Drop attacks: a practical guide

'Drop attacks' encompass both falls and transient loss of consciousness, but the term is not clearly defined. We offer our definition and explore the differential diagnoses. The most common causes are cardiovascular. We discuss clinical and electrographic criteria that suggest underlying arrhythmia or other serious cardiac disorders that require further investigation, and the potential diagnoses that may underlie these 'worrying syncopes'. Vestibular dysfunction also commonly causes collapses, sometimes without typical vertigo. These two common conditions may coexist especially in the elderly. Falls in elderly people often require assessment through a lens of frailty and multifactorial risk factors, rather than seeking a unitary diagnosis. Some drop attacks may be due to longstanding epilepsy and we discuss how to approach these cases. Functional neurological disorder is a common cause in younger people, for which there may also be clinical clues. We review the rarer causes of collapse that may be described as drop attacks, including cataplexy and hydrocephalic attacks.

950 Successful Relaunching of NELA at an Inner-City District General Hospital: Need for Multidisciplinary Approach

Introduction

The national case ascertainment rate for National Emergency Laparotomy Audit (NELA) over 179 hospitals is 84.5%. Our hospital is one of the few hospitals despite being eligible, had not submitted any data to the NELA for the past three years.

Method

We retrospectively collected data for all the patients that underwent laparotomy for a period of 2 years. The mean age of patients was 58 years. We found 83 patients who fit NELA inclusion criteria from January 2020 to November 2021.

Results

The 83 patients were divided into low risk (<5%) and high risk (>5%) and further analysed. The overall mortality was higher than the national (24% v/s 9.3%). Areas of excellent performance against NELA standards (i.e., > 80% compliance) included Consultant's involvement in theatres, Surgeons in 96.9% cases and Anaesthetist in 88.9% cases compared to National average of 96.9% and 93.9% respectively. Areas with poor compliance were Geriatrics involvement pre-operatively (14.7%) when compared to national average (24.7%). Pre-op assessment was done in 48% cases approximately half of national average of 84%. Post operatively 81.4% of the high-risk patients were directly admitted to ITU which was the same as the national average of 85%.

Conclusion

There were various factors which resulted in a low compliance rate. NELA is a useful audit for the comparison of national care. It allows for reflective practice at local level with aim to deliver a uniform standard of care.

574 The Successful Resurrection of NELA in a District General Hospital

Aim

The NELA requirements of data collection is known to be mandatory. Our DGH had three years of noncompliance. We present an executed plan in the collection of retrospective and prospective process to achieve national standard.

Method

A new structural setup with anaesthetic and surgical teams was formalised. A recruitment of 13 foundation doctors was made and each were induced to NELA with a teaching session. Allocation of 15–20 hospital numbers with a primary deadline of seven days to achieve full entry was expected. A formal NELA certificate and recognition for taking part from the divisional director was issued. A prospective strategy was initiated with patient ownership from the joint anaesthetic and surgical team involved. A NELA login with local access was setup, plus paper format readily available for rare access situations. A two-email reminder system with further escalation process was introduced if entry was incomplete. The escalation being contact from the clinical lead / divisional director. This information was highlighted at a local meeting plus a familiarity of the NELA database was ensured.

Results

A large proportion of the retrospective data has been collected over a short time period due to a clear incentivised scheme. Prospectively there has not been any escalation emails needed since the new setup.

Conclusion

Areas of problems were identified with a wide range of solutions being put forward. A multi collaborative approach was needed plus positive cooperation from the clinical lead, clinical director, and the divisional director to ensure the successful new era.

P-028 Microfluidics as a methodology for sperm selection. A prospective functional study

Study question

Is microfluidics an optimal technique to improve the sperm selection process in comparison with standard techniques like Density Gradient Centrifugation or Swim-up?

Summary answer

A significant increase in sperm quality was obtained when microfluidics was compared to density gradient centrifugation but improvement evidence regarding swim-up is not yet demonstrated.

What is known already

Assisted reproduction clinics for in vitro fertilization treatments have developed several techniques to perform sperm selection, being density gradient centrifugation (DGC) and swim-up the most widely used. However, sperm selection is a procedure that requires bulky and expensive equipment, long waiting times and gamete manipulation, which results in cellular stress. The SwimCount Harvester is a microfluidic-based device capable of performing sperm selection and overcoming the problems of other sorting systems. In our study, we analyzed several sperm quality parameters between these three sperm selection techniques.

Study design, size, duration

This was a prospective, cohort and observational study including 111 semen samples from patients and donors (mean age 33,7±9,3 years) between February 2021 and January 2022. The semen sample from each patient or donor was divided into two volumes, one part, the sperm selection was performed using the SwimCount Harvester and the other part using DGC or Swim-up. These sperm selection techniques were used to isolate sperm based on fluid dynamics and cell motility.

Participants/materials, setting, methods

Fresh ejaculate and sperm selected samples from each patient were analyzed according to the 2010 WHO-criteria to assess concentration, motility, morphology and vitality, using automatic image analysis. The excessive histone retention indicating defective chromatin compaction was assessed using aniline blue staining. Sperm chromatin fragmentation (SCF) was assessed by TUNEL on at least 20.000 sperm using flow cytometry. Kruskal-Wallis test was performed in order to assess statistical differences of the variables between the sperm selection methods.

Main results and the role of chance

The SwimCount Harvester was compared to DGC (n = 95). Ejaculated sperm yielded an average concentration of 53,2±34,2x106/mL. After DGC and SwimCount Harvester, the sperm concentration was 11,1±8,8 and 12,5±11,2x106/mL, respectively. The motility of fresh sperm sample improved from 41,9±10,4% to 71,6±10,6% after DGC and 76,8±10,0% after SwimCount Harvester (P < 0,05). The percentage of normal sperm increased from 2,1±1,2%, for the fresh samples, to 3,5±1,4% and 4,2±1,6% for the samples processed by DGC and microfluidics, respectively (P < 0,05). The percentage of live sperm increased from 74,0±8,1% and 77,5±8,7% in fresh sperm and after DGC, respectively to 85,9±9,0% after using microfluidics (P < 0,05). In the same way, the normal sperm chromatine structure percentage increased from 67,4±7,5% to 75,4±7,9% for the sperm samples selected by DGC and 77,7±8,9% when the SwimCount Harvester was used (P < 0,05). A decrease in SCF was observed from 12,9±8,4% in samples selected by DGC to 10,4±5,1% in raw samples (P > 0,05). However, after sperm selection using SwimCount Harvester, SCF fell to 4,6±4,1%, showing significant differences between both sperm selection methods (P < 0,05). Similar results were obtained for oligozoospermic samples (n = 6). When the SwimCount Harvester was compared with the Swim-up (n = 10), non-significant improvements were observed for all the parameters studied due to the reduced sample size.

