The "great imitator": IgG4-related disease of the oral cavity. Two case reports and scoping review

This study aimed to review the lesser-known intraoral manifestations of immunoglobulin G4-related disease (IgG4-RD). In this paper we report an unprecedented case of oral IgG4-RD mimicking angiolymphoid hyperplasia with eosinophilia (ALHE), and another case presenting as plasma cell gingivitis. We then performed a scoping review of published cases of IgG4-RD involving the oral cavity. The following data were collected for each case: age, sex, intraoral site(s) involved, clinical appearance, imaging features, serum IgG4 values, histopathology, treatment, and follow-up duration. Fifty-one cases of oral IgG4-RD were published in literature. The hard palate and jaw bones were the two main locations reported, while the histological identification of a IgG4/IgG plasma cells ratio ≥40% was fundamental for diagnosis. Conversely, the pathological features of storiform fibrosis and obliterative phlebitis were not common. Future reports regarding oral IgG4-RD should report clear adherence to the recognized international diagnostic criteria of the disease.

Venous and arterial thromboembolic risk of Janus kinase inhibitors: a systematic review with meta-analysis

OBJECTIVE

Preliminary data led licencing authorities to alert clinicians of an increased venous thrombotic risk associated to the use of Janus kinase (JAK) inhibitors (JAKi). We performed a systematic review to estimate the risk of venous and arterial thrombosis associated to JAKi for the treatment of immune-mediated inflammatory diseases (IMIDs).

METHODS

Randomized controlled trials (RCTs) on JAKi in patients with IMIDs were identified by the MEDLINE and EMBASE databases until October 2021. Risk of bias was assessed according to Cochrane criteria. The beta-binomial model was applied to calculate pooled odds ratio (OR) and corresponding 95% CI. The PROSPERO registration number is CRD42022324143.

RESULTS

We have included one phase I, 21 phase II, three phase II-III and 36 phase III RCTs for a total of 19 443 patients in the JAKi group and 6354 in the control group. Thirty-one (unweighted rate 0.16%; 95% CI: 0.10, 0.21) events were reported in the JAKi group and 20 (unweighted rate 0.22%; 95% CI: 0.12, 0.32) in the control group in a mean follow-up of 16.8 weeks. IMID patients treated with JAKi did not have an increased thromboembolic risk compared with those treated with placebo (OR 0.82; 95% CI: 0.43, 1.56). No statistically different results were seen in subanalyses for each investigated IMID, drug and dosage.

CONCLUSION

JAKi do not increase thromboembolic risk compared with placebo in IMID patients enrolled in selected RCTs.

Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

BACKGROUND

Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.

RESULTS

Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).

CONCLUSION

Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.

Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy

STUDY PURPOSE

The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases.

METHODS

The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection.

RESULTS

Not applicable.

CONCLUSION

DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications

INTRODUCTION

Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use.

METHODS

Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy.

RESULTS

The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase.

DISCUSSION

Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX.

CONCLUSION

MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.

JAK inhibitors and psoriatic arthritis: A systematic review and meta-analysis

BACKGROUND

Despite the therapeutic armamentarium for the treatment of psoriatic arthritis (PsA) has considerably expanded over the last thirty years, additional drugs are needed to improve care of this disease. JAK inhibitors (JAKinhibs) are small molecules able to interfere with the JAK/STAT pathway, involved in the pathogenesis of PsA. Tofacitinib and Upadacitinib were recently approved for the treatment of PsA. Our aim was to assess the efficacy and safety of JAKinhibs for the treatment of PsA.

METHODS

A systematic review of the literature was performed to identify RCTs by electronic search of MEDLINE and EMBASE database until April 2021. RCTs were considered eligible if included only patients with PsA treated with JAKinhibs. The pooled efficacy and safety outcomes were calculated by meta-analysis and expressed as odds ratio (OR) and 95% confidence intervals (95% CI). Statistical heterogeneity was assessed with the I² statistic.

RESULTS

Five RCTs for a total of 3293 PsA patients treated with different JAKinhibs or placebo were included (2 phase III studies on Tofacitinib, 1 phase II study on Filgotinib and 2 phase III studies on Upadacitinib). All the studies were judged at low risk of bias according to Cochrane criteria. JAKinhibs showed a significantly higher ACR20 response rate compared to placebo (OR 3.78, 95% CI 2.72-5.24, I^2 = 57%, random effect model).and were associated with a non-statistically significant higher risk of serious adverse events (OR 1.12, 95% CI 0.14-2.82, I^2 = 46%, random effect model).

CONCLUSIONS

This is the first systematic review that performed a comprehensive evaluation of the efficacy and safety of JAKinhibs for PsA in RCTs. Our analysis suggests a statistically significant benefit of JAKinhibs that appear to be effective and safe over placebo for the treatment of PsA.

OP0310 GENDER AND FIBROMYALGIA SEVERITY: REAL LIFE DATA FROM THE ITALIAN REGISTRY

Background:

Fibromyalgia (FM) patients report chronic widespread pain, fatigue, cognitive difficulties and sleep disturbances, often associated with anxiety and/or depression (1). FM syndrome more frequently affects women and many papers describe gender-related differences in the perception, description and expression of pain (2), but up to now, the impact of gender on the clinical severity of FM is still a controversial topic.

Objectives:

The aim of this study was to analyse the data from a web-based registry of FM patients in order to detect a relationship between gender and disease severity.

Methods:

Adult patients with FM, diagnosed on the basis of the 2010/2011 American College of Rheumatology (ACR) diagnostic criteria (3), were recruited at 19 Italian rheumatology centres between November 2018 and April 2019. Those affected by other conditions that could interfere with the assessment of FM, e.g. psychiatric disorders, were excluded from the study. The severity of the disease was evaluated by validated FM-specific questionnaires: the revised Fibromyalgia Impact Questionnaire (FIQR) (4), the modified Fibromyalgia Assessment Status (ModFAS) questionnaire (5), and the Polysymptomatic Distress Scale (PDS) (6). The data obtained were collected in the Italian Fibromyalgia Registry, an online registry created with the support of the Italian Society of Rheumatology (SIR).

