P14.77 Efficacy and safety of Tumor-Treating Fields associated with Depatux M and metronomic temozolomide for recurrent glioblastoma: a case-report

BACKGROUND

Patients with glioblastoma (GBM) have a poor prognosis following an extensive resection, radiotherapy (RT) and concomitant/adjuvant temozolomide (TMZ). Once GBM progresses after SOC, lomustine is the standard second-line treatment, while rechallenge with TMZ may be employed in selected patients with methylated promoter of MGMT, and bevacizumab is reserved for patients with extensive edema and need for steroids. New treatment modalities have been investigated at first recurrence, including alternating electric fields (TTFields) or antibody direct against epidermal growth factor receptor (EGFR), such as depatuximab mafodontin (ABT-414, Depatux-M), that have shown some activity in terms of disease control and progression-free survival (PFS).

CLINICAL PRESENTATION

In September 2018, a 38 year-old man developed reduced strength in left upper limb and daily focal seizures. MRI showed an enhancing right fronto-temporal lesion which was subtotally removed with a diagnosis of glioblastoma (IDH 1/2 wild type, MGMT methylated - 40%, EGFR amplified, EGFRvIII positive). As the patient had a poor KPS (50), in October 2018 a hypofractionated RT (DFT 40 Gy/15 fractions) with concomitant TMZ (140 mg/day) was performed, followed by adjuvant standard TMZ (340 mg/day); however, chemotherapy was stopped after 3 cycles due to local progression on MRI coupled with strength worsening, increased seizure frequency, and need for steroids. Pseudoprogression was ruled out due to tumor growth out of the field of RT. Based on the high level of methylation of the MGMT promoter and EGFR amplification, a combined treatment with metronomic TMZ (100 mg/day continuously) plus Depatux-M (1.25 mg/kg every 2 weeks) was started (February 2019), but a brain MRI performed after 3 months of treatment displayed no significant changes on both MRI and neurological status. At this time point (May 2019) TTFields treatment was added. An initial decrease of tumor size was observed on MRI after 5 months, while a reduction of tumor size more than 90% has been progressively achieved after 1 year of treatment (April 2020). Moreover, a seizure-free status was observed without changing the antiepileptic medication. The patient developed a grade 3 ocular side effect (CTCAE version 5.0) with photophobia, blurred vision, foreign body sensation in the eyes after 6 months of treatment, which improved after dose delays and dose reduction of Depatux-M. The patient is still alive, and free of progression after 30 months and 25 months from diagnosis and first recurrence, respectively.

CONCLUSION

To our knowledge, this is the first report of a recurrent GBM with a significant and long-lasting neuroradiological response following a combined treatment with TTFields, Depatux-M, and intensified schedule of TMZ. A synergistic effect of TTFields with compounds interfering with the microtubular system should be further investigated.

P14.42 Neratinib for treatment of leptomeningeal metastases from HER2-positive breast cancer in extended access program: preliminary results

BACKGROUND

Leptomeningeal metastases (LM) occur in 5% of human epidermal growth factor receptor 2 (HER2) breast cancer (BC) with a poor overall survival (OS) of 3 months. Neratinib is an oral, irreversible tyrosine kinase pan-inhibitor that was approved by FDA for the treatment of HER2-enriched BC, who completed a prior adjuvant trastuzumab-based therapy. The aim of the study was to evaluate the activity of neratinib in LM from HER2-positive BC after the failure of multiple lines of treatment, including trastuzumab.

PATIENTS AND METHODS

Inclusion criteria were as follows: age ≥ 18 years; histological diagnosis of primary HER2-positive BC; newly-diagnosed LM according to LANO criteria; KPS ≥60 at the time of diagnosis of LM; coexistence of BM that have or not received WBRT or radiosurgery; systemic disease with a life expectancy of at least 3 months; concomitant drugs, including capecitabine, trastuzumab, TDM-1, pertuzumab, and hormone therapy were allowed, with the exclusion of lapatinib or other investigational agents. Neratinib was administered 240 mg daily continuously. The primary endpoint was the OS after the diagnosis of LM. Secondary endpoints were progression-free survival (PFS) following the diagnosis of LM, neurological benefit, radiological response rate, and tolerability.

RESULTS

From January 2018 to April 2021, 9 patients with LM have been enrolled. Median age at the time of diagnosis of LM was 44 years (95%CI 36–59) with a median KPS of 80 (95%CI 60–90). Median time since LM onset from the diagnosis of primary BC was 42 months (95%CI 11–166), and patients underwent a median number of adjuvant treatments before LM of 3 (95%CI 2–5). Three patients developed LM alone, and other 6 had LM associated with multiple brain metastases. Six-months and 1-year OS were 66.7% and 22.3%, respectively, with a median OS of 8 months (95%CI 3–13*). Median PFS was 3.5 months (95%CI 2–6) after the start of treatment. A neurological improvement was reported in 2/9 patients (22.2%), while in other 4/9 patients (44.5%) was achieved a neurological stabilization lasting for a median time of 5 months (95%CI 2–19). The best radiological response was a stable disease in 5/9 patients (55.6%), while no complete or partial response were achieved according to LANO and RANO criteria, respectively. A CSF clearance was observed in 1 patient only (11.1%) following two months of neratinib. Grade III-IV adverse events were not reported, and 2 patients only (22.2%) had mild diarrhea correlated with neratinib.

CONCLUSION

This is the first study that shows that neratinib might be a safe and effective treatment in LM from heavily pretreated HER2-positive BC.

