Development of respiratory care guidelines for Duchenne muscular dystrophy in the UK: key recommendations for clinical practice

Significant inconsistencies in respiratory care provision for Duchenne muscular dystrophy (DMD) are reported across different specialist neuromuscular centres in the UK. The absence of robust clinical evidence and expert consensus is a barrier to the implementation of care recommendations in public healthcare systems as is the need to increase awareness of key aspects of care for those living with DMD. Here, we provide evidenced-based and/or consensus-based best practice for the respiratory care of children and adults living with DMD in the UK, both as part of routine care and in an emergency.

METHODOLOGY

Initiated by an expert working group of UK-based respiratory physicians (including British Thoracic Society (BTS) representatives), neuromuscular clinicians, physiotherapist and patient representatives, draft guidelines were created based on published evidence, current practice and expert opinion. After wider consultation with UK respiratory teams and neuromuscular services, consensus was achieved on these best practice recommendations for respiratory care in DMD.

RESULT

The resulting recommendations are presented in the form of a flow chart for assessment and monitoring, with additional guidance and a separate chart setting out key considerations for emergency management. The recommendations have been endorsed by the BTS.

CONCLUSIONS

These guidelines provide practical, reasoned recommendations for all those managing day-to-day and acute respiratory care in children and adults with DMD. The hope is that this will support patients and healthcare professionals in accessing high standards of care across the UK.

Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK

Background

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting.

Methods

26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey.

Results

24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD.

Conclusion

We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

A self-adaptive hardware with resistive switching synapses for experience-based neurocomputing

Neurobiological systems continually interact with the surrounding environment to refine their behaviour toward the best possible reward. Achieving such learning by experience is one of the main challenges of artificial intelligence, but currently it is hindered by the lack of hardware capable of plastic adaptation. Here, we propose a bio-inspired recurrent neural network, mastered by a digital system on chip with resistive-switching synaptic arrays of memory devices, which exploits homeostatic Hebbian learning for improved efficiency. All the results are discussed experimentally and theoretically, proposing a conceptual framework for benchmarking the main outcomes in terms of accuracy and resilience. To test the proposed architecture for reinforcement learning tasks, we study the autonomous exploration of continually evolving environments and verify the results for the Mars rover navigation. We also show that, compared to conventional deep learning techniques, our in-memory hardware has the potential to achieve a significant boost in speed and power-saving.

Imaging biomarkers of lung ventilation in interstitial lung disease from 129Xe and oxygen enhanced 1H MRI

PURPOSE

To compare imaging biomarkers from hyperpolarised ¹²⁹Xe ventilation MRI and dynamic oxygen-enhanced MRI (OE-MRI) with standard pulmonary function tests (PFT) in interstitial lung disease (ILD) patients. To evaluate if biomarkers can separate ILD subtypes and detect early signs of disease resolution or progression.

STUDY TYPE

Prospective longitudinal.

POPULATION

Forty-one ILD (fourteen idiopathic pulmonary fibrosis (IPF), eleven hypersensitivity pneumonitis (HP), eleven drug-induced ILD (DI-ILD), five connective tissue disease related-ILD (CTD-ILD)) patients and ten healthy volunteers imaged at visit 1. Thirty-four ILD patients completed visit 2 (eleven IPF, eight HP, ten DIILD, five CTD-ILD) after 6 or 26 weeks.

FIELD STRENGTH/SEQUENCE

MRI was performed at 1.5 T, including inversion recovery T₁ mapping, dynamic MRI acquisition with varying oxygen levels, and hyperpolarised ¹²⁹Xe ventilation MRI. Subjects underwent standard spirometry and gas transfer testing.

ASSESSMENT

Five ¹H MRI and two ¹²⁹Xe MRI ventilation metrics were compared with spirometry and gas transfer measurements.

STATISTICAL TEST

To evaluate differences at visit 1 among subgroups: ANOVA or Kruskal-Wallis rank tests with correction for multiple comparisons. To assess the relationships between imaging biomarkers, PFT, age and gender, at visit 1 and for the change between visit 1 and 2: Pearson correlations and multilinear regression models.

RESULTS

The global PFT tests could not distinguish ILD subtypes. Percentage ventilated volumes were lower in ILD patients than in HVs when measured with ¹²⁹Xe MRI (HV 97.4 ± 2.6, CTD-ILD: 91.0 ± 4.8 p = 0.017, DI-ILD 90.1 ± 7.4 p = 0.003, HP 92.6 ± 4.0 p = 0.013, IPF 88.1 ± 6.5 p < 0.001), but not with OE-MRI. ¹²⁹Xe reported more heterogeneous ventilation in DI-ILD and IPF than in HV, and OE-MRI reported more heterogeneous ventilation in DI-ILD and IPF than in HP or CTD-ILD. The longitudinal changes reported by the imaging biomarkers did not correlate with the PFT changes between visits.

DATA CONCLUSION

Neither ¹²⁹Xe ventilation nor OE-MRI biomarkers investigated in this study were able to differentiate between ILD subtypes, suggesting that ventilation-only biomarkers are not indicated for this task. Limited but progressive loss of ventilated volume as measured by ¹²⁹Xe-MRI may be present as the biomarker of focal disease progresses. OE-MRI biomarkers are feasible in ILD patients and do not correlate strongly with PFT. Both OE-MRI and ¹²⁹Xe MRI revealed more spatially heterogeneous ventilation in DI-ILD and IPF.

Delivery of non-invasive ventilation to people living with motor neuron disease in the UK

Objective

Non-invasive ventilation (NIV) improves survival and quality of life in motor neuron disease (MND), but many patients fail to receive effective ventilation. This study aimed to map the respiratory clinical care for MND patients at a service and individual healthcare professional (HCP) level to understand where attention may be needed to ensure all patients receive optimal care.

Methods

Two online surveys of HCPs working with MND patients in the UK were conducted. Survey 1 targeted HCPs providing specialist MND care. Survey 2 targeted HCPs working in respiratory/ventilation services and community teams. Data were analysed using descriptive and inferential statistics.

Results

Responses from 55 HCPs providing specialist MND care who worked at 21 MND care centres and networks and 13 Scotland Health Boards were analysed from Survey 1. Responses from 85 HCPs from respiratory/ventilation services and 73 HCPs from community teams, representing 97 services were analysed from Survey 2.

Significant differences in practice were identified at each stage of the respiratory care pathway as well as evidence of the need for improvement. This included when patients were referred to respiratory services, the time taken waiting to commence NIV, the availability of sufficient NIV equipment and provision of services, particularly out of hours.

