Dependency and frailty in the older haemodialysis patient

BACKGROUND

Frailty among older adults undergoing hemodialysis is increasingly prevalent, significantly impacting cognitive function, mobility, and social engagement. This study focuses on the clinical profiles of very older adults in hemodialysis, particularly examining the interplay of dependency and frailty, and their influence on dialysis regimens.

METHODS

In this observational, descriptive study, 107 patients aged over 75 from four outpatient centers and one hospital unit were examined over a year. Patient data encompassed sociodemographic factors, dialysis specifics, analytical outcomes, lifestyle elements, and self-reported post-treatment fatigue. Malnutrition-inflammation scale was used to measure the Nutritional status; MIS scale for malnutrition-inflammation, Barthel index for dependency, Charlson comorbidity index; FRIED scale for frailty and the SF12 quality of life measure.

RESULTS

The study unveiled that a substantial number of older adults on hemodialysis faced malnutrition (55%), dependency (21%), frailty (46%), and diminished quality of life (57%). Patients with dependency were distinctively marked by higher comorbidity, severe malnutrition, enhanced frailty, nursing home residency, dependency on ambulance transportation, and significantly limited mobility, with 77% unable to walk. Notably, 56% of participants experienced considerable post-dialysis fatigue, correlating with higher comorbidity, increased dependency, and poorer quality of life. Despite varying clinical conditions, dialysis patterns were consistent across the patient cohort.

CONCLUSIONS

The older adult cohort, averaging over four years on hemodialysis, exhibited high rates of comorbidity, frailty, and dependency, necessitating substantial support in transport and living arrangements. A third of these patients lacked residual urine output, yet their dialysis regimen mirrored those with preserved output. The study underscores the imperative for tailored therapeutic strategies to mitigate dependency, preserve residual renal function, and alleviate post-dialysis fatigue, ultimately enhancing the physical quality of life for these patients.

Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries-The @IT.2020 multicenter study

BACKGROUND

Pollen allergy poses a significant health and economic burden in Europe. Disease patterns are relatively homogeneous within Central and Northern European countries. However, no study broadly assessed the features of seasonal allergic rhinitis (SAR) across different Southern European countries with a standardized approach.

OBJECTIVE

To describe sensitization profiles and clinical phenotypes of pollen allergic patients in nine Southern European cities with a uniform methodological approach.

METHODS

Within the @IT.2020 multicenter observational study, pediatric and adult patients suffering from SAR were recruited in nine urban study centers located in seven countries. Clinical questionnaires, skin prick tests (SPT) and specific IgE (sIgE) tests with a customized multiplex assay (Euroimmun Labordiagnostika, Lübeck, Germany) were performed.

RESULTS

Three hundred forty-eight children (mean age 13.1 years, SD: 2.4 years) and 467 adults (mean age 35.7 years SD: 10.0 years) with a predominantly moderate to severe, persistent phenotype of SAR were recruited. Grass pollen major allergenic molecules (Phl p 1 and/or Phl p 5) ranged among the top three sensitizers in all study centers. Sensitization profiles were very heterogeneous, considering that patients in Rome were highly poly-sensitized (sIgE to 3.8 major allergenic molecules per patient), while mono-sensitization was prominent and heterogeneous in other cities, such as Marseille (sIgE to Cup a 1: n = 55/80, 68.8%) and Messina (sIgE to Par j 2: n = 47/82, 57.3%). Co-sensitization to perennial allergens, as well as allergic comorbidities also broadly varied between study centers.

CONCLUSIONS

In Southern European countries, pollen allergy is heterogeneous in terms of sensitization profiles and clinical manifestations. Despite the complexity, a unique molecular, multiplex, and customized in-vitro IgE test detected relevant sensitization in all study centers. Nevertheless, this geographical diversity in pollen allergic patients imposes localized clinical guidelines and study protocols for clinical trials of SAR in this climatically complex region.

Haematology and biochemistry in healthy llamas at sea level

In the last years, there has been an increasing interest in llamas, not only as part of a productive system, but mostly as companion animals. Most reports regarding clinical biochemistry and haematology include few llamas and details about their health status are not available. The present study aims to provide haematological and biochemical parameters for llamas of known health status. Twenty-three non-pregnant females and seven males that live in Buenos Aires, Argentina (34°36'S, 58°22'W, at sea level) were studied. Llamas were clinically healthy, in good nutritional status. Animals were kept at grass and were fed hay bale or pellets and water ad libitum. Blood samples were collected by jugular venipuncture in spring. Packed cell volume, leucocyte count, differential white cell count, platelets count, urea, creatinine, total proteins, albumin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, glucose, calcium and phosphate were assessed. No significant differences were observed between males and females, except for platelet count and calcium, which was greater in males (P˂0.01). Values obtained for the different parameters were similar to those previously reported, except for monocytes, alkaline phosphatase, glucose and calcium, that were lower and lymphocytes and platelets count, that were higher in this study. In conclusion, different ambient and methodological conditions might affect some parameters. The parameters hereby presented are representative of llama's population living at sea level in South America.

Intraoperative Performance with the Exoscope in Spine Surgery: An Institutional Experience

BACKGROUND

Exoscope use in spinal neurosurgery has become a promising surgical option providing enhanced operative field visibility and ergonomics. However, data on its use in spine surgery are underreported in the literature. We aimed to assess the intraoperative outcomes in exoscope-assisted spine surgery compared with similar procedures performed using the operative microscope.

METHODS

A retrospective review was performed of all spinal surgeries performed using an exoscope and, subsequently, an equal number of operative microscope cases performed by 2 senior surgeons at a single institution from 2016 to 2023. The variables included demographics, clinical presentation, surgical treatment, and operative outcomes.

RESULTS

A total of 123 exoscope spinal surgeries were performed on 116 unique patients with a mean age of 67 ± 14 years, of whom 60 (52%) were women. The microscope group included 126 surgeries on 120 unique patients with a mean age of 62 ± 14 years, of whom 53 (45%) were women. The mean blood loss (28 mL vs. 132 mL; P = 0.0009), operative time (83 minutes vs. 103 minutes; P = 0.006), and length of stay (1.04 days vs. 1.73 days; P = 0.02) were significantly less for the exoscope group than for the microscope group.

CONCLUSIONS

The use of the exoscope resulted in a shorter operative time, less blood loss, a shorter length of stay, and favorable clinical outcomes compared with the use of the operative microscope. Neurosurgeons should consider this seemingly efficacious and ergonomically favorable visual technology for spinal surgeries.

"It just made me feel better": qualitative examination of the implementation of a novel virtual psychosocial support program for adolescents with cancer

PURPOSE

Adolescents with cancer routinely report feelings of isolation and exclusion, including from medical decision-making. To address this problem and support adolescents, we designed and implemented the novel, virtual, weekly Teens4Teens peer support group and patient education program. We examined the views of participating adolescents, program guest speakers, and program moderators as they pertained to the need for the program, its feasibility, acceptability, and perceived impact.

METHODS

We recruited all available adolescents, moderators, and guest speakers who participated in Teens4Teens to take part in audio-recorded, semi-structured interviews. Interviews were transcribed, coded, and analyzed using thematic analysis.

RESULTS

We conducted 21 interviews across participant groups. We identified four broad themes: pathways into the Teen4Teens program, Teens4Teens implementation capacity, perspectives of the positive impact of Teens4Teens, and suggestions to improve Teens4Teens. These themes described a perceived need for adolescent-centered psychosocial programming in pediatric cancer care, provided lessons on how best to build and apply such a program, and highlighted the value of the program for both adolescents' and clinicians' acceptability, feasibility, and perceived utility.

CONCLUSION

Adolescents, guest speakers, and moderators valued Teens4Teens and made suggestions to improve capacity to routinely implement the program. Adolescent-tailored psychosocial programming, such as Teens4Teens, is positioned to be integrated into clinical care with relative ease and may serve to improve the cancer care experience of adolescents and their families. This study has potential to provide researchers and clinicians with valuable information about the content, design, and delivery of virtual peer support programming for adolescents with cancer.

