Real-world EGFR testing practices for non-small-cell lung cancer by thoracic pathology laboratories across Europe

BACKGROUND

Testing for epidermal growth factor receptor (EGFR) mutations is an essential recommendation in guidelines for metastatic non-squamous non-small-cell lung cancer, and is considered mandatory in European countries. However, in practice, challenges are often faced when carrying out routine biomarker testing, including access to testing, inadequate tissue samples and long turnaround times (TATs).

MATERIALS AND METHODS

To evaluate the real-world EGFR testing practices of European pathology laboratories, an online survey was set up and validated by the Pulmonary Pathology Working Group of the European Society of Pathology and distributed to 64 expert testing laboratories. The retrospective survey focussed on laboratory organisation and daily EGFR testing practice of pathologists and molecular biologists between 2018 and 2021.

RESULTS

TATs varied greatly both between and within countries. These discrepancies may be partly due to reflex testing practices, as 20.8% of laboratories carried out EGFR testing only at the request of the clinician. Many laboratories across Europe still favour single-test sequencing as a primary method of EGFR mutation identification; 32.7% indicated that they only used targeted techniques and 45.1% used single-gene testing followed by next-generation sequencing (NGS), depending on the case. Reported testing rates were consistent over time with no significant decrease in the number of EGFR tests carried out in 2020, despite the increased pressure faced by testing facilities during the COVID-19 pandemic. ISO 15189 accreditation was reported by 42.0% of molecular biology laboratories for single-test sequencing, and by 42.3% for NGS. 92.5% of laboratories indicated they regularly participate in an external quality assessment scheme.

CONCLUSIONS

These results highlight the strong heterogeneity of EGFR testing that still occurs within thoracic pathology and molecular biology laboratories across Europe. Even among expert testing facilities there is variability in testing capabilities, TAT, reflex testing practice and laboratory accreditation, stressing the need to harmonise reimbursement technologies and decision-making algorithms in Europe.

AAV-based gene therapy prevents and halts the progression of dilated cardiomyopathy in a mouse model of phosphoglucomutase 1 deficiency (PGM1-CDG)

Phosphoglucomutase 1 (PGM1) deficiency is recognized as the third most common N-linked congenital disorders of glycosylation (CDG) in humans. Affected individuals present with liver, musculoskeletal, endocrine, and coagulation symptoms; however, the most life-threatening complication is the early onset of dilated cardiomyopathy (DCM). Recently, we discovered that oral D-galactose supplementation improved liver disease, endocrine, and coagulation abnormalities, but does not alleviate the fatal cardiomyopathy and the associated myopathy. Here we report on left ventricular ejection fraction (LVEF) in 6 individuals with PGM1-CDG. LVEF was pathologically low in most of these individuals and varied between 10% and 65%. To study the pathobiology of the cardiac disease observed in PGM1-CDG, we constructed a novel cardiomyocyte-specific conditional Pgm2 gene (mouse ortholog of human PGM1) knockout (Pgm2 cKO) mouse model. Echocardiography studies corroborated a DCM phenotype with significantly reduced ejection fraction and left ventricular dilation similar to those seen in individuals with PGM1-CDG. Histological studies demonstrated excess glycogen accumulation and fibrosis, while ultrastructural analysis revealed Z-disk disarray and swollen/fragmented mitochondria, which was similar to the ultrastructural pathology in the cardiac explant of an individual with PGM1-CDG. In addition, we found decreased mitochondrial function in the heart of KO mice. Transcriptomic analysis of hearts from mutant mice demonstrated a gene signature of DCM. Although proteomics revealed only mild changes in global protein expression in left ventricular tissue of mutant mice, a glycoproteomic analysis unveiled broad glycosylation changes with significant alterations in sarcolemmal proteins including different subunits of laminin-211, which was confirmed by immunoblot analyses. Finally, augmentation of PGM1 in KO mice via AAV9-PGM1 gene replacement therapy prevented and halted the progression of the DCM phenotype.

Internuclear Ophthalmoplegia as an Isolated Symptom of Brainstem Wake-up Stroke Responsive to Intravenous Thrombolysis: Evidence from MRI

BACKGROUND

Internuclear ophthalmoplegia (INO) is a disorder of eye movements caused by a lesion involving the medial longitudinal fasciculus (MLF) within the brainstem, and it is characterized by adduction impairment combined with contralateral dissociated abduction nystagmus. The frequency of acute ischemic stroke (AIS) presenting with INO as a predominant symptom is very low, and many patients suffering from this brainstem AIS are precluded from intravenous thrombolysis (IVT).

OBJECTIVE

To provide for the first time a magnetic resonance imaging (MRI) evidence of response to the IVT in brainstem wake-up stroke presenting with INO as an isolated symptom.

METHODS

Here, we described a rare case of pons AIS presenting with INO as a unique symptom of awakening. In order to differentiate an ischemic stroke from other stroke mimics, and to determine whether the patient was within the therapeutic window for IVT (wake-up stroke), brain MRI including DWI and FLAIR sequences was acquired.

RESULTS

A left paramedian pontine DWI/FLAIR mismatch was detected and the patient was considered eligible for IVT. After IVT, the patient made a full recovery with complete resolution of INO. Follow-up MRI at 1 month demonstrates the absence of ischemic lesions.

CONCLUSION

Our case provides neuroradiological evidence of IVT efficacy in brainstem stroke, and it should prompt clinicians to rapidly perform MRI in wake-up onset INO and to just as quickly administer IVT, since INO is a functionally disabling deficit. Finally, this case demonstrates the value of MRI in diagnostic, prognostic, and therapeutic workup of posterior circulation wake-up stroke.

