Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A novel method for quantification of cefazolin local tissue concentration in blood, fat, synovium, and bone marrow using liquid chromatography - mass spectrometry

To be effective, the concentration of antibiotic used must exceed the minimum inhibitory concentration (MIC) against infecting organisms at and in the surgical site. Few studies follow antibiotic levels for tissues that are manipulated during surgery. The aim of this work was to develop and validate a novel LC-MS method as well as an efficient extraction technique for the quantification of cefazolin in local tissues and whole blood. This method uses the same efficient extraction method across multiple tissue types affected by orthopedic surgery: blood, fat, synovium, and bone marrow. The ability to quantify cefazolin in these tissues will help identify surgical techniques and antibiotic dosing protocols that better protect patients from infection. The internal standard, 13C2,15N-cefazolin, co-elutes with cefazolin, and was used in calibration curves and tissue extracts as well as for cefazolin recovery and matrix effects. The protocol was rigorously tested, including measurements of reproducibility and calibration curve quality. The recovery of the extraction method ranges from 94% to 113% across all sample types. There is little to no matrix effect on cefazolin signal (98-120%). The developed method was used to determine cefazolin concentrations in tissues of 10 patients undergoing a total knee replacement. Cefazolin blood concentrations were approximately 500 times higher than in adipose, synovium, and bone marrow tissues. This clinical data shows that although the minimum inhibitory concentration is largely surpassed in blood, the concentration of cefazolin in fat, synovium, and bone marrow could be insufficient during a knee replacement. This method of cefazolin quantification will help surgeons optimize antibiotic concentrations in the local tissues during knee replacement surgery and potentially reduce serious post-surgical infections.

Pathogenic SCN2A variants cause early-stage dysfunction in patient-derived neurons

Pathogenic heterozygous variants in SCN2A, which encodes the neuronal sodium channel NaV1.2, cause different types of epilepsy or intellectual disability (ID)/autism without seizures. Previous studies using mouse models or heterologous systems suggest that NaV1.2 channel gain-of-function typically causes epilepsy, whereas loss-of-function leads to ID/autism. How altered channel biophysics translate into patient neurons remains unknown. Here, we investigated iPSC-derived early-stage cortical neurons from ID patients harboring diverse pathogenic SCN2A variants [p.(Leu611Valfs*35); p.(Arg937Cys); p.(Trp1716*)] and compared them with neurons from an epileptic encephalopathy (EE) patient [p.(Glu1803Gly)] and controls. ID neurons consistently expressed lower NaV1.2 protein levels. In neurons with the frameshift variant, NaV1.2 mRNA and protein levels were reduced by ~ 50%, suggesting nonsense-mediated decay and haploinsufficiency. In other ID neurons, only protein levels were reduced implying NaV1.2 instability. Electrophysiological analysis revealed decreased sodium current density and impaired action potential (AP) firing in ID neurons, consistent with reduced NaV1.2 levels. In contrast, epilepsy neurons displayed no change in NaV1.2 levels or sodium current density, but impaired sodium channel inactivation. Single-cell transcriptomics identified dysregulation of distinct molecular pathways including inhibition of oxidative phosphorylation in neurons with SCN2A haploinsufficiency and activation of calcium signaling and neurotransmission in epilepsy neurons. Together, our patient iPSC-derived neurons reveal characteristic sodium channel dysfunction consistent with biophysical changes previously observed in heterologous systems. Additionally, our model links the channel dysfunction in ID to reduced NaV1.2 levels and uncovers impaired AP firing in early-stage neurons. The altered molecular pathways may reflect a homeostatic response to NaV1.2 dysfunction and can guide further investigations.

Humoral and cell-mediated immune responses to BNT162b2 vaccine against SARS-CoV-2 in people with cystic fibrosis

People with cystic fibrosis (pwCF) were considered to be clinically vulnerable to COVID-19 and were therefore given priority in the vaccination campaign. Vaccines induced a humoral response in these patients that was comparable to the response observed among the general population. However, the role of the cell-mediated immune response in providing long-term protection against SARS-CoV-2 in pwCF has not yet been defined. In this study, humoral (antibody titre) and cell-mediated immune responses (interferon-γ release) to the BNT162b2 vaccine were measured at different time points, from around 6-8 months after the 2nd dose and up to 8 months after the 3rd dose, in 118 CF patients and 26 non-CF subjects. Subjects were sampled between November 2021 and September 2022 and followed-up for breakthrough infection through October 2022. pwCF mounted a cell-mediated response that was similar to that observed in non-CF subjects. Low antibody titres (<1st quartile) were associated with a higher risk of breakthrough infection (HR: 2.39, 95 % CI: 1.17-4.88), while there was no significant association with low INF-γ levels (<0.3 IU/mL) (HR: 1.38, 95 % CI: 0.64-2.99). Further studies are needed in subgroup of pwCF receiving immunosuppressive therapy, such as organ transplant recipients. This data is important for tailoring vaccination strategies for this clinically vulnerable population.

OnabotulinumtoxinA in elderly patients with chronic migraine: insights from a real-life European multicenter study

INTRODUCTION

Although migraine prevalence decreases with aging, some older patients still suffer from chronic migraine (CM). This study aimed to investigate the outcome of OnabotulinumtoxinA (OBT-A) as preventative therapy in elderly CM patients.

METHODS

This is a post hoc analysis of real-life prospectively collected data at 16 European headache centers on CM patients treated with OBT-A over the first three treatment cycles (i.e., Cy1-3). We defined: OLD patients aged ≥ 65 years and nonOLD those < 65-year-old. The primary endpoint was the changes in monthly headache days (MHDs) from baseline to Cy 1-3 in OLD compared with nonOLD participants. The secondary endpoints were the responder rate (RR) ≥ 50%, conversion to episodic migraine (EM) and the changes in days with acute medication use (DAMs).

RESULTS

In a cohort of 2831 CM patients, 235 were OLD (8.3%, 73.2% females, 69.6 years SD 4.7). MHDs decreased from baseline (24.8 SD 6.2) to Cy-1 (17.5 SD 9.1, p < 0.000001), from Cy-1 to Cy-2 (14.8 SD 9.2, p < 0.0001), and from Cy-2 to Cy-3 (11.9 SD 7.9, p = 0.001). DAMs progressively reduced from baseline (19.2 SD 9.8) to Cy-1 (11.9 SD 8.8, p < 0.00001), to Cy-2 (10.9 SD 8.6, p = 0.012), to Cy-3 (9.6 SD 7.4, p = 0.049). The 50%RR increased from 30.7% (Cy-1) to 34.5% (Cy-2), to 38.7% (Cy-3). The above outcome measures did not differ in OLD compared with nonOLD patients.

CONCLUSION

In a population of elderly CM patients with a long history of migraine OBT-A provided a significant benefit, over the first three treatment cycles, as good as in non-old patients.

Pediatric emergency care admissions for somatic symptom disorders during the COVID-19 pandemic

During the COVID-19 pandemic, children and adolescents with psychiatric disorders experienced an exacerbation of their symptoms with more access to the emergency department (ED). However, little is known about the experience of somatic symptom disorders (SSDs) during the COVID-19 pandemic in children. Therefore, we aimed to compare the rates of pediatric ED admissions for SSDs before and during the COVID-19 pandemic and to understand whether the relative risk of ED admissions for SSDs changed between the two periods. We retrospectively enrolled all children between 4 and 14 years admitted for SSDs in the pediatric ED of Santobono-Pausilipon Hospital, Naples, Italy, from March 11th, 2020, to March 11th, 2021 (pandemic period), and in the same time period of the previous year (pre-pandemic period). We identified 205/95,743 (0,21%) children with SSDs presenting in ED in the pre-pandemic year and 160/40,165 (0,39%) in the pandemic year (p < 0.05). Considering the accesses for age, we observed a relative decrease of the accesses for SSDs over 12 years old (IRR 0,59; CI 0,39-0,88), while we found no differences under 12 years old (IRR 0,87; CI 0,68-1,10).   Conclusion: In this study, we found that despite the massive decrease in pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders' admissions to the pediatric ED increased, suggesting an impact of the pandemic also on pediatric psychiatric disorders. What is Known: • During the COVID -19 pandemic, children and adolescents with a psychiatric disorder experienced exacerbation of their symptoms with more accesses in Emergency Department. What is New: • We found that despite the massive decrease of the pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders admissions in healthy children to the pediatric Emergency Department increased ,suggesting an impact of the pandemic also on the pediatric psychiatric disorders.