A Sarcopenia Index Derived from Malnutrition Parameters in Elderly Haemodialysis Patients

(1) Background: Persons with chronic kidney disease may have sarcopenia characterized by the loss of muscle mass and loss of muscle strength. However, EWGSOP2 criteria to diagnose sarcopenia are technically challenging, especially in elderly persons on hemodialysis. Sarcopenia may be associated with malnutrition. We aimed at defining a sarcopenia index derived from malnutrition parameters for use in elderly haemodialysis patients. (2) Methods: A retrospective study of 60 patients aged 75 to 95 years treated with chronic hemodialysis was conducted. Anthropometric and analytical variables, EWGSOP2 sarcopenia criteria and other nutrition-related variables were collected. Binomial logistic regressions were used to define the combination of anthropometric and nutritional parameters that best predict moderate or severe sarcopenia according to EWGSOP2, and performance for moderate and severe sarcopenia was assessed by the area under the curve (AUC) of receiver operating characteristic (ROC) curves. (3) Results: The combination of loss of strength, loss of muscle mass and low physical performance correlated with malnutrition. We developed regression-equation-related nutrition criteria that predicted moderate sarcopenia (elderly hemodialysis sarcopenia index-moderate, EHSI-M) and severe sarcopenia (EHSI-S) diagnosed according to EWGSOP2 with an AUC of 0.80 and 0.866, respectively. (4) Conclusions: There is a close relationship between nutrition and sarcopenia. The EHSI may identify EWGSOP2-diagnosed sarcopenia from easily accessible anthropometric and nutritional parameters.

P-020 PERFORMANCE OF AN ATRAUMATIC AND VERSATILE LIGHT-ACTIVATED ADHESIVE FOR HERNIA MESH FIXATION

Aim

This study evaluates the versatility and performance of a novel adhesive for atraumatic hernia mesh fixation. The TISSIUM adhesive is a biodegradable and biocompatible viscous liquid that can be precisely applied to different tissue and mesh.1 Once in place, the surgeon utilizes a light probe to polymerize the adhesive, creating a flexible elastomeric connection that provides strong, durable and atraumatic mesh fixation.

Materials and Methods

The performance of the TISSIUM adhesive when used with a range of marketed mesh and against peritoneum (n=7) and muscle (n=3) was evaluated using a standardized lap-shear bench method using porcine tissues. The shear strength was compared to resorbable tacks (n=8) (against peritoneum as standard of care in IPOM) and self-adhesive meshes (n=4) and fibrin glue (n=3) (against muscle as classically used in the retromuscular approach).

Results

Lap-shear data revealed that the TISSIUM adhesive performance was equivalent to resorbable tacks when fixing meshes to the peritoneum. Similar testing protocol demonstrated that the TISSIUM adhesive shear strength was 6 to 13 times superior to non- penetrating fixation devices such as fibrin glue or self-adhesive mesh.

Conclusions

The use of the TISSIUM Adhesive for hernia mesh fixation is compatible with various mesh materials used in hernia repair and, in a bench model, outperforms existing non-penetrating methods in diverse tissue planes demonstrating the potential to help the surgeon achieve more effective and efficient atraumatic repair in a range of hernia procedures.

Low-level constitutional mosaicism of BRCA1 in two women with young onset ovarian cancer

Germline pathogenic variants in BRCA1 and BRCA2 cause hereditary breast and ovarian cancer. The vast majority of these variants are inherited from a parent. De novo constitutional pathogenic variants are rare. Even fewer cases of constitutional mosaicism have been reported and these have mostly been described in women with breast cancer. Here we report low-level constitutional mosaicism identified by Next Generation Sequencing in two women with ovarian cancer. A BRCA1 c.5074G > A p.(Asp1692Asn) variant detected in the first female at 42 years, classed as likely pathogenic, was found in ~ 52% of reads in DNA extracted from tumour, ~ 10% of reads in DNA extracted from peripheral blood leukocytes and ~ 10% of reads in DNA extracted from buccal mucosa. The second BRCA1 c.2755_2758dupCCTG p.(Val920AlafsTer6) variant was detected in a female aged 53 years, classed as pathogenic, and was found in ~ 59% of reads in DNA extracted from tumour, ~ 14% of reads in DNA extracted from peripheral blood leukocytes and similarly in ~ 14% of reads in both DNA extracted from buccal mucosa and urine sample. Sanger sequencing confirmed the presence of these variants at a corresponding low level consistent with mosaicism that may not have been detected by this method alone. This report demonstrates the clinical benefit for two women of BRCA1/BRCA2 germline NGS testing at a depth that can detect low-level mosaicism. As well as informing appropriate treatments, tumour sequencing results may facilitate the detection and interpretation of low-level mosaic variants in the germline. Both results have implications for other cancer risks and for relatives when providing a family cancer risk assessment and reproductive risk. The implications for laboratory practice, clinical genetics management and genetic counselling for constitutional mosaicism of BRCA1/BRCA2 are discussed.

P-064 Clinical outcomes of 127 patients with recurrent implantation failure treated with testicular sperm aspiration (TESA)

Study question

Are the embryological, clinical and newborn outcomes using aspirated testicular sperm improved in cases with recurrent implantation failure previously treated with ejaculated sperm?

Summary answer

Aspirated testicular sperm enabled to obtain significant higher embryological, clinical and newborn outcomes in cases with recurrent implantation failure previously treated with ejaculated sperm.

What is known already

High levels of sperm DNA fragmentation (SDF) were associated to poor clinical outcomes (1-Simon et al., 2017). Testicular sperm display lower SDF than ejaculated sperm (2-Sakas and Alvarez, 2010), improving clinical outcomes in cases with abnormal semen parameters (3-Awaga et al., 2018; 4-Kang et al., 2018), recurrent implantation failure (RIF) and pregnancy loss (RPL) (5-Esteves et al., 2017), and elevated SDF (6-Ambar et al., 2021). As only a few studies are specifically dedicated to RIF, we expanded the number of cases and first provided full demographic, stimulation, embryological, clinical and newborn outcomes.

References

1-(https://doi.org/10.4103/1008-682X.182822);

2-(https://doi.org/10.1016/j.fertnstert.2009.10.046);

3-(https://doi.org/10.1016/j.rbmo.2018.08.017);

4-(https://doi.org/10.1038/s41598-018-26280-0);

5-(https://doi.org/10.1016/j.fertnstert.2017.06.018);

6-(https://doi.org/10.5534/wjmh.200084

Study design, size, duration

We retrospectively evaluated during consecutive years (2010-2020) 63 patients with recurrent implantation failure, which accepted to perform testicular sperm aspiration (TESA) as an alternative treatment. These patients presented a long history of failed treatments (153 cycles) using ejaculated sperm. From these cycles, no pregnancy ensued. The present study compares 127 treatment cycles, 80 with testicular sperm (17 cases repeated TESA) and 47 with ejaculated sperm from the same patients performed at the present IVF clinic.

Participants/materials, setting, methods

Patients were screened for karyotype abnormalities, for Y-chromosome microdeletions (7-Gonçalves et al., 2016), and for SDF with the TUNEL assay (8-Sá et al., 2015). Conventional semen analysis was performed according to World Health Organization guidelines (9-WHO, 2010). Male evaluation and TESA was performed by the same experienced urologist (LF) according to established protocols (10-Madureira et al 2014). The procedure was performed entirely on an outpatient basis, with no complications reported.

References

7-(https://doi.org/10.4103/1008-682X.172827);

8-(https://doi.org/10.1016/j.rbmo.2015.06.019);

9-(https://apps.who.int/iris/handle/10665/44261);

10-(https://doi.org/10.1111/j.2047-2927.2014.00231.x).

