Gene expression and copy number profiling of follicular lymphoma biopsies from patients treated with first-line rituximab without chemotherapy

The Nordic Lymphoma Study Group has performed two randomized clinical trials with chemotherapy-free first-line treatment (rituximab +/- interferon) in follicular lymphoma (FL), with 73% of patients alive and 38% without any need of chemotherapy after 10.6 years median follow-up. In order to identify predictive markers, that may also serve as therapeutic targets, gene expression- and copy number profiles were obtained from 97 FL patients using whole genome microarrays. Copy number alterations (CNAs) were identified, e.g. by GISTIC. Cox Lasso Regression and Lasso logistic regression were used to determine molecular features predictive of time to next therapy (TTNT). A few molecular changes were associated with TTNT (e.g. increased expression of INPP5B, gains in 12q23/q24), but were not significant after adjusting for multiple testing. Our findings suggest that there are no strong determinants of patient outcome with respect to GE data and CNAs in FL patients treated with a chemotherapy-free regimen (i.e. rituximab +/- interferon).

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

Combined regression score predicts outcome after neoadjuvant treatment of oesophageal cancer

BACKGROUND

Histopathologic regression following neoadjuvant treatment (NT) of oesophageal cancer is a prognostic factor of survival, but the nodal status is not considered. Here, a score combining both to improve prediction of survival after neoadjuvant therapy is developed.

METHODS

Seven hundred and fifteen patients with oesophageal squamous cell (SCC) or adenocarcinoma (AC) undergoing NT and esophagectomy were analysed. Histopathologic response was classified according to percentage of vital residual tumour cells (VRTC): complete response (CR) without VRTC, major response with <10% VRTC, minor response with >10% VRTC. Nodal stage was classified as ypN0 and ypN+. Kaplan-Meier and Cox regression were used for survival analysis.

RESULTS

Survival analysis identified three groups with significantly different mortality risks: (1) low-risk group for CR (ypT0N0) with 72% 5-year overall survival (5y-OS), (2) intermediate-risk group for minor/major responders and ypN0 with 59% 5y-OS, and (3) high-risk group for minor/major responders and ypN+ with 20% 5y-OS (p < 0.001). Median survival in AC and SCC cohorts were comparable (3.8 (CI 95%: 3.1, 5.3) vs. 4.6 years (CI 95%: 3.3, not reached), p = 0.3).

CONCLUSIONS

Histopathologic regression and nodal status should be combined for estimating AC and SCC prognosis. Poor survival in the high-risk group highlights need for adjuvant therapy.

[Complementary or alternative medicine in oncology : Chances or risks?]

BACKGROUND

Approximately half of all cancer patients use complementary or alternative medicine.

AIM

The results of the German S3 guidelines on complementary oncology are presented and placed into the context of patient consultation.

MATERIAL AND METHODS

The core recommendations of the S3 guidelines are summarized including an overview of the evidence.

RESULTS

Selected methods of complementary medicine can be used with the aim of improving the quality of life and reducing side effects. Comprehensive data are available for physical activity with respect to survival, quality of life and supportive therapy. For most other methods the evidence is relatively low. Therefore, weighing up the benefits and risks more frequently resulted in negative recommendations in the guidelines, especially for methods based on substances. Exceptions to this are three micronutrients (vitamins B12, D and selenium), as even in the case of a well-balanced diet, deficiency symptoms are possible. Therefore, routine measurement of the blood levels of these micronutrients is recommended.

CONCLUSION

The questions from patients on what they can do by themselves should be answered respectfully and based on evidence. The benefits and risks of complementary methods must be carefully considered. To do this, regular questioning of patients on the interest in complementary methods is recommended. The decisive benefit of complementary medicine is the chance for patients to become active themselves. Therefore, all recommendations refer to the discussion with the patient, which do not formulate a therapy but are consultation recommendations: should be recommended instead of should be done.

Evidence for neutrino emission from the nearby active galaxy NGC 1068

A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

Implementing public health and social measures: an integral part of the health emergency management cycle

Public health and social measures (PHSM) have been utilized as a tool to reduce the infection rates and disease burden throughout the COVID-19 pandemic and continue to play an important role even with vaccination campaigns well underway in preventing severe disease. In order to systematically track, analyze and report qualitative and quantitative data o PHSM implementation across the European Region and assist countries in the COVID-19 response, the COVID-19 Incident Management Support team at the WHO Regional Office for Europe developed PHSM Severity Index and PHSM Dashboard. The PHSM Severity Index captures the types, severity and timing of PHSMs implemented by a country across six main indicators. By providing standardized data on PHSM implementation, the PHSM Severity Index can support and inform the development of policy at country and regional levels. PHSM data, severity methodology and policy tools developed throughout the COVID-19 pandemic should be adapted to provide a foundation for preparedness for future large-scale health emergencies. In addition, discerning the epidemiological impact of specific PHSM and their combinations currently is a priority for policy-makers and can guide countries’ transition strategies. Analysing the impact of PHSM on COVID-19 transmission is of critical importance, especially as variants of concern bring new waves of COVID-19 cases and may challenge countries’ vaccination and response strategies. Reference PHSM in Response to COVID-19 (who.int)

Supporting decision making on public health and social measures in response to COVID-19- The PHSM calibration tool

 

Public health and social measures (PHSM) are preventative measures taken by individuals, communities and government institutions at national and local levels to prevent and reduce transmission of an infectious disease - in this instance SARS-CoV-2. The decision to introduce, adapt or lift PHSM should be based primarily on a situational assessment of the intensity of transmission of SARS-CoV-2 and the capacity of the health system to respond to subsequent increases in hospital admissions, but must also consider the effects these measures may have on the general welfare of society and individuals. The WHO Regional Office for Europe developed an online public health and social measures (PHSM) calibration tool to assist Member States in decision-making relating to PHSM implementation during the COVID-19 pandemic. The tool, designed to be used primarily by policy-makers in national and local government authorities, provides guidance based on a situational-level assessment framework that is determined by the level of community transmission and the overall capacity of health systems and public health services within a country or region to respond. By using a combination of country-reported and user-input data, the tool automatically generates a situational assessment and corresponding PHSM guidance for users, summarized in a downloadable report.

