Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study

PURPOSE

To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections.

MATERIALS AND METHODS

Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2.

RESULTS

Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67).

CONCLUSIONS

Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02930070.

MiR-4262 promotes cell apoptosis and inhibits proliferation of colon cancer cells: involvement of GALNT4

A role of microRNA-4262 (miR-4262) in the carcinogenesis of colon cancer remains undetermined. In this study, we studied the effects and mechanisms of miR-4262 to the colon cancer cell proliferation and apoptosis. We found that the levels of miR-4262 significantly down-regulated in colon cancer tissue, compared to the paired adjacent non-tumor colon tissue. The miR-4262 levels in colon cancer cell lines were significantly lower than those in control normal colon tissues. Transfection with the miR-4262 mimic decreased the cell proliferation and increased cell apoptosis in colon cancer cells, while transfection with the antisense of miR-4262 (as-miR-4262) increased cell proliferation and suppressed cell apoptosis in colon cancer cells. Bioinformatics analyses showed that GALNT4 was a potential target gene of miR-4262. The luciferase activities assay and Western blot verified that miR-4262 targeted GALNT4 mRNA to modulate its protein levels. When we treated cells with miR-4262 and GALN4 siRNA, the cell viability was significantly decreased. Together, our study suggests that aberrantly expressed miR-4262 may affect cell apoptosis and proliferation of human colon cancer cells via GALNT4, which appears to be a promising therapeutic target for colon cancer.

Clinical Performance Evaluation of VersaTrek 528 Blood Culture System in a Chinese Tertiary Hospital

Background: The aim of this study was to evaluate the clinical performance of VersaTrek 528 compared to BACTEC FX 400 blood culture (BC) systems.

Materials and Methods: Simulated and clinically obtained BCs were used in the study. Confirmed bacterial species (n = 78), including 43 Gram-positives, 30 Gram-negatives, and 5 Candida albicans strains, were each inoculated into BC bottles. Clinically obtained BCs were subdivided into two groups, A and B. In group A were 72 BC sets (pair: aerobic and anaerobic) in which a set inoculated with 5 ml blood was processed in the VersaTrek BC system, whilst the one inoculated with 10 ml blood was processed in the FX BC system. In group B, 76 BC sets (pairs) corresponding to 152 VersaTrek bottles and 152 FX bottles were inoculated with the same volume (10 ml) of blood, and processed in each system.

Results: In the simulated BC study, 90% (63/70) of the VersaTrek aerobic bottles were positive, which was higher than that of FX 400 (59/70, 84%), but was not statistically significant (P = 0.423). In contrast, FX 400 anaerobic bottles had a higher positive rate than the other BC system (84 vs. 77%), although it was statistically insignificant (P = 0.267). Time to detection of organisms in the two BCs was comparable for both aerobic (P = 0.131) and anaerobic bottles (P = 0.104). In clinical BCs of group A, FX BC system had slightly higher positive rates for both aerobic (11.1 vs. 9.7%, P = 0.312) and anaerobic (8.3 vs. 6.9%, P = 0.375) bottles. However, the difference was not statistically significant. In group B, VersaTrek aerobic bottles had a higher positive rate compared to the other BC system (10.5 vs. 5.2%, P = 0.063). In terms of positive rates of sub-studies A and B, VersaTrek and FX BC systems were comparable.

Conclusion: There was no significant difference between the two BC systems in the detection of bacteria and fungi in simulated BCs. In clinical BCs, the performance of the VersaTrek BC system, with inoculation of 5 or 10 ml patient’s blood, was comparable to the FX system with inoculation of 10 ml patient’s blood.

Abstract 938: Detection of actionable mutations in plasma cfDNA samples from patients with non-small cell lung carcinoma using a novel amplicon-based Firefly NGS assay

Background: Detection of EGFR, KRAS and BRAF mutations can help guide cancer treatment for non-small cell lung cancer (NSCLC) patients. To identify an easy to use, accurate, multiplex molecular diagnostic assay, we evaluated the performance of a novel next-generation sequencing (NGS)-based cell-free DNA (cfDNA) assay, Firefly assay, which employs a concatemer-based noise suppression mechanism with an amplicon workflow.

Methods: Performance of amplicon based Firefly assay, with a panel covering EGFR, BRAF, and KRAS mutations designed for targeted therapy selection of NSCLC was first evaluated using a cfDNA reference standard and blank control samples. This panel was then used to analyze plasma cfDNA samples from 134 NSCLC cancer patients and 50 non-cancerous controls, and results were compared with tumor tissue ARMS and cfDNA ddPCR results.