Main results and the role of chance

The mean ages were 35.5±3.4 (26-42)-female and 38.1±5.7 (29-59)-male. There were 4 abnormal karyotypes (3-female, 1-male), all without known relevance. Most cases had asthenozoospermia and teratozoospermia (65.1%), or oligoasthenoteratozoospermia (41.8%). Of the 19 cases with <5M/ml, none presented Y-chromosome microdeletions. Although we do not routinely perform SDF testing, 15 patients had previous SDF values (12, >20%; 8, >36%). Female basal characteristics and testicular evaluation were under normal values. The TESA procedure took about 15-20 min, and the time of laboratorial search around 30-60 min. Cases using testicular sperm showed significant higher rates of fertilization (64% vs 73%-p=0.005), blastocyst development (47% vs 62%-p=0.010), implantation (6% vs 27%-p=0.000), clinical pregnancy (10% vs 39%-p=0.001), live birth delivery (5% vs 28%-p=0.005) and newborn (5% vs 32%-p=0.000) than ejaculated sperm. No significant differences were observed regarding the rates of embryo cleavage (95% vs 94.8%) and high quality embryos (89.4% vs 94%), in the mean number of transferred embryos (1.8±0.4 vs 1.9±0.4), or in the abortion rate (2 cases-50% vs 7 cases-25.9%). Cases using testicular sperm had 22 frozen-thawed embryo transfer cycles, enabling per initiated cycle a cumulative pregnancy rate of 45%, live birth delivery rate of 31.3% and newborn rate of 37.5% (32 newborn).

Limitations, reasons for caution

Although presenting the higher number of cycles using TESA in the treatment of RIF, this number needs to be increased for drawing more definitive conclusions, as these women present a diversity of conditions, rendering subgrouping difficult. In the future, it would also be important to evaluate SDF in all cases.

Wider implications of the findings

In conclusion, the present results gave further evidence for the superiority of using testicular sperm instead of ejaculated sperm in cases with recurrent implantation failure. Data also evidences the security of using testicular sperm aspiration, as there were no pregnancy or delivery complications, or congenital anomalies among the 32 newborn.

Trial registration number

Not Applicable

POS0466 RESISTANT STARCH DIET IMPROVES DISTINCT GUT MICROBIOTA STRUCTURES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND ANTIPHOSPHOLIPID SYNDROME

Background

Fiber-poor diets are linked to a reduction in gut microbiota diversity and gut barrier integrity, which is thought to promote the susceptibility to chronic inflammatory disorders1,2. We have previously shown that dietary resistant starch (RS) improves lupus-like disease in a murine model of SLE3 through the modulation of microbiota composition. If similar dysbiotic microbial community structures exist in subsets of SLE patients and if a RS intervention may be efficacious in those patients remains unclear.

Objectives

To test if the dietary RS content in SLE and SLE-related antiphospholipid syndrome (APS) affect gut microbial taxa associated with SLE in published cohorts to date.

Methods

We obtained stool and blood samples as well as diet history for up to 3 visits (0, 4 and 8 weeks) from 12 SLE (n=28) and 15 APS (n=44) patients as well as 20 controls (n=48) as previously published4-6. Microbiota composition was defined by 16S rRNA V4 region sequencing on the Illumina platform and correlated with dietary fiber content extracted from a diet questionnaire. We used the FDA reference list to determine dietary RS contents in patients` regular diets and defined RS quantities as being low if less than 2.5 g/day and as medium if 2.5 to 15 g/day. None of the patients achieved high RS greater than 15 g/day. Mann-Whitney or Kruskal-Wallis tests were performed to compare bacteria relative abundances among the different groups. Simple linear regression was performed to relate the bacterial abundance to RS content and other metadata.

Results

Medium intake of RS was associated with beneficial Bifidobacterium spp. in SLE patients (p=0.016) but not APS (p=0.509). Instead, APS patients who consumed medium quantities of RS in their diets had less gut bacterial taxa that are capable of producing cardiolipins (among them Collinsella; p=0.009) and Ruminococcus gnavus (p=0.0142), a species previously associated with lupus nephritis7. A recent Japanese metagenome-wide study8 associated Streptococcus spp. and related redox reaction genes with SLE, which may also affect oxidative processes in APS9. We therefore also explored Streptococcus levels in SLE and APS patients and found unexpectedly a significant reduction of streptococci in a subset of APS (p=0.004) but not SLE patients (p=0.451) in medium compared to low RS dietary content. Streptococcus abundance was correlated with both Collinsella (R2=0.3141; p=<0,0001) and Ruminococcus gnavus (R2=0.1687; p=<0,0056) in APS patients.

Conclusion

Medium compared to low RS quantities in the regular diets of SLE and APS patients were associated with unique alterations in gut microbial community structures. Bifidobacterium increased in SLE patients with diets containing medium RS whereas APS patients with medium RS carried less cardiolipin-synthesizing taxa and lupus-related pathobionts. In particular, Streptococcus species recently strongly associated with SLE and redox reactions in Japanese patients in a metagenome-wide study8, were significantly suppressed in APS patients on medium RS diets. This modulatory effect was not seen in SLE patients or control subjects consuming medium RS. Together, these findings support distinct dietary effects on autoimmune gut microbiomes depending on the disease state. They also suggest potential beneficial effects of increased RS content on gut microbiota in SLE and APS patients. Fully resolving gut microbial signatures and clinical characteristics in these patients may identify the ideal subset to benefit from an interventional pilot trial with RS.

References

[1] Thorburn et al., 2014, Immunity 19, 833-842

[2] Ruff et al, 2020, Nat Rev Microbiol 18, 521-538

[3] Zegarra-Ruiz et al., 2019, Cell Host Microbe 25, 113-127

[4] Greiling et al., 2018, Science Transl Med 10, 1–15

[5] Manfredo Vieira et al, 2018, Science 359, 1156-1161

[6] Ruff et al., 2019, Cell Host Microbe 26, 1–14

[7] Azzouz et al., 2019, Ann Rheum Dis 78, 947–956

[8] Tomofuji et al., 2021, Ann Rheum Dis 80, 1575–1583

[9] Giannakopoulos and Krilis, 2013, New Engl J Med 368, 1033-1044

Acknowledgements

The work was supported by grants from the National Institutes of Health (NIH) (R01AI118855, T32AI07019), Arthritis National Research Foundation, Arthritis Foundation, Lupus Research Alliance, and Maren Foundation.

Disclosure of Interests

Márcia Pereira: None declared, Iryna Kulyk: None declared, Sylvio Redanz: None declared, William E Ruff: None declared, Teri M. Greiling: None declared, Carina Dehner: None declared, Odelya Pagovich: None declared, Daniel Zegarra Ruiz: None declared, Cassyanne Aguiar: None declared, Doruk Erkan: None declared, Martin Kriegel Speakers bureau: Novartis, BMS, GSK, MSD, Grant/research support from: AbbVie, Employee of: Roche.

Comparative Study on the Efficiency of Mercury Removal From Wastewater Using Bacterial Cellulose Membranes and Their Oxidized Analogue

A comparative study was conducted on the efficiency of mercury removal using bacterial nanocellulose (BNC) membranes obtained from the fermentation of the microorganism Komagataeibacter medellinensis, in contrast with its oxidized analog obtained by modifying the bacterial nanocellulose membranes via oxidation with 2,2,6,6-Tetramethylpiperidine-1-oxyl. Both types of membranes (modified and unmodified) were characterized to identify variations in the Physico-chemical parameters after modification. FTIR spectra confirmed the chemical modification of cellulose in all reaction conditions by the presence of a new characteristic band at ∼1730 cm⁻¹, corresponding to the new carboxylic groups produced by the oxidative process, and the decline of the band at ∼1,650 cm⁻¹, corresponding to the hydroxyl groups of the C6 carbon. While the XRD profiles indicated that the percentage of BNC crystallinity decreased and the SEM images showed that the nanoribbon network was interrupted as the amount of oxidizing agent increased. The kinetics of mercury removal from both types of membrane was evaluated by calculating the concentration of mercury at different times and establishing a mathematical model to describe the kinetics of this process. The modified membranes improved significantly the adsorption process of the metal ion and it was found that the modification that results in the greatest adsorption efficiency was BNC-m 7.5 with a value of 92.97%. The results obtained suggest that the modification of the bacterial nanocellulose membranes by oxidation transcendentally improves the mercury removal capacity, outlining the modified membranes as an excellent material for mercury removal in wastewater.

