Quantitative analysis of myocardial blood flow in surgically revascularized and not revascularized myocardial segments. A pilot PET study

PURPOSE

To prospectively compare changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) in multivessel coronary artery disease (MVCAD) patients undergoing incomplete revascularization (IR) versus complete revascularization (CR) by coronary artery bypass grafting (CABG).

METHODS

Seven male patients (age 68 ± 9 years) with MVCAD underwent myocardial perfusion PET/CT with [13N]ammonia before and at least 4 months after CABG. Segmental resting and stress MBF as well as MFR were measured. Resting and during stress left ventricle ejection fraction (LVEF) were also calculated.

RESULTS

Three patients (43%) underwent CR and four (57%) IR. Among 119 myocardial segments, 101 (85%) were revascularized, and 18 (15%) were not. After CABG, stress MBF (mL/min/gr) and MFR are significantly increased in all myocardial segments, with a greater increase in the revascularized segments (p = 0.013). In both groups, LVEF significantly decreased during stress at baseline PET (p = 0.04), but not after CABG.

CONCLUSION

Stress MBF and MFR significantly improve after CABG in both revascularized and not directly revascularized myocardial segments. IR strategy may be considered in patients with high surgical risk for CR.

End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches

INTRODUCTION

Parastomal hernia (PSH) is the most common and challenging complication after stoma creation, with an estimated 50% incidence 2 years after the index surgery. Mesh repair is the treatment of choice. Laparoscopic and/or robotic approaches allow acceptable outcomes.

MATERIALS AND METHODS

A systematic literature review from January 2012 to November 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Embase, PubMed, and Scopus search were performed to select articles dealing with minimally invasive surgical treatment for PSH after end colostomy.

RESULTS

603 studies were found, and 24 were chosen. When compared to open surgery, laparoscopy showed decreased postoperative complications and recurrence. The main laparoscopic approaches are the keyhole (KH), the Sugarbaker (SB), and the sandwich technique. Continuous improvement in surgery, mesh technology, and surgeons' expertise led to an amelioration of surgical outcome and recurrence rate after repair. Recent studies showed comparable outcomes for SB and KH techniques, while novel surgical approaches have been proposed in an attempt to further increase the operative and long-term results. Reports on PSH robotic repairs are scarce and describe small series results, suggesting a role of the initial learning curve as a risk factor for complications.

CONCLUSION

End-colostomy PSH surgical repair still represents a challenge for surgeons. Recent evidence has not shown a significant advantage in postoperative complications and recurrence with a specific repair among SB, KH, and sandwich technique. The paucity of data on robotic surgery does not allow to draw definitive conclusion. Further primary, multicentric, and larger cohort studies are needed.

Prevalence of Fabry disease and GLA variants in young patients with acute stroke: The challenge to widen the screening. The Fabry-Stroke Italian Registry

BACKGROUND

Fabry disease (FD) is a treatable X-linked lysosomal storage disorder caused by GLA gene variants leading to alpha-galactosidase A deficiency. FD is a rare cause of stroke, and it is still controversial whether in stroke patients FD should be searched from the beginning or at the end of the diagnostic workup (in cryptogenic strokes).

METHODS

Fabry-Stroke Italian Registry is a prospective, multicentric screening involving 33 stroke units. FD was sought by measuring α-galactosidase A activity (males) and by genetic tests (males with reduced enzyme activity and females) in patients aged 18-60 years hospitalized for TIA, ischemic stroke, or intracerebral hemorrhage. We diagnosed FD in patients with 1) already known pathogenic GLA variants; 2) novel GLA variants if additional clinical, laboratory, or family-derived criteria were present.

RESULTS

Out of 1906 patients, we found a GLA variant in 15 (0.79%; 95%CI 0.44-1.29) with a certain FD diagnosis in 3 (0.16%; 95%CI 0.03-0.46) patients, none of whom had hemorrhage. We identified 1 novel pathogenic GLA variant. Ischemic stroke etiologies in carriers of GLA variants were: cardioaortic embolism (33%), small artery occlusion (27%), other causes (20%), and undetermined (20%). Mild severity, recurrence, previous TIA, acroparesthesias, hearing loss, and small artery occlusion were predictors of GLA variant.

CONCLUSION

In this large multicenter cohort the frequency of FD and GLA variants was consistent with previous reports. Limiting the screening for GLA variants to patients with cryptogenic stroke may miss up to 80% of diagnoses. Some easily recognizable clinical features could help select patients for FD screening.

The role of skin tests with polyethylene glycol and polysorbate 80 in the vaccination campaign for COVID-19: results from an Italian multicenter survey

Summary

Background. International guidelines suggested skin tests with Polyethylene-glycol (PEG) and polysorbate 80 (PS-80), to investigate a possible hypersensitivity to these excipients either to identify subjects at risk of developing allergic reactions to Covid-19 vaccines, or in patients with suspected IgE mediated hypersensitivity reactions (HR) to the Covid-19 vaccine. The main purpose of this study was to investigate the prevalence of PEG and PS sensitization in patients with a clinical history of HR to drugs containing PEG/PS and in patients with a suspected Covid-19 vaccine immediate HR. Methods. This was a multicenter retrospective study conducted by allergists belonging to 20 Italian medical centers. Skin testing was performed in 531 patients with either a clinical history of suspected hypersensitivity reaction (HR) to drugs containing PEG and/or PS-80 (group 1:362 patient) or a suspected HR to Covid-19 vaccines (group 2: 169 patient), as suggested by the AAIITO/SIAAIC guidelines for the "management of patients at risk of allergic reactions to Covid-19 vaccines" [1]. Results. 10/362 (0.02%) had positive skin test to one or both excipients in group 1, 12/169 (7.1%) in group 2 (p less than 0.01). In group 2 HRs to Covid-19 vaccines were immediate in 10/12 of cases and anaphylaxis occurred in 4/12 of patients. Conclusions. The positivity of skin test with PEG and or PS before vaccination is extremely rare and mostly replaceable by an accurate clinical history. Sensitization to PEG and PS has to be investigated in patients with a previous immediate HR to a Covid-19 vaccine, in particular in patients with anaphylaxis.

