Dynamic prediction of survival using multivariate functional principal component analysis: A strict landmarking approach

Dynamically predicting patient survival probabilities using longitudinal measurements has become of great importance with routine data collection becoming more common. Many existing models utilize a multi-step landmarking approach for this problem, mostly due to its ease of use and versatility but unfortunately most fail to do so appropriately. In this article we make use of multivariate functional principal component analysis to summarize the available longitudinal information, and employ a Cox proportional hazards model for prediction. Additionally, we consider a centred functional principal component analysis procedure in an attempt to remove the natural variation incurred by the difference in age of the considered subjects. We formalize the difference between a 'relaxed' landmarking approach where only validation data is landmarked and a 'strict' landmarking approach where both the training and validation data are landmarked. We show that a relaxed landmarking approach fails to effectively use the information contained in the longitudinal outcomes, thereby producing substantially worse prediction accuracy than a strict landmarking approach.

Orthogonal proteomics methods warrant the development of Duchenne muscular dystrophy biomarkers

BACKGROUND

Molecular components in blood, such as proteins, are used as biomarkers to detect or predict disease states, guide clinical interventions and aid in the development of therapies. While multiplexing proteomics methods promote discovery of such biomarkers, their translation to clinical use is difficult due to the lack of substantial evidence regarding their reliability as quantifiable indicators of disease state or outcome. To overcome this challenge, a novel orthogonal strategy was developed and used to assess the reliability of biomarkers and analytically corroborate already identified serum biomarkers for Duchenne muscular dystrophy (DMD). DMD is a monogenic incurable disease characterized by progressive muscle damage that currently lacks reliable and specific disease monitoring tools.

METHODS

Two technological platforms are used to detect and quantify the biomarkers in 72 longitudinally collected serum samples from DMD patients at 3 to 5 timepoints. Quantification of the biomarkers is achieved by detection of the same biomarker fragment either through interaction with validated antibodies in immuno-assays or through quantification of peptides by Parallel Reaction Monitoring Mass Spectrometry assay (PRM-MS).

RESULTS

Five, out of ten biomarkers previously identified by affinity-based proteomics methods, were confirmed to be associated with DMD using the mass spectrometry-based method. Two biomarkers, carbonic anhydrase III and lactate dehydrogenase B, were quantified with two independent methods, sandwich immunoassays and PRM-MS, with Pearson correlations of 0.92 and 0.946 respectively. The median concentrations of CA3 and LDHB in DMD patients was elevated in comparison to those in healthy individuals by 35- and 3-fold, respectively. Levels of CA3 vary between 10.26 and 0.36 ng/ml in DMD patients whereas those of LDHB vary between 15.1 and 0.8 ng/ml.

CONCLUSIONS

These results demonstrate that orthogonal assays can be used to assess the analytical reliability of biomarker quantification assays, providing a means to facilitate the translation of biomarkers to clinical practice. This strategy also warrants the development of the most relevant biomarkers, markers that can be reliably quantified with different proteomics methods.

Multiomic characterization of disease progression in mice lacking dystrophin

Duchenne muscular dystrophy (DMD) is caused by genetic mutations leading to lack of dystrophin in skeletal muscle. A better understanding of how objective biomarkers for DMD vary across subjects and over time is needed to model disease progression and response to therapy more effectively, both in pre-clinical and clinical research. We present an in-depth characterization of disease progression in 3 murine models of DMD by multiomic analysis of longitudinal trajectories between 6 and 30 weeks of age. Integration of RNA-seq, mass spectrometry-based metabolomic and lipidomic data obtained in muscle and blood samples by Multi-Omics Factor Analysis (MOFA) led to the identification of 8 latent factors that explained 78.8% of the variance in the multiomic dataset. Latent factors could discriminate dystrophic and healthy mice, as well as different time-points. MOFA enabled to connect the gene expression signature in dystrophic muscles, characterized by pro-fibrotic and energy metabolism alterations, to inflammation and lipid signatures in blood. Our results show that omic observations in blood can be directly related to skeletal muscle pathology in dystrophic muscle.

Longitudinal Assessment of Creatine Kinase, Creatine/Creatinineratio, and Myostatin as Monitoring Biomarkers in Becker Muscular Dystrophy

BACKGROUND AND OBJECTIVES

The slow and variable disease progression of Becker muscular dystrophy (BMD) urges the development of biomarkers to facilitate clinical trials. We explored changes in 3 muscle-enriched biomarkers in serum of patients with BMD over 4-year time and studied associations with disease severity, disease progression, and dystrophin levels in BMD.

METHODS

We quantitatively measured creatine kinase (CK) using the International Federation of Clinical Chemistry reference method, creatine/creatinine_ratio (Cr/Crn) using liquid chromatography-tandem mass spectrometry, and myostatin with ELISA in serum and assessed functional performance using the North Star Ambulatory Assessment (NSAA), 10-meter run velocity (TMRv), 6-Minute Walking Test (6MWT), and forced vital capacity in a 4-year prospective natural history study. Dystrophin levels were quantified in the tibialis anterior muscle using capillary Western immunoassay. The correlation between biomarkers, age, functional performance, mean annual change, and prediction of concurrent functional performance was analyzed using linear mixed models.

