Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Regulating emotions about secrets

Secrecy is common and psychologically costly. Research shows that secrets have high emotional stakes, but no research has directly tested how people regulate their emotions about secrets. To fill this gap, we conducted an experimental study (Study 1), then moved to studying secrecy "in the wild" to capture regulatory processes as they unfold in everyday life (Studies 2 and 3). In Study 1 (N = 498), people reported using different strategies to regulate emotions about secrets compared to matched nonsecrets. In two daily diary studies (NStudy 2 = 174, 1,059 surveys; NStudy 3 = 240, 2,764 surveys), participants reported engaging in acceptance, distraction, and expressive suppression most-and social sharing least-to manage emotions about secrets. Moreover, in testing which kinds of secrets required most regulation, Study 3 suggested that significant, negative, controllable, and socially harmful secrets were associated with greater use of rumination, distraction, and suppression; perceived immorality of keeping secrets was associated with greater use of reappraisal; and secret discoverability did not differentially predict regulation strategies. Our findings indicate that when regulating emotions about their secrets, people appear to prioritize their intention to keep secret information hidden, despite potential well-being costs that may come with enacting this intention. Understanding the regulatory processes involved in secrecy is a foundation on which future research can build to identify ways of alleviating the burden of secrecy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Artificial intelligence in the diagnosis and treatment of acute appendicitis: a narrative review

Artificial intelligence is transforming healthcare. Artificial intelligence can improve patient care by analyzing large amounts of data to help make more informed decisions regarding treatments and enhance medical research through analyzing and interpreting data from clinical trials and research projects to identify subtle but meaningful trends beyond ordinary perception. Artificial intelligence refers to the simulation of human intelligence in computers, where systems of artificial intelligence can perform tasks that require human-like intelligence like speech recognition, visual perception, pattern-recognition, decision-making, and language processing. Artificial intelligence has several subdivisions, including machine learning, natural language processing, computer vision, and robotics. By automating specific routine tasks, artificial intelligence can improve healthcare efficiency. By leveraging machine learning algorithms, the systems of artificial intelligence can offer new opportunities for enhancing both the efficiency and effectiveness of surgical procedures, particularly regarding training of minimally invasive surgery. As artificial intelligence continues to advance, it is likely to play an increasingly significant role in the field of surgical learning. Physicians have assisted to a spreading role of artificial intelligence in the last decade. This involved different medical specialties such as ophthalmology, cardiology, urology, but also abdominal surgery. In addition to improvements in diagnosis, ascertainment of efficacy of treatment and autonomous actions, artificial intelligence has the potential to improve surgeons' ability to better decide if acute surgery is indicated or not. The role of artificial intelligence in the emergency departments has also been investigated. We considered one of the most common condition the emergency surgeons have to face, acute appendicitis, to assess the state of the art of artificial intelligence in this frequent acute disease. The role of artificial intelligence in diagnosis and treatment of acute appendicitis will be discussed in this narrative review.

Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition

We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

A Higher Kick Frequency Swimming Training Program Optimizes Swim-to-Cycle Transition in Triathlon

ABSTRACT

Ambrosini, L, Presta, V, Vitale, M, Menegatti, E, Guarnieri, A, Bianchi, V, De Munari, I, Condello, G, and Gobbi, G. A higher kick frequency swimming training program optimizes swim-to-cycle transition in triathlon. J Strength Cond Res XX(X): 000-000, 2023-The purpose of this study was to evaluate the effect of an 8-week swimming training program on biomechanical and physiological responses during a swim-to-cycle simulation. Fifteen triathletes were randomly allocated to 3 groups: a 6-beat-kick group (K6), a 4-beat-kick group (K4), and a control group (CG). Biomechanical and physiological parameters were evaluated during a 400-m swim and a 10-minute cycle segment before (Pretraining) and after (Posttraining) the program. A lower stroke frequency (p = 0.004) and a higher stroke length (p = 0.002) was found in K6 compared with CG at Posttraining. A reduction in the K6 emerged between Pretraining and Posttraining during cycling for heart rate (p = 0.005), V̇O2 (p = 0.014), and energy expenditure (p = 0.008). A positive association emerged between swim kick index and cycling cadence in the K6 group. The improvement in stroke frequency and length observed in the K6 group could be explained as an improvement in swimming technique. Similarly, the reduction in energy expenditure during cycling at Posttraining for the K6 group suggests an improvement in the working economy. Triathlon coaches and athletes should consider the inclusion of high swim kick into their training programs to enhance swim and cycling performance, which can ultimately lead to an improvement in the swim-to-cycle transition and the overall triathlon performance.

Right frontal cingulate cortex mediates the effect of prenatal complications on youth internalizing behaviors

Prenatal and perinatal complications represent well-known risk factors for the future development of psychiatric disorders. Such influence might become manifested during childhood and adolescence, as key periods for brain and behavioral changes. Internalizing and externalizing behaviors in adolescence have been associated with the risk of psychiatric onset later in life. Both brain morphology and behavior seem to be affected by obstetric complications, but a clear link among these three aspects is missing. Here, we aimed at analyzing the association between prenatal and perinatal complications, behavioral issues, and brain volumes in a group of children and adolescents. Eighty-two children and adolescents with emotional-behavioral problems underwent clinical and 3 T brain magnetic resonance imaging (MRI) assessments. The former included information on behavior, through the Child Behavior Checklist/6-18 (CBCL/6-18), and on the occurrence of obstetric complications. The relationships between clinical and gray matter volume (GMV) measures were investigated through multiple generalized linear models and mediation models. We found a mutual link between prenatal complications, GMV alterations in the frontal gyrus, and withdrawn problems. Specifically, complications during pregnancy were associated with higher CBCL/6-18 withdrawn scores and GMV reductions in the right superior frontal gyrus and anterior cingulate cortex. Finally, a mediation effect of these GMV measures on the association between prenatal complications and the withdrawn dimension was identified. Our findings suggest a key role of obstetric complications in affecting brain structure and behavior. For the first time, a mediator role of frontal GMV in the relationship between prenatal complications and internalizing symptoms was suggested. Once replicated on independent cohorts, this evidence will have relevant implications for planning preventive interventions.

Secrecy in Everyday Life

Secrecy is common, yet we know little about how it plays out in daily life. Most existing research on secrecy is based on methods involving retrospection over long periods of time, failing to capture secrecy "in the wild." Filling this gap, we conducted two studies using intensive longitudinal designs to present the first picture of secrecy in everyday life. We investigated momentary contextual factors and individual differences as predictors of mind-wandering to and concealing secrets. Contextual factors more consistently predicted secrecy experiences than person-level factors. Feeling more negative about a secret predicted a greater likelihood of mind-wandering to the secret. Interacting with the secret target was linked with a greater likelihood of secret concealment. Individual differences were not consistently associated with mind-wandering to secrets. We conclude that daily experiences with secrets may be better predicted by momentary feelings rather than individual differences such as personality traits.

