Socio-demographic, clinical and pharmacological features were collected. Diagnosis of delirium was based on a two-step approach according to 4AT criteria and DSM5 criteria. Outcomes were: dates of hospital discharge, Intensive Care Unit (ICU) admission, or death, whichever came first. Univariable and multivariable proportional hazards Cox regression models were estimated, and risks were reported as hazard ratios (HR) along with their 95% confidence intervals (95% CI). Results: A total of 47/214 patients (22%) were diagnosed with delirium (21 hypoactive, 15 hyperactive, and 11 mixed). In the multivariable model, four independent variables were independently associated with the presence of delirium: dementia, followed by age at admission, C-reactive protein (CRP), and Glasgow Coma Scale. In turn, delirium was the strongest independent predictor of death/admission to ICU (composite outcome), followed by Charlson Index (not including dementia), CRP, and neutrophil-to-lymphocyte ratio. The probability of reaching the composite outcome was higher for patients with the hypoactive subtype than for those with the hyperactive subtype. Conclusions: Delirium was the strongest predictor of poor outcome in COVID-19 patients, especially in the hypoactive subtype. Several clinical features and inflammatory markers were associated with the increased risk of its occurrence. The early recognition of these factors may help clinicians to select patients who would benefit from both non-pharmacological and pharmacological interventions in order to prevent delirium, and in turn, reduce the risk of admission to ICU or death.

Overview of the EU PAS register post-authorization studies performed in Europe from September 2010 to December 2018

BACKGROUND

The European post-authorisation study (EU PAS) register is a repository launched in 2010 by the European Medicines Agency (EMA). All EMA-requested PAS, commonly observational studies, must be recorded in this register. Multi-database studies (MDS) leveraging secondary data have become an important strategy to conduct PAS in recent years, as reflected by the type of studies registered in the EU PAS register.

OBJECTIVES

To analyse and describe PAS in the EU PAS register, with focus on MDS.

METHODS

Studies in the EU PAS register from inception to 31^st December 2018 were described concerning transparency, regulatory obligations, scope, study type (e.g. observational study, clinical trial, survey, systematic review/meta-analysis), study design, type of data collection and target population. MDS were defined as studies conducted through secondary use of >1 data source not linked at patient-level. Data extraction was carried out independently by 14 centres with expertise in pharmacoepidemiology, using publicly available information in the EU PAS register including study protocol, whenever available, using a standardised data collection form. For validation purposes, a second revision of key fields for a 15% random sample of studies was carried out by a different centre. The inter-rater reliability (IRR) was then calculated. Finally, to identify predictors of primary data collection-based studies /vs those based on secondary use of healthcare databases) or MDS (vs. non-MDS), odds ratios (OR) and 95% confidence intervals (CI) were calculated fitting univariate logistic regression models.

RESULTS

Overall, 1,426 studies were identified. Clinical trials (N=30; 2%), systematic reviews/meta-analyses (N=16; 1%) and miscellaneous study designs (N=46; 3%) were much less common than observational studies (N=1,227; 86%). The protocol was available for 63% (N=360) of 572 observational studies requested by a competent authority. Overall, 36% (N=446) of observational studies were based fully or partially on primary data collection. Of 757 observational studies based on secondary use of data alone, 282 (37%) were MDS. Drug utilisation was significantly more common as a study scope in MDS compared to non-MDS studies. The overall percentage agreement among collaborating centres that collected the data concerning study variables was highest for study type (93.5%) and lowest for type of secondary data (67.8%).

CONCLUSIONS

Observational studies were the most common type of studies in the EU PAS register, but 30% used primary data, which is more resource-intensive. Almost half of observational studies using secondary data were MDS. Data recording in the EU PAS register may be improved further, including more widespread availability of study protocols to improve transparency.