Comparative study of non-contrast silent and time-of-flight magnetic resonance angiographic sequences in the evaluation of intracranial dural arteriovenous fistula

AIM

To compare the performance of two non-contrast magnetic resonance angiography (MRA) sequences, silent MRA and time of flight (TOF) MRA, in the evaluation of intracranial dural arteriovenous fistula (DAVF).

MATERIALS AND METHODS

Forty consecutive patients with DAVF were enrolled and evaluated prospectively using silent MRA, TOF MRA, and digital subtraction angiography (DSA). The location, Cognard classification, arterial feeders, and venous drainage were evaluated. The therapeutic strategy and possible route were predicted on both silent and TOF MRA and these were compared with DSA during subsequent endovascular treatment.

RESULTS

Sensitivity and accuracy of silent and TOF MRA for localisation (96.4% versus 96% and 96% versus 95%, respectively) and classification (96% versus 94% and 96% versus 93.5%, respectively) were high. Silent MRA showed higher sensitivity than TOF MRA for arterial feeders and draining veins (87% versus 79% and 81.6% versus 67%). This improved to a sensitivity of 96.4% and 89% when prominent feeders were considered. The sensitivity and accuracy were 92.6% and 85.8% for immediate draining veins. Both silent and TOF MRA were accurate for therapeutic planning (96% versus 85%), although silent MRA was more accurate.

CONCLUSION

Silent MRA can more reliably evaluate the various angioarchtectural components of DAVF compared to TOF MRA.

Postnatal cytomegalovirus infection and pulmonary vascular disease in extremely premature infants: A case series

BACKGROUND

Pulmonary vascular disease (PVD) is a major determinant of both morbidity and mortality in extremely low birth weight infants. It is biologically plausible that postnatal cytomegalovirus (pCMV) infection may lead to PVD in premature infants secondary to pneumonitis or via derangement of pulmonary vascular development directly through endothelial dysfunction. Uncertainty remains, however, regarding thresholds for intervention in premature infants with cardiorespiratory instability and presumed CMV infection likely secondary to the limited understanding of the natural history of the disease.

METHODS/RESULTS

We describe four cases of premature infants with clinical and echocardiography features of PVD, in the setting of postnatally acquired CMV. All patients had atypical PVD trajectories, refractory to vasodilator treatment, which improved after initiation of CMV treatment.

CONCLUSION

We highlight the need to consider postnatally acquired CMV infection in patients with PVD non-responsive to standard pulmonary vasodilator therapies or disease severity which is out of proportion of the usual clinical trajectory. Treatment of extremely premature infants with CMV-associated PVD may have positive impact on cardiorespiratory health, although duration of therapy remains uncertain.

Evaluation of quality of life's prognostic factors in people with functional seizures

AIMS

Functional non-epileptic seizures significantly impact the quality of life of patients. We aimed to identify prognostic factors associated with the quality of life in individuals with functional non-epileptic seizures.

SUBJECTS AND METHODS

Adult patients diagnosed with definite or documented functional seizures based on LaFrance's criteria (n=72) were enrolled at the time of diagnosis. Quality of life was assessed using the Quality of Life in Epilepsy Inventory-31 (QOLIE-31) at diagnosis and at a six-month follow-up. Demographic and medical information was collected, and psychiatric comorbidities were evaluated using validated scales.

RESULTS

Comparisons between diagnosis and follow-up did not reveal any factors associated with improvement in quality of life at six months after diagnosis. However, multivariable analysis, adjusted for age, sex, diagnosis delay, and frequency of functional seizures showed a significant cross-sectional relationship with a QOLIE-31 score decrease of 0.66 [95% CI -0.93;-0.39], -0.32 [-0.61; -0.03], and -0.22 [-0.42; -0.02] for an increase of 1 point of BDI-2 score, BAI score, and CTQ score respectively.

CONCLUSION

Psychiatric comorbidities, particularly depression and anxiety, are associated with worse quality of life in patients with functional seizures. This underscores the crucial importance of multidisciplinary care involving both neurological and psychiatric expertise when managing individuals with functional seizures.

Pulmonary alveolar proteinosis diagnosis after re‑evaluation for chronic cough unresponsive to empirical antituberculosis therapy

This study extends the reports of PAP in SA, in this case a 29-year- old HIV-negative black African woman with no history of smoking. Patients with respiratory symptoms who are microbiologically negative for TB should be carefully evaluated for an alternative diagnosis.

An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

Gastric Radiotherapy in the UK - Current Practice and Opinion on Future Directions

PURPOSE/OBJECTIVE(S)

Gastric radiotherapy (RT) is more commonly practiced in the US compared to the UK, where postoperative chemoradiotherapy (CRT) is reserved for selected high-risk patients, and preoperative CRT is not standard of care pending the results of phase 3 trials, TOPGEAR and CRITICSII. CRT for inoperable, non-metastatic gastric cancer is also not recommended in the UK, despite being listed in NCCN guidelines. Recent systematic review of definitive gastric CRT (dCRT) conducted by the authors found median overall survival of 11-26.4 months, clinical complete response rates of 8-45% and acceptable rates of ≥G3 toxicity, supporting further research. Given these promising findings and perceived low uptake of gastric RT in the UK, we set out to establish current UK practice, opinion and RT technique to inform the development of a UK gastric RT protocol and future clinical trials.

MATERIALS/METHODS

A 19 question survey was developed. Following local ethical approval and pilot by 4 clinical oncologists, the final survey was distributed electronically on 13/12/22 to UK Consultant Clinical Oncologists specializing in esophago-gastric (OG) cancer. Responses were anonymous. Survey was closed 6/2/23 and data analyzed using JISC/spreadsheet software.

RESULTS

A total of 43 clinicians completed the survey. For gastric cancer, 28.6%, 7.1% and 9.5% would agree/strongly agree with use of postoperative (postopRT), preoperative (preopRT) or definitive RT (dRT) respectively, compared to 26.2%, 45.2% and 46.6% for type III gastro-esophageal junction tumors. 93% had prescribed palliative gastric RT in the last 3 years compared to 40.5% postopRT, 16.7% dRT and 9.5% preopRT. Main reasons for infrequent use were; rarely indicated within standard UK practice 88.4%, lack of UK gastric RT protocol 53.5%, toxicity concerns 44.2%. 45Gy/25# was most commonly used for preopRT (66%) and postopRT (86%), and 50Gy/25# for dRT (58%). 96% use IMRT/VMAT, 85% CT simulation with IV/oral contrast, 69% gastric filling protocol and 54% 4DCT. When ranked out of 10 (1 = low 10 = high), clinician confidence in accurately delineating gastric volumes mean rank was 4.33 for postopRT, with 9% rating ≥8/10, and 4.52 for dCRT/preopRT with 17% rating ≥8/10. However, 48.8% were experienced in outlining upper abdominal nodes and 62.8% duodenum. 93% would find a detailed outlining protocol useful, 81.4% wanted some form of peer review, 76.7% a nodal atlas, and 74.4% a workshop with an expert. 77.6% would be supportive of a future clinical trial of dCRT, with 23.4% needing more supporting evidence. No-one would not support a future trial in this setting.