Results:

We analyse data from 2.381 patients affected by FM, 2.184 females (91.7%) and 197 males. No significant differences in mean age, disease duration, or BMI between the two genders were reported. The women expressed greater disease burden as indicated by higher scores for each completed test: higher mean ModFAS score (25.23 ± 8.83 Vs 23.37 ± 9.22; p = 0.005), mean FIQR score (58.62 ± 23.22 Vs 51.68 ± 23.06; p <0.001), and mean PDS score (18.77 ± 7.34 Vs 17.19 ± 7.25; p = 0.004). Figure 1 shows the mean scores of each item of the FIQR divided by gender. Women reported significantly higher values on all the items of FIQR except three (feeling overwhelmed, FIQR-11; depression, FIQR-16; and anxiety, FIQR-18). It is interesting to note that men self-reported higher levels of depression (FIQR-16).

Figure 1.

Mean scores for each FIQR item by gender.

Conclusion:

Our findings demonstrate that women with FM are globally more impaired than men (even if some psychological aspects of the disease are comparable), thus reinforcing the idea that gender plays a role in symptoms and functional impairments associated with the disease.

References:

[1]Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311:1547-55.

[2]Nascimento, et al. Gender role in pain perception and expression: an integrative review. BrJP. 2020; 3: 58-62

[3]Wolfe F, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol 2011;38:1113–22.

[4]Burckhardt CS, et al. The fibromyalgia impact questionnaire: development and validation. J Rheumatol 1991;18:728–33.

[5]Salaffi F, et al. Diagnosis of fibromyalgia: comparison of 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status. Rheumatol 2020; 0:1-8.

[6]Wolfe F, et al. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res. 2013; 65:777–85

Disclosure of Interests:

None declared.

AB0565 JAK INHIBITORS AND PSORIATIC ARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Despite the therapeutic armamentarium for the treatment of psoriatic arthritis (PsA) has considerably expanded over the last thirty years, there is a huge necessity of finding effective drugs for this disease. JAK inhibitors (JAKi) are small molecules able to interfere with the JAK/STAT pathway, involved in the pathogenesis of PsA (1). Up to now Tofacitinib is the only JAKi approved by the European Medicines Agency (EMA) for the treatment of PsA but in the next few years the number of approved JAKi is expected to rise significantly.

Objectives:

To assess the efficacy and safety of different JAKi for the treatment of PsA.

Methods:

A systematic review of the literature was performed to identify randomized controlled trials (RCTs), by electronic search of MEDLINE and EMBASE database until October 2020. Studies were considered eligible if they met the following criteria: I) study was a RCT; II) only patients with PsA were included; III) JAKi was compared to placebo in addition to the standard of care. Two reviewers (FC and AZ) performed study selection, with disagreements solved by the opinion of an expert reviewer (AS). The outcomes were expressed as odds ratio (OR) and 95% confidence intervals (95% CI). Statistical heterogeneity was assessed with the I2 statistic.

Results:

We identified 557 potentially relevant studies. A total of 554 studies were excluded based on title and/or abstract screening. Three RCTs for a total of 947 PsA patients treated with JAKi were included (2,3,4). Two were phase III studies on the efficacy and safety of Tofacitinib (OPAL Beyond and OPAL Broaden) and one was a phase II study on Filgotinib (Equator). All three studies were judged at low risk of bias according to Cochrane criteria (5). The primary efficacy outcome in all the studies was the number of patients who achieved the response rate of the American College of Rheumatology 20 score (ACR20). The outcomes evaluation was performed at 12 week for the Filgotinib trial and at 16 week for the Tofacitinib trials. We used for the main analyses the group of patients randomized to Tofacitinib 5 mg because this is the only dosage approved by the EMA for the treatment of PsA. JAKi showed a significantly higher ACR20 response rate compared to placebo (OR 3.54, 95% CI 1.76 - 7.09, I^2 = 74%). JAKi also showed a significantly higher ACR50 response rate (OR 3.36, 95% CI 2.22 - 5.09, I^2 = 0%), ACR70 response rate (OR 2.82, 95% CI 1.67 - 4.76, I^2 = 20%), PsARC response rate (OR 2.67, 95% CI 1.26 - 5.65, I^2 = 79%), PASI75 response rate (OR 3.15, 95% CI 1.61 - 6.15, I^2 = 45%) compared to placebo. JAKi were also associated with significantly better HAQ-DI (mean difference -0.23 95% CI -0.31 - -0.14) and fatigue, measured with FACIT-F (mean difference 3.54 95% CI 2.13 - 4.94). JAKi compared to placebo were associated with a non-statistically significant different risk of serious adverse events (OR 0.56, 95% CI 0.11 - 2.91, I^2 = 38%).

Conclusion:

This is the first published systematic review that performed a comprehensive and simultaneous evaluation of the efficacy and safety of JAKi for PsA in RCTs. Our analysis suggests a statistically significant benefit of JAKi, that appears to be effective and safe over placebo. The impact of these data on international clinical guidelines needs further investigation.

References:

[1]George E Fragoulis, et al. JAK-inhibitors. New players in the field of immune-mediated diseases, beyond rheumatoid arthritis, Rheumatology, Volume 58, Issue Supplement_1, February 2019, Pages i43–i54

[2]Mease P, et al. Tofacitinib or adalimumab versus placebo for psoriatic arthritis. N Engl J Med 2017; 377: 1537-50.

[3]Gladman D, et al. Tofacitinib for psoriatic arthritis in patients with an inadequate response to TNF inhibitors. N Engl J Med 2017; 377: 1525-36.

