Metformin with neoadjuvant chemoradiation to improve pathologic response in rectal cancer: A pilot phase I/II trial

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A prospective pilot phase I/II study on metformin given concurrently with neoadjuvant chemoradiation (CRT) in non-diabetic rectal cancer patients.

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Three patients had a clinical complete response (cCR) and did not have surgical resection.

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Of the 12 patients who underwent surgery, there were two pCRs. For the combined pCR/cCR rate of 33% (95% CI 19–47%), a total of 85 patients will be required to yield a 95% CI with a 10% margin of error.

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These pilot results are encouraging, and will serve to refine the design and conduct of a future phase 2 trial to determine whether adding metformin to CRT improves pCR/cCR rates.

Purpose

Neoadjuvant radiotherapy with or without chemotherapy decreases the risk of local recurrence after surgery for rectal cancer. Emerging data suggest that diabetic patients on metformin may have improved cancer outcome after radiotherapy. A single institutional pilot study was performed to determine if metformin given concurrently with long course chemoradiation (CRT) may improve pathologic complete response (pCR) in non-diabetic rectal cancer patients. The study was designed to construct a confidence interval (CI) for the pCR rate to determine the sample size for a phase 2 trial.

Methods

Non-diabetic patients with biopsy confirmed rectal cancer deemed candidates for long course neoadjuvant CRT were invited to participate. Radiation consisted of 50.4 Gy in 28 daily fractions with concurrent daily capecitabine (825 mg/m² twice daily). Participants self-administered metformin (500 mg of twice daily) 2 weeks prior to, during and for 4 weeks after CRT.

Results

A total of 16 patients were accrued. One patient withdrew from the study. Only grade 1 or 2 adverse events were observed. Three patients had a clinical complete response (cCR) and did not undergo surgery. Of the 12 patients who underwent surgery, there were two pCRs. For the combined pCR/cCR rate of 33% (95% CI 19–47%), a total of 85 patients will be required to yield a 95% CI with a 10% margin of error.

Conclusions

Adding metformin to neoadjuvant CRT for rectal cancer does not appear to enhance toxicities. These results will be used to refine the design and conduct of a future phase 2 trial to determine whether adding metformin to CRT improves pCR/cCR rates.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven.

METHODS

This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms.

DISCUSSION

The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Left ventricular hypertrabeculation - an unanswered question

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Supported by the ÚNKP-19-3-II New National Excellence Program of the Ministry for Innovation and Technology

Left ventricular (LV) hypertrabeculation (H-TRAB) is a morphological description when the LV is highly trabeculated, but it remains below the diagnostic criterion of  noncompaction cardiomyopathy (NCMP). Although, it is a frequent finding on cardiac MRI scans its diagnostic and prognostic relevance remains controversial.  

In this cardiac MRI study, we aimed to describe the LV functional and feature-tracking strain values of healthy subjects with LV H-TRAB to decide whether it is a normal variant or an NCMP-like pattern.

We included 189 adult participants with good LV ejection fraction (EF), and without co-morbidities. 63 of them had a morphology of LV H-TRAB (H-TRAB, age: 37.1 ± 14.4 years; EF: 66.4 ± 5.1%), 63 patients were diagnosed with NCMP (age: 36.3 ± 14.0 years, EF: 65.8 ± 5.5%) and the remaining 63 people were healthy controls (38.3 ± 14.0 years, EF: 69.0 ± 4.9%). MR examinations were performed with 1,5T Philips Achieva and Siemens Aera devices. The  Medis Suite software was used for post-processing analysis, the MedCalc software for statistics, p < 0.05 was considered statistically significant. No significant differences were found between the functional parameters of the H-TRAB and NCMP groups. However, the EF was decreased, the end-diastolic (EDVi),  and end-systolic volume (ESVi), the myocardial mass (LV-massi), and trabeculated muscle mass (LV-trabi) values were increased in both groups compared to controls (H-TRAB vs. control: EF: 6.4 ± 5.4 vs. 69.0 ± 5.0%, EDVi: 74.4 ± 14.3 vs. 69.7 ± 12.8 ml/m2, ESVi: 25.1 ± 6.7 vs. 21.7 ± 5.8 ml/m2, LV-massi: 77.0 ± 15.1 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.0 ± 5.1 vs. 20.1 ± 4.0 g/m2; NCMP vs. control: EF: 65.8 ± 5.5 vs. 69.0 ± 5.0%, EDVi: 77.8 ± 15.0 vs. 69.7 ± 12.8 ml/m2, ESVi: 26.7 ± 7.9 vs. 21.7 ± 5.8 ml/m2, LV-massi: 76.8 ± 18.0 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.9 ± 7.5 vs.

