[Therapeutic Plasma Exchange in a Patient with Chronic Hemodialysis and a New Diagnosis of Myasthenia Gravis]

Case ReportC.S.T. (♂, 71 years old) is a patient with multiple and severe comorbidities, undergoing thrice-weekly chronic hemodialysis since 2008 due to the progression of post-lithiasic uropathy. Over the past 2 months, the patient had been experiencing progressive ptosis of the eyelids, muscle weakness, and ultimately dysphagia and dysarthria that emerged in the last few days. Urgently admitted to the Neurology department, electromyography (EMG) was performed, leading to a diagnosis of predominant cranial myasthenia gravis (with borderline anti-acetylcholine receptor antibody serology). Prompt treatment with pyridostigmine and steroids was initiated. Considering the high risk of acute myasthenic decompensation, therapeutic plasma exchange (TPE) with centrifugation technique was promptly undertaken after femoral CVC placement. TPE sessions were alternated with hemodialysis. The patient's condition complicated after the third TPE session, with septic shock caused by Methicillin-Sensitive Staphylococcus Aureus (MSSA). The patient was transferred to the Intensive Care Unit (ICU). Due to hemodynamic instability, continuous veno-venous hemodiafiltration (CVVHDF) with citrate anticoagulation was administered for 72 hours. After resolving the septic condition, intermittent treatment with Acetate-Free Biofiltration (AFB) technique was resumed. The patient completed the remaining three TPE sessions and, once the acute condition was resolved, was transferred back to Neurology. Here, the patient continued the treatment and underwent a rehabilitation program, showing significant motor and functional recovery until discharge. Conclusions. The multidisciplinary interaction among Nephrologists, Neurologists, Anesthesiologists, and experts from the Immunohematology and Transfusion Medicine Service enabled the management and treatment of a rare condition (MG) in a high-risk chronic hemodialysis patient.

[New Mutation of CYP24A1 in a Case of Idiopathic Infantile Hypercalcemia Diagnosed in Adulthood]

Mutations in the 24-hydroxylase gene CYP24A1 have been recognized as causes of childhood idiopathic hypercalcemia (IIH), a rare disease (incidence <1:1,000,000 live births) characterized by increased vitamin D sensitivity, with symptomatic severe hypercalcemia. IIH was first described in Great Britain two years after the start of a program of vitamin D supplementation in milk for the prevention of rickets, manifesting in about 200 children with severe hypercalcemia, dehydration, growth failure, weight loss, muscle hypotonia, and nephrocalcinosis. The association between the epidemic occurrence of IIH and vitamin D administration was quickly attributed to intrinsic hypersensitivity to vitamin D, and the pathogenic mechanism was recognized in the inactivation of Cytochrome P450 family 24 subfamily A member 1 (CYP24A1), which was identified as the molecular basis of the pathology. The phenotypic spectrum of CYP24A1 mutation can be variable, manifesting predominantly with childhood onset and severe symptomatology (severe hypercalcemia, growth retardation, lethargy, muscle hypotonia, dehydration), but also with juvenile-adult onset forms with nephrolithiasis, nephrocalcinosis, and alterations in phosphocalcium homeostasis. We describe the case of a patient in whom the diagnosis of IIH was made in adulthood, presenting with finding of nephrocalcinosis in childhood, and with subsequent onset of severe hypercalcemia with hypercalciuria, hypoparathyroidism, hypervitaminosis D, and recurrent renal lithiasis. Genetic investigation revealed the presence in homozygosity of the c_428_430delAAG_p.Glu143del variant in the CYP24A1 gene with autosomal recessive transmission, a mutation not reported in the literature.

Sustainability assessment of waste and wastewater recovery for edible mushroom production through an integrated nexus. A case study in Lazio

With a global population of eight billion people, improving the sustainability and nutritional quality of diets has become critical. Mushrooms offer a promising solution because of their nutritional value and ability to be grown from agricultural residues, in line with the circular economy. This study, therefore, focuses on assessing the environmental compatibility of Agaricus bisporus mushroom production in Italy, the world's third largest per capita consumer, by using a Life Cycle Assessment (LCA) and an integrated Water-Energy-Nitrogen-Carbon-Food (WENCF) nexus analysis. The LCA results reveal that for a functional unit of 23,000 kg of the substrate, the production process emits 2.55 × 104 kg of CO2 eq. Sensitivity analysis shows that changing input quantities can reduce environmental impacts by about 5 %. In addition, one scenario evaluates the environmental effects of recycling resources by introducing water and ammonium sulfate from scratch instead of continuous recycling, along with water purification. The study shows that sustainable food production can mitigate resource depletion, climate-altering emissions, and intersectoral competition. Using agro residues for mushroom cultivation and optimizing resource management contribute to environmental sustainability. This approach could not only improve the resilience and efficiency of the food system but could also improve the sustainability of diets. In conclusion, this study highlights the importance of adopting sustainable and circular approaches in mushroom production to address global challenges related to food sustainability.

Employment trajectories of young women with breast cancer: an ongoing prospective cohort study in Italy and Switzerland

PURPOSE

Despite extensive research on cancer and work-related outcomes, evidence from longitudinal cohort studies is limited, especially in young women with breast cancer (BC). We aimed to investigate employment trajectories in young BC survivors and to identify potential factors associated with changes in work activity.

METHODS

The HOHO European prospective multicenter cohort study enrolled 300 young women (≤ 40 years) with newly diagnosed BC. Women completed surveys at baseline and every 6 months for 3 years, then yearly for up to 10 years to assess, among other variables, employment status, sociodemographic, medical, and treatment data. Symptoms were assessed by the Breast Cancer Prevention Trial symptom scales and single items from the Cancer Rehabilitation Evaluation System. Univariable and multivariable multinomial logistic regression analyses identified factors associated with changes in employment status.

RESULTS

Among the 245 women included in this analysis, 85% were employed at the last individual post-baseline assessment (1 to 10 years). At 5 years, women had a 29.4% probability (95% CI: 23.6-35.5) of experiencing any reduction and a 14.9% probability (95% CI: 10.6-19.9) of experiencing any increase in work activities. Being enrolled in Switzerland (vs. Italy) and reporting more trouble in performing daily activities were significantly associated with work reduction.

CONCLUSION

Our results suggest that most young BC survivors remain employed in the long-term.

IMPLICATIONS FOR CANCER SURVIVORS

Regular evaluation of symptoms which may interfere with daily life and identification of financial discomfort is critical in providing timely and individually tailored interventions and in limiting unwanted reductions in work activities.

Interrupting Endocrine Therapy to Attempt Pregnancy after Breast Cancer

BACKGROUND

Prospective data on the risk of recurrence among women with hormone receptor-positive early breast cancer who temporarily discontinue endocrine therapy to attempt pregnancy are lacking.

METHODS

We conducted a single-group trial in which we evaluated the temporary interruption of adjuvant endocrine therapy to attempt pregnancy in young women with previous breast cancer. Eligible women were 42 years of age or younger; had had stage I, II, or III disease; had received adjuvant endocrine therapy for 18 to 30 months; and desired pregnancy. The primary end point was the number of breast cancer events (defined as local, regional, or distant recurrence of invasive breast cancer or new contralateral invasive breast cancer) during follow-up. The primary analysis was planned to be performed after 1600 patient-years of follow-up. The prespecified safety threshold was the occurrence of 46 breast cancer events during this period. Breast cancer outcomes in this treatment-interruption group were compared with those in an external control cohort consisting of women who would have met the entry criteria for the current trial.

RESULTS

Among 516 women, the median age was 37 years, the median time from breast cancer diagnosis to enrollment was 29 months, and 93.4% had stage I or II disease. Among 497 women who were followed for pregnancy status, 368 (74.0%) had at least one pregnancy and 317 (63.8%) had at least one live birth. In total, 365 babies were born. At 1638 patient-years of follow-up (median follow-up, 41 months), 44 patients had a breast cancer event, a result that did not exceed the safety threshold. The 3-year incidence of breast cancer events was 8.9% (95% confidence interval [CI], 6.3 to 11.6) in the treatment-interruption group and 9.2% (95% CI, 7.6 to 10.8) in the control cohort.

CONCLUSIONS

Among select women with previous hormone receptor-positive early breast cancer, temporary interruption of endocrine therapy to attempt pregnancy did not confer a greater short-term risk of breast cancer events, including distant recurrence, than that in the external control cohort. Further follow-up is critical to inform longer-term safety. (Funded by ETOP IBCSG Partners Foundation and others; POSITIVE ClinicalTrials.gov number, NCT02308085.).

Effect of COVID-19 pandemic on utilisation of community-based mental health care in North-East of Italy: A psychiatric case register study

AIMS

WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services' utilisation, by considering psychiatric diagnoses and type of mental health contacts.