POS1344 EVALUATING THE MULTIVISCERAL INVOLVEMENT ON ADULT-ONSET STILL’S DISEASE TO RETRIEVE IMAGING-BASED DIFFERENCES IN PATIENTS WITH AND WITHOUT MACROPHAGE ACTIVATION SYNDROME; RESULTS FROM A SINGLE-CENTRE OBSERVATIONAL STUDY

Background:

Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder usually affecting young adults, burdened by life-threatening complications, mainly macrophage activation syndrome (MAS), a secondary form of hemophagocytic lymphohistiocytosis [1]. In this context, the importance of an accurate assessment of AOSD is suggested to promptly recognise the multivisceral involvement of the disease which is associated with life-threatening complications. The assessment of the most aggressive subsets of the disease could guide the clinicians when to apply additional resources but avoiding unnecessary expenditures in patients with a less severe clinical picture.

Objectives:

In this study, we aimed at describing the multivisceral involvement of the disease to retrieve imaging-based differences in AOSD patients with and without MAS.

Methods:

The present evaluation has been designed as a cross-sectional study to descriptively compare the multivisceral involvement in AOSD patients with and without MAS. Patients admitted to our Institution, who underwent a total body CT scan, were selected from our historical cohort and assessed. Clinical and CT scan characteristics of AOSD patients with and without MAS were compared. Clinical and CT scan characteristics of AOSD patients with and without MAS were analysed by parametric or non-parametric t tests for all continuous variables, and chi squared test was used for categorical ones, as appropriate. Furthermore, possible correlations among radiological outcomes with laboratory markers and systemic score were estimated by using a point-biserial coefficient correlation.

Results:

This study evaluated 39 AOSD patients (men 64.1%), mean age of 48.8±16.6 years). Out of those, 14 patients (35.9%) were complicated by MAS. These patients showed higher values of ferritin [AOSD: 770.0 (1306.5) ng/mL vs MAS: 2926.3 (4918.5) ng/mL p=0.003] and systemic score (AOSD: 4.6±1.4 vs MAS: 6.9±1.7, p<0.0001). AOSD patients with MAS presented a higher prevalence of lung disease than others (AOSD: 56.0% vs MAS 85.7% p=0.048). Lung disease correlated with the systemic score (coefficient 0.491, p=0.003). AOSD patients with MAS were more frequently characterised by hepatomegaly (AOSD: 12.0% vs MAS: 50.0% p=0.019) and splenomegaly (AOSD: 16.0% vs MAS 50.0% p=0.033), respectively, than others. Hepatomegaly correlated with CRP (coefficient 0.421, p=0.016), ferritin (coefficient 0.397, p=0.020), and systemic score (coefficient 0.391, p=0.022). Furthermore, the presence of splenomegaly correlated with the systemic score (coefficient 0.439, p=0.009). CT scan features of abdominal effusions were more frequently observed in AOSD patients with MAS than those without this complication (AOSD: 12.0% vs 57.1% p=0.007). Finally, a higher percentage of AOSD patients with MAS showed a significant lymph node enlargement, either mediastinal or abdominal, than others on CT scan (AOSD: 36.0% vs MAS 71.4% p=0.048). The presence of lymphadenomegaly correlated with the systemic score (coefficient 0.368, p=0.032).

Conclusion:

Our findings showed a higher prevalence of multiorgan involvement in AOSD patients with MAS, suggesting imaging-based differences, although other studies are needed to fully assess this issue. Pulmonary disease, hepatomegaly, splenomegaly, lymph nodes enlargement, and abdominal effusions were associated with these more aggressive patients.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018 Sep;93:24-36.

Disclosure of Interests:

None declared

AB0156 INCIDENCE OF CERVICAL SPINE INVOLVEMENT IN RHEUMATOID ARTHRITIS, RESULTS FROM A SINGLE CENTRE OBSERVATIONAL STUDY

Background:

Rheumatoid arthritis (RA) manifests as a chronic, symmetrical articular disease; any synovial joint may be involved and the cervical spine is another possible affected site [1,2]. Although the cervical spine involvement is a very severe complication of RA, the exact incidence of cervical spine abnormalities in RA is not fully elucidated yet.

Objectives:

In this work, we aimed at evaluating the incidence of a cervical spine involvement and associated clinical characteristics in patients with RA in a single centre observational study.

Methods:

In this study, we performed a retrospective analysis of prospectively followed-up patients with RA attending our Rheumatologic Clinic, University of L’Aquila, L’Aquila, Italy, between January 2010 and December 2020. Patients who met the diagnostic criteria of 1987 ACR and/or ACR/EULAR 2010 criteria were assessed. Each patient was investigated for cervical spine involvement occurrence, particularly the atlas-axis cervical involvement. Instrumental imaging evaluation of the cervical spine was performed in all patients with clinical suspicion of involvement, by both MRI and CT examinations. MRI examinations were performed on a 1.5 Tesla scanner, acquiring T1, T2, and STIR sequences on sagittal, coronal and axial planes. CT examinations were performed on a multidetector 320-row CT scanner (Aquilion One,Toshiba) acquired with a thin collimation; soft tissue or bone algorithms were applied for image data reconstruction and analysis.

Incident cases of cervical spine involvement were reported as incidence proportion and incidence rate per 1000 person-years at risk.

