Polythylene glycol severe allergy and SARS-CoV-2 vaccines: usefulness of testing with PEG 1500 extract

Summary

Background. Polyethylene glycol (PEG) is being used for first time as an excipient for mRNA anti-SARS-CoV-2 vaccines containing PEG 2000, highlighting it as a potential cause of anaphylaxis. Methods. We evaluated 126 patients with moderate-high risk of allergy to SARS-CoV-2 vaccines referred to our department from March-December 2021. Skin tests were performed with PEG 1500 extract (Roxall), using a stepwise approach, with readings at 30 minutes: prick tests with 0.1%, 1% and 10% concentrations; if negative, intradermal tests with 0.0001%, 0.001% and 0.01% concentrations. The same protocol was applied to 5 healthy controls Results. Six patients had positive immediate intradermal tests with PEG 1500, all with severe PEG allergy: one with a near-fatal anaphylaxis after glucocorticoid injection containing PEG 3350 and five with systemic allergic reactions after mRNA vaccines containing PEG 2000 (Pfizer-BioNTech or Moderna). One patient developed anaphylaxis during intradermal test. These six patients were negative to polysorbate 80. The remaining 120 patients had negative tests to PEG 1500; seven had positive tests to polysorbate 80. All controls had negative tests. Conclusions. To our knowledge this is the first study describing the allergy work-up testing with PEG 1500 commercial extract in the scope of SARS-CoV-2 vaccination. The algorithm designed for skin tests revealed to be a useful tool. Severe PEG allergy was diagnosed in 5% of patients, contraindicating PEG-containing vaccines. PEG allergy was excluded in one hundred patients that afterwards took SARS-CoV-2 vaccines containing PEG 2000. Investigation should be conducted in specialized drug allergy centers..

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs <7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

Small-scale agricultural grassland management can affect soil fungal community structure as much as continental scale geographic patterns

A European transect was established, ranging from Sweden to the Azores, to determine the relative influence of geographic factors and agricultural small-scale management on the grassland soil microbiome. Within each of five countries (factor ‘Country’), which maximized a range of geographic factors, two differing growth condition regions (factor ‘GCR’) were selected: a favorable region with conditions allowing for high plant biomass production and a contrasting less favorable region with a markedly lower potential. Within each region, grasslands of contrasting management intensities (factor ‘MI’) were defined: intensive and extensive, from which soil samples were collected. Across the transect, ‘MI’ was a strong differentiator of fungal community structure, having a comparable effect to continental scale geographic factors (‘Country’). ‘MI’ was also a highly significant driver of bacterial community structure, but ‘Country’ was clearly the stronger driver. For both, ‘GCR’ was the weakest driver. Also at the regional level, strong effects of MI occurred on various measures of the soil microbiome (i.e. OTU richness, management-associated indicator OTUs), though the effects were largely regional-specific. Our results illustrate the decisive influence of grassland MI on soil microbial community structure, over both regional and continental scales, and, thus, highlight the importance of preserving rare extensive grasslands.

The world upside down – after 20 years follow-up of dextro-transposition of the great arteries

Introduction

Congenital Heart Disease (CHD) affects under 1% of newborns and thanks to its prognosis improvement, most patients survive until adulthood. Dextro-transposition of the great arteries (dTGA) is a CHD classically palliated with atrial switch (ATS) procedure and nowadays corrected with an arterial switch (ARS), with better clinical outcomes. Nevertheless, several post-ATS patients remain alive and questions persist regarding their long-term prognosis.

Purpose

To observe a group of dTGA patients followed in an Adult CHD outpatients clinic, access their comorbidities, surgical interventions, complications and clinical outcomes.

Methods

We retrospectively analyzed a group of dTGA patients born between 1974 and 2001. Clinical features were collected and time-to-event statistics were analyzed. Adverse event was defined as at least one of the follows: death, stroke, myocardial infarction or coronary revascularization, arrhythmia and ventricular, valvular or conduct dysfunction.

Results

A total of 80 patients were enrolled with a mean follow-up of 26 years after surgery: 46% were female, median age 27 (19–57) year-old. Concerning other concomitant defects, 25% had ventricular septal defect, 12% pulmonary stenosis, 3% aortic coarctation and 1% single coronary ostium. ATS palliation was performed in 54% of patients (Senning procedure in 95%) and ARS (Jatene procedure) in 45% of patients; median age at procedure was 13 months and 10 days, respectively. During follow-up, almost all patients submitted to ARS remained in sinus rhythm (97%) versus 64% of ATS patients (p=0.037). The latter group had higher incidence of arrythmias (40% vs 3%, p=0.013), mostly atrial flutter or fibrillation (present in 28%), followed by bradyarrhythmia (10%); median time from surgery to first arrhythmic event in these patients was 23 years. Also, systemic ventricle systolic dysfunction (SVSD) and chronotropic incompetence were significantly higher in ATS (41% vs 3%, p<0.001 and 46% vs 9%, p=0.005, respectively); mean time to SVSD was 29 years. In respect to long-term outcomes in ARS, the most frequent complications were moderate to severe aortic regurgitation, pulmonary stenosis and regurgitation, occurring in 21%, 7% and 3%, respectively. Concerning both groups, mean time to first adverse-event was 21 years. Regarding gender and demographic features, there were no differences in time-to-adverse-event, comparing patients living in urban versus rural neighbourhoods and female versus male (Log Rank, p=0.368 and p=0.693). Only one patient died, submitted to ATS, at 46 years-old, from chronic heart failure.

Conclusion

After a long-term free of events, ATS patients experienced more arrhythmic complications and SVSD. ARS complications were anastomosis related. This report highlights the efforts that should be made to identify late complication is this particular population. Of note, no demographic or gender differences were observed.