Conclusion

We have highlighted significant disparity in MND respiratory care practices. Increased awareness of the factors that influence NIV success and the performance of individuals and services is important for optimal practice.

JS09.7.A Reirradiation for recurrent high grade glioma (HGG) patients: results of a single arm prospective phase 2 study

Background

Standard of care for recurrent high grade glioma (HGG) is missing. Several treatment options have been investigated including re-irradiation (re-RT). Results are promising but provided by retrospective studies. We designed a single arm prospective phase II study aiming to evaluate efficacy, and toxicity of re-irradiation.

Material and Methods

Adults patients with good performance status, HGG diagnosis reclassified according to the new 2021 fifth edition WHO CNS classification, an interval time (IT) from previous RT ≥ 6 months were included. Outcome was evaluated by MRI imaging at 1 month, and every 3 months thereafter. Toxicities were evaluated in terms of radionecrosis occurrence, and neurocognitive status.

Results

Ninety recurrent HGG patients were treated, 11 oligodendroglioma grade 3, 18 astrocytoma grade 3 and 4, and 61 glioblastoma grade 4. The median age was 54 years, and majority had KPS 90-100. The median IT between first-RT and re-RT was 24 months. Re-surgery has been performed in 56.6%, and chemotherapy in 53.3%. The median follow up time was 64 months; median overall survival (OS) time,1,2,3-year OS rates were 17 months (95%CI 14-19), 66.7%±4.9, 32.6%±5.0, and 22.2 ± 4.7. Prognostic factors impacting on survival were age (p = 0.0154), IT between first RT and re-RT (p = 0.0051), glioma grade (p = 0.0090), and IDH status (p = 0.0001). Radionecrosis grade 2-3 occurred in 9 (10%) patients; neurocognitive functions remained stable until disease progression.

Conclusion

Re-RT proved to be a safe and feasible treatment option with low toxicity. Younger patients with grade 3 IDH mutated gliomas, and a longer IT had the better outcome.

Optical diffraction tomography of 3D microstructures using a low coherence source

Optical diffraction tomography (ODT) is a label-free technique for three dimensional imaging of micron-sized objects. Coherence and limited sampling of 3D Fourier space are often responsible for the appearance of artifacts. Here we present an ODT microscope that uses low temporal coherence light and spatial light modulators to retrieve reliable 3D maps of the refractive index. A common-path interferometer, based on a spatial light modulator, measures the complex fields transmitted by a sample. Measured fields, acquired while scanning the illumination direction using a digital micro-mirror device, are fed into a Rytov reconstruction algorithm to obtain refractive index maps whose accuracy is directly evaluated on microfabricated 3D test objects. Even for challenging shapes such as pyramids, bridges, and dumbbells, we obtain volumetric reconstructions that compare very well with electron microscopy images.

The impact of RF wattage level on local impedance and procedural parameters in AF ablation cases

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance (LI) measurement can provide information on catheter tip contact, but also changes in LI during ablation can inform the extent and effectiveness of RF energy delivery. To date the relationship between highly LI measurements and contact force (CF) during atrial fibrillation (AF) ablation at different levels of energy delivery is still lacking.

Purpose

We aimed to evaluate the impact of power setting on LI and key procedural parameters in AF ablation cases.

Methods

A novel CF ablation catheter equipped with dedicated algorithm was used to measure LI at the distal electrode of this catheter. Radiofrequency (RF) catheter applications ≥45 watts were categorized as high power (HP) and applications &lt;45w as standard power (SP). Ablations were also grouped according to different levels of CF (&lt;5g, 5-14g, 15-24g and ≥25g). Data are reported as mean±SD.

Results

Sixty-two consecutive pts undergoing RF catheter ablation of AF from the CHARISMA registry were included A total of 4619 ablation spots performed around PVs were analyzed (58% paroxysmal, 84% de novo, RF deliveries per pt=76±27, RF delivery time=9.1±5s, CF=12.3±8g). The majority of these were HP applications (n=4192, 91%). The mean LI was 158±17Ω prior to ablation and 138±14Ω after ablation (p&lt;0.0001, absolute LI drop of 21.9±8Ω) with a LI drop rate equal to 4.4±3Ω/s. HP ablations had significantly shorter RF delivery times, 8.8±4s vs 12±7s (p&lt;0.0001), larger LI drops (22.2±8Ω vs 19.3±9Ω, p&lt;0.0001) and higher LI drop rates (4.5±3Ω/s vs 3.6±2Ω/s, p&lt;0.0001) than SP, respectively. For both HP and SP settings, the magnitude of LI drop increased and RF delivery time decreased with increasing amounts of CF. The largest differences between HP and SP were found when CF was &lt;15g (RF delivery time: 9±5s at HP vs 12.9±7s at SP, percentage of difference 26.3%, p&lt;0.0001; LI drop: 21.2±8Ω at HP vs 18.6±9Ω, percentage of difference -14.3%, p&lt;0.0001). No major complications occurred during the procedures. All PVs were successfully isolated.

Conclusions

This preliminary experience suggests that, HP ablation is effective and safe and resulting in shorter RF delivery times and larger LI drops than SP ablation.

Novel cryo-balloon technology for a successful pulmonary vein isolation: acute outcome and follow-up from a large multicenter Italian clinical setting

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, limited data exist on acute and follow-up outcome of this system in a multicentric clinical practice.

Purpose

We reported the preliminary experience of this novel technology in a multicenter Italian registry.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 6 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &gt;60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Rhythm monitoring during the follow-up examinations was performed via the clinical assessment of AF recurrence, ECG and Holter monitoring, according to the clinical practice of each center. All patients were followed-up for at least 6 months after the procedure. Arrhythmia recurrences within the first 3 months (blanking period) were classified as early recurrences and were not considered procedural failures

Results

Six-hundred twenty-four cryoapplications from 112 pts (439 PVs) were analyzed (n=89, 79.5% paroxysmal AF, n=23, 20.5% persistent AF, mean age 61.5±9 years, 76% male, 22% with an history of AT, mean LVEF 49±10%). PVI was achieved in all pts using only cryoablation. The mean number of freeze applications per pt was 5.6±2.1 (1.4±1.2 for LSPV, 1.5±1.1 for LIPV, 1.3±0.8 for RSPV and 1.3±0.8 for RIPV), with 318 (72.4%) PVs treated with a single cryoablation (92, 21% with 2 cryoablation; 29, 6.6% with more than 2 cryoablations). Fourty-four (39.3%) pts were treated with a single application to each of the PVs. Over a median of 296[245 to 382] days of follow-up, five (4.5%) patients experienced an early recurrence of AF/AT during the 90-day blanking period. Overall, 12 patients (10.7%) suffered an AF/AT recurrence after the 90-day blanking period (median time to recurrence 200[124 to 297] days). Specifically, 8 (7.1%) patients had AF recurrence only, 3 (2.7%) had AT recurrence only and 1 (0.9%) experienced both events. One (0.9%) patient underwent a repeated ablation procedure. The proportion of patients exhibiting AF/AT recurrences was similar between AF types (10 out 89, 11.2% for paroxysmal AF vs 2 out 23, 8.7% for persistent AF, p=1.00) with a hazard ratio of 0.9 (95%CI: 0.2 to 3.9, log-rank p=0.8894). One transient phrenic nerve palsy was observed, with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported.

