An integrated program to expand donor utilization in pediatric heart transplantation: Case report of successful transplant with multiple donor risk factors

BACKGROUND

Pediatric heart transplantation (HT) continues to be limited by the shortage of donor organs, distance constraints, and the number of potential donor offers that are declined due to the presence of multiple risk factors.

METHODS

We report a case of successful pediatric HT in which multiple risk factors were mitigated through a combination of innovative donor utilization improvement strategies.

RESULTS

An 11-year-old, 25-kilogram child with cardiomyopathy and pulmonary hypertension, on chronic milrinone therapy and anticoagulated with apixaban, was transplanted with a heart from a Hepatitis C virus positive donor and an increased donor-to-recipient weight ratio. Due to extended geographic distance, an extracorporeal heart preservation system (TransMedics™ OCS Heart) was used for procurement. No significant bleeding was observed post-operatively, and she was discharged by post-operative day 15 with normal biventricular systolic function. Post-transplant Hepatitis C virus seroconversion was successfully treated.

CONCLUSIONS

Heart transplantation in donors with multiple risk factor can be achieved with an integrative team approach and should be taken into consideration when evaluating marginal donors in order to expand the current limited donor pool in pediatric patients.

Use of a severe acute respiratory coronavirus virus 2 (SARS-CoV-2) strand-specific assay to evaluate for prolonged viral replication >20 days from illness onset

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) real-time reverse-transcription polymerase chain reaction (rRT-PCR) strand-specific assay can be used to identify active SARS-CoV-2 viral replication. We describe the characteristics of 337 hospitalized patients with at least 1 minus-strand SARS-CoV-2 assay performed >20 days after illness onset. This test is a novel tool to identify high-risk hospitalized patients with prolonged SARS-CoV-2 replication.

An explorative single-arm clinical study to assess craving in patients with alcohol use disorder using Virtual Reality exposure (CRAVE)-study protocol

BACKGROUND

Alcohol use disorder (AUD) belongs to the most burdensome clinical disorders worldwide. Current treatment approaches yield unsatisfactory long-term effects with relapse rates up to 85%. Craving for alcohol is a major predictor for relapse and can be intentionally induced via cue exposure in real life as well as in Virtual Reality (VR). The induction and habituation of craving via conditioned cues as well as extinction learning is used in Cue Exposure Therapy (CET), a long-known but rarely used strategy in Cognitive Behavioral Therapy (CBT) of AUD. VR scenarios with alcohol related cues offer several advantages over real life scenarios and are within the focus of current efforts to develop new treatment options. As a first step, we aim to analyze if the VR scenarios elicit a transient change in craving levels and if this is measurable via subjective and psychophysiological parameters.

METHODS

A single-arm clinical study will be conducted including n = 60 patients with AUD. Data on severity of AUD and craving, comorbidities, demographics, side effects and the feeling of presence in VR will be assessed. Patients will use a head-mounted display (HMD) to immerse themselves into three different scenarios (neutral vs. two target situations: a living room and a bar) while heart rate, heart rate variability, pupillometry and electrodermal activity will be measured continuously. Subjective craving levels will be assessed before, during and after the VR session.

DISCUSSION

Results of this study will yield insight into the induction of alcohol craving in VR cue exposure paradigms and its measurement via subjective and psychophysiological parameters. This might be an important step in the development of innovative therapeutic approaches in the treatment of patients with AUD.

TRIAL REGISTRATION

This study was approved by the Charité-Universitätsmedizin Berlin Institutional Review Board (EA1/190/22, 23.05.2023). It was registered on ClinicalTrials.gov (NCT05861843).

Consolidative Radiotherapy for Residual PET-Avid Disease on Day +30 Post CAR T-Cell Therapy in Non-Hodgkin Lymphoma

PURPOSE/OBJECTIVE(S)

Up to30% of non-Hodgkin lymphoma (NHL) patients achieve a partial response (PR) to anti-CD19 Chimeric Antigen Receptor T-cell Therapy (CART) on day +30. Most PR patients relapse and only 30% achieve spontaneous complete response (CR) without additional therapies. This study is the first to report on the role of consolidative radiotherapy (cRT) for PR PET-avid disease on day +30 post-CART in NHL.

MATERIALS/METHODS

Aretrospective review across 3 institutions from 2018 to 2022 identified 60 patients with B-cell NHL who received CART and achieved PR (Deauville 4-5) with <5 PET-avid disease sites on day +30. Progression-free survival (PFS) was defined from CART infusion to any disease progression. Overall survival (OS) was defined from CART infusion to death. Local relapse-free survival (LRFS), calculated based on the total number of PR sites, was defined from CART infusion to local relapse (LR) in the PR site identified on day +30. cRT was defined as comprehensive (compRT) - treated all PR PET-avid sites - or focal (focRT).