[4]Mease P, et al. Efficacy and safety of filgotinib, a selective Janus kinase 1 inhibitor, in patients with active psoriatic arthritis (EQUATOR): results from a randomised, placebo-controlled, phase 2 trial. Lancet 2018;392:2367–77.

[5]Higgins JP, et Al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-560

Figure 1.

ACR20 response rate of Jaki over Placebo

Disclosure of Interests:

None declared.

AB0716 FIBROMYALGIA SYNDROME SEVERITY ACCORDING TO AGE CATEGORIES: RESULTS FROM A NATIONAL REGISTER

Background:

Fibromyalgia syndrome (FM) is characterised by a complex symptom spectrum, dominated by the presence of chronic widespread pain, fatigue and unrefreshing sleep. FM affects between 2 and 3% of the general population. It is a condition that mainly involves middle-aged women, although it is increasingly being diagnosed in younger people. The severity of symptoms can vary greatly between individual patients, and is influenced by many factors (e.g. sex, body mass index) [1]. To date, there is little information about changes in severity in accordance with patient age.

Objectives:

The aim of this study was to investigate variations in symptom severity in FM patients according to age categories.

Methods:

A cross-sectional study of adult FM patients diagnosed according to the American College of Rheumatology 2010/2011 criteria was performed. The case series was included from an Italian national registry [2]. Patients were grouped according to five age categories: 18-40 years, 41-50 years, 51-60 years, 61-70 years, over 71 years. Symptom severity was assessed through the revised Fibromyalgia Impact Questionnaire (FIQR) and domains, including FIQR physical function (items 1-9), FIQR health status (items 10-11), and FIQR symptoms (items 12-21). Between-group characteristics were analysed using one-way analysis of variance (ANOVA).

Results:

This study included a total of 2889 patients, 403 aged 18-40 years, 756 aged 40-50 years, 1035 aged 50-60 years, 528 aged 60-70 years, and 167 over 70 years, respectively. The mean (standard deviation [SD]) score of the total FIQR was 52.68 (11.82). Total FIQR and individual domains all showed a normal distribution. Analysing the data by age category, there were statistically significant differences between the categories for the total FIQR (p = 0.030). The age categories with the highest disease severity were those above 71 years (FIQR 62.14, SD 22.45), and between 51-60 years (FIQR 60.31, SD 22.89) (Table 1). Significant differences between age categories were also found for the domains physical function (p = 0.006) and health status (p = 0.012), but not for the domain symptoms (p = 0.164).

Table 1.

Mean values of FIQR total score and domains according to age categories.

FIQR and domains18-40 years41-50 years51-60 years61-70 years≥71 yearsp*FIQR total, mean (SD)57.90 (21.76)59.25 (23.30)60.31 (22.89)57.13 (23.59)62.14 (22.45)0.030FIQR physical function, mean (SD)15.51 (7.56)16.44 (7.77)16.77 (7.51)15.96 (7.82)17.68 (7.26)0.006FIQR health status, mean (SD)11.19 (5.85)11.24 (5.99)11.49 (5.93)10.57 (6.11)12.21 (5.97)0.012FIQR symptoms, mean (SD)31.32 (10.48)31.56 (11.32)32.10 (11.01)30.68 (11.47)32.24 (11.34)0.164

Abbreviations and legend. FIQR = revised Fibromyalgia Impact Questionnaire; SD = standard deviation; * = one-way analysis of variance (ANOVA).

Conclusion:

Distinguishing the disease severity in FM patients according to age categories, a bimodal distribution emerges, with the disease severity being greatest in patients over 71 years and in the 51-60 years decade. The main differences in severity, according to what can be detected through the FIQR, are attributable to the domains physical function and health status, which show higher scores in the two classes with higher severity.

References:

[1]Sarzi-Puttini P et al., Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol 2020; 16: 645–660.

[2]Salaffi F et al., The Italian Fibromyalgia Registry: a new way of using routine real-world data concerning patient-reported disease status in healthcare research and clinical practice. Clin Exp Rheumatol 2020; Suppl 123: 65-71.

Acknowledgements:

Società Italiana di Reumatologia (SIR) and Italian Ministry of Health

Disclosure of Interests:

None declared

The role of IL-6 and IL-6 blockade in COVID-19

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces a dysregulated hyperinflammatory response.

AREAS COVERED

Authors review evidence on IL-6 and IL-6 blockade in coronavirus disease 2019 (COVID-19) and discuss the pathophysiological and prognostic roles of this cytokine and the clinical impact of pharmacological blockade of IL-6 . The material includes original articles and reviews published from March 2020 to March 2021 and searched on PubMed, medRxiv, and bioRxiv.

EXPERT OPINION

IL-6 is one of the most prominent pro-inflammatory cytokines. Increased levels are recorded in COVID-19 patients, especially those with severe-to-critical disease. Evidence is accumulating on the relevance of IL-6 as a prognostic marker in COVID-19. Since IL-6 is a druggable target for several inflammatory diseases, pharmacological blockers of the IL-6 signaling pathway were repurposed to blunt the abnormal SARS-CoV-2-induced cytokine release. Data are limited to few randomized controlled trials that reported encouraging, though not conclusive, results, indicating the usefulness of IL-6 blockade early in the course of the disease in patients with hyperinflammation and no or limited organ damage. Further research is warranted to explore the role of IL-6 in different COVID-19 phenotypes and identify subgroups of patients who may mostly benefit from IL-6 pathway inhibition.

The association between body mass index and fibromyalgia severity: data from a cross-sectional survey of 2339 patients

Objective

Various studies have shown that overweight and obesity are central features of FM, but the real impact of a high BMI on clinical severity in patients with FM is still controversial. The aim of this study was to analyse the relationships between BMI categories and measures of symptom severity and functional impairment using data from a Web-based registry of patients with FM.

