Hypofractionated Radiotherapy for Prostate Cancer (HRT20) Trial: Results

PURPOSE/OBJECTIVE(S)

Radiotherapy is a definitive standard treatment for men with localized prostate cancer. Improvements in technology allow higher doses of radiation delivered to the prostate in less days, with lower doses to surrounding healthy tissues trying to reduce side effects. Several studies demonstrated that hypofractionated radiotherapy of 60 Gy is non-inferior to conventional radiotherapy fractionation. To report the first results in toxicity and biochemical relapse free survival of HRT20 trial after 5 years of recruitment. The HRT20 trial is registered (NCT03851926).

MATERIALS/METHODS

A prospective observational study enrolled 298 men with localized prostate cancer (pT1b-T3aN0M0) started in October 2016. Median age was 75 (53-91). Median PSA was 14.5ng/ml. Using NCCN classification: 12,6% were low risk, 50.5% were intermediate and 36.9 % were high risk patients. The median duration of the treatment was 30 days (23-41) The clinical target volume (CTV) consisted of the prostate and seminal vesicles when affected. The CTV-planning target volume (PTV) margin was 0.8 cm. The primary end point evaluated assessed by CTCAE 4.0 was related later adverse events and the second end point was biochemical relapse free survival by Phoenix definition. WMAT plans calculations were carried out using the Monaco TPS version 5.10 based on a single arc arrangement. Univariate and multivariate logistic analyses were carried out.

RESULTS

After median follow up of 56 months. The 5-year incidence rates of grade 2 and 3 late gastrointestinal toxicities were 6.3% and 3.1%, respectively, and those of grade 2 and 3 late genitourinary toxicities were 7.9% and 1%, respectively. PTV volume was found to be correlated with late rectal bleeding (p = 0.02). Also, urinary tract obstruction was correlated with PTV volume. The proportion of patients who were biochemical failure free at 5 years was 88·3% (95% CI 86·0-90·2) Multivariate analysis indicated that risk stage (p = 0.03) and number of positive needles biopsy cores (p = 0.02) were prognostic factor for biochemical relapse-free survival rates.

CONCLUSION

The findings of this study indicate that hypofractionated is well tolerated and it is associated with good 5-years tumor-control outcomes in patients with localized prostate cancer. Long-term follow-up continues.

IL-37-a putative therapeutic agent in cardiovascular diseases

Although it is a member of the Interleukin (IL)-1 family, IL-37 is unique in that it has wide-ranging anti-inflammatory characteristics. It was originally thought to prevent IL-18-mediated inflammation by binding to the IL-18-binding protein. However, upon discovery that it binds to the orphan receptor, IL-1R8, further studies have revealed an expanded role of IL-37 to include several intracellular and extracellular pathways that affect various aspects of inflammation. Its potential role specifically in cardiovascular diseases (CVD) stemmed initially from the discovery of elevated plasma IL-37 levels in human patients with acute coronary syndrome and atrial fibrillation. Other studies using mouse models of ischemia/reperfusion injury, vascular calcification and myocardial infarction have revealed that IL-37 can have a beneficial role in these conditions. This review will explore recent research on the effects of IL-37 on the pathogenesis of CVD.

Predictors of heart failure hospitalization and cardiovascular mortality in patients with chronic right ventricle pacing

Background

Left ventricle (LV) dysfunction after chronic right ventricle (RV) pacing, also known as pacemaker induced cardiomyopathy (PICM) is a relatively common finding, ranging from 15–20% of patients. It has been associated to a high burden RV pacing, age, male gender and intrinsic and paced QRS duration. However, clinical relevance of LV dysfunction in this population has not been studied.

Purpose

The aim of the study was to identify predictors of heart failure (HF) hospitalization and cardiovascular (CV) mortality in patients with RV pacing.