C6 IN VIVO CHIARI NETWORK REMOVAL. COMPLICATION OR INNOCENT SURPRISE

A 78 years old man was admitted to our hospital because of a syncope and evidence of complete AV– block, low ventricular rate and suitable for definitive PM implantation. He had no other pathologies or previous surgical interventions. A transthoracic echocardiography was performed and any particular structural anomaly was detected and the left ventricular ejection fraction was normal. In the electrophysiology laboratory, a vascular access through the left axillary vein was used to insert a passive fixation catheter for the right ventricular using a 9 F sheath. When the ventricular lead reached the right atrium it was impossible to advance it farther into the right ventricle; the lead was blocked near tricuspid anulus without any possibility to move it towards any direction despite many and vigorous manual traction maneuvers were attempted. Immediately, a transesophageal echocardiography was performed and it showed the lead entrapment into a mobile structure, likely a Chiari network.The patient needed a PM implantation as soon as possible and also a temporary PM could further complicate the procedure. Since the hospital did not have a cardiac surgery department and our crew was not familiar with lead extractions, an expert hemodynamist, who suggested to remove the lead by using a snare, was consulted. The tip of the lead was stuck in the atrial wall so it was impossible to capture it as expected. So, from right femoral vein access, a 6F pig–tail catheter was inserted through a a 45 cm– 8 F Terumo Destination sheath in order to give more stability to the pig–tail catheter until it hooked the lead. A 0.035 mm normal hydrophilic Terumo wire was later passed into the pig–tail catheter, snared and externalized with an AndraSnare 25 catheter inserted through another 6F introducer. A vigorous traction was performed simultaneously pulling both the ends of the wire from the bottom and the lead from the top. After a few seconds, the lead was unstuck and removed from the axillary vein [Fig. 1a,b]. At the external examination, the tines of the lead were found attached to a net–like structure that was actually the Chiari network that had been completely removed from the atrium [Fig 2–3]. A transthoracic echocardiogram ruled out any pericardial effusion. The anatomical finding was sent to tissue analysis and was confirmed to be the tendon material. After that the patient was immediately implanted with a VDD PM without any complications, and dismissed after 2 days.

New-Onset Anemia and Associated Risk of ESKD and Death in Non-Dialysis CKD Patients: A Multi-Cohort Observational Study

Background

Anemia is a common complication of chronic kidney disease (CKD), but its incidence in nephrology settings is poorly investigated. Similarly, the risks of adverse outcomes associated with new-onset anemia are not known.

Methods

We performed a pooled analysis of three observational cohort studies including 1031 non-anemic CKD patients with eGFR <60 mL/min/1.73 m² regularly followed in renal clinics. We estimated the incidence of mild anemia (hemoglobin 11–12 g/dL in women and 11–13 g/dL in men) and severe anemia (hemoglobin <11 g/dL or use of erythropoiesis-stimulating agents) during a 3-year follow-up period. Thereafter we estimated the risk of end-stage kidney disease (ESKD) and all-cause death associated with new-onset mild and severe anemia.

Results

The mean age was 63 ± 14 years, 60% were men and 20% had diabetes. The mean estimated glomerular filtration rate (eGFR) was 37 ± 13 mL/min/1.73 m² and the median proteinuria was 0.4 g/day [interquartile range (IQR) 0.1–1.1]. The incidence of mild and severe anemia was 13.7/100 patients-year and 6.2/100 patients-year, respectively. Basal predictors of either mild or severe anemia were diabetes, lower hemoglobin, higher serum phosphate, eGFR <30 mL/min/1.73 m² and proteinuria >0.50 g/day. Male sex, moderate CKD (eGFR 30–44 mL/min/1.73 m²) and moderate proteinuria (0.15–0.50 g/day) predicted only mild anemia. The incidence of anemia increased progressively with CKD stages (from 8.77 to 76.59/100 patients-year) and the proteinuria category (from 13.99 to 25.02/100 patients-year). During a median follow-up of 3.1 years, 232 patients reached ESKD and 135 died. Compared with non-anemic patients, mild anemia was associated with a higher adjusted risk of ESKD {hazard ratio [HR] 1.42 [95% confidence interval (CI) 1.02–1.98]} and all-cause death [HR 1.55 (95% CI 1.04–2.32)]. Severe anemia was associated with an even higher risk of ESKD [HR 1.73 (95% CI 1.20–2.51)] and death [HR 1.83 (95% CI 1.05–3.19)].

Conclusions

New-onset anemia is frequent, particularly in patients with more severe renal damage and in those with diabetes mellitus. The occurrence of anemia, even of a mild degree, is associated with mortality risk and faster progression towards ESKD.

Recurrent Miller-Fisher syndrome overlapping Guillain-Barrè syndrome and Bickerstaff brainstem encephalitis: A case report

Miller-Fisher syndrome (MFS) together with Guillan-Barré syndrome (GBS) and Bickerstaff brainstem encephalitis (BBE) are considered to form a continuous clinical spectrum of the same disease, possibly affecting the peripheral and/or central nervous systems, with monophasic symptoms. The frequency of overlapping clinical signs and the risk of recurrence are independent and very low, but no cases of GQ1b-seropositive recurrent MFS overlapping with GBS and BBE have been described so far. Here, we describe for the first time an atypical case of recurrent GQ1b-seropositive MFS overlapping GBS and BBE, 12 years after a previous GQ1b-seronegative typical MFS episode. Our case expands the clinical spectrum of recurrent MFS, and it should prompt clinicians to investigate the presence of anti-ganglioside antibodies in recurrent MFS even when these were negative in the previous episode, especially in those presenting with overlapping spectrum symptoms and a critically ill picture during the second episode.