RESULTS

Thirty-four patients with 106 visits were included. Eight patients were nonambulant at baseline. Cr/Crn and myostatin were highly patient specific (intraclass correlation coefficient for both = 0.960). Cr/Crn was strongly negatively correlated, whereas myostatin was strongly positively correlated with the NSAA, TMRv, and 6MWT (Cr/Crn rho = -0.869 to -0.801 and myostatin rho = 0.792 to 0.842, all p < 0.001). CK showed a negative association with age (p = 0.0002) but was not associated with patients' performance. Cr/Crn and myostatin correlated moderately with the average annual change of the 6MWT (rho = -0.532 and 0.555, p = 0.02). Dystrophin levels did not correlate with the selected biomarkers nor with performance. Cr/Crn, myostatin, and age could explain up to 75% of the variance of concurrent functional performance of the NSAA, TMRv, and 6MWT.

DISCUSSION

Both Cr/Crn and myostatin could potentially serve as monitoring biomarkers in BMD, as higher Cr/Crn and lower myostatin were associated with lower motor performance and predictive of concurrent functional performance when combined with age. Future studies are needed to more precisely determine the context of use of these biomarkers.

A case series of fetal lymphatic malformations and a review of the literature

Lymphatic malformations are rare benign developmental anomalies of the lymphatic system that can be diagnosed by prenatal ultrasound. Depending on their anatomical site and size, the lesions can cause a variety of aesthetic and functional deficits. Several treatment options are available, the most suitable is still under debate. The experience gained at our Centre and the review of the literature can be useful to improve prenatal counseling, that is challenging due to the heterogeneity of clinical presentation and treatment.

Response to treatment and prognostic significance of supradiaphragmatic disease in patients with high-grade serous ovarian cancer

OBJECTIVES

This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated.

METHODS

Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or ¹⁸F-FDG PET/CT preoperatively and at follow-up to evaluate response to chemotherapy. At follow-up visits, site of recurrence diagnosed by imaging techniques was systematically recorded as it occurred. Progression-free and overall survival were measured by using Kaplan-Meier and Cox models.

RESULTS

A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8-176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes.

CONCLUSIONS

Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.

Penalized regression calibration: A method for the prediction of survival outcomes using complex longitudinal and high-dimensional data

Longitudinal and high‐dimensional measurements have become increasingly common in biomedical research. However, methods to predict survival outcomes using covariates that are both longitudinal and high‐dimensional are currently missing. In this article, we propose penalized regression calibration (PRC), a method that can be employed to predict survival in such situations. PRC comprises three modeling steps: First, the trajectories described by the longitudinal predictors are flexibly modeled through the specification of multivariate mixed effects models. Second, subject‐specific summaries of the longitudinal trajectories are derived from the fitted mixed models. Third, the time to event outcome is predicted using the subject‐specific summaries as covariates in a penalized Cox model. To ensure a proper internal validation of the fitted PRC models, we furthermore develop a cluster bootstrap optimism correction procedure that allows to correct for the optimistic bias of apparent measures of predictiveness. PRC and the CBOCP are implemented in the R package pencal, available from CRAN. After studying the behavior of PRC via simulations, we conclude by illustrating an application of PRC to data from an observational study that involved patients affected by Duchenne muscular dystrophy, where the goal is predict time to loss of ambulation using longitudinal blood biomarkers.

Capacity building primary care responses to domestic violence in Brazil: designing a training model

Background

Violence against women (VAW) is a public health challenge in Brazil. The country ranks 6th globally for femicide, with a high prevalence of domestic violence, amplified by the pandemic. Primary healthcare (PHC) workers can play a significant role caring for survivors, but their training on how to identify and respond to survivors is a major gap. This study aimed to investigate frontline PHC workers' needs and concerns in the care of VAW survivors, aiming to co-design a participatory model of capacity building to be implemented in the Brazilian PHC.

Methods

This study is based on participatory action-research (PAR) through participant observation and in-depth interviews with an interdisciplinary team of 13 PHC workers from Paranaguá, South of Brazil. Data were collected between Aug/2020-Jan/2021, transcribed, coded and synthetized through thematic analysis.

Results

Major needs and concerns were: 1) unanimous need of capacity building for all PHC workers and managers; 2) training ideally should be face-to-face, and more than one day, based in practical cases (not just in theory); 3) clarifying the role of the cross-sectoral network and referral options; 4) contents needs to address confidentiality, qualified listening, empathy and respect, with practical guidance on how to approach survivors. Other issues included: integrating VAW approaches with violence against children and adolescents; ensuring PHC units have a private room to care for survivors; and electing a key professional in each unit, with more specialized knowledge, to support survivors and staff.

Conclusions

This PAR revealed key issues to collaboratively design a capacity building model for PHC in Brazil, tailored to local needs. The next step will be applying for funding to implement a pilot training.

Key messages

Frontline PHC workers routinely attend cases of VAW, therefore their insights are essential to design capacity building to care for survivors in PHC settings. Training healthcare workers to care for survivors of violence needs to address local concerns, targeting knowledge, skills and competences.

Online-based intervention on LGBTI+ health promotion in Brazil: development and preliminary impacts

Background

Brazil reports public healthcare gaps concerning lesbian, gay, bisexual, transgender, and intersex (LGBTI+) people. Massive Open Online Courses (MOOCs) are online-based teaching interventions, however their use is still scarce in Brazil. We aim to describe the development and to analyze preliminary impacts of the first online-based intervention through MOOCs for LGBTI+ health promotion in Brazil.