Methods

Retrospective and unicentric study. We studied 2418 patients undergoing single or dual-chamber pacemaker implantation between 2012–2018. Patients were included if they had an echocardiogram prior to implantation and a repeated echocardiogram >3 months after implantation. Baseline LV ejection fraction (LVEF) had to be >50%. PICM was defined as ≥10% decrease in LVEF, resulting in LVEF <50%. Alternative causes of LV dysfunction were excluded. Primary endpoint was heart failure hospitalization. Secondary endpoint was cardiovascular mortality. Competing-risk regression analysis was performed to identify predictors of HFH and CV mortality.

Results

Of 2418 patients, 495 meeting study criteria and 105 (21.2%) met PICM criteria. Follow-up period was 56.1±28.5months. There were no differences in basal LVEF (60.1±0.5% in non-PICM patients vs 59.5±0.5 in PICM patients, p=0.51). Mean LVEF at follow-up was 37.7±0.9 vs 56.7±0.3, p<0.001. After logistic multivariable analysis, factors associated with PICM were alcohol consumption (OR 3.0, 95% CI 1.1–8.0,p=0.032), right bundle branch block (RBBB) (OR 1.9, 95% CI 1.06–3.51,p=0.031), higher RV pacing burden (OR 1.0, 95% CI 1.0–1.1,p=0.008) and higher basal LV end-diastolic diameter (OR 1.1, 95% CI 1.0–1.1,p=0.016).

HFH occurred in 144 patients (29.1%). Factors associated with HFH after multivariable analysis were any decrease in LVEF (LVEF>55% as reference: LVEF 46–55% (HR 2.1, 95% CI 1.3–3.3,p=0.002); LVEF 36–45% (HR=1.5, 95% CI 0.7–3.0; p=0.306), LVEF≤35% (HR 2.44, 95% CI 1.11–5.37,p=0.027), age (HR 1.0, 95% CI 1.0–1.1,p=0.037), alcohol consumption (HR 3.4, 95% CI 1.9–6.1,p<0.001), presence of atrial fibrillation (HR 1.7, 95% CI 1.06–2.70,p=0.027) and paced QRS duration (HR 1.0, 95% CI 1.0–1.02,p=0.031).

CV mortality occurred in 54 patients (10.9%). Factors associated with CV mortality after multivariable analysis were a decrease in LVEF (LVEF 46–55% (HR 1.6, 95% CI 0.8–3.2,p=0.217); LVEF 36–45% (HR=1.6, 95% CI 0.6–4.2,p=0.33); LVEF≤35% (HR 4.6, 95% CI 2.0–10.7,p<0.001), RBBB (HR 2.1, 95% CI 1.1–3.9,p=0.026) and lower haemoglobin (HR 0.8, 95% CI 0.7–0.99,p=0.033).

Conclusion

In patients with RV pacing, factors associated with PICM were alcohol consumption, RBBB, RV pacing burden and basal LV end-diastolic diameter. HF hospitalization and CV mortality are common (29.1% and 10.9%). Any decrease in LVEF is associated with an increase in CV events.

Funding Acknowledgement

Type of funding sources: None.

Brachial-ankle pulse wave velocity with a custom device

BACKGROUND AND OBJECTIVES

The brachial-ankle pulse wave velocity (baPWV) is one of the most widely used arterial stiffness variables for assessing vascular risk. The abiPWV is a device that calculates various PWVs and the blood pressure ankle-brachial index (ABI). The device can also determine baPWV. The aim of this study was to calculate the baPWV with abiPWV, validate it with a reference device (VaSera) and study its clinical usefulness.

PATIENTS AND METHODS

We studied 113 patients (mean age, 53±12years), 59 (52%) of whom were women, and 10 (8.8%) of whom had a previous cardiovascular event. The participants were classified according to cardiovascular risk factors (CRFs) into groupI (none), groupII (1 or 2 CRFs) and groupIII (3 or more CRFs). The patients with a previous cardiovascular event were included in groupIII. All participants had their baPWV measured with abiPWV and VaSera.

