Universitair Ziekenhuis Leuven

ABSTRACT Introduction The wide-reaching consequences of a restrictive diet are often underestimated or poorly recognized both by the public and many physicians. Deficiency symptoms may go unnoticed leading to unnecessary investigations and ineffective treatments, and a delay in a simple and directed treatment: suppletion of the missing nutrients. Case presentation This case-report describes a 68-year-old man in a high-income country who presented with a 3-week history of painful, indurated edema of the lower legs, immobility due to pain, and dyspnea. Treatment with antibiotics and LMWH was ineffective. Laboratory tests showed anemia (Hb 7.7 g/dL), elevated C-reactive protein (48 mg/L) and elevated D-dimers. He was hospitalized for further investigation. Folate and iron deficiencies were found. Pulmonary embolism and deep venous thrombosis were ruled out, as were systemic inflammatory diseases and infectious causes. PET-CT revealed lung changes suggestive of pulmonary hemorrhage and findings suspicious for bilateral lower leg fasciitis. Detailed dietary history revealed a severely restricted intake (limited to bread, white rice, butter, honey and coffee) for over 20 years. Skin biopsy and exclusion of differential diagnoses confirmed the clinical suspicion of scurvy due to vitamin C deficiency. Nutritional supplementation and dietary expansion led to rapid clinical improvement. Conclusions Although scurvy is more common in low- and middle-income countries, it still occurs in high-income settings. It should be considered in at-risk patients presenting with suggestive symptoms.

Abstract Injuries of the triangular fibrocartilage complex (TFCC), particularly those involving the foveal insertion, may lead to significant ulnar-sided wrist pain, grip weakness, dysfunction, and progressive degenerative changes within the distal radioulnar joint (DRUJ). Arthroscopic repair is the preferred surgical approach for peripheral TFCC tears requiring intervention. Multiple techniques have been described to address the peripheral and/or foveal attachments of the TFCC. This report presents an arthroscopic repair method that concurrently addresses both foveal and peripheral TFCC tears using a single combined suture construct. This approach has the potential to enhance the stability of TFCC fixation and improve overall DRUJ stability.

Abstract Few studies have described physiological and cardiac rhythm responses to maximal voluntary breath-holding in elite freedivers. This case study presents minute ventilation, PETO 2 , PETCO 2 , involuntary breathing movements (IBMs; surface electromyography), SpO 2 , muscle and cerebral oxygenation (near-infrared spectroscopy), and cardiac rhythm changes (electrocardiogram) before, during, and after a dry, maximal, voluntary breath-hold in a world champion freediver. Glossopharyngeal insufflation prior to the breath-hold increased forced vital capacity from 6.92 L (138% predicted) to 9.04 L (180% predicted). Compared to resting end-tidal gas pressures, the breathe-up in preparation of the breath-hold increased PETO 2 (108 mmHg to 135 mmHg) and decreased PETCO 2 (36 mmHg to 21 mmHg). The breath-hold was 06’07” in duration, of which 02’20” was spent in the easy-going phase and 03’47” in the struggle phase – the latter encompassing a total of 48 IBMs. Throughout the breath-hold, PETO 2 decreased to 38 mmHg and PETCO 2 increased to 65 mmHg. SpO 2 decreased from 97% to 73%. Muscle oxygenation decreased from 50% to 22%, whereas cerebral oxygenation remained relatively stable until the final ∼20 s of the breath-hold (∼68% to ∼62%). Heart rate variability-based markers of autonomic cardiac activity decreased during the easy-going phase, increased during the struggle phase, and normalized after. Asymptomatic bradycardia with competition between sinus bradycardia and junctional rhythm and (supra)ventricular extrasystoles manifested throughout the struggle phase and resolved after breath-hold cessation. This report of a world champion freediver shows that a long voluntary breath-hold induced transient asymptomatic cardiac arrhythmias, likely linked to the physiological stress of extreme voluntary breath-holding.

