Matching-Adjusted Indirect Comparison of Brexucabtagene Autoleucel (ZUMA-2) and Pirtobrutinib (BRUIN) in Patients with Relapsed/Refractory Mantle Cell Lymphoma Previously Treated with a Covalent Bruton Tyrosine Kinase Inhibitor

INTRODUCTION

Patients with relapsed/refractory (R/R) mantle cell lymphoma (MCL) often require multiple lines of treatment and have a poor prognosis, particularly after failing covalent Bruton tyrosine kinase inhibitor (cBTKi) therapy. Newer treatments such as brexucabtagene autoleucel (brexu-cel, chimeric antigen receptor T cell therapy) and pirtobrutinib (non-covalent BTKi) show promise in improving outcomes.

METHODS

Without direct comparative evidence, an unanchored matching-adjusted indirect comparison was conducted to estimate the relative treatment effects of brexu-cel and pirtobrutinib for post-cBTKi R/R MCL. Using logistic propensity score models, individual patient-level data from ZUMA-2 brexu-cel-infused population (N = 68) were weighted to match pre-specified clinically relevant prognostic factors based on study-level data from the BRUIN cBTKi pre-treated cohort (N = 90). The base-case model incorporated the five most pertinent factors reported in ≥ 50% of both trial populations: morphology, MCL International Prognostic Index, number of prior lines of therapy, disease stage, and prior autologous stem cell transplant. A sensitivity analysis additionally incorporated TP53 mutation and Ki-67 proliferation. Relative treatment effects were expressed as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

In the base-case model, brexu-cel was associated with higher rates of objective response (OR 10.39 [95% CI 2.81-38.46]) and complete response (OR 10.11 [95% CI 4.26-24.00]), and improved progression-free survival (HR 0.44 [95% CI 0.25-0.75]), compared to pirtobrutinib. Overall survival and duration of response favored brexu-cel over pirtobrutinib but the differences crossed the bounds for statistical significance. Findings were consistent across the adjusted and unadjusted analyses.

CONCLUSIONS

Findings suggest that brexu-cel may offer clinically and statistically significant benefits regarding objective response, complete response, and progression-free survival compared to pirtobrutinib among patients with R/R MCL after prior cBTKi therapy. Given the short follow-up and high degree of censoring in BRUIN, an analysis incorporating updated BRUIN data may provide more definitive overall survival results.

The phenomenon of skin contraction in CO2 LASER surgical incisions using superpulse and continuous emission mode - preliminary study

The skin contraction phenomenon occurs due to the energy emitted by the surgical CO2 LASER affecting the collagen architecture and intracellular water content in tissues. The study aimed to assess how gender, age, breed, body-weight, CO2 LASER emission mode, and potency influence skin contraction following the incision. The study involved 80 dogs (N = 80) of both genders, multiple breeds, undergoing major surgery with CO2 LASER. Subjects were grouped based on LASER potency (12 or 15 Watts) and emission mode (Superpulse-SP or Continuous-CT): GSP12, GSP15, GCT12, and GCT15. A 10 mm incision was performed using the surgical CO2 LASER beam, consistently employing a focal point of 0.4 mm, positioned at a distance of 1 mm from the skin surface, and always maintained perpendicular to it, and resulting lengths measured with a digital caliper. Results were considered significant for p-value < 0.05. GSP12 showed minimal contraction, while GCT15 exhibited the most significant. Male subjects in GCT12, GCT15, and GSP12 experienced less contraction than females. Purebred dogs had greater contraction than mixed breeds. GSP12 individuals showed age-related contraction decrease (p < 0.01), with skin contracting by 0.09 mm per year. Weight and skin contraction trended towards significance (p = 0.06), with a 0.02 mm increase per unit weight. For a constant power of 12 W, the analysis of the relationship between the emission mode of the LASER beam and the final skin contraction (GSP12 vs. GCT12) revealed statistically significant differences (p < 0.01). This study suggests that the use of the Continuous mode of LASER emission, regardless of the power used, is associated with a higher level of final skin contraction. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: Project approval registration number by the Research and Teaching Ethics Committee (CEIE),Faculty of Veterinary Medicine-University of Lisbon (FMV_ULisboa), Lisboa-Portugal, N/Refª 015/2022.

Indirect treatment comparison of brexucabtagene autoleucel (ZUMA-2) versus standard of care (SCHOLAR-2) in relapsed/refractory mantle cell lymphoma

The SCHOLAR-2 retrospective study highlighted poor overall survival (OS) with standard of care (SOC) regimens among patients with relapsed/refractory (R/R) mantle cell lymphoma (MCL) who failed a covalent Bruton tyrosine kinase inhibitor (BTKi). In the ZUMA-2 single-arm trial, brexucabtagene autoleucel (brexu-cel; autologous anti-CD19 CAR T-cell therapy) demonstrated high rates of durable responses in patients with R/R MCL who had previous BTKi exposure. Here, we compared OS in ZUMA-2 and SCHOLAR-2 using three different methods which adjusted for imbalances in prognostic factors between populations: inverse probability weighting (IPW), regression adjustment (RA), and doubly robust (DR). Brexu-cel was associated with improved OS compared to SOC across all unadjusted and adjusted comparisons. Hazard ratios (95% confidence intervals) were 0.38 (0.23, 0.61) for IPW, 0.45 (0.28, 0.74) for RA, and 0.37 (0.23, 0.59) for DR. These results suggest a substantial survival benefit with brexu-cel versus SOC in patients with R/R MCL after BTKi exposure.

Central Nervous System Tuberculosis in Immunocompromised Patients: A Case Report Emphasizing Immune Status and Early Recognition and Treatment

