Neoadjuvant chemotherapy with dose-dense MVAC in muscle-invasive bladder cancer: a tertiary center experience

PURPOSE

Neoadjuvant chemotherapy in muscle-invasive bladder cancer (MIBC) patients has proven beneficial in overall survival. However, the optimal regimen is still a matter of debate.

MATERIALS AND METHODS

In this retrospective analysis, we evaluate the results obtained in 42 patients treated in our center with 4 cycles of neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) followed by radical cystectomy from August 2015 to October 2020. All patients had cT2 or higher non-metastatic MIBC. Clinical and pathological outcomes are reported.

RESULTS

Of the 42 patients, 90.5% were men (n = 38) and the mean age was 65 years. All of them had ECOG 0-1 at diagnosis and most tumors had an initial clinical stage T2N0 (76%). Thirty-six patients (85.7%) completed 4 cycles of neoadjuvant treatment, and 21.4% required a dose reduction. The most frequent adverse event (AE) was grade 1-2 asthenia (81%), while neutropenia was the most frequent grade 3 or higher AE (38%). Complete pathological response (ypT0, ypN0) was achieved in 50% of patients (n = 21), and down-staging was observed in 57.1% (n = 24). Only one patient presented radiological progressive disease during neoadjuvant treatment (2.4%), and after a mean follow-up time of 31.5 months, 33.3% of patients experienced disease recurrence.

CONCLUSIONS

Neoadjuvant chemotherapy with 4 cycles of dd-MVAC is an effective regimen with high rates of pathological complete responses and down-staging along with an acceptable toxicity profile. DD-MVAC should be considered as an alternative to cisplatin and gemcitabine in patients with good clinical performance status.

Stafne's bone defect: a systematic review

BACKGROUND

This systematic review integrated the available data published in the literature on Stafne's bone defect (SBD), considering the clinical, imaging and histopathological results.

MATERIAL AND METHODS

An electronic search was undertaken in six databases. Eligibility criteria were: articles in English, Spanish, and Portuguese describing case reports or case series of SBD, reported up to September/2021. Risk of bias was assessed using the Joanna Briggs Institute tool.

RESULTS

A total of 98 articles were retrieved, involving 465 individuals with SBD and were included for quantitative analysis. Mean age was 52.78 years (range: 11-89 years), with male predilection (n=374/80.85%). Radiographs were the most frequent imagiological exams (n=298/64.09%), followed by computed tomography (n=98/21.08%). SBD was more prevalent in the posterior mandible (n=361/93.77%) as a hypodense radiolucent lesion (n=250/77.40%). Mean size was 1.58 cm (range: 0.3-.8.0 cm). Two-hundred-and-two lesions (97.37%) were unilocular and 126 (91.97%) were classified as well-defined. Clinical symptoms were reported in 73 cases, while 68 cases (93.15%) were asymptomatic. Only 34 cases (12.32%) were submitted to histopathological examination. Mean follow-up time was 26.42 ±25.39 months.

CONCLUSIONS

SBD is more frequent in male patients in the fifth and sixth decade of life. Classic SBD is radiographically characterized as a single, unilocular and well-defined lesion in the posterior region of the jaw with a radiolucent/hypodense appearance.

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

The influence of overweight and obesity in the oral health of a sample of portuguese adults

Background

Overweight and obesity may lead to different problems in various body systems and in the oral cavity. Dental caries and periodontal disease have been related with overweight. The aim of this study was to assess how overweight and obesity have impact on the lifestyle, oral habits and oral pathologies.

Methods

We conducted an observational cross-sectional study where we applied a questionnaire to 140 individuals from Lisbon and Viseu, Portugal., which 70 had a normal Body Mass Index (BMI) (control group) and 70 had an excessive BMI. We also made an oral observation in each individual to record the permanent teeth decayed, missing and filled index (DMFT), the Community Periodontal Index and the oral hygiene status.

Results

From the final sample, 30% of the subjects with overweight brushed their teeth once a day or less, while the majority (62.9%) of the control group brushed twice a day. In the oral examination, 70% had calculus, while in the control group only 22.5% presented calcified plaque. The DMFT was higher among the obesity group in comparison with the control group. Regarding periodontal disease, the participants with overweight need more dental intervention (81.4%) in contrast with the control group (14%).

Conclusions

Most overweight and obese individuals present precarious oral hygiene habits, higher prevalence of dental caries, and worse periods of periodontal health. They are not aware of the repercussions of the association between their cariogenic diet, oral health and overweight.