Reference

https://phsm.euro.who.int/calibrationTool

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

P11.15.B First multicentric real-life experience with the combination of lomustine and temozolomide in newly diagnosedMGMT promoter methylatedIDH wildtype glioblastoma

Background

The CeTeG/NOA-09 trial assessed in a randomized phase 3 setting, whether combined treatment of lomustine together with temozolomide was superior to temozolomide treatment alone in newly diagnosed MGMT (O(6)-methylguanine-DNA-methyltransferase) promoter methylated glioblastoma patients. Survival was significantly improved from 31.4 months with temozolomide alone to 48.1 months with the combination of lomustine plus temozolomide. In view of this encouraging data - suggesting this combination could have a significant impact on the survival of newly diagnosed glioblastoma patients - we were curious to assess safety and efficacy of this regimen under real-life conditions.

Material and Methods

We collected clinical and radiographic data from adult newly diagnosed MGMT promoter methylated IDH (isocitrate dehydrogenase) wildtype glioblastoma patients treated at five neuro-oncology centers in Germany. As a requirement for inclusion, first-line treatment with lomustine plus temozolomide had to be performed for at least six weeks (one course). The available radiographic data was independently reviewed by an experienced board-certified neuro-radiologist.

Results

In total, 70 patients were included. Median progression-free survival of the full cohort was 14.4 months and median overall survival was 36.0 months. Patients who received TTFields (Tumor Treating Fields) treatment for eight weeks or longer together with the combination of lomustine plus temozolomide (n=22, 31%) had a prolonged progression-free survival compared to those patients who received TTFields treatment less than eight weeks or did not receive treatment with TTFields (n=48, 69%) (21.5 months versus 11.2 months; HR: 2.118, 95% CI: 1.245-3.605; p=0.0105). In a multivariable Cox regression analysis the use of TTFields for eight weeks or longer together with the combination of lomustine plus temozolomide as well as the application of at least five courses of CeTeG therapy emerged as independent prognostic factors for progression-free survival and overall survival. Pseudoprogression occurred in n=16 (33%) of the patients. We observed no treatment related deaths and high-grade hematotoxicity in n=31 (44%) of the patients.

Conclusion

The results from this multicentric trial that investigated newly diagnosed MGMT promoter methylated IDH wildtype glioblastoma under real-life conditions indicate toxicity and survival estimates comparable to the CeTeG/NOA-09 trial. The use of TTFields for at least eight weeks in combination with this regimen was independently associated with extended progression-free and overall survival.

OS06.5.A Investigating safety and efficacy of TTFields prior and concomitant to radiotherapy in newly diagnosed glioblastoma - the PriCoTTF phase I/II trial

Background

The EF-14 phase III trial demonstrated improved survival for patients with newly diagnosed glioblastoma (nGBM) when TTFields therapy was added to adjuvant temozolomide chemotherapy. TTFields at 200 kHz are applied to the tumor utilizing arrays on the patients’ scalp. In preclinical studies, a synergistic inhibiting effect on glioblastoma cell proliferation was found for the combination of TTFields and radiotherapy. Based on these findings, we conduct the phase I/II PriCoTTF trial in adult nGBM patients to investigate the safety and efficacy of TTFields therapy initiated prior and concomitant to radiochemotherapy.

Material and Methods

Per study protocol, TTFields therapy is initiated following surgery and completed wound healing. Continuing throughout radiochemotherapy and adjuvant chemotherapy, TTFields therapy is used for approximately 9 months in total with TTFields rechallenge allowed at recurrence. Radiotherapy is conducted with arrays applied on the patients’ scalp. A total recruitment of 33 patients was sought, with 20 patients in arm A receiving normo-fractionated radiotherapy, and 13 elderly patients in arm B receiving hypo-fractionated radiotherapy. Safety and tolerance are the study’s primary endpoint, analyzed by a selection of pre-specified treatment-limiting toxicities (TLTs).

Results

A total of 33 patients have been enrolled. Patients' characteristics were mostly typical for glioblastoma, except for a rather low fraction of patients with gross total resection (GTR, 22.5%). The distribution of adverse events of common toxicity criteria (CTC) grade 3 or higher was comparable to that of established glioblastoma trials. Notably, skin toxicity of CTC grade 3 or higher was quite uncommon (n=2, 6%). As no patient developed TLTs, the study's primary endpoint was met. Median TTFields treatment duration was 8.4 months. Overall survival data was not mature enough (event rate 48%) to allow for a definite conclusion. Notably, on multivariable Cox regression, the number of days with TTFields adherence of more than 23 hours was independently associated with overall survival (HR 0.96, 95% confidence interval 0.93 - 0.99, p=0.008).

Conclusion

The PriCoTTF trial met its primary endpoint indicating that combined TTFields and radiotherapy is safe and well tolerated. High-grade skin toxicity was quite uncommon and the patients with high TTFields adherence seem to perform particularly well. An extended follow-up is required to provide first estimates regarding putative efficacy. At that point in time, the reduced overall TTFields duration and fraction of patients with GTR need to be factored in.

P11.14.A Systematic review of phase III trials in newly diagnosed glioblastoma 2005-2021

Background

Despite a plethora of studies since the EORTC/NCIC trial in 2005, glioblastoma (GBM) prognosis remains poor. We here identify and compare glioblastoma phase III trials in terms of efficacy and baseline characteristics in an attempt to summarize the experience of the past 16 years.

Methods

A systematic literature search using PubMed and ClinicalTrials.gov was conducted to provide an overview of clinically relevant GBM phase III trials (years 2005-2021) of adult patients younger than 70 years of age. Search results were screened according to predefined inclusion criteria and either excluded or included in further analysis on study design, baseline characteristics, and survival results.

Results

Eleven trials from the literature and clinical trial database fulfilled the search criteria. Among these trials, a total of three GBM phase III trials reported overall survival (OS) benefit, including the EORTC/NCIC study (NCT00006353), EF-14 (NCT00916409) and CeTeG/NOA09 (NCT01149109). All three studies demonstrate similar hazard ratios, which translate into risk reduction of about 40%. Furthermore, low toxicity profile and mostly preserved quality of life were attributed to the treatments tested. Looking at the study designs, eight out of eleven trials were open label randomized trials, including all of the positive ones, and only three negative trials employed treatment blinding and a placebo control. Canonical baseline characteristics (extent of resection, age, gender, MGMT promoter methylation status) did not significantly differ between positive and negative trials. IDH mutation status was analyzed in only two trials, each showing a small percentage of IDH-mutant tumors only.

Conclusion

This analysis on GBM phase III trials conducted between 2005 and 2021 revealed that the majority of trials did not show a significant improvement in overall survival. CeTeG/NOA-09 and EF-14 are the only two studies with positive overall survival outcome since the EORTC/NCIC trial in 2005.

