Low voltage in limb leads in arrhythmogenic cardiomyopathy

 

Low voltage in limb leads characterizes left ventricular involvement in arrhythmogenic cardiomyopathy. A large collective of patients with arrhythmogenic cardiomyopathy including 438 patients (268 males, mean age 46.8±11.6 years) were analyzed.

Method

Low voltage in limb leads were analyzed in typical patients with arrhythmogenic cardiomyopathy. Several other ECG features such a slow voltage in precordial leads, epsilon waves, right precordial T wave inversions, QRS fragmentation, typical appearance in lead aVR, amplitude of T wave inversion in special right ventricular leads, and developing complete right bundle branch block.

Results

Low voltage in limb leads was found in 60 patients (15%). Two patients represented with low voltage in limb leads and T wave inversions in inferolateral leads charactizing arrhythmogenic left ventricular leads with moderate reduction of left ventricular function with a large aneurysm of the apex. The other patients presented with sustained RBBB-VT. In 38 patients low voltage in limb leads and typical ECG findings of arrhythmogenic cardiomyopathy were found. These patients had arrhythmogenic biventricular cardiomyopathy of moderate reduction of left ventricular function and typical arrhythmias. Low voltage in limb and precordial leads was found in 14 patients with two cardiac deaths due to therapy-resistant heart failure. In 6 cases low voltage in limb and precordial leads and developing complete right bundle branch block were found. Four patients were tranplanted, two cases died due to heart failure. These 20 patients characterize advances, end-stage disease arrhythmogenic cardiomyopathy.

Conclusion

Standard ECG can differentiate between arrhythogenic left ventricular, arrhythmogenic biventricular, and arrhythmogenic advanced end-stage cardiomyopathy

Funding Acknowledgement

Type of funding sources: None.

Consolidation nivolumab and ipilimumab versus observation in limited-disease small-cell lung cancer after chemo-radiotherapy - results from the randomised phase II ETOP/IFCT 4-12 STIMULI trial

BACKGROUND

Concurrent chemotherapy and thoracic radiotherapy followed by prophylactic cranial irradiation (PCI) is the standard treatment in limited-disease small-cell lung cancer (LD-SCLC), with 5-year overall survival (OS) of only 25% to 33%.

PATIENTS AND METHODS

STIMULI is a 1:1 randomised phase II trial aiming to demonstrate superiority of consolidation combination immunotherapy versus observation after chemo-radiotherapy plus PCI (protocol amendment-1). Consolidation immunotherapy consisted of four cycles of nivolumab [1 mg/kg, every three weeks (Q3W)] plus ipilimumab (3 mg/kg, Q3W), followed by nivolumab monotherapy (240 mg, Q2W) for up to 12 months. Patient recruitment closed prematurely due to slow accrual and the statistical analyses plan was updated to address progression-free survival (PFS) as the only primary endpoint.

RESULTS

Of the 222 patients enrolled, 153 were randomised (78: experimental; 75: observation). Among the randomised patients, median age was 62 years, 60% males, 34%/65% current/former smokers, 31%/66% performance status (PS) 0/1. Up to 25 May 2020 (median follow-up 22.4 months), 40 PFS events were observed in the experimental arm, with median PFS 10.7 months [95% confidence interval (CI) 7.0-not estimable (NE)] versus 42 events and median 14.5 months (8.2-NE) in the observation, hazard ratio (HR) = 1.02 (0.66-1.58), two-sided P = 0.93. With updated follow-up (03 June 2021; median: 35 months), median OS was not reached in the experimental arm, while it was 32.1 months (26.1-NE) in observation, with HR = 0.95 (0.59-1.52), P = 0.82. In the experimental arm, median time-to-treatment-discontinuation was only 1.7 months. CTCAE v4 grade ≥3 adverse events were experienced by 62% of patients in the experimental and 25% in the observation arm, with 4 and 1 fatal, respectively.

CONCLUSIONS

The STIMULI trial did not meet its primary endpoint of improving PFS with nivolumab-ipilimumab consolidation after chemo-radiotherapy in LD-SCLC. A short period on active treatment related to toxicity and treatment discontinuation likely affected the efficacy results.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

POS1490-HPR “WHERE DOES IT HURT?”: IDENTIFYING PAIN CONTENT AND ITS CONTEXT WITHIN PAEDIATRIC AND ADOLESCENT RHEUMATOLOGY TRAINING

Background:

Complex pain symptoms present across a wide spectrum of long-term musculoskeletal conditions in paediatric rheumatology. Pain training should therefore be part of a core curriculum for the professionals working in this speciality, but it is unclear to what extent this is the case currently.

Objectives:

To identify the extent of pain-specific content included in the training of healthcare professionals in paediatric and adolescent rheumatology in the UK.

Methods:

A systematic search of documental data using key internet search engines was conducted using combinations of the following terms: ‘training’, ‘curriculum’, ‘competency’, ‘paediatric’, ‘adolescent’ and ‘rheumatology’. A targeted search of online content from the main professional organisations followed; doctors (Royal College of Paediatric and Child Health [RCPCH]), nurses (Royal College of Nursing [RCN]), physiotherapists (Chartered Society of Physiotherapy), occupational therapists (Royal College of Occupational Therapists) and psychologists (British Psychological Society). Documents from professional learned societies such as The British Society of Paediatric and Adolescent Rheumatology (BSPAR) and The Scottish Paediatric and Adolescent Rheumatology Network (SPARN) were also included. Document search strategies were designed by the authors in partnership with healthcare professionals. Data were extracted and analysed following a summative content analysis. Pain-related terms were quantified. Latent content was interpreted qualitatively to explore the context in which pain-related phrases were presented.

Results:

Nine documents were identified. Pain-related terms represented 0.17% of all words across texts (used 55 times in total). Most pain terms were found in documents aimed at doctors (n=40, 72.7%). Of the pain terms used, most were used in the context of referring to specific pain syndromes such as chronic regional pain, generalized idiopathic pain and pain amplification. Content around the assessment and management of pain was vague and no detail was given as to how health professionals should perform these tasks. There was no reference to pain intensity, location or emotion. There were several problematic conceptual issues in the way pain was presented, with pain mostly portrayed either in the context of inflammatory or non-inflammatory pain and rarely in the context of both. Musculoskeletal pain was also positioned as a ‘somatic’ symptom, potentially conveying an interpretation of pain as being psychologically mediated.

Conclusion:

Training for healthcare professionals in paediatric rheumatology would benefit from updates informed by contemporary pain theories and evidence-based practices. This is key to ensuring that children and young people with chronic pain receive effective pain care from tertiary care services focused on treating musculoskeletal disease.

Table 1.

Documents and pain terms identified

ProfessionTitleOrganisations, year.% of document covered by pain termsDoctorsGeneric syllabus level 1.RCPCH, 2018.0.14%DoctorsGeneric syllabus level 2.RCPCH, 2018.0.14%DoctorsGeneric syllabus level 3.RCPCH, 2018.0.06%DoctorsPaediatric rheumatology level 3.RCPCH, 2018.0.48%DoctorsCompetencies for the special interest module in paediatric rheumatologyRCPCH, 2014.0.43%NursesCompetencies for rheumatology nurses.RCN, 2020.0.05%NursesCompetencies for clinical nurse specialists/advanced nurse practitioners.BSPAR, 2014.0.29%NursesRole of the paediatric rheumatology nurse.SPARN, 2016.0%Allied Health Professionals (AHPs)Competencies for AHPsBSPAR, 2019.0.73%

Disclosure of Interests:

None declared