Tuberculosis (TB) remains a global health challenge. Although pulmonary TB is the most frequent presentation, extrapulmonary involvement can occur, especially in immunocompromised patients. HIV-positive individuals are particularly vulnerable to opportunistic infections, such as TB, and CNS involvement is more prevalent in these patients, often leading to a poorer prognosis. CNS TB management is challenging due to nonspecific symptoms and delayed diagnosis, contributing to high mortality. It can manifest diffusely as tuberculous meningitis (TBM), localized as tuberculoma or tuberculous abscess, or as extradural and intradural spinal infections. TBM is the primary CNS manifestation, bearing significant morbidity and mortality, and rarely complicates with involvement of the spinal cord, termed tuberculous myelitis, which is associated with an unfavorable prognosis. A 61-year-old male, smoker with a history of substance abuse, undergoing seven months of antiretroviral therapy (ART) for HIV-1, presented with a two-day history of altered consciousness, sphincter incontinence, and fever. He also reported headaches, dizziness, and sleep disturbances over the past months. The examination revealed fever, asthenia, prostration, disorientation, neck rigidity, and bilateral lower limb weakness. Initial tests indicated lymphopenia, hyponatremia, and a slightly elevated C-reactive protein. Cranial CT showed no abnormalities. Lumbar puncture yielded abnormal cerebrospinal fluid (CSF), xanthochromic, hyperproteinorrheic (2316 g/L), hypoglycorrhagic (24mg/dl), with pleocytosis predominantly of mononuclear cells (98%). Compared to the values prior to ART treatment, the patient had a decreased HIV-1 viral (44 copies/ml) load but also a decreased CD4+ cell count (43 cells/mm3). Given the patient's rapid clinical deterioration, immunosuppression history, and a positive interferon-gamma release assay (IGRA) prior to ART, treatment with antituberculous drugs and dexamethasone was started at admission. Subsequently, Mycobacterium tuberculosis was identified through polymerase chain reaction (PCR) of the CSF. Cranial and spinal MRI revealed leptomeningeal enhancement from C2-C3 to the cauda equina, consistent with meningitis, without intracranial extension, and findings suggestive of myelitis, without evidence of tuberculomas or spinal cord osseous involvement. One week after treatment, the recovery of higher neurological functions became evident. Improvement in lower limb motor deficits had a delayed trajectory, with marginal progress observed at discharge. After an eight-week incubation, CSF mycobacterial culture analysis yielded negative results. This case discusses the importance of early suspicion and intervention in CNS infection prognosis. Attention to signs and symptoms beyond the most frequent ones is crucial, particularly in immunocompromised individuals like HIV patients. Identifying CSF features in different CNS infections and group-specific particulars facilitates the prompt initiation of treatment. Additionally, in co-infected patients (HIV and CNS TB), considering factors such as ART duration, CD4+ cell count, and viral load is important, in influencing the disease's incidence, course, and prognosis.

When Sex Matters: Differences in the Central Nervous System as Imaged by OCT through the Retina

BACKGROUND

Retinal texture has gained momentum as a source of biomarkers of neurodegeneration, as it is sensitive to subtle differences in the central nervous system from texture analysis of the neuroretina. Sex differences in the retina structure, as detected by layer thickness measurements from optical coherence tomography (OCT) data, have been discussed in the literature. However, the effect of sex on retinal interocular differences in healthy adults has been overlooked and remains largely unreported.

METHODS

We computed mean value fundus images for the neuroretina layers as imaged by OCT of healthy individuals. Texture metrics were obtained from these images to assess whether women and men have the same retina texture characteristics in both eyes. Texture features were tested for group mean differences between the right and left eye.

RESULTS

Corrected texture differences exist only in the female group.

CONCLUSIONS

This work illustrates that the differences between the right and left eyes manifest differently in females and males. This further supports the need for tight control and minute analysis in studies where interocular asymmetry may be used as a disease biomarker, and the potential of texture analysis applied to OCT imaging to spot differences in the retina.

Prevalence of Autism Spectrum Disorder in the Centro region of Portugal: a population based study of school age children within the ASDEU project

Introduction

Accurate prevalence estimates for Autism Spectrum Disorder (ASD) are fundamental to adequately program medical and educational resources for children. However, estimates vary globally and across Europe, and it is therefore wise to conduct epidemiological studies in defined geo-cultural contexts.

Methods

We used a population screening approach to estimate the prevalence of ASD in the Centro region of Portugal, using a harmonized protocol as part of the Autism Spectrum Disorders in the European Union (ASDEU) project.

Results

The overall prevalence was estimated at 0.5% (95% CI 0.3-0.7), higher in schools with Autism Units (3.3%, 95%CI 2.7-3.9) than in regular schools (0.3%, 95% CI 0.1-0.5) or schools with Multiple Disability Units (0.3%, 95% CI 0.04-0.6).

Discussion

The results indicate that the diagnosis of ASD is followed by the most effective educational policies in Centro Region. The variability in prevalence estimates across the different regions from the ASDEU project, and globally, is discussed.

Paediatric Mediastinal Lipoblastoma

Teaching Point: Lipoblastoma should be considered in the differential diagnosis of painful rapidly growing fatty mass within the mediastinum in infants or young children under three years old.

Case report: Fourth branchial cleft cyst: a case of acute suppurative thyroiditis

This case report presents a 4 year-old-female patient with a neck mass who was diagnosed with an infected fourth branchial cleft cyst with left thyroid lobe involvement through fistulation. The case emphasizes the importance of considering uncommon etiologies, such as congenital anomalies, as a differential diagnosis when evaluating pediatric neck masses. The patient was prescribed broad-spectrum antibiotics, which led to the regression of the mass and inflammatory signs. Close follow-up in endocrinology and otorhinolaryngology appointments was maintained, and after 7 months, hypoplasia of the left lobe was observed. Thyroid function was reevaluated, and after two years, no recurrences were noted. The case highlights the significance of a comprehensive examination and assessment of corresponding clinical features, which can significantly reduce the rate of misdiagnoses and achieve an individualized diagnosis.

A Challenging Case of Wilson's Disease

Wilson's disease (WD) is an inherited disorder characterized by the accumulation of copper in various organs, particularly the liver, central nervous system, and cornea. The clinical presentation of WD can vary widely. Diagnosis requires a combination of clinical and biochemical findings. We present a case of a 20-year-old woman who presented to the Emergency Room with progressive motor decline. She exhibited characteristic neurological symptoms and signs, such as hypomimia, bradyphrenia, bradykinesia, dysarthria, sialorrhea, upper limb dystonia, and wing-beating tremor. Ophthalmological examination revealed corneal deposits known as Kayser-Fleischer rings. Laboratory investigations demonstrated low levels of ceruloplasmin and elevated serum copper. Brain MRI showed typical signs of copper deposition in the basal ganglia. The Leipzig criteria were used to confirm the diagnosis. Treatment with penicillamine and zinc acetate resulted in symptom improvement. This case highlights the diverse presentation of WD and the importance of early diagnosis and prompt treatment initiation.

Evidence for an association of prenatal exposure to particulate matter with clinical severity of Autism Spectrum Disorder

Early-life exposure to air pollutants, including ozone (O₃), particulate matter (PM_2.5 or PM₁₀, depending on diameter of particles), nitrogen dioxide (NO₂) and sulfur dioxide (SO₂) has been suggested to contribute to the etiology of Autism Spectrum Disorder (ASD). In this study, we used air quality monitoring data to examine whether mothers of children with ASD were exposed to high levels of air pollutants during critical periods of pregnancy, and if higher exposure levels may lead to a higher clinical severity in their offspring. We used public data from the Portuguese Environment Agency to estimate exposure to these pollutants during the first, second and third trimesters of pregnancy, full pregnancy and first year of life of the child, for 217 subjects with ASD born between 2003 and 2016. These subjects were stratified in two subgroups according to clinical severity, as defined by the Autism Diagnostic Observational Schedule (ADOS). For all time periods, the average levels of PM_2.5, PM₁₀ and NO₂ to which the subjects were exposed were within the admissible levels defined by the European Union. However, a fraction of these subjects showed exposure to levels of PM_2.5 and PM₁₀ above the admissible threshold. A higher clinical severity was associated with higher exposure to PM_2.5 (p = 0.001), NO₂ (p = 0.011) and PM₁₀ (p = 0.041) during the first trimester of pregnancy, when compared with milder clinical severity. After logistic regression, associations with higher clinical severity were identified for PM_2.5 exposure during the first trimester (p = 0.002; OR = 1.14, 95%CI: 1.05-1.23) and full pregnancy (p = 0.04; OR = 1.07, 95%CI: 1.00-1.15) and for PM₁₀ (p = 0.02; OR = 1.07, 95%CI: 1.01-1.14) exposure during the third trimester. Exposure to PM is known to elicit neuropathological mechanisms associated with ASD, including neuroinflammation, mitochondrial disruptions, oxidative stress and epigenetic changes. These results offer new insights on the impact of early-life exposure to PM in ASD clinical severity.

