Clinical and demographic factors modify the association between plasma phosphorylated tau-181 and cognition

INTRODUCTION

Plasma phosphorylated tau181 (p-tau181) associations with global cognition and memory are clear, but the link between p-tau181 with other cognitive domains and subjective cognitive decline (SCD) across the clinical spectrum of Alzheimer's disease (AD) and how this association changes based on genetic and demographic factors is poorly understood.

METHODS

Participants were drawn from the Alzheimer's Disease Neuroimaging Initiative and included 1185 adults aged >55 years with plasma p-tau181 and neuropsychological test data. Linear regression models related plasma p-tau181 to neuropsychological composite and SCD scores with follow-up models examining plasma p-tau181 interactions with cognitive diagnosis, APOE ε4 carrier status, age, and sex on cognitive outcomes.

RESULTS

Higher plasma p-tau181 was associated with worse memory, executive functioning, and language abilities, and greater informant-reported SCD. Visuospatial abilities and self-report SCD were not associated with plasma p-tau181. Associations were generally stronger in MCI or dementia, APOE ε4 carriers, women, and younger participants.

DISCUSSION

Higher levels of plasma p-tau181 are associated with worse neuropsychological test performance across multiple cognitive domains; however, these associations vary based on disease stage, genetic risk status, age, and sex.

Sex and Education Modify the Association Between Subjective Cognitive Decline and Amyloid Pathology

Background

Subjective cognitive decline (SCD) may be an early risk factor for dementia, particularly in highly educated individuals and women. This study examined the effect of education and sex on the association between SCD and Alzheimer's disease (AD) biomarkers in non-demented older adults.

Method

Vanderbilt Memory and Aging Project participants free of clinical dementia or stroke (n=156, 72±6 years, 37% mild cognitive impairment, 33% female) completed fasting lumbar puncture, SCD assessment, and Wide Range Achievement Test-III Reading subtest to assess reading level at baseline as a a proxy for educational quality. Cerebrospinal fluid (CSF) biomarkers for AD (β-amyloid 42 (Aβ42), Aβ42/40 ratio, phosphorylated tau (p-tau), tau, and neurofilament light (NfL)) were analyzed in batch. Linear mixed effects models related SCD to CSF AD biomarkers and follow-up models assessed SCD x sex, SCD x reading level , and SCD x education interactions on AD biomarkers.

Result

In main effect models, higher SCD was associated with lower Aβ42 and Aβ42/40 ratio (p-values<0.004). SCD was not associated with tau, p-tau, or NfL levels ( p- values>0.38). SCD score interacted with sex on Aβ42/40 ratio ( p =0.03) but no other biomarkers ( p -values>0.10). In stratified models, higher SCD was associated with lower Aβ42/40 ratio in men ( p =0.0003) but not in women ( p =0.48). SCD score interacted with education on Aβ42 ( p =0.005) and Aβ42/40 ratio ( p =0.001) such that higher education was associated with a stronger negative association between SCD and amyloid levels. No SCD score x reading level interaction was found (p-values> 0.51) though significant associations between SCD and amyloid markers were seen in the higher reading level group (p-values<0.004) but not the lower reading level group (p-values>0.12) when stratified by a median split in reading level.

Conclusion

Among community-dwelling older adults free of clinical dementia, higher SCD was associated with greater cerebral amyloid accumulation, one of the earliest pathological AD changes. SCD appears most useful in detecting early AD-related brain changes in men and individuals with higher quantity and quality of education. SCD was not associated with CSF markers of tau pathology or neurodegeneration. These findings suggest that considering sex and education is important when assessing SCD in older adults.

Associations of Sex, Race, and Apolipoprotein E Alleles With Multiple Domains of Cognition Among Older Adults

Importance

Sex differences are established in associations between apolipoprotein E (APOE) ε4 and cognitive impairment in Alzheimer disease (AD). However, it is unclear whether sex-specific cognitive consequences of APOE are consistent across races and extend to the APOE ε2 allele.

Objective

To investigate whether sex and race modify APOE ε4 and ε2 associations with cognition.

Design, Setting, and Participants

This genetic association study included longitudinal cognitive data from 4 AD and cognitive aging cohorts. Participants were older than 60 years and self-identified as non-Hispanic White or non-Hispanic Black (hereafter, White and Black). Data were previously collected across multiple US locations from 1994 to 2018. Secondary analyses began December 2021 and ended September 2022.

Main Outcomes and Measures

Harmonized composite scores for memory, executive function, and language were generated using psychometric approaches. Linear regression assessed interactions between APOE ε4 or APOE ε2 and sex on baseline cognitive scores, while linear mixed-effect models assessed interactions on cognitive trajectories. The intersectional effect of race was modeled using an APOE × sex × race interaction term, assessing whether APOE × sex interactions differed by race. Models were adjusted for age at baseline and corrected for multiple comparisons.