Limitations, reasons for caution

The database of samples processed using swim-up and oligozoospermic samples is too small to draw reliable conclusions. Although significantly better results are obtained in sperm samples selected by the SwimCount Harvester with respect to DGC, a clinical study using the microfluidic device in assisted reproduction cycles has to be performed.

Wider implications of the findings

The SwimCount Harvester, in addition to significantly improving sperm selection and quality, is a reliable alternative to integrate numerous laboratory steps into a single automated procedure, reducing workload, the amount of culture media and equipment used, gamete handling and the stress that produces. Moreover, microfluidics may eliminate inter-laboratory variability.

Trial registration number

This project has received funding from the Eurostars-2 joint program with co-funding from CDTI and the European Union's Horizon 2020 Research and Innovation Framework Program E! 113740/ CIIP-20201009.

P-224 The sex of the human embryos affects the oxidation profile of the spent culture media

Study question

Is the oxidative status of the spent culture media used in ICSI treatments related to embryo sex and newborn characteristics?

Summary answer

Female embryos produce higher levels of oxidative stress in the culture media than male embryos.

What is known already

Sex-associated differences in embryo development have previously been observed. Studies suggest that male embryos have a faster pre-implantation development, higher morphological grading and lower glucose consumption (Nasiri et al, 2018). The thermochemiluminiscence (TCL) assay quantifies the oxidative status of biological samples by catalyzing an oxidative reaction through heating and counting the photons emitted per second. TCL parameters are directly correlated to the content of oxidant agents in the sample. Previous analysis used TCL assay to relate higher oxidative metabolism in embryos with higher viability. Analysis of spent culture media with TCL could be a potential biomarker for embryo sex prediction.

Study design, size, duration

Prospective observational study over 86 transferred blastocysts (all single embryo transfer) that reached life-birth, belonging to ICSI treatments, including autologous and oocyte donation, performed in a single fertility clinic during three consecutive years. The oxidative status of the spent culture media was analyzed and compared with the characteristics of the newborns.

Participants/materials, setting, methods

Embryo cohorts were cultured in individual wells in an Embryoscope incubator, using single-step Gems culture media (Genea Biomedx). The best embryo of the cohort was selected for transfer using morphologic (ASEBIR) and morphokinetic criteria (KID Score algorithmTM, Vitrolife, (KS)). Spent culture media was analyzed in the Fertissimo TCL Analyzer (Carmel Diagnostics, Israel) and oxidation parameters were compared with the sex, weight and height of the newborns through ANOVA, C2 and Pearsons Correlation coefficient (PCC) tests.

Main results and the role of chance

The sex ratio of the embryos (male to female) resulted 59.3%. The sex ratio was increasingly higher the better morphological classification: C = 16.7%, B = 56.0%, A: 73.3%. KS did not give significantly different scores to the embryos depending on their sex: average KS (female)=6.78 vs average KS (male)=7.03, P = 0.621. No correlation was found between KS or the morphological classification and the weight and height of the babies: PCC (KS-height)=0.158, P = 0.349; PCC (KS-weight)=0.082, P = 0.569; average newborn height: C = 51.67±1.15cm, B = 50.57±3.48cm, A = 50.92±1.95cm, P = 0.791, average newborn weight: C = 3,386.00±459.11g, B = 3,283.35±658.12g, A = 3,229.07±732.13g, P = 0.877. TCL ratio (slope of the time curve of photon emission, representing the level of oxidant agents in the sample) was statistically significantly higher in the culture media of female embryos than of male embryos: Ratio (female)=119.54±13.37 vs Ratio (male)=111.62±15.80, P = 0.017. No statistically significant difference was found in the TCL Ratio between the three morphological classes, although the tendency of the data is towards lower levels with increasing morphological classification: Ratio (C)=120.40±14.43, ratio (B)=116.32±14.39 and ratio (A)=111.27±16.62, P = 0.237. No correlation was found between the TCL parameters and the weight and height of the newborn: PCC (Ratio-height)=-0.173, P = 0.198; PCC (Ratio-weight) 0.036, P = 0.753.

Limitations, reasons for caution

Patient demographics, habits and male sperm characteristics were not considered for the analysis, but might impact embryo characteristics and intrauterine development of the fetus. A larger scale study should be performed to validate results.

Wider implications of the findings

The differential oxidative load embryos exert over the culture medium might be related to a glucose consumption-associated sex dimorphism. Measuring the oxidative status of the culture medium could serve as a non-invasive biomarker for embryo sex selection. This technique could be an interesting option in carriers of sex-linked diseases.

Trial registration number

not applicable

TOTAL risk score for predicting safe very early discharge in patients with ST-elevation myocardial infarction (STEMI)

Background/Introduction

Previously validated risk scores for identifying low-risk patients after ST-segment elevation myocardial infarction (STEMI) have led to acceptance of the safety and feasibility of discharge after 48–72 hours of hospitalization, reducing hospital length of stay and costs. With ongoing improvements in outcomes, it may be possible to select patients who are safe to discharge very early (24–48 hours) but this has never been evaluated.

Purpose

We sought to develop and validate a novel risk score for identifying low-risk patients suitable for very early discharge (≤48 hours of hospitalization) post-STEMI.

Methods

We derived a novel risk score using data from patients enrolled in the Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in Patients with STEMI (TOTAL). The TOTAL database was randomly divided into a derivation cohort with 2/3 of the composite events and non-events and remaining 1/3 as the internal validation cohort. Using the derivation cohort, we identified risk factors for cardiovascular death (CV) or non-fatal cardiac arrest by performing a univariate and multivariable stepwise regression analysis of baseline clinical and angiographic characteristics. Each co-variate was assigned an integer score based on regression coefficients and the novel TOTAL risk score was developed by adding points from each risk factor profile. We externally validated the TOTAL score using data from the Radial versus Femoral Access for Coronary Intervention (RIVAL) trial.

Results

The TOTAL derivation cohort included 6331 participants with 287 events (CV death/cardiac arrest). Twelve independent risk-factors associated with risk of CV death and non-fatal cardiac arrest at 1 year were selected and weighted for the TOTAL risk score (Table 1). In the TOTAL validation cohort (n=3166), patients with a TOTAL score of 0–4 points (n=779 (24.6%)) were categorized as very low risk with only a 0.1% risk of CV death/cardiac arrest observed within 24 hours of hospitalization, and no further events observed between 24 hours and 30 days post-STEMI. In the RIVAL validation dataset (n=1451), patients with a TOTAL score of 0–4 points (n=737 (50.7%)) had a 0.3% risk of CV death/cardiac arrest within 24 hours, with no further events observed between 24 hours and 72 hours of hospitalization.