The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias

BACKGROUND

Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias.

METHODS

Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD.

RESULTS

Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation.

CONCLUSIONS

Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.

Air pollution and coronary vasomotor disorders in patients with myocardial ischemia and non-obstructive coronary arteries

Background

Coronary vasomotor abnormalities are an important cause of myocardial ischemia in patients with non-obstructive coronary artery disease (NOCAD). However, the role of air pollution in determining vasomotor disorders has never been investigated.

Purpose

In this study, we evaluated the association between long-term exposure to particulate matter (PM) PM2.5 and PM10 and coronary vasomotor disorders in NOCAD patients.

Methods

Patients with myocardial ischemia and NOCAD undergoing intracoronary provocative test with acetylcholine (ACh) were prospectively enrolled. The test was considered positive for epicardial coronary spasm in the presence of focal or diffuse epicardial coronary diameter reduction ≥90% in comparison with the relaxed state following intracoronary nitroglycerin administration given to relieve the spasm, associated with the reproduction of the patient's symptoms and ischaemic ECG shifts. Both patients with chronic myocardial ischemia (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) were enrolled. Based on each case's home address, exposure to PM2.5 and PM10 was assessed. Only patients with &gt;2 years of available data on air pollution exposure prior to coronary angiography were included.

Results

We enrolled 287 patients (median age 62.0 years [52.0–70.0], 149 [51.9%] males): 161 (56.1%) INOCA and 126 (43.9%) MINOCA. One hundred seventy-six patients (61.3%) had positive provocative test. Exposure to PM2.5 (Figure 1) and PM10 was higher in patients with a positive provocative test (p&lt;0.001). PM2.5 and PM10 were independent predictors of a positive coronary provocative test after adjustment for confounders. Interestingly, among patients with a positive provocative test, PM2.5 and PM10 were both independent predictors of MINOCA (p&lt;0.001 and p=0.001, respectively; Figure 2) as clinical presentation, while only PM2.5 was independently associated with the occurrence of epicardial spasm as opposed to microvascular spasm (p&lt;0.001).

Conclusions

We provide novel insights into the missing link between air pollution and ischemic heart disease. In particular, higher exposure to air pollution in patients with myocardial ischemia and NOCAD is associated with coronary vasomotor abnormalities, and PM2.5 is an independent risk factor for the occurrence of epicardial spasm and for MINOCA as clinical presentation.

Funding Acknowledgement

Type of funding sources: None.

Atherosclerotic Coronary Plaque features in patients with Acute Coronary Syndrome and Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder characterized by airflow limitation, persistent respiratory symptoms and chronic lung inflammation. Previous studies reported a robust relationship between COPD and coronary artery disease (CAD). Local and systemic inflammation, known to play a role in atherosclerosis development, has been reported in patients with COPD, and has been proposed as one of the possible pathogenetic factors linking COPD and CAD. However, data on atherosclerotic coronary pattern and coronary inflammation in COPD patients are lacking.

Purpose

To study the characteristics of atherosclerotic coronary plaques and local inflammation by using optical coherence tomography (OCT) in COPD patients presenting with acute coronary syndromes (ACS).

Methods

ACS patients undergoing intracoronary OCT imaging of the culprit vessel were retrospectively identified. Coronary plaque characteristics and OCT-defined macrophage infiltration (MØI) were assessed by OCT. ACS patients were divided into 2 groups according to the presence or the absence of an established diagnosis of COPD, and coronary plaque features and MØI both at the culprit plaque site and along the culprit vessel were compared between the two groups.

Results

Among 146 ACS patients (mean age, 66,1±12,7 years, 109 males), 47 (32,2%) had COPD. Patients with COPD were older, were more frequently on therapy with an angiotensin receptor blocker, had lower hemoglobin, total cholesterol and triglycerides levels, and had higher serum creatinine levels. The prevalence of different mechanisms of ACS were similar between COPD and noCOPD patients (plaque rupture: 57,4% vs. 45,4%, plaque erosion: 23,4% vs. 32,3%, calcified plaque: 19,1% vs. 22,2%, respectively, overall p=0,381). OCT analysis of plaque microstructures showed that COPD patients had significantly higher prevalence of MØI (78,7% vs. 54,4%, p=0,005), thin cap fibroatheroma (TCFA) (48,9% vs. 22,2%, p=0,001), spotty calcium (68,1% vs. 26,3%, p&lt;0,001) and calcifications (83,0% vs. 66,7%, p=0,040) at the culprit site than noCOPD patients. In the multivariate logistic regression analysis performed to adjust for clinical features, COPD was independently associated with MØI both at the culprit site (OR: 4,726, CI: 1,599; 13,971, p=0,005) and along the culprit vessel (OR: 2,193, CI: 1,110; 4,332, p=0,024). Similarly, COPD was independently associated with the presence of TCFA both at the culprit site (OR: 5,737, CI: 1,877; 17,540, p=0,002) and along the culprit vessel (OR: 2,796, CI: 1,408; 5,553, p=0,003).

Conclusions

In ACS patients undergoing OCT imaging of the culprit vessel, COPD was an independent predictor of local plaque inflammation and plaque vulnerability both at the culprit site and along the culprit vessel. Our results may suggest that a higher inflammatory milieu in COPD patients might enhance local coronary inflammation, promoting CAD development and plaque vulnerability.

Funding Acknowledgement

Type of funding sources: None.

Intranasal Esketamine + CBT: a 6 months follow-up of a resistant depression complicated case

Introduction

TRD is a highly disabling condition, often responsible for chronic clinical course, high number of relapses and elevated suicide risk. Intranasal esketamine is currently the only available pharmacological therapy specifically indicated for TRD, as add-on therapy to antidepressant treatment with SSRI or SNRI.

Objectives

The purpose of the study was to evaluate the safety and efficacy of intranasal esketamine associated with CBT in a complex clinical case of TRD, over a six-month follow-up.

Methods

A 67-year-old patient with TRD was selected for treatment with intranasal esketamine+CBT as add-on to antidepressant therapy. Before each treatment session the HAM-D rating scale was administered. The patient underwent weekly CBT sessions throughout the 6 months follow-up. The effect on physical well-being and social functioning was evaluated by means of Short-Form-Health-Survey-36.

Results

After the first two administrations of intranasal esketamine the total score on HAM-D decreased by 10 units (from 26 to 16). After 6 weeks of treatment decreased from 26 to 12 with the disappearance of suicidal ideation present at T0. After 6 months the total HAM-D score decreased from 26 to 8. Treatment was well tolerated, with mild adverse effects, confined to the first two hours post-administration. In particular, mild sedation, dizziness, slight transient blood pressure rise were reported, never required medical intervention and resolved spontaneously during the observation period.

Conclusions

Intranasal esketamine add-on therapy + CBT was an effective and safe treatment allowing to achieve and maintain symptomatic remission in a complex case of TRD, improving quality of life, social functioning, and reducing suicidal ideation over a six-month follow-up.

Disclosure

No significant relationships.

High-definition electro-anatomical mapping of Koch’s Triangle including AV node potentials recordings in consecutive AVNRT patients

Funding Acknowledgements

Type of funding sources: None.

Background

Activation mapping of Koch’s Triangle, even when coupled with high density mapping, is incomplete without recordings of AV nodal electrical activity.

Purpose

To identify, through a highly specific methodology and high-density electro-anatomical mapping (HDM), the slow AVN potential (AVNP) and the precise activation modality of Koch’s Triangle in SR in atrio-ventricular nodal reentrant tachycardia (AVNRT) patients.

Method

The 3D KT geometry was created from the Orion mapping and the Rhythmia Mapping System. KT was divided into 8 distinct regions moving from an antero-septal to postero-septal areas and bounded by tricuspid annulus (TA) anteriorly and tendon of Todaro posteriorly. AV nodal potential activity was recorded by non-standard bipolar electrogram filtering at 0.50–300 Hz. The AVNP was defined as a slow frequency potential between atrial and ventricular EGM similar to that reported by Scherlag and Jackman, and it was confirmed by high frequency atrial pacing. The AVNP was annotated at the end of electrogram when it was followed in the same recording by a sharp potential; otherwise it was annotated at the center. Data are reported as mean±SD.