Methods

Adult patients with an ACR 2010/2011 diagnosis of FM underwent a complete physical examination and laboratory tests and were asked to complete a package of questionnaires covering their sociodemographic and treatment details, in addition to the following disease-specific questionnaires: the revised Fibromyalgia Impact Questionnaire (FIQR), the modified Fibromyalgia Assessment Status questionnaire (ModFAS) and the Polysymptomatic Distress Scale (PDS).

Results

A total of 2339 patients were recruited and divided into two weight categories, underweight/normal (U/N, n = 1127, 48.2%) and overweight/obese (O/O, n = 1212, 51.8%). The total and subscales of FIQR, ModFAS and PSD scores were significantly higher in the O/O patients, as were all the mean scores of the individual FIQR items (P < 0.001 for all).

Conclusion

Our findings demonstrate that O/O patients with FM are significantly more impaired than U/N patients in all the symptomatological and functional domains as measured using the FIQR, ModFAS and PDS, thus suggesting that being O/O has an additional effect on symptoms and function.

Long-term methotrexate use in rheumatoid arthritis patients: real-world data from the MARTE study

BACKGROUND

The MARTE study investigated the demographic, clinical, and therapeutic characteristics of rheumatoid arthritis (RA) patients ongoing methotrexate (MTX) treatment for longer than 8 years.

METHODS

This cross-sectional, observational study considered 587 RA patients from 67 Rheumatology Units across Italy. Data collected included demographic, clinical, and therapeutic characteristics, focusing on MTX prescription patterns (route of administration, dosing regimens, treatment duration, and discontinuation).

RESULTS

As initial therapy, 90.6% of patients received one conventional synthetic Disease Modifying Anti Rheumatic Drug (csDMARD), with treatment started within the first 3 months from diagnosis in half of the patients. MTX was the first csDMARD in 46.2% of patients. The prevalent route of administration at diagnosis was the intramuscular (60.5%), while at study entry (baseline) 57.6% were receiving subcutaneous MTX. Patients who required a higher MTX dose at study entry were those who received a significantly lower starting MTX dose (P<0.001). Significantly higher MTX doses were currently required in men (P<0.001), current smokers (P=0.013), and overweight patients (P=0.028), whereas patients on oral therapy received significantly lower doses of MTX (P<0.001).

CONCLUSIONS

The MARTE study confirms once again the potential of the proper use of MTX in the treatment of RA. Data from our study suggest that a higher dose of MTX should be used since the first stages in overweight patients, men, and smokers.

AB0667 ACHILLES PAIN PERSISTENCE IN PATIENTS AFFECTED BY SPONDYLOARTHRITIS: ULTRASONOGRAPHIC AND BIOMECHANICAL STUDY

Background:

Enthesis anatomy and biomechanics have a key role in Spondyloarthritis (SpA) pathogenesis (1) but few data are available about the influence of structural and biomechanical changes of Achilles tendon (AT) on persisting pain in longstanding SpA patients.

Objectives:

To correlate AT pain in longstanding SpA patients with ultrasonographic detectable disorders and biomechanical abnormalities.

Methods:

We performed a monocentric cross-sectional analysis including 35 consecutive patients affected by SpA (13 with Psoriatic Arthritis, 9 with Enteropathic SpA, 6 with Ankylosing Spondylitis and 7 with Undifferentiated SpA) under treatment with anti- TNF agents. A rheumatologic clinical and clinimetric evaluation (AT VAS pain, BASDAI, BASFI, HAQ), an ultrasound study of AT according to the Madrid Sonographic Enthesis Index (MASEI) score and a podiatrist biomechanical evaluation [Foot posture index (FPI), degree of ankle dorsiflexion with the knee extended and flexed] were performed.

Results:

Study population (13 F; 22 M; mean age 54.9 ±13.9 years; mean disease duration 9.5 ± 5.0 years; mean BMI 25.8 ±4.4) showed a mean AT VAS pain of 3.4 ± 2.2, a mean HAQ of 0.6 ± 0.6, a mean BASDAI of 3.3 ±2.1 and a mean BASFI of 2.2 ±1.9. At the ultrasonographic evaluation 47% (33/70) of the AT entheses analysed presented a dishomogeneous echostructure, 31% (22/70) structural thickness, 53% (37/70) calcifications, 10% (7/70) erosions, 44% (31/70) a retrocalcanear bursitis. A power Doppler positivity was found only in 0.07% (5/70) of the AT.

At the biomechanical evaluation 50% (35/70) of the feet showed a FPI score between 0 and + 5 (neutral foot), 46% (32/70) a FPI score between +6 and +9 (slight foot pronation) and 6% (4/70) a FPI score between -1 and -4 (slight foot supination).

The mean degree of ankle dorsiflexion with extended knee was 8.4 ± 3.9 with the 61% (43/70) of the patients with a maximum dorsiflexion < 10° of whom 46% (20/43) do not recover after the knee flexion.

We found a between the mean degree of left ankle dorsiflexion with extended/flexed knee both with ultrasound-revealed left AT enthesis calcifications (p=0.014/0.037) and with left AT enthesis thickness (p=0.049/0.035), and a significant association between the mean degree of right ankle dorsiflexion and extended/flexed knee and ultrasound-revealed right AT calcifications (p=0.008/0.012). Moreover, we noticed an inverse correlation between the mean overall degree of ankle dorsiflexion with extended/flexed knee and the BASFI values (p=0.007/0.004). AT VAS pain was statistically related with Achilles PDUS signal persistence (p=0.048) but not with US signs of chronic entesopathy or biomechanical alterations [calcification (p=0.39), erosions (p=0.74)]. The limits of the study were the low number of patients recruited and the lack of a control group.

Conclusion:

In this monocentric study on a cohort of SpA patients, we demonstrated a statistically significant correlation between ankle–subtalar joint complex biomechanics alterations, ultrasonographic signs of chronic enthesopathy and clinimetric index of functional disability. Residual Achilles pain seems to be related to US signs of active enthesitis.