Results:

In this evaluation, 347 consecutive patients, (mostly female 87.6%, mean age of 66.1 ± 11.3 years) attending our Rheumatologic Clinic, were studied. The incidence proportion of cervical spine involvement was 2.0% [0.6 – 3.4%], occurring in 7 out of 347 patients, and identified by both MRI and CT scan. Considering over 1623 person-years, an incidence rate of 4.0 × 1000 [3.0 – 5.0] person-years was also estimated. All our patients with cervical spine involvement were characterised by female gender, rheumatoid factor, ACPA, fulfilment of ACR 1987 classificative criteria, and poorly controlled disease activity. Smoking habit and extra-articular manifestations were also frequently reported. Glucocorticoids, methotrexate, and infliximab were mainly administered in these patients. This therapeutic strategy resulted in a complete resolution of the inflammatory synovitis in all but one patient. The latter developed a cervical spinal instability resulting in neurological progression and required a subsequent surgical management.

Conclusion:

The cervical spine involvement is an uncommon but serious manifestation of RA, since possibly causing severe neurologic damage. A poorly controlled inflammatory process would be an important risk factor for developing a cervical spine involvement in RA, thus, a proper management is required, from an early accurate recognition to a timely therapeutic strategy. MRI could provide a useful clinical tool to early evaluate the cervical spine involvement in RA. Finally, considering the low incidence, further studies are needed to fully estimate the exact incidence of this manifestation, mostly in poorly symptomatic patients.

References:

[1]Shlobin NA, Dahdaleh NS. Cervical spine manifestations of rheumatoid arthritis: a review. Neurosurg Rev. 2020 Oct 10. Neurosurg Rev. 2020 Oct 10. doi: 10.1007/s10143-020-01412-1.

[2]Kothe, R.Rheumatoid instability in the cervical spine: Diagnostic and therapeutic strategies. Orthopade. 2018 Jun;47(6):489-495.

Disclosure of Interests:

None declared

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

POS0308 TRAJECTORIES OF FATIGUE IN EARLY RA OVER 10 YEARS: RESULTS FROM THE ESPOIR COHORT

Background:

Fatigue is one of the most prevalent symptom reported by persons with RA. RA-related fatigue is a complex concept with biological, psychological and social interactions.

Objectives:

In a cohort of early RA patients, to determine and characterize fatigue trajectories over 10 years of follow-up and identify predictors of trajectory membership.

Methods:

Patients fulfilling the 2010 ACR/EULAR criteria for RA included in the ESPOIR cohort. We used a cluster analysis to obtain fatigue (assessed by fatigue visual analogue scale) trajectories over the course of 10 years from enrolment. Chi-square tests or ANOVA were performed to evaluate differences of baseline variables between fatigue trajectories. Using a multinomial logistic regression we could identify predictors of trajectory membership.

Results:

We analysed 598 patients with mean disease duration at enrolment of 26.2 ± 40.9 days. Cluster analysis revealed 3 trajectories: high (18%), moderate (52%) and low fatigue (30%). Compared to patients with moderate or low fatigue trajectory, patients with high fatigue trajectory were predominantly women and reported significantly higher duration and intensity of morning stiffness, HAQ score, number of tender joints, levels of pain, number of awakenings due to arthritis, levels of physician and patient global assessment and more frequent sleep problems, and increased psychological distress. Female patients with pain, psychological distress and presence of sicca symptoms had higher risk of being in high trajectory group.

Conclusion:

These findings suggest that levels of fatigue are rather stable over time in each trajectory. Baseline clinical measures and baseline patient-reported measures of functional status better distinguished the three fatigue trajectories. We did not find differences between trajectories in baseline laboratory measures. Inflammatory activity was not a predictor of being in high trajectory fatigue group.

References:

[1]Pollard LC, Choy EH, Gonzalez J, Khoshaba B, Scott DL. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford) 2006;45:885–9

[2]Repping-Wuts H, van Riel P, van Achterberg T. Fatigue in patients with rheumatoid arthritis: what is known and what is needed. Rheumatology (Oxford) 2009;48:207–9.

[3]Pilgaard T, hagelund L, Stallknecht SE, jensen HH, Esbensen BA. Severity of fatigue in people with rheumatoid arthritis, psoritic artrhitis and spondyoarthritis- Results of cross-sectional study. Plos One. 2019;14:e0211831

[4]Feldthusen C, Grimby-Ekman A, Forsblad-d’Elia H, Jacobsson L, Mannerkorpi K. Explanatory factors and predictors of fatigue in persons with rheumatoid arthritis: a longitudinal study. J Rehabil Med 2016 28;48:469–76.

[5]Madsen SG, Danneskiold-Samsøe B, Stockmarr A, Bartels EM. Correlations between fatigue and disease duration, disease activity, and pain in patients with rheumatoid arthritis: a systematic review. Scand J Rheumatol. 2016;45:255-61.

[6]Olsen CL, Lie E, Kvien TK, Zangi HA. Predictors of fatigue in rheumatoid arthritis patients in remission or in a low disease activity state. Arthritis Care Res (Hoboken) 2016;68:1043–8.

[7]Druce K, Jones GT, Macfarlane GJ, Verstappen SMM, Basu N. The longitudinal course of fatigue in rheumatoid arthritis: results from the Norfolk Arthritis Register. J Rheumatol 2015;42:2059–65.