METHODS

The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A 'difference in differences' approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated.

RESULTS

In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients' characteristics considered (except for people aged 18-24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (-33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions.

CONCLUSIONS

Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.

Abstract GS4-09: Pregnancy Outcome and Safety of Interrupting Therapy for women with endocrine responsIVE breast cancer: Primary Results from the POSITIVE Trial (IBCSG 48-14/BIG 8-13)

Background: Pregnancy after breast cancer (BC) is of substantial importance for many young women at diagnosis and during follow-up. BC treatment including standard endocrine therapy (ET) (5-10 years) may reduce ovarian reserve and the chances of subsequent successful pregnancy, given conception is contraindicated during ET. A temporary interruption of ET to attempt and carry a pregnancy in this population has never been prospectively studied.

Methods: POSITIVE is a single-arm, prospective, investigator-initiated, international trial evaluating the safety and pregnancy outcomes of interrupting ET for young women with early-stage hormone-receptor-positive (HR+) BC who desire pregnancy. The primary objective is to assess the risk of BC relapse associated with ET interruption for ~2 years to achieve pregnancy. Women ≤42 years with stage I-III HR+ BC who received adjuvant ET (SERM alone, GnRH analogue plus SERM or AI) for 18 to 30 months and wished to interrupt ET to attempt pregnancy were eligible. The primary endpoint is breast cancer free interval (BCFI) defined as the time from enrollment to the first BC event (local, regional, distant recurrence or a new invasive contralateral BC). Planned sample size was 500 patients. Three interim analyses of BCFI were reviewed by the Data Safety Monitoring Committee (DSMC) to assure a 95% chance of stopping the trial early if the annual BCFI event rate exceeded 4%; with primary analysis triggered after 1600 patient years of follow-up (pyfu) and no more than 46 BCFI events defined as the safety threshold. The DSMC recommended continuing the study following each interim analysis. We now report the primary results.

Results: From 12/2014 to 12/2019, 518 women were enrolled. At enrollment, the median age of participants was 37 years (27-43 years); 75.0% were nulliparous, 93.4% had stage I/II disease, 66.3% node-negative. Median time from BC diagnosis to enrollment was 29 months (IQR: 25-32). Tamoxifen alone was the most prescribed ET (41.7%), followed by tamoxifen+ovarian function suppression (35.7%). 62.0% of participants had received neo/adjuvant chemotherapy. At a median follow-up of 41 months (1638 pyfu), 44 participants had experienced a BCFI event, not exceeding the pre-specified safety threshold of 46 events. The 3-year BCFI failure percent was 8.9% (95% CI: 6.3 to 11.6%), similar to the 9.2% (95% CI: 7.6 to 10.8%) calculated in the comparative external control cohort from the SOFT/TEXT trials (Sun et al, Breast 2020). Of 497 women followed for pregnancy status, 368 (74.0%) had at least one pregnancy, 317 (63.8%) had at least one live birth, with a total of 365 babies born. Based on competing risk analysis, 76.3% of patients resumed ET (half within 26 months), 8.3% had BCFI event/death before ET resumption, and 15.4% had not resumed ET yet.

Conclusions: The POSITIVE trial demonstrates that for young women with early HR+ BC desiring pregnancy, temporary interruption of ET to attempt pregnancy does not confer a greater short-term risk of recurrence than that observed in a modern historical control group that did not interrupt ET. Most participants have had a live birth. Further follow-up is planned to confirm long-term safety. These results should be considered in counselling BC patients desiring future pregnancy.

Citation Format: Ann Partridge, Olivia Pagani, Samuel M. Niman, Monica Ruggeri, Fedro Alessandro A. Peccatori, Hatem A. Azim, Marco Colleoni, Cristina Saura, Chikako Shimizu, Anna Saetersdal, Judith Kroep, Audrey Mailliez, Ellen Warner, Virginia F. Borges, Frédéric Amant, Andrea Gombos, Akemi Kataoka, Christine Rousset-Jablonski, Simona Borstnar, Junko Takei, Jeong Eon Lee, Janice Walshe, Manuel Ruiz Borrego, Halle Moore, Christobel Saunders, Vesna Bjelic-Radisic, Snezana Susnjar, Fatima Cardoso, Karen L. Smith, Teresa Ferreiro Vilarino, Karin Ribi, Kathryn Ruddy, Sarra El-Abed, Martine Piccart, Larissa A. Korde, Aron Goldhirsch, Richard D. Gelber. Pregnancy Outcome and Safety of Interrupting Therapy for women with endocrine responsIVE breast cancer: Primary Results from the POSITIVE Trial (IBCSG 48-14/BIG 8-13) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS4-09.

Health Technology Assessment for COVID19: an approach for the Horizon Scanning of health innovations

Background

The COVID-19 pandemic definitely changed the approach to technologies evaluation, firstly in terms of timeliness. In order to answer to this need, a new methodology was proposed, joining the elements of horizon scanning with the Multi-Criteria Decision Analysis (MCDA). In this work we describe the results of 2 case studies of application.

Methods

By means of an assessment matrix, a multidisciplinary expert panel gave a score based on a Likert scale and related to potential value and perceived risk for each technology. Economic, clinical and ethical criteria were considered as a summary of Health Technology Assessment (HTA) main domains. The final scores were then weighted by the MCDA and a scatter plot defined 4 positioning scenarios according to the balance of values and risks resulted, each conducting to an appropriate recommendation (full HTA report or reject). A Monte Carlo simulation was also carried out for the assessment of variability of results.

Results

An individual protection device for COVID-19 and a contact tracing app were assessed. The first technology was placed in the “Danger Zone” of the graph, because of its high costs and organizational complexity. The second one was placed in the “Comfort Zone” of the graph, due to low costs and easiness of implementation and management. For this innovation a recommendation for a full HTA and a pilot testing was given. In both cases, the Monte Carlo simulation confirmed the results of previous analyses.

Conclusions

The implementation of this new tool presented for the large amount of innovations created in response to COVID-19 could be supportive for decision makers, especially in pandemic times when a rapid answer is necessary. Improvements in the subjective judgement process, by introducing an objective approach, is now ongoing as it could enhance the strength of the final decision.

Key messages

In a pandemic time as the current, HTA should be as rapid as possible without losing scientific robustness. The methodology described could be an answer in support to the decision-making process, allowing an adequate and quick priority setting.

Is COVID 19 introducing a new model of internal medicine ward?

Background

Covid 19 has recently been defined as a syndemia, because it combines the epidemic emergency of Sars Cov 2 with that of non-communicable diseases. This aspect is particularly known in internal medicine wards (IM), which have had to split up to support these new criticalities.

Methods

Delphi method has been used to make the Ishikawa's diagram to analyze the reasons of the death in COVID ward. Each item was attributed a score according to a pros/cons and opportunities/threats system, derived from evidence in the literature. Scores were presented in a Cartesian graph showing the positioning according to the potential value and the perceived risk associated with the items. In the end, the performances of MC (Covid ward, split in I wave, II wave and overall) and MCF (internal medicine Covid-free ward) have been compared through the Barber's nomogram.

Results

MCF hospitalized 790 patients (-23,90% compared to 2019), Overall-MC patients: 50% of the 2019 MCF. Main cause of mortality-risk: patients originating from local facilities (+7%) and comorbidities (58% Chronic renal failure, 41% cancer, 90% age, 70% COVID 19 WHO stage 3. >3 comorbidities: 100%, ≥5: 24,7%). Length of stay: 8-60 days (mean value, MV: 17) for MC, 2-12 (MV 8) for MCF. Turnover Index: 10 day for MC II, 8 MC I, 1 for MCF. 25% of patients in MC have been treated with Non Invasive Ventilation (NIV), with high cost hospitalization-related.

Conclusions

Internal-Medicine ward model is a ward strictly tied to the community both before and after hospitalization. COVID 19 proposes a new model of IM, nearly subintensive ward, with NIV and continuous monitoring of vital signs, long length of stay and low turnover index. Is this the internal medicine ward for the future?

Key messages

COVID 19 proposes a new model of Internal Medicine ward, nearly subintensive ward, with Non Invasive Ventilation and continuous monitoring of vital signs, long length of stay and low turnover index.

Covid 19 mortality is strictly connected with the origin from territorial health-assisted residences.

Device therapy for the major complications detection and early treatment of patients with natural and iatrogenic comorbidities admitted to internal medicine wards

Background

Whith advances in devices miniaturization and wireless technologies, wereable “on body” ECG patch devices are unobtrusive and easy to use. Continuous ECG monitoring in the short term is indicated in patients who, due to age, comorbidities and polytherapy, are at greater risk of arrhythmias. Since 2017, a randomized-open label study is being conducted at the admission of acute patients in Internal Medicine Unit for 72 hours with continuous monitoring of vital parameters and the 5 leads-ECG (VP-ECG CM) trace by the mean of a tele-cardiology program.

