Impact of pregnancy vaccine uptake and socio-demographic determinants on subsequent childhood Measles, Mumps and Rubella vaccine uptake: A UK birth cohort study

BACKGROUND

We examined the association between socio-demographic determinants and uptake of childhood Measles, Mumps & Rubella (MMR) vaccines and the association between pregnant women's pertussis vaccine uptake and their children's MMR vaccine uptake.

METHODS

We used nationally-representative linked mother-baby electronic records from the United Kingdom's Clinical-Practice-Research-Datalink. We created a birth cohort of children born between 01.01.2000 and 12.12.2020. We estimated the proportion vaccinated with first MMR vaccine by age 2 years and first and second MMR vaccines by age 5 years. We used survival-analysis and Cox proportional hazard models to examine the association between deprivation, ethnicity and maternal age and pertussis vaccination in pregnancy and children's MMR uptake.

RESULTS

Overall, 89.4 % (710,797/795,497) of children had first MMR by age 2 years and 92.6 % (736,495/795,497) by age 5 years. Among children still in the cohort when second MMR was due, 85.9 % (478,480/557,050) had two MMRs by age 5 years. Children from the most-deprived areas, children of Black ethnicity and children of mothers aged < 20 years had increased risk of being unvaccinated compared with children from the least-deprived areas, White children and children of mothers aged 31-40 years: first MMR by 5 years, adjusted Hazard Ratios (HR):0.86 (CI:0.85-0.87), HR:0.87 (CI:0.85-0.88) & HR:0.89 (CI:0.88-0.90) respectively. Deprivation was the determinant associated with the greatest risk of missed second MMR: adjusted HR:0.82 (CI:0.81-0.83). Children of mothers vaccinated in pregnancy were more likely than children of unvaccinated mothers to have MMR vaccines after adjusting for ethnicity, deprivation, and maternal age (First and Second MMRs adjusted HRs:1.43 (CI:1.41-1.45), 1.49 (CI:1.45-1.53).

CONCLUSION

Children from most-deprived areas are less likely to have MMR vaccines compared with children from least-deprived areas. Mothers who take up pregnancy vaccines are more likely to have their children vaccinated with MMR. Healthcare services should promote and facilitate access to both maternal and childhood vaccines during pregnancy.

Prenatal maternal cortisol, stress and anxiety, and childhood obesity at 5 years: a nested case-control study

BACKGROUND

Paediatric obesity is a global public health issue. Prenatal maternal mental health is potentially implicated in the development of childhood obesity. This study examined associations between prenatal maternal cortisol, self-reported stress, anxiety and depression in the second trimester, and childhood overweight and obesity at 5 years of age.

METHODS

A nested case-control study was conducted using data from the Irish prospective longitudinal birth cohort SCOPE BASELINE. Cases were children with overweight or obesity, operationalised as having a BMI z-score above +2 standard deviations. Controls were children with a BMI z-score between -0.5 and 0.5 standard deviations at 5 years of age. Two to one matching by sex was conducted. Thirty-eight cases and 83 sex-matched controls were included. Maternal serum cortisol concentration and self-reported stress, anxiety and depression were measured at 15 ± 1 and 20 ± 1 weeks gestation. Conditional logistic regression analyses were conducted to examine associations between prenatal maternal cortisol and self-reported stress, anxiety and depression, and childhood overweight and obesity.

RESULTS

Despite some evidence for associations between anxiety and depression, and child BMI z-scores in univariate analyses, adjusted models indicated no associations between prenatal maternal stress (OR: 1.02, 95% CI: 0.94-1.12), anxiety (OR: 1.03, 95% CI: 0.97-1.09), depression (OR: 1.04, 95% CI: 0.91-1.19), or cortisol concentration (OR: 0.99, 95% CI: 0.99-1.00) and child BMI z-score.

CONCLUSION

Our findings do not provide support for associations between foetal exposure during the second trimester of pregnancy and maternal cortisol, stress and anxiety, and childhood overweight or obesity at 5 years of age.

A core outcome set for school-based physical activity interventions: an international consensus

Background

Studies of school-based physical activity interventions vary in the outcomes they measure. This prevents comparisons of results to establish impacts. We aimed to develop a core outcome set agreed by key stakeholders for future studies of school-based physical activity interventions.

Methods

We used a modified-Delphi consensus method. First, we conducted a systematic review to identify outcomes measured in relevant studies and listed these in a Delphi survey. Next, we recruited key stakeholders to complete 2 survey rounds: Round 1 was to rate each outcome from ‘not important' to ‘critical', and Round 2 was to re-rate the outcomes based on feedback from Round 1. Outcomes rated ‘critical' by 70% of stakeholders (i.e., reaching consensus) were highlighted. Then, using the full list of outcomes, we conducted a children's workshop to include their views. Finally, we held a stakeholder meeting to discuss results and agree consensus.

