Computational Approaches and Observer Variation in the 3D Musculoskeletal Modeling of the Heads of Anolis

High-resolution imaging, 3D modeling, and quantitative analyses are equipping evolutionary biologists with new approaches to understanding the variation and evolution of the musculoskeletal system. However, challenges with interpreting DiceCT data and higher order use of modeled muscles have not yet been fully explored, and the error in and accuracy of some digital methods remain unclear. West Indian Anolis lizards are a model clade for exploring patterns in functional adaptation, ecomorphology, and sexual size dimorphism in vertebrates. These lizards possess numerous jaw muscles with potentially different anatomies that sculpt the adductor chamber of the skull. Here we test approaches to quantifying the musculoskeletal shape of the heads of two species of Anolis: A. pulchellus and A. sagrei. We employ comparative approaches such as DiceCT segmentation of jaw muscles, 3D surface attachment mapping, and 3D landmarking with the aim of exploring muscle volumes, 3D muscle fiber architecture, and sexual dimorphism of the skull. We then compare sources of measurement error in these 3D analyses while also presenting new 3D musculoskeletal data from the Anolis feeding apparatus. These findings demonstrate the accessibility and repeatability of these emerging techniques as well as provide details regarding the musculoskeletal anatomy of the heads of A. pulchellus and A. sagrei which show potential for further research of comparative biomechanics and evolution in the clade.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Addressing high cervical cancer rates in the Rio Grande Valley along the Texas-Mexico border: a community-based initiative focused on education, patient navigation, and medical provider training/telementoring

AIMS

Cervical cancer incidence and mortality rates are approximately 55% higher in the Rio Grande Valley (RGV) along the Texas-Mexico border compared with the average rates in the US. Our aim was to improve cervical cancer prevention efforts in the RGV through a comprehensive multilevel intervention initiative focused on community education, patient navigation, and training of local providers.

METHODS

We initiated a program in the RGV which consisted of (1) community education, (2) patient navigation, and (3) a training/mentoring program for local medical providers including hands-on training courses coupled with telementoring using Project ECHO® (Extension for Community Health Outcomes). We assessed the number of women undergoing cervical cancer screening, diagnosis, and treatment at three participating clinics caring for underserved women in the region.

RESULTS

From November 2014 to October 2018, 14,846 women underwent cervical cancer screening. A total of 2030 (13.7%) women underwent colposcopy for abnormal results (179% increase over baseline) and 453 women underwent loop electrosurgical excision procedures (LEEPs) for treatment of cervical dysplasia. Invasive cancer was diagnosed in 39 women who were navigated to a gynecologic oncologist for treatment. Seven local medical providers were trained to perform colposcopy and/or LEEP. Project ECHO telementoring videoconferences were held every 2 weeks for a total 101 sessions with an average of 22 participants per session and a total of 180 patient cases presented and discussed.

CONCLUSIONS

Our program led to a large number of women undergoing diagnosis and treatment of cervical dysplasia in the RGV. If sustained, we anticipate these efforts will decrease cervical cancer rates in the region. The program is currently being expanded to additional underserved areas of Texas and globally to low- and middle-income countries.

Cardiac pressure overload exposes hidden anthracycline-induced cardiotoxicity: results from a preclinical large-animal trial

Aim

The purpose of this work is to elucidate if low cumulative doxorubicin doses has a differential cardiac impact in pigs with or without pre-existing LV pressure overload. Impact of interventions on LV anatomy, function and tissue composition was evaluated by serial cardiac magnetic resonance (CMR). At the end of the in vivo protocol, hearts were processed to evaluate differential molecular pathways in both groups.

Methods

A total of 95 pigs were included. 52 animals underwent supravalvular aortic banding to generate LV hypertrophy, while another did not. 4 months after banding (a time where LV hypertrophy is prominent), animals in both groups were randomized to receive intravenous doxorubicin (1 mg/kg once per week, for 5 weeks) or saline. Thus, 4 study groups (N=15–22 per group) comprised the study population (banding yes/no, doxorubicin yes/no). All individuals underwent to serial Cardiac Magnetic Resonance exams every month and were sacrificed fo ex vivo analysisat 4 months after doxorubicin injections. To discriminate between doxorubicin effect in banding/no banding groups but also the effect of banding in doxorubicin protocols, t-test was used for two-group comparisons after two-way ANOVA test. Differences were considered statistically significant at p&lt;0.05. Logrank test was performed to compare survival curves.