Funding Acknowledgement

Type of funding sources: None. Gender analysis

Supporting Frontline Staff During the COVID-19 Pandemic

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic that emerged in early 2020 put unprecedented physical, mental, and emotional strain on the staff of health care organizations, who have been caring for a critically ill patient population for more than a year and a half. Amid the ongoing pandemic, health care workers have struggled to keep up with new information about the disease, while also coping with the anxiety associated with caring for affected patients. It has also been a continual challenge for nurse leaders to provide adequate support for staff members and keep them informed about frequently changing practices and protocols. In this article, nursing leaders at an academic medical center in Boston reflect on the initial COVID-19 patient surge, which occurred from March to June 2020, and identify key actions taken to provide clinical and emotional support to frontline staff who cared for these patients. Lessons learned in this period provide insight into the management of redeployed staff, use of emotional support and debriefing, and relationship between access to information and staff morale. The knowledge gained through these initial experiences has been a vital resource as health care workers continue to face challenges associated with the ongoing pandemic.

Does age at aortic coarctation repair have an impact on left ventricle size and function?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Adults with repaired aortic coarctation (CoA) require lifelong follow-up due to late complications, including left ventricular (LV) myocardial dysfunction. Age at the time of CoA repair is an important prognostic factor in these patients (pts).

Purpose

To evaluate LV size, ejection fraction (EF) and global longitudinal strain (GLS) values using 2D speckle tracking echocardiography (STE) in a population of adult pts with repaired CoA and to assess the relationship between these echocardiographic parameters and age at the time of CoA repair.

Methods

Retrospective analysis of adult pts with repaired CoA, followed in a Grown Up Congenital Heart Disease Centre. Pts with hemodynamically significant concomitant cardiac lesions were ruled out. Epidemiologic and clinical data were obtained from clinical records. Transthoracic echocardiograms were reviewed in order to assess GLS using 2DSTE (Echopac Software, GE).

Results

The study population consisted of 63 pts (61.9% male), with a mean age of 35.3 years at the time of the echocardiographic evaluation. The mean age at the time of the CoA repair was 117 months (95% CI 89.8-144.1 months).

Surgical repair was performed in 46 pts (73%): resection with subclavian artery flap aortoplasty (n = 21); patch aortoplasty (n = 15) and head-to-head anastomosis (n = 10). In 10 pts there was no data regarding the type of surgical repair. Seven pts (11.1%) were submitted to percutaneous intervention (6 with aortic stent implantation and 1 with balloon aortic angioplasty).

Mean LVEF was 63.4% (CI 95% 55.6 – 71.2%) and mean LV end-diastolic diameter (LVEDD) was 50mm (CI 95% 43-57mm). Mean GLS was - 17.3 (CI 95% 14.8- 19.8), which is inferior to the mean normal values reported for the software used.

Age at the time of CoA repair had a statistically significant positive linear relationship with LVEDD (r= 0.282; p= 0.026) and a linear negative relationship with both GLS (r= -0,29; p= 0.022) and LVEF (r= -0.33; p= 0.05).

Conclusion

Older age at the time of CoA repair was associated with increased LVEDD and decreased GLS and LVEF. Also, GLS may be an important tool for the identification of subclinical LV dysfunction in adult pts with repaired CoA.

A Phase I/II Clinical Trial to evaluate the efficacy of baricitinib to prevent respiratory insufficiency progression in onco-hematological patients affected with COVID19: A structured summary of a study protocol for a randomised controlled trial

OBJECTIVES

Baricitinib is supposed to have a double effect on SARS-CoV2 infection. Firstly, it reduces the inflammatory response through the inhibition of the Januse-Kinase signalling transducer and activator of transcription (JAK-STAT) pathway. Moreover, it reduces the receptor mediated viral endocytosis by AP2-associated protein kinase 1 (AAK1) inhibition. We propose the use of baricinitib to prevent the progression of the respiratory insufficiency in SARS-CoV2 pneumonia in onco-haematological patients. In this phase Ib/II study, the primary objective in the safety cohort is to describe the incidence of severe adverse events associated with baricitinib administration. The primary objective of the randomized phase (baricitinib cohort versus standard of care cohort) is to evaluate the number of patients who did not require mechanical oxygen support since start of therapy until day +14 or discharge (whichever it comes first). The secondary objectives of the study (only randomized phase of the study) are represented by the comparison between the two arms of the study in terms of mortality and toxicity at day+30. Moreover, a description of the immunological related changes between the two arms of the study will be reported.

TRIAL DESIGN

The trial is a phase I/II study with a safety run-in cohort (phase 1) followed by an open label phase II randomized controlled trial with an experimental arm compared to a standard of care arm.