Worst Itch Numerical Rating Scale for Prurigo Nodularis: A Psychometric Evaluation

BACKGROUND

Study TR03 evaluated the safety and efficacy of nalbuphine ER for prurigo nodularis (PN) (NCT02174419).

OBJECTIVE

We conducted supplementary analyses to assess the psychometric properties of the Worst Itch Numeric Rating Scale (WI-NRS), the TR03 primary endpoint.

METHODS

Study TR03 was a double-blind, placebo-controlled, phase 2 trial in PN patients with documented scores ≥5 on the WI-NRS (0 [no itch]-10 [worst itch imaginable]) on ≥5 of 7 days before baseline. Using TR03 data, the WI-NRS's psychometric properties, including reliability, validity, and ability to detect change, were evaluated. A responder threshold was estimated to facilitate interpretation of WI-NRS score changes.

RESULTS

Among 62 treated patients, improvements in mean [SD] (median) WI-NRS scores were observed between baseline (8.2 [1.21] (8.1)) and Week 10 (5.8 [2.43] (6.0)). The WI-NRS had an intraclass correlation coefficient of 0.96 (95% confidence interval, 0.93-0.98) in 42 patients who had stable Itch verbal rating scale (VRS) scores from Week 9-10, supporting strong test-retest reliability. Construct validity was supported, with strong correlations at Week 10 with Average Itch NRS (r=0.87) and Itch VRS single-day/weekly mean scores (r=0.81/0.89) and moderate correlations with ItchyQoL^TM total/domain scores (r=0.41-0.43). The WI-NRS discriminated between predefined severity subgroups based on the Itch VRS and detected changes in itching severity (effect-size estimate: -2.05; standardized response mean: -1.21). An anchor-based threshold based on a two-category improvement in the single-day Itch VRS suggests a responder threshold of ≥3.8 points (~40% improvement).

CONCLUSIONS

The WI-NRS demonstrates good measurement properties, supporting its use in evaluating treatment change in PN.

Spatial and seasonal analysis and geovisualization of Fasciola hepatica-free bovine bacillary hemoglobinuria outbreaks in eastern Uruguay, 1999-2019

Bovine bacillary hemoglobinuria (BBH) produced by Clostridium novyi type D, is an endemic, highly fatal disease of cattle in the temperate grassland region of eastern Uruguay. A previous study showed that in this region, BBH is not associated with Fasciola hepatica or any other known focal-ischemic liver injury, so the reasons for its high incidence remains undetermined. The objective of this study was to analyze data from 45 Fasciola hepatica-free BBH outbreaks (1999-2019) in order to find common animal, seasonal and/or geographical risk factors, which may explain the occurrence of the epizootics. Fisher's goodness-of-fit testing showed a significantly higher case proportion of adult cows (N = 368, 80.5%) and lower of calves (N  =8, 1.8%), as compared to the expected proportions of the censused population in the study area and historical submissions computed from the laboratory database (Chi-Sq = 346.2 and 174.8, df = 7, P < 0.00). Time series decomposition showed a bi-seasonal pattern, with a larger peak in spring and early summer (October to January) and a smaller increase in autumn (March-May). The lowest seasonal indices were on mid-summer (February) and winter (June-September). A combination of spatial statistics was used to assess the different spatial features of the disease and consistency of the findings. Global spatial autocorrelation showed BBH was significantly clustered (Moran's I = 0.407, P < 0.001). Both smoothed Anselin's Local Indicator of Spatial Autocorrelation and Kulldorff's spatial scan Poisson and Bernoulli models, detected roughly the same high-risk areas in the southeastern part of the Merin Lagoon basin, with the most likely cluster centered in the large wetland biosphere reserve "Eastern Wetlands and Coastal Strip" (RR = 9.12, P < 0.001). Outbreaks were georeferenced (latitude, longitude) and thematic dot-mapping geovisualization in Google Earth™ showed that the results were robust and truly geographic in nature. Most outbreaks (40/45, 88.8%) occurred on wetlands areas and large river valleys, characterized by poorly drained and frequently flooded soils, indicating that moisture-laden soils are the natural habitat of C. novyi type D. Grasslands in these endemic areas support rapid fattening of cattle during spring-summer, and somewhat less in autumn, in almost exact correspondence with BBH peaks, suggesting a close causal association in high-risk areas. Risk is significantly higher in adult cows probably because the spore content in the liver is highest in this category. The altered lipid metabolism and lipotoxicity in the liver may be the precipitating factor for spore germination and epizootic occurrence.

TWMP-01. RESECTION OF SUPPLEMENTARY MOTOR AREA GLIOMAS: REVISITING SUPPLEMENTARY MOTOR SYNDROME AND THE ROLE OF THE FRONTAL ASLANT TRACT

INTRODUCTION

The supplemental motor area (SMA) is an eloquent region that is frequently a site for gliomas or the region is included in the resection trajectory to deeper lesions.

METHODS

Patient, tumor and outcome data were collected retrospectively from the UCSF tumor registry for patients who underwent surgical resection for newly diagnosed supratentorial diffuse glioma (WHO Grade II - IV) between 2010 and 2019 in the SMA region and the extent of SMA resection was determined by volumetric assessment. Tumors were registered to a standard brain atlas to create a frequency heat map of tumor volumes and resection cavities.

RESULTS

Although the volume of tumor within the SMA region did not correlate with the development of SMA syndrome, patients with SMA syndrome had larger resection cavities in the SMA region (25.4% SMA resection vs. 14.2% SMA resection, p = 0.039). The size of the resection cavity in the SMA region did not correlate with the severity of the SMA syndrome. Patients who developed SMA syndrome had cavities that were located more posteriorly in the SMA region and in the cingulate. When the frontal aslant tract (FAT) was preserved, 50% of patients developed SMA syndrome post-operatively; whereas 100% of patients who had disruption of the FAT during surgery developed SMA syndrome (p = 0.06). There was no difference in the overall survival for newly diagnosed glioblastoma patients with SMA syndrome compared to those without SMA syndrome (1.6 years vs. 3.0 years, p = 0.33).

CONCLUSION

For patients with SMA gliomas, larger resections and resections involving the posterior SMA region and posterior cingulate gyrus increased the likelihood of a post-operative SMA syndrome. Although SMA syndrome occurred in all cases where the FAT was resected, FAT preservation does not reliably avoid SMA syndrome post-operatively.

[Interest of a geostatistical approach to analyze the geographical disparities in human papillomavirus vaccine coverage in France]

BACKGROUND

The use of geostatistical methods remains rare in health studies. In order to assess the usefulness of the geostatistical approach in epidemiology, we chose to apply these methods to the vaccination coverage rate (VCR) against human papillomavirus (HPV) in France. Indeed, HPV vaccine coverage remains low in France and geographical disparities are sizable. The objective of this study was to identify the socioecological factors that may explain these geographical variations.

METHODS

Sociological, economic and behavioral data for 2016 have been gathered (demographics and public health database, web and social networks) and were correlated with the HPV VCR vaccine coverage over the French territory. Homogeneous geographical areas defined by strong correlations for groups of variables were selected. In each homogeneous area, principal component analysis was performed and a geostatistical approach provided an estimate predicting vaccine coverage at a given scale.

