Validated machine learning tools to distinguish immune checkpoint inhibitor, radiotherapy, COVID-19 and other infective pneumonitis

BACKGROUND

Pneumonitis is a well-described, potentially disabling, or fatal adverse effect associated with both immune checkpoint inhibitors (ICI) and thoracic radiotherapy. Accurate differentiation between checkpoint inhibitor pneumonitis (CIP) radiation pneumonitis (RP), and infective pneumonitis (IP) is crucial for swift, appropriate, and tailored management to achieve optimal patient outcomes. However, correct diagnosis is often challenging, owing to overlapping clinical presentations and radiological patterns.

METHODS

In this multi-centre study of 455 patients, we used machine learning with radiomic features extracted from chest CT imaging to develop and validate five models to distinguish CIP and RP from COVID-19, non-COVID-19 infective pneumonitis, and each other. Model performance was compared to that of two radiologists.

RESULTS

Models to distinguish RP from COVID-19, CIP from COVID-19 and CIP from non-COVID-19 IP out-performed radiologists (test set AUCs of 0.92 vs 0.8 and 0.8; 0.68 vs 0.43 and 0.4; 0.71 vs 0.55 and 0.63 respectively). Models to distinguish RP from non-COVID-19 IP and CIP from RP were not superior to radiologists but demonstrated modest performance, with test set AUCs of 0.81 and 0.8 respectively. The CIP vs RP model performed less well on patients with prior exposure to both ICI and radiotherapy (AUC 0.54), though the radiologists also had difficulty distinguishing this test cohort (AUC values 0.6 and 0.6).

CONCLUSION

Our results demonstrate the potential utility of such tools as a second or concurrent reader to support oncologists, radiologists, and chest physicians in cases of diagnostic uncertainty. Further research is required for patients with exposure to both ICI and thoracic radiotherapy.

A Novel Radiogenomics Biomarker for Predicting Treatment Response and Pneumotoxicity From Programmed Cell Death Protein or Ligand-1 Inhibition Immunotherapy in NSCLC

INTRODUCTION

Patient selection for checkpoint inhibitor immunotherapy is currently guided by programmed death-ligand 1 (PD-L1) expression obtained from immunohistochemical staining of tumor tissue samples. This approach is susceptible to limitations resulting from the dynamic and heterogeneous nature of cancer cells and the invasiveness of the tissue sampling procedure. To address these challenges, we developed a novel computed tomography (CT) radiomic-based signature for predicting disease response in patients with NSCLC undergoing programmed cell death protein 1 (PD-1) or PD-L1 checkpoint inhibitor immunotherapy.

METHODS

This retrospective study comprises a total of 194 patients with suitable CT scans out of 340. Using the radiomic features computed from segmented tumors on a discovery set of 85 contrast-enhanced chest CTs of patients diagnosed with having NSCLC and their CD274 count, RNA expression of the protein-encoding gene for PD-L1, as the response vector, we developed a composite radiomic signature, lung cancer immunotherapy-radiomics prediction vector (LCI-RPV). This was validated in two independent testing cohorts of 66 and 43 patients with NSCLC treated with PD-1 or PD-L1 inhibition immunotherapy, respectively.

RESULTS

LCI-RPV predicted PD-L1 positivity in both NSCLC testing cohorts (area under the curve [AUC] = 0.70, 95% confidence interval [CI]: 0.57-0.84 and AUC = 0.70, 95% CI: 0.46-0.94). In one cohort, it also demonstrated good prediction of cases with high PD-L1 expression exceeding key treatment thresholds (>50%: AUC = 0.72, 95% CI: 0.59-0.85 and >90%: AUC = 0.66, 95% CI: 0.45-0.88), the tumor's objective response to treatment at 3 months (AUC = 0.68, 95% CI: 0.52-0.85), and pneumonitis occurrence (AUC = 0.64, 95% CI: 0.48-0.80). LCI-RPV achieved statistically significant stratification of the patients into a high- and low-risk survival group (hazard ratio = 2.26, 95% CI: 1.21-4.24, p = 0.011 and hazard ratio = 2.45, 95% CI: 1.07-5.65, p = 0.035).

CONCLUSIONS

A CT radiomics-based signature developed from response vector CD274 can aid in evaluating patients' suitability for PD-1 or PD-L1 checkpoint inhibitor immunotherapy in NSCLC.

190 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): FACTORS ASSOCIATED WITH THE BURDEN EXPERIENCED BY CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

To date, little research has been carried out exploring the burden experienced by informal caregivers of People with Dementia (PwD). We explored factors that influence the burden experienced by caregivers of PwD over 12 months.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed model analyses were used to investigate associations of caregiver burden (measured by the Zarit-Burden Interview; ZBI) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety, depression, and caregiver distress); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, transportation needs, education level, occupation and living situation of the PwD, and employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, and indices of dependence of PwD.