References:

[1]The enthesis organ concept and its relevance to the spondyloarthropathies. Benjamin, M and McGonagle, D. s.l.: Adv Exp Med Biol, 2009, Vol. 649.

[2]The Synovio-entheseal Complex and Its Role in Tendon and Capsular Associated Inflammation. McGonagle, E D, Aydin, SZ and Tan, AL. 0, s.l.: J Rheumatol Suppl, 2012, Vol. 89

Disclosure of Interests:

None declared

Estimating bacteria diversity in different organs of nine species of mosquito by next generation sequencing

BACKGROUND

Symbiosis in insects is accumulating significant amount of studies: the description of a wide array of mutualistic associations across the evolutionary history of insects suggests that resident microbiota acts as a driving force by affecting several aspects of hosts biology. Among arthropods, mosquito midgut microbiota has been largely investigated, providing crucial insights on the role and implications of host-symbiont relationships. However, limited amount of studies addressed their efforts on the investigation of microbiota colonizing salivary glands and reproductive tracts, crucial organs for pathogen invasion and vertical transmission of symbiotic microorganisms. Using 16S rRNA gene sequencing-based approach, we analysed the microbiota of gut, salivary glands and reproductive tracts of several mosquito species, representing some of the main vectors of diseases, aiming at describing the dynamics of bacterial communities within the individual.

RESULTS

We identified a shared core microbiota between different mosquito species, although interesting inter- and intra-species differences were detected. Additionally, our results showed deep divergences between genera, underlining microbiota specificity and adaptation to their host.

CONCLUSIONS

The comprehensive landscape of the bacterial microbiota components may ultimately provide crucial insights and novel targets for possible application of symbionts in innovative strategies for the control of vector borne diseases, globally named Symbiotic Control (SC), and suggesting that the holobiont of different mosquito species may significantly vary. Moreover, mosquito species are characterized by distinctive microbiota in different organs, likely reflecting different functions and/or adaptation processes.

Effect of GLP-1 and GIP on C-peptide secretion after glucagon or mixed meal tests: Significance in assessing B-cell function in diabetes

BACKGROUND

The aim of the study was to investigate the different B-cell responses after a glucagon stimulation test (GST) versus mixed meal tolerance test (MMTT).

METHODS

We conducted GST and MMTT in 10 healthy people (aged 25-40 years) and measured C-peptide, gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1) at different time points after the administration of 1 mg i.v. glucagon for GST or a liquid mixed meal for MMTT.

RESULTS

The GST stimulated C-peptide showed a mean increase of 147.1%, whereas the mean increase of MMTT stimulated C-peptide was 99.82% (Δincrease = 47.2%). Maximum C-peptide level reached with the MMTT was greater than that obtained with the GST (C-pept max MMTT = 2.35 nmol/L vs C-pep max GST = 1.9 nmol/L). A positive and linear correlation was found between the GST incremental area under the curve C-peptide and the MMTT incremental area under the curve C-peptide (r = 0.618, P = .05). After GST, there was no increment of GIP and glucagon like peptide-1 levels compared to baseline levels. A positive and linear correlation between GIP and C-peptide levels was observed only for the MMTT (r = 0.922, P = .008) indicating that in the GST, the C-peptide response is independent of the incretin axis response.

CONCLUSIONS

Although the 2 stimulation tests may elicit a similar response in C-peptide secretion, B-cell response to MMTT depends on a functionally normal incretin axis. These results may have implications when investigating the B-cell response in people with diabetes and for studies in which stimulated C-peptide secretion is used as primary or secondary outcome for response to therapy.

Average treatment effect of hepatic resection versus locoregional therapies for hepatocellular carcinoma

Background

When comparing the efficacy of surgical and non-surgical therapies for hepatocellular carcinoma (HCC), a major limitation is the causal inference problem. This concerns the impossibility of seeing both outcomes of two different treatments for the same individual at the same time because one is inevitably missing. This aspect can be addressed methodologically by estimating the so-called average treatment effect (ATE).

Methods

To estimate the ATE of hepatic resection over locoregional therapies for HCC, data from patients treated in two tertiary care settings between August 2000 and December 2014 were used to obtain counterfactual outcomes using an inverse probability weight survival adjustment.

Results

A total of 1585 patients were enrolled: 815 underwent hepatic resection, 337 radiofrequency ablation (RFA) and 433 transarterial chemoembolization (TACE). The option of operating on all patients who had tumour ablation returned an ATE of +9·8 months for resection (effect size 0·111; adjusted P = 0·064). The option of operating on all patients who had TACE returned an ATE of +27·9 months (effect size 0·383; adjusted P &lt; 0·001). The ATE of surgery was negligible in patients undergoing ablation for very early HCCs (effect size 0·027; adjusted P = 0·627), independently of albumin–bilirubin (ALBI) grade; or in patients with ALBI liver function grade 2 (effect size 0·083; adjusted P = 0·213), independently of tumour stage. In all other instances, the ATE of surgery was notably greater. Operating on patients who had TACE with multinodular HCC beyond the Milan criteria resulted in a mild ATE (effect size 0·140; adjusted P = 0·037).

Conclusion

ATE estimation suggests that hepatic resection is a better treatment option than ablation and TACE in patients with HCC.