Purpose

Objective of this study is to perform a cost-effectiveness evaluation of the VP-ECG CM program in inpatient settings.

Methods

Data were used in order to evaluate costs, the program effectiveness and the QALY gains using wireless monitoring compared to nurses traditional one. Costs were estimated by mean of the identification, measuring and valorization of the resources uptake. Cost drivers included: time spent by personnel, cost of the device, consumables, medical treatments, diagnostic exams and complications. The perspective of the Italian National Health Service was adopted. The incremental analysis was performed in order to present the cost per complication avoided and the cost per QALY gained. Net monetary benefit was also calculated. Either a deterministic and probabilistic analysis were performed by means of a bootstrap simulation allowing for re-sampling. A cost-effectiveness-acceptability curve was estimated, considering a cost-effectiveness threshold of €35,000/QALY.

Results

On 143 patients, arrhythmias and acute coronary syndrome were detected 4.3% in the experimental arm and 1.9% in the control arm, whilst 29,5% major complications were detected in the experimental arm vs 43.5% in the control and reduction in the number of sudden deaths (16% control and 9.3% experimental). Time spent by nurses in the control arm (58 minutes/day/patient) was the most relevant cost driver and allowed a saving ranging €54–90/patient. This saving overwhelmed the costs for the equipment whilst the other costs remained unchanged, thus allowing for the VP-ECG CM to be dominant versus the standard of care. One way and multiway sensitivity analyses confirmed the robustness of our results with p-value 0,05 involved in the bootstrap presenting dominance of the VP-ECG CM.

Conclusions

Notwithstanding the concerns of a loss of control in patient management, telemedicine (digital health infrastructure and driver) could perform healthcare transformation enabling physicians to increase the volume of patients seen, reduce the time to diagnosis, improve efficiency and efficacy of disease management, and reduce unnecessary clinic visits and hospital admissions. The miniaturized technologies can improve patient adherence, and the detection, characterization and monitoring of cardiac arrhythmias – readily digitalized markers and phenotypes of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None. Wireless Monitoring Study flowchart

Who are the women who enrolled in the POSITIVE trial: A global study to support young hormone receptor positive breast cancer survivors desiring pregnancy

Background

Premenopausal women with early hormone-receptor positive (HR+) breast cancer receive 5–10 years of adjuvant endocrine therapy (ET) during which pregnancy is contraindicated and fertility may wane. The POSITIVE study investigates the impact of temporary ET interruption to allow pregnancy.

Methods

POSITIVE enrolled women with stage I-III HR + early breast cancer, ≤42 years, who had received 18–30 months of adjuvant ET and wished to interrupt ET for pregnancy. Treatment interruption for up to 2 years was permitted to allow pregnancy, delivery and breastfeeding, followed by ET resumption to complete the planned duration.

Findings

From 12/2014 to 12/2019, 518 women were enrolled at 116 institutions/20 countries/4 continents. At enrolment, the median age was 37 years and 74.9 % were nulliparous. Fertility preservation was used by 51.5 % of women. 93.2 % of patients had stage I/II disease, 66.0 % were node-negative, 54.7 % had breast conserving surgery, 61.9 % had received neo/adjuvant chemotherapy. Tamoxifen alone was the most prescribed ET (41.8 %), followed by tamoxifen + ovarian function suppression (OFS) (35.4 %). A greater proportion of North American women were <35 years at enrolment (42.7 %), had mastectomy (59.0 %) and received tamoxifen alone (59.8 %). More Asian women were nulliparous (81.0 %), had node-negative disease (76.2%) and received tamoxifen + OFS (56.0 %). More European women had received chemotherapy (69.3 %).

Interpretation

The characteristics of participants in the POSITIVE study provide insights to which patients and doctors considered it acceptable to interrupt ET to pursue pregnancy. Similarities and variations from a regional, sociodemographic, disease and treatment standpoint suggest specific sociocultural attitudes across the world.

•

Fertility and pregnancy are priority concerns for young breast cancer survivors.

•

POSITIVE explores a transient interruption of endocrine therapy to allow conception.

•

Patients' characteristics highlight features considered suitable to study enrolment.

•

Overall, patients enrolled had a relatively high median age and low-risk disease.

•

Variations emerged across continents suggesting specific sociocultural attitudes.

Classification of first-episode psychosis using cortical thickness: A large multicenter MRI study

Machine learning classifications of first-episode psychosis (FEP) using neuroimaging have predominantly analyzed brain volumes. Some studies examined cortical thickness, but most of them have used parcellation approaches with data from single sites, which limits claims of generalizability. To address these limitations, we conducted a large-scale, multi-site analysis of cortical thickness comparing parcellations and vertex-wise approaches. By leveraging the multi-site nature of the study, we further investigated how different demographical and site-dependent variables affected predictions. Finally, we assessed relationships between predictions and clinical variables. 428 subjects (147 females, mean age 27.14) with FEP and 448 (230 females, mean age 27.06) healthy controls were enrolled in 8 centers by the ClassiFEP group. All subjects underwent a structural MRI and were clinically assessed. Cortical thickness parcellation (68 areas) and full cortical maps (20,484 vertices) were extracted. Linear Support Vector Machine was used for classification within a repeated nested cross-validation framework. Vertex-wise thickness maps outperformed parcellation-based methods with a balanced accuracy of 66.2% and an Area Under the Curve of 72%. By stratifying our sample for MRI scanner, we increased generalizability across sites. Temporal brain areas resulted as the most influential in the classification. The predictive decision scores significantly correlated with age at onset, duration of treatment, and positive symptoms. In conclusion, although far from the threshold of clinical relevance, temporal cortical thickness proved to classify between FEP subjects and healthy individuals. The assessment of site-dependent variables permitted an increase in the across-site generalizability, thus attempting to address an important machine learning limitation.

Abstract PS12-17: Baseline characteristics of women enrolled in the POSITIVE trial (pregnancy outcome and safety of interrupting therapy for women with endocrine responsIVE breast cancer)

Background: Pregnancy is a major concern for young breast cancer (BC) survivors. Conception after BC in women with hormone receptor positive (HR+) disease is affected by the standard 5-10 years of adjuvant endocrine therapy (ET) during which pregnancy is contraindicated and fertility may be waning. The POSITIVE Trial (IBCSG 48-14/BIG 8-13/Alliance A221405/NCT02308085) investigates the impact of temporary ET interruption to allow pregnancy.

Methods: POSITIVE enrolled premenopausal women with stage I-III HR+ early BC, ≤42 years of age, who had received adjuvant ET (SERM alone, ovarian function suppression (OFS) plus SERM or AI) for 18 to 30 months, and wished to interrupt ET to attempt pregnancy. An interruption of ET for up to 2 years was foreseen to allow pregnancy (after a 3-month ET washout period), delivery, and breastfeeding if desired/feasible. Resumption of ET to complete 5-10 years of treatment was planned as soon as pregnancy/breastfeeding was completed or after it was ensured conception was not possible. We report baseline characteristics of participants enrolled in POSITIVE by region of enrollment.

Results: From 12/2014 to 12/2019, 518 participants were enrolled at 116 centers in 20 countries across 4 continents. The table shows the baseline characteristics of the enrolled women.

Several differences were seen across regions: A higher proportion of participants &lt;35 yrs (43%) enrolled in North America than in Europe (33%) or Asia (26%). Eighty-one percent of Asian women had no children at enrollment compared to 75% and 68% of European and North American women, respectively. Consistently, a greater percent of women in Asia (56%) had used fertility preservation measures, compared to Europe (53%) and North America (43%). Stage distribution was also different across continents: a greater percent of Asian participants had stage I, grade 1 and node-negative disease (51%, 29% and 76 %, respectively) compared to European (46%, 14% and 67%) and North American (43%, 16% and 55%) women. Only 19% of Asian women had either 1-3 positive nodes and grade 3 tumors, the proportion increased to 28% and 35% in Europe and to 41% and 38% in North America, respectively. North American women were more likely to have had mastectomy (60% vs. Asian (44%) and European (41%)); European women were more likely to have had chemotherapy (69% vs. North American (56%) and Asian (42%)). ET administration prior to enrollment differed substantially by region: Most North American women had SERM (T) alone (58%), and when OFS was added to oral ET, it was combined with AI in 19% and with T in 8% of participants, respectively. In Asia most women received T + OFS (55%), followed by T alone (36%), and AI + OFS (6%). In Europe, T + OFS was the most frequent treatment (40%), followed by T alone (37%) and AI + OFS (17%). Median duration of ET before enrollment was similar across regions (22-24 months).

Conclusion: Regional variation of baseline characteristics of women enrolled in the POSITIVE trial may provide important insights into different medical and sociocultural attributes and attitudes of the study participants and investigators from those regions.