CONCLUSION

Gastric RT is not often practiced in the UK, due to lacking evidence and toxicity concerns. Given the growing evidence and supportive OG community, it is time to consider a trial of dCRT in the UK, which must include detailed RT protocols, atlases and educational materials to improve clinician confidence and ensure good RT quality assurance.

Impact of the COVID-19 Pandemic on Outcomes for Patients with Lung Cancer Receiving Curative-intent Radiotherapy in the UK

AIMS

Previous work found that during the first wave of the COVID-19 pandemic, 34% of patients with lung cancer treated with curative-intent radiotherapy in the UK had a change to their centre's usual standard of care treatment (Banfill et al. Clin Oncol 2022;34:19-27). We present the impact of these changes on patient outcomes.

MATERIALS AND METHODS

The COVID-RT Lung database was a prospective multicentre UK cohort study including patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between April and October 2020. Data were collected on patient demographics, radiotherapy and systemic treatments, toxicity, relapse and death. Multivariable Cox and logistic regression were used to assess the impact of having a change to radiotherapy on survival, distant relapse and grade ≥3 acute toxicity. The impact of omitting chemotherapy on survival and relapse was assessed using multivariable Cox regression.

RESULTS

Patient and follow-up forms were available for 1280 patients. Seven hundred and sixty-five (59.8%) patients were aged over 70 years and 603 (47.1%) were female. The median follow-up was 213 days (119, 376). Patients with stage I-II non-small cell lung cancer (NSCLC) who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.859) or death (P = 0.884); however, they did have increased odds of grade ≥3 acute toxicity (P = 0.0348). Patients with stage III NSCLC who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.216) or death (P = 0.789); however, they did have increased odds of grade ≥3 acute toxicity (P < 0.001). Patients with stage III NSCLC who had their chemotherapy omitted had no significant increase in distant relapse (P = 0.0827) or death (P = 0.0661).

CONCLUSION

This study suggests that changes to radiotherapy and chemotherapy made in response to the COVID-19 pandemic did not significantly affect distant relapse or survival. Changes to radiotherapy, namely increased hypofractionation, led to increased odds of grade ≥3 acute toxicity. These results are important, as hypofractionated treatments can help to reduce hospital attendances in the context of potential future emergency situations.

Feeding rumen-protected lysine prepartum alters placental metabolism at a transcriptional level

Rumen-protected Lys (RPL) fed to Holstein cows prepartum resulted in a greater intake and improved health of their calves during the first 6 wk of life. However, whether increased supply of Lys in late gestation can influence placental tissue and, if so, which pathways are affected remain to be investigated. Therefore, we hypothesize that feeding RPL during late gestation could modulate placental metabolism, allowing for improved passage of nutrients to the fetus and thus influencing the offspring development. Therefore, we aimed to determine the effects of feeding RPL (AjiPro-L Generation 3, Ajinomoto Health and Nutrition North America) prepartum (0.54% DM of TMR) on mRNA gene expression profiles of placental samples of Holstein cows. Seventy multiparous Holstein cows were randomly assigned to 1 of 2 dietary treatments, consisting of TMR top-dressed with RPL (PRE-L) or without (control, CON), fed from 27 ± 5 d prepartum until calving. After natural delivery (6.87 ± 3.32 h), placentas were rinsed with physiological saline (0.9% sodium chloride solution) to clean any dirtiness from the environment and weighed. Then, 3 placentomes were collected, one from each placental region (cranial, central, and caudal), combined and flash-frozen in liquid nitrogen to evaluate the expression of transcripts and proteins related to protein metabolism and inflammation. Placental weights did not differ from cows in PRE-L (15.5 ± 4.03 kg) and cows in CON (14.5 ± 4.03 kg). Feeding RPL prepartum downregulated the expression of NOS3 (nitric oxide synthase 3), involved in vasodilation processes, and SOD1, which encodes the enzyme superoxide dismutase, involved in oxidative stress processes. Additionally, feeding RPL prepartum upregulated the expression of transcripts involved in energy metabolism (SLC2A3, glucose transporter 3; and PCK1, phosphoenolpyruvate carboxykinase 1), placental metabolism and cell proliferation (FGF2, fibroblast growth factor 2; FGF2R, fibroblast growth factor 2 receptor; and PGF, placental growth factor), Met metabolism (MAT2A, methionine adenosyltransferase 2-α), and tended to upregulate IGF2R (insulin-like growth factor 2 receptor). Placental FGF2 and LRP1 (low-density lipoprotein receptor-related protein 1) protein abundance were greater for cows that received RPL prepartum than cows in CON. In conclusion, feeding RPL to prepartum dairy cows altered uteroplacental expression of genes and proteins involved in cell proliferation, and in metabolism and transport of glucose. Such changes are illustrated by increased expression of SLC2A3 and PCK1 and increased protein abundance of FGF2 and LRP1 in uteroplacental tissue of cows consuming RPL.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Women's Understanding of Windows of Susceptibility and the Role of the Environment in Breast Cancer Risk

Emerging evidence suggests women who are exposed to harmful environmental exposures, especially during certain critical periods across the lifespan, may increase their breast cancer risk. Such windows of susceptibility (WoS) occur throughout a woman's lifetime, during which she is especially vulnerable to the effects of harmful environmental exposures. This interaction makes the reduction of harmful environmental toxicants during those time periods a priority for community health promotion. Communicating about environmental exposures and their impact on women's health requires an assessment of sense-making around, and understanding of, the link between breast cancer and the environment. To that end, focus groups were conducted to assess the themes that emerge when women make sense of (a) their own breast cancer risk, (b) the environment-cancer connection, and (c) WoS. Results provide insight into how women understand these issues which can inform messaging strategies focused on reducing harmful environmental exposures. Implications are discussed within the context of communication efforts tailored to educate women, particularly mothers with daughters in the prepubertal and pubertal WoS who are particularly vulnerable to harmful environmental exposures.

Design of an adaptive randomized clinical trial of intravenous citrulline for sickle cell pain crisis in the emergency department

Background

Vaso-occlusive pain crisis (VOC) is the most frequent cause for Emergency Department (ED) visits and hospital admissions for patients with sickle cell disease (SCD). Nitric oxide plays a critical role in the pathogenesis of vaso-occlusion. The amino acid, citrulline, is the main endothelial nitric oxide booster that offers the potential to ameliorate vaso-occlusion and decrease the risk of hospitalization.

Objective

In this two-part study, the goal of the first part is to determine the pharmacokinetic profile of intravenous (IV) l-citrulline and optimal dose for the second part of the study, which is to determine the efficacy and tolerability of the intervention in patients with SCD.

Design

A phase I/IIA open-label dose-finding study with subsequent double-blind, placebo-controlled, randomized Study of l-citrulline in children and adolescents with SCD presenting to the ED in VOC.

Methods

Part 1: Subjects experiencing VOC are enrolled in an open-label, ascending dose of IV l-citrulline to identify the optimum dose with endpoints of pharmacokinetic parameters, pain scores, reduction of opioid use, quality of life, proportion admitted to the hospital for treatment of pain, readmission rates, and assessment of adverse events. Part 2 of the trial is a double-blind, placebo-controlled adaptive "pick-the-winner" design to evaluate the efficacy and tolerability of IV l-citrulline in patients with SCD while receiving standard of care therapy for VOC.