Results

We identified 50 outcomes from the systematic review. Sixty-five stakeholders (16 educators, 13 health professionals, 12 parents, 24 researchers) representing 9 countries completed both survey rounds; 13/50 outcomes reached consensus. Children (n = 16) identified 8 outcomes of importance; 3 were consistent with the survey results. Stakeholders attending the meeting (n = 13) reached consensus on 14 outcomes to be included in the core outcome set: fitness, physical activity intensity, energy, sleep, diet, happiness, stress, depression, anxiety, wellbeing, self-esteem, enjoyment, concentration, and focus. These core outcomes were reviewed and agreed by all 65 stakeholders.

Conclusions

Our core outcome set agreed by international stakeholders includes physical and mental health, and cognitive function. We recommend its use in future studies of school-based physical activity interventions. Findings from future studies can be compared and combined which will be relevant to public health policy makers and educators.

Key messages

School-based physical activity interventions should measure physical and mental health, and cognitive function. Wide use of this core outcome set will enable findings to be compared and combined.

Artificial intelligence in radiation oncology: A review of its current status and potential application for the radiotherapy workforce

OBJECTIVE

Radiation oncology is a continually evolving speciality. With the development of new imaging modalities and advanced imaging processing techniques, there is an increasing amount of data available to practitioners. In this narrative review, Artificial Intelligence (AI) is used as a reference to machine learning, and its potential, along with current problems in the field of radiation oncology, are considered from a technical position.

KEY FINDINGS

AI has the potential to harness the availability of data for improving patient outcomes, reducing toxicity, and easing clinical burdens. However, problems including the requirement of complexity of data, undefined core outcomes and limited generalisability are apparent.

CONCLUSION

This original review highlights considerations for the radiotherapy workforce, particularly therapeutic radiographers, as there will be an increasing requirement for their familiarity with AI due to their unique position as the interface between imaging technology and patients.

IMPLICATIONS FOR PRACTICE

Collaboration between AI experts and the radiotherapy workforce are required to overcome current issues before clinical adoption. The development of educational resources and standardised reporting of AI studies may help facilitate this.

Once Weekly Application of Urea 40% and Bifonazole 1% Leads to Earlier Nail Removal in Onychomycosis

Introduction

Onychomycosis is a chronic nail fungal infection resulting in nail damage and a decreased quality of life. Chemical avulsion of the nail with urea and bifonazole -removes fungally infected debris, increasing antifungal treatment efficacy and penetration. Previous clinical ob-servations describe patients who applied their urea and -bifonazole ointment less frequently, achieving earlier nail removal. In this study, we analyzed the relationship between duration of urea and bifonazole application and time to nail avulsion.

Methods

χ² tests, multiple regression analysis, and ANOVA were performed to analyze the similarities between treatment regimens (daily, every 3 days, or once a week), association of regimens or patient characteristics to nail removal, and compare time to nail removal between each regimen, respectively.

Results

Daily application of ointment and sealing resulted in an average length of time (±SD) to nail removal of 18.7 days (±6.8 days); once every 3 days resulted in nail removal at 12.7 days (±6.2 days) and once per week at 11 days (±4.46 days) (p < 0.001). Age was the only patient factor that affected duration to nail removal.

Conclusion

Once weekly application of ointment with sealing for a 1-week duration is associated with a decrease in time to complete chemical avulsion of the nail by approximately 1 week.

Impact of school-based physical activity interventions in primary schools: measuring what matters

Background

A growing number of small studies suggest that school-based physical activity initiatives can help children achieve the recommended 60 minutes of physical activity per day. However, the heterogeneity of outcomes and measures used in small studies prevents pooling of results to demonstrate whether short-term health benefits are sustained. Qualitative studies suggest many benefits that are not represented by outcomes in trials to date. The aim of this study was to generate a list of outcomes that have been studied to develop a core outcome set (COS) acceptable to key stakeholders for future studies evaluating school-based physical activity initiatives.

Methods

We searched six databases (MEDLINE, EMBASE, PsycINFO, CINAHL, CENTRAL and Cochrane Database of Systematic Reviews) systematically for reviews of school-based physical activity interventions, and extracted relevant studies to identify the outcomes and measures used in each paper. A long list was generated from the literature and a previous workshop with stakeholders. This study is registered with COMET (#1322), and with PROSPERO (CRD42019146621).

Results

75/121 cited studies drawn from 53/2409 reviews met our inclusion criteria. We grouped 65 outcomes into 3 domains: (i) physical activity and health (ii) social and emotional health, and (iii) educational attainment. We will conduct two Delphi survey rounds with four stakeholder groups (health professionals, researchers, educators and parents) to rate the importance of each outcome. A core outcome set will be generated from a consensus process.

Conclusions

There is currently a large variation of outcomes and measures studied that precludes evidence synthesis of the impact of school-based physical activity interventions. Consensus methods are needed to focus research on the outcomes that matter the most to key stakeholders and to provide tools for future studies to assess long-term impact.

Key messages

Variations in outcomes studied precludes evidence synthesis of SBPA intervention impacts. A core outcome set is needed to ensure future SBPA interventions measure outcomes that matter the most.

Topical and device-based treatments for fungal infections of the toenails

BACKGROUND

Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails.

OBJECTIVES

To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis.