Affiliation: POSITIVE Investigators, International Breast Cancer Study Group, Alliance for Clinical Trials in Oncology, Breast International Group, North American Breast Cancer Group

CharacteristicRegion: Europe / North America / Asia-Pacific61% / 23% / 16%Median age at enrollment, yrs (IQR)37 (33-39)Caucasian race77%No children prior to enrollment74%Prior fertility preservation measures taken51%Stage I / II46% / 45%0 / 1 positive nodes65% / 21%Grade 2 / 348% / 33%HER2-negative74%Mastectomy46%Chemotherapy61%ET: SERM alone / SERM+OFS / AI+OFS41% / 35% / 16%Median duration of prior ET, mos (IQR)23 (20-27)

Citation Format: Ann H Partridge, Samuel M Niman, Monica Ruggeri, Fedro A Peccatori, Hatem A Azim, Jr, Marco Colleoni, Cristina Saura, Chikako Shimizu, Anna Barbro Sætersdal, Judith Kroep, Ellen Warner, Virginia F Borges, Andrea Gombos, Akemi Kataoka, Christine Rousset-Jablonski, Simona Borstnar, Hideko Yamauchi, Jeong Eon Lee, Janice M Walshe, Manuel Ruíz Borrego, Halle CF Moore, Christobel Saunders, Fatima Cardoso, Snezana Susnjar, Vesna Bjelic-Radisic, Karen L Smith, Martine Piccart, Larissa A Korde, Aron Goldhirsch, Richard D Gelber, Olivia Pagani. Baseline characteristics of women enrolled in the POSITIVE trial (pregnancy outcome and safety of interrupting therapy for women with endocrine responsIVE breast cancer) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS12-17.

The prognostic value of the Koret CT score in dogs following traumatic brain injury

Traumatic brain injury (TBI) is a common condition in veterinary medicine with relatively high mortality rate. Recently, a study that correlated abnormal computed tomography (CT) findings with outcome in dogs with head trauma established a prognostic scoring system termed Koret CT score (KCTS). The purpose of this study was to evaluate the accuracy of the KCTS in making short- and long-term prognosis in dogs presented within 72 h of TBI. Thirty-five dogs that were admitted to a hospital during 2010-2019 with TBI and were CT-scanned within 72 h of injury were included in the study. Retrospectively collected data included signalment, modified Glasgow Coma Scale score (MGCS), CT findings, and outcome, i.e. short-term (defined as 10 days) and long-term (6 months) survival. CT images were reviewed and the KCTS was calculated for all dogs. Association between KCTS and outcome was examined. A significant negative association was found between KCTS and both short- and long-term survival. The area under receiver operating characteristic curve for KCTS for short- and long-term survival was 0.9 and 0.87, respectively. Furthermore, the probability of survival in the short term was predicated by the KCTS in an almost linear fashion and a score of 3 points or less on the KCTS was associated with survival with 85% sensitivity and 100% specificity. These results validate the prognostic value of the KCTS in dogs with TBI and provide a complementary tool for serial clinical and neurological evaluation.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination

BACKGROUND

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

METHODS

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

RESULTS

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

CONCLUSIONS

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Estimation of historical control rate for a single arm de-escalation study - Application to the POSITIVE trial

BACKGROUND

Although randomized controlled clinical trials are optimal to evaluate the effect of an experimental therapy, single-arm trials are required whenever randomization is unethical or not feasible, such as de-escalation studies. We propose using prospectively identified historical controls to place results of single-arm, de-escalation trials into context.

METHODS

POSITIVE is a prospective, single-arm study in young women with hormone-receptor-positive early breast cancer to determine if temporarily interrupting adjuvant endocrine therapy in order to become pregnant increases the risk of a breast cancer event. After 272 women enrolled in POSITIVE, we identified a cohort of 1499 SOFT/TEXT patients potentially eligible to enroll in POSITIVE who did not interrupt endocrine therapy. Method I used the SOFT/TEXT cohort to calculate annualized hazard rates by a piecewise exponential model. Method II used the SOFT/TEXT cohort to group-match SOFT/TEXT patients to POSITIVE patients; sample sets of SOFT/TEXT patients were randomly drawn 5000 times to obtain sets having patient, disease, and treatment characteristics more balanced with POSITIVE participants.

RESULTS

Compared with SOFT/TEXT, POSITIVE participants were younger, less likely to be overweight/obese, had fewer positive nodes, and fewer received aromatase inhibitor or chemotherapy. The estimated 3-year breast cancer free interval event rates were 9.5% (95% CI: 7.9%,11.1%) for Method I and 9.4% (95% CI: 7.8%,10.9%) for Method II, compared with 5.8% initially assumed when POSITIVE was designed.

CONCLUSION

External control datasets should be identified before launching single-arm, de-escalation trials and methods applied during their conduct to provide context for interim monitoring and interpretation of the final analysis.

Abstract OT1-04-02: POSITIVE: A study evaluating pregnancy, disease outcome and safety of interrupting endocrine therapy for premenopausal women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/big 8-13)

Background: Young patients with breast cancer (BC) are often diagnosed before completing their families. The best available retrospective evidence suggests that pregnancy after BC does not negatively impact disease outcomes overall and in patients with endocrine responsive disease, and is safe for the offspring. However, given also the possibility of extended adjuvant endocrine therapy (ET) (5-10 years), it is not feasible for many of these women to delay pregnancy until completion of therapy. Prospectively evaluating the safety of temporary interruption of ET to allow conception is an unmet, patient-oriented, medical need.

Trial Design: Young patients with endocrine responsive early BC who desire pregnancy will interrupt ET for up to 2 yrs to attempt child-bearing. As resumption of menses and conception depends on many factors (e.g. patient’s age and adjuvant treatment received), the 2-yr interruption period is approximate, intended to include treatment wash-out (3 mos), conception (~3-6 mos), delivery (~9 mos), and breast feeding (~6 mos). Patients will be strongly advised to resume ET as soon as pregnancy attempts/deliveries are concluded, and to complete the planned 5-10 yrs of ET.

Major Eligibility Criteria

- Histologically-proven stage I-III endocrine-responsive BC.

- Patient’s wish to become pregnant.

- Age ≥ 18 and ≤ 42 years at enrollment.

- Adjuvant ET (selective estrogen receptor modulator [SERM] alone, GnRH analogue plus SERM or aromatase inhibitor) for ≥18 months but ≤30 months, stopped within 1 month prior to enrollment.

- Premenopausal status at BC diagnosis.

Specific Aims

1. To assess the risk of BC relapse associated with temporary interruption of ET to permit pregnancy.

2. To evaluate pregnancy success rate and offspring outcome.

Statistical Methods: With 500 pts enrolled and followed for a median of 3 years, the statistical design is based on the 95% CI for the 3-year BC recurrence rate. Interim monitoring assumes a 2% BC recurrence risk/yr with continuous ET and a recommendation to stop the study early if the BC risk exceeds 4%/yr with ET interruption.

Translational Research will evaluate fertility, pregnancy and BC biology determinants (e.g. ovarian function, uterine evaluation and circulating tumor DNA). Fresh frozen paraffin embedded tissue of the primary tumour will be collected to evaluate parameters related to the biology of BC in young women. All material will be banked centrally.

Psycho-oncological Companion Study (POCS) will evaluate fertility concerns, psychological well-being and decisional conflict. It is mandatory in North America and open to interested centers elsewhere.

Accrual: Target: 500; Actual: 421 (30 June 2019)

Psycho-oncological Companion Study Accrual: Target: ~200; Actual: 196 (30 June 2019)

Contact Information: POSITIVE is conducted and sponsored by the International Breast Cancer Study Group. The Alliance for Clinical Trials in Oncology is the US sponsor for NCTN. Contact Monica Ruggeri, IBCSG Coordinating Center, monica.ruggeri@ibcsg.org, or Trial Coordinators at ibcsg48_positive@fstrf.org.

Citation Format: Olivia Pagani, Ann H Partridge, Fedro A Peccatori, Hatem A Azim, Chikako Shimizu, Cristina Saura, Ellen Warner, Anna B Sætersdal, Judith R Kroep, Monica Ruggeri, Richard D Gelber. POSITIVE: A study evaluating pregnancy, disease outcome and safety of interrupting endocrine therapy for premenopausal women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/big 8-13) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT1-04-02.

