[Translated article] Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Interobserver reliability of classifying shoulder calcific tendinopathy on plain radiography and ultrasound

INTRODUCTION

Shoulder calcific tendinopathy is a frequent cause of shoulder pain. Diagnosis is usually based on ultrasound (US) and/or X-ray. US is considered an inherently operator-dependent imaging modality and, interobserver variability has previously been described by experts in the musculoskeletal US. The main objective of this study is to assess the interobserver agreement for shoulder calcific tendinopathy attending to the size, type, and location of calcium analyzed in plain film and ultrasound among trained musculoskeletal radiologists.

MATERIAL AND METHODS

From June 2018 to May 2019, we conducted a prospective study. Patients diagnosed with shoulder pain related to calcific tendinopathy were included. Two different experienced musculoskeletal radiologists evaluated independently the plain film and the US.

RESULTS

Forty patients, with a mean age of 54.6 years, were included. Cohen's kappa coefficient of 0.721 and 0.761 was obtained for the type of calcium encountered in plain film and the US, respectively. The location of calcification obtained a coefficient of 0.927 and 0.760 in plain film and US, respectively. The size of the calcification presented an intraclass correlation coefficient (ICC) of 0.891 and 0.86 in plain film and US respectively. No statistically significant differences were found in either measurement.

CONCLUSION

This study shows very good interobserver reliability of type and size measurement (plain film and US) of shoulder calcifying tendinopathy in experienced musculoskeletal radiologists.

Novel Radioenhancer NBTXR3 Activated by Radiotherapy in Cisplatin-Ineligible Locally Advanced HNSCC Patients: Final Results of a Phase I Trial

PURPOSE/OBJECTIVE(S)

New approaches are needed for frail or elderly patients with locally advanced head and neck squamous cell carcinoma (LA HNSCC) who are unfit to receive cisplatin with concurrent radiotherapy (RT). NBTXR3 is a first-in-class radioenhancer, composed of functionalized hafnium oxide nanoparticles, administered by a single intratumoral (IT) injection and activated by RT. NBTXR3 locally amplifies the anti-tumoral response of RT without adding toxicity to surrounding healthy tissue as shown in a randomized trial in soft tissue sarcoma. This two-part study: dose-escalation followed by the dose-expansion part reported here, evaluated the safety and preliminary efficacy for NBTXR3 activated by RT in elderly or frail patients ineligible to cisplatin.

MATERIALS/METHODS

This trial enrolled patients who had previously untreated AJCC 8th Stage III-IVA or T3, T4 SCC of the oral cavity or oropharynx (OPC) ineligible to cisplatin. Eligible patients received a single IT injection of NBTXR3 at the recommended dose (22% of the baseline tumor volume) followed by RT (IMRT 70 Gy in 35 fractions). The primary objectives of the dose expansion part were to test the recommended dose, to confirm its safety, and obtain preliminary evidence of efficacy. The secondary objectives included the evaluation of progression-free survival (PFS) and overall survival (OS).

RESULTS

Fifty-sixpatients in the dose expansion part were treated from April 2019-January 2022; 44 patients were evaluable for objective tumor response. In the all-treated population, median age was 71.9 years. 64.3% had age-adjusted Charlson Comorbidity Index scores ≥4, 55.4% had OPC (45.2% HPV+) and 80% had T3-4. Median injected volume of NBTXR3 was 13.6 [0.5-57.1] mL. Grade ≥ 3 adverse events reported as potentially related to NBTXR3 or to injection procedure were 1.2% and 0.4% of all AEs reported, respectively. In the evaluable population, the best objective response rate of the NBTXR3 injected lesion was 81.8% with a complete response rate of 63.6%. The best overall response rate (injected and non-injected lesions) was 79.5%. Final analyses on PFS and OS with long-term follow-up will be presented.