P17.04.B Combination of Trofosfamide and Etoposide in Recurrent Glioma

Background

Disease relapse almost inevitably occurs in patients with adult-type diffuse glioma. Standard of care treatment options at tumor relapse are still not well defined. Frequently used drugs for adult-type diffuse glioma recurrence include lomustine (CCNU) and bevacizumab. Few studies indicate that the combination of trofosfamide/etoposide, given their high lipid solubility with good blood-brain barrier penetrance, may be feasible in pediatric glioblastoma patients. In this retrospective analysis, we determined tolerability and feasibility of combined trofosfamide/etoposide treatment at disease recurrence of patients with adult-type diffuse glioma.

Material and Methods

We collected clinicopathological data from adult patients with adult-type diffuse glioma treated with the combination of trofosfamide/etoposide at the Division of Clinical Neurooncology at the University Hospital Essen. Only those patients were considered eligible who received trofosfamide/etoposide treatment for more than four weeks (one course). Trofosfamide (100mg/m2/day) and Etoposide (25mg/m2/day) was administered orally in a “one week on, one week off” scheme. A cohort of patients receiving empiric treatment at the investigators’ discretion balanced for tumor entity and canonical prognostic factors (number of previous treatments, MGMT promoter methylation, IDH mutation status, KPS, age, extent of resection) served as control. We collected toxicity data as it pertained to CTCAE (Common Terminology Criteria for Adverse Events, version 5.0) and survival data to explore putative efficacy.

Results

A total of 33 patients were eligible for this analysis. In the IDH wild-type glioblastoma (n=18) subgroup, median progression-free survival (3.8 months versus 2.9 months, HR: 2.09, 95% CI: 1.010-4.312, p=0.0227; PFS-6: 39% versus 6%) and median overall survival (10.4 months versus 5.7 months, HR: 3.05, 95% CI: 1.393-6.655, p=0.0008) were significantly prolonged as compared to the control cohort. In a multivariable Cox regression analysis, treatment with trofosfamide/etoposide emerged as statistically significant prognostic marker regarding progression-free survival and overall survival. We observed high-grade adverse events (CTCAE grade≥III ) in 21 (64%) of all recurrent glioma patients with hematotoxicity comprising most adverse events (n=18, 86%). Lymphopenia was by far the most observed hematotoxic adverse event (n=13, 62%). Among non-hematologic high-grade adverse events was transaminase elevation (n=3, 14%).

Conclusion

This study provides first indication that the combination of trofosfamide/etoposide is safe in patients with adult-type diffuse gliomas and may be associated with prolonged survival in adult patients with recurrent IDH wildtype glioblastoma. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective controlled trial.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

Physical Activity After Heart Transplantation: Characteristics, Motifs, Barriers, and Influence of COVID-19 Pandemic

Purpose

After heart transplantation (HTX), regular physical activity (PA) is crucial to counteract transplant-related alterations and improve functional performance. Not much is known about the long-term implementation of PA and potential problems that may occur. The potential influence of COVID-19 pandemic is unknown.

Methods

Online questionnaire survey: 158 patients (53±14 yrs, 65% male, 8±7 yrs after HTX) were included. Recruitment was carried out via HTX outpatient departments, transplant sport associations, self-aid groups and social media. The questionnaire included 77 to 138 items divided into 6 categories and 3 time points (pre heart failure, after HTX before COVID-19, after HTX during COVID-19). The survey was approved by the local ethics committee.

Results

88% reported regular PA after HTX (before COVID-19) and 75% had taken up PA within the first year. Patients stated higher level of PA after HTX, compared to the pre heart failure period (p<0.05). Patients who completed cardiac rehabilitation (70%), started leisure-time PA significantly earlier (p<0.05) and with higher frequency (p<0.05). Figure 1 shows the most important motifs/barriers for regular PA and changes over the reported period. Satisfaction with sports facilities was moderate and 39% complained about the need for improvement (e.g. exercise education). 61% performed exercise training without a professional supervision. Exercise monitoring was mostly done using heart rate respond (52%), but frequently no monitoring was used (32%). During COVID-19, patients were more dissatisfied with their level of regular PA (p<0.01) or physical condition (p<0.05) and emphasized the beneficial effect of PA on their mental balance.

Conclusion

After HTX, most patients try to integrate regular PA in their leisure-time behavior, but complain about a lack of detailed exercise education and appropriate sports facilities. Participation in a cardiac rehabilitation after HTX may have positive long-term impact on PA levels.

Search for Relativistic Magnetic Monopoles with Eight Years of IceCube Data

We present an all-sky 90% confidence level upper limit on the cosmic flux of relativistic magnetic monopoles using 2886 days of IceCube data. The analysis was optimized for monopole speeds between 0.750c and 0.995c, without any explicit restriction on the monopole mass. We constrain the flux of relativistic cosmic magnetic monopoles to a level below 2.0×10^{-19}  cm^{-2} s^{-1} sr^{-1} over the majority of the targeted speed range. This result constitutes the most strict upper limit to date for magnetic monopoles with β≳0.8 and up to β∼0.995 and fills the gap between existing limits on the cosmic flux of nonrelativistic and ultrarelativistic magnetic monopoles.

First results of a regenerative transcatheter heart valve implant from autologous tissue in a long-term animal model

Background

The perfect heart valve replacement remains to be found regarding longevity, freedom of anticoagulation and availability in each size.

Purpose

Examination of a new technique for a regenerative, immunocompatible, transcatheter pulmonary valve implant from autologous pericardium was performed in an adult sheep model.

Methods

For each valve implant a pericardial patch was harvested by left antero-lateral mini-thoracotomy, placed on one of two slightly different shaped moulds either made of acrylic glass (AG) or printed in a 3D Printer (3D) and transferred into a container filled with a biological crosslinking agent at a non-toxic concentration to stabilize the given shape. After a median of 3 days (d) they were unpacked, sewn into a self-expandable nitinol stent with a diameter of 26 or 30mm and implanted via the jugular vein into pulmonary valve position of the same animal using a custom-made delivery system (1). Three groups (Gr) were planned: Gr 1) 4 animals with at least 6 d of crosslinking and AG mould; Gr 2) 5 animals with at least 3 d of crosslinking and AG mould; Gr 3) 6 animals with at least 3 d crosslinking and 3D mould. Follow ups (FU) were performed every 3 months (mo) evaluating valve function by intracardiac echocardiography (ICE) and cardiac MRI for up to 20.5 mo. All experiments were approved and conducted according to German federal law.