Conclusion

In this first multicentric experience, the novel cryo-balloon system proved to be safe and effective and resulted in a very low rate of AF/AT recurrence during follow-up.

Accuracy comparison of the new and previous Kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Background

Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose

The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods

15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results

A total of 74 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 74.2% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 82.9%, and the negative predictive value was 85.2%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion

This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation.

Funding Acknowledgement

Type of funding sources: None.

Outcome of a modified sympathicotomy for cardiac neuromodulation of untreatable ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

OBJECTIVES This study aimed to describe the results of a modified sympathicotomy (uniportal VATs with stellate ganglion sparing) for cardiac sympathetic denervation (CSD) in the setting of untreatable ventricular tachycardia.

BACKGROUND. CSD, in patients with refractory ventricular tachycardia (VT), is comprehensively recognized as an important treatment option for patients with structural heart disease as well as congenital inherited arrhythmia syndrome. A recent case series demostrated  the feasibility of the modified technique.

METHODS We consecutively enrolled 8 patients with refractory VT. Baseline demographic, medical, and surgical data as well as arrhythmia outcomes and procedural complications were evaluated.

RESULTS A total of 8 patients ( 7 pts NIDCM, 1 pt IDCM with mean age:68+-8 years) were enrolled for the treatment of refractory VT with a modified CSD technique. Mean sympathicotomy length were 7.3 (SD 3) min per side. 3/8 patients underwent monolateral (LCSD) sympathicotomy due to strong adesion in the right pleural cavity. Mean follow up was 13 months (SD 6). No complication occurred during the sympathicotomy. An overall reduction in VT burden and VT number was observed after the CSD despite an in-hospital early recurrence in 3 patients.

CONCLUSIONS A modified CSD (sympathicotomy T2–T5) with stellate ganglion sparing and the use of unipolar radiofrequency is feasible, effective, and safe in the setting of untreatable VT. Abstract Figure. VT trend

Novel cryo-balloon ablation technology for pulmonary vein isolation in patients with atrial fibrillation: preliminary experience from a multicenter clinical practice

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, no data exist on procedural characteristics of this system in a multicentric clinical practice.

Purpose

We aimed to characterize the initial experience of this technology in the Italian clinical practice.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 5 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &gt;60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block.

Results

Two-hundred sixty-two cryoapplications from 49 pts (194 PVs) were analyzed. PVI was achieved with cryoablation only in all pts. The mean number of freeze applications per pt was 5.3 ± 1.5 (1.3 ± 0.6 for LIPV, LSPV and RSPV, 1.6 ± 1.3 for RIPV), with 143 (73.7%) PVs treated in a single-shot fashion (38, 19.6% with 2 shots; 13, 6.7% with more than 2 shots). Sixteen (33%) pts were treated with a single freeze to each of the PVs. The mean nadir temperature was -55.5 ± 6.9 °C and was colder than -50°C in 83% of the PVs. TTI information was evaluable in 120 (46%) cryoapplications with a median TTI of 47 [32-75] sec (median temperature at TTI = -49 [-53 to -42] °C). The mean time to target -40 °C (TTT) was 30.1 ± 6.9 sec with a TTT &lt; 60 sec achieved in 99.2% of the cryoapplications; the mean thaw time to 0 °C was 18.6 ± 5.8 sec (thaw time &gt;15 sec in 70.3% of the cryoapplications). The mean PV occlusion grade (rank 1-4) was 3.6 ± 0.6 (grade 2 in 5.2% of the cases, grade 3 in 25.6% and grade 4 in 69.2%). No complications were observed at 30 days post-procedure.

Conclusion

In this first multicentric experience in a clinical practice setting, the novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. Cooling parameters seem to be slightly different from reference cryo-balloon technology.

Accuracy comparison of the new and previous kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Funding Acknowledgements

Type of funding sources: None.

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose. The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods. 15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results. A total of 72 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 76.5% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 80.3%, and the negative predictive value was 88.6%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion. This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation. Abstract Figure. Occlusion tool software 1.4.6 vs 1.4.7

A novel ventricular map of electrograms duration as a method to identify areas of slow conduction during ablation of ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

Background – Wave front inhomogeneous propagation is crucial for reentry circuit generation. Bipolar EGM duration is indicative of local conduction delay and may identify areas of low conduction as a functional substrate. This study aimed to create a map of EGM duration during the VT (VEDUM Map) to identify the area of the slowest conduction and to verify if RF delivery at this area allows to rapidly interrupt the VT.

Methods – 24 high-density VTs maps (21 patients) were analyzed. Activation maps and voltage maps during SR were performed. An offline remap confirmed with MathLab software was customized to visualize the longest duration electrogram during VT.

Results – All of the VTs were interrupted during the first RF delivery (mean time 7,3 ± 5,4 sec (range 3-25 sec)) at the area with the longest EGM duration (212 ± 47 ms (range 113-330 ms)). . In 9 pts (37,5%) the longest EGM was located at the entrance or exit area of the activation maps while in 5 pts (21%) the EGM covered the full diastolic phase. Finally, in 10 pts the longest EGM occurred in the mid-exit-diastolic phase.

Conclusions - A novel Ventricular map of Electrograms DUration (VEDUM Map) is highly accurate in defining a conductive vulnerable zone of the VT circuit. The longest EGM duration within the isthmus is highly predictive of rapid VT termination. Quantitative variablesQualitative variablesMeanMedianStandard DeviationAge71738.40BMI26.624.54.02LV EDV16315442.7LV EDD61.2629.9LV EF38.7369.74VT cycle lenght (TCL)35537556.4EGM max. duration in VT21220847EGM max dur / TCL58.260.512Maximum EGM duration localization in CLProto = 12.5%Meso = 33.3%Tele = 25%Full = 20.8%Myocardium voltage characteristics in VEDUM EGMHealthy = 25%Transition = 20.8%Scar = 41.7%Critical Isthmus area12.3107.3VT Interruption during RFYes = 79.2%No = 20.8%Time (seconds) to interruption765Access typeEndo = 58.3%Epi = 29.2%Clinical and procedural dataAbstract Figure.