Summary

This ED based sickle cell adaptive trial will determine the optimal dose for IV citrulline and whether the intervention improves outcome as a potential novel therapy for VOC in SCD.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Microvascular dysfunction is associated with impaired myocardial work in obstructive and nonobstructive hypertrophic cardiomyopathy: a multimodality approach

Introduction

Myocardial work is a dynamic non-invasive method for assessing myocardial deformation. Microvascular dysfunction is a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between impaired myocardial work, evaluated by echocardiography, and left ventricular (LV) ischemia, detected by cardiac magnetic resonance (CMR).

Methods

Prospective assessment of HCM patients' (P) myocardial strain parameters with 2D speckle-tracking echocardiography. All P underwent CMR protocol (1.5-T) for the analysis of stress perfusion and late gadolinium enhancement (LGE). Perfusion defects were quantified as burden of ischemia (% of LV mass). Results were stratified according to obstructive (oHCM) and nonobstructive (nHCM) HCM as well as according to the presence of significant replacement fibrosis (LGE of ≥15% or &lt;15% of LV mass). Multivariate regression analyses were used to explore the relation between myocardial work and the burden of ischemia.

Results

75 P with HCM (63% male, age 55±15 years), 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH and 28% exhibiting LV outflow tract obstruction (mean maximal LVOT gradient of 89±60 mmHg). Perfusion defects were found in 68 P (90.7%), with a mean of 22.5±16.9% of LV mass and 29 P (38.7%) had LGE ≥15% of LV mass.

A lower global work index (GWI) significantly correlated with higher burden of myocardial perfusion defects (r=−0.520, β-estimate −0.019, 95% CI −0.028 to −0.010, p&lt;0.001). Likewise, impaired values of global work efficiency (GWE) were linked to higher percentage of hypoperfusion (r=−0.477, β-estimate −0.713, 95% CI −1.250 to −0.176, p&lt;0.001). Moreover, impaired global constructive work (GCW) (r=−0.519, β-estimate −0.021, 95% CI −0.030 to −0.013, p&lt;0.001) and a higher global wasted work (GWW) (r=0.280, p=0.017) were associated with a higher burden of perfusion defects (Figure 1).

GWI showed a higher correlation with perfusion defects in oHCM P (r=−0.518, p=0.019) vs. nHCM P (r=−0.492, p&lt;0.001), and the same was also found with GWE (oHCM: r=−0.591, p=0.006 vs. nHCM: r=−0.317, p=0.022) (Figure 2A). Furthermore, GCW showed a slightly higher correlation with hypoperfusion in oHCM P (r=−0.564, p=0.010) vs. nHCM P (r=−0.520, p&lt;0.001). There was no significant difference between oHCM and nHCM P regarding GWW.

In P with LGE ≥15%, GWI showed a better correlation with perfusion defects (r=−0.489, p=0.007) vs. P with LGE of &lt;15% (r=−0.369, p=0.007). Moreover, GCW showed a higher correlation with hypoperfusion in P with LGE ≥15% (r=−0.455, p=0.013) comparing with P with LGE &lt;15% LV mass (r=−0.359, p=0.019) (Figure 2B). No difference was found regarding GWE and GWW according to LGE burden.

Conclusion

In our cohort of P with HCM, impaired GWI, GWE and GCW and a higher GWW were significantly correlated with the presence of myocardial ischemia in CMR. This correlation was greater in P with oHCM and in P with LGE of ≥15% of LV mass.

Funding Acknowledgement

Type of funding sources: None.

OS01.7.A Detection of methylation-based prognostic signatures in liquid biopsy specimens from patients with meningiomas

Background

Detection of distinct epigenetic biomarkers in circulating cell-free DNA (cfDNA) of liquid biopsy (LB) specimens (e.g. blood) fosters opportunity for prognostication of central nervous system (CNS) tumors and has not been thoroughly explored in patients with meningiomas.

Material and Methods

We profiled the cfDNA methylome (EPIC array) in serum specimens from patients with meningiomas (MNG; n= 63) and harnessed internal and external meningioma tissue methylome data with reported follow up (n=48). To predict recurrence risk (RR), we consolidated a tissue cohort with at least 5 years of follow up and divided them into confirmed recurrence (CR; either reported progressive disease in post-surgical imaging, or additional resections following initial surgery) and confirmed no-recurrence (CNR: no confirmed disease progression w/in at least 5-years of follow-up). Then through application of an iterative process consisting of multiple tissue- and serum-based supervised analyses, we identified risk-specific methylation markers with serum specific features which, when inputted into a random forest algorithm allowed for segregation of both tumor tissue and liquid biopsy specimens according to recurrence risk. We estimated immune cell composition using MethylCIBERSORT, where a reference methylome atlas of chosen immune cell types was utilized to deconvolute the MNG samples.

Results

The resulting recurrence risk classifier demonstrated an appreciable predictive power in classifying samples as high or low recurrence risk across the tumor tissue cohort (ACC: 87.5%, CUI+: 85.2%). When compared to another classifier, our model demonstrated statistically significant agreement across primary meningioma samples (κ=0.269, p=0.002), and more accurately predicted samples to recur across an expanded time window (time to recurrence &gt;5yrs). Across resulting liquid biopsy classifications, recurrence risk subgroups were analogous with reported risk factors, including WHO grade, extent of resection, and tumor location. Recurrence risk subgroups (high and low) also demonstrated differential estimated immune cell contributions, with low-risk samples exhibiting a “hot” profile, or enrichment of B-Cells, CD56- and CD4 T-Cells, and natural killer cells. Notably, the estimated neutrophil to lymphocyte ratio, previously purported to be relevant to tumor prognosis, was appreciably higher for those meningioma samples with the highest recurrence risk.

Conclusion

DNA methylation markers identified in the serum are suitable for the development of machine learning-based models which present high predictive power to prognosticate patients with meningioma and estimate a differential immune profile across recurrence risk groups. After validation in an external cohort, this noninvasive approach may improve the presurgical therapeutic management of patients with meningiomas.

OS08.3.A Distinct systemic and tumor microenvironment immune landscapes discriminate across sellar tumor types and controls through a methylation-based deconvolution method

Background

Systemic (Sys) and tumor microenvironment (TME) immune milieus play a pivotal role in tumor development, outcome and immunotherapy response predictions across a variety of central nervous system tumors. Genome-wide methylation profiling can reliably discriminate and estimate immune cell proportions present in the blood and within the tumor and has not been reported across sellar tumor types (STT).

Material and Methods

We estimated cell composition in liquid biopsy (LB, serum/plasma) and tissue specimens from 42 STT collections (i.e., pituitary neuroendocrine tumors [PitNETs; n=37] and craniopharyngiomas [CP; n=5]), and 26 nontumor controls (LB: 11; Tissue: 15) using MethylCIBERSORT, a methylation-based deconvolution algorithm and established immune cell signatures as reference. LB methylation was profiled with EPIC array. Correlations between estimated cell proportions across sample sources were explored (Spearman). Immune cell proportion hierarchical k-means clustering was performed across tissue and LB specimens. Similarly, mean comparisons between and across sample types and subgroups of interest were performed [Non-parametric Kruskal-Wallis, Wilcoxon rank-sum tests; p&lt;0.05].