Results

In 11 of 13 animals minimally-invasive implantation was successful. One animal died because of ventricular fibrillation, in the other the implant dislocated into the right ventricle, so it had to be sacrificed. Direct post-implantation valve insufficiency was evaluated in 9 animals using ICE or angiography. In Gr 1 insufficiency was non-existent (n=2), in Gr 2 moderate or severe (n=2) and in Gr 3 non-existent or mild (n=5). Long term function as shown in figure 1 decreased rapidly in Gr 1 and 2 with median MRI regurgitation fractions (RF) in Gr 1 of 31% at 3 mo (n=3), 41% at 6 mo (n=3), 48% at 9 mo (n=2), 47% at 12 mo (n=3) and in Gr 2 of 43% at 3 and 54% at 6 mo (n=1) after implantation. Median RF in Gr 3 was small with 9% at 3 mo (n=4), 8% at 6 mo (n=3), 8% at 9 mo (n=3), 12% at 13 mo (n=3), 8% at 17 mo (n=2) and 20.5 mo (n=2). We never witnessed valve stenosis in any group at any point in time.

Conclusion

Gr 3 showed promising results regarding long time function of the implant which encourages further research with higher validity. The reason for failing of Gr 1 and 2 remains a topic of discussion. Regardless, valuable experience was gained in crafting and conducting the implantation of this new regenerative heart valve implant.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EXIST research transfer program of the federal ministry of education and research

Detecting a broader spectrum of cardiac pathologies in electrocardiogram data by applying a deep neural network designed to detect a specific cardiac disease

Background/Introduction

The electrocardiogram (ECG) is a widely used and inexpensive tool that provides extensive insights into the cardiac structure and function. Artificial intelligence (AI) algorithms, especially deep learning (DL) models, are efficient computer based instruments with which large and complex datasets can be processed for identification of e.g. specific diseases. PhysioNet is a NIH research resource for complex signals including a large amount of labelled ECG time-series data. Our aim was to evaluate the diagnostic performance of an AI architecture developed to detect a specific cardiac pathology in a large ECG data set including a broad range of cardiac abnormalities.

Methods

The PhysioNet ECG dataset provided as part of the PhysioNet Challenge 2020 consists of five distinct databases with a total of 43100 12-Lead ECG recordings of varying length stemming from patients from China, Russia, Europe and the United States. Each ECG recording is annotated with diagnoses based on a set of 111 possible labels, which express either a cardiac pathology, e.g. atrial flutter or anterior wall ischemia, or unspecific changes in the ECG, e.g. a prolonged qt interval or low qrs voltages. Based on these labels we defined 10 groups merging PhysioNet labels describing related cardiac abnormalities (see Table 1). We adapted a recently published DL model which used raw ECG time-series data of all 12-leads rather than extracted features as model input. This DL model was adapted to the larger number of output variables and then trained on 80% (n=34480 ECGs) of the PhysioNet dataset. The remaining 20% (n=8620 ECGs) of the PhysioNet dataset were used to evaluate the diagnostic performance of the AI model. Sensitivities, specificities and the areas under the receiver operator characteristic curves (AUROC) were used as performance metrices.

Results

The AI model, that was initially designed to detect a specific cardiac pathology, performed well in the large PhysioNet dataset providing AUROCs ranging from 0.78 to 0.95 to detect the defined 10 cardiac abnormality groups. Interestingly, the AI model was able to detect disease groups with changes in the chronological sequence of the ECG, e.g. arrhythmia, with comparable precision as disease groups associated primarily with changes in the ECG amplitude like e.g. ischemia. Detailed results are presented in Table 2.

Conclusion(s)

Our evaluation shows that an AI model that uses raw ECG time-series data rather than extracted features as model input can be easily transferred to other large datasets with different prediction variables. This might also serve as a proof of concept that raw data instead of pre-selected features should be used as model input if developing AI applications for medical use cases.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): FlexiFunds by Forschungscampus Mittelhessen

Meta-analysis of randomized controlled trials and individual patient data comparing minimally invasive with open oesophagectomy for cancer

BACKGROUND

Minimally invasive oesophagectomy (MIO) for oesophageal cancer may reduce surgical complications compared with open oesophagectomy. MIO is, however, technically challenging and may impair optimal oncological resection. The aim of the present study was to assess if MIO for cancer is beneficial.

METHODS

A systematic literature search in MEDLINE, Web of Science and CENTRAL was performed and randomized controlled trials (RCTs) comparing MIO with open oesophagectomy were included in a meta-analysis. Survival was analysed using individual patient data. Random-effects model was used for pooled estimates of perioperative effects.

RESULTS

Among 3219 articles, six RCTs were identified including 822 patients. Three-year overall survival (56 (95 per cent c.i. 49 to 62) per cent for MIO versus 52 (95 per cent c.i. 44 to 60) per cent for open; P = 0.54) and disease-free survival (54 (95 per cent c.i. 47 to 61) per cent versus 50 (95 per cent c.i. 42 to 58) per cent; P = 0.38) were comparable. Overall complication rate was lower for MIO (odds ratio 0.33 (95 per cent c.i. 0.20 to 0.53); P < 0.010) mainly due to fewer pulmonary complications (OR 0.44 (95 per cent c.i. 0.27 to 0.72); P < 0.010), including pneumonia (OR 0.41 (95 per cent c.i. 0.22 to 0.77); P < 0.010).

CONCLUSION

MIO for cancer is associated with a lower risk of postoperative complications compared with open resection. Overall and disease-free survival are comparable for the two techniques.

LAY SUMMARY

Oesophagectomy for cancer is associated with a high risk of complications. A minimally invasive approach might be less traumatic, leading to fewer complications and may also improve oncological outcome. A meta-analysis of randomized controlled trials comparing minimally invasive to open oesophagectomy was performed. The analysis showed that the minimally invasive approach led to fewer postoperative complications, in particular, fewer pulmonary complications. Survival after surgery was comparable for the two techniques.

Design of a compact and versatile radiation heater with an additively manufactured Nb radiation shield for UHV high-temperature sample preparation

A compact, ultrahigh vacuum, radiative heater based on pyrolytic boron nitride that efficiently directs nearly all of its radiation to the sample was designed and constructed. It is shown that the heater reaches temperatures of 1300 K experimentally at 60% of its maximum power. A COMSOL Multiphysics® simulation and an analytical model predict an ultimate temperature of up to 1500 K. Furthermore, the heater does not introduce any contamination to the sample. This is accomplished by a custom-made Nb radiation shield, which was manufactured by selective laser melting and holds a flag-style sample holder. Before manufacturing, the whole assembly was simulated with COMSOL Multiphysics to validate the design of the radiation shield.