Olaparib and durvalumab in patients with relapsed small cell lung cancer (MEDIOLA): An open-label, multicenter, phase 1/2, basket study

INTRODUCTION

Preclinical studies have demonstrated increased efficacy with combined DNA damage response inhibition and immune checkpoint blockade compared with either alone. We assessed olaparib in combination with durvalumab in patients with relapsed small cell lung cancer (SCLC).

METHODS

Patients with previously treated limited or extensive-stage SCLC received oral olaparib 300 mg twice daily, as run-in for 4 weeks, then with durvalumab (1500 mg intravenously every 4 weeks) until disease progression. Primary endpoints were safety, tolerability, and 12-week disease control rate (DCR). Secondary endpoints included 28-week DCR, objective response rate (ORR), duration of response, progression-free survival, overall survival, change in tumor size, and programmed death-ligand 1 (PD-L1) expression subgroup analyses.

RESULTS

Forty patients were enrolled and analyzed for safety; 38 were analyzed for efficacy. Eleven patients (28.9% [90% confidence interval (CI), 17.2-43.3]) had disease control at 12 weeks. ORR was 10.5% (95% CI, 2.9-24.8). Median progression-free and overall survival were 2.4 (95% CI, 0.9-3.0)months and 7.6(95% CI, 5.6-8.8)months, respectively. The most common adverse events (≥40.0%) were anemia, nausea, and fatigue. Grade ≥ 3 adverse events occurred in 32 patients (80.0%). PD-L1 levels, tumor mutational burden, and other genetic mutations were evaluated, but no significant correlations with clinical outcomes wereobserved.

CONCLUSIONS

Tolerability of olaparib with durvalumab was consistent with the safety profile of each agent alone. Although the 12-week DCR did not meet the prespecified target (60%), four patients responded, and median overall survival was promising for a pretreated SCLC population. Further analyses are required to identify patients most likely to benefit from this treatment approach.

Boroxine benzaldehyde complex for pharmaceutical applications probed by electron interactions

RATIONALE

2,4,6-Tris(4-formylphenyl)boroxine (TFPB) is a substituted boroxine containing a benzaldehyde molecule bonded to each boron atom. Boroxine cages are an emerging class of functional nanostructures used in host-guest chemistry, and benzaldehyde is a potential radiosensitizer. Reactions initiated by low-energy electrons with such complexes may dictate and bring new fundamental knowledge for biomedical and pharmaceutical applications.

METHODS

The electron ionization properties of TFPB are investigated using a gas-phase electron-molecule crossed beam apparatus coupled with a reflectron time-of-flight mass spectrometer in an orthogonal geometry. Ionization and threshold energies are experimentally determined by mass spectra acquisition as a function of the electron energy.

RESULTS

The abundance of the molecular precursor cation in the mass spectrum at 70 eV is significantly lower than that of the most abundant fragment C₇ H₅ O⁺ . Twenty-nine cationic fragments with relative intensities >2% are detected and identified. The appearance energies of six fragment cations are reported, and the experimental first ionization potential is found at 9.46 ± 0.11  eV. Moreover, eight double cations are identified. The present results are supported by quantum chemical calculations based on bound state techniques, electron ionization models and thermodynamic thresholds.

CONCLUSIONS

According to these results, the TPFB properties may combine the potential radiosensitizer effect of benzaldehyde with the stability of the boroxine ring.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial

BACKGROUND

A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI.

METHODS

This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety.

DISCUSSION

We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI.

TRIAL REGISTRATION

ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

A Role for Gene-Environment Interactions in Autism Spectrum Disorder Is Supported by Variants in Genes Regulating the Effects of Exposure to Xenobiotics

Heritability estimates support the contribution of genetics and the environment to the etiology of Autism Spectrum Disorder (ASD), but a role for gene-environment interactions is insufficiently explored. Genes involved in detoxification pathways and physiological permeability barriers (e.g., blood-brain barrier, placenta and respiratory airways), which regulate the effects of exposure to xenobiotics during early stages of neurodevelopment when the immature brain is extremely vulnerable, may be particularly relevant in this context. Our objective was to identify genes involved in the regulation of xenobiotic detoxification or the function of physiological barriers (the XenoReg genes) presenting predicted damaging variants in subjects with ASD, and to understand their interaction patterns with ubiquitous xenobiotics previously implicated in this disorder. We defined a panel of 519 XenoReg genes through literature review and database queries. Large ASD datasets were inspected for in silico predicted damaging Single Nucleotide Variants (SNVs) (N = 2,674 subjects) or Copy Number Variants (CNVs) (N = 3,570 subjects) in XenoReg genes. We queried the Comparative Toxicogenomics Database (CTD) to identify interaction pairs between XenoReg genes and xenobiotics. The interrogation of ASD datasets for variants in the XenoReg gene panel identified 77 genes with high evidence for a role in ASD, according to pre-specified prioritization criteria. These include 47 genes encoding detoxification enzymes and 30 genes encoding proteins involved in physiological barrier function, among which 15 are previous reported candidates for ASD. The CTD query revealed 397 gene-environment interaction pairs between these XenoReg genes and 80% (48/60) of the analyzed xenobiotics. The top interacting genes and xenobiotics were, respectively, CYP1A2, ABCB1, ABCG2, GSTM1, and CYP2D6 and benzo-(a)-pyrene, valproic acid, bisphenol A, particulate matter, methylmercury, and perfluorinated compounds. Individuals carrying predicted damaging variants in high evidence XenoReg genes are likely to have less efficient detoxification systems or impaired physiological barriers. They can therefore be particularly susceptible to early life exposure to ubiquitous xenobiotics, which elicit neuropathological mechanisms in the immature brain, such as epigenetic changes, oxidative stress, neuroinflammation, hypoxic damage, and endocrine disruption. As exposure to environmental factors may be mitigated for individuals with risk variants, this work provides new perspectives to personalized prevention and health management policies for ASD.