Minimal fluoroscopic approaches and factors associated with radiation dose when high-definition mapping is used for supraventricular tachycardia ablation: insight from the CHARISMA registry

Funding Acknowledgements

Type of funding sources: None.

Background

Limited data exist on factors associated with radiation exposure during ablation procedures when a high definition mapping technology is used.

Purpose

To report factors associated with radiation exposure and data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) ablation procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. We included in this analysis consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary. The effective dose (ED) was calculated using accepted formula. For our purpose high dose exposure was defined as an ED greater than the median value of ED of the population exposed to radiation.

Results

This analysis included 325 patients (mean age = 56 ± 17 years, 57% male) undergoing SVT procedures (152 AVNRT, 116 AFL, 41 AP and 16 AT). During the study, 27481 seconds of fluoroscopy was used (84.6 ± 224 seconds per procedure), resulting in a mean equivalent ED of 1.1 ± 3.7 mSv per patient. The mean reconstructed RA volume was 99 ± 54 ml in a mean mapping time of 12.2 ± 7 min. The mean number of radiofrequency ablations (RFC) to terminate each arrhythmia was 9.4 ± 9 (mean RFC delivery time equal to 6.7 ± 6 min). 192 procedures (59.1%) were completed without any use of fluoroscopy; during the remaining 133 procedures (39.9%), 206.6 ± 313.4 seconds of fluoroscopy was used (median ED = 1.2 mSv). In a minority of the cases (n = 25, 7.7%) the fluoroscopy time was higher than 5 minutes (median ED = 6.5 mSv), whereas radiologic exposure time greater than 1 minute occurred in ninety cases (27.7%, median ED = 2.1 mSv). On multivariate logistic analysis adjusted for baseline confounders the RFC application time (OR = 1.0014, 95%CI: 1.0007 to 1.0022; p = 0.0001) was independently associated to an ED greater than 1.2 mSv, whereas female gender had an inverse association (0.54, 0.29 to 0.98; p = 0.0435). Acute success was reached in 97.8% of the cases. During a mean of 290.7 ± 169.6 days follow-up, no major adverse events related to the procedure were reported. Overall, the recurrence rate of the primary arrhythmia during follow-up was 2.5%.

Conclusions

In our experience, arrhythmias ablation through minimal fluoroscopy approach with the use of a novel ablation technology is safe, feasible, and effective in common right atrial arrhythmias. High-dose exposure occurred in a very limited number of cases, without any reduction of the safety and acute and long-term effectiveness profile.

Risk assessment of biological hazards in University laboratories: checklist and critical control points

Results

The results highlighted that 40 laboratories fall into the "low risk" and the remaining 2 into the "moderate risk" category.

Conclusions

Labs with risk factors are a minority. These were properly identified using the proposed methodology.

Background and aim

Biomedical research in academic settings is an important issue for Public Health and Environment protection. As workplaces, the facilities for research expose their personnel to different hazards and health risks. The University of L'Aquila (Italy) carried out a field study aimed at creating and applying a checklist intended for laboratory staff.

Methods

The proposed checklist was derived from the procedure illustrated in the Appendix (procedure followed for the identification of a numerical index of biological risk for university facilities) and consists of 9 items. The study was conducted in 42 laboratories.

Outcome of Hospitalization for COVID-19 in Patients with Interstitial Lung Disease. An International Multicenter Study

Rationale: The impact of coronavirus disease (COVID-19) on patients with interstitial lung disease (ILD) has not been established.Objectives: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age-, sex-, and comorbidity-matched population.Methods: An international multicenter audit of patients with a prior diagnosis of ILD admitted to the hospital with COVID-19 between March 1 and May 1, 2020, was undertaken and compared with patients without ILD, obtained from the ISARIC4C (International Severe Acute Respiratory and Emerging Infection Consortium Coronavirus Clinical Characterisation Consortium) cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished idiopathic pulmonary fibrosis from non-idiopathic pulmonary fibrosis ILD and used lung function to determine the greatest risks of death.Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to the hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching, patients with ILD with COVID-19 had significantly poorer survival (hazard ratio [HR], 1.60; confidence interval, 1.17-2.18; P = 0.003) than age-, sex-, and comorbidity-matched controls without ILD. Patients with an FVC of <80% had an increased risk of death versus patients with FVC ≥80% (HR, 1.72; 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR, 2.27; 1.39-3.71).Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.

Novel occlusion tool software for pulmonary vein occlusion verification in atrial fibrillation cryoballoon ablation

Background

Optimal pulmonary vein (PV) occlusion, checked with selective contrast injection, is mandatory to obtain an effective PV isolation with a cryoballoon.

Purpose

The purpose of this study was to verify the feasibility of a new dielectric sensing system in assessing PV occlusion during cryoballoon ablation in patients with atrial fibrillation (AF).

Methods

We enrolled 25 consecutive patients with paroxysmal or persistent AF. After transseptal access a detailed image reconstruction of left atrium and PVs was achieved with a decapolar circular mapping catheter and a novel dielectric imaging system. The degree of PV occlusion with the inflated cryoballoon catheter was verified by a new occlusion tool software of the dielectric imaging system and compared to the angiography with dye injection in each PV.

Results

A total of 114 PV cryoballoon occlusion were tested. The new occlusion tool software showed a 91.7% sensitivity and 81.5% specificity in assessing a complete PV occlusion verified with dye injection. The positive predictive value was 84.6% and the negative predictive value was 89.8%. Acute isolation was achieved in all PVs. No 30 days complications were observed.

Conclusion

This is the first study that demonstrates the feasibility of a new occlusion tool software, using the novel dielectric imaging system, in verifying the degree of PV occlusion during cryoballoon ablation.

Funding Acknowledgement

Type of funding source: None

Minimal fluoroscopy approach in current clinical practice with a novel ablation technology for supraventricular tachycardia: a large multicenter experience from an Italian registry

Background

Electrophysiological studies and ablation procedures expose both physicians and patients to a large amount of radiation. Most of 3-D mapping systems provide improved tracking of catheters, possibly allowing relevant reductions in radiation exposure. No data exists on the ability of the Rhythmia mapping system to minimize fluoroscopy time and dose.

Purpose

To report preliminary data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. For our purpose consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary.