SEARCH METHODS

We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events.

MAIN RESULTS

We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment.

AUTHORS' CONCLUSIONS

Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.

Innovating Qualitative Framing Analysis for Purposes of Media Analysis Within Public Health Inquiry

Public health is said to lack methodological diversity and creativity in media analysis. Although the framing paradigm offers important conceptual and operational insights for undertaking media analysis in public health research, frames are described as "elusive" to measure with their analysis a "methodological black box." With this article, we aim to foster creative thinking around media analysis in public health and to make the "black box" of framing analysis more transparent, by illustrating the innovation and application of a qualitative framing analysis technique in original public health research. We provide a "how to" guide for this framing analysis method and use data to illustrate methodological challenges encountered during the research. The findings drawn from this method are contrasted with findings gained from thematic analysis applied to the same data. The article concludes by considering the benefits of this type of framing analysis within public health scholarship.

Abstract 167: Semaphorin3D signaling in the invasion and metastasis of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) is a devastating disease, with the lowest stage-combined 5-year survival rate of any cancer type at 8%. One major attribute for this poor prognosis is the lack of effective treatments in preventing and controlling metastasis. Previously, our lab has identified the secreted protein Semaphorin3D (Sema3D) to be involved in the invasion and metastasis of PDA. Sema3D is part of the axon guidance gene family, recently been reported to be the most frequently altered gene family in PDA. We have previously found Sema3D interacts with its co-receptors PlexinD1 and Neuropilin-1 to cause increased invasion and metastatic capabilities in PDA cells. We found expression of Sema3D and PlexinD1 increases progressively during PDA development. In addition, tumoral knockdown of Sema3D prolongs survival and reduces metastasis of PDA-bearing mice. Also, Sema3D abundance was found to be significantly associated with human metastatic disease formation. However, the molecular signaling of Sema3D in aiding increased PDA cell invasion and metastasis is unknown. In the present study, we found treatment of mutant KrasG12D PDA, KPC cells, with Sema3D increases the activation of ADP-ribosylation factor 6 (Arf6). Interestingly, mutant KrasG12D has recently been reported to signal with Arf6 causing increased glycolytic metabolic changes. We found treating KPC cells with Sema3D increased glycolytic gene expression and increased tumor cell lactic acid secretion. Blockage of PlexinD1, the Sema3D receptor, with neutralizing antibodies inhibits this increase in glycolytic gene expression. Additionally, Panc02 PDA cells, not expressing mutant Kras, intriguingly do not show increased Arf6 activation after Sema3D treatment, suggesting Sema3D signaling could provide a selective role in mutant Kras expressing cells. Also, we investigated the role of Sema3D-induced increased acidity on tumor associated macrophage polarization. Bone-marrow derived macrophages were polarized to an M1, anti-tumor, or M2, pro-tumor phenotype and co-cultured with KPC cells treated with Sema3D or control protein. Macrophages isolated from the co-culture treated with Sema3D had decreased expression of anti-tumor M1 and increased expression of pro-tumoral M2 polarization markers compared to control. Futhermore, to study Sema3D expression in PDA in vivo, we crossed conditional Sema3D knockout mice to KRASG12D TP53R172H PDX-1-CRE+/+ (KPC) mice to create the KRASG12D TP53R172H Sema3D-/- PDX-1-CRE+/+ KPCS mouse model. Current studies are using the KPCS model to evaluate the role of Sema3D in PDA tumor development and metastasis, as well as, examine changes in tumor associated macrophage polarization. Taken together, this study provides enhanced mechanistic understanding of the role of Sema3D in aiding tumor progression and metastasis and, provides support for targeting the axon guidance pathway for PDA metastasis.

Citation Format: Noelle R. Jurcak, Stephen Muth, Kenji Fujiwara, Agnieszka Rucki, Kelly Foley, Adrian Murphy, Elizabeth M. Jaffee, Lei Zheng. Semaphorin3D signaling in the invasion and metastasis of pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 167.

Anti-pancreatic tumor efficacy of a Listeria-based, Annexin A2-targeting immunotherapy in combination with anti-PD-1 antibodies

BACKGROUND

Immune checkpoint inhibitors are not effective for pancreatic ductal adenocarcinoma (PDAC) as single agents. Vaccine therapy may sensitize PDACs to checkpoint inhibitor treatments. Annexin A2 (ANXA2) is a pro-metastasis protein, previously identified as a relevant PDAC antigen that is expressed by a GM-CSF-secreting allogenic whole pancreatic tumor cell vaccine (GVAX) to induce an anti-ANXA2 antibody response in patients with PDAC. We hypothesized that an ANXA2-targeting vaccine approach not only provokes an immune response but also mounts anti-tumor effects.

METHODS

We developed a Listeria-based, ANXA2-targeting cancer immunotherapy (Lm-ANXA2) and investigated its effectiveness within two murine models of PDAC.