Results

Twenty successful SP ablation cases of typical AVNRT from 7 centers were included. RA acquired points during SR were 2512±1400 (123±67 acquired inside the KT, KT area of 41±64 mm2). The time of a complete RA mapping was 19.2±8 min. The AVNP was detected in all cases (n=20, 100%). At the mid-region of the KT, AVNP was identified in 20 (100%) cases; at postero-septal regions bounded anteriorly by the TA and posteriorly by the lateral wall toward the crista terminalis AVN was present in 17 (85%) cases; at mid-postero-septal regions AVN was detected in 15 (75%) cases. In all patients, the first activation in the KT was recorded in the antero-septal region at the expected site of the fast pathway; then the wavefront spread in two directions: anteriorly toward the His-bundle and posteriorly toward the base of KT colliding with the wavefront coming from the opposite direction through the slow pathway. In all patients, abolition of the SP and acute procedural success was achieved in the first procedure with 5.4±3 RF ablations. In 30 out 35 (86%) ablation sites, ablations were done at sites with concurrent detectable AVNP. No complications occurred.

Conclusions

High-density mapping using a non-standard bipolar electrograms filtering at 0.50–300 Hz showed multiple electrograms in SR including low frequency potential that may represent the electrical activity of compact node and inferior extensions.

P53 SURGICAL CUTDOWN VERSUS PERCUTANEOUS ACCESS IN TRANSFEMORAL TAVI: A RETROSPECTIVE SINGLE–CENTER EXPERIENCE

Background

The transfemoral (TF) approach is the most common route in TAVI, but it is still associated with risk of bleeding and vascular complications. Nowadays, it is not evident a clear superiority of percutaneous (PC) versus surgical cutdown (SC) approach. The aim of our retrospective study is to compare the outcomes of the two different types of accesses.

Methods

From January 2018 to December 2021, 377 patients underwent TF–TAVI. The mean age was of 81,17 ± 8,62 years, with a percentage of female of 55,6%. The mean STS score was of 4,37 ± 2,28. The mean LVEF was of 57,22 ± 9,93%. Forty patients underwent a previous cardiac surgery. Seventeen valve–in–valve procedures were performed. The baseline clinical and echocardiographic data and operative features were prospectively collected. The primary endpoint was 30–day bleeding and vascular complications defined according to VARC–2 criteria. Secondary endpoints were clinical outcomes and in–hospital mortality. The PC group included 246 patients, while the SC group 128 patients.

Results

The baseline characteristics in the two groups were not statistically different, except for male sex (40,9% vs 52,3% p = 0.04) and NYHA Class III–IV (55,8% vs 25,7% p = 0.00) in PC and SC group, respectively (Table 1 and Table 2).

Conclusions

The rates of major vascular complications and major bleeding did not differ statistically between the two groups. The SC approach is associated with a significant lower rate of minor vascular complications, but a higher in–hospital mortality. The choice of the access should probably be based on the operator‘s experience and patient‘s vascular anatomy.

P22 USE OF THE LIFE–VEST IN PATIENTS WITH HIGH ARRHYTHMIC RISK: EXPERIENCE OF A SPOKE CENTER IN THE COVID–19 PERIOD

Background

Patients with newly found dilated heart disease have a high risk of sudden death. During the COVID period, the follow–up of these patients was difficult due to the limitation of access to the hospital and the impossibility of performing tests with high decision–making power (cardiac MRI) at third–level hospitals.

Purpose

To evaluate the use of the Life–Vest in patients with newly found dilated heart disease as a protection system for early discharge and the related cost/benefit ratio in relation to an early ICD implant.

Methods

In the COVID period, a Life–Vest was applied to 18 patients with newly found dilated heart disease (4 post ischemic and 16 without coronary artery disease), to monitoring ventricular arrhythmias and to protect them against any life–threatening ventricular tachycardias. These patients showed an high arrhythmic risk for ventricular tachycardias, (VT found on monitoring) and an unfavorable echocardiographic aspect. Each week, the patient‘s telemetry was remotely viewed and a telephone assessment was performed for clinical conditions. A control echocardiogram was performed at 30 days to evaluate the FE and the possible continuation of monitoring.

Results

Of the 18 patients (mean age 59 years) analyzed, 5 (28%) underwent ICD implantation for persistent severe reduction in FE during 3 months after diagnosis and 13 (72%) normalized FE (duration average follow–up 50 days); there are no significant differences between the postischemic and non–postischemic DCM groups. The cost of renting the Life–Vest is about 4000 euros for 40 days and the average cost for an ICD implant, considering the device and the costs related to the days of hospitalization and use of human resources/advanced technological support, amounts to about 20700 euros. Considering these data, we observed a saving of approximately 261900 euros for 18 observed patients. To this saving must be added the costs related to the reduction of the days of hospitalization (average 5 days) and the costs to any future replacement of the ICD.

Conclusion

In patients with newly found dilated heart disease at high arrhythmic risk, the use of the Life–Vest reduces the days of hospitalization, allows patients to be discharged safely and generates substantial savings for the National Health System.

P46 THREE–DIMENSIONAL ECHOCARDIOGRAPHY EVALUATION OF MITRAL VALVE ANATOMY AFTER PERCUTANEOUS EDGE TO EDGE REPAIR

Background

Transcatheter edge–to–edge repair (TEER) is a safe strategy for high–risk patients with significant mitral regurgitation (MR). We aimed to characterize by three–dimensional echocardiography (3D–E) acute reshaping of mitral valve apparatus, with specific reference to the underlying MR mechanism (functional (FMR)and degenerative (DMR))

Methods

We prospectively enrolled 15 patients(November 2020 to September 2021),(median age 81 y.o, range 79–84, 50% male, 1 urgent procedure) with severe mitral valve regurgitation who underwent intra–procedural 3D–E before and after device deployment. Using a dedicated semiautomatic software, we obtain parametric quantification of mitral valve anatomy to describe acute changes in FMR and DMR.

Results

Eight patients (53%) were affected by FMR of whom one case was performed as bridge to heart transplantation candidacy. In the remaining 7 DMR cases, P2 prolapse was present in 5 (71%), commissural flail and A2 flail in 2 cases. Procedural success (MR &lt; 2) was achieved in 14 cases (93%). 30–day survival was 100% in elective cases. A second clip was necessary in 8 patients (53%). After TEER, the FMR group experienced an immediate annular reshaping, with reduction of antero–posterior diameter (p 0.05), next to a recovery of physiological saddle–shape, defined by lower non–planar angle (p = 0.001) and higher annulus height (p ≤ 0.001). The DMR group showed a trend of decrease of maximum annular velocity, addressing a stabilizing effect of the device.The deployment of a second clip has no significant effect of the annular reshaping in both groups.

Conclusions

TEER causes multiple effects on mitral valve geometry which variesaccording to MR mechanism. Three–D parametric quantification of MV anatomy identifiedspecific parameters of acute annular remodeling. FMR exhibited pronounced modification. This “annuloplasty–like” effect may play a role in the late freedom from MR.

P156 TRANSCATHETER CLOSURE OF ATRIAL SEPTAL DEFECT IN OVER 60 YEARS OLD PATIENTS

Background

Ostium secundum ASD (ASDII) is the most common type of congenital heart disease in adults. Percutaneous closure has emerged as the first–line treatment for the majority of ASDII. However, the occurrence of Pulmonary Hypertension (PH) with combined pre– and post–capillary component may render ASD management challenging in elderly patients.

Methods

We report the hemodynamic data and clinical findings of elderly patients (&gt; 60 years old) undergoing transcatheter closure of an ASDII at our department.

