Adapted physical activity and therapeutic exercise in late-onset Pompe disease (LOPD): a two-step rehabilitative approach

Aerobic exercise, training to sustain motor ability, and respiratory rehabilitation may improve general functioning and quality of life (QoL) in neuromuscular disorders. Patients with late-onset Pompe disease (LOPD) typically show progressive muscle weakness, respiratory dysfunction and minor cardiac involvement. Characteristics and modalities of motor and respiratory rehabilitation in LOPD are not well defined and specific guidelines are lacking. Therefore, we evaluated the role of physical activity, therapeutic exercise, and pulmonary rehabilitation programs in order to promote an appropriate management of motor and respiratory dysfunctions and improve QoL in patients with LOPD. We propose two operational protocols: one for an adapted physical activity (APA) plan and the other for an individual rehabilitation plan, particularly focused on therapeutic exercise (TE) and respiratory rehabilitation.

Published Erratum: Duplicate publication: The Cochrane Rehabilitation eBook: a knowledge translation tool to transfer evidence to different rehabilitation audiences

This article was accidentally published in Volume 54 issue 5 as well as Volume 54 issue 4 of publishing year 2018 with different DOIs and different page numbers. The correct and citable version of the article remains Antimo MORETTI, Francesca GIMIGLIANO, Chiara ARIENTI, Joel POLLET, Carlotte KIEKENS, Stefano NEGRINI. The Cochrane Rehabilitation eBook: a knowledge translation tool to transfer evidence to different rehabilitation audiences. Eur J Phys Rehabil Med 2018 August;54(4):622-3. DOI: 10.23736/S1973-9087.18.05373-X

Somatic gene editing ameliorates skeletal and cardiac muscle failure in pig and human models of Duchenne muscular dystrophy

Frameshift mutations in the DMD gene, encoding dystrophin, cause Duchenne muscular dystrophy (DMD), leading to terminal muscle and heart failure in patients. Somatic gene editing by sequence-specific nucleases offers new options for restoring the DMD reading frame, resulting in expression of a shortened but largely functional dystrophin protein. Here, we validated this approach in a pig model of DMD lacking exon 52 of DMD (DMDΔ52), as well as in a corresponding patient-derived induced pluripotent stem cell model. In DMDΔ52 pigs1, intramuscular injection of adeno-associated viral vectors of serotype 9 carrying an intein-split Cas9 (ref. 2) and a pair of guide RNAs targeting sequences flanking exon 51 (AAV9-Cas9-gE51) induced expression of a shortened dystrophin (DMDΔ51-52) and improved skeletal muscle function. Moreover, systemic application of AAV9-Cas9-gE51 led to widespread dystrophin expression in muscle, including diaphragm and heart, prolonging survival and reducing arrhythmogenic vulnerability. Similarly, in induced pluripotent stem cell-derived myoblasts and cardiomyocytes of a patient lacking DMDΔ52, AAV6-Cas9-g51-mediated excision of exon 51 restored dystrophin expression and amelioreate skeletal myotube formation as well as abnormal cardiomyocyte Ca2+ handling and arrhythmogenic susceptibility. The ability of Cas9-mediated exon excision to improve DMD pathology in these translational models paves the way for new treatment approaches in patients with this devastating disease.

Do Dietary Supplements and Nutraceuticals Have Effects on Dental Implant Osseointegration? A Scoping Review

