Preoperative Carbon Ion Radiotherapy (CIRT) with Chemotherapy in Resectable and Borderline Resectable Pancreatic Adenocarcinoma (PCa): A Multicenter Prospective Phase II Clinical Study (Pioppo Study NCT 03822936)

PURPOSE/OBJECTIVE(S)

Preoperative chemoradiation and surgery may improve survival for resectable (Re) or borderline resectable (BRe) PCa. However, there is a lack of evidence regarding the feasibility of combined chemotherapy (CT) and CIRT in the neoadjuvant setting for Re/BRe PCa, especially in the Caucasian population. To assess the safety and efficacy of this challenging combination, we designed a prospective multicentric single-arm phase II trial MATERIALS/METHODS: PIOPPO trial was opened in September 2014. We prospectively treated patients with Re/BRe Pca with a neoadjuvant CT (3 cycles of FOLFIRINOX) and a short-course of CIRT (38.4 GyRBE, 8 fractions, 4 fractions per week) planned with 4D-imaging and delivered with breath-gating and rescanning. Four-6 weeks after CIRT patients (pts) received surgery followed by adjuvant-CT (FOLFIRINOX for 9 or gemcitabine for 6 cycles). After each step patients underwent a re-staging. The primary endpoint was Local Progression Free Survival (LPFS).

RESULTS

Fourteen (47%) of the foreseen 30 pts were evaluated for enrollment. There were 4 screening failures for duodenum infiltration. Ten Caucasian pts (M = 7; 70%; F = 3;30%) with a median age of 65.5 (range:46-76) started the treatment. There were four (40%) Re and 6 (60%) BRe Pca. 100% of the Re and 50% of BRe PCa completed the planned combined treatment for a total of 7 (70%) pts. Three (30%) pts developed systemic progression after CT and underwent palliative care (2 cases) or a second line of CT (1 case). With regards to toxicities, we recorded 2 (28.6%) cases of neutropenia during CT, none acute CIRT toxicity and one (14%) case of intra-operative ulceration of the gastro-enteric anastomosis. Moreover, we reported one (14%) case of fatal liver failure due to portal vein stenosis due to the combo approach (CT+CIRT+surgery). Six (86%) pts experienced Tumor Regression Grade (TRG) = 2 according to the College of American Pathologists (CAP) and 1 (14%) a TRG = 3. At the last follow-up, among pts who completed the scheme, 2 (28%) are currently alive and disease-free at 57 and 49 months, respectively. With a median follow-up of 13 months, the median LPFS was 9.4 months (range:4.9-57), with 1 case (14%) of systemic progression and 3 cases (43%) of local recurrence + systemic progression. The study was early closed due to low accrual in August 2022.

CONCLUSION

Although the small sample size limits the interpretation of the endpoints, a neoadjuvant approach combining CT and a short course of CIRT for resectable/borderline Pca seems feasible. Liver toxicity was similar to the Japanese series and needs to deepen investigation on the vascular dose constraints and surgical techniques. Considering the worse outcomes, a better selection of patients to treat also with a centralized imaging interpretation is mandatory.

Impact of myocardial injury on mortality and adverse events in hospitalized patients with influenza: a prospective cohort study

Background and aim

Myocardial injury (MINJ) defined as elevated high-sensitivity cardiac troponin level (hs-cTnT) above normal values is a well-recognized prognostic marker in different clinical conditions, nonetheless, its relevance in Influenza remains poorly defined. We aimed to analyse incidence, predictors, short and mid-term prognostic role of MINJ in hospitalized patients (pts) with Influenza.

Material and methods

During 2018–2019 Influenza epidemic, a prospective multicentre observational cohort study was conducted enrolling all hospitalized adult patients with laboratory confirmed Influenza infection. MINJ was prospectively assessed at admission and defined as hs-cTnT >14 ng/L. Primary endpoint was all-cause death at 28-days. Secondary endpoints were all-cause death at 28-days or intensive care unit (ICU) admission/mechanical ventilation and all-cause death at follow up.

Results

145 consecutive pts were enrolled. MINJ was evident in 94 (65.5%) pts. At a 28-days follow up, 7 deaths (4.8%) occurred, all in patients with MINJ at admission (log rank p=0.048). MINJ showed a strong association with the occurrence of death, ICU admission or mechanical ventilation (OR 5.74, 95% CI 1.28–53.29; p=0.015). At a median follow-up of 32.7 months, 15 (10.3%) deaths occurred, all among patients with MINJ at index hospitalization leading to a significantly high mortality rate at follow-up among patients with MINJ (log-rank p=0.003).

Conclusions

Influenza related MINJ is common and identifies patients at higher likelihood of short-term adverse events and midterm mortality.

Funding Acknowledgement

Type of funding sources: None.

Impact of gender on survival of out-of-hospital cardiac arrest presenting with refractory ventricular arrhythmias and role of coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Clinical presentation and outcome of out-of-hospital cardiac arrest (OHCA) presenting with shockable rhythm may vary between males and females. Very limited data exist on gender-related differences in OHCAs with refractory ventricular arrhythmias (VA) and, in particular, on distribution and prevalence of coronary artery disease (CAD).

Purpose

The aim of this study was to characterize gender-related outcome, prevalence and severity of CAD in OHCA victims presenting with shockable rhythm and refractory VA.

Methods

All OHCAs presenting with shockable rhythm occurred between 2015 and 2019 in the province of Pavia (Italy) and in the Canton Ticino (Switzerland) were included.