Results

This analysis included 266 patients (mean age = 57±17 years, 57% male) undergoing SVT procedures (120 AVNRT, 91 AFL, 32 AP, 11 AT and 12 other right atrial procedures). In all cases, diagnostic EP and ablation catheters were positioned using a low fluoroscopic electroanatomic guided approach. The mean fluoroscopy time needed for each procedure was 55±128 s. The median reconstructed RA volume was 92 [63–131] ml in a median mapping time of 11 [7–17] min. The median number of radiofrequency ablations to terminate each arrhythmia was 6 [3–12] (total RF delivery time of 291 [180–505] s). Sixty-five percent of the procedures (n=174) were completed with less than 10 s of fluoroscopy. Low fluoroscopy approach with less than 10 s (minimal fluoroscopy approach) was most frequently obtained in case of AVNRT (91, 76%) compared to other arrhythmias' ablation (83, 57%, p=0.001) Achievement of a minimal fluoroscopic approach was not affected by operator's experience (65% vs 66%, p=1.00, respectively within physician with more or less of 10 years of active practice), whereas it was affected by presence of a fellow in training during the procedure (72% without fellow vs 26% with fellow, p&lt;0.0001). A 100% rate of acute success was observed, and no procedure-related complications occurred. At multivariate logistic regression analysis adjusted for baseline confounders, both the total number of RF ablations (OR: 0.93 (95% CI:0.88 to 0.96; p=0.0053) and the presence of a fellow in training during the procedure (OR: 0.29; 95% CI: 0.1 to 0.87; p=0.0278) had an inverse association to the achievement of a minimal fluoroscopic approach.

Conclusions

In our preliminary experience, arrhythmias' ablation through minimal fluoroscopy approach with the use of a novel ablation technology seems to be safe, feasible, and effective in common right atrial arrhythmias. Use of fluoroscopy can be dramatically reduced in most cases, without any reduction of the safety and acute effectiveness profile.

Funding Acknowledgement

Type of funding source: None

P441Targeted ablation of residual luminal pulmonary vein potentials through high density mapping: preliminary results from the CHARISMA registry

Background

A high incidence of pulmonary vein (PV) reconnection has been reported in patients (pts) with clinical recurrences of AF. Low-voltage activity beyond PVs (e.g. antral activity) may contribute to ablation failures in the long term. Detailed characterization of PV antra through high density mapping (HDM) and automated algorithm is still lacking. 

Purpose

to characterize PV gaps and the low-voltage activity in tissue such as the PV antra during and after ablation of PVs in AF pts. 

Methods

Consecutive pts undergoing AF ablation from the CHARISMA registry with complete characterization of residual PV antral activity were included. A complete map of the left atrium and PVs was performed prior and after ablation through the Rhythmia HDM system. A novel map analysis tool (Lumipoint - LM -) that automatically identifies split potentials and continuous activation was used sequentially on each PV component, in order to assess the presence of gaps (PVG) and residual potential within the antral scar (RAP, defined as any low voltage high frequency fractionated signal propagating within the antral scar without conduction into the vein) and characterize electrical propagation. After ablation we reassessed with repeat voltage and propagation maps that electrical quiescence was achieved. Ablation endpoint was PV isolation. 

Results

Thirty-six cases of AF ablation were analyzed (11 de novo, 25 redo). A total of 36 PVG in 13 (36%) patients were detected after remap (1 case of de novo) or initial map of redo patients (12 cases). A total of 34 RAP in 20 cases (56%) were found: 4 (36%) cases of de novo (all after ablation and remap) and 16 (64%) cases of redo (all after initial map). In 7 (19%) cases we found at least one RAP in pts with complete absence of PV conduction. 100% of PVG (n = 36) and 89% of RAP (n = 29) were fully detected though a first pass automated annotation. In 5 RAPs (11%) an additional temporal consistency of low-voltage signal relative to neighboring activation was needed due to the very low voltage EGM (≤0.1 mV). PVGs were more common at right PV sites (n = 26, 72%) and anterior PV sites (n = 20, 55.6%) whereas RAPs were detected more frequently at left PV sites (n = 20, 59%) and anterior PV sites (n = 21, 62%). RAP showed a lower median voltage compared with PVG (0.22[0.2-0.3]mV for RAP vs 0.97[0.6-1.3]mV for PVG, p &lt; 0.0001) whereas the median number of EGM peaks were higher (6.5[5-8] for RAP vs 3[2-4] for PVG, p &lt; 0.0001). No complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study pts. 

Conclusion

In our preliminary experience, local vulnerabilities in antral lesion sets were commonly discernible using HDM system both in de novo or redo patients when no PV conduction was present. The applied workflow seemed to be useful to quickly pinpoint and accelerate the search of local PV activity or concealed low-voltage activity.

P1452Low fluoroscopy approach with a novel ablation technology in right side procedures: a large multicenter experience from the CHARISMA registry

Funding Acknowledgements

NO FUNDING

Background

Electrophysiological studies and ablation procedures expose both physicians and patients to a significant amount of radiation. Nowadays, most of 3-D mapping systems allow for improved tracking of catheters with possible reduction in radiation exposure. No data exists on the ability to minimize fluoroscopy time and dose while using the Rhythmia mapping system.

Purpose

To report preliminary data on feasibility and safety of a low fluoroscopic approach using the Rhythmia mapping system in SVT procedures.

Methods

The CHARISMA study is a non-randomized, multicenter, prospective study in which consecutive patients indicated for arrhythmia were enrolled. For our purpose consecutive right-side procedures performed through a low fluoroscopy approach with the Rhythmia mapping system were analyzed. The mapping system was used to create the 3D geometry of chambers of interest and anatomic reference points and to visualize the catheters from the beginning to the end of the procedure. Fluoroscopy was used only if deemed necessary.

Results

204 unselected consecutive cases of SVT from 11 centers were included in the study (mean age = 55 ± 18 years, 53% male, 85 AVNRT, 75 AFL, 28 AP, 9 AT and 7 other right atrial procedures). In all the cases, diagnostic EP and ablation catheters were positioned using only the low fluoroscopic guided mapping approach. During the study, a total of 7157 s of fluoroscopy was needed in 204 patients (51 ± 137 s per procedure). One hundred fourty-one procedures (69%) were completed with less than 10 seconds of fluoroscopy, whereas in 169 (83%) of the cases the fluoroscopy time was lower than 60 seconds. Low fluoroscopy approach with less than 10 seconds was less frequently obtained in case of AFL (46, 61.3%) compared to AVNRT ablation (65, 76.5%, p = 0.041) whereas no differences were found comparing with AP (21, 75%, p = 0.248). The median reconstructed RA volume was 94[65-133] ml in a median mapping time of 11 [6-16] min. The median number of radiofrequency ablations to terminate each arrhythmia was 5 [3-12] (total RF delivery time of 293 [180-505] sec). A 100% rate of acute success was observed in our case series. No complications occurred.

