Electromechanical changes of the myocardium after anthracycline chemotherapy

Funding Acknowledgements

Type of funding sources: None.

Background and objectives

The most common side effects of chemotherapeutics in breast cancer is on the cardiovascular system. Global longitudinal strain (GLS) is the only parameter recommended for follow-up in current guidelines with limited evidence. Other strain imaging parameters and electrical changes after chemotherapy is not well studied. It is not known whether electrical or mechanical changes occur initially. The aim of this study is to evaluate repolarization parameters on ECG and mechanical changes together after chemotherapy in breast cancer patients.

Subjects and method

Consecutive patients who received chemotherapy due to breast cancer were included. Strain echocardiography and ECGs were performed pre-treatment (T0) and 3rd month after chemotherapy (T2). Additionally, just in three hours of first dose of chemotherapy (T1) another ECG was performed.  QT and QT correction for heart rate (QTc), QT dispersion (QT disp) and QTc dispersion (QTc disp), T wave peak to end time (Tpe) and Tpe corrected for QT-QTc measurements were performed (figüre 1 and 2). GLS, longitudinal strain for myocardial layers, circumferential strain (CS), radial strain (RS) and torsion measurements were performed. All mechanical and electrical parameters from different time intervals were compared.

Results

Thirty-five consecutive patients (35 females, mean age 48.9 ± 11.8 years) who received chemotherapy (mean doxorubicin cumulative dose 415 ± 32 mg/m2) due to breast cancer were included. There was no significant change in mean GLS values before and after treatment (T0 -%18.8 ± 6.82, T1 18.6 ± 3.5 p = 0,863 respectively). However, there was a significant decrease in CS, RS and torsion (T0 -%17,2 ± 3,5, T1-%13 ± 2,84 p <0,001, T0 %45,1 ± 8,3, T1 %35,6 ±10 p <0,001 and T0 %12,1 ± 3.5, T1 %7.7 ± 2.1 p <0,001, respectively). QT, QTc, QTc disp and Tpe, Tpe/QTc parameters were prolonged just after chemotherapy and were still prolonged 3 months after ((QTc: T1 440.01 ± 27.63, T2 468.00 ± 38.98, T3 467.86 ± 35.09), (QTc disp T1 55.48 ± 20.22, T2 78.59 ± 16.15, T3 66.16 ± 14.62), (Tpe (QTc) T1 104 ± 18.52, T2 148.62 ± 19.16, T3 139.77 ± 21.63), (Tpe/QTc T1 0.213 ± 0.05, T2 0.281 ± 0.08, T3 0.258 ± 0.06).

Conclusion

  Electrical and mechanical functions of the heart could be impaired together acutely even three months after doxorubicin chemotherapy. Cardio toxicity should be evaluated in terms of both electrically and mechanically.

Abstract Figure. ECG repolarization parameters

Cross-sectional adherence with the multitarget stool DNA test for colorectal cancer screening in a large, national study of insured patients

27

Background: Colorectal cancer (CRC) is the second most deadly and fourth most frequently diagnosed cancer in the United States. Early detection can improve CRC outcomes, but overall screening rates (62%) remain below the 80% goal set by the National Colorectal Cancer Roundtable. Multiple options are endorsed for average-risk CRC screening, including the multi-target stool DNA (mt-sDNA) test, which includes patient and provider navigation support. Cross-sectional adherence with the mt-sDNA test was previously reported in a large Medicare population (71%). In the current study we investigated cross-sectional adherence with the mt-sDNA test in a broader, national sample of insured patients. Methods: Aggregate data from Exact Sciences Laboratories LLC (ESL; Madison, WI) were retrospectively analyzed in compliance with HIPAA requirements. Study participants included individuals ages 50 years and older who were covered by commercial insurance or Medicare, had a valid mt-sDNA test order placed between January 1–December 31, 2018, and received a test kit shipped from ESL. Cross-sectional adherence, defined as successful completion and return of the test kit within 365 days of the shipment date, was assessed overall and by patient- and provider-level factors. Results: In total, 1,420,460 participants met the study criteria (61.2% women; mean age 65.7 years). Overall cross-sectional adherence was 66.8%. Adherence was 72.1% in participants with Traditional Medicare, 69.1% in participants with Medicare Advantage, and 61.9% in participants with commercial insurance (p<0.001). Adherence increased by participant age (p<0.001): 60.8% for ages 50-64, 71.3% for ages 65-75, and 74.7% for ages 76+ years. For Traditional Medicare patients, ages 65-75, adherence was 73.6%. Participants with mt-sDNA tests ordered placed by gastroenterologists had a higher adherence rate (78.3%) than those with orders placed by primary care clinicians (67.2%) (p<0.001). Adherence rates were highest among patients with ordering providers in the Pacific region (71.4%) and West North Central region (70.1%), and lowest in the Mid-Atlantic region (65.7%), New England (65.2%), West South Central region (64.6%), and Puerto Rico and US territories (60.7%). Conclusions: Novel data from this large, national sample of insured patients demonstrate high cross-sectional adherence with the mt-sDNA test (66.8%), supporting the substantial contribution this guideline-endorsed option plays in average-risk CRC screening. At the patient-level, adherence increased with patient age, and was highest in those covered by Traditional Medicare. Provider-level stratification showed the highest adherence for mt-sDNA tests ordered by gastroenterologists. This study adds to data regarding the impact of accompanying navigation support and at-home convenience of mt-sDNA on screening completion rates.