Results

Out of 3592 OHCAs, 685 presented with shockable rhythm and, of them, 212 had a refractory VA. Overall, male gender was independently associated with a lower probability of survival both at hospital admission and at 30-days (OR 0.63, 95% CI 0.58-0.67, p <0.001 and OR 0.82 95% CI 0.74-0.91, p <0.001, respectively) and presented with a more severe CAD. Male gender was 5-times more frequently associated with OHCA presenting with refractory VA. Despite of a more favourable OHCA presentation (i.e. more often OHCA witnessed, public place occurrence and CPR initiated by bystander) male patients with refractory VA had a lower likelihood of survival (OR 0.25, 95% CI 0.21-0.30). A higher prevalence (81%) of CAD was observed in OHCAs presenting with refractory VA but not a higher number of diseased vessels.

Conclusions

Male gender is more frequently associated with refractory VA, lower probability of survival and higher prevalence and severity of CAD. CAD severity, however, does not significantly affect refractory VA presentation.

MPFL reconstruction and tibial tuberosity transposition in patients with patellar instability: May it troubleshots also trochlear dysplasia?

Purpose

This study aimed to highlight short- and medium-term outcomes of combined medial patello-femoral ligament (MPFL) reconstruction and anterior tibial tuberosity (ATT) transposition surgery in patients with recurrent patellar instability and different degrees of trochlear dysplasia.

Methods

Between January 2014 and May 2019, 25 patients with patellar instability underwent a surgical procedure combining the lowering/transposition of the ATT and the MPFL reconstruction. Each patient were preoperative assessed by Kujala score, International Knee Documentation Committee (IKDC), Tegner activity level scale. The assessment of instability predisposing factors was carried out with patellar height, tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, sulcus angle, patellar tilt and MPFL injuries. Functional outcomes were evaluated with Kujala, IKDC and Tegner scores at 3, 6 and 12 months after surgery.

Results

The average age of the patients was 20 years (range 13–43 years). Pre- operative Caton–Deschamps index was pathological in 10 (40%). Sulcus angle was elevated in 13 patients (52%) and TT-TG distance was irregular in 17 patients (68%). Trochlear dysplasia was present in 13 patients (9 type A, 3 type B, 1 type C according to Dejour’s Classification). No re-dislocation occurred during the follow-up. There was a significant increase in the Kujala, IKDC and Lysholm scores after 3, 6 and 12 months, and the results were compared for the different follow-up times and patient’s trochlear dysplasia degree.

Conclusion

This prospective observational longitudinal study identified good clinical outcomes in patients who underwent MPFL reconstruction and ATT transposition for patellar instability. Finally, the different risk factors for patellar instability examined, particularly the presence of trochlear dysplasia, did not significantly influence the final functional results, which range from good to excellent without re-dislocation episodes.

1124 Is Delayed Presentation A Prognostic Factor for The Survival of Patients with Esophageal Atresia More Than Associated Anomalies? Comparison Between Different Social Realities

Background

The aim is to evaluate if different social reality could represent a prognostic factor as associated anomalies affecting survival of neonates with esophageal atresia (EA).

Method

Retrospective analysis of records of neonates with EA with or without Tracheoesophageal Fistula (TEF) from January 2011 to September 2018 at Policlinico San Matteo Pavia, Italy(SMAT) and the All India Institute of Medical Sciences New Delhi, India (AIIMS).Survival was correlated with the presence of anomalies, different types and the number of organ systems involved.Age at presentation and birth weight were considered to find an association with mortality.

Results

Out of 180 patients,162 were from AIIMS and 18 from SMAT.The overall mortality was 28.85%, which occurred at AIIMS, being 0% at SMAT.83.33% at SMAT and 72.84% at AIIMS had associated anomalies.The mortality was 25% for neonates without an anomaly, being 26.15% for those with one (p > 0.05).No statistically significant correlation between outcome and associated anomalies was found.Instead, survival declines gradually as the age at presentation increases.

Conclusions

The presence of associated anomalies paradoxically does not affect the outcome because incidence of delayed presentation has a stronger effect than the presence of associated anomalies. Sensibilization is necessary to improve survival in EA neonates in developing countries, such as India.

A snapshot of the immunogenicity, efficacy and safety of a full course of BNT162b2 anti-SARS-CoV-2 vaccine in cancer patients treated with PD-1/PD-L1 inhibitors: a longitudinal cohort study

Background

Very few cancer patients were enrolled in coronavirus disease-2019 vaccine studies. In order to address this gap of knowledge, real-world studies are mandatory. The aim of this study was to assess both humoral and cellular response after a messenger RNA vaccination schedule.

Patients and methods

Eighty-eight consecutive cancer patients treated with programmed cell death protein 1/programmed death-ligand 1 inhibitors were enrolled from the beginning of the vaccination campaign for frail patients. Blood samples for humoral and cell-mediated immune response evaluation were obtained before vaccination (T0), before the second administration (T1) and 21 days after the second dose (T2). The primary endpoint was the evaluation of the percentage of participants showing a significant increase in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific T cells, measured by an enzyme-linked immunospot assay, after the second dose of BNT162b2 vaccine. The proportion of patients who reached the primary endpoint is computed together with its exact binomial 95% confidence interval.

Results

In SARS-CoV-2-naïve subjects, spike-specific T-cell response was almost undetectable at T0 [median 0.0 interferon-γ (IFN-γ) spot forming units (SFU)/million peripheral blood mononuclear cell (PBMC) interquartile range (IQR) 0-7.5] and significantly increased at T1 and T2 (median 15.0 IFN-γ SFU/million PBMC, 25th-75th 0-40 versus 90 IFN-γ SFU/million PBMC, 25th-75th 32.5-224, respectively) (P < 0.001). Focusing on naïve and experienced SARS-CoV-2 subjects, no differences were reported both in terms of CD4- and CD8-specific T-cell response, suggesting that BNT162b2 is able to elicit both adaptive responses after complete vaccination schedule, regardless of previous SARS-CoV-2 exposure. The level of SARS-CoV-2 neutralizing antibodies was low at T1 in SARS-CoV-2-naïve subjects [median 1 : 5 (IQR 1 : 5-1 : 20)] but reached a significantly higher median of 1 : 80 (25th-75th 1 : 20-1 : 160) at T2 (P < 0.0001). Moreover, no COVID-19 cases were documented throughout the period of study.