Disclosure of Interests:

None declared

Mean differences and individual changes in nursing students' attitudes toward statistics: The role of math background and personality traits

Nursing students have compulsory statistics courses in their degree program, but they usually have negative attitudes toward statistics that may hinder their learning. The present study aims: (i) to investigate nurse students' attitudes toward statistics and the relationships with mathematical background and personality traits; (ii) to stress individual changes in attitude that occur during the course; and (iii) to explore if mathematical background and personality traits influence these changes. We adopted a one-group pre-post survey study. Fifty nursing students were enrolled in an introductory statistics course at the Sapienza University of Rome in Italy during the 2018-2019 academic year. Participants were surveyed at the beginning and end of the course administering a multidimensional measure of attitude toward statistics. Multiple regression analyses were run to establish the relative impact of mathematical background and Big Five personality factors on attitude components, as well as the changes in these attitude components. Results confirmed the predictive role of mathematic competence on some attitude dimensions and showed that also personality traits influenced attitudes toward statistics. However, the observed changes in attitudes during the course were minimally influenced by these factors. Findings suggest that course pedagogy can enhance students' attitudes regardless their mathematical background and personality.

Quality of life and psychopathology in candidates to bariatric surgery: relationship with BMI class

PURPOSE

This cross-sectional study aimed at comparing the quality of life (Qol), the prevalence of psychiatric diagnosis and pharmacological treatment in 104 candidates to bariatric surgery according to the degree of obesity (class 2 vs. class ≥ 3 obesity).

METHODS

All surgical candidates underwent a detailed psychiatric interview based on DSM-5 criteria, including sociodemographic, clinical, psychological and psychiatric data. Participants completed the Binge Eating Scale (BES) and the 12-Item Short Form Health Survey (SF-12).

RESULTS

Overall, bariatric candidates reported a significant impairment in the physical (PCS 38.8 [95% CI 36.2-41.5]) and mental (MCS 42.2 [95% CI 40.4-43.9]) components of Qol compared to population norms (p < 0.001 for both). Subjects with class 2 obesity scored significantly lower in the MCS compared to those with class 3 (38.7 (8.1) vs. 43.6 (8.4), p = 0.008). No other statistically significant differences were found between the two groups in terms of sociodemographic and clinical variables.

CONCLUSION

These data support the usefulness of Qol assessment in bariatric candidates as a sensible screening parameter, especially in patients with lower BMI, in whom MCS could identify the need for early psychosocial intervention.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Fractional flow reserve (FFR) guided vs angiography guided coronary artery bypass graft (CABG): a systematic review and meta-analysis

Background

A strategy of percutaneous coronary intervention (PCI) driven by FFR (Fractional Flow Reserve) has demonstrated to reduce adverse events through the “deferring” of unnecessary stenting procedures compared to PCI guided by angiographic evaluation of stenosis. Coronary Artery Bypass Graft (CABG) represents another option for revascularization, being superior to PCI in patients with diffuse disease. In this setting, some evidence has been provided about physiological driven CABG procedures, but studies reported contrasting results regarding clinical benefits and outcomes at follow up.

The aim of this meta-analysis is to evaluate clinical and procedural impact of FFR versus angiographic guided surgical revascularization and assess outcomes at follow up.

Methods

All randomized controlled trials (RCTs) or observational studies with multivariable adjustment or propensity matching were included. MACE (Major Adverse Cardiac Events) was the primary end point, while its single components (death, myocardial infarction and revascularization) along with number of grafts and percent of off-pump CABG were the secondary ones. Of 86 studies identified, 4 articles were included in this review, representing a combined total of 777 patients (426 angio-guided and 351 FFR-guided). Mean age was 66±2.1, 80% man, 74% hypertension, 71% hyperlipidemia, 33% diabetes, 39% smokers. Mean EuroSCORE I was 2.7. 18% a prior MI, and 25% a prior PCI. Coronary lesions were allocated as follow: 36% left anterior descending artery, 32% circumflex artery, 27% right coronary artery. Mean follow up was 30 months. At the follow up, rates of MACE did not differ (MACE OR 1.31:0.88–1.96), as those of death (OR 1.47:0.86–2.51), of MI (OR 1.80:0.89–3.63), and of target vessel revascularization (1.03: 0.54–1.97.). FFR-guided CABG was associated with more off-pump surgical procedure (OR 0.58, IC 0.34–0.97) and shorter hospitalization time (8.2±2.49 vs 8,87±3,25 p&lt;0.01). FFR- guided CABG was associated more frequently with off-pump surgical procedure (OR 0.58:0.34–0.97) with fewer anastomes (2.5 vs 3), leading to higher rates of global arteria revascularization in FFR group (56% vs. 45%) and higher rates of venous grafts in angio-guided group (55% vs. 44%). Shorter hospitalization time was recorded in FFR patients (8.2±2.49 vs 8,87±3,25 days, p&lt;0.01). Graft patency at follow up was not statistically higher in the FFR guided group (OR 0.67, CI 95% 0.32–1,39, all CI 95%).

Conclusions

FFR-guided surgical revascularization is associated with more off-pump procedures, a lower number of surgical anastomoses and more arterial grafts compared to angiography guided CABG. These differences lead to a shorter hospitalization time in the FFR-guided group compared to the angiography-guided group. No difference between two groups in MACE, overall death and MI was observed during the follow up. RCT with longer follow up are needed to evaluate long term outcomes.

Funding Acknowledgement

Type of funding source: None

Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture

Hip fracture patients are complex, and orthopaedic management is limited to the surgery phase. To provide better evaluation pre-operatively and an optimal level of post-operative care, an orthogeriatrician was introduced in the orthopaedic team. This ensured that time to surgery from admission consistently was below 48 h, decreasing hospitalization time after surgery and total length of stay.

