Biphasic Porous Bijel-Like Structures with Hydrogel Domains as Controlled Drug Delivery Systems

Bijels are a peculiar type of Pickering emulsion that have a bicontinuous morphology and are stabilised by a jammed layer of nanoparticles (NPs). Due to their double nature, their usage has increased in recent years in various fields, such as biological and food applications. In fact, they can release both hydrophilic and hydrophobic compounds simultaneously. An improvement to this structure is the use of a hydrophobic monomer like polycaprolactone as the organic phase, which is able to polymerise during the formation of the structure. Unfortunately, the structures formed in this way always have some drawbacks, such as their thermal stability or degradation when submerged in an aqueous medium. A number of studies have been carried out in which some parameters, such as the NPs or the monomer, were changed and their effect on the final product evaluated. In this work, the effect of modifying the aqueous phase was studied. In particular, the effect of adding alginate, a biopolymer capable of forming a stable hydrogel in the presence of divalent cations, was analysed, as was the difference between soaking or not in CaCl2, the final system. Specific attention was paid to their swelling behaviour (150% vs. 25% of the blank sample), rheological properties (G' 100 kPa vs. 20 kPa of the blank sample) and their release performances. In this framework, complete release of hydrophilic drug vs. 20% in the blank sample was observed together with improved release of the hydrophobic one with 35% in 8 h vs. 5% in the case of the blank sample. This strategy has been proven to influence bijels' properties, opening the doors to many different uses.

Cross-cultural adaptation of the PROFFIT Instrument to measure financial toxicity in people living with cancer within a UK population

BACKGROUND

This study aimed to develop a British version of the Patient Reported Outcomes for Fighting Financial Toxicity of Cancer (PROFFIT): originally designed to measure financial toxicity in cancer for an Italian universal healthcare system. The instrument was carefully evaluated for crosscultural equivalence, face validity and practicality.

METHODS

A systematic approach to cross-cultural adaptation was used, including forward translation, synthesis, backward translation, consolidation of translations with an expert committee, and cognitive interviews. As part of the cognitive interview process, 18 cancer patients completed a structured interview of 60-90 min in length.

RESULTS

The translated and modified PROFFIT questionnaire demonstrated good psycho-linguistic properties, including high compliance (only one item was revised for clarity), high retrieval from memory, high decision-making processes, and high response processes.

CONCLUSION

PROFFIT has been found to be functional and adaptable in a new social environment. The tool may be useful for tailoring interventions to address and measure financial hardships within the cancer population, which appear to be a current challenge for public health.

POLICY SUMMARY

Even in universal healthcare systems, financial toxicity due to the increase in outof-pocket expenses poses a significant problem. The FT phenomenon warrants proper attention in the United Kingdom since it may negatively impact financial well-being, quality of life, psychosocial health, and treatment adherence.

Sex dimorphism and cancer immunotherapy: May pregnancy solve the puzzle?

In the immunoncology era, growing evidence has shown a clear sex dimorphism in antitumor immune response with a potential impact on outcomes upon immunecheckpoint blockade (ICI) in patients with cancer. Sex dimorphism could affect tumor microenvironment composition and systemic anticancer immunity; however, the modifications induced by sex are heterogeneous. From a clinical perspective, six metanalyses have explored the role of sex in cancer patients receiving ICI with conflicting results. Environmental and reproductive factors may further jeopardize the sex-related heterogeneity in anticancer immune response. In particular, pregnancy is characterized by orchestrated changes in the immune system, some of which could be long lasting. A persistence of memory T-cells with a potential fetal-antigen specificity has been reported both in human and mice, suggesting that a previous pregnancy may positively impact cancer development or response to ICI, in case of fetal-antigen sharing from tumor cells. On the other hand, a previous pregnancy may also be associated with a regulatory memory characterized by increased tolerance and anergy towards cancer-fetal common antigens. Finally, fetal-maternal microchimerism could represent an additional source of chronic exposure to fetal antigens and may have important immunological implications on cancer development and ICI activity. So far, the role of pregnancy dimorphism (nulliparous vs parous) in women and the impact of pregnancy-related variables remain largely underexplored in cancer patients. In this review, we summarize the evidence regarding sex and pregnancy dimorphism in the context of immune response and anticancer immunotherapy and advocate the importance of analyzing pregnancy variables on ICIs clinical trials.

Confirmatory validation analysis of the PROFFIT questionnaire to assess financial toxicity in cancer patients

BACKGROUND

The Patient Reported Outcome for Fighting FInancial Toxicity (PROFFIT) questionnaire was developed to measure financial toxicity (FT) and identify its determinants. The aim of the present study was to confirm its validity in a prospective cohort of patients receiving anticancer treatment.

PATIENTS AND METHODS

From March 2021 to July 2022, 221 patients were enrolled at 10 Italian centres. Selected items of the EORTC-QLQ-C30 questionnaire represented the anchors, specifically, question 28 (Q-28) on financial difficulties, and questions 29-30 measuring global health status/quality of life (HR-QOL). The study had 80% power to detect a 0.20 correlation coefficient (r) between anchors and PROFFIT-score (items 1-7, range 0-100, 100 indicating maximum FT) with bilateral alpha 0.05 and 80% power. Confirmatory factor analysis was conducted. FT determinants (items 8-16) were described.

RESULTS

Median age of patients was 65 years, 116 (52.5%) were females, 96 (43.4%) had low education level. Confirmatory factor analysis confirmed goodness of fit of the PROFFIT-score. Significant partial correlation of PROFFIT-score was found with Q-28 (r = 0.51) and HR-QOL (r = -0.23). Mean (SD) PROFFIT-score at baseline was 36.5 (24.9); it was statistically significantly higher for patients living in South Italy, those with lower education level, those who were freelancer/unemployed at diagnosis and those who reported significant economic impact from the COVID-19 pandemic. Mean (SD) scores of determinants ranged from 17.6 (27.1) for item 14 (support from medical staff) to 49.0 (36.3) for item 10 (expenses for medicines or supplements). PROFFIT-score significantly increased with worsening response to determinants.

CONCLUSIONS

External validation of PROFFIT-score in an independent sample of patients was successful. The instrument is now being used in clinical studies.

Usefulness of Dermoscopy in Eruptive Syringomas in an Elderly Woman

Introduction

Eruptive syringomas (ES) are a rare variant of syringomas, benign adnexal tumors of eccrine sweat glands' ducts. They mostly affect young-to middle-aged women, but rarely they may also occur in the elderly, requiring generally no specific treatment.

Case Presentation

We present the case of a 76-year-old woman with sudden onset of ES. Clinical examination evidenced brown-to-orange papules and plaques on the anterior neck, corresponding dermatoscopically to orange-brownish structureless areas, with barely hinted peripheral incomplete network, superimposed on areas of light pink. Histology showed dermal proliferation of epithelial cells forming cords and ductules, confirming the clinical-dermoscopic suspect of ES. The lesions remained stable at 12-month follow-up without treatment.

Discussion

This case highlights the role of dermoscopy to help differentiate ES from other clinically similar but more serious entities, such as histiocytosis, mastocytosis, and lichen planus, and to schedule the required confirmatory biopsy in due time without haste.

Research ethics with real-world data (RWD) on COVID-19 infections: the unCoVer study

Issue

The aim of the Horizon 2020 unCoVer project (Unravelling Data for Rapid Evidence-Based Response to COVID-19) is to coordinate research expertise in utilising Real World Data (RWD) to investigate the underlying risk factors for COVID-19 infection and severity, the effectiveness of treatments and the impact on health systems. RWD is particularly useful in a dynamic health context as it is relevant, timely, and more ecologically valid. Pooling clinical databases and integrating epidemiological principles and powerful biostatistical tools optimises resources and fully exploits routinely-collected data.