Results

From 2000 to 2021, 82 elderly patients were scheduled (mean age 65,4+ 4,4) of which 60 (73%) were female. Systemic arterial hypertension and supraventricular arrhythmias were the most common comorbidities accounting respectively 51% and 38% of cases. The right ventricular overload supported the ASD closure in 76 cases (93%) and paradoxical embolism in the remaining 6 (7%). 17 patients (21%) were in NYHA class III– IV. At right heart catheterization, 33 patients had normal pulmonary arterial pressure and 49 patients showed a mean pulmonary artery pressure &gt; 20 mmhg. In the latter cohort, 33 showed a pulmonary artery wedge pressure (PAWP) &lt; 15 mmHg (Group I) and 16 &gt; 15 mmHg (Group II). The device implantation was completed in all patients except one with elevated pulmonary vascular resistance (PVR) of the Group I. For 14 patients of Group II, balloon occlusion test was required during the catheterization. ASD closure was achieved promptly in 10 patients. However, to reduce the risk of acute pulmonary oedema, in one case we created a small fenestration in the occluder device and in other case we retained the patency of additional defect (both patients exhibiting slightly PAWP increase during balloon occlusion test). In one patient showing significantly PAWP increase during balloon test, delayed ASD closure was performed ensuring the improvement of hemodynamic parameters at 3 months initiation of medical therapy with angiotensin–converting enzyme inhibitor and loop diuretic diuretics. For the remaining 4 patients, the percutaneous closure was not been done because of prohibitive hemodynamic parameters. Overall, ASD closure was performed successfully in 94% of cases.

Conclusions

Age and comorbidities are not absolute contraindications to ASDII percutaneous closure. In the complex cases, both medical therapies and balloon occlusion test may be use to support the decision–making process.

C84 PERCUTANEOUS TREATMENT OF INTERATRIAL MULTIFENESTRATE ANEURYSM IN PAEDIATRIC POPULATION: INFLUENCE OF THE LAYOUT DURING MID–TERM AND LONG–TERM FOLLOW–UP

Background

Multifenestrate aneurysms of interatrial septum (ISA) are a challenge in paediatric age, not only for the complex anathomy, but also for small body surface and small dimensions of cardiac chambers of the patients, that may limit the use of large and multiple devices. Aim of the study: to evaluate the efficacy of percutaneous closure of multifenestrate aneurysms during mid–term and long–term follow–up; to evaluate if the morphological characteristics of interatrial septum may influence the success of the procedure.

Materials and Methods

We retrospectively analyzed 63 patients (mean–age 9,12±3,12 years) undergone to cardiac catheterism from 2000 to 2021, for percutaneous closure of interatrial aneurysm in our division of Cardiology, subdivided into 3 groups on the basis of side and morphological characteristics of the interatrial aneurysm: Group I (2 o more defects DIA&gt;5 mm); Group II (one defect &gt;5 mm and more than one further fenestrations); Group III (multiple fenestrations).

Results

Percutaneous closure was efficacy in 60 patients (95%), while in 3 patients (5%) surgery closure was necessary. In half of the treated patients (30) we used 2 devices. Complications occurred in 4 patients (6%). Only in 2 patients occurred major complications (Atrio–Ventricular Block that needed PMK implantation and partial displacement of device, treated by removal and percutaneous replanting). Residual shunts, not emodynamically significant appear in the immediate post–operative period in 26% and during the follow–up in 18%. The group I was associated with greater risk of failure of the procedure (P &lt; 0.01) and need of implantations of more than one devices (P &lt; 0.01).

Conclusions

Percutaneous closure of multifenestrate aneurysm of interatrial septum in paediatric age are effective and shows low incidence of failure and complications. If is present residual shunt is not significant. The anathomy of interatrial septum influences procedural outcome.

P383 THIRD–DEGREE ATRIOVENTRICULAR BLOCK AND HYPERCALCEMIA: NOT ALWAYS JUST THE HEART

A 81–year–old lady was admitted to the ER due to anorexia, fever and oliguria. Previous medical history was unknown as she had arrived in Italy one month before and her son was not aware of it. Upon arrival she was soporous and bradicardic. Physical examination consisted of mild pulmonary rales, diffuse abdominal pain and leg edema. ECG showed a third–degree atrioventricular block with narrow QRS and average heart rate of 40 bpm with no signs of ischemia. X–ray showed mild congestion. She was admitted to CCU. Blood tests showed hypoglicemia (53 mg/dL), anemia (Hb 9.9g/dL), low platelet count, renal dysfunction (creatinine 1.43mg/dL), high C–reactive protein, normal potassium but high calcemia (13 mg/dL). To investigate hypercalcemia parathyroid hormone was dosed and was in range, so a CT scan was needed to rule out pancreatitis, cancer or bone lesions. Also a cardiac echo was done: it showed a hypertrophic left ventricle with preserved contractility, no significant valvular dysfunctions, normal right sections with pulmonary hypertension, no pericardial effusion. While performing the subcostal view however multiple formations were seen at the hepatic level. CT scan confirmed multiple pathological conglomerating lymphadenopathies in the abdomen towards the femoral region, reaching 5 cm of diameter; no bone lesions were found. Inguinal lymph node biopsy was performed. Due to persistent complete AV block along with persistent hypercalcemia and hypoglycemia despite medical therapy, considering the electrolyte imbalance not corrigible due to a malignancy a pacemaker was implanted. The result of the lymph node biopsy was consistent with a form of Diffuse Large B–Cell Lymphoma. This case highlights how a 3–rd degree AV block may present with non–specific symptoms. When it is found it may not always represent a pure cardiac problem as sometimes it is the epiphenomenon of a systemic disease. Particularity of this case is that cardiologists are less used to take into consideration calcium balance. Nevertheless, although infrequent, hypercalcemia is a cause of significant conduction disease. After having looked for it, searching for its etiology is mandatory as some could be reversible and thus the AV block as well. For this reason, when a complete AV block is found ruling out hypercalcemia is fundamental, taking into consideration that the conduction disease may represent the first red flag of an unknown malignancy

ECG monitoring of post-stroke occurring arrhythmias: an observational study using 7-day Holter ECG

Post-stroke arrhythmias represent a risk factor for complications and worse prognosis after cerebrovascular events. The aims of the study were to detect the rate of atrial fibrillation (AF) and other cardiac arrhythmias after acute ischemic stroke, by using a 7-day Holter ECG which has proved to be superior to the standard 24-h recording, and to evaluate the possible association between brain lesions and arrhythmias. One hundred and twenty patients with cryptogenic ischemic stroke underwent clinical and neuroimaging assessment and were monitored with a 7-day Holter ECG. Analysis of the rhythm recorded over 7 days was compared to analysis limited at the first 24 h of monitoring. 7-day Holter ECG detected AF in 4% of patients, supraventricular extrasystole (SVEB) in 94%, ventricular extrasystole (VEB) in 88%, short supraventricular runs (SVRs) in 54%, supraventricular tachycardia in 20%, and bradycardia in 6%. Compared to the first 24 h of monitoring, 7-Holter ECG showed a significant higher detection for all arrhythmias (AF p = 0.02; bradycardia p = 0.03; tachycardia p = 0.0001; SVEB p = 0.0002; VEB p = 0.0001; SVRs p = 0.0001). Patients with SVRs and bradycardia were older (p = 0.0001; p = 0.035) and had higher CHA₂DS₂VASc scores (p = 0.004; p = 0.026) respectively, in the comparison with patients without these two arrhythmias. An association was found between SVEB and parietal (p = 0.013) and temporal (p = 0.013) lobe lesions, whereas VEB correlated with insular involvement (p = 0.002). 7-day Holter ECG monitoring proved to be superior as compared to 24-h recording for the detection of all arrhythmias, some of which (SVEB and VEB) were associated with specific brain areas involvement. Therefore, 7-day Holter ECG should be required as an effective first-line approach to improve both diagnosis and therapeutic management after stroke.

Cost-effectiveness of implementing a digital psychosocial intervention for patients with psychotic spectrum disorders in low- and middle-income countries in Southeast Europe: Economic evaluation alongside a cluster randomised trial

Background

DIALOG+ is a digital psychosocial intervention aimed at making routine meetings between patients and clinicians therapeutically effective. This study aimed to evaluate the cost-effectiveness of implementing DIALOG+ treatment for patients with psychotic disorders in five low- and middle-income countries in Southeast Europe alongside a cluster randomised trial.

Methods

Resource use and quality of life data were collected alongside the multi-country cluster randomised trial of 468 participants with psychotic disorders. Due to COVID-19 interruptions of the trial’s original 12-month intervention period, adjusted costs and quality-adjusted life years (QALYs) were estimated at the participant level using a mixed-effects model over the first 6 months only. We estimated the incremental cost-effectiveness ratio (ICER) with uncertainty presented using a cost-effectiveness plane and a cost-effectiveness acceptability curve. Seven sensitivity analyses were conducted to check the robustness of the findings.