RESULTS

HPV VCR spatial variations in France cannot be fully explained by a single model. In urban areas, a low rate of HPV VCR is preferentially associated with unfavorable socioeconomic factors (poverty, unemployment, immigration). In rural areas, HPV VCR is preferentially associated with sociocultural factors (socio-professional categories, education level, interest in alternative medicines the anti-vaccine movement). Two secondary geographical areas were defined: the Île-de-France region and 12 departments in northeastern France. In the Île-de-France region, the association with the economic factors one again appears as in urban areas in general. The northeasteran departments represent a particular case insofar as HPV VCR is relatively high, notwithstanding economic poverty indicators.

CONCLUSION

Geostatistical modeling successfully identifies new potential explanations for HPV VCR geographical disparities in France. These results could help to adapt or develop future vaccination programs in specific areas by taking into account the sociological, economic and behavioral characteristics of their populations.

Assessment of the uterine dose in digital mammography and digital breast tomosynthesis

INTRODUCTION

Digital Mammography (DM-2D) and more recently Digital Breast Tomosynthesis (DBT), are two of the most effective imaging modalities for breast cancer detection, often used in screening programmes. It may happen that exams using these two imaging modalities are inadvertently performed to pregnant women. The objective of this study is to assess the dose in the uterus due to DM-2D and DBT exams, according to two main irradiation scenarios: in the 1st scenario the exposure parameters were pre-selected directly by the imaging system, while in the 2nd scenario, the maximum exposure parameters were chosen.

METHODS

The mammography equipment used was a Siemens Mammomat Inspiration. A physical anthropomorphic phantom, PMMA plates (simulating a breast thickness of 6 cm) and thermoluminescent dosimeters (TLDs) were used to measure entrance air kerma values on the phantom's breast and abdomen in order to successively estimate the mean glandular dose (MGD) and the dose in the uterus. For the two irradiation scenarios chosen, two-breast imaging modalities were selected: 1) DBT in Cranio-Caudal (CC) view (with 28 kV and 160 mAs as exposure parameters), 2) DBT and DM in Medio Lateral-Oblique (MLO) and CC views (with 34 kV and 250 mAs as exposure parameters).

RESULTS

In the 1st scenario, the TLD measurements did not detect significant dose values in the abdomen whereas the MGD estimated using the D.R. Dance model was in close agreement with data available in the literature. In the 2nd scenario, there was no significant difference in MGD estimation between the different views, whereas the air kerma values in the abdomen (in DBT mode, CC and MLO) were 0.049 mGy and 0.004 mGy respectively. In CC DM-2D mode the abdomen air kerma value was 0.026 mGy, with no significant detected value in MLO view.

CONCLUSIONS

For the dose in the uterus, the obtained values seem to indicate that DM-2D and DBT examinations inadvertently performed during pregnancy do not pose a significant radiological risk, even considering the case of overexposure in both breasts.

IMPLICATIONS FOR PRACTICE

The accurate knowledge of the doses in DM-2D and DBT will contribute to raise the awareness among medical practitioners involved in breast imaging empowering them to provide accurate information about dose levels in the uterus, improving their radiation risk communication skills and consequently helping to reduce the anxiety of pregnant women undergoing this type of examinations.

Self-reported adverse reactions to subcutaneous airborne allergen immunotherapy: a real-life, single center study

Summary

Objective. To estimate the prevalence of self-reported adverse reactions (AdR) to subcutaneous airborne allergen immunotherapy (SCIT) and to describe factors associated with its occurrence. Methods. Real-life, observational, descriptive study of all patients treated with SCIT at a Portuguese allergy unit between 03/2017 and 06/2019, and who answered ≥1 time to a pre-SCIT evaluation questionnaire assessing the occurrence of local and/or systemic AdR in the previous administration. Results. 939 questionnaires from 231 patients (42% female, 35% with asthma) were included. Most (60%) SCIT preparations had multiple allergens with concentration adjusted to prevent dilution (MA-NoDil), 26% were single allergen with standard concentration (SA-SC), 10% single allergen with higher than standard concentration (SA-HC), and 4% mixtures without concentration adjustment (MA-Dil). SCIT-related AdR were self-reported in 313 (33%) administrations, 97% at the injection site and 11% grade 1 systemic symptoms. In a multivariable model, being a female and having asthma were associated with higher risk of AdR. MA-NoDil SCIT presented a lower risk of AdR compared to SA-SC SCIT. Conclusions. SCIT-related AdR were self-reported in 1/3 of the administrations, most at the injection site. The risk of AdR was higher in females and in patients with asthma. The lower risk of adverse reactions observed in SCIT preparations with multiple allergens with no dilutional effect should be further explored in future, targeted studies.

The relationship between perfectionism, generalized problematic internet use and bulimic behaviours

Introduction

Perfectionism is a consistent risk factor for various psychopathological conditions, including psychological distress and eating disorders. Recently, we have shown, for the first time, that there is a relationship between perfectionism and generalized problematic internet use/GPIU (Sobral et al. 2020). Specifically, we found that the role of perfectionism in psychological disorder is partially mediated by GPIU. On the other hand, it has been suggested that the widespread use of digital media can lead to negative body image perception and abnormal eating attitudes and behaviors.

Objectives

To explore, for the first time, the relationship between perfectionism, GPIU and disordered eating behavior.

Methods

475 university students (78.9% girls; mean age 20.22±1.695) answered the Portuguese validated versions of: Composite Multidimensional Perfectionism Scale, GPIU Scale and Eating Attitudes Test-25. SPSS and Hayes’ Process Macro (2020) were used.

Results

Bulimic Behaviours/BB significantly and moderately correlated with Perfectionist efforts (r=.263), Perfectionist concerns (r=.284) and GPIU (r=.25) (all p<.001). The mediation analyses revealed that GPIU is a partial mediator of the relationship between both perfectionism dimensions and BB.

Conclusions

The evidence that both negative and “positive” perfectionism dimensions are associated to eating pathology is in line with our previous research. The present study adds, for the first time, that one of the perfectionism pathways of influence on BB operates through UGPI. Assessment and intervention to diminish eating psychopathology should focus on perfectionism and compulsive traits which could be involved in both ED and GPIU and in their comorbidity.

Disclosure

No significant relationships.

Ecophysiological Performance of Proteaceae Species From Southern South America Growing on Substrates Derived From Young Volcanic Materials

Southern South American Proteaceae thrive on young volcanic substrates, which are extremely low in plant-available phosphorus (P). Most Proteaceae exhibit a nutrient-acquisition strategy based on the release of carboxylates from specialized roots, named cluster roots (CR). Some Proteaceae colonize young volcanic substrates which has been related to CR functioning. However, physiological functioning of other Proteaceae on recent volcanic substrates is unknown. We conducted an experiment with seedlings of five Proteaceae (Gevuina avellana, Embothrium coccineum, Lomatia hirsuta, L. ferruginea, and L. dentata) grown in three volcanic materials. Two of them are substrates with very low nutrient concentrations, collected from the most recent deposits of the volcanoes Choshuenco and Calbuco (Chile). The other volcanic material corresponds to a developed soil that exhibits a high nutrient availability. We assessed morphological responses (i.e., height, biomass, and CR formation), seed and leaf macronutrient and micronutrient concentrations and carboxylates exuded by roots. The results show that G. avellana was less affected by nutrient availability of the volcanic substrate, probably because it had a greater nutrient content in its seeds and produced large CR exuding carboxylates that supported their initial growth. Embothrium coccineum exhibited greater total plant height and leaf P concentration than Lomatia species. In general, in all species leaf macronutrient concentrations were reduced on nutrient-poor volcanic substrates, while leaf micronutrient concentrations were highly variable depending on species and volcanic material. We conclude that Proteaceae from temperate rainforests differ in their capacity to grow and acquire nutrients from young and nutrient-poor volcanic substrates. The greater seed nutrient content, low nutrient requirements (only for G. avellana) and ability to mobilize nutrients help explain why G. avellana and E. coccineum are better colonizers of recent volcanic substrates than Lomatia species.