Usefulness of the 6-minute walk test vs cardiopulmonary exercise test for exercise prescription in coronary artery disease patients going into a phase III cardiac rehabilitation program

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Determining the intensity of exercise is a very important component to obtain the dose-benefits associated with exercise, while maitaining the safaty of the patient with coronary artery disease (CAD) in a cardiovascular rehabilitation (CR) programme. The cardiopulmonary exercise test (CPET) is the gols standard for exercise prescription according to the intend intensisty of aerobic workout. However, its availability is not a reality in many CR centres. The 6-minute walk test (6MWT) is a valid and widely used method because it is low-cost and simple to apply. Nevertheless, it is still unknown the corresponding intensity reached on a 6MWT compared to the one reached on a CPET in already physically active patients with CAD starting a CR phase III programme.

Purpose

To use the peak heart rate (HR) of the 6MWT as a method to prescribe the intensity of aerobic exercise in CAD patients starting a phase III CR programme and to compare it with the ventilatory threshold (VT) of the CPET.

Methods

In this retrospective study, a cohort of patients with CAD enrolled in a phase III CR programme. At the beginning of the programme, all patients performed a 6MWT and a CPET in the same week with at least 48-hour difference. The HR on the 6MWT was recorded continuously using a HR polar (H10 Polar) and on CPET using a twelve-lead ECG. Other parameters were assessed such as objective physical activity (accelerometer) and body composition.

Results

Eighty patients (87.5% males, 60.8 ± 9.4 years old) with CAD were included in this study. Patients were, on average, physically active (361 ± 182 minutes/week of moderate to vigorous physical activity) and overweight (body mass index: 27.7 ± 3.5 kg/m2). The VO2 peak reached on the CPET was 20.3 ± 5.4 ml/kg/min and the percentage of predicted maximum HR was 78.3 ± 11.4 %. The first and second VT corresponded to 75.6 ± 7.8% and 91.2 ± 4.5% of the peak HR obtained with CPET, respectively. The 6MWT HR peak was 113 ± 16 bpm (90.0 ± 13.0 HR peak CPET) and did not differ from the HR of the second VT with a mean value of 115 ± 16 bpm (91.2 ± 4.5% HR peak CPET), p&gt;0.05. Although, the 6MWT HR peak was significantly higher than the HR oh the first VT (95 ± 14 bpm, p&lt;0.001). In a subgroup analysis, the patients who, during the 6MWT, reached more the 90% of the HR peak CPET (n=35, 44% oof the sample) were the ones with lower functional capacity (VO2 peak: 18.4 ± 5.4 ml/kg/min vs 21.7 ± 5.0 ml/kg/min, p=0.006) and higher age (64.4 ± 8.7 years old vs 60.8 ± 9.4 years old, p=0.002).

Conclusion(s)

In the absence of a CPET, the use of a 6MWT HR peak in physically active patients with CAD starting a phase III CR programme has shown to be an efficient method to prescribe moderate to vigorous exercise intensity, corresponding to the second VT. Higher intensities on the 6MWT might be reached in active elderly patients with reduced functional capacity.

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

Abstract PD10-03: BEGONIA: Phase 1b/2 study of durvalumab (D) combinations in locally advanced/metastatic triple-negative breast cancer (TNBC): Results from Arm 1 D + paclitaxel (P), Arm 2 D+P + capivasertib (C), and Arm 5 D+P + oleclumab (O)

Background: Chemotherapy, together with immune checkpoint inhibitors, improves outcomes vs chemotherapy alone for patients (pts) with metastatic (m)TNBC PD-L1+ disease. Most of these pts progress within a year. In a previous study, D (anti-PD-L1) combined with chemotherapy enhanced antitumor immune responses in early TNBC (Loibl. Ann Oncol 2019). In TNBC, activation of the PI3K/AKT/PTEN pathway and high CD73 expression are common. BEGONIA is an ongoing 2-part, multicenter, multi-arm, open-label platform study, evaluating safety and efficacy of D or D+P combined with novel therapies as first-line treatment for mTNBC (NCT03742102). Preliminary results from 2 arms were presented at ASCO 2021 (Abstract #1023). Here, we report results from Arm 1 D+P, Arm 2 D+P+C, and Arm 5 D+P+O. C is an oral, selective, ATP-competitive catalytic inhibitor of all 3 AKT isoforms, and O is a mAb targeting CD73. Methods: Eligible pts had untreated, unresectable, locally advanced or metastatic TNBC. In Arms 1 and 5, pts received D 1500 mg IV Q4W + P 90 mg/m2 IV day (d)1, d8, d15 of every cycle. Pts in Arm 5 also received O 3000 mg IV on d1 and d15 for the first 2 cycles, then Q4W. In Arm 2, pts received D 1500 mg IV Q4W + P 80/90 mg/m2 IV in 4-week cycles (d1, d8, d15, 1 week off) + C 400 mg BID in 4-week cycles (d2-5 × 3 weeks, 1 week off). Primary objectives were safety and tolerability. Secondary endpoints included objective response rate (ORR) and duration of response. Tumors were assessed Q8W per RECIST v1.1. The first 6 pts treated in Arms 2 and 5 were evaluated for dose-limiting toxicities (DLTs), with additional pts enrolled if treatment was tolerated. PD-L1 expression was assessed retrospectively. Previously presented data from Arm 1 D+P, are included for reference (Schmid. ASCO 2021, #1023). Results: In Arm 2 (data cutoff Mar 2021), 30 pts received D+P+C (15 P[80], 15 P[90]; total 13 ongoing); 2 pts (6.7%) discontinued all treatment due to AEs. The rates of dose delays were 13 pts (43%) for D and 15 (50%) for P; dose interruptions were 1 (3%) for D, 12 (40%) for P, 15 (50%) for C; dose reductions were 12 (40%) for P and 14 (47%) for C. Treatment-related (tr)SAEs and G3/4 trAEs were experienced by 7 (23%) and 22 (73%) pts. In Arm 5 (data cutoff Sep 2020), 33 pts received D+P+O (14 ongoing); no pts discontinued due to AEs. The rates of dose delays were 13 pts (39%) for D, 10 (30%) for P, 10 (30%) for O; dose interruptions were 2 (6%) for D, 10 (30%) for P, 3 (9%) for O; and dose reductions were 12 (36%) for P. trSAEs and G3/4 trAEs were experienced by 1 (3%) and 5 (15%) pts. In both arms, there were no DLTs or deaths due to AEs. The Table presents follow-up time and efficacy outcomes for Arms 1, 2, and 5. Responses were observed regardless of PD-L1 expression. The potential value of mutations in the PI3K pathway and CD73 expression as predictive biomarkers will be discussed for Arms 2 and 5, respectively. Updated data for Arm 1 will be presented. Conclusions: The safety profiles of triplet combinations in Arms 2 and 5 were consistent with the individual agents; however, in Arm 2, there was a relatively high rate of G3/4 trAEs but a low discontinuation rate for AEs. Although BEGONIA was not designed to compare activity across arms and numbers were small, the ORR of each triplet therapy was numerically similar to D+P. Biomarker analysis may elucidate pts that benefit from the combination of C or O with D+P. Funding: AstraZeneca

Table. Efficacy outcomes in Arms 1, 2, and 5 of BEGONIAArm 1Arm 2Arm 5D+P N=23D+P(80)+C n=15D+P(90)+C n=15All D+P+C N=30D+P+O N=33Duration of follow-up at data cutoff, months, median (range)16.6 (8.5-19.8)6.7 (2-9)16.8 (6-21)8.2 (2-21)8.6 (4.1-14.6)Confirmed ORR, n (%)13 (56.5)8 (53.3)8 (53.3)16 (53.3)15 (45.5)95% CI34.5-76.826.6-78.726.6-78.7NC28.1-63.3CR, n10111PR12871514SD (Unconfirmed PR)7 (3)6 (2)4 (2)10 (4)13 (4)PD31345Percentage with ongoing response at data cutoff53.8%75.0%25.0%50.0%66.7%Arm 1 data cutoff was Sep 2020. C, capivasertib; CI, confidence interval; CR, complete response; D, durvalumab; NC, not calculable; O, oleclumab; ORR, objective response rate; P, paclitaxel; PD, progressive disease; PR, partial response; SD, stable disease.