Results

The average cost of delivering DIALOG+ was €91.11 per participant. DIALOG+ was associated with an incremental health gain of 0.0032 QALYs (95% CI –0.0015, 0.0079), incremental costs of €84.17 (95% CI –8.18, 176.52), and an estimated ICER of €26,347.61. The probability of DIALOG+ being cost-effective against three times the weighted gross domestic product (GDP) per capita for the five participating countries was 18.9%.

Conclusion

Evidence from the cost-effectiveness analyses in this study suggested that DIALOG+ involved relatively low costs. However, it is not likely to be cost-effective in the five participating countries compared with standard care against a willingness-to-pay threshold of three times the weighted GDP per capita per QALY gained.

Improving treatment of patients with psychosis in low-and-middle-income countries in Southeast Europe: Results from a hybrid effectiveness-implementation, pragmatic, cluster-randomized clinical trial (IMPULSE)

Background

In Southeast Europe (SEE) standard treatment of patients with psychosis is largely based on pharmacotherapy with psychosocial interventions rarely available. DIALOG+ is a digital psychosocial intervention designed to make routine care therapeutically effective. This trial simultaneously examined effectiveness of DIALOG+ versus standard care on clinical and social outcomes (Aim 1) and explored intervention fidelity (Aim 2).

Methods

A hybrid type II effectiveness–implementation, cluster-randomized trial was conducted in five SEE countries: Bosnia and Herzegovina, Kosovo*, Montenegro, North Macedonia, and Serbia. The intervention was offered to patients six times across 12 months instead of routine care. The outcomes were subjective quality of life (primary), clinical symptoms, satisfaction with services, and economic costs. Intervention fidelity was operationalized as adherence to the protocol in terms of frequency, duration, content, and coverage. Data were analyzed using multilevel regression.

Results

A total of 81 clinicians and 468 patients with psychosis were randomized to DIALOG+ or standard care. The intervention was delivered with high fidelity. The average number of delivered sessions was 5.5 (SD = 2.3) across 12 months. Patients in the intervention arm had better quality of life (MANSA) at 6 months (p = 0.03). No difference was found for other outcomes at 6 months. Due to disruptions caused by the COVID-19 pandemic, 12-month data were not interpretable.

Conclusions

DIALOG+ improved subjective quality of life of individuals with psychosis at 6 months (after four sessions), albeit with small effect size. The intervention has the potential to contribute to holistic care of patients with psychosis.

Treatment of lean PCOS teenagers: a follow-up comparison between Myo-Inositol and oral contraceptives

OBJECTIVE

Polycystic ovary syndrome (PCOS) is an endocrinological and metabolic disorder widely diffused and diagnosed in women of reproductive age. The pathology exhibits alteration of the reproductive functions, including conditions as hyperandrogenism, menstrual cycle irregularity, type 2 diabetes. These conditions are visible in the patients through phenotypical manifestations as hirsutism, acne, and obesity. Even if the syndrome is characterized by common features among both adult and adolescent women, the diagnostic criteria are different for the two age categories and to date still controversial. We investigated different treatments in PCOS adolescents with non-severe metabolic conditions, to evaluate which could be the appropriate therapeutical approach for these patients.

PATIENTS AND METHODS

We enrolled lean teenagers with PCOS, and we divided the patients in two age ranges: 13-16 years old and 17-19 years old. They were treated for 3 months either with oral contraceptive pills (OCP) drospirenone/ethinylestradiol (group A), myo-Inositol (myo-Ins) (group B), or OCP plus myo-Ins (group C). Data were analyzed with a descriptive statistics summarizing quantitative variables including median, 25th and 75th percentiles.

RESULTS

We pointed out that the group of 13-16 years old lean teenagers treated with myo-Ins exhibit a significant decrease of weight and body mass index (BMI), and an effective improvement the metabolic and hormonal parameters achieved with a non-pharmacological treatment. In the older teenagers aged 17-19 years, data highlights that myo-Ins treatment in combination with OCP prevents the increases of weight and BMI, improves the metabolic profile of the patients, and strongly ameliorates the hormonal parameters analyzed.

CONCLUSIONS

The results indicate a different scenario in the two age ranges considered and interestingly suggest an important role of myo-Ins in the PCOS context. A therapy based on this natural compound alone or in combination with OCP seems effective to improve both metabolic and hormonal parameters of PCOS adolescents and thus could represent a novel and valid option to consider for the treatment of this syndrome.

Trends in the use of mechanical and bioprosthetic aortic valve replacement in the era of transcatheter aortic valve replacement

Background

The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and co-morbidities, since bioprosthetic AVR (bAVR) as compared to mechanical AVR (mAVR), are associated with a more rapid structural deterioration. However, refinements in bioprosthetic valves and the introduction of transcatheter aortic valve replacement (TAVR) (potential for valve-in-valve procedures), will most likely influence valve selection in the future. The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined.

Purpose

The goal of our study was to assess trends in utilization of bAVR and mAVR in the United States while, assessing in-hospital mortality over time.

Methods

The National Inpatient database (2009–18) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 700,896 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older, [bAVR (69.8 years) vs mAVR (62.7 years) p&lt;0.001]. Heart failure, cardiac arrhythmias, hypertension, diabetes with complications and renal failure were more common in those undergoing a bAVR. Through the course of the study period, the rates of mAVR decreased across all age groups (p trend &lt;0.001), including patients younger than 50 years (p trend &lt;0.001). Both crude (OR = 1.20 95% CI 1.13–1.27) and adjusted (OR = 1.34 95% CI 1.25–1.44) inpatient mortality was higher amongst mAVR recipients.

Conclusions

In the contemporary TAVR era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with significantly less co-morbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding the causes accounting for the higher mortality after mAVR, future research should focus on developing TAVR friendly bAVR; possibly enhancing our ability to perform percutaneous valve-in-valve procedures in the future.

Funding Acknowledgement

Type of funding sources: None.

Clinical characteristics, management, and outcomes of patients with electrical storm: single centre experience

Background

Electrical storm (ES) is a life-threatening condition caused by recurrent malignant ventricular arrhythmia (≥3 episodes of ventricular tachycardia (VT) or ventricular fibrillation within 24 hours). ES patient management is challenging and can involve antiarrhythmic medication, sedation, and invasive procedures such as catheter ablation.

Purpose

The aim of this study is to report the clinical profile and management of ES patients who attended an arrhythmia reference centre.

Methods

Patients who presented with ES at our centre over a five-year period were consecutively enrolled. Patient data were retrospectively collected from hospital records. Patients with in-hospital death were excluded form data analysis.

Results

Seventy-six patients were included (84% male, mean age 73±10 years). 55% of patients had ischemic heart disease. The mean left ventricle ejection fraction (LVEF) was 33±4%, with 22% of patients having a severe reduction in systolic ventricular function (EF &lt;35%). Baseline characteristics are reported in Table 1. During hospitalisation, 30% of patients underwent coronary angiography and 30% of these had percutaneous coronary revascularization. Patients were managed with pharmacological treatment, including continuous infusion of antiarrhythmic drugs (45% of patients received at least one antiarrhythmic), sedation (12%), and electrolytic solutions (38%). More details on ES management are reported in Table 2. All patients were evaluated for transcatheter ablation. After a mean of 6 days, 25% underwent transcatheter VT ablation during hospitalisation. In 7 patients (9%), catheter ablation was planned and performed during a subsequent hospitalisation.

At discharge, 93% of patients received beta blockers and 68% received amiodarone. Overall, 65% were discharged with at least two antiarrhythmic drugs. The mean length of hospitalisation was 10±9 days, with 6±4 days spent in the intensive care unit. Eighteen patients (23%) had at least one subsequent hospitalisation for ES. After a mean follow-up of 20 months, the cumulative mortality rate was 27%, without a significant difference in mortality rates between ablated and non-ablated patients (27% and 28%, respectively). Baseline mean creatinine levels were higher (1.73±1.1 vs. 1.27±0.1 mg/dl, p&lt;0.05), and LVEF was lower (27±3% vs. 35±17%, p&lt;0.05) in patients who died during follow-up as compared to survivors. A trend toward a longer QTc interval duration (482±47 vs. 467±28 ms) and longer QRS duration (139±36 vs. 131±7 ms) was also found among patients who died during follow-up.