Conclusions

In our preliminary experience, arrhythmias ablation through low fluoroscopy approach and the use of a novel ablation technology seems to be safe, feasible, and effective in common right atrial arrhythmias. Use of fluoroscopy can be nearly avoided in most cases, without any reduction of the safety and effectiveness profile.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis

OBJECTIVE

To report mode of delivery and immediate neonatal outcome in women infected with COVID-19.

DESIGN

Retrospective study.

SETTING

Twelve hospitals in northern Italy.

PARTICIPANTS

Pregnant women with COVID-19-confirmed infection who delivered.

EXPOSURE

COVID 19 infection in pregnancy.

METHODS

SARS-CoV-2-infected women who were admitted and delivered from 1 to 20 March 2020 were eligible. Data were collected from the clinical records using a standardised questionnaire on maternal general characteristics, any medical or obstetric co-morbidity, course of pregnancy, clinical signs and symptoms, treatment of COVID 19 infection, mode of delivery, neonatal data and breastfeeding.

MAIN OUTCOME AND MEASURES

Data on mode of delivery and neonatal outcome.

RESULTS

In all, 42 women with COVID-19 delivered at the participating centres; 24 (57.1%, 95% CI 41.0-72.3) delivered vaginally. An elective caesarean section was performed in 18/42 (42.9%, 95% CI 27.7-59.0) cases: in eight cases the indication was unrelated to COVID-19 infection. Pneumonia was diagnosed in 19/42 (45.2%, 95% CI 29.8-61.3) cases: of these, 7/19 (36.8%, 95% CI 16.3-61.6) required oxygen support and 4/19 (21.1%, 95% CI 6.1-45.6) were admitted to a critical care unit. Two women with COVID-19 breastfed without a mask because infection was diagnosed in the postpartum period: their newborns tested positive for SARS-Cov-2 infection. In one case, a newborn had a positive test after a vaginal operative delivery.

CONCLUSIONS

Although postpartum infection cannot be excluded with 100% certainty, these findings suggest that vaginal delivery is associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

TWEETABLE ABSTRACT

This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

Assessing two-way interactions between cells and inorganic nanoparticles

A safe and effective use of nanoparticles in biology and medicine requires a thorough understanding, down to the molecular level, of how nanoparticles interact with cells in the physiological environment. This study evaluated the two-way interaction between inorganic nanomaterials (INMs) and cells from A549 human lung carcinoma cell line. The interaction between silica and zinc oxide INMs and cells was investigated using both standard methods and advanced characterization techniques. The effect of INMs on cell properties was evaluated in terms of cell viability, chemical modifications, and volume changes. The effect of cells and culture medium on INMs was evaluated using dynamic light scattering (DLS), scanning electron microscopy and energy-dispersive X-ray spectroscopy (SEM-EDS), high performance liquid chromatography (HPLC), gas chromatography-mass spectroscopy (GC-MS), Fourier transform infrared spectroscopy (FTIR), and thermogravimetric analysis (TGA). No cytotoxic effect was detected in the case of silicon oxide INMs, while for high doses of zinc oxide INMs a reduction of cell survival was observed. Also, increased cell volume was recorded after 24 h incubation of cells with zinc oxide INMs. A better dimensional homogeneity and colloidal stability was observed by DLS for silicon oxide INMs than for zinc oxide INMs. SEM-EDS analysis showed the effectiveness of the adopted dispersion procedure and confirmed in the case of zinc oxide INMs the presence of residual substances derived from organosilane coating. HPLC and GC-MS performed on INMs aqueous dispersions after 24 h incubation showed an additional peak related to the presence of an organic contaminant only in the case of zinc oxide INMs. FTIR Chemical Imaging carried out directly on the cells showed, in case of incubation with zinc oxide INMs, a modification of the spectra in correspondence of phospholipids, nucleic acids and proteins characteristic absorption bands when compared with untreated cells. Overall, our results confirm the importance of developing new experimental methods and techniques for improving the knowledge about the biosafety of nanomaterials.

Long-range detection of acoustic vibrations by speckle tracking

When a rough surface is illuminated by a laser beam, it scatters the light, producing a random interference pattern also known as speckle pattern. By imaging the speckle pattern with a line-scan CCD, we are able to measure the acoustic vibrations of a scattering surface, which can be up to 300 m distant. We also show that our instrument can be used as a laser microphone capable of detecting ambient sound such as a human voice.

The optimisation of noninvasive ventilation in amyotrophic lateral sclerosis: a systematic review

Background

Noninvasive ventilation (NIV) prolongs survival and quality of life in amyotrophic lateral sclerosis (ALS); however, its benefits depend upon the optimisation of both ventilation and adherence. We aimed to identify factors associated with effective initiation and ongoing use of NIV in ALS to develop evidence-based guidance and identify areas for further research.

Methods

We searched 11 electronic databases (January 1998 to May 2018) for all types of quantitative and qualitative studies. Supplementary grey literature searches were conducted. Records were screened against eligibility criteria, data were extracted from included studies and risk of bias was assessed. We present findings using a narrative synthesis.

Results

We screened 2430 unique records and included 52 quantitative and six qualitative papers. Factors reported to be associated with NIV optimisation included coordinated multidisciplinary care, place of initiation, selection of interfaces, ventilator modes and settings appropriate for the individual patient, and adequate secretion management. The literature indicated that patients with significant bulbar dysfunction can still derive considerable benefit from NIV if their needs are met. Research emphasises that obstructive airway events, mask leak and uncontrolled secretions should be addressed by adjustments to the interface and machine settings, and the concomitant use of cough augmentation.

Conclusion

This review highlights that NIV optimisation requires an individualised approach to respiratory management tailored to the differing needs of each patient. Ultimately, this should lead to improved survival and quality of life. This review expands on recommendations in current international guidelines for NIV use in ALS and identifies areas for future research.

Genetic variability of the measles virus hemagglutinin gene in B3 genotype strains circulating in Northern Italy

Sequencing the whole measles virus hemagglutinin (H) gene, in conjunction with a 450-nucleotide region of the nucleoprotein gene (N-450), is helpful for the identification of new genotypes and as an auxiliary in outbreak characterization. In addition, it is essential to be able to predict the antigenic changes of the H protein to gain a better monitoring of the response to the vaccine. In this study, we obtained the full-length H gene sequences from 19 measles virus (MV) strains belonging to two B3 genotype variants circulating in Lombardy (Northern Italy) between July 2015 and February 2016 and evaluated the variability of the whole MV-H gene. Furthermore, we compared the obtained H amino acid sequences to all MV sequences available in the GenBank database (n = 1152 in total) and analyzed the amino acid substitutions in the H protein within clades where the Italian strains were included. We identified a higher variability in the H gene compared to the N-450 region and our results support previous studies, highlighting that the H gene is more informative for characterizing the MV B3 genotype than the N-450 sequence. Some of the amino acid substitutions were fixed in the viral population and, remarkably, some of the amino acid substitutions were typically present only in the Italian sequences. Accumulating further molecular information about MV-H gene will be necessary to enable in-depth analyses of the variability of this gene in the vaccinated population.