Results

Pigs receiving doxorubicin after cardiac pressure overload showed an increased mortality compared with the other groups (p=0.006). Only this group developed a progressive cardiotoxicity phenotype, characterized as a significant decline in cardiac function compared with control operated animals (49.7% ± 8.1 vs 79.6% ± 6.7, p&lt;0.001), but also with non-operated pigs receiving the same anthracycline regime (vs 63.9% ± 4, p&lt;0.001). Cardiac deterioration was based mainly on systolic dysfunction compared with control operated animals (38.2 ml indexed ± 3.5 vs 13.6±6.6, p=0.01) and non-operated pigs treated with doxorubicin (vs 26.6 ml indexed ± 6.6, p&lt;0.001). In-vivo CMR tissue characterization revealed elevation on T2 relaxation times compared with Control animals (46.2 ms ± 3.5 vs 41.8±2.7, p=0.04) with no Extracellular Volume expansion. Ex-vivo histological analyses showed presence of intra-cardiomyocyte vacuolization in the Banding + DOXO group (p=0.01). Regarding mitochondrial phenotype, animals with Banding + DOXO exhibited a fragmented phenotype with extremely damaged mitochondria. Animals with only aortic banding exhibit increasing cardiac hyperkinesia and cardiac hypertrophy at the end of the study.

Conclusion(s)

We demonstrated that a very low dosage of doxorubicin is enough to exert cardiotoxicity in a pressure overload scenario. Characterized as a deterioration in cardiac function, myocardial edema, classical histological lesions and mitochondrial damage. Providing preclinical evidence that modest anthracycline protocols may be harmful for patients with cardiac comorbidities.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ERC MATRIX

432 Nemvaleukin alfa, a novel engineered IL-2 cytokine, in combination with the anti-PD-1 antibody pembrolizumab in patients with recurrent/metastatic head and neck squamous cell carcinoma (ION-01 study)

Background

Nemvaleukin alfa (nemvaleukin, ALKS 4230) is a novel engineered cytokine that selectively binds to the intermediate-affinity IL-2R to preferentially activate and expand anti-tumor CD8+ T and NK cells with minimal expansion of regulatory T cells (Treg), thereby leveraging antitumor effects of the IL-2 pathway while mitigating potential toxicity that limits use.1 Nemvaleukin single-agent activity has been demonstrated in checkpoint inhibitor-experienced patients, and deep and durable responses have been achieved in combination with pembrolizumab in multiple tumor types (eg, breast, head and neck, gastrointestinal, genitourinary, gynecological).2

Methods

ION-01 (NCT04144517) is a nonrandomized trial in adult patients with histologically/cytopathologically confirmed diagnosis of metastatic/recurrent head and neck squamous cell carcinoma. Eligible patients have progressive disease after ≥8 weeks on anti-PD-(L)1 therapy. The primary endpoint is the rate of new or improved antitumor response after the addition of nemvaleukin. Secondary objectives include characterization of the antitumor response and evaluation of safety and tolerability of the combination regimen. Patients receive intravenous nemvaleukin (3 μg/kg) once daily for the first 5 days and pembrolizumab (200 mg) on day 1 of each 21-day cycle. Tumor imaging and biopsies were performed at baseline and at pre-specified times. We present preliminary safety and antitumor activity (RECIST v1.1) data as of June 2021.

Results

Fourteen patients with progressive disease received combination therapy with nemvaleukin and pembrolizumab; 8 had no prior response to pembrolizumab, 6 had previous best response of stable disease or partial response. Mean (± SD) age was 62 ± 12 years, 86% were male, and all were Caucasian. Prior anti-cancer therapy included radiotherapy (93%) and surgery (50%). ECOG performance status was 0 (14%) and 1 (86%) at baseline. Treatment-related adverse events of any grade in ≥30% of patients were chills (64.3%), pyrexia (57.1%), fatigue (42.9%), and nausea (35.7%). Five patients had stable disease as best response. One patient achieved a partial response (complete response in the target lesion) and remains on treatment (8+ cycles). Expansion of CD8+ T and NK cells with minimal Treg expansion was observed.