A phase 1 trial of adoptive transfer of vaccine-primed autologous circulating T cells in ovarian cancer

We have previously shown that vaccination with tumor-pulsed dendritic cells amplifies neoantigen recognition in ovarian cancer. Here, in a phase 1 clinical study ( NCT01312376 /UPCC26810) including 19 patients, we show that such responses are further reinvigorated by subsequent adoptive transfer of vaccine-primed, ex vivo-expanded autologous peripheral blood T cells. The treatment is safe, and epitope spreading with novel neopeptide reactivities was observed after cell infusion in patients who experienced clinical benefit, suggesting reinvigoration of tumor-sculpting immunity.

Targeting of multiple tumor-associated antigens by individual T cell receptors during successful cancer immunotherapy

The T cells of the immune system can target tumors and clear solid cancers following tumor-infiltrating lymphocyte (TIL) therapy. We used combinatorial peptide libraries and a proteomic database to reveal the antigen specificities of persistent cancer-specific T cell receptors (TCRs) following successful TIL therapy for stage IV malignant melanoma. Remarkably, individual TCRs could target multiple different tumor types via the HLA A∗02:01-restricted epitopes EAAGIGILTV, LLLGIGILVL, and NLSALGIFST from Melan A, BST2, and IMP2, respectively. Atomic structures of a TCR bound to all three antigens revealed the importance of the shared x-x-x-A/G-I/L-G-I-x-x-x recognition motif. Multi-epitope targeting allows individual T cells to attack cancer in several ways simultaneously. Such "multipronged" T cells exhibited superior recognition of cancer cells compared with conventional T cell recognition of individual epitopes, making them attractive candidates for the development of future immunotherapies.

Surgical complications of oncological treatments: A narrative review

Gastrointestinal complications are common in patients undergoing various forms of cancer treatments, including chemotherapy, radiation therapy, and molecular-targeted therapies. Surgical complications of oncologic therapies can occur in the upper gastrointestinal tract, small bowel, colon, and rectum. The mechanisms of action of these therapies are different. Chemotherapy includes cytotoxic drugs, which block the activity of cancer cells by targeting intracellular DNA, RNA, or proteins. Gastrointestinal symptoms are very common during chemotherapy, due to a direct effect on the intestinal mucosa resulting in edema, inflammation, ulceration, and stricture. Serious adverse events have been described as complications of molecular targeted therapies, including bowel perforation, bleeding, and pneumatosis intestinalis, which may require surgical evaluation. Radiotherapy is a local anti-cancer therapy, which uses ionizing radiation to cause inhibition of cell division and ultimately lead to cell death. Complications related to radiotherapy can be both acute and chronic. Ablative therapies, including radiofrequency, laser, microwave, cryoablation, and chemical ablation with acetic acid or ethanol, can cause thermal or chemical injuries to the nearby structures. Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication. Furthermore, it is important to know the stage and prognosis of the disease, and a multidisciplinary approach is necessary to personalize the surgical treatment. The purpose of this narrative review is to describe complications related to different oncologic therapies that may require surgical interventions.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Pattern of Distribution of Lymph Node Metastases in Individual Stations in Middle and Lower Gastric Carcinoma

(1) Background: Lymph node (LN) dissection is the cornerstone of curative treatment of GC. The pattern of distribution of LN metastases is closely related to several factors. The aim of this study is to evaluate the factors determining the distribution of nodal metastases in a population of N+ distal GC patients undergoing gastrectomy and D2 lymphadenectomy. (2) Methods: The medical charts of 162 N+ GC patients who underwent surgical resection over a 15-year period were retrospectively analyzed. Clinical, pathological and anatomical characteristics were evaluated to identify the factors affecting the patterns and prevalence of metastases in individual LN stations. (3) Results: LN metastasis is correlated with the depth of the tumor and to diffuse-type tumors. A higher number of metastatic nodes was documented in patients with middle-third tumors (8.2 ± 7.3 vs. 4.5 ± 5.0 in lower-third tumors, p = 0.0001) and in patients with tumors located on the lesser curve. Station 4 showed the highest rate of metastases (53.1%). Concerning stations 7 to 12, station 8 showed the highest metastasis rate (28.4%). Metastases at stations 1, 2, 4 and 7 to 11 were dominant in middle-third cancer, whereas stations 5 and 6 were dominant in lower-third cancers. Station 4, 5, 6, 10 and 11 metastases were dominant when the cancer was located on the greater curve, whereas stations 1, 2, 7, 8 and 12 were dominant in lesser-curve cancers. (4) Conclusions: The study documented that in patients with distal GC, the distribution of nodal metastases at individual stations is closely related to primary tumor location.

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BACKGROUND

Perforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.

METHODS

A retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.

RESULTS

A total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 ± 37.2 vs LapA 88.47 ± 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 ± 12 vs LapA 10.3 ± 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.

CONCLUSIONS

Based on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Impact of treatment with dimethyl fumarate on sleep quality in patients with relapsing-remitting multiple sclerosis: A multicentre Italian wearable tracker study

Background

Sleep disorders are common in patients with multiple sclerosis and have a bidirectional interplay with fatigue and depression.

Objective

To evaluate the effect of treatment with oral dimethyl fumarate on the quality of sleep in relapsing-remitting multiple sclerosis.

Methods

This was a multicentre observational study with 223 relapsing-remitting multiple sclerosis subjects starting treatment with dimethyl fumarate (n=177) or beta interferon (n=46). All patients underwent subjective (Pittsburgh Sleep Quality Index) and objective (wearable tracker) measurements of quality of sleep. Fatigue, depression, and quality of life were also investigated and physical activity was monitored.

Results

Patients treated with dimethyl fumarate had significant improvement in the quality of sleep as measured with the Pittsburgh Sleep Quality Index (p<0.001). At all-time points, no significant changes in Pittsburgh Sleep Quality Index score were observed in the interferon group. Total and deep sleep measured by wearable tracker decreased at week 12 with both treatments, then remained stable for the total study duration. Depression significantly improved in patients treated with dimethyl fumarate. No significant changes were observed in mobility, fatigue and quality of life.

Conclusion

In patients with relapsing-remitting multiple sclerosis, the treatment with dimethyl fumarate was associated with improvements in patient-reported quality of sleep. Further randomised clinical trials are needed to confirm the benefits of long-term treatment with dimethyl fumarate.

Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors

BACKGROUND

Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.

AIM

To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.

METHODS

To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.

RESULTS

The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.

CONCLUSION

Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.