Description of the problem

RWD sharing poses new practical and ethical challenges to research. The unCoVer network has developed a federated data platform to access diverse databases for advanced analytics. This data access process entails GDPR, and regulatory and ethical nuances. The use of large-scale data from heterogeneous sources across multiple jurisdictions for research purposes presents a complex systems challenge.

Effects & Lessons

A dedicated team of unCoVer network members is responsible for addressing these challenges. Here, we describe the ethical and regulatory aspects of RWD sources, the role of the Data Protection Authorities and the Data Protection External Authority Board (DP-EAB) of the Uncover project, and the documentation involved, including a data processing agreement and a data transfer agreement. We provide an overview of the main principles for sharing RWD whilst maintaining integrity and security and how this translates into procedures to protect the rights, security, and well-being of human research participants. This represents a practical framework for researchers.

Key messages

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review

Background

Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies.

Methods

We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021.

Results

We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables.

Conclusions

Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13925-z.

Cultural adaptation of the Italian version of the Patient-Reported Outcomes Common Terminology Criteria for Adverse Event (PRO-CTCAE®)

INTRODUCTION

US National Cancer Institute's (NCI) Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE^®) is a library of 78 symptom terms and 124 items enabling patient reporting of symptomatic adverse events in cancer trials. This multicenter study used mixed methods to develop an Italian language version of this widely accepted measure, and describe the content validity and reliability in a diverse sample of Italian-speaking patients.

METHODS

All PRO-CTCAE items were translated in accordance with international guidelines. Subsequently, the content validity of the PRO-CTCAE-Italian was explored and iteratively refined through cognitive debriefing interviews. Participants (n=96; 52% male; median age 64 years; 26% older adults; 18% lower educational attainment) completed a PRO-CTCAE survey and participated in a semi-structured interview to determine if the translation captured the concepts of the original English language PRO-CTCAE, and to evaluate comprehension, clarity and ease of judgement. Test-retest reliability of the finalized measure was explored in a second sample (n=135).

RESULTS

Four rounds of cognitive debriefing interviews were conducted. The majority of PRO-CTCAE symptom terms, attributes and associated response choices were well-understood, and respondents found the items easy to judge. To improve comprehension and clarity, the symptom terms for nausea and pain were rephrased and retested in subsequent interview rounds. Test-retest reliability was excellent for 41/49 items (84%); the median intraclass correlation coefficient was 0.83 (range 0.64-0.94).

DISCUSSION

Results support the semantic, conceptual and pragmatic equivalence of PRO-CTCAE-Italian to the original English version, and provide preliminary descriptive evidence of content validity and reliability.

Novel cryo-balloon technology for a successful pulmonary vein isolation: acute outcome and follow-up from a large multicenter Italian clinical setting

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, limited data exist on acute and follow-up outcome of this system in a multicentric clinical practice.

Purpose

We reported the preliminary experience of this novel technology in a multicenter Italian registry.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 6 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Rhythm monitoring during the follow-up examinations was performed via the clinical assessment of AF recurrence, ECG and Holter monitoring, according to the clinical practice of each center. All patients were followed-up for at least 6 months after the procedure. Arrhythmia recurrences within the first 3 months (blanking period) were classified as early recurrences and were not considered procedural failures

Results

Six-hundred twenty-four cryoapplications from 112 pts (439 PVs) were analyzed (n=89, 79.5% paroxysmal AF, n=23, 20.5% persistent AF, mean age 61.5±9 years, 76% male, 22% with an history of AT, mean LVEF 49±10%). PVI was achieved in all pts using only cryoablation. The mean number of freeze applications per pt was 5.6±2.1 (1.4±1.2 for LSPV, 1.5±1.1 for LIPV, 1.3±0.8 for RSPV and 1.3±0.8 for RIPV), with 318 (72.4%) PVs treated with a single cryoablation (92, 21% with 2 cryoablation; 29, 6.6% with more than 2 cryoablations). Fourty-four (39.3%) pts were treated with a single application to each of the PVs. Over a median of 296[245 to 382] days of follow-up, five (4.5%) patients experienced an early recurrence of AF/AT during the 90-day blanking period. Overall, 12 patients (10.7%) suffered an AF/AT recurrence after the 90-day blanking period (median time to recurrence 200[124 to 297] days). Specifically, 8 (7.1%) patients had AF recurrence only, 3 (2.7%) had AT recurrence only and 1 (0.9%) experienced both events. One (0.9%) patient underwent a repeated ablation procedure. The proportion of patients exhibiting AF/AT recurrences was similar between AF types (10 out 89, 11.2% for paroxysmal AF vs 2 out 23, 8.7% for persistent AF, p=1.00) with a hazard ratio of 0.9 (95%CI: 0.2 to 3.9, log-rank p=0.8894). One transient phrenic nerve palsy was observed, with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported.

Conclusion

In this first multicentric experience, the novel cryo-balloon system proved to be safe and effective and resulted in a very low rate of AF/AT recurrence during follow-up.

P377 CHALLENGING RISK STRATIFICATION IN BRUGADA SYNDROME: A CASE OF VENTRICULAR TACHYCARDIA IN A LOW–RISK PATIENT

A 22–year–old healthy athlete was referred to our hospital for electrocardiographic findings consistent with intermittent type–1 Brugada pattern. A routine electrocardiogram (ECG) performed during a check–up showed sinus rhythm, normal PR interval and QRS duration, rSR’ with a coved type ST–segment elevation in V2 lead (Figure 1).The patients denied history of syncope or palpitations and his family history did not show sudden cardiac death or Brugada syndrome (BrS). Transthoracic echocardiography was normal and a 12–lead Holter monitoring revealed the intermittence of the type–1 Brugada pattern. The patient was hospitalized for further investigation. On admission, ECG showed a type–2 Brugada pattern; therefore, Ajmaline challenge test (1 mg/kg injection in 10 minutes) was performed and resulted positive. Subsequently, the patient underwent an electrophysiological study (EPS) which was negative for induction of sustained arrhythmias. The protocol adopted consisted of double extrastimuli programmed electrical stimulation until refractoriness (drive 600/220 ms and 400/210 ms), at double sites (right ventricle apex and right ventricular outflow tract). Furthermore a genetic test was performed using next–generation sequencing, showing a heterozygous mutation in the SCN5A gene, encoding for sodium channel alpha subunit (variant c.5363delA), not previously described in the literature. Since the low arrhythmic risk, the patient was implanted with a loop recorder (ILR, Medtronic Reveal LINQ), entering a program of home monitoring. After a 15–months follow–up, an episode of ventricular polymorphic tachycardia lasting 2 minutes and 11 seconds, associated with lightheadedness and palpitations, was detected by the remote monitoring (Figure 2). The patient was therefore hospitalized. During the in–hospital stay a cardiac magnetic resonance was performed to exclude other underlying diseases, identifying an enlarged right ventricle (EDVi 114 ml/m2) and abnormal free wall motion (Figure 3), thus reaching one major criteria of arrhythmogenic cardiomyopathy (however not sufficient for the diagnosis). The patient was then implanted with a subcutaneous implantable cardiac defibrillator (Boston Scientific EMBLEM MRI S–ICD). We presented a case of complex arrhythmic risk stratification in a possible overlap of an arrhythmogenic cardiomyopathy and a Brugada Syndrome in a young athlete who experienced a sustained ventricular tachycardia during loop–recorder monitoring.