20.1 ± 4.0 g/m2; p ≤ 0.05). The global circumferential strain (GCS) differed significantly between these groups: its absolute value was the lowest in the NCMP and the highest in the control group (NCMP vs. H-TRAB vs. control: -30.2% vs. -34.3% vs. -35.9%; p < 0.05). Similar results were found in the comparison of the mean segmental circumferential strain values of the apical-, mid- and basal-parts between the three groups. The absolute values of these parameters were the lowest in the NCMP patients, followed by the H-TRAB, and were the highest in the control group.

These results suggest that the LV functional and strain values of the H-TRAB population are more similar to NCMP patients than healthy controls. Further studies are necessary to determine the pathological implications and consequences of this morphology.

Right ventricular non-compaction: myth or reality?

Funding Acknowledgements

Type of funding sources: None.

Noncompaction cardiomyopathy (NCMP) is characterized by excessive left ventricular (LV) trabeculation. The involvement of the right ventricle (RV) is still questionable, furthermore, the normal range for RV trabeculation is undefined. 

Our aim was to describe the RV functional and strain values of patients with NCMP with preserved LV ejection fraction (EF) using cardiac MRI and to compare these parameters with healthy control subjects, furthermore, we aimed to define the normal range for RV trabeculation. 

We included 81 NCMP patients with good LV-EF (mean age: 37.0 ± 14 years; EF: 69.4 ± 13.2%) and without comorbidities. Their parameters were compared to an age and sex matched control group (mean age: 37.2 ± 13.7 years; EF: 77.2 ± 15.0%).

MR examinations were performed with 1,5T Philips Achieva and Siemens Aera devices. The Medis Suite software was used for post-processing analysis, the MedCalc software for statistics, p < 0.05 was considered statistically significant. 

The RV trabecular mass index (RV-TRABi) was significantly greater and the RV-EF significantly smaller in the NCMP group compared with the controls (NCMP vs. control; TRABi: 20.6 ± 7.0 vs. 16.9 ± 4.2 g/m2; RV-EF: 62.8 ± 5.5 vs. 64.5 ± 4.5%; p < 0.05).

As for the RV global longitudinal strain (GLS) the results were close to significant (NCMP vs. control: -25.1 ± 4.0 vs. -26.4 ± 4.3%; p = 0.05). We defined the normal range of RV-TRABi with a lower limit of 8.2 g/m2 (90% confidence interval (CI): 6.8-9.5) and the upper limit of 22.1 g/m2 (90% CI: 23.6-26.5). 27.2% of the NCMP patients exceeded the upper limit of RV-TRABi. 

The described differences in the RV-EF, RV-TRABi and RV-GLS draws attention to the possibility of the involvement of RV in patients with NCMP. Further follow-up studies would be necessary to evaluate the clinical importance of these alterations.

Two in one: Neuregulin 1 improves cardiac diastolic and kindney funtcion in chronic kidney disease in rats

Introduction

The prevalence of chronic renal disease (CKD) is continuously increasing in developed countries. Uremic cardiomyopathy characterized by left ventricular hypertrophy (LVH) and diastolic dysfunction (DD) is a common cardiovascular complication of CKD. Cardiac microvascular low-grade inflammation and altered expression of endothelium derived Neuregulin-1 (NRG-1) are contributed to left ventricular DD. Our aim was to charachterize the effects of CKD on the expression of NRG-1 and 2) NRG-1 treatment on myocardial hypertrophy, diastolic dysfunction and renal function in the rat model of CKD.