Implantable defibrillator-detected heart failure status predicts ventricular tachyarrhythmias

Background

The occurrence of ventricular tachyarrhythmias is associated with increased mortality and hospitalizations for heart failure in implantable cardioverter defibrillator (ICD) patients. Nonetheless, the temporal relationship between heart failure worsening and ventricular tachyarrhythmias has been scarcely explored so far.

Purpose

We hypothesized that in patients with heart failure and reduced ejection fraction with ICDs, physiological sensor-based heart failure status, as reflected in the HeartLogic index, would predict appropriate device therapies for ventricular tachyarrhythmias (shocks and antitachycardia pacing).

Methods and results

568 patients implanted with ICDs (n=410, 72%) or cardiac resynchronization therapy-defibrillators (CRT-D, n=158, 28%) endowed with the HeartLogic algorithm were included in this prospective observational multicenter analysis. Over a follow-up of 25 [25th-75th percentile: 15–35] months, 122 (21%) patients received an appropriate device therapy (shock, n=74, 13%), while the HeartLogic index crossed the threshold value 1200 times (0.71 alerts/patient-year) in 370 subjects (65%). The occurrence of at least one HeartLogic alert was significantly associated with both appropriate shocks (HR: 2.44, 95% CI: 1.49–3.97, p=0.003) and any ICD therapies (HR: 1.95, 95% CI: 1.37–2.85, p=0.003). Using a time-dependent Cox model, the weekly IN-alert state was the strongest predictor of ICD shocks (HR: 2.94, 95% CI: 1.73–5.01, p&lt;0.001), after correction for age, secondary prevention, and use of CRT. As compared to clinically stable subjects with no therapies, patients experiencing shocks had significantly higher baseline values of the HeartLogic index, third heart sound amplitude, and respiratory rate. Beginning about one month prior to the arrhythmic event, we noticed further increase of the combined index and the third heart sound amplitude, a decrease of thoracic impedance, and higher resting heart rate (Figure 1).

Conclusions

The HeartLogic index is an independent predictor of appropriate defibrillator therapies. The combined index and its individual physiological components change well before the arrhythmic event, suggesting the existence of a window of opportunity to prevent shocks.

Funding Acknowledgement

Type of funding sources: None.

SARS-CoV-2 and the pancreas: What do we know about acute pancreatitis in COVID-19 positive patients?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause pancreatic damage, both directly to the pancreas via angiotensin-converting enzyme 2 receptors (the transmembrane proteins required for SARS-CoV-2 entry, which are highly expressed by pancreatic cells) and indirectly through locoregional vasculitis and thrombosis. Despite that, there is no clear evidence that SARS-CoV-2 is an etiological agent of acute pancreatitis. Acute pancreatitis in coronavirus disease 2019 (COVID-19) positive patients often recognizes biliary or alcoholic etiology. The prevalence of acute pancreatitis in COVID-19 positive patients is not exactly known. However, COVID-19 positive patients with acute pancreatitis have a higher mortality and an increased risk of intensive care unit admission and necrosis compared to COVID-19 negative patients. Acute respiratory distress syndrome is the most frequent cause of death in COVID-19 positive patients and concomitant acute pancreatitis. In this article, we reported recent evidence on the correlation between COVID-19 infection and acute pancreatitis.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient’s presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

Smart Immunosensors for Point-of-Care Serological Tests Aimed at Assessing Natural or Vaccine-Induced SARS-CoV-2 Immunity

Innovative and highly performing smart voltammetric immunosensors for rapid and effective serological tests aimed at the determination of SARS-CoV-2 antibodies were developed and validated in human serum matrix. Two immunosensors were developed for the determination of immunoglobulins directed against either the nucleocapsid or the spike viral antigen proteins. The immunosensors were realized using disposable screen-printed electrodes modified with nanostructured materials for the immobilization of the antigens. Fast quantitative detection was achieved, with analysis duration being around 1 h. Signal readout was carried out through a smart, compact and battery-powered potentiostat, based on a Wi-Fi protocol and devised for the Internet of Things (IoT) paradigm. This device is used for the acquisition, storage and sharing of clinical data. Outstanding immunosensors' sensitivity, specificity and accuracy (100%) were assessed, according to the diagnostic guidelines for epidemiological data. The overall performance of the sensing devices, combined with the portability of the IoT-based device, enables their suitability as a high-throughput diagnostic tool. Both of the immunosensors were validated using clinical human serum specimens from SARS-CoV-2 infected patients, provided by IRCCS Ospedale San Raffaele.

P-563 The effect of embryo culture time on concordance rates between invasive and non-invasive preimplantation genetic testing for aneuploidies (niPGT-A) in spent culture media (SCM) analysis

Study question

To evaluate different embryo culture times (day5 versus day6) to understand the ideal time-frame for the performance of concordance analysis between invasive and non-invasive PGT-A(niPGT-A)

Summary answer

Different levels of ploidy concordance rates were observed between day5 and day6 groups: 72,6% versus 84,8%, respectively

What is known already

The recent data supports that a non-invasive approach for evaluating embryo ploidy status may be an alternative to standard invasive methods. Embryo cell-free DNA(cfDNA) released into culture media during in-vitro embryo development represents the potential source for this analysis. The release of cfDNA from embryos is expected to be directly proportional to embryo culture time and late-stage released cfDNA may be more representative of the embryo. Therefore, it is important to estimate the most effective time frame of the culture that will provide the most conclusive data from spent-culture-media(SCM) without adversely affecting the development of the embryo

Study design, size, duration

A total of 334 SCM from blastocyst stage embryos have been included in this study. The SCM samples were divided in 2 subgroups according to the embryo culture time as day5 (n = 154) and day6 (n = 180). The cfDNA of SCM samples were amplified by whole genome amplification(WGA) and analyzed by next generation sequencing(NGS) in parallel to day5 or day6 trophectodermal(TE) biopsied samples of their corresponding embryos. Ploidy status and concordance were compared between two groups

Participants/materials, setting, methods

Day3 embryos were washed and transferred in 20µl fresh culture media until the biopsy. SCM samples were collected in PCR tubes and stored at -20 °C while embryos were biopsied for standard PGT-A analysis. Both SCM and corresponding TE biopsy samples were amplified by Sureplex(Vitrolife). Then TE and SCM samples were analyzed by next-generation sequencing(NGS) using MiSeq® System (Illumina). Data analysis has been done by Bluefuse Multi Software 4.5(Illumina) for all SCM and TE samples