Psychological Factors Affecting the Willingness to Accept a Possible Tyrosine Kinase Inhibitor (TKI) Discontinuation in Chronic Myeloid Leukaemia (CML) Patients

PURPOSE

Patients with chronic myeloid leukemia (CML) who present a sustained deep molecular response (DMR) for a stable period of time might benefit from discontinuing tyrosine kinase inhibitors (TKIs). A significant number of patients seem able to reach this stage due to the availability of TKIs. However, many patients remain reluctant about TKI discontinuation and may refuse treatment interruption. The purpose of this study was to explore the clinical and psycho-cognitive factors that may influence the decision to discontinue TKI therapy, thereby gaining a better understanding of patients' viewpoints on TKI discontinuation.

PATIENTS AND METHODS

One hundred and nineteen patients diagnosed with CML aged between 34 and 69 were enrolled (67 males and 52 females). Different clinical information and psycho-cognitive aspects such as attitude toward risk behaviours, risk preferences, need for cognitive closure, and tendency to resist to changes were assessed through the administration of a battery of questionnaires.

RESULTS

A higher tendency toward risk behaviours and the tendency to focus on possible gain in the short term rather than on losses might represent important predictors for the willingness to accept TKI discontinuation. Possible relapses following interruption of the therapy are the most common reason for concern. Furthermore, lower levels of resistance to change and having previously experienced the desire to interrupt the therapy might lead patients to accept a higher probability of relapse risk when facing such a decision.

CONCLUSION

TKI discontinuation appears appealing and challenging at the same time for many CML patients, and different factors may influence this decision. Psychology plays a crucial role in assisting physician-patient communication and informed decision-making.

Unravelling data for rapid evidence-based response to COVID-19: a summary of the unCoVer protocol

INTRODUCTION

unCoVer-Unravelling data for rapid evidence-based response to COVID-19-is a Horizon 2020-funded network of 29 partners from 18 countries capable of collecting and using real-world data (RWD) derived from the response and provision of care to patients with COVID-19 by health systems across Europe and elsewhere. unCoVer aims to exploit the full potential of this information to rapidly address clinical and epidemiological research questions arising from the evolving pandemic.

METHODS AND ANALYSIS

From the onset of the COVID-19 pandemic, partners are gathering RWD from electronic health records currently including information from over 22 000 hospitalised patients with COVID-19, and national surveillance and screening data, and registries with over 1 900 000 COVID-19 cases across Europe, with continuous updates. These heterogeneous datasets will be described, harmonised and integrated into a multi-user data repository operated through Opal-DataSHIELD, an interoperable open-source server application. Federated data analyses, without sharing or disclosing any individual-level data, will be performed with the objective to reveal patients' baseline characteristics, biomarkers, determinants of COVID-19 prognosis, safety and effectiveness of treatments, and potential strategies against COVID-19, as well as epidemiological patterns. These analyses will complement evidence from efficacy/safety clinical trials, where vulnerable, more complex/heterogeneous populations and those most at risk of severe COVID-19 are often excluded.

ETHICS AND DISSEMINATION

After strict ethical considerations, databases will be available through a federated data analysis platform that allows processing of available COVID-19 RWD without disclosing identification information to analysts and limiting output to data aggregates. Dissemination of unCoVer's activities will be related to the access and use of dissimilar RWD, as well as the results generated by the pooled analyses. Dissemination will include training and educational activities, scientific publications and conference communications.

Low-temperature ordering of the dimer phase of a two-dimensional model of core-softened particles

Purely pairwise interactions of the core-softened type, i.e., featuring a soft repulsion followed by a hard-core interaction at shorter distance, give rise to nontrivial equilibrium structures entirely different from the standard close packing of spheres. In particular, in a suitable low-temperature region of their phase diagram, such interactions are well known to favor a transition from a fluid to a cluster crystal. The residual mutual interaction between individual clusters can lead to the formation of patterns of their reciprocal orientations. In this work, we investigate two examples of such models in two dimensions, at the density most appropriate to the dimer phase, whereby clusters consist of just two particles, studying them with optimization techniques and Monte Carlo simulations. We focus on the dimer crystal, and unveil a second phase transition at extremely low temperature. This transition leads from a triangular dimer lattice with randomly disordered dimer orientations at high temperature to a reduced-symmetry ground state with nematic orientational order and a slightly distorted structure characterized by a centered-rectangular lattice at low temperature.

Cross-sectional study to develop and describe psychometric characteristics of a patient-reported instrument (PROFFIT) for measuring financial toxicity of cancer within a public healthcare system

OBJECTIVES

To measure and explain financial toxicity (FT) of cancer in Italy, where a public healthcare system exists and patients with cancer are not expected (or only marginally) to pay out-of-pocket for healthcare.

SETTING

Ten clinical oncological centres, distributed across Italian macroregions (North, Centre, South and Islands), including hospitals, university hospitals and national research institutes.

PARTICIPANTS

From 8 October 2019 to 11 December 2019, 184 patients, aged 18 or more, who were receiving or had received within the previous 3 months active anticancer treatment were enrolled, 108 (59%) females and 76 (41%) males.

INTERVENTION

A 30-item prefinal questionnaire, previously developed within the qualitative tasks of the project, was administered, either electronically (n=115) or by paper sheet (n=69).

PRIMARY AND SECONDARY OUTCOME MEASURES

According to the protocol and the International Society for Pharmacoeconomics and Outcomes Research methodology, the final questionnaire was developed by mean of explanatory factor analysis and tested for reliability, internal consistency (Cronbach's α test and item-total correlation) and stability of measurements over time (test-retest reliability by intraclass correlation coefficient and weighted Cohen's kappa coefficient).

RESULTS

After exploratory factor analysis, a score measuring FT (FT score) was identified, made by seven items dealing with outcomes of FT. The Cronbach's alpha coefficient for the FT score was 0.87 and the item-total correlation coefficients ranged from 0.53 to 0.74. Further, nine single items representing possible determinants of FT were also retained in the final instrument. Test-retest analysis revealed a good internal validity of the FT score and of the 16 items retained in the final questionnaire.

CONCLUSIONS

The Patient-Reported Outcome for Fighting FInancial Toxicity (PROFFIT) instrument consists of 16 items and is the first reported instrument to assess FT of cancer developed in a country with a fully public healthcare system.

TRIAL REGISTRATION NUMBER

NCT03473379.

Efficacy of Sofosbuvir/Ledipasvir in Adolescents With Chronic Hepatitis C Genotypes 1, 3, and 4: A Real-world Study

OBJECTIVES

Sofosbuvir/Ledipasvir (SOF/LDV) has been approved by the European Medicine Agency (EMA) for the treatment of children and adolescents (at least 3 years of age) with chronic hepatitis C (CHC) genotype 1, 3, and 4 infection. The aim of this study was to evaluate the efficacy and safety of SOF/LDV in adolescents (12 to <18 years old) with CHC in the real-world setting.

METHODS

Prospective, open-label, multicentre study involving 12 Italian centres. Patients received the fixed-dose combination of SOF/LDV (400/90 mg) once daily ± ribavirin as per EMA approval and recommendations. The key efficacy endpoint was sustained virological response 12 weeks after the end of treatment (SVR12) as per intention-to-treat analysis. Safety was assessed by adverse events and clinical/laboratory data.

RESULTS

Seventy-eight consecutive adolescents (median age 15.2 years, range 12-17.9; girls 53.8%) were enrolled and treated between June 2018 and December 2019. Genotype distribution was as follows: genotype 1 (82.1%), 3 (2.5%), and 4 (15.4%). Seventy-six (97.4%) patients completed treatment and follow-up. Overall, SVR12 was 98.7%. One patient was lost to follow-up after 4 weeks of treatment; 1 patient completed treatment and missed the follow-up visit. No virological breakthrough or relapse were observed. No patient experienced grade 3 to 4 adverse event or serious adverse event.

CONCLUSIONS

The results of this real-world study confirmed the high efficacy and the optimal safety profile of SOF/LDV for treatment of CHC in adolescents.

Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with premature ventricular complexes and implications for sports' eligibility assessment

Background

Premature ventricular complexes (PVCs) are a common clinical problem and a critical issue with regard to sports eligibility in sportsmen. Although PVCs can be considered a benign feature of the athlete's heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity. The optimal diagnostic evaluation of athletes with PVCs is currently uncertain.

Purpose

To evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with PVCs.

Methods

We conducted a prospective, single-arm, open-label double center study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to PVCs were included in our study. These athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently, an invasive diagnostic work-up was performed, including EPS with programmed electrical stimulation, EAM and EAM-guided EMB if deemed necessary. When clinically indicated, catheter ablation was performed. Sports eligibility status was re-assessed at six months' follow-up according to Italian sports medicine guidelines.

Results

After diagnostic evaluation, 20 subjects out of 107 (19%) had a diagnosis of heart disease, most commonly myocarditis (n=8), arrhythmogenic right ventricular cardiomyopathy (ARVC, n=7) or dilated cardiomyopathy (DCM, n=2). On multivariate logistic-regression analysis, QRS complex/T wave abnormalities on ECG (OR 23), non left bundle branch block and inferior axis PVC morphology (OR 13), echocardiogram abnormalities (OR 24) and low-voltage areas on EAM (OR 33) were significantly associated with diagnosis of a concealed cardiac disease. Nondiagnostic abnormalities on cMRI were common in this population of athletes, prevalently involving the right ventricle. EAM-guided EMB was performed in 12 subjects (11%) and catheter ablation in 56 (52.3%). After six months, 63 athletes (59%) were judged eligible to participate in competitive sports and 23 subjects (21%) were deemed eligible to participate in non-competitive sports.

Conclusions

Almost one fifth of sportsmen presenting with PVCs have a concealed heart disease, most commonly myocarditis or ARVC. Non-outflow tract PVCs' morphology and abnormalities on ECG, echocardiogram and EAM are predictive of structural heart disease's detection, whereas nondiagnostic findings on cMRI can be misleading in athletes. Invasive diagnostic tests, including EAM and EAM-guided EMB, play a critical role in case of diagnostic uncertainty. More than ¾ of subjects were judged eligible to participate in sports at 6 months' follow-up.

Funding Acknowledgement

Type of funding source: None

P1110Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with complex ventricular arrhythmias and implications for sports" eligibility assessment

Background

ventricular Arrhythmias (VAs) are a common clinical problem and a critical issue with regards to sports" eligibility in athletes. Although VAs can be considered a benign feature of the athlete’s heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity.

Purpose

to evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electrophysiology study (EPS), electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with complex VAs and to derive a multiparametric risk score in order to easily predict structural heart diseases’ diagnosis.

Methods

we conducted a prospective, single-arm, open-label single center, observational study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to complex VAs were enrolled. The athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently EPS, EAM and EAM-guided EMB were performed if deemed necessary. Sports eligibility status was re-assessed at 6 months’ follow-up. A multivariable logistic regression model was built, considering cMRI as the gold standard exam.

Results

after diagnostic evaluation, 55 subjects (26.4%) had a diagnosis of heart disease, most commonly myocarditis (n = 27) and arrhythmogenic right ventricular cardiomyopathy (ARVC, n = 16). After 6 months, 100 athletes (48.1%) were judged eligible to participate in competitive sports and 46 subjects (22.1%) were deemed eligible to participate in non-competitive sports. On multivariable logistic-regression analysis, abnormalities on ECG (OR 5.3) or on echocardiogram (OR 3.7), sustained VA inducibility on EPS (OR 17.7) and low-voltage areas on EAM (OR 7.7) proved all predictive of concealed structural heart diseases’ diagnosis. We derived two simple risk scores: a 40-points risk score and an 8-points risk score (obtained by weighing each variable according to the regression model’s ORs). Both these risk scores’ performance proved very good (AUC = 0.856 for the 40-points score and AUC = 0.852 for the 8-points score, figure 1).

Conclusions

approximately 1/4 of athletes presenting with complex VAs have a concealed heart disease, most commonly myocarditis or ARVC. ECG, echocardiogram and EAM abnormalities and sustained VAs inducibility on EPS are predictive of structural heart diseases’ detection. Therefore, these diagnostic tests should be routinely included in the evaluation of athletes with complex VAs. A risk score including the results of these tests can greatly help in the prediction of concealed structural heart diseases’ diagnosis. More than 2/3 of subjects were judged eligible to participate in sports at 6 months’ follow-up.

Abstract Figure 1. ROC curves for diagnosis

P1033Impact of workflow modifications in atrial fibrillation ablation for reducing the incidence of silent cerebral lesions with a new multi-electrode radiofrequency balloon catheter

Background

Silent cerebral lesions (SCL) often occur after invasive cardiac procedures. Reported SCL incidence with AF ablation varies (incidence, up to 50%), depending on technology used, procedural workflow, and detection method.

Objective

To evaluate the impact of ablation workflow modifications on SCL incidence following pulmonary vein isolation radiofrequency (RF) ablation with a novel multi-electrode RF balloon catheter in patients with symptomatic paroxysmal AF (PAF).

Methods

In the RADIANCE feasibility study of the balloon catheter, all enrolled patients who underwent ablation were screened for SCL using pre- and post-procedural diffusion-weighted MRI. Several modifications were made to the ablation workflow in a subsequent European registration study (SHINE) of the same catheter: eliminating dual transseptal access, using an over-the-wire mini lasso, continuously irrigating all side ports, bolus dosing with heparin before transseptal puncture, maintaining activated clotting time (ACT) at 350–400 sec, and setting a maximum temperature limit of 55°C (previously, 60–65°C). Interim data are presented for SHINE (data cutoff, 22 Oct 2018).

Results

In the neurological assessment evaluable (NAE) populations of RADIANCE (n=38) and SHINE (n=30), respectively, mean ages were 60.8±10.04 and 59.7±7.83 years, and 57.9% and 70.0% were male. One patient in each study had a history of TIAs. SCL incidences were 23.7% (10 lesions in 9 patients) in RADIANCE and 7.1% (2 lesions in 2 patients) in SHINE (excluding 1 SCL that occurred in a patient who failed to meet inclusion criteria [age>75] and 1 SCL that occurred after data cut-off). SHINE NAE enrollment has since completed with no further SCL occurrences. Overall, mean ACTs were 344.3±24.55 sec in RADIANCE and 381.6±73.31 sec in SHINE (p=0.01); in patients with SCL, mean ACTs were 349.3±25.65 and 417.8±87.33 sec, respectively.

Conclusion(s)

Modifications to the workflow led to a decrease in the SCL incidence for PAF ablation using the novel RF balloon catheter.

Acknowledgement/Funding

These studies were sponsored by Biosense Webster, Inc.

P3682Myocardial structural abnormalities in nonischemic patients presenting with ventricular arrhythmias

Background

The diagnosis of concealed cardiomyopathies in patients with ventricular arrhythmias (VAs) is one of the major challenging issues faced by physicians.

Purpose

We aimed at reporting the cardiomyopathic substrate in patients with recurrent arrhythmias of ventricular origin.

Methods

Consecutive patients with unexplained VAs underwent a complete diagnostic work-out, including endomyocardial biopsy (EMB).