CONCLUSION

NBTXR3 IT injection followed by activation with RT was confirmed to be feasible and well tolerated in elderly or frail patients with LA HNSSC and significant comorbidities. The high rate of best overall response suggests that NBTXR3+RT is effective in this elderly population ineligible to cisplatin with a high unmet medical need. These results support our ongoing phase III study comparing NBTXR3/RT ± cetuximab vs. RT ± cetuximab in platinum-based chemotherapy ineligible elderly patients with LA-HNSCC: NANORAY 312 (NCIT04892173).

Implementation of a hybrid healthcare model in rheumatic musculoskeletal diseases: 6-months results of the multicenter Digireuma study

OBJECTIVES

Rheumatic and musculoskeletal diseases (RMDs) require a tailored follow-up that can be enhanced by the implementation of innovative tools. The Digireuma study aimed to test the feasibility of a hybrid follow-up utilizing an electronic patient reported outcomes (ePROs)-based monitoring strategy in patients with RMDs.

METHODS

Adult patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) were recruited for a 6-month bicentric prospective follow-up consisting of face-to-face and digital assessments. Patients were asked to report disease-specific ePROs on a pre-established basis, and could also report flares, medication changes, and recent infections at any time. Four rheumatologists monitored these outcomes and contacted patients for interventions when deemed necessary. Results from face-to-face and digital assessments were described.

RESULTS

Of 56 recruited patients, 47 (84%) submitted any ePROs to the digital platform. Most patients with RA were female (74%, median age of 47 years), while 48% of patients with SpA were female (median age 40.4 years). A total of 3,800 platform visits were completed, with a median of 57 and 29 visits in patients with RA and SpA, respectively. Among 52 reported alerts, 47 (90%) needed contact, of which 36 (77%) were managed remotely. Adherence rates declined throughout the study, with around half of patients dropping out during the 6 months follow-up.

CONCLUSION

The implementation of a hybrid follow-up in clinical practice is feasible. Digital health solutions can provide granular knowledge of disease evolution and enable more informed clinical decision making, leading to improved patient outcomes. Further research is needed to identify target patient populations and engagement strategies.

[Translated article] Comparative biomechanical study of two configurations of cemented screws in a simulated proximal humerus fracture fixed with locking plate

INTRODUCTION

Screw tip augmentation with bone cement for fixation of osteoporotic proximal humerus fractures seems to improve stability and to decrease the rate of complications related to implant failure. However, the optimal augmentation combinations are unknown. The aim of this study was to assess the relative stability of two augmentations combinations under axial compression load in a simulated proximal humerus fractures fixed with locking plate.

MATERIAL AND METHODS

A surgical neck osteotomy was created in five pairs of embalmed humeri with a mean age of 74 years (range 46-93 years), secured with a stainless-steel locking-compression plate. In each pair of humeri, on the right humerus were cemented the screws A and E, and in the contralateral side were cemented screws B and D of the locking plate. The specimens were first tested cyclically in axial compression for 6000 cycles to evaluate interfragmentary motion (dynamic study). At the end of the cycling test, the specimens were loaded in compression force simulating varus bending with increasing load magnitude until failure of the construct (static study).

RESULTS

There were no significant differences in interfragmentary motion between the two configurations of cemented screws in the dynamic study (p=0.463). When tested to failure, the configuration of cemented screws in lines B and D demonstrated higher compression load to failure (2218N vs. 2105, p=0.901) and higher stiffness (125N/mm vs. 106N/mm, p=0.672). However, no statistically significant differences were reported in any of these variables.

CONCLUSIONS

In simulated proximal humerus fractures, the configuration of the cemented screws does not influence the implant stability when a low-energy cyclical load is applied. Cementing the screws in rows B and D provides similar strength to the previously proposed cemented screws configuration and could avoid complications observed in clinical studies.

Constrictive pericarditis with massive calcification in systemic sclerosis treated with pericardiectomy: a case report

BACKGROUND

Calcific constrictive pericarditis is a very rare complication of systemic sclerosis. This is the first report of a surgically treated calcific constrictive pericarditis in systemic sclerosis.