RESULTS

The baPWV correlation between the 2 devices was r=0.93 (P<.001), and the percentage error calculated with the Bland-Altman analysis was 4.5%. The baPWV measured with abiPWV (in m/s) was as follows: groupI, 10.5±1.6; groupII, 13.8±2.9 (P<.001 when compared with groupI); and groupIII, 14.1±2.7 (P<.001 when compared with groupI). There were no differences between groupsII and III. The results with VaSera were comparable to those of abiPWV.

CONCLUSIONS

Measuring baPWV with the abiPWV is safe and has a similar clinical utility to that of VaSera. Incorporating this function into the options of abiPWV makes it a complete device for assessing arterial stiffness.

Resource utilization and costs associated with achieved LDL-C levels in patients following a myocardial infarction treated with lipid-lowering therapies in Spain

Background/Introduction

Reduction in low-density lipoprotein cholesterol (LDL-C) significantly reduces cardiovascular (CV) risk, especially in patients with atherosclerotic CV disease. There is, however, a lack of evidence on the association between achieved LDL-C and resource utilization and costs.

Purpose

Assess the association of achieved LDL-C levels and resource use and costs in patients treated with lipid-lowering therapies (LLT) following a myocardial infarction (MI).

Methods

Retrospective observational study using the BIG-PAC® database, with anonymized electronic medical records from 1.9 million inhabitants from 7 regions in Spain.

Eligible patients were adults (≥18 years), hospitalized for an MI (index date) between January 2015 and December 2017, treated with LLTs (statins and/or ezetimibe) during follow-up (up to 18 months), and with recorded LDL-C values at baseline and follow-up.

Direct (related to health care interventions) and indirect (related to loss of productivity) costs were estimated in 2018€.

Costs incurred during follow-up were computed by achieved LDL-C. Achieved LDL-C was obtained in the year following the MI and at least 2 months after the index date. LDL-C categories were defined as per the 2016 and 2019 ESC/EAS guidelines for dyslipidaemias management: &lt;55 mg/dL, 55–69 mg/dL, 70–99 mg/dL, 100–129 mg/dL and ≥130 mg/dL. Results were adjusted for age, gender, CV disease history and comorbidities.

Results

6025 patients were included. Mean age (SD) was 69.7 (12.2) and 77% were male.

Resource use (not reported in this abstract) and costs monotonically increased with achieved LDL-C. Mean total costs ranged from 5044€ for patients with LDL-C &lt;55 mg/dL to 7567€ for patients with LDL-C ≥130 mg/dL (Table 1).

Only 11% (641/6025) of patients reached recommended LDL-C levels for very-high-risk patients as per 2016 ESC/EAS guidelines (&lt;70 mg/dL), and 1% (68/6025) the LDL-C levels (&lt;55 mg/dL) proposed in the 2019 guidelines.

Conclusions

Achieving lower LDL-C levels following an MI may be associated to lower resource use and costs. Many patients do not achieve recommended LDL-C levels despite treatment with LLT. These data suggest that use of more intense LLT, with a greater reduction in LDL-C, would be beneficial from a clinical and economic perspective.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen (Europe) GmbH

Brachial-ankle pulse wave velocity with a custom device

BACKGROUND AND OBJECTIVES

The brachial-ankle pulse wave velocity (baPWV) is one of the most widely used arterial stiffness variables for assessing vascular risk. The abiPWV is a device that calculates various PWVs and the blood pressure ankle-brachial index (ABI). The device can also determine baPWV. The aim of this study was to calculate the baPWV with abiPWV, validate it with a reference device (VaSera) and study its clinical usefulness.

PATIENTS AND METHODS

We studied 113 patients (mean age, 53 ± 12 years), 59 (52%) of whom were women, and 10 (8.8%) of whom had a previous cardiovascular event. The participants were classified according to cardiovascular risk factors (CRFs) into group I (none), group II (1 or 2 CRFs) and group III (3 or more CRFs). The patients with a previous cardiovascular event were included in group III. All participants had their baPWV measured with abiPWV and VaSera.