Results

Ninety-seven patients were enrolled (76.3% male, age 39.7±13.3 yrs). The presenting arrhythmic manifestation was aborted cardiac arrest in 30 (30.9%) patients, sustained ventricular tachycardia (VT) in 9 (9.3%), nonsustained VT in 15 (15.5%) and frequent premature ventricular complexes in 43 (44.3%). Overall, 350 biopsies were collected (3.6/patient). The incidence of procedure-related complications was 5.1% (n=5): 4 major complications (1 rupture of a tricuspid chorda tendinea w/o hemodynamic impairment, 1 dissection of right external iliac artery treated with stent, 1 thrombotic occlusion of left superficial femoral artery which required surgical treatment, 1 TIA) and 1 minor complication (groin hematoma) occurred. The final diagnosis was arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) (n=41; 42.3%), followed by myocarditis (n=20; 20.6%), dilated cardiomyopathy (n=6; 6.2%), cardiac sarcoidosis (n=6; 6.2%), and myocarditis in ARVD/C (n=5; 5.1%). Among the 25 patients whose final diagnosis was consistent with myocarditis, an acute stage of the disease was documented in 7 (7.2%), while a chronic myocarditis in 18 (18.5%). Additionally, according to medical history and diagnostic workout, in 2 of the 6 patients the dilated cardiomyopathy had a likely post-inflammatory etiology. Absence of myocardial abnormalities was documented in 15 (15.5%) patients: this group included 1 case of methadone-induced torsade de pointes. The remaining 4 (4.1%) patients were diagnosed with a cardiac hypertrophy (n=2, 2.1%, secondary to exercise or Fabry disease), a dilated mitochondrial cardiomyopathy (n=1, 1.0%), a dilated cardiomyopathy in Emery-Dreifuss muscular dystrophy (n=1; 1.0%).

Conclusion

In our series, approximately 45% of patients with unexplained VAs had a final diagnosis of ARVD/C.

P4422Myocarditis: a deceitful but not infrequent athletes' enemy

Introduction

Myocarditis represents a not negligible cause of sudden death (SD) in athletes, representing the cause of 4%-14% cardiac arrests and deaths in athletes. Preparticipation screening including 12-leads basal electrocardiogram could drastically reduce SD in athletes and screening programs are therefore now recommended by most medical and sport association. At the moment, no data in literature are available about incidence of concealed myocarditis in athletes but there is general consensus about disqualification from competitive sport in the presence of myocardial fibrosis (MF).

Purpose

Purpose of our study was to quantify incidence of MF consistent with past myocarditis in athletes that referred to our Sport Cardiology Center for ventricular arrhythmias (VA) +/− repolarization abnormalities (RA) detected at preparticipation screening.

Methods

In our study we retrospectively evaluated all athletes with VA +/− RA and we quantified how many were found to have MF consistent with myocarditis at cardiac MRI. Furthermore, we evaluated characteristics of presentation in terms of clinical symptoms of myocarditis and frequency and morphology of VA. Finally, we analyzed findings of invasive diagnostic workout when performed.

Results

In the last two years we evaluated 111 athletes for VA +/− RA and we found MF consistent with myocarditis in 18 (16%) of them. Only 2/18 referred past febrile status probably correlated with myocarditis and 1 had symptoms consistent with acute myocarditis. Number of VA was not correlated with MF fibrosis, while polymorphic VA and exercise-correlated VA were the most frequent finding. 5/18 (28%) had also rest and/or exercise induced RA. 10/18 (55%) athletes underwent electrophysiological study without any induction of arrhythmias. 7/18 (39%) underwent also electroanatomical mapping (EAM) with pathological findings in 5/7 (71%). All of these 5 underwent endomyocardial biopsy guided by EAM and in 2 cases bioptic findings were consistent with arrhythmogenic cardyomyopahty (ACM). All 18 athletes were disqualified from competitive sport as for Italian Sport Medicine protocols.

Conclusion

MF consistent with past myocarditis is a not infrequent finding in athletes with VA with or without RA. Morphology and exercise behavior of VA are the most important “alarm bell”, while VA number is not correlated with MRI pathological findings. Sometimes MF interpreted as consistent with past myocarditis is actually the manifestation of ACM. Identification of these diseases is of extreme importance for athletes' safety.

P3687Abnormal voltage recordings in patients with ventricular arrhythmias: comparison between right and left cardiomyopathy

Background

Arrhythmogenic Cardio-Myopathy (ACM) is characterized by epi-endocardial fibro-fatty replacement. Depending on the most affected ventricle, right dominant (RDACM) or left dominant (LDACM) phenotypes can be defined. RDACM voltage mapping characteristics have already been described, with late potentials strongly correlating with arrhythmia recurrence risk; LDACM voltage features have not been described yet.

Purpose

To analyze voltage map characteristics in LDACM patients (pts) and compare them with RDACM; to assess if there is any correlation between late potentials and recurrence rate in LDACM as well.

Methods

We retrospectively enrolled all consecutive ACM patients treated c/o our center and diagnosed according to the 2010 Task Force Criteria. Procedural and follow up data were collected. Patient were sorted by ventricular involvement lateralization. Recurrence rates were evaluated and linearly regressed for the presence of late potentials.

Results

89 ACM patients were enrolled (67 RDACM, 22 LDACM; 76% males, 69±4 y.o.) in our study. All patients underwent endocardial voltage mapping; procedurally, 43 (48%) pts underwent catheter ablation, while 46 (52%) were managed conservatively with anti-arrhythmic drugs.

Bipolar pathological potentials were found in 43 (64%) and 13 (59%), unipolar pathological potentials in 45 (67%) and 14 (63%), while late potentials in 19 (31%) and 8 (36%) in the RDACM and LDACM group respectively [p = 0.66, p=0.63, and p=0.33].

The average follow-up was 18 months [14–48]; 15 (22%) in the RDACM and 9 (40%) in LDACM arrhythmic recurrences were respectively encountered; recurrences in both groups were regressed for the presence of late potentials. Results were as follows: the presence of late potentials correlated with recurrences with an 4,3 [1.15–16.1; p=0.03] OR and with an 11 [0.4–85; p=0.022] OR in the RDACM and LDACM group respectively.

Conclusion

Pathologically low unipolar, bipolar and late potentials can be found in comparable % both in RDACM and LDACM; like in RDACM, late potentials represent an important risk factor for arrhythmic recurrence in LDACM as well.

P993Diagnostic accuracy of cardiac magnetic resonance and endomyocardial biopsy for arrhythmogenic right ventricular dysplasia/cardiomyopathy and myocarditis

Introduction

Patients with myocarditis may fulfill the cardiac magnetic resonance (CMR) criteria set forth by the 2010 Task Force for arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), thereby increasing the risk of misdiagnosis.

Purpose

We sought to evaluate the role of CMR and endomyocardial biopsy (EMB) in the differential diagnosis between myocarditis and ARVD/C.

Methods

Consecutive patients presenting with ventricular arrhythmias, underwent a complete diagnostic work-out, which included CMR and EMB. The final diagnosis served as the gold standard to assess the diagnostic accuracy of CMR and EMB.

Results

Overall, 74 consecutive patients presenting with VAs underwent a complete diagnostic workout at our institution. The cohort was 70.3% male, with a mean age of 38.9±12.1 years. A final diagnosis of ARVD/C was made in 30 (40.5%) patients, whereas 19 (25.7%) had a diagnosis of myocarditis.

The McNemar's test showed significant differences in the diagnostic performance of EMB and cardiac MRI (p=0.003 for ARVD/C, p=0.04 for myocarditis).

At receiver operating characteristic (ROC) analyses, the area under the curve (AUC) to discriminate between controls and ARVD/C patients was 0.711 (95% CI: 0.59–0.83) for MRI and 0.944 (95% CI: 0.88–1.00) for biopsy (p<0.001). The AUC to discriminate between controls and patients with myocarditis was 0.656 (95% CI: 0.51–0.80) for MRI and 0.893 (95% CI: 0.80–0.99) for biopsy (p=0.006).

Diagnostic performance of CMR and EMB

Conclusion

Even though CMR has good diagnostic performances as single technique, a complete diagnostic work-out including EMB may frequently reduce the risk of misdiagnoses.

