COVID-19 era: time for temporary mechanical circulatory support?

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III in Spain (Co-funded by European Social Fund "Investing in your future").

INTRODUCTION

The Coronavirus disease 19 (COVID-19) pandemic has impacted clinical practice with important changes in the most affected areas, resulting in increased mortality from heart disease (myocardial infarction). The feasibility of continuing a temporary mechanical circulatory support (MCS) program is unknown.

PURPOSE

Our objective was to analyze the survival of patients requiring short-term MCS with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP® during the COVID-19 pandemic.

METHODS

Retrospective study including all VA-ECMO and Impella CP® implants in a referral hospital since March 2020 compared to previous implants results.

RESULTS

Out of 167 short-term MCS implanted from 2013, 25 (15%) were conducted during the time of COVID-19 pandemic: 19 VA-ECMO and 6 Impella CP® (Table).

Compared to preCOVID-19 implants, patients requiring MCS in the COVID era presented more frequently right ventricular dysfunction (p = 0.005) and showed a trend towards older age (p = 0.069) and lower left ventricular ejection fraction (p = 0.063), without other significant differences regarding the baseline situation and implant technique (Table). Encephalopathy was more frequent in the COVID-19 era, with no differences in other complications (Table).

Survival at discharge was 43.7% in the pre-COVID era vs 36% during COVID-19 pandemic, without finding statistically significant differences (p = 0.313).

CONCLUSION

Survival after temporary MCS did not get worse significantly during the COVID-19 pandemic. The possibility of short-term MCS should be maintained for cardiogenic shock and other cases of hemodynamic instability.

Ovarian stimulation does not influence the uterine immune environment in healthy infertile women

RESEARCH QUESTION

There is some controversy regarding the impact of ovarian stimulation on immune cells in women undergoing IVF. The study's aim was to determine whether ovarian stimulation affected immune uterine cells in healthy women undergoing IVF.

DESIGN

This prospective cohort study included 28 patients undergoing IVF and 47 healthy oocyte donors. Endometrial biopsies were taken in a natural cycle and after ovarian stimulation. All participants had a normal karyotype, pelvic ultrasound and cervical cytology results and thyroid-stimulating hormone concentration, as well as normal glucose and insulin concentrations and inherited and acquired thrombophilia test results. Screening tests including human papillomavirus were normal. Immune cells were analysed using three techniques: fluorescence-activated cell sorting, immunohistochemistry and gene expression. A human leukocyte antigen (HLA)-C tetramer was used as an 'artificial embryo'. The expression of genes including those for tumour necrosis factor (TNF)-α and interleukin-10 (IL-10) was analysed.

RESULTS

A comparison was made of the percentage and gene expression of CD56^brightCD16^- uterine natural killer (uNK), CD56^dimCD16⁺ natural killer cells, CD56^-CD16⁺ natural killer cells and TregCD25⁺CD4⁺FoxP3⁺ cells, uNK binding to the HLA-C tetramer, and TNF-α and IL-10 expression. No between- or within-group differences were observed in natural versus ovarian stimulation cycles.

CONCLUSIONS

Ovarian stimulation does not affect the uterine immune cell population or HLA-C binding in healthy women undergoing ovarian stimulation. Further studies are underway to find out if different responses might be seen in women with previous autoimmune disorders.

Abstract ES7-2: Practical approach to the axilla after neoadjuvant chemotherapy: What the clinical trials don't address

Neoadjuvant chemotherapy (NAC) was initially used in patients with inoperable breast cancer to improve resectability, but it is also beneficial in women with operable breast cancer, particularly with respect to the axilla. Nodal pathologic complete response (pCR) rates among clinically node-positive patients treated with modern systemic therapy range from 35-49%. The ability to downstage the axilla and potentially avoid axillary lymph node dissection (ALND) is one of the greatest surgical advantages of NAC.

The optimal approach to the axilla after NAC varies based on the clinical nodal stage prior to NAC. In clinically node-negative patients, the use of sentinel lymph node biopsy (SLNB) after NAC has been well studied, with high identification rates and false-negative rates that are similar to the upfront surgery setting. In addition, regional recurrence rates are no different between clinically node-negative patients treated with SLNB alone after NAC, or those treated with upfront SLNB.

In clinically node-positive patients, 3 single-arm prospective trials have demonstrated that SLNB after NAC results in a false-negative rate <10%, provided that the SLN technique is optimized with the use of dual mapping and retrieval of ≥3 negative SLNs. However, not all clinically node-positive patients are candidates for downstaging to SLNB with NAC. The prospective trials primarily enrolled patients with cT1-3N1 disease, and therefore study results should not be extrapolated to those patients presenting with cT4 and/or cN2/N3 disease, where ALND remains the standard of care. A more complicated issue is whether all clinically node-positive patients should even be considered for NAC, as the response rates in the nodes vary based on tumor subtype. Patients with hormone receptor (HR) positive/HER2 negative cancers have the lowest rates of nodal pCR compared to HER2 positive and triple-negative breast cancers. Specifically, patients with invasive lobular cancers have a low probability of nodal pCR with NAC, raising the question as to whether NAC should even be considered in these patients due to limited surgical downstaging.