Multiparametric imaging guided HDR interventional radiotherapy (brachytherapy) boost in localized prostate cancer: a multidisciplinary experience

OBJECTIVE

The aim of this study was to report a monoinstitutional multidisciplinary experience about the use of multiparametric imaging to identify the areas with higher risk of relapse in localized prostate cancer, with the purpose of allowing a biologically planned target dose escalation.

PATIENTS AND METHODS

We performed a retrospective evaluation of patients diagnosed with prostate cancer who received treatments at our Interventional Oncology Center with interstitial interventional radiotherapy from 2014 to 2022. Inclusion criteria were histologically confirmed localized prostate cancer; and National Comprehensive Cancer Network (NCCN) risk class unfavorable intermediate or high/very high risk. The diagnostic work-up included multiparametric Magnetic resonance imaging (MRI), multiparametric Transrectal ultrasound (TRUS), Positron Emission Tomography Computed Tomography (PET-CT) with choline or PSMA (or alternatively bone scan). All patients were assessed and received one treatment with interstitial high-dose-rate interventional radiotherapy (brachytherapy) delivering external beam radiotherapy (46 Gy). All procedures were performed using transrectal ultrasound guidance under general anesthesia and the prescribed doses were 10 Gy to the whole prostate, 12 Gy to the peripheral zone and 15 Gy to the areas at risk.

RESULTS

We report the data of 21 patients who were considered for the statistical analysis with a mean age of 62.5 years. The mean PSA nadir was 0.03 ng/ml (range 0-0.09). So far, no biochemical nor radiological recurrences have been recorded in our series. Regarding acute toxicity, the most commonly reported side effects were G1 urinary in 28.5% of patients and G2 urinary in 9.5%; all recorded acute toxicities resolved spontaneously.

CONCLUSIONS

We present a real-life experience of biologically planned local dose escalation by interventional radiotherapy (brachytherapy) boost, followed by external beam radiotherapy in patients with intermediate unfavorable- or high/very high risk. The local control and the biochemical control rates are proved to be excellent and the toxicity profile tolerable.

A retrospective multicentric study on the effectiveness of intravenous brivaracetam in seizure clusters: Data from the Italian experience

OBJECTIVE

Nearly half of people with epilepsy (PWE) are expected to develop seizure clusters (SC), with the subsequent risk of hospitalization. The aim of the present study was to evaluate the use, effectiveness and safety of intravenous (IV) brivaracetam (BRV) in the treatment of SC.

METHODS

Retrospective multicentric study of patients with SC (≥ 2 seizures/24 h) who received IV BRV. Data collection occurred from January 2019 to April 2022 in 25 Italian neurology units. Primary efficacy outcome was seizure freedom up to 24 h from BRV administration. We also evaluated the risk of evolution into Status Epilepticus (SE) at 6, 12 and 24 h after treatment initiation. A Cox regression model was used to identify outcome predictors.

RESULTS

97 patients were included (mean age 62 years), 74 (76%) of whom had a history of epilepsy (with drug resistant seizures in 49% of cases). BRV was administered as first line treatment in 16% of the episodes, while it was used as first or second drug after benzodiazepines failure in 49% and 35% of episodes, respectively. On the one hand, 58% patients were seizure free at 24 h after BRV administration and no other rescue medications were used in 75 out of 97 cases (77%) On the other hand, SC evolved into SE in 17% of cases. A higher probability of seizure relapse and/or evolution into SE was observed in patients without a prior history of epilepsy (HR 2.0; 95% CI 1.03 - 4.1) and in case of BRV administration as second/third line drug (HR 3.2; 95% CI 1.1 - 9.7). No severe treatment emergent adverse events were observed.

SIGNIFICANCE

In our cohort, IV BRV resulted to be well tolerated for the treatment of SC and it could be considered as a treatment option, particularly in case of in-hospital onset. However, the underlying etiology seems to be the main outcome predictor.

Characterization and optimization of a β detector for 18F radio-guided surgery

Radio-Guided Surgery (RGS) is a nuclear medicine technique to support the surgeon during surgery towards a complete tumor resection. It is based on intraoperative detection of radiation emitted by a radio-pharmaceutical that bounds selectively to tumoral cells. In the past years, an approach that exploits β^- emitting radiotracers has been pursued to overtake some limitations of the traditional RGS based on γ emission. A particle detector dedicated to this application, demonstrating very high efficiency to β^- particles and remarkable transparency to photons, has been thus developed. As a by-product, its characteristics suggested the possibility to utilize it with β⁺ emitting sources, more commonly in use in nuclear medicine. In this paper, performances of such detector on ¹⁸F liquid sources are estimated by means of Monte Carlo simulations (MC) and laboratory measurements. The experimental setup with a ¹⁸F saline solution comprised a "positron signal" spot (a 7 × 10 mm cylinder representing the tumor residual), and a surrounding "far background" volume, that represented for the detector an almost isotropic source of annihilation photons. Experimental results show good agreement with MC predictions, thus confirming the expected performances of the detector with ¹⁸F, and the validity of the developed MC simulation as a tool to predict the gamma background determined by a diffuse source of annihilation photons.

A hybrid classical-quantum approach to speed-up Q-learning

We introduce a classical-quantum hybrid approach to computation, allowing for a quadratic performance improvement in the decision process of a learning agent. Using the paradigm of quantum accelerators, we introduce a routine that runs on a quantum computer, which allows for the encoding of probability distributions. This quantum routine is then employed, in a reinforcement learning set-up, to encode the distributions that drive action choices. Our routine is well-suited in the case of a large, although finite, number of actions and can be employed in any scenario where a probability distribution with a large support is needed. We describe the routine and assess its performance in terms of computational complexity, needed quantum resource, and accuracy. Finally, we design an algorithm showing how to exploit it in the context of Q-learning.

