North Central Asia isotopic database for archaeological samples

The North Central Asia Isotopic Database (NCAID) is an open-access dataset of stable isotope measurements from archaeological remains, spanning from the Early Neolithic until present-day in North Central Asia. With 3,143 individual entries corresponding to data accumulated over more than 20 years of research, this comprehensive dataset encompasses measurements of stable carbon and nitrogen isotopes in organic fractions from archaeological humans, animals, and plants. NCAID incorporates diverse supporting information, providing geographical information, archaeological context descriptions, and chronology. This resource facilitates research into past human lifeways, paleo-environments/climates, and animal management practices throughout North Central Asia and will be continually updated as more novel data is released.

Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Challenging the Role of Subtotal Resection Following Proton Radiotherapy for Adenoid Cystic Carcinoma of the Head and Neck

PURPOSE/OBJECTIVE(S)

To report long-term outcomes of patients with adenoid cystic carcinoma (ACC) of the head and neck treated with proton radiotherapy.

MATERIALS/METHODS

On this IRB-approved, single institutional prospective outcomes registry, 56 patients were included with de novo, nonmetastatic adenoid carcinoma of the head and neck treated with primary (n = 9) or adjuvant proton therapy from June 2007 to December 2021. The cohort had 30 women and 26 men with a median age of 57 years (range, 10-81 years). Twenty-nine percent (n = 16) had intracranial extension, 23% (n = 13) had orbital extension, and 55% (n = 31) had clinical cranial nerve involvement at the time of radiotherapy. Thirty patients underwent gross total resection (GTR), 26 had gross disease at the time of treatment undergoing a subtotal resection (STR) (n = 17) or biopsy alone (n = 9). The median dose to the primary site was 72.6 GyRBE (range, 64-74.4 GyRBE) delivered in either once (n = 19) or twice (n = 37) daily treatments. Thirty patients received either elective nodal irradiation (ENI) in a node negative neck or concurrent chemotherapy.

RESULTS

With a median follow-up of 6.2 years (range, 0.9 - 14.7 years), the 5-year local-regional control (LRC), disease free survival (DFS), cause-specific survival (CCS) and overall survival (OS) were 88%, 85%, 89%, and 89%, respectively. Cranial extension (p = 0.003) and gross residual tumor (p = 0.0388) were factors associated with decreased LRC. While LRC for those with a GTR was 96%, those with STR or biopsy alone were 81% and 76%, respectively. T-stage (p = 0.0154), cranial extension (p = 0.0056), extent of resection (p = 0.0355), and gross residual tumor (p = 0.0094) were associated with decreased DFS. T-stage (p = 0.0099), extent of surgery (p = 0.029) and gross residual tumor (p.0071) were associated with decreased CCS. The 5-year cumulative incidence of clinically significant late grade ³3 toxicity was 15% and the crude incidence at most recent follow-up was 23% (n = 13). There was no LRC benefit with ENI (p = 0.94).

CONCLUSION

Proton therapy provides excellent disease control for head and neck ACC with acceptable toxicity. Gross residual disease at the time of treatment and intracranial involvement were significant prognostic features for worse outcomes. STR did not confer benefit over biopsy only at 5-years and may question the role of extensive and morbid operations if GTR is not technically feasible.

Inhibition, Attentional Control and Binding Abilities in Relation to Dissociative Symptoms Among PTSD Patients

INTRODUCTION

The relationship between dissociation and cognitive abilities remains controversial. Empirical studies have reported positive, negative and non-existent associations between dissociation and cognition. These inconsistent results may be due to the fact that the studies focused mainly on trait dissociation, while dissociation is not stable but transient. After validating the French version of the Clinician Administered Dissociative States Scale (CADSS), the aim of the present study was to evaluate the relationship between state dissociation and cognitive abilities.

METHOD

We recruited 83 patients suffering from post-traumatic stress disorder (PTSD) and assessed them twice. At T1, they performed a neutral Stroop task and a neutral binding task. At T2 (one to three weeks later), after a script-driven dissociative induction, they performed an emotional Stroop task and an emotional binding task. Between the two sessions, they completed questionnaires at home evaluating PTSD severity, trait dissociation and cognitive difficulties. State dissociation was assessed at T1 and T2 using the Clinician-Administered Dissociative States Scale (CADSS).

RESULTS

We found good psychometric properties of the French version of the CADSS. After inducing dissociation, significantly lower attentional performance was found among patients with than without dissociative reactions. We found a significant positive correlation between state dissociation and increased attention and memory difficulties after induction.

CONCLUSION

The French version of the CADSS is a reliable and valid tool to assess state dissociation, which is correlated with attentional difficulties. Attentional training is recommended to help patients control dissociative symptoms.

Ex Vivo Electrochemical Monitoring of Cholinergic Signaling in the Mouse Colon Using an Enzyme-Based Biosensor

Cholinergic signaling, i.e., neurotransmission mediated by acetylcholine, is involved in a host of physiological processes, including learning and memory. Cholinergic dysfunction is commonly associated with neurodegenerative diseases, including Alzheimer's disease. In the gut, acetylcholine acts as an excitatory neuromuscular signaler to mediate smooth muscle contraction, which facilitates peristaltic propulsion. Gastrointestinal dysfunction has also been associated with Alzheimer's disease. This research focuses on the preparation of an electrochemical enzyme-based biosensor to monitor cholinergic signaling in the gut and its application for measuring electrically stimulated acetylcholine release in the mouse colon ex vivo. The biosensors were prepared by platinizing Pt microelectrodes through potential cycling in a potassium hexachloroplatinate (IV) solution to roughen the electrode surface and improve adhesion of the multienzyme film. These electrodes were then modified with a permselective poly(m-phenylenediamine) polymer film, which blocks electroactive interferents from reaching the underlying substrate while remaining permeable to small molecules like H2O2. A multienzyme film containing choline oxidase and acetylcholinesterase was then drop-cast on these modified electrodes. The sensor responds to acetylcholine and choline through the enzymatic production of H2O2, which is electrochemically oxidized to produce an increase in current with increasing acetylcholine or choline concentration. Important figures of merit include a sensitivity of 190 ± 10 mA mol-1 L cm-2, a limit of detection of 0.8 μmol L-1, and a batch reproducibility of 6.1% relative standard deviation at room temperature. These sensors were used to detect electrically stimulated acetylcholine release from mouse myenteric ganglia in the presence and absence of tetrodotoxin and neostigmine, an acetylcholinesterase inhibitor.

Association of Circulating Tumor DNA Testing Before Tissue Diagnosis With Time to Treatment Among Patients With Suspected Advanced Lung Cancer: The ACCELERATE Nonrandomized Clinical Trial

Importance

Liquid biopsy has emerged as a complement to tumor tissue profiling for advanced non-small cell lung cancer (NSCLC). The optimal way to integrate liquid biopsy into the diagnostic algorithm for patients with newly diagnosed advanced NSCLC remains unclear.

Objective

To evaluate the use of circulating tumor DNA (ctDNA) genotyping before tissue diagnosis among patients with suspected advanced NSCLC and its association with time to treatment.

Design, Setting, and Participants

This single-group nonrandomized clinical trial was conducted among 150 patients at the Princess Margaret Cancer Centre-University Health Network (Toronto, Ontario, Canada) between July 1, 2021, and November 30, 2022. Patients referred for investigation and diagnosis of lung cancer were eligible if they had radiologic evidence of advanced lung cancer prior to a tissue diagnosis.

Interventions

Patients underwent plasma ctDNA testing with a next-generation sequencing (NGS) assay before lung cancer diagnosis. Diagnostic biopsy and tissue NGS were performed per standard of care.