Stroke and mortality rates after valve-in-valve TAVR and comparison with data from redo SAVR

Background and purpose

Early registry data described a potentially increased risk for cerebrovascular events and mortality in patients undergoing transcatheter aortic valve replacement (TAVR) as valve-in-valve (viv) procedures. Further data of small patient cohorts described divergent results for cerebrovascular events and mortality in patients undergoing TAVR as viv procedures for failed surgical bioprotheses in comparison with patients on redo surgical aortic valve replacement (SAVR). We performed a meta-analysis of stroke rates and mortality for viv TAVR procedures basing on the current literature.

Methods

We included all case series (≥10 patients), case-control studies and randomized controlled trials comparing viv TAVR and redo SAVR procedures with respect to cerebrovascular events and mortality rates. Additionally, we included all case series and registries with patients undergoing viv TAVR. After a structured literature research, 17 studies were eligible. For statistical analysis risk ratios and confidence intervals using Mantel-Haenszel test and the I-statistic to quantify possible heterogeneity were calculated. A P-value &lt;0.05 was defined as statistical significant difference.

Results

Eleven case series and registries reporting on stroke and mortality in 8,509 patients undergoing viv TAVR were eligible for analysis. The quantitative analysis of non-comparative studies showed a calculated 30-day stroke rate of 2.2% and 30-day mortality rate of 4.2% after viv TAVR. Data on the 1-year rates were sporadically reported, therefore meta analysis was not appropriately feasible.

Six studies reporting on 498 participants undergoing viv TAVR (N=254) and redo SAVR (N=244) were eligible. The median age ranged from 72.3 to 80.2 years for viv TAVR and from 66.2 to 78.8 years for redo SAVR patients. The STS score was 7.2–7.4% (viv TAVR) and 5.8–7.7% (redo SAVR), respectively. A total of 3/226 participants treated with viv TAVR and 4/214 patients undergoing redo SAVR experienced a stroke during the first 30 postoperative days (N=4 trials, RR 0.86, 95% CI 0.20 to 3.59, p=0.83, I2 = 0%). None of the studies reported sufficient data on the 1-year stroke incidence. The 30-day mortality was 4.3% for viv TAVR and 4.5% for redo SAVR patients. This difference was not significantly different (N=6 trials, RR 0.90, 95% CI 0.40 to 2.05, p=0.80, I2 = 0%). The 1-year mortality rates were 13.3% and 13.6%, respectively (N=2 trials, RR 0.98, 95% CI 0.49 to 1.94, p=0.94, I2 = 0%).

Conclusion

In the current literature favorable stroke and mortality rates at 30 days for patients undergoing viv TAVR are documented. Similar stroke and mortality rates comparing viv TAVR and redo SAVR patients at 30 days were found as well as similar 1-year mortality. A selection bias for the viv TAVR and redo SAVR patients may exist, but cannot be dissolved with this registry analysis, only showing a trend of younger and lower risk patients receiving a redo SAVR procedure.

Funding Acknowledgement

Type of funding source: None

eV-Scale Sterile Neutrino Search Using Eight Years of Atmospheric Muon Neutrino Data from the IceCube Neutrino Observatory

The results of a 3+1 sterile neutrino search using eight years of data from the IceCube Neutrino Observatory are presented. A total of 305 735 muon neutrino events are analyzed in reconstructed energy-zenith space to test for signatures of a matter-enhanced oscillation that would occur given a sterile neutrino state with a mass-squared differences between 0.01 and 100  eV^{2}. The best-fit point is found to be at sin^{2}(2θ_{24})=0.10 and Δm_{41}^{2}=4.5  eV^{2}, which is consistent with the no sterile neutrino hypothesis with a p value of 8.0%.

Characteristics of the Diffuse Astrophysical Electron and Tau Neutrino Flux with Six Years of IceCube High Energy Cascade Data

We report on the first measurement of the astrophysical neutrino flux using particle showers (cascades) in IceCube data from 2010-2015. Assuming standard oscillations, the astrophysical neutrinos in this dedicated cascade sample are dominated (∼90%) by electron and tau flavors. The flux, observed in the sensitive energy range from 16 TeV to 2.6 PeV, is consistent with a single power-law model as expected from Fermi-type acceleration of high energy particles at astrophysical sources. We find the flux spectral index to be γ=2.53±0.07 and a flux normalization for each neutrino flavor of ϕ_{astro}=1.66_{-0.27}^{+0.25} at E_{0}=100  TeV, in agreement with IceCube's complementary muon neutrino results and with all-neutrino flavor fit results. In the measured energy range we reject spectral indices γ≤2.28 at ≥3σ significance level. Because of high neutrino energy resolution and low atmospheric neutrino backgrounds, this analysis provides the most detailed characterization of the neutrino flux at energies below ∼100  TeV compared to previous IceCube results. Results from fits assuming more complex neutrino flux models suggest a flux softening at high energies and a flux hardening at low energies (p value ≥0.06). The sizable and smooth flux measured below ∼100  TeV remains a puzzle. In order to not violate the isotropic diffuse gamma-ray background as measured by the Fermi Large Area Telescope, it suggests the existence of astrophysical neutrino sources characterized by dense environments which are opaque to gamma rays.

The Bacterial Connection between the Oral Cavity and the Gut Diseases

More than 100 trillion symbiotic microorganisms constitutively colonize throughout the human body, including the oral cavity, the skin, and the gastrointestinal tract. The oral cavity harbors one of the most diverse and abundant microbial communities within the human body, second to the community that resides in the gastrointestinal tract, and is composed of >770 bacterial species. Advances in sequencing technologies help define the precise microbial landscape in our bodies. Environmental and functional differences render the composition of resident microbiota largely distinct between the mouth and the gut and lead to the development of unique microbial ecosystems in the 2 mucosal sites. However, it is apparent that there may be a microbial connection between these 2 mucosal sites in the context of disease pathogenesis. Accumulating evidence indicates that resident oral bacteria can translocate to the gastrointestinal tract through hematogenous and enteral routes. The dissemination of oral microbes to the gut may exacerbate various gastrointestinal diseases, including irritable bowel syndrome, inflammatory bowel disease, and colorectal cancer. However, the precise role that oral microbes play in the extraoral organs, including the gut, remains elusive. Here, we review the recent findings on the dissemination of oral bacteria to the gastrointestinal tract and their possible contribution to the pathogenesis of gastrointestinal diseases. Although little is known about the mechanisms of ectopic colonization of the gut by oral bacteria, we also discuss the potential factors that allow the oral bacteria to colonize the gut.