RESULTS

We show that Lm-ANXA2 prolonged the survival in a transplant model of mouse PDACs. More importantly, priming with the Lm-ANXA2 treatment prior to administration of anti-PD-1 antibodies increased cure rates in the implanted PDAC model and resulted in objective tumor responses and prolonged survival in the genetically engineered spontaneous PDAC model. In tumors treated with Lm-ANXA2 followed by anti-PD-1 antibody, the T cells specific to ANXA2 had significantly increased INFγ expression.

CONCLUSIONS

For the first time, a listeria vaccine-based immunotherapy was shown to be able to induce a tumor antigen-specific T cell response within the tumor microenvironment of a "cold" tumor such as PDAC and sensitize the tumor to checkpoint inhibitor therapy. Moreover, this combination immunotherapy led to objective tumor responses and survival benefit in the mice with spontaneously developed PDAC tumors. Therefore, our study supports developing Lm-ANXA2 as a therapeutic agent in combination with anti-PD-1 antibody for PDAC treatment.

Abstract 3026: Role of AnnexinA2, Sema3D and PlexinD1 in mediating perineural invasion as a mechanism of metastasis in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) is a devastating malignant disease. Upon diagnosis, eighty percent of patients present with metastatic disease. Perineural invasion, the spreading of cancer to the space surrounding or invading the nerve, is often found in surgically removed pancreatic tumors and is associated with a worse overall prognosis including high risk of recurrence and metastasis. Perineural invasion is thought to represent the initial steps of metastasis; however, the mechanism that mediates the role of neurons in precancerous inflammation and pancreatic cancer initiation is not known. We have previously found that Annexin A2 (AnxA2), is a metastasis-associated protein in PDA and is not required for primary PDA growth but is essential for the metastasis in genetically engineered spontaneous pancreatic tumor producing KPC mice. Knock-down of AnxA2 results in diminished metastasis and prolonged survival in mouse liver metastasis models of PDA. Moreover, the presence of perineural invasion is AnxA2 dependent in this model. By comparing tumor cells of AnxA2 wild type vs. knock-out KPC mice, we identified Semaphorin 3D (Sema3D) and PlexinD1 (PlxnD1) were among the most differentially expressed genes. We found that AnxA2 regulates the secretion of Sema3D. Originally characterized as axon guidance genes, ligand Sema3D along with its receptor PlxnD1 and co-receptor, Neuropilin 1 (NP1), are among the cellular pathways most frequently altered at the genetic level in PDA. Moreover, we found that knock down of Sema3D or PlxnD1 suppresses metastasis formation in mouse models of PDA (Foley et al. Science Signaling 2015). In the present study, our lab has found that PNI was present in 9/10 human PDA samples with abundant Sema3D expression compared to only 3/10 human PDA samples with low Sema3D expression. Using a Dorsal Root Ganglion (DRG) invasion assay, we found paracrine signaling between DRG and pancreatic cancer cells is important for increasing tumor cell invasion toward DRGs. Using small interfering RNA for AnxA2 in tumor cells, we find that decrease in AnxA2 significantly decreases tumor invasion. Furthermore, knock down of Sema3D from tumor cells, using shRNA, shows significant decrease in tumor cell invasion toward DRGs. We have also tested the role of the Sema3D receptor, PlexinD1, on DRGs in regulating the invasion of tumor cells towards nerves. A neutralizing antibody for PlexinD1 treated on DRGs caused significant decrease in tumor cell invasion in comparison to DRGs treated with IgG isotype control. These results demonstrate that AnxA2, Sema3D and PlexinD1 are involved in paracrine signaling between the tumor cells and nerves. Taken together, we conclude AnxA2/Sema3D/PlexinD1 signaling may aid in mediating perineural invasion of tumor cells towards nerves as a mechanism of metastasis in pancreatic ductal adenocarcinoma.

Citation Format: Noelle R. Jurcak, Kenji Fujiwara, Agnieszka A. Rucki, Kelly Foley, Adrian Murphy, Stephen Muth, Abigail Brittingham, Elizabeth M. Jaffee, Lei Zheng. Role of AnnexinA2, Sema3D and PlexinD1 in mediating perineural invasion as a mechanism of metastasis in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3026.

Hemodialysis-Associated Febrile Episodes: Surveillance before and after Major Alteration in the Water Treatment System

Surveillance for bacteremic or pyrogenic episodes associated with hemodialysis was undertaken before and after the reconstruction of the water treatment system at our University medical center. The new water system included a holding tank with iodination treatment. The water delivered to individual dialysis stations had only occasional positive bacterial cultures (3 of 21 samples before completion of construction, 2 of 16 samples afterwards) and intermittent detection of endotoxin (6 of 21 samples before completion of construction, 9 of 16 samples afterwards) at monthly sampling. Among 51 individual dialysis treatments (25 patients) before reconstruction and 56 treatments (29 patients), after, only 2 and 3 febrile events were identified, respectively. All of these were associated with underlying infectious illness and not with the hemodialysis procedure itself. Overall, we conclude that pyrogenic episodes associated directly with hemodialysis treatment are infrequent, and that the addition of a water storage tank with iodination treatment does not appear to increase the risk of bacteremia or pyrogenic episodes.