Methods

Male Wistar rats were used and randomized into 3 groups: 1) Sham-operated,2) CKD induced by 5/6 nephrectomy (CKD) and 3) NRG-1-treated CKD group (CKD+NRG-1). In this group, 2 weeks after the CKD induction, the rats were treated with recombinant human NRG-1 (rhNRG-1) at the dose of 10 μg/kg/d for consecutive 10 days with tail vein injection of NRG-1. Serum and urea creatinine levels were measured to verify the development of CKD and transthoracic echocardiography was performed to monitor cardiac morphology and function. Furthermore, total RNA was isolated and RT-qPCR was performed to evaluate the expression levels of inflammatory chemokine and cytokines (TNF-α, TGF-β). In addition, NRG-1 protein levels were assessed in both kidney and heart tissue by ELISA. To clarify the underling anti-fibrotic mechanism, human ventricular cardiac fibroblasts (HCF) were cultured and treated with the TGF-β (20 ng/ml), and TGF-β + hrNRG-1 for 24 h, respectively. Confocal microscopy was used to detect α-smooth muscle actin (α-SMA) expression, marker for fibroblast to myofibroblast transtion.

Results

10 weeks after the 5/6 nephrectomy, serum carbamide and creatinine levels were significantly increased and creatinine clearence was significantly decreased as compared to sham-operated animals proving the development of chronic kidney disease (CKD). This was accompanied by a significant decrease in NRG-1 protein expression levels in both cardiac and kidney tissue. Of note, NRG-1 treatment markedly reduced these changes, suggesting its renoprotective effects in CKD. In addition, In CKD animals, the significantly increased anterior, posterior and septal wall thicknesses with decreased end-diastolic and end-systolic diameters proved the development of concentric left ventricular hypertrophy. In CKD, the septal e' was significantly decreased and E/e' increased indicating the developemnt of diastolic dysfunction. These parameters were significantly improved by NRG-1 treatment. Mechanistically, NRG-1 treatment reduced the expression of inflammatory cytokines in compared to untreat group. Furthermore, TGF-β induced α-SMA and Col I upregulation was markedly reduced by hrNRG-1 treatment.

Conclusions

NRG-1 treatment improved both renal and cardiac funtion in CKD, via a mechansim including the anti-inflammatory and anti-fibrotic properties of NRG-1.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Österreichischer Austauschdienst

Cardiovascular phenotyping of the first mouse model of Sarcoidosis

Introduction

Sarcoidosis is a potentially life-threatening, inflammatory, granulomatous disease that affects multiple organs including the heart. Heretofore, its unknown etiology had hindered the creation of experimental models and the understanding of the molecular mechanisms of pathogenesis behind it.

Purpose

To extensively phenotype the heart of the first mouse model of sarcoidosis created through deletion of the tuberous sclerosis 2 (Tsc2) gene in the CD11c-positive macrophage population.

Methods

Tsc2 fl/fl CD11c Cre+ (Tsc2-KO; n=7) and Tsc2 fl/fl CD11c Cre- (Tsc2-WT; n=7) mice were subjected to echocardiography at 25 weeks of age (woa) to assess myocardial dimensions and function. Hearts of 13 and 25woa animals were subjected to histological and immunological stains to assess tissue changes, subtype inflammatory infiltrates and examine the localization of key proteins shown to be re-distributed in patients.

Results

At 13 woa, Tsc2-KO animals show inflammatory infiltrates; subtyped mainly as macrophages as well as evidence of myocyte destruction. At 25 woa, the number of inflammatory cells is significantly higher and there is heavy fibrotic replacement primarily in the septum and trabeculae. Older animals also show giant cells and non-necrotizing granulomas. The hearts show heterogeneous gap junction remodeling known to constitute an arrhythmogenic substrate and lack of immunoreactive signal for the desmosomal protein plakoglobin from the cell-cell junctions just as described in patients. The left ventricular ejection fraction and LV morphology was not significantly different between the two groups (EF: 64±4% in Tsc2-KO vs 64±2% in Tsc2-WT; LV end-systolic diameter: 4.51±0.54 mm in Tsc2-KO vs 4.59±0.29 mm in Tsc2-WT). However, there was a strong trend towards increasing filling pressure (E/e'ratio; 14.24±4.01 vs 12.15±2.54) and mean pulmonary pressure (21±6 vs 18±3 mmHg) in Tsc2-KO mice compared to controls suggesting diastolic dysfunction.