Results: Firefly assay demonstrated superior sensitivity and specificity with median detection of 100% at allele frequency of 0.1% for 20ng of cfDNA and zero false positive in all blank control samples. In cfDNA from plasma collected before treatment, EGFR mutation detection by Firefly assay was 94% concordant with tumor tissue ARMS. Firefly assay demonstrated strong per-variant detection-rate concordance (98%) and allele frequency concordance (R2 = 0.95) when compared with cfDNA ddPCR result.

Conclusions: The amplicon based Firefly assay offers multiplex capacity, de novo variant detection, high sensitivity and specificity. Thus, Firefly assay is a kitable NGS solution for cfDNA analysis, which can help guide targeted therapy selection, drug resistance detection, and disease monitoring in NSCLC and other cancer patients.

Citation Format: Lin Wang, Li Weng, Xiao Chen, Min Li, Qiaomei Guo, Wenjun Yu, Tobias Wittkop, Hongyan Wang, Malek Fahem, Shengrong Lin, Grace Q. Zhao, Jiatao Lou. Detection of actionable mutations in plasma cfDNA samples from patients with non-small cell lung carcinoma using a novel amplicon-based Firefly NGS assay [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 938.

[Pigmented extramammary Paget's disease accompanied with condyloma acuminatum: a case report]

Pigmented extramammary Paget's disease (PEMPD) is an uncommon intraepithelial adenocarcinoma and a rare variant of Paget's disease, characterized as a superficial pigmented scaly macule clinically and an increased number of melanocytes scattered between the Paget's cells histologically. So it may be confused clinically and histologically with melanocytic tumors, dermatitis and other dermatoses. Different therapeutic attitudes are required in this case of adenocarcinoma in situ as opposed to melanoma and dermatitis. Condyloma acuminatum (CA) is a common sexually transmitted disease caused by human papilloma virus infection, which is also called as genital warts. In this article, we first reported a case of a 65-year-old Chinese man who had pigmented extramammary Paget's disease complicated with CA. This patient presented with verrucous papules on the scrotum for 3.5 years, infiltrative erythema with itch on the mons pubis for 3 years, and scrotum and penis involved gradually for 4 months. Physical examination showed a 8 cm×10 cm dark red patch on the upper part of the scrotum, penis and mons pubis, as well as few maculopapules and nodules. Histopathologic examination of the lesion on the scrotum revealed a focus of Paget's disease, characterized by the presence of large round cells with abundant pale or granular/dusty cytoplasm, pleomorphic vesicular nuclei and prominent nucleoli (Paget's cells), while the histology of the verrucous lesion was consistent with CA. Immunohistochemistry was performed, which showed diffuse positive staining with CK, CEA, PAS, CK20, EMA, CK7, and Ki-67 (40%), HER2 in Paget's cells and negative with P53, P16, CK5/6, S100, MelanA, HMB45, estrogen receptor, progesterone receptor, and gross cystic disease flid protein 15 (GCDFP15). Human papillomavirus-11 (HPV-11) was positive by genotyping using gene amplification in the lesion of scrotum. According to clinical features and laboratory findings, a diagnosis of PEMPD complicated with CA was made. Local excision of the lesion was performed and sent for histological examination, with all margins clear of tumor. Both aforementioned diseases often occur in the vulva. Even so, it has been rarely reported coexisting of the above two diseases, of which the clinical significance and association are also unclear. In this article, we also reviewed the literature relating to PEMPD, and on this basis, the profile of this disease is discussed including its pathogenesis, clinical manifestation, diagnosis, treatment and advances. Due to PEMPD occasionally accompanied with an underlying carcinoma, it's essential to make an accurate diagnosis. Besides, review of the literature reveals that pigmented variant of Paget's disease could be initially misdiagnosed as melanocytic tumors and other dermatoses unless the entity is considered in the differential diagnosis and additional confirmatory studies are performed.

Comparison of Space Glucose Control and Routine Glucose Management Protocol for Glycemic Control in Critically Ill Patients: A Prospective, Randomized Clinical Study

Background:

The Space Glucose Control (SGC) system is a computer-assisted device combining infusion pumps with the enhanced Model Predictive Control algorithm to achieve the target blood glucose (BG) level safely. The objective of this study was to evaluate the efficacy and safety of glycemic control by SGC with customized BG target range of 5.8–8.9 mmol/L in the critically ill patients.