RESULTS

Followingday +30 PET scan, 45 PR patients were observed and 15 received cRT. Only one patient received consolidative systemic therapy and belonged to the cRT group. Prior to CART, bridging RT was given to 13 patients (9 in observation group and 4 in cRT group). There were no significant differences in the pre-CART and day +30 baseline characteristics, including the median size and SUVmax of the PR sites, between the two groups. However, the median number of PR sites on day +30 was higher in the cRT group (2 [range 1-3] vs 1 [range 1-3], p = 0.003). The median equivalent 2 Gy dose was 39.1 (Interquartile range 36.8-41) Gy, and the most common cRT regimen was 37.5 Gy in 15 fractions. The median follow-up was 21 months. Among the observed patients, 15 (33%) achieved spontaneous CR, and 27 (60%) experienced disease progression with all relapses involving the initial PR sites. Among patients who received cRT, 10 (67%) achieved CR, and 3 (20%) had disease progression with no relapses in the radiated PR sites. None of the 10 cRT patients achieving CR relapsed or required subsequent therapies. The 2-year PFS was 80% and 37% (p = 0.012) and the 2-year OS was 78% and 43% (p = 0.12) in the cRT and observation groups, respectively. Patients consolidated with compRT (n = 12) had superior 2-year PFS (92% vs 37%, p = 0.003) and 2-year OS (86% vs 43%, p = 0.048) compared to observed or focRT patients (n = 48). There were no grade 3+ RT-related toxicities. A total of 90 PR sites were identified; 64 were observed and 26 received cRT. Fourteen (22%) observed PR sites achieved spontaneous sustained CR and 42 (66%) experienced LR. Twenty-four (92%) PR sites consolidated with cRT achieved sustained CR and none experienced LR. The 2-year LRFS was 100% in the cRT sites and 31% in the observed sites (p<0.001).

CONCLUSION

NHL patients who achieve PR by PET to CART are at high risk of local progression. cRT for residual PET-avid disease on day +30 post-CART appears to alter the pattern of relapse and improve LRFS and PFS.

The Role of Radiation Therapy in the Management of Gray Zone Lymphoma

PURPOSE/OBJECTIVE(S)

Gray zone lymphoma (GZL) is a relatively rare disease predominantly affecting young adults with purportedly poor outcomes with current treatment approaches. The role of radiation therapy (RT) in the management of GZL is not well established. This is the largest study to report on the outcomes of GZL patients treated with and without RT.

MATERIALS/METHODS

A retrospective review of 30 patients with GZL treated across 3 institutions from 2009 to 2021 was performed. Event-free survival (EFS) was defined from initiation of frontline chemotherapy (CHT) to disease progression/relapse, initiation of salvage therapy, or death. Local control (LC) was defined from RT start date to in-field recurrence.

RESULTS

The median age was 32 (range: 18-86) years, and 16 (53%) patients had early stage (I-II) disease. Bulky mediastinal disease was present in 63% of patients, and the median tumor diameter was 10 (range: 1.5-18) cm. Patients received ABVD (20%), RCHOP (33%), or REPOCH (47%) as frontline CHT. Among 25 patients with interim PET/CT scan, there were 6 rapid early responders and 14 slow early responders (SER), with 2-year EFS of 33% and 24%, respectively (p = 0.13). After the completion of CHT, 15 (50%) patients achieved complete response (CR) and 10 (33%) achieved partial response (PR), with 2-year EFS of 46% and 10%, respectively (p = 0.004). RT was given to 9 patients in CR (n = 3) or in PR (n = 6). The median RT dose was 36 (30.6-48.6) Gy, at 1.8-2 Gy/fraction. Those receiving RT had bulkier disease at diagnosis (p = 0.049) and lower rates of CR following CHT (p = 0.03). After RT, 3/6 (50%) PR patients converted to CR. At a median follow-up of 4 years, the 2-year EFS was 26% for all patients, 33% for RT and 23% for noRT (p = 0.44). Among patients who did not receive upfront RT and experienced progression (n = 17), 16 (94%) relapsed in pre-existing sites. The 5-year OS was 80% for all patients, 88% for RT and 78% for no RT (p = 0.63). Patients who achieved PR to CHT and received RT had better 2-year EFS (17% vs 0%, p = 0.007) compared to patients who did not receive RT. Similarly, patients with SER who received RT had superior 2-year EFS (33% vs 13%, p = 0.038). Patients with bulky mediastinal disease had a 2-year EFS of 43% with RT and 11% without RT (p = 0.08). After 1st line treatment, 22 (73%) patients relapsed and 18 were successfully salvaged with a sustained CR. The most common salvage regimen involved high dose CHT followed by hematopoietic cell transplantation (HCT) (n = 15). RT was given for 7 patients in the relapsed/refractory setting (consolidative peri-HCT n = 4; definitive salvage n = 3) and 5 (71%) achieved a sustained CR. Among the 16 patients who received RT in the upfront (n = 9) or salvage (n = 7) setting, 3 patients experienced in-field recurrence translating to 2-year LC of 79%.

CONCLUSION

GZL patients have high risk of relapse and maximal upfront combined modality therapy should be considered. RT provides good local control and improves EFS particularly for SER, PR, and bulky mediastinal disease.