P307Magnetic resonance, electroanatomical mapping, and endomyocardial biopsy to solve the diagnostic and sport eligibility dilemma in a cohort of competitive athletes with ventricular arrhythmias

Background

Ventricular arrhythmias (VAs) are a frequent finding in agonist athletes (athl) at routine sport medicine visits. VAs impact on sport eligibility, their management, and the sudden arrhythmic death risk evaluation in athletes currently represents one of the greatest challenges across both the cardiology and sport medicine field.

Purpose

To describe how an advanced multi-methodical evaluation allowed diagnosis, risk stratification, targeted therapy and sport eligibility reassessment in a competitive athl cohort with ventricular arrhythmias and pathological findings at magnetic resonance (MR).

Methods

All consecutive competitive athl with denied sport eligibility due to ventricular arrhythmias that underwent an advanced invasive evaluation at our institute were enrolled.

A baseline and stress ECG, and late gadolinium enhanced evaluation (LGE) at MR were performed prior to invasive evaluation in all athl.

Invasive evaluation performed in all athl comprised of an electrophysiological study (EPS) to assess arrhythmic inducibility, an endo-cavitary electro-anatomical mapping (EAM), and a EAM and MR guided endo-myocardial biopsy (EMB). A defined diagnosis was postulated in all cases, specific therapeutic interventions were started and sport eligibility status reassessed after 6 months from discharge.

Results

Thirty-two competitive athl were enrolled in our study (32±6 y.o.; 77% male; 4±1 1h-training session/week); 26 (81%) athl practiced a mixed aerobic-anaerobic, 5 (16%) a pure-aerobic, while only 1 (3%) a pure anaerobic sport.

Arrhythmic presentation leading to sport eligibility revoke was: in 13 (40%) athl frequent (>2000/day) premature ventricular contractions (PVCs) at rest, in 2 (6%) PVCs during stress ECG, in 6 (18%) non-sustained ventricular tachycardia (VT), in 8 (25%) sustained VT, and in 3 (11%) ventricular fibrillation/cardiac arrest during sport practice.

MR alterations were described in all cases, and LGE at MR was found in 31 (87%) athl; a definite radiological diagnosis was obtained in 13 (40%) athl.

A normal myocardium at EMB was found only in 3 (8%) pts; in 15 (45%) a leukocyte infiltrate pattern compatible with myocarditis, in 11 (39%) fibro-fatty replacement, in 2 (5%) a mitochondrial disease and in 1 (3%) a sarcoidosis were proven, and diagnosis were consequently postulated.

EPS showed complex VAs inducibility in 8 (25%) cases, while a trans catheter ablation was performed in 10 (31%) athl. A total of 9 (28%) implantable cardioverter devices (ICDs) were implanted, for primary or secondary prevention.

According to invasive diagnostic findings and sport medicine guidelines, 8 (25%) athl had their sport eligibility statuts re-instated.

Conclusion

An invasive multi-methodical assessment allowed in all cases to reach a diagnosis and to start a targeted therapy in a cohort of competitive athl with VA and a pathological MR, granting in a significant (25%) percentage sport eligibility status re-instatement.

Long-term neuropsychological sequelae, emotional wellbeing and quality of life in patients with acquired thrombotic thrombocytopenic purpura

Neurological symptoms related to microthrombosis are the hallmark of acute manifestations of acquired thrombotic thrombocytopenic purpura (TTP). Despite the achievement of hematological remission, patients may report persisting neurological impairment that affects their quality of life. To assess the long-term neuropsychological consequences of acute TTP, we recruited 35 acquired TTP patients (77% females, median age at onset 41 years, interquartile range: 35–48) regularly followed at our out-patient clinic of thrombotic microangiopathies in Milan (Italy) from December 2015 to October 2016. Patients underwent a psychological evaluation of memory and attentional functions, emotional wellbeing and health-related quality of life at least three months after their last acute TTP event (median 36 months, interquartile range: 17–54). During the psychological consultation, 17 patients (49%) referred persisting subjective neurological impairment in the frame of a remission phase, with at least one symptom as disorientation, loss of concentration, dizziness, lack of balance, headache and diplopia. Neuropsychological assessment revealed lower scores than the Italian general population pertaining to direct, indirect and deferred memory. A higher degree of impairment of memory domains was found in patients with neurological involvement at the time of presentation of the first acute TTP episode. Anxiety and depression were detected in seven (20%) and 15 (43%) patients, respectively. Health-related quality of life was lower than the Italian general population, with mental domains more impacted than physical domains (mean difference 58.43, 95% confidence interval: 71.49–45.37). Our study demonstrates compromised memory and attention functions, persisting anxiety/depression symptoms and a generally reduced quality of life in patients recovering from acute acquired TTP. New clinical strategies should be considered to improve these symptoms.

Measuring financial toxicity of cancer in the Italian health care system: Initial results of the patient reported outcome for fighting financial toxicity of cancer project (proFFiT)

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Background: Financial toxicity in cancer patients has been initially reported in the United States and subsequently in other countries, including Italy, despite its health care system is grounded on universal coverage. Considering that the way healthcare and welfare systems are shaped does impact on financial problems faced by cancer patients, we are developing an instrument for evaluating occurrence, gravity, and consequences of financial toxicity in Italy, and hopefully for fighting it. Methods: Concept elicitation, item generation and qualitative analyses represented the initial tasks of the project. Literature review, focus groups with 34 cancer patients or caregivers in three regions located in nothern, central, and southern Italy, and semi-structured interviews with 97 oncologists were conducted for concept elicitation. A recursive process was used to identify themes in the data to inform instrument until saturation was reached. Importance analysis questionnaires were administered to further 44 cancer patients to evaluate and revise the draft item pool. A multi-disciplinary committee (including oncologists, psychologists, statisticians, patient association’s representatives, nurses, social science researchers and economists) oversights the project. Results: Overall, 156 concepts were distributed among 10 themes (bureaucracy, medical care, domestic economy, emotion, family, job, health workers, welfare state, free time, transportation). After controlling for redundancy, 55 candidate items were generated and 30 items, with at least one per each theme, remained after importance analysis. Out of the 30 items, 23 (77%) refer to material conditions, 4 (13%) to psychological response and 3 (10%) to coping behaviors. Conclusions: The first results of the proFFiT project show that most of the items selected by patients are related to material conditions that cause, or derive from, financial hardship. The final questionnaire will be ready by the end of 2019. Supported by Fondazione AIRC IG grant 2017-20402. Clinical trial information: NCT03473379 .

Development and validation of a patient-reported outcome tool to assess cancer-related financial toxicity in Italy: a protocol

INTRODUCTION

Financial toxicity (FT) is a well-recognised problem in oncology. US-based studies have shown that: (a) cancer patients have a 2.7 times risk of bankruptcy; (b) patients who declare bankruptcy have a 79% greater hazard of death; (c) financial burden significantly impairs quality of life (QoL) and (d) reduces compliance and adherence to treatment prescriptions. The aim of the project is to develop and validate a patient-reported-outcome (PRO) measure to assess FT of cancer patients in Italy, where, despite the universal health coverage provided by the National Health Service, FT is an emerging issue.

METHODS AND ANALYSIS

Our hypothesis is that a specific FT measure, which considers the relevant sociocultural context and healthcare system, would allow us to understand the main determinants of cancer-related FT in Italy, in order to address and reduce these factors. According to the International Society for Pharmaco-economics and Outcomes Research guidelines on PROs, the project will include the following steps: (1) concept elicitation (from focus groups with patients and caregivers; literature; oncologists; nurses) and analysis, creating a coding library; (2) item generation (using a format that includes a question and a response on a 4-point Likert scale) and analysis through patients' cognitive interviews of item importance within different coding categories to produce the draft instrument; (3) factor analysis and internal validation (with Cronbach's alpha and test-retest for reliability) to produce the final instrument; (4) external validation with QoL anchors and depression scales. The use of the FT measure in prospective trials is also planned.