Methods:

It is a randomized controlled trial of seventy critically ill patients with mechanical ventilation and hyperglycemia (BG ≥ 9.0 mmol/L). Thirty-six patients in the SGC group and 34 in the routine glucose management group were observed for three consecutive days. Target BG for both groups was 5.8–8.9 mmol/L. The primary outcome was the percentage time in the target range.

Results:

The percentage time within BG target range in the SGC group (69 ± 15%) was significantly higher than in the routine management group (52 ± 24%; P < 0.01). No measurement was ≤2.2 mmol/L, and there was only one episode of hypoglycemia (2.3–3.3 mmol/L) in each group. The average BG was significantly lower in the SGC group (7.8 ± 0.7 mmol/L) than in the routine management group (9.1 ± 1.6 mmol/L, P < 0.001). Target BG level was reached earlier in the SGC group than routine management group (2.5 ± 2.9 vs. 12.1 ± 15.3 h, P = 0.001). However, the SGC group performed worse for daily insulin requirement (59.8 ± 39.3 vs. 28.4 ± 36.7 U, P = 0.001) and sampling interval (2.0 ± 0.5 vs. 3.7 ± 0.5 h, P < 0.001) than the routine management group did. Multiple linear regression showed that the intervention group remained a significant individual predictor (P < 0.001) of the percentage time in target range.

Conclusions:

The SGC system, with a BG target of 5.8–8.9 mmol/L, resulted in effective and reliable glycemic control with few hypoglycemic episodes in critically ill patients with mechanical ventilation and hyperglycemia. However, the workload was increased.

Trial Registration:

http://www.clinicaltrials.gov, NCT 02491346; https://www.clinicaltrials.gov/ct2/show/NCT02491346?term=NCT02491346&cond=Hyperglycemia&cntry1=ES%3ACN&rank=1.

Robust, tunable, and high purity triggered single photon source at room temperature using a nitrogen-vacancy defect in diamond in an open microcavity

We report progress in the development of tunable room temperature triggered single photon sources based on single nitrogen-vacancy (NV) centres in nanodiamond coupled to open access optical micro-cavities. The feeding of fluorescence from an NV centre into the cavity mode increases the spectral density of the emission and results in an output stream of triggered single photons with spectral line width of order 1 nm, tunable in the range 640 - 700 nm. We record single photon purities exceeding 96% and estimated device efficiencies up to 3%. We compare performance using plano-concave microcavities with radii of curvature from 25 μm to 4 μm and show that up to 17% of the total emission is fed into the TEM₀₀ mode. Pulsed Hanbury-Brown Twiss (HBT) interferometry shows that an improvement in single photon purity is facilitated due to the increased spectral density.

MiR-124 induces autophagy-related cell death in cholangiocarcinoma cells through direct targeting of the EZH2-STAT3 signaling axis

Cholangiocarcinoma (CCA) is a lethal cancer associated with chronic inflammation that has increased in prevalence in recent decades. The dysregulated expression of microRNAs (miRNAs) has been detected in various types of malignancies, and depending on the target genes this can result in miRNAs functioning as tumor suppressors or oncogenes. In this study, we investigated the role of miR-124 in cholangiocarcinoma (CCA) and found that its expression was significantly downregulated in the tumor tissue of patients and in CCA cell lines. Our results provided evidence that miR-124 induces apoptotic cell death and triggers the autophagic flux in CCA cells. EZH2 and STAT3 were identified as direct targets of miR-124. The effect of miR-124 on EZH2 expression in CCA cells was evaluated using cell transfection, xenotransplantation into nude mice and a luciferase reporter assay. Silencing of EZH2 restored the effects of miR-124, whereas overexpression of EZH2 abrogated the effects of miR-124. Silencing of Beclin1 or ATG5 abrogated the effects of miR-124 or siEZH2. In vivo, overexpression of miR-124 dramatically induced autophagy-related cell death and suppressed tumorigenicity. Taken together, our findings indicated that downregulation of miR-124 expression was associated with disease progression in human CCA and we revealed that miR-124 exerts a tumor suppressive function in CCA by inducing autophagy-related cell death via direct targeting of the EZH2-STAT3 signaling axis.

