The data project: a shared approach between stakeholders of the healthcare system in definition of a therapeutic algorithm for inflammatory arthritis

Rheumatic musculoskeletal diseases or RMD [rheumatoid arthritis (RA) and spondyloarthritis (SpA)] are systemic inflammatory diseases for which there are no biomarkers capable of predicting treatments with a higher likelihood of response in naive patients. In addition, the expiration of the anti-TNF blocking drugs' patents has resulted in the availability of anti-TNF biosimilar drugs with the same efficacy and safety than originators but at significantly reduced prices. To guarantee a personalized therapeutic approach to RMD treatment, a board of rheumatologists and stakeholders from the Campania region, Italy, developed a clinically applicable arthritis therapeutic algorithm to guide rheumatologists (DATA project). The general methodology relied on a Delphi technique forecast to produce a set of statements that summarized the experts' consensus. Selected clinical scenarios were discussed in light of the available evidence, and there were two rounds of voting on the therapeutic approaches. Separate discussions were held regarding rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The decision-making factors for each disease were clinical presentation, demographics, and comorbidities. In this paper, we describe a virtuous process between rheumatologists and healthcare system stakeholders that resulted in the development of a shared therapeutic algorithm for RMD patients naive to bDMARDs.

Acquisition of optical coherence tomography angiography metrics during hemodialysis procedures: A pilot study

BACKGROUND AND AIMS

The observation of optical microcirculation gives us an extraordinary way to directly assess in vivo the responses of human circulation to stress stimuli. We run a pilot study to analyze optical coherence tomography angiography (OCT-A) metrics at determined time-points during a hemodialysis (HD) session to understand how these metrics gradually change and to evaluate possible correlations with patients' characteristics.

METHODS

After the eligibility screening, 15 patients (23 eyes) were included in the study. OCT-A parameters were collected at established time-points: Before treatment (t0), at first hour (t1), at second hour (t2), at third hour (t3), and finally at the end of HD treatment (t4). Patients were finally shared in hypotensive group if they occurred in a hypotensive episode during subsequent month methods or no hypotensive group. The instrument software automatically segmented OCT-A scans into four en-face slabs: The superficial capillary plexus (SCP), the deep capillary plexus (DCP), the outer retinal plexus and the choriocapillaris plexus. In this study we focus on SCP, DCP plexuses.

RESULTS

Overall, the majority of ophthalmic parameters remained unaffected and comparable at dialysis end; a significant reduction being observed at the end vs. starting of HD only for deep capillary plexus (DCP: Whole, fovea, and parafovea) and for central choroid thickness (CCT) (p < 0.05). An overall trend during the session showed in general a decrease with a significance in particular for DCP (whole, fovea, and parafovea) and for CCT (P = 0.006). In the hypotension group, Superficial capillary plexus (SCP: Fovea and parafovea) significantly increased comparing post vs. pre-dialysis values while CCT significantly decreased. Analyzing the trend during treatment only CCT maintained a significant trend (p for trend = 0.002). In the no-hypotension group, neither pre- vs. post-analysis and trend analysis showed a statistical significance.

CONCLUSION

Main achievement of our study was to measure, for the first time in literature, single parameters at different time-points of a HD session. As a result of this process we did not notice a brusque decreasing or increasing of OCT-A metrics but we can characterize the different effect of HD on the two distinct areas distinguishing ocular vessels: Retinal and choroidal circulation. As interesting sub-analysis, Hypotensive group showed for CCT a decreasing trend with a difference statistically significant respect to the group with no-hypotension maintaining a constant trend. In our opinion, these results suggest the role of autonomic system on vessel control in patients affected by uremia.

Distinctive gut microbiomes of ankylosing spondylitis and inflammatory bowel disease patients suggest differing roles in pathogenesis and correlate with disease activity

BACKGROUND

Multiple studies have confirmed dysbiosis in ankylosing spondylitis (AS) and inflammatory bowel disease (IBD); however, due to methodological differences across studies, it has not been possible to determine if these diseases have similar or different gut microbiomes.

RESULTS

In this study, faecal and intestinal biopsies were obtained from 33 Australian AS patients (including 5 with concomitant IBD, 'AS-IBD'), 59 IBD patients and 105 healthy controls. Stool samples were also obtained from 16 Italian AS patients and 136 Swedish AS patients. Focusing on the Australian cohort, AS, AS-IBD and IBD patients differed from one another and from healthy controls in both alpha and beta diversity. AS patients with and without clinical IBD could be distinguished from one another with moderate accuracy using stool microbiome (AUC=0.754). Stool microbiome also accurately distinguished IBD patients from healthy controls (AUC=0.757). Microbiome composition was correlated with disease activity measured by BASDAI and faecal calprotectin (FCP) levels. Enrichment of potentially pathogenic Streptococcus was noted in AS, AS-IBD and IBD patients. Furthermore, enrichment of another potentially pathogenic genus, Haemophilus, was observed in AS, AS-IBD, IBD, AS patients with increased BASDAI, and IBD patients with faecal calprotectin >100 μg/mg. Apart from these genera, no other taxa were shared between AS and IBD patients.

CONCLUSIONS

In conclusion, the distinct gut microbiome of AS and AS-IBD patients compared to IBD patients and healthy controls is consistent with immunological and genetic evidence suggesting that the gut plays a different role in driving AS compared with IBD. However, enrichment of two potentially pathogenic genera in both diseases suggests that the presence of a shared/common microbial trigger of disease cannot be discounted.

AB0936 Neuropathic pain in Psoriatic Arthritis: analysis of populations treated with anti TNF and anti IL17

Background

Psoriatic arthritis (PsA) is a disease characterized by chronic pain and it is often associated with the presence of fibromyalgia (FMS) with an estimated prevalence of 18%. Several studies demonstrated the central role of neuropathic pain in FMS. However, patients with inflammatory diseases such as PsA frequently complain of complex pain symptoms, with neuropathic characteristics. Therefore, in PsA we can recognize both an inflammatory pain and a neuropathic pain that can be exacerbated both by the concomitant fibromyalgia or depending only on the PsA itself. In fact, In the context of PsA, the presence of neuropathic pain features has been documented in 28% of patients. This could be a reason why the low remission rate in these patients. Finally, Studies on murin models revealed a possible role of IL17, key cytokine of PsA pathogenesis, in mechanism of neuropathic pain.