Several factors affect dental implant osseointegration, including surgical issues, bone quality and quantity, and host-related factors, such as patients' nutritional status. Many micronutrients might play a key role in dental implant osseointegration by influencing some alveolar bone parameters, such as healing of the alveolus after tooth extraction. This scoping review aims to summarize the role of dietary supplements in optimizing osseointegration after implant insertion surgery. A technical expert panel (TEP) of 11 medical specialists with expertise in oral surgery, bone metabolism, nutrition, and orthopedic surgery performed the review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) model. The TEP identified micronutrients from the "European Union (EU) Register of nutrition and health claims made on foods" that have a relationship with bone and tooth health, and planned a PubMed search, selecting micronutrients previously identified as MeSH (Medical Subject Headings) terms and adding to each of them the words "dental implants" and "osseointegration". The TEP identified 19 studies concerning vitamin D, magnesium, resveratrol, vitamin C, a mixture of calcium, magnesium, zinc, and vitamin D, and synthetic bone mineral. However, several micronutrients are non-authorized by the "EU Register on nutrition and health claims" for improving bone and/or tooth health. Our scoping review suggests a limited role of nutraceuticals in promoting osseointegration of dental implants, although, in some cases, such as for vitamin D deficiency, there is a clear link among their deficit, reduced osseointegration, and early implant failure, thus requiring an adequate supplementation.

Pharmacological Therapy of Osteoporosis: What's New?

Osteoporosis and fragility fractures are relevant health issues because of their impact in terms of morbidity, mortality, and socioeconomic burden. Despite this alarming scenario, both underdiagnosis and undertreatment are common features of osteoporotic patients, particularly those who have already sustained a fragility fracture. Pharmacotherapy of osteoporosis is the main treatment option for these patients because of strong evidence about the efficacy of available drugs targeting bone metabolism. However, several issues can interfere with the effectiveness of anti-osteoporotic drugs in clinical practice, such as lack of awareness of both healthcare providers and patients, poor adherence to therapy, and safety in long-term treatment. Therefore, new therapeutic strategies have been proposed to overcome these problems, such as sequential therapy or emerging molecules mainly targeting the stimulation of bone formation. In particular, abaloparatide has been demonstrated to reduce major nonvertebral fracture risk compared with both placebo and teriparatide, although the European Medicines Agency (EMA) refused the marketing authorization because the benefits of this drug did not outweigh its risks. On the other side, EMA has recently approved romosozumab, a monoclonal antibody directed against sclerostin and the only available therapeutic option targeting Wnt signaling, as both bone-forming and antiresorptive intervention to treat osteoporosis and fragility fractures.

Multifactorial Assessment of Risk of Falling in 753 Post-Menopausal Women: A Multicenter Cross-Sectional Study by the Italian Group for the Study of Metabolic Bone Diseases

OBJECTIVE

To assess physical performance, number of falls, previous fragility fractures, and ongoing pharmacological therapy in a cohort of post-menopausal women, according to their risk of falling.

METHODS

In this multicenter cross-sectional study, we recruited in a 3-year period (May 2016 to April 2019), women aged >60 years referred to seven Osteoporosis and Bone Metabolism Outpatient Services of the Italian Group for the Study of Metabolic Bone Diseases. The study population was divided into three groups according to the risk of falling, assessed through the Elderly Fall Screening Test (EFST): low risk (EFST score=0-1); moderate risk (EFST=2-3); high risk (EFST=4-5). Outcome measures were: 4-meter gait speed (4MGS); unipedal stance time (UST); number of falls in the previous year; previous fragility fractures; ongoing pharmacological therapy.

RESULTS

We analyzed 753 women (mean aged 70.1±9.2 years): 378 (50.2%) at low risk of falling, 247 (32.8%) at moderate risk, and 128 (17.0%) at high risk. 4MGS and UST resulted as pathological in the 93.9% and 99.2%, respectively, of women at high risk. There were significant differences among groups for both outcomes (p<0.001). There was also a significant difference among groups (p<0.001) in terms of previous falls and fragility fractures. Lastly, there were significant differences (p<0.05) among groups in using antihypertensive drugs, antiplatelet agents, anticoagulants, antidepressants, anti-osteoporotic drugs, and vitamin D, and/or calcium supplementation.

CONCLUSION

Physical performance, prevalence of falls and fragility fractures, and an assessment of pharmacological therapy should be investigated in post-menopausal women because of their significant correlation with risk of falling.