Results

Of 32 427 participants who met inclusion criteria, there were 19 007 females (59%), 4453 Black individuals (14%), and 27 974 White individuals (86%); the mean (SD) age at baseline was 74 years (7.9). At baseline, 6048 individuals (19%) had AD, 4398 (14%) were APOE ε2 carriers, and 12 538 (38%) were APOE ε4 carriers. Participants missing APOE status were excluded (n = 9266). For APOE ε4, a robust sex interaction was observed on baseline memory (β = -0.071, SE = 0.014; P = 9.6 × 10-7), whereby the APOE ε4 negative effect was stronger in females compared with males and did not significantly differ among races. Contrastingly, despite the large sample size, no APOE ε2 × sex interactions on cognition were observed among all participants. When testing for intersectional effects of sex, APOE ε2, and race, an interaction was revealed on baseline executive function among individuals who were cognitively unimpaired (β = -0.165, SE = 0.066; P = .01), whereby the APOE ε2 protective effect was female-specific among White individuals but male-specific among Black individuals.

Conclusions and Relevance

In this study, while race did not modify sex differences in APOE ε4, the APOE ε2 protective effect could vary by race and sex. Although female sex enhanced ε4-associated risk, there was no comparable sex difference in ε2, suggesting biological pathways underlying ε4-associated risk are distinct from ε2 and likely intersect with age-related changes in sex biology.

Pilot investigation of an activity-based approach to building hardiness

BACKGROUND

The purpose was to describe an activity-based psychological hardiness training programme delivered by an occupational therapist and examine its acceptability and effectiveness in improving hardiness.

METHOD

Participants (N=28) completed the 6-hour programme, which included pre/post-programme completion of the Dispositional Resilience Scale-15 (DRS-15) and a Program Evaluation Form. Paired t-tests were used to determine differences between pre-training and post-training scores on the DRS-15.

RESULTS

Results showed a significant increase (p<0.05) in total hardiness, commitment, and control scores on the DRS-15 from pre-training to post-training and good-excellent ratings for all categories on the Program Evaluation Form.

CONCLUSIONS

This programme evaluation described an occupational therapist's role in providing an activity-based psychological hardiness training programme and provided preliminary support for the acceptability of an activity-based approach to training psychological hardiness for service members.

Motor features associated with cognition in non-demented individuals with essential tremor

INTRODUCTION

Essential tremor (ET) is a clinically heterogeneous disease characterized by motor and non-motor features, including cognitive impairment. In a cross-sectional analysis, we determined whether the presence and severity of motor features of ET are associated with cognitive performance.

METHODS

Participants enrolled in a study that used motor and neuropsychological measures to characterize a cohort of ET subjects. Action tremor severity and additional motor features (rest tremor, intention tremor, cranial tremor, dystonia, tandem gait missteps) were assessed in non-demented participants. Participants completed a cognitive test protocol assessing domains of memory, executive function, attention, visuospatial ability, and language. An average z-score was calculated to represent global cognition.

RESULTS

There were 204 ET participants (mean age 78.6, range 55-95). Participants with 10 missteps were more likely to have MCI than those with 0 or 1 misstep (p < 0.001). In unadjusted linear regression models, action tremor severity (p = 0.010), rest tremor (p < 0.001), and tandem gait missteps (p < 0.001) were negatively associated with global cognition. In adjusted models, only tandem gait missteps were negatively associated with global cognition (p < 0.001). Missteps were also negatively associated with memory (p < 0.001), executive function (p < 0.001), attention (p = 0.011), and visuospatial function (p = 0.043). No other motor features were associated with global cognition in adjusted models (p > 0.05).

CONCLUSION

Among non-demented participants with ET, there is an association between cognitive performance and tandem gait missteps, but no other motor features of ET. This is a first step in establishing impaired tandem gait as a possible indicator of cognitive impairment in patients with ET.

The association of vasomotor symptoms during the menopausal transition and cognition in later life

OBJECTIVE

The majority of women experience vasomotor symptoms (VMS) during the menopausal transition. Whether self-reported VMS are associated with cognitive test performance later in life remains unclear. The goal of this study was to determine whether a greater burden of VMS is associated with poor later-life cognition.

METHODS

The Wisconsin Longitudinal Study is a prospective study of randomly selected Wisconsin high school graduates of the class of 1957. At ages 65 and 72, a random subset of participants completed six cognitive tests, including similarities, letter and category fluency, immediate and delayed word recall, and digit ordering. Nested regression models were used to examine the association between extent of VMS, assessed at age 54, and baseline cognition at 65, adjusting for early-life socioeconomic status, women's reproductive health variables, intelligence quotient, and midlife income. This series of models was also used to examine the association between VMS and change in cognition score from age 65 to 72. In sensitivity analyses, models were repeated in a sample using multiple imputation for missing covariates.

RESULTS

Of the 5,326 women enrolled, 874 had data onVMS, covariates, and all cognitive tests. In an unadjusted model, higher VMS were associated with a lower similarities score (b = -0.09 95% CI -0.16 to -0.02) at age 65 but no other cognitive tests. In adjusted models, VMS were not related to cognition at age 65 or change in cognition. Results remained similar with multiple imputation.

CONCLUSIONS

Our study does not support a relationship between self-reported VMS and cognition later in life.

POS1422 USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND RISK OF MULTIPLE MYELOMA IN PERSONS WITH RHEUMATOID ARTHRITIS

Background

Biologic therapies used in the management of rheumatoid arthritis (RA) target several cytokines that have been implicated in the pathogenesis of multiple myeloma (MM). Yet little is known about the association between use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (b or tsDMARDs) in RA and the incidence of MM.