Conclusion

Hearts of the Tsc2 fl/fl CD11c Cre+ animals show a phenotype highly reminiscent of cardiac sarcoidosis in patients. We anticipate that this model will be very useful in deciphering molecular mechanisms of pathogenesis as well as testing much-needed mechanism-based therapies.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation - PG/18/27/33616

Methylation of the hippo signalling effector YAP by SETD7 drives myocardial ischemic injury

Introduction

Myocardial ischemia/reperfusion (I/R) injury is one of the most deleterious cardiovascular conditions and a leading cause of mortality. The Hippo pathway effector YAP critically regulates cardiomyocyte proliferation and survival during myocardial I/R injury. However, the mechanisms regulating YAP activation in this setting remain poorly understood. Post-translational modifications of proteins, namely methylation, modulate pathways implicated in myocardial I/R injury. The methyltransferase SETD7 is emerging as a regulator of cell survival via methylation of histone and non-histone proteins. Whether SETD7 participates to myocardial I/R injury remains elusive.

Purpose

To investigate the role of SETD7 in regulating Hippo signaling during myocardial I/R injury.

Methods

Neonatal rat ventricular myocytes (NRVM) were exposed to normal glucose levels or glucose deprivation (GD) for 15 h, in the presence of the selective SETD7 inhibitor [(R)-PFI-2] or its inactive enantiomer [(S)-PFI-2]. Western blot and real time PCR were employed to investigate the effects of energy stress on SETD7 and the Hippo pathway, while apoptosis was assessed by Caspase-3 activity assay. YAP activity was assessed through chromatin immunoprecipitation assay (ChIP), its localization was examined by confocal microscopy while mono-methylation was assessed by immunoblotting. SETD7 knockout (SETD7−/−) mice and wild-type (WT) littermates (male, 8–12 weeks old) underwent 1 h of left anterior descending (LAD) coronary artery ligation followed by 24 h of reperfusion. Infarct size was assessed by TTC staining and shown as infarct size per ventricle surface (I/V). Cardiac function was investigated at 24h by conventional and Tissue Doppler Imaging (TDI) echocardiography.

Results

GD in NRVMs led to upregulation of SETD7 and physical interaction with the pro-survival transcriptional cofactor YAP, resulting in its direct mono-methylation. Furthermore SETD7-dependent methylation of YAP led to its cytosolic retention and subsequent reduction of YAP binding to the promoter of pro-survival genes. Of note, pharmacological inhibition of SETD7 by (R)-PFI-2 blunted YAP mono-methylation while restoring its nuclear retention. Mechanistically, SETD7 inhibition promoted YAP binding to catalase and superoxide dismutase (SOD) gene promoters, thus preventing GD-induced mitochondrial oxidative stress and apoptosis. In line with our in vitro findings, SETD7−/− mice showed decreased infarct size as compared to WT littermates and preserved cardiac systolic (ejection fraction, fractional shortening) and diastolic function, as assessed by both conventional and TDI echocardiography.

Conclusions

We show that SETD7-dependent methylation of YAP is required for its inactivation, thus leading to myocyte oxidative stress and apoptosis. Pharmacological modulation of SETD7 by (R)-PFI-2 may represent a new therapeutic approach to prevent myocardial ischemic damage through modulation of the Hippo pathway.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation

Mid-Infrared Imaging Is Able to Characterize and Separate Cancer Cell Lines

Malignancies are still responsible for a large share of lethalities. Macroscopical evaluation of the surgical resection margins is uncertain. Big data based imaging approaches have emerged in the recent decade (mass spectrometry, two-photon microscopy, infrared and Raman spectroscopy). Indocianine green labelled MS is the most common approach, however, label free mid-infrared imaging is more promising for future practical application. We aimed to identify and separate different transformed (A-375, HT-29) and non-transformed (CCD986SK) cell lines by a label-free infrared spectroscopy method. Our approach applied a novel set-up for label-free mid-infrared range classification method. Transflection spectroscopy was used on aluminium coated glass slides. Both whole range spectra (4000-648 cm^-1) and hypersensitive fingerprint regions (1800-648 cm^-1) were tested on the imaged areas of cell lines fixed in ethanol. Non-cell spectra were possible to be excluded based on mean transmission values being above 90%. Feasibility of a mean transmission based spectra filtering method with principal component analysis and linear discriminant analysis was shown to separate cell lines representing different tissue types. Fingerprint region resulted the best separation of cell lines spectra with accuracy of 99.84% at 70-75 mean transmittance range. Our approach in vitro was able to separate unique cell lines representing different tissues of origin. Proper data handling and spectra processing are key steps to achieve the adaptation of this dye-free technique for intraoperative surgery. Further studies are urgently needed to test this novel, marker-free approach.