Conclusions

Our data have demonstrated that the administration of a full course of BNT162b2 vaccine elicited a sustained immune response against SARS-CoV-2 regardless of the type of cancer and/or the type of immune checkpoint inhibitors.

•

In SARS-CoV-2-naïve subjects, spike-specific T-cell response was significantly increased after the second dose of vaccine

•

In patients treated with chemo-immunotherapy, T-cell response seems to be lower with borderline statistical significance

•

Between naïve and experienced patients, no differences were reported in terms of CD4- and CD8-specific T-cell response

•

In naïve patients, the level of SARS-CoV-2 neutralizing antibodies reached a significantly higher median of 1 : 80 after the second dose

•

No COVID-19 cases were documented throughout the period of study

POS0830 FACTORS INFLUENCING PATIENT-REPORTED OUTCOMES IN ANCA-ASSOCIATED VASCULITIS

Background:

Patient-reported outcomes (PROs) are currently poorly integrated in the clinical evaluation of disease activity in patients with ANCA-associated vasculitis (AAV).

Objectives:

To assess the distribution of the Patient Global Assessment (PtGA) in patients with AAV in stable remission, and to identify correlates of PtGA; to assess the discordance between PtGA score and PhGA.

Methods:

Patients with a diagnosis of AAV [eosinophilic granulomatosis with polyangiitis, granulomatosis with polyangiitis, microscopic polyangiitis] in stable, complete remission (defined by a BVAS=0) and with a Physician Global Assessment (PhGA)=0 were included. A questionnaire including several aspects of disease captured by PROs was collected. PtGA on a 0-100 mm visual analogue scale (VAS) was assessed, with higher scores representing higher/worse levels of disease activity. Similarly, VAS for pain, chronic damage according to the patient’s opinion, general health (GH), fatigue, and sleep quality were collected. The worst symptom in the patient’s opinion affecting the overall assessment of disease activity was recorded. The Cragg Hurdle model was used to assess the predictors of PtGA.

Results:

65 patients were included, female 57%, mean age 61±12 years. Mean disease duration at enrollment was 8±6 years. Mean vasculitis damage index (VDI) was 4.4 ±2.3, with 45% of patients having a VDI ≥ 5. Despite having been classified as being in remission, PtGA was elevated in 37% of patients. We explored several correlates of PtGA. Higher degree of damage accrual (VDI) did not influence the patient’s evaluation of current disease activity. Similarly, we did not identify a correlation between older age, educational level, number of organ-systems involved, number of comorbidities, the number of previous major or minor relapses, higher disease duration, nor the type of AAV diagnosis (figure 1, panel A). Only sex significantly correlated with PtGA scores: 19 (51%) of female patients reported an elevated PtGA compared to only 5 (18%) of male (p=0.009). PtGA resulted to be significantly correlated with other (mostly modifiable) PROs including VAS pain, perception of the level of chronic damage accrual, GH, and fatigue (figure 1, panel B). The agreement between patients’ and physicians’ assessments of disease activity was 63%. Patients reported pain, followed by chronic respiratory symptoms to be the worst-experienced ongoing manifestations affecting their evaluation of disease activity.

Conclusion:

A significant proportion of patients with AAV considered to be in remission by the physician still declares to have persistent aspects of uncontrolled disease. PtGA is significantly influenced by persistent pain and fatigue, which warrant better assessment in the future.

Disclosure of Interests:

None declared

Quality of life and psychopathology in candidates to bariatric surgery: relationship with BMI class

PURPOSE

This cross-sectional study aimed at comparing the quality of life (Qol), the prevalence of psychiatric diagnosis and pharmacological treatment in 104 candidates to bariatric surgery according to the degree of obesity (class 2 vs. class ≥ 3 obesity).

METHODS

All surgical candidates underwent a detailed psychiatric interview based on DSM-5 criteria, including sociodemographic, clinical, psychological and psychiatric data. Participants completed the Binge Eating Scale (BES) and the 12-Item Short Form Health Survey (SF-12).

RESULTS

Overall, bariatric candidates reported a significant impairment in the physical (PCS 38.8 [95% CI 36.2-41.5]) and mental (MCS 42.2 [95% CI 40.4-43.9]) components of Qol compared to population norms (p < 0.001 for both). Subjects with class 2 obesity scored significantly lower in the MCS compared to those with class 3 (38.7 (8.1) vs. 43.6 (8.4), p = 0.008). No other statistically significant differences were found between the two groups in terms of sociodemographic and clinical variables.

CONCLUSION

These data support the usefulness of Qol assessment in bariatric candidates as a sensible screening parameter, especially in patients with lower BMI, in whom MCS could identify the need for early psychosocial intervention.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Post-ROSC electrocardiogram timing in the management of out-of-hospital cardiac arrest: results of an international multicentric study (PEACE study)

Background

Electrocardiogram (ECG) is a key tool to triage out-of-hospital cardiac arrest (OHCA) patients after achieving a sustained return of spontaneous circulation (ROSC). According to current guidelines, an immediate coronary angiography is indicated only when the post-ROSC ECG discloses a ST-elevation myocardial Infarction (STEMI). Moreover, the 12-lead ECG should be recorded as soon as possible after ROSC, although it is reasonable that in the early post-ROSC stages ECG could reflect the ischemia secondary to cardiac arrest besides that of coronary origin possibly causing an overdiagnosis of STEMI (false positive).