Conclusion

The TOTAL risk score identified a very low risk subset of patients for whom early discharge, 24–48 hours post-STEMI, is likely safe. These findings have the potential to change practice and support early discharge after STEMI.

Funding Acknowledgement

Type of funding sources: None.

O-121 Exploring non-invasive methods to predict Ploidy Status: Combination of blastocyst morphology image analysis and proteomic profiles by using Artificial Neural Networks

Study question

Is the blastocyst morphology image analysis combined with the protein content of spent embryo culture medium a suitable way to predict embryo ploidy?

Summary answer

Morphological variables from blastocyst image analysis combined with IL-6 or MMP-1 concentration in spent culture medium showed more than 80% of accuracy for euploidy prediction.

What is known already

An artificial intelligence model based on the proteomic profile of euploid embryos and morphological data from blastocyst time-lapse images has been recently published (Bori et al., 2020). The most promising artificial neural network (ANN) algorithm considered 20 morphological variables extracted from image analysis and two proteins detected in embryo culture medium (MMP-1 and IL-6). The overall success rate on blind test data was 72.7% for live birth prediction. The main aim of the present study was to check if the same morphological variables combined with MMP-1 or IL-6 with a cost-effective technique could discriminate between euploid and aneuploid embryos.

Study design, size, duration

This prospective study included 120 embryos from the preimplantation genetic testing for aneuploidies (PGT-A) program. A single blastocyst image was obtained for each embryo and their spent culture medium was collected on the day 5/6 of embryo development (day of trophectoderm biopsy). Morphological variables were extracted for all the blastocyst. On the other hand, we quantified IL-6 levels of 67 embryos and MMP-1 levels of 53 embryos. Resulting parameters were used to predict PGT-A results.

Participants/materials, setting, methods

Blastocyst images were imported into Matlab software and segmented into regions of interest. We obtained 20 mathematical variables related to measurements of areas, number of pixels and texture analysis. Chromosome analysis was performed using next-generation sequence technology. In parallel, 20 µL of spent culture medium from each blastocyst was analyzed with ELISA kits (IL-6 or MMP-1). Protein concentrations and morphological variables were used as input data for an ANN associated with genetic algorithms.

Main results and the role of chance

The euploid rate for the set of embryos included in the IL-6 group was 51.4%. The ANN was trained with 49 embryos and blind tested with 18 embryos. Following results correspond to euploidy prediction on the blind test. The sensitivity, specificity, accuracy and area under the ROC curve (AUC) were: 0.56, 0.78, 0.67 and 0.72 considering only IL-6 values; 0.88, 0.78, 0.83 and 0.61 considering IL-6 values and blastocyst morphological data extracted from the image analysis. The euploid rate for the set of embryos included in the MMP-1 group was 51.9%. The ANN was trained with 39 embryos and blind tested with 14 embryos. Following results correspond to euploidy prediction on the blind test. The sensitivity, specificity, accuracy and AUC were: 0.71, 0.57, 0.64 and 0.67 considering only MMP-1 values; 0.86, 0.86, 0.86 and 0.61 considering MMP-1 values and morphological data extracted from the image analysis.

Limitations, reasons for caution

The detection limit in protein quantification is the main limitation of our study. The small number of embryos and the specific culture medium used should be considered for the model application.

Wider implications of the findings

Our preliminary results showed that blastocyst morphology and embryo secretomics could be useful for euploidy prediction by using artificial intelligence techniques. These findings may contribute to the emerging era of non-invasive preimplantation genetic testing (ni-PGT-A).

Trial registration number

not applicable

OP0229 THE GROUP FOR RESEARCH AND ASSESSMENT OF PSORIASIS AND PSORIATIC ARTHRITIS (GRAPPA) TREATMENT RECOMMENDATIONS 2021

Background:

Since the 2015 GRAPPA treatment recommendations were published, therapeutic options and management strategies for psoriatic arthritis (PsA) have advanced considerably.

Objectives:

The goal of the GRAPPA recommendations update is to develop high quality, evidence-based recommendations for the treatment of PsA, including related conditions and comorbidities.

Methods:

GRAPPA rheumatologists, dermatologists and patient research partners (PRPs) updated overarching principles for the management of adults with PsA by consensus. Principles considering use of biosimilars and tapering/discontinuing of therapy were added to this update. Systematic literature searches based on data publicly available from three databases (MEDLINE, EMBASE, and Cochrane CENTRAL) were conducted from the end of the previous recommendations’ searches through August 2020. Additional abstract searches were performed for conference presentations in 2017-2020. Searches covered PsA treatments (peripheral arthritis, axial arthritis, enthesitis, dactylitis, skin, and nail disease). Additional searches were performed for related conditions (uveitis and IBD) and comorbidities evaluating their impact on safety and treatment outcomes. Individual groups assessed the risk of bias and applied the GRADE system to generate strong or conditional recommendations for therapies within the domain groups and for the management of comorbidities and related conditions. These recommendations were then incorporated into an overall treatment schema.

Results:

Updated, evidence-based treatment recommendations are shown (Table 1). Since 2015, many new medications have been incorporated. Additional results for older medications, such as methotrexate, have been published across PsA domains. Based on the evidence, the treatment recommendations developed by individual groups were incorporated into the overall schema including principles for management of arthritis, spondylitis, enthesitis, dactylitis, skin, and nail disease in PsA, and associated conditions (Figure 1). Choice of therapy for an individual should ideally address all of the domains that impact on that patient, supporting shared decision making with the patient involved. Additional consideration in the recommendations was given to key associated conditions and comorbidities as these often impact on therapy choice.

Conclusion:

These GRAPPA treatment recommendations provide up to date, evidence-based guidance to providers who manage and treat adult patients with PsA. These recommendations are based on domain-based strategy for PsA and supplemented by overarching principles developed by consensus of GRAPPA members.