Hedgehog signaling stimulates Tenascin C to promote invasion of pancreatic ductal adenocarcinoma cells through Annexin A2

Pancreatic adenocarcinoma (PDA) is characterized by a dense desmoplastic reaction that comprises 60-90% of the tumor, while only 10-40% of the tumor is composed of malignant epithelial cells. This desmoplastic reaction is composed of stromal fibroblast cells, extracellular matrix proteins, and immune cells. Accumulating evidence has suggested that the stromal and epithelial cell compartments interact during the pathogenesis of this disease. Therefore, it is important to identify the signaling pathways responsible for this interaction to better understand the mechanisms by which PDA invades and metastasizes. Here, we show that secreted stromal factors induce invasion of PDA cells. Specifically, hedgehog signaling from the tumor cells induces tenascin C (TnC) secretion from the stromal cells that acts back upon the tumor cells in a paracrine fashion to induce the invasion of PDA cells through its' receptor annexin A2 (AnxA2). Therefore, blocking the interaction between TnC and AnxA2 has the potential to prevent liver metastasis in PDA.

Heterogeneous Stromal Signaling within the Tumor Microenvironment Controls the Metastasis of Pancreatic Cancer

Understanding how stromal signals regulate the development of pancreatic ductal adenocarcinoma (PDAC) may suggest novel therapeutic interventions in this disease. In this study, we assessed the metastatic role of stromal signals suggested to be important in the PDAC microenvironment. Src and IGF-1R phosphorylated the prometastatic molecule Annexin A2 (AnxA2) at Y23 and Y333 in response to stromal signals HGF and IGF-1, respectively, and IGF-1 expression was regulated by the Sonic Hedgehog (Shh) pathway. Both Shh and HGF were heterogeneously expressed in PDAC stroma, and only dual inhibition of these pathways could significantly suppress AnxA2 phosphorylation, PDAC growth, and metastasis. Taken together, our results illuminate tumor-stromal interactions, which drive metastasis, and provide a mechanism-based rationale for a stroma-directed therapy for PDAC. Cancer Res; 77(1); 41-52. ©2016 AACR.

Current progress in immunotherapy for pancreatic cancer

Pancreatic cancer remains one of the most lethal cancers with few treatment options. Immune-based strategies to treat pancreatic cancer, such as immune checkpoint inhibitors, therapeutic vaccines, and combination immunotherapies, are showing promise where other approaches have failed. Immune checkpoint inhibitors, including anti-CTLA4, anti-PD-1, and anti-PD-L1 antibodies, are effective as single agents in immune sensitive cancers like melanoma, but lack efficacy in immune insensitive cancers including pancreatic cancer. However, these inhibitors are showing clinical activity, even in traditionally non-immunogenic cancers, when combined with other interventions, including chemotherapy, radiation therapy, and therapeutic vaccines. Therapeutic vaccines given together with immune modulating agents are of particular interest because vaccines are the most efficient way to induce effective anti-tumor T cell responses, which is required for immunotherapies to be effective. In pancreatic cancer, early studies suggest that vaccines can induce T cells that have the potential to recognize and kill pancreatic cancer cells, but the tumor microenvironment inhibits effective T cell trafficking and function. While progress has been made in the development of immunotherapies for pancreatic cancer over the last several years, additional trials are needed to better understand the signals within the tumor microenvironment that are formidable barriers to T cell infiltration and function. Additionally, as more pancreatic specific antigens are identified, immunotherapies will continue to be refined to provide the most significant clinical benefit.

TGF-β blockade depletes T regulatory cells from metastatic pancreatic tumors in a vaccine dependent manner

Our neoadjuvant clinical trial of a GM-CSF secreting allogeneic pancreas tumor vaccine (GVAX) revealed the development of tertiary lymphoid aggregates (TLAs) within the pancreatic ductal adenocarcinoma (PDA) tumor microenvironment 2 weeks after GVAX treatment. Microarray studies revealed that multiple components of the TGF-β pathway were suppressed in TLAs from patients who survived greater than 3 years and who demonstrated vaccine-enhanced mesothelin-specific T cell responses. We tested the hypothesis that combining GVAX with TGF-β inhibitors will improve the anti-tumor immune response of vaccine therapy. In a metastatic murine model of pancreatic cancer, combination therapy with GVAX vaccine and a TGF-β blocking antibody improved the cure rate of PDA-bearing mice. TGF-β blockade in combination with GVAX significantly increased the infiltration of effector CD8⁺ T lymphocytes, specifically anti-tumor-specific IFN-γ producing CD8⁺ T cells, when compared to monotherapy controls (all p < 0.05). TGF-β blockade alone did not deplete T regulatory cells (Tregs), but when give in combination with GVAX, GVAX induced intratumoral Tregs were depleted. Therefore, our PDA preclinical model demonstrates a survival advantage in mice treated with an anti-TGF-β antibody combined with GVAX therapy and provides strong rational for testing this combinational therapy in clinical trials.