PARTICIPANTS

The study will be performed at the Institut Català d'Oncologia, a tertiary level oncological referral center in the Catalonia region (Spain). The eligibility criteria are: patients > 18 years affected by oncological diseases; ECOG performance status < 2 (Karnofsky score > 60%); a laboratory confirmed infection with SARS-CoV-2 by means of real -time PCR; radiological signs of low respiratory tract disease; absence of organ dysfunction (a total bilirubin within normal institutional limits, AST/ALT≤2.5 X institutional upper limit of normal, alkaline phosphatase ≤2.5 X institutional upper limit of normal, coagulation within normal institutional limits, creatinine clearance >30 mL/min/1.73 m² for patients with creatinine levels above institutional normal); absence of HIV infection; no active or latent HBV or HCV infection. The exclusion criteria are: patients with oncological diseases who are not candidates to receive any active oncological treatment; hemodynamic instability at time of study enrollment; impossibility to receive oral medication; medical history of recent or active pulmonary embolism or deep venous thrombosis or patients at high-risk of suffering them (surgical intervention, immobilization); multi organ failure, rapid worsening of respiratory function with requirement of fraction of inspired oxygen (FiO₂) > 50% or high-flow nasal cannula before initiation of study treatment; uncontrolled intercurrent illness (ongoing or severe active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements); allergy to one or more of study treatments; pregnant or breastfeeding women; positive pregnancy test in a pre-dose examination. Patients should have the ability to understand, and the willingness to sign, a written informed consent document; the willingness to accept randomization to any assigned treatment arm; and must agree not to enroll in another study of an investigational agent prior to completion of Day +28 of study. An electronic Case Report Form in the Research Electronic Data Capture (REDCap) platform will be used to collect the data of the trial. Removal from the study will apply in case of unacceptable adverse event(s), development of an intercurrent illness, condition or procedural complication, which could interfere with the patient's continued participation and voluntary patient withdrawal from study treatment (all patients are free to withdraw from participation in this study at any time, for any reasons, specified or unspecified, and without prejudice).

INTERVENTION AND COMPARATOR

Treatment will be administered on an inpatient basis. We will compare the experimental treatment with baricitinib plus the institutional standard of care compared with the standard of care alone. During the phase I, we will define the dose-limiting toxicity of baricitinib and the dose to be used in the phase 2 part of the study. The starting baricitinib dose will be an oral tablet 4 mg-once daily which can be reduced to 2 mg depending on the observed toxicity. The minimum duration of therapy will be 5 days and it can be extended to 7 days. The standard of care will include the following therapies. Antibiotics will be individualized based on clinical suspicion, including the management of febrile neutropenia. Prophylaxis of thromboembolic disease will be administered to all participants. Remdesivir administration will be considered only in patients with severe pneumonia (SatO₂ <94%) with less than 7 days of onset of symptoms and with supplemental oxygen requirements but not using high-flow nasal cannula, non-invasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO). In the randomized phase, tocilizumab or interferon will not be allowed in the experimental arm. Tocilizumab can be used in patients in the standard of care arm at the discretion of the investigator. If it is prescribed it will be used according to the following criteria: patients who, according to his baseline clinical condition, would be an ICU tributary, interstitial pneumonia with severe respiratory failure, patients who are not on mechanical ventilation or ECMO and who are still progressing with corticoid treatment or if they are not candidates for corticosteroids. Mild ARDS (PAFI <300 mmHg) with radiological or blood gases deterioration that meets at least one of the following criteria: CRP >100mg/L D-Dimer >1,000μg/L LDH >400U/L Ferritin >700ng/ml Interleukin 6 ≥40ng/L. The use of tocilizumab is not recommended if there are AST/ALT values greater than 10 times the upper limit of normal, neutrophils <500 cells/mm3, sepsis due to other pathogens other than SARS-CoV-2, presence of comorbidity that can lead to a poor prognosis, complicated diverticulitis or intestinal perforation, ongoing skin infection. The dose will be that recommended by the Spanish Medicine Agency in patients ≥75Kg: 600mg dose whereas in patients <75kg: 400mg dose. Exceptionally, a second infusion can be assessed 12 hours after the first in those patients who experience a worsening of laboratory parameters after a first favourable response. The use of corticosteroids will be recommended in patients who have had symptoms for more than 7 days and who meet all the following criteria: need for oxygen support, non-invasive or invasive mechanical ventilation, acute respiratory failure or rapid deterioration of gas exchange, appearance or worsening of bilateral alveolar-interstitial infiltrates at the radiological level. In case of indication, it is recommended: dexamethasone 6mg/d p.o. or iv for 10 days or methylprednisolone 32mg/d orally or 30mg iv for 10 days or prednisone 40mg day p.o. for 10 days.

MAIN OUTCOMES

Phase 1 part: to describe the toxicity profile of baricitinib in COVID19 oncological patients during the 5-7 day treatment period and until day +14 or discharge (whichever it comes first). Phase 2 part: to describe the number of patients in the experimental arm that will not require mechanical oxygen support compared to the standard of care arm until day +14 or discharge (whichever it comes first).

RANDOMISATION

For the phase 2 of the study, the allocation ratio will be 1:1. Randomization process will be carried out electronically through the REDcap platform ( https://www.project-redcap.org/ ) BLINDING (MASKING): This is an open label study. No blinding will be performed.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

The first part of the study (safety run-in cohort) will consist in the enrollment of 6 to 12 patients. In this population, we will test the toxicity of the experimental treatment. An incidence of severe adverse events grade 3-4 (graded by Common Terminology Criteria for Adverse Events v.5.0) inferior than 33% will be considered sufficient to follow with the next part of the study. The second part of the study we will perform an interim analysis of efficacy at first 64 assessed patients and a definitive one will analyze 128 assessed patients. Interim and definitive tests will be performed considering in both cases an alpha error of 0.05. We consider for the control arm this rate is expected to be 0.60 and for the experimental arm of 0.80. Considering this data, a superiority test to prove a difference of 0.20 with an overall alpha error of 0.10 and a beta error of 0.2 will be performed. Considering a 5% of dropout rate, it is expected that a total of 136 patients, 68 for each study arm, will be required to complete study accrual.

TRIAL STATUS

Version 5.0. 14^th October 2020 Recruitment started on the 16^th of December 2020. Expected end of recruitment is June 2021.