Gender-specific effects of capsiate supplementation on body weight and bone mineral density: a randomized, double-blind, placebo-controlled study in slightly overweight women

INTRODUCTION

Overweight and obesity are highly prevalent conditions associated with premature morbidity and mortality worldwide. Capsiate, a nonpungent analogue of capsaicin, binds to TRP vanilloid 1 (TRPV1) receptor, which is involved in adipogenesis, and could be effective as a weight-lowering agent.

METHODS

Eighteen slightly overweight women were enrolled in this randomized, double-blind, placebo-controlled study. Nine patients were included in the capsiate intervention group and received 9 mg/day of capsinoids and 9 patients received placebo for 8 weeks. All patients underwent weight and waist circumference assessment before and after treatment. Body composition and bone mineral density (BMD) were also detected by dual-energy X-ray absorptiometry (DXA).

RESULTS

Fourteen patients completed the study. The treatment with capsiate or placebo for 8 weeks was not associated with significant changes in weight or waist circumference. After treatment, there was a significant improvement in BMD values measured at the spine in the capsiate group (1.158 vs 1.106 g/cm², + 4.7%; p = 0.04), but not in the group treated with placebo. Similarly, the capsiate group showed a 9.1% increase (p = 0.05) in the adipose tissue and an 8.5% decrease in lean mass measured at the supraclavicular level, whereas these changes were not statistically significant in the placebo group.

CONCLUSIONS

Treatment with capsiate for 8 weeks led to negligible changes in body weight in a small sample of slightly overweight women, but our findings suggest a potential effect of capsaicin on bone metabolism in humans.

Dapagliflozin improves Myocardial Flow Reserve in patients with Type 2 Diabetes: the DAPAHEART Trial

Objective

Cardiovascular (CV) outcome trials have shown that in patients with type 2 diabetes (T2D), treatment with sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduces CV mortality and admission rates for heart failure (HF). However, the mechanisms behind these benefits are not fully understood. This study was performed to investigate the effects of the SGLT-2i dapagliflozin on whole body insulin sensitivity, myocardial perfusion, and metabolism in patients with T2D without HF.

Research design and methods

This was a single-center, prospective, randomized, double-blind controlled clinical trial including 16 patients with T2D randomized to SGLT-2i dapagliflozin (10 mg) or placebo. Whole body glucose uptake (WBGU) and myocardial glucose uptake (MGU) were measured with PET/CT with FDG during euglycemic hyperinsulinemic clamp. Stress (i.v. adenosine infusion) and resting myocardial blood flow (MBF) and myocardial flow reserve (MFR) were calculated by PET/CT with 13N-ammonia.

Results

16 patients were randomized (8 dapagliflozin; 8 placebo). The groups were well-matched for baseline characteristics (age, diabetes duration, HbA1c, renal and heart function). Dapagliflozin significantly improved MFR (2.56±0.26 vs 3.59±0.35) compared with placebo group (2.34±0.21 vs 2.38±0.24; p for interaction =0.001) and was associated to a reduction of resting MBF corrected for cardiac workload (p=0.045). A trend toward an increase in stress MBF was also detected (p=0.058). Moreover, in dapagliflozin group we observed an increase of WBGU of borderline statistical significance (p=0.06) and no effects on MGU (p=0.41).

Conclusions

At the best of our knowledge, our study, for the first time, demonstrated that SGLT-2 inhibition increases MFR in T2D patients. The data presented provide a new potential explanation of cardiovascular benefits with SGLT-2i as they make patients more tolerant to the detrimental impact of obstructive coronary atherosclerosis on MFR.

Funding Acknowledgement

Type of funding sources: None.

The Adipose Organ Is a Unitary Structure in Mice and Humans

Obesity is the fifth leading cause of death worldwide. In mice and humans with obesity, the adipose organ undergoes remarkable morpho-functional alterations. The comprehension of the adipose organ function and organization is of paramount importance to understand its pathology and formulate future therapeutic strategies. In the present study, we performed anatomical dissections, magnetic resonance imaging, computed axial tomography and histological and immunohistochemical assessments of humans and mouse adipose tissues. We demonstrate that most of the two types of adipose tissues (white, WAT and brown, BAT) form a large unitary structure fulfilling all the requirements necessary to be considered as a true organ in both species. A detailed analysis of the gross anatomy of mouse adipose organs in different pathophysiological conditions (normal, cold, pregnancy, obesity) shows that the organ consists of a unitary structure composed of different tissues: WAT, BAT, and glands (pregnancy). Data from autoptic dissection of 8 cadavers, 2 females and 6 males (Age: 37.5 ± 9.7, BMI: 23 ± 2.7 kg/m²) and from detailed digital dissection of 4 digitalized cadavers, 2 females and 2 males (Age: 39 ± 14.2 years, BMI: 22.8 ± 4.3 kg/m²) confirmed the mixed (WAT and BAT) composition and the unitary structure of the adipose organ also in humans. Considering the remarkable endocrine roles of WAT and BAT, the definition of the endocrine adipose organ would be even more appropriate in mice and humans.

How I treat HER2-positive early breast cancer: how long adjuvant trastuzumab is needed?

Since its first approval in 2006, 1 year of adjuvant trastuzumab has been the standard of care for early-stage HER2-positive breast cancer. Nevertheless, the optimal duration of adjuvant trastuzumab was uncertain, and the standard 12-month duration has been questioned by a number of different trials. Although most of these studies were formally negative, a patient-level meta-analysis presented at the 2021 European Society for Medical Oncology (ESMO) meeting first showed the non-inferiority of 6-month trastuzumab. Through this review, we sought to take a closer look at the meta-analysis and the included trials to explain why we believe that non-inferiority should be interpreted with caution. Indeed, here we underline how the meta-analysis’ results were mainly driven by the PERSEPHONE study, an old trial that tested non-standard chemo-trastuzumab regimens in a relatively low-risk population with doubtful endpoints. In summary, considering all the limitations of this analysis and the increasing use of effective anthracycline-free de-escalation strategies, we are convinced that 1-year trastuzumab should remain the standard of care.