Combined radiotherapy and concurrent tumor treating fields (TTFields) for glioblastoma: Dosimetric consequences on non-coplanar IMRT as initial results from a phase I trial

Background

Glioblastoma is a rapidly proliferating tumor. Patients bear an inferior prognosis with a median survival time of 14-16 months. Proliferation and repopulation are a major resistance promoting factor for conventionally fractionated radiotherapy. Tumor-Treating-Fields (TTFields) are an antimitotic modality applying low-intensity (1-3 V/cm), intermediate-frequency (100-300 kHz) alternating electric-fields. More recently interference of TTFields with DNA-damage-repair and synergistic effects with radiotherapy were reported in the preclinical setting. This study aims at examining the dosimetric consequences of TTFields applied during the course of radiochemotherapy.

Methods

Cone-beam-computed-tomography (CBCT)-data from the first seven patients of the PriCoTTF-phase-I-trial were used in a predefined way for dosimetric verification and dose-accumulation of the non-coplanar-intensity-modulated-radiotherapy (IMRT)-treatment-plans as well as geometric analysis of the transducer-arrays by which TTFields are applied throughout the course of treatment. Transducer-array-position and contours were obtained from the low-dose CBCT’s routinely made for image-guidance. Material-composition of the electrodes was determined and a respective Hounsfield-unit was assigned to the electrodes. After 6D-fusion with the planning-CT, the dose-distribution was recalculated using a Boltzmann-equation-solver (Acuros XB) and a Monte-Carlo-dose-calculation-engine.

Results

Overdosage in the scalp in comparison to the treatment plan without electrodes stayed below 8.5% of the prescribed dose in the first 2 mm below and also in deeper layers outside 1cm² at highest dose as obtained from dose-volume-histogram comparisons. In the clinical target volume (CTV), underdosage was limited to 2.0% due to dose attenuation by the electrodes in terms of D95 and the effective-uniform-dose. Principal-component-analysis (PCA) showed that the first principal-position-component of the variation of repeated array-placement in the direction of the largest variations and the perpendicular second-component spanning a tangential plane on the skull had a standard deviation of 1.06 cm, 1.23 cm, 0.96 cm, and 1.11 cm for the frontal, occipital, left and right arrays for the first and 0.70 cm, 0.71 cm, 0.79 cm, and 0.68 cm, respectively for the second-principal-component. The variations did not differ from patient-to-patient (p > 0.8, Kruskal-Wallis-tests). This motion led to a diminution of the dosimetric effects of the electrodes.

Conclusion

From a dosimetric point of view, dose deviations in the CTV due to transducer-arrays were not clinically significant in the first 7 patients and confirmed feasibility of combined adjuvant radiochemotherapy and concurrent TTFields.

PriCoTTF Trial: A phase I/II trial of TTFields prior and concomitant to radiotherapy in newly diagnosed glioblastoma.

DRKS-ID: DRKS00016667.

Date of Registration in DRKS: 2019/02/26.

Investigator Sponsored/Initiated Trial (IST/IIT): yes.

Ethics Approval/Approval of the Ethics Committee: Approved.

(leading) Ethics Committee Nr.: 18–8316-MF, Ethik-Kommission der Medizinischen.

Fakultät der Universität Duisburg-Essen.

EUDAMED-No. (for studies acc. to Medical Devices act): CIV-18-08-025247.

Skeletal deterioration in COL2A1-related spondyloepiphyseal dysplasia occurs prior to osteoarthritis

OBJECTIVE

Spondyloepiphyseal dysplasia, a combination of progressive arthropathy with variable signs of skeletal dysplasia, can be a result of mutations in the collagen, type II, alpha 1 (COL2A1) gene. However, the bone involvement (e.g., density, microstructure) in this disorder has hitherto not been studied.

DESIGN

A 50-year-old female patient and her 8-year-old son with flattening of vertebral bodies and early-onset osteoarthritis were genetically tested using a custom designed gene bone panel including 386 genes. Bone microstructure and turnover were assessed using high-resolution peripheral quantitative computed tomography (HR-pQCT) and serum bone turnover markers, respectively. Furthermore, the bone and cartilage phenotype of male mice heterozygous for the loss-of-function mutation of Col2a1 (Col2a1^+/d) was analyzed compared to wildtype littermates using μ-CT and histomorphometry.

RESULTS

We identified a dominant COL2A1 mutation (c.620G > A p.(Gly207Glu)) indicating spondyloepiphyseal dysplasia in the female patient and her son, both being severely affected by skeletal deterioration. Although there was no osteoarthritis detectable at first visit, the son was affected by trabecular osteopenia, which progressed over time. In an iliac crest biopsy obtained from the mother, osteoclast indices were remarkably increased. Col2a1^+/d mice developed a moderate skeletal phenotype expressed by reduced cortical and trabecular parameters at 4 weeks. Importantly, no articular defects could be observed in the knee joints at 4 weeks, while osteoarthritis was only detectable in 12-week-old mice.

CONCLUSIONS

Our results indicate that collagen type II deficiency in spondyloepiphyseal dysplasia leads to skeletal deterioration with early-onset in humans and mice that occurs prior to the development of osteoarthritis.

Time-Integrated Neutrino Source Searches with 10 Years of IceCube Data

This Letter presents the results from pointlike neutrino source searches using ten years of IceCube data collected between April 6, 2008 and July 10, 2018. We evaluate the significance of an astrophysical signal from a pointlike source looking for an excess of clustered neutrino events with energies typically above ∼1  TeV among the background of atmospheric muons and neutrinos. We perform a full-sky scan, a search within a selected source catalog, a catalog population study, and three stacked Galactic catalog searches. The most significant point in the northern hemisphere from scanning the sky is coincident with the Seyfert II galaxy NGC 1068, which was included in the source catalog search. The excess at the coordinates of NGC 1068 is inconsistent with background expectations at the level of 2.9σ after accounting for statistical trials from the entire catalog. The combination of this result along with excesses observed at the coordinates of three other sources, including TXS 0506+056, suggests that, collectively, correlations with sources in the northern catalog are inconsistent with background at 3.3σ significance. The southern catalog is consistent with background. These results, all based on searches for a cumulative neutrino signal integrated over the 10 years of available data, motivate further study of these and similar sources, including time-dependent analyses, multimessenger correlations, and the possibility of stronger evidence with coming upgrades to the detector.