Impact of cell-free DNA fungal polymerase chain reaction panels on healthcare-associated infection mould investigations

Launch of in-house sensitive cell-free deoxyribonucleic acid (cfDNA) mould polymerase chain reaction (PCR) assays increased detection of moulds meeting suspected healthcare-associated infection (HAI) criteria. Definition was based on time from admission and mould detection in culture or via molecular methods. We created a modified mould HAI algorithm incorporating clinical context into the case definition, which allowed for better capture of possible mould HAIs, decreased number of investigations, and improved utilization of Infection Prevention and Control (IPC) resources.

1927. Use of a SARS-CoV-2 Strand-specific Assay to evaluate for Prolonged Viral Replication among Hospitalized Patients. Tertiary Care Center, California 2020–2022

Background

Determining if a patient with SARS-CoV-2 remains infectious is an infection control challenge in healthcare settings; specially, among critically ill or profoundly immunosuppressed patients. We use an assay that detects minus-strand RNA as a surrogate for actively replicating SARS-CoV-2. We report positive strand-specific assays in relationship to time since admission and describe patients with a detectable strand-specific assay >20 days since admission.

Methods

We use a 2-step rRT-PCR specific to the minus strand of the SARS-CoV-2 envelope gene. The strand-specific assay is used to evaluate for infectivity in asymptomatic patients with a positive admission screening or pre-procedural test or if ongoing replication is suspected (critical illness or profound immunosuppression). We retrieved strand-specific test results for patients hospitalized at Stanford Healthcare during August 2020–March 2022. We describe clinical characteristics for patients with a detectable minus strand-specific test >20 days since admission.

Results

A total of 774 strand-specific tests were collected from 624 hospitalized patients. A total of 523 patients had only one test (84%) and 101 (16%) had ≥2 tests. The test positivity rate varied by time since admission: 19% in tests performed 0–5 days, 28% in 6–10 days, 22% in 11–20 days, and 41% in those >20 days since admission. Among 35 patients tested >20 days since admission, 13 (37%) had ≥1 detectable minus strand-specific test. Most were male (n=8, 62%) and mean age was 59. Of 13 patients with a detectable assay, seven (54%) had prolonged viral replication with persistent symptoms and detectable minus strand assays for >20 days from symptom onset. Of these seven patients, four had a transplant (3 lung, 1 liver), 1 ovarian cancer, 1 CAR-T cell therapy, and 1 ESRD without immunosuppression. The remaining eight patients with a detectable assay >20 days since admission had illness onset while hospitalized.

Conclusion

Among hospitalized patients with SARS-CoV-2 infection, we found a varying positivity rate according to the timing of testing, possibly reflecting different indications for the test. The strand-specific assay may help assess for infectiousness in profoundly immunocompromised patients.

Disclosures

Aruna Subramanian, MD, Gilead Sciences: Grant/Research Support|Regeneron, Inc: Grant/Research Support.

1527. Use of a SARS-CoV-2 Strand-specific Assay to detect Relapse or Ongoing Infection at a Tertiary Care Center, California 2020–2022

Background

Determining if a patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains infectious can be challenging in patients with severe disease or those profoundly immunosuppressed. We use an assay that detects minus-strand RNA as a surrogate for actively replicating SARS-CoV-2. Here, we describe a cohort of patients who had strand-assay reversion: a detectable minus strand-specific assay after having had an undetectable value which may signify relapse of infection or reinfection.

Methods

We used a 2-step rRT-PCR specific to the minus strand of the SARS-CoV-2 envelope gene. The strand-specific assay is used to evaluate for infectivity in asymptomatic patients with a positive screening admission or pre-procedural test or in cases when ongoing infection was suspected (critical illness or profound immunosuppression). We collected minus strand-specific assays performed at Stanford Healthcare during August 2020–April 2022. We describe basic demographics and clinical characteristics for patients who reverted from undetectable to detectable using the minus strand-specific assay.

Results

A total of 2,505 strand-specific tests were collected from August 2020–April 2022 from 2,064 patients. A total of 292 (14%) had two or more strand-specific tests. Of them, 19 (7%) had an undetected minus strand-specific assay followed by a subsequent detectable value. Of them, seven (37%) had a minus strand-specific CT value of < 33. Most were male (n=4), median age was 54 (range: 8–62). All were profoundly immunosuppressed: Four had hematologic malignancies and three were post transplantation (kidney, lung, bone marrow). Median time from onset of symptoms or first positive test to reversion was 41 days (range:27–159). Median time from undetectable to detectable minus strand specific test was 26 days (range:4–34). All cases were considered relapses or ongoing infection rather than a new infection.

Conclusion

Among patients with SARS-CoV-2 infection and consecutive strand-specific testing, a small proportion reverted from negative to positive. Most were profoundly immunosuppressed. The strand-specific assay can be an important tool in the evaluation of suspected cases of relapse or reinfection.

Disclosures

Aruna Subramanian, MD, Gilead Sciences: Grant/Research Support|Regeneron, Inc: Grant/Research Support.

1095. Retrospective Review of SARS-CoV-2 Infection in Immunocompromised Children at a Single Pediatric Institution

Background

Immunocompromised individuals are considered higher risk for severe COVID-19 disease. Much of this data was collected from adults with limited pediatric reporting, although a recent study showed no worse outcome in immunocompromised children. In this study, we characterize our experience of immunocompromised children who were hospitalized with acute SARS-CoV-2 infection and aimed to identify a sub-group of patients who had worse outcomes.