TRIAL REGISTRATION

AEMPs: 20-0356 EudraCT: 2020-001789-12, https://www.clinicaltrialsregister.eu/ctr-search/search (Not publically available as Phase I trial) Clinical trials: BARCOVID19, https://www.clinicaltrials.gov/ (In progress) FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol."

Coronary artery fistulas: a single-center case series

Introduction

Coronary artery fistulas (CAFs) are rare anomalous connections between a coronary artery and a major vessel or cardiac chamber. Currently they are being increasingly encountered due to the more widespread use of various imaging modalities and coronary angiography. Although the vast majority of CAFs are incidentally diagnosed and have no clinical relevance, they can cause significant morbidity such as myocardial infarction, congestive heart failure and endocarditis.

Methods

A consecutive series of 55867 coronary arteriograms performed in our Cardiology Department from 2007 to 2019 was retrospectively investigated for the presence of coronary artery fistulas. Patients clinical, angiographic and therapeutic data up to november 2019 were analyzed. Data were obtained from medical records of hospital stay and subsequent consultations.

Results

We identified 50 patients who were diagnosed with one or more CAFs, with ages between 5 and 85 years (mean 59 years). 62% (n=31) were males.

The great majority of patients had a single fistula (n=34, 68%), 11 patients had two fistulas (22%), 1 patient had 3 fistulas (2%) and 4 patients had multiple fistulas (8%).

CAFs arose more frequently from the left anterior descending artery (n=27), followed by the right coronary (n=18), left circumflex (n=15), left main (n=5) and intermediate artery (n=2). The most frequent drainage site was the pulmonary artery (n=38).

The majority of CAFs were incidentally found (n=32; 64%) and thought to have no significance for the patients' clinical status. As for the rest of the patients, CAFs were diagnosed during evaluation of: a heart murmur (n=7); exertional chest pain with no associated significant atherosclerotic coronary artery disease (n=7); exertional dyspnea (n=2); positive exercise stress test (n=1); NSTEMI and cardiac arrest (n=1).

Regarding treatment, watchful waiting was the main approach (n=40; 80%). 3 patients had their CAFs closed during surgery for another heart condition (CABG/aortic valve replacement). In 1 patient, heart surgery was specifically conducted for fistula closure. 6 patients (12%) underwent fistula transcatheter closure.

Conclusion

CAFs are rare coronary anomalies and the majority has no clinical relevance, so watchful waiting is the commonest approach. When they are hemodynamically significant or symptoms/complications arise, surgical or transcatheter closure should be considered. This study describes the angiographic, clinical and therapeutic data of CAFs detected along the last 12 years in a single tertiary care center catheterization laboratory.

Funding Acknowledgement

Type of funding source: None

A systematic review on resource allocation in public health

Background

Research in resource allocation is a need arising from State interference by the allocative function, which seeks to promote resource adjustments with the provision of certain goods and public services (Musgrave, 1974; Musgrave & Musgrave, 1980, Longo & Troster, 1993). In this perspective, a research question arises: how has international literature on the field of Business, Management and Accounting been approaching resource allocation in public health?

Methods

Systematic Literature Review through the Scopus Database. keywords: “public health” and “resource allocation”. The types were Article and Review. Language: English, since it is internationally accepted in scientific articles, and Portuguese, in order to include Brazilian research. Search period: from 1976 to 2017. Areas: “Business, Management and Accounting”. The performed analysis technique was qualitative meta-synthesis and by using the MAXQDA Analytics Pro 18 software.

Results

The first identified study was in 2000 Sweden, pulished in Health Care Management Science. The most recente in 2017 Brazil, published in Evaluation and Program Planning. Among the countries that presented the largest production, the United States is highlighted (4). Dispersion of publication among reviews was noted. Generally, publications are grouped in four perspectives: adequate allocation, resource management and effective cost; resource allocation for treating specific diseases; resource allocation for decision-making; and health evaluation and the need of informing resource allocation. The prevailing lack of theoretical grounding must be highlighted.

Conclusions

Can be inferred that this production is recent, that it does not possess a specific focus or outline, as there is a variety of approaches, most of them being geared towards healthcare and disease control, such as cancer, diabetes, overweight, rabies, malaria and infectious diseases.

Key messages

International literature indicates that the theme is yet unexplored in the field of Business, Management e Accounting and most studies are geared towards healthcare and disease control. Allocation in the public-health policy as a function of the role of the State in providing the necessary budget for financial availability and not cost-wise, suggests lack of research.

18F-FDG PET/CT quantitative parameters as prognostic factor in localized and inoperable lung cancer

AIM

To assess the utility of ¹⁸F-FDG PET/CT quantitative parameters as prognostic factor in patients diagnosed with localized and inoperable lung cancer treated by stereotactic body radiotherapy (SBRT).

MATERIAL AND METHODS

Fifty patients (42 men) diagnosed in the last 7years with early-stage lung cancer and treated with SBRT alone were assessed by a prospective study. After PET/CT study, metabolic parameters maximum SUV (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were determined at different thresholds. The prognostic factors for overall survival (OS), cause-specific survival (CS) and disease-free survival (DFS) were analysed by Cox proportional hazards model and the survival analysis by Kaplan-Meier method.

RESULTS

The average follow-up was 39.6months, with 21 recurrences and 24 dead. Univariate analysis determined MTV₃₀ and MTV₄₀ as predictors for OS; MTV₃₀, MTV₄₀, TLG₃₀ and TLG₄₀ for CS, and MTV₂, MTV₃₀, MTV₄₀, TLG₂, TLG₃₀ and TLG₄₀ for DFS. Survival analysis found statistically significant differences for CS and DFS depending on tumor size and for DFS considering the cut-off values of MTV₂ and TLG₂ (threshold SUVmax=2). SUVmax, age and sex were not shown to be significant factors.