Abstract B071: Detecting ultra low-frequency variants and fusions using a novel amplicon-based Accu-CometTM method

We report the development of an ultra-accurate NGS technology, Accu-CometTM, which employs a concatemer-based error correction with amplicon workflow for the fast detection of low-frequency mutations including single-nucleotide variants (SNVs) and fusion events. We tested a non-small cell lung cancer (NSCLC) panel covering variants of EGFR, BRAF, and KRAS, as well as Alk fusion. Simulated cfDNA and cfDNA from healthy individuals were used to test the assay’s sensitivity and specificity. The analytic sensitivity of this panel was 100% detection at an allele frequency of 0.1% for 20ng of cf-DNA input. Similarly, the analytic sensitivity of the Alk fusion panel was 75% detection at an allele frequency of 0.1%, and 100% detection at an allele frequency of 0.25% for the same input. Clinical validation was performed via a comparative analysis of 171 NSCLC patients at different cancer stages and with different treatment plans. Among our patient cohort, 5 EGFR variants (19del, T790M, L858R, G719X, L861X) were detected. We also tested 47 noncancerous control samples and detected no false-positive variants at the reported cancer hot spots. Accu-CometTM demonstrated strong per-variant detection-rate concordance (&gt; 96%) compared to ddPCR results, and &gt;90% concordance when compared to tumor tissue ARMS result. The multiplex capacity, ultra sensitivity, and easy robust work flow of Accu-CometTM makes it well suited for supporting targeted therapy selection, drug resistance detection, and treatment monitoring.

Citation Format: Ling Wang, Grace Q. Zhao, Li Weng, Xiao Chen, Min Li, Xue Yang, Jun Zhao, Hongyan Wang, Kang Ying, Malek Faham, Shengrong Lin, Jiatao Lou. Detecting ultra low-frequency variants and fusions using a novel amplicon-based Accu-CometTM method [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B071.

[Left atrial appendage volume is a valuable predictor of atrial fibrillation recurrence after radiofrequency catheter ablation]

Objective: To investigate the association between the left atrial appendage (LAA) volume and atrial fibrillation (AF) recurrence after radiofrequency catheter ablation. Methods: We prospectively enrolled sixty-two patients with AF (40 cases with paroxysmal AF, 22 cases with persistent AF) who successfully underwent a first AF catheter ablation and had performed contrast-enhanced cardiac computed tomography (CT) prior to the procedure to measure LAA volumes in our hospital from January 2012 to August 2015. Circumferential pulmonary vein isolation was performed under the guidance of three-dimension mapping system (CARTO system). Linear ablation or ablation of complex fractioned atrial electrograms was also undertaken if necessary. All patients were followed up at the 3rd, 6th and 12th months after ablation by 24-hour ambulatory Holter monitoring, and were divided into the non-recurrence group (n=42) and the AF recurrence group (n=20). Univariate and multivariate Cox proportional hazards regression analysis were used to assess the factors related to AF recurrence. The receiver operating characteristic (ROC) curve was calculated to assess the best cut-off value of LAA volume to predict AF recurrence. Kaplan-Meier method was used to evaluate the rate of freedom from AF recurrence. Results: Mean LAA volume in all patients was (9.5±3.6)ml. AF recurrence occurred in 20 patients (32%) during the follow-up period. The LAA volume was significantly larger in the AF recurrence group than in the non-recurrence group ((11.5±3.8)ml vs. (8.3±3.1)ml, P=0.002). In the univariate regression analysis, LAA volume (HR=1.36, 95%CI 1.14-1.82, P<0.001), persistent AF (HR=4.43, 95%CI 1.52-12.06, P<0.001) and hypertension (HR=1.61, 95%CI 1.13-2.04, P=0.041) were risk factors of AF recurrence. However, multivariate regression analysis revealed that LAA volume (HR=1.32, 95%CI 1.12-1.51, P<0.001) and persistent AF (HR=4.22, 95% CI 1.48-11.05, P<0.001) were independent predictors for AF recurrence after ablation. The receiver operating characteristic (ROC) curve analysis revealed that a LAA volume >8.80 ml was associated with AF recurrence after ablation (sensitivity: 94% and specificity: 66%, area under the curve=0.76). Kaplan-Meier analysis showed a lower rate free from AF recurrence in the group with LAA volume >8.80 ml (P<0.001). Conclusion: Larger LAA volume is associated with AF recurrence after catheter ablation in patients with AF. A LAA volume greater than 8.80 ml could be used to predict AF recurrence after ablation.

Procalcitonin-guided antibiotic therapy in intensive care unit patients: a systematic review and meta-analysis

Background

Serum procalcitonin (PCT) concentration is used to guide antibiotic decisions in choice, timing, and duration of anti-infection therapy to avoid antibiotic overuse. Thus, we performed a systematic review and meta-analysis to seek evidence of different PCT-guided antimicrobial strategies for critically ill patients in terms of predefined clinical outcomes.