Main Outcome and Measures

The primary end point was time from referral to treatment initiation among patients with advanced nonsquamous NSCLC using ctDNA testing before diagnosis (ACCELERATE [Accelerating Lung Cancer Diagnosis Through Liquid Biopsy] cohort). This cohort was compared with a reference cohort using standard tissue genotyping after tissue diagnosis.

Results

Of the 150 patients (median age at diagnosis, 68 years [range, 33-91 years]; 80 men [53%]) enrolled, 90 (60%) had advanced nonsquamous NSCLC. The median time to treatment was 39 days (IQR, 27-52 days) for the ACCELERATE cohort vs 62 days (IQR, 44-82 days) for the reference cohort (P < .001). Among the ACCELERATE cohort, the median turnaround time from sample collection to genotyping results was 7 days (IQR, 6-9 days) for plasma and 23 days (IQR, 18-28 days) for tissue NGS (P < .001). Of the 90 patients with advanced nonsquamous NSCLC, 21 (23%) started targeted therapy before tissue NGS results were available, and 11 (12%) had actionable alterations identified only through plasma testing.

Conclusions and Relevance

This nonrandomized clinical trial found that the use of plasma ctDNA genotyping before tissue diagnosis among patients with suspected advanced NSCLC was associated with accelerated time to treatment compared with a reference cohort undergoing standard tissue testing.

Trial Registration

ClinicalTrials.gov Identifier: NCT04863924.

Pudendal Neuralgia: Two case reports with laparoscopic nerve decompression

Pudendal neuralgia (PN) is a rare and underestimated condition. The reported incidence by the International Pudendal Neuropathy Association is 1/100000. However, the actual rate may be significantly higher, with a propensity for women. It is most frequently caused by an entrapment of the nerve at the level of the sacrospinous and sacrotuberous ligament, also known as pudendal nerve entrapment syndrome. Due to the late diagnosis and inadequate management, pudendal nerve entrapment syndrome often leads to considerable reduction in the quality of life and high health care costs. The diagnosis is made using Nantes Criteria, in conjunction with the patient's clinical history and physical findings. Clinical examination with an accurate assessment of the territory of the neuropathic pain is mandatory to set the therapeutic strategy. The aim of the treatment is to control the symptoms and it usually starts with conservative approaches which include analgesics, anticonvulsants, and muscle relaxants. Surgical nerve decompression can be proposed after failure of conservative management. The laparoscopic approach is a feasible and appropriate technique to explore and decompress the pudendal nerve, and to rule out other pelvic conditions that can cause similar symptomatology. In this paper, the clinical history of two patients affected by compressive PN is reported. Both patients underwent laparoscopic pudendal neurolysis suggesting that the treatment for PN should be individualised and carried out by a multidisciplinary team. When conservative treatment fails, laparoscopic nerve exploration and decompression is an adequate option to propose and should be performed by a trained surgeon.

Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes

Suicide by firearm remains one of the leading causes of violence-related injury death in the United States each year. The mortality rate from these injuries is high, resulting in a paucity of outcome data in the literature regarding injuries to the maxillofacial region. This has largely been attributed to a lack of funding for research in this area compared to other leading causes of mortality in the United States. The aim of this study was to detail the authors' experience and approach to complex maxillofacial reconstruction using both local reconstructive methods and microvascular free tissue transfer. A retrospective cohort study was designed, including patients who sustained self-inflicted gunshot wounds to the maxillofacial region between January 1, 2012 and May 1, 2020. Forty-one patients met the inclusion criteria. The majority of the patients were male (87.8%). Mean patient age was 44.2 ± 16.6 years. Alcohol or drugs, and a psychiatric history were present in a majority of the cases. The most involved anatomical region was the midface (75.6% of cases). Seven patients required free tissue transfer for reconstruction, with many needing multiple flaps. Self-inflicted gunshot wounds represent challenging reconstruction scenarios, often in the setting of severe psychological trauma, and require a multidisciplinary team to ensure the optimal outcome.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

5xFAD mice do not have myenteric amyloidosis, dysregulation of neuromuscular transmission or gastrointestinal dysmotility

BACKGROUND

Alterations in gastrointestinal (GI) function and the gut-brain axis are associated with progression and pathology of Alzheimer's Disease (AD). Studies in AD animal models show that changes in the gut microbiome and inflammatory markers can contribute to AD development in the central nervous system (CNS). Amyloid-beta (Aβ) accumulation is a major AD pathology causing synaptic dysfunction and neuronal death. Current knowledge of the pathophysiology of AD in enteric neurons is limited, and whether Aβ accumulation directly disrupts enteric neuron function is unknown.

METHODS

In 6-month-old 5xFAD (transgenic AD) and wildtype (WT) male and female mice, GI function was assessed by colonic transit in vivo; propulsive motility and GI smooth muscle contractions ex vivo; electrochemical detection of enteric nitric oxide release in vitro, and changes in myenteric neuromuscular transmission using smooth muscle intracellular recordings. Expression of Aβ in the brain and colonic myenteric plexus in these mice was determined by immunohistochemistry staining and ELISA assay.

KEY RESULTS

At 6 months, 5xFAD mice did not show significant changes in GI motility or synaptic neurotransmission in the small intestine or colon. 5xFAD mice, but not WT mice, showed abundant Aβ accumulation in the brain. Aβ accumulation was undetectable in the colonic myenteric plexus of 5xFAD mice.

CONCLUSIONS

5xFAD AD mice are not a robust model to study amyloidosis in the gut as these mice do not mimic myenteric neuronal dysfunction in AD patients with GI dysmotility. An AD animal model with enteric amyloidosis is required for further study.

Contrast-induced nephropathy following PCI: can we calculate a safe contrast volume?

Introduction

Acute kidney injury (AKI) due to contrast induced nephropathy (CIN) is a common complication after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS), and is associated with prolonged hospitalizations and elevated cardio and renovascular morbidity. Scientific evidence demonstrates that the mean volume of contrast (VolC) and ratio with creatinine clearance (CrCl) (VolC/CrCl) are independent predictors of CIN, but the accepted optimal value remains controversial.

Objective

Population characterization. To evaluate whether the calculation of VolC using the VolC/ClCr ratio &lt;3.7 used in our Cath lab during PCI of ACS allows preventing the development of AKI by CIN, and whether the development of early vs late AKI influences outcomes.

Methods

Retrospective study between 2017/2020, composed of n=378 patients who suffered ACS. Descriptve analysis was carried out regarding the demographic and clinical characteristics of the patients. Chi-Square test was used for categorical variables and the T-Student test for numerical variables, with a significance level of 95%.

Results

A total of 378 patients were identified, with a mean age of 64.5±11.2 years, 78.6% were male. 60.1% had hypertension, 48.4% dyslipidemia, 24.3% diabetes, 2.6% chronic renal failure (CRF) and 1.6% heart failure. Of these, 12.7% developed AKI (&lt;24h in 1.9% vs ≥24h in 10,8%). Indepedent prognostic factors for development of AKI were smokers (AKI ≥24h 7 (4.8%) vs AKI&lt;24h 2 (1.4%), p=0.001), diabetes (AKI≥24h 17 (19%) vs AKI &lt;24h 2 (2.2%), p=0.007), CRF (AKI ≥24h 6 (60%) vs AKI &lt;24h 1 (10%), p=0.001), CrCl (AKI ≥24h 65.8±27.1, p=0.001), ratio VolC/CrCl (AKI ≥24h 3.3±2.5, p=0.001) and LVEF (AKI ≥24h 51.4±9.7, p=0.001). Mortality afected 4.2% of the patients, and was more frequente in AKI subjects (AKI ≥24h 7 (70%) vs AKI &lt;24h 1 (10%), p=0.001). Using a ratio &lt;3.7 allowed to prevent AK &lt;24h but not AKI ≥24h (AKI &lt;24h ratio &lt;3.7 = 3 (1%) vs ratio ≥3.7 = 9 (4.1%), p=0.001) (AKI ≥24 ratio &lt;3.7 = 30 (25%) vs ratio ≥3.7 = 11 (9.7%), p=0.001). A ratio &lt;2.0 allowed to prevent both early and late AKI (AKI &lt;24h ratio &lt;2.0 = 0 (0%) vs ratio ≥2.0 = 7 (4.5%), p=0.001) (AKI ≥24 ratio &lt;2.0 = 11 (5.6%) vs ratio ≥2.0 = 30 (19.1%), p=0.001).