Methods

We reviewed charts of all immunocompromised children hospitalized with SARS-CoV-2 RT-PCR positive results at our hospital from March 2020-April 2022. Disease severity was characterized according to the NIH COVID-19 guidelines. Clinical characteristics and outcomes were assessed. Individuals were grouped into solid organ transplant recipients, solid tumors, liquid tumors, and stem cell transplant recipients. Proportions were calculated per group in addition to the exact binomial confidence intervals (95%).

Results

We identified 39 pediatric aged patients ranging from 7 months to 20 years of age with a median age of 10. 35.9% (14/39) of individuals were solid organ transplant recipients, 25.6% (10/39) had solid tumors, 33% (13/39) had liquid tumors, and 5% (2/39) were stem cell transplant recipients. 17.9% were asymptomatic, 66.7% had mild disease, and 15.4% had severe/critical COVID-19 disease. The median time of positive SARS CoV-2 RT-PCR was 32 days. Six children had prolonged SARS-CoV-2 RT-PCR positive testing between 29-97 days with a mean of 49 days. Viral strand specific RNA testing for replicating virus was also persistently positive. Six experienced severe/critical disease resulting in death of three. Most of the patients were treated with predominantly T cell depleting agents (∼74%). However, four patients who had prolonged active critical infection were treated with B cell depleting agents or had known B cell dysfunction.

Conclusion

The majority of the immunocompromised children in our cohort had mild COVID-19 disease. A subset of individuals experienced ongoing prolonged RT-PCR positivity and testing indicating persistent viral replication, with three demonstrating an inability to control the virus and resulting in death. Worse outcomes may be related to their immune dysfunction and use of B cell depleting agents.

Disclosures

All Authors: No reported disclosures.

P-251 Cumulus cell analysis as a non-invasive oocyte selection strategy to reduce the number of oocytes/embryos cultured and increase pregnancy rates

Study question

Can non-invasive gene expression analysis of cumulus cells (CC) improve efficiency in ART by prioritizing oocytes for further culture and fresh single embryo transfer?

Summary answer

CC analysis can be used for the selective processing of oocytes. This may reduce culture work and improve the outcome in ICSI elective SETs (eSET).

What is known already

In an interventional, blinded, prospective cohort study (Van Vaerenbergh et al. 2021), 113 patients underwent a fresh Day3 eSET with embryos ranked and transferred based on morphology and CC gene expression (Aurora Test), while 520 control patients underwent a Day3 eSET without the Aurora Test. This resulted in a significant higher clinical pregnancy of 61% in the patients with eSET based on CC ranking applied on good morphology embryos, compared to 29% in the controls with eSET based on embryo morphology only. Live birth rate was also significantly increased, while time-to-pregnancy was significantly reduced with 3 transfer cycles.

Study design, size, duration

In a retrospective analysis, in a subset of patients with at least 6 growing follicles and at least five 2PN oocytes (n = 80), it was investigated whether the Aurora Test, used to select transferrable Day3-embryos, could also be applied to select oocytes on Day0/1. The effect of processing only the three highest ranked oocytes (based on the Aurora Test) on embryo development and clinical pregnancy was studied compared to processing all oocytes.

Participants/materials, setting, methods

Patients included in this single centre study had their first or second GnRH-antagonist ICSI cycle, were younger than 40y, had normal BMI, were stimulated with HP-hMG and scheduled for Day3 eSET. Two-sided statistical analysis (p &lt; 0,05) was performed between a strategy of processing only the top 3 Aurora ranked oocytes, according to CC gene expression, and a strategy of processing all available oocytes.

Main results and the role of chance

On average, 8 MII oocytes were obtained per patient and the average fertilization rate was 83%. In total, 407 good quality embryos (GQE) on Day3 were generated from these 80 patients when utilising all 639 oocytes. Processing the three top-ranked oocytes only (240/639 oocytes) would have reduced the number of embryos to 169 GQE and would have resulted in 2.1 GQE on average on Day3 per patient; 75/80 (94%) patients would have had a fresh Day3 transfer resulting in a 63% clinical pregnancy rate. Processing all 639 available 2PN oocytes (standard of care) resulted in a fresh Day3 transfer in all 80 patients and a similar 64% clinical pregnancy rate (ns). However, 399 more oocytes would need to be processed. The strategy of restricting the number of oocytes to be processed would not have compromised cumulative cycle outcome. Considering all subsequent freeze/thawing cycles the cumulative clinical pregnancy rate calculated per all 80 patients would increase to 90%.

Limitations, reasons for caution

The limitation of this approach is that the Aurora Test requires individual oocyte denudation and individual oocyte vitrification. Secondly, this new strategy should be validated in a prospective study.

Wider implications of the findings

By applying this oocyte selection strategy patients would benefit from a high pregnancy rate in the fresh transfer cycle, while the lab would see reduction in embryo culture work, because freeze/thawing cycles and culture of embryos with lower competence would be prevented.