Conclusion

In our centre, ischemic heart disease was the most common heart disease in patients presenting with ES. In more than one third of patients, VT transcatheter ablation was performed as a therapeutic strategy in addition to drug therapy. Among patients who died during the follow-up, baseline creatinine levels were higher and LVEF was lower compared with survivors.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Incidence, predictors and prognostic role of complications occurring during provocative testing with acetylcholine in patients with myocardial ischemia and non-obstructive coronary arteries

Background

Coronary provocative test with acetylcholine (ACh) is of utmost importance and increasingly used in patients with myocardial ischemia and non-obstructive coronary arteries. However, data on safety, predictors and prognostic role of complications during intracoronary provocative testing are scarce.

Purpose

We assessed the safety of ACh provocative test in patients with myocardial ischemia and non-obstructive coronary arteries. Moreover, we evaluated the predictors and the prognostic implications of complications occurring during the provocative test.

Methods

We prospectively enrolled consecutive patients undergoing intracoronary ACh provocative test for suspected myocardial ischaemia with angiographic evidence of non-obstructive coronary arteries. Complications during the ACh test were collected. Occurrence of major adverse cardiac events (MACE), arrhythmic events at 24-hours ECG dynamic Holter monitoring and angina status were assessed at follow-up.

Results

We enrolled 310 patients (mean age 60.6±11.9; 169 [54.5%] chronic coronary syndromes [CCS] and 141 [45.5%] with myocardial infarction and non-obstructive coronary arteries [MINOCA]). The overall incidence of complications was low (9%) with a similar incidence in MINOCA and CCS (10 [7.1%] vs 18 [10.7%], p=0.276, respectively). At multivariate logistic regression analysis, a previous history of paroxysmal atrial fibrillation (Odds Ratio [OR] 12.324, Confidence Interval [CI] 95% [4.641; 32.722], p=0.015) and moderate/severe diastolic dysfunction (OR 3.827, CI95% [1.296; 11.304], p=0.015) were independent predictors for occurrence of complications. The occurrence of complications was not associated with a worse clinical outcome at follow-up (median follow-up 22 months) in terms of both MACE, arrhythmic events and angina burden.

Conclusion

Intracoronary provocative testing with ACh test is safe in patients with myocardial ischemia and non-obstructive coronary arteries, without differences between MINOCA and CCS. History of paroxysmal atrial fibrillation and moderate/severe diastolic dysfunction predicted the occurrence of complications during ACh test. Of importance, our data can reassure clinicians, as the occurrence of complications did not portend a worse prognosis at follow-up in terms of MACE, arrhythmic events and angina burden.

Funding Acknowledgement

Type of funding sources: None. Complications and clinical presentationClinical outcome at follow-up

Does the availability of transcatheter aortic valve replacement impact inpatient outcomes after surgical aortic valve replacement? Analysis of the national inpatient sample

Background

With the introduction of transcatheter aortic valve replacement (TAVR), the treatment of aortic stenosis (AS) has experienced a paradigm shift, altering patient selection for surgical aortic valve replacement (SAVR) over the past decade. What remains to be determined is the impact of a hospital's ability to offer TAVR, in the contemporary era, on inpatient outcomes following SAVR.

Purpose

The goal of this study was to assess inpatient mortality and the use of mechanical aortic valve replacement (mAVR) in patients undergoing SAVR at TAVR versus non-TAVR centers in the United States.

Methods

The National Inpatient Sample (2011–18), a probability sample of inpatient visits in the United States, was used to study trends in admissions for SAVR at TAVR and non-TAVR centers; in-hospital mortality was trended over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 559,365 inpatient visits for SAVR with 75.2% (95% CI 74.2%-76.2%) and 24.7% (95% CI 23.8%-25.8%) receiving bioprosthetic SAVR (bAVR) and mAVR, respectively at TAVR centers and 64.5% (95% CI 63.3%-65.6%) and 35.5% (95% CI 34.4%-36.7%) receiving bAVR and mAVR, respectively at non-TAVR centers. SAVR recipients at non-TAVR centers were older when compared to recipients at TAVR centers (68.3±0.09 vs 66.9±0.11 years p&lt;0.001). Heart failure, cardiac arrhythmias, peripheral vascular disorders, complicated hypertension and diabetes, renal failure and liver disease were more common in patients undergoing SAVR at TAVR-centers. During the study period, both crude (OR = 0.78 95% CI 0.73–0.83) and adjusted (OR = 0.79 95% CI 0.73–0.86) inpatient mortality was lower amongst SAVR recipients at TAVR centers. The utilization rates of mAVR at both TAVR and non-TAVR centers decreased over time amongst all age groups (p trend &lt;0.001).

Conclusions

Patients undergoing SAVR at TAVR centers were younger and had more co-morbidities compared to patients undergoing SAVR at non-TAVR centers. Although patients undergoing SAVR at TAVR centers had significantly more co-morbidities, inpatient mortality was lower at TAVR centers compared to non-TAVR centers. Further research is needed to determine whether the impact of a multidisciplinary cardiac approach resulted in significant differences in patient selection for SAVR, due to the availability of TAVR, influencing patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Long-term exposure to ambient air pollution portends a higher risk of coronary plaque vulnerability and instability in patients with acute coronary syndrome: an optical coherence tomography study

Background

Air pollution is an emerging key player in determining the residual risk of coronary events. However, pathophysiological mechanisms linking air pollution and coronary events have been not adequately investigated.

Purpose

We assessed the relationship between exposure to air pollutants and mechanisms of coronary instability evaluated by optical coherence tomography (OCT) in patients with acute coronary syndrome (ACS).

Methods

ACS patients undergoing OCT imaging were retrospectively selected. Mechanism of culprit lesion instability was classified as plaque rupture (PR) or intact fibrous cap (IFC) by OCT, and the presence of macrophage infiltrates (MØI) and thin-cap fibroatheroma (TCFA) at the culprit site was also assessed. Based on each case's home address, exposure to several pollutants was evaluated, including particulate matter 2.5 (PM2.5), particulate matter 10 (PM10), and carbon monoxide (CO). Only patients with &gt;2 years of available data on air pollution exposure prior to ACS were enrolled.

Results

We included 136 patients [median age 67.0 years (56.2–76.0), 104 (76.5%) male]. Sixty-six patients (48.5%) had PR as mechanism of plaque instability. Patients with PR were exposed to significantly higher PM2.5 levels compared to IFC, and PM2.5 was an independent predictor for PR (OR=1.133, 95% CI [1.020–1.258], p=0.019). Moreover, exposure to higher levels of PM2.5, PM10 and CO was an independent predictor for the presence of TCFA, while PM2.5 and CO levels predicted the presence of MØI. Interestingly, PM2.5, PM10 and CO levels were positively and significantly correlated with serum levels of C-reactive protein. ROC curves were constructed to assess the ability of PM2.5 to predict the presence of plaque rupture, TCFA or MØI. The AUC for PM2.5 to predict plaque rupture was 0.62 (95% CI: 0.52–0.71, p=0.018), for TCFA was 0.71 (95% CI: 0.61–0.80, p&lt;0.001) and for MØI was 0.80 (95% CI: 0.71–0.88, p&lt;0.001). Using a PM2.5 cut-off value of 13.40 μg/m3, the sensitivity and specificity for MØI were 81% and 66%, respectively.

Conclusions

We provide novel insights into the missing link between air pollution and increased risk of coronary events. In particular, exposure to higher concentrations of air pollutants is a risk factor for vulnerable plaque features and for plaque rupture as mechanism of coronary instability mediated by systemic and local plaque inflammation. Of importance, the thresholds of air pollutants that predicted the presence of vulnerable plaque features are far lower than commonly accepted safety thresholds used to start preventive measures for public health, suggesting that further efforts are needed in order to reduce the adverse effects on the cardiovascular system.

Funding Acknowledgement

Type of funding sources: None. Air pollutants exposure and OCT featuresROC curve analysis

Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid (99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation

BACKGROUND

To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients.

METHODS

Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years.

RESULTS

Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period.

CONCLUSIONS

99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.

Cognitive recovery in people with relapsing/remitting multiple sclerosis: A randomized clinical trial on virtual reality-based neurorehabilitation

BACKGROUND

Multiple sclerosis (MS) can adversely affect several domains of cognitive function, including attention, information processing, memory and learning, executive functions and visuospatial skills. In recent years, technological innovations have proven effective in improving motor and cognitive impairment in neurological patients, including those affected by MS.