Results

We identified three immune-clusters across tissue specimens which distinguished controls (k3-cluster) from sellar tumor specimens (k1- and k2- clusters), primarily attributable to differential B-cell and monocyte proportions. Interestingly, a subset of PitNET and CP, belonging to the k2-cluster, presented a distinct immune profile compared to their K1-sellar tumor counterparts. Analysis of plasma-derived immune clusters revealed that PitNETs were distributed across four distinct immune patterns and CP clustered together with controls and a PitNET subset. One of the PitNET clusters was enriched with patients that died during follow-up and presented an enrichment of CD4-(including the regulatory subtype), CD8 and CD56-T and depletion of natural killer cells. Differences across serum- and tissue-derived clusters were present but less prominent than their plasma counterparts. No correlation between immune cell proportions across other clinicopathological features within each tumor type (sex, age, histotypes, invasion etc) was observed.

Conclusion

Our results suggest that PitNETs are characterized by differential TME and systemic immune subtypes which also distinguish these tumors from CP and controls. Additionally, distinct systemic immune composition between tissue and LB sources, more readily observed in plasma, suggest that the systemic response to the presence of the tumor is distinct from the immune response noted in the TME. Tumor immune subtyping may allow the stratification of STT according to immunotherapy response vulnerabilities.

SCOPE 2 - Still Answering the Unanswered Questions in Oesophageal Radiotherapy? SCOPE 2: a Randomised Phase II/III Trial to Study Radiotherapy Dose Escalation in Patients with Oesophageal Cancer Treated with Definitive Chemoradiation with an Embedded Phase II Trial for Patients with a Poor Early Response using Positron Emission Tomography/Computed Tomography

The SCOPE 2 trial of definitive chemoradiotherapy in oesophageal cancer investigates the benefits of radiotherapy dose escalation and systemic therapy optimisation. The trial opened in 2016. The landscape of oesophageal cancer treatment over the lifetime of this trial has changed significantly and the protocol has evolved to reflect this. However, with the recent results of the Dutch phase III ART DECO study showing no improvement in local control or overall survival with radiotherapy dose escalation in a similar patient group, we sought to determine if the SCOPE 2 trial is still answering the key unanswered questions for oesophageal radiotherapy. Here we discuss the rationale behind the SCOPE 2 trial, outline the trial schema and review current data on dose escalation and outline recommendations for future areas of research.

Concomitant pulmonary disease is common among patients with extrapulmonary TB

BACKGROUND :

Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB).

METHODS :

We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018.

RESULTS :

Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16).

CONCLUSIONS :

A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

A reassessment of TBT action levels for determining the fate of dredged sediments in the United Kingdom

As part of reviewing the United Kingdom (UK) action levels (ALs) of contaminants for managing the disposal of dredged marine sediment material, tributyl tin (TBT) has been reassessed. TBT is a banned biocide capable of causing severe harm to the marine environment. Its presence is routinely screened for prior to marine disposal of dredged sediment material. Dredged sediment TBT concentrations have been studied using UK monitoring data obtained between 2000 and 2018. The changes in these TBT concentrations have guided the reassessment of ALs. Recent toxicity studies have also guided the reassessment of TBT ALs. This study, which itself forms part of a larger review by the Department for Environment, Food and Rural Affairs, has concluded that current UK TBT ALs may no longer be fit for purpose. A more environmentally protective approach for controlling release of TBT into the marine environment is recommended.

Microvascular dysfunction and myocardial fibrosis impact on left ventricular myocardial deformation in hypertrophic cardiomyopathy: per segment analysis by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular hypertrophy (LVH) and microvascular dysfunction are hallmarks of hypertrophic cardiomyopathy (HCM). We hypothesized that microvascular dysfunction contributes to LV myocardial deformation impairment.

Methods

Prospective evaluation of adult patients with HCM (patients with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume, late gadolinium enhancement (LGE) and stress perfusion. Three-dimensional strain analysis was obtained by using feature-tracking from cine images. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for longitudinal, circumferential and radial strain were performed.

Results

A total of 1200 myocardial segments were analysed (Table 1) (75 patients, 63% male, age 54.6 ± 14.7 years) including 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH, 28% exhibiting LV outflow tract obstruction. The mean MLVWT was 20 ± 4.5mm.

Higher values of longitudinal strain (lower deformation) were found in segments with MLVWT ≥15mm (β-estimate: 2.31, 95% CI 0.91-3.70, p &lt; 0.001) and in patients with obstructive HCM (β-estimate: 2.44, 95% CI 1.15-3.72, p &lt; 0.001]) (Table 2). No association was found between perfusion defects, LGE and longitudinal strain.

Higher values of circumferential strain (lower deformation) were found in segments with MLVWT 12-14mm (β-estimate: 2.31, 95% CI 1.36-3.25, p &lt; 0.001), MLVWT ≥15mm (β-estimate: 5.29, 95% CI 4.47-6.12, p &lt; 0.001), with perfusion defects (β-estimate: 2.75, 95% CI 2.0-3.5, p &lt; 0.001), with LGE (β-estimate: 2.49, 95% CI 1.77-3.22, p &lt; 0.001) and in patients with obstructive HCM (β-estimate: 1.25, 95% CI 0.44-2.06, p = 0.003).

Lower radial strain values were found in segments with MLVWT 12-14mm (β-estimate: -10.64, 95% CI -13.95 to -7.33, p &lt; 0.001), with MLVWT ≥15mm (β-estimate: -20.67, 95% CI -23.36 to -17.97, p &lt; 0.001), with perfusion defects (β-estimate: -10.60, 95% CI -13.08 to -8.13, p &lt; 0.001), and with LGE (β-estimate: -10.49, 95% CI  -12.86 to -8.11) (table 2).

Diabetes, hypertension and BMI &gt; 25 kg/m2 were also associated with impaired myocardial deformation. Male gender correlated with worse radial and circumferential strain values.

No association was found between parametric mapping values and LV myocardial deformation.

Conclusion

In patients with HCM, three-dimensional speckle tracking parameters for LV systolic function were particularly impaired in segments with LVH, microvascular dysfunction or fibrosis. LVH was associated with abnormal longitudinal, circumferential and radial strain while perfusion defects and LGE correlated with impaired circumferential strain and radial strain. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariate analysis

Segmental analysis of microvascular dysfunction and tissue characterization in hypertrophic cardiomyopathy by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

While left ventricular hypertrophy (LVH) and myocardial fibrosis are frequently evaluated in hypertrophic cardiomyopathy (HCM), microvascular dysfunction is often overlooked. The aim of this study was to assess the association between wall thickness, microvascular dysfunction and tissue characteristics in HCM patients (P), comparing individual myocardial segments.

Methods

Prospective evaluation of adult P with HCM (P with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume (ECV), late gadolinium enhancement (LGE) and stress perfusion. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for perfusion defects and tissue characteristics were performed.