Clinical and molecular practice of European thoracic pathology laboratories during the COVID-19 pandemic. The past and the near future

Background

This study evaluated the consequences in Europe of the COVID-19 outbreak on pathology laboratories orientated toward the diagnosis of thoracic diseases.

Materials and methods

A survey was sent to 71 pathology laboratories from 21 European countries. The questionnaire requested information concerning the organization of biosafety, the clinical and molecular pathology, the biobanking, the workload, the associated research into COVID-19, and the organization of education and training during the COVID-19 crisis, from 15 March to 31 May 2020, compared with the same period in 2019.

Results

Questionnaires were returned from 53/71 (75%) laboratories from 18 European countries. The biosafety procedures were heterogeneous. The workload in clinical and molecular pathology decreased dramatically by 31% (range, 3%-55%) and 26% (range, 7%-62%), respectively. According to the professional category, between 28% and 41% of the staff members were not present in the laboratories but did teleworking. A total of 70% of the laboratories developed virtual meetings for the training of residents and junior pathologists. During the period of study, none of the staff members with confirmed COVID-19 became infected as a result of handling samples.

Conclusions

The COVID-19 pandemic has had a strong impact on most of the European pathology laboratories included in this study. Urgent implementation of several changes to the organization of most of these laboratories, notably to better harmonize biosafety procedures, was noted at the onset of the pandemic and maintained in the event of a new wave of infection occurring in Europe.

•

Biosafety measures used in the first wave of the COVID-19 crisis were heterogeneous in 53 European pathology laboratories.

•

A dramatic decrease of the workload in pathology laboratories was noted.

•

No case of healthcare workers contaminated with SARS-CoV-2 associated with samples handling was identified.

P776 Stress ecocardiography and speckle tracking analysis in patients with heart failure and preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is characterized by heart failure symptoms despite preserved LV systolic function together with at least one among left ventricle hypertrophy/left atrial enlargement plus diastolic dysfunction (DD) and increased brain natriuretic peptide levels. Rest echocardiography could still be normal despite patients experience HF symptoms. Speckle tracking analysis (STE) analyzes myocardial deformation and is able to identify subtle left ventricular dysfunction.

PURPOSE

to analyze the added value of stress echocardiography to improve diagnostic accuracy in patients with normal ejection fraction and unexplained dyspnoea by evaluating DD, lung B lines and STE.

METHODS

Main inclusion criteria were: suspected heart failure, EF &gt; 40%, DD up to moderate at rest (E/e"&lt;14), age &lt; 85 and &gt;18 years, satisfactory acoustic window. Exclusion criteria were: comorbidities limiting the prognosis, valvulopathy more than moderate, coronary artery disease, moderate to severe DD at rest (E/e"≥14; E/A≥2), pregnancy or lactation. Each patient underwent physical stress echo and STE by GE Vivid 7, (AFI).

RESULTS

After measuring diastolic function parameters variation with stress, HFpEF was diagnosed in 8 patients, who had baseline non-diagnostic echocardiogram (Table 1). In the remaining 20 patients a non-cardiac etiology of dyspnoea was diagnosed (NCD). EF did not significantly change from rest to stress either in HFpEF group (58 ± 6 vs 61 ± 8.7 p:0.62) or in DNC group (59 ± 8 vs 62.2 ± 7.4; p:0.26). GLS values tended to decrease in patients with HFpEF (-18.5 ± 2.2 at baseline vs -15.96 ± 6.67 at peak stress; p:0.33), and it was stable in DNC (-17.69 ± 1.15 at baseline vs - 18.04 ± 2.02 at peak stress; p:0.64).

CONCLUSIONS

Study of diastolic function during stress echocardiography is a useful diagnostic tool to reveal HFpEF in patients with dyspnea and unremarkable baseline echocardiogram. STE could offer useful adjunctive diagnostic information but further studies are needed to confirm its value.

Table 1 HFpEF NCD p HFpEF NCD p GLS -18,5 ± 2,2 -17,6 ± 1,15 0,23 -15,96 ± 6,67 18,04 ± 2,02 0,26 E/A 0,8 ± 0,1 1 ± 0,7 0,55 1,67 ± 0,7 1,26 ± 0,6 0,07 E/e’ 10,1 ± 2,2 9,9 ± 3,7 0,4 16,4 ± 0,9 13,8 ± 5 0,16 PAP 25,6 ± 4,1 22,33 ± 0,55 0,57 49,8 ± 9,65 28,27 ± 4,35 0,001 LA 35,5 ± 8,5 23,44 ± 4,9 0,001 34,45 ± 4,88 27,32 ± 7,33 0,018 EF 58 ± 6 59 ± 8 0,6 61 ± 8,7 62,2 ± 7,4 0,7 Echocardiographic parameters at baseline and at peak stress in patients with HFpEF and with NCD

P1462 Additive value of global longitudinal strain measurement in patients with known or suspected ischaemic heart disease undergoing stress echo

BACKGROUND

Speckle-tracking echocardiography (STE) can be applied in a large variety of clinical conditions.

Global longitudinal strain (GLS) shows high diagnostic accuracy for the detection of myocardial

ischemia as it reflects changes in subendocardial fibers deformation that are more exposed to

ischemic damage, even before alterations in segmental kinetics are revealed.