Main results and the role of chance

A successful DNA amplification rate (&gt;30ng/µl) was obtained in both day5 and day6 groups with 95,5% (147/154) and 99,4% (179/180) respectively. The DNA concentration after WGA was ranging between 30.1-122.5ng/µl and 38.5-123.2ng/µl in day5 and day6 groups respectively. Not conclusive (NC) results including a noisy NGS profile and chaotic chromosome aneuploidies (&gt;5 chromosomes) were excluded in both groups. Therefore, 64,6% (95/147) of SCM samples in day5 group and 81,0% (145/179) of SCM samples in day6 group were conclusive for NGS analysis. The ploidy concordance rate between SCM and TE samples (euploid vs euploid, aneuploid vs aneuploid) was 72,6% (69/95) in day5 and 84,8% (123/145) in day6 group. In day5 group, the false-negative rate was 10.5% (10/95), and false-positive rate was 16.8% (16/95) while in day6 group the false-negative rate was 6,8% (10/145), and false-positive rate was 8,2% (12/145). Sensitivity and specificity were calculated as 83,6% and 52,9% in day5 group, and 90,9% and 65,7 in day6 group respectively

Limitations, reasons for caution

We have high number of samples in our study, but larger prospective studies may change the significance of ploidy concordance. One of the important issues in SCM analysis is the maternal DNA contamination risk which cannot be revealed always. Therefore the use of molecular markers would increase the reliability

Wider implications of the findings

A non-invasive approach for aneuploidy screening may be an alternative to standard PGT-A procedure with invasive embryo biopsy but the evaluation of ideal culture time is crucial for the performance of niPGT-A method. Our study demonstrates that the late collection time of SCM provides significantly better ploidy concordance rates

Trial registration number

Not applicable

Rapid Quantification of SARS-Cov-2 Spike Protein Enhanced with a Machine Learning Technique Integrated in a Smart and Portable Immunosensor

An IoT-WiFi smart and portable electrochemical immunosensor for the quantification of SARS-CoV-2 spike protein was developed with integrated machine learning features. The immunoenzymatic sensor is based on the immobilization of monoclonal antibodies directed at the SARS-CoV-2 S1 subunit on Screen-Printed Electrodes functionalized with gold nanoparticles. The analytical protocol involves a single-step sample incubation. Immunosensor performance was validated in a viral transfer medium which is commonly used for the desorption of nasopharyngeal swabs. Remarkable specificity of the response was demonstrated by testing H1N1 Hemagglutinin from swine-origin influenza A virus and Spike Protein S1 from Middle East respiratory syndrome coronavirus. Machine learning was successfully used for data processing and analysis. Different support vector machine classifiers were evaluated, proving that algorithms affect the classifier accuracy. The test accuracy of the best classification model in terms of true positive/true negative sample classification was 97.3%. In addition, the ML algorithm can be easily integrated into cloud-based portable Wi-Fi devices. Finally, the immunosensor was successfully tested using a third generation replicating incompetent lentiviral vector pseudotyped with SARS-CoV-2 spike glycoprotein, thus proving the applicability of the immunosensor to whole virus detection.

The subcutaneous ICD replacement in the clinical practice: preliminary observations from the multicentre RHYTHM DETECT

Funding Acknowledgements

Type of funding sources: None.

Background

Experience with the subcutaneous implantable cardioverter-defibrillator (S-ICD) is expanding rapidly. However, few data on generator replacement exist.

Purpose

The aim of this analysis was to describe the procedural characteristics of the pulse generator replacement in the current Italian practice and to provide a preliminary insight in the possible acute complications associated with first elective S-ICD generator replacements.

Methods

We analyzed 106 consecutive patients enrolled in the Rhythm Detect registry who underwent elective replacement of the S-ICD generator from September 2019 to July 2021. Procedures were accomplished according to the local clinical practice. A chest X-ray was performed, and the PRAETORIAN score was assessed and compared with the one measured after the first implantation.

Results

All replacements were performed in electrophysiology laboratories, 50% in day-hospital regimen, by 1 or 2 expert operators. Procedures were performed using local (87%) or general anaesthesia (13%). The median procedure duration was 40 (30-45) min. The previous S-ICD generator was in a subcutaneous pocket in 58 (55%) patients, and in an intermuscular pocket in the remaining patients. The PRAETORIAN score of the previous system was low (&lt;90) in 93% of patients and intermediate in 7% of patients. In all patients with the device in an intermuscular pocket, the PRAETORIAN score was &lt;90. During the replacement procedure, 22 S-ICD (3 with PRAETORIAN ≥90 before replacement) were removed from the initial subcutaneous position and placed in an intermuscular pocket. After replacement all patients with intermuscular devices had a score &lt;90, and the overall proportion of patients with low-risk PRAETORIAN score raised to 97%. Defibrillation testing was performed only in 10% of patients, while testing was performed in 77% of patients at the first implantation procedure. No procedure-related complications occurred.

Conclusions

S-ICD replacements seem easy to perform with no peri-procedural complications. The adoption of an intermuscular pocket is associated with optimal positioning according to the PREATORIAN score, and seems preferred also in many cases of generators previously placed subcutaneously. In the Italian clinical practice conversion testing is rarely performed at device replacement.

Device-detected sleep-disordered breathing predicts implantable defibrillator therapy in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Sleep-disordered breathing is highly prevalent in heart failure (HF) and it has been suggested as a risk factor for malignant ventricular arrhythmias. The Respiratory Disturbance Index (RDI) algorithm computed by select implantable cardioverter defibrillators (ICDs) can identify severe sleep apnea (SA).

Purpose

In the present analysis we evaluated the association between ICD-detected SA and the incidence of appropriate ICD therapy in patients with HF.

Methods

We enrolled 411 HF patients (age 69±10years, 77% male, ejection fraction 32±8%), implanted with an ICD endowed with an algorithm (ApneaScan, Boston Scientific) that calculates the RDI each night. In this analysis the weekly mean RDI value was considered. The endpoint was the first appropriate ICD shock. The median follow-up was 26 months [25th–75th percentile: 16-35].

Results

During follow-up, one or more ICD shocks were documented in 58 (14%) patients.

Patients with shocks were younger (66±13years versus 70±10years, p=0.038), and more frequently implanted for secondary prevention (21% versus 10%, p=0.026). The maximum RDI value calculated during the entire follow-up period did not differ between patients with and without shocks (55±15episodes/h versus 54±14episodes/h, p=0.539). However, the ICD-detected RDI showed a considerable variability during follow-up. The overall median of the weekly RDI was 33episodes/h [25th–75th percentile: 24-45]. Using a time-dependent Cox regression model, the continuously measured weekly mean RDI≥45episodes/h was independently associated with shock occurrence (HR:4.63, 95%CI:2.54-8.43, p&lt;0.001), after correction for baseline confounders (age, secondary prevention).

Conclusions

In HF patients, patients were more likely to receive appropriate ICD shocks during periods of time when they exhibited more sleep-disordered breathing.