Detection of Intraspinal Spirocerca lupi in Canine Cerebrospinal Fluid by Polymerase Chain Reaction

Aberrant migration of Spirocerca lupi into the spinal cord is an important cause of severe progressive neurological dysfunction in dogs. Although early diagnosis is essential to prevent deterioration, ante-mortem diagnosis of this condition remains challenging. The aim of this study was to evaluate the detection of the 18S ribosomal DNA (rDNA) S. lupi gene in the cerebrospinal fluid (CSF) of presumptively-affected dogs using polymerase chain reaction (PCR). Dogs with a non-compressive spinal cord lesion, pleocytosis with presence of eosinophils in the CSF and a characteristic clinical presentation were included. CSF samples from eight dogs were available for the study, of which seven were definitively diagnosed with intraspinal spirocercosis by PCR of either the CSF samples (6/7) or tissue samples obtained at necropsy examination (3/7), or both (2/7). Of these seven positive cases, only one dog had a negative CSF PCR, indicating a sensitivity of 86% for detecting nematode DNA in the CSF of infected dogs using this PCR protocol. The nematode DNA sequences obtained from the CSF of six dogs and the spinal cord tissue of three dogs were 98-100% identical to the publicly available sequences of S. lupi, confirming the diagnosis. These findings indicate that PCR targeting the 18S rDNA of S. lupi in CSF is useful for the ante-mortem diagnosis of canine intraspinal spirocercosis.

Abstract OT1-01-06: POSITIVE: A study evaluating Pregnancy, disease outcome and safety of interrupting endocrine therapy for premenopausal women with endocrine responsIVE breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13)

Background

Young patients with breast cancer (BC) are often diagnosed with the disease before completing their families. The best available retrospective evidence suggests that pregnancy after BC does not negatively impact disease outcomes in patients with endocrine responsive BC and is safe for the offspring. However, given the possibility of extended adjuvant endocrine therapy (ET) (5-10 years), it is not feasible for many of these women to delay pregnancy until completion of therapy and thus there is a need to study the safety of interrupting ET to allow pregnancy. To date, no prospective study has been conducted in BC survivors attempting future pregnancy.

Trial Design

Young patients with endocrine responsive early BC who desire pregnancy will interrupt ET for up to 2 yrs to attempt pregnancy. As resumption of menses and conception depends on many factors (e.g. patient's age and adjuvant treatment received), the 2-yr interruption period is approximate, intended to include treatment wash-out (3 mos), conception (˜3-6 mos), delivery (˜9 mos), and breast feeding (˜6 mos). Patients will be strongly advised to resume ET as soon as pregnancy attempts/deliveries are concluded, and to complete the planned 5-10 yrs of ET.

Major Eligibility Criteria

- Histologically-proven stage I-III endocrine-responsive BC.

- Patient's wish to become pregnant.

- Age ≥ 18 and ≤ 42 years at enrollment.

- Adjuvant ET (selective estrogen receptor modulator [SERM] alone, GnRH analogue plus SERM or aromatase inhibitor) for ≥18 months but ≤30 months, stopped within 1 month prior to enrollment.

- Premenopausal status at BC diagnosis.

Specific Aim

To assess the risk of BC relapse associated with the interruption of ET to permit pregnancy, and to evaluate pregnancy success rate and offspring outcome.

Statistical Methods

With 500 pts enrolled and followed for a median of 3 years, the statistical design is based on the 95% CI for the 3-year BC recurrence rate. Interim monitoring assumes a 2% BC recurrence risk/yr with continuous ET and a recommendation to stop the study early if the BC risk exceeds 4%/yr with ET interruption.

Translational Research will investigate various ovarian function and uterine parameters and circulating tumour DNA. Fresh frozen paraffin embedded tissue of the primary tumour will be collected to evaluate parameters related to the biology of BC in young women. All material will be banked centrally.

Psycho-oncological Companion Study (POCS) will evaluate fertility concerns, psychological well-being and decisional conflict. It is mandatory in North America and open to interested centers elsewhere.

Accrual: Target: 500; Actual: 262 (30 June 2018)

Psycho-oncological Companion Study Accrual: Target: 200; Actual: 138 (30 June 2018)

Citation Format: Pagani O, Partridge AH, Peccatori F, Azim HA, Colleoni M, Saura C, Kroep JR, Warner E, Gombos A, Sætersdal AB, Ruggeri M, Gelber RD, Sun Z. POSITIVE: A study evaluating Pregnancy, disease outcome and safety of interrupting endocrine therapy for premenopausal women with endocrine responsIVE breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-01-06.

Economic evaluation of Zepatier for the management of HCV in the Italian scenario

BACKGROUND

Hepatitis C virus (HCV) is a major health issue worldwide. New generation of direct-active antiviral medications is an epoch-making turning point in the management of HCV infections.

OBJECTIVE

Conducing a cost-effectiveness analysis comparing the combination of elbasvir/grazoprevir and sofosbuvir + pegylated interferon/ribavirin for the management of all HCV patients (even those in the initial stages of fibrosis).

METHODS

A Markov model was built on the natural history of the disease to assess the efficacy of the alternatives. The outcomes are expressed in terms of quality adjusted life-years (QALYs) and result in terms of incremental cost-effectiveness ratio).

RESULTS

Elbasvir/grazoprevir implies an expenditure of €21,104,253.74 with a gain of 19,287.90 QALYs and sofosbuvir + pegylated interferon/ribavirin implies an expenditure of €31,904,410.11 with a gain of 18,855.96 QALYs. Elbasvir/grazoprevir is thus a dominant strategy.

CONCLUSION

Consideration should be given to the opportunity cost of not treating patients with a lower degree of fibrosis (F0-F2).

Cost-effectiveness analysis of Daclatasvir/Sofosbuvir for the treatment of the HCV patients failed after the first line with second generation of DAAs in Italy

BACKGROUND

Daclatasvir (DCV) combinated with Sofosbuvir (SOF) has shown good efficacy and safety profile for HCV patients. The aim was to evaluate the cost-effectiveness of DCV/SOF regimen versus HCV alternative treatments for patients who failed to achieve the SVR12 after a first DAA treatment from Italian perspective (PITER cohort).

METHODS

A Markov model of HCV chronically infected patients was used to develop two scenarios: 1) DCV+ SOF versus Ledipasvir (LDV)+ SOF in Genotype (Gt)1 and Gt4; 2) DCV+ SOF versus no retreatment option in Gt1, Gt3, and Gt4. The percentage of patients who failed the first line with SOF/Simeprevir/Ribavirin (RBV) or SOF/RBV and were retreated or not according to evidences from PITER cohort, were used to populate the model. HCV resources consumption and SVR rates were quantified using PITER data. Transition probabilities and utility rates were derived from the literature. The outcomes were expressed in terms of Quality adjusted life years (QALYs). Probabilistic sensitivity analysis (PSA) was performed considering a cost-effectiveness threshold of € 30,000/QALY.

RESULTS

In the base-case analysis, DCV+ SOF represents a cost-effectiveness therapy with ICERs lower than the threshold. The PSA showed robust results, ICERs remain below the threshold in 94% and 99% simulations in Scenario 1 and 2, respectively.

Cost-Effectiveness Analysis of Lesinurad/Allopurinol Versus Febuxostat for the Management of Gout/Hyperuricemia in Italy

BACKGROUND

Until very recently the only therapeutic alternative for the management of patients affected by gout/hyperuricemia that did not respond to a first-line treatment based on allopurinol alone or who cannot tolerate allopurinol was febuxostat, a xanthine oxidase non-purine-selective inhibitor. Lately, however, a new therapeutic alternative has become available for the management of this pathology: lesinurad, a urate transporter inhibitor.

OBJECTIVE

To objective of this study was to evaluate the cost effectiveness of lesinurad/allopurinol in comparison with febuxostat as a second-line therapeutic strategy for the management of patients affected by gout and hyperuricemia that did not respond to a first-line therapy based on allopurinol alone.

METHODS

A Markov model was built based on the natural history of the pathology; patients entered the model according to their level of serum uric acid concentration and flowed across it according to their response to the therapy. The analysis was carried out considering the perspective of the Italian National Health Service on a lifetime horizon and 6-month cycles. Costs and quality-adjusted life-years (QALYs) were discounted at a 3.5% yearly rate. The results of the model were expressed in terms of incremental cost-effectiveness ratio (ICER). Both a one-way and a multi-way Monte-Carlo analysis were carried out in order to check the robustness of the results achieved.

RESULTS

The ICER derived from the comparison was equal to €77.53/QALY on the lifetime horizon, as there was a higher level of costs associated with the combination as compared with febuxostat (€10,658.27 vs. €10,645.87, for a differential of €12.40) and a higher level of QALYs achieved (7.77 vs. 7.61, for a differential of 0.16).

CONCLUSIONS

The lesinurad/allopurinol combination is recommended for the treatment of patients affected by gout/hyperuricemia in the Italian Health System as it appears to be cost effective and thus sustainable for the Italian healthcare sector.