Purpose

To assess whether the time from ROSC to ECG acquisition could affect the percentage of false positive ECG for STEMI.

Methods

We performed a retrospective, international, multicenter study (PEACE Study - NCT04096079). We included all patients over 18 years of age hospitalized after an OHCA due to medical cause at one of the three participating high-volume hospitals of three different European countries between 2015, 1st January and 2018, 31st December. We considered for the present study only patients who underwent coronary angiography and in whom a post-ROSC ECG was available. For the electrocardiographic diagnosis of STEMI the criteria established by the ESC 2017 guidelines were used, while the execution of a percutaneous coronary angioplasty (PTCA) was evaluated as an angiographic endpoint. We used logistic regression to evaluate the association of time to acquisition and the endpoint. We computed odds ratios and 95% confidence intervals (OR, 95% CI).

Results

Population consisted of 370 patients (77.6% male, mean age 61±13 years, median ROSC-ECG time 15 minutes). Post-ROSC ECG was positive for STEMI in 198 patients and in 39 of them (10.5%) a PTCA was not performed during urgent coronary angiography, representing the false positive (FP) ECG. Dividing the population in three tertiles according to the time from ROSC to ECG (≤7 mins; 8–33 mins; &gt;33 mins), the percentage of FP-ECG in the first tertile (18.5%) was statistically significantly higher than in the second (7.2%, OR 2.9 (95% CI 1.1–7.5) p=0.025) and third (5.8%, OR 3.7 (95% CI 2.2–6.5) p&lt;0.001) as also shown in the Figure. These differences remained significant when adjusting for sex, age, number of segments involved at ECG (anterior, lateral, posterior, inferior and right), QRS duration &gt;120 msec, ECG heart rate &gt;100 bpm and adrenaline administered &gt;1 mg.

Conclusion

Our study offers the first demonstration that the acquisition of the 12-leads ECG too early after ROSC can misleadingly lead to the diagnosis of STEMI. Despite further validation are required, our data suggest that it may be reasonable to delay the acquisition of the ECG at least 8 minutes after ROSC or to repeat the acquisition if the first ECG, resulting diagnostic for STEMI, was performed very early.

Figure 1

Funding Acknowledgement

Type of funding source: None

Regional cardiac uptake of 99-Tc-DPD is a novel powerful and independent prognostic marker in cardiac ATTR wild type amyloidosis

Background

Skeletal scintigraphy with bone tracers is a key tool for cardiac ATTR diagnosis. However its prognostic value has not been systematically assessed.

Purpose

We evaluated the prognostic relevance of a quantitative method to assess regional 99mTc-DPD uptake by SPECT in the heart of ATTRwt patients.

Methods

All ATTRwt patients (n=229) undergoing clinical assessment and bone scintigraphy at our center (from 2012 to 2019) were enrolled. Theyreceived approximately 700 MBq of 99mTc-DPD. Planar whole body acquisition 10' after the injection followed by cardiac SPECT after 3 hours were performed. SPECT data were reconstructed into 64x64 matrices with an ordered-subset expectation maximization algorithm. For each wall region and for the apex, a circular region of interest (ROI, 20 pixels) was manually drawn and a value equating to the number of counts contained in the ROI was obtained. Partial correlation of ln-transformed ROI and biomarkers was retrieved from a multivariable regression model, while controlling for each cardiac wall region. Multivariable Cox regression was used to assess the prognostic role of lnROI while adjusting for wall region, NT-proBNP, cTnI and eGFR. Hazard ratios and 95% confidence intervals (HR, 95% CI) were computed. The Harrell's c statistic was reported for model discrimination. The interaction of biomarker and regional wall on survival was assessed; also, to account for intra-subject correlation of measures, within subject robust standard errors were computed.

Results

Median follow-up was 21 months (IQR 11, 40) and 39 (17%) patients died. Median age was 76 years (IQR, 72–80), NT-proBNP 2944 ng/L (IQR, 1815–5319), cTnI 0.095 ng/L (IQR, 0.062–0.144) and eGFR 62 mL/min (IQR, 51–77). ROI did not correlate with any of NT-proBNP, eGFR, age, cTnI or mLVWT (R&lt;1% in all cases). All analyses were adjusted for cardiac wall. At the multivariable Cox regression (Harrell's c=0.75), there was a linear increase in the risk of death associated with lnROI (HR 2.14, P=0.014), which was independent of cardiac wall region, NTproBNP, cTnI and eGFR. Only cTnI maintained a significant prognostic value. The association of lnROI and mortality was not modified by the site of measurement test for interaction with cardiac wall p=0.818). At the predefined subgroup analysis, the risk of death was similar for all walls; we computed the optimal cut-off for 12 months survival at the apex (a region usually lately involved) to 4193 (AUC: 0.68, sensitivity 80%, specificity 68%). At the multivariable Cox regression (Harrell's c 0.76), apex ROI&gt;4193 was an independent predictor of death (HR 3.60, 95% CI 1.45–8.93, p=0.006) and outperformed all the biomarkers tested.

Conclusions

Quantitative assessment of ROI uptake at cardiac SPECT is a powerful predictor of survival in ATTRwt patients, independent of and outperforming the other known prognostic factors. This observation warrants validation with prolonged follow-up and in independent patient series.