INTRODUCTION

Hip fractures are a major health issue in elderly and frail patient. The integration of orthogeriatric care within the orthopaedic team could be useful to optimize the clinical conditions of these patients in perioperative phases and stabilize them after surgery, reducing hospital length of stay. The present study evaluates the role of an orthogeriatrician in the management of patients with a hip fracture.

MATERIALS AND METHODS

Data about patients admitted and operated from February to September 2018 and from February to September 2019 were collected from the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno database. A total of 352 patients were identified and divided in two groups according to the year in which the orthogeriatrician was working in Orthopaedic Department. Records regarding age, sex, side and type of fracture, time of admission, day of surgery and discharge were collected and length of stay, days from the admission to surgery and days from surgery to discharge were calculated.

RESULTS

There were no statistically significant differences in the pre-surgery phases of both groups, and all patients were operated at a mean of 2.1 days ± 1.8 SD from admission (p > 0.05). No statistically significant difference between demographic data in both groups (p > 0.01) was observed. There was, however, statistically significant reduction of hospitalization time after surgery and total LOS from 2018 to 2019 (p < 0.01).

CONCLUSION

An Orthogeriatric doctor in an Orthopaedic and Traumatology Department may lead a multidisciplinary approach to manage elderly patients with hip fractures, ensuring that the time to surgery from admission is less than 48 h, and reducing hospitalization time after surgery and total length of stay.

Prognostic implication of sodium nitroprusside vasodilator test in pulmonary hypertension and left heart disease: insights from PUSHON registry

Background

Definition of combined post and pre-capillary pulmonary hypertension (Cpc-PH) is controversial, despite involving up to 25% of patients with heart failure with reduced ejection fraction (HFrEF). The 2019 World Symposium on PH focused on conflicting results and potential misleading interpretation of mean transpulmonary gradient (TPG) and diastolic transpulmonary gradient (DPG) in predicting outcomes in type 2 PH patients. A new Cpc-PH definition has been proposed, basing on pulmonary arterial wedge pressure (PAWP) &gt;15 mmHg and pulmonary vascular resistance (PVR) &gt;3 WU. In this setting, the role of vasodilator challenge has marginally been explored.

Purpose

This study aims to investigate whether vasodilator test increases prognostic accuracy in PH-LHD comparing to PVR and TPG.

Methods

125 patients with a first diagnosis of PH-LHD were selected within the PUlmonary hypertenSion in rigHt heart catheterization (PUSHON) registry. All patients underwent right heart catheterization and sodium nitroprusside vasodilator infusion. Hemodynamic response was defined as decrease of mean pulmonary arterial pressure (mPAP) &lt;25 mmHg with maintenance of systemic systolic arterial pressure &gt;85 mmHg. Primary endpoint was a composite of cardiac death, heart transplantation and urgent LVAD implant at 2 years.

Results

34 (27%) patients were sodium nitroprusside responders. Normalization of mPAP during acute vasodilator challenge was associated with higher event-free survival at 2 years (HR 2.46, 95% C.I. 1.29–4.69, p=0.006). Responders to nitroprusside showed lower baseline pressure regimens in pulmonary artery (sPAP 56.4±12.9 vs 63.2±12.4 mmHg, p=0.009; mPAP 38.1±6.9 vs 44.7±8.8 mmHg, p=0.001) and lower Wedge Pressure (25.1±6.6 vs 29.8±6.6 mmHg, p=0.001). Also, patients with positive vasodilator test showed better right ventricular function expressed by TAPSE (17.2±4.3 vs 15.4±3.8 mm, p=0.05) and higher EF (34.6±15.3% vs 28.1±13.1%, p=0.023). Interestingly, nitroprusside responders exhibited lower DPG (−0.11±5.30 vs 2.04±5.21 p=0.04). At multivariate analysis PVR and TPG ≥12 mmHg fail to independently predict primary endpoint, while positive vasodilator response was independently associated with better outcome (OR 0.22, 95% C.I. 0.09–0.52, p=0.001). The same results were confirmed in the Cpc-PH subgroup (OR 0.54, 95% C.I. 0.08–0.78, p=0.018).

Conclusions

Nitroprusside vasodilator response was associated with a higher event-free survival at 2 years follow-up in our cohort of patients with PH-LHD. Larger studies with prospective hemodynamic evaluations are needed to support our hypothesis.

Figure 1

Funding Acknowledgement

Type of funding source: None

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5 years follow-up RCTs

Introduction

5-year survival of patients with ULM (Unprotected Left Main) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.

Methods and results

Randomized Controlled Trials (RTCs) comparing Percutaneous Coronary Intervention (PCI) vs. Coronary Artery Bypass Graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE (a composite endpoint of all-cause mortality, myocardial infarction [MI], stroke and repeat revascularization) along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to use of first vs. last generation coronary stents. Subgroup comparisons were performed according to Syntax Score (below or above 33) and to age (using cutoffs of each trial's subgroup analysis). 4 RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation and 1540 with last generation stents. At 5 years rates of all-cause death did not differ (OR 0.93: 0.71–1.21), as those of CV death and stroke. CABG reduced rates of MACCE (OR 0.69: 0.60–0.79), mainly driven by MI (OR 0.48: 0.36–0.65) and revascularization (OR 0.53: 0.45–0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of Syntax Score (OR 0.76: 0.59–0.97 for values &lt;32 and OR 0.63: 0.47–0.84 for values ≥33) while was not evident for “younger” patients (OR 0.83: 0.65–1.07 vs. OR 0.65: 0.51–0.84 for “older” patients, all CI 95%).