Objectives

To evaluate the role of anti-TNF and antiIL-17 in neuropathic pain in PsA patients treated with the first biological drug (bDMARDS).

Methods

A cross-sectional evaluation was conducted on 38 PsA patients classified by Classification criteria for Psoriatic Arthritis (CASPAR), referred to the PsA outpatient clinic of “University of Campania Luigi Vanvitelli”. Thirty patients were treated with anti-TNF (mean age 53 years, 17F, 13M), 8 were treated with anti-IL17 (mean age 50 years, 5F, 3M), for almost 6 months. For each patient, an assessment of disease activity using DAPSA and physical function was carried out. The presence of comorbid fibromyalgia syndrome (FMS) was evaluated according to ACR 2016 criteria. We investigated neuropathic pain features through the PainDETECT Questionnaire (PDQ).

Results

Nine patients treated with anti TNF were in DAPSA remission; 18 patients had low disease activity, 3 had High disease activity, FMS was detected in 11 of 30 patients, no one in DAPSA remission for PsA. Characteristics of neuropathic pain (PDQ ≥ 19) were found in 13 (43.3%) patients overall; unlikely neuropathic pain (PDQ < 12) in 16 (53.3%) patients. In the first group 7 patients had FMS, in the second group 3 had FMS. So, our analysis revealed the presence of neuropathic pain in 6 patients (54,5%) with PsA treated with antiTNF with no FMS; all of them were in low disease activity. The same analysis was conducted on anti IL17 treated population: 4 patients were in DAPSA remission, 2 patients in low disease activity, 2 patients in high, disease activity. FMS was diagnosed in 3 patients, 1 of them was in DAPSA remission for PsA. PDQ>19 was found only in 1 patient, who had FMS in comorbidity; the others had no neuropathic pain. So, we had no PsA patient treated with antiIL17, that manifested symptoms of neuropathic pain.

Conclusion

The contribute of IL-17 in developing of neuropathic pain suggests the possible role of anti IL17 as therapy; our results support this tesis suggesting a possible role of anti IL17 in treatment of neuropathic pain. A limit to our work is given by the low sample size for which further studies are necessary to confirm this data.

References

[1]Ramjeeawon A, Neuropathic-like pain in psoriatic arthritis: evidence of abnormal pain processing. Clin Rheumatol. 2019;

[2]Sun C, IL-17 contributed to the neuropathic pain following peripheral nerve injury by promoting astrocyte proliferation and secretion of proinflammatory cytokines. Mol Med Rep. 2017

[3]Martinez-Lavin M: Fibromyalgia is a neuropathic pain syndrome. J Rheumatol 2006;

Disclosure of Interests

None declared

POS1211 SEROLOGICAL RESPONSE TO BNT162b2 mRNA ANTI-SARS-CoV-2 VACCINATION IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES: RESULTS FROM THE RHEUVAX COHORT

Background

To date, globally considered, the literature suggests that AIRD may be at higher risk of infection and death due to COVID19 compared to the general population. Vaccination against SARS-CoV-2 reduces the risk of hospitalization and mortality. However, immunological alteration associated with Autoimmune Inflammatory Rheumatic Diseases (AIRD) and immunosuppressive medications may impair the response to vaccination. Emerging data suggest that immunosuppressive treatment may negatively impact the response to anti-SARS-CoV-2 vaccines in the AIRD population; data are robust for some treatments, more controversial for others.

Identifying patients at higher risk of lack of protection is essential for shielding them and for adapting therapeutic protocol and vaccination timing.

Objectives

In the light of the current COVID19 epidemic and the availability of effective vaccines, this study aims to identify predictors of non-response to anti-SARS-CoV-2 vaccines in patients affected by AIRD.

Methods

An observational cross-sectional study was conducted evaluating the serological response and the persistence of antibodies at eight weeks in IRD patient cohort and non-IRD control.

IRD and age and sex-matched controls volunteer among the health professionals (CTRL) who underwent vaccination with two doses of BNT162b2 were recruited for this study. Anti-Trimeric Spike protein antibodies were assayed eight ± one week after the second vaccine dose. Univariate and logistic regression analyses were performed to identify predictors of non-response and low antibody titers.

Results

Samples were obtained from 237 IRD patients (m/f 73/164, mean age 57, CI 95% [56-59]): 4 autoinflammatory diseases (AI), 62 connective tissue diseases (CTD), 86 rheumatoid arthritis (RA), 71 spondylarthritis (SpA) and 14 vasculitis (Vsc). 232 CTRL were recruited (m/f 71/161, mean age 57, CI 95% [56-58]).

Globally, IRD had a lower seroconversion rate (88.6% vs 99.6%, CI 95% OR [1.61-5.73], p<0.0001) and lower antibody titer compared to controls (median (IQR) 403 (131.5-1012) vs 1160 (702.5-1675), p<0.0001). After logistic regression, age, corticosteroid (CCS), Abatacept (ABA), and Mycophenolate Mofetil (MMF) use were predictors of non-response.

The antibody titers eight weeks after the second dose of vaccine were lower in AIRD compared to controls, median (IQR) 403 (131.5-1012) vs 1160 (702.5-1675), p<0.0001 with no difference between sexes and age groups. CTD, RA and SpA had lower antibodies levels. However, the logistic regression model identified treatment with MMF, ABA, CCS, Methotrexate (MTX), Rituximab (RTX), Janus Kinase inhibitors (JAKi) and TNF inhibitors (TNFi) as independent predictors of serum titer. ABA, RTX, MMF, and MTX had the strongest effect size.

Conclusion

The response to anti-SARS-CoV-2 vaccines is often impaired in AIRD patients under treatment and may pose them at higher risk of severe COVID-19. Although this work focused on serological response, most of the treatment the impaired vaccine response are known to act on T cells, possibly also influencing the cellular response. Evidence-based protocols are required to time vaccination and treatment to improve immunization of AIRD patients.