CASE PRESENTATION

A 53 years-old woman, affected by limited systemic sclerosis, had a diagnosis of calcific constrictive pericarditis. She had a medical history of congestive heart failure since 2022. The patient was treated with pericardiectomy. Via a median sternotomy, the pericardium was dissected and removed from the midline to the left phrenic nerve, thus freeing the heart. 3 months after the pericardiectomy, there was a significant clinical improvement.

DISCUSSION AND CONCLUSIONS

The calcific evolution of a chronic pericarditis is a rare complication of systemic sclerosis. This case represents, at best of our knowledge, the first report of calcific constrictive pericarditis, in systemic sclerosis, treated with pericardiectomy.

A phase I trial of LXS196, a protein kinase C (PKC) inhibitor, for metastatic uveal melanoma

BACKGROUND

Up to 50% of patients with uveal melanoma develop metastases (MUM) with a poor prognosis and median overall survival of approximately 1 year.

METHODS

This phase I study evaluated the safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy of the oral protein kinase C inhibitor LXS196 in 68 patients with MUM (NCT02601378). Patients received LXS196 doses ranging from 100-1000 mg once daily (QD; n = 38) and 200-400 mg twice daily (BID; n = 30).

RESULTS

First cycle dose-limiting toxicities (DLTs) were observed in 7/38 (18.4%) QD and 2/17 (11.8%) BID patients. Hypotension was the most common DLT, occurring at doses ≥500 mg/day, and manageable with LXS196 interruption and dose reduction. Median duration of exposure to LXS196 was 3.71 months (range: 1.81-15.28) for QD and 4.6 months (range: 0.33-58.32) for BID dosing. Clinical activity was observed in 6/66 (9.1%) evaluable patients achieving response (CR/PR), with a median duration of response of 10.15 months (range: 2.99-41.95); 45/66 had stable disease (SD) per RECIST v1.1. At 300 mg BID, the recommended dose for expansion, 2/18 (11.1%) evaluable patients achieved PR and 12/18 (66.7%) had SD.

CONCLUSION

These results suggest manageable toxicity and encouraging clinical activity of single-agent LXS196 in patients with MUM.

Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 2022

In 2021, the Food and Drug Administration Oncology Center of Excellence announced Project Optimus focusing on dose optimization for oncology drugs. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Taskforce met to review and discuss the optimization of dosage for oncology trials and to develop a practical guide for oncology phase I trials. Defining a single recommended phase II dose based on toxicity may define doses that are neither the most effective nor the best tolerated. MDICT recommendations address the need for robust non-clinical data which are needed to inform trial design, as well as an expert team including statisticians and pharmacologists. The protocol must be flexible and adaptive, with clear definition of all endpoints. Health authorities should be consulted early and regularly. Strategies such as randomization, intrapatient dose escalation, and real-world eligibility criteria are encouraged whereas serial tumor sampling is discouraged in the absence of a strong rationale and appropriately validated assay. Endpoints should include consideration of all longitudinal toxicity. The phase I dose escalation trial should define the recommended dose range for later testing in randomized phase II trials, rather than a single recommended phase II dose, and consider scenarios where different populations may require different dosages. The adoption of these recommendations will improve dosage selection in early clinical trials of new anticancer treatments and ultimately, outcomes for patients.

Streamlining clinical research: an ESMO awareness call to improve sponsoring and monitoring of clinical trials

BACKGROUND

During recent years, the burden of bureaucracy in clinical research has increased dramatically, adversely impacting the activity of investigators and clinical research teams. Although compliance with the Declaration of Helsinki, the guidelines for Good Clinical Practice (GCP), and other applicable regulations remains unquestionable, their overinterpretation and substitution by the internal operating procedures of sponsors and Contract Research Organizations (CROs) have increased the administrative burden. A survey conducted by the European Society for Medical Oncology (ESMO) Clinical Research Observatory (ECRO) among 940 investigators confirmed that they considered that the administrative burden in clinical research is excessive; that administrative procedures could be reduced without affecting the safety and the rights of the patients and the quality of the data; and that bureaucracy represents an obstacle for clinical research.