Conclusions

Nemvaleukin and pembrolizumab combination therapy was generally well tolerated; adverse events were consistent with those observed with intravenous nemvaleukin in ARTISTRY studies [2]. Peripheral immune cell expansion profiles are comparable to that observed with the same regimen in the ARTISTRY 1 phase 1 study. Emerging data from pretreatment and on-treatment paired biopsies will further characterize specific antitumor effects of nemvaleukin and pembrolizumab in this patient population.

Acknowledgements

The authors would like to thank all the patients who are participating in this study and their families. The study is sponsored by Alkermes, Inc. Medical writing and editorial support was provided by Parexel, and funded by Alkermes, Inc.

Trial Registration

ClinicalTrials.

gov NCT04144517

References

Lopes JE, Fisher JL, Flick HL, et al. ALKS 4230: a novel engineered IL-2 fusion protein with an improved cellular selectivity profile for cancer immunotherapy. J Immunother Cancer 2020;8:e000673. doi: 10.1136/jitc-2020-000673.

Boni V, Winer IS, Gilbert L, et al. ARTISTRY-1: Nemvaleukin alfa monotherapy and in combination with pembrolizumab in patients (pts) with advanced solid tumors. J Clin Oncol 2021;39(Suppl 15):abstr 2513.

Ethics Approval

This study was approved by Quorum Review IRB (now Advarra IRB), approval number QR 33752.

Oral anticoagulation therapy with rivaroxaban in elderly patients with atrial fibrillation. Results from EMIR study

Background

Atrial fibrillation (AF) in elderly patients increases both bleeding and thromboembolic risks. Elderly patients benefit as much from anticoagulation therapy with positive net clinical benefit. However, there have been few studies that focused on the efficacy and safety of direct oral anticoagulants in elderly patients.

The aim of this subanalysis from EMIR study was to assess the effectiveness of rivaroxaban in patients older than 75 years old.

Methods

EMIR Study (acronym from 'Estudio observacional para la identificaciόn de los factores de riesgo asociados a eventos cardiovasculares Mayores en pacientes con fIbrilaciόn auricular no valvular tratados con un anticoagulante oral directo (Rivaroxaban)') was an observational, multicenter, post-authorization and prospective study that involved AF patients under oral anticoagulation with rivaroxaban at least 6 months before enrolment. We analyzed baseline clinical characteristics and adverse events after 2.5 years of follow up.

Results

We analyzed 1,433 patients with median age of 74.7 (67.7–81.6). Of them 691 (48.2%) were ≥75 years. Elderly patients had higher prevalence of cardiovascular risk factors such previous stroke (16.8% vs 8.5%; p&lt;0.001), heart failure (25.0% vs 20.6%; p&lt;0.001), higher CHA2DS2-VASc (4.4±1.3 vs 2.7±1.2; p&lt;0.001) and HAS-BLED (1.9±1.0 vs 1.2±1.0; p&lt;0.001) scores. After 2.5 (2.2–2.6) years of follow-up, we observed low rate of adverse events in patients under rivaroxaban therapy. We observed higher rate of adverse events in elderly population for thromboembolic events (1.13%/year vs 0.36%/year; p=0.017) and major bleeding events (1.80%/year vs 0.36%/year; p&lt;0.001) but those adverse rates were lower than expected according to previous studies (i.e. ROCKET-AF trial, rivaroxaban group had 4.86%/year of major bleeding or in XANTUS study was 3.2%/year of major bleeding in patients &gt;75 years). We did not observe differences between groups from MACE (1.13%/year vs 1.01%/year; p=0.875) or cardiovascular death (0.86%/year vs 0.42%/year; p=0.170).

Conclusion

In real-world elderly population, rivaroxaban showed higher rates of thromboembolic and major bleeding events in elderly patients but with annual rates lower than expected according to previous studies like ROCKET-AF or XANTUS. Similar annual rates in elderly were observed for MACE and cardiovascular mortality than in younger patients, being rivaroxaban a good therapeutic alternative even for the elderly.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania S.L.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

POS0501 SUSTAINED 2-YEAR REMISSION OF THE DISEASE IN A CLINIC OF EXCELLENCE IN RHEUMATOID ARTHRITIS. EXPERIENCE OF THE CLINICAL REGISTRY IN COLOMBIA

Background:

Rheumatoid arthritis (RA) is a chronic autoimmune disease with no cure, characterized by episodes of exacerbation and remission, which requires permanent use of medications. Clinics of excellence are multidisciplinary and centralized programs that improve adherence to treatments. Information on the benefits of these models of care has been published but is not definitive. In Colombia, the clinical registry of patients with RA is kept in the Cuenta de Alto Costo (CAC).