References

[1]Kroon, F. P. B. et al. Risk and prognosis of SARS-CoV-2 infection and vaccination against SARS-CoV-2 in rheumatic and musculoskeletal diseases: a systematic literature review to inform EULAR recommendations. Ann. Rheum. Dis. (2021).

Acknowledgements

The authors would like to thank Dr Daniela Iacono, Dr Carlo Iandoli, Dr Alessandra Milone, Dr Anna Pellegrlino, Dr Elisabetta Seguino and Mrs Maria Puca, for their contribution in data and blood samples collection, Dr Giorgia Della Polla for the valuable suggestions on data analysis. The authors are grateful also to all patients and the volunteers for their contribution.

Disclosure of Interests

None declared

AB1174 ADVERSE EVENTS AFTER TWO DOSES OF BNT162b2 ANTI-SARS-CoV-2 VACCINE IN PATIENTS WITH RHEUMATIC MUSCULOSKELETAL DISEASES: RESULTS FROM A SINGLE CENTER ITALIAN STUDY

Background

Vaccination against COVID19 is the most important prevention tool against the current pandemic. However, since the approval of anti-COVID19 mRNA vaccines by EMA, safety and tolerability in patients with rheumatic musculoskeletal diseases has always been a much-discussed topic, given their novel, unprecedented mechanism of action and the concern for potential disease flares.

Objectives

To assess the safety and type of adverse events after two doses of BNT162b2 anti-SARS-CoV-2 vaccine in patients affected by rheumatologic diseases.

Methods

241 patients who received two doses of BNT162b2 were invited to take part to a follow-up live visit 2 months after completion of the primary vaccination cycle. Data regarding age, sex, diagnosis, treatment and adverse events after vaccination were collected for each patient during the visit. Pearson chi-square and Fisher exact tests were used to compare the distribution of each type of adverse event between male and female and among Rheumatoid Arthritis, Spondyloarthritis and Connective Tissue Disease patients.

Results

Mean age of recruited patients was 57 years (IQR 49-65) and F:M ratio was 2.49:1 (172 F/69 M). Number and percentage of individuals for each disease category were represented as follows: Rheumatoid Arthritis 87 (36,10%), Spondyloarthritides 72 (29,88%), Connective Tissue Diseases 65 (26,97%), Autoinflammatory Diseases 4 (1,66%), Vasculitides 13 (5,39%). 42 subjects (17,42%) reported no adverse events, whereas local reactions such as pain and swelling at injection site were the most commonly reported side effect, (154 subjects, 63,9%, Table 1). Constitutional symptoms, comprising fatigue, muscle and joint pain, fever, chills and headache, were described in 54,77% of the interviews (132 subjects, Table 1). No patient experienced severe allergic reactions after vaccination. Statistical comparison among disease categories showed no differences in the distribution of adverse events. When analysing for sex, joint pain appeared to be reported significantly more frequently in male patients (p=0.002), while chills were more present in female patients (p=0.033). None of the interviewed subjects reported any sign or symptom relatable to disease flares.

Table 1All pts n (%)Female n (%)Male n (%)RA n (%)SpA n (%)CTD n (%)24117269877265Local reactions154 (63,90)110 (63,95)44 (63,77)53 (60,92)46 (63,89)43 (66,15)-Pain152 (63,07)108 (62,79)44 (63,77)53 (60,92)45 (62,50)42 (64,62)-Swelling4 (1,66)3 (1,74)1 (1,45)1 (1,15)2 (2,78)1 (1,54)Constitutional symptoms132 (54,77)98 (56,98)34 (49,28)46 (52,87)38 (52,78)37 (56,92)-Fatigue75 (31,12)58 (33,72)17 (24,64)25 (28,74)21 (29,17)22 (33,85)-Headache35 (14,52)29 (16,86)6 (8,70)10 (11,49)10 (13,89)14 (21,54)-Muscle pain37 (15,35)28 (16,28)9 (13,04)14 (16,09)10 (13,89)12 (18,46)-Joint pain14 (5,81)5 (2,91)9 (13,04)7 (8,05)4 (5,56)1 (1,54)-Fever35 (14,52)24 (13,95)11 (15,94)15 (17,24)5 (6,94)11 (16,92)-Chills22 (9,13)20 (11,63)2 (2,90)7 (8,05)8 (11,11)6 (9,23)Gastrointestinal symptoms19 (7,88)14 (8,14)5 (7,25)7 (8,05)5 (6,94)5 (7,69)-Nausea17 (7,05)13 (7,56)4 (5,80)5 (5,75)5 (6,94)5 (7,69)-Vomiting1 (0,41)1 (0,58)0 (0,00)0 (0,00)0 (0,00)1 (1,54)-Diarrhea3 (1,24)2 (1,16)1 (1,45)2 (2,30)0 (0,00)1 (1,54)Lymphoadenopathy2 (0,83)2 (1,16)0 (0,00)0 (0,00)0 (0,00)2 (3,08)Severe allergic reactions0 (0,00)0 (0,00)0 (0,00)0 (0,00)0 (0,00)0 (0,00)Other5 (2,07)4 (2,33)1 (1,45)2 (2,30)1 (1,39)2 (3,08)None42 (17,43)29 (16,86)13,00 (18,84)19 (21,84)12 (16,67)9 (13,85)

Table notes. RA: Rheumatoid Arthritis; SpA: Spondyloarthritides; CTD: Connective Tissue Diseases; Other: comprising reports of increased heart rate, visual disturbances, conjunctival hyperaemia, transient hyperglycaemia.

Conclusion

Vaccination with two doses of BNT162b2 was safe and generally well tolerated. No reports of signs or symptoms of disease reactivation were found in our cohort.

Disclosure of Interests

None declared

OP0042 BLOCKING OF CD103+ TISSUE RESIDENT MEMORY T CELLS (TRM) AS A THERAPEUTIC STRATEGY IN SJOGREN’S SYNDROME

Background:

Tissue-resident memory T cells (TRM), are a recently identified T cells population featuring tissue localization and expression of markers of tissue homing, CD69 and CD103. Recently, the expansion of CD8+ TRMs and their involvement in the sialadenitis was described in a murine model of SS. However, CD4+ and CD8+ TRM’s functional relevance in pSS is still not fully understood, and the TRM therapeutic targeting unexplored.