Funding Acknowledgement

Type of funding source: None

6128Losartan vs Nebivolol vs the association of both on the progression of aortic root dilation in genotyped Marfan Syndrome: 48 months open label randomized controlled phase III trial

Background

Marfan Syndrome (MFS) is a rare multisystemic genetic disease caused by mutations in the Fibrillin 1 (FBN1) gene. Aortic root aneurysm, potentially evolving to dissection and rupture, is the most important clinical complication. Beta blockers (BB) and Angiotensin II receptor blockers (ARB), these latter exerting an anti-TGFbeta1 effect, are current cornerstones of medical therapy in patients diagnosed with MFS and presenting aortic root aneurysm. The study aimed at comparing the effect of single drug (nebivolol and losartan) vs. the combination of both (losartan + nebivolol) in limiting the progression of the growth of the aortic root diameter (ARD) in FBN1 genotyped patients with aortic root aneurysm (z-score>2), who had not undergone prior aortic surgery.

Methods

We designed a controlled, open-label, single-blinded, 1:1:1 randomized, phase III single-centre study [NCT00683124]. Calculated sample size was 291 (power 90%, type I error 5%, 20% attrition, expected dropout 20%). ARD data collection was performed with annual 2D-transthoracic echocardiograms for four years. ARDs were measured with 2D-transthoracic echocardiogram as absolute values, aortic root ratio (ARR), and z-score. The primary endpoint was the modification of ARD z-score at 48 months. The analysis of the primary endpoint aimed at showing differences of ARD z-score comparing:

– The combined treatment arm (group A).

– The group aggregating both single treatment arms (group B).

– The nebivolol arm (group C).

– The losartan arm (group D).

Results

We enrolled 262 patients (126 adults, aged 17–55, and 136 children, aged 1–16); 236/262 (22 dropout; 4 lost at follow-up) completed the planned follow-up: 81 in the group A, 79 in the BB in the group C and 76 in the group D. No patient developed acute aortic dissection. Both drugs administered either individually or in combination were well tolerated without evidence of side effects. At 48 months, the ARD Z-score decreased from baseline to end-follow-up in all treatment arms. The decrease was significantly higher in the combined treatment arm (A) than in the single treatment aggregated arm (group B) with a difference in ARD z-score change of 0.17 (p=0.009) in the combined arm (A). Similarly, the decrease of z-score was inferior in the nebivolol arm and in the losartan arm than in the combined arm (by 0.16, p=0.032, and by 0.18, p=0.019, respectively). After Bonferroni correction for these post-hoc comparisons only the decrease of z-score in the losartan arm remained significantly inferior (p<0.025).

Conclusions

This study shows that the current cornerstones of medical therapy in MFS (ARB and BB) are effective in limiting the progression of the growth of the aortic root diameter: their combination exploits a synergistic effect. The combined administration of BB and ARB in patients with aortic root aneurysm is a sustainable, well tolerated treatment that effectively limits the rate of progression of aortic root dilation.

Acknowledgement/Funding

The financial support of Telethon, Italy (Grant no. GGP08238) is gratefully acknowledged.The drugs are a gift of Menarini and MSD

P5531A systematic follow-up strategy after percutaneous coronary intervention based on patient risk profile: the prospective POST-PCI registry

Background

Redundant clinical and non-invasive examinations after percutaneous coronary intervention (PCI) increase the cost of medical care with no outcome improve. A multidisciplinary consensus document (MCD) providing a follow-up (FU) strategy based on 3 clinical and angiographic risk profile (A high, B intermediate, and C low) has been recently proposed.

Aim

To evaluate the potential reduction of cardiologic consults (CC), stress tests (ST), and echocardiograms (EC) with the application of the MCD after PCI.

Methods

The Post-PCI registry is a multicenter, observational, prospective data collection carried out during a four-week period that included consecutive patients undergoing PCI at 31 Italian Hospitals both for acute coronary syndromes (ACS) or stable coronary artery disease (SCAD). FU strategies were left at investigator's discretion. A comparison between the CC, ST and EC performed in the first 12-months with the potential suggested by the MCD was evaluated.

Results

A total of 1113 patients were included; 12-months follow up was available in 90% of the cases (mean age 68±11 years old, 58% ACS). Based on MCD risk profile 17% were in A, 74% in B and 9% in C strategy. On average observed CC and ST were significantly lower compared to the expected based on MCD (respectively 1.63±1.07 vs 1.91±0.28, and 0.41±0.59 vs 0.61±0.84; on the contrary EC were significantly higher (0.64±0.73 vs 0.34±0.75, all: p<0.001). The excess rate for CC, ST and EC as compared to MCD was respectively 25%, 14% and 8% for the strategy A, 14%, 25% and 50% for the strategy B and 26%, 54% and 40% for the strategy C. At multivariable logistic analysis the MCD strategy was an independent predictor (in a model with age, sex, consulting physician, public or private hospital) of an increased number of cardiac examination in patients at intermediated and low risk [B group OR 2.56 (95% CI 1.38–4.75), C group 27.00 (95% CI 8.13–89.62)]. The other independent predictor was age, with a reduced number of examination for elderly (>75 years old) patients [OR 0.59 (CI 95% 0.43–0.80)].

Conclusion

Our data suggest that in a real word population of patients undergoing PCI, a follow-up strategy based on clinical and anatomical risk profile would allow to a reduction of cardiac tests and consultations, particularly in patients at intermediated and low risk leading to an increase of appropriateness of prescription and to a cost reduction of medical care.

Acknowledgement/Funding

The Post-PCI registry was supported by the Italian Society of Interventional Cardiology (SICI-GISE) receiving an unrestricted grant from Astra Zeneca

P4726Functional mitral regurgitation treated with percutaneous repair: a relative survival analysis of a national Swiss cohort

Introduction

Percutaneous treatment of functional mitral regurgitation (FMR) with MitraClip (MC) has led to discordant results in recent randomized clinical trials. We aimed at estimating excess mortality (EM) and to evaluate its predictors in a large Swiss FMR population treated with MC.