Objectives:

To demonstrate the difference in the percentages of sustained remission at 2 years, between an institution with non-centralized management or standard of care (Hospital Militar Central-HMC) compared to another institution with centralized management or clinic of excellence (BIOMAB-IPS) and determine if the results are determined by any of the intervention variables or by the program.

Methods:

The 2-year clinical records for the CAC were compared between an institution with non-centralized management (HMC) in comparison with another institution with centralized management (BIOMAB-IPS), performing a sociodemographic description, measuring control of the disease DAS28 clinimetry, Fisher’s test non-parametric bivariate analysis, multiple regression model, and population matching with Propensity score Matching (PSM).

Results:

Complete information was obtained from 2 years of follow-up, in centralized management 3457 patients and for the non-centralized unit 114 patients. Most of them corresponded to 2962 women (82%), with time of illness of 9.5 years and 10.2 years, respectively, without statistically significant differences. A difference was observed in the 2 programs to maintain remission at 2 years, in favor of the centralized program 54.7% vs 28.6.2% (p <0.00). With the binomial generalized linear regression model, it was confirmed that this difference was not explained by variables such as the use of biological therapy (RR = 0.77; 95% CI 0.69-0.86), use of DMARDs (RR = 0.71; 95% CI 0.62-0.82) and number of rheumatology consultations (RR = 0.97; 95% CI 0.92-1.02) in comparison with the centralized care model (RR = 2.32; 95% CI 1.58-3.35). Due to the biases between the groups due to the non-probability sampling, a PSM was performed, with a 1: 1 match, caliper of 0.065, obtaining a pseudo population with well-balanced covariates (see table 1). In the common support area, statistically significant differences were documented in sustained remission over 2 years, in favor of the centralized care group 45 vs 17.9% (p = 0.001).

Conclusion:

With the information from the clinical records, statistical strategies can be used to evaluate important differences in centralized care programs, observing favorable results of these types of care that are not related to isolated elements of the program, but to the overall effect of the program.

References:

[1]Austin PC. Double propensity-score adjustment: A solution to design bias or bias due to incomplete matching. Stat Methods Med Res. 2017;26(1):201–22.33333

Disclosure of Interests:

Juan Manuel Bello-Gualtero: None declared, Esperanza Peña: None declared, Pedro Iván Santos Moreno: None declared, Jasmin Vesga Gualdrón Employee of: Baxter, Ginna Saavedra: None declared, Clara Perez: None declared

Stem cells from human dental pulp and apical papilla: Morphological and synchrotron radiation analysis

Background

Material and Methods

Results

Conclusions

Implication of heat shock proteins in rotavirus entry into Reh cells

The mechanisms of rotavirus entry into the target cell are described as a multi-step event in which the virions are bound to sialic acid (SA), followed by interaction with heat shock cognate protein 70 (Hsc70), some integrins and protein disulfide isomerase (PDI). However, the cell surface receptor molecules facilitating the entry of tumor cell-adapted rotavirus are not completely characterized. Using infection blocking assays with antibodies to some heat shock proteins (HSPs) and also some inhibitors of these cellular proteins, we were able to identify the cell surface Hsp90, Hsp70, Hsc70, Hsp60, Hsp40, PDI and integrin β3 as receptors of tumor cell-adapted rotavirus in Reh cells. Furthermore, the results also indicated that these rotavirus receptors are associated with lipid microdomains (rafts). Our findings provide evidence that rotavirus tropism for these human acute lymphocytic leukemia cells is explained by the relatively high expression of some HSPs in rafts. The results shown here encourage further research aim at evaluating the potential use of rotaviruses as an oncolytic agent for the treatment of some cancers. Keywords: heat shock proteins; rotavirus; cell receptor; cancer; oncolytic virus.