Methods

We adopted mixed qualitative and quantitative approaches, based on participatory-action research: 1) to design the content and format of the MOOC, we conducted 10 focus groups during 2018 and 2019 with key stakeholders in three different Brazilian State capitals, identifying needs and challenges and linking it with guidelines of the National Policy for Comprehensive Health of LGBTI+ people; 2) based on step 1, we developed the MOOC, producing reading content, video-classes and multimedia; 3) we quantitatively analyzed, through a survey, its impact and reach after six months.

Results

The results showed that: a) focus groups were essentials to inform the priorities to design a tailored MOOC; b) the MOOC had 30 hours of autonomous learning activities divided into two modules, with problem-based evaluation; c) the first ten-month of the course had a total of 5,000 people enrolled with a completion rate of approximately 30%; d) 1,700 successfully completed the course; e) 582 participants joined the survey post-course evaluation and for 370 (63.6%) of them, this was the first training activity on LGBTI+ health.

Conclusions

Results point to a high interest in LGBTI+ health and high demand for training on this topic among health professionals. The MOOC format was successful and reliable in enabling the teaching-learning process.

Key messages

Participatory action research was able to inform the content of the first MOOC for LGBTI+ health in Brazil. The MOCC had high interest, and for the majority of concluding participants it was the first activity and formal education about LGBTI+ health.

On community structure validation in real networks

Community structure is a commonly observed feature of real networks. The term refers to the presence in a network of groups of nodes (communities) that feature high internal connectivity, but are poorly connected between each other. Whereas the issue of community detection has been addressed in several works, the problem of validating a partition of nodes as a good community structure for a real network has received considerably less attention and remains an open issue. We propose a set of indices for community structure validation of network partitions that are based on an hypothesis testing procedure that assesses the distribution of links between and within communities. Using both simulations and real data, we illustrate how the proposed indices can be employed to compare the adequacy of different partitions of nodes as community structures in a given network, to assess whether two networks share the same or similar community structures, and to evaluate the performance of different network clustering algorithms.

Prediction of complex gastroschisis: The evolution of therapeutic techniques and their relation with fetal sonographic features

BACKGROUND

To analyze prenatal ultrasound (US) markers to predict treatment and adverse neonatal outcome in fetal gastroschisis.

METHODS

It was conducted a retrospective single-center study considering all pregnancies with isolated gastroschisis that were treated in our department between 2008 and 2020. 17 US markers were analyzed. Moreover, the association between prenatal ultrasound signs and neonatal outcomes was analyzed: need of bowel resection, techniques of reduction, type of closure, adverse neonatal outcomes, time to full enteral feeding, length of total parenteral nutrition and length of hospitalization.

RESULTS

The analysis included 21 cases. We found significant associations between intestinal dilation (≥10 mm) appeared before 30 weeks of gestation and the need of bowel resection (p = 0.001), the length of total parenteral nutrition (p = 0,0013) and the length of hospitalization (p = 0,0017). Intrauterine growth restriction (IUGR) is a risk factor for serial reduction (p = 0,035). There were no signs significantly associated with the type of closure. Hyperbilirubinemia is related with gestational age (GA) at the diagnosis of intra-abdominal bowel dilation (IABD) (p = 0.0376) and maximum IABD (p = 0.05). All newborns with sepsis had echogenic loops in uterus (p = 0.026). The relation between the GA at delivery and the GA at the extra-abdominal bowel dilation (EABD)≥10 mm was r = 0.70.

CONCLUSION

We showed the significant role of the early presence of bowel dilation in predicting intestinal resection and adverse outcomes. All IUGR fetuses needed staged reduction through the silo-bag technique. The echogenic bowel was related to neonatal sepsis, while IABD was associated with hyperbilirubinemia.

Longitudinal metabolomic analysis of plasma enables modeling disease progression in Duchenne muscular dystrophy mouse models

Duchenne muscular dystrophy is a severe pediatric neuromuscular disorder caused by the lack of dystrophin. Identification of biomarkers is needed to support and accelerate drug development. Alterations of metabolites levels in muscle and plasma have been reported in pre-clinical and clinical cross-sectional comparisons. We present here a 7-month longitudinal study comparing plasma metabolomic data in wild-type and mdx mice. A mass spectrometry approach was used to study metabolites in up to five time points per mouse at 6, 12, 18, 24 and 30 weeks of age, providing an unprecedented in depth view of disease trajectories. A total of 106 metabolites were studied. We report a signature of 31 metabolites able to discriminate between healthy and disease at various stages of the disease, covering the acute phase of muscle degeneration and regeneration up to the deteriorating phase. We show how metabolites related to energy production and chachexia (e.g. glutamine) are affected in mdx mice plasma over time. We further show how the signature is connected to molecular targets of nutraceuticals and pharmaceutical compounds currently in development as well as to the nitric oxide synthase pathway (e.g. arginine and citrulline). Finally, we evaluate the signature in a second longitudinal study in three independent mouse models carrying 0, 1 or 2 functional copies of the dystrophin paralog utrophin. In conclusion, we report an in-depth metabolomic signature covering previously identified associations and new associations, which enables drug developers to peripherally assess the effect of drugs on the metabolic status of dystrophic mice.