Methods

We searched for relevant studies in PubMed, Embase, Web of Knowledge, and the Cochrane Library up to 25 February 2017. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in adult ICU patients managed with a PCT-guided algorithm or according to standard care. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI).

Data synthesis

We included 13 trials enrolling 5136 patients. These studies used PCT in three clinical strategies: initiation, discontinuation, or combination of antibiotic initiation and discontinuation strategies. Pooled analysis showed a PCT-guided antibiotic discontinuation strategy had fewer total days with antibiotics (MD − 1.66 days; 95% CI − 2.36 to − 0.96 days), longer antibiotic-free days (MD 2.26 days; 95% CI 1.40–3.12 days), and lower short-term mortality (RR 0.87; 95% CI 0.76–0.98), without adversely affecting other outcomes. Only few studies reported data on other PCT-guided strategies for antibiotic therapies, and the pooled results showed no benefit in the predefined outcomes.

Conclusions

Our meta-analysis produced evidence that among all the PCT-based strategies, only using PCT for antibiotic discontinuation can reduce both antibiotic exposure and short-term mortality in a critical care setting.

Electronic supplementary material

The online version of this article (10.1186/s13613-017-0338-6) contains supplementary material, which is available to authorized users.

High-flow oxygen therapy in immunocompromised patients with acute respiratory failure: A review and meta-analysis

PURPOSE

Acute respiratory failure remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is need. We aimed to evaluate the effect of high-flow nasal cannula oxygen therapy (HFNC) compared with other oxygen technique for this patient population.

METHODS

We searched Cochrane library, Embase, PubMed databases before Aug. 15, 2017 for eligible articles. A meta-analysis was performed for measuring short-term mortality (defined as ICU, hospital or 28-days mortality) and intubation rate as the primary outcomes, and length of stay in ICU as the secondary outcome.

RESULTS

We included seven studies involving 667 patients. Use of HFNC was significantly association with a reduction in short-term mortality (RR 0.66; 95% CI, 0.52 to 0.84, p=0.0007) and intubation rate (RR 0.76, 95% CI 0.64 to 0.90; p=0.002). In addition, HFNC did not significant increase length of stay in ICU (MD 0.15days; 95% CI, -2.08 to 2.39; p=0.89).

CONCLUSIONS

The results of current meta-analysis suggest that use of HFNC significantly improve outcomes of acute respiratory failure in immunocompromised patients. Owing to the quality of the included studies, further adequately powered randomized controlled trials are needed to confirm our results.

Detecting ultra low-frequency variants and gene fusions in lung cancer patients using an amplicon-based Firefly NGS method

e23062

Background: The analysis of EGFR, KRAS, and BRAF mutations and Alk fusion is critical for guiding targeted therapy selection, detecting drug resistance, and monitoring residual disease in patients with NSCLC. Designing next-generation sequencing (NGS) assays for detecting low-frequency variants, however, is an ongoing challenge. The limited availability of cfDNA combined with the breadth of coverage necessary to create meaningful, clinically-actionable results requires a solution with multiplex capacity which, in turn, requires greater technological sensitivity and specificity. Here we aim to develop such a solution: an ultra-accurate NGS technology using concatmer-based error correction with amplicon workflow for fast detection of rare mutations including SNV and fusion. Methods: We developed an amplicon-based panel covering variants of EGFR, BRAF, and KRAS, as well as a panel to detect Alk fusion. CfDNA simulate and cfDNA from healthy individuals were used to test assay sensitivity and specificity. Further validation was performed via a comparative analysis of 64 late-stage lung cancer patients using both Firefly -Comet and ddPCR. Results: Analytical sensitivity of the EGFR-TKI 3-gene panel was 100% detection at an allele frequency of 0.1% for 20ng of cfDNA input. Similarly, analytical sensitivity of the Alk fusion panel was 75% detection at an allele frequency of 0.1% and 100% at an allele frequency of 0.25% for the same input. Among our patient cohort, 5 EGFR variants (19del, T790M, L858R, G719X, L861X) and 2 KRAS variant (G12X) were detected. Firefly-Comet demonstrated strong per-variant detection-rate concordance ( > 99%) compared to ddPCR results. The PPV is 100% and the NPV is 98.7%. Statistical analysis of reported allele frequency concordance between Firefly-Comet and ddPCR reveals R-Sq > 0.9. Conclusions: In summary, we have developed Firefly-Comet, an easy-to-use amplicon-based NGS assay capable of detecting single-digit copies of somatic mutants and gene fusions in cfDNA. The multiplex capacity of Firefly-Comet makes it well-suited for supporting targeted therapy selection, drug resistance detection, and treatment monitoring.