Objectives:

The study aimed to address the role of CD4+ and CD8+ TRMs in the pathogenesis of pSS and to explore the therapeutic targeting of the tissue residency marker of TRM CD103.

Methods:

An animal model of experimental (ESS) obtained by immunization of female C57BL/6 mice (n=10) with salivary glands (SG) protein extract and Freund’s complete adjuvant used to investigate the dynamic of infiltration of SG by CD4+ and CD8+ TRMs, their frequency, and the impact of CD103 blockade. For the therapeutic intervention, at 10-weeks post-immunization, the salivary gland was cannulated via Wharton’s duct, and an anti-CD103 neutralizing antibody or vehicle-injected. The mice’s saliva flow rate was assessed, and SGs were analyzed by Flow-cytometry and immunohistochemistry (IHC).

The frequency and localization of TRMs was analyzed in minor SG of sicca syndrome (nSS) and pSS patients (n=39) by flow cytometry and IHC. The expression of genes involved in the tissue retention of TRMs was assessed in SG by RT-PCR.

Results:

Upon the ESS progression, a significant progressive increase in CD45+CD103+ cells frequency was observed from 5wk to 20wk post-immunization (p<0.001), where the CD8+ were the most abundant, followed by CD4+. Consistently, CD103+CD8+ T cells were detected within the lymphocytic infiltration of SG from ESS mice. Sorted purified SG CD10+CD3+CD8+ T cells showed higher Granzyme B, TNF-alpha expression compared to CD103-CD3+CD8+ at both mRNA and protein levels. Notably, ESS mice treated with anti-CD103 showed improvement in salivary function (p<0.05) and reduced lymphocytic infiltrations measured as focus score (FS) (p<0.01) and area-fraction (p<0.01). Consistently, anti-CD103 treatment consistently reduced CD103+ cells and IFN-gamma+, Granzyme B+, and TNFa+ CD8+ cells. We next performed phenotypic analysis of CD45+CD103+ immune cells in the SG of pSS patients observing an increase in both with CD8+CD103+CD69+ and CD4+CD103+CD69+ (p<0.05). Finally, IHC showed that the expansion of TRMs in pSS salivary glands was accompanied by a down-regulation of E-cadherin glandular expression and their migration outside the epithelium in the context of inflammatory infiltrates. SG of patients with pSS showed a significant up-regulation of BLIMP1, KFL-2, and S1PR1 and down-regulation of ITGB2. CXCL9 and CXCL10, and IL-15 involved in the tissue recruitment and long-term survival of TRMs were significantly modulated in pSS salivary glands.

Conclusion:

TRM are expanded and activated in the SG of pSS and ESS, participating in the organization of tissue inflammation. Although the mechanisms behind this expansion are still not fully understood, CD103 could be a valuable novel therapeutic target to prevent lymphocytic infiltrations and glandular destruction in Sjogren syndrome.

Disclosure of Interests:

None declared

POS1210 PREVALENCE OF COVID-19 AMONG PATIENTS WITH RHEUMATIC DISEASES: AN OBSERVATIONAL SURVEY DURING THE TWO WAVES IN ITALY

Background:

The new coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) is a source of concern for the management of patients suffering from rheumatic and musculoskeletal diseases (RMDs) treated with immunomodulatory therapies (1).

Objectives:

We aimed to analyze the prevalence of SARS-CoV-2 infection in patients with RMDs living in Italy.

Methods:

During the first wave (March-May 2020) and during the second wave (October-December 2020) of COVID-19, we conducted a survey to investigate the incidence of SARS-CoV-2 infection in patients with RMDs followed at the Rheumatology Unit of the University of Campania, Italy. The demographic data, medication use, the frequency of respiratory symptoms and the incidence of COVID-19 confirmed by nasopharyngeal swab were collected with questionnaires administered by phone. The prevalence of COVID-19 of our cohort was compared to that of the general population (2).

Results:

During the first wave, we collected data from 900 patients with RMDs (Table 1): 320 patients with rheumatoid arthritis (RA), 295 patients with spondyloarthropathies (SpA), 283 patients with systemic lupus erythematosus (SLE), 2 patients with vasculitis. 546 (60%) were treated with bDMARD/tsDMARDs. Overall, a total of 11/900 (1%) cases were tested for COVID-19 due to compatible symptoms. 2 (0.2%) adult patients treated with bDMARDs were registered as swab test positive by PCR for COVID-19. 2 patients without confirmed COVID-19 developed pneumonia that required admission to hospital. No deaths occurred among the patients with confirmed COVID-19.

During the second wave, data were collected from 470 patients who accepted to take part of the study (Table 1). 49 presented with symptoms that were compatible with COVID-19. 139 patients were tested whereas 30 patients (6%) had a swab confirmation of SARS-CoV-2 infection. Among them, 16 (53%) were treated with bDMARDs and a patient was treated with tofacitinib. we found no increase in COVID-19 prevalence in patients treated with bDMARD/tsDMARDs (p>0.05). A patient with SLE developed pneumonia that required admission to hospital and died.

Lacking distinct prevalence data between first and second waves, we found no differences in total COVID-19 prevalence between general population living in Campania (215.752/5.802.000; 3.7%) and patients with RMDs (32/900; 3.5%). However, we had a significant increase in COVID-19 prevalence in our cohort during the second wave compared to the first. Nevertheless, no increase in mortality or hospitalization was recorded, confirming the safety of immunomodulatory therapies in patients with RMDs.

Conclusion:

In this cohort of patients with RMDs in a geographical region with a high prevalence of COVID-19, the risk of SARS-CoV-2 infection does not appear different from that observed in the general population.

References:

[1]Wang L., Wang Y., Ye D. Int J Antimicrob Agents. 2020:105948.

[2]http://www.protezionecivile.gov.it/ (accessed 28.01.21)

Table 1.

Demographics and clinical characteristics of 900 patients with rheumatic diseases during the COVID-19 Pandemic.