Peripheral blood transcriptome profiling enables monitoring disease progression in dystrophic mice and patients

DMD is a rare disorder characterized by progressive muscle degeneration and premature death. Therapy development is delayed by difficulties to monitor efficacy non-invasively in clinical trials. In this study, we used RNA-sequencing to describe the pathophysiological changes in skeletal muscle of 3 dystrophic mouse models. We show how dystrophic changes in muscle are reflected in blood by analyzing paired muscle and blood samples. Analysis of repeated blood measurements followed the dystrophic signature at five equally spaced time points over a period of seven months. Treatment with two antisense drugs harboring different levels of dystrophin recovery identified genes associated with safety and efficacy. Evaluation of the blood gene expression in a cohort of DMD patients enabled the comparison between preclinical models and patients, and the identification of genes associated with physical performance, treatment with corticosteroids and body measures. The presented results provide evidence that blood RNA-sequencing can serve as a tool to evaluate disease progression in dystrophic mice and patients, as well as to monitor response to (dystrophin-restoring) therapies in preclinical drug development and in clinical trials.

Measurement of E × B drift of impurities in the C-2W inner divertor using spatial heterodyne spectroscopy

Edge control in the C-2W field-reversed configuration experiment is crucial for the stability and energy confinement of the core plasma. Such edge control is achieved by electrical biasing on the end-on electrode plates. The radial electric field generated by the electrode biasing can be measured by E × B induced drift of impurity ions. Spatial heterodyne spectroscopy (SHS) is a promising method of high light throughput spectroscopy. Doppler shifted spectra of O⁴⁺ ion emission lines have been measured using a novel, in-house built SHS system. The electric field in the jet plasma inside the inner divertor of C-2W was estimated using the temporal profile of the rotational velocity of the oxygen ions. SHS system details, obtained measurements, and the methods of improving the system performance will be discussed.

Low dystrophin variability between muscles and stable expression over time in Becker muscular dystrophy using capillary Western immunoassay

Becker muscular dystrophy (BMD) is the milder allelic variant of Duchenne muscular dystrophy, with higher dystrophin levels. To anticipate on results of interventions targeting dystrophin expression it is important to know the natural variation of dystrophin expression between different muscles and over time. Dystrophin was quantified using capillary Western immunoassay (Wes) in the anterior tibial (TA) muscle of 37 BMD patients. Variability was studied using two samples from the same TA biopsy site in nine patients, assessing nine longitudinal TA biopsies, and eight simultaneously obtained vastus lateralis (VL) muscle biopsies. Measurements were performed in duplicate with two primary antibodies. Baseline dystrophin levels were correlated to longitudinal muscle strength and functional outcomes. Results showed low technical variability and high precision for both antibodies. Dystrophin TA levels ranged from 4.8 to 97.7%, remained stable over a 3–5 year period, and did not correlate with changes in longitudinal muscle function. Dystrophin levels were comparable between TA and VL muscles. Intra-muscle biopsy variability was low (5.2% and 11.4% of the total variability of the two antibodies). These observations are relevant for the design of clinical trials targeting dystrophin production, and may urge the need for other biomarkers or surrogate endpoints.

The House of the Brazilian Woman: impacts of a cross-sectoral public health policy for abused women

Issue

Violence against women is a serious public health concern in Brazil; the country ranks 5th globally for femicide and has high rates of intimate partner violence. In response, a national policy created the House of the Brazilian Woman (HBW). HBWs aimed at caring for abused women, are staffed 24/7 with multi-disciplinary teams; cross-sectoral services include: psychosocial support; healthcare; specialized police; courts; public attorney's offices; temporary shelter; and access to financial support.

Description of the Problem

The purpose of this study was to characterize the preliminary impacts of the HBW of Curitiba. Based on mixed-methods participatory action-research, data were collected between 2018-2020. We present quantitative measures describing the individuals served and a thematic analysis of in-depth interviews with HBW staff.

Results

Since its opening, in 2016, the HBW of Curitiba has served around 50,000 users, including women and perpetrators. The most prevalent type of violence reported was psychological (67%, n = 14,343), followed by physical (25.8%, n = 5,531), economic (5.2%, n = 1,104) and sexual (2%, n = 428). Positive qualitative impacts perceived by staff were: 1) improved women's empowerment; 2) the importance of centralized resources; 3) acting as a support to ensure existing legal protections. The main challenges were: 1) high demand; 2) discontinuous care; 3) negative impacts on staff's health.

Lessons

The HBW of Curitiba is a key cross-sectoral service for abused women, part of a greater national policy to prevent violence and support women. Despite serving a large number of women in a short period of time challenges remain including integration with other parts of the network and considerations of staff burnout.

Key messages

Effective cross-sectoral policies for abused women are paramount for comprehensive women’s health. Having cross-sectoral services in just one place operating 24/7 has high impact for abused women.

Poisson–Tweedie mixed-effects model: A flexible approach for the analysis of longitudinal RNA-seq data

We present a new modelling approach for longitudinal overdispersed counts that is motivated by the increasing availability of longitudinal RNA-sequencing experiments. The distribution of RNA-seq counts typically exhibits overdispersion, zero-inflation and heavy tails; moreover, in longitudinal designs repeated measurements from the same subject are typically (positively) correlated. We propose a generalized linear mixed model based on the Poisson–Tweedie distribution that can flexibly handle each of the aforementioned features of longitudinal overdispersed counts. We develop a computational approach to accurately evaluate the likelihood of the proposed model and to perform maximum likelihood estimation. Our approach is implemented in the R package ptmixed, which can be freely downloaded from CRAN. We assess the performance of ptmixed on simulated data, and we present an application to a dataset with longitudinal RNA-sequencing measurements from healthy and dystrophic mice. The applicability of the Poisson–Tweedie mixed-effects model is not restricted to longitudinal RNA-seq data, but it extends to any scenario where non-independent measurements of a discrete overdispersed response variable are available.