Conclusion

In patients submitted to ACS PCI, the development of AKI increases mortality, especial if AKI emerge after 24h. We report a more suitable ratio VolC/ClCr &lt;2.0, that allow us to calculate a safe VolC that will help to prevent both early and late AKI in selected patients wtih ACS.

Funding Acknowledgement

Type of funding sources: None.

Can carotid angioplasty stenting be better than endarterectomy or best medical treatment for patients with carotid stenosis?

Background

Carotid stenosis is responsible for a considerable amount of strokes and related deaths. Carotid angioplasty stenting (CAS), endarterectomy (CEA) and best medical treatment (BMT) are important in preventing major cardiovascular (CV) events.

Methods

We conducted a systematic review and meta-analysis, with randomized controlled trials (RCT), to compare CAS with CEA and BMT regarding the short and long-term major periprocedural and follow-up CV events (stroke, myocardial infarction, and death) in symptomatic and asymptomatic carotid stenosis. We searched for RCT published from 2008 to 2021 in databases such as Pubmed/MEDLINE, B-On, Embase, Clinical Trials from U.S. National Library of Medicine and International Clinical Trials Registry Platform, between July of 2018 and January of 2019, and in October of 2021.

Results

Nine RCT were included, with a total of 9162 participants for CAS versus (vs) CEA, and 513 participants for CAS vs TMO. Compared with CEA, CAS is associated with periprocedural stroke and death in symptomatic patients (HR=1.65, 95% CI: 1.29–2.11, p=0.05, I2=62%), due to higher stroke events than deaths. That association does not occur in asymptomatic patients in which CAS is not associated with periprocedural stroke or death (CAS=8.55%, CEA=7.05%, p=0.09). During follow-up there were no significant differences between CAS and CEA in symptomatic patients regarding stroke (HR=1.51, 95% CI: 1.23–1.84, p=0.57, I2=0%) and death (HR=1.10, 95% CI: 0.93–1.30, p=0.69, I2=0%). Periprocedural myocardial infarction (MI) incidence is higher in CEA (CAS=1.1%; CEA=2.3%; p=0.03), without influence of symptomatic status. CAS is not inferior to CEA, in both symptomatic and asymptomatic patients with high surgery risk, as for periprocedural and one year CV major events (CAS=12.2%, CEA=20.1%, absolute difference = −7.9, 95% CI: −16.4–0.7, p=0.004). BMT had no significant findings vs CAS in asymptomatic patients (HR=3.5, 95% CI: 0.42–29.11, p=0.246).

Conclusion

CAS is not inferior to CEA as for the periprocedural and one-year major CV events in patients with normal surgery risk. However, there is a higher risk of periprocedural stroke in CAS for symptomatic patients, and of periprocedural MI in CEA with no influence of symptomatic status. CAS seams to prevent middle and long-term ipsilateral stroke in symptomatic patients. BMT has yet to prove not to be inferior to CAS in asymptomatic patients.

Funding Acknowledgement

Type of funding sources: None.

Plasma-first: accelerating lung cancer diagnosis and molecular profiling through liquid biopsy

Introduction:

Molecular profiling of tumor tissue is the gold standard for treatment decision-making in advanced non-small cell lung cancer (NSCLC). Results may be delayed or unavailable due to insufficient tissue, prolonged wait times for biopsy, pathology assessment and testing. We piloted the use of plasma testing in the initial diagnostic workup for patients with suspected advanced lung cancer.

Methods:

Patients with ⩽15 pack-year smoking history and suspected advanced lung cancer referred to the lung cancer rapid diagnostic program underwent plasma circulating-tumor DNA testing using a DNA-based mutation panel. Tissue testing was performed per standard of care, including comprehensive next-generation sequencing (NGS). The primary endpoint was time from diagnostic program referral to cancer treatment in stage IV NSCLC patients (Cohort A) compared to a contemporary cohort not enrolled in the study (Cohort B) and an historical pre-COVID cohort referred to the program between 2018 and 2019 (Cohort C).

Results:

From January to June 2021, 20 patients were enrolled in Cohort A; median age was 70.5 years (range 33–87), 70% were female, 55% Caucasian, 85% never smokers, and 75% were diagnosed with NSCLC. Seven had actionable alterations detected in plasma or tissue (4/7 concordant). Fusions, not tested in plasma, were identified by immunohistochemistry for three patients. Mean result turnaround time was 17.8 days for plasma NGS and 23.6 days for tissue (p = 0.10). Mean time from referral to treatment initiation was significantly shorter in cohort A at 32.6 days (SD 13.1) versus 62.2 days (SD 31.2) in cohort B and 61.5 days (SD 29.1) in cohort C, both p < 0.0001.

Conclusion:

Liquid biopsy in the initial diagnostic workup of patients with suspected advanced NSCLC can lead to faster molecular results and shorten time to treatment even with smaller DNA panels. An expansion study using comprehensive NGS plasma testing with faster turnaround time is ongoing (NCT04862924).

Abstract P225: Dahl Salt-sensitive And Salt-resistant Rats Exhibit Highly Disparate Blood Pressure Responses To Lifetime High Fat Diet Feeding

In an effort to understand obesity associated hypertension, we and others are using Dahl salt-sensitive (SS) rats fed a high fat diet as an experimental model. One reason for choosing this rat strain is that it is well-known that SS rats exhibit accelerated hypertension development not just in response to high salt intake but to numerous other stimuli as well, when compared to Dahl salt resistant (SR) rats. However, it is not known whether this general dichotomous sensitivity to hypertension development in SS and SR rats also extends to the impact of high fat feeding. Therefore, in the present study we tested the hypothesis that high fat feeding would cause a smaller increase in blood pressure in SR rats versus SS rats in both females and males (n=8 each). To explore possible strain differences in the mechanisms known to contribute to obesity associated hypertension, we also compared the activity of the renin angiotensin and sympathetic nervous systems in SS and SR rats. Rats were fed a high fat diet (60% kcal fat) from weaning. Blood pressure was measured by telemetry starting at 12 weeks of age. At 12 weeks, mean arterial pressures (MAP, mmHg) were 109±8 and 158±6 in male SR and SS rats, and 108±1 and 150±5 in female SR and SS rats, respectively. By 18 weeks MAP were 109±7 and 175±4 in male SR and SS rats, and 108±1 and 180±4 in female SR and SS rats, respectively. In males, plasma renin was lower, and aldosterone the same, in SS rats than SR rats. However, SS rats showed larger falls in blood pressure during week-long ACE inhibitor treatment and to acute sympathoinhibition with hexamethonium than did SR rats. In females, plasma renin and aldosterone both were higher in SS rats than SR rats. Female SS rats also showed larger falls in blood pressure to chronic ACE inhibition and acute ganglion blockade than did SR rats. These results confirm that both male and female SR rats are highly resistant to obesity associated hypertension, and that less robust activation by high fat diet of the renin angiotensin and sympathetic nervous systems may be a causative factor.

571 Evaluating the Effectiveness of Extracorporeal Shockwave Lithotripsy (ESWL) for Ureteric Stones During COVID-19 Pandemic - A Single Centre Experience

Aim

Reliance on ESWL for treating ureteric stone has increased during the COVID-19 pandemic. We examined the outcomes for ureteric stones treated with our on-site lithotripter to assess the success rate and determine the variables that could affect the outcome results.