•

The standard 1-year duration of adjuvant trastuzumab has been questioned by a number of trials.

•

At ESMO 2021, the meta-analysis by Earl et al. showed that 6-month adjuvant trastuzumab is not inferior to 12-month.

•

The PERSEPHONE trial was the main driver of the meta-analysis’ results, but it has several limitations.

•

Alternative anthracycline-free de-escalation strategies proved to be effective for HER2+ early breast cancer patients.

•

12-month adjuvant trastuzumab should remain the standard of care.

Predictors of long-term survival in patients undergoing residential cardiac rehabilitation (rCR) after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study

Purpose

To evaluate exercise-based rCR derived outcome predictors in patients referred after TAVR.

Methods

Data of 232 patients (aged 82±6 years, 45%males) admitted to an average 3-week rCR program after TAVR (walking, up to 30 minutes of cycling or treadmill session twice daily, respiratory and calisthenic training) from January 2009 to December 2017 and home discharged, were retrospectively collected at 10 rCR Divisions of Istituti Clinici Scientifici Maugeri. Comorbidity (cumulative illness rated state-comorbidity index) (CIRS-CI) score, echocardiography on admission, disability (Barthel Index) (BI) score at discharge, six minutes walking test distance (6MWT) on discharge and maximal training session intensity (MTSI expressed in METs per minutes) were collected. All-cause mortality was assessed up to 3 years after rCR discharge.

Results

During a 3-year follow-up, there were 74 (32%) deaths. At univariate analysis, at discharge non survivors compared to survivors had significantly higher comorbidity rate (CIRS-ICC 5.2±2.3 vs 4.1±1.9, p=0.000) and disability level (BI 80.4±24 vs 88.8±17, p=0.000). Moreover, they had worse renal function (creatinine 1.6±0.9mg/dl vs 1.2±0.4, p=0.000), were more often on diuretic therapy (73% vs 53.2%, p=0.003) and on beta-blocker therapy (73% vs 57,6%, p=0.042) and had a markedly reduced functional capacity (6MWTD 221±100m vs 265±105m, p=0.001). At multivariate logistic stepwise analysis a lower comorbidity (CIRS-ICC), a more preserved renal function (creatinine level), a reduced use of diuretic therapy and 6MWT at discharge confirmed their power as independent predictors of survival at follow up (Table, Harrel's C = 0.707)

Conclusions

Patients attending rCR after TAVR are very old with significant comorbidity; overall mortality at 3-year follow-up after CR discharge is substantial. Our results suggest the need to implement ad-hoc long-term care strategies based on residual exercise capacity, comorbidity score and renal function for tailoring follow-up in patients discharged from rCR after TAVR.

Funding Acknowledgement

Type of funding sources: None. Table 1

Fabry-Stroke Italian Registry (FSIR): a nationwide, prospective, observational study about incidence and characteristics of Fabry-related stroke in young-adults. Presentation of the study protocol

Background

TIA and stroke, both ischemic and hemorrhagic, may complicate Fabry disease at young-adult age and be the first manifestation that comes to the clinician’s attention. No definite indications have yet been elaborated to guide neurologists in Fabry disease diagnostics. In current practice, it is usually sought in case of cryptogenic strokes (while Fabry-related strokes can also occur by classical pathogenic mechanisms) or through screening programs in young cerebrovascular populations. Data on recurrence and secondary prevention of Fabry’s stroke are scanty.

Methods

The study had a prospective observational design involving 33 Italian neurological Stroke Units. Considering the incidence of TIA/stroke in the European population aged < 60 years and the frequency of Fabry disease in this category (as foreseen by a pilot study held at the Careggi University-Hospital, Florence), we planned to screen for Fabry disease a total of 1740 < 60-year-old individuals hospitalized for TIA, ischemic, or hemorrhagic stroke. We investigated TIA and stroke pathogenesis through internationally validated scales and we gathered information on possible early signs of Fabry disease among all cerebrovascular patients. Every patient was tested for Fabry disease through dried blood spot analysis. Patients who received Fabry disease diagnosis underwent a 12-month follow-up to monitor stroke recurrence and multi-system progression after the cerebrovascular event.

Discussion

The potential implications of this study are as follows: (i) to add information about the yield of systematic screening for Fabry disease in a prospective large cohort of acute cerebrovascular patients; (ii) to deepen knowledge of clinical, pathophysiological, and prognostic characteristics of Fabry-related stroke.

Lessons from peculiar cases of anaphylaxis: why allergists should be prepared for the unexpected

Summary

Anaphylaxis is the most severe systemic hypersensitivity reaction, it can be caused by a number of well identified triggers such as foods, drugs, stinging insects and facilitated by predisposing clinical conditions. However, sometimes anaphylaxis shows up with uncommon or peculiar characteristics which could delay diagnosis and therapeutic treatment. In this report we aimed to describe less accounted / difficult-to-approach shapes of anaphylaxis to facilitate clinicians to suspect these severe reactions even in uncommon conditions. We choose to present data on anaphylaxis regarding simulation, mode of exposure to sensitizing agents, pregnancy, exposure to animals, intimate behaviour, psychological stress and other situations.