PURPOSE

Aim of our study was to assess whether the measurement of global longitudinal strain during

stress-echo can provide additional information compared to the assessment of conventional

parameters such as left ventricular ejection fraction (LVEF) and wall motion abnormalities. We

also evaluated the added value of strain in patients with complete (CRP) and incomplete

revascularization (IRP).

METHODS

We enrolled 69 patients, 39 with known (IHD) and 30 with suspected ischaemic heart disease

(SIHD) with indication to perform a stress echocardiogram. Inclusion criteria were: known or

suspected CAD, age &lt;85 and &gt;18, adeguate acoustic window. Cardiological evaluation and stress

echo were performed in all patients. Primary end point was evaluating whether in patients with

negative stress test the presence of reduced GLS identifies patients with an adverse prognosis at

follow up and to assess if in IRP and negative stress test there is evidence of left subclinical ventricular

dysfunction identifiable by GLS analysis compared to CRP.

RESULTS

LVEF was significantly reduced in IHD patients compared to SIHD patients (54 ± 7vs 60 ± 4 at rest;

55 ± 8vs62 ± 3 at peak; p &lt; 0.0001). We also observed a significant reduction of GLS in IHD patients

compared to SIHD patients (-16.7 ± 4,3vs-19 ± 2.2 - p = 0.07 at rest, -18 ± 4.6vs22 ± 3.4-p = 0.004 at

peak). In CRP patients GLS did not change significantly with a tendency to improve (-17.6 ± 4 at rest

vs -19 ± 4.5 at peak - p = 0.4). Instead in IRP patients, significant reduction of GLS was observed at

peak (17.5 ± 0.7 at rest vs 14.2 ± 0.3 at peak, p value 0,03). LVEF did not significantly differ in CRP

(54 ± 5 at baseline vs 55 ± 7 at peak, p = 0.5) and IRP (52 ± 9 at baseline vs. 52 ± 9 at peak, p =

0.9) .

CONCLUSIONS

Our study shows that strain analysis during stress echocardiography can provide additional information in identifying a subclinical reduction of myocardial function at baseline and

a reduction in contractile reserve under stress, secondary to coronary flow reduction. Being GLS a

powerful prognostic marker probably patients with negative stress test and incomplete

revascularization, reduced baseline GLS and reduction of GLS at peak exercise represent a population at higher risk of coronary artery disease progression and development of left ventricular dysfunction who need a closer follow up. To verify our hypothesis we plan to increase our sample size and to

prospectively follow up our patients.

P2882Sustainable organization of a management model for CIED remote control: data from a single tertiary center

Introduction

The remote control (RC) of CIED has become necessary, though the human resources and technical facilities needed are limited. In most of Centers, the ratio of RC CIED /CIED with in-office follow up, is continuously increasing and is expected to reach the 100% of CIED remotely controlled.

We sought assess an organizational model based on available facilities and a long-term projection of RC data burden. Pacemakers, ICD and implantable loop recorders were considered.

Methods

The total population served by the Hospital area has been obtained (271.260 citizens), timed at December 31st 2014. By checking our Hospital data files, the total number of followed up CIED patients timed at January 1st 2011 (3995; 1.47% of all population), was compared with the same data timed at January 1st 2015 (3902; 1.43% of all population), in order to the check for the “stability” of that data over time.

At the analyzed time 1582/3902 (40,5%) of CIED were followed by RC.

We have then considered an yearly average of 465 CIEDs implanted/replaced (yearly implants 2012 to 2015) and excluded a roughly 10% of them because not provided of RC facilities (unwilling patients or CIED not RC “ready”); all the other patients were provided with RC. On these basis, we can assume a ratio of RC CIEDs /non-RC CIED, deemed to increase by 10 to 11% per year, to reach the break-even of 100% of RC CIEDs, in 2021 (projection).

The number of RC transmissions (Tx) have been gathered in 5 types of events (Fig. left upper).

The timing of RC patient managing from opening the CIED web site to complete patient file assessment (RC file analysis) performed by expert nurses, was arbitrarily calculated over a sample of 10 Tx per day in 3 different days.

Results

Of 3902 CIED patient, 1582 (40.5%) were RC followed up (3261 pacemakers, 594 ICDs and 47 implantable loop recorder); the CIED brands were represented as follows: Medtronic 685 (43.3%); St. Jude 180 (11.4%), Boston Sc. 330 (20.8%), Biotronik 318 (20.1%) and Livanova (previously SorinGroup) 69 (4.4%).

During the year 2015 we received a total number of 10396 Tx: 128 (1.2%) red alert; 1944 (18.6%) yellow alert, 141 (1.3%) atrial fibrillation; 403 (3.9%) lost Tx (disconnected transmitters or un-compliant patients for remote interrogation) and 7780 (75%) Tx “OK” with NO events. (Fig. right upper).

The projection model at 2021 with 100% RC patients (break-even) shows a total 25990 Tx: 320 red alert; 1944 yellow alert, 352 atrial fibrillation; 1007 lost Tx and 19459 Tx “OK”. The 2021 monthly Tx would be 2320 (26 red alert; 405 yellow alert, 29 atrial fibrillation; 91 lost Tx and 1769 (75%) Tx “OK”) (Fig. both lower panels)

The RC file analysis was roughly calculated around 3 minutes (116 hours/month); 5.8 hours/business day (Monday–Friday).

Conclusion

The rate of RC followed up CIEDs will inexorably increase by time. The projection management model presented could help to build a sustainable organization.