Objectives

Our objective was to estimate the association between b/tsDMARD use and the risk of MM among persons with RA using Veterans Health Administration (VHA) data. We hypothesized that b-/tsDMARD use is associated with a lower incidence of MM compared with conventional synthetic DMARDs (csDMARDs).

Methods

In this retrospective cohort study, we identified patients >18 years of age diagnosed with RA in any United States VHA facility from 1/1/2002 and 12/31/2018. All patients met the following inclusion criteria: 1) two or more International Classification of Diseases Version 9 or 10 (ICD9 or ICD10) codes for RA at least 7 days apart but no more than 365 days apart 2) a prescription for a csDMARD within 90 days of the first RA diagnosis 3) one inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating a regular user of VHA). Medication data was derived from the outpatient prescription fills, bar coded medication administration (BCMA), and intravenous (IV) data domains. The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with MM before the diagnosis of RA were excluded. Incident MM was determined by 1 or more ICD9/10 code or ICD-oncology codes. Multivariable Cox proportional hazards model were performed to estimate the hazard ratio for developing MM among those during and following the use of a b-/tsDMARD relative to b-/tsDMARD-naïve persons adjusting for age, gender, race, and ethnicity.

Results

27,540 veterans with RA met study eligibility criteria, of whom 8,322 (30%) had taken a b-/tsDMARD. Over the study period there were 77 incident MM over a total of 192,000 person years. There were 55 events in users of csDMARDs, an incidence rate (IR) of 0.40 (95% CI 0.30-0.52) per 1000 person-years and 22 in persons currently or formerly using b-/tsDMARDs (IR 0.41, 0.25-0.61 per 1000 person years). The unadjusted hazard ratio for MM following bDMARD use relative to csDMARD only use was 1.04 (0.63, 1.73), which increased to 1.28 (0.76, 2.16) after adjusting for demographic characteristics (Table 1).

Table 1.

Multivariable Cox proportional hazards model for association between use of disease modifying anti-rheumatic drugs and incident multiple myeloma.

Clinical characteristicHazards ratio (95% CI)csDMARDReferenceb-/tsDMARD use1.28 (0.76-2.16)Age*1.04 (1.02-1.07)Female0.58 (0.20-1.62)RaceReferenceWhite2.11 (1.15-3.86)Black0.70 (0.10-5.08)OtherHispanic Ethnicity0.71 (0.17-2.92)

Abbreviations: b-/tsDMARD- biologic or targeted synthetic disease modifying anti-rheumatic drug; CI: confidence interval

*Hazards ratio reflects risk per every 1-year increase in age

Model adjusted for age, gender, race, and ethnicity

Conclusion

In this nationwide VA study, we did not observe an association between bDMARD use and the incidence of MM. Of note, the median interval from initiation of a bDMARD to the end of follow-up was approximately 5.8 years, which does not allow for an examination of a possible longer term influence.

Disclosure of Interests

None declared

POS1434 USE OF BIOLOGIC OR TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND THE RISK OF LYMPHOMA IN RHEUMATOID ARTHRITIS

Background

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development (1). Whether the decrease in inflammatory burden seen with use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (bDMARDs or tsDMARDs) translates into a lower risk of lymphoma in RA needs to be studied.

Objectives

The objective of our study was to examine the effect of administration of b/tsDMARDS on the incidence of lymphoma relative to conventional synthetic DMARDs (csDMARDs) in an inception cohort of Veterans with RA.

Methods

We identified patients >18 years of age diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the VA Corporate Data Warehouse (CDW). To be included, each patient was required to meet the following criteria: 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart; 2) a prescription for a csDMARD within 90 days of the first RA diagnosis; and 3) an inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VA). The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with prevalent lymphoma were excluded. Lymphoma diagnoses were identified using International Classification of Diseases Version 9, 10 and Oncology (ICD9, ICD10, ICDO) codes.

We used marginal structural models as described by Hernan et al (2) and time-varying Cox models to control for confounding by indication while evaluating this association. We adjusted for baseline demographics (age, sex, race, ethnicity, year of cohort entry, rheumatology visits), and time-varying CRP and time-varying Rheumatoid Disease Comorbidity Index (RDCI) (3) to control for confounding.

Results

27,421 Veterans with RA met our eligibility criteria. Most of the Veterans (56%) were in the age range 61-80 years old; 89% male, 76% White, 14% African American. 8,225 (30%) patients were treated with a b-/tsDMARD. The crude incidence rates were 1.71 (95% CI 1.5-1.94) per 1000 person-years for those only on csDMARDs and 1.78 (95% CI 1.44-2.18) for patients during or following use of a b/tsDMARDs. After adjustment with both time-fixed and time-varying covariates using marginal structural models, the incidence of lymphoma was not different between patients who did and did not use a b/tsDMARD (hazard ratio=1.06, 95% CI= 0.82-1.37) (Table 1).

Table 1.

Estimates of Effect of bDMARD or tsDMARD use on Lymphoma relative to use of csDMARDs

Marginal Structural Models; adjusted for:@Demographics1.04(0.80, 1.34)#Demographics + CRP1.06(0.82, 1.37)

* per 1000 person-years

@Demographics = age, gender, race, ethnicity, rheumatology visits, and year of cohort entry

#Adjusts for CRP, baseline rheumatology visits (yes/no) and RDCI.