Rimeporide as a first- in-class NHE-1 inhibitor: Results of a phase Ib trial in young patients with Duchenne Muscular Dystrophy

Rimeporide, a first-in-class sodium/proton exchanger Type 1 inhibitor (NHE-1 inhibitor) is repositioned by EspeRare for patients with Duchenne Muscular Dystrophy (DMD). Historically, NHE-1 inhibitors were developed for cardiac therapeutic interventions. There is considerable overlap in the pathophysiological mechanisms in Congestive Heart Failure (CHF) and in cardiomyopathy in DMD, therefore NHE-1 inhibition could be a promising pharmacological approach to the cardiac dysfunctions observed in DMD. Extensive preclinical data was collected in various animal models including dystrophin-deficient (mdx) mice to characterise Rimeporide’s anti-fibrotic and anti-inflammatory properties and there is evidence that NHE-1 inhibitors could play a significant role in modifying DMD cardiac and also skeletal pathologies, as the NHE-1 isoform is ubiquitous. We report here the first study with Rimeporide in DMD patients. This 4-week treatment, open label phase Ib, multiple oral ascending dose study, enrolled 20 ambulant boys with DMD (6–11 years), with outcomes including safety, pharmacokinetic (PK) and pharmacodynamic (PD) biomarkers. Rimeporide was safe and well-tolerated at all doses. PK evaluations showed that Rimeporide was well absorbed orally reaching pharmacological concentrations from the lowest dose, with exposure increasing linearly with dose and with no evidence of accumulation upon repeated dosing. Exploratory PD biomarkers showed positive effect upon a 4-week treatment, supporting its therapeutic potential in patients with DMD, primarily as a cardioprotective treatment, and provide rationale for further efficacy studies.

Longitudinal serum biomarker screening identifies malate dehydrogenase 2 as candidate prognostic biomarker for Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is a fatal disease for which no cure is available. Clinical trials have shown to be largely underpowered due to inter-individual variability and noisy outcome measures. The availability of biomarkers able to anticipate clinical benefit is highly needed to improve clinical trial design and facilitate drug development.

METHODS

In this study, we aimed to appraise the value of protein biomarkers to predict prognosis and monitor disease progression or treatment outcome in patients affected by DMD. We collected clinical data and 303 blood samples from 157 DMD patients in three clinical centres; 78 patients contributed multiple blood samples over time, with a median follow-up time of 2 years. We employed linear mixed models to identify biomarkers that are associated with disease progression, wheelchair dependency, and treatment with corticosteroids and performed survival analysis to find biomarkers whose levels are associated with time to loss of ambulation.

RESULTS

Our analysis led to the identification of 21 proteins whose levels significantly decrease with age and nine proteins whose levels significantly increase. Seven of these proteins are also differentially expressed in non-ambulant patients, and three proteins are differentially expressed in patients treated with glucocorticosteroids. Treatment with corticosteroids was found to partly counteract the effect of disease progression on two biomarkers, namely, malate dehydrogenase 2 (MDH2, P = 0.0003) and ankyrin repeat domain 2 (P = 0.0005); however, patients treated with corticosteroids experienced a further reduction on collagen 1 serum levels (P = 0.0003), especially following administration of deflazacort. A time to event analysis allowed to further support the use of MDH2 as a prognostic biomarker as it was associated with an increased risk of wheelchair dependence (P = 0.0003). The obtained data support the prospective evaluation of the identified biomarkers in natural history and clinical trials as exploratory biomarkers.

CONCLUSIONS

We identified a number of serum biomarkers associated with disease progression, loss of ambulation, and treatment with corticosteroids. The identified biomarkers are promising candidate prognostic and surrogate biomarkers, which may support drug developers if confirmed in prospective studies. The serum levels of MDH2 are of particular interest, as they correlate with disease stage and response to treatment with corticosteroids, and are also associated with the risk of wheelchair dependency and pulmonary function.

The prognostic value of antenatal ultrasound in cases complicated by fetal ovarian cysts

OBJECTIVE

Ovarian cysts are relatively common prenatal findings in female fetuses. The aim of this study is to evaluate the ability of antenatal ultrasound in predicting spontaneous regression or a need for surgery.

DESIGN

All cases of fetal ovarian cysts treated in our Department between 2007 and 2016 were included. Patients underwent a sonographic monitoring in utero and after birth until spontaneous or surgical resolution. Subjects were divided into two groups according to their postnatal management. Receiver-operating characteristics (ROC) curves were used to test the predictive ability for postnatal surgery of the cyst's mean and maximum diameters; their optimal cut off points were also determined.

RESULTS

38 cases of antenatally-detected fetal ovarian cysts were included. 12/38 cases underwent surgery (Group A). 26/38 cases were resolved spontaneously (Group B). Cyst size of those which were surgically excised significantly differed from those that regressed spontaneously. ROC curve pointed to 45 mm and 47 mm as optimal cut off points for the mean and the maximum cystic diameters, respectively.