Detection and isolation of the α-proteobacterium Asaia in Culex mosquitoes

Investigations of microbiota within mosquitoes continue to widen the spectrum of possible symbiont-based applications against vector-borne diseases. In this context, α-proteobacteria of the genus Asaia (Rhodospirillales: Acetobacteraceae) are emerging as possible endosymbiotic candidates, particularly in paratransgenic approaches aimed at interrupting pathogen transmission. Previous studies have shown that Asaia spp. distribution among Anopheles gambiae and Anopheles stephensi (Diptera: Culicidae) mosquitoes displayed positive rates of infection in isolated midguts, salivary glands and reproductive tissues. Similarly, Asaia has been detected in Aedes albopictus (Stegomyia albopicta) and Aedes aegypti (Stegomyia aegypti) (Diptera: Culicidae) populations. Within the Culex pipiens complex (Diptera: Culicidae), Asaia infection is still largely unexplored. Here, we summarize a preliminary survey of laboratory-reared Cx. pipiens complex and field-collected Culex quinquefasciatus for the presence of Asaia spp., and present the first identification of Asaia in some of the members of the Cx. pipiens complex and the first description in West African populations of Cx. quinquefasciatus.

Imaging in resectable colorectal liver metastasis patients with or without preoperative chemotherapy: results of the PROMETEO-01 study

Background:

The aim of the PROMETEO-01 Study was to define the diagnostic accuracy of imaging techniques in colorectal cancer liver metastasis (CRCLM) patients.

Methods:

Patients referred to Bologna S. Orsola-Malpighi Hospital performed a computed-tomography scan (CT), magnetic resonance (MR), 18F-FDG-PET/CTscan (PET/CT) and liver contrast-enhanced-ultrasound (CEUS); CEUS was also performed intraoperatively (i-CEUS). Every pathological lesion was compared with imaging data.

Results:

From December 2007 to August 2010, 84 patients were enrolled. A total of 51 (60.71%) resected patients were eligible for analysis. In the lesion-by-lesion analysis 175 resected lesions were evaluated: 67(38.3%) belonged to upfront resected patients (group-A) and 108 (61.7%) to chemotherapy-pretreated patients (group-B). In all patients the sensitivity of MR proved better than CT (91% vs 82% P=0.002), CEUS (91 vs 81% P=0.008) and PET/CT (91% vs 60% P=0.000), whereas PET/CT showed the lowest sensitivity. In group-A the sensitivity of i-CEUS, MR, CT, CEUS and PET/CT was 98%, 94%, 91%, 84% and 78%, respectively. In group-B the i-CEUS proved equivalent in sensitivity to MR (95% and 90%, respectively, P=0.227) and both were significantly more sensitive than other procedures. The CT sensitivity in group-B was lower than in group-A (77% vs 91%, P=0.024).

Conclusions:

A thoraco-abdominal CT provides an adequate baseline evaluation and guides judgment as to the resectability of CRCLM patients. In the subset of candidates for induction chemotherapy to increase the chance of liver resection, the most rational approach is to add MR for the staging and restaging of CRCLM.

Hyaluronan derivatives bearing variable densities of ferulic acid residues

A synthetic procedure has been developed to conjugate ferulic acid (FA) to an important natural polysaccharide derivative such as hyaluronic acid (HA). The activation of FA with 1,1'-carbonyldiimidazole (CDI) has been investigated. Two reactive intermediates, namely monoimidazolide 2 [i.e. (E)-3-(4-hydroxy-3-methoxyphenyl)-1-(1H-imidazol-1-yl)prop-2-en-1-one] and bisimidazolide 3 [i.e. (E)-4-(3-(1H-imidazol-1-yl)-3-oxoprop-1-enyl)-2-methoxyphenyl 1H-imidazole-1-carboxylate] were characterized from the point of view of their structure and reactivity. The ready isolation of bisimidazolide 3 and its reactivity support its potential usefulness in the feruloylation of molecular or macromolecular materials bearing hydroxyl moieties. Bisimidazolide derivative 3 has been found to be an effective reagent in the feruloylation of HA to give HAFA graft copolymers showing different grafting degrees (GD), which could be modulated by varying the reaction conditions. A series of HAFA derivatives showing different GD values has been prepared and submitted to an extensive macromolecular and rheological characterization in order to ascertain that the grafting of HA with FA does not degrade the polysaccharide backbone and to evaluate the role of GD in affecting solubility and rheological properties. The results suggested that relatively low GD values were sufficient to confer physical cross-linking capabilities resulting in the features of a strong gel of HAFA dispersions.

The role of hybrid procedures in the treatment of critical limb ischemia

Patients affected by critical limb ischemia (CLI) represent a complex and high risk clinical problem, and a multidisciplinary approach is often demanded. The amputation rate in patients affected by CLI is still high. Introduction of endovascular procedure shook up the CLI concept of treatment. The increasing experience of Vascular Surgeons in endovascular technique forced these specialist to match classic surgical skills and endovascular tools in order to achieve the best treatment for each patients. The combination of the two techniques identifies the hybrid procedure. Aim of this paper is to define indication, necessity and results of the hybrid procedure in patients suffering from CLI.

Endovascular first as "preliminary approach" for critical limb ischemia and diabetic foot

The treatment of the critical limb ischemia (CLI) and diabetic foot (DB) is still object of discussion and the gold standard for revascularization has not yet been identified. In these two decades the introduction of endovascular procedures had a large impact on the surgical revascularization and were added to the practice of vascular surgeons in patients who cannot be candidates for a bypass. This may be due to significant comorbidities, a reduced life expectancy, infection or gangrene in the possible sites of distal anastomoses, the unavailability of suitable veins, or the absence of an adequate "landing zone" for the distal part of the bypass. Various studies have evaluated the role of PTA in DF and CLI that resulted favourable in terms of feasibility, technical efficacy, the reduced number of complications, and limb salvage rates. Anyway, long-term patency is better after bypass surgery than after angioplasty, which is burdened by a high restenosis rate. In our experience we tried to practice endovascular approach as a first choice. If the procedure cannot be concluded safely, we continue the intervention surgically or use a hybrid approach. The endovascular-first strategy seems to be the future regardless of comorbidity of the patient and the degree of pathology. The vascular surgeon remains the only specialist that can decide the correct intervention without pressure or been forced and, last but not least, the only one who can independently perform hybrid interventions.