Conclusion

For patients with ULM disease, PCI and CABG yielded same survival benefit at 5 years. CABG reduced risk of MI, revascularization and MACCE especially in older patients and in those with diffuse coronary disease.

Funding Acknowledgement

Type of funding source: None

Incidence, predictors and outcomes of Valve-in-valve (ViV) Transcatheter aortic valve replacement (TAVR): a systematic review and meta-analysis

Background

Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up.

Methods

Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points.

Results

Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and &gt;25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p&lt;0.001), Logistic Euroscore (p&lt;0.01) and valve diameter ≤21 mm (p&lt;0.05) at 30 days, and stenosis as reason for failure (p=0.05) at 1 year were identified as possible predictors of survival.

Conclusions

Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients.

Outcome of VIV TAVI

Funding Acknowledgement

Type of funding source: None

P513Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience

Funding Acknowledgements

None of the author have conflict of interest to disclose.

Background

 As transcatheter aortic-valve implantation (TAVI) procedures have increased, the need of a permanent pacemaker (PPM) is a complication to be taken into account. 

Objective

 The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for PPM requirement after TAVI.

Methods

 The present is a single centre, retrospective study. All consecutive patients with severe symptomatic aortic stenosis who underwent TAVI had continuous ECG monitoring. Pre and post TAVI 12-leads ECG were analysed. We arbitrarily divided the patients into early and late PPM implantation (beyond the 3rd day after TAVI). The primary endpoint of the study was to identify electrocardiographic predictors of PPM implantation after TAVI, and the secondary endpoint was to identify other clinical or procedure-related predictive factors.

Results

 Of 431 patients who underwent TAVI, 77 (18%) required a PPM, and 30 (7%) had late PPM implantations. Pre-operative RBBB implies more than five-fold increase of the risk of PPM implantation after TAVI (OR 5,43, CI 2.11 - 13.99, P = 0.000), whereas the history of syncope is associated with a two-fold increase of the risk (OR 2.00, CI 1.01 - 3.96, P = 0.044), and maintains its predictive value also in the late PPM subgroup (OR 2.76, CI 1.11 – 6.82, P = 0.028).

Conclusions

 It is hard to predict the need of a PPM in the individual patients, but careful evaluation of pre-operative 12-lead ECG looking for pre-existing RBBB and an history of syncope, can individuate the group of patients with an increased risk of PPM requirement.

P1789Outcomes of different approaches for severe aortic stenosis: “"The Deferred-TAVI”, a multicentre study investigating medical and percutaneous therapy in the era of TAVI

Background

In the era of TAVI, also very high surgical risk patients can be treated and the importance of the Heart Team is to address the patient to the right therapy. In some cases due to comorbidities, lack of symptoms and patients' decision not always a final decision is achieved after the first clinical evaluation and the final strategy could be deferred for months.

Purpose

The study aims to analyze outcomes in patients with severe aortic stenosis differently treated according to the various approaches proposed by the Heart Team.

Methods

All the patients with a diagnosis of severe aortic stenosis considered at high and very high surgical risk were enrolled. Three international cardiology departments participated in this multicentre study. All the patients were divided into four groups according to the Heart Team decision of approach. Patients with indication to medical therapy only (DTO Drug therapy only), Patients first deferred from heart team decision, personal reasons or lack of symptoms and then addressed to medical therapy (D-DTO Deferred-Drug therapy only), Patients deferred and then addressed to TAVI within 3 months (D-TP Deferred TAVI Procedure), Patients with direct indication to TAVI (ITP Immediate TAVI procedure). Primary endpoint were overall survive at follow up comparing the differences between the four groups and the impact of the deferred strategy.

Results

795 patients were enrolled (80 DTO, 451 ITP, 264 initially deferred and then 155 D-DTO and 109 D-TP). Median follow-up was 465 days. Overall survive of the four groups at 1 year was 74% DTO, 73% D-DTO, 77% D-TP and 78% ITP, at 2 years 62% DTO, 38% D-DTO, 62% D-TP and 68% ITP, at 3 years 39% DTO, 11% D-DTO, 25% D-TP and 56% ITP (p≤0,001 at log rank test). At the multivariate analysis, compared to the referral group DTO, D-DTO was associated with higher mortality (HR=1,90; IC [95%]: 1,05–3,58; p=0,03 at 2 years; HR 1,66; IC [95%]: 1,01–2,76; p<0,05, at 3 years), while D-TP was not associated with lower mortality risk (HR 1,31 IC [95%]: 0,62–2,76; p=0,72 at 2 years, HR 1,37 IC [95%]: 0,77–2,44; p=0,77 at 3 years). ITP was associated with lower mortality risk only at 3 years (HR 0,60; IC [95%]: 0,42–0,99; p<0.05). Comparing the group deferred (D-DTO and D-TP) to the group not deferred (DTO and ITP), the deferred group was associated with higher mortality risk (HR 1,86; IC [95%]: 1,30–2.65; p=0,001 at 2 years, HR 2,21; IC [95%]: 1,61–3,05; p<0,001 at 3 years).

Conclusions

The Heart team decision on the approach of treatment strongly influence the survive of the patient. Compared to direct medical therapy, there is a higher risk of mortality for patients initially deferred and then treated with medical therapy and there is no survival benefit for patients initially deferred and then treated with TAVI. The choice of deferring the treatment of patients with severe aortic stenosis clearly decrease long term survive at follow up regardless the strategy of the approach.