CONCLUSIONS

Cyst size and echo-structure seemed good predictors for prognosis after birth. The optimal cut off points of the cysts mean and maximum diameters in predicting postnatal surgery have been identified as 45 mm and 47 mm, respectively.

Moderate and severe fetal pyelectasis: Correlation between prenatal aspects and postnatal outcome

BACKGROUND

Renal pelvic dilatation (RPD) is a frequent finding in fetal ultrasound. The aim of the study is to correlate the prenatally detected moderate and severe pyelectasis with the postnatal outcome.

METHODS

A retrospective analysis involving 90 cases of prenatally detected moderate and severe RPD referred to our prenatal diagnosis centre with 18 months of urological follow-up. Prenatal ultrasound was correlated with postnatal renal function, assessed by plasmatic creatinine and/or renal scintigraphy performed before surgery.

RESULTS

Cases were divided between two groups according to postnatal management: group A including 35 newborns (38.9%) that needed surgical treatment and group B with 55 patients (61.1%) who were managed conservatively. The group A presented higher median RPD (18 mm, IQR 12-25 mm) compared to the group B (11 mm, IQR 10-14 mm). The most common anomaly detected within group A was pelvi-ureteric junction (PUI) obstruction (43%). Within group B 32 cases (58%) showed spontaneous resolution of hydronephrosis during postnatal follow up. In case of moderate pyelectasis the risk of postnatal surgery was 25% and raised to 60% for severe RPD. In our study, 29 newborns showed pathologic scintigraphies: 25 required surgery while 4 did not find indication for surgery due to ipsilateral renal function irreversible damage. 6 patients had high creatinine level (>0.6 mg/dl). 35 cases out of 90 (39%) developed monolateral irreversible renal function impairment.

CONCLUSION

Moderate and severe RPD are often correlated with postnatal renal damage, therefore a close multidisciplinary follow-up is required. Prenatal scanning is highly predictive of postnatal outcome and can address properly the prenatal counseling.

Blood-derived biomarkers correlate with clinical progression in Duchenne muscular dystrophy

BACKGROUND

Duchenne Muscular Dystrophy is a severe, incurable disorder caused by mutations in the dystrophin gene. The disease is characterized by decreased muscle function, impaired muscle regeneration and increased inflammation. In a clinical context, muscle deterioration, is evaluated using physical tests and analysis of muscle biopsies, which fail to accurately monitor the disease progression.

OBJECTIVES

This study aims to confirm and asses the value of blood protein biomarkers as disease progression markers using one of the largest longitudinal collection of samples.

METHODS

A total of 560 samples, both serum and plasma, collected at three clinical sites are analyzed using a suspension bead array platform to assess 118 proteins targeted by 250 antibodies in microliter amount of samples.

RESULTS

Nine proteins are confirmed as disease progression biomarkers in both plasma and serum. Abundance of these biomarkers decreases as the disease progresses but follows different trajectories. While carbonic anhydrase 3, microtubule associated protein 4 and collagen type I alpha 1 chain decline rather constantly over time, myosin light chain 3, electron transfer flavoprotein A, troponin T, malate dehydrogenase 2, lactate dehydrogenase B and nestin plateaus in early teens. Electron transfer flavoprotein A, correlates with the outcome of 6-minutes-walking-test whereas malate dehydrogenase 2 together with myosin light chain 3, carbonic anhydrase 3 and nestin correlate with respiratory capacity.

CONCLUSIONS

Nine biomarkers have been identified that correlate with disease milestones, functional tests and respiratory capacity. Together these biomarkers recapitulate different stages of the disorder that, if validated can improve disease progression monitoring.

Model-based clustering for populations of networks

Until recently obtaining data on populations of networks was typically rare. However, with the advancement of automatic monitoring devices and the growing social and scientific interest in networks, such data has become more widely available. From sociological experiments involving cognitive social structures to fMRI scans revealing large-scale brain networks of groups of patients, there is a growing awareness that we urgently need tools to analyse populations of networks and particularly to model the variation between networks due to covariates. We propose a model-based clustering method based on mixtures of generalized linear (mixed) models that can be employed to describe the joint distribution of a populations of networks in a parsimonious manner and to identify subpopulations of networks that share certain topological properties of interest (degree distribution, community structure, effect of covariates on the presence of an edge, etc.). Maximum likelihood estimation for the proposed model can be efficiently carried out with an implementation of the EM algorithm. We assess the performance of this method on simulated data and conclude with an example application on advice networks in a small business.

Tertiary cytoreductive surgery in recurrent epithelial ovarian cancer: A multicentre MITO retrospective study

OBJECTIVES

To evaluate the impact of tertiary cytoreductive surgery (TCS) on survival in recurrent epithelial ovarian cancer (EOC), and to determine predictors of complete cytoreduction.

METHODS

A multi-institutional retrospective study was conducted within the MITO Group on a 5-year observation period.