Citation Format: Peter Schmid, Zbigniew Nowecki, Seock-Ah Im, Wei-Pang Chung, Simon Lord, Anne Armstrong, Cynthia X Ma, Robert Huisden, Ross Stewart, Rakesh Kumar, Gaia Schiavon, Hannah Dry, Ana Nunes, Kyung Hae Jung, Yeon Hee Park. BEGONIA: Phase 1b/2 study of durvalumab (D) combinations in locally advanced/metastatic triple-negative breast cancer (TNBC): Results from Arm 1 D + paclitaxel (P), Arm 2 D+P + capivasertib (C), and Arm 5 D+P + oleclumab (O) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD10-03.

Population wide testing pooling strategy for SARS-CoV-2 detection using saliva

SARS-CoV-2 pandemic has forced frequent testing of populations. It is necessary to identify the most cost-effective strategies for the detection of COVID-19 outbreaks. Nasopharyngeal samples have been used for SARS-CoV-2 detection but require a healthcare professional to collect the sample and cause discomfort and pain to the individual. Saliva has been suggested as an appropriate fluid for the diagnosis of COVID-19. We have investigated the possibility of using pools of saliva samples to detect SARS-CoV-2 in symptomatic and asymptomatic patients. Two hundred and seventy-nine saliva samples were analyzed through RT-PCR of Envelope, Nucleocapsid and Open Reading Frame 1ab genes. Reproducibility assays showed an almost perfect agreement as well as high sensitivity (96.6%), specificity (96.8%), positive predicted value (96.6%), and negative predicted value (96.8%). The average Cycle Threshold of the genes detected was 29.7. No significant differences (p > 0.05) were detected when comparing the cycle threshold average of two consecutive reactions on the same positive saliva samples. Saliva samples have a higher median viral load (32.6) than in nasopharyngeal samples (28.9), although no significant differences were detected (p > 0.05). Saliva-pool samples allowed effective SARS-CoV-2 screening, with a higher sensibility (96.9%) on 10-sample pools than in 20-sample pools (87.5%). Regardless of pools size specificity was high (99.9%) and an almost perfect agreement was observed. Our strategy was successfully applied in population wide testing of more than 2000 individuals, showing that it is possible to use pooled saliva as diagnostic fluid for SARS-CoV-2 infection.

Triphenylboroxine stability under low energy electron interactions

Triphenylboroxine (TFB) has chemical properties of great interest in organic synthesis allowing the development of promising molecular architectures. Based on the possibility of geometric arrangement of N-coordinated boron atoms, the...

Multiple bezoars causing small bowel obstruction: a unique case of resolution with upper and low GI endoscopy

Reports of obstructing foreign bodies in the small bowel are rare and the majority describe surgical resolution. We report a case of successful endoscopic treatment of small bowel obstruction (SBO) caused by multiple bezoars. A 92-year-old woman presented to the emergency department with a history of persistent vomiting. Computed tomography (CT) showed gastric distension and an intraluminal ovaloid foreign body with heterogenous density in the second portion of the duodenum, suggestive of bezoar.

COVID-19 in a pediatric cohort—retrospective review of chest computer tomography findings

Background

Radiological features of the novel 2019 coronavirus disease (COVID-19) have been mainly described in adults. Available literature states that imaging findings in children are similar but less pronounced. The aim of this study is to describe and illustrate the chest computer tomography (CT) features of pediatric COVID-19.

Results

This retrospective study was based on the review of all the chest CTs performed in pediatric patients with confirmed COVID-19 disease between March 8th and May 26th 2020 (n = 24). The presence of comorbidities and coinfection was assessed, as well as timing of CT examination in relation to the onset of symptoms. CT findings were categorized as typical, indeterminate, atypical, and negative for COVID-19 according to International Expert Consensus Statement on Chest Imaging in Pediatric COVID-19 Patient Management. This study found that CT findings were abnormal in 17 (71%) patients, with 5 (21%), 9 (38%), and 3 (13%) patients considered to have typical, indeterminate, and atypical findings, respectively. The most common CT patterns were multiple ground-glass opacities (58%), followed by consolidations (50%). Six patients showed predominantly peripheral distribution of parenchymal abnormalities. A halo sign was identified in 3 patients and a perilobular pattern was identified in one of the cases with typical findings.

Conclusions

Chest CT findings in children infected with SARS-CoV-2 can be subtle or absent. Besides recognizing typical findings, radiologists should be able to identify features that favor different or concomitant diagnosis.

Texture Analysis and its Applications in Biomedical Imaging: A Survey

Texture analysis describes a variety of image analysis techniques that quantify the variation in intensity and pattern. This paper provides an overview of several texture analysis approaches addressing the rationale supporting them, their advantages, drawbacks, and applications. This surveys emphasis is in collecting and categorising over five decades of active research on texture analysis. Brief descriptions of different approaches are presented along with application examples. From a broad range of texture analysis applications, this surveys final focus is on biomedical image analysis. An up-to-date list of biological tissues and organs in which disorders produce texture changes that may be used to spot disease onset and progression is provided. Finally, the role of texture analysis methods as biomarkers of disease is summarised.

Hyperbaric oxygen therapy as a complementary treatment for radiation proctitis: Useless or useful? – A literature review

Radiotherapy (RT) is the backbone of multimodality treatment of more than half of cancer cases. Despite new modern RT techniques, late complications may occur such as radiation proctitis (RP). The natural history of RP is unpredictable. Minor symptoms may resolve spontaneously or require conservative treatment. On the other hand, for similar and uncomplicated clinical contexts, symptoms may persist and can even be refractory to the progressive increase in treatment measures. Over the last decades, an enormous therapeutic armamentarium has been considered in RP, including hyperbaric oxygen therapy (HBOT). Currently, the evidence regarding the impact of HBOT on RP and its benefits is conflicting. Additional prospective and randomised studies are necessary to validate HBOT’s effectiveness in the ‘real world’ clinical practice. This article reviewed the relevant literature on pathophysiology, clinical presentation, different classifications and discuss RP management including a proposal for a therapeutic algorithm with a focus on HBOT.