CRP = C-Reactive Protein, RDCI = Rhematic Disease Comorbidity Index, CI = Confidence Interval, b/tsDMARD = biologic or targeted synthetic DMARD, csDMARD = conventional synthetic DMARD

Conclusion

In this large study using the nationwide VA data, we did not observe an association between the use of b/ts DMARDs and an increased risk of lymphoma.

References

[1]Baecklund E, Iliadou A, Askling J, Ekbom A, Backlin C, Granath F, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701.

[2]Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11(5):550-60.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis care & research. 2015;67(6):865-72.

Disclosure of Interests

None declared

Early prognosis of respiratory virus shedding in humans

This paper addresses the development of predictive models for distinguishing pre-symptomatic infections from uninfected individuals. Our machine learning experiments are conducted on publicly available challenge studies that collected whole-blood transcriptomics data from individuals infected with HRV, RSV, H1N1, and H3N2. We address the problem of identifying discriminatory biomarkers between controls and eventual shedders in the first 32 h post-infection. Our exploratory analysis shows that the most discriminatory biomarkers exhibit a strong dependence on time over the course of the human response to infection. We visualize the feature sets to provide evidence of the rapid evolution of the gene expression profiles. To quantify this observation, we partition the data in the first 32 h into four equal time windows of 8 h each and identify all discriminatory biomarkers using sparsity-promoting classifiers and Iterated Feature Removal. We then perform a comparative machine learning classification analysis using linear support vector machines, artificial neural networks and Centroid-Encoder. We present a range of experiments on different groupings of the diseases to demonstrate the robustness of the resulting models.

A Lifecourse Perspective on Female Sex-Specific Risk Factors for Later Life Cognition

PURPOSE OF REVIEW

The prevalence of Alzheimer's disease and related dementias is greater in women compared to men. We provide a review of female sex-specific risk factors across the lifecourse for cognition in older adulthood, highlighting areas that need further study.

RECENT FINDINGS

Pregnancy may affect late-life cognition, with adverse pregnancy outcomes associated with an increased risk of cognitive decline but parity providing a protective effect. Cumulative estrogen exposure, influenced by age of menarche, menopause, and exogenous estrogen use, may modify a woman's risk for dementia. Menopause transition-associated symptoms may impact cognitive health at the time of the symptoms, but long-term effects remain unknown. As compared to natural menopause, surgical menopause seems to increase the risk for cognitive impairment. Studies that have assessed the association between women's reproductive health and cognition have produced conflicting results. Future studies that address these inconsistencies among diverse populations are needed to better care for women throughout their lives.

POS0287 USE OF BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RELATION TO THE RISK OF LYMPHOMA: A COHORT STUDY OF US VETERANS WITH RHEUMATOID ARTHRITIS

Background:

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development. However, the association of the use of biologic disease modifying anti-rheumatic drugs (bDMARDs) in patients with RA on lymphoma risk needs further evaluation.

Objectives:

Examine the effect of administration of bDMARDS on the incidence of lymphoma in an inception cohort of RA.

Methods:

We identified patients diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the Veteran’s Health Administration (VHA) databases. To be included, each patient was required to meet the following criteria: 1) 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart 2) a prescription for a conventional synthetic DMARD (csDMARD) within 90 days of the first RA diagnosis 3) One inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VHA). We excluded patients for any of the following if they preceded the first RA diagnosis: 1) a prior single RA diagnostic code 2) a prescription for any DMARD medication 3) a concomitant diagnosis of another inflammatory arthritis (e.g. psoriatic arthropathy) 4) a diagnosis of lymphoma. Index date for the study is the date of the first qualifying RA diagnosis. Lymphoma diagnoses were identified through VHA records using the International Classification of Diseases-Oncology codes.

Results:

We identified 27,536 veterans with RA in the study period meeting the inclusion and exclusion criteria. Of these, 53% (n=14,705) were in the age range 60 to 80 years. The cohort was 89% male, 75.5% White, 13.7% African American. Over the study period, 1.2% (n=332) of the study population developed a lymphoma.

Conclusion:

Using the nationwide VHA we have identified a large inception cohort of patients with RA of whom 1.2% developed lymphoma over study follow-up. This data will be used in future analyses to produce estimates of the effect of biologic medications on lymphoma risk, adjusting for confounding by indication and other variables.

Table 1.

Baseline characteristics of the cohort based on bDMARD exposure status

CharacteristicbDMARD-naive (n= 19,095)bDMARD-exposed (n=8,441)Overall Lymphomas Age (years)171161 18-4046 40-606378 60-8010074 >8043 Males17,206 (90%)7,270 (86%)Race White14,150 (74%)6,627 (76%) Black2,674 (14%)1,090 (13%) Asian96 (0.5%)46 (0.5%) Native American or Pacific Islander371 (2%)187 (2.2%) Missing1,804 (9%)491 (6%)

Acknowledgements:

The work in this abstract is supported by Investigator Award from the Rheumatology Research Foundation to Dr Singh.

Disclosure of Interests:

None declared

0860 Sleep Disorders In Female Military Personnel

Introduction

Sleep is an essential biological function and the disruption of sleep has deleterious consequences. Military personnel experience unique stressors related to their service, elevating the risk of developing sleep disorders. The etiologies and impact of sleep disorders on military women’s health is poorly understood. This study is the first to prospectively assess whether military women with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA) have different gender roles, military service-associated factors, and biological characteristics than military men with the same disorders.