As all patients in the prospective trials had an ALND, the frequency with which ALND could be avoided with the use of NAC in clinically node-positive patients was not addressed, although more recent data have demonstrated that approximately 50% will achieve a nodal pCR and avoid ALND. Indications for ALND after NAC include any positive SLN (including micrometastases and isolated tumor cells), failed mapping, or patients presenting with inoperable breast cancer. Nodal recurrence rates among clinically node-positive patients treated with SLNB alone after NAC are largely unknown, with only one small study demonstrating low regional recurrence rates.

Ultimately, the optimal treatment strategy to avoid ALND in patients with operable breast cancer is complex and based on a combination of tumor subtype, clinical nodal status, and type of breast surgery performed. With the continued use of modern systemic therapy and improved radiation techniques for breast cancer, our ability to de-escalate surgical care and reduce the morbidity of surgery, while still maintaining excellent disease control, has become our new standard of care.

Citation Format: Barrio A. Practical approach to the axilla after neoadjuvant chemotherapy: What the clinical trials don't address [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES7-2.

In situ monitoring of isophorone diisocyanate-based flexible polyurethane foams formation

Novel isophorone diisocyanate-based flexible polyurethane foams were prepared by the one-step method in a computerized foam qualification system (FOAMAT). The experimental conditions to obtain this type of foams, in relation to the nature and concentration of catalysts as well as the reaction temperature, were established as no data were available in scientific literature. The chemical reactions occurring during the foam generation process were monitored in situ by attenuated total reflectance-FTIR spectroscopy. The kinetics of the foam generation was fitted to an nth order model and the data showed that the foaming process adjusted to a first-order kinetics. The physical changes as pressure, foam height, and dielectric polarization were monitored by the FOAM software (FOAMAT). According to these parameters, the foaming process was divided into four steps: bubble growth, bubble packing, cell opening, and final curing.

Strabometry precision: intra-examiner repeatability and agreement in measuring the magnitude of the angle of latent binocular ocular deviations (heterophorias or latent strabismus)

BACKGROUND AND PURPOSE

This study was designed to compare heterophoria measurements obtained using the methods: prisms cover test (prism alternate cover test), von Graefe technique, Maddox rod test and modified Thorington test. Given the different methodological features of these tests, our working hypothesis was that these tests would not be interchangeable and repeatability would vary.

METHODS

Horizontal deviation measurements were made at: far distance (six meters) and near distance (40 centimeters) on two occasions in 61 young subjects of mean age 19.7 years (range 18 -32 years), with essentially normal eyes and vision, who were not familiar with the methods used. Statistical repeatability and agreement were determined using the Bland and Altman method.

RESULTS

Repeatability: No difference between the results of the various heterophoria tests was statistically significant. Coefficients of repeatability were always best when the tests were conducted at far, the cover test being the most repeatable. Agreement: Mean differences between absolute values ranged from 1.7 prism diopters to 5.1 prism diopters for measurements at far and from 2.1 prism diopters to 3.4 prism diopters at near.

CONCLUSIONS

The alternating prism cover test was the most repeatable test for measuring latent horizontal deviations. Among the subjective tests, the modified Thorington test was the most repeatable. The low level of agreement observed between the different tests makes their interchangeable use in clinical practice not recommended.

Repeatability intraexaminer and agreement in amplitude of accommodation measurements

BACKGROUND

Clinical measurement of the amplitude of accommodation (AA) provides an indication of maximum accommodative ability. To determine whether there has been a significant change in the AA, it is important to have a good idea of the repeatability of the measurement method used. The aim of the present study was to compare AA measurements made using three different subjective clinical methods: the push-up, push-down, and minus lens techniques. These methods differ in terms of the apparent size of the target, the end point used, or the components of the accommodation response stimulated. Our working hypothesis was that these methods are likely to show different degrees of repeatability such that they should not be used interchangeably.

METHODS

The AA of the right eye was measured on two separate occasions in 61 visually normal subjects of mean age 19.7 years (range 18 to 32). The repeatability of the tests and agreement between them was estimated by the Bland and Altman method. We determined the mean difference (MD) and the 95% limits of agreement for the repeatability study (COR) and for the agreement study (COA).