Abstract P3-12-07: Conservative breast reconstruction: Outcomes of 146 consecutive cases of prepectoral, subcutaneous implant-based breast reconstruction in a single-Institution series

Aims. To evaluate acute and late toxicity-related factors among breast cancer (BC) patients who underwent prepectoral breast reconstruction (BR).

Methods. We performed a retrospective analysis of BC patients who underwent therapeutic or prophylactic mastectomy from October 2012 to May 2016 at our Center. We recorded individual patient-related features (i.e. age, body mass index [BMI], smoke-history, comorbidity, BRCA-carrier), BC-related treatments characteristics (i.e. axillary surgery, adjuvant radiotherapy [RT], adjuvant chemotherapy, primary systemic therapy [PST], endocrine therapy, and use of trastuzumab). Toxicity profile was evaluated in terms of complications related to BR; we recorded acute and late toxicity data and prosthesis/implant explant rate.

Results. We analyzed 146 consecutive BC patients treated with subcutaneous BR, 117 therapeutic and 29 prophylactic mastectomies. Thirty-seven patients received postmastectomy RT. Significant factors related to acute toxicity were: previous RT (34.5% [RT] vs 8.5% [no RT]; p=0.001), BMI (31.3% [BMI ≥25] vs 8.8% [&lt;25]; p=0.003), previous breast surgery (22.2% [surgery] vs 8.7% [no surgery]; p=0.027), and diabetes (100% [diabetes] vs 11.9% [no diabetes]; p=0.002). Factors significantly correlated to implant/prosthesis explant were: current or previous smoking exposition (13.8% [smokers] vs 2.6% [non-smokers]; p=0.029) and PST (18.8% [PST] vs 3.5% [no PST]; p=0.022); axillary lymph node dissection (ALND) was significantly related to late toxicity (5.7% [ALND] vs 0%; p=0.04). At a 3-year median follow up, three deaths, five locoregional recurrences (LRR), and fourteen distant metastasis (DM) occurred among 117 patients treated by therapeutic mastectomy. Overall survival was 78.1%, LRR free-survival was 95%, and DM free-survival was 71.6%. Postmastectomy RT was not significantly related to acute, late toxicity, and explant occurrence.

Conclusions. In our experience prepectoral subcutaneous implant-based BR is a safe and effective approach, with low rates of acute toxicity. Major risk factors were evidenced for patients previously treated with RT or surgery, and in case of diabetes or BMI ≥25; postmastectomy RT seems not to be related to higher rate of toxicity. ALND seems to be the only factor significantly related to late toxicity. PST, and smoking exposition were significantly associated with higher rate of implant/prosthesis explant. However, further investigations and mature follow-up are warranted to confirm these encouraging results.

Citation Format: Meattini I, Bernini M, Saieva C, Desideri I, Scotti V, Salvestrini V, Visani L, Mariotti M, Delli Paoli C, Olmetto E, Maragna V, Orzalesi L, Sanchez L, Nori J, Bianchi S, Livi L. Conservative breast reconstruction: Outcomes of 146 consecutive cases of prepectoral, subcutaneous implant-based breast reconstruction in a single-Institution series [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 P3-12-07.

Abstract P4-16-04: Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial

Background. Several randomized trials demonstrated aromatase inhibitors (AI) superiority in terms of disease-free survival (DFS) compared to tamoxifen treatment for postmenopausal hormone receptor-positive breast cancer (BC) patients. Anyway, AI toxicity profile is a concern due to estrogen suppression. Pivotal trials demonstrated a significant bone mineral density (BMD) loss due to AI, with a consistent 5-year risk of bone fractures, thus impacting on patients' quality of life. Bisphosphonates represent an effective treatment in postmenopausal osteoporosis fractures prevention. However, an adequate patient's selection for adjuvant bisphosphonates treatment during AI endocrine therapy is still a challenge. Final results of BONADIUV trial presented at San Antonio Breast cancer Symposium in 2016 showed that treatment with ibandronate, as compared to placebo, significantly improved BMD change in osteopenic women treated with adjuvant AI, and consistently protected patients' bone loss. We present the secondary 5-year analysis on survival outcomes of the trial.

Patients and methods. The BONADIUV trial is a single-blind, randomized, placebo-controlled phase 2 study designed to evaluate the impact of ibandronate treatment on BMD in osteopenic women taking AI. Between January 2011 and May 2014, 171 osteopenic patients (lumbar spine [LS] and/or trochanter -1&lt; T-score &lt;-2.5), were randomized in a 1:1 ratio to receive either placebo or oral monthly ibandronate (150 mg). Treatment duration was 2 years, with 6-months evaluation. Primary endpoint was the mean BMD difference between the two arms at a 2-year follow up. Secondary analysis on survival outcomes (overall survival [OS] and invasive DFS [iDFS]) have been performed at 5-year median follow-up time. ClinicalTrials.gov identifier: NCT02616744.

Results. At the database cutoff time for the present analysis on May 4, 2018, median follow up was 63.3 months (mean 61.2; range 2.7-87.3) for whole series, 64.9 months (range 33.8-84.0) for the placebo arm, and 62.2 months (range 24.2-87.3) for the ibandronate arm. Ten patients in the placebo group and 17 patients in the ibandronate group withdrew the allocated arm before any follow up data collection, and so were excluded from the analysis, performed on 144 patients (72 patients per arm). At the database cutoff time, the OS rate was 97.2% in the placebo group and 100% in the ibandronate arm. We observed four loco-regional relapse (three in the placebo arm, one in the ibandronate arm; p=0.33), three distant metastases (none in the placebo arm, three in the ibandronate arm; p=0.075), and three contralateral BC (one in the placebo arm, two in the ibandronate arm; p=0.65). The number of iDFS events did not differ between groups: four in the placebo group and six in the ibandronate group (p=0.56). Up to data cutoff, two deaths have occurred; none in the placebo arm and two in the ibandronate arm (p=0.15). The OS rate did not differ between arms.

Conclusions. The secondary analysis of survival outcomes showed no difference between arms in terms of OS and iDFS rates. Further large investigations and mature follow-up from the published ones are awaited.