Methods

This is a prospective observational study of military personnel with sleep disturbances. The study will evaluate women and men matched for sleep disorder. Participants will complete an evaluation to include polysomnography (PSG), sleep questionnaires and validated clinical assessments of associated disorders of interest. The baseline demographics, questionnaire, and PSG results will be analyzed to assess for commonalities or differences between genders.

Results

We have enrolled 45 patients (24% female). Males had a higher BMI (29.1) than females (26). Males were also older (38) than females (35). The leading diagnosis in males was OSA (44%) and insomnia in females (64%). In males, the apnea-hypopnea index (AHI) was 11.3/hr, arousal index (ARI) was 20/hr, and sleep efficiency (SE) was 86.5%. Total sleep time (TST), wake after sleep onset (WASO), and sleep onset latency (SOL) were 364.6, 40.9, and 12.6 minutes, respectively. In females, the average AHI was 6.6/hr, ARI was 15/hr, and SE was 87.2%. Their TST, WASO, and SOL were 359, 44, and 12.6 minutes, respectively.

Conclusion

Military personnel are at increased risk of sleep disorders. Literature comparing male and female characteristics and sleep disorders is scarce. In this study, baseline demographics were similar in both groups but insomnia was the leading diagnosis for women. This emphasizes the importance of adequate recognition and treatment of insomnia in this group.

Support

This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

1186 Developing And Testing A Web-based Provider Training For Cognitive Behavioral Therapy Of Insomnia

Introduction

Chronic insomnia is a common, debilitating disorder and a risk factor for significant medical morbidity, mental health problems, and workplace difficulties. Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia. However, few providers are trained in CBT-I, in part due to a bottleneck in training availability and the time and cost associated with current training platforms. To address this training deficit, our team developed and evaluated CBTIweb.org, a web-based provider training course for CBT-I.

Methods

Feedback from alpha- and beta-testing of CBTIweb.org was collected and used to optimize course content and functionality. Then, a comparison study was conducted in which licensed providers were randomized to complete either the online CBTIweb.org course (n=21) or an in-person CBT-I training (n=23). During all phases of development, providers completed a Computer System Usability Questionnaire (CSUQ), investigator-developed website usability and content questionnaires, and pre/post-training competency assessments.

Results

Independent samples t-tests indicated significant improvements in CSUQ, and website usability and content questionnaires responses from alpha- to beta-testing (all ps &lt; .05). Linear mixed-effects modeling revealed significant within-subject increases in knowledge acquisition (F(34.7) = 65.4, p &lt; 0.001; baseline = 69% correct, post-training = 92% correct) when collapsed across in-person and web-based groups. The interaction group by time interaction was non-significant (F(34.7) = 1.7, p = 0.204), indicating similar gains in knowledge (i.e., equivalence) between the in-person and the CBTIweb.org training formats.

Conclusion

Alpha and beta testers of CBTIweb.org reported high levels of satisfaction while also noting areas for improvement, which were used to update the site. Findings suggest the final CBTIweb.org product successfully trained clinicians compared to an in-person workshop, given knowledge acquisition improvements. CBTIweb.org is an efficient and effective training platform for clinicians to gain knowledge and competence in the most effective treatment for insomnia.

Support

W81XWH-17-1-0165

0483 Predictors of Cognitive Behavioral Therapy for Insomnia (CBT) Outcomes in Active Duty U.S. Army Personnel

Introduction

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged.

Methods

The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active duty service members who received in-person CBTi in a randomized clinical trial.

Results

Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI).

Conclusion

Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.

Support

This study was conducted with support from the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program award W81XWH-10-1-0828 (PI: Dr Taylor).

1073 Sleep Disorders Contribute To Anger In Service Members With Posttraumatic Stress Disorder

Introduction

The emotion of anger and behavioral acts of aggression can lead to severe negative consequences, including family violence, legal charges, and death. Anger can be a symptom of posttraumatic stress disorder (PTSD), particularly in service members. Service members report difficulties managing their anger and trouble with the subsequent results. Factors that differentiate service members with PTSD who have anger related problems from those who do not are still unknown. Impaired sleep is associated with negative mood states in the general population and may be a risk factor for anger in those with PTSD. This project examines how sleep disorders commonly diagnosed in service members (i.e., obstructive sleep apnea and insomnia) relate to PTSD and anger.

Methods

Ninety-three service members with comorbid PTSD, insomnia, and nightmares (mean age = 35.86 years, SD = 8.38, 27% female, 45% white) completed polysomnography and other measures as part of a clinical trial. A multiple regression model examined how total Apnea Hypopnea Index (AHI), AHI during REM sleep, insomnia (Insomnia Severity Index), age, and race related to PTSD symptoms (Clinical Administered PTSD Scale-5: CAPS-5). A second multiple regression model examined the same variables’ associations with anger (Dimensions of Anger Reactions-5; DAR-5).

Results

More than a third of the sample (37%) met criteria for OSA (AHI scores&gt;5) and 99% met criteria for insomnia (ISI&gt;10). Total AHI and REM AHI were not associated with CAPS-5 scores or ISI. Across OSA and PSG indices, only greater REM AHI (b=.07, p&lt;.05) and Insomnia (b=.43, p&lt;.05) were positively associated with DAR-5 anger scores. Total AHI was unrelated to anger.