First waveSecond waveWomen, n 660 (73 %) 366(77%)Age, years, median (range)56 (54-57)53 (51-55)Rheumatoid Arthritis320 (35.5%)143 (30%)Spondyloarthritis295 (32%)110 (23%)Systemic Lupus Erythematosus283 (31%)217 (46 %)Vasculitis2 (0.2%)1 (0.2%)Prior ILD56 (6%)22 (4.6%)Smokers220 (24%)118 (25%)Hydroxychloroquine215 (23%)155 (32%)Steroids337 (37%)194 (41%)Prednisone equivalent dose, median (range)5 (0-75)5 (0-50)bDMARD/tsDMARDs546 (60%)247 (52%)csDMARDS387 (43%)185 (39%)Angiotensin-converting enzyme (ACE) inhibitors178 (19.8%)101 (21%)Angiotensin II receptor blockers(ARBs)153 (17%)61 (13%)Fever64 (7%)30 (6.3%)Cough83 (9%)36 (7%)Shortness of breath34 (3%)15 (3%)Sore throat32 (3%)11 (2.3%)Rhinorrhoea36 (3%)11 (2.3%)Headache5 (0.5%)2 (0.4%)Anosmia10 (1%)24 (5%)Myalgia2 (0.2%)1 (0.2%)Gastrointestinal symptoms24 (2.6%)3 (0.6%)Pneumonia2 (0.2%)2 (0.4%)Admission to hospital2 (0.2%)9 (1.9%)Swab confirmation of SARS-CoV-2 infection230

Disclosure of Interests:

None declared.

Machine learning applied to X-ray tomography as a new tool to analyze the voids in RRP Nb3Sn wires

The electro-mechanical and electro-thermal properties of high-performance Restacked-Rod-Process (RRP) Nb₃Sn wires are key factors in the realization of compact magnets above 15 T for the future particle physics experiments. Combining X-ray micro-tomography with unsupervised machine learning algorithm, we provide a new tool capable to study the internal features of RRP wires and unlock different approaches to enhance their performances. Such tool is ideal to characterize the distribution and morphology of the voids that are generated during the heat treatment necessary to form the Nb₃Sn superconducting phase. Two different types of voids can be detected in this type of wires: one inside the copper matrix and the other inside the Nb₃Sn sub-elements. The former type can be related to Sn leaking from sub-elements to the copper matrix which leads to poor electro-thermal stability of the whole wire. The second type is detrimental for the electro-mechanical performance of the wires as superconducting wires experience large electromagnetic stresses in high field and high current conditions. We analyze these aspects thoroughly and discuss the potential of the X-ray tomography analysis tool to help modeling and predicting electro-mechanical and electro-thermal behavior of RRP wires and optimize their design.

Abstract OT1-01-04: A multicenter, phase 1b, first-in-human dose-escalation study of ADXS31-164, a Listeria monocytogenes-LLO immunotherapy, in patients with HER2-expressing solid tumors

Background: Wild type Listeria monocytogenes (Lm) is taken up by antigen-presenting cells (APCs) and has the capability to escape destruction in the phagolysosome and proliferate in the cytosol of the APC. ADXS31-164 is a live attenuated Lm-listeriolysin O (LLO) immunotherapy bioengineered to express the intracellular domain 1 and extracellular domains 1 and 2 of chimeric human epidermal growth factor receptor 2 (cHER2) as a fusion protein to a truncated form of the LLO (tLLO) in the cytoplasm of APCs. The resultant immunologic response generates tumor antigen-specific cytotoxic T lymphocytes while also inhibiting regulatory T cells and myeloid-derived suppressor cells in the tumor microenvironment. Preclinical studies have shown ADXS31-164 can delay the progression of tumors in both transplantable and autochthonous HER2-expressing mouse tumor models.

Trial Design: This is an open-label, multicenter Phase 1b trial (NCT02386501). Patients will receive ADXS31-164 every 3 weeks until progression of disease or unacceptable toxicity. Dose escalations will be performed according to a standard 3+3 design starting at 1 × 109 colony forming units (CFU) to a maximum dose level of 1 × 1010 CFU.

The maximum tolerated dose (MTD) will be identified as the dose level in which a dose-limiting toxicity is seen in 2 of 6 patients; the previous dose level will be selected as the recommended Phase 2 dose (RP2D). Once the MTD and RP2D have been identified, up to 4 HER2-overexpressing tumor-specific expansion cohorts will be evaluated. Treatment cycles can be repeated at the RP2D (or less) for each patient until a study discontinuation criterion is met or the subject completes 1 cycle of treatment post-observation of complete response. Blood samples will be evaluated for immunologic effects in cycle 1 only. Descriptive statistics will be used to evaluate the safety and tolerability of ADXS31-164.

Objectives: The primary aim of this trial is to evaluate safety and tolerability of ADXS31-164 in patients with solid tumors that express HER2, and to select the RP2D. Secondary objectives include tumor response rates and progression-free survival (measured by Response Evaluation Criteria In Solid Tumors [RECIST] 1.1 and immune-related RECIST criteria). Exploratory analyses will describe and evaluate data from correlative immunologic studies.

Key Eligibility Criteria: Patients aged ≥18 years with HER2-positive tumors determined by fluorescence in situ hybridization (FISH) or immunohistochemistry (IHC, at least 1 positive in 1% of the evaluable tumor cells) and an Eastern Cooperative Oncology Group performance status of 0–1 are eligible. Additional criteria include a diagnosis of locally advanced/metastatic solid tumor that has progressed or become intolerant to standard therapy or for which no standard therapy is available, measurable and/or evaluable disease per RECIST 1.1, and a left ventricular ejection fraction within normal limits.

Citation Format: Tan AR, Olszanski A, Golan T, Mauro D, Rugo H. A multicenter, phase 1b, first-in-human dose-escalation study of ADXS31-164, a Listeria monocytogenes-LLO immunotherapy, in patients with HER2-expressing solid tumors. [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 OT1-01-04.