RESULTS

The COR for the push-up, push-down, and minus lens techniques were +/-4.76, +/-4.00, and +/-2.52D, respectively. Higher values of AA were obtained using the push-up procedure compared to the push-down and minus lens methods. The push-down method also yielded a larger mean AA than the negative-lens method. MD between the three methods were high in clinical terms, always over 1.75D, and the COA differed substantially by at least +/-4.50D. The highest agreement interval was observed when we compared AA measurements made using minus lenses and the push-up method (+/-5.65D).

CONCLUSIONS

The minus lens method exhibited the best repeatability, least MD (-0.08D) and the smallest COR. Agreement between the three techniques was poor.

High AC/A accommodative esotropia strabismus treated with contact lenses: a single case design (N=1) study

BACKGROUND AND PURPOSE

The purpose was to determine the efficacy of two types of contact lenses (spherical disposable and aplanatic) as treatment in a patient with esotropia with a high Accommodative Convergence/Accommodation Ratio (AC/A). Due to the possibility of the appearance of accommodative insufficiency in this kind of patient, (i.e., following many years of bifocal glasses use), the elimination of the plus addition lens is advisable. Nevertheless, in some patients, this change leads to the appearance of a residual angle of esodeviation in near vision. It was expected that monofocal aplanatic contact lenses could achieve, due to their optical characteristics, an accurate and orthotropic binocular alignment, without aggravating an undesirable manifestation of the accommodative insufficiency.

METHODS

An experimental design of a single case (N=1) was used in which the subject acted as his own control. With bifocal glasses the subject displayed stability in his binocular and accommodative system at every distance of vision for the past three years. We compared the efficacy of two different types of hydrophilic contact lenses to control the angle of deviation, both at distance and at near vision.

RESULTS

Neither of the two contact lenses produced the results of stability and the correct binocular alignment that had been achieved with bifocal glasses. This subject experienced a worse manifest esodeviation in distance vision with aplanatic lenses than with the disposable ones.

CONCLUSIONS

These monofocal contact lenses did not create acceptable binocular alignment and stability in a subject with a high AC/A accommodative esotropia.

[Pseudotumor cerebri associated with maxillary sinusitis: clinico-pathological study]

INTRODUCTION

The pseudotumor cerebri is characterized by increased intracranial pressure in the absence of a space occupying lesions or obstruction to the circulation of cerebrospinal fluid (CSF). Increased pressure but normal composition of the CSF is the diagnostic criterion. Ear infections and other infections such as sinusitis have been cited as possible, but rare, causes.

CLINICAL CASE

A 12 year old girl presented with diplopia 10 days after starting treatment for sinusitis. On examination there was paresia of the VI cranial nerve to the left eye and marked bilateral papilledema. She had normal visual acuity with visual field measurements showing increased blind spot field in both eyes. Resonance studies only showed maxillary sinusitis. CSF pressure was 35 cm H2O, with 40 lymphomonocytes and normal biochemical findings. After 15 cm of CSF had been removed treatment was started with acetazolamide, dexamethasone and cefotaxime. A week later the diplopia had disappeared and the CSF pressure was 25, with no cells present. Two months later the visual fields and fundus oculi were normal. After follow-up for one year there was no recurrence.

CONCLUSIONS

We describe a case of pseudotumor cerebri associated with maxillary sinusitis. We do not know whether this is a chance association or whether there was a pathophysiological basis. The possibility should be considered so as to treat the cause or predisposing factor. The initial CSF pleocytosis would support the possibility of a relationship of the pseudotumor with an infectious condition (meningeal irritation or para-infectious pleocytosis meningeal irritation or para-infections pleocytosis in the context of an ENT infection), which might have precipitated the problem by interfering with the reabsorption of CSF.

[Prospective therapeutic trial of masking treatment in patients with tinnitus]

We report the results of a therapeutic trial of patients with tinnitus of different characteristics that was unresponsive to other medical or surgical treatments. Treatment was based on a combination of biofeedback training designed to reduce stress and either pure masking therapy or masking therapy consisting of a hearing aid and masker. The results showed an improvement in subjective perceptions and in the audiometric parameter of pitch in a significant percentage of patients.

Metabolism of 3H-noradrenaline released from isolated rat hypothalamus by extracts of black widow spider glands

In the isolated rat hypothalamus preincubated with 3H-noradrenaline, an extract from the venom glands of Latrodectus mactans elicited on overflow of tritium which consisted of 70--71% 3H-noradrenaline and 18% 3H-3,4-dihydroxyphenylglycol. Exposure to cocaine or pargyline diminished the formation of 3H-3,4-dihydroxyphenylglycol, suggesting that the glycol is formed presynaptically after neuronal reuptake of the transmitter released by the venom. Our data suggest that the venom depolarizes the noradrenergic neurones of rat hypothalamus, and that the depolarization leads to calcium-dependent release of 3H-noradrenaline.