Key messages

• Oral health behaviors are related with other health conditions, namely obesity and this is a fundamental public health issue.

• Primary preventive strategies should be established having in consideration the oral health status of adults in treatment for obesity and in weight control programs.

Chronic obstructive pulmonary disease exacerbations' management in Portuguese hospitals - EvaluateCOPDpt, a multicentre, observational, prospective study

INTRODUCTION AND OBJECTIVES

In order to improve the quality of chronic obstructive pulmonary disease (COPD) patients' care, better knowledge of clinical practice and the factors associated with patient outcomes are needed. This study aimed to evaluate the relation between clinical practice and the outcomes of patients admitted for COPD exacerbations in Portuguese hospitals.

MATERIALS AND METHODS

Observational, multicentre, prospective study with a 60-days follow-up period, in 11 hospitals, including patients aged ≥ 30 years, admitted to hospital for at least 24 hours due to an acute exacerbation of COPD. Demographic and clinical data were collected, including sex, age, smoking habits, hospitalisations, pulmonary function, comorbidities, COPD symptoms, and treatment. Sixty days after discharge, COPD exacerbations management, outcome measures, and readmission data were evaluated through a structured phone follow-up interview.

RESULTS

196 patients were included (85.7% male, mean age 71.2 years), the majority admitted through the emergency service. Ex-smokers and current smokers accounted for 51% and 36%, respectively. On admission, 72.4% were on LAMA, 54.6% on LABA, and 45.5% were on LABA/LAMA. Inhaled corticosteroids (ICS) were used in 37.3% and systemic steroids (SCS) in 10.3%. 35.7 % had had at least one exacerbation, with hospitalisation, in the previous year. There was no spirometry data for 23.2%. On hospitalisation, 98.5% of patients were treated with oxygen and 38.3% with non-invasive ventilation. Additionally, 93.4% used SCS and 60.2% ICS. Antibiotics were administered to 85.2%. 95.4% of patients were discharged; 9 died, 5 of whom had a COPD-related death. The median length of stay was 12 days for discharged patients and 33 days for patients who died. At discharge, 79.1% were prescribed with LAMA, 63.6% SCS, 61.5% LABA and 55.6% LAMA+LABA. 26,2% were prescribed with ICS+LABA+LAMA. At follow-up, 44.4% had a scheduled medical appointment within the 60 days after being discharged, and 28.3% were later readmitted due to exacerbation, of whom 52.8% were hospitalised.

CONCLUSIONS

The severity of COPD, particularly in exacerbations, is directly related to impaired lung function and quality of life, mortality, and significant health system costs. Knowledge about COPD exacerbations' management in acute hospital admissions in Portugal may help stimulate a national discussion and review of existing data to engage clinicians, policymakers, managers, and patients, raising awareness and promoting action on COPD.

Cyclodextrin-based delivery systems in parenteral formulations: a critical update review

Parenteral formulations are indispensable in clinical practice and often are the only option to administer drugs that cannot be administrated through other routes, such as proteins and certain anticancer drugs - which are indispensable to treat some of the most prevailing chronic diseases worldwide (like diabetes and cancer). Additionally, parenteral formulations play a relevant role in emergency care since they are the only ones that provide an immediate action of the drug after its administration. However, the development of parenteral formulations is a complex task owing to the specific quality and safety requirements set for these preparations and the intrinsic properties of the drugs. Amongst all the strategies that can be useful in the development of parenteral formulations, the formation of water-soluble host-guest inclusion complexes with cyclodextrins (CDs) has proven to be one of the most advantageous. CDs are multifunctional pharmaceutical excipients able to form water-soluble host-guest inclusion complexes with a wide variety of molecules, particularly drugs, and thus improve their apparent water-solubility, chemical stability, and bioavailability, to make them suitable for parenteral administration. Besides, CDs can be employed as building blocks of more complex injectable drug delivery systems with enhanced characteristics, such as nanoparticles and supramolecular hydrogels, that has been found particularly beneficial for the delivery of anticancer drugs. However, only a few CDs are considered safe when parenterally administered, and some of these types are already approved to be used in parenteral dosage forms. Therefore, the application of CDs in the development of parenteral formulations has been a more common practice in the last few years, due to their significant worldwide acceptance by the health authorities, promoting the development of safer and more efficient injectable drug delivery systems.