A novel phosphoglucomutase-deficient mouse model reveals aberrant glycosylation and early embryonic lethality

Patients with phosphoglucomutase (PGM1) deficiency, a congenital disorder of glycosylation (CDG) suffer from multiple disease phenotypes. Midline cleft defects are present at birth. Overtime, additional clinical phenotypes, which include severe hypoglycemia, hepatopathy, growth retardation, hormonal deficiencies, hemostatic anomalies, frequently lethal, early-onset of dilated cardiomyopathy and myopathy emerge, reflecting the central roles of the enzyme in (glycogen) metabolism and glycosylation. To delineate the pathophysiology of the tissue-specific disease phenotypes, we constructed a constitutive Pgm2 (mouse ortholog of human PGM1)-knockout (KO) mouse model using CRISPR-Cas9 technology. After multiple crosses between heterozygous parents, we were unable to identify homozygous life births in 78 newborn pups (P = 1.59897E-06), suggesting an embryonic lethality phenotype in the homozygotes. Ultrasound studies of the course of pregnancy confirmed Pgm2-deficient pups succumb before E9.5. Oral galactose supplementation (9 mg/mL drinking water) did not rescue the lethality. Biochemical studies of tissues and skin fibroblasts harvested from heterozygous animals confirmed reduced Pgm2 enzyme activity and abundance, but no change in glycogen content. However, glycomics analyses in serum revealed an abnormal glycosylation pattern in the Pgm2^+/- animals, similar to that seen in PGM1-CDG.

Salubrinal enhances eIF2α phosphorylation and improves fertility in a mouse model of Classic Galactosemia

Loss of galactose-1 phosphate uridylyltransferase (GALT) activity in humans results in Classic Galactosemia, and the GalT-deficient (GalT^-/-) mouse mimics the patient condition. GalT^-/- ovaries display elevated endoplasmic reticulum (ER) stress marker, BiP, and downregulated canonical phosphatidylinositol 3-kinase (Pi3k)/protein kinase B (Akt) growth/pro-survival signaling. Numbers of primordial follicles are reduced in the mutants, recapitulating the accelerated ovarian aging seen in human patients. We previously found that oral administration of the compound Salubrinal (an eIF2α phosphatase inhibitor), resulted in reduction of ovarian BiP expression, rescued Pi3k/Akt signaling, and a doubling of primordial follicles in GalT^-/- adults. Here, we further characterized galactosemic stress in GalT^-/- mice versus wild-type (WT) controls, and examined whether Salubrinal treatment improved broader reproductive parameters. We assessed the expression levels of factors of the unfolded protein response (UPR), and found that BiP, phospho-Perk, and phospho-eIF2α were all elevated in GalT^-/- ovaries. However, neither IKK activation (NFκB pathway) nor alternative Xbp1 splicing downstream of ER membrane protein Ire1α activation was induced, suggesting an Xbp1-independent UPR in galactosemic stress. Moreover, Salubrinal treatment significantly increased the number of ovulated eggs in mutant animals after gonadotrophic superovulation. Salubrinal treatment also normalized estrus cycle stage lengths and resulted in significantly larger litter sizes than vehicle-treated mutants. Overall, we show that Salubrinal protects against galactosemia-induced primordial follicle loss in a fashion that includes suppressing the de-phosphorylation of eIF2α, and that intervention in this way significantly improves and extends ovarian function, fertility, and fecundity.

Impact of 3 Major Maintenance Immunosuppressive Protocols on Long-term Clinical Outcomes: Result of a Large Multicenter Italian Cohort Study Including 5635 Renal Transplant Recipients

BACKGROUND

Although optimization of immunosuppressive schemes in renal transplantation have minimized acute posttransplant complications, long-term outcomes are still not optimal and most of the chronic graft damage is drug-related. Therefore, to define the best long-term maintenance immunosuppressive regimen is of major importance in renal transplantation. To assess this objective, we undertook a large, multicenter cohort study in Italy.

METHODS

We retrospectively analyzed data of 5635 patients (enrolled from 1983 to 2012) and we assessed the impact of 3 major immunosuppressive regimens (calcineurin inhibitors+antimetabolites+corticosteroids [CNI+ANT+CS] vs CNI+mammalian target-of-rapamycin (mTOR) inhibitors+CS [CNI+mTOR-I+CS] vs CNI+CS) on long-term clinical outcomes by employing several statistical algorithms.

RESULTS

The overall difference in the incidence of outcome over time was not statistically different within the first 5 years of follow-up (P = .13); however, it became significant at 10 years and 20 years (P < .01), with the CNI+CS group showing the lowest cumulative incidence of outcome. Compared with the CNI+ANT+CS group, the CNI+mTOR-I+CS group patients had a significantly higher risk of outcome (hazard ratio [HR], 1.30; P = .024); the difference remained significant and even increased in magnitude after adjustment for potential confounders (HR, 1.38; P = .006). Similarly, patients in the CNI+CS group had a significantly higher risk of the outcome (HR, 1.64; P < .001).

CONCLUSION

Our data confirm that CNI+ANT+CS is the "gold standard" therapy in renal transplantation, but, whenever required, the introduction of mTOR-Is instead of ANT may not dramatically modify major clinical outcomes. The use of mTOR-I could be a valuable pharmacologic tool to minimize CNI complications and insure adequate immunosuppression.

Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P &lt; 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

[IHC, FISH, CISH, NGS in non-small cell lung cancer: What changes in the biomarker era?]

Lung cancer is the leading cause of cancer deaths in France, with about 30,000 deaths per year. The overwhelming majority (90 %) are tobacco-related. The prognosis is dark but great therapeutic advances have been made with the development of targeted therapies first and then immunotherapy afterwards. These medications are conditioned to the expression of biomarkers that require specific tools in routine to measure them. We will detail in this chapter several techniques of anatomopathology, cytogenetics and molecular biology necessary for the detection of biomarkers in lung cancers, and their applications in thoracic oncology in 2018.