Neglected femoral neck fractures in cerebral palsy: a narrative review

Hip fractures are severe conditions with a high morbidity and mortality, especially when the diagnosis is delayed, and if formulated over 30 days after the injury, is termed a 'neglected femoral neck fracture' (NFNF).Cerebral palsy (CP) is probably one of the major risk factors for NFNF in Western countries, mainly because of both cognitive and motor impairments. However, considering the high prevalence of fractures in these patients, the incidence of NFNF in this population is probably underestimated, and this condition might result in persistent hip or abdominal pain.Several techniques are available for the treatment of NFNF (i.e. muscle pedicle bone graft, fixation with fibular graft, valgisation osteotomy), but most of them could affect motor function.Motor function must be preserved for as long as possible, in order to enhance the quality of life of CP patients.After discussing published NFNF cases in CP patients and available treatment options, a practical approach is proposed to facilitate the orthopaedic surgeon to both early identify and appropriately manage these challenging fractures. Cite this article: EFORT Open Rev 2020;5:58-64. DOI: 10.1302/2058-5241.5.190019.

Neuromuscular Diseases and Bone

Neuromuscular diseases (NMDs) are inherited or acquired conditions affecting skeletal muscles, motor nerves, or neuromuscular junctions. Most of them are characterized by a progressive damage of muscle fibers with reduced muscle strength, disability, and poor health-related quality of life of affected patients. In this scenario, skeletal health is usually compromised as a consequence of modified bone-muscle cross-talk including biomechanical and bio-humoral issues, resulting in increased risk of bone fragility and fractures. In addition, NMD patients frequently face nutritional issues, including malnutrition due to feeding disorders and swallowing problems that might affect bone health. Moreover, in these patients, low levels of physical activity or immobility are common and might lead to overweight or obesity that can also interfere with bone strength features. Also, vitamin D deficiency could play a critical role both in the pathogenesis and in the clinical scenario of many NMDs, suggesting that its correction could be useful in maintaining or enhancing bone health, especially in the early phases of NMDs. Last but not least, specific disease-modifying drugs, available for some NMDs, are frequently burdened with adverse effects on bone tissue. For example, glucocorticoid therapy, standard of care for many muscular dystrophies, prolongs long-term survival in treated patients; nevertheless, high dose and/or chronic use of these drugs are a common cause of secondary osteoporosis. This review addresses the current state of knowledge about the factors that play a role in determining bone alterations reported in NMDs, how these factors can modify the biological pathways underlying bone health, and which are the available interventions to manage bone involvement in patients affected by NMDs. Considering the complexity of care of these patients, an interdisciplinary and multimodal management strategy based on both pharmacological and non-pharmacological interventions is recommended, particularly targeting musculoskeletal issues that are closely related to functional independence as well as social implications.

Bone alterations in inflammatory bowel diseases

Inflammatory bowel diseases (IBDs) are characterized by a multifactorial partially unknown etiology that involves genetic, immunological and environmental factors. Up to 50% of IBD patients experience at least one extraintestinal manifestation; among them is the involvement of bone density which is referred to as metabolic bone disease (MBD), including osteopenia and osteoporosis. Bone alterations in IBDs population appear to have a multifactorial etiology: Decreased physical activity, inflammation-related bone resorption, multiple intestinal resections, dietary malabsorption of minerals and vitamin D deficiency, genetic factors, gut-bone immune signaling interaction, steroid treatment, microbiota and pathogenic micro-organisms interaction, and dietary malabsorption of minerals, that, all together or individually, may contribute to the alteration of bone mineral density. This review aims to summarize the prevalence and pathophysiology of metabolic bone alterations in IBD subjects outlining the main risk factors of bone fragility. We also want to underline the role of the screening and prophylaxis of bone alterations in Crohn’s disease and ulcerative colitis patients and the importance of treating appropriately MBD.

Pharmacotherapeutic options for complex regional pain syndrome

INTRODUCTION

Complex regional pain syndromes (CRPS) are rare painful conditions characterized by considerable variability in possible triggering factors, usually traumatic, and in the clinical scenario. The limited knowledge of the pathophysiological mechanisms has led to countless treatment attempts with multiple conservative and surgical options that act by different mechanisms of action.