Trial registration number

NA

Advancing TB research using digitized programmatic data

The use of real-world data from national TB care programs has great potential to answer key research questions in TB control and is now opportune due to increasing digital data collection and storage. We summarize an expert stakeholder workshop conducted on this topic in October 2019, with perspectives from academics, national TB program officers, and data managers. We discuss challenges and opportunities in the use of TB programmatic data for research and describe digital data availability in two large, high TB burden countries, Brazil and South Africa. From this, we posit that with a standardized data collection set, improved data management, and greater collaboration, more TB programmatic data can be used for research with measurable public health impact.

Live virus vaccination of pediatric solid organ transplant candidates within 1 month prior to transplantation: A multicenter experience

BACKGROUND

Solid organ transplant (SOT) recipients are at increased risk of vaccine-preventable illness due to the high degree of immunosuppression required following transplantation. The current recommendation is to vaccinate with live attenuated vaccines, including Measles, Mumps, and Rubella (MMR) and Varicella (VAR) vaccines, at least 4 weeks prior to transplant. However, data to support the time interval between vaccine and transplant are limited.

METHODS

We conduct a literature review of the natural history of the viruses and length of viremia following live-attenuated viral vaccines, and we describe a series of 5 cases from 2 pediatric transplant centers in which live attenuated viral vaccines were administered within 21 days prior to SOT.

RESULTS

None of the 5 children who received MMR or VAR 8-21 days prior to liver (2) and heart (3) transplant suffered from vaccine-related viral illness after transplant, even in the presence of significant immunosuppression with T-cell-depleting agents.

CONCLUSION

These cases support that shorter intervals of live vaccine administration prior to transplant may be safe, allowing the vaccination of a larger cohort of SOT candidates. Increasing pretransplant vaccinations is crucial since, in most cases, live viral vaccines are contraindicated posttransplantation, and the most effective vaccine approaches utilize prime-boost strategies, priming before and boosting after transplant.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

Assessment of aeration control strategies for biofilm-based partial nitritation/anammox systems

The objective of this work was to compare the nitrogen removal in mainstream, biofilm-based partial nitritation anammox (PN/A) systems employing (1) constant setpoint dissolved oxygen (DO) control, (2) intermittent aeration, and (3) ammonia-based aeration control (ABAC). A detailed water resource recovery facility (WRRF) model was used to study the dynamic performance of these aeration control strategies with respect to treatment performance and energy consumption. The results show that constant setpoint DO control cannot meet typical regulatory limits for total ammonia nitrogen (NH_x-N). Intermittent aeration shows improvement but requires optimisation of the aeration cycle. ABAC shows the best treatment performance with the advantages of continuous operation and over 20% lower average energy consumption as compared to intermittent aeration.

Skin cancer prevention: a review of current topical options complementary to sunscreens

The incidence of non-melanoma skin cancer (NMSC) is dramatically increasing worldwide, despite the increased use of improved sunscreens. In 2014, the Surgeon General estimated that 2.2-5.0 million people were treated annually for NMSC. As the number of newly diagnosed skin cancers continues to rise, there is a need for additional preventative measures beyond sunscreens. Several newer topical products that focus on boosting DNA repair, modulating DNA transcription, decreasing inflammation and selectively targeting precancerous cells may play an important role in future skin cancer prevention.

Comparing the Resistance, Resilience, and Stability of Replicate Moving Bed Biofilm and Suspended Growth Combined Nitritation-Anammox Reactors

Combined partial nitritation-anammox (PN/A) systems are increasingly being employed for sustainable removal of nitrogen from wastewater, but process instabilities present ongoing challenges for practitioners. The goal of this study was to elucidate differences in process stability between PN/A process variations employing two distinct aggregate types: biofilm [in moving bed biofilm reactors (MBBRs)] and suspended growth biomass. Triplicate reactors for each process variation were studied under baseline conditions and in response to a series of transient perturbations. MBBRs displayed elevated NH₄⁺ removal rates relative to those of suspended growth counterparts over six months of unperturbed baseline operation but also exhibited significantly greater variability in performance. Transient perturbations led to strikingly divergent yet reproducible behavior in biofilm versus suspended growth systems. A temperature perturbation prompted a sharp reduction in NH₄⁺ removal rates with no accumulation of NO₂^- and rapid recovery in MBBRs, compared to a similar reduction in NH₄⁺ removal rates but a high level of accumulation of NO₂^- in suspended growth reactors. Pulse additions of a nitrification inhibitor (allylthiourea) prompted only moderate declines in performance in suspended growth reactors compared to sharp decreases in NH₄⁺ removal rates in MBBRs. Quantitative fluorescence in situ hybridization demonstrated a significant enrichment of anammox in MBBRs compared to suspended growth reactors, and conversely a proportionally higher AOB abundance in suspended growth reactors. Overall, MBBRs displayed significantly increased susceptibility to transient perturbations employed in this study compared to that of suspended growth counterparts (stability parameter), including significantly longer recovery times (resilience). No significant difference in the maximal impact of perturbations (resistance) was apparent. Taken together, our results suggest that aggregate architecture (biofilm vs suspended growth) in PN/A processes exerts an unexpectedly strong influence on process stability.