P04.09 Patterns of care and impact on survival of first salvage therapy in high-risk grade II gliomas following initial temozolomide

BACKGROUND

Initial chemotherapy with temozolomide (TMZ) may provide benefit in high-risk low-grade gliomas. To date, no standard treatment is validated at first progression. The aim of this retrospective study was to investigate the optimal salvage therapy after the first progression and the factors that influence the PFS and overall survival (OS).

MATERIAL AND METHODS

we evaluated 71 patients with an histological diagnosis of grade II glioma according to WHO 2016 classification, who were included in a phase II AINO (Italian Association for Neuro-Oncology) trial, and progressed following initial chemotherapy with TMZ. Molecular data were available in all patients: 32 (45.1%) patients were oligodendrogliomas IDH 1/2 mutated and 1p19q codeleted, 11 (15.5%) were diffuse astrocytomas IDH mutant, and 28 (39.4%) were diffuse astrocytomas IDH wild-type. Thirty-five (49.3%) patients were MGMT methylated. Median follow up was 144 months (range 23–180).

RESULTS

thirty-one patients (43.7%) underwent second surgery, 24 patients (33.8%) second-line chemotherapy (rechallenge with TMZ or nitrosoureas), and 16 patients (22.5%) radiotherapy with a median PFS of 58 months (IC 95% 49–116). The association between prognostic factors and type of salvage therapy revealed a prevalence of younger age (≤ 45 years), non-enhancing tumor and location in eloquent area among patients treated with second surgery or chemotherapy, while aolder age (> 45 years) and contrast-enhancing tumors prevailed among patients receiving radiotherapy. Overall, median PFS was 60 months after second surgery (IC95% 43–116) and chemotherapy (IC95% 51–69), and 38 months after radiotherapy (IC95% 15–64) (p 0.09). No significant benefit in length of PFS was achieved in oligodendrogliomas undergoing second surgery (60 months) as compared with oligodendrogliomas treated with radiation or chemotherapy (58 months, p 0.11). PFS of diffuse astrocytomas IDH wild-type following second surgery (53 months) did not differ from that of patients treated with adjuvant treatments (65 months, p 0.28). Overall, median OS from the first salvage therapy was 117 months (IC95% 93 - 123+): 120 months (IC95% 108–140+) after second surgery, 94 months (IC95% 75–117+) after chemotherapy, and 62 months (IC95% 27–112) after radiotherapy (p 0.04). Median OS (123 months, IC95% 106–154) was prolonged in oligodendrogliomas receiving second surgery as compared to those receiving radiotherapy or chemotherapy (93 months, IC 95% 61–112, p 0.07), while median OS in diffuse astrocytomas IDH wild-type did not differ between those who received second surgery or radiotherapy or chemotherapy.

CONCLUSION: W

hen feasible, reoperation as first salvage treatment following initial TMZ in grade II gliomas seems to offer a probability of a longer OS as compared with second-line chemotherapy or radiotherapy, and this could hold true especially for oligodendrogliomas.

P14.85 Brain metastasis from Hodgkin’s Lymphoma: case report and literature review

BACKGROUND

Central nervous system (CNS) metastases from Hodgkin’s Lymphoma (HL) are very rare, occurring in 0.02–0.5% of cases. They are usually associated to systemic relapse of the disease. Treatment options for HL brain metastases include surgery, radiotherapy, and systemic chemotherapy.

CASE REPORT

A 54 year-old woman presented with thoracic pain and dyspnea. Chest CT showed a thoracic bulky mass larger than 10 cm. Biopsy confirmed HL stage IIA, nodular sclerosing variant. No typical B symptoms, such as fever, night sweats or weight loss, were observed. The patient underwent chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD scheme), followed by 30Gy mediastinic radiotherapy (RT), which led to complete remission in September 2017. After 3 months, she presented with headache and rapidly progressing gait disorder. MRI showed a contrast-enhanced lesion in the right occipital lobe, with central necrosis and massive edema. Total-body CT scan and FDG-PET ruled out either the presence of new solid tumors or systemic relapses of HL. Gross total resection of the brain lesion was carried out, and HL histology was confirmed. CSF analysis from lumbar puncture was normal. Afterwards, the patient underwent 2 cycles of high dose cytarabine, but she rapidly progressed, and received salvage RT (30 Gy). Nevertheless, further systemic progression occurred: the patient developed headache, diplopia and dysphagia and, unfortunately, she died 6 months after the diagnosis of brain metastasis.

DISCUSSION

Thus far, only 45 cases of CNS HL have been reported from 2000 to 2018. Whole brain radiotherapy, with or without chemotherapy, was the most common treatment. In our patient, we chose surgical resection for the solitary brain metastasis followed by chemotherapy, delaying RT at recurrence. In the literature, median overall survival of patients diagnosed with brain metastases from HL is 18 months (1–273): 17 patients (38%) showed a progression (local / systemic: 12/17 - 71%), while 28 (62%) showed complete remission after a median follow-up of 20 months (6–273).

CONCLUSION

Intracranial localisation of Hodgkin’s Lymphoma is a rare entity but still has to be taken into account. Advanced brain imaging could be of help in case of uncertain radiological presentation. A multidisciplinary approach is needed as there is no consensus on the best treatment to choose: surgery, radiotherapy and chemotherapy should be considered on individual basis.