Chronic immune thrombocytopenic purpura

First generation thrombopoietic growth factors (rhTPO and PEG-rHuMGDF), investigated in the early 2000s, proved effective in increasing platelet count in normal volunteers, in thrombocytopenia due to chemotherapy and also in a few cases of immune thrombocytopenic purpura (ITP). These agents did not complete their clinical development since one of them induced antibodies in the recipients that cross reacted with endogenous thrombopoietin (TPO), thus causing thrombocytopenia. This promoted the ingenious design of a new generation of thrombopoietic growth factors having no sequence homology with natural TPO. The two main agents are romiplostim, a peptibody already approved for clinical use in USA and eltrombopag, a non-peptide, orally active small molecule. In open label and placebo-controlled trials both agents proved to predictably increase platelet count in normal volunteers and in patients with ITP. With appropriate dosages (1–10 µg/kg weekly sub cutaneously for romiplostim; 50–75 mg/die per os for eltrombopag ) a platelet increase becomes significant after 7–10 days and peaks between 10–14 days. By dis -continuing treatment, platelet count returns to baseline level in 10–15 days. The response rate with both agents is above 70–80%, also in patients that had undergone several lines of treatment, or that have failed splenectomy. The response is maintained during the treatment, but is almost invariably lost even after several months of successful administration. Due to the lack of a curative potential and to the incomplete knowledge of long-term side effects, the place of these new drugs in the management of ITP is still unsettled and their use is best restricted to refractory patients or in preparation of splenectomy. It seems however that a new paradigm in the treatment of ITP has been established where the focus is not on reducing platelet consumption but on increasing platelet production.

Influence of childhood trauma on diagnosis and substance use in first-episode psychosis

BackgroundChildhood trauma has been significantly associated with first-episode psychosis, affective dysfunction and substance use.AimsTo test whether people with first-episode psychosis who had experienced childhood trauma, when compared with those who had not, showed a higher rate of affective psychosis and an increased lifetime rate of substance use.MethodThe sample comprised 345 participants with first-episode psychosis (58% male, mean age 29.8 years, s.d. = 9.7).ResultsSevere sexual abuse was significantly associated with a diagnosis of affective psychosis (χ² = 4.9, P = 0.04) and with higher rates of lifetime use of cannabis (68% v 41%; P = 0.02) and heroin (20% v 5%; P = 0.02). Severe physical abuse was associated with increased lifetime use of heroin (15% v 5%; P = 0.03) and cocaine (32% v 17%; P = 0.05).ConclusionsPatients with first-episode psychosis exposed to childhood trauma appear to constitute a distinctive subgroup in terms of diagnosis and lifetime substance use.

Economic Analysis and Budget Impact of Tenofovir and Entecavir in the First-Line Treatment of Hepatitis B Virus in Italy

BACKGROUND

Chronic hepatitis B is a common, progressive disease, particularly when viral replication is detected. Oral antivirals can suppress viral replication and prevent or delay the development of cirrhosis and liver-related complications. The treatments of chronic hepatitis B cannot totally cure the disease but can prevent its progression to hepatocellular carcinoma, decreasing the levels of both morbidity and mortality. To date, there are several therapies indicated by the international guidelines as first-line treatments for the management of hepatitis B; two of the most effective are those based on either tenofovir or entecavir.

OBJECTIVE

The aim of this study is to evaluate the cost-effectiveness of tenofovir and entecavir in the treatment of naïve patients with chronic hepatitis B. The two treatments are compared with the "no treatment" and to one another.

METHODS

The cost-effectiveness analysis was conducted using a Markov model; patients entered one of the following health states: chronic hepatitis, cirrhosis (compensated or decompensated), hepatocellular carcinoma, liver transplantation or death. The analysis was carried out from the perspective of the Italian National Health Service by considering a life-time horizon with cycles lasting 1 year and with costs and QALYs (quality-adjusted life years) discounted at a rate of 3.5%. The results of the model were analysed in terms of incremental cost-effectiveness ratio (ICER).

RESULTS

ICERs for tenofovir and entecavir emerging from the comparison versus "no treatment" were equal to €10,274.73 and €16,300.44 per QALY gained, respectively, on the life-time horizon. Tenofovir was dominant in the direct comparison with entecavir, indicating more QALYs and a lower consumption of resources. The Monte Carlo simulation demonstrated that in 97% (tenofovir) and in 85% (entecavir) of the scenarios performed, the cost per QALY fell below the threshold of €30,000/QALY. The budget impact analysis showed savings for tenofovir amounting to 33% compared to entecavir in the first year on treatment and to 31% in following years.

CONCLUSIONS

Entecavir and tenofovir are recommended for the treatment of patients with chronic Hepatitis B in the Italian Health System. In particular, tenofovir appeared to be the more cost-effective drug for the management of chronic hepatitis B virus (HBV) infections. These results could help decision makers and clinicians to address their decision when choosing a first-line treatment for the management of people affected by chronic HBV.

Sexual-dimorphism of the planum temporale in schizophrenia: An MRI study

Introduction

Anatomical alterations in the Superior Temporal Gyrus (STG) have been reported in schizophrenia. The STG is one of the most asymmetric and lateralized structure of the brain, and the process of lateralization seems to vary according to gender. Although it has been suggested that patients with schizophrenia do not show normal brain lateralization, only few studies investigated it in the STG considering the effects of sex.

Objectives

The objective of this study is to evaluate sexual dimorphism in STG volumes in a sample of patients with schizophrenia compared to age-and sex-matched healthy controls.

Methods

Seventy-two right-hander males (40 schizophrenia patients and 32 controls) and 45 right-hander females (18 schizophrenia patients and 27 controls) underwent clinical evaluation and a 1.5 T MRI scan. Gray and white matter volumes of regions of interests within the STG were detected, including the Heschl's Gyrus (HG) and the planum temporale (PT).

Results

Female patients with schizophrenia presented a reduction in left PT gray matter volumes (F = 4.58, P = 0.03) and a lack of the normal PT asymmetry index (t = 0.27; P = 0.79) compared to female controls (t = 5.47; P < 0.001). No differences were found between males for volumes or laterality. Also, in patients with schizophrenia STG gray and white volumes negatively correlated with positive symptoms (r = −0.33, P = 0.02 and r = −0.29, P = 0.03 respectively), whereas left PT gray matter volumes were negatively associated to duration of illness (r = −0.27, P = 0.04).

Conclusions

Sexual dimorphism plays a key role on PT in schizophrenia, underlying the importance of gender as a modulator of brain morphology and lateralization of schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Admission to In-patient Psychiatric Care in the Veneto Region (Italy), Specialisation vs. Personal Continuity of Care Approach. Preliminary Findings from the COFI Study-Italian Sites

Introduction

In Italy, considerable variations exist in the organisation of out- and in-patient mental health care. One main issue is whether to prioritise specialisation (distinct clinicians for inpatient and outpatient care) or personal continuity of care (same primary clinician for a given patient within the two settings).

Aims

To study the use of psychiatric in-patient units in the Veneto region (Italy) and to evaluate differences between personal continuity of care and specialization systems.

Methods

Study conducted in the context of the COFI, multisite naturalistic EU-funded research aiming to compare the two care approaches in 5 European countries. In Italy, baseline data collection was carried out in 14 in-patient units. Data on hospitalisation, diagnosis, severity of the illness (Clinical Global Impression Scale- CGI) and patients’ appraisal of inpatient care (Client Assessment of Treatment Scale- CAT) were collected.

Results

Overall, 1118 patients were assessed. Most frequent diagnostic categories were mood (41.6%) and psychotic (38.3%) disorders, while anxiety disorders were less represented (11.9%). The majority of patients were at least at their second admission (69.4%) and had been voluntary admitted (91.5%). Length of stay and CGI scores were significantly higher for patients with mood and psychotic disorders. No difference in CGI score between the two systems was found. Patients in the continuity of care systems reported higher level of satisfaction with initial treatment and longer hospital stay (P < .001).

Conclusions

These preliminary findings suggest higher service satisfaction for personal continuity system, possibly reflecting a more individualised and comprehensive focus on the patient's needs, rather than on symptoms reduction only.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Trauma and Migration in First Episode Psychosis

Introduction

Researches show that the period of migration, or the migration process itself, may confer an increased risk for psychosis. Some studies have addressed whether the high rates of psychosis found in migrants could be due to higher genetic or environmental risk factors. Facing severe or chronic stress such as trauma, social isolation, low socio-economic status, late-life social adversity may result in long term, sometimes permanent, alterations of the biological stress response system, leading to the onset of psychosis.

Objectives

This study aims to examine, in a large sample of first episode psychosis patients, whether negative social experiences like stressful life events and difficulties, trauma and isolation have significantly higher frequencies in migrants with respect to natives.

Methods

The present study is conducted within the framework of the EUGEI (European Network of National Schizophrenia Networks Studying Gene Environment Interactions) study, a Europe-wide incidence and case–control study of psychosis conducted in 12 centers chosen to include areas with large first and subsequent generation migrant populations.