Rabdomiólise em militares: uma missão de reconhecimento para prevenção

O treinamento físico regular faz parte do cotidiano militar, com intuito de aprimorar competências físicas essenciais para tarefas de combate. No entanto, quando executado de forma extenuante ou desenvolvido em condições climáticas adversas pode ocasionar o desenvolvimento da rabdomiólise por esforço físico. A rabdomiólise por esforço físico é definida como uma síndrome decorrente da necrose das células musculares, com sintomas variáveis, como dor muscular, fraqueza e aumento plasmático de enzimas musculares. A severidade da rabdomiólise por esforço físico varia individualmente, porém, pode se tornar clinicamente relevante, contribuindo para a hospitalização, insuficiência renal aguda, incapacidade permanente ou óbito. Sendo assim, o objetivo desta revisão narrativa é apresentar possíveis causas e fatores de risco para rabdomiólise, discutir sua fisiopatologia, seus possíveis diagnósticos e suas principais complicações, enfatizando o contexto militar.

EXTH-17. LOCAL DELIVERY OF CYTOKINES AND SYNTHETIC IMMUNOMODULATORS INCREASES T CELL INFILTRATION AND SIGNIFICANTLY IMPROVES SURVIVAL IN A POORLY IMMUNOGENIC MODEL OF GLIOBLASTOMA

BACKGROUND

Severe local and systemic immune suppression in glioblastoma (GBM) contributes to the failure of single-agent immunotherapies in clinical trials. In this study, we evaluated the efficacy of locally delivered combination immunotherapy in a poorly immunogenic murine GBM model.

METHODS

Immunomodulators used in these studies included: IL-15 and IL-7 (T cell activation), LIGHT (T cell tumor infiltration), FLT3L (dendritic cell maturation/proliferation), a surface T cell engager (T cell killing of tumor cells), and a bispecific PD-L1/T cell engager (T cell killing targeted to PD-L1-expressing cells). We first assessed T cell-mediated cytotoxicity in vitro against SB28, a poorly immunogenic murine GBM cell line, after expressing these immunomodulators in combination. Next, tumor growth inhibition in vivo was evaluated in syngeneic C57BL/6 mice, initially by establishment of intracranial tumors with pre-transduced SB28 cells, and subsequently by delivering these immunomodulators to pre-established naïve SB28 tumors using neural stem cells (NSCs) and retroviral replicating vectors (RRV).

RESULTS

SB28 cells transduced with immunomodulators activated dose-dependent T cell-mediated cytotoxicity in vitro. Mice with pre-transduced intracranial SB28 gliomas showed significantly longer survival (minimum survival: 60 days, long-term survival in 57% of mice) vs. control mice (median survival: 20 days) (p&lt; 0.001), and significantly increased tumor infiltration of CD4+ and CD8+ T cells. NSC- and RRV-mediated immunomodulator delivery to pre-established SB28 gliomas also resulted in significantly increased survival of treated mice vs. controls (median survival: 31 days vs. 22 days, p&lt; 0.001). Immunomodulator-treated tumors again showed significantly increased infiltration of CD4+ and CD8+ T cells, along with decreased CD11b+ cell infiltration.

CONCLUSIONS

A novel combination therapy for GBM immunotherapy activated T cell killing of SB28 GBM cells in vitro and achieved a significant survival benefit in vivo, associated with anti-tumor alterations to the GBM tumor microenvironment. Further studies to optimize the efficiency of combinatorial immunomodulator delivery are currently underway.

NCOG-51. CORRELATION BETWEEN TUMOR VOLUME AND SERUM PROLACTIN AND IMPACT OF TUMOR CELLULAR DENSITY ON PROLACTINOMA SURGICAL OUTCOMES IN A COHORT OF 181 PATIENTS

INTRODUCTION

Prolactinomas are common pituitary adenomas managed medically or surgically.

METHODS

Reviewed 181 prolactinomas resected transsphenoidally 2012-2019. Tumor volumes were quantified using BrainLab Smartbrush. Pearson correlation analysis and linear regression were used to identify associations between tumor volumes and serum prolactin. Tumor density was defined as serum prolactin divided by tumor volume.

RESULTS

Mean tumor volume was 6.33cm3 and mean pre-op prolactin was 803.4ug/L, with men having larger (12.11 vs 2.93cm3;p&lt; 0.001) and women having denser (173.9 vs 107.6ug/L/cm3;p=0.011) prolactinomas. Pearson correlation (R=0.688;p&lt; 0.001) and linear regression revealed a strong association between pre-op volume and prolactin levels, with 96.9g/L increase in prolactin/cm3 increase in volume (p&lt; 0.001); this holds true for men (R=0.584;p&lt; 0.001) and women (R=0.939;p&lt; 0.001), with women demonstrating greater prolactin/cm3 tumor density (186.5 vs 75.0ug/L;p&lt; 0.001). MiB index did not correlate with pre-op volume (p=0.449) or pre-op prolactin (p=0.452). Logistic regression showed decreased biochemical remission with increasing pre-op volume (OR=0.891;p&lt; 0.001). Increased MiB index (p=0.971) and p53 (p=0.525) staining did not affect remission rates. Positive PIT-1 staining was associated with higher remission rates (OR=2.508;p=0.005). Patients without remission had denser tumors (149.9 vs. 100.6ug/L/cm3;p=0.013), with Pearson correlation yielding R=0.736 between pre-op volume and pre-op prolactin (p&lt; 0.001), and R=0.476 between residual volume and post-op prolactin (p&lt; 0.001). Patients without remission exhibited 142.9ug/L increase in prolactin/cm3 of pre-op volume (p&lt; 0.001), higher than the 58.9ug/L increase in prolactin/cm3 in patients with remission (p&lt; 0.001). Patients without remission had residual tumors with 68.4ug/L increase in prolactin/cm3 of remaining volume after resection (p&lt; 0.001).

CONCLUSION

Our analysis revealed significant correlation between prolactinoma volume and serum prolactin levels. Patients without remission had greater tumor cellular density than those with remission. The volume-prolactin correlation persisted post-operatively, although surgery reduced tumor density. These results could identify prolactinomas for which surgery could achieve biochemical remission.

NCOG-54. SAFETY OF TRANSSPHENOIDAL SURGERY FOR NONFUNCTIONING PITUITARY ADENOMA IN ELDERLY PATIENTS

INTRODUCTION

Life expectancy has increased over the past century, shifting the demographic distribution towards older age groups. Elderly patients comprise up to 14% of patients with pituitary tumors, with most lesions being nonfunctioning adenomas (NFPAs). Here, we compare clinical and surgical outcomes and post-operative complications between non-elderly adult (age ≥ 18 years and ≤ 65 years) and elderly (age &gt; 65 years) NFPA patients.

METHODS

Retrospective review of 908 patients undergoing transsphenoidal surgery for NFPA at a single institution from 2007-2019.

RESULTS

Elderly patients represented 32.4% of patients. Both groups were similar in gender (57.3% vs 60.5% male;P=0.4), tumor size (2.56 vs 2.46 cm;P=0.2), and cavernous sinus invasion (35.8% vs 33.7%;P=0.6). Regarding post-operative outcomes, length of stay (1 vs 2 days; P=0.5), extent of resection (59.8% vs 64.8% GTR;P=0.2), CSF leak requiring surgical revision (4.3% vs 1.4%;P=0.06), 30-day readmission (8.1% vs 7.3%;P=0.7), infection (3.1% vs 2.0%;P=0.5), and new hypopituitarism (13.9% vs 12.0%;P=0.3) were similar between both groups. Elderly patients were less likely to have adjuvant radiation (8.7% vs 16.3%;P=0.009), future re-operation (3.8% vs 9.5%;P=0.003), and post-operative diabetes insipidus (DI) (3.7% vs 9.4%;P=0.002), and more likely to have post-operative hyponatremia (26.7% vs 16.4%;P&lt; 0.001) and new cranial nerve deficit (1.9% vs 0.0%;P=0.01). Elderly patients’ post-operative sodium peaked and troughed on POD3 (mean=138.7 mEq/L) and POD9 (mean=130.8 mEq/L), respectively, compared to non-elderly patients (peak POD2 mean=139.9 mEq/L, trough POD8 mean=131.3 mEq/L).