Abstract P3-03-05: Establishment and evaluation of ER+ breast cancer models using an optimized methodology for exogenous hormone delivery

Preclinical in vivo models of estrogen receptor positive (ER+) breast cancer rely on exogenous supplementation of hormones for growth. This requirement leads to animal toxicity and mortality over time, limiting development and drug testing in these types of models. Efficacy of test agents, particularly endocrine therapies, may also be altered in these models due to excessive hormone exposure, highlighting the need to improve methods for the establishment and testing of ER+ breast models.

We have developed an alternative method of hormone supplementation in ER+ breast cancer models and optimized this method for testing of endocrine therapies. Using two cell-based breast models, we demonstrated improved breast tumor take and time to tumor volume endpoint while reducing animal toxicity and mortality associated with standard hormone supplementation. Subsequent studies identified the lowest effective dose (LED) of supplement for hormone dependent model growth with a preclinically relevant time to tumor volume endpoint. Activity of endocrine therapies including tamoxifen, letrozole, fulvestrant and exemestane were compared at the standard and LED hormone concentrations. In these studies tamoxifen treatment resulted in tumor regressions which was not appreciably improved using the LED dose of supplement. However letrozole activity was improved in the LED study suggesting hormone supplementation can impact activity of some agents. Using this process we also generated a panel of ER+ patient-derived xenograft (PDX) models, including two novel hormone therapy responsive models from chemo-naïve or hormone therapy pretreated patients, designated ST986 and ST2177, respectively.

This improved method of hormone supplementation diminishes the adverse effects of standard hormone supplementation and provides utility for development of anticancer therapies in ER+ breast models.

Citation Format: Wick MJ, Vaught T, Meade J, Gamez L, Farley M, Tolcher AW, Rasco D, Patnaik A, Drengler RL, Rosenthal A, Papadopoulos KP. Establishment and evaluation of ER+ breast cancer models using an optimized methodology for exogenous hormone delivery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-03-05.

Carfilzomib and the cardiorenal system in myeloma: an endothelial effect?

Carfilzomib (Cfz) has been associated with an ~5% incidence of unexplained and unpredictable cardiovascular toxicity in clinical trials. We therefore implemented a detailed, prospective, clinical cardiac and renal evaluation of 62 Cfz-treated myeloma patients, including serial blood pressure (BP), creatinine, troponin, NT-proBNP and pre- and post-treatment echocardiograms, including ejection fraction (EF), average global longitudinal strain and compliance. Pre-treatment elevations in NT-proBNP and BP, as well as abnormal cardiac strain were common. A rise in NT-proBNP occurred frequently post-treatment often without corresponding cardiopulmonary symptoms. A rise in creatinine was common, lessened with hydration and often reversible. All patients had a normal EF pre-treatment. Five patients experienced a significant cardiac event (four decline in EF and one myocardial infarction), of which 2 (3.2%) were considered probably attributable to Cfz. None were rechallenged with Cfz. The ideal strategy for identifying patients at risk for cardiac events, and parameters by which to monitor for early toxicity have not been established; however, it appears baseline echocardiographic testing is not consistently predictive of toxicity. The toxicities observed suggest an endothelial mechanism and further clinical trials are needed to determine whether or not this represents a class effect or is Cfz specific.

Sentinel lymph node status in vulval cancer: systematic reviews of test accuracy and decision-analytic model-based economic evaluation

BACKGROUND

Vulval cancer causes 3-5% of all gynaecological malignancies and requires surgical removal and inguinofemoral lymphadenectomy (IFL). Complications affect > 50% of patients, including groin wound infection, lymphoedema and cellulitis. A sentinel lymph node (SLN) is the first groin node with the highest probability of malignancy. SLN biopsy would be useful if it could accurately identify patients in whom cancer has spread to the groin, without removing all groin nodes. SLNs can be identified by isosulfan blue dye and/or technetium-99 ((99m)Tc) radioactive tracer during lymphoscintigraphy. The blue dye/(99m)Tc procedure only detects SLN, not metastases - this requires histological examination, which can include ultrastaging and staining with conventional haematoxylin and eosin (H&E) or immunohistochemistry.

OBJECTIVES

To determine the test accuracy and cost-effectiveness of the SLN biopsy with (99m)Tc and/or blue dye compared with IFL or clinical follow-up for test negatives in vulval cancer, through systematic reviews and economic evaluation.

DATA SOURCES

Standard medical databases, including MEDLINE, EMBASE, Science Citation Index and The Cochrane Library, medical search gateways, reference lists of review articles and included studies were searched to January 2011.