ETHICS AND DISSEMINATION

The protocol is approved by the ethical committees of all the participating centres. The project will tentatively produce a validated tool by the spring 2021. The project might also represent a model and the basis for future cooperation with other European countries, with different healthcare systems and socioeconomic conditions.

TRIAL REGISTRATION NUMBER

NCT03473379.

Efficacy and safety of prolonged-release tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus - a Phase 2, open-label, single-arm, one-way crossover study

There are limited clinical data regarding prolonged‐release tacrolimus (PR‐T) use in pediatric transplant recipients. This Phase 2 study assessed the efficacy and safety of PR‐T in stable pediatric kidney, liver, and heart transplant recipients (aged ≥5 to ≤16 years) over 1 year following conversion from immediate‐release tacrolimus (IR‐T), on a 1:1 mg total‐daily‐dose basis. Endpoints included the incidence of acute rejection (AR), a composite endpoint of efficacy failure (death, graft loss, biopsy‐confirmed AR, and unknown outcome), and safety. Tacrolimus dose and whole‐blood trough levels (target 3.5–15 ng/ml) were also evaluated. Overall, 79 patients (kidney, n = 48; liver, n = 29; heart, n = 2) were assessed. Following conversion, tacrolimus dose and trough levels remained stable; however, 7.6–17.7% of patients across follow‐up visits had trough levels below the target range. Two (2.5%) patients had AR, and 3 (3.8%) had efficacy failure. No graft loss or deaths were reported. No new safety signals were identified. Drug‐related treatment‐emergent adverse events occurred in 28 patients (35.4%); most were mild, and all resolved. This study suggests that IR‐T to PR‐T conversion is effective and well tolerated over 1 year in pediatric transplant recipients and highlights the importance of therapeutic drug monitoring to maintain target tacrolimus trough levels.

Etiology, presenting features and outcome of children with non-cirrhotic portal vein thrombosis: A multicentre national study

OBJECTIVES

Non-cirrhotic portal vein thrombosis (PVT) is a main cause of portal hypertension in children. We describe the characteristics at presentation and outcome of a cohort of patients with PVT to determine clinical features and predictors of outcome.

METHODS

We recorded: (1) Associated factors: prematurity, congenital malformations, neonatal illnesses, umbilical vein catheterization (UVC), deep infections, surgery; (2) congenital and acquired prothrombotic disorders; (3) features at last follow up including survival rate and need for surgery.

RESULTS

187 patients, mean age at diagnosis 4 ± 3.7 years, had a history of prematurity (61%); UVC (65%); neonatal illnesses (79%). The diagnosis followed the detection of splenomegaly (40%), gastrointestinal bleeding (36%), hypersplenism (6%), or was incidental (18%). Of 71 patients who had endoscopy at presentation 62 (87%) had oesophageal varices. After 11.3 years' follow up 63 (34%) required surgery or TIPS. Ten-year survival rate was 98%, with 90% shunt patency. Spleen size, variceal bleeding and hypersplenism at presentation were predictors of surgery or TIPS (p < 0.05).

CONCLUSION

PVT is associated with congenital and acquired co-morbidities. History of prematurity, neonatal illnesses and UVC should lead to rule out PVT. Large spleen, variceal bleeding and hypersplenism at presentation predict the need for eventual surgery in a third of cases.

Comparative pharmacokinetics of tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus to prolonged-release tacrolimus formulation

This study was a Phase II, open-label, multicenter, single-arm, cross-over study comparing the pharmacokinetics (PK) of tacrolimus in stable pediatric kidney, liver, or heart allograft recipients converted from immediate-release tacrolimus (IR-T) to prolonged-release tacrolimus (PR-T). In Days -30 to -1 of screening period, patients received their IR-T-based regimen; during Days 1-7, patients received study IR-T (same dose as screening). On Day 7, the first 24-hours PK profile was taken; patients were then converted to PR-T (1 mg:1 mg), with a second 24-hours PK profile taken on Day 14. The primary end-point was tacrolimus area under the blood concentration-time curve over 24 hours (AUC₂₄ ); secondary end-points were maximum concentration C_max and concentration at 24 hours C₂₄ . The predefined similarity interval for confidence intervals (CIs) of least squares mean (LSM) ratios was 80%-125%. The PK analysis set comprised 74 pediatric transplant recipients (kidney, n = 45; liver, n = 28; heart, n = 1). PR-T:IR-T LSM ratio (90% CI) was similar overall for AUC₂₄ , _max , and C₂₄ , and for kidney and liver recipients for AUC₂₄ (LSM ratio, kidney 91.8%; liver 104.1%) and C₂₄ (kidney 90.5%; liver 89.9%). Linear relationship was similar between AUC₂₄ and C₂₄ , and between PR-T and IR-T (rho 0.89 and 0.84, respectively), suggesting that stable pediatric transplant recipients can be converted from IR-T to PR-T at the same total daily dose, using the same therapeutic drug monitoring method.

Long-term follow-up of children and young adults with autoimmune hepatitis treated with cyclosporine

BACKGROUND

Cyclosporine (CSA) is an alternative treatment for autoimmune hepatitis (AIH), however, its unknown long-term safety and efficacy have limited its use.

AIMS

Examine the long-term outcome of children and young adults with AIH treated with CSA for at least 4 years.

METHODS

Twenty patients were included in this retrospective study: 15 with classical AIH and 5 with autoimmune hepatitis/autoimmune sclerosing cholangitis overlap syndrome (ASC). CSA was administered as first (12 patients) or second-line (8 patients) treatment, alone or in combination with azathioprine or mycophenolate mofetil and/or prednisone.

RESULTS

CSA determined initial clinical and biochemical remission in all patients. At the end of follow-up (median 8.6; range 4-20.4 years), all patients are alive with their native liver; 15 in complete remission (75%), 2 with incomplete response to treatment and 3 listed for liver transplant. Side effects were mild and transitory after dose tapering or, in 1 case, after CSA withdrawal. Hypertrichosis and moderate gingival hyperplasia were the most frequent. Two patients presented mild transient glomerular filtration rate (GFR) reduction. Median GFR at the beginning and end of treatment was not statistically different for all patients.

CONCLUSIONS

CSA was effective and safe in the long-term treatment of our cohort of patients with AIH, tailoring the treatment remains key-points during CSA administration.

Level of empowerment and decision-making style of women with epilepsy in childbirth age

OBJECTIVES

This research investigates level of empowerment, decisional skills, and the perceived relationship with the clinician, of women in childbirth age, also in relationship with clinical variables such as epilepsy type, seizure frequency, therapy, and pregnancy status. In particular, as concerning therapy, we were interested in women who take valproic acid (VPA), for its specific balance of risks and benefits, especially in pregnant women.

METHODS

The sample is composed of 60 women with epilepsy (6 were excluded), who underwent a standardized clinical protocol for assessment of level of empowerment, decisional skills, and of their judgment about how they feel to be involved by their clinician in medical decision making.

RESULTS

Overall, the sample does not show signs of low empowerment level nor of abnormal decision-making patterns. The type of epilepsy, the frequency of seizures, and the treatment type (VPA versus no VPA) do not impact on empowerment, on decision styles, nor on medical relationship, with the only exception of a specific decision style, the avoidant style, that is more frequent in women treated with VPA with respect to those taking other therapies. Interestingly, regarding VPA dosage, we found that women taking equal or more than 700 mg/day of VPA have lower scores on empowerment in all dimensions compared with women with a VPA dosage lower than 700 mg/day.