Willingness of women with early estrogen receptor-positive breast cancer to take adjuvant CDK4/6 inhibitors

Background

The steady decline in breast cancer (bca) mortality has come at the cost of increasingly toxic and expensive adjuvant therapies. Trials evaluating the addition of 2 or 3 years of cyclin-dependent kinase 4/6 (cdk4/6) inhibitors to adjuvant endocrine therapy (et) are ongoing, but the willingness of patients to take such additional therapy is unknown.

Methods

We surveyed 100 consecutive postmenopausal women with nonmetastatic estrogen receptor-positive bca who had initiated adjuvant et within the preceding 2 years. Participants were asked about perceived recurrence risk, bca worry, and overall health. They were then asked about their willingness to accept 2 years of treatment with an additional oral drug that would reduce recurrence by 40% for a range of baseline recurrence risks in 2 hypothetical scenarios.

Results

Mean age of the 99 evaluable participants was 61.7 years. In the scenario with no drug toxicity, 85% of respondents were likely to accept the new drug for a reduction in recurrence to 30% from 50%, but only 49% would take the drug if risk was reduced to 3% from 5%. In a scenario with drug-induced fatigue, the corresponding drug acceptance rates were 55% and 39% respectively. For the second scenario, bca worry was correlated with increased willingness to take the drug, even for only a 2% absolute reduction in recurrence risk.

Conclusions

The willingness of patients with estrogen receptor-positive bca to take an adjuvant cdk4/6 inhibitor will greatly depend on the expected benefit and toxicities described to them as well as on worry about bca recurrence.

Towards the sustainable food consumption in central Europe: Stochastic relationship between water footprint and nutrition

Sustainable nutrition (SN) considers the environmental impact of food production. This study aims to analyse the relationship between nutrient density and water footprint (WF) of the most consumed food items in Hungary and to create a classification of nutrients. Based on a comprehensive analysis of literature and different data sources, the authors analysed the stochastic relationship between WF and nutrient density of different food items by Spearman's rank correlation. The analysis proved significant (P<0.05) relationship between nutrient density and WF of the most relevant food items in Hungary. Based on the classification, there are nutrients that are overconsumed among the Hungarian population and positively correlate with WF (e.g., cholesterol) and there are nutrients that are under-consumed among the Hungarian population and negatively correlate with WF (e.g., dietary fibres). In general, it can be concluded that the re-structuration of food consumption patterns in Hungary is an important and urgent task, which serves both the public health and ecologic goals. These efforts should be based on a complex evaluation of the problem. This study was one initial step to analyse SN focused on Hungary and further studies are definitely needed.

P364 The first prospective study of non-compaction cardiomyopathy patients with preserved ejection fraction using cardiac magnetic resonance feature tracking

Feature tracking (FT) is a new cardiac magnetic resonance (CMR) technique for strain measurement to reveal changes e.g. in noncompaction cardiomyopathy (NCMP) patients with good ejection fraction (EF).

Our aim was to describe, first in the literature, the functional and CMR-FT strain values of NCMP patients with good EF and to compare them with their previous scans taken 4 years ago.

At the Heart and Vascular Center of Semmelweis University 6743 CMR examinations were done between 2009-2015 and 232 NCMP patients were diagnosed. We followed up 27 patients, who had a previous examination at least 4 years ago, had no co-morbidities and whoes EF were above 50% (mean age: 37 ± 14.4 years, 18 males, mean follow up: 5.7 ± 1.5 years). Their parameters were compared to a matched control (C) group.

The Medis Suite software was used for analysis, the MedCalc software for statistics, (p &lt; 0.05).