Conclusion

Elevated REM AHI and insomnia were associated with greater anger in service members with PTSD. Current treatments for anger are only moderately effective. Assessing and treating comorbid sleep disorders may reduce anger and enhance successful PTSD treatment.

Support

Consortium to Alleviate PTSD (W81XWH-13-2-0065), DVA (I01CX001136-01), GDHS (W91YTZ-13-C-0015) for DVBIC.

Paying people to lose weight: the effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity - a systematic review

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Abstract P2-08-01: Results from a randomized placebo-controlled phase 2 trial evaluating exemestane ± enzalutamide in patients with hormone receptor–positive breast cancer

This abstract was withdrawn by the authors.

Abstract P5-08-28: Incidence of germline BRCA1- and BRCA2-mutated breast cancer in the US

Background: Breast cancer is the most common cancer and second leading cause of cancer death among women in the United States (US).1 Inherited mutations in germline breast cancer susceptibility gene 1 and 2 (gBRCAm) are associated with increased risk of developing cancers, including breast cancer.2 No published reports of gBRCAm incidence within an unselected US breast cancer population are available based on a comprehensive literature review (CLR). The main objective of this analysis is to estimate the incidence of gBRCAm breast cancer in the US.

Methods: For this analysis the Surveillance, Epidemiology, and End Results (SEER) Program 18 registries captured incidence of breast cancer by stage, age and gender.3 The size of the US population was based on United Nation's population projections and standardized to the 2010 population.4 Age-specific gBRCAm distribution and gBRCAm-specific hormonal subtype for estrogen-receptor and progesterone-receptor (ER/PR), and human epidermal growth factor receptor-2 (HER2) estimates were determined from a CLR.5-8 Tumor cells negative for ER/PR and HER2 are referred to as triple-negative breast cancer (TNBC).

Results: In 2016, it is projected that approximately 250,000 individuals will be diagnosed with invasive breast cancer (all genders). Median age range of the population with invasive breast cancer is 65-69 years and 99% are females. Majority (72%) of female invasive breast cancer cases are ER/PR+ whereas 11% of cases are TNBC. Corroborating with current publications, gBRCAm is estimated at 5% for individuals less than 50 years old and 1% among all ages. Median age range of the gBRCAm cohort is 40-44 years. After applying currently available gBRCAm specific literature parameters, the majority (55%) of gBRCAm diagnoses are TNBC.

Conclusion: In the US, patients with gBRCAm represent a small proportion (1%) of all breast cancer tissues evaluated. Majority of gBRCAm patients are diagnosed with TNBC (55%) and are younger (median age range 40-44 years) than overall breast cancer population. Age differences noticed in gBRCAm may have been due to disparity in genetic screening practices among breast cancer population in the US rather than a reflection of gBRCAm expressions. These estimates of gBRCAm incidence are driven by limited reports on an unselected population of breast cancer gBRCAm cohort; therefore sensitivity analysis is required to assess the robustness of these estimates.

1. American Cancer Society. Facts and Figures 2016.

2. Miki Y et al. Science. 1994;266:66-71.

3. Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) Research Data (1973-2013), National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2016, based on the November 2015 submission.

4. United Nations Population Division. World Population Prospects, the 2015 Revision. http://esa.un.org/unpd/wpp/.

5. van den Broek et al. Eur J Hum Genet. 2015;23:588-95.

6.Turkovic L et al. BMC Cancer. 2010;10:466.

7. Atchley DP et al. J Clin Oncol. 2008;26:4282-4321.

8. Spurdle AB et al. Breast Cancer Res. 2014;16:3419.

Citation Format: Kim R, Peterson A, Isherwood A, Uppal H, Barlev A. Incidence of germline BRCA1- and BRCA2-mutated breast cancer in the US [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-28.

Abstract OT2-01-13: A phase 3, open-label, randomized, 2-arm international study of the oral dual PARP inhibitor talazoparib in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA)

Background: Cancer cells with deleterious mutations in breast cancer susceptibility genes 1 and 2 (BRCA1/2) are deficient in the DNA double-strand break repair mechanism, rendering them highly dependent on the single-strand break repair pathway, regulated by poly(ADP-ribose) polymerase (PARP). Inhibition of PARP results in synthetic lethality in cells with a BRCA1/2 mutation because of accumulation of irreparable DNA damage; PARP inhibitors have the potential to be selectively toxic for BRCA-mutated cells. In addition to catalytic inhibition, it has been shown that some PARP inhibitors induce PARP trapping at sites of DNA damage. The capacity to trap PARP-DNA complexes varies widely across different PARP inhibitors and is not correlated with PARP catalytic inhibition. Preclinical models have shown trapping PARP on DNA is more potent at inducing cancer cell death than enzymatic inhibition of PARP alone. Talazoparib is a dual-mechanism PARP inhibitor that both inhibits the PARP enzyme and effectively traps PARP on DNA, preventing DNA damage repair and resulting in cell death in BRCA1/2-mutated cells. In preclinical studies, talazoparib at nanomolar concentrations showed the highest efficiency at trapping PARP-DNA complexes relative to other PARP inhibitors. In a previous phase 1/2 clinical study, talazoparib as monotherapy (1 mg once daily) resulted in a 50% response rate and an 86% clinical benefit rate at 24 weeks in 14 patients with a germline BRCA1/2 mutation and advanced breast cancer (aBC).