Results

Across all domains, caregiver burden significantly increased over time (p<0.001) and less burden was experienced by caregivers of older PwD (p<0.05). In PWB, higher caregiver depression levels predicted higher levels of caregiver burden (p=0.033). In the SCR domain, caregivers of PwD who were independent in their transport needs experienced lower levels of burden (p=0.002). No other factors within the PFH or MED domains reached significance in predicting caregiver burden.

Conclusion

This longitudinal analysis elucidates potential predictors of caregiver burden and highlights the need for future research to be carried out in this area. In particular, psychological well-being in caregivers was shown to significantly impact on the experience of burden. Interventions to alleviate caregiver burden should be tailored to include support for psychological well-being.

192 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): 12-MONTH TRAJECTORY OF QUALITY OF LIFE IN PEOPLE WITH DEMENTIA

Background

Research is needed to examine how Quality of Life (QoL) changes as dementia progresses. We explored QoL trajectories over a 12-month period and examined factors that influence QoL in People with Dementia (PwD).

Methods

Fifty-two PwD and their informal caregivers participated in the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed-model analyses were used to investigate associations of self-rated QoL and caregiver-rated QoL (measured by the DEMQoL and DEMQoL Proxy, respectively) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety and depression); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, education level, occupation and living situation of the PwD, employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, indices of dependence of PwD).

Results

Across all domains, caregivers’ ratings of QoL for PwD decreased over time (p=0.012). In PWB, greater levels of depression (p=0.007) and anxiety in the PwD (p<0.001) predicted lower self-rated QoL, and higher caregiver anxiety levels predicted lower caregiver-rated QoL (p=0.012). In PFH, having a caregiver administer medication (p=0.03) was associated with higher self-rated QoL. Interestingly, caregiver-rated QoL was higher for PwD who took longer to return to sitting during the QTUG (p=0.043). In MED, being independently mobile (p=0.012) predicted higher self-rated QoL. No other factors within the SCR domain reached significance in predicting QoL.

Conclusion

This longitudinal analysis elucidates potential predictors of QoL in PwD. Psychological well-being in PwD and their caregivers was shown to significantly impact on QoL, and so, these factors should be routinely included in future research studies and clinical assessments.

194 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): SMART HEALTH TECHNOLOGY ACCEPTABILITY BY INFORMAL CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

The prevalence of dementia is increasing worldwide, and innovative strategies are required to meet increasing demands on health services. The Connected HEalth Sustaining home Stay in Dementia (CHESS) Study aimed to provide support to People with Dementia (PwD) and their caregivers in their homes. We aimed to quantitatively assess the acceptance of smart connected health technology by caregivers of PwD through use of standardised questionnaires.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the intervention arm of the CHESS Study. An additional 25 dyads acted as control participants. Questionnaire data were collected following completion of the CHESS study from 27 informal caregivers from the CHESS Technology group and 16 informal caregivers from the Control group. Measures of health technology acceptability included the System Usability Scale (SUS), the eHealth Literacy Scale (eHEALS), the Technology Readiness Index 2.0 (TRI), and the Unified Theory of Acceptance and Use of Technology Scale (UTAUT). Univariate analyses of variance were used to explore differences between groups.

Results

Internal consistency (Cronbach’s alpha) was high for all measures (range 0.68 – 0.96). The SUS score for the technology group was high (M=70.07, SD=17.69), indicating that the CHESS technology had a high level of usability. All participants had a high level of eHealth literacy (M=33.61, SD=10.51). Both groups performed similarly on the TRI and UTAUT, however the control group indicated greater discomfort with health technology and felt less secure in providing their personal information electronically to healthcare professionals than the technology group.

Conclusion

Caregivers across the technology and control groups had high levels of eHealth literacy and found health technology to be generally acceptable. The CHESS technology in particular was rated as highly usable on the SUS by those who used it. These findings offer support for a Connected Health model of care.

24 REVERSING FRAILTY AND ENHANCING RESILIENCE WITH EXERCISE AND DIETARY EDUCATION (REFEREE): A PRIMARY CARE RANDOMISED CONTROLLED TRIAL

Background

There is a need for effective primary-care interventions that help older people combat frailty and build resilience. This study aims to test the effectiveness of a co-designed exercise and dietary protein intervention.

Methods

This was a multicentre, randomised-controlled, parallel-arm trial in six Irish primary-care practices. We enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to April 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment with a GP. Intervention comprised exercises, emphasising strength, and dietary protein guidance. At three-month follow-up, effectiveness was measured by comparing SHARE-Frailty Instrument between groups, on intention-to-treat basis. Secondary outcomes included muscle mass, bone mass and biological age measured by Bioelectrical Impedance Analysis (BIA). Ease of intervention and health difference were measured on Likert scales.