METHODS

A panel of physicians with extensive experience in clinical research, composed by members of the ECRO and the ESMO Scientific Medical and Public Policy divisions, analyzed clinical trial procedures related to administrative workflow, pharmacovigilance, and medical care.

RESULTS

The panel identified situations that generate debate between investigators and sponsors/CROs and selected real clinical scenarios that exemplify such situations. The panel discussed and proposed specific recommendations for those situations, based on GCP.

CONCLUSIONS

This initiative aspires to streamline clinical research procedures and to become a platform for discussion among all clinical trial stakeholders, with the aim of promoting the sustainability of clinical research and the care of cancer patients.

In heart failure, self-care behavior is an independent determinant of health-related quality of life, regardless of the severity of this patients

Background

Poor self-care behaviour is associated with a higher risk of readmission and mortality in patients with heart failure (HF). The interplay between self-care and patient-reported outcomes such as health-related quality of life (QoL) has not been fully established.

Purpose

To describe the association between self-care and QoL in real-world cohort of HF patients.

Methods

We conducted an observational, prospective, cohort study of 1120 consecutive patients with chronic HF. We used the modified European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure self-care. Scores were inverted and standardized (higher scores indicate better selfcare). To assess QoL, we used the Minnesota Living with Heart Failure Questionnaire (MLHFQ) (higher scores indicate worse QoL). Written informed consent, complete clinical and psychosocial information of patients were obtained at baseline. To determine the impact of global self-care and its dimensions (autonomy-based adherence, consulting behaviour and provider-based adherence), multivariate linear regressions models (backwards stepwise methods) to predict

QoL were constructed. The multivariate parametric and non-parametric associations between EHFSCBS-9 scoresand the β estimated risk of impairment of QoL (defined as MLHFQ scores ≥ median values) were explored using General Additive Models (GAM). All models were adjusted by age, sex and prognostic factors such as LVEF, NYHA, NT-proBNP levels and recent hospitalization among other well-known determinants of HF severity.

Results

A total of 484 patients (43%) were women, mean age was 72±11 years, and mean LVEF was 45±17%. Mean MLHFQ scores were 45±24. Mean EHFSCBS-9 scores were 69±28. There was a significant inverse correlation between EHFScBS-9 and MLHFQ scores (r=−0.158; p-value<0.0001). As shown in Table 1, self-care behaviour and its 3 domains were independent predictors of QoL in 7 out of the 16 associations explored. These models confirmed a weak linear relationship between EHFSCBS-9 scores and MLHFQ scores particularly between global selfcare and consulting behaviour dimension with global, emotional and social dimensions of QoL. Interestingly, when QoL was dichotomized as impaired/preserved QoL, GAM showed a significant non-parametric “U-shape” relationship (p-value<0.05) between EHFScBS-9 scores and the risk of impairment in QoL (Figure 1).

Conclusions

We have shown that self-care behaviour is an independent predictor of health related QoL in HF regardless the level of disease severity. Global self-care and consulting behaviour were particularly and significantly associated with global QoL and emotional and social dimensions of QoL. Interestingly the relationship between self-care scores and the risk of impaired global QoL was non-linear showing a “U-shape” association pointing out that patients with extreme levels of self-care were more likely to experience impairments in QoL.

Funding Acknowledgement

Type of funding sources: None.

Fragility influences the impact of self-care behavior on patient-reported outcomes further of psychosocial factors of self-perceived health status in patients with heart failure

Background

Poor self-care behaviour is associated with a higher risk of readmission and mortality in patients with heart failure (HF). Psychosocial factors are key determinants of patient-reported outcomes (PROMs) such as health-realted quality of life (QoL). Little is known about the interplay between self-care and psychosocial factors on PROMs in HF.