IndicationStrongForConditional ForConditionalAgainstStrongAgainstInsufficient evidencePeripheral Arthritis DMARD NaïvecsDMARDs, TNFi, PDE4i, IL-12/23i, IL-17i, IL-23i, JAKiNSAIDs, oral CS, IA CS,IL-6i,Peripheral Arthritis DMARD IRTNFi, IL-12/23i, IL-17i, IL-23i, JAKiPDE4i, other csDMARD, NSAIDs, oral CS, IA CS,IL-6i,Peripheral ArthritisbDMARD IRTNFi, IL-17i, IL-23i, JAKi,NSAIDs, oral CS, IA CS, IL-12/23i, PDE4i, CTLA-4-IgIL-6i,Axial arthritis, Biologic NaïveNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKiCS SIJ injections, bisphosphonatescsDMARDs, IL-6i,IL-12/23i, IL-23iAxial PsA, Biologic IRNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKi csDMARDs, IL-6i,IL-12/23i, IL-23iEnthesitisTNFi, IL-12/23i, IL-17i, PDE4i, IL-23i, JAKiNSAIDs, physiotherapy, CS injections, MTXIL-6i,Other csDMARDsDactylitisTNFi IL-12/23i, IL-17i, IL-23i, JAKi, PDE4iNSAIDs, CS injections, MTXOther csDMARDsPsoriasisTopicals, phototherapy, csDMARDs, TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i, JAKi AcitretinNail psoriasisTNFi, IL12/23i, IL17i, IL23i, PDE4iTopical CS, tacrolimus and calcipotriol combination or individual therapies, Pulsed dye laser, csDMARDs, acitretin, JAKiTopical Cyclosporine / Tazarotene, Fumarate, Fumaric Acid Esters, UVA and UVB Phototherapy, AlitretinoinIBDTNFi (not ETN), IL-12/23i, JAKiIL-17iUveitisTNFi (not ETN)

Disclosure of Interests:

Laura C Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Gilead, Eli Lilly, Janssen, Medac, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Pfizer, and Novartis, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Janssen, Novartis Pharma, Pfizer, Roche, and UCB, Nadia Corp: None declared, Heidi Bertheussen Consultant of: Pfizer, Kristina Callis-Duffin Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Lilly, Janssen, Novartis, Pfizer, Sienna Biopharmaceuticals, Stiefel Laboratories, UCB, Ortho Dermatologics, Inc, Regeneron Pharmaceuticals, Inc., Anaptys Bio, Boehringer Ingelheim., Cristiano Barbosa Campanholo Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Jeffrey Chau: None declared, Lihi Eder Consultant of: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Grant/research support from: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Daniel Fernandez Consultant of: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Grant/research support from: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Oliver FitzGerald Speakers bureau: AbbVie, Janssen and Pfizer Inc, Consultant of: BMS, Celgene, Eli Lilly, Janssen and Pfizer Inc, Grant/research support from: AbbVie, BMS, Eli Lilly, Novartis and Pfizer Inc, Amit Garg Consultant of: Abbvie, Amgen, Asana Biosciences, Bristol Myers Squibb, Boehringer Ingelheim, Incyte, InflaRx, Janssen, Pfizer, UCB, Viela Biosciences, Grant/research support from: Abbvie, Dafna D Gladman Consultant of: Abbvie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Jansen, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Amgen, Eli Lilly, Jansen, Novartis, Pfizer and UCB, Niti Goel: None declared, Suzanne Grieb: None declared, Philip Helliwell Speakers bureau: Janssen, Novartis, Pfizer, Consultant of: Eli Lilly, M Elaine Husni Consultant of: Abbvie, Amgen, Janssen, Novartis, Lilly, UCB, Regeneron, and Pfizer, Deepak Jadon Speakers bureau: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Arnon Katz: None declared, Dhruvkumar Laheru: None declared, John Latella: None declared, Ying Ying Leung Speakers bureau: Novartis, AbbVie, Eli Lilly, Janssen, Consultant of: Pfizer and Boehringer Ingelheim, Grant/research support from: Pfizer and conference support from AbbVie, Christine Lindsay Shareholder of: Amgen, Employee of: Aurinia pharmaceuticals, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Luis Mazzuoccolo Speakers bureau: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Consultant of: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Roland McDonald: None declared, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead Sciences, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead Sciences, Janssen, Novartis, Pfizer, SUN and UCB, Denis O’Sullivan: None declared, Alexis Ogdie Consultant of: AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, and Pfizer, Grant/research support from: Novartis and Pfizer and Amgen, Wendy Olsder: None declared, Lori Schick: None declared, Ingrid Steinkoenig: None declared, Maarten de Wit Consultant of: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Danielle van der Windt: None declared, Arthur Kavanaugh Speakers bureau: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB

Triacetyluridine treats epileptic encephalopathy from CAD mutations: a case report and review

Refractory epilepsy and encephalopathy are frequently encountered in patients with inborn errors of metabolism. We report a case of an 8-year-old girl with history of developmental delay, autism and intractable epilepsy that was found to have a pathogenic variant in CAD. We briefly review the biochemical pathway of CAD and the preclinical and clinical studies that suggest uridine supplementation can rescue the CAD deficiency phenotypes. Our case demonstrates a relatively late-onset case of refractory epilepsy with a rapid response to treatment using the uridine pro-drug triacetyluridine (TAU), the FDA-approved treatment for hereditary orotic aciduria.

Systemic lupus erythematosus presenting with holocord myelitis

This is a report of a case of a 25-year-old woman, who presented with a rapidly progressive sensory-motor flaccid quadriparesis which had developed over a few days along with bladder and bowel involvement. She had a past history of photosensitive rash and joint pains along with mild-to-moderate grade fever; for which she had never been evaluated. Serological markers for systemic lupus erythematosus (SLE) were strongly positive and helped in establishing the diagnosis of SLE-related holocord myelitis. High-dose intravenous glucocorticoid followed by intravenous pulse cyclophosphamide was used to treat her and there was a significant improvement. In this case report, the diagnosis of SLE was made for the first time in a patient presenting with holocord myelitis.

Low-dose ACTH test for evaluation of hypothalamus-pituitary-adrenal axis preoperatively and 3-month follow-up in non-functioning pituitary adenomas

BACKGROUND

Peri-operative glucocorticoids are routinely administered to patients undergoing trans-sphenoidal surgery for non-functional pituitary adenomas (NFPA) irrespective of hypothalamus-pituitary-adrenal (HPA) axis status.

PURPOSE

Evaluation of HPA axis before and 12 weeks after endoscopic trans-sphenoidal adenomectomy (E-TSA) utilizing low-dose (1 μg) ACTH stimulation test (LDACTH) to determine the need for glucocorticoid administration in patients with NFPA. We also determined the factors that can predict occurrence of hypocortisolism at 12 weeks after surgery.