Methods: This open-label, randomized, 2-arm, international phase 3 trial (EMBRACA)

compares the efficacy and safety of talazoparib with protocol-specific physician's choice (capecitabine, eribulin, gemcitabine or vinorelbine) in patients with aBC. The primary objective is progression-free survival by central imaging. Secondary objectives are objective response rate, overall survival, safety and pharmacokinetics of talazoparib. Exploratory objectives include health-related quality of life measurements and biomarker research in blood and tumor samples that may permit characterization of mechanisms involved in tumor sensitivity and resistance to talazoparib. Key patient eligibility criteria include aged ≥18 years with histologically/cytologically confirmed breast cancer; locally advanced and/or metastatic disease appropriate for systemic single-agent cytotoxic chemotherapy; deleterious or pathogenic germline BRCA1/2 mutations by central laboratory; ≤3 prior cytotoxic chemotherapy regimens for advanced disease (prior platinum is allowed provided patients did not relapse within 6 months in the adjuvant setting or did not progress on platinum therapy); prior treatment with a taxane and/or anthracycline unless medically contraindicated; and ECOG performance status ≤2. Patients (N=429) will be randomized 2:1 to receive either talazoparib capsules (1 mg/day, 21-day cycles) or physician's choice treatment. This trial is currently enrolling patients from the USA, Europe, Israel, Ukraine, Russia, Korea, Australia, Taiwan and Brazil (NCT01945775).

This study is funded by Medivation, Inc.

Citation Format: Litton J, Ettl J, Hurvitz SA, Mina LA, Rugo HS, Lee K-H, Yerushalmi R, Woodward N, Goncalves A, Moreno F, Roche H, Im Y-H, Martin M, Bhattacharya S, Peterson A, Hannah A, Eiermann W, Blum J. A phase 3, open-label, randomized, 2-arm international study of the oral dual PARP inhibitor talazoparib in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-13.

Abstract P5-06-01: Talazoparib antitumor effects in BRCA-deficient breast cancer models

Background: BRCA1 and BRCA2 functions are essential for the DNA double-strand break repair process in living cells with DNA damages. Therefore, germline pathogenic mutations in BRCA1/2 increases the risk of developing cancer.1, 2Poly(ADP-ribose) polymerase (PARP) enzymes are proteins responsible for DNA single-strand break repair. Persistent inhibition of PARP-dependent DNA repair in BRCA-deficient breast cancer cells leads to increased DNA damages resulting in cancer cell death. Talazoparib is a novel and potent, orally bioavailable, small molecule PARP inhibitor. Talazoparib's dual mechanism of action inhibits PARP enzyme activity and effectively traps PARP on DNA, preventing DNA repair, resulting in cell death in BRCA1/2-mutated cells.3 In tissue culture studies, talazoparib is more potent at trapping PARP on DNA to induce cancer cell death compared to other PARP inhibitors.4 Previous studies have demonstrated talazoparib inhibited growth in tumors harboring BRCA1/2 gene mutations. In the MX-1 breast cancer model with BRCA1-deficiency, talazoparib inhibited cell growth in vitro and induced regression in solid mouse xenografts.5 Here, we demonstrate antitumor effects of talazoparib monotherapy in a panel of breast cancer cells and patient-derived breast cancer models with pathologic BRCA1/2 mutations.

Method: A panel of human breast cancer cell lines was treated with talazoparib to determine its cytotoxic effects. BRCA1/2 mutations status was correlated to talazoparib cytotoxic effects. At the molecular level, BRCA1/2-mutant and wild type breast cancer cell lines were treated with dose-escalating talazoparib to also assess the relationship between PARP-DNA trapping complex formation and treatment response. Patient-derived breast cancer xenograft models were used to assess talazoparib monotherapy on tumorigenesis. Immunohistochemistry assays were performed to determine Ki-67, gH2AX and caspase 3 marker expression following talazoparib treatment.

Results: Cytotoxicity was observed in 50% (7/14) cell lines at IC50 values that are achieved in the clinic. BRCA1/2 alterations were detected in 21.4% (3/14) of cell lines sensitive to talazoparib treatment. In 14 patient-derived breast cancer xenograft models selected for this study, 57.1% (8/14) responded to talazoparib monotherapy. Of these, 35.7% had mutations in the BRCA1 (28.6%) and BRCA2 (7.1%) genes. Stable disease was observed in 14.2% (2/14). One stable model had BRCA1 mutations. Tumor regression was observed in 42.8% (6/14) of the models treated with talazoparib monotherapy. Importantly, 66.7% (4/6) of patient-derived breast cancer models that regressed on talazoparib monotherapy had mutations in BRCA1/2 genes.

Conclusions: Cytotoxicity was observed with talazoparib monotherapy in breast cancer cell lines and in patient-derived xenograft tumor models harboring BRCA1 or BRCA2 mutations. Our data demonstrate therapeutic potential of talazoparib monotherapy in breast cancer associated with pathologic BRCA1/2 mutations.

1.Couch FJ et al. J Clin Oncol. 2015;33:304-11.