Role of paraoxonase-1 as a diagnostic marker for feline infectious peritonitis

Feline infectious peritonitis (FIP) is characterised by the presence of systemic inflammation accompanied by oxidative stress. Paraoxonase-1 (PON-1) is a negative acute phase reactant produced by the liver. A paraoxon-based method has been validated to measure PON-1 activity in feline serum. The aim of this study was to investigate the usefulness of PON-1 activity as a biomarker to discriminate FIP from other diseases with similar clinical signs. Of 159 cats enrolled, 71 were healthy, 34 had FIP and 54 had another disease but presented with clinical signs that could be consistent with FIP. PON-1 activity was lower (P <0.0001) in cats with FIP (median, 26.55 U/L; range, 5.40-78.20 U/L) compared to healthy (median, 87.5 U/L; range, 46.60-215.50 U/L) and Non-FIP Sick group cats (median, 57.90 U/L; range, 3.80-122.60 U/L). Two receiver operating characteristic curves were used to determine the thresholds that maximised the performance of PON-1 activity in predicting FIP both from a screening and diagnostic point of view. A threshold of 78.30 U/L yielded a sensitivity of 100%, a specificity of 50.4%, and a negative likelihood ratio of 0.00 (screening curve). While a threshold of 24.90 U/L maximised specificity (94.4%), had a sensitivity of 44.1%, and increased the likelihood ratio to 7.94, making PON-1 activity a good confirmatory test for FIP (diagnostic curve). Using these thresholds, serum PON-1 activity showed good diagnostic performance in discriminating FIP affected cats from cats with other inflammatory conditions.

Intravenous brivaracetam in status epilepticus: A multicentric retrospective study in Italy

PURPOSE

to evaluate the use, effectiveness, and adverse events of intravenous brivaracetam (BRV) in status epilepticus (SE).

METHODS

a retrospective multicentric study involving 24 Italian neurology units was performed from March 2018 to June 2020. A shared case report form was used across participating centres to limit biases of retrospective data collection. Diagnosis and classification of SE followed the 2015 ILAE proposal. We considered a trial with BRV a success when it was the last administered drug prior the clinical and/or EEG resolution of seizures, and the SE did not recur during hospital observation. In addition, we considered cases with early response, defined as SE resolved within 6 h after BRV administration.

RESULTS

56 patients were included (mean age 62 years; 57 % male). A previous diagnosis of epilepsy was present in 21 (38 %). Regarding SE etiology classification 46 % were acute symptomatic, 18 % remote and 16 % progressive symptomatic. SE episodes with prominent motor features were the majority (80 %). BRV was administered as first drug after benzodiazepine failure in 21 % episodes, while it was used as the second or the third (or more) drug in the 38 % and 38 % of episodes respectively. The median loading dose was 100 mg (range 50-300 mg). BRV was effective in 32 cases (57 %). An early response was documented in 22 patients (39 % of the whole sample). The use of the BRV within 6 h from SE onset was independently associated to an early SE resolution (OR 32; 95 % CI 3.39-202; p = 0.002). No severe treatment emergent adverse events were observed.

CONCLUSION

BRV proved to be useful and safe for the treatment of SE. Time to seizures resolution appears shorter when it is administered in the early phases of SE.

Prognostic value of pericoronary adipose tissue and coronary vascular function by cardiac 82Rb PET/CT imaging in patients with suspected coronary artery disease and normal myocardial perfusion imaging

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pericoronary adipose tissue, due to its proximity to coronary arteries, has been proposed contribute to the progression of coronary atherosclerosis.

Purpose

The aim of this study was to evaluate the prognostic value of pericoronary fat thickness (PCFT), coronary artery calcium (CAC) score and myocardial perfusion reserve (MPR) by hybrid 82Rubidium (82Rb) PET/CT imaging in patients with suspected coronary artery disease (CAD) and normal myocardial perfusion imaging (MPI).

Methods

A total of 640 patients without overt CAD and with normal rest-stress 82Rb PET/CT MPI were studied. PCFT was calculated on CT images as the maximum fat thickness (mm) between heart surface and visceral epicardium surrounding the main coronary arteries. CAC score was categorized as 0, &lt;400 or ≥400. MPR was considered reduced when &lt;2. Endpoints events were cardiac death, nonfatal myocardial infarction and coronary revascularization.

Results

During a follow-up of 42 ± 13 months, 29 events occurred (cumulative event rate 5%). Patients with events were older (66 ± 13 vs. 60 ± 13 years, p &lt; 0.01), had higher PCFT (13 ± 2 vs 11 ± 2 mm, p &lt; 0.001), higher prevalence of CAC score ≥400 (48% vs. 21%, p &lt; 0.01), and lower MPR (2.1 ± 0.7 vs. 2.7 ± 0.7, p &lt; 0.001) compared to those without. A higher prevalence of MPR &lt;2 was observed in patients with events (48% vs. 18, p &lt; 0.001) compared to those without. Patients with reduced MPR had higher PCFT compared to those with normal MPR (12 ± 2 vs. 11 ± 1 mm, p &lt; 0.01). A PCFT value of 11.2 mm was the best trade-off between sensitivity and specificity to detect a reduced MPR. Event rate was higher in patients above this threshold compared to those below (8% vs. 1.5%, p &lt; 0.001). At Cox univariate analysis, age (p &lt; 0.05), PCFT &gt;11.2 mm (p &lt; 0.001), CAC score ≥400 (p &lt; 0.01), and MPR &lt;2 (p &lt; 0.001) were predictors of events. At multivariate analysis, only PCFT &gt;11.2 mm and MPR &lt;2 were independent predictors of events (both p &lt; 0.01). At incremental analysis, adding PCFT &gt;11.2 to a model including clinical data and MPR &lt;2 increased the global chi-square from 26 to 35 (p &lt; 0.01). Classification tree analysis produced 3 terminal groups. For patients with MPR &lt;2, no further split was needed (event rate 12% vs. 3%, p &lt; 0.001). On the contrary, patients with MPR ≥2 were further stratified by PCFT (event rate 7% in patients with and 0.3% in those without (p &lt; 0.001) PCFT &gt;11.2.

Conclusions

In patients with suspected CAD and normal stress MPI, coronary vascular dysfunction and high PCFT are associated with increased cardiac risk. PCFT could help in identifying patients at higher risk of events. Combined evaluation of anatomical and functional vascular abnormalities by 82Rb PET/CT might allow a better risk stratification.