Abstract Background: RIB demonstrated clinically and statistically significant PFS and overall survival (OS) benefit in all of its phase 3 trials in HR+/HER2− advanced breast cancer (ABC; ML-2, -3, -7). We studied clinical characteristics and biomarkers of pts who derived long-term treatment benefit. We present an exploratory analysis of the ML trials of all 1L pts with long-term response (LTR; PFS >4 y) to RIB and 1L postmenopausal pts with very long-term response (VLTR; PFS >5 y). Methods: In the ML trials, pre- (ML-7) and postmenopausal (ML-2, -3) pts with HR+/HER2− ABC received RIB + ET or placebo + ET. Only pts who received 1L RIB were included in this pooled analysis. Pts with early relapse (treatment-free interval [TFI] ≤12 months on [neo]adjuvant ET) and those in ML-7 treated with tamoxifen were excluded. Overall median follow-up (mfu) was 6.1 y (ML-2, 6.7 y; ML-3, 5.9 y; ML-7, 4.5 y). Given the median PFS of ≈2 y reported with CDK4/6i in 1L ABC, more than doubling that time (PFS >4 y) was considered LTR. VLTR was defined as PFS >5 y, calculated only for postmenopausal pts (ML-2, -3) as mfu in ML-7 was <5 y. Biomarker analyses were performed using baseline ctDNA and tumor samples. Nominal P values (unadjusted) were calculated to compare characteristics of pts with LTR and non-LTR. Results: Of 666 pts treated with 1L RIB + ET included in the analysis, 109 were on treatment at data cutoff. A total of 153 pts (23.0%) had LTR; 164 pts (24.6%) were censored before LTR cutoff. Median PFS (mPFS) in pts with LTR was 6.8 y (95% CI: 6.4 y-NE [not estimable]); median OS (mOS) was NE (95% CI: 7 y-NE). Age, body mass index, and menopausal status were balanced between pts with LTR and non-LTR ( Table ). Similar proportions of premenopausal (34/150 [22.7%]) and postmenopausal pts (119/516 [23.1%]) had LTR. Pts with LTR were less likely than those with non-LTR to have liver metastasis (16.3% vs 25.5%) and less likely to have ≥3 metastatic sites (30.1% vs 43.0%). Similar proportions of pts with LTR vs non-LTR had bone-only disease (24.2% vs 19.5%). ctDNA analysis used a panel of 558 genes; gene expression analysis used 800 genes. Pts with LTR had a lower mean ctDNA fraction and were less likely to have CCND1 or TP53 alteration detected by ctDNA. Additionally, they had lower gene expression of CCNE1 and a higher proportion of luminal A disease (PAM50 based). Of 516 postmenopausal pts, 88 (17.1%) had VLTR; further analysis will be provided in the presentation. Conclusions: In the ML studies, 1 of 4 pts treated with 1L RIB were able to derive LTR (PFS >4 y). Pts with LTR had mPFS of 6.8 y, and mOS was NE. Although LTR was more evident in pts with better prognostic factors, noticeably, some pts with unfavorable prognostic factors were still able to achieve LTR. This exploratory analysis suggests long-term benefit with 1L RIB in keeping a good number of pts with HR+/HER2− ABC free of disease progression for more than 4 y. Citation Format: F. Andre, P. A. Fasching, A. Prat, P. Neven, Y. Lu, A. Bardia, G. Curigliano, V. Kaklamani, P. Razavi, Y. Yap, F. Su, E. Roux, K. Pantoja, J. Wu, A. Lteif, D. Juric. Pooled analysis of patients (pts) treated with 1st-line (1L) ribociclib (RIB) + endocrine therapy (ET) in the MONALEESA (ML) studies: long-term progression-free survival (PFS) [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PD5-10.