RESULTS

The baPWV correlation between the 2 devices was r = 0.93 (p < .001), and the percentage error calculated with the Bland-Altman analysis was 4.5%. The baPWV measured with abiPWV (in m/s) was as follows: group I, 10.5 ± 1.6; group II, 13.8 ± 2.9 (p < .001 when compared with group I); and group III, 14.1 ± 2.7 (p < .001 when compared with group I). There were no differences between groups II and III. The results with VaSera were comparable to those of abiPWV.

CONCLUSIONS

Measuring baPWV with the abiPWV is safe and has a similar clinical utility to that of VaSera. Incorporating this function into the options of abiPWV makes it a complete device for assessing arterial stiffness.

P581Electronic health records (EHRs) data validation in atherosclerotic/cardiovascular clinical phenotypes

Background

Research efforts to develop strategies to effectively identify patients and reduce the burden of cardiovascular diseases is essential for the future of the health system. Most research studies have used only coded parts of electronic health records (EHRs) for case-detection obtaining missed data cases, reducing study quality and in some case bias findings. Incorporating information from free-text into case-detection through Big Data and Artificial Intelligence techniques improves research quality. Savana has developed EHRead, a powerful technology that applies Natural Language Processing, Machine Learning and Deep Learning, to analyse and automatically extracts highly valuable medical information from unstructured free text contained in the EHR to support research and practice.

Purpose

We aimed to validate the linguistic accuracy performance of Savana, in terms of Precision (P), Recall (R) and overall performance (F-Score) in the cardiovascular domain since this is one of the most prevalent disease in the general population. This means validating the extent to which the Savana system identifies mentions to atherosclerotic/cardiovascular clinical phenotypes in EHRs.

Methods

The project was conducted in 3 Spanish sites and the system was validated using a corpus that consisted of 739 EHRs, including the emergency, medical and discharge records, written in free text. These EHRs were randomly selected from the total number of clinical documents generated during the period of 2012–2017 and were fully anonymized to comply with legal and ethical requirements. Two physicians per site reviewed records (randomly selected) and annotated all direct references to atherosclerotic/cardiovascular clinical phenotypes, following the annotation guidelines previously developed. A third physician adjudicated discordant annotations. Savana's performance was automatically calculated using as validation resource the gold standard created by the experts.

Results

We found good levels of performance achieved by Savana in the identification of mentions to atherosclerotic/cardiovascular clinical phenotypes, yielding an overall P, R, and F-score of 0.97, 0.92, and 0.94, respectively. We also found that going through all the EHRs and identifying the mentions to atherosclerotic/cardiovascular clinical phenotypes, the expert spent ∼ 60h while Savana ∼ 36 min.

Conclusion(s)

Innovative techniques to identify atherosclerotic/cardiovascular clinical phenotypes could be used to support real world data research and clinical practice. Overall Savana showed a high performance, comparable with those obtained by an expert physician annotator doing the same task. Additionally, a significant reduction of time in using automatic information extraction system was achieved.

'Real-life' experience in asthmatic children treated with omalizumab up to six-years follow-up

INTRODUCTION AND OBJECTIVES

Omalizumab is present in international guidelines for the control of severe asthma, but data on the long-term effects in children are limited. Our objective was to perform a 'real-life' long-term trial of omalizumab in children with allergic asthma.

MATERIALS AND METHODS

An observational single center 'real-life' study was performed. Data for treatment, lung function, side effect, asthma exacerbations and hospitalizations were recorded at six months and annually.

RESULTS

Forty-eight patients <18 years of age were enrolled. Median treatment period was 2.9 (0.5-6). Fluticasone dose for the maintenance treatment decreases significantly at six months (452mcg/day to 329.89mcg/day, respectively). This difference was maintained throughout the follow-up. Nobody used oral corticosteroid after six months. The rate of hospital admissions and visits to the emergency department for asthma exacerbations decreased significantly in the third years and fourth years follow-up, respectively. There was an improvement in lung function. Mean values of FEV₁ and FEF_25-75% before treatment were 79.88 and 62.94, respectively; after six months of treatment a statistically significant change was seen with a mean FEV₁ of 92.29 and FEF_25-75% of 76.31 (p=0.0001). Lung function values were above normal throughout the six years of treatment. No side effects were reported.