CONCLUSION

Pre-treatment quantitative assessment using metabolic parameters MTV₂ and TLG₂ as well as tumor size proved to be prognostic factors in patients diagnosed with localized and inoperable lung cancer treated by SBRT. Results could help to personalize treatment.

Non-Arrhenius behavior and fragile-to-strong transition of glass-forming liquids

Characterization of the non-Arrhenius behavior of glass-forming liquids is a broad avenue for research toward the understanding of the formation mechanisms of noncrystalline materials. In this context, this paper explores the main properties of the viscosity of glass-forming systems, considering super-Arrhenius diffusive processes. We establish the viscous activation energy as a function of the temperature, measure the degree of fragility of the system, and characterize the fragile-to-strong transition through the standard Angell's plot. Our results show that the non-Arrhenius behavior observed in fragile liquids can be understood through the non-Markovian dynamics that characterize the diffusive processes of these systems. Moreover, the fragile-to-strong transition corresponds to a change in the spatiotemporal range of correlations during the glass transition process.

Angiotensin II receptor agonist antibodies are associated with microvascular damage in lupus nephritis

Angiotensin II type 1 receptor agonist antibodies (AT1R-AAs) have been associated with hypertension, atherosclerosis and vascular inflammation in human diseases. The aim of the study was to evaluate the prevalence of AT1R-AAs in active lupus nephritis (LN) patients and their association with vascular damage. One hundred and seven active LN patients underwent a complete clinical examination, measurement of AT1R-AAs, ambulatory blood pressure monitoring, carotid intima-media thickness measurement and morphometric analysis of subintimal fibrosis and medial hyperplasia of the vessels in the kidney tissue. Plasma AT1R-AAs were positive in 58 (54.2%) patients. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score, complement C3 and C4 levels and titers of anti-dsDNA antibodies were higher in the group with positive AT1R-AAs compared with those with negative AT1R-AAs. The AT1R-AA titers correlated with anti-dsDNA antibody titers and with complement C3 and C4 serum levels. In the kidney biopsy, the percentage of subintimal fibrosis and the area of medial hyperplasia were greater in the AT1R-AA-positive patients. No differences in arterial pressure, carotid intima-media thickness and response to therapy were detected. In conclusion, AT1R-AAs are prevalent in active LN patients and are associated with histologic features of microvascular damage.

Determination of Decoquinate in Animal Feeds by Liquid Chromatography: Collaborative Study

The performance characteristics of a liquid chromatographic (LC) method for the analysis of decoquinate (DEC) in supplements, premixes, and complete animal feeds at medicating and trace levels were collaboratively studied. DEC is extracted from ground feed samples with 1 calcium chloridemethanol solution using mechanical agitation for 90 min. After centrifugation for 5 min and dilution (if necessary), an aliquot of the extract is diluted with water. The diluted extracts are filtered and analyzed by reversed-phase LC with fluorescence detection. Suspect positive trace-level samples are confirmed by using an alternate excitation wavelength. Fourteen test samples of medicated feeds, supplement, and medicated premix, along with 8 test samples for trace-level analysis, were sent to 13 collaborators (one in Canada, 4 in Europe, and 8 in the United States). Test samples were analyzed as blind duplicates. Acceptable results were received from 12 laboratories for the medicated test samples and from 13 laboratories for the trace-level samples. Repeatability relative standard deviation estimates ranged from 1.3 to 5.6. Reproducibility relative standard deviations estimates ranged from 2.8 to 6.1, and HorRat values ranged from 0.22 to 0.74.

Characterization of the non-Arrhenius behavior of supercooled liquids by modeling nonadditive stochastic systems

The characterization of the formation mechanisms of amorphous solids is a large avenue for research, since understanding its non-Arrhenius behavior is challenging to overcome. In this context, we present one path toward modeling the diffusive processes in supercooled liquids near glass transition through a class of nonhomogeneous continuity equations, providing a consistent theoretical basis for the physical interpretation of its non-Arrhenius behavior. More precisely, we obtain the generalized drag and diffusion coefficients that allow us to model a wide range of non-Arrhenius processes. This provides a reliable measurement of the degree of fragility of the system and an estimation of the fragile-to-strong transition in glass-forming liquids, as well as a generalized Stokes-Einstein equation, leading to a better understanding of the classical and quantum effects on the dynamics of nonadditive stochastic systems.

A decade of clinical development of PARP inhibitors in perspective

Genomic instability is a hallmark of cancer, and often is the result of altered DNA repair capacities in tumour cells. DNA damage repair defects are common in different cancer types; these alterations can also induce tumour-specific vulnerabilities that can be exploited therapeutically. In 2009, a first-in-man clinical trial of the poly(ADP-ribose) polymerase (PARP) inhibitor olaparib clinically validated the synthetic lethal interaction between inhibition of PARP1, a key sensor of DNA damage, and BRCA1/BRCA2 deficiency. In this review, we summarize a decade of PARP inhibitor clinical development, a work that has resulted in the registration of several PARP inhibitors in breast (olaparib and talazoparib) and ovarian cancer (olaparib, niraparib and rucaparib, either alone or following platinum chemotherapy as maintenance therapy). Over the past 10 years, our knowledge on the mechanism of action of PARP inhibitor as well as how tumours become resistant has been extended, and we summarise this work here. We also discuss opportunities for expanding the precision medicine approach with PARP inhibitors, identifying a wider population who could benefit from this drug class. This includes developing and validating better predictive biomarkers for patient stratification, mainly based on homologous recombination defects beyond BRCA1/BRCA2 mutations, identifying DNA repair deficient tumours in other cancer types such as prostate or pancreatic cancer, or by designing combination therapies with PARP inhibitors.