Objective Histologic Characterization of Trophoblastic Proliferations

Introduction/Objective

Placental site nodules (PSNs) are rare intermediate trophoblastic lesions characterized by hyalinized cellular aggregates that are small, well-circumscribed, non-necrotic, and paucicellular. PSNs are generally incidental in gynecologic specimens. ETTs are malignant proliferations of intermediate trophoblasts and are generally larger, with nuclear atypia, and higher mitotic rate. Atypical placental site nodules (APSNs) are histologically intermediate between PSN and ETT and not well characterized in the literature to date. There exists room for more objective characterization of PSN and APSN. We use objective measurements to characterize trophoblastic proliferations based on size, location, mitotic rate, number of trophoblasts per high-power field (t-HPF), ki-67 index, beta-hCG, time since last pregnancy, presence of calcification or necrosis, and clinical follow-up.

Methods

The surgical pathology database of a single large academic institution was searched for cases of “placental site nodule,” “atypical placental site nodule,” “epithelioid trophoblastic tumor,” and “placental site trophoblastic tumor”. Clinical and morphologic data were recorded for each case. Ki-67/cytokeratin AE1/AE3 dual immunohistochemical stains were performed to assess the proliferative index of the trophoblastic cells.

Results

70 cases of trophoblastic lesions (53 PSN, 4 APSN, 5 ETT, 8 PSTT) were identified. Results include: PSNs were on average 3.2 mm, 56.5 t-HPF, and 2.6% ki-67. APSNs 4.3 mm, 97.8 t-HPF, and 6.4% ki-67. ETTs 16.5 mm, 161.8 t-HPF, and 12.2% ki-67.

Conclusion

Objective measurements of trophoblastic lesions, as well as correlation with clinical data, may be useful for more accurate classification of these lesions, especially by those who encounter them rarely. To date, the clinical risk, optimal management, and risk for progression of APSNs are not well characterized and thus are worthy of additional study and description. For example, in our data, 14 cases originally signed out at PSN were at least 4 mm, which may re-classify them as APSN.

Case of anti-Zic4 antibody-mediated cerebellar toxicity induced by dual checkpoint inhibition in head and neck squamous cell carcinoma

Combined checkpoint inhibition therapy targeting the programmed cell death 1 (PD-L1) and cytotoxic T-lymphocyte associated protein 4 pathways has been a successful approach in the treatment of metastatic melanoma, leading to its investigation in the treatment of head and neck squamous cell carcinoma (HNSCC) with PD-L1 expression. Despite the potential for excellent responses, an increased rate of autoimmune neurological toxicity and paraneoplastic conditions has been observed when using these treatment modalities. We present the case of a patient with metastatic HNSCC treated with combination ipilimumab/nivolumab who experienced severe cerebellar ataxia with a positive screen for the anti-Zic4 antibody. This is the first case, to our knowledge, of anti-Zic4 antibody-mediated cerebellar toxicity reported in association with HNSCC. Although the patient experienced an impressive partial response with dual checkpoint inhibition, he suffered grade 4 neurotoxicity. Despite exciting advances in cancer immunotherapy, clinicians must be aware of the rare, debilitating and possibly previously undescribed paraneoplastic and autoimmune toxicities that may occur.

Ethical surgical triage of patients with head and neck cancer during the COVID-19 pandemic

BACKGROUND

Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended.

METHODS

An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made.

RESULTS

Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions.

CONCLUSIONS

We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns.

P837 Isolated cleft posterior mitral valve leaflet

A 78-year-old man with a history of hypertension and diabetes mellitus was referred to the ER of our hospital due to an episode of shortness of breath of new onset, associated with dizziness and central thoracic pain of 5 minutes duration. Significant physical examination findings included a V/VI holosystolic murmur at fourth intercostal space with radiation to the axilla. ECG showed no significant abnormalities and cardiac enzymes were within normal ranges The TTE and 3D TOE showed dilated left atrial with normal ventricular size and function with an isolated cleft posterior mitral valve leaflet that bisected into two separate leaflets of identical morphology. Concomitant posterolateral leaflet prolapse was also present with two eccentric, posteriorly, and interatrial septum directed regurgitant jets visualized with colour flow Doppler.