Pharmacological Targeting of Senescence with ABT-263 in Experimental Heart Failure with Preserved Ejection Fraction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fundação Ciência e Tecnlogia

HFpEF is the most common form of heart disease in the elderly and is associated with high morbidity and mortality. Our understanding of HFpEF pathophysiology is limited and development of efficient therapies that alter the clinical course of the disease has proved greatly challenging. Although aging is a risk factor of HFpEF1, the involvement of aging hallmarks such as cell senescent and immunosenescence is unclear. Recently, a link between endothelial senescence and HFpEF development was demonstrated in mice with accelerated aging [1], endorsing anti-aging pharmacologic as potential new therapeutic alternatives for HFpEF. In fact, the senolytic (drugs that selectively promote apoptosis of senescent cells) ABT-263 has already proven efficacy in the context of cardiovascular diseases. Further studies are needed to clarify the relevance of aging and of anti-aging therapies in the context of HFpEF.

Using ZSF1 obese rats (ZSF1-Ob) as model of HFpEF we showed from 18 weeks signs of immunosenescence compared to ZSF1-Ln, namely an increased frequency of circulating myeloid cells and decreased frequency of T and B cells. Concomitantly, expression of pro-inflammatory factors (IL-6, IL-1, TGF-β, TNF-α) was upregulated in peripheral blood mononuclear cells (PBMCs) of ZSF1-Ob which also displayed characteristic features of cell senescence (p21 expression, lysosomal endogenous Beta-galactosidase (SA-B-Gal) senescence-associated secretory phenotype (SASP) and up-regulation of BCL-XL. Importantly, no signs of cellular senescence (SA-B-gal, pH2AX and senescence associated pathways) were found in the main hematopoietic organs (spleen and bone marrow). Alongside, these systemic alterations, an upsurge of cellular senescence was observed in myocardium of ZSF1-Ob rats, particularly in endothelial and hematopoietic cells. Serum of ZSF1-Ob rat was able to induce activation and cellular senescence of cardiac microvascular endothelial cells, indicating that systemic circulating factors may be the upstream mechanism of cellular senescence and dysfunction in HFpEF. Analysis of HFpEF patients and a control cohort adjusted to main co-morbidities further demonstrated accumulation of senescent monocytes in HFpEF patients. In these patients, the senescence marker SA-B-Gal correlated with plasmatic brain natriuretic peptide (BNP) levels and pulmonary artery systolic pressure. Targeting aging hallmarks through the treatment of ZSF1-Ob rat with ABT-263 resulted in a reduction in circulating senescent cells, decreased systemic and local inflammation, re-established immune proportions, restore the levels of circulating BNP and attenuated myocardial remodeling, particularly endothelial dysfunction and fibrosis.

Collectively these findings support that premature cellular senescence contributes to the establishment of a deleterious pro-inflammatory environment in HFpEF and that senolytic agents hold promise for the treatment of this syndrome.

Intercellular transfer of miR-200c-3p impairs the angiogenic capacity of cardiac endothelial cells

As mediators of intercellular communication, extracellular vesicles containing molecular cargo such as microRNAs, are secreted by cells and taken up by recipient cells to influence their cellular phenotype and function. Here, we report that cardiac stress-induced differential microRNA content, with miR-200c-3p being one of the most enriched, in cardiomyocyte-derived extracellular vesicles mediates functional crosstalk with endothelial cells. Silencing of miR-200c-3p in mice subjected to chronic increased cardiac pressure overload resulted in attenuated hypertrophy, smaller fibrotic areas, higher capillary density and preserved cardiac ejection fraction. Interestingly, we were able to maximal rescue microvascular and cardiac function with very low doses of antagomir, which specifically silences miR-200c-3p expression in the non-myocyte cells. Our results reveal vesicle transfer of miR-200c-3p from cardiomyocytes to cardiac endothelial cells, underlining the importance of cardiac intercellular communication in the pathophysiology of heart failure.