CONCLUSIONS

Overall in 'real life' omalizumab in children reduces asthma exacerbations and hospitalizations, improves lung function, and decreases the maintenance therapy. It is shown to be safe for up to six years of treatment in children.

Stem cell-like transcriptional reprogramming mediates metastatic resistance to mTOR inhibition

Inhibitors of the mechanistic target of rapamycin (mTOR) are currently used to treat advanced metastatic breast cancer. However, whether an aggressive phenotype is sustained through adaptation or resistance to mTOR inhibition remains unknown. Here, complementary studies in human tumors, cancer models and cell lines reveal transcriptional reprogramming that supports metastasis in response to mTOR inhibition. This cancer feature is driven by EVI1 and SOX9. EVI1 functionally cooperates with and positively regulates SOX9, and promotes the transcriptional upregulation of key mTOR pathway components (REHB and RAPTOR) and of lung metastasis mediators (FSCN1 and SPARC). The expression of EVI1 and SOX9 is associated with stem cell-like and metastasis signatures, and their depletion impairs the metastatic potential of breast cancer cells. These results establish the mechanistic link between resistance to mTOR inhibition and cancer metastatic potential, thus enhancing our understanding of mTOR targeting failure.

Asymptomatic LTP sensitisation is common in plant-food allergic children from the Northeast of Spain

BACKGROUND

The sensitisation profile at molecular level in plant-food allergy is complex. Several allergens may be involved, with different potential for severe reactions. lipid transfer proteins (LTP) are considered the most relevant plant-food allergens in adults in Mediterranean countries, but less is known in children.

AIM

To describe the clinical pattern and sensitisation profile of children with plant-food allergy and LTP sensitisation from Northeast Spain.

METHODS

Children with history of immediate reaction to plant-food(s), positive skin-prick-test to the culprit plant-food(s) and specific-IgE to plant-food LTPs were analysed.

RESULTS

130 children were included. 69.2% (90/130) had reacted to ≥2 taxonomically unrelated plant-foods. Peach, walnut, hazelnut and peanut were most frequently involved. Reactions severity ranged from anaphylaxis (45.4%, 59/130) to oral symptoms only. Sensitisation to a particular plant-food LTP not always caused clinical symptoms with that plant-food; 69% (40/58) and 63% (17/27) of peach- and walnut-tolerant subjects had positive rPru p 3 and nJug r 3 specific IgE, respectively. 65.4% (85/130) of children were also sensitised to storage proteins, which was associated to anaphylaxis and nut allergy. However, 60% of patients without nuts/seeds allergy were sensitised to storage proteins. Specific-IgE levels to LTPs and/or storage proteins were not useful to predict allergy (vs. tolerance) to peach, walnut, peanut or hazelnut.

CONCLUSIONS

Sensitisation to LTP and/or storage proteins without clear clinical significance is relatively common. Prospective longitudinal studies are required to evaluate the relevance of these silent sensitisations over time. Caution is required when interpreting the results of molecular-based diagnostic tools in clinical practice.

Population genetic analysis of Anisakis simplex s.l. and Anisakis pegreffii (Nematoda, Anisakidae) from parapatric areas and their contact zone

Genetic markers (ribosomal DNA and mitochondrial DNA) were used for molecular dissection of the Anisakis simplex sensu lato (s.l). complex populations. Host fish were caught off Moroccan coasts, where only Anisakis pegreffii is present, the sympatric area comprising Spanish coasts, and the Little Sole Bank fishing area from Nordeast Atlantic Ocean where the only present species is A. simplex sensu stricto(s.s.). Sequence variations in the amplification products were then assessed indirectly by digestion with restriction endonucleases or directly by sequencing for 623 L3 larvae. The sequences were used to infer the relationships between the two species under study using various methodological approaches. We reveal the high genetic diversity of Anisakis simplex s.s. and A. pegreffii in both mitochondrial and nuclear genes. We detected 10 and 2 fixed differences between A. simplex s.s and A. pegreffii in the Cox2 and ITS1, respectively. We found a proportion of putative hybrids below 20% with similar figures on the Atlantic and Mediterranean coasts. Moroccan hybrids were more similar to A. pegreffii reflecting backcrosses between these mixed genotypes and his ancestor A. pegreffii. We discuss the possible interpretation of these putative hybrids.