Cleft mitral valve leaflet (CMVL) is an uncommon congenital cause of mitral regurgitation. Clefts are slit-like holes or defects hypothesized to be a result of incomplete expression of an endocardial cushion defect and most commonly involve the anterior mitral valve leaflet with a paediatric incidence of 1:1340. Clefts affecting only the posterior mitral valve leaflet are extremely rare . Important co-existing anomalies with either posterior and/or anterior CMVL include counterclockwise rotation of the papillary muscles, the presence of an accessory papillary muscle or mitral valve leaflet, atrial septal defects, and mitral valve prolapse. Acquired causes of clefts include infective endocarditis or trauma from surgical exploration.

Regurgitation in CMVL results from blood flow directly through the cleft itself or from malcoaptation from accessory chordae with or without papillary muscle distortion. Early detection through 3D TEE echocardiography can provide accurate anatomical images of the mitral valve structure and identify associated congenital anomalies.

Conclusion

Posterior CMVL is an extremely rare cause of mitral insufficiency. 3D TEE early recognition of this rare clinical entity and co-existent anomalies can identify afflicted patients who can be closely monitored for the progression of symptoms as well as ventricular dysfunction. 3D TEE permits a personalized medicine tailoring the medical treatment to the individual characteristics of each patient.

Abstract P837 Figure. Isolated cleft posterior mitral valve

P1716 Aorto-left atrial fistula with left atrium dissection

Conclusion

Aorto atrial fistulas are rare but important complications of many disease processes of the aorta and aortic valve. Classical clinical signs of continuous murmurs may not be present and echocardiography forms the cornerstone of diagnosis. AAF should be suspected in patients with poorly controlled heart failure and prior aortic surgery. Prompt surgical repair is usually helpful in relieving symptoms and decreasing mortality.

Abstract P1716 Figure. Aortoatrial fistula

P1720 Hammock mitral valve, a challenging echocardiographic diagnosis

Conclusion

Congenital mitral valulophaty is a rare condition in the adulthood. The estimated prevalence is 0,5%. The hammock mitral valve is a more uncommon pathology which affects the mitral valve and subvalvular apparatus. This anomaly, was first described in 1967 and it is characterised by anomalous papillary muscles directly connected to the anterior mitral valve by a fibrous bridge without chordae tendineae in between them. This fibrous bridge hampers the opening and closure of the mitral valve.

Diagnosis requires a high index of suspicion, both ultrasound studies and medical history, to avoid misdiagnosis.

Abstract P1720 Figure.

481 Mass compromising left atrium

Conclusion

Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. Its diagnosis requires a high index of suspicion.

Predisposing factors and catheterization, surgical or pathologic findings should be reviewed in order to identify the pathogenic mechanism . Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, blunt chest trauma and iatrogenic PCI are related to its development.

Abstract 481 Figure. MASS COMPROMISIN LEFT ATRIUM

Factors associated with quit attempts and smoking cessation in Brazil: findings from the International Tobacco Control Brazil Survey

OBJECTIVES

This study aimed to identify factors associated with attempting to quit and successful smoking cessation in a population-based sample of Brazilian smokers.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Data came from the first two waves of the International Tobacco Control Brazil Survey, conducted in 2009 and 2012/2013 in three cities: Rio de Janeiro, São Paulo, and Porto Alegre. Data were collected from 488 adults (aged ≥18 years) who smoked at Wave 1 and who were resurveyed at Wave 2. Crude and adjusted relative risks for two outcomes (making a quit attempt between Wave 1 and Wave 2 and successfully quitting by Wave 2) were estimated. Multivariable multilevel logistic regression models were used, whereby variables were added to the models in a series of blocks.

RESULTS

Nearly two-thirds (65.6%) of smokers attempted to quit between waves, and 23.4% had quit at Wave 2. Intention to quit smoking at Wave 1 was the only variable associated with attempt to quit by Wave 2 (odds ratio [OR] = 2.85; 95% confidence interval [CI] 1.64-4.94; P < 0.001). Smokers of higher socio-economic status (OR high versus low = 1.80; 95% CI 1.05-3.10; P = 0.03) and lower nicotine dependence (OR low Heaviness of Smoking Index [HSI] versus high HSI = 1.94; 95% CI 1.10-3.43; P = 0.02) were more likely to successfully quit. The presence of another adult smoker at home was negatively related to successful quitting (OR = 0.50; 95% CI 0.26-0.94; P = 0.03).

CONCLUSIONS

These results are generally consistent with prior research and have potential to inform governmental interventions to promote tobacco cessation, particularly among disadvantaged groups.