Acute limb ischemia in nonagenarians

AIM

Acute limb ischemia (ALI) is not infrequently associated with limb loss (10-30%) or death of the affected patient (15-30%). These results can be even worse in elderly population. The aim of this study is to quantify safety and efficacy of early revascularization in over 90 years old patients with acute limb ischemia.

METHODS

This is a prospective registry lasting from January 2012 to January 2013. We include all consecutive over 90 years patients treated for ALI (N.=15). A careful preoperative Duplex scan (DS) were performed in each patient. All patients underwent surgery by Fogarty's embolectomy, and endovascular completion procedure if needed (N.=3).

RESULTS

We performed 18 revascularizations (15 lower limbs, 3 upper limbs) in 15 patients (2 staged bilateral femoral, 1 simultaneous bilateral femoral). The mean follow-up was 124 days (4-365). Technical success was obtained in 16 cases (88.9%). At disharge mortality was 5.9% (1 case), and amputation rate was 6.2% (1 pt). The Kaplan-Meier curves at 1 year revealed an estimated freedom from death, amputation and re-occlusion of 76.5%, 88.2%, and 71.3%, respectively.

CONCLUSION

The over 90 years old patient represent a challenging case for vascular surgeon. Vascular procedures involve high mortality rate but emergent revascularization by Fogarty Embolectomy in ALI is safe and effective even in older patient.

Tips and tricks to avoid periprocedural neurological complications in carotid artery stenting

Execution of carotid artery stenting (CAS) requires not only excellent manual dexterity, and a high level of competence, but also in-depth knowledge of the carotid pathology, of the materials available on the market and of the different techniques to apply in given situations. Actually each individual moment of the procedure can be determining for the final result. This review describes each individual step of CAS, including arterial access, carotid engagement, pre-dilatation, the characteristics and use of cerebral protection devices, stent selection and deployment, and post-dilatation. Technical notes and some suggestions are provided on how to minimize the event of periprocedural neurological complications.

Carotid artery stenting in recently symptomatic patients

Treatment of acute stroke is time-dependent, with the best outcomes resulting from the earliest interventions. However, for patients with acute ischemic stroke due to a high-grade stenosis of the internal carotid artery, despite maximal medical treatment, an effective intervention to improve their neurologic symptoms and clinical outcome has not yet been established. There are two major concerns: first, cerebral revascularization in the acute stage remains challenging because of the possibility that hemorrhagic infarction or hyperperfusion syndrome will occur after revascularization; second, alarms about carotid artery stenting in patients with acute symptoms are related to the fact that, while with carotid endarterectomy the plaque is completely removed, after stenting it is only remodelled and its stabilization is essential to avoid embolic events during the procedure and in the post-operative period. Although level 1 evidence seems clearly in favor of carotid endarterectomy in symptomatic patients, carotid stenting has been proposed as a possible alternative in selected cases if the procedure is performed in high-volume center with documented low perioperative stroke and death rates. This review summarizes indications and results for carotid artery stenting in recently symptomatic patients.

Endovascular approach to Leriche syndrome

The chronic obstruction of the aortic bifurcation and iliac axis was definide by the French surgeon Rene Leriche, whose name it bears today. The advancing age of the population move the definition from a syndrome, as reported from Leriche, to complex aortoiliac vascular lesions current multidisciplinary guidelines recommend to treat extensive aortoiliac occlusive disease by surgical revascularization. Surgery provides good long-term patency, but at the cost of substantial perioperative morbidity. Development of new technologies and techniques has led to increased use of endovascular therapy for extensive aortoiliac disease. This review article summarized current multidisciplinary guidelines indication in endovascular treatment of extensive aorto-iliac disease and the various worldwide single centre experience published on endovascular treatment of Leriche Syndrome.

Siena EVAR Score

AIM

Although several randomized trial and monocentric study reported good results EVAR of abdominal aortic aneurysm (AAA), the long-term results of EVAR is still debated for the incidence of complication and the necessity of reintervention and or surgical conversion. The aim of the present study was to generate a score to grade the risk of reintervention/conversion after EVAR.

METHODS

We present a five-year prospective study. All patients with AAA and treated by EVAR were inserted in the study. Patients with ruptured AAA or treated with fenestrated-graft or chimney technique were excluded from the analysis. The rates of reintervention, surgical conversion and aneurysm-related death were recorded at 6 months after the procedure. Complication predictors were analyzed and was generated a numeric score for all the variables to predict the patient individual risk.

RESULTS

During the study period 976 EVAR procedures were successfully performed. No patients were lost during follow-up. We report 23 reinterventions (2.35%), the majority were performed electively. In six cases (0.61%) was performed conversion to surgical repair (1 graft infection, 3 for continuous growing of the aneurysmal sac and 2 cases for a ruptured AAA). In our experience, we report 4 deaths (0.4%) due to aneurysm rupture (1 case), acute myocardial infarction (2 cases) and colon cancer (1 case). The procedures were defined at low, moderate or high risk, respectively, according to whether the Siena EVAR Score was defined as EVAR1 (score <3), EVAR2 (3-6) or EVAR3 (>6).

CONCLUSION

Our Score could be an useful tool to predict patients individual risk after EVAR but, to be validated, needs to be analyzed in independents cohorts in different Center.

Primary amputation: is there still a place for it?