RESULTS

A total of 103 EOC patients with a ≥6month treatment-free interval (TFI) undergoing TCS were included. Complete cytoreduction was achieved in 71 patients (68.9%), with severe post-operative complications in 9.7%, and no cases of mortality within 60days from surgery. Multivariate analysis identified the complete tertiary cytoreduction as the most potent predictor of survival followed by FIGO stage I-II at initial diagnosis, exclusive retroperitoneal recurrence, and TCS performed ≥3years after primary diagnosis. Patients with complete tertiary cytoreduction had a significantly longer overall survival (median OS: 43months, 95% CI 31-58) compared to those with residual tumor (median OS: 33months, 95% CI 28-46; p<0.001). After multivariate adjustment the presence of a single lesion and good (ECOG 0) performance status were the only significant predictors of complete surgical cytoreduction.

CONCLUSIONS

This is the only large multicentre study published so far on TCS in EOC with ≥6month TFI. The achievement of postoperative no residual disease is confirmed as the primary objective also in a TCS setting, with significant survival benefit and acceptable morbidity. Accurate patient selection is of utmost importance to have the best chance of complete cytoreduction.

Adult Autism Subthreshold Spectrum (AdAS Spectrum): Validation of a questionnaire investigating subthreshold autism spectrum

AIM

Increasing literature has shown the usefulness of a dimensional approach to autism. The present study aimed to determine the psychometric properties of the Adult Autism Subthreshold Spectrum (AdAS Spectrum), a new questionnaire specifically tailored to assess subthreshold forms of autism spectrum disorder (ASD) in adulthood.

METHODS

102 adults endorsing at least one DSM-5 symptom criterion for ASD (ASDc), 143 adults diagnosed with a feeding and eating disorder (FED), and 160 subjects with no mental disorders (CTL), were recruited from 7 Italian University Departments of Psychiatry and administered the following: SCID-5, Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale 14-item version (RAADS-14), and AdAS Spectrum.

RESULTS

The AdAS Spectrum demonstrated excellent internal consistency for the total score (Kuder-Richardson's coefficient=.964) as well as for five out of seven domains (all coefficients>.80) and sound test-retest reliability (ICC=.976). The total and domain AdAS Spectrum scores showed a moderate to strong (>.50) positive correlation with one another and with the AQ and RAADS-14 total scores. ASDc subjects reported significantly higher AdAS Spectrum total scores than both FED (p<.001) and CTL (p<.001), and significantly higher scores on the Childhood/adolescence, Verbal communication, Empathy, Inflexibility and adherence to routine, and Restricted interests and rumination domains (all p<.001) than FED, while on all domains compared to CTL. CTL displayed significantly lower total and domain scores than FED (all p<.001). A significant effect of gender emerged for the Hyper- and hyporeactivity to sensory input domain, with women showing higher scores than men (p=.003). A Diagnosis* Gender interaction was also found for the Verbal communication (p=.019) and Empathy (p=.023) domains. When splitting the ASDc in subjects with one symptom criterion (ASD₁) and those with a ASD, and the FED in subjects with no ASD symptom criteria (FED₀) and those with one ASD symptom criterion (FED₁)_, a gradient of severity in AdAS Spectrum scores from CTL subjects to ASD patients, across FED₀, ASD₁, FED₁ was shown.

CONCLUSIONS

The AdAS Spectrum showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of ASD. The questionnaire performed differently among the three diagnostic groups and enlightened some significant effects of gender in the expression of autistic traits.

NEAT: an efficient network enrichment analysis test

BACKGROUND

Network enrichment analysis is a powerful method, which allows to integrate gene enrichment analysis with the information on relationships between genes that is provided by gene networks. Existing tests for network enrichment analysis deal only with undirected networks, they can be computationally slow and are based on normality assumptions.

RESULTS

We propose NEAT, a test for network enrichment analysis. The test is based on the hypergeometric distribution, which naturally arises as the null distribution in this context. NEAT can be applied not only to undirected, but to directed and partially directed networks as well. Our simulations indicate that NEAT is considerably faster than alternative resampling-based methods, and that its capacity to detect enrichments is at least as good as the one of alternative tests. We discuss applications of NEAT to network analyses in yeast by testing for enrichment of the Environmental Stress Response target gene set with GO Slim and KEGG functional gene sets, and also by inspecting associations between functional sets themselves.

CONCLUSIONS

NEAT is a flexible and efficient test for network enrichment analysis that aims to overcome some limitations of existing resampling-based tests. The method is implemented in the R package neat, which can be freely downloaded from CRAN ( https://cran.r-project.org/package=neat ).

Is aortic lymphadenectomy indicated in locally advanced cervical cancer after neoadjuvant chemotherapy followed by radical surgery? A retrospective study on 261 women

OBJECTIVES

The aim of this study was to estimate the rate of aortic lymph nodes (LN) metastases/recurrences among patients affected by locally advanced stage cancer patients (LACC), treated with neoadjuvant chemotherapy (NACT) and radical surgery.

METHODS

Retrospective evaluation of consecutive 261 patients affected by LACC (stage IB2-IIB), treated with NACT followed by radical surgery at National Cancer Institute, Milan, Italy, between 1990 and 2011.

RESULTS

Stage at presentation included stage IB2, IIA and IIB in 100 (38.3%), 50 (19.2%) and 111 (42.5%) patients, respectively. Squamous cell carcinoma accounted for more than 80%, followed by adenocarcinoma or adenosquamous cancers (20%). Overall, 56 women (21.5%) had LN metastases. Four out of 83 women (5%) who underwent both pelvic and aortic LN dissection had aortic LN metastases, and all women had concomitant pelvic and aortic LN metastases. Only one woman out of 178 (0.5%) who underwent pelvic lymphadenectomy only, had an aortic LN recurrence. Overall 2% of women (5/261) had aortic LN metastases/recurrence.