CONCLUSIONS

Shared decision making including improved decision quality, more informed choices and better treatment concordance, should be a central part of epilepsy care. In addition, for clinicians it would be useful to have specific tools to know if the patient has really understood the risks and benefits of antiepileptic drugs (AEDs), particularly VPA, and all treatment alternatives.

Biased Perceptions and Personality Traits Attribution: Cognitive Aspects in Future Interventions for Organizations

In most European countries, the proportion of females and males pursuing a career in Technology and Engineering is quite different. The under-representation of women in these jobs may be attributable to a variety of factors, one of which could be the negative and stereotyped perception of these work sectors as unsuitable for women. The purpose of this study was to determine whether stereotyped perceptions impact the job representation of males and females in the Construction Industry, which is a particularly male-dominated work sector. Three construction organizations in the West Midlands (United Kingdom) were studied by means of ethnographic interviews and observations. Three (6.7%) of the 45 research participants (mean age 44.3) were women (focusing only in people working in Construction sites). There was a high differentiation of activities between the males and females. Biased perceptions and personality traits attribution played a fundamental role in such a differentiation. Despite some main limitations (low generalisability, lack of longitudinal findings), this study focused on some important practical implications for current work policies: changing the mindsets of people (starting from school age), using new flexible strategies and creating the role of internal advocates. The findings provide definitive evidence of the need to increase the promotion of social communication and public campaigns on gender equalities in male-dominated work sectors, taking into account the cognitive processes behind gender differences. The findings also give new hints on re-thinking the contribution of Psychology, particularly Cognitive Psychology, in fields with allegedly wide gender gaps.

Role of low field MRI in detecting knee lesions

Objective: The aim of this work is to evaluate the diagnostic accuracy of 0.3T sectoral MR imaging, compared with arthroscopy, for meniscal, cruciate ligaments and chondral knee lesions. Materials and Methods: We conducted a retrospective study analyzing all the consecutive knees subjected to arthroscopy at our institution between January 2014 and June 2017 and preceded within 3 months by knee MR examination at our institution with 0.3 T equipment. Patients with history of a new trauma in the time interval between MR exam and arthroscopy were excluded from the study. Two independent experienced radiologists evaluated in double blind the MR findings of menisci, cruciate ligaments and articular cartilage. Both radiological findings were independently compared with those of the arthroscopic report considered as gold standard. For each of the examined targets we calculated the following parameters: sensitivity, specificity, accuracy, positive and negative predictive value; interobserver concordance statistically calculated using Cohen’s Kappa test. Results: 214 knees (95R/119L) of 214 patients (143M/71F) aged from 18 to 72 years (mean 44) were included and analyzed. We found a good diagnostic accuracy of the low field MR in identifying the injuries of the menisci (93%) and the crossed ligaments (96%), but a lower accuracy for the articular cartilage (85%). Sensitivity resulted 90% for menisci, 73% for ligaments and 58% for cartilage. Specificity was 91% for menisci, 97% for ligaments and 92% for cartilage. Inter-observer concordance resulted to be excellent for cruciate ligaments (K of Cohen’s test = 0.832), good (K = 0.768) for menisci, modest to moderate for articular cartilage (K from 0.236 to 0.389) with worse concordance for tibial cartilage. Conclusions: Low-field MR sectoral device with dedicated joint equipment confirms its diagnostic reliability for the evaluation of meniscal and cruciate ligaments lesions but is weak in evaluating low grade chondral lesions. (www.actabiomedica.it)

Impact on Prehospital Delay of a Stroke Preparedness Campaign: A SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial)

BACKGROUND AND PURPOSE

Public campaigns to increase stroke preparedness have been tested in different contexts, showing contradictory results. We evaluated the effectiveness of a stroke campaign, designed specifically for the Italian population in reducing prehospital delay.

METHODS

According to an SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial) design, the campaign was launched in 4 provinces in the northern part of the region Emilia Romagna at 3-month intervals in randomized sequence. The units of analysis were the patients admitted to hospital, with stroke and transient ischemic attack, over a time period of 15 months, beginning 3 months before the intervention was launched in the first province to allow for baseline data collection. The proportion of early arrivals (within 2 hours of symptom onset) was the primary outcome. Thrombolysis rate and some behavioral end points were the secondary outcomes. Data were analyzed using a fixed-effect model, adjusting for cluster and time trends.

RESULTS

We enrolled 1622 patients, 912 exposed and 710 nonexposed to the campaign. The proportion of early access was nonsignificantly lower in exposed patients (354 [38.8%] versus 315 [44.4%]; adjusted odds ratio, 0.81; 95% confidence interval, 0.60-1.08; P=0.15). As for secondary end points, an increase was found for stroke recognition, which approximated but did not reach statistical significance (P=0.07).

CONCLUSIONS

Our campaign was not effective in reducing prehospital delay. Even if some limitations of the intervention, mainly in terms of duration, are taken into account, our study demonstrates that new communication strategies should be tested before large-scale implementation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01881152.

Medical decision making and risky choices: psychological and medicolegal consequences of HIV and HCV contamination of blood products

Aims

The overall goal of this article is to make a scientific comment about the psycho-social consequences of hemophilia patients affected by human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) and to point out the related medicolegal issues.

Methods

This commentary takes into account some published evidences about the current scenario of hemophilia patients infected by HIV and/or HCV who received contaminated blood products in the late 1970s through 1985.

Results

Several psychological and medicolegal consequences are related with HIV and HCV contamination of blood products. A multidisciplinary approach is needed to treat all the difficulties experienced by these patients and to ensure good clinical decisions in medical practice.

Conclusion

The literature on the psychosocial functioning of hemophilia patients with human HIV and HCV infection offers a number of implications, including medicolegal issues, that can be discussed for guaranteeing a good level of care and safeguard of this group of patients.

Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: A meta-synthesis of qualitative evidence

Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies is necessary. A greater employment of psychological skills, enhancing communication abilities and tools to overcome disempowering attitudes should inform care organisation, resulting in more efficient and satisfactory use of services. Public health communication about prevention and management of frailty should be founded on a paradigm of resilience, balanced acceptance, and coping. Addressing stakeholders’ views about the preventability of frailty was seen as a salient need.

A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory

Stress has been extensively studied as a psychosomatic factor associated with breast cancer. This study aims to review the prevalence of post-traumatic stress disorder (PTSD), its associated risk factors, the role of predicting factors for its early diagnosis/prevention, the implications for co-treatment, and the potential links by which stress could impact cancer risk, by closely examining the literature on breast cancer survivors. The authors systematically reviewed studies published from 2002 to 2016 pertaining to PTSD, breast cancer and PTSD, and breast cancer and stress. The prevalence of PTSD varies between 0% and 32.3% mainly as regards the disease phase, the stage of disease, and the instruments adopted to detect prevalence. Higher percentages were observed when the Clinician Administered PTSD Scale was administered. In regard to PTSD-associated risk factors, no consensus has been reached to date; younger age, geographic provenance with higher prevalence in the Middle East, and the presence of previous cancer diagnosis in the family or relational background emerged as the only variables that were unanimously found to be associated with higher PTSD prevalence. Type C personality can be considered a risk factor, together with low social support. In light of the impact of PTSD on cognitive, social, work-related, and physical functioning, co-treatment of cancer and PTSD is warranted and a multidisciplinary perspective including specific training for health care professionals in communication and relational issues with PTSD patients is mandatory. However, even though a significant correlation was found between stressful life events and breast cancer incidence, an unequivocal implication of distress in breast cancer is hard to demonstrate. For the future, overcoming the methodological heterogeneity represents one main focus. Efficacy studies could help when evaluating the effect of co-treating breast cancer and post-traumatic stress symptoms, even if all the criteria for a Diagnostic and Statistical Manual of Mental Disorders diagnosis are not fulfilled.