Accuracy of profiling of circulating tumor DNA for CRC MRD and monitoring using NGS technology equipped with concatemer-based error correction

e23067

Background: Circulating tumor DNA (ctDNA) is a promising biomarker for the detection of minimal residual disease and monitoring treatment in patients with CRC. The performance demands of any technology used for this purpose, however, are tremendous. Here we aim to develop a high-performance multiplex NGS platform suitable for cancer MRD using ctDNA. Methods: We have developed Firefly, a NGS method capable of detecting low-frequency variants with high precision in plasma cfDNA. In our protocol, denatured double-stranded cfDNA is circularized and converted into long tandem repeats using rolling-circle amplification enabling consensus-based concatemer error correction. We demonstrated Firefly’s performance sensitivity and specificity by testing our technology on cfDNA samples with known variant frequencies and cfDNA collected from healthy individuals (n = 82). Further analysis of Firefly as a tool for MRD and treatment monitoring was performed by tracking ctDNA mutation profile concordance between 81 CRC tumor samples and their corresponding plasma samples collected from patients before and after treatment. Results: Performance sensitivity of Firefly NGS was 0.1% with an error-rate was 1 in 1 Million for 20ng of input ctDNA. Concordance analysis was performed on CRC tumor/plasma pairings derived from patients with CRC using, Accu-Act, a 61-gene assay. The number of tumor-matching mutations detected in plasma varied greatly on a per-patient basis (range, 0-28). Pre and post-treatment ctDNA profiling was performed on all 81 patients included in our study (surgery, n = 56; chemotherapy/radiotherapy, n = 30). Among patients who underwent surgery, 46% had detectable tumor-matching mutations in their plasma. Among patients who received neoadjuvant therapy, 70% ctDNA fluctuations consistent with tumor reduction based on surgical tumor regression grades evaluation(TRG1-3). Conclusions: We report a novel ultra-accurate NGS-based ctDNA assay suitable for MRD and monitoring in CRC patients. Firefly should ultimately make a significant contribution in the development of personalized cancer treatment.

Positive End-Expiratory Pressure Effect of 3 High-Flow Nasal Cannula Devices

BACKGROUND

High-flow nasal cannula (HFNC) is supposed to provide additional PEEP compared with conventional oxygen therapy. However, the exact determinants of this PEEP effect are unclear. We investigated the factors that might affect the PEEP and compared PEEP performance among 3 HFNC devices.

METHODS

Three available HFNC devices were evaluated: the AIRVO 2 device and 2 mechanical ventilators (SV300 and Monnal T75). A device consisting of a test lung (5600i) and an airway model (AMT(IE)) was used to simulate spontaneous breathing. The flows ranged from 0 to their maximum flow with an interval of 10 L/min. The pressures were measured at 4 sites (nasopharynx, supraglottis, carina, and lung) under compliances of 50 and 100 mL/cm H₂O and tidal volume of 300, 500, and 700 mL with the mouth closed or open. The influencing factors were determined by multiple linear regression. The sum of squares reduction test was used to compare working curves of PEEP effect among 3 devices. Pairwise comparisons were conducted by using Tukey's multiple comparisons test within an overlap of flow from 0 to 50 L/min.

RESULTS

A quadratic curved relationship between PEEP and flow was observed (coefficients were 8.97 × 10^-3 for flow and 4.79 × 10^-4 for a quadratic element of flow, respectively) but evanished when the mouth was open. The PEEP increased along with lung compliance (coefficient was 2.58 × 10^-3). Despite the difference in working curves, both the mechanical ventilators performed slightly better than the AIRVO 2 device at higher flows (40 and 50 L/min).

CONCLUSIONS

The mouth status, flow, and compliance were the 3 major influencing factors of PEEP effect, whereas performance of the 2 mechanical ventilators was slightly superior to that of the AIRVO 2 device at higher flows.