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.

P650 A rare form of cardiac mass: primary cardiac lymphoma

Funding Acknowledgements

We declare no conflict of interest and no financial support

A rare form of cardiac mass

primary cardiac lymphoma

Introduction

Primary tumors of the heart are rare and constitute 5% of all cardiac masses. Primary cardiac lymphoma is a curable form of cancer that responds well to early diagnosis and chemotherapy.

Case report

56 year old male patient presented to our outpatient clinic with abdominal swelling. Echocardiography revealed a mass lesion that surrounded the right ventricle and restricted ventricular diastolic function. The mass lesion was poorly discernable from normal myocardial tissue. Magnetic resonance imaging (MRI) showed an infiltrative mass lesion that filled the right pericardial space, and that surrounded the junction between vena cava superior and the right atrium, as well as the root of the aorta. Subxyphoidal biopsy revealed diffuse large B cell lymphoma. Patient died on the 10th day of chemotherapy.

Discussion

Primary cardiac lymphoma constitutes only 2% of all primary cardiac tumors. Cardiac lymphomas are curable in early stages with chemotherapy without the need for surgical excision. Cardiac lymphoma should be kept in mind when faced with a cardiac mass lesion and imaging modalities such as MRI and PET scanning and tissue biopsy should be utilized before planning surgical interventions since these lesions respond well to chemotherapy

Abstract P650 Figure.

P256 Takotsubo syndrome early after treatment due to non cardiotoxic chemotheraphy agents

Case report

A 65 years old female attended emergency department with epigastric pain after chemotherapy. She had vinorelbine and gemcitabine treatment for malignant urotelial renal carcinoma. The patient was consulted with cardiology department, because of progressive high troponin T levels. She had no prior history except urotelial carsinoma for one year and hypertension for seven years. Her prior chemotherapy protocols included carboplatine and docetaxel. She did not describe typical angina pectoris or shortness of breath.

Electrocardiography (ECG) at admission had symmetrical T wave inversion on precordial derivations (figure 1). Echocardiography (echo) showed typical apical ballooning of the left ventricle (figure 2 and 3). We do not know the patient’s prior cardiac performance and acute coronary syndrome and Takotsubo syndrome were our preliminary diagnosis. Normal coronary arteries were seen on coronary angiography, ventriculography revealed apical ballooning movement of the left ventricle (Figure 4) and this supported our diagnosis as Takotsubo syndrome. She was already on valsartane 160 mg daily for hypertension and we included metoprolol 50 mg daily and enoxoparine 6000 IU s.c twice a day. For several days deep symmetrical T wave inversion persisted on ECG. After third day her ECG changings resolved (Figure 5) and echo images had recovered. The patient was discharged uneventfully and is followed.

Abstract P256 figures

Indirect Costs and Family Burden of Pediatric Crohn's Disease in the United States

BACKGROUND

Crohn's disease (CD) negatively impacts patient quality of life and results in greater healthcare utilization. For pediatric CD patients, the burden also extends to their caregivers. We aimed to estimate work loss and productivity costs among caregivers of pediatric CD patients.