We compared the patient’s previous (PREV) and recent (REC) functional parameters but did not find significant changes. Comparing the global longitudinal and global circumferential strains (GLS, GCS) and rotation (R) no difference was found between the PREV and the REC values. The GCS showed significant difference between NCMP and C groups (-30.2 ± 5.0 vs -35.9 ± 4.5; p &lt; 0.0001). We compared the segmental longitudinal and circumferential strain values of PREV vs. REC groups and NCMP vs C groups and found significant differences just in a few segments. The left ventricular (LV) apical part’s mean longitudinal strain value showed significant decrease on the REC scans compared to the PREV (PREV vs REC: -24.4 ± 7.7 vs -20.6 ± 5.1%; p &lt; 0.05) and a non-significant decrease compared to the C (C vs REC: -22.8 ± 7.5 vs -20.6 ± 5.1%; p= n.s.).

The ratio of the average longitudinal strain value of the apical and basal part of the left ventricle was significantly smaller in the REC group compared to the PREV but did not differ from the C subjects ( PREV vs. REC: 1.5 ± 0.8 vs 1.0 ±0.3; C vs REC: 1.5 ± 0.3 vs 1.2 ± 0.5; p &lt; 0.05)

We did not find worsening in the functional parameters of NCMP patients with good EF by the end of the follow up period. However, subclinical changes can be detected in the affected apical part of LV when using FT suggesting the need for follow up.

P1824 Feature tracking strain values of noncompaction cardiomyopathy patients: differences in the light of ejection fraction

Feature tracking (FT) is a new cardiac magnetic resonance (CMR) technique for strain measurement which may give additional information about the progression of noncompaction cardiomyopathy (NCMP).

First in the literature, we compared the strain and functional parameters of NCMP patients with reduced (R) and good (G) ejection fraction (EF) using CMR-FT.

From the total of 164 CMR proven R NCMP patients, who were examined between 2009 and 2018 at the Heart and Vascular Center of Semmelweis University, we selected 26 non-ischaemic, contrast agent-free examinations (age: 56 ± 10.6 years; EF: 32.7 ± 10.0%; male = 19). According to their EF they were divided into medium (M; EF: 35-50%; n = 10) and significantly reduced EF (SR; EF &lt;35%; n = 16) subgroups. We searched 25 NCMP patients with good EF (age: 37 ± 14.4 years; EF: 65.9 ± 5.3%; male = 16) and 26 control persons (age: 52 ± 10.7 years; EF: 70.8 ± 5.1%; male = 16) to the above mentioned groups.

The Medis Suite program was used for analysis and the MedCalc software for statistics, (p &lt; 0.05).

Significant differences were found between the functional parameters of R and G patients. The global longitudinal strain (GLS) and global circumferential strain (GCS) values of the R group were decreased significantly compared to G and C groups. (R vs G; GLS: -9.5 ± 4.3 vs -20.9 + 3.2%; GCS: -12.5 ± 6.1 vs -30.5 ± 5.0%, p &lt; 0.0001; R vs C; GLS: -9.5 ± 4.3 vs -23.3 ± 4.4%; GCS: -12.5 ± 6.1 vs -35.6 ± 5.1%, p &lt; 0.0001).

All the segmental strain values of R group were decreased compared to G and C groups, moreover this significancy was observed between the M and SR subgroups as well.

The strain values of the R group in all the basal, mid and apical part of the left ventricle (LV) were reduced equally.

The average longitudinal strain values of the apical part of the LV in the SR subgroup were significantly reduced compared to the average strains of the basal part (apical vs basal: -8.9 ± 3.0 vs -11.9 ± 4.4 %, p &lt; 0.05). In addition, we found positive correlation in the R subgroup between the GCS and the mass of trabeculated muscle (r = 0.58, p = 0.002) .

Our study shows that the global and segmental strain values decreased significantly in proportion to the reduction of the EF which describes well the progression of heart failure in NCMP. However, the decreased strain values of the hypertrabeculated apical part might be specific to NCMP.

P2580Changes in extracellular vesicles during and after STEMI and potential influences of remote ischemic conditioning

Background

Due to their role in transportation of different molecules, such as microRNAs and mRNAs, extracellular vesicles (EVs) enable inter-cellular communication. Therefore, they are potential biomarkers in several kinds of disease. Information on their kinetics during acute and subacute ST-elevation myocardial infraction (STEMI) is limited and potential influence of remote ischemic conditioning (RIC) has not been investigated in humans so far.