Method

A retrospective review using electronic records and images of patients who underwent ESWL for ureteric stones (January to December 2020). Univariate and multivariate analysis used to determine stone-free rate predictors (Stone Free rate/SFR: No residual stones on post-ESWL imagining).

Results

A total of 36 patients underwent ESWL for ureteric stones. Mean age was 58 years (21–90), and mean stone size was 8 mm (5–20). Stones were located in the proximal (67%) or lower ureter (33%). Overall SFR was 64% (67% proximal, 33% distal). 64% of patients required only one session to be stone free, with 60% stone free after two sessions. Stones <10mm had a SFR of 67%, compared to 58% for stone >10 mm. The only statistically significant predictor was stone size (longest dimension, p=0.04). No statistical significance with stone location (P=0.09), skin-to-stone distance (SSD) (P=0.7), stone density (P=0.3) or stone volume (P=0.3). In treatment failure, time to definitive ureteroscopy was 4 weeks.

Conclusion

Our overall SFR was slightly lower than expected but comparable to available literature. This data highlights the importance of patient selection for ESWL and would be useful in counselling about local success rate. More than half of the patients required only one session for stone clearance and stone size was the only significant predictor for successful ESWL.

Plasma first: Accelerating lung cancer diagnosis through liquid biopsy

3039

Background: Molecular profiling of tumor tissue is the gold standard for treatment decision making in advanced non-small cell lung cancer. Results may be delayed or unavailable due to insufficient tissue samples or prolonged wait times for biopsy, pathology assessment and testing. We piloted the use of plasma molecular testing as part of the initial diagnostic work-up for patients with suspected advanced lung cancer (NCT04863924). Methods: Patients with radiologic evidence of advanced lung cancer referred to the lung rapid diagnostic program underwent plasma circulating tumor DNA (ctDNA) testing using InVisionFirst-Lung, a next-generation sequencing (NGS) assay targeting 37 genes. Standard tissue testing was performed with comprehensive NGS (Oncomine). The primary endpoint was time to treatment in stage IV NSCLC patients compared to an historical pre-COVID-19 cohort (2018-9). Secondary endpoints included actionable targets identified in plasma, % of patients starting targeted therapy based on liquid biopsy and result turnaround time (TAT). Results: Between July 1 to December 31, 2021, 60 patients were enrolled. Median age was 70 years (range 33-91), 52% were female, 57% Caucasian, 48% never smokers. Of these, 73% had NSCLC, 12% small cell, 10% non-lung pathology and 5% declined tissue biopsy. Of 44 NSCLC patients, 5 (11%) had early-stage disease and underwent curative therapy. Most stage IV patients (79%) had systemic treatment. Median time to treatment initiation in the study cohort was 34 days (n = 31, range 10-90) versus 62 days (n = 101, range 13-159) in the historical cohort (p<0.0001). Two thirds (N = 23) of stage IV NSCLC patients had actionable alterations identified, (30% in current/ex-smokers); 18 started targeted therapy including 10 based on plasma results before tissue results were available. Median TAT was 7 days for plasma from blood draw to reporting (range 4-14) and 26 days for tissue molecular testing (range 11-42), p<0.0001. Concordance was high between plasma and tissue testing (70%). Liquid biopsy identified actionable alterations for 3 patients not identified by tissue NGS. In 4 cases, plasma testing failed to identify actionable alterations detected in tissue, due to undetectable plasma ctDNA. Conclusions: Liquid biopsy in the initial diagnostic workup of patients with suspected advanced NSCLC leads to faster molecular results and shortens time to treatment compared to tissue testing alone. Supplementing the current standard of tissue molecular testing with a plasma-first approach during the diagnostic work up of patients with suspected advanced lung cancer may increase access to precision medicine and improve patient outcomes. Clinical trial information: NCT04863924. [Table: see text]

Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study

Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.

Integrating comprehensive genomic sequencing of non-small cell lung cancer into a public healthcare system

OBJECTIVES

Standard molecular testing for patients with stage IV non-small cell lung cancer (NSCLC) in the Canadian publicly funded health system includes single gene testing for EGFR, ALK, and ROS-1. Comprehensive genomic profiling (CGP) may broaden treatment options for patients. This study examined the impact of CGP in a publicly funded health system.

METHODS

Consenting patients with stage IV NSCLC without known targetable alterations underwent CGP on diagnostic samples. Patients that had progressed on targeted therapy were also eligible. The CGP assay was a hybrid capture next generation sequencing (NGS) panel (Oncomine Comprehensive Assay Version 3, ThermoFisher). The number of actionable alterations, changes in treatment, clinical trial eligibility and costs as a result of CGP were evaluated and patient willingness-to-pay.

RESULTS

Of 182 screened patients,134 (74%) had successful CGP testing. Twenty percent had received prior targeted therapy. Incremental actionable alterations were identified in 31% of patients. The most common novel targets identified were mutations in ERBB2 (exon 20 insertions), MET (exon 14 skipping) and KRAS (G12C). At data cut off (31/12/2020), 16% of patients had a change in treatment as a result of CGP. Additional clinical trial options were identified for 75% of patients. The incremental direct laboratory cost for CGP beyond public reimbursement for single gene tests was $747 CAD/case.

CONCLUSION

CGP identifies additional actionable targets beyond single gene tests with a direct impact on patient treatment and increased clinical trial eligibility. These benefits highlight the value of CGP in patients with NSCLC in public health systems.

The economic value of liquid biopsy for genomic profiling in advanced non-small cell lung cancer

Background:

Liquid biopsy (LB) can detect actionable genomic alterations in plasma circulating tumor circulating tumor DNA beyond tissue testing (TT) alone in advanced non-small cell lung cancer (NSCLC) patients. We estimated the cost-effectiveness of adding LB to TT in the Canadian healthcare system.

Methods:

A cost-effectiveness analysis was conducted using a decision analytic Markov model from the Canadian public payer (Ontario) perspective and a 2-year time horizon in patients with treatment-naïve stage IV non-squamous NSCLC and ⩽10 pack-year smoking history. LB was performed using the comprehensive genomic profiling Guardant360™ assay. Standard of care TT for each participating institution was performed. Costs and outcomes of molecular testing by LB + TT were compared to TT alone. Transition probabilities were calculated from the VALUE trial (NCT03576937). Sensitivity analyses were undertaken to assess uncertainty in the model.

Results:

Use of LB + TT identified actionable alterations in more patients, 68.5 versus 52.7% with TT alone. Use of the LB + TT strategy resulted in an incremental cost savings of $3065 CAD per patient (95% CI, 2195–3945) and a gain in quality-adjusted life-years of 0.02 (95% CI, 0.01–0.02) versus TT alone. More patients received chemo-immunotherapy based on TT with higher overall costs, whereas more patients received targeted therapy based on LB + TT with net cost savings. Major drivers of cost-effectiveness were drug acquisition costs and prevalence of actionable alterations.

Conclusion:

The addition of LB to TT as initial molecular testing of clinically selected patients with advanced NSCLC did not increase system costs and led to more patients receiving appropriate targeted therapy.

C56. Isolated Right Ventricular Non-Compaction Cardiomyopathy (IRVNC) in Adolescence: A Case Report

Background

Non-compaction ventricular myocardium (NCVM) is a rare genetic cause of cardiomyopathy which mostly affects the left ventricle. A limited case of IRVNC was reported which render a limited knowledge for clinician.