Purpose

To describe the interaction of self-care and psycho-social factors on QoL in a real-world cohort of HF patients.

Methods

We conducted an observational, prospective, cohort study of 1120 consecutive patients with chronic. We used the modified European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure self-care (inverted and standardised: higher scores indicate better self-care). To assess QoL, we used Minnesota Living with Heart Failure Questionnaire (MLHFQ) (higher scores indicate worse QoL). General linear models (GLM) were constructed to explore the interaction between psychosocial factors and poor self-care (defined as EHFSCBS-9 ≤lower tertile) on adjusted MLHFQ scores. To determine the impact of self-care, multivariate linear regressions models to predict QoL were constructed stratified according to selected psycho-social determinants. All models were adjusted by age, sex and psycho-social determinants of QoL including literacy, cognitive function (Pfeiffer test), dependency (Barthel and Lawton & Brody test), social support (Duke UNC and APGAR Familyfunction), depressive symptoms (15-item Geriatric Depression Scale) and fragility (Barber test scores ≥1).

Results

A total of 484 patients (43%) were women, mean age was 72±11 years, and mean LVEF was 45±17%. Mean MLHFQ scores were 45±24. Mean EHFSCBS-9 scores were 69±28. There was a significant inverse correlation between EHFScBS-9 and MLHFQ scores (r=−0.158; p-value <0.0001). Fragility was present in 883 patients (79%). In adjusted GLM, poor self-care (F=10.2; p-value=0.001) and fragility (F=17.9; p-value <0.001) were independent predictors of higher adjusted scores in the MLHFQ indicating worse QoL. As shown in Figure 1, the interaction between fragility and self-care was significant (F=6.8; p-value = 0.009). Linear regression models (Table 1) stratified according the absence (panel A) or the presence (panel B) of fragility showed that fragility modulated the association between self-care behaviour and QoL. Only in patients without fragility, self-care were independent predictors of QoL. On the other hand, in patients with fragility, self-care behaviour did not longer influence self-perceived health status in patients with HF.

Conclusions

We have shown that self-care behaviour is an independent predictor of PROMs in HF regardless the presence of important psycho-social determinants of QoL only when fragility status is taken into account. Fragility modulates the influence of self-care and QoL, including each one of its dimensions.

Funding Acknowledgement

Type of funding sources: None.

DAMOCLES project show that cognitive function is a strong determinant of the influence of self-care behavior on health-related quality of life in patients with heart failure

Background

Poor self-care is associated with a poorer outcomes in patients with heart failure (HF). Psycho-social factors are determinants of patient-reported outcomes (PROMs) such as health-realted quality of life (QoL). However, little is known about the interplay between self-care and psychosocial factors such as cognitive function on PROMs in patients with HF.

Purpose

Describe the effect of self-care on QoL across cognitive function and explore whether the interaction between self-care and cognitive function may account for this effect.

Methods

1120 patients with chronic HF from DAMOCLES study were analyzed. We used the modified European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure self-care (inverted and standardised: higher scores indicate better self-care). To assess QoL, we used Minnesota Living with Heart Failure Questionnaire (MLHFQ) (higher scores indicate worse QoL). Cognitive function was evaluated using Mini-Mental State Examination (MMSE) and Short Portable Mental State Questionnaire (SPMSQ) Tests. Cognitive impairment was defined as abnormal age-and-literacy-adjusted scores. General linear models (GLM) were constructed to explore the interaction between cognitive function and poor self-care (defined as EHFSCBS-9 ≤lower tertile) on adjusted MLHFQ scores. To determine the impact self-care, multivariate linear regressions models to predict QoL were constructed stratified according to cognitive function. All models were adjusted by determinants of HF severity.