Methods

We conducted a randomized, controlled trial in patients with first-ever STEMI; all patients received primary percutaneous coronary intervention (PCI). Additionally, the interventional group received a protocol of RIC (5 min inflation of a blood pressure cuff on the left upper arm to 200mmHg, 5 min deflation, 4 repetitions in total), whereas controls received sham-intervention (cuff placement). Citrate-plasma for EV analysis was taken prior to (baseline) and immediately after PCI, as well as after 24 hours, 4 days and 1 months. EVs were characterized by a high-sensitive flow cytometer using fluorescence-triggering. EVs were defined as being positive for the intra-vesicular marker CalceinAM or superficial expression of phosphatidylserine (PS; target of Lactadherin) in addition to another superficial epitope. Mixed-models were used to investigate changes over time; time and RIC were treated as fixed effects, patients were treated as random effects to account for the multiple testing design.

Results

We included 32 patients (16 RIC, 16 control). There was a significant impact of RIC on the changes in platelet (CD41) EVs from baseline (P=0.03, Figure). Furthermore, pro-coagulatory platelet EV (PS+/CD41+) were influenced by time after STEMI (after PCI P=0.017; 24h P=0.005) with significant interaction with RIC immediately and 24h after PCI (P for interaction of time with RIC; after PCI P=0.024, after 24h P=0.008). Likewise, monocyte (CD14) EVs increased significantly with time (4 days P=0.005, 1 Month P<0.001) with significant reduced levels of monocyte EVs by RIC at these time points (P for interaction at 4 days = 0.0493; and 1 month <0.001). There was also a significant change from baseline without any effect of RIC observed in inflammatory/leucocyte EVs (CD66b+; P for change from baseline for all time points <0.001). Pro-coagulatory and inflammatory (PS+/CD15+) EVs were significantly reduced over time (at 24h P=0.007; at 4 days P=0.049, at 1 month P=0.002). Finally, endothelial (CD31+/CD41-) EVs were significantly increased at 1 month after STEMI (P=0.032).

Conclusion

Several circulating EV sub-population are influenced by the acute phase of STEMI. RIC significantly impacts on the changes in platelet EVs during the initial phase after STEMI. Future studies are needed to clarify the functional importance of theses changes and whether this influence is part of a cardioprotective effect of RIC.

Acknowledgement/Funding

LBC for Cardiovascular Research Vienna; ATVB Vienna, a grant of the “Medical Scientific Fund of the Mayor of the City of Vienna”

Predictors of Post-operative Pain and Opioid Consumption in Patients Undergoing Liver Surgery

BACKGROUND

Post-operative pain management is a critical component of perioperative care. Patients at risk of poorly controlled post-operative pain may benefit from early measures to optimize pain management. We sought to identify risk factors for post-operative pain and opioid consumption in patients undergoing liver resection.

METHODS

This is a multi-institutional prospective nested cohort study of patients undergoing open liver resection. Opioid consumption and pain scores were collected following surgery. To estimate the effects of patient factors on opioid consumption (oral morphine equivalents-OME) and on pain scores (NRS-11), we used generalized linear models and multivariable linear regression model, respectively.

RESULTS

One hundred and fifty-three patients who underwent open liver resection between 2013 and 2016 were included in the study. The mean patient age was 62.2 years, and 43.3% were female. Younger patients were significantly more likely to use more opioids in the early post-operative period (16.7 OME/10 years, p < 0.001). Patient factors that were significantly associated with increased NRS-11 pain scores also included younger patient age (difference in pain score of 0.3/10 years with cough and 0.2/10 years at rest, p < 0.01 for both) as well as a history of analgesic use (difference in pain score of 0.9 with cough and 0.6 at rest, p < 0.01 and p = 0.07, respectively).

CONCLUSION

Younger patients and those with a history of analgesic use are more likely to report higher post-operative pain and require higher doses of opioids. Early identification of these patients, and measures to better manage their pain, may contribute to optimal perioperative care.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

[Three-dimensional reconstruction of solid tumors : Morphological evidence for tumor heterogeneity]

BACKGROUND

In histopathological routine diagnostics, three-dimensional tissue samples are analyzed histologically and/or immunohistochemically in two-dimensional sectional planes due to the high expenditure of time and the lack of digitization possibilities.