Methods

FMR patients enrolled in the MitraSwiss Registry (479 pts) with a mean age of 74.7±9.42 years were evaluated. We computed and plotted EM up to 5 years after implant using the Swiss 2008–20013 mortality tables, stratified by age and sex. A Poisson regression was used to model EM as a function of age, sex, pre-implant RV/RA gradient, calendar period (2011–2013; 2014–2015,2016–2017), ischemic vs non ischemic aetiology, acute procedural success and residual MR.

Results

Patient's survival at 1,2,3,4 and 5 years were respectively 0.84, 0.72, 0.59, 0.53 and 0.48. FMR patients treated with MC showed excess mortality of +13% (95% CI,10%-18%), +22% (95% CI,17%-28%), +34% (95% CI,27%-41%), +37% (95% CI,28%-46%) and +39% (95% CI,28%-50%) at each time point as compared to the Swiss population, with not differences over the entire follow up (p=0.481). Age group, sex, RV/RA gradient calendar period, ischemic vs non ischemic and residual MR were not associated with excess mortality while a clear association was recognized with acute procedural success (p=0.011).

Conclusions

In FMR patients treated with MC a persistent EM was observed at a 5 years follow up. Acute procedural success is the only determinant of EM with a 65% lower EM as compared to procedural failures.

P970DK-crush is the best treatment strategy to reduce stent oriented clinical outcome, results from a network meta-analysis of twenty-six randomized clinical trials comparing different stent techniques

Background

Coronary bifurcation disease (CBD) accounts for approximately 20% of all and is associated with worse short- and long- term clinical outcomes. Provisional stenting (PS) is the preferred choice, however, this approach may not be suitable in all CBD anatomies, therefore several elective two-stents techniques have been described, however there is lack of randomized evidence to guide interventionalist across different stent techniques. Objectives. To identify the best percutaneous coronary interventions (PCI) technique for CBD.

Methods

We systematically review randomized clinical (RCTs) of patients receiving CBD PCI with either PS or six type of elective two-stent techniques (DK-crush, TAP, culotte, dedicated bifurcation stents, crushing, T-stenting) and compare device oriented clinical events (DOCE) in a network meta-analysis. DOCE was defined as composite of cardiac death, target-vessel myocardial infarction, stent thrombosis, target lesion revascularization OR target vessel revascularisation.

Results

We included 26 RCTs leading to a pooled population of 10339 patients-years with 1229 DOCE. Compared to PS, the DK-crush technique had a lower DOCE with RR=0.62, [0.42–0.92]. Figure. DK-crush had the highest likelihood (model likelihood=90.2%, SUCRA=98.0%) of being the best treatment to reduce DOCE.

Figure 1

Conclusions

In the management CBD, when a two-stent technique is required as upfront strategy, the DK- Crush technique should be privileged as it showed to reduce stent-related clinical outcomes (DOCE) when compared to other bifurcation techniques.

Perspectives of the International Society for Cell & Gene Therapy Gastrointestinal Scientific Committee on the Intravenous Use of Mesenchymal Stromal Cells in Inflammatory Bowel Disease (PeMeGi)

Inflammatory bowel disease (IBD), namely, Crohn's disease and ulcerative colitis, remains a grievous and recalcitrant problem incurring significant human and health care costs, even in consideration of the growing incidence. Initial goals of care aimed to achieve the induction and maintenance of clinical remission. The advent of novel treat-to-target approaches using patient stratification, early introduction of immunosuppressants and rapid escalation to biologics or early use of combination therapy has refocused the goals of care toward the achievement of mucosal healing. This is in an attempt to preserve intestinal function, decrease hospitalization and surgery rates and improve the quality of life of affected patients. Cellular therapeutics for the treatment of IBD offers an unprecedented opportunity to change the current paradigm from single-targeted to systems-targeted therapy, trying to dampen the whole inflammatory cascade instead of a only molecule. Therefore, as we move forward, the importance of designing informative and possibly adaptive trial designs, standardizing methodologies, harmonizing goals of therapy and evaluating methods cannot be underemphasized. In this article, we review the current literature on the application of mesenchymal stromal cells for the treatment of IBD in an effort to establish a consensus on designing efficient and consistent clinical trials for the intravenous use of this cellular therapy in IBD.

Thyroid Hormone and Thyrotropin Regulate Intracellular Free Calcium Concentrations in Human Polymorphonuclear Leukocytes: In Vivo and in vitro Studies

Intracellular free calcium concentrations ([Ca++]1) were studied in polymorphonuclear leukocytes (PMNs) from 13 athyreotic patients who had been previously treated by total thyroidectomy and radioiodine therapy for differentiated thyroid carcinoma, and from age- and sex-matched euthyroid healthy controls. Patients were studied twice, when hypothyroid (visit 1) and after restoration of euthyroidism by L-T4 TSH-suppressive therapy (visit 2). PMNs from patients at visit 1 had significantly lower resting [Ca++]1 levels compared to both visit 2 and controls. Values at visit 2 did not differ from those of the controls. Stimulus-induced [Ca++]1 rise was also significantly blunted at visit 1 and normalized at visit 2, possibly through a differential contribution of distinct intracellular Ca++ stores, as suggested by the response pattern to the chemotactic agent, N-formyl-Met-Leu-Phe (fMLP), to the selective SERCA pump inhibitor, thapsigargine, and to the mitochondrial uncoupler, carbonyl cyanide p-trifluoromethoxyphenyl-hydrazone (FCCP). In vitro treatment of PMNs from healthy subjects with high TSH concentrations impaired intracellular Ca++ store function. Both resting [Ca++]1 levels and fMLP-induced [Ca++]1 rise increased in the presence either of low-concentration TSH or of T4, but effects of TSH and T4 were not additive. T3, rT3, and TRIAC had no effect. In conclusion, this study provides evidence for a direct relationship between thyroid status and [Ca[Ca++]1 homeostasis in human PMNs, mainly related to direct actions of TSH and T4 on these cells.