Orientação espacial no pré-escolar: lateralidade e posição relativa

Neste artigo explora-se a orientação espacial, particularmente a lateralidade e posição relativa, em crianças da Educação Pré-escolar dos 3 aos 5 anos. A investigação centrou-se em três questões principais: a) Que conhecimentos têm as crianças sobre a sua posição relativa? b) De que forma as crianças descrevem o meio? c) Como se posiciona a criança em relação ao meio? Realizou-se uma intervenção pedagógica de 8 sessões, com 25 crianças duma sala de pré-escolar de ensino público. As tarefas de caráter individual e grande grupo centraram-se na orientação espacial, envolvendo noções de lateralidade (ao lado; esquerda/direita) e posição relativa (em cima/baixo; à frente/atrás; dentro/fora). Os resultados sugerem mudanças na capacidade de descrição da localização de objetos e pessoas, utilizando termos específicos adequados com mais frequência e maior facilidade, levando à melhoria da comunicação matemática. Ademais, as crianças demostraram serem capazes de perceber a sua posição no espaço e a dos objetos nele inseridos.

The folding space of proteinβ2-microglobulin is modulated by a single disulfide bridge

Protein beta-2-microglobulin (β2m) is classically considered the causative agent of dialysis related amyloidosis, a conformational disorder that affects patients undergoing long-term hemodialysis. The wild type (WT) form, the ΔN6 structural variant, and the D76N mutant have been extensively used as model systems ofβ2m aggregation. In all of them, the native structure is stabilized by a disulfide bridge between the sulphur atoms of the cysteine residues 25 (at B strand) and 80 (at F strand), which has been considered fundamental inβ2m fibrillogenesis. Here, we use extensive discrete molecular dynamics simulations of a full atomistic structure-based model to explore the role of this disulfide bridge as a modulator of the folding space ofβ2m. In particular, by considering different models for the disulfide bridge, we explore the thermodynamics of the folding transition, and the formation of intermediate states that may have the potential to trigger the aggregation cascade. Our results show that the dissulfide bridge affects folding transition and folding thermodynamics of the considered model systems, although to different extents. In particular, when the interaction between the sulphur atoms is stabilized relative to the other intramolecular interactions, or even locked (i.e. permanently established), the WT form populates an intermediate state featuring a well preserved core and two unstructured termini, which was previously detected only for the D76N mutant. The formation of this intermediate state may have important implications in our understanding ofβ2m fibrillogenesis.

Controlling the pandemic during the SARS-CoV-2 vaccination rollout

There is a consensus that mass vaccination against SARS-CoV-2 will ultimately end the COVID-19 pandemic. However, it is not clear when and which control measures can be relaxed during the rollout of vaccination programmes. We investigate relaxation scenarios using an age-structured transmission model that has been fitted to age-specific seroprevalence data, hospital admissions, and projected vaccination coverage for Portugal. Our analyses suggest that the pressing need to restart socioeconomic activities could lead to new pandemic waves, and that substantial control efforts prove necessary throughout 2021. Using knowledge on control measures introduced in 2020, we anticipate that relaxing measures completely or to the extent as in autumn 2020 could launch a wave starting in April 2021. Additional waves could be prevented altogether if measures are relaxed as in summer 2020 or in a step-wise manner throughout 2021. We discuss at which point the control of COVID-19 would be achieved for each scenario.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

Crosstalk Between ATP-P2X7 and Adenosine A2A Receptors Controlling Neuroinflammation in Rats Subject to Repeated Restraint Stress

Depressive conditions precipitated by repeated stress are a major socio-economical burden in Western countries. Previous studies showed that ATP-P_2X7 receptors (P_2X7R) and adenosine A_2A receptors (A_2AR) antagonists attenuate behavioral modifications upon exposure to repeated stress. Since it is unknown if these two purinergic modulation systems work independently, we now investigated a putative interplay between P_2X7R and A_2AR. Adult rats exposed to restraint stress for 14 days displayed an anxious (thigmotaxis, elevated plus maze), depressive (anhedonia, increased immobility), and amnesic (modified Y maze, object displacement) profile, together with increased expression of Iba-1 (a marker of microglia “activation”) and interleukin-1β (IL1β) and tumor necrosis factor α (TNFα; proinflammatory cytokines) and an up-regulation of P_2X7R (mRNA) and A_2AR (receptor binding) in the hippocampus and prefrontal cortex. All these features were attenuated by the P_2X7R-preferring antagonist brilliant blue G (BBG, 45 mg/kg, i.p.) or by caffeine (0.3 g/L, p.o.), which affords neuroprotection through A_2AR blockade. Notably, BBG attenuated A_2AR upregulation and caffeine attenuated P_2X7R upregulation. In microglial N9 cells, the P_2X7R agonist BzATP (100 μM) or the A_2AR agonist CGS26180 (100 nM) increased calcium levels, which was abrogated by the P_2X7R antagonist JNJ47965567 (1 μM) and by the A_2AR antagonist SCH58261 (50 nM), respectively; notably JNJ47965567 prevented the effect of CGS21680 and the effect of BzATP was attenuated by SCH58261 and increased by CGS21680. These results provide the first demonstration of a functional interaction between P_2X7R and A_2AR controlling microglia reactivity likely involved in behavioral adaptive responses to stress and are illustrative of a cooperation between the two arms of the purinergic system in the control of brain function.

[Forecasting the Pandemic: The Role of Mathematical Models]

N/a.

Characterization of the retinal changes of the 3×Tg-AD mouse model of Alzheimer’s disease

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder whose diagnosis remains a notable challenge. The literature suggests that cerebral changes precede AD symptoms by over two decades, implying a significantly advanced stage of AD by the time it is usually diagnosed. In the study herein, texture analysis was applied to computed optical coherence tomography ocular fundus images to identify differences between a group of the transgenic mouse model of the Alzheimer’s disease (3×Tg-AD) and a group of wild-type mice, at the ages of one and two-months-old. A substantial difference between groups was found at both time-points across all neuroretina’s layers. Here, the inner nuclear layer stands out both in the level of statistically significant differences and on the extension of these differences which span through the imaged area. Also, the progression of AD is suggested to be spotted by texture analysis as demonstrated by the significant difference found in the inner plexiform and the outer nuclear layers from the age of one to the age of two-months-old. These findings demonstrate the potential of the use of the retina and texture analysis to the diagnosis of AD and monitor AD progression. Besides, the differences between groups found in this study suggest that the 3×Tg-AD model may be inappropriate to study early changes associated with the AD and other animal models should be tested following the same path and rationale. Moreover, these results also suggest that the human genes present in these transgenic mice may have an impact on the neurodevelopment of offspring which would justify the significant changes found at the age of one-month-old.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Prediction of lithium response using clinical data

OBJECTIVE

Promptly establishing maintenance therapy could reduce morbidity and mortality in patients with bipolar disorder. Using a machine learning approach, we sought to evaluate whether lithium responsiveness (LR) is predictable using clinical markers.