[Biomarkers predictive of PD1/PD-L1 immunotherapy in non-small cell lung cancer]

Immune checkpoint inhibitors (ICI), targeting the PD1/PD-L1 axis has shown their efficacy in lung cancer but only in a restricted population of patients, thus it is mandatory to identify biomarkers predicting the clinical benefit. In this article we will describe and analyzed biomarkers already published, from protein, to RNA and at last DNA markers, discussing each markers feasibility and interest. In the future, combined analysis of several markers will probably be proposed, particularly with the increasing complexity of therapy schema with molecules association.

[Analysis of immune microenvironment by multiplex immunohistochemistry in locally advanced non-small cell lung cancer: Principles and perspectives]

Recent therapeutic advances in non-small cell lung cancer allow a better understanding of the interactions between the tumour and its direct immune environment. The identification of new immune biomarkers integrating both cell subpopulations and their interactions is a real issue in oncology. New techniques of tissue analysis, particularly multiplex immunohistochemistry, consisting of a labelling of several antigens of interest by immunofluorescence on the same slide, provide a better understanding of the tumour environment. Integration of these modalities of analysis to the therapeutic decision is promising, because it allows an increased characterization of each tumour, particularly interesting with radiotherapy and immunotherapy. This article describes the potential of these assays in locally advanced non-small cell lung cancer.

Clinical, electrophysiological, and imaging study in essential tremor-Parkinson's disease syndrome

INTRODUCTION

Essential tremor-Parkinson's disease (ET-PD) syndrome is a clinical condition in which individuals with a long-lasting history of Essential tremor (ET) eventually develop Parkinson's disease (PD). The aim of the study was to investigate the accuracy performances of clinical, neurophysiological, and imaging biomarkers in differentiating patients affected by ET-PD syndrome from patients with ET or PD.

METHODS

Nineteen patients affected by ET-PD syndrome, 48 ET patients, and 37 tremor-dominant PD (t-PD) patients were included. Electrophysiological studies, including blink-reflex recovery cycle and tremor parameters analyses, were performed in all groups. Nigro-striatal and cardiac sympathetic denervation were also investigated. Sensitivity, specificity and accuracy of clinical, electrophysiological, and radiological features in differentiating ET-PD syndrome from ET and PD were calculated.

RESULTS

ET-PD patients had significantly lower rigidity (p = 0.007) and higher postural/kinetic tremor (p = 0.007) scores, in comparison to t-PD patients. ET-PD patients, differently from PD patients, had a synchronous pattern of resting tremor and, differently from ET patients, had abnormal blink-reflex recovery cycle. ET-PD patients also showed reduced nigro-striatal and cardiac sympathetic uptakes, albeit to a lesser extent than in PD patients. The highest accuracy values were found for the synchronous pattern of resting tremor (97.1%) in distinguishing ET-PD from PD, and for presence of abnormal blink-recovery cycle (100%) in distinguishing ET-PD syndrome from ET.

CONCLUSION

Our study demonstrates that some electrophysiological parameters, such as a synchronous resting tremor pattern and the abnormal blink-recovery cycle were the most accurate biomarkers in distinguishing patient with ET-PD syndrome from those with ET or those with PD.

Tremor induced by Calcineurin inhibitor immunosuppression: a single-centre observational study in kidney transplanted patients

INTRODUCTION

Tremor is the most frequent and disabling neurological side effect under Calcineurin inhibitor-induced immunosuppression, but no studies have defined its phenomenology, severity, distribution, the impact on quality of life, as well as of other neurological symptoms associated.

METHODS

126 consecutive kidney-transplanted patients, under treatment with Cyclosporin A, Tacrolimus and non-Calcineurin inhibitors, within therapeutic range, were enrolled. Participants underwent a deep neurological examination by two blinded to the treatment raters, and a blood sampling to assess plasmatic immunosuppressant level and nephrological function tests. Tremor and cerebellar signs were scored according to the Fahn-Tolosa-Marin and the SARA scale. Parkinsonism was excluded applying the UPDRS (part III).

RESULTS

Tremor was more common and severe in the Tacrolimus group, similar to impairment in ADL. Regardless of treatment, tremor involved both upper and lower limbs and was activated by action, but in about 50% of cases presented in action and rest condition. Plasmatic level of Tacrolimus was higher in patients with tremor than in those without, while cholesterol was significantly lower. Cerebellar and neuropathic signs were overall mild and were not significantly different across the three groups comparing patients with and without tremor.

CONCLUSIONS

Non-Calcineurin inhibitors such as Sirolimus have the lowest propensity to induce tremor and with a milder severity, while Calcineurin inhibitors, especially Tacrolimus, the highest, and regardless of the formulation. Plasmatic concentration of Tacrolimus was higher in tremulous patients; further research needs to validate the role of cholesterol plasmatic concentration in predicting the occurrence of tremor in patients on Tacrolimus.

Well being in patients on CAPD and hemodialysis

In the present multicenter study, 120 pts who had been treated by both hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) for at least 6 months each, were invited to answer questions on 34 matters, to compare symptoms and their well-being while on the two treatments. Patients were invited to choose HD or CAPD and indicate the reasons for their choice. For 28 patients the first treatment was HD and for 92 CAPD. The mean time between the change of therapy and the study was 46±35 months. Their final choices were found to be strictly related to the present treatment (p<0.001). The reasons for choice of CAPD were: more free time (21%), more freedom (67%), better well being (44%), less worry (5%); for HD they were: more free time (53%), better well-being (39%), less worry (13%), no need for a peritoneal catheter and fewer clinical complications (19%). The catheter was considered more cumbersome than the A.V. fistula, the time involved was considered to be shorter on HD by 52 patients and on CAPD by 39, thirst and cramps were considered to be more frequent and severe on CAPD by half of the patients. The prevalence and severity of problems and symptoms and choice of treatment were not related to sex, job, education or age.