[The 455th case: swollen leg, jaundice and mental disturbance]

A 17-year-old young man with a history of swollen leg and intermittent jaundice was presented to Peking Union Medical College Hospital with acute fever and mental disturbance. He developed deep venous thrombosis, acute myocardial infarction and plantar skin necrosis during the past four years, and was presented with an acute episode of fever, thrombocytopenia, acute kidney injury, acute myocardial infarction, mental disturbance, and obstructive jaundice. Laboratory tests showed schistocytes on peripheral blood smear.High titer of antiphospholipid antibodies was detected.Strikingly, the activity of a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS13)was significantly decreased without the production of inhibitors. Images indicated stenosis of the common bile duct, common hepatic duct, and cystic duct, which caused dilation of bile ducts and the gall bladder. Corticosteroids and anticoagulation therapy were effective at first, but the disease relapsedonce the corticosteroids tapered down. Plasma exchange was administrated for 17 times, which was effective temporarily during this episode. Methylprednisolone pulse therapy, intravenous immunoglobulin, rituximab, anticoagulation therapy, and bile drainage, were all tried but still could not control the disease. The patient's family agreed to withdraw treatment after he developed septic shock.

Changes of central venous oxygen saturation define fluid responsiveness in patients with septic shock: A prospective observational study

PURPOSE

To evaluate whether the changes of central venous oxygen saturation (Scvo₂) after fluid challenge can define fluid responsiveness in patients with septic shock.

METHODS

In this prospective observational study, septic shock patients with invasive cardiac output monitoring requiring fluid challenge were included. Cardiac index (CI) and Scvo₂ were measured before and after fluid challenges. The changes of CI (ΔCI) and the changes of Scvo₂ (ΔScvo₂) were calculated and analyzed using Pearson correlation. Receiver operating characteristics curve (ROC) analysis was used to classify fluid responders and nonresponders. Area under ROC was calculated.

RESULTS

Forty patients were included and 18 patients (45%) were fluid responders. In the responders, CI increased from 3.4±1.1 to 4.4±1.0 L min^-1 m^-2 and Scvo₂ from 69.6%±9.8% to 77.1%±8.9% (both P<.001) after fluid challenge. In the nonresponders, neither CI nor Scvo₂ changed (4.1±1.3 vs 4.1±1.3 L min^-1 m^-2, 71.0%±13.8% vs 70.6%±14.1%, both P>.05). The correlation between ΔScvo₂ and ΔCI was significant (r=0.702, P<.001). The area under ROC of ΔScvo₂ to define fluid responsiveness was 0.88 (95% confidence interval [95% CI], 0.76-0.99). A ΔScvo₂ threshold value of 5.0% discriminated responders from nonresponders with sensitivity of 0.78 (95% CI, 0.52-0.93) and specificity of 0.95 (95% CI, 0.75-1.00).

CONCLUSIONS

The changes of Scvo₂ correlate with the changes of CI, and the changes of Scvo₂ define fluid responsiveness in patients with septic shock.

Prognostic factors for severe Pneumocystis jiroveci pneumonia of non-HIV patients in intensive care unit: a bicentric retrospective study

BACKGROUND

Pneumocystis jiroveci pneumonia (PJP) in non-HIV patients is still a challenge for intensivists. The aim of our study was to evaluate mortality predictors of PJP patients requiring Intensive care unit (ICU) admission.

METHODS

Retrospectively review medical records of patients with diagnosis of PJP admitted to four ICUs of two academic medical centers from October 2012 to October 2015.

RESULTS

Eighty-two patients were enrolled in the study. Overall hospital mortality was 75.6 %. Compared with survivors, the non-survivors had older age (55 ± 16 vs. 45 ± 17, p = 0.014), higher APACHE II score (20 ± 5 vs. 17 ± 5, p = 0.01), lower white blood cell count (7.68 ± 3.44 vs. 10.48 ± 4.62, p = 0.005), less fever (80.6%vs. 100 %, p = 0.033), more hypotension (58.1 % vs. 20 %, p = 0.003), more pneumomediastinum (29 % vs. 5 %, p = 0.027). Logistic regression analysis demonstrated that age [odds ratio (OR)1.051; 95 % CI 1.007-1.097; p = 0.022], white blood cell count [OR 0.802; 95 % CI 0.670-0.960; p = 0.016], and pneumomediastinum [OR 16.514; 95 % CI 1.330-205.027; p = 0.029] were independently associated with hospital mortality.

CONCLUSIONS

Mortality rate for non-HIV PJP patients requiring ICU admission was still high. Poor prognostic factors included age, white blood cell count and pneumomediastinum.