Hydrostatic pressure mimicking diurnal spinal movements maintains anabolic turnover in bovine nucleus pulposus cells in vitro

Treatment strategies for progressive intervertebral-disc degeneration often alleviate pain and other symptoms. With the goal of developing strategies to promote the regeneration of the nucleus pulposus (NP), the present study tried to identify the biological effects of hydrostatic (HP) and osmotic pressures on NP cells. The study hypothesis was that a repetitive regimen of cyclic HP followed by constant HP in high-osmolality medium would increase anabolic molecules in NP cells. Bovine NP cells/clusters were enclosed within semi-permeable membrane pouches and incubated under a regimen of cyclic HP for 2 d followed by constant HP for 1 d, repeated 6 times over 18 d. NP cells showed a significantly increased expression of anabolic genes over time: aggrecan, chondroitin sulfate N-acetylgalactosaminyltransferase 1, hyaluronan synthase 2, collagen type 2 (p < 0.05). In addition, the expression of catabolic or degenerative genes (matrix metalloproteinase 13, collagen type 1) and cellular characteristic genes (proliferating cell nucleic antigen, E-cadherin) was suppressed. The amount of sulfated glycosaminoglycan increased significantly at day 18 compared to day 3 (p < 0.01). Immunostaining revealed deposition of extracellular-matrix molecules and localization of other specific molecules corresponding to their genetic expression. An improved understanding of how cells respond to physicochemical stresses will help to better treat the degenerating disc using either cell- or gene-based therapies as well as other potential matrix-enhancing therapies. Efforts to apply these tissue-engineering and regenerative-medicine strategies will need to consider these important physicochemical stresses that may have a major impact on the survivability of such treatments.

The impact of experiences of violence on the physical and mental health of a portuguese sample

Introduction

Violent Experiences result in economic and social costs for society, impacting on emotions in families, on health (both physical and mental), and overall quality of life, causing potential damages. Thus, it becomes relevant to do research on this impact, aiming at raising awareness and promoting prevention.

Objectives

The purpose of the study is to estimate the impact of experiences of violence on both physical and mental health taking into account variables such as age, gender, and marital status.

Methods

This is a cross-sectional study sampling 1407 Portuguese speaking adults, with an age average of 42 years old (DP=17.28). The measures used were: The SF-36 questionnaire to assess quality of life, physical and mental health, and the Experiences of Violence Questionnaire.

Results

The sample was divided into two groups (victims and non-victims). The group of participants that were not subjected to violence presents more positive results. In relation to the comparison between genders, it was verified that males present more positive results having into account all dimensions SF-36 when compared to women. Also, older participants (53 years old or more) presents lower results of general health.

Conclusions

Violence and health, increasingly related due to the impact it has on the subjects’ physical and mental health and quality of life.

Disclosure

No significant relationships.

Metabolically healthy obesity in a young population assisted by the Family Health Strategy in Brazil

Background

Obesity is increasing in younger populations, and is associated with a high cardiovascular (CV) risk, however, it is not clear whether metabolically healthy obesity (MHO) may have a lower CV risk or if it is just an earlier stage of the disease.

Objective

To evaluate the prevalence and CV risk factors associated with MHO in a young population assisted by a Family Health Care unit in a large urban center in Brazil.

Methods

A cross-sectional population study for CV risk assessment in adults aged 20-50 years old from a FHC unit in Rio de Janeiro. Demographic, anthropometric data and CV risk factors were recorded. All underwent office blood pressure (OBP) measurements, laboratory evaluation (lipid and glycidic profile). Obesity was defined as a BMI ≥ 30 kg/m2 and MHO are those who have less than 3 of the following criteria: hypertension, diabetes, total cholesterol ≥ 200 mg/dL, HDL&lt;40 mg/dL (men) and 50 mg/dL (women), triglycerides&gt;150 mg/dL and increased waist circumference.

Results

A total of 632 individuals were evaluated (60% female; mean age 37 ± 9 years). The prevalence of obesity was 26%, of which 73% were classified as MHO. Obeses are older, with a higher prevalence of physical inactivity (51% vs 41%, p = 0.03), hypertension (44% vs 19%, p &lt; 0.001), dyslipidemia (50% vs 36%, p = 0.002) and diabetes (7% vs 2%, p = 0.001) with higher systolic OBP. MHO compared to unhealthy ones are significantly younger and smoke less. Despite being obese, they have lower BMI (33.6 vs 35.2 kg/m2, p = 0.02) and abdominal circumference (102 vs 110 cm, p = 0.03), with lower diastolic BP.

Conclusions

MHO was more prevalent in this young population and seems to have a lower CV risk, however it is not clear whether these younger and less obese individuals are only at an earlier stage of the disease. Perhaps the CV diseases onset is postponed for a few years. Even so, these individuals should not be excluded from public health policies as a form of primary prevention.

Key messages

In this young population, MHO was more prevalent and presented a lower CV risk. The follow-up of MHO will show if they are really healthy or if they are at an early stage of the disease.