Case Summary

A 16-y.o male presented to our emergency unit with recurrent syncope, chest discomfort, palpitation which exaggerated by strenuous exercise. There was no familial history of sudden death. On admission, BP of 102/64 mmHg and bradycardia of 49 bpm were remarkable. Electrocardiography revealed sinus arrhythmia, 49 bpm with early repolarization on precordial leads and LVH. Laboratory tests were in normal limits. Echocardiography revealed hyper-trabeculated RV with no LV-dysfunction. CMR was performed and showed normal LV dimension and function. Right atrium and RV were dilated with RV-dysfunction. RV trabeculae were indicative for IRVNC (NC/C ratio of 4.3). Holter ECG monitoring was done and remarkable for sinus arrhythmia without sinus pause nor ventricular arrhythmia.

Anticoagulant was given for embolic prevention in the non-compacted area. ACEi, β-blockers, and diuretic were not given due to hypotension, bradycardia and no signs of congestion. The patient showed clinical improvement and discharged after 5 days of hospitalization.

Discussions

Recently, there has been no specific criteria and cut off for IRNVC. Earlier studies mentioned that ILVNC criteria could be used for diagnosing IRNVC, as we used in our case. In the future, it’s necessary to determine new cut off points dedicated for IRVNC. Furthermore, close follow-up is needed as complications such as arrhythmia, embolic events and heart failure might occurred.

C56. Isolated Right Ventricular Non-Compaction Cardiomyopathy (IRVNC) in Adolescence: A Case Report

Background

Non-compaction ventricular myocardium (NCVM) is a rare genetic cause of cardiomyopathy which mostly affects the left ventricle. A limited case of IRVNC was reported which render a limited knowledge for clinician.

Case Summary

A 16-y.o male presented to our emergency unit with recurrent syncope, chest discomfort, palpitation which exaggerated by strenuous exercise. There was no familial history of sudden death. On admission, BP of 102/64 mmHg and bradycardia of 49 bpm were remarkable. Electrocardiography revealed sinus arrhythmia, 49 bpm with early repolarization on precordial leads and LVH. Laboratory tests were in normal limits. Echocardiography revealed hyper-trabeculated RV with no LV-dysfunction. CMR was performed and showed normal LV dimension and function. Right atrium and RV were dilated with RV-dysfunction. RV trabeculae were indicative for IRVNC (NC/C ratio of 4.3). Holter ECG monitoring was done and remarkable for sinus arrhythmia without sinus pause nor ventricular arrhythmia.

Anticoagulant was given for embolic prevention in the non-compacted area. ACEi, β-blockers, and diuretic were not given due to hypotension, bradycardia and no signs of congestion. The patient showed clinical improvement and discharged after 5 days of hospitalization.

Discussions

Recently, there has been no specific criteria and cut off for IRNVC. Earlier studies mentioned that ILVNC criteria could be used for diagnosing IRNVC, as we used in our case. In the future, it’s necessary to determine new cut off points dedicated for IRVNC. Furthermore, close follow-up is needed as complications such as arrhythmia, embolic events and heart failure might occurred.

1248 “Passing the Surgical Torch”- A Review of Appropriate Surgical Handover Protocol on The Acute Surgical Take

Aim

Effective handover between shifts is vital to protect patient safety. The Royal College of Surgeons has detailed the necessary information needed for each patient at handover. We aimed to assess compliance with this handover protocol.

Method

Weekday surgical handover was reviewed over an 8-week period of time. Data was collected on documentation of diagnosis, up to investigations/bloods, clinical state of patient, management plan and resuscitation status/ceiling of care and COVID status.

Results

210 patients were reviewed. Of these, a clear diagnosis was documented for 152 patients. Up to date imaging results if applicable was documented in 111 of 153 patients. Up to date bloods were included in 140 of 210 patients. COVID status was only noted in 31 of 210 patients and DNAR status in only 24. After re-audit of 197 a clear diagnosis was seen in 183 patients, COVID status was documented in 170 patients and DNAR status in 169.

Conclusions

Surgical handover is hugely crucial for provision of patient care. Following clear guidance from the royal college of surgeons, better compliance with handover was noted, including a critical improvement in COVID and DNAR status.

Unraveling the hepatoprotective effects of blueberries in a hypercaloric diet-induced rat model of prediabetes by metabolomic and transcriptomic approaches

Background

We previously described protective effects of blueberry juice (BJ) against hepatic steatosis evolution in a hypercaloric diet-induced rat model of prediabetes; however, the underlying mechanisms, are still scarcely explored. Herein, we aim to elucidate the molecular pathways underpinning BJ hepatoprotection on the dysmetabolism evolution in a rat model of prediabetes.

Methods

A rat model of evolutive prediabetes [Male Wistar rats, 8 weeks old] was developed by ingestion of a high-sucrose (HSu, 35%) diet for 9 weeks (W9), supplemented with a high-fat diet (HF, 60%) for further 14 weeks (HSuHF, W23), vs control with standard diet. Half of the animals (n = 10/group) daily received BJ (25g/Kg BW, orally) between W9 and W23. Along with metabolic characterization, BJ effects on serum and hepatic metabolic surrogates were elucidated using a 1H NMR based metabolomic approach. Moreover, the liver expression of genes (RT-PCR) involved in insulin signaling, lipid metabolism, inflammatory response and mitochondrial respiration was also explored. Values are means ± S.E.M (ANOVA followed by post-hoc tests).

Results

HSuHF+BJ rats restored hepatic levels of betaine and tend to recover the depletion of glutathione content found in HSuHF animals’ livers. Moreover, BJ positively affected the hepatic mRNA expression of key enzymes and mediators involved in fatty acid oxidation, insulin signalling, inflammatory response, as well as mitochondrial respiratory chain-related genes, which were all downregulated (P &lt; 0.05) in HSuHF animals’ livers.

Conclusions

Altogether, these molecular findings contribute to explain the mechanisms by which BJ elicits protection against hepatic steatosis and mitochondrial dysfunction induced by hypercaloric diets in the frame of prediabetes evolution.

Cardiac magnetic resonance evaluation of takotsubo cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Takotsubo Cardiomyopathy(TCM)is a reversible pathology with clinical features practically indistinguishable from AMI.Cardiac magnetic resonance(CMR)is uniquely suited in differentiating TCM from other forms of acute ventricular dysfunction.CMR can also identify potential complications.

Purpose

The aim of this study was to characterize TCM features,as well as to evaluate diagnostic and prognostic impact of CMR in these patients.

Methods

A 7-years prospective study,which included patients of our center proposed to CMR with presumptive diagnosis of MINOCA based on acute chest pain,troponin raise and absence of angiographically significant coronary disease (luminal stenosis &lt;50%).We analysed clinical characteristics, electrocardiograms, echo and coronariography.A presumptive diagnosis was elaborated and comparison was made with the TCM definitive one after CMR.We applied a protocol to evaluate TCM patients’ left and right ventricles(LV;RV)both anatomically and functionally, and search for late gadolinium enhancement(LGE).

Results

A total of 93 patients were evaluated,of which 16 had the final diagnosis of TCM.Takotsubo-cardiomyopathy patients were all female,with a mean age of 69 ± 14years old.At admission,75% had ST segment elevation, so emergent coronariography was performed. The median highest troponin I was 2,235[1,30-4,27]ng/mL.CMR confirmed 25%(n = 4) of presumptive diagnosis of TCM. On the other 75%initial diagnosis was changed to TCM after CMR:50%(n = 6) and 17%(n = 2)of patients had an initial presumptive diagnoses of reperfunded STEMI and NSTEMI,respectively. In 33% the initial diagnosis was myocarditis.From CMR evaluation of TCM patients, left atrial dilation was found in 31%(mean indexed area 18 ± 1,5cm2/m2).A majority (81%) presented with preserved ejection fraction(EF)(mean LV EF 59 ± 10%).Regional contractility abnormalities were described in 19%,being hypokinesia in all mid and apical segments in 2 cases, and diffuse in one.LV dysfunction was present in 13%(mean LV EF 32 ± 2%) and RV"s in 2cases (mean RV EF 42%),with only one with biventricular EF depression.Mean LV end diastolic indexed volume(EDIV)was 72 ± 23mL/m2,with only 2 with LV dilation(LV EDIV 120 ± 7mL/m2),non had dilated RV.Mild pericardial effusion was found in 38%,mild mitral regurgitation in 8patients and moderate in 1.A complication was registered:LV outflow tract protomesossystolic acceleration with mild anterior leaflet prolapse,without SAM.No LV thrombus was identified.LGE was observed in 2(13%)of patients:in one it was found on the apex,on the other one the pattern was linear intramyocardial on mid segment of inferior septum.