In irritable bowel syndrome, postprandial abdominal distention is associated with a reduction of intestinal tone

BACKGROUND

The pathophysiology of abdominal distention in irritable bowel syndrome (IBS) is still a matter of debate, but the relationship between modifications of intestinal tone and abdominal volume has never been analyzed.

METHODS

Eighty-four patients affected by IBS and reporting moderate to severe abdominal distention were enrolled. Thirty-nine presented abdominal distention immediately after and forty-five presented abdominal distention independently of meal intake. Twenty healthy volunteers (HV), comparable for gender and age, were also enrolled. All the subjects underwent fasting and postprandial recto-sigmoid volume monitoring with barostat and abdominal girth measurement to evaluate abdominal distention.

KEY RESULTS

In comparison with HV (75±13 mL) and with patients with meal-unrelated abdominal distention (135±56 mL), in the subgroup of patients with severe meal-related abdominal distention recto-sigmoid tone response to the meal was significantly reduced (mean increase of balloon volume 184±89 mL; P<.001), paralleling abdominal girth increase and occurring immediately after test meal intake. Meal-induced abdominal girth modification was significantly correlated with meal-related modification of recto-sigmoid tone (r=.71) and abdominal symptoms.

CONCLUSIONS

In patients with IBS suffering from severe postprandial abdominal distention, a postprandial reduction of intestinal tone is associated with this bothersome symptom. Further studies are needed to evaluate whether drugs acting on the modification of intestinal tone could be useful in the treatment of these patients.

Global Performance Status Score: A New Tool to Assess Physical Performance in Kidney Transplant Patients

BACKGROUND

Information on physical performance in renal transplantation is limited because of the shortage of specifically designed evaluation instruments. Therefore, we elaborated and validated the Global Performance Status (GloPerSta) score to provide a new and comprehensive tool, exploring the different components of physical performance in kidney transplant patients.

METHODS

We elaborated the GloPerSta score on the basis of the data obtained from a cross-sectional study, in which we evaluated the physical performance of a cohort of kidney transplant patients. The results of these analyses were weighted to describe the different contribution of any single test, via the generation of a structural equation model, resulting in the definition of the GloPerSta. Then, to internally validate this score, we studied its correlation with clinical parameters and quality of life (evaluated as KDQOL-SF, Kidney Disease Quality of Life-Short Form) in the same patient population.

RESULTS

We enrolled 132 patients in whom the functional tests revealed a great heterogeneity. GloPerSta allowed the stratification of the patients in 3 different physical performance categories (low: score 0-11; medium: 12-22; high: 23-33). Internal validation showed that GloPerSta was directly and significantly correlated with the quality of life and allograft function, independent of the time from transplantation.

CONCLUSIONS

The GloPerSta is a reliable tool to assess physical performance in a kidney transplant population. Its application might be of help in identifying patients needing intensive and personalized rehabilitation programs.

Kidney Intragraft Homing of De Novo Donor-Specific HLA Antibodies Is an Essential Step of Antibody-Mediated Damage but Not Per Se Predictive of Graft Loss

Donor-specific HLA antibody (DSA)-mediated graft injury is the major cause of kidney loss. Among DSA characteristics, graft homing has been suggested as an indicator of severe tissue damage. We analyzed the role of de novo DSA (dnDSA) graft homing on kidney transplantation outcome. Graft biopsy specimens and parallel sera from 48 nonsensitized pediatric kidney recipients were analyzed. Serum samples and eluates from graft biopsy specimens were tested for the presence of dnDSAs with flow bead technology. Intragraft dnDSAs (gDSAs) were never detected in the absence of serum dnDSAs (sDSAs), whereas in the presence of sDSAs, gDSAs were demonstrated in 72% of biopsy specimens. A significantly higher homing capability was expressed by class II sDSAs endowed with high mean fluorescence intensity and C3d- and/or C1q-fixing properties. In patients with available sequential biopsy specimens, we detected gDSAs before the appearance of antibody-mediated rejection. In sDSA-positive patients, gDSA positivity did not allow stratification for antibody-mediated graft lesions and graft loss. However, a consistent detection of skewed unique DSA specificities was observed over time within the graft, likely responsible for the damage. Our results indicate that gDSAs could represent an instrumental tool to identify, among sDSAs, clinically relevant antibody specificities requiring monitoring and possibly guiding patient management.

Acquisition of C3d-Binding Activity by De Novo Donor-Specific HLA Antibodies Correlates With Graft Loss in Nonsensitized Pediatric Kidney Recipients

Alloantibody-mediated graft injury is a major cause of kidney dysfunction and loss. The complement-binding ability of de novo donor-specific antibodies (dnDSAs) has been suggested as a prognostic tool to stratify patients for clinical risk. In this study, we analyzed posttransplant kinetics of complement-fixing dnDSAs and their role in antibody-mediated rejection development and graft loss. A total of 114 pediatric nonsensitized recipients of first kidney allograft were periodically monitored for dnDSAs using flow bead assays, followed by C3d and C1q assay in case of positivity. Overall, 39 patients developed dnDSAs, which were C1q(+) and C3d(+) in 25 and nine patients, respectively. At follow-up, progressive acquisition over time of dnDSA C1q and C3d binding ability, within the same antigenic specificity, was observed, paralleled by an increase in mean fluorescence intensity that correlated with clinical outcome. C3d-fixing dnDSAs were better fit to stratify graft loss risk when the different dnDSA categories were evaluated in combined models because the 10-year graft survival probability was lower in patients with C3d-binding dnDSA than in those without dnDSAs or with C1q(+) /C3d(-) or non-complement-binding dnDSAs (40% vs. 94%, 100%, and 100%, respectively). Based on the kinetics profile, we favor dnDSA removal or modulation at first confirmed positivity, with treatment intensification guided by dnDSA biological characteristics.