Pharmacogenomics as a tool to prevent drug-related hospitalization of elderly cardiology-oncology patients receiving chemotherapeutic agents and multiple symptomatic treatments: a pilot study planned for the Italian health system

OBJECTIVE

Current precision medicine approaches offer powerful tools to optimize medication regimens; however, the potential impact of these tools in cancer patients with multiple drug treatments has not fully appreciated yet. Here we describe a planning project scheduled to start in the next six months.

PATIENTS AND METHODS

The overall endpoint of this project is to explore the potential association between the presence of individual genetic profile and severe toxicity rates in so-called "frail" cancer patients, using a nested case-control study design. The pilot study includes the detection of the individual pharmacogenetic profile of 150 (cases), prospect enrolled cancer "frail" patients, and 150 (control) retrospectively paired enrolled individuals. Methods for addressing the primary endpoint include: (a) Evaluation of cost-effectiveness analysis by recording QALY criteria; (b) Data recording by a brief self-administered questionnaire used to evaluate the adherence of a patient's tests and the impact of this genotyping on the patient's adverse drug reactions (ADR); (c) A sample size of paired (for age, gender, education, social status, geriatric syndromes, number of medications and comorbidities) 150 (cases) and 150 (controls); (d) Genotyping method choice by current widely diffuse platforms.

RESULTS

The investigators believe that genotype screening and the management of the overall cost of health care personalized therapy has the potential to reduce the health care costs of the Italian national health system (SSN).

CONCLUSIONS

Finally, the innovative issue of this project is to advocate the creation of a new model of the co-operative team (Physicians, pharmacist, geneticist and lab manager) that join for planning the most appropriated personalized therapy for their patient.

Evidence of exposure to SARS-CoV-2 in cats and dogs from households in Italy

SARS-CoV-2 emerged from animals and is now easily transmitted between people. Sporadic detection of natural cases in animals alongside successful experimental infections of pets, such as cats, ferrets and dogs, raises questions about the susceptibility of animals under natural conditions of pet ownership. Here, we report a large-scale study to assess SARS-CoV-2 infection in 919 companion animals living in northern Italy, sampled at a time of frequent human infection. No animals tested PCR positive. However, 3.3% of dogs and 5.8% of cats had measurable SARS-CoV-2 neutralizing antibody titers, with dogs from COVID-19 positive households being significantly more likely to test positive than those from COVID-19 negative households. Understanding risk factors associated with this and their potential to infect other species requires urgent investigation.

Residential cardiac rehabilitation (rCR) derived survival predictors in patients after transcatheter aortic valve replacement (TAVR): a retrospective multicenter study

Purpose

To evaluate exercise-based rCR derived outcome predictors in patients referred after TAVR.

Methods

Data of 434 patients (aged 81±6 years) admitted to an average 3-week rCR program after TAVR (walking, up to 30 minutes of cycling or treadmill session twice daily, respiratory and calistenic training) from January 2009 to December 2017 and home discharged, were retrospectively collected at 10 Italian rCR Division of Istituti Clinici Maugeri SpA. Comorbidity (cumulative illness rated state-comorbidity index) (CIRS-CI) score, echocardiography on admission, Disability (Barthel Index) (BI) score, Morse Fall Scale score (MFS), six minutes walking test distance (6MWT) on admission and discharge and maximal training session intensity (MTSI expressed in METs per minutes) were collected. The mortality was assessed up to 3 years after rCR discharge.

Results

During a 3-years follow up there were 120 (28%) deaths. At t-test analysis non survivors compared to survivors had significantly higher CIRS CI (p=0.000), MFS score on admission (p=0.008) and discharge (p=0.017), serum creatinine level on admission (p=0.000) and discharge (p=0.000); moreover they had significantly lower BI score on admission (p=0.000) and discharge (P=0.000), left ventricle ejection fraction (p=0.008),6MWT on admission (p=0.001) and discharge (p=0.000) and MTSI (p=0.022) in comparison to survivors.

At multivariate logistic stepwise analysis, BI score on admission and serum creatinine level at discharge were the only independent predictors of mortality (Table 1); the AUC of the final logistic model was 0.72.

Conclusions

Patients attending rCR after TAVR seem to be very old; overall mortality at 3 years follow up in patients discharged home after rCR is substantial. Disability profile on admission (measured by Barthel Index) and impaired renal function on discharge (measured by creatinine levels) are independently correlated to death at long term follow up.

Funding Acknowledgement

Type of funding source: None

Predictors of fatigue severity in early, de novo Parkinson disease patients: A 1-year longitudinal study

INTRODUCTION

Fatigue is one of the most common and disabling nonmotor symptom in Parkinson's disease (PD). The aim of the present study was to investigate the 1-year course of fatigue in a consecutive sample of de novo drug-naïve patients with PD, and at systematically searching for baseline motor and nonmotor predictors associated with fatigue severity over time.

METHODS

Fifty-five consecutive de novo PD patients (age: 64.71 ± 7.74 years) underwent a comprehensive examination, including Parkinson Fatigue Scale, Epworth Sleepiness Scale, Parkinson's Disease Sleep Scale, Beck Depression Inventory, Parkinson's Anxiety Scale, Apathy Evaluation Scale, and an extensive neuropsychological evaluation. Bivariate and multiple regression analyses were performed to identify baseline predictors independently related to fatigue severity at 1-year follow-up.

RESULTS

Prevalence rate of fatigue (defined by PFS cut-off) increased from 22% at baseline to 38% at 1-year follow-up. A similar increase in prevalence was observed for excessive daytime sleepiness, and apathy. Among patients with fatigue at baseline, 91% had fatigue at follow-up too (i.e., persistent fatigue). Multivariate regression analysis identified fatigue (p < 0.01), daytime sleepiness (p < 0.01), and emotional apathy (p < 0.01) as the main baseline variables significantly predicting fatigue severity at 1-year follow-up.

CONCLUSION

In early PD, fatigue increases and persists over time, and its severity is related to higher baseline levels of fatigue, excessive daytime sleepiness, and emotional apathy. These results warrant to monitor fatigue since the early stage of disease, and suggest that treating excessive daytime sleepiness and emotional apathy might prevent its worsening.