2. Petrucelli N et al. Genet Med. 2010;12:245-59.

3. Wang B et al. J Med Chem. 2016;59:335-57.

4. Murai J et al. Mol Cancer Ther. 2014;13:433-43.

5. Shen Y et al. Clin Cancer Res. 2013;19:5003-15.

Citation Format: Phan VT, Protter AA, Peterson A, Uppal H. Talazoparib antitumor effects in BRCA-deficient breast cancer models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-06-01.

Abstract P4-22-08: A single-arm phase 2 study to assess clinical activity, efficacy and safety of enzalutamide with trastuzumab in HER2+ AR+ metastatic or locally advanced breast cancer

Background:Androgen receptor (AR) expression has been observed in up to 77% of human epidermal growth factor receptor 2–positive (HER2+) breast cancer (BC).References:1 Enzalutamide (ENZA) is a potent AR inhibitor approved for patients (pts) with metastatic castration-resistant prostate cancer. In vitro, ENZA enhances antitumor activity of trastuzumab in HER2+ AR+ cell lines and inhibits proliferation in trastuzumab-resistant HER2+ cell lines.2

Methods:Pts with metastatic or locally advanced BC that was HER2+ AR+ by local or central laboratory assessment were enrolled in a single-arm, Simon 2-stage phase 2 study (NCT02091960). Key eligibility criteria included availability of a tissue sample, presence of measurable or evaluable disease per RECIST v1.1, progression on prior trastuzumab and ≥1 prior line of anti-HER2 therapy as the most recent regimen. Brain metastases and history of seizure were exclusionary. Evaluable pts were those with centrally confirmed nuclear AR expression≥10% by immunohistochemistry who received ≥1 dose of ENZA and had ≥1 postbaseline tumor assessment. Pts received ENZA 160 mg daily and trastuzumab 6 mg/kg every 21 days until disease progression. The primary objective was clinical benefit rate at 24 weeks (CBR24), defined as complete or partial response (CR or PR) or stable disease (SD) for ≥24 weeks in evaluable pts. Additional endpoints included safety and progression-free survival (PFS). CBR24 in ≥3 of 21 evaluable pts was required to continue to stage 2 and enrollment of up to 66 evaluable pts total. This design yields a 1-sided type 1 error of 5% and 90% power when the true response is 25%.

Results:Here we present results from stage 1 (data cutoff: Mar 23, 2016), with 22 evaluable pts enrolled (pts 21 and 22 enrolled simultaneously); 18 had received ≥4 prior lines of therapy. Median duration of ENZA exposure was 144 days (range, 22-495), mean number of complete trastuzumab infusions was 6.5. CBR24 was 27.3% (95% confidence interval [CI], 10.7-50.2); 2 confirmed PR and 4 SD ≥24 weeks. Median PFS was 108 days (95% CI, 56-144). All pts experienced ≥1 adverse event (AE) any grade; 5 pts experienced AEs grade ≥3. ENZA-related AEs were reported in 16 pts (72.7%), the most common (in ≥10% of pts) were fatigue (22.7%), nausea (18.2%), diarrhea (13.6%) and arthralgia (13.6%). Serious AEs were reported in 6 pts (27.3%; 2 each of infection and back pain, 1 each of abdominal pain, nausea, vomiting, pyrexia, urinary retention and pulmonary edema). Two pts discontinued due to drug-related AEs: 1 related to both drugs, 1 related to trastuzumab. One on-study death from pulmonary edema was reported, which was not considered related to either drug.

Conclusion:Stage 1 met its primary objective. No new safety signals were identified, and the safety profile in this study was similar to that in men with prostate cancer and women with other BC subtypes treated with ENZA. These results are encouraging for a heavily pretreated population with advanced HER2+ AR+ BC. Enrollment in stage 2 continues with the combination of ENZA and trastuzumab.

1. Micello D et al. Virchows Arch. 2010;457:467-476.

2. Richer J. Presented at AACR Advances in Breast Cancer, San Diego, CA, 2013.

Citation Format: Krop I, Cortes J, Miller K, Huizing MT, Provencher L, Gianni L, Chan S, Trudeau M, Steinberg J, Sugg J, Liosatos M, Paton VE, Peterson A, Wardley A. A single-arm phase 2 study to assess clinical activity, efficacy and safety of enzalutamide with trastuzumab in HER2+ AR+ metastatic or locally advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-08.

CRISPR: express delivery to any DNA address

The sudden emergence and worldwide adoption of CRISPR gene-editing technology confronts humanity with unprecedented opportunities and choices. CRISPR's transformative impact on our future understanding of biology, along with its potential to unleash control over the most fundamental of biological processes, is predictable by already achieved applications. Although its origin, composition, and function were revealed only recently, close to 3000 CRISPR-based publications have appeared including insightful and diversely focused reviews referenced here. Adding further to scientific and public awareness, a recent symposium addressed the ethical implications of interfacing CRISPR technology and human biology. However, the magnitude of CRISPR's rapidly emerging power mandates its broadest assessment. Only with the participation of a diverse and informed community can the most effective and humanity-positive CRISPR applications be defined. This brief review is aimed at those with little previous exposure to the CRISPR revolution. The molecules that constitute CRISPR's core components and their functional organization are described along with how the mechanism has been harnessed to edit genome structure and modulate gene function. Additionally, a glimpse into CRISPR's potential to unleash genetic changes with far-reaching consequences is presented.