Semaphorin 3D autocrine signaling mediates the metastatic role of annexin A2 in pancreatic cancer

Most patients with pancreatic ductal adenocarcinoma (PDA) present with metastatic disease at the time of diagnosis or will recur with metastases after surgical treatment. Semaphorin-plexin signaling mediates the migration of neuronal axons during development and of blood vessels during angiogenesis. The expression of the gene encoding semaphorin 3D (Sema3D) is increased in PDA tumors, and the presence of antibodies against the pleiotropic protein annexin A2 (AnxA2) in the sera of some patients after surgical resection of PDA is associated with longer recurrence-free survival. By knocking out AnxA2 in a transgenic mouse model of PDA (KPC) that recapitulates the progression of human PDA from premalignancy to metastatic disease, we found that AnxA2 promoted metastases in vivo. The expression of AnxA2 promoted the secretion of Sema3D from PDA cells, which coimmunoprecipitated with the co-receptor plexin D1 (PlxnD1) on PDA cells. Mouse PDA cells in which SEMA3D was knocked down or ANXA2-null PDA cells exhibited decreased invasive and metastatic potential in culture and in mice. However, restoring Sema3D in AnxA2-null cells did not entirely rescue metastatic behavior in culture and in vivo, suggesting that AnxA2 mediates additional prometastatic mechanisms. Patients with primary PDA tumors that have abundant Sema3D have widely metastatic disease and decreased survival compared to patients with tumors that have relatively low Sema3D abundance. Thus, AnxA2 and Sema3D may be new therapeutic targets and prognostic markers of metastatic PDA.

Genetic diversity, virulence and fitness evolution in an obligate fungal parasite of bees

Within-host competition is predicted to drive the evolution of virulence in parasites, but the precise outcomes of such interactions are often unpredictable due to many factors including the biology of the host and the parasite, stochastic events and co-evolutionary interactions. Here, we use a serial passage experiment (SPE) with three strains of a heterothallic fungal parasite (Ascosphaera apis) of the Honey bee (Apis mellifera) to assess how evolving under increasing competitive pressure affects parasite virulence and fitness evolution. The results show an increase in virulence after successive generations of selection and consequently faster production of spores. This faster sporulation, however, did not translate into more spores being produced during this longer window of sporulation; rather, it appeared to induce a loss of fitness in terms of total spore production. There was no evidence to suggest that a greater diversity of competing strains was a driver of this increased virulence and subsequent fitness cost, but rather that strain-specific competitive interactions influenced the evolutionary outcomes of mixed infections. It is possible that the parasite may have evolved to avoid competition with multiple strains because of its heterothallic mode of reproduction, which highlights the importance of understanding parasite biology when predicting disease dynamics.

The relationship between serum urea levels and outcome in acute epistaxis

OBJECTIVES

To establish whether, for the patient presenting with epistaxis, there is a relationship between clinical outcome and serum urea levels measured on initial attendance at the accident and emergency (A&E) department.

METHODOLOGY

Records were reviewed from all patients attending a single teaching hospital A&E department between 1st January 2010 and 11st February 2011 with a diagnosis of epistaxis. Patients were analysed according to their admission serum urea and creatinine levels and then grouped according to clinical outcome.

RESULTS

We identified 278 patients (145 males, 133 females), 82 of which required hospital admission. Eleven required blood transfusion, and five required surgical arrest of the haemorrhage. No patients died. Serum urea and creatinine levels were measured in 119/278 patients. The mean serum urea level was significantly higher in patients admitted for further management of epistaxis than in patients who were discharged from the A&E department (9.35 mmol/l vs. 6.74 mmol/l, respectively; p = 0.003). There was no significant difference in mean serum urea levels between patients who were transfused and patients who were not, or between patients who went to the operating theatre and patients who did not.

CONCLUSIONS

Elevated serum urea levels on hospital admission are related to more severe clinical outcome in epistaxis.

A preclinical murine model of hepatic metastases

Numerous murine models have been developed to study human cancers and advance the understanding of cancer treatment and development. Here, a preclinical, murine pancreatic tumor model of hepatic metastases via a hemispleen injection of syngeneic murine pancreatic tumor cells is described. This model mimics many of the clinical conditions in patients with metastatic disease to the liver. Mice consistently develop metastases in the liver allowing for investigation of the metastatic process, experimental therapy testing, and tumor immunology research.

Bacterial endophyte communities of two wheatgrass varieties following propagation in different growing media

Bacterial endophyte communities of two wheatgrass varieties currently being used in the revegetation of military training ranges were studied. Culturable and direct 16S rDNA PCR amplification techniques were used to describe bacterial communities present in Siberian and slender wheatgrass seeds, leaf tissues, and root tissues following propagation in either sand or a peat-based growing mix. Our hypothesis was that the resulting plant endophytic communities would be distinct, showing not only the presence of endophytes originating from the seed but also the characteristics of growth in the two different growing media. Both culture and culture-independent assays showed the likely translocation of Actinobacteria, Firmicutes, and Gammaproteobacteria from seed to mature plant tissues as well as subsequent colonization by exogenous organisms. Statistical analysis of 16S terminal restriction fragment profiles identified growing media as having a greater significant effect on the formation of the endpoint endophytic communities than either plant tissue or wheatgrass variety. In silico digests of the ribosomal database produced putative identifications indicating an increase in overall species diversity and increased relative abundances of Firmicutes and Cyanobacteria following propagation in sand and Betaproteobacteria following propagation in the peat-based growing mix. Results indicated a substantial translocation of endophytes from seed to mature plant tissues for both growing media and that growing medium was a dominant determinant of the final taxonomy of the endpoint plant endophytic communities.