Results

359 adults were assessed for eligibility and 168 enrolled. 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, frailty proportions were 17.7% in the intervention and 16.9% in the control group. At follow-up, they were 6.3% and 18.2%, respectively. The odds ratio (OR) of being frail for the intervention group was 0.23 times that of the control group (95% confidence interval: 0.07-0.72; P=0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%; P=0.018). Number needed to treat was 8.4. BIA parameters improved, bone mass significantly (P=0.040). 66.2% found the intervention easy, 69.0% reported feeling better.

Conclusion

A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health. Frailty was reversed in more than 1 in 9 participants.

193 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): HEALTH-RELATED QUALITY OF LIFE IN CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

Caregivers of People with Dementia (PwD) can experience high levels of distress, which can negatively affect their physical and psychological well-being. We explored factors that influence Health-Related Quality of Life (HRQoL) of caregivers of PwD over 12 months.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed model analyses were used to investigate associations of caregiver HRQoL (measured by the EuroQol Visual Analogue Scale; EQVAS) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety, depression, and caregiver distress); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, transportation needs, education level, occupation and living situation of the PwD, and employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, and indices of dependence of PwD.

Results

In the PWB domain, greater levels of caregiver depression (p<0.001) and a greater change over time in caregiver distress related to PwD behavioural disturbances (p=0.008) predicted lower caregiver HRQoL. In the PFH domain, HRQoL was lower for caregivers of PwD who were frail (p=0.04) and had severe comorbidities (p=0.037). None of the factors within the SCR or MED domains reached significance.

Conclusion

This longitudinal analysis elucidates potential predictors of HRQoL in caregivers of PwD. In particular, caregiver depression and distress related to behavioural disturbances in PwD were shown to significantly impact on HRQoL ratings. Caregiver interventions should be tailored to include support for psychological well-being.

A comparison of machine learning methods for predicting recurrence and death after curative-intent radiotherapy for non-small cell lung cancer: Development and validation of multivariable clinical prediction models

BACKGROUND

Surveillance is universally recommended for non-small cell lung cancer (NSCLC) patients treated with curative-intent radiotherapy. High-quality evidence to inform optimal surveillance strategies is lacking. Machine learning demonstrates promise in accurate outcome prediction for a variety of health conditions. The purpose of this study was to utilise readily available patient, tumour, and treatment data to develop, validate and externally test machine learning models for predicting recurrence, recurrence-free survival (RFS) and overall survival (OS) at 2 years from treatment.

METHODS

A retrospective, multicentre study of patients receiving curative-intent radiotherapy for NSCLC was undertaken. A total of 657 patients from 5 hospitals were eligible for inclusion. Data pre-processing derived 34 features for predictive modelling. Combinations of 8 feature reduction methods and 10 machine learning classification algorithms were compared, producing risk-stratification models for predicting recurrence, RFS and OS. Models were compared with 10-fold cross validation and an external test set and benchmarked against TNM-stage and performance status. Youden Index was derived from validation set ROC curves to distinguish high and low risk groups and Kaplan-Meier analyses performed.

FINDINGS

Median follow-up time was 852 days. Parameters were well matched across training-validation and external test sets: Mean age was 73 and 71 respectively, and recurrence, RFS and OS rates at 2 years were 43% vs 34%, 54% vs 47% and 54% vs 47% respectively. The respective validation and test set AUCs were as follows: 1) RFS: 0·682 (0·575-0·788) and 0·681 (0·597-0·766), 2) Recurrence: 0·687 (0·582-0·793) and 0·722 (0·635-0·81), and 3) OS: 0·759 (0·663-0·855) and 0·717 (0·634-0·8). Our models were superior to TNM stage and performance status in predicting recurrence and OS.

INTERPRETATION

This robust and ready to use machine learning method, validated and externally tested, sets the stage for future clinical trials entailing quantitative personalised risk-stratification and surveillance following curative-intent radiotherapy for NSCLC.

FUNDING

A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.

117 Management of Spinal Accessory Nerve Palsy

Aim

To discuss our strategies employed in our peripheral nerve injury unit for spinal accessory nerve (SAN) injury and a potential algorithm for future use.

Method

A retrospective analysis was undertaken on 9 patients with SAN injury undergoing surgical intervention. Neurophysiological results were obtained. MRC grades were compared at presentation and post-operatively. DASH (Disability of the arm, shoulder, and hand) scores were also collected post-operatively.

Results

7 patients presented to us following an iatrogenic injury to the SAN.

6 patients underwent neurolysis only, 3 underwent nerve transfer, 2 underwent nerve grafting (1 autologous, 1 processed nerve allograft).