AREAS COVERED

In this narrative review, the authors discuss key points about CRPS definitions, diagnostic criteria and pitfalls, pathophysiological hypotheses, and treatment strategies with particular reference to pharmacotherapy. The article was based on a literature search using PubMed while the available guidelines for the management of CRPS were also examined.

EXPERT OPINION

According to the quality of evidence, pharmacological interventions for CRPS seem to be more effective all the more so when they act on peripheral mechanisms, particularly on nociceptive pain, and when applied early in the disease, while reliable evidence about central mechanisms of chronic pain in CRPS is lacking. In our opinion, drug therapy should be preferred as early as possible, particularly in warm forms of CRPS to prevent significant functional limitation, psychological distress, and social and economic fallout.

Stentoplasty of calcaneal fractures: Surgical technique and early outcomes

Calcaneus is the most common site of hindfoot fracture, frequently caused by fall from height or high energy trauma. The therapeutic strategy ranged from non-operative to ORIF (Open Reduction Internal Fixation). Indications for percutaneous fixation include soft tissue damage or relative contraindications to open surgery. Minimally invasive percutaneous calcaneoplasty should be an alternative to ORIF aiming to reach a stable reduction, early functional recovery and short hospital stay. The aim of our study was to evaluate the clinical and radiographic outcomes of calcaneus fractures treated with balloon calcaneoplasty (BCP) by using a new generation vertebral augmentation system, VBS™-Vertebral Body Stent-DePuy Synthes. A total of 10 patients treated with VBS™ system were recruited for the study. Nine fractures were caused by a fall from height and one case by traffic accident. The mean follow-up was 8.9 months (range 2.6-23.1). The fractures were categorized according to Sanders and Essex-Lopresti classifications (5: type II, 3: type III and 2: type IV; 9: "joint depression" type and 1 case "tongue" type). Radiographic measurement (Böhler's and Gissane's angles) were evaluated at both pre-operative and immediate postoperative time. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score as well as a subjective evaluation (Visual Analog Scale, VAS) were used for the clinical assessment at the last follow-up. Mean preoperative Böhler's angle was 12.3 ± 8.41° (95% CI 6.3-18.3°), whereas mean preoperative Gissane's angle was 123.66 ± 20.47° (95% CI 109.0-138.3°). At postoperative follow-up mean Böhler's angle increased to 21.51 ± 4.17° (95% CI 18.5-24.5°; p < 0.01), and mean postoperative Gissane's angle was 121.74°±6.82° (95% CI 116.8°-126.6°). Mean AOFAS at the last follow-up was 70.4 ± 17.44 (95% CI 57.9-82.8). Our study demonstrates that percutaneous calcaneoplasty using VBS™ is an effective treatment for calcaneus fracture and capable to implement correction manoeuvre with clinical and radiographic outcomes comparable with other percutaneous stentoplasty.

Mapping the primary outcomes reported in Cochrane systematic reviews regarding stroke with the International Classification of Functioning, Disability and Health domains: current trend and future recommendations

BACKGROUND

The International Classification of Functioning, Disability and Health (ICF) serves as a framework for defining and categorizing health and functioning. ICF could be used to classify research outcomes in a systematic manner.

AIM

The aim of this study was to classify the primary outcomes used in Cochrane Systematic Reviews (CSRs) into the ICF domains of functioning; to describe the differences in primary outcomes in reviews related to rehabilitation intervention and non-rehabilitation intervention; and to describe the trend of outcome selections according year of publication.

DESIGN

Methodological paper.

POPULATION

Adult stroke population.

METHODS

We analyzed the primary outcomes used in the CSRs published by the Cochrane Stroke Review Group up to December 2017. The primary outcomes were extracted and classified into the ICF domains of functioning (body functions, body structures and activity and participation).