Diabetic foot (DF) continues to present a significant challenge to the vascular surgeon. Despite great advances in the treatment of DF, including open revascularization and endovascular techniques, significant numbers of amputations are still performed. The effect of aggressive revascularization on ultimate limb salvage rates continues to be debated. In the US the amputation rate has increased from 19 to 30 per 100000 persons years over the last two decades primarily due to an increase in diabetes and advancing age. Despite advances in cardiovascular treatment, in patients over 85 year of age an amputation rate of 140 per 100000 persons/year has been reported with a primary amputation (PA) still carrying an excessively high mortality rate of 13-17%. Amputation has been historically regarded as a life saving therapeutic measure. At the time the advances of surgical techniques in revascularization, diagnostic modalities and effectiveness in antimicrobial agents have unintentionally designated amputation to be the last treatment option. Nowadays we have a variety of therapeutic options to correct, modify, or circumvent the obstructive vascular pathology, such as angioplasty, atherectomy, stenting, stent graft and the traditional open surgical approach using endarterectomy, patch angioplasty, or bypass revascularization and even sympathectomy to enhance cutaneous perfusion to the toes. However it is understandable that many older patients who have received multiple limb preservation procedures have spent most of the remaining days of their lives in and out of the hospital or in a long-term care facility where high technical and sophisticated wound care techniques can be provided.

Renal aneurysms: surgical vs. endovascular treatment

Renal artery aneurysms (RAA) are rare (general population incidence is 0.09%). At this time, the appropriateness of the type of intervention ‑ surgical or endovascular ‑ is based on single center experiences rather than large randomized trials. Endovascular therapy offers less morbidity but surgery has excellent long-term results. In reality, the choice of the treatment relies on the operative risk. A patient with a RAA and good surgical risk should be offered open surgery. If the patient is deemed to be at high risk from surgery then the choice of the type of endovascular treatment (stent grafting, coil/glue embolization, multilayer stenting) should be based on the location and shape of the RAA. RAA should be treated by surgeons/interventionalists who have demonstrated expertise in renal artery procedures.

Modular branched neurotensin peptides for tumor target tracing and receptor-mediated therapy: a proof-of-concept

The aim of this study was to demonstrate that oligo-branched peptides can be effective either for spotlighting tumor cells that overexpress peptide receptors, or for killing them, simply by exchanging the functional moiety coupled to the conserved receptor-targeting core. Tetra-branched peptides containing neurotensin (NT) sequence are described here as selective targeting agents for human colon, pancreas and prostate cancer. Fluorophore-conjugated peptides were used to measure tumor versus healthy tissue binding in human surgical samples, resulting in validation of neurotensin receptors as highly promising tumor-biomarkers. Drug-armed branched peptides were synthesized with different conjugation methods, resulting in uncleavable adducts or drug-releasing molecules. Cytotoxicity on human cell lines from colon (HT-29), pancreas (PANC-1) or prostate (PC-3) carcinoma indicated branched NT conjugated with MTX and 5-FdU as the most active agents on PANC-1 (EC(50) 4.4e-007 M) and HT-29 (1.1e-007 M), respectively. Tetra-branched NT armed with 5-FdU was used for in vivo experiments in HT-29-xenografted mice and produced a 50% reduction in tumor growth with respect to animals treated with the free drug. An unrelated branched peptide carrying the same drug was completely ineffective. In vitro and in vivo results indicated that branched peptides are valuable tools for tumor selective targeting.

Open vascular surgery as a starting point for endovascular surgery

What distinguishes vascular surgeons from other specialists who treat patients with vascular disease is their ability to combine skills in both open and endovascular treatments. Open vascular surgery should be considered the "starting point" for endovascular surgery, since training and practice in vascular surgery require extensive knowledge of the basic science and a thorough education in general surgical techniques. In addition, surgeons must possess detailed specialized knowledge of the anatomy and physiology of arteries, veins and lymphatics and of the pathological processes which may affect them. This scientific and technical background is also imperative for endovascular surgery. Open vascular surgery can also be considered as a potential finishing point of endovascular surgery. In fact, open surgery is still often the only solution for complex cases considered unsuitable for an endovascular approach, or for different types of complications following endovascular treatments. As endovascular surgery is increasingly considered as the initial treatment option for many patients with vascular disease, it is crucial that vascular surgery training programs develop methods to maintain the open surgical skills of their trainees. The only way for vascular surgeons to remain the premier specialists to care for patients with vascular disease is for them to combine skills in both open and endovascular treatments.

Proctorship for CAS training: a pilot study of safety and reproducibility

AIM

The literature continues reporting a high complication rate for carotid artery stenting (CAS) during the learning-curve phase (LCP). The aim of this study was to report a simple and reproducible method designed to improve CAS results during the LCP.

METHODS

Between February 2007 and December 2009, a qualified vascular surgeon ran a proctorship program for CAS. The program was divided into four practical phases: in the teaching phase (a) the first 20 CAS were performed by the proctor assisted by a trainee surgeon; in the training phase (b) for the 21st to the 50th CAS the trainee surgeon was supervised by the proctor; in the skilled phase (c), between the 51st and the 80th procedure, a trainee surgeon performed CAS while the proctor was scrubbed-in but operating only on demand; in the final phase (d), following the 81st CAS, the procedure was performed without the proctor's presence. The inclusion criterion was carotid stenosis ≥70% and patient selection was performed for the first 40 cases based on patient and lesion characteristics. The procedure for CAS was standardized.

RESULTS

Four trainees performed 604 CASs in two centers. The procedural success rate of CAS was 98.8% (N.=594/604) without any differences among the four trainees (P=0.902). The overall TIA, myocardial infarction, minor, major and fatal stroke rate at 30 days was respectively 1.7% (N.=10), 0.8% (N.=5), 1.2% (N.=7), 0.64% (N.=4) and 0.3% (N.=2). The effectiveness of this program was demonstrated by a significant decrease in the proctor's intervention between phase b and phase c (P<0.001) and by a similar trend in the complication rate achieved by the four trainees, in all phases and centers (P=0.075 and 0.788, respectively).

CONCLUSION

This preliminary experience of a proctorship program in the LCP, together with patient selection and standardization of the procedure and materials used, seems to be safe and reproducible. Moreover, possibly randomized, studies comparing different CAS training techniques are needed in order to validate our findings.