OBJECTIVE

The study aims to evaluate cognitive outcomes after rehabilitation training with the Virtual Reality rehabilitation system (VRRS) in patients suffering from MS.

METHODS

All patients were randomized into either the control group (CG: 15 patients) receiving conventional cognitive rehab or the experimental group (EG) using virtual reality (VR) (15 patients). Both groups underwent the same amount of cognitive training, 3 times a week for 8 weeks. They were submitted to neuropsychological assessment before (T0) and after the rehabilitation treatment (T1).

RESULTS

Our data showed that both conventional and VR cognitive rehabilitation approaches improved mood (p < 0.001) and visuospatial skills. However, only in the EG a significant improvement in specific cognitive domains (p < 0.001), including learning ability, short-term verbal memory, lexical access ability, as well as quality of life related to mental states, was found.

CONCLUSIONS

The present study demonstrated that VR can be a motivational and effective tool for cognitive recovery in MS patients.

Role of surgical treatment in endometriosis

Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).¹Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.

Short communication: Seroprevalence of paratuberculosis in Italian water buffaloes (Bubalus bubalis) in the region of Campania

Paratuberculosis is a chronic enteric disease affecting virtually all ruminants, but only anecdotal information is currently available about the occurrence of this disease in water buffaloes (Bubalus bubalis). We carried out a survey study aimed at determining the prevalence of paratuberculosis in 2 provinces in the region of Campania, Italy, where about half of all Italian buffaloes are reared. From May 2017 to December 2018, we collected 201,175 individual serum samples from 995 buffalo herds. The sera were collected from animals over 24 mo old and were tested using a commercial ELISA test. The herd-level apparent prevalence result was 54.7%, and the animal-level apparent prevalence was 1.8%. The herd-level true prevalence was estimated using a Bayesian approach, demonstrating a high herd-level prevalence of paratuberculosis in water buffaloes from the Campania area. These findings suggest that the urgent adoption of paratuberculosis herd-control programs for water buffaloes in this area would be beneficial.

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases

BACKGROUND

Lemierre syndrome is characterized by head/neck vein thrombosis and septic embolism usually complicating an acute oropharyngeal bacterial infection in adolescents and young adults. We described the course of Lemierre syndrome in the contemporary era.

METHODS

In our individual-level analysis of 712 patients (2000-2017), we included cases described as Lemierre syndrome if these criteria were met: (i) primary site of bacterial infection in the head/neck; (ii) objectively confirmed local thrombotic complications or septic embolism. The study outcomes were new or recurrent venous thromboembolism or peripheral septic lesions, major bleeding, all-cause death and clinical sequelae.

RESULTS

The median age was 21 (Q1-Q3: 17-33) years, and 295 (41%) were female. At diagnosis, acute thrombosis of head/neck veins was detected in 597 (84%) patients, septic embolism in 582 (82%) and both in 468 (80%). After diagnosis and during in-hospital follow-up, new venous thromboembolism occurred in 34 (5.2%, 95% CI 3.8-7.2%) patients, new peripheral septic lesions became evident in 76 (11.7%; 9.4-14.3%). The rate of either was lower in patients who received anticoagulation (OR: 0.59; 0.36-0.94), higher in those with initial intracranial involvement (OR: 2.35; 1.45-3.80). Major bleeding occurred in 19 patients (2.9%; 1.9-4.5%), and 26 died (4.0%; 2.7-5.8%). Clinical sequelae were reported in 65 (10.4%, 8.2-13.0%) individuals, often consisting of cranial nerve palsy (n = 24) and orthopaedic limitations (n = 19).

CONCLUSIONS

Patients with Lemierre syndrome were characterized by a substantial risk of new thromboembolic complications and death. This risk was higher in the presence of initial intracranial involvement. One-tenth of survivors suffered major clinical sequelae.

Brain-derived neurotrophic factor is associated with coronary macrophage infiltrates in patients with acute coronary syndrome

Background

Brain-derived neurotrophic factor (BDNF) is a neurotrophine that plays a key role in the regulation of both central and peripheral nervous system. Moreover, BDNF is secreted in multiple tissues and exerts systemic, autocrine, and paracrine effects in the cardiovascular system. Of importance, BDNF expression was enhanced in macrophages and smooth muscle cells in atherosclerotic coronary arteries and may be involved in thrombus formation. Thus, BDNF has been suggested as an important link between inflammation and thrombosis, potentially involved in the pathogenesis of acute coronary syndrome (ACS).

Purpose

In our study we aimed at assessing serum levels of BDNF in patients with ACS, evaluating differences according to clinical presentation [ST-segment elevation myocardial infarction (STEMI) vs. Non-ST-segment elevation ACS (NSTE-ACS)]. Moreover, we assessed the presence of optical coherence (OCT)-defined macrophage infiltrates (MØI) in the culprit vessel of ACS patients and evaluated their relationship with BDNF levels.

Methods

ACS patients were prospectively selected. Blood samples were collected at admission and serum levels of BDNF were subsequently assessed. Presence of OCT-defined MØI along the culprit vessel was assessed.

Results

166 ACS patients were enrolled [mean age 65.3±11.9 years, 125 (75.3%) male, 109 STEMI, 57 NSTE-ACS]. Serum levels of BDNF were higher among STEMI patients compared with NSTE-ACS [median (IQR) 2.48 pg/mL (1.54–3.34) vs. 2.12 pg/mL (1.34–2.47), p=0.007], while C-reactive protein levels did not differ between the two groups. OCT assessment was performed in 53 patients and MØI were detected in 27 patients. Of importance, patients with MØI in the culprit vessel had higher levels of BDNF compared with patients without MØI [median (IQR) 2.23 pg/mL (1.38–2.53) vs. 1.41 pg/mL (0.93–2.07), p=0.023], while C-reactive protein levels did not differ between the two groups. Of note, at multivariate regression analysis BDNF levels were independent predictor of MØI [OR: 2.20; 95% CI (1.02–4.74), p=0.043].

Conclusions

Serum levels of BDNF may reliable identify the presence of local macrophage inflammatory infiltrates in patients with ACS. Moreover, BDNF levels are higher in patients with STEMI compared with NSTE-ACS. Taken together, these data suggest that BDNF may represent an interesting link between local inflammatory activation and enhanced thrombosis in ACS.

BDNF serum levels

Funding Acknowledgement

Type of funding source: None

Perilipin-2 is associated with a higher risk of microvascular obstruction in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background

Coronary microvascular obstruction (MVO) is a noxious condition frequently occurring in patients with ST-elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI). However, multiple mechanisms are involved in the pathogenesis of MVO and not yet fully understood. Recent studies suggested that perilipin 2 (PLIN2) may play an important role in lipid metabolism of macrophages resident in atherosclerotic plaques along with a role in enhancing oxidative stress.

Purpose

To study the association between PLIN2 and MVO in STEMI patients undergoing primary PCI. We also assessed the role of PLIN2 to predict future major cardiovascular events (MACEs).

Methods

STEMI patients undergoing primary PCI were enrolled. PLIN2 was dosed within 24 hours from admission in peripheral blood monocytes. MVO was assessed using TIMI flow grade and myocardial blush grade on coronary angiogram after PCI, and patients were stratified accordingly (MVO or noMVO). Major adverse cardiac events (defined as a composite of cardiac death, non-fatal myocardial infarction, re-admission for heart failure and target vessel revascularization) were assessed at clinical follow-up.