METHOD

Our data are the largest existing sample of direct interview-based clinical data from lithium-treated patients (n = 1266, 34.7% responders), collected across seven sites, internationally. We trained a random forest model to classify LR-as defined by the previously validated Alda scale-against 180 clinical predictors.

RESULTS

Under appropriate cross-validation procedures, LR was predictable in the pooled sample with an area under the receiver operating characteristic curve of 0.80 (95% CI 0.78-0.82) and a Cohen kappa of 0.46 (0.4-0.51). The model demonstrated a particularly low false-positive rate (specificity 0.91 [0.88-0.92]). Features related to clinical course and the absence of rapid cycling appeared consistently informative.

CONCLUSION

Clinical data can inform out-of-sample LR prediction to a potentially clinically relevant degree. Despite the relevance of clinical course and the absence of rapid cycling, there was substantial between-site heterogeneity with respect to feature importance. Future work must focus on improving classification of true positives, better characterizing between- and within-site heterogeneity, and further testing such models on new external datasets.

P1466 Pacman heart documented by multimodality echocardiographic techniques

We report a case of a 78-year old female with hypertension, dyslipidemia, atrial fibrillation under warfarin therapy and previously diagnosed HFpEF. She also had a history of recurrent episodes of bilateral inferior limb acute ischemia requiring urgent embolectomy and one previous cardioembolic stroke. She had no history of ischemic heart disease.

She was admitted to our center due to acute decompensated heart failure (NYHA class III). On physical examination there was evidence of pulmonary congestion with bilateral crackles, without heart murmurs. ECG showed AF rhythm, without any other significant changes.

The transthoracic echocardiogram (TTE) showed moderate biventricular hypertrophy with apical predominance and good systolic function. A partial loss of myocardial tissue in the mid segment of the interventricular septum was noticed, with no left-to-right shunt on color Doppler, apparently without interventricular communication (figure A).

For further elucidation of this finding a contrast-enhanced TTE was performed, revealing a serpiginous route through the septum to a small contained cavity within it (figure B). 3D TTE en face views additionally clarified the semilunar shape of this septal defect and its movement during the cardiac cycle, closing during systole and opening during diastole (figure C).

At this point, clinical history and previous diagnostic exams were reviewed. A thoracic CT conducted 3 years before in another clinical context showed that the ventricular septal defect was already present, with similar characteristics (figure D).

As doubts persisted about the existence of interventricular communication, cardiac catheterization with oximetry and ventriculography was performed and interventricular shunt was excluded. There was no evidence of coronary artery disease. Cardiac MRI was not possible due to lack of patient collaboration.

Final diagnosis was a partial ventricular septal defect (PVSD), probably congenital. The patient was discharged under optimized medical therapy.

PVSDs, which are rarely reported in the literature, are thought to be congenital (sporadic or familial) or a consequence of myocardial infarction. They have been described as "Pacman" heart due to the shape changes during the cardiac cycle, becoming slit-like or even absent during systole, like an opening/closing mouth, resembling the Pacman video game. Related complications include conduction disturbances, rupture and disturbed systolic function.

We describe a rare case of a partial ventricular septal defect, documented by multimodality echocardiographic techniques: 2D TTE first showed an incomplete defect of the mid interventricular septum; contrast-enhanced TTE revealed its serpiginous route to a small cavity; 3D TTE en face views further illustrated its semilunar shape and characteristic movement during the cardiac cycle.

Abstract P1466 Figure.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

INTRODUCTION

Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage.

CASE REPORT

An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings.

CONCLUSION

We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance.

Abstract P1718 Figure. Panel A,B,C,D,E,F.

P1310 Prosthetic valve endocarditis or thrombus?

One cause of constitutional syndrome in patients previously submitted to valve replacement surgery is a prosthetic endocarditis; this occurs in 1-6% of valve surgeries and has an adverse prognosis. Although this is a likely etiology, it is important to keep other possibilities in mind. This clinical case is about a 61 years old male, with known history of smoking, atrial fibrillation anticoagulated with warfarin (with low TTR), and rheumatic fever in childhood, with severe aortic stenosis/regurgitation and moderate mitral regurgitation. In August 2018 he was admitted in our hospital with mitral valve endocarditis cause by Streptococcus agalactiae. He was submitted to an aortic and mitral valve replacement surgery with 2 bioprothesis. Three months later he was admitted again with weight loss, fatigue, dyspnea for small efforts and worsening anemia. The first diagnosis hypothesis was prosthetic endocarditis. The echocardiogram showed normo-functioning aortic bioprothesis; obstructive mitral bioprothesis with an image suggestive of a vegetation; and a de novo mass in the left auricle, compatible with a thrombus. This clinical case was discussed in Heart Team: as the patient was clinically stable, it was opted for an initial conservative approach; although there was a strong clinical suspicion that all the clinical case was due to thrombotic manifestations (assuming that the vegetations had a non-infectious origin), he was nonetheless medicated with vancomycin, gentamicin and rifampicin, as the diagnosis of early culture negative prosthetic endocarditis could not be discarded. He was anticoagulated with enoxaparin. In the reevaluation echocardiogram there was a significative reduction of the left atrial thrombus and disappearance of the mitral valve vegetation image, with improvement of the mitral valve prosthetic gradients. The case was discussed again in Heart Team: due to the clinical evolution, the hypothesis that this was all caused by a thrombotic manifestation grew stronger; it was opted not to submit the patient to a new surgery and the antibiotic therapy was suspended. To study the pro-thrombotic state and the constitutional syndrome, a full body CT was requested: "hilar-mediastinal and bilateral hilar adenopathy; right supraclavicular adenopathy; splenomegaly with infarcted area." The right hilar adenopathy was biopsied; the pathologic exam revealed non-small cells lung carcinoma. The patient was discharged, medicated with warfarin and oriented to outpatient Oncology consult. Any cancer can be associated with thrombotic manifestations. In this case, considering the heavy smoking burden, lung cancer is one of the first etiologies to consider. The thrombotic manifestations of the non-small cells lung carcinoma are due to a paraneoplastic mechanism and might precede the cancer diagnosis. This clinical case highlights the importance of thinking of different etiologies in the differential diagnosis of a constitutional syndrome.

Abstract P1310 Figure. Left auricle mass

P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm

P863 Large pericardial effusion two months after transcatheter aortic valve implantation: case report of a post-cardiac injury syndrome

We present a case of a 87-year-old female with a symptomatic severe aortic stenosis (aortic valve area 0.9 cm2, mean transvalvular pressure gradient 44 mmHg). She was refused to surgical aortic valve replacement due to marked aortic root calcification. A transcatheter aortic valve (ACCURATE neo™ 27) was electively implanted. In immediate post-procedure, the patient presented an episode of hypotension, rapidly reverted with supportive treatment. A transthoracic echocardiogram (TTE) showed a circumferential mild pericardial effusion (PE) without prosthetic valve disfunction and with preserved biventricular systolic function. Due to paroxysmal episodes of atrial fibrillation, it was decided to withdraw anti-aggregation and to start anticoagulation. Four days after transcatheter aortic valve implantation (TAVI) the patient presented newer intraventricular and atrioventricular conduction disturbance (left bundle branch block and type-I second-degree atrioventricular block). A definitive pacemaker was implanted without complications. PE maintained stable and seven days after TAVI the patient was discharged from hospital.