Data about age, gender, migration history, trauma, life events, ethnicity, social class and family history of mental disorders have been collected.

Results

Preliminary data on the relationship between trauma and migration in first episode psychosis will be presented.

Conclusions

Since migration is an important stressful life event, and difficulties in integration in host countries may remain chronic, it is important to identify in each context the most vulnerable minority groups in order to implement targeted prevention interventions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Brain anatomy of symptom stratification in schizophrenia: A voxel based morphometry study

Introduction

Although some magnetic resonance imaging (MRI) studies have investigated the existence of a relationship between clinical severity and neuroanatomical alterations in patients with schizophrenia (SCZ), the biological signature associated with illness severity in schizophrenia is still uncertain.

Objectives

This study aims to investigate structural brain abnormalities in SCZ with particular regards to the identification of potential deficits associated to the severity of illness.

Methods

1.5 T MRI data were acquired for 61 subjects with SCZ and 59 matched healthy controls (HC). The patient group was divided in two subgroups based on clinical severity, one composed by 34 mild-to-moderately ill patients and the other one by 27 severely ill patients, and compared with matched HC.

Results

The whole group of patients with SCZ had significantly reduced gray matter (GM) volumes in left inferior and middle temporal gyrus compared to HC (P < 0.05, pFWE corrected). Furthermore, compared to HC, patients with mild-to-moderate illness showed decreased GM volumes in inferior temporal gyrus (P < 0.05, pFWE corrected) whereas those with severe illness had reduced right cerebellum (P < 0.05, cFWE corrected). No differences were observed between the two subgroups of patients.

Conclusions

Our results showed significant GM volume reductions in left inferior and middle temporal gyrus in patients with SCZ compared to matched HC, confirming the role of this region in the pathophysiology of SCZ. Furthermore, we identified specific cerebellar gray matter volume reductions in patients with severe illness, which may contribute to stratify patients with SCZ according to their clinical phenotype expression, ultimately helping in guiding targeted therapeutic/rehabilitation interventions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract OT3-02-01: POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine-responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13)

Background

Young breast cancer (BC) patients often face the disease before completing their family planning. The best available retrospective evidence suggests that pregnancy after BC does not negatively impact disease outcomes in patients with endocrine-responsive BC and is safe for offspring. However, given the possibility of prolonged adjuvant endocrine therapy (ET) (5-10 yrs), it is not feasible to wait until completion of therapy in many of these women and thus there is a need to explore the safety of temporary interruption of ET to allow pregnancy. To date, no prospective study has been conducted in young women attempting future pregnancy.

Trial Design

Young patients with endocrine-responsive early BC and pregnancy desire will interrupt ET for up to 2 yrs to attempt pregnancy. As resumption of menses and conception depends on many factors, e.g. patient's age and adjuvant treatment received, the 2-yr interruption period is approximate, intended to include treatment wash-out (3 mos) conception (∼3-6 mos), delivery (∼9 mos), breast feeding (∼6 mos). Patients will be strongly advised to resume ET as soon as pregnancy attempts are concluded and to complete the planned 5-10 yrs ET.

Major Eligibility Criteria

* Histologically-proven stage I-III endocrine-responsive BC.

* Age ≥ 18 and ≤ 42 years at enrollment.

* Adjuvant ET (SERM alone, GnRH analogue plus SERM or AI) for ≥18 mos but ≤30 mos, stopped within 1 mo prior to enrollment.

* Patient wishes to become pregnant.

* Premenopausal status at BC diagnosis.

Specific Aim

To assess the risk of BC relapse associated with temporary interruption of ET to permit pregnancy and to evaluate pregnancy success and offspring outcome.

Statistical Methods

A true risk of BC recurrence of 2% per year is assumed for patients who do not interrupt ET. With 500 patients enrolled in 4.0 yrs and an additional 1.6 yrs of follow up, there will be approximately 1600 patient-yrs of follow up and a median follow up of approximately 3 yrs at the time of the primary analysis, anticipated to occur 5.6 yrs after enrolment of the first patient. If the true risk of BC recurrence is 2% per yr, we anticipate 31 BC recurrences and an estimated 3-yr breast cancer free interval (BCFI) event of 5.6% (95% CI 4.0% to 7.9%).

Translational Research will investigate different ovarian function and uterine parameters; and circulating tumour DNA. FFPE tissue of the primary tumour will be collected to integrate different parameters related to biology of BC arising in young women. All material will be banked centrally.

Psycho-oncological Companion Study on fertility concerns, psychological well-being and decisional conflicts is mandatory in the US and open to interested centers elsewhere.

Accrual: Target: 500; Actual: 39 (30 Apr 2016)

Psycho-oncological Companion Study Accrual: Target: 200; Actual: 29 (30 Apr 2016)

Contact Information

POSITIVE is conducted and sponsored by the International Breast Cancer Study Group. The Alliance for Clinical Trials in Oncology is the US sponsor for NCTN network. Contact Monica Ruggeri, IBCSG Coordinating Center, monica.ruggeri@ibcsg.org, or Trial Coordinators at ibcsg48_positive@fstrf.org.

Citation Format: Pagani O, Partridge AH, Azim Jr. HA, Peccatori F, Ruggeri M, Sun Z. POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine-responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-02-01.

Transcriptomic analyses and leukocyte telomere length measurement in subjects exposed to severe recent stressful life events

Stressful life events occurring in adulthood have been found able to affect mood and behavior, thus increasing the vulnerability for several stress-related psychiatric disorders. However, although there is plenty of clinical data supporting an association between stressful life events in adulthood and an enhanced vulnerability for psychopathology, the underlying molecular mechanisms are still poorly investigated. Thus, in this study we performed peripheral/whole-genome transcriptomic analyses in blood samples obtained from 53 adult subjects characterized for recent stressful life events occurred within the previous 6 months. Transcriptomic data were analyzed using Partek Genomics Suite; pathway and network analyses were performed using Ingenuity Pathway Analysis and GeneMANIA Software. We found 207 genes significantly differentially expressed in adult subjects who reported recent stressful life experiences (n=21) compared with those without such experiences (n=32). Moreover, the same subjects exposed to such stressful experiences showed a reduction in leukocyte telomere length. A correlation analyses between telomere length and transcriptomic data indicated an association between the exposures to recent stressful life events and the modulation of several pathways, mainly involved in immune-inflammatory-related processes and oxidative stress, such as natural killer cell signaling, interleukin-1 (IL-1) signaling, MIF regulation of innate immunity and IL-6 signaling. Our data suggest an association between exposures to recent stressful life events in adulthood and alterations in the immune, inflammatory and oxidative stress pathways, which could be also involved in the negative effect of stressful life events on leukocyte telomere length. The modulation of these mechanisms may underlie the clinical association between the exposure to recent Stressful life events in adulthood and an enhanced vulnerability to develop psychiatric diseases in adulthood.

Splanchnic vein thrombosis in myeloproliferative neoplasms: risk factors for recurrences in a cohort of 181 patients

We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd–Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.

Abstract OT2-01-08: POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13)

Background

Young breast cancer (BC) patients often face the disease before completing their family planning. The best available retrospective evidence suggests that pregnancy after BC does not negatively impact disease outcome in patients with endocrine sensitive BC and is safe for the offspring. However, given the need for prolonged adjuvant endocrine therapy for 5-10 years, it is not feasible to wait until completion of therapy in most of these women and thus there is a need to explore the safety of temporary interruption of endocrine therapy to allow pregnancy. To date, no definitive prospective study has been conducted in young women desiring future pregnancy.

Trial Design

Young patients with endocrine responsive early BC and pregnancy desire will interrupt endocrine treatment for up to 2 yrs to attempt pregnancy. As resumption of menses and conception depends on many factors, e.g. patient's age and adjuvant treatment received, the 2-yr interruption period is approximate, intended to include treatment wash-out (3 mos) conception (∼3-6 mos), delivery (∼9 mos), breast feeding (∼6 mos). Patients will be strongly advised to resume ET as soon as pregnancy attempts are concluded, and to complete 5-10 yrs ET at the local investigator discretion.

Major Eligibility Criteria

-Histologically-proven stage I-III endocrine-responsive BC.

-Age ≥ 18 and ≤ 42 years at enrollment.

-Adjuvant endocrine therapy (SERM alone, GnRH analogue plus SERM or AI) for ≥18 months but ≤30 months, stopped within 1 month prior to enrollment.

-Patient wishes to become pregnant.

-Premenopausal status at BC diagnosis.

Specific Aim

To assess the risk of BC relapse associated with temporary interruption of ET to permit pregnancy and to evaluate pregnancy success.