METHODS

Sixty-three consecutive patients with NFPA requiring surgical excision were enrolled in this study. Glucocorticoids were administered to patients with demonstrable hypocortisolism [preoperative peak cortisol < 16 μg/dL during LDACTH test, postoperative day 3 (POD-3) 0800 hrs Cortisol < 8 μg/dL or stimulated cortisol (LDACTH) < 16 μg/dL at 12 weeks].

RESULTS

Hypocortisolism was present in 43 patients (68.2%) pre-operatively and persisted in 33 patients (52.4%) on POD-3. Thirty-three patients (52.4%) had hypocortisolism at 12 weeks after surgery. Eleven patients (17.4%) did not require glucocorticoids during the entire study period and 30 patients (47.6%) did not require glucocorticoids after 3 months. None of the patients developed adrenal crisis during the study. Hypocortisolism on the third post-operative day was the single significant predictor of hypocortisolism at 12 weeks after the surgery. There was a significant correlation between POD-3 0800 hrs cortisol ≥ 8μg/dL and stimulated cortisol (LDACTH) ≥16μg/dL at 12 weeks (r = 0.62, p < 0.0001). POD-3 0800 hrs cortisol ≥ 8 μg/dL had 73% sensitivity and 79% specificity in predicting eucortisolism at 12 weeks.

CONCLUSIONS

HPA function is preserved in significant proportion of NFPA patients undergoing E-TSA. Perioperative glucocorticoids should be given only in patients with demonstrable preoperative hypocortisolism on 1 μg ACTH test. Postoperative day 3 0800 hrs cortisol is a reasonable predictor of HPA axis status at 12 weeks after surgery.

Computed tomographic analysis of the prevalence of International Frontal Sinus Anatomy Classification cells and their association with frontal sinusitis

OBJECTIVES

To determine the radiological prevalence of frontal cells according to the International Frontal Sinus Anatomy Classification in patients undergoing computed tomography of the paranasal sinuses for clinical symptoms of chronic rhinosinusitis, and to examine the association between cell classification and frontal sinusitis development.

METHODS

A total of 180 (left and right) sides of 90 patients were analysed. The prevalence of each International Frontal Sinus Anatomy Classification cell was assessed. Logistic regression analysis was used to compare the distribution of various cells in patients with and without frontal sinusitis.

RESULTS

The agger nasi cell was the most commonly occurring cell, seen in 95.5 per cent of patients. The prevalence rates for supra agger cells, supra agger frontal cells, supra bullar frontal cells, supra bullar cells, supra-orbital ethmoid cells and frontal septal cells were 33.3 per cent, 22.2 per cent, 21.1 per cent, 36.1 per cent, 39.4 per cent and 21.1 per cent, respectively. There was no significant difference in the occurrence of any of the cell types in patients with frontal sinusitis compared to those without (p > 0.05).

CONCLUSION

The presence of any of the International Frontal Sinus Anatomy Classification cells was not significantly associated with frontal sinusitis.

Validation of global item for assessing impact on quality of life of patients with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease. The HS core outcome set calls for a patient global assessment (PtGA).

OBJECTIVES

To assess the validity, reliability and responsiveness of a candidate single-item PtGA for HS-specific health-related quality of life (HRQoL).

METHODS

Cognitive debriefing interviews were conducted with patients with HS in Denmark and the USA. A cross-sectional observational study was done with adults with HS in the USA and Denmark. Candidate PtGA item, demographic items and multiple patient-reported scales - the Hidradenitis Suppurativa Quality of Life (HiSQOL), Dermatology Life Quality Index (DLQI) and numerical rating scale (NRS) for pain - were concurrently administered to evaluate convergent and known-groups validity. Scales with a single-item assessment of change were readministered 24-72 h later, to evaluate reliability and responsiveness.

RESULTS

After cognitive debriefing, the candidate PtGA for HS-specific HRQoL was finalized with five response levels. Convergent validity of the PtGA was supported by significant correlations with HiSQOL score [r = 0·79, 95% confidence interval (CI) 0·75-0·82] and DLQI (r = 0·78, 95% CI 0·74-0·82). The PtGA displayed known-groups validity with DLQI score bands based on significance of an anova (P < 0·001). Good test-retest reliability was supported by the intraclass correlation coefficient (0·82, 95% CI 0·78-0·85) for those who reported stable HS. Responsiveness was assessed by differences in PtGA score against a patient-reported assessment of change, which showed significant differences towards improvement.

CONCLUSIONS

The single-item PtGA exhibits reliability, validity and responsiveness in assessing HS-specific HRQoL in HS, making it a good provisional tool for HS clinical research.

Cardiac rhythm abnormalities - An underestimated cardiovascular risk in adult patients with Mucopolysaccharidoses

Patients with Mucopolysaccharidosis (MPS) have an increased risk of cardiovascular complications, conduction tissue abnormalities and arrhythmia; all rare but underestimated. It has been reported that conduction system defects are progressive in this group of patients and may result in sudden cardiac death. The aim of this study is to review our current practice and suggest best practice guidelines regarding the frequency of cardiac rhythm monitoring in this patient group. Seventy-seven adult MPS patients who attended metabolic clinics between 2013 and 2019 were included in this retrospective observational study. Patients were affected with different MPS types: MPS I (n = 33), MPS II (n = 16), MPS IV (n = 19), VI (n = 8) and VII (n = 1). The assessments included: 12‑lead electrocardiogram (ECG), 24-h ECG (Holter monitor), loop recorder/pacemaker interrogation assessment. Data from 12‑lead ECG (available from 69 patients) showed a variety of abnormalities: T wave inversion in a single lead III (n = 19), left ventricular hypertrophy (n = 14), early repolarization (n = 14), right axis deviation (RAD, n = 11), partial RBBB (n = 9), right bundle branch block (RBBB) (n = 1) and first degree AV block (n = 1). ECG changes of bundle branch block, RAD (left posterior fascicular block) could represent conduction tissue abnormality and equally could be related to the underlying lung tissue abnormality which is present in most of the patients with MPS. T wave abnormality in a single lead is usually insignificant in healthy individuals; however in MPS patients it could be as a result of chest shape. Among the 34 patients for who 24-hour ECG was available, sinus tachycardia was the most common rhythm noted (n = 9), followed by sinus bradycardia (n = 4), atrial fibrillation (AF) (n = 1) and atrio-ventricular nodal re-entry tachycardia (AVNRT) (n = 1). Permanent pacemaker was inserted in two patients. AF was observed in one patient with MPS II. In conclusion, we postulate that regular cardiac monitoring is required to warrant early detection of underlying conduction tissue abnormalities. In addition, 12‑lead ECG is the first line investigation that, if abnormal, should be followed up by 24-hour Holter monitoring. These findings warrant further research studies.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Weekly adalimumab treatment decreased disease flare in hidradenitis suppurativa over 36 weeks: integrated results from the phase 3 PIONEER trials

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic skin disease characterized by inflammatory lesions that flare unpredictably. The impact of weekly adalimumab (ADAew) on HS flare is not well-characterized.