Remotely-driven management of diuretic therapy in heart failure patients with a multiparametric ICD algorithm

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Background

HeartLogic algorithm combines data from multiple sensors to predict future heart failure (HF) decompensation in patients with an implantable defibrillator (ICD) . An optimal strategy to manage algorithm alerts is not yet known, although decongestive treatment with diuretics is the most frequent alert-triggered action reported so far.

Purpose

We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.

Methods

The study was conducted in eight Italian high-volume arrhythmia centers. The algorithm was activated in 229 ICD patients during a median follow-up was 17 months [25th–75th percentile: 11-24] between December 2017 and July 2020. Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient’s status and to prevent HF worsening. The study protocol did not mandate any specific intervention algorithm, and physicians were free to remotely implement clinical actions, to schedule extra in-office visits when deemed necessary for additional investigations or for interventions, or to adopt an active monitoring approach. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.

Results

We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. Overall, timely diuretic changes were associated with a shorter "in-alert" state duration in comparison with late changes, i.e. 28 days [25th-75th percentile: 20-43] versus 62 days [25th-75th percentile: 44-118], p&lt;0.001. By contrast, major and minor diuretic augmentations resulted in comparable durations, i.e. 47 days [25th-75th percentile: 30-58] versus 38 days [25th-75th percentile: 23-79], p=0.954. Of the 56 decongestive treatment adjustments, 47 resolved the alert condition, while in the remaining 9 cases, further treatments were required (augmented HF therapy during hospitalization or unscheduled intravenous decongestive therapy in outpatients). The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95%CI: 1.02-1.20, p=0.013) and with late interventions (odds ratio: 5.11, 95%CI: 1.09-24.48, p=0.041). No complications were reported after drug adjustments.

Conclusions

Decongestive treatment adjustments triggered by HeartLogic alerts, even when such adjustments were completely dependent on the physicians’ clinical expertise and were not standardized. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.

Therapeutic strategies in Crohn’s disease in an emergency surgical setting

Crohn’s disease (CD) remains a chronic, incurable disorder that presents unique challenges to the surgeon. Multiple factors must be considered to allow development of an appropriate treatment plan. Medical therapy often precedes or complements the surgical management. The indications for operative management of CD include acute and chronic disease complications and failed medical therapy. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage represent indications for emergency surgery. These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality. A multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care. Moreover, the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations. In this review, we aimed to discuss the acute complications of CD and their treatment.

Emotional Dysregulation in Adults from 10 World Societies: An Epidemiological Latent Class Analysis of the Adult-Self-Report

Background/Objective

Method

Results

Conclusions

Long-term Cognitive Outcomes and Socioprofessional Attainment in People With Multiple Sclerosis With Childhood Onset

Background and Objectives

Patients with pediatric-onset multiple sclerosis (MS) can be especially vulnerable to cognitive impairment (CI) due to the onset of MS during a critical period for CNS development and maturation. The objective of this longitudinal study was to assess long-term cognitive functioning and socioprofessional attainment in the Italian pediatric MS cohort, previously assessed at baseline and 2 and 5 years.

Methods

The 48 patients evaluated at the 5-year assessment were screened for inclusion. All participants were assessed with a cognitive test battery exploring 4 different cognitive abilities. Depression, fatigue, and socioprofessional attainment were also assessed. Mean cognitive z scores were calculated for the whole cohort, and their evolution over time was analyzed with an analysis of variance for repeated measurements test. Predictors of cognitive worsening or improvement were assessed with a linear mixed-model analysis.

Results

Thirty-three participants were included (mean follow-up 12.8 ± 0.8 years). The global cognitive performance worsened at year 2 and improved at year 5, although the z score remained significantly lower than at baseline (−0.9 ± 1.2 vs −0.3 ± 0.9, p = 0.002). There was no significant variation between years 5 and 12 (−0.7 ± 1.1, p = 0.452). Higher IQ (>90) at baseline (effect 0.3, 95% CI 0.1–0.5, p = 0.017) and lower number of relapses in the 2 years before baseline (effect −0.1, 95% CI −0.1 to 0.1, p = 0.025) predicted better cognitive performances. Eighteen (54.5%) patients failed at least 2 tests compared with healthy controls and were defined as cognitively impaired. The presence of CI predicted worse socioprofessional attainment (β = 4.8, 95% CI 1.4–8.2, p = 0.008).

Discussion

The longitudinal cognitive trajectory in pediatric-onset MS has a heterogeneous course over time, with a decline in the first years followed by a partial recovery over the long term. However, at the last follow-up evaluation, the proportion of impaired patients was more than double compared with baseline, with a negative impact on the individual’s socioprofessional attainment in adulthood. This study underscores how cognitive reserve may partially mitigate the negative effects of brain damage, highlighting the critical importance of intellectual enrichment early during the disease course.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

P–582 High level of concordance between invasive and non-invasive preimplantation genetic testing for aneuploidies (niPGT-A) at day5 and day6–7

Study question

To explore ploidy concordance between invasive and non-invasive PGTA (niPGT-A) at different embryo culture time.

Summary answer

High level (&gt;84%) of concordance rate for ploidy and sex, sensitivity (&gt;88%), and specificity (76%) were obtained for both day6/7 samples and day5 samples.

What is known already

The analysis of embryo cell free DNA (cfDNA) that are released into culture media during in vitro embryo development has the potential to evaluate embryo ploidy status. However, obtaining sufficient quality and quantity of cfDNA is essential to achieve interpretable results for niPGT-A. More culture time is expected to be directly proportional to the release of more cfDNA. But embryo culture time is limited due to in-vitro embryo survival potential. Therefore, it is important to estimate the duration of the culture that will provide the maximum cfDNA that can be obtained without adversely affecting the development of the embryo.

Study design, size, duration

A total of 105 spent culture media (SCM) from day5-day7 blastocyst stage embryos have been included in this cohort study. The cfDNA of SCM samples were amplified and analyzed for niPGT-A by NGS analysis. The SCM samples were divided into 2 subgroups according the embryo culture hours (Day5 and Day6/7 group). The DNA concentration, informativity and euploidy results have then been compared with their corresponding embryos after trophectoderm biopsy (TE) and PGT-A analysis by NGS

Participants/materials, setting, methods

Embryos cultured until Day3 washed and cultured again in 20µl fresh culture media until embryo biopsy on Day5, 6, or 7. After biopsy SCM samples were immediately collected in PCR tubes and conserved at –20 °C until whole genome amplification by MALBAC® (Yicon Genomics). The TE and SCM samples were analyzed by next-generation sequencing (NGS) using Illumina MiSeq® System. NGS data analysis has been done by Bluefuse Multi Software 4.5 (Illumina) for SCM and TE samples

Main results and the role of chance

Only the SCM samples which have an embryo with a conclusive result were included in this cohort (n = 105). Overall 97.1% (102/105) of SCM samples gave a successful DNA amplification with a concentration ranging 32.4–128.5ng/µl. Non-informative (NI) results including a chaotic profile (&gt;5 chromosome aneuploidies) were observed in 17 samples, so 83.3%(85/102) of SCM samples were informative for NGS data analysis. Ploidy concordance rate with the corresponding TE biopsies (euploid vs euploid, aneuploid vs aneuploid) was 84.7% (72/85). Sensitivity and specificity were 92,8% and 76,7%, respectively with no significant difference for all parameters for day 6/7 samples compared with day 5 samples. The false-negative rate was 3.5% (3/85), and false-positive rate was 11.7% (10/85).