δ15N of lichens reflects the isotopic signature of ammonia source

Although it is generally accepted that δ¹⁵N in lichen reflects predominating N isotope sources in the environment, confirmation of the direct correlation between lichen δ¹⁵N and atmospheric δ¹⁵N is still missing, especially under field conditions with most confounding factors controlled. To fill this gap and investigate the response of lichens with different tolerance to atmospheric N deposition, thalli of the sensitive Evernia prunastri and the tolerant Xanthoria parietina were exposed for ten weeks to different forms and doses of N in a field manipulation experiment where confounding factors were minimized. During this period, several parameters, namely total N, δ¹⁵N and chlorophyll a fluorescence, were measured. Under the experimental conditions, δ¹⁵N in lichens quantitatively responded to the δ¹⁵N of released gaseous ammonia (NH₃). Although a high correlation between the isotopic signatures in lichen tissue and supplied N was found both in tolerant and sensitive species, chlorophyll a fluorescence indicated that the sensitive species very soon lost its photosynthetic functionality with increasing N availability. The most damaging response to the different N chemical forms was observed with dry deposition of NH₃, although wet deposition of ammonium ions had a significant observable physiological impact. Conversely, there was no significant effect of nitrate ions on chlorophyll a fluorescence, implying differential sensitivity to dry deposition versus wet deposition and to ammonium versus nitrate in wet deposition. Evernia prunastri was most sensitive to NH₃, then NH₄⁺, with lowest sensitivity to NO₃^-. Moreover, these results confirm that lichen δ¹⁵N can be used to indicate the δ¹⁵N of atmospheric ammonia, providing a suitable tool for the interpretation of the spatial distribution of NH₃ sources in relation to their δ¹⁵N signal.

RAD51 foci as a functional biomarker of homologous recombination repair and PARP inhibitor resistance in germline BRCA-mutated breast cancer

Background

BRCA1 and BRCA2 (BRCA1/2)-deficient tumors display impaired homologous recombination repair (HRR) and enhanced sensitivity to DNA damaging agents or to poly(ADP-ribose) polymerase (PARP) inhibitors (PARPi). Their efficacy in germline BRCA1/2 (gBRCA1/2)-mutated metastatic breast cancers has been recently confirmed in clinical trials. Numerous mechanisms of PARPi resistance have been described, whose clinical relevance in gBRCA-mutated breast cancer is unknown. This highlights the need to identify functional biomarkers to better predict PARPi sensitivity.

Patients and methods

We investigated the in vivo mechanisms of PARPi resistance in gBRCA1 patient-derived tumor xenografts (PDXs) exhibiting differential response to PARPi. Analysis included exome sequencing and immunostaining of DNA damage response proteins to functionally evaluate HRR. Findings were validated in a retrospective sample set from gBRCA1/2-cancer patients treated with PARPi.

Results

RAD51 nuclear foci, a surrogate marker of HRR functionality, were the only common feature in PDX and patient samples with primary or acquired PARPi resistance. Consistently, low RAD51 was associated with objective response to PARPi. Evaluation of the RAD51 biomarker in untreated tumors was feasible due to endogenous DNA damage. In PARPi-resistant gBRCA1 PDXs, genetic analysis found no in-frame secondary mutations, but BRCA1 hypomorphic proteins in 60% of the models, TP53BP1-loss in 20% and RAD51-amplification in one sample, none mutually exclusive. Conversely, one of three PARPi-resistant gBRCA2 tumors displayed BRCA2 restoration by exome sequencing. In PDXs, PARPi resistance could be reverted upon combination of a PARPi with an ataxia-telangiectasia mutated (ATM) inhibitor.

Conclusion

Detection of RAD51 foci in gBRCA tumors correlates with PARPi resistance regardless of the underlying mechanism restoring HRR function. This is a promising biomarker to be used in the clinic to better select patients for PARPi therapy. Our study also supports the clinical development of PARPi combinations such as those with ATM inhibitors.

Robust singlet fission in pentacene thin films with tuned charge transfer interactions

Singlet fission, the spin-allowed photophysical process converting an excited singlet state into two triplet states, has attracted significant attention for device applications. Research so far has focused mainly on the understanding of singlet fission in pure materials, yet blends offer the promise of a controlled tuning of intermolecular interactions, impacting singlet fission efficiencies. Here we report a study of singlet fission in mixtures of pentacene with weakly interacting spacer molecules. Comparison of experimentally determined stationary optical properties and theoretical calculations indicates a reduction of charge-transfer interactions between pentacene molecules with increasing spacer molecule fraction. Theory predicts that the reduced interactions slow down singlet fission in these blends, but surprisingly we find that singlet fission occurs on a timescale comparable to that in pure crystalline pentacene. We explain the observed robustness of singlet fission in such mixed films by a mechanism of exciton diffusion to hot spots with closer intermolecular spacings.

Quantifying the relative effects of environmental and direct transmission of norovirus

Norovirus is a common cause of outbreaks of acute gastroenteritis in health- and child-care settings, with serial outbreaks also frequently observed aboard cruise ships. The relative contributions of environmental and direct person-to-person transmission of norovirus have hitherto not been quantified. We employ a novel mathematical model of norovirus transmission, and fit the model to daily incidence data from a major norovirus outbreak on a cruise ship, and examine the relative efficacy of potential control strategies aimed at reducing environmental and/or direct transmission. The reproduction number for environmental and direct transmission combined is [Formula: see text] [6.1,9.5], and of environmental transmission alone is [Formula: see text] [0.9,2.6]. Direct transmission is overwhelmingly due to passenger-to-passenger contacts, but crew can act as a reservoir of infection from cruise to cruise. This is the first quantification of the relative roles of environmental and direct transmission of norovirus. While environmental transmission has the potential to maintain a sustained series of outbreaks aboard a cruise ship in the absence of strict sanitation practices, direct transmission dominates. We find that intensive promotion of good hand washing practices may prevent outbreaks. Isolation of ill passengers and cleaning are beneficial, but appear to be less efficacious at outbreak control.