Results

75 P (total of 1200 myocardial segments analysed), 63% male, mean age 55 ± 15 years, MLVWT of 20 ± 4.5mm (61% asymmetric septal LVH, 29% apical LVH and 8% concentric LVH). 28% presented LV outflow tract obstruction.

MLVWT was greater in the basal and mid septum (table 1). Among the 424 segments (35.3%) with a perfusion defect, 286 (23.8%) had a defect only in the endocardial layer and 138 (11.5%) in both endocardial and epicardial layers with defects more often detected in hypertrophied segments. This association was verified in segments with MLVWT 12-14mm and MLVWT ≥15mm (OR 7.83, 95% CI 5.75-10.67, p &lt; 0.001) (table 2). Among the 660 segments with normal MLVWT (≤11mm), 123 (19%) presented perfusion defects. A perfusion defect was more frequent in segments of obstructive HCM P (OR 1.48, 95% CI 1.13-1.92, p = 0.004).

Microvascular dysfunction was associated with changes in tissue characteristics. For the same thickness, segments with perfusion defects had a higher T1 mapping (β-estimate 20.91, 95% CI 16.87-24.96, p &lt; 0.001) and T2 mapping mean values than those without. Furthermore, regardless of MLVWT, segments with perfusion defects had LGE more often (OR 4.16, 95% CI 3.19-5.41, p &lt; 0.001) and a higher ECV. On the other hand, among the 424 segments with a perfusion defect, 115 (27%) did not present LGE.

MLVWT was associated with tissue characteristics. Comparing to non-hypertrophied segments, T1 mapping mean value was higher in segments with MLVWT 12-14mm and with ≥15mm (β-estimate 37.71, 95% CI 31.2-44.21, p &lt; 0.001). Segments with MLVWT ≥15mm showed a significantly superior ECV mean value comparing to non-hypertrophied segments. LGE was more frequent in the more hypertrophied segments: MLVWT 12-14mm and ≥15mm (OR 9.02, 95% CI 6.42-12.67, p &lt; 0.001) (Table 2).

Conclusion

Microvascular dysfunction is more prevalent in obstructive HCM, particularly in the more hypertrophied segments. The presence of microvascular dysfunction is associated with diffuse tissue abnormalities and replacement fibrosis. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariable analyses

Changes in the Management of Patients having Radical Radiotherapy for Lung Cancer during the First Wave of the COVID-19 Pandemic in the UK

AIMS

In response to the COVID-19 pandemic, guidelines on reduced fractionation for patients treated with curative-intent radiotherapy were published, aimed at reducing the number of hospital attendances and potential exposure of vulnerable patients to minimise the risk of COVID-19 infection. We describe the changes that took place in the management of patients with stage I-III lung cancer from April to October 2020.

MATERIALS AND METHODS

Lung Radiotherapy during the COVID-19 Pandemic (COVID-RT Lung) is a prospective multicentre UK cohort study. The inclusion criteria were: patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between 2nd April and 2nd October 2020. Patients who had had a change in their management and those who continued with standard management were included. Data on demographics, COVID-19 diagnosis, diagnostic work-up, radiotherapy and systemic treatment were collected and reported as counts and percentages. Patient characteristics associated with a change in treatment were analysed using multivariable binary logistic regression.

RESULTS

In total, 1553 patients were included (median age 72 years, 49% female); 93 (12%) had a change to their diagnostic investigation and 528 (34%) had a change to their treatment from their centre's standard of care as a result of the COVID-19 pandemic. Age ≥70 years, male gender and stage III disease were associated with a change in treatment on multivariable analysis. Patients who had their treatment changed had a median of 15 fractions of radiotherapy compared with a median of 20 fractions in those who did not have their treatment changed. Low rates of COVID-19 infection were seen during or after radiotherapy, with only 21 patients (1.4%) developing the disease.

CONCLUSIONS

The COVID-19 pandemic resulted in changes to patient treatment in line with national recommendations. The main change was an increase in hypofractionation. Further work is ongoing to analyse the impact of these changes on patient outcomes.

Cardiac magnetic resonance in the assessment of pericardial abnormalities: a case series

Background

Cardiac magnetic resonance (CMR) has a unique role in evaluating pericardial disease, permitting non-invasive tissue analysis, and haemodynamic assessment.

Case summary

In Case 1 of recurrent pericarditis, CMR confirmed reactivation of inflammation with late gadolinium enhancement and native T1/T2 mapping techniques, prompting therapeutic changes. In constrictive pericarditis, CMR is the only modality capable of differentiating a subacute potentially reversible form (Case 2), from a chronic, burnt out irreversible phase characterized by constrictive physiology (Case 3).

Discussion

Cardiac magnetic resonance is an effective tool to tailor individual therapy, particularly in cases of recurrent and constrictive pericarditis. Late gadolinium enhancement provides diagnostic and prognostic information, and multiparametric mapping has emerged as a promising tool with incremental diagnostic value.

Predictive factors of postoperative outcome in the elderly after resective epilepsy surgery

OBJECTIVE

To evaluate the efficiency of resective epilepsy surgery (RES) in patients over 50 years and determine prognostic factors.

RESULTS

Over the 147 patients over 50 years (54.9±3.8 years [50-69]) coming from 8 specialized French centres for epilepsy surgery, 72.1%, patients were seizure-free and 91.2% had a good outcome 12 months after RES. Seizure freedom was not associated with the age at surgery or duration of epilepsy. In multivariate analysis, seizure freedom was associated with MRI and neuropathological hippocampal sclerosis (HS) (P=0.009 and P=0.028 respectively), PET hypometabolism (P=0.013), temporal epilepsy (P=0.01). On the contrary, the need for intracranial exploration was associated with a poorer prognosis (P=0.001). Postoperative number of antiepileptic drugs was significantly lower in the seizure-free group (P=0.001). Neurological adverse event rate after surgery was 21.1% and 11.7% of patients had neuropsychological adverse effects overall transient.

CONCLUSIONS

RES is effective procedure in the elderly. Even safe it remains at higher risk of complication and population should be carefully selected. Nevertheless, age should not be considered as a limiting factor, especially when good prognostic factors are identified.

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

BACKGROUND

A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.

METHODS

As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: - 'what do you think of the TEQ?', and 'how can it be utilised?'

RESULTS

Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses' professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core 'caring' value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.

CONCLUSIONS

Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Effectiveness among MSM of an HIV PrEP program developed in a Parisian sexual health center

Background

HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' adherence and follow-up. To enhance follow-up quality and care engagement, the PrEP program developed in our Parisian sexual health center offers accompanying measures throughout the patients' course of care, relying notably on an identified and easily accessible referent. This trained paramedic counselor in sexual health provides support in organizing appointments, phone and email follow-up to answer daily questions, as well as one-on-one sessions of therapeutic support and counseling. This study aimed to assess the effectiveness of such a PrEP program among men who have sex with men (MSM).

Methods

This retrospective observational study included all MSM who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal hospital sexual health center, Paris, France. Sociodemographic characteristics, sexual practices including very high risk situations (chemsex practice and/or sexually transmitted diseases at initiation and/or history of post-exposure prophylaxis [PEP]) and course of care during the first year were described. A novel metric developed by Hendrickson et al., the PrEP success ratio at 12 months, was used to assess effectiveness of PrEP.