Evaluation of the inflammatory markers CCL8, CXCL5, and LIF in patients with anastomotic leakage after colorectal cancer surgery

PURPOSE

Anastomotic leakage constitutes a dreaded complication after colorectal surgery, leading to increased morbidity and mortality as well as prolonged hospitalization. Most leakages become clinically apparent about 8 days after surgery; however, early detection is quintessential to reduce complications and to improve patients' outcome. We therefore investigated the significance of specific protein expression profiles as putative biomarkers, indicating anastomotic leakage.

METHODS

In this single-center prospective cohort study serum and peritoneal fluid samples-from routinely intraoperatively inserted drainages-of colorectal cancer patients were collected 3 days after colorectal resection. Twenty patients without anastomotic leakage and 18 patients with an anastomotic leakage and without other complications were included. Protein expression of seven inflammatory markers in serum and peritoneal fluid was assessed by multiplex ELISA and correlated with patients' clinical data.

RESULTS

Monocyte chemoattractant protein 2 (CCL8/MCP-2), leukemia-inhibiting factor (LIF), and epithelial-derived neutrophil-activating protein (CXCL5/ENA-78) were significantly elevated in peritoneal fluid but not in serum samples from patients subsequently developing anastomotic leakage after colorectal surgery. No expressional differences could be found between grade B and grade C anastomotic leakages.

CONCLUSION

Measurement 3 days after surgery revealed altered protein expression patterns of the inflammatory markers CCL8/MCP2, LIF, and CXCL5/ENA-78 in peritoneal fluid from patients developing anastomotic leakage after colorectal surgery. Further studies with a larger patient cohort with inclusion of different variables are needed to evaluate their potential as predictive biomarkers for anastomotic leakage.

Pulmonary hypertension and valvular heart disease

Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.

P1805Troponin-T, NT-proBNP and creatinine at presentation predict outcomes in patients with cardiac sarcoidosis

Background

Cardiac sarcoidosis (CS) is an infiltrative inflammatory condition defined by infiltration of noncaseating granulomas into the heart. Based on the location of sarcoid lesion involvement, patients can present with symptoms of congestive heart failure, arrhythmias, and even sudden cardiac death.

Purpose

Diagnosis of CS has been somewhat challenging, with the Heart Rhythm Society (HRS) and Japanese Ministry of Health and Welfare (JMHW) being the 2 widely accepted diagnostic guidelines. Endomyocardial biopsy is the gold standard to prove definite CS but has a low sensitivity. Imaging studies have been helpful as non-invasive methods to diagnose probable CS but these can be logistically difficult and expensive. Thus, investigating for laboratory biomarkers that can act as both diagnostic and prognostic can be crucial in how we diagnose and manage CS in the future.

Methods

Patients meeting HRS for CS were evaluated at a single institution (n=217). Biomarkers of interest included angiotensin-converting enzyme (ACE), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin-T, 1,25 dihydroxyvitamin D (1,25-OHVit-D), and creatinine. Biomarkers were stratified by clinical variables of interest and their association with prognosis was examined. The primary endpoint was LVAD implantation, transplantation, or death.

Results

Mean values on presentation were: ACE 32.9±28, ESR 12±13, CRP 7.4±19, NT-proBNP 1630±2923, Troponin-T 0.03±0.1, 1,25-OHVit-D 55.5±20, and creatinine 1.12±0.3. None of the biomarkers differed by sex, definite or probable CS, or a history of immunosuppression. ACE levels were associated with the presence of cardiac fibrosis on cardiac MRI (mean difference 14.7, p=0.032). Troponin-T (p=0.006; HR 1.06 per 0.01 ng/mL), NT-proBNP (p=0.0003; HR 1.31 per 1,000 pg/mL), and creatinine (p=0.01; HR 4.02 per mg/dL) were each associated with the primary endpoint (52/217 patients).

Biomarkers associated with long term outcomes in patients with cardiac sarcoidosis Biomarker Hazard ratio P value Troponin-T 1.06 (1.02–1.11)* 0.006 NT-pro BNP 1.31 (1.15–1.48)** 0.0003 Creatinine 4.02 (1.41–9.94)*** 0.01 *Per 0.01 ng/mL change; 99th percentile upper reference limit <0.01 ng/mL; **per 1,000 pg/mL change; ***per 1 mg/dL change.

Conclusion

Troponin-T, NT-proBNP, and creatinine at presentation predict outcomes in patients with CS. Further investigation on the utility of biomarkers for assessment of disease activity and treatment response is warranted.

P6491Predictive effect of mitral annular size on persistent mitral valve dysfunction after transcatheter edge-to-edge mitral valve repair for functional mitral regurgitation

Background

In patients with functional mitral regurgitation (FMR), deformation of the mitral valve (MV) apparatus leads to deteriorating coaptation of both leaflets. The MV geometry is essential to predict procedural success of using the MitraClip™ for FMR patients. Persistent such mitral regurgitation (MR) and post-procedural mitral stenosis (MS) are parameters for an increasing mortality rate after MitraClip implantation. The anterior-to-posterior mitral annulus diameter (MAD) is simple to evaluate with a high reproducibility rate. However, the predictive effect has not been determined to date.

Purpose

We evaluated the predictive effect of baseline anterior-to-posterior MAD on persistent MV dysfunctions after MitraClip™ implantation.

Methods

We investigated the prevalence of procedural failure (MR at discharge > grade 2+) and post-procedural MS (mean transmitral gradient (mTMG) at discharge ≥6 mmHg) in a patient cohort with FMR (n=190), who underwent MitraClip™ implantation. We measured the MV apparatus geometry on mid-systole using transoesophageal echocardiography before the index procedure. The MAD was stratified by interquartile ranges (IQR) in the comparison. (≤34 mm, 35 to 37 mm, 38 to 40 mm, and ≥41 mm, respectively)

Results

The mean age was 75±9 years, and 63 patients (33%) were female. The mean left ventricular ejection fraction was 34±14%. Moderate-to-severe (3+) or severe MR (4+) were documented in all patients before the procedure. Transthoracic echocardiography at discharge revealed residual MR (>2+) in 10 patients (5%) and post-procedural MS in 13 patients (7%), in which one patient presented with both residual MR and MS.