Abstract P2-09-25: Clinical and pathologic characteristics of breast cancers determined to be HER2-positive by fluorescence in-situ hybridization (FISH) using alternative chromosome 17 probes

Background:

Based on updated 2013 ASCO/CAP guideline for HER2 testing, cases with a HER2/CEP17 ratio &lt; 2.0 but with an average HER2 copy number &gt; 4.0 and &lt;6.0 signals/cell are considered equivocal. In such cases, HER2 testing using alternative chromosome 17 probes was proposed as one way to resolve the equivocal FISH results. Using the alternative probe method increases the number of cancers categorized as HER2 positive but brings to question if these cancers truly represent HER2 amplified breast cancers and derive the same benefit from anti-HER2 therapies.

Methods:

Since 2013, all breast cancers at our institution that were HER2 equivocal by traditional FISH but classified as HER2 positive using the alternative probe method were assessed for clinical and pathologic features including histologic type and grade, TNM stage, HER2: alternative probe ratio, treatment, and clinical outcome.

Results:

We identified 24 invasive breast cancers considered HER2 positive by the alternative probe method: 23 (96%) were estrogen receptor-positive (ER+) and 20 (83%) were progesterone receptor- positive. Histologically, only 2 were invasive lobular carcinomas; all others were ductal or had ductal and lobular features. Most cancers (63%) had low or intermediate histologic grade: Grade 1 (n=3); Grade 2 (n=12); Grade 3 (n=9). Clinical information was available for 18 patients: 2 had metastatic disease, 1 had a local recurrence after mastectomy and 15 patients had early stage disease; 9 with node negative disease and 6 with nodal involvement. HER2 IHC was equivocal (2+) in 16 (66.7%) cases, positive (3+) in 4 (16.7%) cases, and negative (0 or 1+) in 4 (16.7%) cases. The average HER2 copy number was 4.77, the average HER22:p53 ratio was 2.61. Repeat HER2 testing on a 2nd tumor sample was performed in 8 cases: HER2-positivity was confirmed in only 2 (25%) cases and by the alternative probe only. Treatment information was available for 17 patients: 1 had T1aN0M0 lesion and did not get chemotherapy, 16 received chemotherapy and 13 received trastuzumab-based chemotherapy. Eleven patients with early stage disease received chemotherapy and trastuzumab. Of these patients, 10/11 were ER+, 7/11 were node negative and 5/11 had grade 2 tumors, yet only one tumor was assessed by oncotype recurrence score ( RS = 29). Three patients received chemotherapy and trastuzumab in the neoadjuvant setting: 1 had a complete pathologic response, 1 a partial response, and 1 has not yet gone to surgery. One additional patient received neoadjuvant chemo alone and achieved a partial response.

Conclusions:

Breast cancers considered HER2+ by the alternative probe method but not by traditional FISH are almost always ER-positive and most have low or intermediate histologic grade. Repeat HER2 testing on a subsequent tumor sample did not confirm HER2-positivity in 75% of cases. Almost all patients with early stage disease received chemotherapy and trastuzumab based on the alternative probe results without molecular assessment to predict chemotherapy response. Intrinsic molecular subtyping using PAM50 analysis on these cancers is underway to determine how many are HER2-enriched by molecular assessment.

Citation Format: Desai NV, Torous V, Cruz C, Schnitt SJ, Tung N. Clinical and pathologic characteristics of breast cancers determined to be HER2-positive by fluorescence in-situ hybridization (FISH) using alternative chromosome 17 probes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-25.

Continuous Flow Peritoneal Dialysis: A New Double Lumen Catheter

Continuous flow peritoneal dialysis (CFPD) is a therapy originally utilized in the sixties. It was then abandoned because of technical reasons, but, today, a new interest in this technique is emerging, because of new technical solutions and new hardware capabilities. CFPD is a peritoneal dialysis technique in which a certain amount of fluid is maintained in the peritoneal cavity, while a continuous inflow and outflow is provided via twin catheters or through a double lumen catheter. In this paper a new double lumen catheter is presented. The catheter is characterized by the presence of a diffuser in the inflow lumen, while a standard coiled shape characterizes the outflow lumen. The diffuser allows the use of high dialysate flows without peritoneal damage and with an excellent distribution of the fluid. The other feature of the catheter is the removable hub which allows for an easy subcutaneous tunneling of the catheter with a subsequent connection to the y segment. The special shape also guarantees a minimum recirculation during treatment. Data obtained in the first implanted catheter showed a progressive increase in small solute clearances in relation to an increase of the flow and the tidal volume in the peritoneal cavity. In particular, urea clearances up to 48 ml/min and creatinine clearances up to 39 ml/min were obtained. No major complications were observed after one year of use of the catheter.

Neurogenic stuttering: a review of the literature

INTRODUCTION

Neurogenic stuttering is a disorder of neurologic origin in the rhythm of speech during which the patient knows exactly what he wants to say but is unable to because of an involuntary prolongation, cessation or repetition of a sound.

AIM

To assemble new insights regarding the epidemiology, pathophysiology, diagnosis, evaluation and treatment of neurogenic stuttering.