METHODS

Data were from Truven MarketScan databases (2000-2012). Patients were <18 years old with ≥2 ICD-9 CD diagnostic codes. Controls were those without CD or ulcerative colitis and were matched to patients by age, Charlson Comorbidity Index, index year, and insurance plan category. Continuous enrollment was required ≥6 months before and ≥12 months after index, defined as the patient's first CD diagnosis date. Outcomes included hours of work loss and associated productivity costs of caregivers 1-year postindex. Work loss and productivity costs were compared between caregivers of patients and controls. Adjustments for unbalanced baseline factors were made using a generalized linear regression model.

RESULTS

Each cohort included 200 study participants and their caregivers. Unadjusted annual hours of work loss after first diagnosis were 214.4 ± 171.5 and 169.6 ± 157.5 for caregivers of CD patients and controls, respectively (P = 0.007). Annual productivity costs were 27.2% ($1122) higher for caregivers of CD patients than controls, estimated at $5243 and $4,121, respectively (P = 0.004). Adjusted cost analyses yielded similar findings. Over the course of a patient's childhood, accumulated productivity losses were $24,118 for CD patients and $18,957 for control caregivers.

CONCLUSIONS

Caregivers of pediatric CD patients have significantly higher loss in productivity costs compared with controls.

Clinical and prognostic features of patients with pandemic 2009 influenza A (H1N1) virus in the intensive care unit

OBJECTIVE

To investigate the clinical and prognostic features of patients admitted to intensive care unit (ICU) with pandemic 2009 influenza A (H1N1) virus.

METHODS

Patients admitted to the intensive care unit for severe pneumonia associated with pandemic 2009 influenza A (H1N1) virus were evaluated.

RESULTS

The study included 20 patients with the mean age of 36±13. Of the 20 subjects, 17 (85%) had underlying conditions. Of the 20 patients, 11(55%) were discharged and 9 (45%) died. Cardinal symptoms were fever, myalgia, and hemoptysis with the rates of 85 %, 75 % and 45 %, respectively. All patients had pneumonic infiltrations in their chest roentgenograms. Main laboratory findings were lymphopenia, high creatin phosphokinase (CPK) and Lactate dehydrogenase (LDH) levels. All patients had positivity on real time reverse transcription-polymerase chain reaction (RT-PCR). None of the patients had pandemic 2009 influenza A (H1N1) virus vaccination. None of them had taken oseltamivir within 48 hours. Main reasons for mortality were cardiovascular complications and ventilatory associated pneumonia due to Acynetobacter baumannii.

CONCLUSION

Early diagnosis and antiviral treatment in these cases seem to be the best approach to avoid serious illness. Special attention should be given to patients having underlying conditions such as cardiovascular and pulmonary diseases and pregnancy.

Bronchobiliary fistula due to hydatid disease of the liver: a case report

As a complication of hydatid cyst disease of the liver, bronchobiliary fistula is a rare condition and manifests as bilioptysis. We report the case of a 34 year-old man with echinococcosis of the liver who developed a bronchobiliary fistula which manifested as chronic cough and bile stained sputum. A chest X-ray showed an unilateral infiltrate in the costodiaphragmatic angle. Bronchoscopy revealed bile filling the right basal bronchi. Magnetic resonance cystography revealed that the hepatic bile ducts communicated with the right basal pleural space. Percutaneous transhepatic drainage was applied. When the patient was reevaluated, the hydatid cyst had eroded into the pleural space, and a pleural effusion had developed. The condition of the patient deteriorated. Hence, surgical therapy was performed. After surgery, the condition of the patient improved. He was discharged from the hospital in good condition.

Functional and radiological impairment in women highly exposed to indoor biomass fuels

OBJECTIVE

The aim of this study was to describe the lung function and the computed tomographic features in a selected group of non-smoking women with chronic obstructive pulmonary disease and biomass fuel exposure.

METHODOLOGY

Thirty female patients currently exposed to biomass smoke were prospectively investigated for further evaluation using high resolution computed tomography (HRCT), pulmonary function tests and blood gas analysis.