Cerebral Hemodynamic Changes to Transcranial Doppler in Asymptomatic Patients with Fabry's Disease

BACKGROUND

Patients with Fabry's disease (FD) may be asymptomatic or show a spectrum of clinical manifestations, including cerebrovascular disease, mainly affecting posterior circulation. Few and conflicting studies on cerebral blood flow (CBF) velocity by transcranial Doppler sonography (TCD) in asymptomatic FD (aFD) subjects have been published. Our study aims to assess TCD in aFD subjects to identify any preclinical CBF change.

METHODS

A total of 30 aFD subjects were consecutively recruited and compared to 28 healthy controls. Brain magnetic resonance imaging was normal in all participants. TCD was used to study blood flow velocity and indices of resistance of intracranial arteries from the middle cerebral artery (MCA), bilaterally, and from the basilar artery (BA). Cerebral vasomotor reactivity (CVR) was also evaluated from MCA.

RESULTS

No difference was found between groups for MCA parameters of CBF velocity and CVR. Compared to controls, a higher mean blood flow velocity and a lower resistance index from BA were observed in FD subjects. No correlation was found between any BA-derived TCD parameter and the level of lyso-globotriaosylceramide.

CONCLUSIONS

aFD subjects show evidence of altered CBF velocity in posterior circulation. Preclinical detection of neurovascular involvement in FD might allow appropriate management and prevention of future cerebrovascular complications and disability.

Multimodal surveillance of healthcare associated infections in an intensive care unit of a large teaching hospital

BACKGROUND

Healthcare-associated infections (HAIs), or nosocomial infections, represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients hospitalized in intensive care units (ICUs). Surveillance systems are recommended by national and international institutions to gather data on HAIs in order to develop and evaluate interventions that reduce the risk of HAIs.

STUDY DESIGN

Here we describe the methodology and the results of the surveillance system implemented in the ICU of the Policlinico Umberto I, a large teaching hospital in Rome, from April 2016 to October 2018.

METHODS

The multimodal infection surveillance system integrates four different approaches: i) active surveillance of inpatients; ii) environmental microbiological surveillance; iii) surveillance of isolated microorganisms; and iv) behavioral surveillance of healthcare personnel. Data were collected on catheter-related bloodstream infections, ventilation-associated pneumonia, catheter-associated urinary tract infections and primary bloodstream infections that developed in patients after 48 h in the ICU. For environmental surveillance 14 points were selected for sampling (i.e. bed edges, medication carts, PC keyboards, sink faucets). The system of active surveillance of HAIs also included surveillance of microorganisms, consisting of the molecular genotyping of bacterial isolates by pulsed-field gel electrophoresis (PFGE). From 1 November 2016, monitoring of compliance with guidelines for hand hygiene (HH) and proper glove or gown use by healthcare personnel was included in the surveillance system. After the first six months (baseline phase), a multimodal intervention to improve adherence to guidelines by healthcare personnel was conducted with the ICU staff.

RESULTS

Overall, 773 patients were included in the active surveillance. The overall incidence rate of device-related HAIs was 14.1 (95% CI: 12.2-16.3) per 1000 patient-days. The monthly device-related HAI incident rate showed a decreasing trend over time, with peaks of incidence becoming progressively lower. The most common bacterial isolates were Klebsiella pneumoniae (20.7%), Acinetobacter baumannii (17.2%), Pseudomonas aeruginosa (13.4%) and Staphylococcus aureus (5.4%). Acinetobacter baumannii and Klebsiella pneumoniae showed the highest proportion of isolates with a multidrug-resistant profile. A total of 819 environmental samples were collected, from which 305 bacterial isolates were retrieved. The most frequent bacterial isolates were Acinetobacter baumannii (27.2%), Staphylococcus aureus (12.1%), Enterococcus faecalis (11.1%), Klebsiella pneumoniae (5.2%) and Pseudomonas aeruginosa (4.7%). All Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae environmental isolates were at least multidrug-resistant. Genotyping showed a limited number of major PFGE patterns for both clinical and environmental isolates of Klebsiella pneumoniae and Acinetobacter baumannii. Behavioral compliance rates significantly improved from baseline to post-intervention phase.

CONCLUSIONS

By integrating information gathered from active surveillance, environmental microbiological surveillance, surveillance of bacterial isolates and behavioral surveillance of healthcare personnel, the multimodal infection surveillance system returned a precise and detailed view of the infectious risk and microbial ecology of the ICU.

Evidence of exposure to SARS-CoV-2 in cats and dogs from households in Italy

SARS-CoV-2 originated in animals and is now easily transmitted between people. Sporadic detection of natural cases in animals alongside successful experimental infections of pets, such as cats, ferrets and dogs, raises questions about the susceptibility of animals under natural conditions of pet ownership. Here we report a large-scale study to assess SARS-CoV-2 infection in 817 companion animals living in northern Italy, sampled at a time of frequent human infection. No animals tested PCR positive. However, 3.4% of dogs and 3.9% of cats had measurable SARS-CoV-2 neutralizing antibody titers, with dogs from COVID-19 positive households being significantly more likely to test positive than those from COVID-19 negative households. Understanding risk factors associated with this and their potential to infect other species requires urgent investigation.

One Sentence Summary

SARS-CoV-2 antibodies in pets from Italy.

THU0306 ROLE OF 18-FDG PET/CT IN DIAGNOSIS AND FOLLOW UP OF LARGE VESSELS VASCULITIS

Background:

18-FDG PET/CT is a functional imaging method which allows to identify inflammation of vessel walls. The use of PET in large vessels vasculitis(LVV) at disease onset and during follow up is still debate either to confirm clinical remission either to drive the therapy choice. American Society of Nuclear Cardiology (ASNC) recently advanced recommendations aimed to standardize the application of PET in LVV(1).

Objectives:

The aim of our study was to assess the clinical role of PET performed in patients affected by LVV at the diagnosis and during the follow up.