The mean time frame from presentation to operation was 13 months. MRC grading of shoulder function increased from a mean MRC 2 to 4 at a mean of 8 months post-operatively. DASH scores of the 7 participating patients were 30.8 at a mean of 47 months post-operatively. 2 patients had experienced a sensory deficit.

Conclusions

Nerve grafting allows bridging of a gap when the injury is well defined with a suitable window for re-innervation. Allograft has a role in small gaps where there may be concerns with autograft. Nerve transfer may allow earlier re-innervation and be a more reliable option where the proximal extent of nerve injury is poorly defined. We found nerve wraps to be a useful addition when an injured nerve may be adherent to a heavily scarred bed. We will present some worked examples along with a potential algorithm for a surgical strategy.

SGLT-2 inhibitors in patients with and without a history of heart failure: a meta-analysis

Background

Sodium-glucose co-transporter 2 (SGLT-2) inhibitors emerged as a new groundbreaking therapy for patients with heart failure. Recent evidence showed significant benefits in patients with heart failure with reduced ejection fraction (HFrEF), regardless of diabetic status. Whether these medications also improve outcomes in patients without a history of heart failure or with heart failure with preserved ejection fraction (HFpEF) remains unknown.

Purpose

We sought to perform an updated meta-analysis of randomized controlled trials to evaluate the effects of SGLT-2 inhibitors on cardiovascular (CV) outcomes according to the history and type of heart failure.

Methods

All randomized, placebo-controlled trials of SGLT-2 inhibitors reporting similar CV outcomes were evaluated for inclusion. PubMed was searched from January 1, 2010 to February 1, 2021. Articles were independently reviewed and selected by two reviewers. The primary outcome was the composite of first hospitalization for heart failure and CV death. Secondary outcomes included its single components and all-cause mortality. Pooled hazard ratios (HR) and 95% confidence intervals (CI) were used as effect estimates and calculated with a random-effects model. Heterogeneity was assessed with the I2 index, and random-effects meta-regression was used to assess the interaction between treatment effect and history of heart failure and type of heart failure (HFrEF vs. HFpEF).

Results

Data from eight trials and a total of 56,665 patients (n=31,609 in SGLT-2 group, n=25,056 in placebo group) were included. Five studies enrolled high-risk patients with diabetes mellitus, while 3 studies enrolled patients with symptomatic heart failure. SGLT-2 inhibitors reduced the risk of first hospitalization for heart failure and CV death in patients with (HR 0.75 95% CI 0.70–0.81) and without (HR 0.78 95% CI 0.67–0.90; Figure 1) a history of heart failure. Similarly, patients with (HR 0.85 95% CI 0.78–0.93) or without (HR 0.85 95% CI 0.74–0.98) a history of heart failure treated with SGLT-2 inhibitors had a significant reduction in all-cause mortality. SGLT-2 inhibitors reduced the risk of CV death regardless of the history of heart failure, although the reduction was border-line statistically significant in patients without a history of heart failure (HR 0.81 95% CI 0.66–1.00; Figure 2). All subgroup interaction testing between patients with and without a history of heart failure was negative for all the above endpoints. Among patients with HFpEF, SGLT-2 inhibitors were associated with a nonsignificant trend towards reduced risk of the primary outcome (HR 0.80 95% CI 0.63–1.02).

Conclusions

SGLT-2 inhibitors significantly improve CV outcomes in patients with or without history of heart failure, and this effect seems to be consistent among those with HFrEF and HFpEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. CV death or HF hospitalizationFigure 2. Meta-analysis CV death

173 Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-Centre Study

Introduction

This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and to identify notable findings related to treatment variations.

Method

This is a retrospective bi-centre study collecting patient details from a District General Hospital and a Regional Hand Unit. We assessed 61 consecutive patients with distal radius fractures (AO grade A = 19, B = 9, C = 33) fixed using Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union.

Results

All but two fractures united within six weeks. Mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8kg which was comparable to the contralateral side at 31.5kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic.

Conclusions

Variable-angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures.

O64: GENOMIC PROFILING USING CIRCULATING NUCLEIC ACIDS IN STAGE IV MELANOMA PATIENTS RECEIVING IMMUNOTHERAPY REVEALS A NOVEL GENE AMPLIFICATION LANDSCAPE AND ALLOWS FOR DETECTION OF ACTIONABLE GENE MUTATIONS

Introduction

Serial monitoring for disease progression and therapeutic efficacy at the molecular level in metastatic melanoma is hampered by a lack of reliable blood borne biomarkers. Molecular profiling of melanoma tumours is almost impractical in metastatic disease due to risks of procedure related morbidity and sampling inefficiency in representing tumour heterogeneity. Cell free DNA allows monitoring of molecular changes in melanoma over the course of immunotherapy. We investigated the utility of somatic mutation and gene amplification analyses in melanoma patients receiving immunotherapy.