OBJECTIVE

To evaluate the impact of disease flare on health-related quality of life (HRQOL) in moderate-to-severe HS patients and to determine the effect of ADAew on disease flare using integrated data from two phase 3 trials over 36 weeks.

METHODS

In period A (12 weeks), Dermatology Life Quality Index (DLQI) score change from baseline was compared in patients who flared and those who did not, regardless of treatment. The proportion of patients experiencing flare, duration of flare and time to flare was evaluated for ADAew vs. placebo (PBO). In period B (24 weeks), proportion of patients experiencing flare who received continuous ADAew treatment through 36 weeks was assessed.

RESULTS

HRQOL was markedly improved among those who did not experience flare. In period A, the proportion of patients who experienced flare was significantly lower with ADAew vs. PBO (12.3% vs. 35.3%, P < 0.001). ADAew patients also had longer time to first flare (101 days vs. 57 days; P < 0.001) and shorter flare duration (18.9 days vs. 32.0 days, respectively; P = 0.001) vs. PBO. Through 36 weeks of treatment, 20.2% of ADAew patients flared, and for those who achieved at least a partial clinical response to ADAew at 12 weeks, only 5.7% flared.

CONCLUSIONS

Flare reduction is an important measure in HS that correlates with clinically meaningful improvement in HRQOL. ADAew reduces HS flare through 12 and subsequent 36 weeks of treatment.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

The Hidradenitis Suppurativa Quality of Life (HiSQOL) score: development and validation of a measure for clinical trials

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition that can have a large negative impact on health-related quality of life (HRQOL). A reliable and validated measure of HS-specific HRQOL in clinical studies is needed.

OBJECTIVES

To develop and validate the Hidradenitis Suppurativa Quality Of Life (HiSQOL©) scale, for clinical trial measurement of HS-specific HRQOL.

METHODS

In stage 1, qualitative concept elicitation interviews were conducted with patients with HS in Denmark (n = 21) and the U.S.A. (n = 21). In stage 2, cognitive debriefing interviews were performed with U.S. (n = 30) and Danish patients with HS (n = 30). In stage 3 an observational study of 222 patients with HS in the U.S.A. was conducted for item reduction, measure validation and assessment of psychometric properties. In stage 4, an observational study of 215 patients with HS in Denmark was conducted to confirm the psychometric structure derived in stage 3. In both studies the Dermatology Life Quality Index, Hospital Anxiety and Depression Scale and numerical rating scale for pain were also included.

RESULTS

In concept elicitation, 99 items were generated, which were reduced to 41 after removing duplicates. In cognitive debriefing, two items were added and one item removed. A 42-item instrument was psychometrically assessed. Based on psychometric analyses and patient input, the instrument was reduced to 17 items that had strong psychometric properties in both the U.S. and Danish samples.

CONCLUSIONS

The HiSQOL is a reliable and valid instrument to measure HS-specific HRQOL in clinical trials.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

5970Morbidity and mortality in patients precluded for transvenous pacemaker implantation: experience with the Micra transcatheter pacemaker

Background

The Micra transcatheter pacemaker has proven to be a safe and effective alternative to transvenous pacemakers (TVPs). However, the safety profile after Micra implantation in patients deemed poor candidates for TVPs is poorly understood.

Purpose

To evaluate the safety and all-cause mortality outcomes in Micra recipients stratified by whether or not they were precluded for therapy with TVP.

Methods

Micra patients from the Micra Transcatheter Pacing (IDE) Study, Continued Access (CA) study, and Post-Approval Registry (PAR) were divided into groups based upon whether or not the implanting physician considered the patient to be precluded from receiving a transvenous pacing system. All-cause mortality was compared between the Micra patient groups and patients receiving a single-chamber transvenous pacing system (SC-TVP) since 2010 from the Medtronic product surveillance registry using univariate and multivariate Cox models.

Results

Among 2,819 patients who underwent a Micra implant attempt, the overall major complication rate through 24 months was 3.5%. In these patients, 548 were deemed precluded from TVP implantation. Prior device infection or bacteremia (38.9%), venous access issues (36.1%) and thrombosis (10.2%) were amongst the most common causes of preclusion for TVP implantation. These patients were younger (71.7 vs. 76.7 years), more frequently on hemodialysis (26.3% vs. 2.5%), and more often had a prior CIED implanted (38.4% vs. 4.4%) than non-precluded patients. Over an average follow-up of 13.5±11.1 months, all-cause mortality was significantly higher in precluded Micra patients compared with SC-TVP patients (HR: 2.16, 95% CI: 1.54–3.2, P<0.001) (Figure 1). However, there was no significant difference in all-cause mortality when comparing non-precluded Micra patients and SC-TVP patients (HR: 1.12, 95% CI: 0.86–1.44, P=0.401). Acute all-cause death (within 1 month) among Micra patients was 2.74% and 1.32% in the precluded and non-precluded TVP groups, respectively. The procedure-related death rate was 0.55% for the TVP precluded group and 0.13% for the not precluded group (P=0.092). The major complication rate through 24-months was similar between the two Micra groups (4.0% vs 3.4%, P=0.630).

All-cause mortality for Micra and SC-TVP

Conclusion

The overall safety profile of Micra remains is in line with previously reported data. All-cause mortality risk (both acute and long term) appears to be higher in patients who were precluded from receiving TVP.

Acknowledgement/Funding

Supported by Medtronic

P3753Does empagliflozin modulate the autonomic system among patients with type 2 diabetes and coronary artery disease? Insights from the Holter sub-study of the EMPA-Heart CardioLink-6 Randomised Trial

Introduction

The mechanism behind how empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, reduces all-cause and cardiovascular mortality among patients with type 2 diabetes (T2DM) and coronary artery disease (CAD) is unknown. Autonomic tone, as reflected by changes in heart rate variability (HRV), is an established prognosticator in patients with CAD and/or heart failure.

Purpose

To assess if empagliflozin treatment changes HRV in subjects with T2DM and CAD.