Conclusion

CMR provides a noninvasive and multidimensional assessment for evaluation of Takotsubo cardiomyopathy.In our population,performing CMR allowed an initial diagnosis modification in 3/4 of the cases and identification of one complication,both with therapeutic and prognostic implications.

Cardiac Magnetic Resonance as a diagnostic tool in arrhythmias

Funding Acknowledgements

Type of funding sources: None.

Introduction

Etiology of cardiac arrhythmias is often difficult to determine.As the gold standard to anatomical and functional cardiac evaluation,Cardiac Magnetic Resonance(CMR)can be a fundamental technique for accurate assessment of myocardial arrhythmic substrates or for arrhythmias management.

Purpose

The aim of this study is to determine diagnostic and arrhythmic risk stratification impact of CMR performed in patients with suspected or confirmed arrhythmias.

Methods

We performed a six-years prospective study of patients with suspected or confirmed arrhythmias which evaluation with other techniques did not provide a definitive diagnosis.These patients underwent CMR for diagnostic and risk stratification assessment.We applied a protocol to evaluate both ventricles’ morphology and functional and late gadolinium enhancement (LGE) presence.

Results

A total of 93 patients were included,of which 66% were male, with a mean age of 45 ± 17 years old. The indications for patients with suspected or confirmed arrhythmias performing CMR evaluation were the following: 33% (n = 31) of the patients had very frequent premature ventricular complexes, 23% (n = 21) had sustained ventricular tachycardia (VT), 5%(n = 5) non-sustained VT, 17%(n = 16) suspected structural heart disease with high arrhythmic potential,10%(n = 9) unexplained recurrent syncope,9 %(n = 8) supraventricular tachycardia and 3% (n = 3) aborted sudden cardiac death. Depressed ejection fraction (EF)(&lt;50%) was present in 10% (n = 9) for LV(mean EF 38 ± 9%) and 15%(n = 14) for RV (mean EF 42 ± 7%). Dilation of LV was found in 25% of patients (n = 23, mean LV volume: 115 ± 7ml/m²), with RV dilation being present in only 1 patient, who had right ventricle arrhythmogenic dysplasia (RVAD) (RV volume: 152ml/m²). In total, 16%had interventricular septum hypertrophy (mean 15 ± 4mm/m2).We found slight anterior leaflet prolapse of mitral valve in 10% (n = 9) of the cases and mild mitral regurgitation in 15% (n = 14). Left atrium dilation was observed in 17% (n = 16) of patients (mean area of 18 ± 2cm2/m2), as right atrium was dilated in only two. In 20% of the patients, CMR contributed to establish a previously unknown diagnosis: 6% (n = 5) have hypertrophic cardiomyopathy,4%(n = 4)a myocarditis sequelae and 2%(n = 2)had RVAD. LV non-compaction,a silent myocardial infarction scar and non-ischemic dilated cardiomyopathy were diagnosed in 3%of the cases each. In 15%(n = 14)we found nonspecific variations, which deserve follow-up. On the remaining patients, CMR was considered normal.

Conclusion

 As a high reproducible, accurate and versatile technique, CMR allowed an increase on diagnosis in 20% of the patients with suspected or confirmed arrhythmias. Consequently, it contributed to the risk stratification of our study population with suspected high arrhythmic potential when the first-line complementary exams were inconclusive.

The value of defining molecular resistance in patients with progressive EGFR and ALK-driven lung cancer in a public system

3126

Background: Repeat molecular profiling, except to detect EGFR T790M, is not routinely performed in Canadian patients with lung cancer progressing on EGFR tyrosine kinase inhibitors (TKIs). We performed genomic profiling on post-progression biopsies in patients with stage IV non-small cell lung cancer (NSCLC) and known EGFR/ ALK aberrations treated with TKIs to identify resistance mechanisms, evaluate options for subsequent treatment, and to assess clinical trial eligibility and costs. Methods: From Feb 2018-Aug 2020, post-progression tumour biopsies from consenting patients at a major cancer centre underwent genomic profiling (ThermoFisher OCA v3.0 including hotspots, fusions, and copy number variations in 161 cancer-associated genes). Outcomes of interest were the identification of resistance mutations, actionable targets, clinical trial eligibility (per clinicaltrials.gov), and costs. Results: Thirty-two patients consented to the study. Most, 84% (n = 27), had successful testing completed while 16% (n = 5) had insufficient tissue. Median age of the cohort was 56 yrs, 59% (n = 16) were female, 74% (n = 20) were never-smokers, 81% (n = 22) had ECOG performance status 0-1, and 67% (n = 18) were Asian. The majority, 81% (n = 22) had EGFR mutated NSCLC, and had progressed on EGFR TKIs (15 with previously identified T790M had progressed on osimertinib), and 19% (n = 5) had ALK fusions. Patients had received a median of 2 prior lines of targeted therapy prior to re-biopsy (IQR 1.5,3). One patient had evidence of small cell transformation and associated TP53 and RB1 mutations, 11% (n = 3) had acquired EGFR C797S mutations, and 11% (n = 3) had acquired ALK resistance point mutations (G1202R n = 2, I1171N n = 1). Genomic profiling identified additional actionable targets in 19% of patients (n = 5: MET exon 14 skip mutation n = 1, MET amplification n = 2, BRAF V600E n = 2). Overall, 33% (n = 9) patients had management-changing resistance mechanisms identified (small cell transformation n = 1, actionable targets n = 5, ALK inhibitor resistance = 3). New clinical trial options based on genomic profiling results were identified for 67% (n = 18) of patients. Incremental costs for repeat genomic profiling were approximately $880 CAD per case. Conclusions: Molecular profiling upon development of resistance to targeted therapy in our cohort revealed actionable resistance mechanisms for over a third of patients and clinical trial options for 67%. These incremental benefits for patients highlight the importance of routine molecular profiling in the setting of acquired TKI resistance in lung cancer.

Evolution of in-hospital management in ST Segment Elevation Myocardial Infarction in Portuguese hospitals over the years

Objectives

To assess the evolution of in-hospital management of ST Segment Elevation Myocardial Infarction (STEMI) over the years in Portuguese hospitals and its impact on in-hospital complications and mortality

Methods

A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of acute coronary syndrome since 2002 until 2019 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical data, revascularization strategy, medication during hospitalization. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess tendencies in categorical variables, and Kruskal-Wallis tests were used to assess tendencies in numerical variables. A p-value &lt;0.05 was considered statistically significant.

Results

During the study, a total of 24425 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years.

We report a progressive increase in patients treated with aspirin, P2Y12 inhibitors (from 22.2% to 97.6% – p&lt;0.001), beta blockers 62.% to 72.4% – p&lt;0.001), ACE inhibitors (68.9% to 78.2% – p&lt;0.001) and statins (72.1% to 88.4% – p&lt;0.001), a progressive decrease in GP 2a3b inhibitors (20.9 to 14.6% – p&lt;0.001), enoxaparin (55.2% to 29.9% – p&lt;0.001), nitrates (82.7% to 16.1% – p&lt;0.001), calcium channel blockers (5.0% to 3.1% – p&lt;0.001) and inotropes (12.0% to 5.6% – p&lt;0.001).