Cardiovascular risk factors and social determinants in a population study in Rio de Janeiro, Brazil

Background

The association of cardiovascular (CV) diseases and their risk factors with socioeconomic status has been well described, but its influence is often underestimated in epidemiological studies in Brazil.

Objective

To evaluate the relationship between the main CV risk factors and socioeconomic indicators in a population of adults registered in a Family Health Care (FHC) unit in a great urban center - Rio de Janeiro, Brazil.

Methods

Cross-sectional population study that included adults aged between 20 and 50 years living in the area covered by the FHC unit in Rio de Janeiro. Demographic data (gender and age), socioeconomic data (education level, profession, employment), CV risk factors (smoking, sedentary lifestyle, obesity, hypertension, diabetes, dyslipidemia) were recorded. The metabolic profile is evaluated through laboratory tests. Those who studied up to high school were considered poorly educated.

Results

604 individuals were enrolled [39% male, mean age: 38.8 ± 8,9 years] The median of schooling was 12 years. 288 individuals had high schooling, 44.5% were male. A total of 130 individuals did not study or work. Women with low education had a higher risk of smoking, obesity and hypertension with no difference regarding labor or study activities. Otherwise, men with low education had a higher risk of sedentary lifestyle and hypertension. Among men, not working or studying increased the risk of smoking and hypertension.

Conclusions

We found an inverse association between socioeconomic conditions and the prevalence of CV risk factors. Women are more affected by low schooling, while men are more affected by their working occupation. The study suggests that socioeconomic factors influence the CV risk, affecting men and women differently, pointing to the need for more comprehensive public health policies that effectively reverse this situation.

Key messages

We found an inverse association between socioeconomic conditions and the prevalence of CV risk factors. Socioeconomic factors influence cardiovascular risk differently according to gender.

Cyclodextrin-based delivery systems for in vivo-tested anticancer therapies

Cyclodextrins (CDs) are naturally occurring macromolecules widely used as excipients on pharmaceutical formulations, evidencing a large spectrum of applications in the pharmaceutical industry. Their unique ability to act as molecular containers by entrapping a wide range of guest molecules in their internal cavity makes them a remarkable excipient to improve drug apparent solubility, stability, and bioavailability, and a valuable tool for the assembly of new drug delivery systems. These features are especially useful when it comes to chemotherapy, as most of the anticancer drugs present both low permeability and reduced water solubility. Therefore, guest-host inclusion complexes offer several potential advantages not only regarding the improvement of pharmaceutical formulations characteristics but also considering the reduction of drug toxic side effects. The combination of CDs with additional technologies and materials constitutes a potential strategy towards the development of advanced and multifunctional CD-based delivery systems. Paclitaxel, curcumin, camptothecin, doxorubicin, and cisplatin are among the most studied molecules with anticancer activities and have been successfully incorporated in such nanosystems. Exciting results using CDs and CD-based delivery systems have been obtained so far, paving the way towards the attainment of intelligent delivery systems to possibly address cancer therapeutics' unmet needs. In this review, a comprehensive exposition concerning in vivo-tested CD and CD-based delivery systems for anticancer therapy is undertaken. Additionally, the authors address the multivalent functionalities of CD-based delivery systems, namely the incorporation of active target ligands, stimuli-responsiveness components, surface functionalization, or further associations with other delivery systems, aiming at improved in vivo anticancer therapies. Graphical abstract.

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Introduction

Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR.

Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms.

Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic.

Conclusion

Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

P229 Primary cardiac angiosarcoma of the right atrium: a rare entity presenting with an atrial arrhythmia

Introduction

Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor.

We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia.

Clinical case

A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain.

Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute.

Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L).

A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia.

The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed:

- Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus).

- Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava.

Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression.

Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped.

The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization.

During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism.

After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month.

Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor.

Abstract P229 Figure. Echocardiogram: right atrium mass

BMI, irAE, and gene expression signatures associate with resistance to immune-checkpoint inhibition and outcomes in renal cell carcinoma

BACKGROUND

Clinical variables may correlate with lack of response to treatment (primary resistance) or clinical benefit in patients with clear cell renal cell carcinoma (ccRCC) treated with anti-programmed death 1/ligand one antibodies.