Methods

In the double-blind EMPA-Heart trial, 97 subjects with T2DM and CAD were randomised to empagliflozin 10 mg/day or placebo for 6 months and underwent 24-hour Holter monitoring at baseline and 6 months. Using automated algorithms, time and frequency HRV domain measures were obtained (standard deviation of NN intervals (SDNN); SD of the average NN intervals for each 5-minute segment (SDANN); root mean square of successive RR interval differences (rMSSD); % interval differences of successive NN intervals >50 ms (pNN50); ratio of low to high frequency (LF/HF)). Changes of these HRV parameters were calculated over 6 months. Between-group differences in HRV parameters were compared using ANCOVA.

Results

Complete Holter data (baseline and 6-month) were available for 68% (n=66) of the cohort. The average heart rate (HR) at baseline/6 months was 69.5±9.8 bpm/72.8±8.1 bpm and 76±10.4 bpm/76.5±10.6 in the placebo group and empagliflozin group, respectively. Both groups had similar changes in average HR over 6 months. Key Holter data are summarised in the table. SDNN and SDANN were higher in the placebo vs. empagliflozin group at 6 months; no significant difference was noted for all other measures.

Empagliflozin 10 mg/day (n=33) Placebo (n=33) Adjusted difference between Empagliflozin and Placebo (ANCOVA) Baseline, Mean (SD) 6-month, Mean (SD) Baseline, Mean (SD) 6-month, Mean (SD) Mean, (95% CI) P-value SDNN (ms) 100.49 (43.74) 98.05 (38.86) 109.35 (30.02) 125.08 (43.83) −18.55 (−34.28, −2.82) 0.022 SDANN (ms) 86.84 (39.34) 83.76 (35.53) 94.70 (28.52) 118.28 (77.41) −20.24 (−37.27, −3.21) 0.021 rMSSD (ms) 27.00 (11.84) 27.22 (13.48) 28.00 (11.58) 27.17 (9.38) −1.23 (−6.02, 3.55) 0.608 pNN50 (%) 7.81 (7.59) 8.32 (9.51) 8.26 (7.8) 6.93 (5.35) 0.51 (−2.61, 3.62) 0.746 LF/HF ratio 1.63 (0.52) 1.65 (0.51) 1.53 (0.43) 1.83 (0.82) −0.08 (−0.38, 0.22) 0.602

Conclusions

Among subjects with T2DM and CAD, changes in HRV over 6 months were similar in the empagliflozin and placebo arms suggesting that the mortality benefit conferred by empagliflozin is not associated with positive modulation of autonomic tone.

Acknowledgement/Funding

This trial was supported by an unrestricted investigator-initiated study grant from Boehringer Ingelheim.

P04.19 Analysis of tumor immune microenvironment and immune checkpoint modulators across infantile and pediatric pilocytic astrocytomas to elucidate the role of immunotherapy in these tumors

BACKGROUND

Pilocytic astrocytomas are the most common central nervous system tumors in pediatric age-group. Although grade I, some of the cases show recurrence and progression, and few might not be amenable to surgery due to location or size, and hence have a less favorable prognosis. Drugs blocking immune check-point interactions such as those including programmed cell death ligand-1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) are now in clinical use for certain tumors. We performed this study to understand the potential candidature of pilocytic astrocytomas in infants and children for immunotherapy by analyzing the expression of immune checkpoint proteins and immune infiltrate, and correlating with clinical details, wherever possible.

MATERIALS AND METHODS

Cases with adequate tissue (2010–2017) diagnosed in pediatric age-group (<18 years) were retreived from the archives of Department of Pathology, AIIMS, New Delhi. Immunohistochemistry for PD-L1 (SP263, Ventana), CTLA-4, CD3, CD8, CD4 and CD68 was performed. Quantification of cytotoxic lymphocytes was done using digital imaging in the core of the tumor.

RESULTS

A total of 50 pilocytic astrocytomas were included, 14 of them were <3 years (infants), while 36 were of pediatric age-group (3–18 years). Overall, male preponderance was noted. Cerebellum was the most common location, followed by 4th venrticle, optic pathway, hypothalamus, cerebrum and thalamus. Almost all CD3 lymphocytes were cytotoxic T-lymphocyes (CD8 positive, CTLs). Helper T-lymphocyte infiltration was not seen. Median CTL density/mm3 was 13/mm3(Range:1–85/mm3). CTLA-4 was positive in 4 cases, positivity ranged from 1–4 cells/lpf. PD-L1 was found to be positive in 7 cases, and the positivity ranged from 1+ to 2+ in 1 to 5% of tumor cells. A median TAM (tumor associated macrophages) density of 44/hpf (range: 1–98/hpf) was noted. There was no correlation of CTL density with PD-L1 or CTLA-4 expression, and neither with TAM density. On correlation with clinical parameters, a higher density of CTLs and TAMs was noted in infants, and a higher proportion of cases revealed PD-L1 positivity, though not statistically significant. There was no correlation of TILs or TAMs with the tumor location.

CONCLUSION

Immune check point blockade using PD-(L)1 or CTLA4 inhibitors may not be a potential therapeutic option for unresectable or recurrent pilocytic astrocytomas, as low positivity rate as well as extremely low percentage of tumor/ immune cells found to be positive. However, alternate forms of immunotherapy might be helpful as most of the cases showed immune infiltrates and a high density of tumor-associated macrophages (TAMs). Large scale studies with larger numbers and longer follow-up periods including in-vitro and clinical studies are warranted for decoding the tumor immunogram.

P14.117 Cost efficient test algorithm for molecular subgrouping of medulloblastomas for day-to-day practice in resource limited countries

INTRODUCTION

Molecular classification of medulloblastomas(MB) is prognostically and therapeutically relevant and helps in better risk-stratification. Translation of this subgrouping to routine practice still remains a challenge. The most pathologist-accessible techniques for molecular subgrouping include immunohistochemistry(IHC), fluorescent in-situ hybridization(FISH) and Nanostring assay. Objectives:(1)Molecular subgrouping of MBs by IHC and FISH, and Nanostring Assay (2)To compare their efficacy against sequencing and DNA methylation, and cost for applicability in resource-constrained centers

METHODS

Ninety-five cases of MB with adequate tissue were included. Molecular subgrouping was performed by IHC for β-catenin, GAB1, YAP1, and p53; FISH for MYC amplification, and sequencing for CTNNB1, and by Nanostring Assay on the same set of MBs. Further, a subset of cases were subjected to 850k DNA methylation array.