Method

Cell free DNA was extracted from plasma using a QIAamp Circulating Nucleic Acid Kit (Qiagen). Pathway focused profiling of somatic mutation status was performed by ARMs PCR using QBiomarker Somatic Mutation PCR Arrays (Qiagen). Gene amplification analysis was performed by Real Time Quantitative PCR (Roche) using RT2 Profiler PCR Arrays (Qiagen).

Result

A total of twenty patients with stage IV melanoma receiving immunotherapy were enrolled in this study. The BRAF p.V600E mutation was detected in the cfDNA of 80% of BRAF positive patients. Cell free DNA was also profiled for a total of 84 genes of the cancer inflammation and immunity pathway. There was a significant difference in the copy numbers of several genes (CTLA-4, CXCL12, CXCL5, IDO1, TGFB, IFNG, IL4, PTGS2, AICDA, HLA-A, CCL4, ACKR3, TP53, MYC) between patients with progressive disease and therapeutic response (n=20, p < 0.05).

Conclusion

We postulate that cell free DNA pathway focused somatic mutation and gene amplification analyses may be useful in evaluating disease progression and therapeutic response.

Take-home message

Genomic analysis of circulating nucleic acids may be useful in evaluating disease progression and therapeutic response in metastatic melanoma.

Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer

Importance

Gut dysbiosis impairs response to immune checkpoint inhibitors (ICIs) and can be caused by broad-spectrum antibiotic (ATB) therapy.

Objective

To evaluate whether there is an association between ATB therapy administered concurrently (cATB) or prior (pATB) to ICI therapy and overall survival (OS) and treatment response to ICI therapy in patients with cancer treated with ICIs in routine clinical practice.

Design, Setting, and Participants

This prospective, multicenter, cohort study conducted at 2 tertiary academic referral centers recruited 196 patients with cancer who received ICI therapy between January 1, 2015, and April 1, 2018, in routine clinical practice rather than clinical trials.

Main Outcomes and Measures

Overall survival calculated from the time of ICI therapy commencement and radiologic response to ICI treatment defined using the Response Evaluation Criteria in Solid Tumors (version 1.1), with disease refractory to ICI therapy defined as progressive disease 6 to 8 weeks after the first ICI dose without evidence of pseudoprogression.

Results

Among 196 patients (137 men and 59 women; median [range] age, 68 [27-93] years) with non-small cell lung cancer (n = 119), melanoma (n = 38), and other tumor types (n = 39), pATB therapy (HR, 7.4; 95% CI, 4.3-12.8; P < .001), but not cATB therapy (HR, 0.9; 95% CI, 0.5-1.4; P = .76), was associated with worse OS (2 vs 26 months for pATB therapy vs no pATB therapy, respectively) (hazard ratio [HR], 7.4; 95% CI, 4.2-12.9) and a higher likelihood of primary disease refractory to ICI therapy (21 of 26 [81%] vs 66 of 151 [44%], P < .001). Overall survival in patients with non-small cell lung cancer (2.5 vs 26 months, P < .001), melanoma (3.9 vs 14 months, P < .001), and other tumor types (1.1 vs 11, P < .001) was consistently worse in those who received pATBs vs those who did not. Multivariate analyses confirmed that pATB therapy (HR, 3.4; 95% CI, 1.9-6.1; P < .001) and response to ICI therapy (HR, 8.2; 95% CI, 4.0-16.9; P < .001) were associated with OS independent of tumor site, disease burden, and performance status.

Conclusions and Relevance

Despite being limited by sample size, geographic origin, and the lack of correlative analyses on patients' gut microbiota, this study suggests that pATB therapy but not cATB therapy is associated with a worse treatment response and OS in unselected patients treated with ICIs in routine clinical practice. Mechanistic studies are urgently required to investigate ATB-mediated alterations of gut microbiota as a determinant of poorer outcome following ICI treatment.

Are the minor high bleeding risk criteria of the academic research consortium truly minor? Insights from a high-volume tertiary care pci centre

Background

The Academic Research Consortium (ARC) has recently published a consensus-based definition to identify patients at high bleeding risk (HBR), reflected by a BARC 3 or 5 bleeding rate of ≥4% at 1 year after percutaneous coronary intervention (PCI). The HBR criteria included in the definition are divided into minor and major categories, with patients deemed to be at HBR if they fulfill at least one major or two minor criteria. As a result, patients who present with only one minor criterion are categorized as non-HBR.

Purpose

To compare the differences in baseline characteristics and 1-year bleeding and ischaemic outcomes between non-HBR patients undergoing PCI that present with only one minor HBR criterion versus those that do not fulfill any HBR criteria.