Citation Format: Meattini I, Scotti V, Desideri I, Saieva C, Visani L, Salvestrini V, Cecchini S, De Feo ML, Mariotti M, Olmetto E, Delli Paoli C, Francolini G, Bernini M, Orzalesi L, Sanchez L, Nori J, Bianchi S, Livi L. Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial [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 P4-16-04.

Drug-Induced Interstitial Lung Disease: A Systematic Review

Background: Drug-induced interstitial lung disease (DIILD) occurs as a result of numerous agents, but the risk often only becomes apparent after the marketing authorisation of such agents. Methods: In this PRISMA-compliant systematic review, we aimed to evaluate and synthesise the current literature on DIILD. Results: Following a quality assessment, 156 full-text papers describing more than 6000 DIILD cases were included in the review. However, the majority of the papers were of low or very low quality in relation to the review question (78%). Thus, it was not possible to perform a meta-analysis, and descriptive review was undertaken instead. DIILD incidence rates varied between 4.1 and 12.4 cases/million/year. DIILD accounted for 3–5% of prevalent ILD cases. Cancer drugs, followed by rheumatology drugs, amiodarone and antibiotics, were the most common causes of DIILD. The radiopathological phenotype of DIILD varied between and within agents, and no typical radiological pattern specific to DIILD was identified. Mortality rates of over 50% were reported in some studies. Severity at presentation was the most reliable predictor of mortality. Glucocorticoids (GCs) were commonly used to treat DIILD, but no prospective studies examined their effect on outcome. Conclusions: Overall high-quality evidence in DIILD is lacking, and the current review will inform larger prospective studies to investigate the diagnosis and management of DIILD.

AARS2-related ovarioleukodystrophy: Clinical and neuroimaging features of three new cases

INTRODUCTION

Adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP), previously known as hereditary diffuse leukoencephalopathy with axonal spheroids (HDLS) or pigmentary orthochromatic leukodystrophy (POLD), is the most frequent non-vascular adult-onset leukoencephalopathy. It is caused by autosomal dominant mutations in CSF1R gene. Recently, also autosomal recessive mutations in AARS2 gene were found to be the cause of an adult-onset leukodystrophy with axonal spheroids. Our aim was to achieve a genetic diagnosis in a cohort of CSF1R-negative patients, performing a sequence analysis of AARS2 gene.

MATERIAL AND METHODS

AARS2 sequencing was performed in 38 CSF1R-negative patients with clinical and magnetic resonance imaging (MRI) findings of adult-onset leukoencephalopathy.

RESULTS

Three patients carrying AARS2 compound heterozygous mutations have been found. All patients were female with ovarian failure and leukoencephalopathy. In 2 patients, MRI findings were consistent with previous reports while the third patient showed focal white matter (WM) lesions in the centrum semiovale and the corpus callosum in the absence of extensive involvement and rarefaction of the WM. MRI spectroscopy showed the presence of increased lactate in 2 patients, thus linking AARS2-related leukoencephalopathy with other mitochondrial leukoencephalopathies with high levels of cerebral lactate.

CONCLUSION

We recommend screening for mutations in AARS2 gene in CSF1R-negative patients, also in the absence of a clear family history and peculiar MRI findings. Our results also suggest that findings of conventional MRI and MR spectroscopy may be useful in prompting the genetic screening.

Pulmonary Artery Size in Interstitial Lung Disease and Pulmonary Hypertension: Association with Interstitial Lung Disease Severity and Diagnostic Utility

Purpose

It is postulated that ILD causes PA dilatation independent of the presence of pulmonary hypertension (PH), so the use of PA size to screen for PH is not recommended. The aims of this study were to investigate the association of PA size with the presence and severity of ILD and to assess the diagnostic accuracy of PA size for detecting PH.

Methods

Incident patients referred to a tertiary PH centre underwent baseline thoracic CT, MRI and right heart catheterisation (RHC). Pulmonary artery diameter was measured on CT pulmonary angiography and pulmonary arterial areas on MRI. A thoracic radiologist scored the severity of ILD on CT from 0 to 4, 0 = absent, 1 = 1–25%, 2 = 26–50%, 3 = 51–75%, and 4 = 76–100% extent of involvement. Receiver operating characteristic analysis and linear regression were employed to assess diagnostic accuracy and independent associations of PA size.

Results

110 had suspected PH due to ILD (age 65 years (SD 13), M:F 37:73) and 379 had suspected PH without ILD (age 64 years (SD 13), M:F 161:218). CT derived main PA diameter was accurate for detection of PH in patients both with and without ILD - AUC 0.873, p =< 0.001, and AUC 0.835, p =< 0.001, respectively, as was MRI diastolic PA area, AUC 0.897, p =< 0.001, and AUC 0.857, p =< 0.001, respectively Significant correlations were identified between mean pulmonary arterial pressure (mPAP) and PA diameter in ILD (r = 0.608, p < 0.001), and non-ILD cohort (r = 0.426, p < 0.001). PA size was independently associated with mPAP (p < 0.001) and BSA (p = 0.001), but not with forced vital capacity % predicted (p = 0.597), Transfer factor of the lungs for carbon monoxide (T_LCO) % predicted (p = 0.321) or the presence of ILD on CT (p = 0.905). The severity of ILD was not associated with pulmonary artery dilatation (r = 0.071, p = 0.459).

Conclusions

Pulmonary arterial pressure elevation leads to pulmonary arterial dilation, which is not independently influenced by the presence or severity of ILD measured by FVC, T_LCO, or disease severity on CT. Pulmonary arterial diameter has diagnostic value in patients with or without ILD and suspected PH.

Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Histopathologic Classification of Breast Cancer in Sweden and Italy: A Comparison between two Pathologists

Two large series of breast cancers (BC), identified in the Pathology Departments of Malmö (Sweden) and Florence (Italy), were independently reviewed by two experienced pathologists, one from each department. Overall, comparison of diagnoses of 372 BCs according to a simplified WHO histologic classification system (in four combined categories) revealed agreement for 74 % of the cases. Concordance, as measured by the kappa statistic, was relatively good (0.53 overall). Kappa values for specific categories were also acceptable, being highest for « invasive lobular » BC (0.63) and lowest for « other types » (0.45). The kappa value for « noninvasive » versus all other categories of invasive BC was 0.53. Some BCs were systematically classified as « noninvasive » by one pathologist and as « invasive ductal with a predominant intraductal component » by the other. Invasive lobular BCs were also diagnosed more frequently by one pathologist. These findings suggest that when planning geographical or temporal comparisons of distribution for BC histologic categories, standardization of classification and a centralized review may play an important role.