P1-09-03: Prevalence of Germline TP53 Mutations in Young Women with HER2−Positive Breast Cancer

Background: Li Fraumeni syndrome is a rare inherited cancer susceptibility condition associated with germline mutations in the TP53 gene, in which breast cancer (BC) is the most frequent tumor. The prevalence of TP53 mutations in population-based series of very young onset BC (&lt;30 years at diagnosis) ranges from &lt;1% to approximately 7%1-4. Recent data show that BC in patients carrying a germline TP53 mutation are commonly HER2 amplified (63-83%)5-7. In this study, we assessed the prevalence of germline TP53 mutations in women with HER2 positive BC diagnosed age ≤ 50 years.

Material & Methods: We identified 347 women with invasive HER2 positive BC diagnosed at age ≤ 50 years using the Clinical Operations and Research Information System (CORIS) at the Dana Farber Cancer Institute. Information on age at diagnosis, histology, hormone receptor and HER2 status as well as personal and family cancer history was confirmed from medical records. 129 patients were excluded for various reasons, including a cancer diagnosis prior to the BC and a documented BRCA1/2 mutation. A combination of Exon Grouping Analysis (EGAN) and Sanger sequencing for detection of TP53 mutations in exons 2–11 including surrounding intronic sequence was performed on 218 germline DNA samples. Multiplex Ligation-dependent Probe Amplification (MLPA) analysis for the detection of TP53 deletions or duplications is ongoing.

Results: A germline TP53 mutation was identified in 4 women diagnosed at age ≤ 50 years (1.8%, 95%CI 0.5−4.6). At BC diagnosis, they were 23, 32, 44 and 50 years. Two BC were ER+/PR+, HER2+ and 2 were ER-/PR-, HER2+. Estimate of prevalence of germline TP53 mutations by age at BC diagnosis are: age ≤ 35, 2/41 (4.9%, 95%CI 0.6−16.6), and age ≤ 45 3/168 (1.8%, 95%CI 0.4−5.1). Among the women with germline TP53 mutations, 2 met the Chompret criteria8 and none the classic LFS criteria.

Discussion: TP53 mutations were identified in a cohort of women with HER2+ BC at young age. As expected, the frequency is higher in younger women, but mutations were seen in all age groups that were evaluated. None of these women met classic LFS criteria by family history. Consideration of TP53 testing should be given to women diagnosed below age 35 who are negative for BRCA1/2 mutations regardless of family history. Analysis of other series will be helpful in reaching more stable estimates of the prevalence of mutation carriers among patients with HER2+ BC at young age.

1. Sidransky D et al. Cancer Res. 1992; 52:2984–2986.

2. Borresen AL et al. Cancer Res.1992; 52:3234–3236.

3. Lalloo F et al. Lancet 2003; 361:1101–02

4. Gonzalez KD et al. J Clin Oncol 2009;27(8):1250–6

5. Wilson JR et al. J Med Genet 2010;47(11):771–774.

6. Melhem-Bertrandt A et al: San Antonio Breast Cancer Symposium 2010: P3-12-01.

7. Masciari S et al: J Clin Oncol 29: 2011 (suppl; abstr 1519)

8. Tinat J et al. J Clin Oncol. 2009;27(26):e108–9

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-09-03.

EFFECT OF JOB SKILLS TRAINING ON EMPLOYMENT AND JOB SEEKING BEHAVIORS IN AN AMERICAN INDIAN SUBSTANCE ABUSE TREATMENT SAMPLE

Employment difficulties are common among American Indian individuals in substance abuse treatment. To address this problem, the Southwest Node of NIDA's Clinical Trials Network conducted a single-site adaptation of its national Job Seekers Workshop study in an American Indian treatment program, Na'Nizhoozhi Center (NCI). 102 (80% men, 100% American Indian) participants who were in residential treatment and currently unemployed were randomized to (1) a three session, manualized program (Job seekers workshop: JSW) or (2) a 40-minute Job Interviewing Video: JIV). Outcomes were assessed at 3-month follow up: 1) number of days to a new taxed job or enrollment in a job-training program, and 2) total hours working or enrolled in a job-training program. No significant differences were found between the two groups for time to a new taxed job or enrollment in a job-training program. There were no significant differences between groups in substance use frequency at 3-month follow-up. These results do not support the use of the costly and time-consuming JSW intervention in this population and setting. Despite of the lack of a demonstrable treatment effect, this study established the feasibility of including a rural American Indian site in a rigorous CTN trial through a community-based participatory research approach.