After stratification by the IQRs of MAD, there were significant differences in body weight (p<0.001), height (p<0.001), and body surface area (p<0.001), but no significant differences in the other baseline characteristics. Notably, significant differences in the prevalence of procedural failure (p=0.004) and post-procedural MS (p=0.022) were observed among the groups. (Figure) Specifically, in the cohort with the 4th IQR (MAD ≥41 mm, n=44), procedural failure was observed in 7 patients (16%), although the prevalence was only 2% in the other IQR groups. Moreover, the cohorts with the 1st and 2nd IQR presented with higher prevalence of post-procedural MS (6 of 46 patients (13%) in the 1st IQR group, and 6 of 51 (12%) in the 2nd IQR group) than those with the 3rd and 4th IQRs. (1 of 49 patients (2%) in the 3rd IQR, and none of 44 patients in the 4th IQR)

Figure 1

Conclusion

In this analysis we showed that the mitral annulus size affected MV dysfunction after MitraClip™. Anterior-to-posterior MAD was useful to predict the procedural result. For FMR candidates with dilated mitral annulus larger than 40 mm, new-generation MitraClip-XTR™ system or other therapeutic concept such as annuloplasty may be reasonable to obtain satisfactory MV function.

P14.62 Safety and adverse event profile post-market surveillance analysis of Tumor Treating Fields (TTFields) in EMEA

BACKGROUND

Tumor Treating Fields (TTFields) are established as modality in glioblastoma (GBM) therapy. GBM is the most aggressive brain tumor in adults, constituting approximately 15 % of all primary brain tumors. At diagnosis, a considerable subgroup of GBM patients is ≥65 years of age. The phase 3 EF-14 trial demonstrated a significant improvement of progression free, overall and longterm survival in newly diagnosed GBM (ndGBM) patients by the addition of TTFields compared temozolomide therapy. No treatment limiting systemic adverse events in the EF-14 trial for ndGBM or in the EF-11 trial for recurrent GBM (rGBM) were observable. Here, we present post-market surveillance data from patients in the EMEA region including elderly patients (≥ 65 years) treated with TTFields.

METHODS

Based on the MedDRA body system (system organ class) and preferred terms surveillance data of patients in the EMEA region were assessed. Additionally, surveillance data of patients < 65 as well as ≥ 65 years of age in this region were separately analyzed.

RESULTS

A total of 11,048 patients were treated with TTFields (ndGBM 53.3 %, rGBM 39.5 %, other diagnoses 7.2 %) of whom 2,252 (20.4 %) patients were treated in the EMEA region. 19.6 % of patients treated in this region were ≥65 years of age at the time of TTFields therapy initiation. One or more adverse events were reported by 64 % of EMEA patients < 65 and in 67 % of elderly EMEA patients. The most prevalent adverse event in both age groups was skin reactions, occurring in 30 % of patients < 65 years of age and 33 % elderly patients. Likewise, further adverse events in elderly patients in the EMEA region were comparable to patients younger than 65 years of age, e.g. heat sensation (< 65; ≥ 65: 4 %; 4 %) and general physical health deterioration (14 %; 18 %).

CONCLUSION

These real-life data demonstrate a good safety profile of TTFields in elderly patients as well as in patients < 65. The most frequent registered adverse event was skin reaction, which is in line with the results of the phase 3 EF-11 trial for rGBM and the EF-14 trial for ndGBM patients. In summary, these results from post-marketing surveillance emphasize the safety of TTFields in GBM treatment, particularly in the elderly population.

[Cardioband®: Where do we stand, who are suitable patients?]

Functional mitral regurgitation (FMR) is characterized by a dilatation of the mitral valve annulus resulting in an insufficient adaptation of the anterior and posterior mitral valve leaflets and/or severe tethering of the leaflets due to dilatation of the left ventricle. The Cardioband® system was introduced in 2015 and is a catheter-based direct mitral valve annuloplasty procedure for treatment of FMR. In the European CE approval study 60 patients with moderate or severe FMR were analyzed per protocol. There were no device or procedure-related deaths. The technical success rate of the procedure, defined as successful implantation and tightening was 97%. At 1 year, the overall survival and survival free of hospital readmission for heart failure were 87% and 66%, respectively. Currently, various interventional treatment procedures are available, such as the edge-to-edge technique as well as direct and indirect annuloplasty. In summary, patients with FMR as a result of a dilatation of the mitral valve annulus appear to be suitable for direct annuloplasty with the Cardioband® system.

[Social reimbursement-the Spanish-German ENT Society's (SDGHNO) Latin America project]

Nowadays, social projects are usually oriented in such a way that after a given period of time, they can either support themselves independently or even allow a pecuniary reimbursement. In the latter case, experts speak of a profit-oriented reimbursement. On the other hand, there is so-called social reimbursement, which in contrast to the abovementioned form is not profit oriented, but, for example, considers its task fulfilled by the fact of successful knowledge transfer. The Spanish-German Society for ENT Medicine and Head and Neck Surgery (SDGHNO) launched the Latin America project in 2001 under the patronage of the then President Prof. Dr. Wolfgang Draf (Fulda). The goal of the SDGHNO was and is to create a professional as well as cultural platform for Spanish- and German-speaking ENT doctors. This platform can and should be used for professional purposes, e.g., for knowledge transfer. Since the beginning of its existence, the Latin America project has thus brought numerous scientific events into being and created specific contacts which have lasted until today or have even been continued and further developed. Particularly successful examples are Chile, Colombia, and Peru. This is a vivid example of social reimbursement, because the participating German-speaking members/speakers carried out their tasks on an entirely voluntary basis. Thus, the SDGHNO did not bear any travel, catering, or accommodation costs. The activities of the SDGHNO within the framework of the Latin America project are explained.

[Therapeutic approach in oligometastatic gastric and esophageal cancer]

The therapeutic approach to patients with oligometastatic gastric cancer and esophageal cancer is currently undergoing a shift towards a more aggressive therapy including surgical resection. In the current German S3 guidelines surgical treatment of metastatic disease is not recommended; however, nowadays interdisciplinary tumor boards have to evaluate such patients increasingly more often. On an individual basis a radical surgical resection of the primary tumor and the metastases is considered and performed in patients who respond well to multimodal chemotherapy concepts. In this review article the currently available data from the literature are discussed and a foundation for individually extended surgical approaches is presented. Together with the currently available results of the FLOT 3 study and the mostly retrospective studies, it seems to be possible to identify patients who would profit from such an aggressive treatment. In the future randomized prospective studies, such as the RENAISSANCE/FLOT 5 study and the GASTRIPEC study will have to evaluate whether an aggressive surgical therapy within multimodal therapy concepts of metastatic gastric and esophageal carcinomas is warranted.