Upstaging papillary lesions to carcinoma on surgical excision is not impacted by patient race

BACKGROUND

The management of papillary lesions is controversial with studies showing different rates of upstaging to malignancy. There is a paucity of research into race as an independent risk factor. The aim of this study is to identify if race is correlated with upstaging to malignancy with a secondary focus of analyzing for other personal and tumor specific risk factors for upstaging.

METHODS

We performed a retrospective review of 123 papillary lesions with univariate analysis to identify risk factors for upstaging.

RESULTS

The incidence of papillary lesions found on core needle biopsy was 6%. Atypical papillary lesions were most likely to be upstaged to malignancy at a rate of 27.7%. Papillary lesions and papillary lesions with hyperplasia were also upstaged to cancer at a lower rate of 8.3% and 12.5%, respectively. A univariate analysis of all papillary lesions and a separate analysis of atypical lesions demonstrated a higher likelihood of upstage based on BIRADS classification. Race, age, size of tumor and other radiographic features were not associated with an increased risk for upstaging to malignancy.

CONCLUSIONS

Atypia remains the most significant contributor to the risk of upstaging papillary lesions to malignancy. Our research supports the practice of excising all atypical papillary lesions with selected excision of those without atypia. In our cohort, there was no association between race and risk of upstaging to malignacy.

Radioactive Iodine-Refractory Differentiated Thyroid Cancer in the Elderly

Most common thyroid cancers are differentiated thyroid cancers (DTCs) and have papillary, follicular, or Hürthle cell morphology. Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the thyroid gland. The incidence of DTC increases with age. While most of the patients with DTC have an excellent prognosis, the outcome can be poor when diagnosed in elderly patients.

PURPOSE OF REVIEW

Current treatment approach for DTC includes surgery, thyroid-stimulating hormone (TSH) suppression, radioactive iodine, external beam radiotherapy, or systemic treatments such as kinase inhibitors. Radioactive iodine therapy (RAI) is the primary first-line systemic treatment for advanced DTC. However, during the course of treatment, the tumor may become refractory to RAI. Elderly patients are more likely to be diagnosed with advanced disease that can be refractory to RAI.

RECENT FINDINGS

The advent of TKIs (tyrosine kinase inhibitors) and their usage in RAI refractory disease has shown improved progression-free survival. These agents are, however, associated with increased toxicity. The variable nature of disease and toxicity associated with the systemic therapy makes it important to have an individualized approach to management, especially in the elderly population who can be more susceptible to toxicities.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Removal of Cu2+ and Ni2+ from Aqueous Solution using SnO2 Nanomaterial effect of: pH, Time, Temperature, interfering cations

Tin oxide, SnO₂, nanomaterial was synthesized and tested for the removal of Cu²⁺ and Ni²⁺ ions from aqueous solutions. Various parameters for the binding were investigated in batch studied, which included pH, time, temperature, and interferences. In addition, isotherm studied were performed to determine the maximum binding capacity for both Cu²⁺ and Ni²⁺ ions. The optimal binding pH determined from the effects of pH were to be at pH 5 for both the Cu²⁺ and Ni²⁺ ions. The isotherm studies were performed at temperatures of 4°C, 25 °C, and 45 °C for both the Cu²⁺ and Ni²⁺ ions and were found to follow the Langmuir isotherm model. The binding capacities for the Cu²⁺ ions were 2.63 mg/g, 2.95 mg/g and 3.27 mg/g at the aforementioned temperatures, respectively. Whereas the binding capacities for Ni²⁺ were 0.79 mg/g, 1.07 mg/g, and 1.46 mg/g at the respective temperatures. The determined thermodynamic parameters for the binding showed that the binding processes for the reactions were endothermic, as the ΔG was observed to decrease with decreasing temperatures. As well the ΔH was 28.73 kJ/mol for Cu²⁺ (III) and 13.37 kJ/mol for Ni²⁺. The ΔS was observed to be 92.65 J/mol for Cu²⁺ and 54.53 J/mol for Ni²⁺. The free energy of adsorption for the Cu²⁺ was determined to be 13.99 kJ/mol and the activation energy for the binding of Ni²⁺ was determined to be 8.09 KJ/mol. The activation energy data indicate that the reaction was occurring through chemisorption.