Abstract OT2-6-13: A randomized phase 2 study of the triplet combination of ridaforolimus (RIDA), dalotuzumab (DALO) and exemestane (EX) compared to the ridaforolimus, exemestane doublet in high proliferation, estrogen receptor positive (ER+) advanced breast cancer

Background: The clinical benefit of combination of mTOR inhibition and anti-hormonal therapy has been previously established and represents a new standard of care for patients with hormone receptor positive (HR+) advanced breast cancer (ABC). Preclinical evaluation of the mTOR pathway demonstrates that dual inhibition of IGFR and mTOR may be additive or synergistic and abrogates the feedback activation of AKT due to rapamycin analog mTOR inhibitors. A completed phase 1 study of the combination of the mTOR inhibitor, RIDA and the anti-IGFR antibody, DALO demonstrated preliminary signals of anti-tumor activity. This was further evaluated in a recently completed phase 2 study of RIDA-DALO compared to exemestane in ER+ ABC. Final safety and efficacy results from that phase 2 study will be reported at this meeting (see Baselga et al). Building upon the clinical synergies of mTOR and EX as well as the biologic relationship of the mTOR and IGFR pathways, a clinical study has been initiated to evaluate the triplet combination of RIDA-DALO-EX compared to RIDA-EX. Methods: This is a multicenter, international, randomized phase 2 study of the triplet combination of RIDA (10 mg by mouth daily for 5 out of every 7 days), DALO (10 mg/kg IV weekly), and EX (25 mg QD) compared to RIDA (30 mg by mouth daily for 5 out of every 7 days) and EX (25 mg QD) in high KI67 (≥15%) expressing ER+, ABC. Approximately 84 patients will be randomized 1:1 to either triplet or doublet therapy. Key eligibility criteria include: HR+ and HER-2 negative measurable ABC, prior therapy with a non-steroidal aromatase inhibitor, and KI67 labeling index ≥15%. The primary endpoint of the study is progression free survival (PFS). Key secondary endpoints include evaluation of percent (%) reduction from baseline in the sum of imaging measurements (target lesion diameters or volumes) at 16 weeks between the two arms, and overall response rates. The sample size is event driven with a target of 38 PFS events, which provides approximately 80% power, at 1-sided alpha of 0.1, to detect a HR of 0.5, corresponding to an approximate 100% improvement in median PFS, from 10.6 to 21.2 months. Safety parameters or adverse experiences of special interest include hyperglycemia, stomatitis, mucosal inflammation, pneumonitis and hearing loss. Accrual has been completed with results expected in May 2014.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-6-13.

Abstract P2-16-04: A phase 2 study of ridaforolimus (RIDA) and dalotuzumab (DALO) in estrogen receptor positive (ER+) breast cancer

Background: Preclinical studies indicate that the dual inhibition of IGFR and mTOR may be additive or synergistic and abrogates the feedback activation of AKT due to rapamycin analog mTOR inhibitors. A phase 1 study of the mTOR inhibitor RIDA and the anti-IGFR antibody DALO demonstrated that the combination was feasible and well-tolerated at doses that were nearly those used for the two single agents. The dose limiting toxicity was stomatitis, similar to RIDA monotherapy. Preliminary signals of anti-tumor activity, including partial responses and prolonged progression free survival (PFS), were observed in ER+ advanced breast cancer (ABC), especially in high proliferation tumors (Ki67 ≥15%). Methods: The trial was a multi-center, international randomized study with PFS as the primary endpoint. Key eligibility included ABC with prior treatment with a non-steroidal aromatase inhibitor. The original phase 2 study design was a two-part, adaptive design intended to first test the combination of RIDA (30 mg by mouth daily for 5 out of every 7 days), -DALO (10 mg/kg IV weekly) against a standard agent, exemestane in Part A. Patients were stratified into high and low proliferation strata based on baseline Ki67. Following a demonstration of PFS benefit of the combination in Part A, Part B was intended to show the PFS benefit of the combination over each single agents by comparing RIDA-DALO to RIDA and DALO. Results: The study was initiated in October 2011. Accrual was suspended after the first 66 patients were randomized due to a higher than expected rate of stomatitis in the RIDA-DALO arm. Preliminary data indicated an overall incidence of any grade stomatitis was 68% (22/33 pts), and of grade 3 stomatitis was 35% (11/33 pts). In an effort to identify a more tolerable regimen, the study was amended to eliminate Part B and to evaluate two sequential reduced dose RIDA-DALO cohorts in a non-randomized design: 20mg and 10mg for 5 out of every 7 days. The dose of DALO was unchanged. Preliminary safety results of overall and grade 3 stomatitis in the 20 mg were 81.5% (22/27 pts) and 37% (10/27 pts), respectively. Although the incidence of overall stomatitis in the 10 mg cohort remained high, 88% (22/25 pts), grade 3 stomatitis was dramatically reduced to 8% (2/25 pts). Conclusion: Preliminary evaluation of safety from this phase 2 study demonstrates that the previously recommended phase 2 dose of RIDA-DALO was not tolerable. However lower doses of RIDA (10 mg) in combination with DALO appeared to be tolerable with markedly reduced rates of grade 3 stomatitis. Final results of efficacy, safety and RNA profiling analysis from the two RIDA-DALO dose cohorts as well as from the randomized portion of the study will be available at the time of the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-04.

Ki67 expression in the primary tumor predicts for clinical benefit and time to progression on first-line endocrine therapy in estrogen receptor-positive metastatic breast cancer

We examined whether baseline Ki67 expression in estrogen receptor-positive (ER+) primary breast cancer correlates with clinical benefit and time to progression on first-line endocrine therapy and survival in metastatic disease. Ki67 values and outcome information were retrieved from a prospectively maintained clinical database and validated against the medical records; 241 patients with metastatic breast cancer were included--who had ER+ primary cancer with known Ki67 expression level--and received first-line endocrine therapy for metastatic disease. Patients were assigned to low (<10 %), intermediate (10-25 %), or high (>25 %) Ki67 expression groups. Kaplan-Meier survival curves were plotted and multivariate analysis was performed to assess association between clinical and immunohistochemical variables and outcome. The clinical benefit rates were 81, 65, and 55 % in the low (n = 32), intermediate (n = 103), and high (n = 106) Ki67 expression groups (P = 0.001). The median times to progression on first-line endocrine therapy were 20.3 (95 % CI, 17.5-38.5), 10.8 (95 % CI, 8.9-18.8), and 8 (95 % CI, 6.1-11.1) months, respectively (P = 0.0002). The median survival times after diagnosis of metastatic disease were also longer for the low/intermediate compared to the high Ki67 group, 52 versus 30 months (P < 0.0001). In multivariate analysis, high Ki67 expression in the primary tumor remained an independent adverse prognostic factor in metastatic disease (P = 0.001). Low Ki67 expression in the primary tumor is associated with higher clinical benefit and longer time to progression on first-line endocrine therapy and longer survival after metastatic recurrence.