METHODS

For accuracy and effectiveness, standard methods were used and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were to January 2011, with no language restrictions. Meta-analyses were carried out with Meta-Disc version 1.4 (Javier Zamora, Madrid, Spain) for accuracy; none was appropriate for effectiveness. The economic evaluation from a NHS perspective used a decision-tree model in DATA TreeAge Pro Healthcare 2001 (TreeAge Software, Inc., Williamstown, MA, USA). Six options (blue dye with H&E, blue dye with ultrastaging, (99m)Tc with H&E, (99m)Tc with ultrastaging, blue dye/(99m)Tc with H&E, blue dye/(99m)Tc with ultrastaging) were compared with IFL. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

For accuracy, of the 26 included studies, most evaluated (99m)Tc/blue dye combined. Four studies had clinical follow-up only for test negatives and five had clinical follow-up for all and IFL for test negatives. Numbers with no SLN found were difficult to distinguish from those with negative SLN biopsies. The largest group of 11 studies using (99m)Tc/blue dye, ultrastaging and immunohistochemistry had a pooled sensitivity of 95.6% [95% confidence interval (CI) 91.5% to 98.1%] and a specificity of 100% (95% CI 99.0% to 100%). Mean SLN detection rates were 94.6% for (99m)Tc, 68.7% for blue dye and 97.7% for both. One study measured global health status quality of life (QoL) and found no difference between SLN biopsy and IFL. One patient preference evaluation showed that 66% preferred IFL rather than a 5% false-negative rate from SLN biopsy. For effectiveness, of 14,038 references, one randomised controlled trial, three case-control studies and 13 case series were found. Approximately 50% died from vulval cancer and 50% from other causes during follow-ups. Recurrences were in the ratio of approximately 4 : 2 : 1 vulval, groin and distant, with more recurrences in node-positive patients. No studies reported QoL. For cost per death averted, IFL was less costly and more effective than strategies using SLN biopsy. For morbidity-free survival and long-term morbidity-free survival, (99m)Tc with ultrastaging was most cost-effective. Strategies with blue dye only and H&E only were never cost-effective. The incremental cost-effectiveness ratio for (99m)Tc with ultrastaging compared with IFL was £4300 per case of morbidity-free survival and £7100 per long-term morbidity-free survival.

LIMITATIONS

The main limitations of this study include the lack of good-quality evidence on accuracy, effectiveness and QoL. A large project such as this takes time to publish, so the most recent studies are not included.

CONCLUSIONS

A sensitive and specific combined metastatic SLN detection test and information on generic QoL in vulval cancer is urgently required.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effect of citral and carvacrol on the susceptibility of Listeria monocytogenes and Listeria innocua to antibiotics

The aim of this study was to evaluate the antibiotic susceptibility of Listeria innocua (L. innocua) and Listeria monocytogenes (L. monocytogenes) cells in the presence of citral and carvacrol at sublethal concentrations in an agar medium. The presence of terpenes in the L. monocytogenes and L. innocua culture medium provided a reduction in the minimal inhibitory concentration (MIC) of all the antibiotics tested. These effects were dependent on the concentration of terpenes present in the culture medium. The combination of citral and carvacrol potentiated antibiotic activity by reducing the MIC values of bacitracin and colistin from 32.0 and 128.0 μg ml⁻¹ to 1.0 and 2.0 μg ml⁻¹, respectively. Thus, both Listeria species became more susceptible to these drugs. In this way, the colistin and bacitracin resistance of L. monocytogenes and L. innocua was reversed in the presence of terpenes. Results obtained in this study show that the phytochemicals citral and carvacrol potentiate antibiotic activity, reducing the MIC values of cultured L. monocytogenes and L. innocua.

SIGNIFICANCE AND IMPACT OF THE STUDY

Phytochemicals citral and carvacrol potentiate antibiotic activity of erythromycin, bacitracin and colistin by reducing the MIC values of cultured Listeria monocytogenes and Listeria innocua. This effect in reducing the MIC values of the antibiotics tested in both micro-organisms was increased when natural antimicrobials were combined. This finding indicated that the combination among terpenes and antibiotic may contribute in reducing the required dosage of antibiotics due to the possible effect of terpenes on permeation barrier of the micro-organism cell membrane.

Modulation of neurotrophin signaling by monoclonal antibodies

The neurotrophin family is comprised of the structurally related secreted proteins nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and neurotrophine-4 (NT-4). They bind and activate the tyrosine kinase receptors Trk A, B, and C in a ligand-specific manner and additionally bind a shared p75NTR receptor. The neurotrophins were originally defined by their ability to support the survival and maturation of embryonic neurons. However, they also control important physiological functions of the adult nervous system including learning and memory, sensation, and energy homeostasis. For example, NGF/trkA signaling is critical for normal and pathological sensation of pain. Likewise, the BDNF/trkB pathway controls feeding and metabolism, and its dysfunction leads to severe obesity. Antibodies can modulate neurotrophin signaling. Thus, NGF blocking agents can attenuate pain in several animal models, and a recombinant humanized NGF blocking antibody (Tanezumab) has shown promising results in human clinical trials for osteoarthritic pain. On the other hand trkB agonist antibodies can modulate food intake and body weight in rodents and nonhuman primates. The power of monoclonal antibodies to modulate neurotrophin signaling promises to turn the rich biological insights into novel human medicines.