Utility of lipid biomarkers in support of bioremediation efforts at army sites

Lipid biomarker analysis has proven valuable in testing the hypothesis that attributes of the extant microbiota can directly reflect the occurrence of contaminant biodegradation. Two past research efforts have demonstrated this utility and are described here. A 4.5 m vertical core was obtained from a diesel fuel oil contamination plume. Core material was assayed for total petroleum hydrocarbons (TPH) and bacterial membrane phospholipids (PLFA) via a single solvent extraction. Microbial viable biomass and the relative abundance of Gram-negative bacterial PLFA biomarkers were found to be significantly correlated with TPH concentration. The core TPH profile also revealed two distinct areas where the average TPH level of 3,000 microg g(-1) fell to near detection limits. Both areas were characterized by a three-fold decrease in the hexadecane/pristane ratio, indicating alkane biodegradation, and a distinct PLFA profile that showed a close similarity to the uncontaminated surface soil. Low-order, incomplete detonations can deposit hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) into training range surface soils. Since surface soils are exposed to temporal and diurnal moisture cycles, we investigated the effect two very different soil moisture tensions had on the in situ microbiota and RDX biodegradation. Saturated soils were characterized by rapid RDX biodegradation, 4 day half-life, a decrease in number of species detected and increase in PLFA biomarkers for Gram-negative proteobacteria (n16:1omega7c, n18:1omega9c, and n18:1omega7c) and Gram-positive firmicutes (i15:0 and a15:0). Terminal restriction fragment length polymorphism (T-RFLP) profiles of endpoint microbial communities indicated a shift from 18 to 36% firmicutes, the loss of gamma-proteobacteria and the emergence of alpha-proteobacteria. These two past research efforts demonstrated the utility of the lipid biomarker analysis in identifying microbial community characteristics that were associated with two very different soil contaminants. Lipid biomarkers defined areas of TPH biodegradation and identified community shifts as a result of soil conditions that affected explosives fate. Information like this can be used to enhance the predictive power of ecological models such as the Army Training and Testing Area Carrying Capacity for munitions model [ATTACC].

Accurate determinations of alpha(s) from realistic lattice QCD

We obtain a new value for the QCD coupling constant by combining lattice QCD simulations with experimental data for hadron masses. Our lattice analysis is the first to (1) include vacuum polarization effects from all three light-quark flavors (using MILC configurations), (2) include third-order terms in perturbation theory, (3) systematically estimate fourth and higher-order terms, (4) use an unambiguous lattice spacing, and (5) use an [symbol: see text](a2)-accurate QCD action. We use 28 different (but related) short-distance quantities to obtain alpha((5)/(MS))(M(Z)) = 0.1170(12).

A community-based clinical selective in end-of-life care

There is a widespread recognition among medical educators and accreditation organizations that medical students and young physicians lack the competency necessary to care for persons near the end of life. This article describes the institutional and attitudinal barriers to innovation in curriculum design. It then presents and evaluates a 1-month selective for fourth year students that focuses on providing end-of-life care to immigrant populations in community-based home hospice. The selective joined biomedical training in pain management and palliative care, a clinical rotation in home hospice care with an analysis of the way that social and ethnic factors inform and influence end-of-life care.

Earnings Supplements and Job Quality among Former Welfare Recipients

The Self-Sufficiency Project (SSP) offered a generous but time-limited earnings supplement to a randomly assigned group of lone parents—who were also long-term social assistance recipients—if they found full-time work and left social assistance. Employment data was collected for this group over a three-year period following the offer, and for a randomly-assigned control group. This article analyzes the characteristics of the first job that SSP participants found after they left social assistance. The occupations and industries of the first job held are analyzed as is SSP’s impact on hourly wages, weekly hours and job stability. The article finds that SSP increased employment in jobs that were no worse (and no better) than the jobs that participants might have taken in the absence of the program.

Interpretation of atypical patterns encountered when using a flow cytometry-based method to detect residual leukocytes in leukoreduced red blood cell components

BACKGROUND

Universal leukoreduction of blood components is becoming the standard of care. Flow cytometry methods are being used for quality control of the leukoreduction process.

METHODS

We provide an atlas of atypical flow cytograms generated by a commercial LeucoCOUNT assay that was used to enumerate residual leukocytes in leukoreduced red blood cell components. Numeric results are derived from a flow cytogram generated by the assay.

RESULTS

Three types of atypical flow cytogram patterns were observed during process validation or routine quality control of leukoreduced red blood cell components. (a) Fixation artifact: Fixation of control or test samples can alter the staining intensity compared with fresh cells. (b) "Rain" pattern: Flow cytometry methods count slightly damaged leukocytes not removed during leukoreduction. Slightly damaged leukocytes appear on a flow cytogram like "rain" falling from a well-defined "cloud" of intact residual leukocytes. Discrepancies between automated flow cytometry results and subjective manual counting methods can occur. (c) Autofluorescence-debris pattern: Cell debris and age-related changes in the sample can cause shifts in the fluorescence staining pattern, resulting in erroneous test results.

CONCLUSION

Review of flow cytograms is essential for accurate reporting of flow cytometry-based methods for enumerating residual leukocytes in leukoreduced blood components.