Use of herbal remedies by multiple sclerosis patients: a nation-wide survey in Italy

Though recent progress in multiple sclerosis (MS) treatment is remarkable, numerous unmet needs remain to be addressed often inducing patients to look for complementary and alternative medicines (CAM), especially herbal remedies (HR). HR use, scarcely investigated in MS, may cause adverse reactions (AR) and interfere with conventional treatment. We performed a survey aimed at evaluating use and attitudes towards HR and factor associated to HR use. Other CAM use and attitudes have been investigated as well. Multiple-choice questionnaires were distributed to MS out patients attending 14 Italian referral Centers. Multivariable logistic regression was used to identify HR use determinants. Present/past HR use for either MS or other diseases was reported in 35.6 % of 2419 cases (95 % CI 36.0-40.0 %). CAM use was reported in 42.5 % of cases. Independent predictors of HR use were represented by higher education, geographic area, dissatisfaction with conventional treatment of diseases other than MS and benefit perception from CAM use. Both HR and CAM use were not always disclosed to the healthcare professional. In conclusion, HR and other CAM appear to be popular among MS patients. The involvement of the healthcare professionals appears to be scarce with potential risk of AR or interference with conventional treatments.

Effects of two-months balanced diet in metabolically healthy obesity: lipid correlations with gender and BMI-related differences

Background

Nowadays no researches has been performed on fatty acid profile (FA) and desaturase activity in metabolically healthy obesity (MHO). The aim of this study was to assessed gender and BMI-related difference in FA, estimated desaturase activities and the efficacy on metabolic changes produced by 2-months well-balance diet in MHO subjects.

Methods

In 103 MHO subjects (30/73 M/F; age:42.2 ± 9.5) FA, estimated desaturase activity, body composition (by DXA), Body Mass Index (BMI), lipid profile, adipokines (leptin, adiponectin, grelin, glucagon-like peptide-1), insulin resistence (by Homestasis metabolic assessment), C-reactive proteine, Atherogenic index of plasma (AIP) and Body Shape Index (ABSI) have been assessed. Gender and BMI related difference have been evaluated and the efficacy produced by 2-months well-balance diet has been considered.

Results

At baseline, obese subjects, compared to overweight, show a significantly higher oleic (p <0.050), monounsaturated fatty acids (p <0.040), C18:0 delta-9 desaturase activity (D9D) (p <0.040) and lower linoleic acid (p <0.020), polyunsaturated fatty acids (p <0.020) and n-6 LCPUFA (p <0.010). Concerning gender-related difference, women show a significantly higher arachidonic acid (p <0.001), polyunsaturated fatty acids (p <0.001), n-6 LCPUFA (p <0.002), and lower monounsaturated fatty acids (p <0.001), D6D activity (p <0.030), C18:0 D9D (0.000) and C16:0 D9D (p <0.030). The 2-months diet was associated with a significantly increase in arachidonic acid (p = 0.007), eicosapentaenoic acid (p = 0.030), docosahexaenoic acid (p <0.001), long chain omega 3 polyunsaturated fatty acids (n-3 LCPUFA) (p <0.001), delta-5 desaturase activity (D5D) (p = 0.002), glucagon like peptide-1 (p <0.001) and a significant decrease in palmitoleic acid (p = <0.030), n-6/n-3 LCPUFA (p <0.001), insulin resistance (p = 0.006), leptin (p = 0.006), adiponectin (p <0.001), grelin (p = 0.030), CRP (p = 0.004), BMI (p <0.001) and android fat mass (p <0.001).

Conclusions

The balanced diet intervention was effective in improving metabolic indices.

Grading the neuroendocrine tumors of the lung: an evidence-based proposal

Lung neuroendocrine tumors are catalogued in four categories by the World Health Organization (WHO 2004) classification. Its reproducibility and prognostic efficacy was disputed. The WHO 2010 classification of digestive neuroendocrine neoplasms is based on Ki67 proliferation assessment and proved prognostically effective. This study aims at comparing these two classifications and at defining a prognostic grading system for lung neuroendocrine tumors. The study included 399 patients who underwent surgery and with at least 1 year follow-up between 1989 and 2011. Data on 21 variables were collected, and performance of grading systems and their components was compared by Cox regression and multivariable analyses. All statistical tests were two-sided. At Cox analysis, WHO 2004 stratified patients into three major groups with statistically significant survival difference (typical carcinoid vs atypical carcinoid (AC), P=0.021; AC vs large-cell/small-cell lung neuroendocrine carcinomas, P<0.001). Optimal discrimination in three groups was observed by Ki67% (Ki67% cutoffs: G1 <4, G2 4-<25, G3 ≥25; G1 vs G2, P=0.021; and G2 vs G3, P≤0.001), mitotic count (G1 ≤2, G2 >2-47, G3 >47; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001), and presence of necrosis (G1 absent, G2 <10% of sample, G3 >10% of sample; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001) at uni and multivariable analyses. The combination of these three variables resulted in a simple and effective grading system. A three-tiers grading system based on Ki67 index, mitotic count, and necrosis with cutoffs specifically generated for lung neuroendocrine tumors is prognostically effective and accurate.