Associating Serenoa Repens, Urtica Dioica and Pinus Pinaster. Safety and Efficacy in the Treatment of Lower Urinary Tract Symptoms. Prospective Study on 320 Patients

Introduction

Serenoa repens (saw palmetto) has been employed for the treatment of lower urinary tract symptoms (LUTS) for several years. Its mechanism of action is believed to be due to antiandrogenic, antiproliferative and antinflammatory properties. An association of Serenoa with the nettle “Urtica dioica” showing antiproliferative activity and the pine “Pinus pinaster” derivative, showing antinflammatory action, has been proposed in recent years. Such an action is hoped to act not only by reducing LUTS but also by preventing the development of prostate cancer.

Material and Methods

During the years 2007 and 2008, 320 patients suffering from LUTS were treated with an association of Serenoa repens 320 mg, Urtica dioica 120 mg and Pinus pinaster 5 mg, named IPBTRE. This treatment was administered to all patients for a minimal duration of 30 days to a maximum of a year, either alone or in association with antibiotics or alpha-blockers, if needed. Outcome analysis was based on evaluation of symptoms, prostate volume and maximum flow rate (Qmax).

Results

From a careful analysis of the data collected in our database, the following observations can be made: ages varied between 19 and 78 years. The patients were affected by BPH in 46% of cases, chronic prostatitis syndrome in 43%, chronic genital-pelvic pain in 7% and other conditions in 4%, the absolute numbers being 147, 138, 22 and 7 patients, respectively. No untoward side effect was reported in any case. Variations in symptom score could be fully evaluated only in 80 of 320 patients (25%), of whom 68 (85%) reported a significant benefit, with special reference to an improvement of pain, urgency, strangury and nocturia. Data on variations in prostate volume, as measured by digital rectal examination, were available in 84 (26.5%) patients. No significant change was observed. Qmax after treatment was measured in 83 (26%) patients. It did not show significant changes from the initial values.

Discussion

The association tested in our study appeared to be safe and well tolerated. No changes in flow rate and prostate volume were observed, but a marked reduction of LUTS was observed in 85% of evaluable cases, especially with regard to pain and irritative symptoms. Whether or not such an association may display a prevention of prostate cancer, may be investigated in additional studies.

Cutaneous Plasmacytoma in a Hemodialysis Patient

Background

Extramedullary plasma cell dyscrasias are rare.

Case report

We report a case of a 56-year-old male Caucasian hemodialysis patient with cutaneous plasmacytoma. The diagnosis was made a few months after surgical removal of his renal graft due to chronic rejection. Investigations for the presence of an associated myeloma were negative. He underwent local radiotherapy with complete resolution of the skin lesion.

Conclusions

Nephrologists should be aware that the frequency of post-transplant lymphoproliferative disorders is increasing in the dialysis population, especially in those previously or currently treated with immunosuppressive drugs.

Effects on balance skills and patient compliance of biofeedback training with inertial measurement units and exergaming in subacute stroke: a pilot randomized controlled trial

Stroke patients have reduced balance and postural control that limits their activities of daily living and participation in social life. Recently, many exergaming systems based on video-biofeedback have been developed for balance training in neurological conditions, however their efficacy remains to be proven. The aim of this study was to investigate the effects on balance skills and patient compliance of biofeedback training based on inertial measurement units and exergaming in subacute stroke. The enrolled subjects were randomized into two groups: subjects allocated to the experimental group performed 10 sessions of biofeedback balance training using inertial sensors, whereas subjects allocated to the control group performed 10 sessions of conventional balance training. All subjects were assessed at T0 (pre-treatment), T1 (posttreatment) and T2 (1-month follow-up). The Berg Balance Scale, Rivermead Mobility Index and modified Barthel Index were used to assess balance, mobility and global disability, respectively. To assess the severity of the stroke and its effects on the patient we used the National Institutes of Health Stroke Scale and the Canadian Neurological Scale. Finally, a static force platform evaluating stabilometric parameters was used to assess balance skills. Fifteen subjects with subacute stroke (4F; age 57.80 ± 13.7) completed the experimental protocol. The analysis showed a significant improvement in balance skills and in the overall clinical outcomes in the experimental group compared with the control group; the experimental group also showed better compliance with the training. The biofeedback system of the device used in this study probably enhances neuroplasticity mechanisms of postural and balance skills in subacute stroke patients.

From paper to informatics: the Post Soft Care-App, an easy-to-use and fast tool to help therapists identify unmet needs in stroke patients

Even after rehabilitation, post stroke patients remain disabled. The Post Stroke Checklist (PSC) was developed to highlight unmet needs of community-dwelling stroke patients. The present study set out to validate Post Soft Care-App, designed to administer the PSC using smartphones and tablets, in order to monitor unmet needs in chronic patients. Fifty-three patients and fifteen physiotherapists were enrolled. The therapists administered the PSC to patients using the app, and then completed a structured questionnaire on its usability and utility. The Post Soft Care-App highlighted the following unmet needs: increased spasticity (56.6%), reduced independence in activities of daily living (47.2%), reduced mobility (45.3%), absence of secondary prevention (45.3%). Therapists positively evaluated Post Soft Care-App as useful, practical, quick to complete (96.2%), and effective in helping improve communication with patients (75.5%). The Post Soft Care-App can be considered a valid assessment tool for helping therapists to monitor functional outcomes in chronic patients.