Methods

The study population consisted of all consecutive patients who underwent PCI with stent implantation in a single high-volume centre from January 2014 to December 2017. Patients were classified as non-HBR if they did not fulfill at least one major or two minor ARC-HBR criteria. The outcomes of interest were major bleeding (composite of peri-procedural and post-discharge bleeding), all-cause death, and myocardial infarction (MI) at 1 year. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Of the 9,623 patients included in the analysis, 5,345 were classified as non-HBR. Within the non-HBR patients, 2,078 (38.9%) presented with only one minor HBR criterion and 3,267 (61.1%) presented with no HBR criteria. Non-HBR patients with one minor criterion were more often female, significantly older, with a higher burden of comorbidities such as diabetes mellitus, hypertension and hyperlipidaemia, and more likely to have multivessel disease as well as a history of prior MI and revascularisation, while non-HBR patients with no criteria were more likely to be smokers and have a higher BMI. Distribution of the minor HBR criteria within the group presenting with one minor criterion are illustrated in the figure. Non-HBR patients with only one minor criterion had a numerically higher rate of major bleeding compared to non-HBR patients with no criteria (3.6% vs. 2.9%, p=0.09). While the rate of all-cause death was significantly higher in the group with only one minor criterion (1.2% vs. 0.4%, p=0.004), there was no difference in the rate of MI between the two groups (2.1% vs. 1.9%, p=0.83). Hazard ratios comparing the two groups are presented in the figure.

Conclusions

Non-HBR patients presenting with only one minor criterion had a numerically higher rate of post-PCI bleeding and significantly higher mortality compared to those without any criteria. Nonetheless, the major bleeding rates of both groups at 1 year were less than the 4% cutoff to qualify as HBR according to the ARC definition, thereby supporting their inclusion as “minor” criteria in the recent ARC-HBR definition.

Figure 1

Funding Acknowledgement

Type of funding source: None

Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials

Background

The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated.

Purpose

Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI.

Methods

In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO.

Results

We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group.

Conclusions

In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality.

Funding Acknowledgement

Type of funding source: None

Forensic evaluation of the Asia Pacific ancestry-informative MAPlex assay

DNA intelligence, and particularly the inference of biogeographical ancestry (BGA) is increasing in interest, and relevance within the forensic genetics community. The majority of current MPS-based forensic ancestry-informative assays focus on the differentiation of major global populations. The recently published MAPlex (Multiplex for the Asia Pacific) panel contains 144 SNPs and 20 microhaplotypes and aims to improve the differentiation of populations in the Asia Pacific region. This study reports the first forensic evaluation of the MAPlex panel using AmpliSeq technology and Ion S5 sequencing. This study reports on the overall performance of MAPlex including the assay's sequence coverage distribution and stability, baseline noise and description of problematic SNPs. Dilution series, artificially degraded and mixed DNA samples were also analysed to evaluate the sensitivity of the panel with challenging or compromised forensic samples. As the first panel to combine biallelic SNPs, multiple-allele SNPs and microhaplotypes, the MAPlex assay demonstrated an enhanced capacity for mixture detection, not easily performed with common binary SNPs. This performance evaluation indicates that MAPlex is a robust, stable and highly sensitive assay that is applicable to forensic casework for the prediction of BGA.

Capmatinib in patients with high-level MET-amplified advanced non–small cell lung cancer (NSCLC): results from the phase 2 GEOMETRY mono-1 study

9509

Background: In the ongoing, multicohort, phase 2 GEOMETRY mono-1 study, capmatinib (INC280) has shown efficacy in METex14–mutated NSCLC patients (pts) who were pretreated (cohort 4) or treatment (tx)-naïve (cohort 5b). Here, we report the efficacy and safety of capmatinib in pts with high-level MET-amplified (gene copy number [GCN] ≥10) advanced NSCLC who were either pretreated with 1 or 2 prior lines of systemic therapy (cohort 1a) or tx-naïve (cohort 5a). Methods: Adult pts (≥18 years), ECOG PS 0–1 who had ALK and EGFR wt, stage IIIB/IV (any histology) MET-amplified NSCLC with GCN≥10 received capmatinib 400 mg twice daily (fasting). Primary and key secondary endpoints were overall response rate (ORR) and duration of response (DOR), respectively, by blinded independent review committee (BIRC) assessment per RECIST v1.1. Other secondary endpoints included investigator-assessed ORR, DOR, disease control rate (DCR), progression-free survival (PFS, BIRC and investigator assessment), overall survival, and safety. Results: As of Jan 06, 2020, 84 pts were evaluable for efficacy (cohort 1a [2nd/3rd line], 69 pts; Cohort 5a [1st line], 15 pts). Tx was ongoing for 3 pts in cohort 1a, none in cohort 5a. Per BIRC assessment in cohorts 1a and 5a, respectively, ORR was 29% and 40%, median DOR was 8.31 months (mo, 20 responders, 95% CI: 4.17–15.44) and 7.54 mo (6 responders, 95% CI: 2.56–14.26), and median PFS was 4.07 (95% CI: 2.86–4.83) and 4.17 (95% CI: 1.45–6.87) mo. Investigator assessment was in line with BIRC assessment (Table). The most common adverse events across all cohorts (≥25%, all grades, N = 364) were peripheral edema (51.1%), nausea (44.8%) and vomiting (28.0%). Data for biomarker analysis and pts with brain metastasis will be presented at the ASCO 2020 meeting. Conclusion: Capmatinib has demonstrated activity in the subset of pts with high-level MET-amplified (GCN≥10) NSCLC, with a higher response rate in tx-naïve pts. Safety profile remains favorable and similar to previous reports of capmatinib. Clinical trial information: NCT02414139 . [Table: see text]