Statistical Methods

A true risk of BC recurrence of 2% per year is assumed for patients who do not interrupt endocrine treatment. With 500 patients enrolled in 4.0 yrs and an additional 1.6 yrs of follow up, there will be approximately 1600 patient-yrs of follow up and a median follow up of approximately 3 yrs at the time of the primary analysis, anticipated to occur 5.6 yrs after enrollment of the first patient. If the true risk of BC recurrence is 2% per yr, we anticipate 31 BC recurrences and an estimated 3-yr breast cancer free interval (BCFI) failure of 5.6% (95% CI 4.0% to 7.9%).

Translational Research will investigate different ovarian function parameters; uterine evaluation; and circulating tumor DNA. FFPE tissue of the primary tumor will be collected to integrate different parameters related to biology of BC arising in young women. All material will be banked centrally.

Psycho-oncological Companion Study on fertility concerns, psychological well-being and decisional conflicts is mandatory in the United States and open to interested centers elsewhere.

Accrual: Target: 500; Actual: 4 (31 May 2015)

Contact Information

POSITIVE is conducted and sponsored by the International Breast Cancer Study Group. Alliance for Clinical Trials in Oncology is US sponsor for NCTN network. Contact Trial Coordinators at ibcsg48_positive@fstrf.org.

Citation Format: Pagani O, Partridge A, Azim Jr HA, Peccatori FA, Ruggeri M, Sun Z. POSITIVE: A study evaluating pregnancy and disease outcome and safety of interrupting endocrine therapy for young women with endocrine responsive breast cancer who desire pregnancy (IBCSG 48-14/BIG 8-13). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-01-08.

Role of the “National Reference Centre for Genetically Modified Organisms (GMO) Detection” in the Official Control of Food and Feed

The National Reference Centre for Genetically Modified Organisms (GMO) detection was established in 2002 within the Istituto Zooprofilattico Sperimentale Lazio e Toscana, with the aim of providing scientific and technical support to the National Health System and to the Ministry of Health within the scope of the regulation of GMO use in food and feed.The recently adopted EU legislation on GMOs (Regulation CE no. 1829/2003 and no. 1830/2003) introduced more rigorous procedures for the authorisation, labelling and analytical control of food and feed consisting, containing or derived from GMOs. The National Reference Centre, besides its institutional tasks as one of the laboratories of the Italian National Health System, collects and analyses data and results of the national official control of GMOs; carries out scientific research aimed at developing, improving, validating and harmonising detection and quantification methods, in cooperation with other scientific institutions, the Community Reference Laboratory and within the European Network of GMOs laboratories (ENGL); collaborates with the Ministry of Health in the definition of control programmes and promotes educational and training initiatives. Objectives defined for 2004-2006, activities in progress and goals already achieved are presented.

A multicomponent decision support system to manage Fusarium head blight and mycotoxins in durum wheat

Mycotoxin contamination is of great concern in durum wheat and pasta production in Italy. A long-term project was conducted to improve mycotoxin management, and this project had six stages, from basic research to large-scale application. In stage 1, research was conducted on the biology and epidemiology of the fungal species involved in the Fusarium head blight (FHB) complex. The results were used in stage 2 to develop a multispecies, mechanistic model that included the effect of host and weather on: (1) inoculum production and dispersal; (2) infection and disease onset; and (3) mycotoxin accumulation. The weather-driven model was then validated under different epidemiological conditions. In stage 3, the model was expanded to include those crop management options that influence the risk of FHB and mycotoxin contamination, i.e. growing area, host species and resistance level of the cultivar, previous crop, and soil tillage. In stage 4, the complete model was included in a web-based decision support system (DSS) named granoduro.net®. The DSS provides plot-specific and up-to-date decision supports about weather, fertilisation, crop growth, weed control, and disease and mycotoxin risk. In stage 5, the DSS, together with Good Agricultural Practices, was applied for 2 years in 25 pilot farms across Italy. DSS use reduced external inputs (i.e. seeds, fungicides, and fertilisers) and costs, maintained or increased crop yield and quality, and kept mycotoxin contamination below the legal limit. Thus, the DSS significantly increased farmer income and reduced emission of greenhouse gasses. In stage 6, in an agreement with Barilla (a pasta producing company), the DSS was successfully used to manage 18,000 ha of durum wheat across Italy during 2013-2014. The DSS is currently being improved to include additional Fusarium species and related toxins, and the sexual stage of Fusarium graminearum. DSSs for common wheat and barley are also under development.

Pregnancy after breast cancer: Are young patients willing to participate in clinical studies?

Young patients with breast cancer (BC) are often concerned about treatment-induced infertility and express maternity desire. Conception after BC does not seem to affect outcome, but information in estrogen-receptor positive (ER+) disease is not definitive. From September 2012-March 2013, 212 evaluable patients with ER+ early BC, <37 years at diagnosis, from 5 regions (Europe/US/Canada/Middle-East/Australia) answered a survey about fertility concerns, maternity desire and interest in a study of endocrine therapy (ET) interruption to allow pregnancy. Overall, 37% of respondents were interested in the study; younger patients (≤30 years) reported higher interest (57%). Motivation in younger patients treated >30 months was higher (83%) than in older women (14%), interest was independent of age in patients treated for ≤30 months. A prospective study in this patient population seems relevant and feasible. The International-Breast-Cancer-Study-Group (IBCSG), within the Breast-International-Group (BIG) - North-American-Breast-Cancer-Groups (NABCG) collaboration, is launching a study (POSITIVE) addressing ET interruption to allow pregnancy.

The cost effectiveness of Botox in Italian patients with chronic migraine

Migraine is a primary headache which World Health Organization ranks in 19th place in the list of disabling diseases. In Europe, in 2004, the total costs for migraine were quantified by Stovner and Berg, Eur J Neurol, 12(s1) (2005) at <euro>27 billion. The objective of this study is to provide an estimate of the incremental cost-effectiveness ratio (ICER) of the treatment of chronic migraine with Botox compared to treatment with placebo in the perspective of the Italian National Health Service and society. To do this we studied the disease progression in a cohort of 688 individuals (patients enrolled in the study PREEMPT) via the application of a Markov model. Over a period of 2 years, the total costs of the experimental arm of the model amounted to <euro>3,274 compared with a gain of 1.34 QALYs. In contrast, the costs of the control arm amounted to <euro>2,395 with a gain of 1.24 QALYs. It follows that the incremental costs amounted to <euro>889 compared to an incremental gain of 0.09 QALYs in favor of the experimental arm. The relationship between costs and incremental QALYs generated an ICER of <euro>9,407/QALY. The incremental cost-effectiveness ratio, therefore, is favorable compared to the value usually considered by NICE as a threshold limit for reimbursement which ranges between <euro>20,000 and <euro>40,000/QALY.

Update on distal deep venous thrombosis. Reports of a multicenter study

AIM

No study of strong methodology could be found to resolve the controversy of optimal treatment of distal deep venous thrombosis (DDVT). Some inconclusive evidence exists on two approaches to care: anticoagulants and compression therapy or compression therapy and Duplex scanning monitoring. Different studies report propagation to popliteal vein in 8% of patients without anticoagulant treatment, while a complete thrombus resolution within 4 weeks occurred in 20% of patients. We report data of a study conducted in patients affected by DDVT and treated with nadroparin administered once daily in association with compression therapy.

METHODS

One hundred and ten patients with DDVT of the gastrocnemius or tibial veins, assessed by Duplex scanning, were enrolled in 8 clinical centres of the Lazio Region. At baseline, patient demographics, medical history (including risk factors for DDVT), circumferences of both calves and ankles, and a VAS-pain scale were recorded. At 7 and 28 days from baseline, patients were re-assessed by Duplex scanning, calves and ankles circumferences and VAS-pain were measured, and the patients were asked about possible side effects.

RESULTS

At the end of the study period, no propagation to the popliteal vein was observed, and no side effects were reported. Overall, the calf circumference in the affected leg significantly decreased from baseline (38.1 cm) to week 1 (37.1 cm), and to week 4 (35.7 cm). Also the VAS-pain scores significantly decreased during the study - the observed means were 58.4, 30.7, and 12.7 at the three visits, respectively. The percentage of partial recanalization of tibial DVT at 7 days was lower than gastrocnemius DVT (31.6% vs. 59.8%) whereas the percentage of total recanalization at 28 days was comparable (52.6% vs. 59.8%). Complete recanalization occurred in 56.4% of all patients.

CONCLUSION

Our study suggests that anticoagulant treatment, associated with compression therapy, is safe and causes clinical improvement (as assessed by calf measurements) and pain relief. Overall complete resolution (56.4%) is significantly higher than in untreated patients (20%). Such results, together with the already reported higher satisfaction of patients for the once-daily administration regimen, should be considered as a viable option for the treatment of DDVT.