CONCLUSION

Our analysis revealed that elderly patients experienced more post-operative hyponatremia, while non-elderly patients experienced more post-operative DI. Elderly patients also experience later peak and trough in serum sodium, suggesting age-related differences in stalk-related morbidities of NFPA resection. Overall, our results show that transsphenoidal surgery for NFPA in elderly patients is safe with low complication rates. We hope our results will guide discussions with elderly patients regarding possible risks and outcomes.

SURG-25. EFFECT OF VENTRICULAR ENTRY DURING GLIOBLASTOMA RESECTION ON PATIENT OUTCOMES

BACKGROUND

Tumor proximity to the ventricle and ventricular entry (VE) during surgery have both been associated with poorer prognoses; however, the interaction between these two factors is poorly understood.

METHODS

The UCSF tumor registry was searched for patients with newly diagnosed and recurrent supratentorial glioblastoma who underwent surgical resection with the senior author between 2013 – 2018. Tumor location with respect to the subventricular zone (SVZ), size, VE, and extent of resection were assessed using pre and postoperative imaging.

RESULTS

In the 200-patient cohort of newly diagnosed and recurrent glioblastoma, 26.5% had VE. Comparing patients with VE to those without VE, there was no difference in postoperative hydrocephalus (1.9% vs. 4.8%, p = 0.36), ventriculoperitoneal shunting (0% vs. 3.4%, p = 0.17), pseudomeningoceles (7.5% vs. 5.4%, p = 0.58), or subdural hematomas (11.3% vs. 3.4%, p = 0.07). Importantly, rates of leptomeningeal disease (7.5% in VE vs. 10.2% w/o VE, p = 0.57) and distant parenchymal recurrence (17.9% in VE vs. 23.1% w/o VE, p = 0.35) were not different between the groups. There was no effect of VE on EOR when controlling for SVZ type. Newly diagnosed patients with tumors contacting the SVZ (Type 1 or 2) had worse survival than patients with tumors that did not contact the SVZ (Type 3 or 4) (1.27 vs 1.84 years, p = 0.014, HR 1.8, CI 1.08 – 3.03), but VE was not associated with worse survival in these patients with high risk SVZ Type 1 and 2 tumors (1.15 vs 1.68 years, p = 0.151, HR 0.59, CI 0.26 – 1.34).

DISCUSSION

VE was well tolerated with complications being rare events. There was no increase in leptomeningeal spread or distant parenchymal recurrence in patients with VE. Finally, VE did not change survival for patients with tumors contacting the ventricle.

Stopping targeted therapy for complete responders in advanced BRAF mutant melanoma

BRAF inhibitors revolutionised the management of melanoma patients and although resistance occurs, there is a subgroup of patients who maintain durable disease control. For those cases with durable complete response (CR) it is not clear whether it is safe to cease therapy. Here we identified 13 patients treated with BRAF +/- MEK inhibitors, who cease therapy after prolonged CR (median = 34 months, range 20-74). Recurrence was observed in 3/13 (23%) patients. In the remaining 10 patients with sustained CR off therapy, the median follow up after discontinuation was 19 months (range 8-36). We retrospectively measured ctDNA levels using droplet digital PCR (ddPCR) in longitudinal plasma samples. CtDNA levels were undetectable in 11/13 cases after cessation and remained undetectable in patients in CR (10/13). CtDNA eventually became detectable in 2/3 cases with disease recurrence, but remained undetectable in 1 patient with brain only progression. Our study suggests that consideration could be given to ceasing targeted therapy in the context of prolonged treatment, durable response and no evidence of residual disease as measured by ctDNA.

The Situation Room as a management tool: the case of the Municipal Health Secretariat of Salvador

Problem

The Salvador Municipal Health Secretariat (MHS) utilizes health data to elaborate technical documents to manage and respond to instances requiring internal or external control. In answer to demands for the modernization and transparency of municipal management, the constitution of a Health Situation Room (HSR) was included in the political agenda of the Secretary, thereby guaranteeing political, technical and operational support for its implementation.

Description of the Problem

To describe the process of construction of the HSR in the Salvador MHS in 2020. The HSR is a physical, virtual and collective space for the analysis of information, which begins with a data search which allows to understand the information flow, identifying the solicitor and the constructor of the information, the data source and the informational object itself.

Results

130 technicians and managers were interviewed, and their responses then categorized into 161 indicators across different themes. The results point out the need to define a spatial analysis unit to be adopted, and to communicate with external actors who demand information, as well as to develop a communication plan for the HSR.

Lessons

To develop an informational culture oriented by local and central protagonism, generating evidence for decision-making and information transparency for the whole of society.

Key messages

The Health Situation Room reduces the time between information-decision-action. The Health Situation Room prioritizes interdisciplinary collaboration and increases the efficiency of the health system.

Hospitalization direct cost of adults with community-acquired pneumonia in Portugal from 2000 to 2009

INTRODUCTION

Hospitalizations due to community-acquired pneumonia (CAP) in mainland Portugal from 2000 to 2009 accounted for 3.7% of all hospital admissions in population with 18 or more years of age. There is no direct-cost data regarding these admissions.

METHODS

In this observational descriptive study all adult hospitalizations associated with CAP diagnosis were retrospectively analyzed for the period between 2000 and 2009. Patients under 18 years old, those with pneumonia as secondary diagnosis, patients with tuberculous or obstructive pneumonia, and immunocompromised patients were excluded from the study. The direct cost of hospitalization was calculated according to the diagnosis-related groups (DRG), established for the respective year of hospitalization.

RESULTS

There were 294,026 hospital admissions with an average annual direct cost of 80 million Euros, which almost doubled between 2000 and 2009. The average direct hospitalization costs per admission, including wards and Intensive Care Units (ICU), amounted to €2,707, with an increasing trend. The average hospitalization cost was €2,515 for admissions resulting in live discharge, and €3,457 for the deceased.

CONCLUSION

The average direct cost of adult hospitalizations associated with CAP amounted to €2,707 in mainland Portugal from 2000 to 2009, showing an increase of 37.5% in hospitalization cost of living and deceased patients. The economic impact of CAP-related hospital admissions justifies the need for better implementation of preventive measures.

P1377Substrate-based ablation in patients with frequent appropriate ICD therapy and dilated cardiomyopathy: long-term experience with high-density mapping

Recurrent ventricular tachydisrhythmias (VT) episodes have a negative impact in the outcome of patients (P) already with an implantable cardioverter-defibrillator (ICD). Elimination of arrhythmic reentry circuits represents a difficult challenge, mainly due to the induction of intolerable VTs, with multiple ECG morphologies, requiring rapid interruption. Substrate guided ablation has been used as a promising approach strategy to treat recurrent VTs. Aim: to assess long-term results of a VT substrate-based ablation using high-density mapping in P with an ICD, severe left ventricular (LV)  dysfunction and recurrent appropriate ICD therapy. Methods: 16P (12 men, non-ischemic cardiomyopathy 67%, 55 ± 13 years, LV ejection fraction 32 ± 6%) and recurrent appropriate shocks despite antiarrhythmic drug therapy and optimal heart failure medication. All P underwent a protocol of ventricular programmed stimulation (600 ms/S3) to obtain baseline VT documentation. A sinus rhythm (SR) voltage map was created using a 3D electroanatomic mapping system (CARTO) with a high-density mapping catheter (PentaRay) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0,5 mV – dense scar; 0,5-1,5 mV – border zone; ≥1,5 mV – healthy tissue) and provide high-resolution electrophysiological mapping. The substrate modification included catheter elimination of local abnormal ventricular activities (LAVA) - fractionated, splited, low-amplitude/long-lasting, late potentials, pre-systolic potentials - and linear ablation to obtain scars homogenization and scar dechanneling. Pace-mapping techniques were used when capture was possible. LV approach was retrograde in 6 cases, transeptal in 4 and endo-epicardial in 2 cases. In 2P the ablation was performed in the right ventricle. Results: VTs were induced and interrupted with bursts or external DC shocks. LAVA were identified and ablated in all P. Eleven P underwent modification of scar areas. The mean duration of the procedure was 153 mn (103-218 mn), with radiofrequency ranging from 18 to 60 mn (mean 33 min), and a mean fluoroscopy time of 16 mn. Non-inducibility was achieved in 75% of the cases. There was 1 pericardial tamponade drained successfully. During a follow-up of 48 ± 18 months, 75% had no VT recurrences, 2P underwent redo ablation, 1P died from stroke. Conclusion: Catheter ablation of VT based on substrate modification guided by high-density mapping is feasible and safe in P with LV dysfunction. This approach may be of clinical relevance, with potential benefits in reducing VT burden.