The Presence of a High Peak Feature Within Low-Average Shear Stimuli Induces Quiescence in Venous Endothelial Cells

Wall shear stress (WSS) is an important stimulus in vascular remodelling and vascular lesion development. The current methods to assess and predict the risk associated with specific unsteady WSS consider the WSS mean values or the presence of reverse phases described by the oscillatory shear index. Recent evidence has shown that the accuracy of these methods is limited, especially with respect to the venous environment. Unsteady WSS are characterised by several features that may individually affect endothelial cells. Consequently, we assessed the effects of averaged WSS (TAWSS), temporal WSS gradient (TWSSG), maximum WSS (WSS peak) and reverse phase (OSI) by applying different WSS profiles to venous EC in-vitro, using a real-time controlled cone-and-plate cell-shearing device for 24 h. We found that TWSSG and WSS peak affect cell elongation and alignment respectively. We also found that the WSS waveforms with a peak of 1.5 Pa or higher significantly correlate with the induction of a protective phenotype. Cell phenotype induced by these high peak waveforms does not correlate to what is predicted by the hemodynamic indices currently used. The definition of reliable hemodynamic indices can be used to inform the computational models aimed at estimating the hemodynamic effects on vascular remodelling.

Antibiotic treatment prior to immune checkpoint inhibitor therapy as a tumor-agnostic predictive correlate of response in routine clinical practice

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Background: Antibiotic therapy (ATB) may impair efficacy of immune checkpoint inhibitors (ICPI) through modulation of gut microbiota. Evidence is however limited to trial participants with non-small cell (NSCLC) and renal cell carcinoma (RCC). In this multi-centre study, we validated the impact of ATB in patients (pts) treated with ICPI in routine practice, irrespective of tumour site. Methods: We analysed a prospective dataset of pts treated with ICPI in 2 centres. We documented timing and duration of ATB administered within 1 month prior to ICPI treatment (pATB) or concurrently (cATB) until ICPI cessation. We evaluated response and overall survival (OS) across ATB+/-. Results: We enrolled 196 pts with NSCLC (n=119), Melanoma (n=38) and other histotypes (n=39). Most pts were male (n=137, 70%) with performance status 0-1 (n=159, 84%) and a median number of 2 metastatic sites (range 0-7). Pts received mostly anti-PD-1/PD-L1 ICPI (n=189, 96%) as first-line metastatic therapy (n=120, 62%). Twenty-nine patients (15%) received pATB with penicillins (n=22, 75%) for ≤7 days (n=26, 89%). Sixty-eight pts (35%) received penicillin-based (n=49, 72%) cATB for ≤7 days (n=39, 88%). Respiratory infections were the commonest indication for both pATB (n=16, 55%) and cATB (n=38, 85%). pATB (p<0.001) but not cATB (p=0.76) was associated with worse OS (26 vs. 2 months, Hazard Ratio 7.4, 95% CI 4.2-12.9) and increased likelihood of primary refractoriness to ICPI (44% vs 81%, p<0.001). pATB consistently worsened OS in NSCLC (26 vs. 2.5 months, p<0.001), melanoma (14 vs 3.9 months, p<0.001) and other tumours (11 vs 1.1 months, p<0.001). In multi-variable analyses pATB (p<0.001, HR 3.4, 95% CI 1.9-6.1) and response to ICPI (p<0.001, HR 8.2, 95% CI 4.0-16.9) predicted for OS independent of histotype, tumour burden, PS. Conclusions: This study suggests pATB to exert an independent detrimental effect on response and survival in unselected pts treated with ICPI in routine clinical practice. Mechanistic studies are urgently required to investigate ATB-mediated alterations of gut microbiota as a determinant of poorer outcome following ICPI treatment.