Calcified coronary lesions impede stent expansion and are associated with poor outcomes after percutaneous coronary interventions. Intravascular lithotripsy (IVL) has emerged as a safe and effective pretreatment to optimise stent implantation. This study assesses the LithiX lithotripsy device, which uses the Hertz contact (HC) mechanism to fragment calcium while minimising injury to surrounding soft tissue, without requiring an external energy source. The multicentre, prospective PINNACLE-I clinical trial enrolled patients with up to two moderately to severely calcified de novo lesions. The primary endpoints were <50% residual stenosis without in-hospital major adverse cardiovascular events (MACE) and the 30-day MACE rate. Clinical events were assessed up to 6 months. Sixty patients with 63 lesions were treated with successful delivery and use of the HC-IVL catheter and a median procedure time of 59.5 min (interquartile range: 40.5-76.0). The primary endpoint was achieved in 98.3%. All patients had residual stenosis <30% after stent placement. The 30-day MACE rate was 1.7%, due to 1 periprocedural target vessel non-Q-wave myocardial infarction. There were no cardiovascular deaths, no definite or probable stent thromboses, nor any device-related events up to 6 months of follow-up. The optical coherence tomography substudy in 32 subjects identified a wide range of calcium morphologies, including calcium arcs of 96-360° and calcified nodules. Following HC-IVL, calcium fractures were achieved in 90.6% of lesions, and the mean fracture depth was 0.81±0.33 mm. Stent expansion at the minimum stent area site was 96.7±25.5%. PINNACLE-I demonstrated the feasibility, safety, and efficacy of the novel HC-IVL to fracture calcified lesions and achieve optimal stent expansion in a broad range of calcium morphologies.

Elective caesarean section is a common and painful procedure. Uncontrolled pain following caesarean section can profoundly and negatively on a wide range of patient and healthcare-centred outcomes. The aim of this systematic review was to update existing recommendations for postoperative pain management after elective caesarean section performed under neuraxial anaesthesia. A systematic review using the PROcedure SPEcific Postoperative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised trials evaluating the efficacy of analgesic, anaesthetic and surgical interventions were retrieved. Systematic reviews and meta-analyses of randomised controlled trials were also reviewed. Trials evaluating pain management for emergency surgical deliveries or caesarean section performed under general anaesthesia were not included. Sixty-one randomised controlled trials were included. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, we recommend that clinicians administer intrathecal morphine 50-100 μg or diamorphine 300 μg pre-operatively, and paracetamol, non-steroidal anti-inflammatory drugs and dexamethasone after delivery. If a neuraxial opioid is not administered, clinicians should use one of a range of recommended fascial plane blocks; alternatively, the wound should be infiltrated with local anaesthetic. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs, with opioids used for rescue. The surgical technique should include a Joel-Cohen incision. The peritoneum should not be closed. An analgesic regimen to manage pain safely and effectively after elective caesarean section based on up-to-date evidence is presented. Consideration has been given to balancing analgesic efficacy and potential adverse effects. Future research should determine the optimal dose of dexamethasone and epidural long-acting opioid, establish the most effective regional analgesic technique and develop standardised outcome sets to better compare techniques.

: The Leuven Postprandial Distress Scale (LPDS) is a validated patient reported outcome (PRO) measure for functional dyspepsia (FD)/postprandial distress syndrome (PDS) patients according to Rome III criteria. However, meal-related nausea or epigastric pain, part of PDS in Rome IV, were not addressed in this construct. Also, focus groups identified fatigue as a frequently reported complaint for which the European Medicines Agency requested further analysis. Our aim is to validate the LPDS in FD/PDS as defined by Rome IV criteria and to optimize the model by assessing the value of adding extra items to this questionnaire. : The questionnaire was validated in 3 different Rome IV FD/PDS patient cohorts recruited for controlled clinical trials. Additional questions in the diary regarding symptom relationship to meal and fatigue were evaluated. Anchor scores were the patient assessment of gastrointestinal symptom severity index, Short-form Nepean dyspepsia index, the overall treatment evaluation and overall symptom severity questionnaires. : The LPDS Construct validity was confirmed for Rome IV-defined PDS. Psychometric analysis did not support inclusion of fatigue, nausea, meal-related or meal-unrelated, and meal-related epigastric pain, due to low loading or poor model fit. : The LPDS questionnaire showed good reliability and responsiveness, and can be confidently used as a validated tool in Rome IV PDS populations. Data did not support adding accessory symptoms to the construct, due to low loading or poor model fit.