Abstract 1375: An ultra-sensitive cell free DNA liquid biopsy assay for cancer treatment monitoring

In order to take advantage of the narrow time window for optimal treatment efficacy, highly sensitive disease monitoring is critical in the successful management of cancer. Currently, treatment efficacy is assessed by using a combination of protein cancer biomarkers and imaging. However, both methods present limitations with regard to specificity or sensitivity due to their dependency on tumor size. Recently, a number of studies have suggested that monitoring cell free DNA (cfDNA) may provide a more specific alternative for tracking cancer treatment with greatly improved sensitivity. Here we introduce a novel next-generation sequencing based mutation detection system aimed at improving the sensitivity, reliability, and clinical utility of cancer treatment monitoring. Our system, comprised of Nebula, a whole genome amplification technology that is capable of amplifying nanogram quantities of cfDNA &gt;1000-fold, and Firefly, a proprietary technology combining molecular biology and computational algorithm for error-suppression, has reduced the rate of random sequencing errors to 10-6. As a result, we are able to detect 1.5 variant copies from 10ng of input cfDNA with a detection rate of 46%. We have validated the Nebula-Firefly assay on a patient cohort with either colorectal (CRC) or lung cancer. Here we report the successful detection of drug resistant mutations and various genomic alterations associated with minimal residual detection (MRD) in sample cfDNA. These initial findings have led to the exploration of Nebula-Firefly as the technological backbone for a noninvasive, scalable approach for the early detection, treatment, and monitoring of cancer.

Citation Format: Grace Zhao, Li Weng, Paul Tang, Johnny Sun, Yi Huang, Lingchen Guo, Hongyan Wang, Xiaozheng Kang, Wei Shen, Kang Ying, Shengrong Lin. An ultra-sensitive cell free DNA liquid biopsy assay for cancer treatment monitoring. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1375.

Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients

Introduction

Patients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality.

Methods

A retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis.

Results

Of the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO₂/FiO₂ ratio, and a low lymphocyte count at the time of ICU admission.

Conclusions

The outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.

CFD Modeling with Experimental Validation of the Internal Hydrodynamics in a Pilot-Scale Slurry Bubble Column Reactor

A multiphase-Eulerian, three-dimensional (3-D), computational fluid dynamics (CFD) model was built to investigate the local hydrodynamics of a pilot-scale (0.29 m ID, 3 m height) Slurry Bubble Column Reactor (SBCR). The model was first validated against the gas holdup radial profiles in an air-water-glass beads system obtained in a 0.254 m ID and 2.5 m height column under ambient conditions at various superficial gas velocities by Yu and Kim (Bubble characteristics in the radial direction of three-phase fluidized beds. AIChE Journal 34, 2069–2072, 1988). The model was next validated against the gas holdup radial profile data for N2-Drakeol-glass beads system obtained in a 0.44 m ID and 2.44 m height reactor, including internals, operating under ambient conditions at various superficial gas velocities by Chen et al. (Fluid dynamic parameters in bubble columns with internals. Chemical Engineering Science 54, 2187–2197, 1999). The model was also validated against experimental data obtained in our lab for N2-Fischer Tropsch (F-T) reactor wax-Fe catalyst system obtained in a pilot-scale, Slurry Bubble column Reactor, SBCR (0.29 m ID, 3 m height) under pressures and temperatures up to 25.9 bar and 490 K, respectively. These three validations led to the selection of the turbulence and interphase drag coefficient models, and the optimization of the solution method, mesh size and structure and the step size. Moreover, the inclusion of RNG k-ε turbulence model coupled with the Wen-Yu (Mechanics of Fluidization. Chemical Engineering Progress Symposium Series 62, 100–111, 1966) / Schiller-Naumann (A drag coefficient correlation. Zeitung Ver. Deutsch. Ing 77, 318–320, 1935) drag correlations, and the mass transfer coefficients were found to provide the most accurate predictions of the experimental data. The CFD model was then used to investigate local gas holdup, liquid recirculation, local turbulence intensities, bubble diameters, and solids distribution throughout our pilot-scale SBCR, operating under typical F-T process conditions. The model predictions showed strong liquid recirculation and backmixing near the walls of the reactor, and the solid-phase velocity vectors closely followed those of the liquid-phase. A relatively high liquid turbulence intensities were observed in the vicinity of the sparger upon startup, however, after reaching a steady state, the liquid turbulence intensities became more evenly distributed throughout the reactor. The liquid turbulence intensities were slightly higher near the center of the reactor, and closely resembled the velocity vectors. Also, the Sauter mean bubble diameters increased, whereas the solids distribution decreased with reactor height above the gas distributor.