Functional Outcome of Fixation of Complex Intra-articular Distal Radius Fractures with a Variable-Angle Distal Radius Volar Rim Plate

Aim To evaluate the outcome of these complex fractures using a volar approach and the DePuy Synthes variable-angle 2.4-mm distal radius rim plate. This plate is precontoured to the volar rim for placement distal to the watershed line allowing purchase of the rim fragment of the lunate facet. Its low profile and smooth edges are designed to minimize flexor tendon irritation. Method We report on a consecutive series of far distal AO-23B3 and AO-23C3 fractures treated using this plate in a tertiary hand center between November 2011 and May 2014. Range of motion, grip strength, and complications were assessed at the final clinical review. Disabilities of the arm, shoulder, and hand (DASH) and patient evaluation measure (PEM) scores were assessed at 12 months after surgery. Results Twenty-six patients were included in this review. Six patients were lost to follow-up at 3 months. This plate was used in isolation in 17 cases, and in combination with a dorsal plate, in cases of dorsal instability after volar plating, in 10 patients. DASH and PEM scores 1 year after surgery were 17.6 and 27%, respectively. Visual analog scores for patient treatment satisfaction and severity of pain showed good satisfaction with treatment and mild intermittent pain on activity. Postoperative range of motion was variable and grip strength was of 71% of the uninjured contralateral side. There were no cases of flexor or extensor tendon rupture. Tendon irritation was noted in two patients. Removal of metal was performed in four patients. Loss of reduction occurred in one case and neurologic complications in two cases. Conclusion This implant is specifically designed for the management of far distal complex intra-articular fractures of the distal radius. Despite the complexity of these fracture patterns and the challenge they pose to accurate reduction and stable fixation, outcomes were satisfactory in this small series. There were no cases of tendon rupture. Removal of metal is not necessary in all cases, but prompt removal should be performed in cases of tendon irritation in view of the risk of tendon rupture.

A regional analysis of epidermal growth factor receptor (EGFR) mutated lung cancer for HSE South

BACKGROUND

EGFR mutated lung cancer represents a subgroup with distinct clinical presentations, prognosis, and management requirements. We investigated the survival, prognostic factors, and real-world treatment of NSCLC patients with EGFR mutation in clinical practice.

METHODS

A retrospective review of all specimens sent for EGFR analysis from December 2009 to September 2015 was performed. Patient demographics, specimen type, EGFR mutation status/type, stage at diagnosis, treatment, response rate, and survival data were recorded.

RESULTS

27/334 (8%) patient specimens sent for EGFR testing tested positive for a sensitising EGFR mutation. The median age was 65 years (40-85 years). Exon 19 deletion represented the most commonly detected alteration, accounting for 39% (n = 11). First-line treatment for those with Exon 18, 19, or 21 alterations (n = 24) was with an EGFR tyrosine kinase inhibitor (TKI) in 79% (n = 19). Objective response rate among these patients was 74% and median duration of response was 13 months (range 7-35 months).

CONCLUSION

The incidence of EGFR mutation in our cohort of NSCLC is 9% which is consistent with mutation incidence reported in other countries. The rate of EGFR mutation in our population is slightly below that reported internationally, but treatment outcomes are consistent with published data. Real-world patient data have important contributions to make with regard to quality measurement, incorporating patient experience into guidelines and identifying safety signals.

Evaluation of 18F-fluorothymidine positron emission tomography ([18F]FLT-PET/CT) methodology in assessing early response to chemotherapy in patients with gastro-oesophageal cancer

BACKGROUND

3'-Deoxy-3'-[18F]fluorothymidine ([18F]FLT) PET has limited utility in abdominal imaging due to high physiological hepatic uptake of a tracer. We evaluated [18F]FLT-PET/CT combined with a temporal-intensity information-based voxel-clustering approach termed kinetic spatial filtering (KSF) to improve tumour visualisation in patients with locally advanced and metastatic gastro-oesophageal cancer and as a marker of early response to chemotherapy. Dynamic [18F]FLT-PET/CT data were collected before and 3 weeks post first cycle of chemotherapy. Changes in tumour [18F]FLT-PET/CT variables were determined. Response was determined on contrast-enhanced CT after three cycles of therapy using RECIST 1.1.

RESULTS

Ten patients were included. Following application of the KSF, visual distinction of all oesophageal and/or gastric tumours was observed in [18F]FLT-PET images. Among the nine patients available for response evaluation (RECIST 1.1), three patients had responded (partial response) and six patients were non-responders (stable disease). There was a significant association between Ki-67 and all baseline [18F]FLT-PET parameters. Area under the curve (AUC) from 0 to 1 min was associated with treatment response.

CONCLUSIONS

The results of this study indicate that application of the KSF allowed accurate visualisation of both primary and metastatic lesions following imaging with the proliferation marker, [18F]FLT-PET/CT. However, [18F]FLT-PET uptake parameters did not correlate with response. Instead, we observe significant changes in tracer delivery following chemotherapy suggesting that further [18F]FLT-PET/CT studies in this tumour type should be undertaken with caution.