Results

Among 100 STEMI patients (mean age, 65.2±12.0 years, 81 males), 33 (33.0%) had MVO. Patients with MVO were older, had higher troponin I peak, C-reactive protein and lower left ventricular ejection fraction on admission. Patients with MVO had significantly higher levels of PLIN2 (1.03±0.28 vs. 0.90±0.16, p=0.019) compared to noMVO patients. Age [OR (95% CI) per year, 1.045 (1.005–1.087), p=0.026] and PLIN2 [OR (95% CI) per unit, 16.606 (2.027–136.030), p=0.009] were associated with MVO at univariate logistic regression analysis. However, only PLIN2 levels [OR (95% CI) per unit, 12.325 (1.446–105.039), p=0.033] were independently associated with MVO at multivariate analysis. Follow up data were available for 76 patients (76%). After a mean follow up of 182.2±126.6 days, 13 MACEs occurred. Patients with MVO had more MACEs [9 (37.5%) vs. 4 (7.7%), p&lt;0.001] compared to noMVO patients. At univariate Cox regression analysis, MVO [HR (95% CI), 6.792 (2.053–22.460), p=0.002], hypercholesterolemia [HR (95% CI), 3.563 (1.094–11.599), p=0.035] and PLIN2 [HR (95% CI) per unit, 82.991 (9.857–698.746), p&lt;0.001] were predictors for MACEs at follow up. At multivariate analysis only PLIN2 [HR (95% CI) per unit, 26.904 (2.461–294.100), p=0.007] was an independent predictor of MACEs.

Conclusions

In STEMI patients undergoing primary PCI, PLIN2 was independently associated with MVO. PLIN2 was an independent predictor of MACEs at clinical follow-up. These findings suggest that PLIN2 may represent a promising therapeutic target, opening the avenue towards novel therapeutic approaches for MVO.

Funding Acknowledgement

Type of funding source: None

Macrophage infiltrates in coronary plaque erosion portend a worse cardiovascular outcome in patients with acute coronary syndrome

Background

Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS). Inflammatory activation is considered a key mechanism of plaque instability in patients with plaque rupture through the release of metalloproteinases and the inhibition of collagen synthesis that in turns lead to fibrous cap degradation. However, the clinical relevance of macrophage infiltration has never been investigated in patients with PE.

Purpose

In our study, we aimed at assessing the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value.

Methods

ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site and in non-culprit segments along the culprit vessel was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years].

Results

We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. In particular, culprit lesion analysis demonstrated that patients with PE with MØI had a significantly thinner fibrous cap [median (IQR) 100 (60–120) μm vs. 160 (95–190) μm, p&lt;0.001], higher prevalence of thrombus [41 (80.4%) vs. 64 (62.7%), p=0.028], lipid plaque [39 (76.5%) vs. 50 (49.0%), p&lt;0.001], TCFA [20 (39.2%) vs. 14 (13.7%), p=0.001], and a higher maximum lipid arc [median [IQR] 250.0° (177.5°-290.0°) vs. 190.0° (150.0°-260.0°), p=0.018) at the culprit lesion compared with PE without MØI. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p=0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression model, PE with MØI [HR=2.95, 95% CI (1.09–8.02), p=0.034] was an independent predictor of MACEs.

Conclusion

Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with a more aggressive phenotype of coronary atherosclerosis with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. These findings are of the utmost importance in the era of precision medicine because clearly show that macrophage infiltrates may identify patients with a higher cardiovascular risk requiring more aggressive secondary prevention therapies and a closer clinical follow-up.

Prognosis

Funding Acknowledgement

Type of funding source: None

Is there a correlation between dyslipidemia and cognitive impairment in patients with multiple sclerosis?

Background. Multiple sclerosis (MS) is an autoimmune and demyelination disease of the central nervous system that causes progressive accumulation of disability over time. Recent studies have highlighted the correlation between metabolic disorders and cognitive dysfunctions. The present study aims to evaluate the correlation between components of the lipid profile and cognitive dysfunctions in patients affected by MS.Methods. 90 MS inpatients were included in this study. We divided the sample into three subgroups to evaluate the influence of the presence of dyslipidemia: G1 (patients with dyslipidemia), G2 (patients without dyslipidemia), G3 (patients with a higher than normal lipid value). Patients underwent rehabilitation treatment which included conventional physiotherapy, speech therapy, psychological support, cognitive rehabilitation, nutritional therapy, robotic rehabilitation, cognitive rehabilitation, and virtual reality.Results. The results showed that the three subgroups had a significant improvement in global cognitive functioning (MOCA p < 0.00), working memory (BRB-NV SRT-LTS p < 0.00) and in attention process (BRB-NV SDMT p < 0.00). Only in the G2, we observed a significant improvement in visuospatial abilities (RAO SPART p < 0.00). Moreover, we found that the cholesterol was negatively correlated with the cognitive functioning score of the patients after rehabilitation and the EDSS score. While the triglyceride scores were negatively correlated with the working memory score before and after rehabilitation. BMI scores were negatively correlated with the visuospatial ability score.Conclusion. Investigating these aspects could help in managing patients, preventing alterations that compromise the patient's quality of life.

Future directions and management of liquid biopsy in non-small cell lung cancer

Lung cancer represents the world’s most common cause of cancer death. In recent years, we moved from a generic therapeutic strategy to a personalized approach, based on the molecular characterization of the tumor. In this view, liquid biopsy is becoming an important tool for assessing the progress or onset of lung disease. Liquid biopsy is a non-invasive procedure able to isolate circulating tumor cells, tumor educated platelets, exosomes and free circulating tumor DNA from body fluids. The characterization of these liquid biomarkers can help to choose the therapeutic strategy for each different case. In this review, the authors will analyze the main aspects of lung cancer and the applications currently in use focusing on the benefits associated with this approach for predicting the prognosis and monitoring the clinical conditions of lung cancer disease.

Enhanced morphological transformation of human lung epithelial cells by continuous exposure to cellulose nanocrystals

Cellulose nanocrystals (CNC), also known as nanowhiskers, have recently gained much attention due to their biodegradable nature, advantageous chemical and mechanical properties, economic value and renewability thus making them attractive for a wide range of applications. However, before these materials can be considered for potential uses, investigation of their toxicity is prudent. Although CNC exposures are associated with pulmonary inflammation and damage as well as oxidative stress responses and genotoxicity in vivo, studies evaluating cell transformation or tumorigenic potential of CNC's were not previously conducted. In this study, we aimed to assess the neoplastic-like transformation potential of two forms of CNC derived from wood (powder and gel) in human pulmonary epithelial cells (BEAS-2B) in comparison to fibrous tremolite (TF), known to induce lung cancer. Short-term exposure to CNC or TF induced intracellular ROS increase and DNA damage while long-term exposure resulted in neoplastic-like transformation demonstrated by increased cell proliferation, anchorage-independent growth, migration and invasion. The increased proliferative responses were also in-agreement with observed levels of pro-inflammatory cytokines. Based on the hierarchical clustering analysis (HCA) of the inflammatory cytokine responses, CNC powder was segregated from the control and CNC-gel samples. This suggests that CNC may have the ability to influence neoplastic-like transformation events in pulmonary epithelial cells and that such effects are dependent on the type/form of CNC. Further studies focusing on determining and understanding molecular mechanisms underlying potential CNC cell transformation events and their likelihood to induce tumorigenic effects in vivo are highly warranted.

Nabiximols plus robotic assisted gait training in improving motor performances in people with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system, affecting ambulation even in people with only mild neurological signs. Patients with MS frequently experience spasticity, which contributes significantly to impair their motor functions, including ambulation, owing to muscle stiffness, spasms, and pain.

OBJECTIVES

To clarify the role of delta-9-tetrahydrocannabinol(THC):cannabidiol(CBD) oromucosal spray, coupled to robot-aided gait training (RAGT) using the Lokomat©Pro to improve functional ambulation in patients with MS.

METHODS

We compared 20 patients with MS, who were treated with THC:CBD oromucosal spray in add-on to the ongoing oral antispastic therapy (OAT) (group A), with 20 individuals with MS (matched for clinical-demographic characteristics) who were treated only with OAT (group B). Both the groups underwent RAGT using the Lokomat-Pro (three 45-minute sessions per week). Our primary outcome measures were the Functional Independence Measure (FIM) and the 10 meters walking test (10MWT). As secondary outcome measures we evaluated the brain cortical excitability by using Transcranial Magnetic Stimulation. Both parameters were taken before and after the end of the RAGT.

RESULTS

FIM improved in group A more than in group B (p<0.001). Moreover, 10MWT decreased in group A more than in group B (p<0.001). These clinical findings were paralleled by a more evident reshape of intracortical excitability in both upper and lower limbs, as suggested by motor evoked potential amplitude increase (p<0.001), intracortical inhibition strengthening (p<0.001), and intracortical facilitation decrease (p=0.01) in group A as compared to group B.

CONCLUSIONS

Our results suggest that the combined THC:CBD-RAGT approach could be useful in improving gait performance in patients with MS.