METHODS

In this multi-institutional collaboration, clinical characteristics of patients with primary resistance (defined as progression on initial computed tomography scan) were compared to patients with clinical benefit using Two sample t-test and Chi-square test (or Fisher's Exact test). The Kaplan-Meier method was used to estimate the distribution of progression-free survival (PFS) and overall survival (OS) in all patients and the subsets of patients with clinical benefit or primary resistance. Cox's regression model was used to evaluate the correlation between survival endpoints and variables of interest. To explore clinical factors in a larger, independent patient sample, The Cancer Genome Atlas (TCGA) was analyzed. RNAseq gene expression data as well as demographic and clinical information were downloaded for primary tumors of 517 patients included within TCGA-ccRCC.

RESULTS

Of 90 patients, 38 (42.2%) had primary resistance and 52 (57.8%) had clinical benefit. Compared with the cohort of patients with initial benefit, primary resistance was more likely to occur in patients with worse ECOG performance status (p = 0.03), earlier stage at diagnosis (p = 0.04), had no prior nephrectomy (p = 0.04) and no immune-related adverse events (irAE) (p = 0.02). In patients with primary resistance, improved OS was significantly correlated with lower International Metastatic RCC Database Consortium risk score (p = 0.02) and lower neutrophil:lymphocyte ratio (p = 0.04). In patients with clinical benefit, improved PFS was significantly associated with increased BMI (p = 0.007) and irAE occurrence (p = 0.02) while improved OS was significantly correlated with overweight BMI (BMI 25-30; p = 0.03) and no brain metastasis (p = 0.005). The cohort TCGA-ccRCC was examined for the correlations between gene expression patterns, clinical factors, and survival outcomes observing associations of T-cell inflammation and angiogenesis signatures with histologic grade, pathologic stage and OS.

CONCLUSIONS

Clinical characteristics including performance status, BMI and occurrence of an irAE associate with outcomes in patients with ccRCC treated with immunotherapy. The inverse association of angiogenesis gene signature with ccRCC histologic grade highlight opportunities for adjuvant combination VEGFR2 tyrosine kinase inhibitor and immune-checkpoint inhibition.

Targeting Cancer Via Resveratrol-Loaded Nanoparticles Administration: Focusing on In Vivo Evidence

Resveratrol (RSV) is a polyphenol endowed with potential therapeutic effects in chronic diseases, particularly in cancer, the second leading cause of death worldwide in the twenty-first century. The advent of nanotechnology application in the field of drug delivery allows to overcome the constrains associated with the conventional anticancer treatments, in particular chemotherapy, reducing its adverse side effects, off target risks and surpassing cancer multidrug chemoresistance. Moreover, the use of nanotechnology-based carriers in the delivery of plant-derived anticancer agents, such as RSV, has already demonstrated to surpass the poor water solubility, instability and reduced bioavailability associated with phytochemicals, improving their therapeutic activity, thus prompting pharmaceutical developments. This review highlights the in vivo anticancer potential of RSV achieved by nanotherapeutic approaches. First, RSV physicochemical, stability and pharmacokinetic features are described. Thereupon, the chemotherapeutic and chemopreventive properties of RSV are underlined, emphasizing the RSV numerous cancer molecular targets. Lastly, a comprehensive analysis of the RSV-loaded nanoparticles (RSV-NPs) developed and administered in different in vivo cancer models to date is presented. Nanoparticles (NPs) have shown to improve RSV solubility, stability, pharmacokinetics and biodistribution in cancer tissues, enhancing markedly its in vivo anticancer activity. RSV-NPs are, thus, considered a potential nanomedicine-based strategy to fight cancer; however, further studies are still necessary to allow RSV-NP clinical translation.

The impact of glycemic variability on length of stay and mortality in diabetic patients admitted with community-acquired pneumonia or chronic obstructive pulmonary disease

AIM

To investigate the influence of glycemic variability (GV) on length of stay and in-hospital mortality in non-critical diabetic patients.

METHODS

A observation retrospective study was performed. Diabetic patients admitted between January and June 2016 with the diagnosis of community-acquire pneumonia (CAP) and/or acute exacerbation of chronic obstructive pulmonary disease (COPD) were enrolled and glycemic control (persistent hyperglycemia, hypoglycemia, mean glucose level (MGL) and respective standard deviation (SD) and coefficient of variation (CV)) were evaluated. Primary outcomes were length of stay and in-hospital mortality.