OS1.4 Liquid biopsy of the CSF in a series of GBM patients: preliminary results

BACKGROUND

Liquid biopsy (LB) by cerebrospinal fluid (CSF) can be useful to identify circulating tumour DNA (ctDNA), thus offering information about the heterogeneity of the neoplastic genome. The aim of our study is to assess the effectiveness of LB of the CSF in detecting ctDNA which mirrors the genetic profile of the tumoural tissue, and to investigate the clinical and radiological aspects influencing the availability of ctDNA.

MATERIAL AND METHODS

Tumoral tissue and CSF samples of 13 GBM patients undergoing surgery was collected. CSF was withdrawn from the very proximity of the tumoural surface before the excision. DNA extracted from tissue samples was analysed by qPCR to identify typical genetic alterations such as copy number variations (EGFR, PDGFRA, CDK4, MDM2, CDKN2A), and point mutations (TP53, PTEN, IDH, NRAS, PI3K1, pTERT). CtDNA extracted from CSF was analysed by droplet digital PCR to assess the presence of the alterations found in the matching tissue. Both contrast-enhanced (CE) and FLAIR volumes of the lesions were measured in the pre-surgical MRI. Linear and logarithmic regressions were employed for the statistical analysis.

RESULTS

From June 2016 to February 2017 we prospectively collected 13 GBM patients. Median age was 73 years. All lesions showed CE at the MRI; other radiological findings included necrosis (84.6%), oedema (76.9%), cortical, ventricular or meningeal involvement (76.9%, 30.8%, and 15.4%). Median volumes of CE and FLAIR lesions were 28.6 and 25.5 cm3, with a median FLAIR/CE ratio of 72.9. Surgery was subtotal (<95%) in all patients. All GBM tissues were tested for the following alterations: EGFR, PDGFRA, CDK4, MDM2, CDKN2A; 76.9% were tested for TP53, PTEN, and IDH mutations; 38.5% for NRAS and pTERT mutations; 30.8% for PI3KR1 mutation. MGMT methylation was assessed in 12 cases (92.3%) and found in 7 (58.3%). Median CSF volume, ctDNA quantity and concentration were 0.45 mL, 59.64 ng, and 0.42 ng/μL. Processable DNA was found in 11 CSF specimens (84.6%), in 8 of which (61.5%) it carried the same alteration expressed by the tumoural cells of the matched tissue, while in 3 cases (23.1%) it seemed to have a different genetic profile; finally, in 2 cases it was not possible to detect any circulating DNA in the CSF. Preliminary data on 13 patients suggest that the ctDNA concentration in the CSF could be related to the FLAIR/CE ratio as measured in the MRI before surgery (p = 0.02). Other correlations between the molecular and the radiological features are still being exploring.

CONCLUSION

Our study confirms that LB of CSF can detect ctDNA carrying the same molecular profile harboured in the tumour. Therefore, it seems to be an accurate method to identify markers useful for the diagnosis and the monitoring of the disease. Additionally, our ongoing study is trying to demonstrate a potential correlation between radiological features of the tumour and availability of ctDNA in CSF.

Comparative evaluation of meniscal pathology: MRI vs arthroscopy

The meniscal pathology of the knee is one of the clinical realities the orthopedic surgeon must daily confront with. The diagnosis is generally both clinical and instrumental; among the different diagnostic imaging techniques, Magnetic Resonance Imaging (MRI) appears to be the most accurate method regarding sensitivity and specificity for the study of meniscal fibrocartilages and articular cartilage. In an attempt to clarify the roles of MRI and diagnostic knee arthroscopy, we performed a retrospective comparative study of the two methods to assess their sensitivity and specificity in the diagnosis of meniscal pathology. We evaluated 105 consecutive patients with a clinical diagnosis of intra-articular knee pathology who were subjected to MRI examination and subsequently to surgical arthroscopy, recording on a graphic card the surgical and radiographic findings expressed by a blinded expert radiologist. Comparison of MRI and arthroscopy data showed, for the internal meniscus, values of 98.5% sensitivity, 94.7% specificity and 93.8% "K" index for MRI compared to arthroscopy, and of 90%, 98.6% and 90.5% for the external meniscus. These results allow us to state that the diagnostic capacity of MRI appears to be very high and therefore crucial in the planning of the correct surgical treatment of individual patients, thanks to its ability to highlight even small changes affecting intra-articular structures.

Surgery within 48 hours in hip fractures in elderly patients exerts a positive effect on post-operative hyponatremia

This study investigated the prevalence of hyponatremia during the hospital stay, in a cohort of elderly patients with hip fractures who underwent surgery within 48 h from admission. Records data were retrieved from the database of the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno, Italy. All elderly patients (≥65 years old) with a documented hip fracture that underwent surgery within 48 h from admission, between 2016 and 2018, were included and divided in 4 subgroups according to their sex and type of fracture. Serum sodium concentration were monitored during the hospital stay and collected at admission, before surgery, after surgery and at discharge. The overall prevalence of hyponatremia was 23.99% (n=71/295), (24.3%, n=57/234 for female patients and 22.9%, n=14/61 for male patients). The percentage of hyponatremic patients with an intracapsular hip fracture was 27.17% (n=25/92), and 22.66% (n=46/203) in patients with an extracapsular hip fracture. The highest value of mean serum sodium concentration (139.2 mmol/L±4.4 SD) was found at the hospital discharge phase, and the lowest value (138.4 mmol/L±4.3 SD) was found during the pre-surgery phase. The lowest mean value of serum sodium was found before surgery, while the highest was after surgery. This could suggest that the early operative treatment and the accurate in-hospital monitoring are effective to treat or prevent this condition.