Tolerance to egg proteins in egg-sensitized infants without previous consumption

BACKGROUND

Egg-sensitized infants who have never eaten egg may react at first ingestion. We sought to determine the association between skin prick test (SPT) and specific IgE (sIgE) to egg proteins (EP) and oral food challenge (OFC) outcomes to find cut-off points which can diagnose egg allergy.

METHODS

One hundred and fifty-four infants up to 18 months, with cow's milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption, were recruited. SPT to EP were performed. If it was positive, sIgE was performed. If positive SPT and/or sIgE (n = 94), OFC was performed between 12 and 18 months. Receiver operating characteristic (ROC) curves were plotted, and the outcome of the OFC was related to SPT and sIgE. The cut-off points with the best diagnostic accuracy were found.

RESULTS

Ninety-four patients were sensitized to egg (69%) and 60 nonsensitized (31%). Of the sensitized, 27 tolerated cooked (CE) and raw egg (RE) (28.7%). Sixty-seven were allergic (71.3%): 29 reacted to CE, seven to egg yolk (EY) and 22 to egg white (EW) and 38 reacted to RE. 69.2% tolerated CE. EW SPT and ovalbumin (OVA) sIgE have the best area under the curve (AUC). The higher positive predictive values (PPV) were obtained for EW SPT and EW sIgE.

CONCLUSIONS

In egg-sensitized infants with EW SPT ≥8 mm and/or EW sIgE ≥8.36 KU/l, egg diagnostic OFC can be avoided as there is 94% probability of becoming positive. In the other patients, OFC should be performed safely and early to avoid unnecessary diets.

The competitor release effect applied to carnivore species: how red foxes can increase in numbers when persecuted

The objective of our study was to numerically simulate the population dynamics of a hypothetical community of three species of small to medium–sized carnivores subjected to non–selective control within the context of the competitor release effect (CRE). We applied the CRE to three carnivore species, linking interspecific competition with predator control efforts. We predicted the population response of European badger, the red fox and the pine marten to this wildlife management tool by means of numerical simulations. The theoretical responses differed depending on the intrinsic rate of growth (r), although modulated by the competition coefficients. The red fox, showing the highest r value, can increase its populations despite predator control efforts if control intensity is moderate. Populations of the other two species, however, decreased with control efforts, even reaching extinction. Three additional theoretical predictions were obtained. The conclusions from the simulations were: 1) predator control can play a role in altering the carnivore communities; 2) red fox numbers can increase due to control; and 3) predator control programs should evaluate the potential of unintended effects on ecosystems.

Sensitization to Anisakis simplex species in the population of northern Morocco

OBJECTIVE

To investigate sensitization to third-stage Anisakis simplex larvae in a randomly selected population in northern Morocco.

METHODS

We studied sera obtained from clinical analysis laboratories in Tangier and Tetuouan and from fishermen at Tangier port. The age of the study population ranged from 6 to 83 years. ImmunoCAP and immunoblotting techniques were used to determine total and specific immunoglobulin (Ig) E values and the chi2 and Fisher exact tests were applied to analyze relationships between study variables.

RESULTS

A seroprevalence of 5.1% was found, with a higher percentage of positive sera in the 31-to-43-year age group. Sensitization was not significantly associated with the origin, sex, occupation, or age of the individuals studied. In sera positive by InmunoCAP, immunoblotting studies detected numerous bands of between 7 kDa and >209 kDa, with a predominance of bands in the approximately 20-kDa to 24-kDa range.

CONCLUSIONS

Although no cases of human anisakiasis have been reported in Morocco to date, part of a randomly selected population in Northern Morocco shows sensitization to A simplex proteins.