Results

Among the 125 MSM included in this study, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of PEP. During the first year, patients attended a median of 3 visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) of patients had a successful PrEP course, with no reported seroconversion.

Conclusions

This experiment highlights the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures set up in our sexual health center could explain the effectiveness of our PrEP program in comparison with previous studies.

Key messages

In a Parisian sexual health center that developed an HIV PrEP program with a trained paramedic counselor in sexual health, 96% of MSM achieved a successful PrEP course at 12 months. Accompanying measures for PrEP users could play a key role in achieving high PrEP success among MSM.

Coronary microvascular dysfunction in hypertrophic cardiomyopathy – impact from tissue characteristics to clinical manifestations

Background

Coronary microvascular dysfunction (CMD) is an important pathophysiological feature in hypertrophic cardiomyopathy (HCM).

Purpose

This study investigated the role of CMD in tissue characteristics, left ventricular (LV) systolic performance and clinical manifestations in HCM.

Methods

This prospective study enrolled patients with HCM without obstructive epicardial coronary artery disease. Each patient underwent cardiovascular magnetic resonance (CMR) including parametric mapping, perfusion imaging during regadenoson-induced hyperemia, late gadolinium enhancement (LGE) and three-dimensional longitudinal, circumferential and radial strains analysis. Electrocardiogram and 24 hours Holter recording were performed to assess arrhythmias.

Results

75P were enrolled, 47 (63%) males, mean age 54.6 (14.8) years; 51 patients (68%) had non obstructive HCM, mean maximum wall thickness (MWT) was 20.2 (4.6)mm, LV ejection fraction 71.6 (8.3)%, ischemic burden 22.5 (16.9)% of LV.

Greater MWT was associated the severity of ischemia (β-estimate: 1.809, 95% CI: 1.073; 2.545; p&lt;0.001).

Ischemic burden was strongly associated with higher values of native T1 (β-estimate: 9.018, 95% CI: 4.721, 13.315; p&lt;0.001).

An association between ischemia and the extent of LGE was found (β-estimate: 2.02, 95% CI: 0.93, 3.10; p&lt;0.001). Ischemia in ≥21% of LV was associated with LGE &gt;15% (AUC 0.766, sensitivity 0.724, specificity 0.659).

In multivariable analysis, in the overall population, MWT and LGE were independently associated with ischemia, however the evidence of association between ischemia and extent of LGE became weaker (β-estimate: 1.070, 95% CI: −0.106; 2.245; p=0.074).

In subgroup analysis, the association between ischemia and LGE remained significant in individuals with MWT 15–20mm, non-obstructive HCM, female and age &lt;40 years.

The severity of ischemia was not associated with markers of LV systolic function, namely LVEF, longitudinal, radial and circumferential strain

A strong evidence of association was found between ischemia and atrial fibrillation/flutter (AF/AFL) (OR: 1.481, 95% CI: 1.020,2.152; p=0.039), but no association was verified with non-sustained ventricular tachycardia.

Conclusion

In HCM, CMD is related to the severity of LV hypertrophy. Ischemia secondary to CMD promotes fibrosis and is associated with an increase in the odds of AF/ALF.

Funding Acknowledgement

Type of funding sources: None.

Utility of silent magnetic resonance angiography in the evaluation and characterisation of intracranial dural arteriovenous fistula

AIM

To evaluate the utility of silent magnetic resonance angiography (MRA) in the diagnosis, characterisation, and therapeutic planning of intracranial dural arteriovenous fistula (DAVF).

MATERIALS AND METHODS

Twenty consecutive patients with DAVF were enrolled prospectively and were evaluated using silent MRA and digital subtraction angiography (DSA) as a part of routine work-up. The diagnosis and location of fistula, Borden and Cognard classification, entire arterial feeders, and venous drainage were analysed. A therapeutic strategy was formulated, and the accessible route and vessel were predicted, which was confirmed on endovascular treatment.

RESULTS

Silent MRA was 100% sensitive and accurate for location and classification of fistulas. Silent MRA showed a sensitivity of 82% and 76.5% for entire arterial feeders and draining veins, which improved to a sensitivity of 90% and 94% when prominent feeders and immediate venous drainage was considered. Among the missed veins, thrombosed sinus, slow sinus flow, small calibre, reduced image quality were the causes. The therapeutic decision matched with DSA in all cases and silent MRA accurately identified the potential accessible feeder in 94% cases.

CONCLUSION

Silent MRA is a promising MR technique that can provide both diagnostic and therapeutic information similar to that obtained from DSA.

AB0039 AGRIN REPAIRS BONE AND CARTILAGE IN VIVO

Background:

Cartilage defects in the joints are reported in 61% of all arthroscopies1&2. The size of the cartilage repair market is estimated to be $2.195 million by 20253. Cartilage defects can evolve into osteoarthritis, in which abnormal load results in cartilage breakdown, joint pain and reduced mobility. Osteoarthritis is the leading cause of permanent disability and absenteeism and affects up to 1/3 of the people over 60yrs. In western countries osteoarthritis costs 1.5-2% of the GDP4. Joint replacement with a prosthesis restores some degree of independence but in up to 20% of patients it does not meet expectations 5 and has a limited life span. There is no pharmacological intervention that arrests or reverts the course of osteoarthritis, despite the desperate need.

We previously published that agrin plays an important role in cartilage homeostasis6. The addition of agrin to chondrocytes in vivo resulted in enhanced cartilage formation, suggesting a potential role for agrin in cartilage repair.

Objectives:

Investigate the potential of agrin for use in cartilage repair.

Methods:

Critical size osteochondral defects were generated in mice and sheep and injected intraarticularly with type I collagen gel containing agrin or vehicle. Animals were monitored for 8 weeks or 6 months respectively. MicroCT, histological analysis, qPCR, linage tracking, reporter assays, chondrogenesis assay, immunohistochemistry were performed.

Results:

A single intraarticular administration of agrin induced regeneration of critical-size osteochondral defects in mice, restoring the tissue architecture and bone-cartilage interface. Agrin stem cells to the site of injury and, through simultaneous activation of CREB and suppression of canonical WNT signalling, induced GDF5 expression and differentiation into stable articular chondrocytes, forming stable articular cartilage. In sheep, agrin treatment resulted in regeneration of bone and cartilage, which promoted increased ambulatory activity.

Conclusion:

Agrin orchestrates repair morphogenesis at the joint surface by modulating multiple signalling pathways, supporting the therapeutic use of agrin for joint surface regeneration.

References:

[1]Curl, W. W. et al. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 13, 456–460 (1997).

[2]Hjelle, K., Solheim, E., Strand, T., Muri, R. & Brittberg, M. Articular cartilage defects in 1,000 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 18, 730–734 (2002).

[3]Cartilage Repair Market Size, Share, Industry Analysis 2018-2025 | AMR. Allied Market Research https://www.alliedmarketresearch.com/cartilage-repair-market.

[4]Hiligsmann, M. et al. Health economics in the field of osteoarthritis: an expert’s consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin. Arthritis Rheum. 43, 303–313 (2013).