There was an increase of the use primary coronary angioplasty (36.4% to 73.2% – p&lt;0.001), and of drug eluting stents (0% to 70.1% – p&lt;0.001) a decrease in the use of fibrinolysis (75.7% to 1.6% – p&lt;0.001), bare metal stents (88.1% to 0.3% – p&lt;0.001) and intra-aortic balloon pump (1.8% to 0% – p=0.009), but not in invasive mechanical ventilation (2.5% to 1.9% – p=0.142).

Less patients had moderate to severely impaired left ventricle ejection fraction (28.8% to 14.9% – p&lt;0.001), and there was a significant reduction in almost all in-hospital complications: re-infarction (2.0% to 1.0% – p&lt;0.001); heart failure (36.2% to 9.9% – p&lt;0.001); cardiogenic shock (10.8% to 3.9% – p&lt;0.001); AV block (5.8% to 2.5% – p&lt;0.001); mechanical complications (2.8% to 0.4% – p&lt;0.001); stroke (1.3% to 0.4% – p&lt;0.001); in-hospital mortality (9.9% to 3.8% – p&lt;0.001); as well as length of stay ([4–10] days to [3–6] days – p&lt;0.001). Exceptions were and increase in major bleeding (0.9% to 1.8% – p&lt;0.001) and resuscitated cardiac arrest (3.9% to 4.5%, p=0.001).

Conclusion

In 17 years, we report a progressive evolution of the in-hospital treatment of STEMI patients in Portuguese hospitals, with a higher prescription of guideline recommended medications, use of invasive reperfusion techniques and last generation stents, resulting in a lower rate of in-hospital complications and mortality.

In-hospital outcomes over the years

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Registo Nacional de Síndromes Coronárias Agudas - Sociedade Portuguesa de Cardiologia

Searching for the final diagnosis using cardiac magnetic resonance in MINOCA patients

Introduction

In patients with clinical evidence of acute myocardial infarction (AMI), absence of obstructive coronary disease does not imply absence of acute thrombotic process. Thereafter, it can be designated as Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). In these cases, performing Cardiac Magnetic Resonance (CMR) can be essential for establishing a final diagnosis, due to evaluation of the presence and pattern of late enhancement.

Purpose

The aim of this study is to evaluate the diagnostic and prognostic impact of cardiac magnetic resonance in patients with a possible diagnosis of MINOCA.

Methods

A 7-years prospective study in our centre, which included all patients proposed to CMR with a presumptive diagnosis of MINOCA due to acute chest pain, troponin raise and absence of angiographically significant coronary disease (luminal stenosis of &lt;50%). All patients performed functional, anatomical evaluation, as so late gadolinium enhancement search. We analysed clinical characteristics, electrocardiographic presentation, echocardiographic and coronariography results. A presumptive diagnosis was elaborated after coronariography and comparison was made with the definitive one after CMR.

Results

A total of 85 patients were included, 53% were male, with a mean age of 49±20 years old. Clinical history of hypertension was observed in 52% patients, 34% had dyslipidaemia, 8% with diabetes, obesity was present in 21% of patients and smoking habits in 33%. At admission, 47% had ST segment elevation, so emergent coronariography was performed. The mean highest troponin I was 7,54±9,39ng/mL. Late gadolinium enhancement was observed in 50 (59%) of patients. After CMR realization a final diagnosis of MINOCA was made in only 13 patients (15%) and in 51 patients (60%) CMR evaluation allowed a diagnosis modification, with impact on patients' management and prognosis. Of these 51 patients, a definitive diagnosis of myocarditis was seen in 65% of cases, of Takotsubo's myocardiopathy in 27%, and hypertrophic cardiomyopathy in 8%. In 21 (25%) of patients, late gadolinium enhancement was not found. However its absence could exclude type 1 AMI as definitive diagnosis.

Conclusion

CMR is a fundamental technique on MINOCA patients' management. In our population, performing CMR allowed initial diagnosis modification in about two thirds of the cases, with important therapeutic and prognostic implications.

Funding Acknowledgement

Type of funding source: None

Evolution of hospital discharge medication and 6 months outcomes of ST-Segment Elevation Myocardial Infarction patients in Portugal over the years

Objectives

To assess the evolution of hospital discharge management, 6 months hospitalization and mortality over the years of all patients admitted with ST segment elevation myocardial infarction (STEMI) in Portugal.

Methods

A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of Acute Coronary Syndrome since 2002 until 2018 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical status, revascularization strategy, discharge medication and 6 months hospitalization and mortality were obtained. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess trends in categorical variables, and Kruskal-Wallis tests were used to assess trends in numerical variables. A p-value &lt;0.05 was considered statistically significant.

Results

During the study, a total of 23807 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years.

We report a progressive and significant increase the use of primary angioplasty versus fibrinolysis (24.3% to 98.4%, p&lt;0.001), in coronary angioplasties (36.4% to 73.2%, p&lt;0.001), in the use of drug-eluting stents (0% to 70.1%, p&lt;0.001), and a decrease in the patients that underwent surgery (6.8% to 1.3%, p&lt;0.001) and intra-aortic balloon pump (1.8% to 0%, p=0.009), resulting in a decrease in in-hospital mortality from 9.9% to 6.1% (p&lt;0.001).

At discharge, we report a progressive increase in the prescription of P2Y12 inhibitors (21.1% to 95.2%, p&lt;0.001), beta-blockers (68.8% to 83.8%, p&lt;0.001), RAAS inhibitors (69.5% to 86.7%, p&lt;0.001) and statins (79.6% to 94.9%, p&lt;0.001), while the prescription of aspirin (94.1% para 94.8%, p=0.428), calcium channel blockers (5.3% to 5.6%, p&lt;0.684) stayed stable, and there was a decrease in the prescription of nitrates (52.9% to 5.8%, p&lt;0.001). Hospital admissions at 6 months consistently and progressively reduced over time (18.6% to 8.5%, p&lt;0.001) as well as mortality (6.7% para 4.3%, p&lt;0.001).

Conclusion

Post discharge treatment of STEMI patients in Portuguese hospitals has evolved according to guidelines, with higher prescription of medication proven to reduce outcomes, resulting in lower hospitalization rates and mortality.

6 Month Outcomes over the years

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Sociedade Portuguesa de Cardiologia

Practical update for the use of bone-targeted agents in patients with bone metastases from metastatic breast cancer or castration-resistant prostate cancer

Bone metastases are a significant source of morbidity and mortality for patients with breast and prostate cancer. In this review, we discuss key practical themes regarding the use of bone-targeted agents (btas) such as bisphosphonates and denosumab for managing bony metastatic disease. The btas both delay the onset and reduce the incidence of skeletal-related events (sres), defined as any or all of a need for radiation therapy or surgery to bone, pathologic fracture, spinal cord compression, or hypercalcemia of malignancy. They have more modest benefits for pain and other quality-of-life measures. Regardless of the benefits of btas, it should always be remembered that the palliative management of metastatic bone disease is multimodal and multidisciplinary. The collaboration of all disciplines is essential for optimal patient care. Special consideration is given to these key questions: ■ What are btas, and what is their efficacy?■ What are their common toxicities?■ When should they be initiated?■ How do we choose the appropriate bta?■ What is the appropriate dose, schedule, and duration of btas?