RESULTS

The mean age was 59 +/- 11 years. The patients were exposed to biomass smoke for 37.4 +/- 10 years. Pulmonary function tests revealed severe obstruction. The most common HRCT findings were increased lung volume or diffuse emphysema, thickening of interlobular septae, focal emphysematous areas, increased cardiothoracic ratio, and increased bronchovascular arborization.

CONCLUSION

Biomass fuel has deleterious effects on pulmonary function and structure leading to obstructive and restrictive pathologies.

Evaluation of diaphragmatic movement with MR fluoroscopy in chronic obstructive pulmonary disease

The aim of this study was to show reduction of the diaphragmatic excursion with MR fluoroscopy in patients with chronic obstructive pulmonary disease (COPD) and to compare the results with pulmonary function test (PFT). The study included 13 men and 10 women (average age 56.2) with COPD, and 9 men and 6 women (average age 55.8) as a control group. MR fluoroscopy images with Spoiled Gradient-echo pulse sequence was obtained during deep inspiration and expiration. After examination, over cine-loop display, the highest and lowest positions of the diaphragm were identified and the distance of excursion was measured. Differences in the diaphragmatic excursion between patient and healthy subjects were compared. We have also compared MR fluoroscopy results with PFT. In each person of both groups, excursion of the diaphragm was demonstrated clearly in cine-loop display. Differences of excursion between deepest and highest point of diaphragm were on average 26 and 20 mm, respectively, in the right and left side in patients and 69 and 56 mm in healthy group. Significant correlation was found between expiratory volume in 1 s and MR fluoroscopy results. MR fluoroscopy study showed that there were significant statistical differences in diaphragmatic excursion between patients with COPD and healthy subjects. Expiratory volume in 1 s is closely associated with the diaphragmatic excursion. MR fluoroscopy would seem to be a useful method for showing diaphragmatic excursion.

Extrahepatic biliary obstruction caused by small-cell lung cancer: a case report

The pancreas is a rare site of metastasis from small-cell lung cancer (SCLC). We present the case of a pancreatic metastasis of small-cell lung cancer associated with jaundice, in which, initially, the case was evaluated as a primary pancreatic carcinoma and pancreaticoduodenectomy was performed. We also review the reported cases of pancreatic metastases from SCLC.

Relapsing polychondritis

In this article, we report on a 40-year-old man with relapsing polychondritis (RP) of the tracheobronchial tree without clinical manifestations of other systems including nasal septum and earlobe cartilage involvement. The illness was diagnosed histologically, and treatment with procaine penicillin was successful. RP is an unusual systemic disorder characterized by widespread inflammation and destruction of cartilage tissues. The main cause is usually autoimmune. In RP various clinical manifestations including nasal chondritis, arthritis, scleritis, damage to tracheal and bronchial cartilage, and aortic, cardiac, and renal involvement may occur. Isolated tracheobronchial involvement is very rare. The diagnosis must be based on a combination of clinical and pathologic features. If diagnosed early, appropriate treatment may prevent life-threatening airway obstruction.

Surgical treatment of hydatid cyst of the lung: review of 30 cases

Hydatid cyst disease is still a problem in Turkey, especially in the east Anatolian region, as well as in many other places in the world. A retrospective review was made of the surgical treatment of 30 patients with pulmonary hydatid cysts during the last 3 yrs. Nineteen patients were male and 11 female with an average age of 23.5 yrs (range 4-44 yrs). Cystotomy and capitonnage were performed in 28 of the 30 cases (93.4%). The transdiaphragmatic route or simultaneous laparotomy was preferred when the liver was involved. Albendazole was used in four patients with multiple hydatid cyst due to probable recurrence in the postoperative period. Cough and chest pain were the prominent symptoms in the majority of cases. A single lobe was affected in 22 patients. Unilateral multiple foci were present in four patients and bilateral multiple foci in four. Six patients had concomitant liver cysts. Morbidity was low and no mortality was seen. No recurrences were seen on control chest radiographs during the last 2-yr follow-up. In the treatment of hydatid cyst of the lung, conservative surgical methods such as cystotomy and capitonnage still remain the treatment of choice. Medical treatment could be used for prophylactic purposes and in some instances, but the percutaneous aspiration method should not be performed.