DEVELOPMENT

A review of all PubMed and Scopus published articles between January 2000 and September 2016 was performed. Thirty-three publications were analyzed. Neurogenic stuttering is a rare entity whose epidemiological incidence is yet not fully established. It is correlated with several neurological diseases and with several possible localizations within the nervous system. Notwithstanding the recent advances in the understanding of the underlying mechanism, it is not yet possible to establish a single pathophysiological mechanism of neurogenic stuttering. The differential diagnosis is complex and requires the detailed knowledge of other language disorders. The treatment is currently based on specific speech language therapy strategies.

CONCLUSION

Neurogenic stuttering is a complex disorder which is not fully understood. Additional studies might help to better explain the underlying pathophysiological mechanism and to open doors to novel therapeutic methods.

Dermal-fat graft for anophthalmic socket in children enucleated for retinoblastoma

Retinoblastoma is the most frequent intraocular tumour in childhood. The definitive treatment is enucleation. The management of the anophthalmic socket consists in the use of a plastic implant. The problem is that they are expensive and they usually extrude. The use of dermal-fat grafts minimises the hemi-facial hypoplasia. They usually grow with the face, and help to expand the orbital bones, thus avoiding the psychological and physical consequences.

OBJECTIVE

To determine if there is hemi-facial hypoplasia, using MRI images after the use of a dermal-fat implant in patients enucleated for RB.

METHOD

The study included patients enucleated for RB in which a dermal-fat implant was used and MRI images were taken in the period between June 2010 and December 2012. Facial growth and cosmesis was measured.

RESULTS

The study included 12 patients, aged between 6 to 41 months. After 24 months of follow up, none of them developed hemifacial hypoplasia. All had a good cosmesis with the prosthesis. There were no complications after the surgery.

CONCLUSIONS

The use of dermal-fat implant is a good option for the anophthalmic socket in patients with RB after enucleation.

Changes in the membrane carbohydrates from sperm cryopreserved with dimethylsulfoxide or polyvinylpyrrolidone of red-tailed hawk (Buteo jamaicencis)

BACKGROUND

That cryopreservation can induce alterations in sperm.

OBJECTIVE

The goal of this study was to evaluate sperm quality and distribution of N-acetylglucosamine, sialic acid and mannose residues in sperm cryopreserved of red-tailed hawk (Buteo jamaicensis).

MATERIALS AND METHODS

We studied twenty samples of ejaculated semen for each cryoprotectant dimethylsulfoxide or polyvinylpyrrolidone. Carbohydrate identification was carried out with lectins Triticum vulgaris agglutinin to N-acetylglucosamine and sialic acid and Concanavalia ensiformis for mannose residues. Sperm viability was not altered but motility decreased significantly with both crioprotectants compared with fresh sperm.

RESULTS

Neither the number of WGA positive sperm nor the distribution of N-acetylglucosamine and/or sialic acid residues were affected by the cryopreservation procedure. The sperm proportion with fluorescence associated with the presence of mannose residues was higher in thawed sperm.

CONCLUSION

Values obtained with the cryopreservation technique proposed in this study by freezing drops in liquid nitrogen, were within normal parameters established for good quality fresh semen. We can say that it can be used for assisted reproduction of Buteo jamaicensis.

Chemical disorder determines the deviation of the Slater-Pauling rule for Fe2MnSi-based Heusler alloys: evidences from neutron diffraction and density functional theory

Fe2MnSi fails to follow the Slater-Pauling rule. This phenomenon is thought to originate from either: (i) an antiferromagnetic arrangement of Mn ions at low temperature and/or (ii) chemical disorder. An important insight on this issue could be achieved by considering Fe2MnSi1-x Ga x compounds, thoroughly studied here by means of magnetization, neutron diffraction and density functional calculations (DFT). Our results indicate that chemical disorder (and not the antiferromagnetic arrangement) is responsible for the deviation of the Slater-Pauling rule on Fe2MnSi-based Heusler alloys. Furthermore, evidences suggest that Ga substitution into Si site favors the Fe/Mn disorder, further enhancing the observed deviation.

Toxicidade aguda e risco ambiental do antibiótico oxitetraciclina para tilápia ( Oreochromis niloticus ), Daphnia magna e Lemna minor

RESUMO O objetivo deste estudo foi classificar o antibiótico Terramicina(r) de acordo com a toxicidade aguda e o risco de intoxicação ambiental para Oreochromis niloticus, Daphnia magna e Lemna minor, com base no seu ingrediente ativo oxitetraciclina (OTC). Além disso, observou-se a ocorrência de sinais de intoxicação aguda em peixes e o efeito da diluição do antibiótico sobre as variáveis de qualidade de água. Alevinos, neonatos e frondes foram expostos a concentrações de OTC. De acordo com os resultados dos testes de toxicidade aguda, a Terramicina(r) foi classificada pela toxicidade aguda e pelo risco de intoxicação ambiental. Para O. niloticus, a CL(I)50; 48h calculada foi de 6,92 mg L-1, para D. magna a CE(I)50; 48h foi de 0,17mg.L-1, enquanto para L. minor a CI(I)50;7d foi de 0,68 mg L-1. A Terramicina(r) foi classificada como muito tóxica para O. niloticus e extremamente tóxica para D. magna e L. minor e causa risco de intoxicação ambiental para os três organismos testados. Concentrações de 7,5 e 8,0 mg L-1 de OTC reduziram a concentração de oxigênio dissolvido na água. De acordo com este estudo, a Terramicina(r) não deve ser utilizada na aquicultura, pois é altamente tóxica e causa risco de intoxicação ambiental aos organismos teste.