First Report of Pepper mottle virus Infecting Tomato in Hawaii

In August 2011, tomato (Solanum lycopersicum L.) fruit from a University of Hawaii field trial displayed mottling symptoms similar to that caused by Tomato spotted wilt virus (TSWV) or other tospoviruses. The foliage from affected plants, however, appeared symptomless. Fruit and leaf tissue from affected plants were negative for TSWV analyzed by double antibody sandwich (DAS)-ELISA and/or TSWV ImmunoStrips (Agdia, Elkhart, IN) when performed following the manufacturer's instructions. Total RNA from a symptomatic and an asymptomatic plant was isolated using an RNeasy Plant Mini Kit (Qiagen, Valencia, CA) and reverse transcribed using Invitrogen SuperScript III reverse transcriptase (Life Technologies, Grand Island, NY) and primer 900 (5'- CACTCCCTATTATCCAGG(T)₁₆-3') following the enzyme manufacturer's instructions. The cDNA was then used as template in a universal potyvirus PCR assay using primers 900 and Sprimer, which amplify sequences encoding the partial inclusion body protein (NIb), coat protein, and 3' untranslated region of potyviruses (1). A ~1,700-bp product was amplified from the cDNA of the symptomatic plant but not the asymptomatic plant. This product was cloned using pGEM-T Easy (Promega, Madison, WI) and three clones were sequenced at the University of Hawaii's Advanced Studies in Genomics, Proteomics, and Bioinformatics laboratory. The 1,747-bp consensus sequence of the three clones was deposited in GenBank (Accession No. JQ429788) and, following primer sequence trimming, found to be 97% identical to positions 7,934 through 9,640 of Pepper mottle virus (PepMoV; family Potyviridae, genus Potyvirus) accessions from Korea (isolate '217' from tomato; EU586126) and California (isolate 'C' from pepper; M96425). To determine the incidence of PepMoV in the field trial, all 292 plants representing 14 tomato cultivars were assayed for the virus 17 weeks after planting using a PepMoV-specific DAS-ELISA (Agdia) following the manufacturer's directions. Plants were considered positive if their mean absorbance at 405 nm was greater than the mean absorbance + 3 standard deviations + 10% of the negative control samples. The virus incidence ranged from 4.8 to 47.6% for the different varieties, with an overall incidence of 19.9%. Although plant growth was not noticeably impaired by PepMoV infection, the majority of fruit from infected plants was unsaleable, making PepMoV a considerable threat to tomato production in Hawaii. PepMoV has been reported to naturally infect tomato in Guatemala (3) and South Korea (2). To our knowledge, this is the first report of this virus in Hawaii and the first report of this virus naturally infecting tomato in the United States. References: (1) J. Chen et al. Arch. Virol. 146:757, 2001. (2) M.-K. Kim et al. Plant Pathol. J. 24:152, 2008. (3) J. Th. J. Verhoeven et al. Plant Dis. 86:186, 2002.

Activity and tolerance of biweekly CapeOx-cetuximab in 1st line therapy of metastatic colorectal cancer (mCRC): Relation to K-ras mutation status

e15018

Background: This novel q2w schedule trial combined oxaliplatin (Ox), flat dose capecitabine (Cape) and cetuximab(C) in first line therapy of mCRC. C was given weekly initially and then q2w. We report the response rate, toxicity and influence of K-ras mutation status in first-line patients treated with biweekly CapeOx-C in this phase II trial. Methods: Pts with previously untreated, histologically confirmed, metastatic colon adenocarcinoma, ECOG PS 0–1, and adequate organ function were eligible. Pts were treated with C (initially 250mg/m2 q week and later amended to 500mg/m2 q2w) and Ox (85mg/m2) combined with flat dose Cape (2500mg po bid x 7days) q2w. Endpoints included response (RECIST), toxicity (CTCAE v3) and relationship to K-ras mutation status as determined in codons 12/13 of exon 2 in genomic tumor DNA by PCR, blinded to clinical data. Results: Between 8/04 and 8/08, 27 pts were enrolled. One pt failed screening, 1 withdrew prior to rx and 2 too early for assessment. 25 pts were treated: M/F (15/10), PS 0/1 (13/12), median age 65 yrs (37–80). 12 pts were treated weekly with C and 13 q2w. 23 pts were eligible for both toxicity and efficacy analysis. The most common grade 3/4 toxicities (N=23) were diarrhea (26%), thrombosis (22%), neuropathy (17%), rash (13%), hand-foot syndrome (9%), hypersensitivity reaction (9%), stomatitis (9%). Toxicity profiles between the two C schedules were comparable. Of 23 pts evaluable for response, there were 2 CR, 12 PR, and 3 SD (ORR 61%; disease control rate (DCR) 74%). K-ras status was determined in 18 pts: 9 were K-ras wild-type (WT) and 9 mutant (MT) with ORR and DCR = 66%, 89% for WT vs. 44%, 44% MT. Time on study was 6 mon for WT vs 3 mon for MT (p<0.05). Grade 0–1 vs. 2–3 skin rash was 33% vs. 67% for WT and. 89% vs. 11% in MT pts. Conclusions: The novel combination of biweekly CapeOx-C, with flat dose Cape was well tolerated and very active (regardless of K-ras status) as first line treatment in mCRC. C 500 mg/m2 q2w appears equal to weekly dosing. Analysis of the K-ras mutation status showed a trend toward increased benefit by response rate and time on study, with more cutaneous toxicity in K-ras WT pts. [Supported in part by grant from BMS.]

[Table: see text]

Tinnitus aurium in persons with normal hearing: 55 years later

Objective

The aim of this study was to investigate the effect of silence on the appearance of auditory phantom perceptions in normal-hearing adults, with specific emphasis on the influence of suggestion.