[5]Dieppe, P., Lim, K. & Lohmander, S. Who should have knee joint replacement surgery for osteoarthritis? Int. J. Rheum. Dis. 14, 175–180 (2011).

[6]Eldridge, S., et al. Agrin mediates chondrocyte homeostasis and requires both LRP4 and α-dystroglycan to enhance cartilage formation in vitro and in vivo. Annals of the rheumatic diseases 75 (6), 1228-1235 (2016).

Acknowledgements:

We thank the technical staff in the ARM Lab and Staff at the University of Aberdeen’s Animal Facility and Microscopy and Histology Facility for support. Funding: We gratefully acknowledge funding support of this work by the MRC (MR/L022893/1, MR/N010973/1,and MR/P026362/1), Versus Arthritis (19667, 21515, 20886, and 21621), Rosetrees Trust (A1205), the Medical College of St Bartholomew’s Hospital Trust, and the William Harvey Research Foundation.

Disclosure of Interests:

Suzanne Eldridge: None declared, Aida Barawi: None declared, Hui Wang: None declared, Anke Roelofs: None declared, Magdalena Kaneva: None declared, Zeyu Guan: None declared, Helen Lydon: None declared, Bethan Thomas: None declared, Anne-Sophie Thorup: None declared, Beatriz F Fernandez: None declared, Sara Caxaria: None declared, Danielle Strachan: None declared, Ahmed Ali: None declared, Kanatheepan Shanmuganathan: None declared, Costantino Pitzalis: None declared, James Whiteford: None declared, Fran Henson: None declared, Andrew McCaskie: None declared, Cosimo De Bari: None declared, Francesco Dell’Accio Consultant of: F.D. has received consultancy fees from Samumed and UCB.

OP0200 BLOCKING ROR2 IMPROVES CARTILAGE INTEGRITY AND PROVIDES PAIN RELIEF IN OSTEOARTHRITIS

Background:

Osteoarthritis (OA) is the leading cause of chronic disability worldwide, affecting 12% of the population, and yet we still do not have a disease-modifying treatment. Cartilage breakdown is the hallmark of OA, and patients suffer from pain and loss of joint function/independence, severely affecting quality of life. Therefore, there is a huge unmet clinical need.

Receptor tyrosine kinase–like orphan receptor 2 (ROR2) is a non-canonical WNT receptor that regulates the planar cell polarity pathway, controlling limb outgrowth during development. During skeletal development, chondrocytes require ROR2 to undergo hypertrophy throughout the process of endochondral bone formation1. Loss of function mutations in humans causes Recessive Robinow Syndrome, leading to limb shortening and brachydactyly2,3.

Although absent from healthy adult articular cartilage, our initial studies identified high expression levels of ROR2 in chondrocytes from patients with OA, suggesting a role in the disease process

Objectives:

To test the potential of ROR2 blockade as a disease-modifying treatment for OA.

Methods:

Human cartilage organoid model in nude mice, menisco-ligament injury (MLI) model of OA in mice, behavioural studies, in vitro studies in cells.

Results:

ROR2/WNT5A signaling was increased in osteoarthritic cartilage. Blocking ROR2 was sufficient to induce articular chondrogenesis and suppress expression of aggrecanases in a mesenchymal stem cell line, and to support cartilage formation in a human cartilage organoid model in nude mice using primary chondrocytes from patients with OA.

In the MLI model of OA, blocking ROR2 in therapeutic regime using atelocollagen-conjugated siRNA resulted in reduced cartilage destruction and in rapid and sustained pain relief. Due to the limited expression pattern of ROR2 in adulthood, no systemic or local toxicity were expected, nor were any observed4.

With the current technology, ROR2 blockade requires intra-articular (IA) injections of siRNA conjugated to atelocollagen every 5 days. Preliminary efficacy data of potentially longer-acting ROR2 blockers are promising.

The mechanism of action of ROR2 blockade was independent of modulation of canonical WNT signaling.

ROR2/WNT5A promoted nuclear localization of YAP, which required both Rho and G-proteins. YAP signaling downstream of ROR2 also required Rho, but not G-proteins. YAP and TEAD inhibition was required, but not sufficient, for the chondrogenic effect of blocking ROR2. Therefore, additional, yet unknown mechanisms must be involved downstream of ROR2.

Conclusion:

ROR2 blockade has potential as a disease-modifying treatment for OA, resulting in cartilage protection and rapid and sustained pain relief in a murine model. This will be crucial for clinical success of any treatment for OA and promote patient compliance.

Our current siRNA-atelocollagen based technology requires IA injections too frequently to be acceptable for patients. We are developing ROR2 blockade which can be administered systemically or IA not more often than every 3 months - work funded by FOREUM.

References:

[1]DeChiara, T. M. et al. Ror2, encoding a receptor-like tyrosine kinase, is required for cartilage and growth plate development. Nat. Genet.24, 271–4 (2000).

[2]Bokhoven, H. Van, Celli, J. & Kayserili, H. Mutation of the gene encoding the ROR2 tyrosine kinase causes autosomal recessive Robinow syndrome. Nature25, 423–426 (2000).

[3]Afzal, A., Rajab, A., Fenske, C. & Oldridge, M. Recessive Robinow syndrome, allelic to dominant brachydactyly type B, is caused by mutation of ROR2. Nature25, 419–422 (2000).

[4]Thorup, A.-S. et al. ROR2 blockade as a therapy for osteoarthritis. Sci. Transl. Med.12, eaax3063 (2020).

Acknowledgements:

We gratefully acknowledge funding support of this work by the Medical College of St Bartholomew’s Hospital Trust, the William Harvey Research Foundation, FOREUM foundation for research in rheumatology (1016807), the MRC (MR/L022893/1, MR/N010973/1, MR/P026362/1, MR/K013076/1), Versus Arthritis (21515, 20886, 21621, 20859), and the DFG Emmy-Noether program (BE4328/5-1).

Disclosure of Interests:

Anne-Sophie Thorup: None declared, Danielle Strachan: None declared, Sara Caxaria: None declared, Blandine Poulet: None declared, Bethan Thomas: None declared, Suzanne Eldridge: None declared, Giovanna Nalesso: None declared, James Whiteford: None declared, Costantino Pitzalis: None declared, Thomas Aigner: None declared, Roger Corder: None declared, Jessica Bertrand: None declared, Francesco Dell’Accio Consultant of: Samumed and UCB

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Association between microvascular dysfunction and impaired myocardial deformation in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Objective

To analyze the relationship between coronary microvascular dysfunction (MCD) and left ventricular (LV) myocardial deformation in hypertrophic cardiomyopathy (HCM). 

Methods

Prospectively inclusion of HCM patients (P). MCD was assessed by CMR, during regadenoson-induced hyperemia. For perfusion assessment, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer). Ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Epicardial coronary artery disease was excluded by computed tomography or invasive coronary angiography.

LV myocardial deformation was evaluated by 2D and 3D speckle-tracking echocardiography (STE), including global longitudinal strain (GLS), peak systolic dispersion (PDS), global circumferential strain (GCS), global radial strain (GRS), area strain, twist and torsion.