RESULTS

One hundred and seventy-four papers with 216 primary outcomes were included in this analysis. Less than half (102/216, 47.2%) of the outcomes could be classified into the ICF domains of functioning. For the outcomes that could be classified into the ICF domains, the majority (72/102, 70.5%) were in the activity and participation domain, followed by body functions (26/102, 25.5%) and body structures (4/102, 4.0%). Of the outcomes that could not be classified into the ICF domains (N.=114), death (81/114, 71.1%) and recurrent stroke (21/114,18.4%) formed the majority of the outcome. There were 75 CSRs on rehabilitation related interventions; the majority of the outcomes (75/97, 77.3%) used in rehabilitation related CSRs could be classified into the ICF framework with more than half (49/75, 65.3%) in the activity and participation domain.

CONCLUSIONS

The majority of the primary outcomes selected by the Cochrane Stroke Review Group in their CSRs could not be classified into the ICF domains of functioning. Death and recurrence of vascular events remains the major outcome of interest. In rehabilitation related interventions, activity and participation domain is the functioning domain most commonly used.

CLINICAL REHABILITATION IMPACT

The systematic use of patients-centered ICF-based outcomes in CSRs could help the application of evidence in clinical decision making.

Effectiveness of denosumab on back pain-related disability and quality-of-life in patients with vertebral fragility fractures

Background: Denosumab is a fully human IgG2 monoclonal antibody that, neutralizing the receptor activator of nuclear factor kappa-Β ligand (RANKL), inhibits the osteoclast-mediated bone resorption. It is yet to be defined if denosumab can reduce osteoporosis-related disability and improve health-related quality-of-life (HRQoL) in patients with fragility fractures.Objective: To assess the effectiveness of denosumab in reducing back pain related disability and improving HRQoL in osteoporotic post-menopausal women with vertebral fractures.Research design and methods: A real practice prospective study was carried out, enrolling women over 50 years with a post-menopausal osteoporosis that experienced at least one vertebral fracture receiving subcutaneous denosumab (60 mg, every 6 months), calcium carbonate (500-1000 mg/day) and cholecalciferol (800 IU/day) for 1 year. Back pain related disability was assessed as the primary outcome using the Spine Pain Index (SPI); secondary outcomes were: SF-12 (Physical Health Composite Score, PCS, and Mental Health Composite Score, MCS), and EuroQol-5D (EuroQol-5D-3L index and EuroQol-Visual Analog Scale, EQ-VAS). All outcome measures were assessed at baseline (T0), after 6 months (T1), and after 12 months (T2) of treatment. Trabecular Bone Score (TBS), lumbar spine (LS) and femoral neck (FN) BMD at T0 and T2 were also evaluated.Results: This study included 140 post-menopausal women, mean age = 70.60 (SD = 8.81) years. There were statistically significant differences after 12 months (T2-T0) in all outcomes assessed: SPI (p < 0.001), SF-12 PCS (p < 0.001), SF-12 MCS (p < 0.001), EQ-5D-3L index (p = 0.039), and EQ-VAS (p = 0.003). Moreover, there was a significant improvement of both LS BMD (p < 0.001) and FN BMD (p < 0.001). No local or systemic adverse events, including new vertebral fractures, osteonecrosis of the jaw and atypical femur fractures, were reported.Conclusions: The data demonstrated that denosumab was effective in reducing back pain related disability and in improving HRQoL in post-menopausal women with vertebral fractures.

Can vitamin D deficiency influence muscle performance in postmenopausal women? A multicenter retrospective study

BACKGROUND

The presence of the vitamin D receptor (VDR) has been recently demonstrated in human muscle supporting the theory of a role of vitamin D in the proliferation and differentiation of muscle cells. So far only few studies investigated the association between vitamin D and muscle performance in postmenopausal women.

AIM

To define the functional impact of vitamin D deficiency.

DESIGN

Multicenter retrospective study.

SETTING

Five Italian outpatient services of Physical and Rehabilitation Medicine (PRM).