Results

Mean age was 72±11 years, 43% were women and mean LVEF was 45±17%. Lower MMSE scores (β=−0,163; p-value <0.001) and >3 errors in the SPMSQ indicating cognitive impairment (β=0.071; p-value = 0.023) were associated with higher scores in the MLHFQ. These associations were confirmed in multivariare linear regression models (β=0.062; p-value = 0.038). In adjusted GLM, poor global self-care (F=4.8; p-value = 0.029) was an independent predictor of higher adjusted scores in the MLHFQ. Interaction term poor self-care by cognitive impairment was significantly associated with MLHFQ scores (F=6.0; p-value=0.014; Figure 1). Multivariate linear regresion models (Table 1) stratified according the absence (panel A) or the presence (panel B) of cognitive impairment showed that cognitive function modulates the association between self-care behaviour and QoL. This effect was only seen in patients without cognitive impairment. In patients with cognitive dysfunction, self-care behaviour did not longer influence self-perceived health status in patients with HF.

Conclusions

Self-care behaviour is an independent predictor of PROMs in HF regardless cognitive disfunction. Cognitive function modulates 1) influence of global self-care and each one of its dimensions on emotional QoL and 2) impact of global self-care and consulting behaviour on global and social QoL.

Funding Acknowledgement

Type of funding sources: None.

In patients with chronic heart failure, there have been no gender differences in the impact of self behavior on patient-reported outcomes

Background

Poor self-care behaviour is associated with a higher risk in heart failure (HF). Gender is a determinant of patient-reported outcomes (PROMs) such as health-realted quality of life (QoL) in HF. Female gender is consistently associated with worse QoL. Whether gender may influence the effect of self-care on PROMS is not known.

Purpose

Describe the effect of self-care on QoL according to gender in a real world cohort of HF patients.

Methods

1120 patients with chronic HF were analysed. We used the modified European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure self-care (inverted and standardised: higher scores indicate better self-care). To assess QoL, we used Minnesota Living with Heart Failure Questionnaire (MLHFQ) (higher scores indicate worse QoL). General linear models (GLM) were constructed to explore the interaction between gender and poor self-care (defined as EHFSCBS-9 ≤lower tertile) on adjusted MLHFQ scores. To determine the impact of global self-care and its dimensions, multivariate linear regressions models to predict QoL were constructed stratified according to gender. All models were adjusted by determinants of HF severity.

Results

Mean age was 72±11 years, 43% were women and mean LVEF was 45±17%. There was a significant inverse correlation between EHFScBS-9 and MLHFQ scores (r=−0.158; p-value<0.0001). Unadjusted MLHFQ scores were consistenly higher in women compared to men (49±23 vs. 43±24; p-value<0.001). In adjusted GLM, female gender (F=4.8; p-value=0.028) and poor global self-care (F=12.6; p-value<0.001) were independent predictors of higher adjusted scores in MLHFQ, indicating worse global QoL. As shown in Figure 1, the interaction term gender by poor self-care was not significantly associated with MLHFQ scores in adjusted GLM (F=0.018; p-value=0.893): the gap between women and men in terms of QoL was observed in both self-care strata and the effect of self care on QoL was observed in both genders. Multivariate linear regresion models (Table 1) stratified according to female gender (panel A) or male gender (panel B) showed that higher scores in the EHFScBS-9 were associated with lower scores in the MLHFQ in women and men. This effect (Table 1) was equally seen in both genders for global QoL and was driven by global self-care, consulting behaviour, and in a lesser extent by autonomy-baseda dherence. The physical dimension of QoL was not affected by self-care in either women or men except for consulting behaviour.

Conclusions

Self-care is an independent predictor of health-related QoL in HF, regardless of the level of disease severity. Global self-care, autonomy-based adherence and consulting behaviour were particularly associated with global QoL and emotional and social dimensions of QoL in women and men. In both genders, the effect of self-care on QoL was driven by its effect on emotional and social dimensions. Provider-based adherence did not influence QoL.

Funding Acknowledgement

Type of funding sources: None.