Inflammation disrupts epithelial barrier function and induces the release of different populations of exosomes

Introduction Age-related macular degeneration (AMD) is a degenerative retinal disease that affects central vision. Most of their phenotypical features are believed to be associated with the dysfunction of retinal pigment epithelium (RPE). The accumulation of damaged proteins in aged RPE is associated with disruption of proteolytic pathways and exocytic activity, with release of intracellular proteins via exosomes (Exo), that are important players in intercellular communication and can contribute to disease progression. However, the impact of their secretion by polarized RPE on outer blood retinal barrier (oBRB) breakdown remains largely elusive

Objectives Our aim was to explore the role of inflammation on the loss of RPE integrity and to understand the relative role of directional secretion of Exo by RPE in the loss of polarity and barrier disruption

Methodology We used a human RPE cell line (ARPE-19), highly polarized RPE primary cultures (pRPE) and porcine eyecups. To mimic the inflammatory conditions present in AMD, cells were treated with two inflammatory stimuli, TNF (10 ng/mL) or LPS (100 ng/mL)

Results TNF and LPS do not affect the viability of the RPE cells. RPE cells developed a confluent monolayer and reached a relatively constant TER of about 40 Ω/cm2 (ARPE-19) or higher than 150 Ω/cm2 (pRPE). Treatment with TNF significantly reduces the TER, decreased immunoreactivity and co-localization of the TJ proteins ZO-1 and occludin and increases MMP-2/-9 activity in the medium. Apical Exo isolated from the RPE cells are enriched in CD63 compared to the basolateral Exo, that are enriched in CD81. The Exo isolated from porcine eyecups, especially with the LPS stimulus, are enriched in CD81 and MMP-2 but have similar levels of CD63

Conclusion Overall, our results show that inflammation induces loss of RPE integrity and release of different populations of Exo. The unravelling of novel drug targets paves the way for development of new therapeutic strategies for AMD.

An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery

The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ² test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.

Demonstrating the value of liquid biopsy for lung cancer in a public health care system

3546

Background: Given the challenges of molecular profiling in patients with advanced lung cancer, this prospective study examines clinical outcomes and utility of liquid biopsy in treatment naive stage IV lung adenocarcinoma patients (Cohort 1) and in the setting of resistance to targeted therapy (Cohort 2; not reported here). Methods: This study is being conducted at 6 Canadian centres (NCT03576937) using Guardant 360 (G360), a validated cell-free DNA next-generation sequencing assay that identifies variants in 74 cancer-associated genes, including fusions and copy number gain. Cohort 1 (N = 150) includes patients with treatment-naïve advanced non-squamous lung carcinoma, ≤10 pack-year smoking history, and measurable disease. Patients received standard of care tumour tissue (TT) molecular profiling ( EGFR, ALK +/- ROS1) and liquid biopsy (LB). The primary endpoint was response rate to first-line therapy (RECIST 1.1); secondary endpoints include incremental targetable alterations identified through G360 ( EGFR, ALK, BRAF, ERBB2, KRAS (G12C), NTRK, MET (amplification, exon 14 skipping), RET, ROS1), turn-around time (TAT) and successful molecular profiling rates. Results: To date, 84 eligible patients with clinical data have been accrued to Cohort 1. Median age is 64 (range 23-91), 64% are female, 85% never smokers, 96% have adenocarcinoma. Actionable targets have been identified in 55% of patients using G360 ( EGFR/ALK in 37%), 39% using standard TT profiling. Eight EGFR/ALK aberrations were identified in TT but not LB, while 6 were identified in LB but not TT. TT profiling for EGFR/ALK was unsuccessful in 8% of patients (insufficient tissue, failed biopsy). Fourteen patients (17%) had no ctDNA alterations detected by G360 (low disease burden vs. non-shedding). Of 75 patients receiving first-line treatment, 57% received targeted therapy, 28% chemotherapy combinations, 11% checkpoint inhibitors and 4% were observed. Treatment decisions were informed by G360 alone in 37% and by G360+TT results in 27% (by physician report). Among 46 evaluable patients, ORR was 54% (25/46). Using G360, ORR was 75% (15/20) in those with actionable alterations and 38.5% (10/26) in those without. Using TT, ORR was 67% (14/21) in those with actionable alterations and 44% (11/25) in those without. Mean TAT was 7.9 days (SD+/-1.7) for LB vs 19.9 days (SD+/- 9.8) for TT. Conclusions: Liquid biopsy using G360 identifies actionable targets beyond tissue profiling alone in newly diagnosed lung cancer patients, has faster TAT and yields similar outcomes with targeted and non-targeted therapy. Clinical trial information: NCT03576937 .

Environmental risk assessment of accidental marine spills: A new approach combining an online dynamic Hazardous and Noxious substances database with numerical dispersion, risk and population modelling

The foreseen rise on maritime transportation of Hazardous and Noxious Substances (HNS) increases the likelihood of accidents, leading to a higher risk of chemical spillage that can have severe ecological impacts. Considering the lack of information on HNS spills, the response to these events is less well established than those involving oil. Moreover, a paramount knowledge of the physicochemical and ecotoxicological properties of the substance involved is required for an effective environmental risk assessment and response to an HNS spill. In the present work, a new online interface, in which a dynamic HNS database feeds a chemical numerical dispersion model, was developed with the aim to improve predictions regarding the behaviour and environmental risk of HNS spills on marine ecosystems. Potential impacts to pelagic organisms were characterized by coupling model outputs with toxicity risk ratios. Furthermore, a simple population model was developed, foreseeing impacts at the ecological level. The integration of the developed tools establishes an innovative framework, which aims to improve predictions related to HNS plumes' behaviour and potential hazards to the marine environment and associated ecosystem services. Further, this new approach fosters an improved preparedness and response to coastal pollution incidents, enhancing effective decision making and management by competent authorities.

A multicentre, randomised trial comparing schedules of G-CSF (filgrastim) administration for primary prophylaxis of chemotherapy-induced febrile neutropenia in early stage breast cancer

BACKGROUND

The optimal duration of filgrastim as primary febrile neutropenia (FN) prophylaxis in early breast cancer patients is unknown, with 5, 7 or 10 days being commonly prescribed. This trial evaluates whether 5 days of filgrastim was non-inferior to 7/10 days.

PATIENTS AND METHODS

In this randomised, open-label trial, early breast cancer patients who were to receive filgrastim as primary FN prophylaxis were randomly allocated to 5 versus 7 versus 10 days of filgrastim for all chemotherapy cycles. A protocol amendment in November 2017 allowed subsequent patients (N = 324) to be randomised to either 5 or 7/10 days. The primary outcome was a composite of either FN or treatment-related hospitalisations. Secondary outcomes included chemotherapy dose reductions, delays and discontinuations. Analyses were carried out by per protocol (primary) and intention-to-treat, and the non-inferiority margin was set at 3% for the risk of having FN and/or hospitalisation per cycle of chemotherapy.

RESULTS

Patients (N = 466) were randomised to receive 5 (184, 39.5%), or 7/10 (282, 60.5%) days of filgrastim. In our primary analysis, the difference in risk of either FN or treatment-related hospitalisation per cycle was -1.52% [95% confidence interval (CI): -3.22% to 0.19%] suggesting non-inferiority of a 5-day filgrastim schedule compared with 7/10-days. The difference in events per cycle for FN was 0.11% (95% CI: -1.05 to 1.27) while for treatment-related hospitalisations it was -1.68% (95% CI: -2.73% to -0.63%). The overall proportions of patients having at least one occurrence of either FN or treatment-related hospitalisation were 11.8% and 14.96% for the 5- and 7/10-day groups, respectively (risk difference: -3.17%, 95% CI: -9.51% to 3.18%).

CONCLUSION

Five days of filgrastim was non-inferior to 7/10 days. Given the cost and toxicity of this agent, 5 days should be considered standard of care. CLINICALTRIALS.

GOV REGISTRATION

NCT02428114 and NCT02816164.