POPULATION

Postmenopausal women.

METHODS

We divided the population in two groups based on the threshold of 30 ng/mL as cut-off to define sufficient and insufficient serum levels of 25-hydroxyvitamin D3 [25(OH)D3]. Outcome measures were: appendicular lean mass (ALM); ALM-to-BMI ratio (ALMBMI); total fat mass (FM); visceral adipose tissue (VAT); Hand Grip Strength (HGS); Knee Isometric Extension Strength (KES); Short Physical Performance Battery (SPPB); 4-meter gait speed (4MGS).

RESULTS

We analyzed the data records of 401 postmenopausal women (mean age 66.93±8.47 years): 203 with hypovitaminosis D (mean age 66.81±8.11 years) and 198 with normal levels of 25(OH)D3 (mean age 67.04±8.84 years). The analysis showed a significant difference between the two groups in terms of: ALMBMI (0.002), FM (P<0.001), VAT mass (0.010), VAT volume (P=0.006), HGS (P<0.001), KES (P<0.001), SPPB score (P<0.001), percentage of people with a 4MGS≤0.8 m/s (P<0.001). Furthermore, there were significant correlations (P<0.001) between serum levels of 25(OH)D3 and HGS (r=0.323), KES (r=0.510), and SPPB sit to stand (r=-0.362) and walking sub-scores (r=-0.312).

CONCLUSIONS

This multicenter study demonstrated that postmenopausal women with vitamin D deficiency had a significant reduction of appendicular muscle strength and physical performance.

CLINICAL REHABILITATION IMPACT

This study reported the frequency of hypovitaminosis D in postmenopausal women and its influence on the reduction of muscle mass, strength, and physical performance in a typical population referring to the physiatrist for musculoskeletal disorders.

The Cochrane Rehabilitation eBook: a knowledge translation tool to transfer evidence to different rehabilitation audiences

Systematic reviews are a powerful method for summarizing and synthesizing evidence and create a methodological opportunity for preparing data integration tables to enable review-level synthesis of the evidence. One of the main tasks of Cochrane Rehabilitation is to make it possible to improve the application of evidence-based clinical practice by all rehabilitation professionals, and to facilitate policy-makers in decision-making according to the best evidence. In this context arises the need to diffuse the high-quality information of Cochrane Systematic Reviews (CSR), through synthetic and easy-to-use messages for the different rehabilitation audiences. Cochrane Rehabilitation has recently launched the production of an eBook including all the evidence coming from the CSR tagged by its Review Committee as of rehabilitation interest with the final aim to enhance the application of evidence in clinical practice, medical education, health system policies, and in the community. This will be a powerful tool for the dissemination of evidence-based practice, education and knowledge, as well as to support political decisions for both effective organization and resource allocation in rehabilitation field.

The combination of vitamin D deficiency and overweight affects muscle mass and function in older post-menopausal women

BACKGROUND

It has been suggested that overweight and obese individuals have an increased risk to develop vitamin D deficiency, commonly associated with poor muscle performance. The relationship among fat mass, vitamin D status, and skeletal muscle is still debated.

AIMS

To evaluate the effects of the combination of hypovitaminosis D and overweight on muscle mass and strength, and physical performance in post-menopausal women.

METHODS

In this cross-sectional study, we recruited post-menopausal women referring to a physiatric outpatient service for the management of osteoporosis over a 36-month period. We compared four groups: (1) normal weight with hypovitaminosis D; (2) overweight with normal serum 25(OH)D₃; (3) overweight with hypovitaminosis D; and (4) normal weight with normal serum 25(OH)D₃ (control group). Outcome measures were: appendicular lean mass-to-BMI ratio; hand grip strength; and short physical performance battery.