Results

31 P enrolled (51%male,age57.8 ± 15.5years). Asymmetric septal hypertrophy was seen in 55%, apical in 29%, concentric in 16%,maximal wall thickness (MWT) of 20.5 ± 4.9mm; 26% with LVOT obstruction; LV ejection fraction 67.9 ± 7.9%.

In 2DSTE analysis, P with more ischemia (&gt;20%of LV) presented more severe impaired GLS and greater PDS, comparing with patients with ≤20% of ischemia.

Similarly, 3DSTE imaging showed worse LV performance in P with greater ischemic burden, expressed by significant difference in GLS, GRS and area strain. GCS also trended to be worse in the presence of &gt;20% of ischemia.

The stronger correlation was found between 2D GLS and ischemic burden (Pearson correlation factor 0.545; p = 0.002).

Conclusion

In HCM, the severity of ischemia secondary to MCD was associated with impairment in LV myocardial deformation evaluated by 2D and 3D STE.

Table 1. Echocardiography Ischemic burden (% of LV) 2D parameters ≤ 20% (n = 15) &gt; 20% (n = 16) p-value GLS (%) -15.6 ± 2.7 -12.1 ± 4.7 0.016 PSD (ms) 73.2 ± 25.6 102.1 ± 57.6 0.150 3D parameters GLS (%) -10.3 ± 4.5 -7.3 ± 3.0 0.010 GCS (%) -12.6 ± 3.0 -10.1 ± 4.5 0.079 GRS (%) 30.8 ± 8.5 22.8 ± 11.4 0.035 Area strain(%) -20.8 ± 4.9 -15.8 ± 6.3 0.020 Twist (deg) 6.0 ± 4.8 4.1 ± 4.0 0.175 Torsion (deg/cm) 1.2 ± 0.9 0.8 ± 0.7 0.232

Acute Ischemic Stroke or Epileptic Seizure? Yield of CT Perfusion in a "Code Stroke" Situation

BACKGROUND AND PURPOSE

The clinical differentiation between acute ischemic stroke and epileptic seizure may be challenging, and making the correct diagnosis could avoid unnecessary reperfusion therapy. We examined the accuracy of CTP in discriminating epileptic seizures from acute ischemic stroke without identified arterial occlusion.

MATERIALS AND METHODS

We retrospectively identified consecutive patients in our emergency department who underwent CTP in the 4.5 hours following the development of an acute focal neurologic deficit who were discharged with a final diagnosis of acute ischemic stroke or epileptic seizure.

RESULTS

Among 95 patients, the final diagnosis was epileptic seizure in 45 and acute ischemic stroke in 50. CTP findings were abnormal in 73% of the patients with epileptic seizure and 40% of those with acute ischemic stroke. Hyperperfusion was observed more frequently in the seizure group (36% versus 2% for acute ischemic stroke) with high specificity (98%) but low sensitivity (35%) for the diagnosis of epileptic seizure. Hypoperfusion was found in 38% of cases in each group and was not confined to a vascular territory in 24% of patients in the seizure group and 2% in the acute ischemic stroke group. The interobserver agreement was good (κ = 0.60) for hypo-, hyper-, and normoperfusion patterns and moderate (κ = 0.41) for the evaluation of vascular systematization.

CONCLUSIONS

CTP patterns helped to differentiate acute ischemic stroke from epileptic seizure in a "code stroke" situation. Our results indicate that a hyperperfusion pattern, especially if not restricted to a vascular territory, may suggest reconsideration of intravenous thrombolysis therapy.

Random-pattern versus perforator-based adipocutaneous skin paddles for postoperative monitoring of free muscle flaps-a comparative retrospective cohort study

INTRODUCTION

Free microvascular muscle flaps represent well-established reconstructive options for complex soft tissue defects. However, due to their lack of cutaneous capillary beds, they are difficult to monitor postoperatively. To this end, random and axial-pattern adipocutaneous skin paddles are often included. The objective of the study was to compare the impact of random-pattern versus perforator-based adipocutaneous skin paddles on operative efficacy and muscle flap safety.

METHODS

Between August 2014 and July 2016, a total of 120 free muscle flaps were included in this retrospective monocentric cohort study. Based on their skin-paddle type, they were either grouped into a 'perforator-based' (group Pb) or 'random-pattern' (group Rp) cohort. The electronic medical records and operative reports of all patients were subsequently reviewed and patient, defect, and flap characteristics of both groups were compared. The effect of the competing skin paddle types on the overall operative time, incidences of flap loss or microvascular complications, and total length of hospital stay were then assessed.

RESULTS

Group Pb comprised 72 flaps, whereas 48 flaps constituted group Rp. Patient, defect, and flap characteristics were similar between both groups. Groups Pb and Rp were comparable regarding patient age (group Pb: 61 (10-90) vs. Rp: 59 (13-81), p = 0.556), ASA (American Society of Anesthesiologists) class (group Pb: 3 (1-4) vs. Rp 3 (1-3), p = 0.977), and comorbidities, summarized by the Charlson comorbidity index (CCI; group Pb: 1 (0-4 vs. Rp: 1 (0-5), p = 0.295). Both types of monitoring skin paddles were equally reliable. There was no significant difference in the mean operation time between both groups (group Pb: 373 ± 122 min vs. Rp: 342 ± 84 min, p = 0.124). In-patient treatment after flap surgery and total length of hospital stay were significantly shorter in group Pb (group Pb: 24 ± 10 days vs. Rp: 32 ± 17 days, p = 0.002 and group Pb: 39 ± 15 vs. Rp: 48 ± 24, p = 0.022).

CONCLUSION

Perforator-based skin paddles are a reliable tool for postoperative perfusion monitoring of free muscle flaps and help avoid additional surgical interventions as opposed to their random-pattern counterparts. Thus, the overall and postoperative length of hospital stay is significantly reduced.

Myocardial work: a new way to predict fibrosis in patients with hypertrophic cardiomyopathy

Aims

Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) adds prognostic information in patients with hypertrophic cardiomyopathy (HCM). Whether Myocardial work (MW), a new parameter on transthoracic echocardiographic (TTE), can predict significant fibrosis in HCM patients is unknown.

Methods

Single-centre evaluation of consecutively recruited HCM patients in which TTE and CMR were performed. MW and related indices were calculated from global longitudinal strain (GLS) and from estimated left ventricular pressure curves. The extent of LGE was quantitatively assessed. LGE ≥15% was chosen to define significant fibrosis.

Logistic regression analysis was used to find the variables associated with LGE ≥15% and cut-off values were determined.

Results

Among the thirty-two patients analysed mean age was 57±16 years, 18 (56%) were male patients and the mean left ventricular ejection fraction by TTE was 67±8%.

Global constructive work (GCW), global work index and GLS were significant predictors of LGE ≥15%. A cut-off ≤1550 mmHg% of GCW was able to predict significant fibrosis with a sensitivity of 92% and a specificity of 79%, while the best cut-off for GLS (&gt;−15%) had a sensitivity of 86% and a specificity of 72%.

Conclusion

GCW was the best parameter to predict significant left ventricular myocardial fibrosis in CMR, suggesting its utility in patients who may not be able to have a CMR study.

Myocardial Work and LGE in CMR in HCM

Funding Acknowledgement

Type of funding source: None