Methods:

We retrospectively evaluated PET/CT of 49 patients affected by clinically active LVV according to LVV visual grading (LVG, grading 0-3) and measured the standardized uptake value(SUV) of large vessels. 38 (77,6%) patients were affected by Giant Cells Arteritis and 11(22,4%) by Takayasu Arteritis. 32(65.3%) patients repeated the imaging after a mean follow-up of 11.5±5.4 months.

All baseline (T0) and follow up (T1) clinical data of disease activity were collected. Patients were treated according to EULAR LVV management recommendations(2). T0 PET/CT study was performed in patients with a clinically active disease defined by suggestive symptoms/signs and/or high inflammatory markers. The mean disease duration before T1 PET/CT examination was 4 months. T0 PET was performed in 25/49 patients(52%) at the diagnosis of LVV, whereas in 24/49(48%) patients with already diagnosed but active LVV disease.

Results:

Baseline PET was positive in 21 patients(42.9%). According to ASNC recommendations, 19 patients (38.8%) presented a LVG=3, 2(4.0%) a LVG=2, 6(12.2%) LVG=1 and 22 (44.9%) LVG=0. Patients performing PET at disease onset(75%) had higher LVG score than patients performing PET during the disease course (25%),p=0,002. At T0, aortic, carotid, axillary and subclavian SUV did not correlate with inflammatory markers.

Follow up PET/CT studies were performed in 32 patients, 13 (40.6%) with a clinically active disease despite therapy, while 19(59.4%) in clinical remission.

Follow up PET was still positive in 8 patients (25%) with a LVG=3, 10 (31.2%) patients presented LVG=1 and 14 (43.8%) LVG=0. T1 PET/CT study showed a significant reduction of SUV values in descending aorta, left and right subclavian arteries, and left and right axillary arteries when compared with first PET/CT study. According to LVG, 12 patients with active PET/CT study at T0 (19 pts) presented a reduction of LVG from score 2 and 3 to grade 1 or 0 (64.2%) at second PET/CT study. Only 3 patients presented an increased LVG score at T1, while in the other 17 patients T1 PET confirmed the previous score. No significant difference was found between LVG scores according with clinical characteristics, but among 8 patients presenting an active T1 PET, 4(50%) were in clinical remission.

Conclusion:

The use of ASNC recommendations for FDG PET/CT in LVV enables to confirm a metabolically active disease in 40% of patients and in 75% of patients at disease onset, suggesting that post-posing the exam could lead to underrate the real extension of disease. Our data, even if limited, suggest that PET/CT could be crucial in management of patients in clinical remission, detecting patients with still metabolically active LVV. Further prospective studies are necessary to evaluate the role of PET/CT in driving therapeutic strategies.

References:

[1]Slart R et all - Eur J Nucl Med Mol Imaging, 2018

[2]Hellmich et all – Ann Rheum Dis 2018

Disclosure of Interests:

Laura Gigante: None declared, Dario Bruno: None declared, Vanessa Feudo: None declared, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer, Lucia Leccisotti: None declared, Alessia Musto: None declared, Pier Giacomo Cerasuolo: None declared, Angelo Zoli: None declared, Alessandro Giordano: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

EAN guideline on palliative care of people with severe, progressive multiple sclerosis

BACKGROUND AND PURPOSE

Patients with severe, progressive multiple sclerosis (MS) have complex physical and psychosocial needs, typically over several years. Few treatment options are available to prevent or delay further clinical worsening in this population. The objective was to develop an evidence-based clinical practice guideline for the palliative care of patients with severe, progressive MS.

METHODS

This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Formulation of the clinical questions was performed in the Patients-Intervention-Comparator-Outcome format, involving patients, carers and healthcare professionals (HPs). No uniform definition of severe MS exists: in this guideline, constant bilateral support required to walk 20 m without resting (Expanded Disability Status Scale score > 6.0) or higher disability is referred to. When evidence was lacking for this population, recommendations were formulated using indirect evidence or good practice statements were devised.

RESULTS

Ten clinical questions were formulated. They encompassed general and specialist palliative care, advance care planning, discussing with HPs the patient's wish to hasten death, symptom management, multidisciplinary rehabilitation, interventions for caregivers and interventions for HPs. A total of 34 recommendations (33 weak, 1 strong) and seven good practice statements were devised.

CONCLUSIONS

The provision of home-based palliative care (either general or specialist) is recommended with weak strength for patients with severe, progressive MS. Further research on the integration of palliative care and MS care is needed. Areas that currently lack evidence of efficacy in this population include advance care planning, the management of symptoms such as fatigue and mood problems, and interventions for caregivers and HPs.

Process of ammonia removal from anaerobic digestion and associated ammonium sulphate production: Pilot plant demonstration

A process for the continuous extraction of ammonia from anaerobic digesters is proposed. In this process, a portion of the sludge treated in the digesters is continuously withdrawn and transferred to a thin film evaporator (TFE) unit, where the ammonia is stripped through a biogas stream. The ammonia-rich biogas is treated with a sulfuric acid/water solution in a reactive absorption unit, with production of ammonium sulphate. The chemistry of a CH₄/CO₂/NH₃ gas phase in thermodynamic equilibrium with a liquid sulfuric acid/water solution is investigated theoretically, with focus on the simultaneous absorption of CO₂ and NH₃ into the liquid phase. Pilot plant experimental data confirm the theoretical results. Further pilot plant experimental results obtained during on-off cycles of the stripping equipment demonstrate that, when the TFE unit is off, ammonia concentration in the digestate rises quickly, while, when the stripping equipment is turned on again, ammonia concentration drops down. On average, during the 180 days of pilot plant experimentation, 4.1 g N-NH₄ per kg of sludge fed to the digester, i.e. 19.3 g N-NH₄ per kg of total solids (TS) fed to the digester, are stripped from digestate and recovered as ammonium sulphate, demonstrating the feasibility of the proposed concept.