RESULTS

We analysed 368 women (mean aged 67.2 ± 7.8 years): 95 normal weight with hypovitaminosis D, 90 overweight with normal levels of 25(OH)D₃, 96 overweight with hypovitaminosis D, and 87 normal weight with normal levels of 25(OH)D₃. Overweight women with hypovitaminosis D had a significant risk of reduced muscle mass (OR 5.70; p < 0.001), strength (OR 12.05; p < 0.001), and performance (OR 5.84; p < 0.001) compared to controls. Normal weight women with hypovitaminosis D had only a greater risk of an impairment of muscle strength (OR 7.30; p < 0.001) and performance (OR 3.16; p < 0.001).

DISCUSSION

According to our findings, both hypovitaminosis D and overweight should be investigated in post-menopausal women because of their negative effects on skeletal muscle mass and function.

CONCLUSIONS

This study demonstrated that hypovitaminosis D is associated to impaired muscle function and its combination with overweight might lead also to muscle wasting in a cohort of post-menopausal women.

Localized morphea after breast implant for breast cancer: A case report

PURPOSE

Early breast cancer follow-up guidelines for patients who underwent surgery suggest a regular and accurate clinical examination of the breast area, for an early identification of cutaneous or subcutaneous breast cancer relapse. Nonetheless, breast skin lesions arising in patients treated with mastectomy for breast cancer can be caused by several diseases. A series of diagnostic hypotheses should be considered, not only focusing on cutaneous metastasis, but also on dermatologic and systemic diseases.

CASE REPORT

In February 2015, a 37-year-old patient underwent a right subcutaneous mastectomy for stage IIA breast cancer. Five months after beginning adjuvant chemotherapy, she noted hyperpigmentation and thickening of the skin on the right breast. Differential diagnosis included local relapse, skin infection, lymphoma, or primary cutaneous disease, and a skin biopsy was performed. The histopathologic specimen showed full-thickness sclerosis, with features of localized morphea. Therapy with clobetasol was prescribed, with progressive resolution of the thickness. The collaboration between many professionals in a multidisciplinary team (oncologist, dermatologist, plastic surgeon, and pathologist) was crucial to achieving the diagnosis.

CONCLUSION

In the literature, some articles describe correlation between connective tissue diseases and silicone breast implants, but the pathogenetic mechanisms are unknown. We report a rare case of breast morphea after positioning a silicone implant in a patient who had undergone mastectomy. This clinical report represents an interesting model of multidisciplinary management of a patient with breast cancer who developed an uncommon dermatologic disease. Further studies are needed to clarify the association between silicone implants and breast morphea.

Abstract P1-14-04: Overall survival in metastatic breast cancer patients in the third millennium: Results of an Italian study

BACKGROUND - Metastatic breast cancer (MBC) is a life-threatening disease. It is important to provide data about real-life MBC patients (pts) to understand the current prognostic factors. The aim of the present observational study, named COSMO (Checking Overall Survival in a MBC Observational study) is to describe the overall survival (OS) in a large cohort of MBC pts, assessing its correlation with specific prognostic factors (demographic, clinic, pathologic and biological).

PATIENTS AND METHODS - The COSMO study is a multicenter, retrospective, cohort study, developed throughout the collaboration of 31 Italian oncological centers. Data about pts diagnosed as metastatic from 01/01/2000 to 31/12/2008, were collected. The association between molecular subtypes, metastatic sites, disease free interval (DFI) and OS were assessed. Pts were classified in three subgroups, based on the biological characteristics of their tumor: luminal, HER2-positive (regardless of hormone receptor) and triple negative (TN). Metastatic sites were categorized as visceral versus non-visceral disease, only bone and central nervous system (CNS) metastases. DFI was calculated from diagnosis to first relapse only for M0 pts.