Prediction of acid lactic-bacteria growth in turkey ham processed by high hydrostatic pressure

High hydrostatic pressure (HHP) has been investigated and industrially applied to extend shelf life of meat-based products. Traditional ham packaged under microaerophilic conditions may sometimes present high lactic acid bacteria population during refrigerated storage, which limits shelf life due to development of unpleasant odor and greenish and sticky appearance. This study aimed at evaluating the shelf life of turkey ham pressurized at 400 MPa for 15 min and stored at 4, 8 and 12 °C, in comparison to the non pressurized product. The lactic acid bacteria population up to 10(7) CFU/g of product was set as the criteria to determine the limiting shelf life According to such parameter the pressurized sample achieved a commercial viability within 75 days when stored at 4 °C while the control lasted only 45 days. Predictive microbiology using Gompertz and Baranyi and Roberts models fitted well both for the pressurized and control samples. The results indicated that the high hydrostatic pressure treatment greatly increased the turkey ham commercial viability in comparison to the usual length, by slowing down the growth of microorganisms in the product.

Experimental evaluation of the nitrite sensitivity coefficient in granular anammox biomass

Nitrite is widely reported to inhibit anammox activity and growth. One modeling approach for nitrite impairment of anammox growth is the use of a nitrite sensitivity coefficient which increases the endogenous decay coefficient of anammox bacteria proportionally to nitrite concentration. The objective of this study was to measure nitrite concentration profiles within active anammox granules incubated at fixed bulk nitrite concentrations and to compare these with nitrite concentration profiles predicted by a biofilm model that incorporates the nitrite sensitivity coefficient. We developed an apparatus for the repeated measurement of nitrite concentration profiles along the radius of granular anammox biomass over a period of 6 days at fixed bulk nitrite concentrations. Granular anammox biomass was obtained from a two-stage bench-scale partial nitritation/anammox reactor system. There was no apparent effect of nitrite concentration on nitrite utilization kinetics after 6 days at exposures up to 90 mg NO(2)(-)-N/L. These findings suggest that anammox bacteria tolerate extended exposures to elevated nitrite concentrations, and in its present form, the nitrite sensitivity coefficient is not applicable for anammox growth modeling.

Limb activation ameliorates body-related deficits in spatial neglect

Many neglect patients show deficits in the mental representation of their contralesional body side or body parts, termed personal neglect. These deficits include impairments in identifying body parts on schematic drawings of human bodies. Limb activation and alertness cues have been shown to modulate neglect transiently, and are effective treatments for several symptoms of the neglect syndrome. Here, we tested on eight patients with right-hemispheric stroke and left-sided spatial neglect whether these two techniques modulate deficits in the mental representation of hands, assessed with a hand-test in which the subjects had to decide whether a depicted schematic hand belongs to the left or right side of the human body. The results showed that neglect patients made marginally significant (p = 0.065) more errors in left-hand-decisions than right-hand-decisions, indicating a neglect-specific disorder. Moreover, we found that left-sided limb activation but not non-lateralized alertness cueing (a loud noise immediately before patients made their perceptual decision) significantly reduced misidentifications for depicted left hands as compared to baseline. No effect of any intervention was observed on error rates for depicted right hands. We conclude that the amelioration of the performance in the hand task is modulated by the activation of the body schema or other body representations through left-sided limb activation.

Renal insufficiency retains adverse prognostic implications despite renal function improvement following Total Therapy for newly diagnosed multiple myeloma

Renal insufficiency (RI) is a frequent complication of multiple myeloma (MM) with negative consequences for patient survival. The improved clinical outcome with successive Total Therapy (TT) protocols was limited to patients without RI. We therefore performed a retrospective analysis of overall survival, progression-free survival and time to progression (TTP) of patients enrolled in TT2 and TT3 in relationship to RI present at baseline and pre-transplant. Glomerular filtration rate was graded in four renal classes (RCs), RC1–RC4 (RC1 ⩾90 ml/min/1.73 m², RC2 60–89 ml/min/1.73 m², RC3 30–59 ml/min/1.73 m² and RC4 <30 ml/min/1.73 m²). RC1–3 had comparable clinical outcomes while RC4 was deleterious, even after improvement to better RC after transplant. Among the 85% of patients with gene expression profiling defined low-risk MM, Cox regression modeling of baseline and pre-transplant features, which also took into consideration RC improvement and MM complete response (CR), identified the presence of metaphase cytogenetic abnormalities and baseline RC4 as independent variables linked to inferior TTP post-transplant, while MM CR reduced the risk of progression and TTP by more than 60%. Failure to improve clinical outcomes despite RI improvement suggested MM-related causes. Although distinguishing RC4 from RC<4, 46 gene probes bore no apparent relationship to MM biology or survival.

Superior vena cava syndrome secondary to thyroid cancer

It is uncommon for thyroid cancer to present with superior vena cava syndrome. Obstruction of superior vena cava can develop as a result of intrinsic and extrinsic spread of the thyroid cancer. The usual presentation of this disease entity is a neck mass with symptoms and signs suggestive of superior vena cava obstruction. Superior vena cava obstruction is commonly caused by lung cancer and lymphoma. However, thyroid cancer can cause superior vena cava obstruction by downward tumour spread into the mediastinum causing extrinsic compression, which will lead to narrowing and thrombosis of the major venous system in the chest. Paraganglioma can also present with superior vena cava obstruction and it mimics thyroid cancer microscopically. Proper staining should be performed to differentiate between the two diseases. This could be the first case of this kind reported in the literature.