Structural connectivity differences in motor network between tremor-dominant and nontremor Parkinson's disease

Motor phenotypes of Parkinson's disease (PD) are recognized to have different prognosis and therapeutic response, but the neural basis for this clinical heterogeneity remains largely unknown. The main aim of this study was to compare differences in structural connectivity metrics of the main motor network between tremor-dominant and nontremor PD phenotypes (TD-PD and NT-PD, respectively) using probabilistic tractography-based network analysis. A total of 63 PD patients (35 TD-PD patients and 28 NT-PD patients) and 30 healthy controls underwent a 3 T MRI. Next, probabilistic tractography-based network analysis was performed to assess structural connectivity in cerebello-thalamo-basal ganglia-cortical circuits, by measuring the connectivity indices of each tract and the efficiency of each node. Furthermore, dopamine transporter single-photon emission computed tomography (DAT-SPECT) with ¹²³ I-ioflupane was used to assess dopaminergic striatal depletion in all PD patients. Both PD phenotypes showed nodal abnormalities in the substantia nigra, in agreement with DAT-SPECT evaluation. In addition, NT-PD patients displayed connectivity alterations in nigro-pallidal and fronto-striatal pathways, compared with both controls and TD-PD patients, in which the same motor connections seemed to be relatively spared. Of note, in NT-PD group, rigidity-bradykinesia score correlated with fronto-striatal connectivity abnormalities. These findings demonstrate that structural connectivity alterations occur in the cortico-basal ganglia circuit of NT-PD patients, but not in TD-PD patients, suggesting that these anatomical differences may underlie different motor phenotypes of PD. Hum Brain Mapp 38:4716-4729, 2017. © 2017 Wiley Periodicals, Inc.

The Complex Role of the ZNF224 Transcription Factor in Cancer

ZNF224 is a member of the Kruppel-associated box zinc finger proteins (KRAB-ZFPs) family. It was originally identified as a transcriptional repressor involved in gene-specific silencing through the recruitment of the corepressor KAP1, chromatin-modifying activities, and the arginine methyltransferase PRMT5 on the promoter of its target genes. Recent findings indicate that ZNF224 can behave both as a tumor suppressor or an oncogene in different human cancers. The transcriptional regulatory properties of ZNF224 in these systems appear to be complex and influenced by specific sets of interactors. ZNF224 can also act as a transcription cofactor for other DNA-binding proteins. A role for ZNF224 in transcriptional activation has also emerged. Here, we review the state of the literature supporting both roles of ZNF224 in cancer. We also examine the functional activity of ZNF224 as a transcription factor and the influence of protein partners on its dual behavior. Increasing information on the mechanism through which ZNF224 can operate could lead to the identification of agents capable of modulating ZNF224 function, thus potentially paving the way to new therapeutic strategies for treatment of cancer.

Heart rate variability in patients with essential tremor: A cross sectional study

OBJECTIVE

To investigate heart rate variability (HRV) in patients with Essential Tremor (ET) in comparison with patients with Parkinson's Disease (PD).

METHODS

This is a cross sectional control study including 10 patients with ET, 10 patients with PD and 10 age-sex-matched controls. In patients and controls, we measured the components of HRV analysis in the frequency domain during a daytime period of 12-h. Selected HRV variables were low-frequency (LF) and high-frequency (HF), conventionally considered to be influenced by the sympathetic system and the parasympathetic system respectively.

RESULTS

HRV variables, in patients with ET, were significantly different from those detected in PD patients and similar to those of controls while in PD patients, they were significantly different from those of controls. At cut off level of 654 ms², LF component correctly distinguished ET patients versus PD with sensitivity, specificity, PPV and accuracy of 100%. By contrast, at cut off level of 737 ms², HF component showed sensitivity, specificity, PPV and accuracy of 80%, 100%, 100%, and 86.67% respectively. DAT-SPECT and cardiac MIBG uptake were both normal in ET patients whereas they were markedly decreased in those with PD.

CONCLUSIONS

In our study, the LF component of HRV analysis distinguishes ET patients from those with PD on an individual basis, thus representing a valid help in everyday clinical practice for differentiation between these patients in absence of scintigraphic investigations.

Glycosaminoglycans, proteoglycans and sulodexide and the endothelium: biological roles and pharmacological effects

The glycocalyx is a jelly layer covering the endothelium constituted by glycosaminoglycans (GAGs), proteoglycans and adsorbed plasma proteins. This structure take part in several physiological and pathological vascular events. The glycocalyx acts as mechanosensor to shear stress and participates to regulation of vascular tone, permeability, coagulation and complement activation. Moreover it regulates the interaction and activation of blood cells with endothelial cells. The presence of a thick, normal glycocalyx is required for physiological vascular functions, whereas these functions are impaired by its damage by noxious agents. Indeed, glycocalyx alterations are involved in the pathogenesis of atherosclerosis, ischemia-reperfusion and diabetic vascular complications. GAGs such as sulodexide are promising agents to control endothelial dysfunction. They act at multiple levels: they promote glycocalyx reconstitution, control glycocalyx degrading enzymes, exert anti-inflammatory effects and have anti-apoptotic and anti-senescence effects on endothelial cells. Clinical studies support the evidence that glycosaminoglycans are useful to restore a normal endothelial function.