RESULTS

Data from 242 patients were analyzed. Fifty-eight percent of the patients were male, with a median age of 77 years (min-max, 29-98). Patients had on average 2.1 glucose readings-day and the MGL was 193.3 mg/dl (min-max, 84.3-436.6). Hypoglycemia was documented in 13.4% of the patients and 55.4% had persistent hyperglycemia. The median length of hospital stay was 10 days (min-max, 1-66) and in-hospital mortality was 7.4%. We found a significant higher in-hospital mortality in older patients, with history of cancer and with nosocomial infections. We did not find any correlation between MGL, SD, CV, hypoglycemia or persist hyperglycemia and in-hospital mortality. A longer length of stay was observed in patients with heavy alcohol consumption and nosocomial infections. The length of stay was negatively correlated with the mean glucose level (r²-0.147; p < 0.05) and positively correlated with the coefficient of variation (p 0.162; p < 0.05).

CONCLUSION

This study confirmed the negative impact of the glycemic variability in the outcomes of diabetic patients admitted with CAP or acute exacerbation of COPD.

Characterization of the dysplastic Walch type C glenoid

Aims

The Walch Type C dysplastic glenoid is characterized by excessive retroversion. This anatomical study describes its morphology.

Patients and Methods

A total of 29 shoulders with a dysplastic glenoid were analyzed. CT was used to measure retroversion, inclination, height, width, radius-of-curvature, surface area, depth, subluxation of the humeral head and the Goutallier classification of fatty infiltration. The severity of dysplasia and deficiency of the posterior rim of the glenoid were recorded.

Results

A type C glenoid occurred in 1.8% of shoulders referred to our tertiary centres. The mean retroversion, inclination, height, width, radius-of-curvature, surface area, and depth of the glenoid were 37°, 3°, 46 mm, 30 mm, 37°, 1284 mm3, and 16 mm, respectively. The mean posterior subluxation was 90%. The Goutallier class was < 2 in 25 shoulders (86%). Glenoid dysplasia was mild in four, moderate in 14, and severe in 11 shoulders. The typical appearance of the posterior glenoid rim had a rounded or ‘lazy J’ morphology. The glenoid neck was deficient in 18 shoulders (62%).

Conclusion

A dysplastic Type C glenoid characteristically has a uniconcave retroverted morphology, a deficient posteroinferior rim and scapular neck, and a reduced depth. These findings help to define the unique anatomical variations and may aid the planning of surgery and the development of components for these patients. Cite this article: Bone Joint J 2018;100-B:1074–9.

Author Correction: Osmotic modulation of chromatin impacts on efficiency and kinetics of cell fate modulation

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Effectiveness and safety of local anesthetic, semi-flexible pleuroscopy - experience from a peripheral hospital

If the seemingly less invasive semi-flexible pleuroscopes are combined with strategies of conscious sedation and local anesthesia the pleuroscopy has the potential to reach an increasing number of hospital settings. Local experiences can provide valuable information pertaining to the reproducibility of this technique in different scenarios. We performed a retrospective analysis of the clinical records of all patients that had undergone local anesthetic semi-flexible pleuroscopy in our unit between February 2015 and July 2017. Data on demographics, previous biochemical, cytological and histopathological analysis, procedure details, diagnostic and therapeutic results, complications and mortality were collected from all patients. Statistical analysis was performed using SPSS v23. A total of 30 patients were included. They were mainly male (66.7%), with a median age of 72 years (minimum 19 years, maximum 87 years). All presented with exudative pleural effusions and the exam was performed for diagnostic reasons. Pleural tissue was obtained in all patients and the overall diagnostic accuracy was 93.3%. Malignancy was the chief group of diagnosis (66.7%), followed by pleural tuberculosis (13.3%). The procedure was well tolerated and self-limited subcutaneous emphysema was the only complication registered (13.3%). No deaths were associated with the procedure. Our results globally overlap those of wider series and reinforce the perception that local anesthetic semi-flexible pleuroscopy is a well-tolerated, safe and highly accurate diagnostic and therapeutic tool which has proved to be both feasible and effective in our experience.

Osmotic modulation of chromatin impacts on efficiency and kinetics of cell fate modulation

Chromatin structure is a major regulator of transcription and gene expression. Herein we explore the use of osmotic modulation to modify the chromatin structure and reprogram gene expression. In this study we use the extracellular osmotic pressure as a chromatin structure and transcriptional modulator. Hyposmotic modulation promotes chromatin loosening and induces changes in RNA polymerase II (Pol II) activity. The chromatin decondensation opens space for higher amounts of DNA engaged RNA Pol II. Hyposmotic modulation constitutes an alternative route to manipulate cell fate decisions. This technology was tested in model protocols of induced pluripotency and transdifferentiation in cells growing in suspension and adherent to substrates, CD34⁺ umbilical-cord-blood (UCB), fibroblasts and B-cells. The efficiency and kinetics of these cell fate modulation processes were improved by transient hyposmotic modulation of the cell environment.