Isatuximab plus atezolizumab in patients with advanced solid tumors: results from a phase I/II, open-label, multicenter study

BACKGROUND

The anti-CD38 antibody isatuximab is approved for the treatment of relapsed/refractory multiple myeloma, but there are no data on its efficacy in solid tumors. This phase I/II study (NCT03637764) assessed the safety and activity of isatuximab plus atezolizumab (Isa + Atezo), an anti-programmed death-ligand 1 (PD-L1) antibody, in patients with immunotherapy-naive solid tumors: epithelial ovarian cancer (EOC), glioblastoma (GBM), hepatocellular carcinoma (HCC), and squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Phase I assessed safety, tolerability, pharmacokinetics, pharmacodynamics, and the recommended phase II dose (RP2D) of isatuximab 10 mg/kg intravenously (i.v.) every week for 3 weeks followed by once every 3 weeks + atezolizumab 1200 mg i.v. every 3 weeks. Phase II used a Simon's two-stage design to assess the overall response rate or progression-free survival rate at 6 months (GBM cohort). Interim analysis was carried out at 6 months following first dose of the last enrolled patient in each cohort. Pharmacodynamic biomarkers were tested for CD38, PD-L1, tumor-infiltrating immune cells, and FOXP3+ regulatory T cells (Tregs) in the tumor microenvironment (TME).

RESULTS

Overall, 107 patients were treated (EOC, n = 18; GBM, n = 33; HCC, n = 27; SCCHN, n = 29). In phase I, Isa + Atezo showed an acceptable safety profile, no dose-limiting toxicities were observed, and RP2D was confirmed. Most patients experienced ≥1 treatment-emergent adverse event (TEAE), with ≤48.5% being grade ≥3. The most frequent TEAE was infusion reactions. The study did not continue to stage 2 based on prespecified targets. Tumor-infiltrating CD38+ immune cells were reduced and almost cleared after treatment. Isa + Atezo did not significantly modulate Tregs or PD-L1 expression in the TME.

CONCLUSIONS

Isa + Atezo had acceptable safety and tolerability. Clinical pharmacodynamic evaluation revealed efficient target engagement of isatuximab via treatment-mediated reduction of CD38+ immune cells in the TME. Based on clinical data, CD38 inhibition does not improve responsiveness to PD-L1 blockade in these patients.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients

INTRODUCTION

Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting.

METHODS

We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels.

RESULTS

The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke.

CONCLUSION

Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Dosage of anti-PD-1 monoclonal antibodies: a cardinal open question

Discovery and clinical development of monoclonal antibodies with the ability to interfere in the regulation of the immune response have significantly changed the landscape of oncology in recent years. Among the active agents licensed by the regulatory agencies, nivolumab and pembrolizumab are paradigmatic as the most relevant ones according to the magnitude of available data derived from the extensive preclinical and clinical experience. Although in both cases the respective data sheets indicate well-defined dosage regimens, a review of the literature permits to verify the existence of many issues still unresolved about dosing the two agents, so it must be considered an open question of potentially important consequences, in which to work to improve the effectiveness and efficiency of use.

The chaperonin CCT controls T cell receptor-driven 3D configuration of centrioles

T lymphocyte activation requires the formation of immune synapses (IS) with antigen-presenting cells. The dynamics of membrane receptors, signaling scaffolds, microfilaments, and microtubules at the IS determine the potency of T cell activation and subsequent immune response. Here, we show that the cytosolic chaperonin CCT (chaperonin-containing TCP1) controls the changes in reciprocal orientation of the centrioles and polarization of the tubulin dynamics induced by T cell receptor in T lymphocytes forming an IS. CCT also controls the mitochondrial ultrastructure and the metabolic status of T cells, regulating the de novo synthesis of tubulin as well as posttranslational modifications (poly-glutamylation, acetylation, Δ1 and Δ2) of αβ-tubulin heterodimers, fine-tuning tubulin dynamics. These changes ultimately determine the function and organization of the centrioles, as shown by three-dimensional reconstruction of resting and stimulated primary T cells using cryo-soft x-ray tomography. Through this mechanism, CCT governs T cell activation and polarity.