Limitations, reasons for caution

The sample size is relatively small. Larger prospective studies are needed. As this is a single-center study, the impact of the variations in embryo culture conditions can be underestimated. Maternal DNA contamination risk cannot be revealed in SCM, therefore the use of molecular markers would increase the reliability.

Wider implications of the findings: Non-invasive analysis of embryo cfDNA analyzed in spent culture media demonstrates high concordance with TE biopsy results in both early and late culture time. A non-invasive approach for aneuploidy screening offers important advantages such as avoiding invasive embryo biopsy and decreased cost, potentially increasing accessibility for a wider patient population.

Trial registration number

Not applicable

Management of the kidney transplant patient with Cancer: Report from a Multidisciplinary Consensus Conference

INTRODUCTION

Cancer is the second most common cause of mortality and morbidity in Kidney Transplant Recipients (KTRs). Immunosuppression can influence the efficacy of cancer treatment and modification of the immunosuppressive regimen may restore anti-neoplastic immune responses improving oncologic prognosis. However, patients and transplant physicians are usually reluctant to modify immunosuppression, fearing rejection and potential graft loss. Due to the lack of extensive and recognised data supporting how to manage the immunosuppressive therapy in KTRs, in the context of immunotherapy, chemotherapy, radiotherapy and loco-regional treatments, a Consensus Conference was organised under the auspices of the European Society of Organ Transplantation and the Italian Society of Organ Transplantation. The conference involved a multidisciplinary group of transplant experts in the field across Europe.

METHODS

The overall process included a) the formulation of 12 specific questions based on the PICO methodology, b) systematic literature review and summary for experts for each question, c) a two-day conference celebration and the collection of experts' agreements. The conference was articulated in three sessions: "Immunosuppressive therapy and immunotherapy", "Systemic therapy", "Integrated Therapy", while the final experts' agreement was collected with a televoting procedure and defined according to the majority criterion.

RESULTS

Twenty-six European experts attended the conference and expressed their vote. A total of 14 statements were finally elaborated and voted. Strong agreement was found for ten statements, moderate agreement for two, moderate disagreement for one and uncertainty for the last one.

CONCLUSIONS

The consensus statements provide guidance to transplant physicians caring for kidney transplant recipients with cancer and indicate key aspects that need to be addressed by future clinical research.

A multiparametric ICD algorithm for heart failure risk stratification and management: an analysis in clinical practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

The HeartLogic algorithm combines multiple implantable cardioverter defibrillator (ICD) sensors to identify patients at risk of heart failure (HF) events.

Purpose

We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events.

Methods

The HeartLogic feature was activated in 366 ICD and cardiac resynchronization therapy ICD patients at 22 centers. The HeartLogic algorithm automatically calculates a daily HF index and identifies periods IN or OUT of an alert state on the basis of a configurable threshold (in this analysis set to 16).

Results

The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients over a median follow-up of 11 months [25-75 percentile: 6-16]. Overall, the time IN the alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations and 8 patients died of HF (rate: 0.12 events/patient-year) during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (HR: 24.53, 95% CI: 8.55-70.38, p &lt; 0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with a lower rate of HF events (HR: 0.37, 95% CI: 0.14-0.99, p = 0.047). No differences in event rates were observed between in-office and remote alert management. By contrast, verification of HF symptoms during post-alert examination was associated with a higher risk of HF events (HR: 5.23, 95% CI: 1.98-13.83, p &lt; 0.001).

Conclusions

This multiparametric ICD algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required in order to effectively manage HeartLogic alerts, while post-alert verification of symptoms seemed useful in order to better stratify patients at risk of HF events.

Safety of omitting defibrillation efficacy testing with subcutaneous defibrillators: a propensity matched case-control study

Funding Acknowledgements

Type of funding sources: None.

Background

Defibrillation efficacy testing (DT) is recommended at implantation of subcutaneous implantable cardioverter–defibrillators (S-ICD). However, prior works found that adherence to this recommendation is declining in clinical practice.

Purpose

To compare survival from all-cause death and first ineffective shock (primary endpoint) and the composite of all-cause death, ineffective shock, inappropriate shock and device-related complication (secondary endpoint) between patients who underwent DT and those with omitted DT.

Methods

We analyzed 1652 consecutive patients who underwent S-ICD implantation in 60 Italian centers from 2013 to 2019.

Results

DT was not performed in 325 (20%) patients (no-DT patients). As compared with the DT group, these patients were older (51 ± 16 vs. 48 ± 15 years; p &lt; 0.01) and had lower ejection fraction (37 ± 16% vs. 46 ± 16%; p &lt; 0.01). The 325 no-DT patients were propensity matched with 325 patients of the DT group. During a median follow up of 19 months, 27 (4.2%) patients died for any-cause. During follow-up, 34 (5.2%) patients received appropriate shocks to treat discrete episodes of VT/VF. The first shock was effective in 30 out of 34 patients (88%), whereas a second shock was required to terminate VT/VF in 3 patients and a third shock in the last one. The primary endpoint occurred in 31 (4.8%) patients, and the risk was not significantly increased in the no-DT cohort (HR = 1.26, 95%CI:0.62-2.55, p = 0.522). Inappropriate shocks were reported in 36 (5.5%) patients and device-related complications in 25 (3.8%) patients during follow-up. Survival from the composite secondary endpoint was comparable between groups (HR = 0.86, 95%CI:0.57-1.32, p = 0.500).

Conclusions

Our data confirmed that DT is frequently omitted in current clinical practice, especially in older patients with worse systolic function. A strategy that omits DT did not appear to compromise the effectiveness of the S-ICD and no additional risk seems associated with DT omission at a mid-term follow-up. These data suggest that routine DT at S-ICD implant might not be necessary. Randomized trials are needed to confirm this finding.

Multiple Arteries Kidney Offer

Kidneys with more than 3 arteries are very rare and decision to use or not these organs can be difficult, because there is an increased risk of post-transplant vascular complications, with a higher risk of worse outcome. Here we report a case of a successful transplant a deceased donor left kidney with 5 arteries, using 2 separate wide patches containing 3 and 2 arteries, respectively. These kidneys should be considered as a source for maximize the number of organs available, but a careful selection of the recipient is also crucial for minimize the risk of complications.