[Assessment of maternal satisfaction with epidural analgesia for pain control during labour]

BACKGROUND

To determine the level of satisfaction and the sociodemographic characteristics of patients who receive epidural analgesia during labour.

MATERIAL AND METHODS

A SERVQHOS questionnaire administered, with consecutive sampling, to 140 patients who had received an epidural anaesthetic for pain control during labour between January and June 2014, at the Hospital San Pedro.

RESULTS

A total of 140 questionnaires were completed. The mean overall satisfaction (SERVQHOS scale) was 4.4 with standard deviation (SD):±0.9, with the best results being obtained in the subjective ítems: (4.3; SD 0.81) compared to the objective ítems (4; SD: 0.9). The large majority (84.3%) showed satisfaction with the epidural anaesthetic, and 100% would ask for it again. No significant differences were found in epidural satisfaction or pain perception related to socioeconomic variables (age, nationality, employment conditions, education level or marital status). As regards nationality, 119 (85%) were Spanish, and 14.3% (20) of other nationalities, with 1 patient not answering the nationality question. As regards marital status, 79.3% (111) were married, 1.4% (2), single, and 2.9% (4) were widows or separated, and 2.9% (4) did not answer. The mean age was 33.3 years (SD: 4.4). Prior to the administration of the epidural anaesthetic 93.2% of the Spanish citizens group described the pain as severe compared to 95% of the other nationalities group, but this difference had no statistical significance (p=.279).

CONCLUSION

The level of satisfaction reported by the patients with this technique was high, with subjective items (good manners and trust) being appreciated more.

MicroRNA-124 loaded nanoparticles enhance brain repair in Parkinson's disease

Modulation of the subventricular zone (SVZ) neurogenic niche can enhance brain repair in several disorders including Parkinson's disease (PD). Herein, we used biocompatible and traceable polymeric nanoparticles (NPs) containing perfluoro-1,5-crown ether (PFCE) and coated with protamine sulfate to complex microRNA-124 (miR-124), a neuronal fate determinant. The ability of NPs to efficiently deliver miR-124 and prompt SVZ neurogenesis and brain repair in PD was evaluated. In vitro, miR-124 NPs were efficiently internalized by neural stem/progenitors cells and neuroblasts and promoted their neuronal commitment and maturation. The expression of Sox9 and Jagged1, two miR-124 targets and stemness-related genes, were also decreased upon miR-124 NP treatment. In vivo, the intracerebral administration of miR-124 NPs increased the number of migrating neuroblasts that reached the granule cell layer of the olfactory bulb, both in healthy and in a 6-hydroxydopamine (6-OHDA) mouse model for PD. MiR-124 NPs were also able to induce migration of neurons into the lesioned striatum of 6-OHDA-treated mice. Most importantly, miR-124 NPs proved to ameliorate motor symptoms of 6-OHDA mice, monitored by the apomorphine-induced rotation test. Altogether, we provide clear evidences to support the use of miR-124 NPs as a new therapeutic approach to boost endogenous brain repair mechanisms in a setting of neurodegeneration.

Drug screening on Hutchinson Gilford progeria pluripotent stem cells reveals aminopyrimidines as new modulators of farnesylation

Hutchinson-Gilford progeria syndrome (HGPS) is a rare genetic disorder characterized by a dramatic appearance of premature aging. HGPS is due to a single-base substitution in exon 11 of the LMNA gene (c.1824C>T) leading to the production of a toxic form of the prelamin A protein called progerin. Because farnesylation process had been shown to control progerin toxicity, in this study we have developed a screening method permitting to identify new pharmacological inhibitors of farnesylation. For this, we have used the unique potential of pluripotent stem cells to have access to an unlimited and relevant biological resource and test 21,608 small molecules. This study identified several compounds, called monoaminopyrimidines, which target two key enzymes of the farnesylation process, farnesyl pyrophosphate synthase and farnesyl transferase, and rescue in vitro phenotypes associated with HGPS. Our results opens up new therapeutic possibilities for the treatment of HGPS by identifying a new family of protein farnesylation inhibitors, and which may also be applicable to cancers and diseases associated with mutations that involve farnesylated proteins.