RESULTS

IHC+FISH classified MBs into 15.8% WNT, 16.8% SHH, and 67.4% non-WNT/non-SHH subgroups; with MYC amplification identified in 20.3% cases of non-WNT/non-SHH. A single showed diffuse strong p53 positivity among the SHH subgroup. Nanostring successfully classified 91.5% MBs into 25.3% WNT, 17.2% SHH, 23% Group3 and 34.5% Group4. However, Nanostring assay failure was seen in eight cases, all of which were >8-years-old formalin-fixed paraffin-embedded tissue blocks. Concordant subgroup assignment was noted in 88.5% cases, while subgroup switching was seen in 11.5% cases. Both methods showed prognostic correlation. Among the 5 discrepant cases, which switched to WNT subgroup by Nanostring, only 2 were found to have CTNNB1 mutation. Methylation profiling performed on discordant cases revealed 1 out of 4 extra WNT identified by Nanostring to be WNT, others aligned with IHC subgroups; extra SHH by Nanostring turned out to be SHH by methylation.

CONCLUSIONS

Both IHC supplemented by FISH and Nanostring are robust methods for molecular subgrouping, albeit with few disadvantages. IHC cannot differentiate between Groups 3 and 4, while Nanostring cannot classify older-archived tumors, and is not available at most centres. WNT subgroup with the best prognosis is best detected by IHC or IHC followed by sequencing for confirmation. Nanostring Assay is better suitable to separate Group 3, the worst prognostic group from Group 4. Thus, both the methods complement each other and can be used in concert for high confidence allotment of molecular subgroups in clinical practice. The cost of IHC plus Nanostring will almost be the same as IHC plus FISH. We recommend a cost-efficient algorithmic approach using histopathological subtype and IHC as the first step followed by Nanostring or FISH, wherever suitable.

P11.05 Reappraisal of CNS embryonal tumors, not otherwise specified and RELA fusion negative supratentorial ependymomas using immunohistochemistry and sequencing for BCOR

BACKGROUND

BCl2 co-repressor (BCOR) gene internal tandem duplications have recently been identified as the defining molecular alteration in a subset of central nervous system (CNS) high grade neuroepithelial tumors (CNS-HGNET). Their clinicopathological profile is yet to be fully elucidated with available data being largely derived from case reports and small case series. Reported cases presented in young children with a male preponderance, were located predominantly in the posterior fossa, and sometimes but not always showed an ependymoma-like morphology. BCOR protein overexpression and exon 15 internal tandem duplications were characteristic. These tumors associated with a poor overall survival.

MATERIAL AND METHODS

We designed a retrospective study (2002–2019) wherein all cases of CNS embryonal tumors, not otherwise specified (NOS), by definition lacking C19MC locus amplification and Lin28A protein expression, and supratentorial ependymomas (ST-EPN), NOS, lacking RELA and YAP1 fusions and L1CAM protein expression were retrieved and subject to immunohistochemistry for BCOR. Those tumors showing nuclear expression of BCOR were subject to sequencing of exon 15 of BCOR gene.

RESULTS

A total of 19 CNS embryonal tumors, NOS, constituting 86% of all CNS embryonal tumors other than medulloblastomas and atypical teratoid rhabdoid tumors, and 11 ST-EPN, NOS constituting 30% of all ST EPNs, were included. Diffuse nuclear staining for BCOR was seen in 6 tumors, including two patients with CNS embryonal tumor, NOS (10 year old male with spinal cord mass; 5-year-old female with left frontal mass) and 4 patients with ST-EPN-NOS (median age 15 years, ranging from 10–28 years, all females). While the CNS embryonal tumors showed high grade small round cell morphology, the remaining showed ependymoma-like morphology, but with increased cellularity and focal to diffuse membranous expression of epithelial membrane antigen and cytokeratins unlike ependymomas. Among these four patients, one was disease free at last follow-up at 17 months, while the remaining suffered recurrences within a median time duration of 26 months after diagnosis (24 months - 36 months).

CONCLUSION

The clinicopathological spectrum of BCOR-altered CNS tumors appears to be wider than that described in literature. We describe BCOR alterations in a subset of ependymoma-like tumors in older children and young adults with a striking female preponderance. BCOR alterations need to be studied on a broad spectrum of pediatric and adults CNS tumors to aid in better understanding of its true prevalence and biological significance.

Evaluation of the Project Echo Tele-Mentoring Model for Knowledge Sharing and Technical Assistance in Cancer Control Planning and Implementation

Background: There is increasing demand for dissemination and implementation of evidence-based guidelines in cancer control. In 2017, the National Cancer Institute's Center for Global Health (NCI-CGH) partnered with University of New Mexico and The University of Texas MD Anderson Cancer Center to provide the Project ECHO (Extension for Community Healthcare Outcomes) model of tele-mentoring as an extension of existing programs that convene relevant stakeholders for knowledge sharing and technical assistance in national cancer control planning. In early 2018, NCI-CGH launched Project ECHO programs in the Caribbean, Asia-Pacific, and sub-Saharan Africa regions, and began plans for implementation in south Asia. As a new approach for the center in program development, NCI-CGH included evaluation measures from the inception of the program to adequately measure its efficacy. Aim: Evaluation of NCI-CGH Project ECHO programs will guide future program development, and assess achievement of the program's goals: (1) to increase individual participant knowledge in specific areas; (2) to improve application of the knowledge learned; and (3) to increase collaboration within and among countries. Methods: Using Project ECHO Evaluation 101, a guide developed by the New York Academy of Medicine, NCI-CGH developed a comprehensive logic model including a concise list of program outcomes prior to the launch of ECHO programs. NCI-CGH used the logic model to develop and pilot-test a Web-based baseline and post-ECHO survey, to be completed by participants in each program, that measures participants' knowledge of cancer control planning principles and strategies. NCI-CGH conducted the baseline survey for all three ECHO programs. The post-ECHO survey will be distributed at the conclusion of each program. Each program is expected to run for approximately six months to one year. Results: Response rates for baseline surveys were: 32% in the Caribbean, 43% in Asia-Pacific, and 78% in sub-Saharan Africa. Respondents (by region) reported high levels of knowledge of the following evidence-based principles and guidelines: the Caribbean - HPV vaccination, Asia-Pacific - cervical cancer early diagnosis, sub-Saharan Africa - raising awareness. Low levels of knowledge were reported for: psychosocial support for cancer patients, family members, and caregivers in the Caribbean; survivorship care for cancer patients in Asia-Pacific; and alcohol consumption control in sub-Saharan Africa. This presentation will highlight baseline and post-ECHO survey analysis findings and the impact of these data on future program development. Conclusion: Inclusion of evaluation measures in the design phase of NCI-CGH Project ECHO tele-mentoring programs enhanced planning efforts by providing a blueprint for developing program curricula, creating an embedded system for gathering data from participants, and informing the pathway to future improvements.