RESULTS - Of 3931 MBC pts enrolled in the study, 3720 were evaluable, with a median age of 61 years (interquartile range, IQR, 51-71). 1804 (62,1%) pts had a luminal disease, 691 (23,8%) HER2-positive, 410 (14.1%) TN. Median DFI was 3.2 years (IQR 1.7- 6.0). Regarding metastatic sites, pts with visceral disease were 2332 (63%); 826 (22,2%) pts had bone isolated metastases; in 306 (8,3%) pts, CNS metastases were reported. With a median follow up of 9 years (IQR 5.7-11.0) and 3098 (83.3%) recorded events, we founded a median OS of 2.8 years (95%CI: 2.7-2.9) years. OS was strictly depending from molecular subtypes with a better prognosis for HER2-positive versus luminal and TN MBC pts, median OS of 3.1 (95%CI 2.8-3.4), 3.0 (95%CI: 2.9-3.1) and 1.5 (95%CI: 1.3-1.7) years respectively (p-value&lt;0.001). 525 (14,1%) pts received trastuzumab. Metastatic sites affect prognosis, with a better OS for bone disease (3.4 years, 95%CI: 3.1-3.6) versus visceral disease (2.2 years 95%CI: 2.0- 2.3). Brain metastasis correlate with the worst prognosis: OS of 1.5 years (95% CI: 0.8 – 1.7). Even DFI shows a correlation with prognosis: pts with DFI&gt;2 years show a median OS of 3 years (95% CI: 2.9 – 3.2), while those with DFI&lt;2 years have a median OS of 2.4 years (95% CI: 2.3-2.6); HR was 0.69 (95%CI: 0,62-0,76) for every five years of increase in DFI (p-value&lt;0.001).

CONCLUSIONS - Molecular subtype is crucial for prognosis: HER2-positive subtype has the best prognosis, while TN subtype has the shorter OS. Having a longer DFI from diagnosis (&gt;2 years) correlate with a better prognosis. Our study confirm that sites of metastasis affects outcome: visceral involvement correlates with poor prognosis and, particularly, pts with brain metastasis represent the worst subgroup, while pts with solely bone disease have the best prognosis. The COSMO study provides a view on the Italian landscape of MBC between 2000 and 2008, adding new insights about pts prognosis.

Citation Format: La Verde N, Collovà E, Blasi L, Pinotti G, Bernardo A, Bonotto M, Garrone O, Brunello A, Cavazzini MG, Bareggi C, Prochilo T, Porcu L, Moretti A, Barni S, On Behalf of COSMO Study Group. Overall survival in metastatic breast cancer patients in the third millennium: Results of an Italian study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-14-04.

Pathogenicity of Fumonisin-producing and Nonproducing Strains of Aspergillus Species in Section Nigri to Maize Ears and Seedlings

Species of Aspergillus section Nigri are commonly associated with maize kernels, and some strains can produce fumonisin mycotoxins. However, there is little information about the extent to which these fungi contribute to fumonisin contamination in grain, the damage they cause to maize ears, or their effects on maize seed germination and seedling health. We compared fumonisin-producing and nonproducing strains of A. niger, A. welwitschiae, A. phoenicis, A. tubingensis, and A. carbonarius from the United States and Italy in laboratory and field studies to assess their ability to contribute to fumonisin contamination, to cause maize ear rot, and to affect seed germination and seedling growth. In laboratory experiments, some strains of each Aspergillus species reduced germination or seedling growth, but there was high variability among strains within species. There were no consistent differences between fumonisin-producing and nonproducing strains. In field studies in Iowa and Illinois, strains were variable in their ability to cause ear rot symptoms, but this was independent of the ability of the Aspergillus strains to produce fumonisins. Contamination of grain with fumonisins was not consistently increased by inoculation with Aspergillus strains compared with the control, and was much greater in F. verticillioides-inoculated treatments than in Aspergillus-inoculated treatments. However, the ratio of the FB analogs FB₂ and FB₁ was altered by inoculation with some Aspergillus strains, indicating that FB₂ production by Aspergillus strains occurred in the field. These results demonstrate the pathogenic capabilities of strains of Aspergillus in section Nigri, but suggest that their effects on maize ears and seedlings are not related to their ability to produce fumonisins, and that fumonisin contamination of grain caused by Aspergillus spp. is not as significant as that caused by Fusarium spp.