Two months after TAVI, the patient was admitted to Intensive care unit (ICU) with increasing asthenia, dyspnea and pleuritic thoracic pain over the preceding two weeks. Laboratory workup exhibited elevation of inflammatory markers (leukocytosis and C-reactive protein). A TTE was performed and showed a large circumferential PE (29 mm) with signs of hemodynamic impact (swinging heart, inferior vena cava dilation with &lt;50% inspiratory collapse, right atrial collapse &gt;1/3 of cardiac cycle, proto-diastolic right ventricular collapse and mitral respiratory flow variation &gt;25%). The patient started treatment with anti-inflammatory drugs (aspirin 1000mg every 8h plus colchicine 0.5mg twice daily) and pericardiocentesis was initially postponed. In spite of clinical and echocardiographic improvement, she maintained elevated inflammatory markers and a moderate PE. Prednisolone 30mg daily was added to initial therapy and serial evaluations showed a pronounced reduction of PE as well as of inflammatory markers. Two weeks after admission to ICU the patient was discharged with a residual PE measuring less than 5mm. The previous recent cardiac intervention and the effective response to anti-inflammatory treatment suggest a post-cardiac injury syndrome.

This case report wants to show that post-cardiac injury syndrome is a diagnosis that should be keep in mind after TAVI.

Abstract P863 Figure. TTE showing large pericardial effusion

P1750 Association of high-sensitivity troponin elevation and LVEF decline in anthracycline-treated breast cancer patients

Introduction

Cancer therapies have been linked to a wide variety of side effects, with cardiotoxicity being the most significant one. Early detection of subclinical cardiac dysfunction in cancer patients (pts) is necessary in order to prevent unfavorable outcomes. High-sensitivity troponin I (hsTI) levels have been proposed as predictors of cancer therapy related cardiotoxicity and may guide cardioprotective therapy initiation.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer pts under chemotherapy in a single center cardio-oncology unit and to assess its relationship with hsTI levels.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to a value below 50%. Elevation of hsTI was defined as at least one measurement above the 99th percentile upper reference limit during follow-up (&gt;34 ng/L).

Pts had an organized follow-up in our cardio-oncology unit, consisting of a clinical, laboratorial (with dosing of cardiac biomarkers) and echocardiographic assessment at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases).

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 17 pts (20.5%) were considered at high risk of cardiac dysfunction due to hsTI elevation.

During follow-up, the percent increase in the hsTI level (from basal level) correlated with CTRCD (p = 0.02). On the other hand, the absolute maximum value of hsTI did not (p = 0.159).

In fact, pts who developed CTRCD had a significantly higher percent increase in the hsTI levels (142.9% +- 57.5%) vs those without CTRCD (14.29% +- 4.6%), p &lt; 0.001. On ROC curve analysis, percent increase in troponin was a good identifier of CTRCD (AUC of 0.986; 95% CI 0.95-1.00; p = 0.022) and the best cut-off value was a 79.8% increase in hsTI (sensitivity: 100%; specificity: 97.2%).

Conclusion

In our population, the percent increase in the hsTI levels correlated with CTRCD. Larger studies are needed to prove this parameter as a predictor of CTRCD.

Abstract P1750 Figure.

P656 Cardiac dysfunction in breast cancer patients treated with anthracyclines: a single-center experience

Introduction

Cardiac dysfunction is a well-documented side effect of cancer treatment, with significant morbidity and mortality. Cardio-oncology units play a vital role in the early identification and management of cancer therapy related cardiovascular side effects and provide a multidisciplinary care for cancer patients.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer patients (pts) under chemotherapy in a single center cardio-oncology unit, and to assess its predictors.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to below 50%. Pts with &gt;15% relative percentage reduction from baseline Global longitudinal strain (GLS) or with elevation of high-sensitivity Troponin I (hsTI) levels were considered to be at high risk for developing CTRCD and started cardioprotective treatment with an ACE inhibitor/ARB and a beta-blocker, as did pts with confirmed CRTCD. Also, in pts under antihypertensive drug therapy, switching drugs to cardioprotective ones was performed in the index consultation.

Follow-up was organized in our cardio-oncology consultation at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases). Interruption of chemotherapy was a joint decision of the oncology and cardiology teams.

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 28 pts (33.7%) were considered to be at high risk due to GLS reduction during follow-up and 17 pts (20.5%) were at high risk due to hsTI elevation.

From all the baseline characteristics, only basal BNP correlated with CTRCD (p = 0.033). Other characteristics such as age, presence of cardiovascular risk factors and the previously proposed Cardiotoxicity Risk Score (CRS) did not.

There was a high percentage of pts (51.8%; n = 43) under cardioprotective drugs. 37% of the pts initiated cardioprotective drugs following cardio-oncology consultation. Chemotherapy was discontinued in only 2 pts (2.4%).

Conclusion

CTRCD is difficult to predict by baseline clinical characteristics. Monitoring and management of CTRCD by a multidisciplinary cardio-oncology team resulted in a high rate of cardioprotective drugs use and low rate of permanent discontinuation of chemotherapy. Further studies are needed to further analyze the relationship between these two variables.

1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report

We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation.

Abstract 1115 Figure. TTE showing right atrial masses

Aging and Proteins: What Does Proteostasis Have to Do with Age?

The world is aging and we must face the challenges that this brings. One of the reasons for the increasing aging of the world's population is the increase in life expectancy and, since we live longer, it is of paramount importance to live well and to prevent age-associated diseases. In this way, it is crucial to improve knowledge of the aging process and of the mechanisms that contribute to it. Ideally it would be of great interest to have a panel of biomarkers of healthy aging that would allow an estimate of the biological age of an individual. One of the changes that greatly contribute to aging is the loss of protein homeostasis, also called proteostasis. To ensure the proper function of cells and to maintain cellular proteostasis, organisms have developed systems to control protein synthesis, folding and degradation. Loss or dysfunction of proteostasis is at the root of many well-studied human neurological diseases, such as Alzheimer's disease and, more recently, it has been implicated in the aging process with some reports showing long-lived animals to have improved proteostasis. Growing evidence suggests a strong link between modifications in the quantity and/or activity of several players involved in proteostasis and longevity. In this review, we give an overview of the main characteristics of aging with focus on proteostasis. We present how changes in components of proteostasis, during aging, impact the lifespan of model organisms. We also briefly review the current state of aging biomarkers and discuss the potential of proteostasis network components as markers of healthy aging.