Primary papillary epithelial tumour of the sella: expanding the spectrum of TTF-1-positive sellar lesions

AIM

To describe four novel primary epithelial tumours of the sella with papillary architecture and Thyroid Transcription Factor 1 (TTF-1) expression.

METHODS

Paraffin-embedded tissue from the four cases and recurrence of patient 1 was investigated with haematoxylin-eosin, special histochemical stains, immunohistochemistry with a broad panel of antibodies and next-generation sequencing. The ultrastructure of one tumour was studied in tissue retrieved from paraffin.

RESULTS

The lesions occurred in three females aged 20, 26 and 42 years and a male aged 49 years. They presented with signs and symptoms secondary to pituitary stalk compression. Preoperative neuroimaging documented mixed solid and cystic, enhancing sellar masses with suprasellar extension. Histologically, the tumours showed thin papillae lined by a single layer of cytokeratin and TTF-1-positive cuboidal and cylindrical cells with mildly atypical nucleus. Next-generation sequencing performed in three cases did not identify any mutations. The main differential diagnosis included metastasis from lung or thyroid carcinoma, extraventricular choroid plexus papilloma and sellar ependymoma.

CONCLUSION

We suggest the descriptive term of primary papillary epithelial tumour of the sella (PPETS) for this entity and propose that it could represent the intracranial equivalent of thyroid-like low-grade nasopharyngeal papillary adenocarcinoma. The cell of origin of PPETS remains undetermined although the intense and ubiquitous expression of TTF-1 may suggest a derivation from the infundibulum or ventricular recess. Our study expands the spectrum of sellar TTF-1-positive tumour and challenges the view that they all derive from pituicytes.

Host engulfment pathway controls inflammation in inflammatory bowel disease

Chronic diseases, including inflammatory bowel disease (IBD) urgently need new biomarkers as a significant proportion of patients, do not respond to current medications. Inflammation is a common factor in these diseases, and microbial sensing in the intestinal tract is critical to initiate the inflammation. We have identified ELMO1 (engulfment and cell motility protein 1) as a microbial sensor in epithelial and phagocytic cells that turns on inflammatory signals. Using a stem cell-based 'gut-in-a-dish' coculture model, we studied the interactions between microbes, epithelium, and monocytes in the context of IBD. To mimic the in vivo cell physiology, enteroid-derived monolayers (EDMs) were generated from the organoids isolated from WT and ELMO1-/- mice and colonic biopsies of IBD patients. The EDMs were infected with the IBD-associated microbes to monitor the inflammatory responses. ELMO1-depleted EDMs displayed a significant reduction in bacterial internalization, a decrease in pro-inflammatory cytokine productions and monocyte recruitment. The expression of ELMO1 is elevated in the colonic epithelium and in the inflammatory infiltrates within the lamina propria of IBD patients where the higher expression is positively correlated with the elevated expression of pro-inflammatory cytokines, MCP-1 and TNF-α. MCP-1 is released from the epithelium and recruits monocytes to the site of inflammation. Once recruited, monocytes require ELMO1 to engulf the bacteria and propagate a robust TNF-α storm. These findings highlight that the dysregulated epithelial ELMO1 → MCP-1 axis can serve as an early biomarker in the diagnostics of IBD and other inflammatory disorders.

Influence of thickness and translucency of lithium disilicate ceramic on degree of conversion of resinous materials

Background

In this study was assessed the degree of conversion (DC) of amine-free resin cements light cured through lithium disilicate-reinforced ceramics at different thicknesses and translucency.

Material and Methods

Specimens were divided into 21 groups (n = 5) according to luting agent used: Variolink Esthetic LC (Light shade), RelyX Ultimate (A1 shade), and Filtek Z350 XT Flow (A1 shade); the ceramic translucency: low (LT) and high (HT); and the ceramic thickness: no ceramic (control), 0.5 mm, 1 mm, and 2 mm. A Teflon mold with (5 x 5 x 0.5 mm) was used to standardize the cement and over it the ceramic block from each group was placed. Set was cured using a polywave LED light (1200 mW/cm2 - Bluephase G2) for 40 s. FTIR spectra of uncured and cured materials was obtained and DC calculated from the height of the peaks 1610 and 1640 cm-1. Data were submitted to ANOVA followed by Tukey’s test (α = 0.05).

Results

There was a significant difference for luting agents (p< 0.0001) and translucency (p = 0.025), but not for thickness (p = 0.73). Dual amine-free RelyX Ultimate showed the lowest DC values and higher translucency promoted higher DC.

Conclusions

Dual amine-free cement showed the lowest monomer conversion and higher translucency ceramics promoted a higher DC.

Key words:Ceramic, degree of conversion, resin cement, thickness, translucency.

Determination of Low-Level Glucose and Fructose in Raw and Refined Crystalline Sugar by High-Performance Anion-Exchange Chromatography: Collaborative Study

A method was developed and a collaborative study was performed under the auspices of the International Commission of Uniform Methods for Sugar Analysis. The collaborators used high-performance anion-exchange chromatography (HPAEC) to determine trace amounts of glucose and fructose in 3 raw and 3 refined sugar samples provided as blind duplicates. Fourteen laboratories participated in the study. Although difficulties were experienced by a few analysts, 10 laboratories reported positive results. Average repeatabilities and reproducibilities for glucose and fructose in raw sugar were slightly above 5 and 10%, respectively, and the average Horwitz ratios were well under 2. Average repeatabilities and reproducibilities for glucose and fructose in refined sugar were 10 and 22%, respectively; although the Horwitz ratios were &gt;2, they were marginal (2.8). The HPAEC results agreed with results obtained by gas chromatography in an independent laboratory. Because the method was collaboratively studied according to the protocol of the International Union of Pure and Applied Chemistry for collaborative studies, and the results meet its criteria, it is recommended that the method be adopted Official First Action by AOAC INTERNATIONAL.

Skin tests and challenge-based drug allergy diagnosis: a retrospective study of patients with confirmed drug allergy

Summary

Objectives. To describe clinical manifestations and performed diagnostic workup, focusing drug challenge tests (DCT), in patients with drug allergy. Methods. Retrospective study including all patients with skin tests (STs) or DCT-based drug allergy diagnosis, between 01/2014 - 06/2018 in a Portuguese allergy unit. Data were collected from electronic and paper-based clinical records. Results. We had 75 drug allergy diagnoses. Most index reactions were mild and major or equal 1 hour after drug intake. 59 (78%) diagnoses were based on DCTs, all based on multistep protocols with major or equal 3 predicted steps. Only 10% of the DCT were positive during up-dosing; timing and severity of the index reaction predicted DCT interruption during up-dosing. Conclusions. Most drug allergy diagnoses were based on multistep DCT. The identified predictors of DCT interruption during up-dosing can support the development of more personalized DCTs protocols.