Bevacizumab dose adjustment to improve clinical outcomes of glioblastoma

BACKGROUND

Glioblastoma (GBM) is one of the most aggressive and vascularized brain tumors in adults, with a median survival of 20.9 months. In newly diagnosed and recurrent GBM, bevacizumab demonstrated an increase in progression-free survival, but not in overall survival.

METHODS

We conducted an in silico analysis of VEGF expression, in a cohort of 1082 glioma patients. Then, to determine whether appropriate bevacizumab dose adjustment could increase the anti-angiogenic response, we used in vitro and in vivo GBM models. Additionally, we analyzed VEGFA expression in tissue, serum, and plasma in a cohort of GBM patients before and during bevacizumab treatment.

RESULTS

We identified that 20% of primary GBM did not express VEGFA suggesting that these patients would probably not respond to bevacizumab therapy as we proved in vitro and in vivo. We found that a specific dose of bevacizumab calculated based on VEGFA expression levels increases the response to treatment in cell culture and serum samples from mice bearing GBM tumors. Additionally, in a cohort of GBM patients, we observed a correlation of VEGFA levels in serum, but not in plasma, with bevacizumab treatment performance.

CONCLUSIONS

Our data suggest that bevacizumab dose adjustment could improve clinical outcomes in Glioblastoma treatment.

OP0317 ACCURACY OF THE OMERACT DEFINITIONS FOR IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS WITH ULTRASOUND: FINAL RESULTS OF THE OMERACT US IN CPPD SUB-TASK FORCE STUDY

Background:

The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].

Objectives:

Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.

Methods:

Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.

Results:

101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1

Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86

Conclusion:

Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.

References:

[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542

Disclosure of Interests:

Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Association of tethering of the second-order chords and prolapse of the first-order chords of the anterior leaflet: A risk factor for early and late repair failure

BACKGROUND AND AIM

Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair.

MATERIALS AND METHODS

We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair.

RESULTS

We described two cases where this phenomenon happened.

CONCLUSIONS

Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.

Degenerative rotator cuff tear, repair or not repair? A review of current evidence

INTRODUCTION

We review the literature and highlight the important factors to consider when counselling patients with non-traumatic rotator cuff tears on which route to take. Factors include the clinical outcomes of surgical and non-surgical routes, tendon healing rates with surgery (radiological outcome) and natural history of the tears if treated non-operatively.

METHODS

A PRISMA-compliant search was carried out, including the online databases PubMed and Embase™ from 1960 to the end of June 2018.

FINDINGS

A total of 49 of the 743 (579 PubMed and 164 Embase™) results yielded by the preliminary search were included in the review. There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Design and conduct of early clinical studies of immunotherapy agent combinations: recommendations from the task force on Methodology for the Development of Innovative Cancer Therapies

The Methodology for the Development of Innovative Cancer Therapies task force considered aspects of the design and conduct of early studies of combinations of immunotherapy agents during their 2018 meeting. The task force defined the relevant data to justify combination clinical trials, which includes a robust hypothesis for the combination, pre-clinical data with evidence of efficacy and an understanding of the pharmacodynamics effects of each agent, and ideally evidence of single agent activity. Evaluation of pharmacodynamic biomarkers is critical in early phase combination trials, and should be incorporated into trial objectives and go/no-go decisions. The task force also identified the need to develop assessment tools and end points that capture the unique patterns of tumour responses to immunotherapy, including pseudoprogression and hyperprogression. At least one additional tumour measurement before baseline and an early CT scan (at 4 weeks for example) would help define the incidence of hyperprogression, although a common definition is needed. Finally, the task force highlighted substantial redundancy and inefficiency in the combination immunotherapy space, and recommended the adoption of innovative trial designs.