CONCLUSIONS

Our data suggest that aortic lymphadenectomy at the time of surgery is not routinely indicated in LACC after NACT, but should reserved in case of bulky LN in both pelvic and/or aortic area. The risk of isolated aortic LN relapse is negligible. Further prospective studies are warranted.

P01-248-Theory of mind, moral judgments and neuropsychological functioning in patients with bipolar disorders

Introduction

Several studies revealed that cognitive functioning in BPD are impaired not only in the acute phase but over time (Mur et al., 2008). On Theory of Mind (ToM) recent studies found a impairment of this ability in remitted patients, supporting the theory that ToM deficits are trait-dependent (Bora et al., 2009) in contrast with another study that suggest a partially dependence(Wolf et al. 2010).

Objectives

We explored: a) ToM in BPD investigating two cognitive processes: emotional recognition, second order beliefs attribution; b) Moral judgments in BPD; c) possible effects of neuropsychological functioning on ToM task and moral dilemmas.

Aims

The principal aim is to investigate the domain specificity of ToM and Moral sense, studying selective impairments.

Method

A total of 20 patients with bipolar I disorder were tested and 20 healthy controls. We use a complete neuropsychological assessment, two ToM tasks (Eyes test, Sullivan's stories) and we added two moral dilemmas to asses moral judgment Results: We found ToM deficits in BDP, with a multiple correlation between ToM and neuropsychological functioning. Also we found for the first time a impairment on personal moral dilemma, with a correlation between emotional recognition and moral judgments.

Conclusion

Patients with BPD are impaired in ToM partially independent of other cognitive dysfunctions and in moral reasoning.

A phase II, randomized trial of neo-adjuvant chemotherapy comparing a three-drug combination of paclitaxel, ifosfamide, and cisplatin (TIP) versus paclitaxel and cisplatin (TP) followed by radical surgery in patients with locally advanced squamous cell cervical carcinoma: the Snap-02 Italian Collaborative Study

BACKGROUND

The efficacy and tolerability of the regimen containing paclitaxel and cisplatin (TP) in the neo-adjuvant treatment of locally advanced squamous cell cervical cancer are unknown. The TIP regimen (TP plus ifosfamide) showed high efficacy but high toxicity and it is used as an internal control.

PATIENTS AND METHODS

In all, 154 patients were randomized to TP (paclitaxel 175 mg/m(2) + cisplatin 75 mg/m(2); n = 80) or TIP (TP + ifosfamide 5 g/m(2); n = 74), three cycles, followed by radical surgery. Pathological response to chemotherapy was classified as optimal [no residual tumor (complete response) or residual disease with < or = 3 mm stromal invasion (PR1)] or suboptimal response.

RESULTS

Patient characteristics (TP/TIP): stage IB2 (56%/64%), IIA (18%/14%), IIB (20%/19%), III-IVA (5%/4%) and median age (42 years/45 years). The optimal response rate in the TP group was 25%, 95% confidence interval (CI) = 16% to 37% and 43%, 95% CI = 31% to 55% in the TIP group. Grades 3-4 leukopenia (6%/53%) and neutropenia (26%/76%) were significantly more frequent on TIP.

CONCLUSION

TP performance was below expectation since the lower 95% confidence limit of the optimal response rate failed to reach the prespecified minimum requirement of efficacy, i.e. 22%. The TIP regimen confirmed its activity but was associated with higher haematological toxicity than TP.

Reversal of compensatory flow in severe intrauterine growth restriction: middle cerebral artery and intracardiac volume flow modifications

AIM

The aim of the study was to investigate cerebral and cardiac volume flow modifications in a group of preterm severely growth restricted (GR) fetuses with absent end diastolic flow (AEDF) in the umbilical artery.

METHODS

Doppler indices of GR fetuses born at less than 32 weeks of gestation with AEDF in umbilical artery were longitudinally analyzed. Ductus venosus S/A, umbilical artery PI, middle cerebral artery (MCA) pulsatility index (PI), MCA volume flow and intracardiac flows were checked daily. The value of volume flow was determined by multiplying the vessel area obtained by means of a power angiography by the integral of the velocimetric curve. In Group 1 the time of delivery was decided when abnormal Doppler index in ductus venosus (S/A>3) was detected. In Group 2, decisions about delivery were based on maternal indications or on various cardiotocographic (CTG) abnormalities. The division in the two groups was made with a retrospective method.

RESULTS

Fifteen GR fetuses were studied: seven cases entered Group 1 and eight cases Group 2. In Group 2 velocimetric (PI) and quantitative (volume flow) values remained stable until delivery. In all cases in Group 1 ductus venosus anomalies (S/A>3) were preceded by 24 hours by cerebral volume flow indices indicating the loss of MCA vasodilatation and by changes in intracardiac volume flow indices, while the PI increase in MCA was present only 24 hours after the changes detected by the volume flow study and were simultaneous to ductus venosus modifications.

CONCLUSION

The decrease in volume flow through the middle cerebral artery occurs at least 24 hours before the increase of middle cerebral artery PI and before the ductus venosus anomalies. Flow through the four cardiac valves show modification in agreement to the changes of the middle cerebral artery flow.