Study Design

Cross-sectional survey.

Subjects and Methods

Fifty-three normal-hearing young Caucasian adults were subjected to two 4-minute sessions in an anechoic sound chamber. In the first session the chamber was empty; in the second session the chamber contained a nonfunctioning loudspeaker. At the end of each session, subjects had to indicate which sounds they perceived from a list of 23 different sounds.

Results

When the loudspeaker was not present, 83 percent of the participants reported that they experienced at least one sound, and the percentage increased to 92 percent when the loudspeaker was present.

Conclusion

These results confirm the emergence of tinnituslike perceptions in a nonclinical population in a silent environment and indicate that suggestive mechanisms play only a minor role in their generation. © 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Patterns of management of rash associated with epidermal growth factor receptor inhibitors (EGFRIs): A national practice survey

14081

Background: Dermatological toxicities are frequent in patients receiving epidermal growth factor inhibitors (EGFRIs), which significantly affect health and quality of life. No current consensus or guidelines exist for the management of these manifestations. In order to gain insight on actual management approaches, a retrospective survey was conducted across oncology practices in the US. Methods: A survey in person was carried out that included 51 questions to 110 practitioners administering EGFRIs in the US, during which time erlotinib, cetuximab and gefitinib were FDA-approved. Open- and closed-ended questions relating to frequency and CTC-graded (G) severity of rash observed, management patterns, and impact on continued EGFRI therapy were evaluated. Statistical testing for correlations was done using Fisher’s exact test. Results: Respondents (resp) included MDs (72%), nurses (23%), NPs (4%), and pharmacists (1%). Majority (>50%) of rash events observed were mild/moderate (G1 in 39% + G2 in 34%). Interventions against rash by resp was based on severity, with G1 treated by 47%, G2 (71%), G3 (87%), G4 (80%). Treatments for G1/2 included only topical agents (TA) by 30% of providers, and combined TA + systemic agents (SA) for G3 (G4) by 48% (30%) of providers. Interestingly, 84% of resp indicated G2 rash improved with TA+SA therapy and only 44% with SA only. Although severe events were reported infrequently (4% and 3% of resp see >50% of G3 and 4 events, respectively), EGFRIs were frequently dose modified (76%) or discontinued (32%) due to rash. Conclusions: Rash is frequent and its management heterogeneous across the US, which increases with rash G. These findings suggest that combined therapy (TA + SA) is more effective than single-agent. Therefore, the high frequency of dose EGFRI modification/discontinuations reported may be minimized by proactive interventions. Trials evaluating proactive and reactive combined TA + SA against rash are currently underway.

No significant financial relationships to disclose.

Phase II study of cetuximab in mucinous peritoneal carcinomatosis

14020

Background: Mucinous peritoneal carcinomatosis is most commonly associated with primariy tumors of the appendix and colon. Typically, spread remains confined to the abdominal cavity. Imaging assessment of these mucinous lesions is difficult, and tumor markers (CEA and CA19.9) are often used as a surrogate for extent of disease. Patients (pts) often undergo surgical debulking, sometimes coupled with intraperitoneal (IP) drug delivery, but recurrence is common. Since mucin genes are regulated by EGFR, our two institutions initiated this study. Methods: Between Sept 2004 and Dec 2005, weekly cetuximab (loading 400 mg/m2 on first dose, followed by 250 mg/m2/week thereafter) was given to 20 pts (4 men, 16 women): 17 of appendiceal origin were entered a median 3 y (6 m-7 y) after diagnosis; 3 were unknown primaries 24, 23, and 2 m after diagnosis. Prior treatment included surgery (18), systemic (17), and intraoperative (4) or subsequent IP therapy (2). Results: Pts received a median of 12 doses (0–51) of cetuximab. No major objective responses were observed; transient > 25% decreases in CEA and CA19.9 were noted in 4/19 pts; markers were never elevated in 1. Stable disease was best response in 3 of 15 evaluable (5 too early). The most common toxicities, as expected, were skin rash, dryness, and nail fragility. Hypersensitivity reactions in 2 patients did not preclude repeated dosing with premedications. The median time to progression from the start of treatment was 3 m. Conclusions: Brisk accrual by two institutions in this rare clinical entity is noteworthy. In this heavily pretreated population, transient decrease in tumor markers and time on study with stable disease were encouraging, prompting plans for a future study of cetuximab with the addition of systemic irinotecan.

[Table: see text]

Lymphoproliferative disease in human peripheral blood mononuclear cell-injected SCID mice. IV. Differential activation of human Th1 and Th2 lymphocytes and influence of the atopic status on lymphoma development

Intraperitoneal transfer of PBMC from EBV+ donors into SCID mice leads to high human Ig levels in mouse serum and B cell lymphoproliferative disease. As these events depend on the activation of coinjected human T cells, we addressed the behavior of the Th1 and Th2 subsets in this model. Production of IFN-gamma, but not of Th2 cytokines such as IL-4, was detected in culture supernatants of PBMC stimulated in vitro with mouse splenocytes. Moreover, anti-CD3 stimulation of the human cells recovered from mice brought about IFN-gamma, but not IL-4, synthesis; on the other hand, PCR and in situ hybridization analysis of ex vivo-recovered cells disclosed the presence of mRNA for both cytokines following in vitro restimulation, thus suggesting posttranscriptional regulation of IL-4 gene expression. When SCID mice were inoculated with PBMC from atopic donors, whose Th1/Th2 profile displays an imbalance toward Th2 cells, tumor development rates were lower, and tumor latency was higher, compared with those in mice injected with PBMC from normal donors. Isotypic analysis of human Ig in mouse serum showed the exclusive presence of IFN-gamma-driven IgG subclasses; in addition, human IgE were low or undetectable in most cases. These findings indicate that following transfer into SCID mice, human Th1 lymphocytes undergo preferential activation, whereas Th2 function is down-regulated. Th1 lymphocytes probably are a major component in promoting EBV+ B cell expansion and tumor development; the individual Th1/Th2 profile could in part account for the as yet unexplained donor variability in tumor generation in this experimental model.