Neoantigen-Specific Adoptive Cell Therapies for Cancer: Making T-Cell Products More Personal

Mutation-derived neoantigens are taking central stage as a determinant in eliciting effective antitumor immune responses following adoptive T-cell therapies. These mutations are patient-specific, and their targeting calls for highly personalized pipelines. The promising clinical outcomes of tumor-infiltrating lymphocyte (TIL) therapy have spurred interest in generating T-cell infusion products that have been selectively enriched in neoantigen (or autologous tumor) reactivity. The implementation of an isolation step, prior to T-cell in vitro expansion and reinfusion, may provide a way to improve the overall response rates achieved to date by adoptive T-cell therapies in metastatic cancer patients. Here we provide an overview of the main technologies [i.e., peptide major histocompatibility complex (pMHC) multimers, cytokine capture, and activation markers] to enrich infiltrating or circulating T-cells in predefined neoantigen specificities (or tumor reactivity). The unique technical and regulatory challenges faced by such highly specialized and patient-specific manufacturing T-cell platforms are also discussed.

P538Single- and Multi-Site Pacing Strategies for Optimal Cardiac Resynchronization Therapy: Impact on Device Longevity and Therapy Cost

Funding Acknowledgements

No funding

Introduction

Multiple left ventricular pacing strategies have been suggested for improving response to cardiac resynchronization therapy (CRT). However, these programming strategies can be obtained by accepting configurations with high pacing threshold and accelerated battery drain. We assessed the feasibility of predefined pacing programming protocols and we evaluated their impact on device longevity and their cost-impact.

Methods

We estimated battery longevity in 167 CRT-D (RESONATE, Boston Scientific) patients based on measured pacing parameters and according to multiple programming strategies: single-site pacing associated with lowest threshold, non-apical location, longest interventricular delay, pacing from two electrodes. To determine the economic impact of each programming strategy, we applied the results of a published model-based cost analysis to a 15-year time-horizon.

Results

Selecting the electrode with the lowest threshold resulted in a median device longevity of 11.5 years. Non-apical pacing and interventricular delay maximization were feasible in most patients (99% non-apical pacing, 65% RV-to-LV interval &gt;80ms), and were obtained at the price of a few months of battery life. Device longevity of &gt;10 years was preserved in 87% of cases of non-apical pacing and in 77% on pacing at the longest interventricular delay. The mean reduction in battery life when the second electrode was activated was 1.5 years. Single-site pacing strategies increased the therapy cost by 4-6%, and multi-site pacing by 12-13%, in comparison with the best-case scenario.

Conclusions

Modern CRT-D systems ensure effective pacing and allow multiple optimization strategies for maximizing service life or for enhancing effectiveness. Single- or multi-site pacing strategies can be implemented without compromising device service life and at an acceptable increase in therapy cost.

Abstract Figure. Image1

P521Conversion test during Subcutaneous Implantable Cardioverter-Defibrillator Implantation in clinical practice: in-hospital and mid-term outcome

Funding Acknowledgements

No funding

OnBehalf

RHYTHM DETECT Registry

Background

With subcutaneous implantable cardioverter–defibrillators (S-ICD), conversion test (CT) is still recommended at implantation. However, prior works found that adherence to this recommendation is declining in clinical practice.

Purpose

To describe current practice regarding CT at S-ICD implantation, and also measure in-hospital outcome of patients who underwent CT and mid-term outcome of patients without CT.

Methods

We analyzed 1652 consecutive patients (49 ± 15 years old, 80% male, 51% with ischemic or non-ischemic dilated cardiomyopathy, 45% with ejection fraction ≤35%) who underwent S-ICD implantation in 60 Italian centers from 2013 to 2019.

Results

CT data were missing in 27 patients. CT was performed in 1300 patients. Successful conversion with ≤65J was obtained in 97.4% of patients. Shock at 80J was not effective in 12 (0.9%) patients. In 10 of these patients the CT was successful after device repositioning, while in 2 patients it was decided to implant a transvenous ICD. Two (0.15%) episodes of electromechanical dissociation (1 fatal) were reported as consequence of CT. CT was not performed in 325 patients (for clinical reasons in 182 patients, for facility preference in 71, ventricular fibrillation not inducible in 72 patients). As compared to the CT group, these patients were older (51 ± 16 vs. 48 ± 15 years; p &lt; 0.01) and had lower ejection fraction (37 ± 16% vs. 46 ± 16%; p &lt; 0.01). 243 non-CT patients had at least 6 months follow-up (median 15 months). In this group, 12 (4.9%) patients had appropriate shocks to treat VT/VF (all successfully terminated with the first shock), and 9 (3.7%) patients had inappropriate shocks.

Conclusions

This analysis showed that CT is frequently omitted in current clinical practice, especially in older patients with worse systolic function. Shocks at CT are very frequently effective and system revision after CT is rarely required. CT is also safe, although serious adverse events cannot be excluded. A strategy that omits CT did not appear to compromise the effectiveness of the S-ICD, but larger populations and longer follow-up are needed to confirm this finding.

P526Are 40 joules enough for successfully defibrillate with subcutaneous implantable cardioverter-defirbrillator?

Funding Acknowledgements

NO FUNDING

OnBehalf

Rhythm Detect Registry

Background

The subcutaneous ICD (S-ICD) is an effective alternative to the traditional transvenous option. Due to its extracardiac design the S-ICD requires a higher shock output than the traditional ICD. Nonetheless, preliminary data suggest that acute defibrillation test may be successful even at energies lower than the usually tested value of 65J, and that optimization of implantation technique may increase the defibrillation safety margin among S-ICD recipients.

Purpose

To evaluate the efficacy of conversion test performed at 40J, and to investigate the association between shock efficacy, clinical characteristics and device position.

Methods

VF was induced and subsequently, conversion test was performed by delivering a 40J shock. Success was defined as termination of VF by the first shock. S-ICD system positioning was evaluated with the PRAETORIAN score using bidirectional chest X-rays. Cranial-caudal S-ICD placement was defined as superior if the entire generator was contained in the cardiac silhouette, inferior if partially or completely outside.

Results

233 consecutive patients (83% male, 49 ± 14 years, BMI 26 ± 4kg/m2, ejection fraction 46 ± 17%, 112 (48%) ischemic/non-ischemic dilated cardiomyopathy) were enrolled and underwent S-ICD implantation with conversion test at 40J. The generator was positioned in an intermuscular pocket in 228 patients (98%). The PRAETORIAN score was &lt;90 (low risk of conversion failure) in 218 (94%) patients. Cranial-caudal generator placement was superior in 188 (81%) patients. Overall, VF termination occurred in 191 (82%) patients with 40J. The BMI was similar in patients with successful and unsuccessful termination (26 ± 4kg/m2 versus 27 ± 6kg/m2, p = 0.195). The efficacy was comparable in patients with dilated cardiomyopathy (86%) versus other conditions (79%, p = 0.153). PRAETORIAN score was not associated with shock efficacy at 40J (82% with score &lt;90 versus 87% with score ≥90, p = 1.000), while a trend toward higher efficacy was seen with superior generator placement (84% versus 73%, p = 0.093).