AIM

Here, we demonstrate the application of three-dimensional reconstruction to solid tumors and analyze inter-/intratumoral heterogeneity with respect to epithelial-mesenchymal transition (EMT).

METHODS

Tissue samples from pancreatic, lung, colorectal, and breast cancers as well as colorectal liver metastases were serially processed in 4μm sections. For individual analyses, alternating stains (cytokeratin AE1/3, zinc finger E‑box-binding homeobox 1 (ZEB1), eCadherin) were performed. Subsequently, the tumor cells were analyzed for their morphology (epitheloid amoeboid, mesenchymal) and the expression of ZEB1 and eCadherin. For statistical analysis, all tumor cell aggregates were hierarchically annotated and analyzed.

RESULTS

Tumor buds are predominantly associated with the main tumor mass. Furthermore, a shutteling of eCadherin could be observed within tumor cell aggregates smaller than nine cells. ZEB1 is only increasingly expressed in tumor cell groups smaller than five cells.

CONCLUSIONS

The initial tumor budding and the subsequent decoupling of the tumor bud from the main tumor mass is most likely a two-part process. However, the EMT is not statistically significantly increased within the tumor bud detached from the main tumor mass. It could be shown that the currently valid and known definition of a tumor bud as a cell cluster of less than or equal to five cells cannot be completely classified in the concept of EMT represented by eCadherin and ZEB1.

Three-dimensional tumor visualization of invasive breast carcinomas using whole-mount serial section histopathology: implications for tumor size assessment

PURPOSE

Linear tumor size (T-size) estimated with conventional histology informs breast cancer management. Previously we demonstrated significant differences in margin and focality estimates using conventional histology versus digital whole-mount serial sections (WMSS). Using WMSS we can measure T-size or volume. Here, we compare WMSS T-size with volume, and with T-size measured conventionally. We also compare the ellipsoid model for calculating tumor volume to direct, WMSS measurement.

METHODS

Two pathologists contoured regions of invasive carcinoma and measured T-size from both WMSS and (simulated) conventional sections in 55 consecutive lumpectomy specimens. Volume was measured directly from the contours. Measurements were compared using the paired t-test or Spearman's rank-order correlation. A five-point 'border index' was devised and assigned to each case to parametrize tumor shape considering 'compactness' or cellularity. Tumor volumes calculated assuming ellipsoid geometry were compared with direct, WMSS measurements.

RESULTS

WMSS reported significantly larger T-size than conventional histology in the majority of cases [61.8%, 34/55; means = (2.34 cm; 1.99 cm), p < 0.001], with a 16.4% (9/55) rate of 'upstaging'. The majority of discordances were due to undersampling. T-size and volume were strongly correlated (r = 0.838, p < 0.001). Significantly lower volume was obtained with WMSS versus ellipsoid modeling [means = (1.18 cm³; 1.45 cm³), p < 0.001].

CONCLUSIONS

Significantly larger T-size is measured with WMSS than conventionally, due primarily to undersampling in the latter. Volume and linear size are highly correlated. Diffuse tumors interspersed with normal or non-invasive elements may be sampled less extensively than more localized masses. The ellipsoid model overestimates tumor volume.

Training in communication of oncology clinicians: a position paper based on the third consensus meeting among European experts in 2018

Background

Since there is sound evidence that communication skills training (CST) programs modify communication behavior of oncology clinicians, they have been widely implemented over the last decades. However, more recently, certain aspects of this training have been criticized.

Methods

Based on this background, a call to re-launch a discussion about the future of CST led to the third European consensus meeting on communication in cancer care, organized by the Swiss Cancer League. During this meeting, which brought together European experts in the field of clinical communication and training of communication in the oncology setting, oncology clinicians, representatives of the European Society of Medical Oncology and a member of the European Oncology Nursing Society, the recommendations of the second European consensus meeting were updated and expanded.

Results

The expanded recommendations recall the guiding principles of communication in cancer care, underline the important role of clinician's self-awareness, and of relational and contextual factors in clinical communication, and provide direction for the further development of communication training.

Conclusion

This third European consensus meeting defines key elements for the development of a next generation of communication training for oncology clinicians.