Conclusions

We observed high S-ICD defibrillation success rate at 40J, suggesting that the safety margin is frequently higher than the usually accepted 15J. We found no difference in efficacy according to the cardiac disease and no association between test failure and body habitus. The intermuscular positioning of the generator resulted in low values of the PRAETORIAN score that however did not appear associated with test efficacy.

855Performance of a multisensor icd algorithm in heart failure patient management

Funding Acknowledgements

No funding

Background

The HeartLogic index combines data from multiple implantable cardioverter-defibrillator (ICD)-based sensors and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Purpose

To describe a multicenter experience of remote HF management of patients who received a HeartLogic-enabled ICD or cardiac resynchronization therapy ICD (CRT-D).

Methods

The HeartLogic feature was activated in 104 patients (76 male, 71 ± 10 years, left ventricular ejection fraction 29 ± 7%). In accordance with a standardized follow-up protocol, remote data reviews and patient phone contacts were performed monthly and at the time of HeartLogic alerts (when the index crossed the nominal threshold value of 16), to assess the patient decompensation status. In-office visits were performed every 6 months or when deemed necessary.

Results

During a median follow-up of 13[11-18] months, 100 HeartLogic alerts were reported (0.82 alerts/pt-year) in 53 patients. 60 HeartLogic alerts were judged clinically meaningful (i.e. associated with worsening of HF or resulted in active clinical actions). Specifically, multiple associated conditions were reported: 45 (75%) symptoms or signs of clinical deterioration of HF, 13 (22%) discontinuations or reductions of prescribed HF therapy, 11 (18%) declines in CRT percentage (with or without new onset atrial fibrillation), 8 (13%) recurrences of previous HF events. For 48 out of 60 alerts the clinician was not previously aware of the condition. Of these, 43 alerts triggered multiple clinical actions. Alert-triggered actions were: 30 (70%) diuretic dosage increases, 15 (35%) other drug adjustments, 6 (14%) HF hospitalizations, 3 (7%) device reprogramming/revisions, 1 (2%) cardioversion, 1 (2%) patient education on therapy adherence. Out of 40 non-clinically meaningful alerts (0.33 alerts/pt-year), 8 (20%) were associated with non-HF therapy changes or interventions, 3 (8%) with pulmonary events, 29 (72%) remained unexplained. The overall number of HF hospitalizations was 16 (rate 0.13 hospitalizations/pt-year). Five HF hospitalizations were not preceded by HeartLogic alert (0.04 hospitalizations/pt-year).

Conclusions

The HeartLogic index provided clinically meaningful information and allowed to remotely identify relevant HF related clinical conditions, with a low rate of unexplained detections and undetected HF events. In this experience, remote monitoring using HeartLogic alerts allowed to drive HF care and take effective clinical actions.

A Self-Calibrating IoT Portable Electrochemical Immunosensor for Serum Human Epididymis Protein 4 as a Tumor Biomarker for Ovarian Cancer

Nowadays, analytical techniques are moving towards the development of smart biosensing strategies for the point-of-care accurate screening of disease biomarkers, such as human epididymis protein 4 (HE4), a recently discovered serum marker for early ovarian cancer diagnosis. In this context, the present work represents the first implementation of a competitive enzyme-labelled magneto-immunoassay exploiting a homemade IoT Wi-Fi cloud-based portable potentiostat for differential pulse voltammetry readout. The electrochemical device was specifically designed to be capable of autonomous calibration and data processing, switching between calibration, and measurement modes: in particular, firstly, a baseline estimation algorithm is applied for correct peak computation, then calibration function is built by interpolating data with a four-parameter logistic function. The calibration function parameters are stored on the cloud for inverse prediction to determine the concentration of unknown samples. Interpolation function calibration and concentration evaluation are performed directly on-board, thus reducing the power consumption. The analytical device was validated in human serum, demonstrating good sensing performance for analysis of HE4 with detection and quantitation limits in human serum of 3.5 and 29.2 pM, respectively, reaching the sensitivity that is required for diagnostic purposes, with high potential for applications as portable and smart diagnostic tool for point-of-care testing.

A Model-Based Design Floating-Point Accumulator. Case of Study: FPGA Implementation of a Support Vector Machine Kernel Function

Recent research in wearable sensors have led to the development of an advanced platform capable of embedding complex algorithms such as machine learning algorithms, which are known to usually be resource-demanding. To address the need for high computational power, one solution is to design custom hardware platforms dedicated to the specific application by exploiting, for example, Field Programmable Gate Array (FPGA). Recently, model-based techniques and automatic code generation have been introduced in FPGA design. In this paper, a new model-based floating-point accumulation circuit is presented. The architecture is based on the state-of-the-art delayed buffering algorithm. This circuit was conceived to be exploited in order to compute the kernel function of a support vector machine. The implementation of the proposed model was carried out in Simulink, and simulation results showed that it had better performance in terms of speed and occupied area when compared to other solutions. To better evaluate its figure, a practical case of a polynomial kernel function was considered. Simulink and VHDL post-implementation timing simulations and measurements on FPGA confirmed the good results of the stand-alone accumulator.

The minimal neuropsychological assessment of MS patients (MACFIMS): normative data of the Italian population

Cognitive impairment is common in multiple sclerosis (MS), and research has emphasized the crucial role of cognitive assessment in disease monitoring. The minimal neuropsychological assessment of MS (MACFIMS) represents one of the neuropsychological batteries most widely used throughout the world. To date, a complete validation, as well as normative values of an alternative form, is lacking in the Italian population, limiting the use of this tool in longitudinal assessment. A total of 200 healthy subjects (127 females and 73 males) were recruited from the community in 8 Italian cities and were evaluated with the MACFIMS at baseline and reassessed with an alternate form of the same battery after 12 months. Regression-based norms that account for demographic influences on test performance were calculated at each time point (baseline and follow-up). The study provides, for the first time, normative values of two forms of the MACFIMS battery for the Italian population. Data application allows clinicians to monitor the performance of cognitive functions over time and to better understand the efficacy of both pharmacological and non-pharmacological interventions in clinical practice and research.

Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report

Background

There are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients.

Case summary

We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.

Discussion

The degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity.

Conclusion

This clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

Electronic supplementary material

The online version of this article (10.1186/s13256-019-2048-1) contains supplementary material, which is available to authorized users.